may/june 2015

Feed
Your
Kneads
Ways to nourish your practice
+ Should You Bill Insurance?
+ 4 Lessons on Chronic Pain
+ Assessing Fascia-Related Dysfunction
+ Healthy Fare for Mind & Body
+ Who Do Your Clients Trust?

T he Emotional Side
of Craniosacral Therapy

The Effectiveness of Massage 9 Tips for Creating a Working with Clients

for Low-Back Pain Comfortable Environment Locked Knees
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 WHATS INSIDE? MAY/JUNE 2015

FEATURES
56
MANAGE CHRONIC PAIN
Here are four lessons on managing
chronic pain from a veteran massage
therapist and his mountain-climbing
client, who learned to quit chasing
a cure and get back to living.
By Mark Liskey

64
FASCIA-RELATED
DYSFUNCTION
Enjoy this feature on palpation and
assessmentan excerpt from the
new Fascia in Sport and Movement
collection edited by Robert Schleip.
By Leon Chaitow

74
FEED YOUR KNEADS
It can be tough to take care of

48
yourself while youre attending to
clients, so here are some tasty ways
to nourish your body and mind.
By Tera Johnson-Swartz

80
INSURANCE BILLING THE EMOTIONAL SIDE
Choosing to bill insurance for sessions is a big OF CRANIOSACRAL
decision for a massage therapist. This expert Considering and understanding
clients emotions may help you better
provides her know-how to help you decide if its
serve their physical challenges.
the right choice for you and your practice. By Jana Panter
By Irene Diamond
88
WHO DO YOUR
CLIENTS TRUST?
We asked consumers who they turn to
for wellness advice. Their responses
and who they trustmay surprise you.
HOW DO YOU PAY IT FORWARD?
119 By Karrie Osborn
 MAY/JUNE 2015

44

30
106
COLUMNS
BEST PRACTICES TECHNIQUE
22 BUSINESS SIDE 91 CLINICAL APPS
IN EVERY ISSUE Overcoming Hurdles for Men The Indirect Approach to Nerve Injury
6 Contributors and Women in Massage By Whitney Lowe
8 Editors Note By Les Sweeney & Kristin Coverly 99 MYOSKELETAL ALIGNMENT
11 Reader Forum
26 TABLE LESSONS TECHNIQUES
13 A Touch of Humor
Exploring Choices in Movement Engage the Brain, Free the Fascia
14 Speak Your Mind: Hand Care
By Douglas Nelson By Erik Dalton
17 News Notes
18 Tell Me: Your Peeps Speak 28 SAVVY SELF-CARE 102 ENERGY WORK
20 Tips for Today: Practice Software Solutions Rituals that Shape Your Day The Case for Hope
111 Happenings By Jennie Hastings Stancu By Cyndi Dale
112 New Products
106 MYOFASCIAL TECHNIQUES
114 Education Resource Listing
Working with Locked Knees
115 Classieds EDUCATION
By Bethany Ward & Til Luchau
117 Display Showcase 30 CLASSROOM TO CLIENT
118 Ad Index
Creating a Comfortable Environment
119 Inspiration & Insight
By Anne Williams
36 PATHOLOGY PERSPECTIVES
Crohns Disease 14
By Ruth Werner
41 FUNCTIONAL ANATOMY
Supinator
By Christy Cael
36 44 SOMATIC RESEARCH
Massage and Low-Back Pain
By Jerrilyn Cambron
 Massage & Bodywork promotes professionalism among practitioners, stimulates healthy Associated Bodywork
dialogue, and expands the knowledge of those in the eld to advance their successwhile & Massage Professionals
remaining mindful of the breadth of bodywork backgrounds, beliefs, and modalities.
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contributors
Irene When not Now that the
Diamond is writing, editing kids have own
excited about or teaching, the coop, Jana
her new Leon Chaitow Panter enjoys
electric sit/ spends the long walks with
stand desk. majority of the her dogs, hilly
She loves year in beautiful Seattle bike
to write, but Corfu, Greece. rides, writing
prefers to be Relaxing with articles exploring
dancing his wife of 44 the depths of
physically years, Alkmini, craniosacral
and metaphorically. Whether keeps him grounded as does therapy, and adventuring with
with her husband or kids, or in swimming, reading, and walking the her husband. She describes a
her ofce, movement is key. Her familys aging dachshund, Dumbo, recent sunrise hot air balloon ride
philosophy: Lifes short. Make who moves at just the right speed! in Sedona as magnicent.
a difference. Have fun.

6 massage & bodywork may/june 2015

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 EDITORS NOTE

Toasting Samuel
Happy Birthday, Samuel Wong ABMP member and
ABMP Certified member. Thank you Massage & Bodywork
for being a delight and inspiration! author Samuel
Readers, Sam is a perfect Wong and Editor-in-
representative of our 80,000-plus loyal Chief Leslie Young
members: dedicated to the profession, cross paths at the
hard-working, leads with his heart, 2013 International
talented, and well-intended. But lets Massage Research
go back to the talented part. Since he Conference in Boston.
was a youngster, Sam knew there was
something special about his touch,
but it wasnt until he was a student
at Northern Virginia Community
College that his massage career found
its wings. He describes himself as a
research massage therapist, and he loves
teaching and writing about the work.
In 2013, I was delighted to meet
Sam and his charming wife, Mercedes,
at the International Massage Therapy
Sam was born in Singapore. He had a fascinating
Research Conference in Boston.
career working in various capacities for the US
It was April 2013the week after
government. The Wongs have traveled around the
the Boston marathon bombings
worldall across Asia, in particular. He retired from
but Sam was keen to connect with
service in 2004, and they make their home in Virginia.
the researchers and practitioners
whod gathered from around the
I cant wait to see how hes going to dazzle me next. Do It Now!
On May 22, Sam turns 76 years young. Last week, he
globe. He had a poster presentation Be like Sam and build
emailed me, so excited to show me the site hed just
on display about using massage to your website today.
built with his ABMP Website Builder member benefit
address symptoms of fibromyalgia.
(www.samuelwong.massagetherapy.com). Hes quick to www.abmp.
A year later, we published his
point out that he will continue to embellish it, but ta-da,
Massage & Bodywork feature East Meets com/members/
its live!
West: Yin Yang Touch in the March/ siteWB.php
If youd like to learn more about Sam and his path,
April 2014 issue. The piece mirrors
youre in luck. Check out New Products on page 112,
not only Sams rich Asian heritage,
where we feature Sams new book, Becoming a Massage
but also his knowledge about, and
Therapist at Age 70. (I had the honor of writing the
dedication to, Eastern and Western
foreword.) This isnt his first book. Also on the shelf
modalities. While reading the article,
are A Diplomat in Guangzhou, A Chinese from Singapore,
I was impressed with his succinct
and Intimate Witnesses: Coping with Challenges.
command of the English language.
Clearly, Sam is the poster child for the descriptor lifelong
He also writes in Chinese, and speaks
learner. Please join me in toasting him, learning from him,
Mandarin (Putonghua) and Cantonese.
and wishing him Happy Birthdayand mannnny more!

LESLIE A. YOUNG, Editor-in-Chief

leslie@abmp.com

8 massage & bodywork may/june 2015

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 9
 READER FORUM

GROIN PULLS
I have been a California massage therapist since
1998. Along the way, I studied and learned the
Muscle Release Technique from Michael Young
of Evergreen, Colorado. The column in the
March/April 2015 issue of Massage & Bodywork,
Groin Pulls by Whitney Lowe [Clinical
Apps, page 90], puts into words the things I
discovered working on athletes. His article is
the first I have ever read on that subject.
My experience with groin pulls came while
serving a football team. An injured player was helped
to the table off the practice field. I had no idea how Access the digital edition archives at
to treat that first client. He was in severe pain and
www.massageandbodyworkdigital.com
needed help walking. I applied the same principle
used to release other cramps and spasms in various on your computer, smartphone, or tablet.
muscles to the groin area and surrounding muscles.
That first clients treatment was very painful for a few
seconds as his buddy held him in place on the table.
Then, he breathed easily, got up from the table, ran
MAHALO MESENTERY!
I just wanted to say a big mahalo for doing the article
back out onto the practice field, and finished practice.
on the mesentery system [Myofascial Techniques,
I have learned much in making the treatment
Working with the Mesentery, by Til Luchau, March/
easier for the client since that first experience.
April 2015, page 106]. As a practitioner of lomilomi,
The method used now has been improved so it is
the abdomen is the key area of concentration, and
uncomfortable, but not painful. I have addressed
where the Hawaiian people believe all ailments
several groin pulls in male and female athletes and
begin. Reading your article just added another
they all benefit greatly from a single treatment.
layer of understanding to this ancient art form in a
The sooner the injury is treated after the injury
scientific way that makes total sense. Great job!
(strain) occurs, the easier it is to relieve.
SASCHA K. THOMPSON, LMT
Thank you for your helpful publication.
PUNALUU, OAHU
TOM SUDERMAN
VISALIA, CALIFORNIA

CLOSING SESSIONS
I enjoyed reading how therapists close their sessions
[Tips for Today, How Do You Close Your Sessions?
by Brandon Twyford, March/April 2015, page 20].
Over the years, my closing techniques have changed.
My most recent opening and closing in my private
practice begins when I step into the massage room.
I gently tap the Woodstock Hanging Gong I have
hanging from the light fixture at the foot of the table
three times, signaling the beginning of the session.
After finishing the massage, I softly ring my Tingsha
cymbals at the foot of the table, letting the client
know the session has ended. Then, I leave the room.
VIOLA CROWDER-MOGER
KILLEEN, TEXAS
EMAIL YOUR LETTERS TO EDITOR@ABMP.COM.
INCLUDE YOUR FULL NAME AND THE CITY AND STATE
IN WHICH YOU RESIDE. WE RESERVE THE RIGHT
TO EDIT LETTERS FOR LENGTH AND CLARITY.
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A TOUCH OF HUMOR

LMT

I understand that you had your heart set on a scalp massage today,
but I think that now might be a good time for us to talk about
the concept of contraindications.

Susan M. Epperly and her husband, Shane, are licensed massage therapy
instructors and clinical massage therapists in private practice in Austin, Texas.
Through their production company, Tiger Lily Studios (www.tigerlilystudios.com),
Susan and Shane create educational content for fellow health and wellness
practitioners. Their most recent project is a growing collection of resources called
Your M.B.A. (Massage Business Advocates) series. The first two ebooks in the
series (Massage Marketing: Parting Gifts and Designing the Perfect Massage
Space) are now available on their website.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 13

 SPEAK YOUR MIND

How do you take care of your hands?

I mainly try to strengthen my hands. Grip strengtheners,
ngertip push-ups, and holding books with my ngers
while standing with hands at my sides. I also
massage my hands, constantly looking for more
points and applying different techniques. As a
bonus, I learn things I can treat clients with.
ATTICUS
DAVIS, CALIFORNIA

When I started my massage therapy

career a year ago, I was very busy about
I stretch my hands and ngers 45 days a week, with 46 clients
each day. My hands and wrists started
before each massage. I also alternate every other to become very sore. So, from what
night between sugar scrub on my hands and I learned in school, I started paying
attention to my body mechanics! That
organic lavender oil, which I gently massage my has helped a great deal throughout the
own hands with. It feels great and reminds me last year. I have kept my wrists straight,
fi ngers relaxed, and shoulders down.
that taking care of me is vital if I want to continue Every so often, I will ice my hands.
to do this work I love until retirement time!
ALEXANDRA SCHMIER, LMT
TAMMY GABLE ONLINE
PROVIDENCE, RHODE ISLAND

I have been practicing massage therapy full time for 22 years and have no problem
with my hands at all. I am mostly thankful for my genetic heritage. Coming from
pure peasant stock, I am fit to dig potatoes or become a massage therapist. Still,
every morning I perform the hand exercise we learned in massage school. I slowly
and deliberately bend each digital phalange until I make a fist, and then slowly
open my hands. I do three sets of 10 reps before I get out of bed. I also plunge my
hands into ice water at the end of my workday, which inhibits inammation and
reduces the appearance of the overtly vascular development in my hands. Also,
I think that in the 22 years I have been practicing, the fact that I have never felt
like I was going to work keeps me from experiencing any overuse systems.

SHEILA FONTANA
GLENWOOD LANDING, NEW YORK

14 massage & bodywork may/june 2015

 I nd this to be an interesting question. I do
I spent five months this year working
not have troubles with my hands. I keep my
for USA Cyclings Elite Development
body well stretched and receive massages
Program in the Netherlands as a
at least every other week. The trouble for
soigneurthe pro cycling teams
me is not in my hands, but my core. This
combination massage therapist,
area holds quite a bit of my massage
medic, nutritionist, chef, sports
work. I ache there more than any other
psychologist, chauffeur, and
spot. Another area is my deltoids. This
all-around caretaker. We routinely
is from all types of things: working
worked 1215-hour days, frequently
out, playing sports, and some massage
with 58 hours of massage a day. The
(deep-tissue work). This is an area that
combination of long hours of deep-tissue
deals with how we sit at our computers,
sports massage, cramped working conditions
when we read, and what we carry, too.
without room for proper body mechanics, and
I am asked about my hands quite a bit.
assorted (often heavy) manual labor made good
I have very small hands, and clients are
hand care essential, and I was regularly found late at
mesmerized by how I can do so well in
night with my hands stuck in the ice coolers during a major racing campaign!
my massages without hurting my hands.
By the end of the season, I was suffering from a torn rotator cuff sustained
My response is that I am a professional
when I didnt let go quickly enough of a bottle grabbed by a cyclist passing
massage therapist and have been taught
at 30 mph, as well as numbness in my hands related to the shoulder injury
how to be proper with my body mechanics
and repetitive stress. The biggest things that have saved my hands: relentless
while doing massage. I am excited about
dedication to isolated exercise, adherence to excellent body mechanics,
my career and just love my work. My
and beginning piano lessons again for the fi rst time since childhoodit is
hope is to continue this work for many,
as much emotional release as it is physical therapy for all the fi ne muscles
many more years. Taking care of myself
of the hand. Now, if only I can bring my piano with me to bike races!
is a priority, which I take very seriously.
SARA CLAWSON
GREENSBORO, NORTH CAROLINA DEEANNA RODIGER
SALEM, OREGON

Warm rice bags

are relaxing, and
I regularly receive
therapeutic massage!
AUDREY POWELL Two words:
COLFAX HEALING ARTS, INC.,
CALIFORNIA
parafn bath.
THERAPY WITH DESTINY
SOUTHFIELD, MICHIGAN

Upcoming Whats your best phrasing
for telling a chatty client
Topics that its time for quiet and
to focus on their session?
Publication Date: July/August
How and when do you ask
clients to rebook?
Publication Date: Sept/Oct
Email your responses
to darren@abmp.com.
Your submission can be
as short as youd like
and up to 250 words.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 15

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 NEWS NOTES
compiled by Brandon Twyford
ABMP Assistant Editor | brandon@abmp.com

Massage Helps
Back-Pain Sufferers
The March 2015 issue of Harvard Mens Health Watch
summarized recent research on the effectiveness of massage
therapy, explaining that when performed in conjunction with
conventional back-pain care, Massage therapy generally
seems to be helpful and it tends to be very safe.
The following tips were provided as recommendations
for getting the best results from massage:
Check with a doctor to make sure massage is safe for the
back condition.
Ask the massage therapist for advice about ways to sit,
walk, or work that may prevent future back pain.
For more information on massage for low-back pain, see Somatic
Research, page 44.
Is your practice listed on the ABMP therapist
nder at www.massagetherapy.com? The
site is a great way for potential clients to
nd practitioners close to them and to learn
more about massage.
Spafinders 2015
Trends Report
Spafi nder has released its 2015 Global Spa +
Wellness Trends Forecast. The report takes an
intense, research-driven view of whats trending
across the global wellness landscape and is
intended to provide companies in the health and
wellness industry with the information they need
to make sound decisions in the coming year.
Common themes in this years forecast
are a desire for simplicity in todays
technologically centered world and a yearning
for community in an age of loneliness.
The top 10 trends in this years forecast are:
Beyond the Stars
Cannabis: New Spa & Wellness Connections
Forest Bathing
Gut Reaction
Hyper-Personalized Beauty
Industrial Revolution: Blue Collar Wellness
My Fitness. My Tribe. My Life.
Spa On Arrival (and En Route)
Wellness Homes, Communities, and Cities
Wellness Traditions from the Islamic World
To learn more about each of these topics,
and to view the full report, visit www.spafi nder.
com/content/2015-global-spa-wellness-trends.

Master of Science Now Open to LMTs

Bastyr University is now offering its Master of Science in Ayurvedic Sciences to LMTs in
the fi rst accredited program of its kind in the United States. Previously open only to licensed
medical professionals, such as doctors and nurses, the two-year graduate program will offer
hands-on clinical training with experienced faculty, with an optional externship in India, where
students observe and assist ayurvedic practitioners in clinics and hospitals.
Ayurevda, the 5,000-year-old medical system of India, offers keys for creating harmony and
balance in life. It offers a way to keep ourselves and others healthy and happy, and to proceed with
the full benefits of what life has to offer, says Dhaval Dhru, MD, director of Bastyrs ayurveda
program.
For more information, contact Bastyr Universitys office of admissions at 425-602-3330 or
admissions@bastyr.edu.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 17

 TELL ME

Your Peeps Speak

Wisdom From Your Colleagues
Some things just cant be
learned in a classroom.
Veteran massage therapists
possess the kind of
experience that simply cant
be taughtit can only be
gained through years of hard
work, making a few mistakes
along the way, and going
through a few dozen gallons
of massage oil. Wouldnt it
WE ASKED YOU:
Whats the most
important piece I have found that the act of
massaging a client is just a
of advice youd small piece of what we do
give to someone as massage therapists. In
order to be successful, you
entering the need to have the mind-set of
being willing to do so much
profession fresh more than just massaging the
out of massage client coming in the door.

be great if you could have school? LINDA SUMMER, TENNESSEE

avoided some of the common

pitfalls new massage
therapists fall into? Have you
Be ready to work
ever wished you could pass
hard your first year.
on a valuable lesson learned
KAYLA STROUD,
to your past self so that you WASHINGTON

didnt have to learn it the hard

way? Have you ever watched
a brand-new massage
therapist at work and thought
to yourself, Dont do that!

Make sure you connect with us to get your voice heard in next issues Tell Me
www.facebook.com/ABMPpage
mp www.massageprofessionals.com
Always keep
@ABMPmassage http://abmp.us/ABMPgplus learning.
DEB INCHA BRUSHERT,
http://abmp.us/LinkedInMT @ABMPmassage WISCONSIN

18 massage & bodywork may/june 2015

 By Brandon Twyford
ABMP Assistant Editor | brandon@abmp.com

Your body
is your single
most important
massage tool ...
take care of it!
MARYANNE GILBERT, COLORADO

Do not discount what you do! You are

worth every penny that you charge.

CHRYSTLE DRYSDALE COUSINS,

PENNSYLVANIA
Be confident in the
massage therapist you
are. You will not be the
right massage therapist
for everyone. Refer out
KEEP YOUR INTENTION
CLEAR AND MAKE EACH
if that is the case. Do not MASSAGE A MEDITATION.
hurt yourself trying to be TIME FLIES WHEN YOU ARE
everything to everybody. DOING WHAT YOU LOVE.

ELIZABETH MAHONE HARLOW,

MARYANN LANE LYONS,
VERMONT
MASSACHUSETTES

Did You Know?

Theres a thriving community of experienced massage therapists exchanging ideas,
best practices, and much more at ABMPs LinkedIn (www.abmp.us/LinkedInMT)
and Facebook (www.facebook.com/abmppage) pages. Got questions about active
isolated stretching, continuing education, or trigger point therapy? With thousands of
massage therapists from around the world participating in daily discussions, theres
sure to be someone online whos happy to help!

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 19

 TIPS FOR TODAY

Online Practice Software Solutions

By Brandon Twyford

The following software solutions each include online scheduling and automatic confirmation and
appointment reminders. In addition to these tools, each product offers a range of extra features. Log in to
www.abmp.com and click on Discounts for Members for great deals on all of these products and more!

BODYWORK BUDDY GENBOOK

Founded by a massage therapist and Genbook is a convenient and
business owner to meet the needs she versatile online scheduling solution
found in her own practice, Bodywork for small service-based businesses.
Buddy is a complete online solution A straightforward and intuitive
for therapists on the go. Its optimized scheduling process makes it simple for
for mobile use and works seamlessly customers to book appointments, and a
across all devices, making it easy for dedicated and knowledgeable customer
therapists to manage their practices care team provides excellent support
from anywhere, on any device. to help with any issues, large or small.

Highlights:
Offers SOAP notes.
Optimized scheduling to
eliminate gaps in your day.
Extensive reporting features, including
tracking for income, expenses,
gift certificates, and packages.
Custom micro site included.
Flat rate; no hidden fees or
setup costs; free 15-day trial.
FULL SLATE
Full Slate scheduling software works
in the background to keep track of
client information, appointment
history, and email communications
with easy-to-use customer
relationship management features.
Highlights:
As part of Intuit, Full Slate
features advanced integration with
Quickbooks Online to help you stay
organized in all aspects of running
your business, and its Checkout
feature allows you to take and record
payments, add tips, apply sales
tax, and email or print receipts.
Email marketing that lets you
automatically send a personalized
thank-you note after each
appointment, birthday greetings,
and reminders for clients to book
their next appointments.
Calendar synchronization with
Google Calendar, iCal, and other
popular calendar systems.
Highlights:
Genbook Manager app for iPhone
and Android lets you connect
with clients, view and manage
schedules, and manage reviews.
YourOffers feature lets you create,
run, and book deals and specials
from within your Genbook account.
Versatile BookNow and Read
my Reviews buttons and links,
with web, email, and social
media sharing integration.
MASSAGEBOOK
MassageBook helps streamline your
bodywork practice to get it running
smoothly, attract more new clients, and
get your existing clients coming back
regularly. MassageBook combines all
the tasks required to run a successful
practiceemail campaigns, gift
certificates, payments, scheduling, and
SOAP notesinto one simple solution.
Highlights:
ABMP members get an enhanced free
account.

20 massage & bodywork may/june 2015


Easy to use, HIPAA-compliant SOAP
notes and intake forms that are tied
to each clients appointment records.
Email marketing, Facebook
integration, and SEO features help
you build your web presence.
Credit card processing:
MassageBooks 2.75 percent per
swipe processing fee matches the
industry leader, Square, but does
one better with seamless integration
with your businesss billing and
accounting information.
MINDBODY
Mindbody is the largest global provider
of business management software for
the wellness industry. Mindbodys easy-
to-use practice management software
helps you organize everyday tasks while
saving time and boosting revenue.
Highlights:
Point-of-sale feature allows you
to collect payment for products,
memberships, and packages, as
well as services, all at once.
Unique profi les for every client,
where you can store birth dates,
contact information, payment and
session histories, photos, and more.
Marketing tools let you target new
clients with discounts, gift cards,
loyalty programs, and promotions.
Get training on setting up your
account, as well as unlimited
technical support.
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 21
Find More Software
Solutions in This Issue:
MINDBODY: page 10
MassageBook: page 12
Timely: page 46
Full Slate: page 84
Artichoke: page 90
Land Software: page 115
SOAP VAULT and treatments have not changed
from one session to the next.
Lets face it: no one loves taking SOAP
Email intake forms ahead of time
notes. But proper documentation
so clients can complete them
protects therapists, increases
before the session begins.
professionalism, and helps ensure
Schedule appointments or enable
excellent continuity of care for
online booking for your clients.
clients. SOAP Vault makes it fast and
Financial reporting gives you detailed
easy to document and store detailed
access to clients appointments
session notes through its web-based
and payment history.
charting program, taking away some
Enhanced security systems, including
of the headache from this normally
around-the-clock on-site professional
tedious aspect of running a practice.
security teams, keep your practices
data safe and secure.
Highlights:
Interactive charting allows you
Brandon Twyford is assistant
to tag anatomical diagrams that
editor at Associated Bodywork &
are then automatically formatted
Massage Professionals. Contact
into the SOAP structure.
him at brandon@abmp.com.
Save time by copying content
from any previously fi nalized
notes when a clients symptoms
Want a Custom App for Your Practice?
Cell Charge (www.cellcharge.com), a full-suite provider of merchant services,
now provides custom-built apps for therapists to engage clients directly on their
smartphones. Think of your custom app as the ultimate digital business card, says
Cell Charge President Dave Garboski.
+ Built-in customer engagement features such as loyalty programs, promotions,
and QR code generators.
+ Fill gaps in your schedule by sending push notications to clients about special
promotions or last-minute cancellations.
+ Seamless integration with Cell Charges merchant services, including credit card
processing and online payment processing.
+ Full app integration with the most popular social networks, including Facebook,
Twitter, and Instagram.
best practices BUSINESS SIDE

Same Profession, Different Challenges

Overcoming the Hurdles Facing Men
and Women in Massage
By Les Sweeney, BCTMB, and Kristin Coverly, LMT

Are you a male in the bodywork profession? Female?

Perfectthis columns for you! Les and Kristin explore the
unique challenges facing both male and female therapists today.

ITS (NOT) A MANS MANS MANS WORLD

Les Sweeney: In 1966, the year I was born, James Brown recorded Its a Mans
Mans Mans World, a song that was characterized by Rolling Stone as biblically
chauvinistic but nonetheless was ranked number 123 of the 500 greatest songs of
all time (and later achieved true immortality when featured on the show Glee).
The massage therapy profession is not a mans world. That is a common
notion that has been expressed to me, and generally held, since the time I
began working in the field in 1994. About one in six massage professionals
are male, a number that has stayed fairly consistent over the past 20 years.
Interestingly, when I look at our ABMP membership data, approximately 23
percent of therapists working at franchise massage clinics are male, while only
15 percent of members who do not work at franchise massage clinics are male.

