Terra Rosa E-Magazine Issue 9, December 2011
Terra Rosa E-Magazine Issue 9, December 2011
Terra Rosa E-Magazine Issue 9, December 2011
E-Magazine
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Disclaimer: The publisher of this e-magazine disclaims any responsibility and liability for loss or damage that may
result from articles in this publication.
Cover Feature
Featured on the cover is Anika-Jovi McCarthy, 11 years old, a Junior Excellence Programme student at Queensland National Ballet (QNB). Anika loves dancing and was recently awarded the 2011 "Most Promising Classical Ballet (junior) Dancer" Trophy at Redlands. She also performs in classical ballet, neo-classical, contemporary, jazz and flamenco at the Eisteddfods, Anika has been rewarded a number of first and second places so far in 2011 at Wynnum, Ipswich, Redcliffe and Redlands. She is also performin in Brisbane, Gold Coast and Beenleigh Eisteddfods in August-September 2011. Last year, Anika won the classical championships in Redlands, Beenleigh and Gold Coast. Anika also trained in competitive Irish dancing and Troupe Eisteddfod dances with Kick Dance Studio, Bulimba where Anika started dancing since she was in pre school. Lisa Wyatt, Kick Dances principal said that Anika excelled in athletics and represented her school St Peters and Pauls at district level. Anikas teacher at QNB is Tracey Myles. Anikas prime dancing support (chauffeur, costume change assistant, massage therapist, etc.) is her mother Maria Victoria McCarthy, a counsellor at Queensland University of Technology (QUT). Maria is a trained reflexologist and has a great interest in bodywork, yoga and meditation. According to Maria, Anika is a good kid, loves music, school, having friends and eats her vegies. Anika is also fond of sailing her little sabot (her dad, John McCarthy is her sailing coach) and likes to beat her 21 year old brother Jonas Trefeu when they play chess. Anika has been accepted to train with the Australian Ballet (interstate training program for gifted children) and excited to meet with fellow young dancers in Melbourne in September. Photograph by Tom Baker, http:// www.tombakerphotographics.com.au/
Text from: Kinesiology: The Skeletal System and Muscle Function, 2ed., Elsevier, 2011. Muscle figure reprinted with permission of the Massage Therapy Journal; artwork by Giovanni Rimasti. Fasces figure from public domain image at rationalwiki.org.
Cautions: Joint mobilisation of the cervical spine is a very powerful technique that has the potential to do great good, but may cause harm instead if not performed correctly. It is extremely important with joint mobilisation (or any type of stretch for that matter) that the stretch is not forced; the client should never experience any pain. Further, if the client has a bulging or herniated disc, or advanced degenerative joint disease (osteoarthritis), joint mobilisation at or near that level is likely contraindicated. In these cases, written permission from the clients physician should be obtained before performing joint mobilisation of the neck.
should be performed slowly and evenly as the joint is stretched into its joint play range of motion; joint mobilisation never involves a fast thrust! Treatment hand contact When performing joint play to the clients neck, there is a choice of possible treatment hand contacts. Figures 2abc illustrate three options: the thumb pad, finger pads, and the radial side of the proximal phalanx of the index finger respectively. In each case, the contact point on the clients body is the vertebral facet (articular process) located approximately halfway between the spinous process and transverse process (Figure 3); in the cervical region, the facets form a wide and comfortable place to contact and move a vertebra.
Figure 1. The relationship between active, passive, and joint play ranges of motion. (Figure from Kinesiology, Kinesiology: The Skeletal System and Muscle Function, 2ed., Elsevier, 2011)
* Pin and stretch is the type of stretching in which one hand pins (fixes) a part of the clients body while the other hand stretches the client around that pinned point. This allows for a more specific stretch to be done than would otherwise be possible.
(b)
Figure 3. The facets of the cervical spine form an ideal contact point for the treatment hand when doing joint mobilisation of the neck. (Figure from The Muscle and Palpation Manual, Mosby, 2008)
(c)
Figure 2. Treatment hand contacts when performing joint mobilisation of the cervical spine. (a) Thumb pad. (b) Finger pads, and (c) radial side of the index finger.
In some ways, placement and use of the stabilisation hand is more challenging than the treatment hand because the role of the stabilisation hand is to hold and move the clients head. If the client does not feel both comfortably and securely