85% 83%
77%

23%
15% 17%
Female Male

ABMP members ABMP members Overall ABMP

working at not working at membership
franchise clinics franchise clinics

Which brings me to my thesis:
massage is one of the few professions
where men do not enjoy an advantage
in the marketplace. In many other
fields, men historically have dominated,
set the ground rules, and, in general,
skewed things to their own advantage.
(Dont believe me? Just ask women.) In
massage, a higher percentage of males
work in franchise clinics because (1) it
is more difficult for males, on average,
to establish and sustain an independent
practice; and (2) working in a clinic
provides a sense of security for males.
These statements might seem a bit
strong, but Im just reporting the facts
here. Surveys show that female clients,
on average, prefer a female therapist;
male clients also prefer a female
therapist. So, whos left for us guys?
When I was in massage school, the
only slight I probably received because I
was male was when we partnered upI
think early in my schooling the women
preferred to pair up with each other
rather than get stuck with the guy
(until they realized what an awesome
therapist I was, he says humbly).
Now, this issue does not mean
males cannot excel and have a
successful career in massage and
bodyworkactually the contrary. As
I have told therapists for two decades,
there is always room for one more
good anything. The massage and
bodywork profession is a mosaicas
evidenced by its name alone. Massage
alone doesnt cover it; where or how
you receive your bodywork can be
varied and unique. Thats what makes
regulation so challenging: things arent
standard. And who delivers the work
is what defi nes the work as well.
Thinking about the qualities
of a good massage therapistor a
successful practicewill help defi ne
the ways that any therapist, male or
female, can build a sustainable career.
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 23
visit abmp.com
There are more than 3,000 male
members of ABMP who have been in
the field for 10 years or more. There
is no reason a male therapist cant be
successful in this field. But that doesnt
mean its easy (or will get easier). To
that end, here are a few things to
remember to make success a reality.
Create an authentic image
that projects who you are
and be consistent.
The essence of massage is relaxation;
a client has to trust you to serve their
needs. Be confident, thoughtful, and
respectful, while remaining true to your
personality. Clients choose therapists
because of their personality, not in
spite of it. Tell your story; dont be
afraid to show who you are. However,
be mindful of your professionalism.
There is plenty of negative publicity
out there about male massage therapists
who have taken liberties with (usually)
female clients. Even joking references
or innuendos are off-limits. Professional
therapists must always maintain
clear boundaries with their clients.
Show your stronger
(and softer) side.
Take advantage of
your uniqueness. Big
strong guy? Bring
those skills to the
table (literally).
Many clients like
deep work, and your
strength may set
you apart. Massage
is many things:
clinical, invigorating,
relaxing, spa-like,
sporting, therapeutic.
Show off your nurturing skills
as wellallow your clients to feel
safe, relaxed, and cared for.
 ITS NOT EASY STREET OVER
Work smart.
HERE, EITHER
Male therapists may be
Kristin Coverly: OK, now for the
at a disadvantage because of
female perspective. Do male therapists
long-held biases, or bad apples who generate
have a unique set of challenges? Sure.
stereotypes, but you can overcome those. Set yourself up
But that doesnt mean its always a
to dispel those myths. Remember that statistic about the percentage of males in
breezy Easy Street sing-along (I
franchise clinics? Thats a way for those males to gain some traction. For some, it
just saw the Annie remake with my
may be too difficult to have your own office when fi rst starting out. Through no
niece) over here on the female side of
fault of your own, clients may decide they need an environment where they feel more
the profession. Weve got our own set
comfortable. If you are interested in practicing independently, you may need to look
of challenges to deal with. The good
into partnering with another therapist (likely female) to establish your viability.
news is that with some preparation and
practice, these are hurdles we can clear.
Focus on your business. Lets explore a few of the common
You are engaged in this field to serve others, but serve yourself as well. And challenges for women in our profession,
that means developing a healthy practice. Every therapistmale or female with the caveat that what follows
has a challenge to cultivate a thriving practice. Make your primary focus this are generalizations that wont apply
year be the growth of your client base. If being a male in a female-prominent to all female therapists and may or
field is a challenge, strive to be the best-marketed practice in your area. Many may not apply specifically to you.
biases are just initial oneseducation and demonstration of your skills, your
work ethic, and your professionalism will make your gender irrelevant.
Challenge: Age
Data shows the median age of massage
Harness your girl power. students is dropping. Does this younger
All good therapists should welcome feedback about their practicewe can always population of female therapists face
improve, and who better to give you constructive input than your sisters in practice? a unique set of challenges? You bet.
You undoubtedly went to massage school with female classmates; have them give Younger therapists have to work
you some guidance and share thoughts. Offer bodywork trades and ask them a little harder to be perceived as
about ways you can improve and make your practice more open and welcoming. professional and competent therapists.
As mentioned, developing a thriving practice is a challenge for anyone. For our purposes here, lets defi ne
Males just may have a few more hurdles than females. But thats not the end of younger as therapists in their 20s.
the world. We men can do it. Instead of listening to James Brown singing, Its a Many employers, based on previous
Mans Mans Mans World, go back a few more years to 1959 and listen to Frank experiences, believe younger employees
Sinatra and High Hopesoops, there goes another rubber tree plant lack professionalism and wont show
Shout out to my brothers in arms (and elbows) out up on time or be able to carry on a
there doing great worklet us know professional conversation (with eye
your secrets of success! Email contact) with clients. Some clients
us at bizfit@abmp.com. believe age equals experience and
talent, which
ends up being
a plus for older
therapists,
but a challenge

Developing a for younger ones.

However, some
clients also believe
thriving practice is a that older therapists may not
be able to deliver the pressure
challenge for anyone. they want (this goes for petite
therapists, too). Frustrating, right?
 BUSINESS SIDE

To increase your confidence in all business

situations, remind yourself that what youre
sellingyour workhelps people.

What can you do? Know the assumptions and plan Challenge: Safety
your countermove. Younger therapists, be prepared to Female therapists also have concerns about physical
address professionalism in a job interview. Older and safety and clients with questionable expectations. We
petite therapists, include client testimonials praising can get nervous when working with new clients in an
your level of pressure in your marketing materials. outcall situation, home office, or isolated office space.
My first rented massage room was in a physical
therapy suite in a large office building. After 6:00
Challenge: Confidence
p.m., the building cleared out and had a slightly dark
Almost all female therapists Ive met in 14 years of
and eerie feel to it, and no one else was working in my
practicing and teaching have struggled with confidence
office suite. For a few evening appointments with first-
at one time or another in areas ranging from setting
time male clients I didnt know, I turned the lights
rates and enforcing policies to promoting their
on in the empty offices and had a friend sit and read
practice. We get into the field because we love helping
in the waiting room during our session so there was
people, but the business of helping people doesnt
someone else present in the space when my new client
always come naturally or feel super comfortable.
arrived. Was this absolutely necessary? Maybe not,
Whether you have your own practice or work
but it gave me the peace of mind that she was nearby
for someone else, your level of confidence when
if I needed her and allowed me to focus on the session.
communicating (verbally and nonverbally) conveys an
You can also set up a buddy system with a friend to
impression of the quality of your work. If you drop eye
check in with each other before and after sessions.
contact, lower your voice, and hunch your shoulders when
Moral of the story: do whatever you need to
sharing your prices, clients will believe you dont think
do to protect your safety and reduce worry. Have
your work is worth that price, so they wont believe its
a solid phone interview with new clients and,
worth it either. Is it uncomfortable to ask for money?
bottom line, be willing to say no if you dont feel
Yes, it can be. But it doesnt have to be! Set a fair price
comfortable scheduling a session with that person.
based on your experience and your local market, and
Most of the time its a bonus to be a female
then practice saying it out loud to people until its easier.
therapist in our profession. What do you do when its
This might sound a little wacky, but try it, it works!
not? I suggest forming a group with your colleagues
To increase your confidence in all business situations,
to help each other with challenging situations when
remind yourself that what youre sellingyour work
they pop up. Its nice to have a community to lean
helps people. Believe that what you offer is valuable.
on when you need support. Find ways to clear those
Trust that you deserve to have a full practice. If you
hurdles so you can keep doing what you love!
have to fake it til you make it for a while, thats
OKyour confidence will grow. Dont let a little
nervousness limit your ability to do what you love.

Les Sweeney is ABMPs president and resident blogger. Contact him at les@abmp.com
and read his blog on www.abmp.com. Kristin Coverly, kristin@abmp.com, is the manager
of professional development at ABMP and teaches workshops for therapists and instructors
across the country. Both are massage therapists with business degrees who care about you
and your practice. Want more? Check out their ABMP BizFit video tips on www.abmptv.com.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 25

best practices TABLE LESSONS

Moving by Design
Exploring Choices in Movement
By Douglas Nelson

Good morning, I said as I

greeted Mrs. S. in my waiting
room. Its wonderful to meet
you. Thank you for being here. If
you would like, you can bring your
things with you back to the room.
Observing the guarded way Mrs. S.
turned to pick up her coat and purse, I
had a pretty good idea of the problem
at hand. This was confirmed as we
settled into my treatment room. I could
see Mrs. S. hesitate, looking for the
right words to convey what she felt.
Essentially, no one knows what
to do with me, she began in a rather
exasperated voice. I have seen many
health-care providers over the last
several years, but I get the sense they do
not understand my situation. Everyone
tries to treat my neck, but I think my
muscles dont know how to respond
appropriately anymore. Most often, the
intervention leaves me worse off than
before. Exercises often make me worse.
The effect isnt always immediateit
might take two or three daysbut I am
in much more pain after doing them.
But if I dont do anything, I will
never get better. Its like my neck
is excessively weak and sensitive,
but I suffer when I try to do the
exercises. Its a damned-if-you-do,
damned-if-you-dont situation.
Honestly, I am not even sure
what I am asking of you. In the
past, massage has made me worse,
but several people suggested you
might approach this differently.

26 massage & bodywork may/june 2015

 When your body
has choices, you
thoracic spine. She was clearly hesitant to do this,
can move by fearing that it would cause pain. Assuring her that she
should only rotate as many degrees as was comfortable,

design, not by I guided her through this process multiple times.

During all of these movements, my palpation of
her tissue was key. At first, the role of the palpation
default. Touch can was simply to listen, not intervene. My hands told
me which muscles were engaging and when. Once I
be a way to learn knew what was happening, my hands could then either
enhance or inhibit movement. This information, in

as well as to treat. turn, was communicated to her nervous system via

my touch, revealing that muscles work in concert
that looking to the left is an experience of the whole
spine, not just the neck. My hands acted like a mirror,
revealing Mrs. S.s nervous system to itself.
I am wondering how different your treatment could
We continued to explore rotation in three ways:
possibly be, but I am willing to explore this with you.
cervical only, thoracic only, and a combination of both.
Any presenting symptom, such as your neck pain,
Thats pretty cool, Mrs. S. said. I never
is the end product of a whole system of underlying
knew I had so many choices in how I move.
factors, I responded. If we change the underlying
You only have a choice when you know what
context, we will affect the outcome. The direct approach
you are doing, I replied. My hands and directive
is to treat the symptom; the indirect approach is to
instructions have helped your nervous system
change the context that created the symptom.
experience what it is presently doing and explore other
How do we do that? Mrs. S. inquired. One more
possible options for movement. When your body
thing to complicate the issue is that I dont do well lying on a
has choices, you can move by design, not by default.
massage table.
Touch can be a way to learn as well as to treat.
Have a seat in front of me and lets explore some
In the ensuing weeks, Mrs. S.s muscles became
possibilities, I instructed. First, I am going to ask you to
much less hyper-reactive, allowing me to work
rotate to look to the left.
more directly. She is now slowly incorporating
As she rotated to the left, the protective guarding
some stretching and strengthening exercises into
of her musculature was amazing to observe and
her daily routine. Most importantly, Mrs. S. is
palpate. The image that comes to mind is stepping on
gaining confidence that there is a way out of the
the gas and then immediately hitting the brakes.
painperhaps the best outcome of all.
Lets try something, I suggested. Rotate as
though you were going to look to your left, but do
Douglas Nelson is the founder and principal instructor for
it with no movement in your neck at all. I want you
Precision Neuromuscular Therapy Seminars and president of the
to feel all the movement coming from right here, I
16-therapist clinic BodyWork Associates in Champaign, Illinois.
said, placing my hand over her thoracic spine.
His clinic, seminars, and research endeavors explore the science
Using my hands on her thoracic spine to enhance her
behind this work. Visit www.nmtmidwest.com, or email him at
proprioception of the thoracic spine in rotation, I had
doug@nmtmidwest.com.
Mrs. S. look to her left again. It took her several times
before she was able to differentiate cervical motion from
thoracic motion. Once this was clear, I asked her to move
only from her cervical spine, inhibiting movement in her

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 27

best practices SAVVY SELF-CARE

Personal Practices
Rituals That Shape Your Day
By Jennie Hastings Stancu

In last issues column, I wrote about three

ways to find support in your life as a
massage therapist or bodyworker: personal
self-care practices, creating a supportive
physical environment, and connecting with
a special person whose job it is to support
you. In this issue, I want to delve more deeply
into personal self-care practices because these
are the rituals that give shape to our days.
I think of personal practices as a way of holding a baseline
in life. We set up routines and rituals that nourish us, help
us release the past, and prepare us for the next great thing.
Returning to these practices again and again over time lays
a foundation of trust for ourselves and for life, while also
supporting our physical, mental, and spiritual health.
FOR YOUR BODY
Life as a massage therapist or bodyworker is physical.
While some people sit in chairs all day and do their work
almost exclusively with their minds, we bodyworkers are
called to join the mind and body to create the tool of our
trade. For this reason, one of the most important personal
practices we can establish is a consistent physical practice.
In my experience, it is difficult and painful to approach
a clients body with presence and engagement if I have not
first found presence and engagement in my own body. What
do I mean by this? Before I can be of any help to another
persons physical experience, I must first be attentive to my
own. Its sort of like what we are reminded of every time we
get on an airplane: Put your own oxygen mask on first!
My physical practice is yoga. Moving through a joint-
freeing series or a few sun salutations is sometimes all
I have time for, while on other days I schedule an hour
or two on the mat. Going out for an early morning walk
or hitting the gym with my husband can also bring me
into my body and prepare me to work with others.
There is no right or wrong way to physically practice
(unless what you are doing crosses the line from restorative
and strengthening to overdoing it and causing injury). All
of the massage therapists and bodyworkers I know who
have found success and longevity in their careers have a
physical practice. It doesnt matter what the practice is
swimming, dancing, martial arts, yoga, or stretching and
weightsas long as it helps energize you from your core,
stretches your muscles, and improves postural alignment.
Keep in mind that as a physical preparation for work,
high-impact activities like running or long-distance biking
may not be as helpful as slow, mindful movements. This
does not mean you shouldnt run or bike, but perhaps
think of these pursuits as a mental or spiritual practice
(with physical benefits) more than a purely physical one.
FOR YOUR MIND
Our minds are powerful tools, and they love to stay busy.
One of the most common challenges I hear from people is
how difficult it is to clear their minds, and I have to agree.
Its been estimated that we have between 60,00080,000
thoughts per day, and most of them we have had many
times before. What can we do when we feel overwhelmed
by the thought loops continually playing in our minds?

28 massage & bodywork may/june 2015

 A spiritual practice
connects us to the
miracle of life and helps
us transcend day-to-day
annoyances by putting
us in relationship to what
is greater than us.

My first suggestion is to do a brain dump. Take a FOR YOUR SPIRIT

blank sheet of paper and a pen and start pouring out all
the thoughts running through your mind. Keep your
hand moving and do not edit. Allow your thoughts to be
jumbled, unclear, and unrelated without judgment.
Once you have dumped what you need to, take a
moment and read what is there. Some of it will simply
be information that shows you what is really on your
mind. Notice what that is. Then, circle the things you
can actually do something about, and create a list of
three small action steps you can take today to move
yourself out of the storm of thought and into inspired
action. Make the steps attainable and commit to them.
Meditation is also a great way to clear the mind.
Spending even five minutes sitting still and listening to your
breath helps to quiet the mind. Many people struggle with
meditation because they cannot stop thinking while they
sit; but even if you cannot fully shut down your thoughts,
meditation is still beneficial. Like everything else,
meditation takes practice. I have created a video series
called Meditation 101 that you can find posted on my
website (www.inspiredmassagetherapist.com) if you would
like to learn more.
Personal practice for your spirit is where things get
the most personal. Only you know what makes your
heart feel full and bright. If you were to create a daily
spiritual practice, what would it look like? A walk
through the forest? Time to write in your journal? A few
moments spent gazing into the eyes of your beloved?
Your spiritual practice may be intertwined with
your physical and mental practices, or it may stand
alone. It can be as brief as a moment or last all day.
To me, a spiritual practice connects us to the miracle
of life and helps us transcend day-to-day annoyances
by putting us in relationship to what is greater than
us. And only you know what that is for you.
Placing your personal practices at the beginning
of the day is the most potent time for them. Physical
practice in the morning helps ease any stiffness caused
by sleeping, and brings heat and energy into the body
for the day. Mental practice allows us to arrive at our
client sessions with a sense of clarity and direction.
Spiritual practice gives us the energy to overcome
obstacles with a sense of excitement and increases our
sense of love and joy. Remember, practice may not make
perfect, but it will support you, no matter what.

Jennie Hastings Stancu is a massage therapist, writer, and a mentor to people with a passion for turning their massage
therapy license into the career of their dreams. She lives in Portland, Maine, and is the author of The Inspired Massage
Therapist (Massage Blossom Books, 2012). Contact her at jennie@massageblossom.com.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 29

education CLASSROOM TO CLIENT

9 Tips for Creating a

Comfortable Massage Environment
By Anne Williams

To create your ideal treatment environment, consider the techniques you will use
and the types of clients you desire. For example, in relaxation-oriented businesses,
images of the outdoors are often used to help clients feel connected to the earth and
nature. And clinical massage businesses benefit from medical charts and images that allow
clients to see and understand the structures involved in their soft-tissue condition.
Consider the following elements when creating your treatment rooms environment.

TIP #1: LIGHTING TIP #3: WINDOW

Dimmer switches are TREATMENTS
ideal for treatment Window treatments are an
rooms. Lights can important design feature in any
be made bright for room and provide privacy, light
cleaning or sanitizing control, and style. In a massage
equipment, adjusted environment, privacy is important.
to a medium setting Window treatments should not
for the health intake be so sheer that people outside
consultation, and turned can see the massage session.
down for the massage. Window treatments also control
Several pools of soft, the amount of light that filters
diffused light or diffuse into the room. When the massage
natural light are more starts, softer, dimmer light is more
relaxing than one bright relaxing. You can choose between
light in a corner or semi-sheer fabrics that diffuse the
a room thats too dark. Avoid candles because open light and rich opaque fabrics that shut it out completely.
flames are a safety hazard and they can pollute Windows are often the main focal point in the
the air, especially when used in small rooms. treatment room. Interesting and well-planned window
treatments add style and eye-catching appeal. They
also absorb sounds from outside and from the room
TIP #2: WALL DECORATIONS
itself, helping create a quieter overall environment
Wall decorations can promote the image of the business,
while conserving energy by insulating the glass.
make a soothing impression on the client, and dampen
sound. Wall decorations can be functional as well as
beautiful. For example, fabric wall hangings lessen noise,
while a stylish mirror gives the client a place to freshen
up at the end of the session and allows the therapist
to check his body mechanics during the session.

30 massage & bodywork may/june 2015

 The wrong sort of music
may be irritating to the
client, while the right
music can evoke strong
TIP #4: EXTRA TOUCHES
Decorative items on shelves, side tables, and windowsills
feelings and beneficial
help create interest and defi ne the roomsand
therapistsstyle. A relaxation business using an all- physiological changes
natural theme might display shells, nonblooming plants
(to avoid allergies), or unique stones. An orthopedic in the client.
business might feature anatomical models of the body.
Rattan baskets, bamboo, and Japanese river stones might
adorn an Eastern bodywork business. Items can be
functional as well as decorative. For example, one ayurvedic
bodywork therapist has different types of Bhutanese,
Indian, and Nepalese bells and chimes on display. They
are beautiful to look at, but also sound lovely when she
rings one to signal the beginning and end of the session.

TIP #5: SOUND AND MUSIC

The auditory environment is important because it
sets the tone for the session and helps to mask outside
noise. Consider the flooring: a tile or wood floor may
cause echoes that are annoying or distracting.
The wrong sort of music may be irritating to the client,
while the right music can evoke strong feelings and beneficial
physiological changes in the client. Research shows that
music decreases anxiety, heart rate, and systolic blood
pressure, even when the person is actively stressed.1 In a single
session of music therapy delivered to hospice patients with
chronic pain conditions, music decreased the participants
overall levels of pain and increased their physical comfort.2
Research also shows that the positive physiological benefits
of music are increased when clients can choose their own
music.3 It is a good idea to have a variety of musical styles
available and to ask clients about their musical preferences
during the consultation. Clients can also be encouraged
to bring their own appropriate music for the session.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 31


TIP #6: REFRESHMENTS
A small snack following a session
provides an opportunity for the client
to wake up and come back to real life
before venturing back out into the busy
world. It doesnt have to be elaborate
it can be as simple as a cup of green tea
after the massage or a complementary
chocolate on Valentines Day. Similarly,
a sports massage therapist may
serve a sports drink at the postevent
massage. In the summer, clients may
leave their treatment with a colorful
popsicle to remind them that massage
is fun. Fresh, fi ltered water should
be provided before, during, and after
the session. Food and drink should be
simple, manageable, and individually
packaged for safety, but focus on the
intention of the offering: to welcome, to
nourish on a spiritual level, and to show
appreciation, care, and thoughtfulness.
32 massage & bodywork may/june 2015
A small snack following
a session provides an
opportunity for the client to
wake up and come back to
real life before venturing
back out into the busy world.
TIP #7: COMFORT AND WARMTH
Once on the massage table, the
client should be enveloped in warm,
soft textures and have bolsters
in place to support the joints in
a relaxed position. Blankets, hot
water bottles, heat lamps, and warm
packs help keep clients comfortable
throughout the session. Lotion
warmers heat massage oil or lotion
so that it does not feel cold when
applied. Never use a microwave
oven to heat oil or lotion, because
microwaves may affect the products
therapeutic properties. Many
products break down when heated,
so it is recommended to use 1-ounce
bottles with fl ip or pump lids. These
small bottles are fi lled with fresh oil
or lotion at the beginning of each
day so that the larger container is
not repeatedly exposed to heat and
can remain in the refrigerator.
Some massage therapists have
chronically cold hands that can
feel shocking to the client at the
beginning of the session. Warm
your hands as much as possible by
holding them under warm water,
holding a warm pack, or rubbing
them briskly before the session.
 CL ASSROOM TO CLIENT

TIP #8: ENTRANCE AND RECEPTION

When choosing a business location, consider its accessibility.
Are doorways, hallways, and restroom entrances wide enough
to accommodate a wheelchair? Is there enough space around
furniture to accommodate someone in a cast and on crutches?
Does a long fl ight of stairs make the business prohibitive for the
elderly or clients with disabilities? Is parking convenient and
user-friendly, or will clients have to spend the fi rst 10 minutes
of the session looking for a space and end up feeling stressed?
The reception area must be friendly, neat, and functional.
Magazines, a retail area, tea or water, comfortable chairs,
and attractive furnishings help ensure clients comfort.

TIP #9: THE DRESSING AREA

Carefully plan the space where clients remove their clothing
before the session and get dressed afterward. A screened-off area
provides a sense of privacy and decreases the clients anxiety that
the therapist might walk into the room unexpectedly. Place a
chair and hooks behind the screen where clients can hang their
clothing. A small container for personal items like keys and
jewelry helps ensure clients do not misplace or forget them. A box
of tissue, disposable wet wipes, and mirror are useful as well.

Notes
1. W. E. Knight and N. S. Rickard, Relaxing Music Prevents Stress-Induced Increases
in Subjective Anxiety, Systolic Blood Pressure and Heart Rate in Healthy Males and
Females, Journal of Music Therapy 38, no. 4 (2001): 25472.

2. R. E. Krout, The Effects of Single-Session Music Therapy Interventions on the

Observed and Self-Reported Levels of Pain Control, Physical Comfort, and
Relaxation of Hospice Patients, American Journal of Hospice and Palliative Care 18,
no. 6 (November-December 2001): 38390.

3. B. Thorgaard et al., Specially Selected Music in the Cardiac LaboratoryAn

Important Tool for Improvement of the Well-Being of Patients, European Journal of
Cardiovascular Nursing 3, no. 1 (April 2004): 216.

Anne Williams is the director of education for Associated Bodywork &

Massage Professionals and author of Massage Mastery: from Student to
Professional (Lippincott Williams & Wilkins, 2012), from which this article was
adapted, and Spa Bodywork: A Guide for Massage Therapists (Lippincott
Williams & Wilkins, 2006). She can be reached at anne@abmp.com.

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education PATHOLOGY PERSPECTIVES

When Food Hurts

Can Massage Help Crohns Disease?
By Ruth Werner

Food is one of lifes great pleasures. Complex or simple, it can This condition can involve one
episode or many. It can be a minor
be used as a source of entertainment, an expression of emotion, or
irritation or excruciatingly painful. No
strictly for sustenance. Disorders that involve the digestive tract can single treatment is universally curative,
and while some patients find long-
be especially challenging because, unlike some pathology-inducing
term relief, others face a lifetime of
behaviors like smoking or alcohol use, eating is not optional. One progressive loss of intestinal function
along with complications that range
way or another, nutrition must have access. And if the gastrointestinal
from joint pain to kidney stones to an
(GI) tract is swollen or clogged with scar tissue, that spells trouble. increased risk for colorectal cancer.
What happens then, when the act of eating has the capacity to trigger
breathtaking pain? How can you function if your intestines are impacted ETIOLOGY
by random attacks creating inflammation and spasm? Andmore At this point, most experts agree that
importantly for our purposescan massage therapy make a difference? Crohns disease is a multifactorial
condition, involving a combination of
genetic predisposition, environmental
exposures, and sometimes a triggering
Since I was little, I was known as the sick girl and the Stomachache Queen.
event that sets off an autoimmune
By the time I was ready to go to college, I had shrunk to 95 pounds. I went to
attack in the digestive tract.
the doctor for a checkup, and he insisted that I see a gastroenterologist; it was
then that I was first diagnosed with Crohns disease at age 17. It was awful.
The testing, the stress, the testing, the stress. In the middle of all this my mom Our Microbiome
said, Im taking you for a massage. One of the most exciting fields of
Meredith Kusmer Jerome research in human health today focuses
Crohns patient and massage therapist on the microbiome of the digestive
tract. Each of us has a unique internal
environment that is influenced by what
WHAT IS CROHNS DISEASE?
we eat, where we live, who we live with,
Crohns disease, named in 1932 for Burrell B. Crohn, is an autoimmune disorder
andamazinglyour parentage. It
that affects the lining of the digestive tract. Crohns disease and ulcerative
seems that some of the bacterial strains
colitis are collectively referred to as inflammatory bowel disease, but they
that serve us in the process of digestion
are etiologically distinct conditions. Where ulcerative colitis is limited to
are inherited from our parents.
the superficial layer of the colon lining, Crohns disease can affect the entire
When that internal environment is
GI tract from mouth to anus, and the associated ulcers and other lesions
consistently disrupted (this is called
can penetrate through the mucosal lining, muscularis, and peritoneum.
dysbiosis), it appears to pave the way
Crohns disease affects somewhere between 700,000 and 1
for several disorders, including obesity,
million people in the United States. Most patients are diagnosed
diabetes, metabolic syndrome, and
between ages 15 and 35. Unlike many autoimmune diseases, Crohns
inflammatory bowel disease, including
disease affects roughly the same number of men as women.
Crohns disease. The precise sequela
from unbalanced gut flora and fauna
to Crohns disease is not completely

36 massage & bodywork may/june 2015

clear, but many experts theorize that a disruption triggers an
inappropriate immune system attack on bacteria in the gut,
which then leads to the many signs, symptoms, and potentially
dangerous complications that characterize this disease.
Our Virome
One particularly interesting line of inquiry has identified
that along with our resident bacteria, fungi, and yeasts, our
colon is also host to a multitude of viruses. This virome
is the subject of much investigation. The residual DNA
found in the stool samples of people with Crohns disease
appears to belong to types of viruses that have not yet
been identified. For some people with Crohns disease,
these intestinal viruses may invade and kill off colonies of
their health-promoting bacteria; this may be what knocks
things out of balance and triggers an autoimmune attack.
Gut Disruptions
Many commonplace activities can disrupt our internal
environment. Antibiotics, diarrhea, and even jet lag
have all been seen to alter the healthy biodiversity in
the colon. Scientists who specialize in studying the
human gut microbiome are investigating whether
changes in that environment precede Crohns disease
flares; this would allow treatment to anticipate the
attack, rather than always trying to catch up.
The inflammation from Crohns disease involves the
unrestrained activity of certain types of T-helper cells,
along with several strongly pro-inflammatory cytokines.
In addition, many people with inflammatory bowel disease
have an abnormal epithelial barrier within the digestive
tract, which allows for inflammatory cells to invade deep
mucosal layers. The result is deep lesions called granulomas
that can extend through all layers of the intestinal wall,
thickening the bowel with excessive scar tissue. And, unlike
ulcerative colitis (which usually involves one large, continuous
lesion), Crohns disease granulomas can appear throughout
the digestive tract in disconnected, patchy skip-lesions.
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 37
SIGNS AND SYMPTOMS
Abdominal pain is
the leading symptom
My pain was mostly in the
of Crohns disease.
lower right quadrant. It felt like
Fever and bloody
acid was being poured in an open
diarrhea may be
cut while a knife was twisting.
present during
flares. Weight loss Meredith Kusmer Jerome
follows, as the ability
to eat healthily is
impaired. When it occurs in children, failure to grow
and delayed puberty are possible signs. This condition
runs in cycles of flare and remission, but even during
quiescent periods, dehydration, diarrhea, and fatigue are
ongoing issues for people who live with Crohns disease.
The most common first lesion in Crohns disease is at the
distal end of the ileus, so cramping pain that focuses in the
lower right quadrant of the abdomen is the most typical early
sign. Unfortunately, this can also look like ulcerative colitis,
appendicitis, celiac disease, diverticular disease, giardia,
irritable bowel syndrome, Clostridium difficile infection, and a
host of other conditions, and each of which requires a different
treatment strategy. Consequently, the testing for Crohns
disease tends to be intrusive, lengthy, and nerve-wracking.
COMPLICATIONS
The complications related to Crohns disease are
potentially very serious. Here are a few:
Stenosis
Most Crohns disease patients experience some level
of stenosis, or narrowing of the digestive tract. Early
in the disease, this is probably from a combination
of inflammation and pain-related spasms. Later in
the process, however, the accumulation of fibrotic
scar tissue can form permanent strictures that limit
the passage of material through the GI tract.
Fistulae
Another important and potentially dangerous complication is
the result of those strictures. As testament to the remarkable
capacity of the human body, the body will attempt to build
a new passageway when material cannot pass through a
tube. These new passageways are called fistulae. In the
case of Crohns disease, these fistulae can link one loop of
intestine to another, or they can go from the intestine to
the urinary bladder, or from the intestine to the uterus,
or sometimes even from the intestine directly to the
skin; this typically happens around the anus. Secondary
infection and abscesses at these fistulae are significant
risks because they allow material to gain access to parts of
the body that dont have protection from fecal bacteria.
Extra-Intestinal Manifestations
Crohns disease affects more than the digestive tract; it
appears to trigger generalized inflammatory reactions in
many areas. These complications are called extra-intestinal
manifestations.
Inflammation of the eyes is common, as is inflammation
of the lungs or the pleurae. The gallbladder, liver, and
pancreas are frequently affected by inflammation related
to Crohns disease. Inflamed and painful joints, kidney
stones, hypercoagulability of the blood, and a blistering
rash that appears on the shins are all signs of dysregulated
inflammation associated with this disease. In addition,
reduced access to nutrition makes people with Crohns
disease especially vulnerable to osteoporosis and anemia.
Finally, people with Crohns disease, especially those
who were diagnosed young and who have multiple lesions,
have a significantly increased risk of colorectal cancer.
TREATMENT
The treatment options for Crohns disease are somewhat
controversial. Many specialists argue whether a bottom-up
(starting with low-impact treatment and ratcheting up as
necessary) or a top-down (getting ahead of the disease
process with biologic drugs and then scaling back
as possible) approach is best. Ultimately, of course,
this decision must be made on a case-by-case basis.
For most patients, pharmacological therapy
calm down the inflammation. She took my pain away. For half an
includes a range of options: 5-aminosalicylic
acids, antibiotics and nutritional supplements,
steroidal anti-inflammatories and immune system
suppressants, or biologic therapies that alter T-cell
activity. Other drugs might also be employed
to manage symptoms and complications.
38 massage & bodywork may/june 2015
Dietary adjustments for people with this condition
mostly center around being sure that adequate nutrition
is achieved, and most patients feel better when they avoid
roughage: raw fruits and vegetables with peels, nuts in
any form other than as nut butter, anything with small
seeds (strawberries, tomatoes), corn, and popcorn.
About two-thirds of all Crohns disease patients have at
least one surgery to remove diseased sections of the GI tract
by the time theyve been diagnosed for 15 years. Because this
condition occurs in disconnected patches, however, a surgery
is not considered to be curative; it can return somewhere else.
MASSAGE FOR CROHNS DISEASE
Little research has been conducted about massage therapy
as an intervention for patients with Crohns disease.
However, general trends suggest that people with chronic
pain conditions are often enthusiastic users of CAM
interventions, and massage is typically the most popular
choice. It is interesting to point out that most inflammatory
bowel disease patients do not use CAM interventions
specifically for disease management, but rather for stress
or other problems they feel contribute to their symptoms.
This is supported by the experiences of several massage
therapists who shared their stories for this article.
Most MTs reported that their clients usually did not
come during a flare, and when they did, only the gentlest,
nonabdominal work was welcomed. At other times, depending
on the clients needs, massage could be conducted without any
special accommodations. Some clients were able to manage
their disease proactively with a careful diet, exercise, and yoga;
others used prednisone and repeated surgeries. A common
theme is that clients feel massage therapy helps them with
the stress associated with having Crohns, and that managing
the stress decreased the likelihood of having another flare.
Id never had a massage before. I didnt tell the therapist
where the pain was, but she knew. She put her hands right on
it, and just held me. Im not sure what she did, but it seemed to
hour, I had no pain. It was amazing. Id never felt anything like it.
Later, I realized that first appointment with a massage
therapist started me down my path to this profession. In some
way, I felt she passed being a massage therapist on to me.
Meredith Kusmer Jerome
 PATHOLOGY PERSPECTIVES

Positioning was also variable:

some clients were able to receive a
bodywork session that required no
adaptation, but others could only receive
work from a side-lying position.
One therapist shared that her
client had been turned away by other
practitioners because of her condition.
This brings up a subtle but important
aspect of living with a chronic disease:
its influence on self-esteem is hard to
estimate. Anxiety, depression,
and a sense of the loss of
the ability to cope with
My first encounter with massage was the best
even minor life stressors
experience I ever had. I just wish everyone with an
may seriously impact a
autoimmune disease could get this kind of help.
persons quality of life.
Whatever the status of your Meredith Kusmer Jerome
next client with Crohns
disease (flare or remission,
under control with minimal
treatment or gearing up for a surgery),
I hope youll feel confident to call on
your patience, your ability to listen with
all your senses, your compassion, and your unique skills to
offer the very best of what massage therapy can give for this Author note: Many thanks to the massage therapists who
population of clients who live with such great challenges. shared their experiences to add depth to this article: Jimmy
Gialelis, Las Vegas, Nevada; a massage therapist in Shelby
Ruth Werner, BCTMB, is a former massage therapist, a writer, Township, Michigan; Kristal Halworth, Tampa, Florida; Lauren
and an NCTMB-approved continuing education provider. She wrote Muser Cates, Alexandria, Virginia; and a special thanks
A Massage Therapists Guide to Pathology (Lippincott Williams & to Meredith Kusmer Jerome, whose history with Crohns
Wilkins, 2013), now in its fifth edition, which is used in massage disease provided the through-line for this conversation.
schools worldwide. Werner is available at www.ruthwerner.com.

Resources
Crohns and Colitis Foundation of America. What is Crohns Disease? Accessed March 2015. www.ccfa.org.

Ghazi, L. J. Crohn Disease. Accessed March 2015. emedicine.medscape.com/article/172940-overview.

Purdy, M. C. Viruses May Play Unexpected Role in Inflammatory Bowel Diseases. Washington
University in St. Louis. Accessed March 2015. www.news.wustl.edu/news/Pages/27891.aspx.
Rawsthorne, P. et al. The Manitoba Inflammatory Bowel Disease Cohort Study: A Prospective Longitudinal
Evaluation of the Use of Complementary and Alternative Medicine Services and Products. Gut 61, no. 4
(April 2012): 5217.
Wu, Gary D. et al. Analysis of the Human Gut Microbiome and Association with Disease. Clinical
Gastroenterology and Hepatology 11, no. 7 (2013): 7747.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 39

education FUNCTIONAL ANATOMY

Supinator
By Christy Cael

Supinator
The supinator muscle is located deep
in the proximal posterior forearm. It lies
deep to the brachioradialis and common
extensor tendon at the lateral elbow. The
supinator is a relatively flat muscle originating
primarily on the dorsal surface of the proximal
ulna, but also on the lateral epicondyle of the
humerus, anterior fibers of the humeroulnar
joint capsule, and proximal radioulnar ligament.
The muscle wraps around the lateral surface
of the radius, inserting broadly on the proximal
radial surfaces, just distal to the radial head.
Proximally, the supinator is divided into
superficial and deep layers. This division creates a
channel for the deep portion of the radial nerve,
also known as the posterior interosseous branch.
The tendon of the biceps brachii is also located
near this Y-shaped portion of the supinator.
Caution should be exercised when palpating the SUPINATOR
insertion of the biceps brachii and the fibers of the Attachments
supinator to avoid compressing the radial nerve.
Origin: Lateral epicondyle of the humerus
When the supinator is activated, it rotates
and supinator crest of the ulna
the radius posteriorly and laterally, supinating
Insertion: Posterior, lateral, and anterior
the forearm. It works synergistically with the
surfaces of proximal one-third of the radius
biceps brachii and brachioradialis to supinate the
forearm, turning the hand palm up. Unlike the Actions
biceps brachii, the supinator is strongest when the Supinates the forearm
elbow is extending or extended. Some of its fibers Slightly extends the elbow
attach to the lateral epicondyle of the humerus, Innervation
allowing it to assist with this movement.
Radial nerve
The supinator reverses the action of the pronator
C5T1
teres and quadratus when turning a screwdriver
or wrench. It is also activated when throwing a
curveball in baseball. Here, the elbow extends while

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 41

FUNCTIONAL ANATOMY

the forearm supinates, generating

the characteristic spin of the curve
ball. Excessive force production
when throwing, carrying objects
in a palm-down position, flipping
objects from a palm-down to a palm-
up position, or twisting movements
may stress or injure the supinator.
Prolonged positioning with the
forearm pronated, such as when Palpating the Supinator
typing, writing, or using a computer
mouse, may lead to elongated Position: client seated with forearm neutral (thumb up).
tension in the supinator and 1. P
 assively flex the elbow and supinate the
associated muscles. Entrapment of
the deep radial nerve, trigger-point forearm to slacken the tissue.
activation, and poor joint mechanics 2. L
 ocate the lateral epicondyle with your thumb,
may result. Trigger points in the
supinator muscle refer pain to the pushing the brachioradialis aside laterally.
lateral elbow and into the web of
3. F
 ollow the muscle distally and slightly anteriorly
the thumb on the dorsal side.
onto the radial head. (Note: avoid compressing the
Christy Cael is a licensed massage radial nerve, which resides in this location.)
therapist, certified strength and
conditioning specialist, and instructor at 4. G
 ently resist as the client supinates the
the Bodymechanics School of Myotherapy forearm to ensure proper location.
& Massage in Olympia, Washington.
Her private practice focuses on injury
treatment, biomechanical analysis,
craniosacral therapy, and massage for
clients with neurological issues. She
is the author of Functional Anatomy:
Musculoskeletal Anatomy, Kinesiology, and
Palpation for Manual Therapists (Lippincott
Williams & Wilkins, 2009). Contact her
at functionalbook@hotmail.com.

Editors note: The Client Homework

element in Functional Anatomy is
intended as a take-home resource for
clients experiencing issues with the
profiled muscle. The stretches identified
in Functional Anatomy should not be Client Homework:
performed within massage sessions or
progressed by massage therapists, in order Active Forearm Supination
to comply with state laws and maintain 1. With or without a small weight, sit with your arm supported, elbow bent, and palm down.
scope of practice. 2. Keeping your shoulder and elbow relaxed, rotate your forearm, turning the palm up.
3. Return your forearm to the palm-down position.
4. Repeat until you feel a loosening and slight fatigue in the elbow.

42 massage & bodywork may/june 2015

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education SOMATIC RESEARCH
Studies Show Effectiveness of Massage
for Addressing Nonspecific Low-Back Pain
By Jerrilyn Cambron
In the United States, 80 percent of adults will
experience back pain at some point in their
lives. Most back pain episodes occur between the
ages of 25 and 45, and interfere with home, work,
and personal life. The cost to employers for back
pain in workers aged 4065 is estimated to be
$7.4 billion per year.1 Even with such a heavy social
and financial burden, we still do not understand the
etiology of back pain and, therefore, diagnose most
back pain cases as nonspecific low-back pain.
Without knowing the reason for the pain, health-care
providers struggle to determine the best form of care.
SWEDISH MASSAGE VS. PHYSICAL THERAPY
In a recent comparative effectiveness study, Fahimeh Kamali
and a team of researchers at Shiraz University of Medical
Sciences compared two of the most common treatments for
back pain: Swedish massage therapy and routine physical
therapy.2 Women with subacute or chronic nonspecific
low-back pain who were referred to a physical therapy
center were assessed for eligibility. Subjects were excluded
if they had acute disc herniation, fracture, malignancy,
pain due to surgery, pain lasting for more than one year,
pain medication use for more than one month, pregnancy,
radicular pain, spondylolysis, spondylolisthesis, or trauma.
Thirty women agreed to participate in the study and
signed an informed consent document. Of these, 15 subjects
were randomized to a Swedish massage group where they
received 15 minutes of low-back massage including deep
stroking, pulling, friction, rolling, and wringing. After
44 massage & bodywork may/june 2015
the massage, the hamstring and paravertebral muscles were
stretched and stabilizing exercises were prescribed. The
remaining 15 subjects were randomized to routine physical
therapy where they received several electrical modalities,
including ultrasound for three minutes, TENS for 20
minutes, and vibration for three minutes. The subjects then
did the same stabilizing exercises as the massage group.
Subjects in both groups received 10 treatment sessions.
Three measures were used to determine the outcome of
the study protocols. Pain was assessed using the Numerical
Rating Scale (NRS), functional disability was measured by the
Oswestry Disability Index, and trunk flexion was measured
by the modified Schober range of motion (ROM) test.
Both massage therapy and physical therapy groups
demonstrated improvements in all three outcome measures
after the 10 visits. However, when the groups were compared
with one another, the massage therapy group demonstrated a
significantly greater decrease in pain and increase in function,
with no difference in trunk flexion. To demonstrate the change
in pain, average NRS measures (out of 10) dropped from
6.0 to 1.8 in the massage group, and from 7.3 to 4.1 in the
physical therapy group. Overall, both low-back pain groups
improved, but the massage group had significantly less pain
and dysfunction compared to the physical therapy group.
There were several limitations of this study, including the
small sample size (n=30) and the lack of male subjects. Also,
there was no long-term follow-up to determine continued
improvement beyond the last treatment session. Following
the subjects for a longer time period may have given a better
view of how long the treatment benefits lasted. Finally, this
study was performed in Iran, so the participants might have
other factors associated with low-back pain and disability
when compared to back pain patients in the United States,
leading to possible questions about generalizability of results.
CHINESE MASSAGE VS. CHINESE
MASSAGE PLUS CORE STABILITY
Recently, another comparative effectiveness trial was
published that compared Chinese massage with a group
who received Chinese massage plus performed core
stability exercises for nonspecific chronic low-back pain.3
The types of outcome measures were similar to the
Kamali study, with pain assessed via the Visual Analog
Scale and disability via the Oswestry Disability Index.
In this study, subjects were recruited from a hospital of
traditional Chinese medicine and were included if they were
less than 55 years old; had nonspecific chronic low-back
pain without any relevant ongoing pathologies such as disc
prolapse, fractures, infection, osteoporosis, spondylolisthesis,
or tumor; and were willing to participate in this study and
sign an informed consent. The exclusion criteria for this
study included other pain syndromes; spinal surgery in the
past six months or having to undergo surgery or invasive
examinations during the study; neurological disease;
psychiatric disease; serious chronic disease that could interfere
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 45
with the outcomes (e.g., cardiovascular disease, epilepsy,
rheumatoid arthritis, or other disqualifying conditions); or
pregnancy or planning to become pregnant during the study.
Of the 92 subjects enrolled in the study, 46 were
randomized to the Chinese massage group, which included
rolling, rubbing, pushing, oblique-pulling, stroking,
and tapotement on the low back for 40 minutes, once
daily, for eight weeks by professional therapists. The 46
subjects randomized to the Chinese massage plus exercise
group received the same treatment in addition to core
stability exercises including plank, side plank, bridge,
straight leg raise, and modified push-up, performed 10
times for one arm or leg, once daily for eight weeks.
The results demonstrated that after two weeks of care,
both groups significantly improved in terms of pain and
disability, with no differences between the groups. After eight
weeks of treatment, both groups continued to demonstrate
significantly improved pain and disability scores. However,
pain and disability scores were significantly lower in the
Chinese massage plus core stability exercise group than in the
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Chinese massage alone group, showing average reductions in
pain (out of 10) from 7.5 to 1.5 in the massage plus exercise
group, and from 7.6 to 2.9 in the massage alone group.
Follow-up occurred in this study for one year
posttreatment. A pain-free period for at least 30 days after
treatment was confi rmed by all of the participants who
were screened. Furthermore, 19 subjects (43.2 percent)
in the massage-only group experienced a recurrence of
back pain, whereas only five subjects (11.6 percent) in the
massage plus exercise group experienced such a recurrence.
This study had fewer limitations than the previous trial
in that both males and females were recruited and there
was a higher sample size (n=92). However, this study was
performed in China, again leading to possible questions
about generalizability of results to American clients.
CONCLUSION
1. Short-term outcomes indicate that subacute or chronic
nonspecific back pain and disability are significantly
improved with Swedish or Chinese massage therapy.
2. When compared to routine physical therapy, Swedish
massage was significantly more beneficial in reducing pain
and disability for nonspecific low-back pain in women.
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 47
SOMATIC RESEARCH
When compared to
routine physical therapy,
Swedish massage
was significantly more
beneficial in reducing
pain and disability for
nonspecific low-back
pain in women.
3. Core stabilizing exercises, in addition to massage, provide
further benefit, with the massage-only group being 6.5 times
more likely to experience a long-term back-pain recurrence
than the massage plus core-stabilizing exercise group.
4. Comparative effectiveness trials are a good way to
compare one beneficial treatment to another in order
to determine which form of care is significantly better.
However, all clients are different. You and your clients
health-care team will need to determine the best form
of care for your clients specific condition.
Notes
1. J. A. Ricci et al., Back Pain Exacerbations and Lost Productive Time Costs in
United States Workers, Spine 31, no. 26 (December 15, 2006): 3,05260.
2. Fahimeh Kamali et al., Comparison Between Massage and Routine Physical
Therapy in Women with Subacute and Chronic Nonspecific Low Back Pain,
Journal of Back and Musculoskeletal Rehabilitation 27, no. 4 (2014): 47580.
3. Yingjie Zhang et al., Chinese Massage Combined With Core Stability
Exercises for Nonspecific Low Back Pain: A Randomized Controlled Trial,
Complementary Therapies in Medicine 23, no. 1 (February 2015): 16.
Jerrilyn Cambron, DC, PhD, MPH, LMT, is an educator at the
National University of Health Sciences and president of the Massage
Therapy Foundation. Contact her at jcambron@nuhs.edu.

By Irene Diamond
To Bill or Not to Bill
Should You Accept Insurance?
There usually comes a time in
every massage therapist's career
where she wonders if billing
insurance companies for clients
care is the right move to make.
It is a big decision, and requires
a comprehensive understanding
of the complex arrangement
between the client, the referring
physician (if required), and you.
Insurance companies only pay
for services that are considered
medically necessary. Therefore, you
must first accept that as a practitioner
billing insurance for services, you are
considered to be a health-care provider.
You must be comfortable with the
concept of being part of the health-
care system. If that doesnt feel right
for you, your answer is clearyou will
not bill insurance for your services.
48 massage & bodywork may/june 2015
Clients often ask
if you accept
their insurance.
You also need to educate yourself about the
different types of coverage, and know the difference
between first-, second-, and third-party billing. You
must be willing and able to undertake a never-ending
process of research: each state and each insurance
company has its own policies and procedures, and you
will need to stay compliant. You will spend a great
deal of time researching laws, trends, and procedures
for working with medical professionals, insurance
companies, and attorneysnot just once, but
continuously, as this information is always changing.
Billing Codes
Two separate code
Insurance billing is a huge topic, and we can only
systems are essential
scratch the surface here, but this article will give you
in medical billing:
an overview of things to consider.
Current Procedural
Terminology (CPT),
7 QUESTIONS TO ASK YOURSELF and International
Before deciding whether this is the right move Classification of
for your practice, consider these questions: Disease (ICD).
1. How often do my clients ask if I can bill their
insurance?
2. How many of my clients have health insurance that
covers massage therapy or other manual therapy?
3. Will my practice grow significantly if I offer
insurance billing?
 4. What changes would I need to make to my
practice? Am I prepared to accommodate
the amount of additional documentation,
follow-up, and paperwork required?
5. Which types of insurance am I willing to accept?
How does this complement or impact my current
practice?
6. Should I hire/contract a medical biller to assist in
serving this part of my practice?
7. Am I able to handle the lack of cash flow while
waiting for payments from the insurance company?
Your ability to wait for payment is one of the most
important factors to consider. Legally, insurance
companies have up to 60 days to respond to your
submission of a claim. When that response comes,
A more appropriate
question would be
whether the clients
insurance company
accepts you.
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 49
it may be a denial of payment, or a
payment for a reduced amount. If
that happens, you must resubmit the
claim, or you will not get paidand
in cases where you are billing workers
compensation insurance, you are
forbidden to attempt to bill the client.
You must be able to run your business
without that income until (and if) you
receive it from the insurance company.
TYPES OF INSURANCE
There are four major categories of
insurance coverage that can be billed
by health-care providers. Each category
operates differently, and in each case,
state law will determine whether a
massage therapist is even allowed
to bill insurance in that category.
Major Medical
This is what most people think
of in the context of billing health
insurance: major insurance providers
such as Aetna, Blue Cross, or Blue
Shield. It is the most difficult and
complicated category of billing.
 You must bill using procedural and
modality billing codes.
The client must have a doctors
prescription for your care.
Your care must follow the prescription.
It usually does not pay in full, so your
claim amount will be reduced.
It will be based on whether or not you are an
In Network or Out of Network provider.
Workers Compensation
This type of insurance covers care for workers
injuries on the job. It is the second most difficult
billing category to manage: there are different
procedures for government jobs, city and state
jobs, and workers at private companies.
You must bill using procedural and modality
billing codes, which will differ based on the
type of casefederal, state, or private.
The client must have a doctors
prescription for your care.
Your care must follow the prescription.
It usually does not pay in full.
It requires a tremendous amount of
ongoing authorization and follow-up.
Motor Vehicle Accident (MVA)
Billing MVA insurance companies (such as AAA,
Allstate, or Geico) is somewhat easier than the
other categories described here. If you choose to
begin billing, I suggest starting with this type.
You must bill using procedural and
modality billing codes.
The client may or may not need a
doctors prescription for your care.
It usually pays in full.
ELIGIBILITY TO BILL INSURANCE
How do you know if youre able to bill insurance for
your services? There are several factors, including
state laws, contractual agreements, and the clients
own policy specifications. Youll need to investigate
all of these areas prior to working with the client.
Clients often ask if you accept their insurance.
A more appropriate question would be whether
the clients insurance company accepts you.
Each insurance company has its own application
process for those hoping to be recognized as
an approved health-care provider, sometimes
including a fee to apply and/or maintain that
status.Visit an insurance companys website to learn
about its billing policies and procedures. Good
information to understand includes acceptable
procedure codes, billing formats, reimbursement
rates, billing address, and phone numbers.
The type of massage you provide is not
the deciding factor in whether you can bill
insurance. As long as the clients physician
has written a prescription for it and considers
it medically necessary, massage therapy
may be eligible for reimbursement.
The key is that there is a physical problem,
the client is going to receive massage therapy
or bodywork for that problem, and the problem
will improve or resolve as a result of the
session. This leads to the next thing you need
to know: how to document your results.

Medicare/Medicaid
WHAT INSURANCE COMPANIES WANT
This government-provided insurance covers
Insurance companies are looking for (1) a specific
care for people living in poverty, children in
condition or diagnosis to be treated; (2) parameters
foster care, adults over the age of 65, those
for treatment; and (3) changes in function as
on social security disability insurance, or
a result of treatment. They want documented
those who have been diagnosed with certain
evidence of continuous improvement as a result
diseases. As a massage therapist, you are not
of your work, usually shown by the clients
able to bill Medicare or Medicaid; federal payers
ability to perform activities of daily living
do not deem massage therapy as medically
and/or the clients ability to do his or her job.
necessary and will not reimburse for it.

50 massage & bodywork may/june 2015

 Massage therapists tend to focus on
pain relief; however, functional gains
are the key to reimbursement. You must
clearly document the client's condition
and symptoms at the start of your care,
as well as your massage treatment and
the outcome of each session. Use of the
accepted SOAP (Subjective, Objective,
Assessment, Plan) documentation
Your NPI Number #
Since 1996, health-care providers have been required by
the federal government to have a National Provider Identifier
(NPI) number. Getting your own NPI number is a free, simple
process that includes providing your state license number.
If you are in a state that is unlicensed, you may want to call
the toll-free number below to ask if you may use a national
certification or another method to verify your qualifications.
process is recommended.
It is essential to identify specifically Contact the NPI Enumerator program via any of the following
how your client is limited by his methods:
or her condition or symptoms and Phone: 800-465-3203
formulate a therapy plan to address it TTY: 800-692-2326
through massage. Each session must Email: customerservice@npienumerator.com
be documented. Some insurance Mail: NPI Enumerator, PO Box 6059, Fargo, ND 58108-6059
companies require you to submit Online: Go to https://nppes.cms.hhs.gov/NPPES/Welcome.do,
your notes along with each claim. click on Apply Online, and follow the steps. Most of the registration
Remember, you are treating with process is straightforward. When you get to Taxonomy, select
the intention of improving function, 22: Respiratory, Rehabilitative & Restorative Service Provider, then
reducing pain, or achieving a clinical scroll down to Massage Therapist.
outcome, based on the diagnosis.
Typically, insurance companies
will not reimburse for palliative or
maintenance care that is not working
toward improvement or resolution QUICK LIST OF TERMINOLOGY
of a specific, diagnosed condition.
Claim: A bill you submit to the insurance company,
Diana Thompsons book Hands
Heal (Lippincott Williams & Wilkins, usually printed on HCFA claim form 1500.
2011; www.lww.com) is a tremendous
resource for client intake processes and Adjustor: The insurance company representative
documentation, and includes specific
assigned to handle the case.
forms and strategies for documenting
treatments to be billed to insurance
companies. Another solid resource is DOS: Date of Service. This is the date you provided
Vivian Madison-Mahoney's Manipulate service, and is included on the claim.
Your Future manual available at
www.massageinsurancebilling.com.
EOB or EOR: Explanation of Benefits or Explanation
of Review. Received with the payment, it explains
Verifying Coverage
Confirming, or verifying, insurance how the claim was paid for each DOS.
coverage is when you contact the
insurance company on your UAC: Usual and Customary. This refers to the
client's behalf to confirm they
amount an insurance company usually pays for a
have coverage. If you perform
services not covered by the specific procedure or modality in your zip code.
clients insurance, the client
is ultimately responsible for
paying the bill (unless it is a
workers compensation case).

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 51

 CPT Codes
CPT codes are used as a standardized way
to accurately describe medical, surgical,
treatment, and diagnostic services. There are
approximately 7,800 five-digit CPT codes,
ranging from 00100 through 99499. An
additional two digits are sometimes added
to clarify or modify the description of the
procedure. CPT codes are updated continuously
by the American Medical Association, and
are used by most insurance companies.
Which codes you may bill are dictated by
the state in which you practice, your scope of
practice, license, and provider agreements. Most
insurance companies will reimburse 97124, the
CPT code for massage therapy. Some may also
recognize other codes, such as 97140 (manual
therapy) and 97122 (neuromuscular reeducation).
It is important that you clarify with the insurance
company which CPT codes you are eligible to bill.
It is also imperative that you know what
each code stands for. If it is a modality code,
you must know how many modalities you are
allowed to bill for in a single session.If it is a
procedure code, you need to know if it is time-
based, and if so, how much time it allows.
Standard appointment times are 60 minutes;
if you need more time, you usually need to
get prior authorization. (As a side note, it is
legal to bill for 60 minutes and only provide
50 minutes of therapy, allowing you to take 10
minutes to complete your documentation.)
52 massage & bodywork may/june 2015
ICD Codes
ICD codes are diagnostic and can only
be assigned by a doctor. They identify
specific signs, symptoms, injuries,
diseases, and conditions, and indicate
exactly what you are going to address.
Doctors can assign as many codes as
are needed to describe the patients
condition.
Because insurance only pays for
medically necessary treatments, you
always need an ICD code from the clients
physician, even if the client self-refers.
The current ICD code system is in its
ninth edition, so codes are designated
ICD-9. The next edition, ICD-10, should be
in use by October 1, 2015.
A Critical
Relationship
CPT and ICD codes have a critical relationship to each
other in medical billing. The diagnosis supports the
medical necessity of the procedure or modality. For
example, a CPT code for massage treatment of the foot
would not be supported by an ICD code diagnosing an
injury to the neck, and such a claim would be quickly
identified and rejected by the insurance company.
 It is not unreasonable to
ask clients to confirm their
own coverage prior to their
first appointment with you,
It is not unreasonable to ask clients
to confirm their own coverage prior to
their first appointment with you, but it
is best practice for you to do it; that way,
you are sure that the client is covered.
On the back of the clients
insurance card there is usually a phone
number for providers to call. Call
the insurance company to confirm
coverage. During the call, you will:
Give the clients identification
number; any group, policy, claim,
or plan numbers; the clients
date of birth; and the name of
the person the plan is under.
Tell the insurance company
which CPT billing codes you will
most likely be using (see CPT
Codes, page 52) and verify that
they will cover those codes.
Check that the policy covers
massage administered by a massage
therapist. Many policies only
cover massage administered by a
physical therapist, physical therapy
assistant, or chiropractor.
Ask if there are any dollar amount
or visit limitations for massage. It
is common for massage therapy
to be lumped in with other
rehabilitative therapies including
physical and occupational therapy,
so be sure to find out how much
coverage the client has, how much
coverage has been used, and when
the amount rolls or renews.
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 53
Check on deductibles and copays www.abmp.com). This document will
(the amount the client is responsible guide your treatment plan: it describes
for paying out of pocket). why you are seeing the client, the
Find out if the client requires a type of treatment you are expected to
referral from his or her primary perform, in what region you should
care provider. Many insurance plans focus your efforts, how often you will
identify a primary care provider see the client, and for how long.
(PCP) who is responsible for The referral must include the
managing referrals to specialists clients name, ICD-9 or 10 code (see
such as a massage therapist. You sidebar page 52), date of referral,
may not be paid if a different treatment requested, and duration
provider referred the client to you. and frequency of treatment. Be
sure it is signed by the referring
physician and contains the contact
Getting Authorization information for that provider. If any
Getting authorization to treat is information is missing, you will need
when you contact the insurance to contact the referring physician
company and ask them to give you and obtain a completed referral
authorization to treat their insured form prior to seeing the client.
(your client). This authorization does Most insurance companies will
not guarantee you will be paid. request a copy of this document when
you send in your claim, so be sure it is
Prescriptions/Referrals for Care complete, accurate, and current.You
After you have confirmed that you are will not be reimbursed if the referral
an authorized provider, that the client has expired or has missing information.
has coverage for the services
you provide, and that the client is
being treated for a specific diagnosis,
you should ask for the clients referral.
A referral is a prescription for
massage (sample available under Client
Forms in the Members section of
but it is best practice
for you to do it; that
way, you are sure that
the client is covered.

Need More Information?
Active myofascial therapist and business-success coach
Irene Diamond works with therapists who want to grow their
practices, make more money, and have more happiness.
Massage & Bodywork readers can requesta free audio
CD in which Diamond interviews three other experts in the
massage profession about their secrets to success. For a
free seven-day course, Get One New Client A Day Marketing
Blitz, visit www.massagesuccess.org. For more information,
visit www.irenediamond.com.
Body Well Therapy is an LMT-owned and managed
massage-services company, specializing in massage for
injury victims through insurance (primarily auto and workers
comp claims).Body Well offers therapists who dont
want to handle their own insurance billing the opportunity
to work with these clients as a Body Well independent
contractor. Body Well directly coordinates and bills therapy
services. Clients may request any specific qualified
massage therapist they wish to provide their therapy.
Requested therapists not already under contract can be
easily contracted by Body Well to provide the prescribed
services at a specified frequency, and at a guaranteed rate
of pay per session. Services can occur at a clients home
or in a massage establishment. Services are available
in all states that license massage therapists.Therapists
can learn more at www.bodywelltherapy.com/accept-
insurance-massage, or call 888-929-9355, ext. 3.
Vivian Madison-Mahoney, LMT, has been educating
massage therapists about massage insurance billing and
marketing for 25 years. For more information, visit
www.massageinsurancebilling.com or call 865-436-3573.
54 massage & bodywork may/june 2015
Sending the Bill
Specific procedures for billing should be outlined
in your provider contract with the insurance
company, or you can call the company directly
and ask what they need from you. You will
most often use a standard form for billing. The
current form is the HCFA/CMS 1500, last
revised in February 2012. Basic information
you will provide on the form includes:
Your name, address, contact information, and NPI
Your clients personal and contact information
Date of injury/onset of illness
Name and NPI of referring physician
ICD-9 or 10 code(s)
CPT codes
Dates of service
Complete prescription from referring physician
This link has a tremendous amount of
information to help you understand the intricacies of
the form:www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNProducts/
downloads/form_cms-1500_fact_sheet.pdf.
Many insurance companies now require
electronic billing rather than mail-in. You may
need to purchase software that contains the proper
CMS 1500 format and capacity to submit bills
electronically. If you want or need to use electronic
billing, there are many companies offering medical
billing software to assist you. Many have free
plans, as well as paid plans. Four examples are
Free Medical Claims (www.freemedicalclaims.
com), Office Ally (www.officeally.com), Practice
Fusion (www.practicefusion.com/medical-billing),
and Practice Suite (www.practicesuite.com).
Some insurance companies require that you
submit your documentation (chart notes or progress
reports) in addition to the form. Be sure to check
where to send the documentation and billing, as
addresses are not always the same for each piece.
If you will be submitting claims via fax
or mail, it is strongly recommended you use
a Tax ID number rather than your social
security number, and include your NPI.
WORKING WITH LEGAL CASES
If you have a client whose injury or condition
means attorneys are involved in the case (for
example, a motor vehicle accident), prepare to
receive requests for documentation from both
sides of the case on multiple occasions.
Even if your client has not told you they will
be working with an attorney, you may receive a
notice from an attorney to submit your records
and billing informationsometimes long after
the client has finished treatment with you.
Dont be alarmed if you receive a visit from a
person with a subpoena for records. Providing these
materials, usually by a specified date, is not optional.
The attorney should provide a current written
permission release from the client along with
the request for records. Absolutely do not release
chart notes or billing records to an attorney
without a signed release from the client. You
are allowed to bill a fee to the attorneys for
administrative costs and per-page copying in
order to provide the information to them.
HIPAA COMPLIANCE
The Health Insurance Portability and
Accountability Act (HIPAA) was enacted by
Congress in 1996. In general, it serves three
purposes: (1) make health insurance more portable
for individuals who change jobs, (2) simplify
health-care record keeping by requiring some
standardization, and (3) enhance patient privacy.
The first two aspects affect you only if you
submit insurance information and/or billing
information electronically (or if you hire a third
party to handle those tasks on your behalf).
The privacy requirements, however, apply to
all health-care providersand, as mentioned, if
you bill insurance you are a health-care provider.
You must familiarize yourself with privacy rights
according to HIPAA and implement them in your
practice. All clients should review your privacy
policies and indicate in writing that they understand
their rights and responsibilities under HIPAA.
Conscientious massage therapists record an
initial health history for each new client (a form
is available under Client Forms in the Members
section of www.abmp.com) and also ask clients on
each subsequent visit whether anything is new on the
health front, making note of any significant changes.
You have a responsibility under law (both HIPAA and
other laws in many states) to maintain these client
files in a secure place, and not to wrongly disclose
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 55
to third parties information linking
an identifiable client to a particular
medical condition or treatment. If you
practice with other individuals, or work
with employees, you are also responsible
for training those individuals about
confidentiality requirements.
HIPAA compliance is far too
complex to cover here, but it is
important that you are aware this
compliance is required of you as a Irene Diamond, RT,
health-care provider billing insurance. consults with many of the
(See Your Practice & HIPAA, most successfulwellness
Massage & Bodywork, March/April providers,helping them
2014, page 82, for more information.) double their client base
For additional information, visit and generate more repeat
www.hhs.gov/ocr/hipaa. and referral business.
Creator ofthe rehabilitation
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As you can see, there is much more TherapyThe Diamond
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However, there will be a steep learning www.irenediamond.com.
curve and possibly a loss of income
compared to your current practice.
Many massage therapists think
billing insurance is the next step up in
growing their practiceand it may be,
for the right business model and the
right type of practitioner. Be aware,
though: many well-established health-
care providers, including chiropractors,
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practice to simplify
their overhead and time
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youve looked at all
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be able to make an
educated decision.
 Les s o n

PAIN
s 4
ON CHRONIC

Notes from a Mountain Guide

By Mark Liskey

56 massage & bodywork may/june 2015

 At
the age of 30, Jayson Simon-Jones suffered
a debilitating back injury that was hard to
explain to fellow mountain guides because it
was virtually invisiblehe had no cast or crutches or other
visible signs of injury. To address the injury, he tried everything
from Rolng to epidural injections. When those didnt
work, he elected to have back surgery, which eliminated
his leg dragging but didnt eliminate the pain completely;
in fact, a six-Vicodin-a-day are-up was not out of the
question. Simon-Jones, like 100 million other Americans,
then faced the challenge of living with chronic pain.1
I had the good fortune to interview Simon-Jones in 2006
and then again in 2015. Though he still sometimes suffers
from severe pain, he continues to work at his dream job as a
mountain guide. More than inspirational, his story provides
valuable lessons that massage therapists can apply to improve
the quality of treatment for clients with chronic pain.

BIOMEDICAL MODEL VERSUS BIOCULTURAL MODEL

Experts agree that in the United States we operate under a
biomedical approach to medicine. A biomedical approach focuses
on treating the patients disease, and a biomedical approach to pain
primarily views and treats pain as a function of tissue damage.
A biocultural approach to medicine goes a step further, taking into
account the patients psychological and social factors when treating
disease. A biocultural approach to pain includes treating the person in
context to his community, not just the biological aspect of his pain.
There is evidence to suggest that a biocultural approach to treating
pain is better for the chronic-pain sufferer. A 1997 cross-cultural
study comparing chronic pain attitudes between New Englanders
and Puerto Ricans found that New Englanders were more likely to
feel stressed and alienated under medical care.2 The New England
doctors treated their patients using a biomedical model, whereas
the Puerto Rican doctors operated under a biocultural model.
Initially, Simon-Jones experienced treatment-related stress in the
same way that many New England participants had in the 1997 study.
The fi rst surgeon I met with was like a mechanic, he says, describing
the meeting that left him feeling agitated, confused, and dejected.
But Simon-Jones persevered, searching until he found a surgeon
who could answer all of his questions. He treated the person,
Simon-Jones explained, not just the symptoms. Simon-Jones had
found a surgeon who practiced medicine in a biocultural way.
What lessons can we take away from Simon-Joness reactions to
the surgeons he interviewed?

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 57

 1
s s o n
Le
DONT INDUCE
OR EXACERBATE
TREATMENT-
RELATED STRESS
For the massage therapist, preventing
treatment-related stress starts with the
intake process. During your intake,
do you ask only questions specific
to pain, or do you give the client an
opportunity to discuss his entire
experience around the pain? Here is
an example of a question that leads the
conversation toward a biomedical slant:
Therapist: Where is the pain?
Client: In my neck. Right here.
Sometimes it goes down my arm.
Though this is an important
question to ask, it is specific only to the
physical pain (biomedical approach).
If not followed by questions that move
the intake process toward the clients
psychological and social experience
of pain (biocultural approach), it may
induce treatment-related stress.
Open-ended questions provide
an opportunity for the chronic-pain
sufferer to fi ll in the story, allowing
you to move toward framing pain in a
biocultural way. Heres an example:
Therapist: Tell me more. When
did it start? How long have you
had it? What have you tried?
Client: Well, I was driving, and
when I came to this intersection, I was
T-boned. I didnt feel the neck pain
right away, but it started to get bad
about two weeks later. The doctor sent
me to physical therapy and that just
made it worse. I was thinking about
going to a chiropractor, but my sister-
in-law, who is an orthopedist, said not
to. But my friend goes to a chiropractor,
and it seems to help him. What do
you think about chiropractors?
58 massage & bodywork may/june 2015
So far, the client has talked
about the driver who hit him, the
doctor who treated him, the physical
therapist who didnt help him, the
sister-in-law who doesnt want him
to go to a chiropractor, and the
friend who does. The therapist can
begin to understand that the clients
pain experience includes significant
confusion and frustration, and can then
acknowledge and validate the clients
emotional experience, thereby reducing
a clients treatment-related stress.
The intake process is not the only
potential hazard for overemphasizing
the biological side of chronic pain.
Once you have the client on the table,
especially if you practice massage from
an orthopedic or sports philosophy, be
careful that your desire to fi x chronic
pain doesnt turn you into a mechanic.
For example, when I became
certified as a neuromuscular therapist, I
was ready to fi x the pain of all chronic-
pain sufferers. At the time, I was
working for a chiropractor who sent
me a client with chronic neck pain. I
did a structural analysis, mapped out a
plan of attack, and worked the muscles
the way I thought they needed to be
worked. It was 100 percent biomedical.
Later that night, the chiropractor
relayed some feedback to me regarding
the chronic neck-pain sufferer. He had
asked her, How was the massage? She
snapped back: That was a massage?!
Needless to say, I stressed her out,
and she didnt come back to see me.
No one, and no one discipline, has
a cure for chronic pain. Its complex
and requires the massage therapist to
put her belief in her specialty training
and/or massage abilities second to the
reality that she is only one component
of a pain-management system.
2
s s o n
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STEER THE CLIENT AWAY
FROM CATASTROPHIZING
CatastrophizingI will only get worse; all is lostis
serious business. Catastrophizing is associated more with a
lower quality-of-life rating than the actual intensity of pain.3
According to scholar and writer David Morris, in a
biomedical setting, Pain that fails to respond to treatment,
or pain that medical authorities cant understand can lead
to catastrophizing. Morris goes on to say that a healthy and
more positive narrative can diminish catastrophizing.4
When I spoke with Simon-Jones, I felt like I was talking to
someone in charge. After all, if you are leading a backcountry
trip in Crested Butte, Colorado, youd better be in charge!
When his chronic pain fi rst started, however, quite the
opposite was true. He had more questions than answers,
and the interactions he had with the medical community
left him feeling that he was headed toward a catastrophe.
Massage therapists are not trained or licensed to treat
catastrophizing. However, if a client is demonstrating this
behavior, dont play along. For example, if Simon-Jones
were on my table saying he would never get back on the
mountain, I wouldnt say anything to reinforce that fear.
Instead, Id encourage him to seek out a support system
to help him develop a more positive narrative. Examples
might be chronic-pain support groups, trained therapists,
or other climbers who made it back to the mountain.
In the massage room, catastrophizing may occur as a
result of a therapist making promises she cant keep. If you
promise a cure, and it doesnt materialize, the clients massage
experience can become another failure, contributing to a
downward emotional spiral. However, if a therapist makes
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 59
realistic treatment goals, explains
her treatment plan, and checks in
regularly with the client to see if the
treatment approach/goal is working,
she can make adjustments without
making the client feel like all is lost.
For example, lets say your goal is
to reduce (not fi x) the clients pain.
You explain to the client that you
are focusing on the levator scapulae
and posterior scalenes. You do your
work, but the client is still in the
same amount of pain the next day.
All is not lost. Because youve
explained your approach and havent
promised more than you can deliver,
youve therapeutically managed client
expectations, and, subsequently,
lowered the chance for catastrophizing.
In addition, youre now in a position
to adjust your treatment for a second
attempt. For example, you could
tell the client that you would like to
shift your focus to the cervical spinal
erectors. And the second attempt
might be the one that helps.
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 3
o n
Less
EMPOWER THE CLIENT
In his chronic-pain journey, Simon-Jones empowered
himself when he fi red his doctors and got new ones. He
also paid out-of-pocket when insurance would not cover
his initial consultation with his choice of doctor. He
handpicked his postsurgery rehab team, which included
a physical therapist and yoga and Pilates instructors. All
were experts in their respective fieldsand all listened
to his concerns. As in the biocultural model, Simon-
Jones surrounded himself with a support system.
You cant fi re your clients doctors (though sometimes
you may want to). So how do you empower your client?
One way is to put yourself in a position to be fi red if the
clients goals are not met. If you establish a therapeutic
relationship that is outcome-based and honestly evaluate
to see if objectives are being met or need to be redefi ned,
you are saying to the client, If its not working, its OK to
move on. In fact, as massage therapists,
its our ethical obligation to do so.
Moving on is an opportunity
to continue with your goal to
help the client. Do you think he
needs to go back to his primary
or pain-management doctor
for a recheck? Is a referral to
a practitioner of a different
massage modality or different
health modality, such as physical
therapy or Pilates, warranted?
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 61
During the treatment session,
you can also empower the client by
establishing the appropriate pain-
relief pressure through a dialogue
where the client has the last word on
the pressure. One way to do this is to
ask: Using this as a starting point,
would you like more or less pressure?
If the client never had a pain-relief
massage before and has no reference
point for pressure, then a scale from
1 to 10 can be used, where 1 indicates
no pain and 10 means a great deal of
pain. Working conservatively between
4 and 6, the client can be instructed
to let you know if the pain ever gets
above 6, thus providing the client with
control over the amount of pressure you
are applying in the massage session.
Using these techniques, youve
empowered your client and,
hopefully, youve shown him
how he can and should
expect to be treated in other
therapeutic relationships.
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 4
s s o n
Le
ACCEPT
It almost seems counterintuitive
to think that accepting the
condition of chronic pain can be
healthyuntil we understand what
experts mean by acceptance.
Acceptance of chronic pain entails
that an individual reduce unsuccessful
attempts to avoid or control pain
and focus instead on participation
in valued activities and the pursuit
of personally relevant goals, writes
researcher Lance M. McCracken.5
There is evidence to support the
theory of acceptance. In one study
that compared coping (behavior in
response to pain and/or behavior
that reduces pain) versus accepting
chronic pain, the authors concluded
acceptance of chronic pain was
associated with less pain, disability,
depression and pain-related anxiety,
higher daily uptime, and better work
status.6 Or, more simply stated: quit
chasing a cure and get back to living.
Simon-Joness story seems like
a textbook case of pain acceptance
theory. He stopped unsuccessful
attempts to control pain, but didnt
avoid situations that may cause
more pain. And he focused on what
gave him pleasureclimbing.
How does a chronic back-pain
sufferer get back into climbing? First,
he accepted that he couldnt climb the
way he used to climb. For example,
overhangs now tweaked his back, so
he avoided them. He also learned
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 63
that an easy climb served as a good
warm-up for a more challenging one.
Through trial and error and some
modifications, Simon-Jones figured
out how to do what he loved doing.
Determining if a client is
nonaccepting can be difficult and
out of your scope of practice. If you
suspect a client is having trouble with
acceptance, refer him to a counselor.
Lastly, the therapist herself may also
struggle with accepting that a clients
pain condition isnt curable. Why?
Because to the therapist, it may feel
like she has failed. But the reality is no
one has cured chronic pain. We need
to do what is best for our clients, not
our egos. That is not to say massage
cant be a valuable tool in helping a
client manage chronic pain once the
client has accepted his pain is chronic.
APPLYING THESE LESSONS
TO YOUR PRACTICE
First, reduce treatment-related stress
during intake by providing open-
ended questions so the client can
tell his story. Next, work to help
a client feel better, rather than
promising to fi x a chronic-pain
issue. Remember, a good support
system and a well-explained treatment
plan with realistic expectations can
reduce castrophizing. Also, empower
the client in the session by providing
a means for him to control tactile
pressure and provide a therapeutic exit
strategy if the treatment isnt helping.
Finally, accepting chronic pain
does not necessarily mean the client
is giving up. It can actually mean the
client is moving on and is creating
the best life possible. We cannot
cure chronic pain, but by applying
Simon-Joness lessons we can help
our clients work toward better pain-
management outcomes.
Notes
1. Institute of Medicine, Relieving Pain in America:
A Blueprint for Transforming Prevention, Care,
Education, and Research, accessed March 2015,
www.iom.edu/Reports/2011/Relieving-Pain-in-
America-A-Blueprint-for-Transforming-Prevention-
Care-Education-Research/Report-Brief.aspx.
2. M. S. Shutty, Jr., D. E. DeGood, and D.
H. Tuttle, Chronic Pain Patients Beliefs
about Their Pain and Treatment Outcomes,
Archives of Physical Medicine and
Rehabilitation 71, no. 2 (1990): 12832.
3. I. E. Lam et al., Quality of Life in Chronic Pain
is More Associated with Beliefs about Pain,
than with Pain Intensity, European Journal
of Pain 9, no. 1 (February 2005): 1524.
4. Author interview with David Morris, January 12,
2006.
5. L. M. McCracken, K. E. Vowles, and C.
Eccleston, Acceptance of Chronic Pain:
Component Analysis and a Revised
Assessment Method, Pain 107, no.
12 (January 2004): 15966.
6. L. M. McCracken and C. Eccleston, Coping
or Acceptance: What to Do About Chronic
Pain? Pain 105, no. 12 (September 2003):
197204.
Mark Liskey is a massage
therapist specializing in neuromuscular
massage. He is a CE provider and
co-owner of PressurePerfect
(www.pressureperfectmassage.com),
a massage company that practices the tenets
of conscious capitalism. He can be reached
at mark@markliskey.com.
Fascia- adaptation or as compensation. motor control, and proprioception.3
Neuromyofascial tissue contraction These slowly evolving adaptive
may result in varying degrees of pain- processes may become both habitual

Related inducing binding, or adhesions,

between layers that should be able
and built-in. For example, in an
individual with a chronically altered

Dysfunction to stretch and glide on each other,
potentially impairing motor function.2
A process evolves that can be
Palpation and Functional neatly summarized as densification
Assessment Methods of previously more pliable tissues,
including fascia. This involves
By Leon Chaitow interference with complex myofascial
relationships, altering muscle balance,
postural pattern involving a forward-
head position, protracted shoulders, a
degree of dorsal kyphosis, and lumbar
lordosis, there will be both a range
of soft-tissue changes, fibrosis, etc.,
as well as the evolution of ingrained,
habitual, postural patterns that are
usually difficult to modify unless the

ascia provides structural

F
and functional continuity
between the bodys hard
and soft tissues. It is a
ubiquitous, elastic-plastic, sensory
component that invests, supports,
separates, connects, divides,
wraps, and gives both shape and
functionality to the rest of the
body, while allowing gliding and
sliding motions, as well as playing
an important role in transmitting
mechanical forces between
structures. At least, that is how
fascia behaves when it is healthy
and fully functional. In reality, due
to age, trauma, or inflammation,
for example, fascia may shorten,
becoming painful and restricted
and fail to painlessly allow coherent
transmission of forces, or smooth
sliding interactions, between
different layers of body tissues.1

ADAPTATION
One way of viewing fascia-related
dysfunction that occurs gradually
over time, happens suddenly
following trauma or inflammation,
or which may be
part of inevitable
age-related This article is adapted from Chapter
25 of Fascia in Sport and Movement,
changes, is as
edited by Robert Schleip, published with
physiological or permission from Handspring Publishing
biomechanical Limited. Leon Chaitows new book, Fascial
Dysfunction (Handspring Publishing,
2014), develops this topic further.

64 massage & bodywork may/june 2015

chronic tissue features are altered
via exercise and/or therapeutic
interventions. Thomas Myers has
expressed this progressive adaptive
phenomenon as involving a process in
which chronic tissue loading leads to
global soft-tissue holding patterns,
where clear postural and functional
imbalance and distress are both
visible, as well as being palpable.4
A shorthand summary of
such processes may describe
them as being the result of:
Overusee.g., repetitive actions.
Misusee.g., postural or
ergonomic insults.
Disusee.g., lack of exercise.
Abusee.g., trauma.
Any combination of these.
Whatever the single or multiple
contributing features may be, the end
result is of structural and functional
modifications that prevent normal
activity, result in discomfort or
pain, and which, themselves, make
further adaptive demands as the
individual attempts to compensate for
restrictions and altered use patterns.
ASSESSMENT OBJECTIVES
When evaluating possible interventions,
whether therapeutic or exercise
related, it is important to ascertain
which tissues, structures, patterns,
and mechanisms may be involved. For
example, is there any evidence of soft-
tissue change involving hypertonicity
or fibrosis? Is there joint or neurological
involvement? Are the tissues inflamed?
In other words: why is this happening?
What causative or maintaining
features are identifiable? What actions
might usefully be taken to modify,
improve, and correct the situation?
As a starting point, in order to
encourage rehabilitation, areas of
restriction need to be identified and
assessed so that they can be encouraged
toward normality. The question of how
best to identify such pathophysiological
changes is, therefore, one of the key
challenges that face practitioners,
before manual and/or movement
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 65
Therapeutic
Options
When the sliding/gliding
motion potential of fascia is
reduced, is painful, or has been lost,
restoration of normal function requires
attention to the causative, as well as the
maintaining, factors associated with the
dysfunctional fascial layers. The intent of
using such findings is to decide on the best ways
of encouraging more normal function. There are, of
course, multiple strategies that aim to improve, correct,
or rehabilitate such dysfunction, but their underlying
ambitions can briey be summarized as follows:
To reduce adaptive loade.g., to modify
overuse, or misuse, or other features that
are contributing to the problem.
To enhance functionalitye.g., to improve
posture, breathing function, nutrition, sleep,
and exercise patterns, as well as the local
mobility and stability of tissues.
To focus on symptom reductionthis might be a poor,
potentially short-term choice unless and until adaptive
demands are reduced and/or function is improved.
therapies or modalities can be safely applied. Fortunately, a range of
palpation and assessment tools is available to help achieve the identification
and localization of dysfunction, as will be described later in this article.
GATHERING EVIDENCE
Clinical decision-making needs to be based on a combination of the unique
history and characteristics of the individual, combined with objective and
subjective information gathered from assessment, observation, palpation, and
examination. The fi ndings of such information-gathering endeavors need to
be correlated with whatever evidence exists, research studies, experience, etc.,
that offer guidance regarding different therapeutic choices. The objectives of
palpation and assessment are, therefore, the gathering of evidence regarding
function and dysfunction so that informed clinical decisions can be made, rather
than being based on guesswork. Whats too tight? Whats too loose? What
functions are impaired? Which kinetic and structural chains are involved?
What are the causes? What can be done to remedy or improve the situation?
There are many functional assessment methods and protocols, as well as
a variety of palpation methods that can assist in this search for information
and answers. Some of these have been tested for reliability; others are
used extensively without any clear evidence that they are reliable.
This leads to a key recommendation: no single piece of evidence gained
from observation, or from the results of functional tests and assessment,
or from palpation, should be used alone as evidence to guide clinical
choices. It is far safer to rely on combinations of evidence that support each
other and that point toward rehabilitation and/or treatment options.
POSTURAL ASSESSMENT the tonic postural muscles), and
A general evaluation of posture and weakness of other muscle groups
movement patterns offers initial (usually the phasic muscles), and
clues as to areas that are either consequent loss of control on integrated
underactive or overactive in their muscle function. The lower-crossed
ranges of motion or functionality. syndrome involves hypertonic, and
therefore shortened, iliopsoas, rectus
femoris, tensor fasciae latae, the
CROSSED SYNDROMES
short adductors of the thigh, and the
Patterns of imbalance, such as upper-
erector spinae group with inhibited
and lower-crossed syndrome patterns,
abdominal and gluteal muscles. This
have classically been interpreted
tilts the pelvis forward on the frontal
as demonstrating hypertonic
plane, while flexing the hip joints and
extensor muscles overwhelming
exaggerating lumbar lordosis.6 In
inhibited abdominal flexors.5
addition, it is not uncommon for the
P. E. Greenman explained this
quadratus lumborum to shorten and
perspective as follows: Muscle
tighten, while the gluteus maximus
imbalance consists of shortening and
and medius weaken. The upper-
tightening of muscle groups (usually
crossed syndrome involves, among
other muscles, hypertonic cervical
extensors, upper trapezius, pectorals,
and thoracic erector spinae, with
inhibited deep-neck flexors and
lower fixators of the shoulders.
J. Keys research team noted that
this pattern may involve a posterior
(pelvic) shift with increased anterior
sagittal rotation or tilt, together with
an anterior shunt/translation of the
thorax and the head.7 In such instances,
diaphragmatic control and altered
pelvic floor function might result.
Information Gathering
1. A general evaluation of postural and movement
patterns offers an overview of what is functional and
which tissues, structures, and areas require further
investigation (see Therapeutic Options, page 65).
2. Testing particular key muscles for relative shortness,
as well as for functional efficiency, allows a more
focused evaluation as to where restrictions exist.
3. Within identified areas, such as shortened muscles,
local areas of dysfunction may be isolated by means
of direct palpation (see notes on ARTT, page 69).
66 massage & bodywork may/june 2015
THE SOFT TISSUE PALPATION
PUZZLE: PROBLEMS ARE
NOT NECESSARILY WHERE
THEY APPEAR TO BE!
In the descriptions of crossed
syndromes, individual muscles are
named. However, it has become
obvious in recent years that the
concept of individual muscles is flawed.
The multiple fascial connections
between named muscles and other
muscles means that their action is not
independent. Force is transmitted in
many directions, offering muscles
additional leverage and functionality,
as well as adding load to sometimes-
distant muscles. Individually named
muscles can no longer be considered
to be discrete and separate, operating
individually. P. Huijing has pointed
out that agonists and antagonists are
coupled structurally and mechanically
via the fascia that connects them,
so that when force is generated by a
prime mover it can be measured in
the tendons of antagonist muscles.8
A. Franklyn-Miller and colleagues
have shown that, for example, a
hamstring stretch produces 240 percent
of the resulting strain in the iliotibial
tract and 145 percent in the ipsilateral
lumbar fascia compared with the
hamstrings.9 Strain (load) transmission,
during contraction or stretching,
therefore affects many other tissues
beyond the muscle being targeted,
largely due to fascial connections.
Importantly, this suggests that apparent
muscular restrictions, such as tight
hamstrings, might not originate in
the affected muscle but elsewhere.
In the case of hamstring restriction,
there may be fascial dysfunction in
the tensor fascia lata, or the ipsilateral
thoracolumbar, creating, encouraging,
or maintaining hamstring symptoms.
This sort of fascial interconnectedness
exists throughout the body, so as
knowledge accumulates as to what
structures are linked to others via

fascia and at which orientation,
understanding sources of dysfunction
should become more predictable.
PALPATION AND ASSESSMENT
AND LOAD-TRANSFER: THE
THORACOLUMBAR FASCIA
Palpation and assessment strategies
need to take account of this load-
sharing phenomenon. The scale of
the palpation puzzle can be seen in
the illustration of the huge number
of potential links available from just
one massive fascial structure, the
thoracolumbar fascia. This ties together
the erector spinae, latissimus dorsi,
quadratus lumborum, psoas, transversus
abdominis, and diaphragm muscles,
as well as countless other minor
muscle structures (Images 1 and 2).
UNRAVELING THE PUZZLE
As we focus attention on the assessment
of relative shortness in named muscles,
we need to maintain awareness that
multiple fascial connections exist that
bind together muscles with different
names into a virtual interconnecting
tensegrity structure. An important
distinction needs to be made in our
search for culprit areas of restriction.
There is a need to identify both the
location of restriction (for example,
shortened hamstrings), as well as the
source of the restriction that could be
in the hamstrings, but also possibly in
the thoracolumbar fascia or elsewhere.
Testing particular key muscles for
relative restriction/loss of full range
of motion, as well as for functional
efficiency, allows a more focused
evaluation as to where restrictions
exist. There are strategies that can
help to identify areas that may be
responsible for dysfunction:
1. General observation: e.g., of
normal posture and movement,
such as standing and walking
as described above (see Active
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 67
FASCIA-REL ATED DYSFUNCTION
Psoas major
Transversus abdominis
Quadratus lumborum
Latissimus dorsi
Thoracolumbar fascia
Anterior layer
Erector spinae
Middle layer
Posterior layer
1
A transverse view of the fascial wrapping that binds together key muscles including quadratus
lumborum, psoas, erector spinae, latissimus dorsi, and transversus abdominis. (Grays Anatomy)
F F
D D
The deep layer of the thoracolumbar fascia and
different fiber directions of attachments to:
A. S acrotuberous ligament connecting to hamstrings
B. Fascia of gluteus medius
C. Fascia of internal oblique
D. Serratus posterior inferior C C
E. Erector spinae muscles
LRLateral raphe provides attachment LR LR
for part of external oblique and latissimus
dorsi, as well as distributing tension from the E E
surrounding hypaxial and extremity muscles
into the layers of the thoracolumbar fascia. B 1 1 B
All of these fascial layers and structures
interconnect with each other via the thoracolumbar
fascia, which, as seen in Image 1, invests the
erector spinae groups as well.
A 2 2 A
1. Posterior superior iliac spine
2. Sacrum
2
Note multiple directions of force transmission in the sacral region.
Palpated tenderness may help to identify directions of restrictive tension
with potential influence on specific muscles. Note that there exist direct
fascial connections between the upper extremity, the trunk, and the
lower extremity. Multiple indirect, less obvious, fascial connections allow
for force transmission of load, with profound clinical implications.

Assessment, available online at
www.massageandbodywork.com).
2. Observation of functional movements
or postures: e.g., walking, long-
sitting, and bending, as well as
V. Jandas hip abduction and hip
extension tests (Images 3A and 3B).10
3. Specific tests for muscle shortness:
(see Table 1, Postural Muscle
Assessment Sequence, available online
at www.massageandbodywork.com).
4. Direct manual palpation: see
palpation exercises described later.
FUNCTIONAL ASSESSMENT:
HIP ABDUCTION TEST,
HIP EXTENSION TEST
There are hundreds of functional
assessment methods that offer evidence
of overuse, inhibition, restriction,
and other aspects of dysfunction,
as well as, potentially, discomfort
or pain, when being demonstrated.
Due to space constraints, just two
examples are described below.
Hip abduction test
This assessment can be performed
by including palpation; however, it is
possible that adding digital touch to
the muscles being evaluated would
add sensory motor stimulation
that might reduce the reliability of
any findings. Observation alone is
encouraged initially, with direct
palpation being added subsequently.
The aim of this test is to screen
for stability of the lumbopelvic region.
The client should be side lying with
the superior leg resting on the lower
leg, which is flexed at the hip and
knee (Image 3A). The uppermost
leg should be in line with the torso.
The client is requested to slowly lift
the leg toward the ceiling. If normal,
the leg should abduct to 20 degrees
with no internal or external rotation,
68 massage & bodywork may/june 2015
3
A Hip abduction test
B Hip extension test
or hip flexion, and without any
ipsilateral hip-hike (pelvic cephalad
elevation). There should be an initial
moderate contraction of the lumbar
erector spinae and/or quadratus
lumborum, in order to stabilize the
pelvis. However, this should not
involve any obvious contraction,
merely an indication of toning.
The test is regarded as positive if
any of the following are observed:
1. Ipsilateral external hip/leg rotation
which suggests overactivity and
probable shortening of the piriformis.
2. Ipsilateral external pelvic rotation,
which suggests piriformis and other
external hip rotator overactivity
and probable shortness.
3. Ipsilateral hip flexion, which suggests
overactivity and probable shortening
of the hip flexors, including the
psoas and/or tensor fascia latae.
4. Cephalad elevation of the
ipsilateral pelvis before 20 degrees
of hip abduction, which suggests
overactivity and shortening of
the quadratus lumborum.
5. An obvious hinging should be
noted at the hip, rather than in the
waist area, if the gluteus medius
and tensor fascia lata are working
optimally, and the quadratus
lumborum is not overactive.
6. Any pain reported in performance
of the abduction movement.
For example, discomfort
noted on the inner thigh may
represent adductor shortness.
7. A ny combination of the above.
Hip extension test
The aim of this test is to evaluate
coordination of a number of muscles
during prone hip extension (Image
3B). The client should lie prone with
the arms at the side and feet extending
beyond the table end. The client is
then requested to lift a specific leg
toward the ceiling. An initial toning

contraction of the thoracolumbar
erector spinae, to stabilize the torso
before the limb extends, is considered
normal if the action is achieved by
coordinated activity of the ipsilateral
hamstrings and gluteus maximus.
The test is considered positive if
any of the following are observed:
1. Knee flexion of the extended
leg suggests overactivity and
probable hamstring shortness.
2. Delayed or absent ipsilateral gluteus
maximus firing. Absence of a
meaningful contraction of the gluteus
maximus at the outset of the extension
movement is considered significant,
as this should be a prime mover.
Inhibition may indicate overactivity
of the erector spinae group and/
or of the ipsilateral hamstrings.
3. False hip extension: the hinging/
pivot point of the leg, during the
first 10-degree extension, occurs
in the low back rather than at the
hip itself, suggesting overactivity
of the erector spinae and inhibition
of the gluteus maximus.
4. Early contraction of the contralateral
periscapular musculature suggests
a functional low-back instability,
involving recruitment of the upper
torso as compensation for inhibition
of the intended prime movers.
Observed posture, together with
observation of movement patterns, as
well as in long-sitting, hip abduction,
and hip extension tests, offers clues as
to which muscles/groups of muscles
may be overactive and potentially
shortened, and which may be inhibited.
This information can be refined by
testing specific muscles for shortness,
as indicated in Table 1 (available online
at www.massageandbodywork.com).
Having identified muscles
with reduced range of motion,
local areas, or areas distant from
them, may be sought that could be
affecting them. These may then be
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 69
DOWNLOAD ASSESSMENT PROTOCOLS
RELATED TO THIS FEATURE AT
WWW.MASSAGEANDBODYWORK.COM.
usefully assessed (see discussion of
thoracolumbar fascia, page 67).
ARTT PALPATION FEATURES
OF LOCAL DYSFUNCTION
Fascial, or general musculoskeletal
dysfunction, involving pain and/or
restriction, for example, is commonly
associated with a number of predictable
features that can be summarized
using the acronym ARTT:
A stands for asymmetry, since
one-sided fascial dysfunction is
more usual than bilateral.
R stands for range of motion
restriction. In almost all cases of
fascial or general musculoskeletal
dysfunction, there will be a
reduction in the range of movement
available to the tissues involved.
T stands for tenderness or sensitivity/
pain, which is common but not
universal. A research team led by
G. Fryer confirmed that sites in
the thoracic paravertebral muscles,
identified by deep palpation as
displaying abnormal tissue texture,
also showed greater tenderness than
adjacent tissues characteristic of
dysfunction.11 Fascial dysfunction
frequently involves a particular quality
of a sharp, cutting, or burning sensation
when moved, compressed, or stretched.
T stands for textural or tissue changes.
Dysfunctional tissues are commonly
associated with hypertonicity, fibrosis,
induration/hardening, edema,
or other palpable modifications
from the norm. Fryers team also
examined the possibility that tissue
texture irregularity of paravertebral
sites might be due to greater cross-
sectional thickness of the paraspinal
muscle bulk.12 Diagnostic ultrasounds
showed that this was not the case.
Changes in the feel of fascia, when
dysfunctional, have been described
as densification: a word that neatly
summarizes what is commonly
palpated. Another Fryer team research
project examined the EMG activity
of deep paraspinal muscles, lying
below paravertebral thoracic muscles
with altered texture, that were
also more tender than surrounding
ones. This demonstrated increased
EMG activity in these dysfunctional
muscles (i.e., they were hypertonic).13
All four elements of ARTT are not
always apparent when dysfunctional
tissues are assessed/palpated. However,
it would be unusual for there to not be
at least two, and ideally three, of these
characteristics in evidence when fascia
is functioning other than optimally.
ARTT exercise
Have the client stand flexing from
the waist, as you stand in front,
viewing the paraspinal musculature
from the head. One side of the
paraspinals will commonly be more
mounded than the other. Note
the level at which this occurs, and
have the individual lie prone.
In this example, lets assume it is
the lower thoracic/upper lumbar area
on the left. At this stage, you will have
established that the A (asymmetry)
in ARTT is identifiable. Now palpate
both left and right sides of this area of
the back in order to evaluate the relative
tone on each side. The more mounded
side, left in this example, will inevitably
be felt to be tighter, more hypertonic.
Testing for the R element
of ARTT is easily achieved by
gently attempting to lengthen the
paraspinal tissues, either via simply
pressing into them, or by trying to
flex the tissues laterally with your
thumb, finger, or hand. There will
be reduced range of motion on
the hypertonic shortened side.
The more variety of tissues,
and individuals of different
ages and physical
condition, that are
involved in palpation exercises,
the more rapidly palpatory
literacy will be achieved.
Once you have sensed the difference
in tone, one side to the other, palpate
a little deeper into the musculature,
possibly from a slightly lateral angle
rather than vertically, and sense
any differences you can identify in
the texture of the tissues. It should
usually be possible to sense greater
rigidity and possibly, depending on
chronicity, some fibrotic elements
on the hypertonic side. If so, you
will have established one of the T
(texture or tissue) elements of ARTT.
Pressure applied into the tissues
on each side should establish that,
in most instances, the hypertonic
side will be tender (producing
the second T) in ARTT.
Translating ARTT into fascial
assessment is less obvious than when
applying it to muscles or joints,
since many fascial restrictions may
be deep and not directly palpable.
However, superficial fascia and loose
areolar tissues are easily evaluated.
EXERCISES: SKIN AND
FASCIA PALPATION
Ideally, the exercises here should be
practiced on normal tissue as well as
on areas where dysfunction is apparent
or suspected. In addition, practice on
tissues that are overlying large muscle
masses and also where there is minimal
muscle between the palpating contact
and underlying bone. The more variety
of tissues, and individuals of different
ages and physical condition, that are
70 massage & bodywork may/june 2015
involved in palpation exercises,
the more rapidly palpatory
literacy will be achieved.14
Exercise 1
Skin drag
Remove any watches or jewelry
before starting the exercise.
With no pressure at all, only the
very lightest of touch of one or two
finger pads, stroke the skin of the
area where the watch had been, so
that you move from skin that was not
covered by the strap, to cross over
that area and back again several times.
Do you notice an obvious difference
as you cross this more moist area,
compared with the dryer areas?
Increased skin hydrosis (sweat)
changes should be palpable. What
you are feeling is known as drag,
and you are using drag palpation
to identify increased hydrosis,
which is often associated with
hypertonicity, tissue dysfunction,
and fascial resistance to sliding.
When you are comfortable that you
can recognize the feeling of drag
and using no pressure at all, only the
very lightest of touch of one or two
finger pads, stroke the skin of your
anterior thigh (for the purpose of
this exercise), in various directions.
Then do the same on the lateral
thigh, overlying the densest
aspects of the iliotibial band.
Try to sense and identify areas of
drag. These will be far less obvious
than the area under a watch strap,
but should make themselves known
when smooth finger movement over
the skin becomes slightly rough.
Exercise 2
Sliding and rolling superficial fascia
Place two or three finger pads
on the skin of the anterior thigh
with minimal compressive force
(ounces only) and slide it (the skin
together with superficial fascia,
to which it is bound) toward the
knee, until you feel resistance.
Then return to where you started
and slide the skin toward the hip.
Compare the ease of movement in
one direction with the other.
Was there greater resistance in
one direction or the other?
Perform the action over areas
that displayed drag sensations,
as well as those that did not.
Now perform the same actions on the
lateral surface of that leg, overlying
the iliotibial band. Compare ease
of movement with the anterior
surface, or areas free of drag, as
well as those displaying drag.
After exploring one leg, perform
the same evaluations on the other
leg, as well as in other easily
accessible areas of the body, such as
the anterior and lateral calf areas,
comparing and remembering the
different feel of these tissues as
you lift, slide, and roll them.
Compare your findings. Was
there greater resistance to sliding
skin/superficial fascia in some
locations compared to others, and
did this correlate with drag?
Was there greater resistance on one
surface of the leg, or one aspect of
the leg, compared with the other?
What differences did you notice
when trying to perform the same
exercises on areas with little muscle
cover, or where there were dense
fascial layers (iliotibial band)?

Exercise 3
Testing skin elasticity
Now gently hold a pinch of skin
between your index and middle
finger pads, and your thumb in
an area already tested for skin
slideability, as in Exercise 2.
Lift this to sense its degree of
elasticity, which will differ greatly
in different areas of the body.
What you are holding is skin and
superficial fascia, together with
some of the adipose/areolar/loose
connective tissue that lie between
those layers and the underlying
dense connective tissue. This
loose material includes a variety
of cells and substances, such as
proteoaminoglycans, which facilitate
the slideability of the various
layers of tissue on each other.
When this facility is reduced or lost,
dysfunction, restriction, and pain
are almost inevitable consequences.
Repeat this light pinch-and-lift
in various parts of the thigh, both
where there is a thick layer of muscle
and also where there is minimal
muscle and more fascial tissue.
Now see if you can roll the skin and
superficial fascia between fingers and
thumbs, in the different areas you
are testing, in various directions.
Did you notice that where reduced
sliding (Exercise 2) was observed, skin
is less easy to lift/stretch and roll?
In general, the greater the degree
of underlying hypertonicity and
shortening, the greater will be
the resistance to free sliding
on underlying structures of
the skin/superficial fascia.
In many instances, there will
be a correlation between drag,
and lack of easy sliding capacity,
and loss of elastic quality.
Note that several elements of
ARTT are being demonstrated via
this exercise. A degree of increased
tenderness is also likely in areas
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 71
where drag is noted, where there is
reduced ability to slide and to roll.
Sometimes rolling the tissue will be
more uncomfortable, adding the final
element of ARTT (tenderness).
6. P. E. Greenman, Principles of Manual Medicine,
Exercise 4
Apply tests 1, 2, and 3 to somebody
elses sacrum and/or lower back and,
as you do so, try to evaluate directions
of relative restriction in the ability of
superficial tissues to slide. You are now
on your way toward palpatory literacy.
CLINICAL SUMMARY
Global evaluation via observation
static and during movement
offers indications of areas that
are restricted or dysfunctional.
Functional assessments allow you
to identify specific structures that
deserve further investigation.
Direct palpation isolates local
areas of tissue change.
Your only remaining concern
is what to do about what you have
identified. Fascia in Sport and Movement
(Handspring Publishing, 2015), from
which this article was adapted, offers
solutions to those concerns.
Notes
1. Helene Langevin et al., Ultrasound
Evidence of Altered Lumbar Connective
Tissue Structure in Human Subjects with
Chronic Low-Back Pain, presentation at
2nd Fascia Research Congress, 2009.
2. F. Grinnel, Fibroblast Mechanics in Three-
Dimensional Collagen Matrices, Fascia
Research II: Basic Science Implications for
Conventional and Complementary Health Care
(Munich: Elsevier GmbH, 2009); W. Fourie
and K. Robb, Physiotherapy Management of
Axillary Web Syndrome Following Breast Cancer
Treatment: Discussing the Use of Soft-Tissue
Techniques, Physiotherapy 95 (2009): 31420.
3. L. Stecco and C. Stecco, Fascial Manipulation:
Practical Part (Italy: Piccini, 2009).
FASCIA-REL ATED DYSFUNCTION
4. Thomas Myers, Anatomy Trains, 2nd ed.
(Edinburgh: Churchill Livingstone, 2009).
5. V. Janda, Evaluation of Muscular Balance,
in Craig Liebenson, ed: Rehabilitation of the
Spine (Baltimore: Williams & Wilkins, 1996).
2nd ed. (Baltimore: Williams & Wilkins, 1996).
7. J. Key, Back PainA Movement Problem:
A Clinical Approach Incorporating Relevant
Research and Practice (Edinburgh:
Churchill Livingstone, 2010).
8. P. Huijing, Muscular Force Transmission: a
Unified, Dual, or Multiple System, Archives of
Physiology and Biochemistry 107 (1999): 292311.
9. A. Franklyn-Miller et al., in Fascial Research
II: Basic Science and Implications for
Conventional and Complementary Health
Care (Munich: Elsevier GmbH, 2009).
10. V. Janda, 1996.
11. G. Fryer, T. Morris, and P. Gibbons, The
Relationship Between Palpation of Thoracic
Paraspinal Tissues and Pressure Sensitivity
Measured by a Digital Algometer, Journal
of Osteopathic Medicine 7 (2004): 649.
12. G. Fryer, T. Morris, and P. Gibbons,
The Relationship Between Palpation of
Thoracic Tissues and Deep Paraspinal
Muscle Thickness, International Journal of
Osteopathic Medicine 8 (2005): 228.
13. G. Fryer, T. Morris, and P. Gibbons, et al.,
The Activity of Thoracic Paraspinal Muscles
Identified as Abnormal with Palpation,
Journal of Manipulative and Physiological
Therapeutics 29, no. 6 (2007): 43747.
14. Leon Chaitow, Palpation and Assessment
Skills (Edinburgh: Churchill Livingstone, 2010).
Leon Chaitow, ND, DO, is a director
of the Ida P. Rolf Research Foundation
and Honorary Fellow of the University
of Westminster in London. For more
information, visit www.leonchaitow.com.
Fee
74
Healthy
Fare
for Body
& Mind
By Tera Johnson-Swartz

massage & bodywork may/june 2015

ed Your Kneads

If you have a high volume of

clients in your practice, you can
surely relate to finding yourself
exhausted and hungry by the
end of the day. Lets face it:
back-to-back massages can zap
every ounce of emotional and
physical energy right out of even
the most vivacious practitioner.
One of the key elements
in MT self-care should be
nourishing ourselves with
healthy food and drinks to keep our stamina as
supportive as the services we provide. However,
sometimes we slack off and indulge in the things
that do the exact opposite, leaving us lethargic,
malnourished, and even downright cranky!
When we look at our profession, we strive
to offer healthy, meaningful exchanges with
our guests; with that in mind, what we put
into our bodies should be equally healthy and
meaningful. Here are some tips to feed your
body and mind during those busier days.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 75

 Learn . . . Pain
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John F. Barnes, PT, LMT, NCTMB
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 FEED YOUR KNEADS

BEST DRINK IN THE HOUSE

We all know water is the ideal choice for hydration. We also know we are
able to gulp greater amounts of it if it is kept at room temperature. Yet, we
still tend to stray away from our best choice to guzzle sodas, caffeinated
tea and coffee, and other less-than-healthy alternatives. Sometimes, all
it takes is a little change in the appearance of water to turn it into a new
and delicious beverage option. Below are some quick recipes to transform
your standard tap or bottled water into an exotic, refreshing drink:
Cucumber CrushChop quarter-inch circles of an entire cucumber
and drop them into your gallon pitcher. Fill with water and leave to
infuse. When your desired taste is reached, strain, pour, and enjoy.
Mini MojitoAdd five quartered limes and 1/8 cup of fresh, whole mint leaves
to a 1-gallon pitcher. If youd like to add a drop or two of stevia extract for a
sweeter taste, do so, and then fill the pitcher with water. Leave the mixture to
blend. When your desired flavor combination is reached, strain, pour, and enjoy.
StrawBasil SplashDrop a cup of freshly rinsed and quartered
strawberries into a 1-gallon pitcher. Add 34 fresh, whole basil leaves and
fill with water. Leave overnight for a stronger blend or just a few hours to
capture the hint of the combined flavorings. Strain, pour, and enjoy.

FOOD KNEADS
Snacks or quick finger foods are almost a necessity when you have only a
1015-minute turnaround between clients. While the initial thought of
snagging a protein or granola bar may seem like the only available option,
we sometimes forget all of the sugar and processed ingredients most of
these quick, go-to options contain. Here are some great alternatives that
provide a balance of protein, fiber, and carbohydrates to keep your body
satisfied until you toss your last set of sheets into the laundry basket.

DIY Trail Mix

Makes 3 cups
Its easy to create your own custom trail mix by perusing your grocery stores bulk bins.

1 cup shelled almonds, cashews, pistachios, or walnuts (or any combination)

1 cup pumpkin or sunflower seeds
cup flaxseed
1 cup dried fruit: banana chips, cherries, cranberries, dates, or raisins (or any combination)
Combine all ingredients and store in an airtight container.

Recipe courtesy Mary Barthelme Abel

 FEED YOUR KNEADS

Wrap It UpIf you know your day
is going to be packed full, take the
time to make a little bag of grab-and-
go snacks. One option to include is
a healthy wrap. Using your favorite
tortilla as a base, spread some
hummus, a couple slices of provolone
cheese, slivered pieces of avocado,
spinach leaves, and, if youre feeling
daring, some thinly sliced apple pieces.
Roll it up and cover it with foil so you
can peel and eat as you go. The cheese
and avocado provide a healthy base of
protein and fats to keep you feeling
full, while the spinach and hummus
add a crunchy, creamy texture.
Go NutsTrail mix can be a saving
grace in balancing sweet and salty
cravings. There are so many different
combinations I couldnt even begin to
narrow down my top choices to just a
few. Health food stores and large chain
grocers
offer a wide
variety of
options
that you
can mix and
match. My only
recommendation
would be to abstain
from picking up mixes
with chocolates or candies in
them. Keeping your sugar intake at
a minimum and your protein levels
high will balance your blood sugars
during a hectic day, so grabbing a
handful of trail mix with chocolate
pieces would likely bring your
sugar rush crashing down right
in the middle of your session.
Quick GrabsWeve all got our
stashes of just-in-case treats, so why
not set the tone for your quick grabs
with what is best for you and your
body. If youre a carb craver and need
them to sustain yourself, keep a stash
of pretzels and almond butter on hand.
If youve got a sweet tooth, try keeping
some grapes in your freezer. If youre
a dairy devil, keep a steady supply of
cheese sticks or plain yogurt
nearby, and if youre a liquid
dieter, make a big batch of smoothies
and freeze them in individual
containers to grab and let thaw
during a session so youve got
something to look forward to
before your next client arrives.
With these tips and treats
in your back pocket, you can take
the time to feed your body and mind
with the food and nutrients it needs.
Sometimes a little bite of sustenance
can feel just as gratifying to our tired
bodies as the very massage were giving.
So, go forth and feed your kneads!
Tera Johnson-Swartz has been a licensed
and insured massage therapist for nearly
10 years.Studying under some of the top
health-care practitioners in the country,
she has developed techniques specifically
beneficial for pain relief and overall well-
being. Beyond massage, she is a freelance
writer, independent childbirth and lactation
educator, health educator and fitness
instructor, and celebrates her freedom of
self-employment with her husband, Michael,
and their two young children, Livingston
and Bess, in Steamboat Springs, Colorado.
Contact her at tera@organicknead.com.

Quick & Easy Fruit Smoothie

Makes 1 smoothie

1 cup low-fat or fat-free vanilla yogurt

1 cup frozen mixed fruit
1 banana
1 teaspoon ground flaxseed
cup orange or apple juice

Combine all ingredients in a blender and process until smooth.

Add more juice if necessary for desired consistency.

Recipe courtesy Mary Barthelme Abel

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 79

 The
Emotional
Side of
Craniosacral
Therapy

Discovering
New
Conduits
for Healing
By Jana
Panter

80 massage & bodywork may/june 2015

 I know youre out there: craniosacral therapists who, like me, see
the world through emotionally tinted glasses. Since craniosacral
therapy (CST) tends to seek the physical plane as the underlying
issue, we particularly sensitive practitioners, who interpret incoming
information through an intuitive filter first and foremost, could use
a little extra support. This article discusses the value of exploring
the emotional plane, including ideas to exercise and strengthen
our perceptions. As we grow bolder in our confidence and our
numbers, we can come together and talk about our feelings. ErrI
mean, we can generate greater acceptance and build community.

When I began my education, my

BACKGROUND
CST was born from osteopathy (a
noninvasive medical practice with an
emphasis on structural balance of the
musculoskeletal system) and, as such,
has a solid grounding in the physical
realm. Much of what CST students
learn and therapists practice is on the
physical plane: bone shears and torsions,
and disruptions in the cranial rhythm. I
want to state clearly and unequivocally:
this is good. Working on the physical
plane is important and effective.
Most practitioners, myself included,
start out learning on the physical
plane. With hands on my classmates,
I practiced feeling sphenoidal
torsions and temporal strains. While
CST is born from bone, it is the
physiologic relationships between
anatomic structures that define it.
The namecranial/sacraland the
descriptions of internal movement
are based on the interactions within
the body (e.g., flexion/extension is
defined by the movement between
the sphenoid and the occiput).
teacher encouraged us to think about
the relationships between anatomical
structures, such as the relationship
between the mandible and the pelvis.
And this is where I seemed to go astray.
I interpreted her questions differently.
I found myself thinking about the
relationship between the structure and
the underlying cause: Why was the
sphenoid in torsion? Where did the
deep sadness in the diaphragm come
from? I was interested in following
clients emotions as the path to
understanding their misaligned bones
and congested organs. I didnt make
the conscious choice to focus on the
emotional plane; it was simply how I
saw, or more accurately, felt things. And
the more I considered the emotional
focus, the deeper the resultswere
for my clients. That kind of positive
reinforcement is tough to deny.
After I finished school and began
to include CST in my practice, I
was fortunate to stumble upon a
wonderful, like-minded mentor who
asked pertinent questions, shared
valuable insights, and confirmed my
CST suppositions. When I would

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 81

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82 massage & bodywork may/june 2015


ask, Is it possible that the clients
liver was unhappy with the election
results or a spat with a loved one?
assuring me and encouraging me to
check with the other organs as well.
As I gained confidence over the
years, I began to speak more boldly
and honestly about my perceptions.
Like any convert, I enthusiastically
shared my discoveries. (I apologize if
you were ever stuck in an elevator with
me.) But my joy wilted as I realized
that many practitioners, especially
newer practitioners, were reluctant to
explore or discuss their interactions
with the clients emotional plane.
The general publics and often
the professions lack of support,
ranging from cynicism to hostility,
can cause allied practitioners to doubt
their instincts and wisdom. Fearing
ridicule, we suppress and invalidate our
perceptions instead of developing our
skills. Furthermore, most of the books
and articles about CST either describe
physical processes and procedures or
work to explain CST scientifically.
Protocol and science are important,
but theres more to this picture.
The essential principles of CST are
to respect the bodys inner wisdom,
listen to the clients body, and trust the
clients inherent knowledge to direct
the therapeutic process. While we as
practitioners have the best of intentions,
it gets tricky when we try to understand
and interpret the body. Sometimes
I find the best path to the core issue
is via the emotions: I understand the
knee is holding tension and wants to
releasebut why is it holding tension?
Is it sad? Lonely? Frustrated?
By expanding our intention and
questions to includethe emotional
plane, the client may travel down a
different, and possiblytruer, path.
Here are three cases that demonstrate
thevalue of exploring the emotional
component ofa problem.
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 83
THE EMOTIONAL SIDE OF CRANIOSACRAL THERAPY
THE EMOTIONAL Sometimes I find
APPROACH IN PRACTICE
The Frozen Shoulder
the best path to
Leona was in her 40s and sat at a
desk all day. She came into my office
the core issue is
with a frozen shoulder. Lifting her
arm above 90 degrees, moving it
via the emotions:
sideways, or lifting more than a few
pounds was extremely painful. She
I understand
had tried acupuncture, massage,
and physical therapy; everything
the knee is holding
had helped briefly but didnt last.
In our first session, I gently held
tension and wants
her shoulder between my hands, and
this triggered a memory. She went back
to release
to a time when she was a young child
walking hand in hand with her father.
but why is it
Suddenly, he yanked her backward,
painfully. Her father had been a gentle
holding tension?
parent, and she felt angry and betrayed
remembering the incident. As I held
her shoulder, she was able to remember
more about it and she verbally shared
different emotions as they emerged:
first confusion, then fear and anger. She
went over the incident several times,
both verbally and within her body, and
she resolved to talk with him about it.
holding her shoulder, she discussed her
(Luckily, he was available for discussion.
conflicted feelingsglad her father
If he had not been, the process probably
protected her, betrayed that he hurt
would have gone differently and taken
her, and angry for the pain. Her body
longer.) At the end of the session, her
went through the motions of when he
shoulder was a little better and she
pulled her back, repeating it several
felt clearer and more energetic.
times. As she discussed her feelings
Leona arrived for her next CST
and as her body went through the
session very excited. Her father had
motions, I focused on actively listening
remembered the incident quite clearly.
(audibly and through my hands) and
He explained that they had been
respecting all the information she
walking along holding hands when
chose to share. Then she became quiet,
Leona saw a balloon in the street and
and I could feel her relax. Afterward,
started to run after it. In that split
her shoulder was much less stiff and
second, her father saw a car coming and
painful. With two more sessions, she
felt her trying to pull away from him.
regained full, pain-free mobility.
Afraid for her safety, he instinctively
pulled hard. With my hands gently
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84 massage & bodywork may/june 2015


The Fussy Baby
A mother came in with her 1-month-old son. He was gassy,
extremely fussy, and he spit up a lot. Her pediatrician had
prescribed antacids, but the mother wanted to try CST.
She lay down on the table with her baby on her chest. I
placed one hand underneath the mom and the other hand
resting lightly on the baby. Through this physical connection
(my hands on her and the baby), she was able to uncover and
articulate her feelings. She talked about her sons birth. She
had started having a home birth, but ended up having an
emergency cesarean
delivery in the hospital.
She was disappointed
and felt like shed failed
herself and her son.
Lying on the
table, the mother
cried while the baby
lay remarkably still,
his eyes wide open.
I felt a deep sadness
from both of them
and simply held them,
letting the emotions
flow. A few days
later, she called me
to report that they were both doing much better. Her son
was much happier and had stopped spitting up. She was
still sad about the delivery, but her sadness no longer held
so much power over her. She was much more focused on
the fact that they were both healthy and he was thriving.
The Jersey Cyst
A client presented with two health problems in her
right-lower abdomen: an old but painful appendectomy
scar and a recently pulled groin muscle. I was a little
surprised, however, to find myself so clearly and quickly
directed (by her body) to her lower abdomen on her left
sidethe side opposite the scar and pulled muscle.
With one hand on her left lower abdomen and
one on her sacrum, I found a large energy cyst (an
encapsulated bubble of energy) that was very solid and
very cold. Usually cold like that means shock release,
but this didnt have that feeling. I didnt know what it
meant, so I acknowledged it, waited a moment to see
if it had anything more to say, and then moved on.
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 85
THE EMOTIONAL SIDE OF CRANIOSACRAL THERAPY
Interestingly, this cyst had Jersey attitude: Hey, Im
a cyst. Whats it to you? Whatcha gonna do about it? It
was poised for a fight. Suddenly I felt like I was up against
Tony Soprano. I was a little intimidated, but mostly found
it amusing. I sat with the cyst for a bit and it dissolved quite
easily, especially for a tough guy from Jersey. At the next
session, the client said her symptomsthe appendectomy
scar and the pulled musclewere much improved.
If you are intrigued by these examples, here are some
ideas on how to develop and nurture your skills.
EXERCISES FOR EXPLORING
THE EMOTIONAL PLANE
Setting your intention on the emotional
plane is often enough to get things started.
As you ground and prepare for the session,
take a moment to open to the possibility
of an emotional constituent or core.
Ask emotionally based questions (verbally
and/or silently), and give the body plenty
of time before asking another question.
This is complicated and the body may
need time to formulate the answer.
Ask Questions
Where should I go? Is there somewhere specific I should
put my hands? What does that part(s) want to say? What
is the parts mood? Is it angry, gloomy, happy?Are there
other feelings, too? What is the color, density, depth,
memory, shape, size, smell, texture, etc., of the sensation?
Thoroughly explore whatever you find.Not all
of these questions will be relevant, but the right
question can spark a clear and/or strong response.
Quantify
If the part is happy, how happy is it: mildly amused or rip-
roaring ecstatic? If its angry, let the anger come out. It may
take time to understand the full extent of the emotion.
Determine the Cause
Why does the body (or body part) have this feeling?Is
the foot sad because it cant dance the jig anymore,
or is it sad because it really wants to kick the persons
brother in the behind, and thats not allowed?
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86 massage & bodywork may/june 2015


Determine the History
Is this feeling new, or has it been there
for a while? What was it before? Why
did itchange?What is the level of
complexity or consistency of the issue
within the body as a whole? A person
can have many conflicting feelings
about an issue, all at the same time.
This may be confusing to the client,
and they may need reassurance that it
is normal and healthy to feel different
things simultaneously.
Determine the Relationship
with the Body follow the clients lead to create the
What is the mood of the entire body,
and how does it relate to the part(s) you
are focused on? Is the mood of that part
consistent with the rest of the body? If
the rest of the bodyis furious, why is
the foot sad? Sometimes anger at self or
at circumstances the client cant control
comes across as resignation and sadness.
Bodies are dynamic and feelings
change. Keep following the sensations
as they progress.Sometimes the
sensation feels like waves in the ocean.
A wave comes in, and then it takes
a moment before the next wave. Be
patient.
Once you feel you have gotten to
the issue and paid your respects, ask
yourself: Did it change? How did it
change? Did it release? Increase? Or
take a different path altogether?
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 87
THE EMOTIONAL SIDE OF CRANIOSACRAL THERAPY
Visualize the Issue
Use visualization to aid in your
OPEN TO POTENTIAL
Does this article speak to you? If so,
explorations. Visualization is the
perhaps you are one of us: craniosacral
process of developing an image in
therapists who see the world through
your minds eye. It can be a safe way
emotionally tinted glasses. Or perhaps
to explore feelings, communicate,
you arent sure, and want to experiment
and get down to the core of the
with the techniques described here.
problem. Feelings can be conflicting,
Either way, CST is remarkably gentle
confusing, or hidden. Clients may
and profoundly effective; opening
be reluctant torecognize how angry
to the emotional plane enables one
they are with someone they love.
more conduit along the clients
The client may present an image
healing path. Whatever your focus,
or, like a police sketch artist, the
when you open to everything the
practitioner may ask questions and
body has to say, you will be amazed
at the depth and diversity of human
image. Finding the rightvisualization
creativity, expression, and feeling,
and following its development
and the potential for healing.
may help facilitate the process.
Clients may use visualization
Jana Panter is a naturopathic physician
to sort out their feelings or convey
and certified craniosacral therapist. She has
something important to you; for
been practicing craniosacral therapy
instance, a client may visualize an
for more than 16 years. She may be
exploding bomb to show you and
reached at jpanter@oceanabodyworks.com.
himself just how significant his anger is.
For more information, visit her website at
www.oceanabodyworks.com. And watch
Experiment
for her new book, But What If You Could?,
Listen.Ask questions. Dont judge
coming soon.
for morality; these are feelings,
not actions. Be completely open to
whatever information comes.Trust
that your clients are telling you what
they need to for their healing path.
If you transgress or head down the
wrong path, apologize, breathe,
and try again. Honor and respect
the person and the message.
Celebrate
Practitioners (and clients) can get too
focused on digging deeper and solving
the next problem. Sometimes when
there is a release or a breakthrough, the
body wants to celebrate. Dance, revel,
and sing in victory. Dont underestimate
the value of celebrating. Live it up!
 Who Do Your
Clients Trust? By Karrie Osborn

Massage therapists know word of mouth is

their best form of advertising. But its not just
friends who can sing your praises. Getting
these referrals can build your business, too.

70%
Medical Doctor
70% of massage consumers* would give a lot of importance
to a medical doctors recommendation for massage. Which
doctors can you create a professional relationship with?
Find a letter of introduction you can use at www.abmp.
com/members/biz_fit/sample_referral_letter.pdf.

59%
Physical Therapist
59% of massage consumers* would give a lot of importance
to a physical therapists recommendation for massage. Find
local physical therapists who do not already have MTs
on staff, and become their manual therapist of choice.

88 massage & bodywork may/june 2015

 45%
Exercise Trainer
45% of massage consumers* would give a
lot of importance to an exercise trainers
recommendation for massage. You might
already practice in a setting that employs
personal trainers. Reach out and make this a
win-win relationship for both of you.

25%
Health-related
newspaper or
magazine article
25% of massage consumers* would give a lot of
importance to an articles recommendation for

41%
massage. Have you shared Body Sense magazine with
your clients? Its a beautiful, easy-to-use education
tool designed specifically for you to give to your clients.
Go to www.abmp.com/bodysense to share it today!
Brother or Sister
41% of massage consumers* would give a lot
of importance to a recommendation from a
sister or brother. Make sure your clients have

40%
plenty of your business cards to take with them
so they can refer Uncle Joe to you, too!

Close Friend
40% of massage consumers* would give a lot of
importance to a recommendation from a close friend.
MTs have long known this is their bread and butter when
it comes to word-of-mouth advertising. Consider upping
the ante and rewarding those clients who frequently refer
friends to you with a free service or discount.

Karrie Osborn is senior editor at Associated Bodywork &

Massage Professionals. Contact her at karrie@abmp.com.

*Based on ABMPs 2015 Consumer Survey,

conducted by Harstad Strategic Research, Inc.
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 technique CLINICAL APPS
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.com

Approach to Nerve Injury

By Whitney Lowe

Nerve injuries can be intimidating for massage PHYSICAL EXAM/EVALUATION

Monica reported delayed upper
therapists. However, they dont have to be if a few
extremity neurological sensations
key evaluation and treatment concepts are applied. In several days after the accident.
The paresthesia symptoms were
this installment, we examine a complex case involving
predominantly on the ulnar side of
a client with neurological symptoms in her hand. her hand, but not in her arm. The
location of symptoms is one of the
most important clues as to where a
predominant nerve injury is located.
To fully understand how to use
this information effectively, lets
first review some key principles of
nerve anatomy and physiology.
There are two basic types of
mechanical nerve injury that can result
from the type of accident Monica
experienced: radiculopathy or a peripheral
neuropathy. Aradiculopathyis an
injury to the nerve root. A common
example is a disc herniation or spinal
tumor pressing on the nerve root.
Aperipheral neuropathyis a nerve
injury that impacts the nerve farther
along its path, distal to the nerve root.
When watching aerial silk artists in action, its not hard to envision the multitude of injuries
These conditions produce distinct
they might sustain as a result of their craft. Image courtesy Kendall Knowles, Central
symptom patterns, but it is not always
Oregon Aerial Arts.
easy to distinguish between them.
You can have both problems
Monica is an aerial silk artist. These performers do complex
simultaneously: nerve root and
acrobatic maneuvers while hanging from large silk ribbons. It is
peripheral nerve impairment. However,
an elegant sport that takes a great deal of strength, flexibility, and
for determining the tissues involved
grace. Three weeks ago, Monica had an accident during practice in
and making good treatment decisions,
which she lost her grip and had to catch herself from falling. The
it is important to be able to make
incident had her horizontal and grabbing the silk with her right
distinctions between the symptom
hand as she fell; her head was thrust in the opposite direction.
patterns of these conditions. There
About a week after the injury, Monica began experiencing
are two important concepts related to
pain along with pins-and-needle sensations (paresthesia)
symptom patterns in radiculopathy and
in her right hand. She sought massage therapy, hoping it would
peripheral neuropathy: dermatomes and
resolve the symptoms and prevent further problems. Clearly,
cutaneous innervation. Understanding
Monica was having neurological symptoms, and although one
these concepts is essential to the
might be tempted to immediately refer a client with neurological
evaluation process of nerve injuries.
involvement, it is not always necessary. Initial assessment indicated
Adermatomeis an area of skin
Monicas injuries might be primarily soft-tissue related, and so it was
innervated by fibers originating from
determined that massage may be appropriate. Further assessment
a single nerve root. For example,
is crucial for effective treatment in a condition like Monicas.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 91

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92 massage & bodywork may/june 2015


C8 dermatome
1
The C8 dermatome. Mediclip
image copyright (1998) Williams
& Wilkins. All Rights Reserved.
Image 1 shows the dermatome region
for the C8 nerve root (there is a C8
nerve root even though there are only
seven cervical vertebra due to an odd
naming convention). The C8 nerve
root exits below the C7 vertebra, and
some of the fibers in the C8 nerve
root form themedial antebrachial
cutaneous nerveand some become part
of theulnar nerve. Notice that the C8
dermatome covers the ulnar aspect of
the hand, but it also extends into the
forearm and back side of the arm.
The fibers from the nerve roots
branch out into the peripheral nerves.
The area of skin that is innervated by a
single peripheral nerve is referred to as
that nervescutaneous innervation.A
peripheral nerve may have fibers that
originate from more than one nerve
root, but a single nerve root can also
branch into more than one peripheral
nerve. Because the nerve could have
fibers from more than one nerve root,
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 93
CLINICAL APPS
Medial
The location
antebrachial
cutaneous nerve of symptoms
is one of
Ulnar nerve the most
important
clues as to
where a
2 Cutaneous innervation in the
upper extremity. Image courtesy
Wikimedia Commons.
predominant
nerve injury is
the nerves cutaneous innervation
could be split across more than one
dermatome. Thus, there is no one-
located.
to-one correspondence between a
peripheral nerve and a dermatome.
Image 2 shows the cutaneous
innervation of several upper extremity
When working with nerve
nerves. In the image, you can see that
injuries, be sure to note
the cutaneous innervation region
any client symptoms
for the medial antebrachial cutaneous
or sensations that
nerve and the ulnar nerve are both
indicate you are putting
contained within the C8 dermatome.
additional pressure on
Lets take a look at the symptom
the nerve and further
patterns in Monicas case to see how
aggravating existing
this anatomical information applies.
nerve compression.
The primary location of
Change your treatment
Monicas symptoms would indicate
strategy if there are
involvement of the ulnar nerve, as
neurological symptoms.
the symptoms are contained within
the cutaneous innervation pattern
for that nerve. However, you cant
rule out nerve root involvement
completely in Monicas case because
her symptoms are still within the C8
dermatome, even if they dont extend
throughout the entire dermatome.
To determine nerve root
involvement (radiculopathy), as opposed
to injury farther along the nerve
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rovi 45
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(peripheral neuropathy), tension or compression forces
are selectively applied at different locations to assess if
symptoms are aggravated. It is not possible to apply those
forces at every single spot along the nerve, so there is
still some degree of approximation of injury location. If
symptoms are increased when the nerve root is stressed,
it indicates a likely radiculopathy. Similarly, if symptoms
are most aggravated when the peripheral nerve is stressed,
nerve injury farther along the branch is more likely.
When examining Monica, none of her symptoms
were reproduced with palpation around her anterior,
posterior, or lateral neck region. However, numerous
neurological structures are deep and inaccessible to
palpation, so that does not mean much by itself.
During range-of-motion evaluation, Monica had
increased neurological sensations in her right hand
with both active and passive lateral flexion of the
cervical region. The brachial plexus is stretched in
both of these movements. It is feasible that the nerve
root or a peripheral nerve could be aggravated with
both of these motions. Monicas symptom pattern
increases our suspicion of neurological tissue damage,
but it does not significantly discriminate between
nerve root or peripheral problems. During active and
passive range-of-motion evaluations with Monica,
no other neck motion caused discomfort. Manual
resistive tests also did not increase symptoms.
One of the most helpful methods for identifying
the location of nerve injury in the upper extremity
is a procedure called a neurodynamic test. In this
test, tension is applied to different regions of the
nerve with sequential steps to assess if symptoms
are aggravated. If symptoms are aggravated in one
particular region but not another, it suggests that
nerve injury is more prominent in that region.
Monicas symptoms are primarily in the ulnar nerve
distribution. The upper limb neurodynamic test 4 is the
procedure designed to emphasize disorders with the ulnar
nerve. It may also give some indication if the nerve root is
involved. The video Upper Limb Neurodynamic Test 4
found in the digital edition of this publication
(www.massageandbodyworkdigital.com) demonstrates
the upper limb neurodynamic test #4, which examines for
pathology in the ulnar nerve. If symptoms are aggravated
most during the motions involving the forearm and
wrist, it suggests the pathology is somewhere between
the elbow and hand. If symptoms are increasingly
aggravated with the motions involving the cervical region
or shoulder, there is a greater likelihood that dysfunction
is somewhere in the nerve structures in that region.
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 95
CLINICAL APPS
With Monica, paresthesia symptoms were aggravated
during the shoulder abduction and lateral cervical
flexion movements. Both movements stretch the upper
brachial plexus. If the problem was primarily at the
nerve root alone, it would be unlikely that symptoms
would be aggravated during shoulder abduction,
because that motion does not significantly stress the
nerve root. In fact, because the neurological structures
of the arm are brought closer to the neck during full
shoulder abduction, symptoms of nerve root problems
in the cervical region frequently decrease with that
movement. Monicas response pattern pointed toward
involvement of the brachial plexus in the neck or
shoulder region and not at the nerve root level.
Another procedure was performed with Monica called
the Wrights abduction test. In this procedure, the arm is
brought into full abduction as far as possible and held
in that position for about 3060 seconds. (Flexing the
elbow during this procedure stretches the ulnar nerve
and may make the test more sensitive). If neurological
symptoms increase during the test time, there is a greater
likelihood of nerve compression occurring in the lower
brachial plexus under the pectoralis minor muscle.
The Wrights abduction test was used to confirm
our findings with the neurodynamic test. The test also
decreases stress on the nerve root if the nerve is not
being restricted in another location. Symptoms are often
decreased with this procedure if the nerve root is the sole
problem. Monica had an increase of symptoms during this
procedure that indicated peripheral nerve involvement.
Monicas symptom patterns appeared only in the ulnar
nerve's cutaneous innervation, and her response pattern to
the various physical examination tests pointed to a greater
likelihood of lower brachial plexus injury somewhere
between the neck and shoulder regions. Due to the nature
of her fall, nerves in this area were likely overstretched
from the forces and motions involved, and the resultant
pattern of muscle splinting is likely further compressing
the brachial plexus and causing an increase in symptoms.
TREATMENT STRATEGIES
Nerve injury treatment poses some unique challenges.
The most important strategy when addressing any soft-
tissue disorder is to make sure to match the physiology
of the tissue injury with the physiological effects of the
treatment approach. If the nerve roots are involved,
there is little that massage can do to address it, because
the structures are too deep. In addition, massage
cant do anything to the nerve directly to help it heal
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96 massage & bodywork may/june 2015


Scalene
muscles
Brachial
plexus
nerves
Pectoralis
minor
3
Brachial plexus nerves
from compression injury. The most important goal is to
get pressure off the nerve so that it can heal on its own.
In Monicas case, it appears that residual muscle tightness
course between the
or splinting was compressing the nerve and further restricting
scalene muscles
its free movement, thereby causing symptoms. Consequently,
and under the
massage treatment focused on reducing tightness in the lateral
pectoralis minor.
cervical muscles, pectoralis minor, and associated muscles,
Image is from
which were likely compressing the lower brachial plexus.
3D4Medicals Essential
Prior to treating the pectoralis minor, it is important
Anatomy 5 application.
to reduce tightness in the overlying pectoralis major
muscle first. Once the pectoralis major is relaxed, deeper
stripping applications can be applied to the pectoralis minor
to reduce tightness or existing myofascial trigger points
that might be causing the muscle to bind and restrict the
brachial plexus. Be sure to note if the client experiences
any symptoms or sensations when working the pectoralis
minor to make sure you dont put additional pressure on the
brachial plexus and further aggravate nerve compression.
Deep stripping applications can also be applied to the
anterior and lateral neck muscles to make sure they are
not binding or restricting the brachial plexus. Special
attention should be focused on the anterior and middle
scalene muscles, as these are the ones most likely to bind
the brachial plexus in the cervical region (Image 3).
One of the key goals of treatment in Monicas condition
is to encourage free movement of the nerve, which might be
bound and restricted by muscle tightness. Once the muscles
surrounding the nerve have been somewhat relaxed with the
massage techniques described above, you may use a neural
mobilization technique. The technique used with Monica
uses the same positions as the neurodynamic test described
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 97
CLINICAL APPS
earlier. The arm is then gently moved
in and out of the stressful position in
order to reduce adhesions that might
have bound or restricted the nerve.
This technique attempts to move the
nerve through its range of motion.
You can see a demonstration of the
neural mobilization technique for
the ulnar nerve in the digital version
of this publication, www.massage
andbodyworkdigital.com.
Monica required once-a-week
sessions for six weeks. Nerves are
slow to heal, and though Monica saw
immediate improvement, the nature of
her art form and activities meant that
there was previously existing tightness
in her upper body musculature that
complicated her situation. Monica
performed stretching activities at home
as well. She also stayed off the silks
completely for two weeks, which was
critical for her to stop the progression
of the condition. However, after that
initial period, she was able to gradually
and gently resume her routines.
CONCLUSION
This case with Monica is an excellent
example of the importance of a
comprehensive assessment for
creating a treatment plan. Though
a client may see another health-care
professional, your assessment and
evaluation skills are crucial parts of
successful treatment for these types of
cases. Though nerve injuries cannot
be directly treated with massage, the
surrounding tissues are often involved
and there are indirect approaches that
can help tremendously in solving these
potentially complicated cases.
Earn CE credit for this article and
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technique
Myoskeletal Enhancers
Engaging the Brain, Freeing the Fascia
By Erik Dalton
According to the Cambridge
Dictionary, the verb enhance
means to improve the
quality, amount, or strength
of something. Similarly, in
Myoskeletal Alignment Techniques
(MAT), the term enhancer is used
as a noun to describe a therapist-
directed movement cue that
neurologically boosts, intensifies,
and heightens a therapeutic
outcome.
In Image 1, I demonstrate a MAT
enhancer for a client presenting with
excessive thoracic kyphosis and upper-
crossed syndrome. Adding the enhancer
to her MAT treatment boosted the
involvement of her nervous system,
allowing better rib-cage mobility,
shoulder-girdle stability, and fascial
front-line extensibility. To help retrain
her brain for this new posture, she was
asked to perform the enhancer daily,
preferably in front of a mirror.
MAT enhancers serve three
primary purposes:
Release musculofascial contractures.
Retrain the brain by introducing
novel sensory information.
Reward the client through improved
proprioception and body awareness.
Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 99
MYOSKELETAL ALIGNMENT TECHNIQUES
CASE STUDY: TREATING
WHIPLASH WITH ENHANCERS
Ben was referred by an orthopedist
for soft-tissue damage sustained in a
rare side-to-side whiplash injury when
his car was hit on the drivers door six
months earlier (Image 2). The neck pain
had subsided, but he could barely turn
his head to the left and was prohibited
from driving until the rotation issue was
corrected. Upon seated examination,
his passive range into right cervical
rotation, flexion, and extension was
normal, but we could only manage
30 degrees of left rotation. A couple
myoskeletal enhancers were used to
1 With chin tucked, the client deeply inhales,
lifts both elbows toward the ceiling, and
pushes her belly out. My left arm assists this
determine if his primary restrictor was trunk-extension effort, while my right palm
neural (protective guarding) or the gently compresses and lifts her rib cage to
result of residual soft-tissue damage. stretch the front line and mobilize motion-
In many pain-free whiplash clients, restricted joint capsules, ribs, and intercostal
muscles. Photos courtesy erikdalton.com.
the neck becomes sensitized, as the
brain still perceives threat even after
the area has healed. In some cases, the
use of novel movement
enhancers can trick the
brain into loosening
the reins and dissolving
the protective muscle
guarding. Heres a
description of one of my
favorite MAT enhancers
that helped this client.
2
Overstretched nerves and connective tissue cause the
brain to layer the area with protective spasms that may
lead to contractures.
MYOSKELETAL ALIGNMENT TECHNIQUES

Treatment began by slowly rotating

Bens head left to the first restrictive
barrier and holding it there. His movement
enhancer was to inhale deeply and slowly
rotate his shoulders and torso as far right
as comfortably possible several times and
relax. Essentially, this maneuver is the same
as asking him to turn his head left, but

3
Ben inhales and slowly looks over his left shoulder while my right fist hooks and
Bens brain did not perceive the torso-twist drags the upper trapezius fascia posteriorly. Upon exhalation, he gently right
enhancer as threatening, and through graded rotates against my isometric hand resistance to a count of five and attempts
exposure (pain-free repetition), his flexibility more left rotation.
improved.
Then it was time to deal with the
right-sided sternocleidomastoid (SCM)
and upper trapezius contractures that
were visible as Ben turned to end range.
Image 3 demonstrates a basic, but effective,
MAT contracture routine that was
chosen to conclude Bens first session.

FOLLOW-UP TREATMENT
When Ben returned the following week, he
was asked to demonstrate the torso-twist
enhancer Id asked him to practice daily in
front of a mirror. I was impressed with his
progress, but still observed strain in his SCM

4
SCM receptor release. Ben lifts and slowly rotates his head left to the barrier
and at the base of his skull as he left rotated while my soft fingertips hook the sternal head of his right SCM. Upon exhalation,
to end range. Notice in Image 4 how my soft he drops the right shoulder and slowly looks toward the table to a count of five
finger pads remain stationary, allowing Ben and relaxes.
to left rotate at his tolerance level, and in
Image 5 how I use an optic-nerve enhancer
via the suboccipital muscles to help align the
atlas-axis joint.
During the three weeks of Bens
treatment, I experimented with many
myoskeletal techniques and enhancers, but
those described in this article proved to be
the most effective. Bens commitment to his
MAT enhancer homework was a major factor
in his recovery, which shortened his time with
me and got him back behind the wheel.

Erik Dalton is executive director of the

Freedom from Pain Institute. Educated in
massage, osteopathy, and Rolfing, Dalton
has maintained a practice in Oklahoma City,
Oklahoma, for more than three decades. For Atlas-axis release. Bens head and neck are flexed 90 degrees and rotated left
more information, visit www.erikdalton.com.

5 to the first restrictive barrier. Using the suboccipital muscles as enhancers,

Ben is asked to inhale and look over his right shoulder while my hands resist to
a count of five. Upon exhalation, his head is rotated left to the next restrictive
barrier. Repeat 35 times.

100 massage & bodywork may/june 2015

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Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 101
technique ENERGY WORK

The Case for Hope

By Cyndi Dale

Years ago, Martin Luther King, Jr. encouraged his followers to accept
disappointment, but to never lose hope.1 His reasoning, as I understand it, is
that a life event has finite bounds. For the moment, we might be defeated. We might
feel like we are losing our battle to anxiety, depression, pain, poverty, or another
condition. The power of light, however, is such that if we hold true to hope, we open
to the infinite. Within the infinite, anything is possible.
As healers, we often struggle to place ourselves between the finite and the infinite, between
what is happening with a client and what they, or we, might wish would happen. Our heart
yearns to assure them that everything is going to be OK, even when our professional integrity,
common sense, or experience might anticipate otherwise. While we dont want to tread where
angels fear to fly, I believe part of the healers role is to encourage hopeespecially if were
also in the position to inspire what I call hopeful activities, or behaviors that could create
beneficial change. Why ignore the potential of grace when we can make a difference or show
the client how to do the same?
For many people, hope is the result of faith. I always suggest clients follow the doctrines of
their religion, unless that faith system seems dangerous or irresponsible, such as what occurs
within a cult or terrorist organization. For instance, I once worked with a client who could
have taken care of a precancerous lump with a simple medical procedure. As a member of a

102 massage & bodywork may/june 2015

 Why ignore the potential of grace
when we can make a difference or
show the client how to do the same?

religion that didnt believe in surgery, she instead The naysaying studies shouldnt stop us from
refused treatment and focused on positive thinking praying for our clients, in whatever form we are
alone. Four years later, she was dead. She left behind comfortable, or encouraging our clients to do the
a 6-year-old daughter. I had strongly advocated she same for themselves. The kicker is that we dont want
listen to her medical professionals; she decided not to our clients to feel pressured, as if prayer necessitates
work with me anymore. perfectionism. We can avoid this by honing in
on one of the more helpful powers of prayer, as
revealed through another prayer-related study.
A COMMON DENOMINATOR
Professors Matt Friese and Michaela
Setting aside the extreme situations, a ritual
Wanke, in an article in Scientific American,
common to most spiritual collectives is prayer. In
provided an explanation for effective prayer
regard to healing, I consider prayer a two-sided
that wasnt supernatural. Their study
coin. We can collect on either side. On one side,
determined that the most effective prayers
prayer involves seeking assistance or guidance
might actually be increasing self-control.
from a Higher Power. On the other side, prayer is
The professors theory is called the strength
the focus of mental intention for the improvement
model, and it assumes that our cognitive and
of a problematic condition. In the first case,
physical resources are limited. For instance, they
assistance comes from a greater force. In the
point out that it would be hard to run a mile after
second case, aid comes from a person or a group.
completing a marathon. Prayer, or some form
Dozens of scientific studies reveal the possibility
of contemplation, was shown to increase the
that prayer can create positive outcomes for needy
cognitive strength of participants, religious or
individuals. The most well-known study is the
not, so they could better perform tasks.5 In other
1988 Byrd study, which exhibited that intercessory
words, they were better able to be self-responsible
prayer to the Judeo-Christian God beneficially
concerning activities that would encourage health.
affected patients admitted to a coronary care unit.2
Think of the kind of conditions that frequently
Other studies, however, reveal everything from
distress your clientseverything from chronic
positive to zero results.3 And one particularly
pain to an injury. How often might they be able to
shocking study, led by cardiologist Herbert Benson,
support their own recovery or well-being if they
MD, and chaplain Dean Marek, showed that a
were not exhausted and overwhelmed? Encouraging
significantly higher number of participants who
your clients to receive support from their Higher
knew they were being prayed for during heart
Power can give them that smidgen of extra
surgery had higher complications than those
strength needed to eat healthy, exercise, attend a
who didnt know if they were being prayed for.
support group, or, yes, get to their bodyworker.
What might be the reason for this
Showing them that you care, that you are focused
unusual outcome? The researchers theorized
on their betterment, and that others are as well,
there was a sort of performance anxiety that
can also make up that vital difference in energy.
caused the prayed-for to feel pressured.4

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 103
ENERGY WORK

Its important to embrace the power

you have as a healer, a power that
slips over the horizon of the healing
activities related to bodywork.

WHAT YOU OFFER
Its important to embrace the power you have as a
healer, a power that slips over the horizon of the healing
activities related to bodywork. From a subtle energy
perspective, your attitude is crucial. You dont even have
to say a thing to support a clients ability to be hopeful
and therefore self-directive; to keep going where it
makes a difference. Energy is information that moves,
and everything is made of it: a disease, pain, thought,
and antidote. Subtle energy is the high-speed quantum
stuff that moves so fast, it can create a change before
you even finish the request for that change. A number
of experiments6 have shown that thoughts, images,
intuitions, and physical sensations can pass between
people who are emotionally close or empathic.7 Most
important, the individual with the greatest or strongest
presence influences the other member of the pair.8
What if you hold hope in your heart, eyes,
and hands for your client? We know that
sustained positive emotions, such as appreciation,
compassion, or love, create coherent patterns
in the heart, which in turn stimulates harmony
and improved health in a persons body.9
If you believe there is a potential for emotional
steadiness, healing, pain relief, or positivity that
lies outside of the finite limitations of the current
situation, that same belief can transfer to your client
and support them in focusing on the internal and
external activities that just might make a difference.
This approach to hope, the desire for the infinite
to affect the finite, allows us to be clearly in the
moment with our clients. We can be empathetic
toward their current state. We can honestly tell them
we understand how hard it is to live in pain, physical
or emotional, and that we relate to their distress.
But we can also hold the aspiration for something
greaterlike graceto move in and promote change.
Recently, I went to the movie Selma, which showcases
Martin Luther King, Jr.s triumph in gaining legal
support for African-Americans right to vote. The
movie was striking on every level. My respect for this
individual and everyone who fought for a basic American
right grew tenfold. I also noticed how many times
King was depicted as battling with hopelessness, and
how many times his own goals and dreams, and the
support of others, lifted him to hopefulness, leading
him to actions that resulted in victories both small
and great. As a healer, you are part of the team of
hope, and all the more important because of it.

104 massage & bodywork may/june 2015

 Notes
1. Remarks by the President in Remembrance of Dr. Martin Luther King, Jr.,
Office of the Press Secretary, The White House, January 17, 2010, State of
the Union address made by President Barack Obama, accessed March 2015,
www.whitehouse.gov/the-press-office/remarks-president-remembrance-dr-
martin-luther-king-jr.

2. R. C. Byrd, Positive Therapeutic Effects of Intercessory Prayer in a Coronary

Care Unit Population, Southern Medical Journal 81, no. 7 (July 1988): 8269.

3. John W. Ehman, Studies of Remote Intercessory Prayer, revised December

4, 2010, accessed March 2015, www.acperesearch.net/intercessory_prayer_
studies.pdf.

4. Benedict Carey, Long-Awaited Medical Study Questions the Power of Prayer,

The New York Times, March 31, 2006, accessed March 2015, www.nytimes.
com/2006/03/31/health/31pray.html?pagewanted=all&_r=0.

5. Piercarlo Valdesolo, Scientists Find One Source of Prayers Power,

Scientific American online, December 13, 2014, accessed March 2015, www.
scientificamerican.com/article/scientists-find-one-source-of-prayers-power/.

6. L. C. Johnson et al., Methodological Challenges Associated with the

Measurement of Neural Energy Transfer, Consciousness Research Abstracts,
April 812, 2002: 13940.

7. J. Grinberg-Zylberbaum et al., The Einstein-Podolsky-Rosen Paradox in the

Human Brain: Transferred Potential, Physics Essays 7, no. 4 (1994): 4228.

8. J. Grinberg-Zylberbaum and J. Ramos, Patterns of Interhemispheric

Correlations During Human Communication, International Journal
of Neuroscience 36, no. 12 (September 1987): 4153; J. Grinberg-
Zylberbaum et al., Human Communication and the Electrophysiological
Activity of the Brain, Subtle Energies 3, no. 3 (1992): 2543.

9. L. Song, G. Schwartz, and L. Russek, Heart-Focused Attention and

Heart-Brain Synchronization: Energetic and Physiological Mechanisms,
Alternative Therapies Health Medicine 4, no. 5 (September 1998):
4462; R. McCraty et al., The Effects of Emotions on Short Term Heart
Rate Variability Using Power Spectrum Analysis, American Journal
of Cardiology 76, no. 14 (November 1995): 108994; R. McCraty,
The Energetic Heart, Institute of HeartMath, 2003, accessed March
2015, www.ssporer.com/downloads/Energetic_Heart.pdf.

Cyndi Dale is an internationally renowned author, speaker,

and intuitive consultant. Her books include the bestselling The
Subtle Body: An Encyclopedia of Your Energetic Anatomy (Sounds
True, 2009), The Complete Book of Chakra Healing (Llewellyn
Publications, 2009), and Advanced Chakra Healing (Crossing
Press, 2005). To learn more about Dale and her products,
services, and classes, please visit www.cyndidale.com.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 105
technique MYOFASCIAL TECHNIQUES

Working with Clients Locked Knees

By Bethany Ward and Til Luchau

If youre a knee-locker and youve ever tried to

stop, you probably appreciate how difficult it is
to change. Maybe youve observed this tendency
in clients and wondered if it was related to some of
their aches and pains. Perhaps youve tried to use
manual techniques to address the pattern in your
clients, only to see them lock their knees when they
get up from the table. Are hyperextended knees
actually a problem? And if they are, is there anything
manual therapy can do about this stubborn habit?
In this column, well discuss factors involved in knee
hyperextension, knee-lockings consequences for the rest of
the body, and a multipronged approach to help clients shift this
pattern.
Referred to in medical literature as genu recurvatum,
locked knees appear to bend backward in standing. A common
pattern among ballet dancers (Image 1), gymnasts, and runway
models, knee hyperextension creates a straighter profile for
the back of the leg. Dancers and gymnasts are often selected
for this quality, and many go to great lengths to increase their
1
knee hyperextension, to the point of having trainers sit on their
Hyperextended knees are common among ballet dancers.
extended legs to further elongate the back line of the leg. Notice how the knees appear to bend backward, with the
Unfortunately, what may be beautiful to the eye can tibia angled in relationship to the line of the femur.
also be difficult to live with. Knees, like the lower back and
neck, are designed to have a slight lordotic (or backward-
facing) curve (Image 2). Individuals who habitually
tissues, making them vulnerable to injury.
stand with knee hyperextension that is greater than 5
What is more, when the femur and tibia
degrees have more frequent knee pain, as well as poor
are not stacked, the rest of the body must
proprioceptive control of knee extension.1 Additionally,
compensateoften resulting in problems at
genu recurvatum is a predictor of ACL injury.2
the ankles, hips, and low back, or even issues
Although knee hyperextension may sometimes be a symptom
in the shoulder girdle and neck. Addressing
of a serious medical condition such as Osgood-Schlatter
locked knees is often crucial to creating long-
disease,3 it is more often a feature of a genetic predisposition to
term relief to problems elsewhere in the body.
general joint laxity. Hypermobile joints (e.g., fingers, elbows,
and wrists) move beyond the normal range with little effort.
Generalized joint laxity occurs in up to one-third of the HYPEREXTENSION ASSESSMENT
population, and is at least twice as common in women as men.4 View your client from the side. If her knees are
In a neutrally positioned knee, the head of the tibia supports locked, you will notice a reversed or flattened
the femur. In a locked knee, the tibia is slightly posterior to knee curve (Image 2). In this pattern, the head
the femur (Image 3), making it impossible to transmit forces of the fibula is posterior to the lateral malleolus
efficiently. Instead, there is constant strain on the knees soft (Image 3). Touch the back of the kneeyoull

106 massage & bodywork may/june 2015

 Watch Til Luchaus technique videos and read his past Myofascial
Techniques articles in Massage & Bodyworks digital edition. The link is
available at www.massageandbodywork.com, www.abmp.com, and on
Advanced-Trainings.coms Facebook page. Working with Clients
Locked Knees

likely feel tissue tension in this area. If you try to gently push
the knee more posteriorly, you will sense immediate resistance.
Keep in mind that locked knees dont occur in isolation. They
undermine support of structures above, and increase load on
areas below. As mentioned, in a neutral leg position, the head of
the trochanter, the head of the fibula, and the lateral malleolus
are vertically aligned. In a locked knee posture, we often see a
tendency toward anterior pelvic tilt, internally rotated femurs,
knee hyperextension, and sometimes, limited ankle dorsiflexion.
Working with chronically hyperextended knees
is a multidimensional task, since it means addressing
short and tight structures, overstretched structures,
and habitual postural patterns. We find we are most
effective when we use a four-pronged approach:
1. Client awareness
2. Myofascial techniques
3. Homework
4. Strength and stability training

1. Client Awareness
Clients cant change what they dont understand. Once you observe
knee hyperextension, have your client observe her stance side-
view in a mirror. Draw her attention to the reduced curve of one
or both knees. To help her feel the difference between a locked
and neutral knee, ask her to intentionally lock out her knees and
notice the tension on
the back of the knee.
Then ask her to just
barely unlock her knees.
Other effective cues
might be, Back off just
enough to reduce the
tightness in the back of
your knees, or, Let
your knees breathe. Ask
your client to describe
the difference between
the locked and balanced
positions. Clients often
describe changes in

2 3
Compared to the more neutral knee (right),
the locked knee (left) appears to bow or bend
backward. Image redrawn from somastruct.com.
In the neutral leg on the right, the lateral malleolus, fibular head, and head
of the trochanter are vertically stacked and self-supporting. The leg on
the left shows how knee hyperextension requires soft-tissue changes and
undermines whole-body support. Image redrawn from somastruct.com.

Free SOAP notes with MassageBook for ABMP members: abmp.us/Massagebook 107
 4 5
Use the Quadriceps: Knee Flexion Technique to lengthen chronically short tissue that can maintain knee hyperextension. Starting with the clients leg in extension
(Image 4), use a soft, open fist to hook into tight areas in the superficial and then deeper fascial layers of the quadriceps complex. Cue the client to slowly flex the
knee, allowing the myofascia to eccentrically lengthen. Images courtesy ActionPotential.

knee tension, hip placement, or weight shift in the feet. Have your wherever there is denser, inelastic tissue around
client hyperextend and soften her knees a few times to compare the superior aspect of the knee. In people with a
the difference and appreciate its effects throughout her body. tendency toward anterior pelvic tilt, we commonly
Take care that your client doesnt overcorrect and stand see internal rotation of the femurs. This may result
with bent (flexed) knees. Over-flexed knee patterns also in hard, tight tissue at the superior medial aspect
place unnecessary strain on the body. Our goal is to help of the patella. If needed, repeat the technique,
the client learn to find balance in standing by aligning the focusing on vastus medius fascia at the knee.
bones and recruiting only the appropriate postural muscles. Although visually assessed hyperextended
Once your client has had a glimpse of this, its time to take knees will most commonly show the tissue
her new awareness to the table, where you will address tension patterns described here, always retest
the fascial patterns related to knee hyperextension. the tissue itself by palpating it before working,
and pay attention to your observations as you
2. Quadriceps: Knee Flexion Technique proceed. You might find denser or shorter tissue
This technique is an excellent approach for releasing any where you least expect itthis is the nature of
fascial inelasticity and shortness in front of the leg that compensatory myofascial patterns. Keep your
can contribute to knee locking. To perform this technique, awareness on the whole body, not just what
have the client lie supine and slightly diagonally on the youd expect based on visual assessment.
table, so the working leg hangs off the edge and bends In addition to shortness in quadriceps,
at the knee (Image 5) without abducting the hip. check for hypertonicity in the iliopsoas and
Once in position, support her leg with your bottom hand under gastrocnemius. Addressing any dorsiflexion
the femur. With the clients leg extended (straight), use a soft, restrictions in the ankles can help make
open fist or sensing forearm to sink into the outer fascial layers repositioning the tibia easier as well (see
just above the knee (Image 4). Angle your pressure superiorly, with Working with Ankle Mobility, Massage &
the intention of freeing the fascia lata (the outer wrapping of the Bodywork, March/April 2011, page 110).
thigh) above the kneecap. As the tissue begins to soften, ask your
client to slowly bend (flex) her knee, which encourages the tissue 3. Homework
to lengthen. Keep sensing with your bottom hand and cue the As clients experience more ease in areas that are
client to move at a smooth, deliberate speed. Repeat a couple times habitually tight, introduce movement reeducation
at this layer, moving your position to address the tightest areas. homework, so they can practice on their own.
On your next pass, gently sink deeper into the quadriceps
femoris tendon (Image 6). In knee hyperextension, rectus Movement Reeducation Exercise A: Weight Shift
femoris and vastus intermedius fascia are often shortened and Before your client leaves the session, return
undifferentiated. You can customize this technique to work to the awareness exercise you began with,
comparing locked and unlocked knees.

108 massage & bodywork may/june 2015

 MYOFASCIAL TECHNIQUES

often provides needed support to hypermobile knees. Whole-

body exercises like single-leg bridge pose, planks, and stability
exercises are ideal. Dont hesitate to refer clients to a qualified
physical therapist or sports and conditioning trainer to help
them strengthen appropriately, especially if there are any
complications or special considerations relevant to exercise,
such as additional musculoskeletal concerns or medical issues.

6 SUMMARY
Although hyperextended knee patterns often change slowly,
addressing them in the ways described here will typically
The four heads of the quadriceps femoris muscle converge as a
tendon (green) on the superior patella. Use the Quadriceps: Knee improve issues throughout the body. At first, clients may be
Flexion Technique to work any areas of this tendon that feel hard or surprised to find that standing with neutral knees actually takes
undifferentiated. Image courtesy Primal Pictures, used by permission.
a bit more effort than their old approachcertainly, it takes
more awareness. But as we engage the whole person through
a variety of sensory and motor activities in every step of this
Have your client lock her knees again. Ask,
approach, clients can often find a softer, more supported posture
Where is the weight in your feet? Is it more
that feels natural to them, and when they do, theyll appreciate
toward your toes? Your heels? Or somewhere in
the increase in available energy and comfort that comes from
between? Knee hyperextension typically shifts
being able to rest into a balanced knee position.
weight either more forward or more back.
Then, suggest she unlock her knees. Ask,
Notes
Where is the weight now? Usually it
1. Katsuhiro Kawahara et al., Effect of Genu Recurvatum on the Anterior
becomes more centered front to back. Cruciate Ligament-Deficient Knee During Gait, Knee Surgery, Sports
Traumatology, Arthroscopy 20, no. 8 (August 2012): 1,47987.
Movement Reeducation Exercise B: Kneecap Lifting
2. Janice K. Loudon et al., The Relationship Between Static Posture
Teach the client to lift her kneecap by tightening her
and ACL Injury in Female Athletes, Journal of Orthopaedic
quadriceps. If the knee is hyperextended, she typically and Sports Physical Therapy 24, no. 2 (1996): 917.
wont be able to lift the patella when standing,
3. Christopher Bellicini and Joseph G. Khoury, Correction of Genu
because the quadriceps will be already contracted.
Recurvatum Secondary to Osgood-Schlatter Disease: A Case
If this is the case, have the client soften her knee,
Report, The Iowa Orthopaedic Journal 26 (2006): 1303.
and practice lifting the kneecap and releasing it.
4. M. Acasuso Daz, E. Collantes Estvez, and P. Snchez Guijo, Joint Hyperlaxity
Draw her attention to the proprioceptive sensations
and Musculoligamentous Lesions: Study of a Population of Homogeneous Age,
of this kind of movement, and of the details of
Sex and Physical Exertion, Rheumatology 32, no. 2 (1993): 12022; Lars-Goran
standing in a way that makes it possible to lift and
Larsson, J. Baum, and G. S. Mudholkar, Hypermobility: Features and Differential
lower the kneecaps. Clients can do this throughout Incidence Between the Sexes, Arthritis & Rheumatism 30, no. 12 (1987): 1,42630.
the day to retrain the tone in their quadriceps.
Encourage clients to practice these techniques
Bethany Ward is a member of the Advanced-Trainings.com faculty,
whenever they find themselves standing and waiting
which offers distance learning and in-person seminars throughout
somewhere. Since the main purpose of these
the United States and abroad. She is also a Certified Advanced
exercises is reeducation, rather than strengthening or
Rolfer, a faculty member at the Rolf Institute of Structural Integration,
stretching, even a little bit of practice can yield results.
and past president of the Ida P. Rolf Research Foundation. Contact
her via bethany@advanced-trainings.com or www.rolfusa.com.
4. Strength and Stability Training
Now that weve addressed chronically short, tight
Til Luchau is a member of the Advanced-Trainings.com
areas with both myofascial work and movement
faculty. He is a Certified Advanced Rolfer and originator of the
reeducation, encourage clients to strengthen and
Advanced Myofascial Techniques approach. Contact him via
stabilize any overstretched, weak areas. Knee-
info@advanced-trainings.com and Advanced-Trainings.coms Facebook
lockers generally need to improve their use
page. His book Advanced Myofascial Techniques, Volume 1 has just
of gluteal and transversus abdominis muscles.
been released, with Volume 2 slated for publication by the end of 2015.
Additionally, strengthening thigh and leg muscles

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 DISPLAY SHOWCASE
Reserve your ad space
NOW for the
July/August 2015 issue.

Space reservation
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Artwork deadline
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NEED SOMETHING? FIND IT HERE AD INDEX
ASSOCIATIONS/CONFERENCES/
ORGANIZATIONS
ABMP .............................................. 114, 117
American Massage Conference..................... 94
Alliance for Massage Therapy Education...110
Florida Massage Convention......................... 62
Massage Therapy Foundation......................118
World Massage Festival................................116
BOOKS/PUBLICATIONS
Curties-Overzet............................................. 86
Massage Publications....................................... 9
Stretching, Inc..............................................117
BUSINESS TOOLS
Artichoke................................................... 90
Full Slate.................................................... 84
MassageBook............................................. 12
MindBodyOnline.......................................10
Timely............................................................ 46
CAREERS
Burke Williams................................................ 4
Massage Envy ............................................. IBC
CONTINUING EDUCATION
Ace Massage Cupping .............................. 82
Active Isolated Stretching Institute.............114
Advanced Trainings/Til Luchau.............. 82
American Bowen Academy............................ 86
Auth Method .............................................43
Babys First Massage.....................................114
Bamboo Fusion.............................................. 82
Center For Massage Therapy
Continuing Education............................... 96
Celebrating 25 years
of supporting the massage therapy profession
through research, education, and community service.
Celebrate with us by donating at massagetherapyfoundation.org
Digital Video
Claire Marie Miller Seminars...........92, 114
Erik Dalton ............................................... 78 Digital Sponsor
Human Kinetics.......................................110 Special Offer for Members
Innersource...................................................114
Institute for Integrative Healthcare........101 Massage & Bodywork
Institute of Somatic Therapy............96, 114 (ISSN 1544-8827; USPS 005-245)
is a bimonthly magazine published by
Integrative Aromatherapy Associated Bodywork & Massage Professionals Inc.,
Certificate Program..................................114 25188 Genesee Trail Road, Suite 200,
International Cupping Therapy Golden CO 80401.
Periodicals rate postage paid at Golden,
Association..........................................84, 114 Colorado, and additional offices.
Kinesio Taping Seminar...............................114
POSTMASTER: Send address changes to ABMP,
Massage Around the World..........................114 25188 Genesee Trail Road,
McKay Method.............................................114 Suite 200, Golden CO 80401.
Myofascial Release Seminars.........................76
Vol. #30, Issue #3 May/June 2015.
Myokinesthetic System ........................... 60 All rights reserved 2015.
Northwest School of Animal Massage......... 96
Precision Neuromuscular Therapy...............43 Naqi.............................................................16
Rolf Institute......................................... 101, 114 Performance Health...................................... 72
Sacred Lomi..................................................117 Sombra................................................... 40
Society of Ortho-Bionomy...........................115
Upledger Institute................................ 34-35 MASSAGE TOOLS
Whitney Lowe/ Tspheres....................................................... 9
Academy of Clinical Massage................... 92 Thumbby.......................................................101
Zero Balancing..............................................115 Thumbsavers.................................................117
FULL LINE OF PRODUCTS MUSIC
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Spa & Bodywork Market.......................... 98
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Biotone............................................... IFC 1 TABLES, CHAIRS, TABLE
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Jojoba Company........................................... 120 Earthlite Massage Tables............................. BC
Oakworks ................................7, 115, 117
 INSPIRATION & INSIGHT

How do you
pay it forward?

I donate hours
upon hours of
massage to my
local womens
shelter and
foster care
agencies.
Morgan Kelly
Hernandez

Hands for Heroes! We make our

services available to returning
veterans across the United States.
www.handsforheroes.net
Anne Milewski

I have raised money

alongside my
massage therapy
students from the
Louisville School
of Massage for
local and national
nonprofit agencies
at the Mighty
Kindness Earth Day
Hootenany for the
past eight years.
Marissa Holden

I volunteer weekly at the Aurora,

Colorado, Ronald McDonald House,
providing chair massage to families.
Susan Coyle Clingman
I make healthy
soup for those
who are sick.
Marina Smith

______
No. ______

The Gift of Bo
dywork

thd ay
r
ls Member

i Post it to our timeline: facebook.com/abmppage

Professiona
& Massage

B
Bodywork

Next issue:
Associated

p y
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day
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Different Strokes
ABMPs Member Newsletter
May/June 2015

EveryBody Deserves a Massage Week

July 1218, 2015
Bring Touch to Your Community

Email Body Sense magazine

to your clients today! see page 3

Supreme Court decision has

state board implications

New Member Benefits Exclusively for You! see page 7

EveryBody
July 1218, 2015
Whether youre a 20-year veteran therapist
or a first-year practitioner, there is something
inherently rewarding in sharing your work
with others. Of course, the paying client is
what helps put food on the table, but there
is a beautiful synergy when you can offer
therapeutic massage or bodywork free of
charge to those who may never have had the
opportunity to experience it before.
EveryBody Deserves a Massage Week
(EBDMW) lets you do just that.
Who in your community could benefit
from nurturing, therapeutic touch? Use this
weeklong event to share your work with
shelter residents, first responders, or crisis
counselors. Offer chair massage to teachers
or hospice caregivers. Or maybe reach out
to a friend who needs some comforting,
healing touch.
You can even tie in your philanthropic
efforts with your practice-building pursuits.
Offer free chair massage to nearby business
owners as a stepping-stone for cross
promotion. Hold a massage-a-thon that not
only brings touch to those who need it, but
lets you promote yourself to the community
through local media. Donate a portion of
your weeks massage earnings to your favorite
charityor better yet, let your clients help
you choose the charity and let them be part
of the process and promotion.
However you decide to celebrate
EveryBody Deserves a Massage Week, we have
the tools to guide you every step of the way.
Go to www.abmp.com/massage-week to get
started. There, youll find additional event
ideas, client forms, a sample press release, and
customizable marketing materials. Cant print
the materials? Call us at 877-208-7546 to
order a sample packet of coupons, postcards,
and posters you can take to a local printer.
Then, document your event with photos
and share it with us (differentstrokes@abmp.
com). We love hearing your stories and may
include them in future publications.
Watch This Video
Learn how to get started!
www.abmp.com/massage-week-intro
DS 2 May June 2015
Deserves a Massage Week
Massage therapists and bodyworkers nationwide
are lending their hearts and hands to raise
awareness of the benefits of massage, bodywork,
and somatic therapies. The practitioner listed
here is participating in an event as a service to
the community.
EveryBody Deserves a Massage Week
www.massagetherapy.com 2015 ABMP
Massage therapists and bodyworkers nationwide
are lending their hearts and hands to raise
awareness of the benefits of massage, bodywork,
and somatic therapies. The practitioner listed
here is participating in an event as a service to
the community.
Massage therapists and bodyworkers nationwide
are lending their hearts and hands to raise
awareness of the benefits of massage, bodywork,
and somatic therapies. The practitioner listed
here is participating in an event as a service to
EveryBody Deserves a Massage Week
www.massagetherapy.com
the community. 2015 ABMP
Print Your
Massage
Week EveryBody Deserves a Massage Week
www.massagetherapy.com 2015 ABMP
Materials
Go to www.abmp.com/massage-week
How Do I Organize an EBDMW Event?
Plan ItWhat do you want your event to be? What are
you passionate about? Do you want to use your work
to raise money for a cause? Have clients participate in
a food drive? Donate your time to a sporting event? Lay
hands on as many massage newcomers as you can?
Prepare ItDo you need additional volunteers to help
with your event? What marketing do you need to do (print
your free materials at www.abmp.com/massage-week)?
Do you need to get any permissions beforehand?
Do ItNow, get busy. Promote your event, talk about
it on social media, encourage others to participate,
and enjoy the process! Let us know how it went
(differentstrokes@abmp.com).
Order a Banner
Call 877-208-7546 to reserve a massage week
banner with a $150 refundable deposit.
 BEST ADVICE
Have you considered
taking insurance billing clients?
Before deciding whether this is the right move
for your practice, consider these questions:
1. How often do my clients ask if I can bill
their insurance?
2. How many of my clients have health
insurance that covers massage therapy or ABMP BizFit Tip
other manual therapy?
3. Will my practice grow significantly if I offer Ethics is a topic all
insurance billing? therapists should
4. What changes would I need to make
revisit frequently.
to my practice? Am I prepared to
We make it easy.
accommodate the amount of
additional documentation,
All ABMP members
follow-up, and paperwork
have access to our
required?
six-part webinar series,
Ethics for the Real
Still not sure whether this is
World with Til Luchau.
the right move for you? Find
Watch all six parts for
more considerations about
free, with an option to
insurance billingas well as
earn one CE hour per
FAQs on the topicin Irene
webinar for just $12
Diamonds article on insurance
each. Log in at
billing in this issue of
www.abmp.com/
Massage & Bodywork.
online_education.
Log in to the Member section for more info at
www.abmp.com. For specific insurance billing questions,
contact Irene Diamond at www.irenediamond.com/contact
and mention you're an ABMP member.

Tell Your Clients

Why They Need You
Body Sense magazine is a simple, beautiful client education tool that
ABMP Certified
helps keep the line of communication open even after clients leave your
Members: You have
table. The benefits of frequent sessions, the knowledge that pain shouldnt access to our latest free
be the only motivator for them to make an ebook, Ethics: A Guide

Body Sense
to Ethics in Massage
appointment, and the true value of your work are & Bodywork. Read the
spring 2015 massage, bodywork & healthy living

just some of the topics we cover in this award- ebook at www.abmp.

winning quarterly digital magazine you can email 6Cleaning
Natural
Spring- com/members/certified_
Ideas central_ebook.php, and
to your clients and prospective clients. for a Healthy Body & Mind
take a short quiz to earn
Yes! You Need
a Massage!
two free CE hours.
Its easy to use:
Ask Our Experts
So my massage session
has ended. Now what?

1. Go to www.abmp.com/bodysense.
PLUS
Massage Helps
Back-Pain Sufferers

2. Click Send Body Sense magazine One MTs Story:

Helping Others,

to your clients now.

Helping Herself
A public education magazine brought to you by

Different Strokes is published by Associated Bodywork & Massage Professionals

800-458-2267 Karrie Osborn, editor, karrie@abmp.com
expectmore@abmp.com James Sutherlin, senior graphic designer, james@abmp.com
ABMP.com Jean Robinson, government relations director, jean@abmp.com
DS 3
 Government Relations
By Jean Robinson
Supreme Court Decision Could
Impact Regulatory Boards
On February 25, 2015, the US Supreme Court
issued its opinion in North Carolina State
Board of Dental Examiners v. Federal Trade
Commission. The courts opinion impacts how
state professional licensing boards must operate.
North Carolina dentists began
teeth-whitening services in the
1990s. By 2003, non-dentist
providers began offering the
same services in spas and
salons. They charged less,
prompting dentists to complain
to the North Carolina State Board
of Dental Examiners. Under North Carolina law, this
board is the agency of the state for the regulation of
the practice of dentistry. North Carolina law further
requires that six of the eight board members must be
licensed, practicing dentists.
In response to the dentists complaints, the board
issued cease-and-desist letters to non-dentist teeth
whiteners, claiming that teeth whitening was within
the scope of practice of dentistry
and that spas and salons offering
this service were practicing
dentistry without a license.
While North Carolina state law
defines the practice of dentistry
to include the removal of stains,
accretions, or deposits from the
human teeth, the states law is
silent about the use of peroxide to
whiten teeth.
The Federal Trade
Commission (FTC) filed a
complaint against the board, claiming that the cease-
and-desist letters violated federal antitrust law, which
prohibits practices that suppress market competition.
The FTC contended that the dentists were using
their licensing arm to chase competitors out of a
lucrative business that required no special medical
or scientific training.
The board tried to dismiss the FTCs lawsuit,
arguing that states are immune from antitrust suits
and that actions by boards constitute actions by the
DS 4 May June 2015
state. The FTC opposed that argument, and the issue
ultimately made its way to the US Supreme Court,
which ruled that a state board, such as the North
Carolina board, on which a controlling number of
decision makers are active market participants in the
occupation the board regulates, must satisfy active
supervision requirement in order to invoke state-
action antitrust immunity. Almost all regulatory
boards will likely be affected since most boards
are comprised of board members practicing the
profession they regulate.
The decision means that any action taken
by a regulatory board that can be viewed as
anticompetitive under federal antitrust law must be
adequately supervised by the state. The state must
review the substance of the anticompetitive decision,
not only the procedures followed to produce it. The
regulatory boards action must promote state policy,
rather than board members individual interests.
Only board actions that are anticompetitive under
federal antitrust law are affected by the Supreme
Courts decision. Regulatory boards will need to
understand what types of actions could constitute
anticompetitive conduct.
Board attorneys and state
administrative staff will have to
provide some direction.
Since the Supreme Court
did not provide a bright line
test as to what does or does
not constitute adequate state
supervision over anticompetitive
conduct, we expect board
attorneys to be more involved
in helping boards distinguish
the difference. We would not be
surprised if board attorneys were more cautious in their
recommendations to boards until states have a chance
to review the mechanisms in place to provide assurance
that board decisions are indeed promoting state policy.
For more information on the Supreme Courts
decision, go to News & Resources at www.abmp.com.
Jean Robinson is ABMPs director of government
relations. Contact her at jean@abmp.com.
ABMPs Continuing
Education Calendar Theres Still Time
Find Your The Boston Marathon is over, but theres
still time to show your support for massage
Next Learning therapy research and ABMPs own Angie
Experience Parris-Raney, who ran as a member of the
Massage Therapy Foundations Running for
ABMPs Online Research team. Go to www.crowdrise.com/
Continuing Education massagetherapyboston2015/fundraiser/
Calendar is waiting angieparrisraney to hear Angies story, read
for you! Weve about her other philanthropic
efforts, and make
recently expanded the
a donation to support
search features in this
this great cause.
members-only tool so
you can now search by
date, class type, instructor, modality, and state.
The list view will note any classes that
offer exclusive ABMP member discounts;
you can also change the view to see classes
by month. Start your search today at
At Your Fingertips
www.abmp.com/members/calendar_ce.php. Did you know you have more than 130
If you teach continuing education classes resourceful, engaging webinars
and would like to advertise them to other at your fingertips? Go to
ABMP members on the CE Calendar, you
can sign up for an account and annual www.abmp.com/online_education
subscription at www.advertising.abmp.com. to see what youre missing!

Get A Free
MassageBook Account
Imagine the time you could save, and the ease you
could bring to your practice, if you had an online
appointment scheduler, client email reminder tools,
electronic SOAP notes and intake forms, and client-
tracking software. You can have these options and more
when you take advantage of your newest ABMP member
discount with MassageBook. All ABMP members receive
an enhanced free account with MassageBook that
offers these great tools:
Enhanced SOAP notesCreate them quickly and easily,
then store the information for the next session.
Facebook integrationYour clients are on social
media, and now they can book appointments with you
right from your Facebook page.
Everything else thats included with a MassageBook
free account (like online booking, email reminders, and
more)Use as many or as few of your tools as you
want; choose the options that work best for you!
Sign up for your free account at marketing.massagebook.com/abmp-discount
It pays to be ABMP Certified: www.abmp.com/go/certifiedcentral DS 5
 ABMP Member Profile
By Karrie Osborn
The Key to Success?
Love What You Do
Since opening his doors more
than two years ago, Jason
Olague has grown his massage
practice to 35 clients a week. This
successful therapist and owner of
Legendary Massage in Tucson,
Arizona, does all the right things:
he receives frequent bodywork,
exercises regularly, and pursues
continuing education with excitement. But his success is
based on something much more inherentthe love for
what he does.
I am massage, he explains. I love to look into the mirror
and tell myself that, because I know [my work] is more than
what Im doing with my hands, elbows, knees, and feet. My
massage comes from my center, and it radiates outward
with my essence and good intention. For that one-hour
session, I give it my all, and I give it my best. Im sure many
things contribute to the success of my practice, but I feel
that this attitude will sustain it indefinitely.
As passionate as he is about his work, Olague says
this was not the career he was pursuing just 11 years
ago. Finishing a degree in biological sciences from the
University of Arizona in 2004, Olague was on track for
medical school. But his undergraduate experiences working
in medical research, getting clinical exposure in hospitals,
and shadowing others prompted his interest in medicine to
wane. I had such difficulty with the culture, the ambiance,
the energy, and the day-to-day processing and activity.
There is indeed a place for it, but I decided that [the
medical profession] was not the angle by which I wanted to
contribute to the health of society.
Jason Olagues energy keeps him at his best for his clients, while his passion for massage helps
keep his appointment book full. Visit his website at www.legendarymassage.com.
DS 6 May June 2015
I love how creative and
artistic my work can be.
Jason Olague
Olague admits there was an ensuing state of panic as
he came to terms with his decision and began rethinking
his path. Physical therapy and chiropractic doctorate
programs, as well as other integrative and alternative
health options, presented themselves, but it wasnt until
he came across the Desert Institute of the Healing Arts in
Tucson, Arizona, that he devised his new plan. At the time,
he thought massage would be an interim career between
the path that could have been and the path still to come.
Instead, he found his true calling.
Ten years later, and Olague cant imagine doing
anything else. I knew it was a career that would evolve;
it was a career that would nurture me and my entire
community, and it was a career to which I could give my
body, mind, and my spirit.
Olague says he continues to fall deeper and deeper in
love with the work he does. I think massage is such a
beautiful practice on so many different levels: I love how
creative and artistic my work can be; I love that my work
touches and changes so many lives for the better, just
as it does for me; I love that my work has an energetic
and physical component; and I love that sometimes there
are no words to describe what I do, while other times its
articulated in a methodical and scientific manner.
Karrie Osborn is senior editor at ABMP.
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It pays to be ABMP Certified: www.abmp.com/go/certifiedcentral DS 7

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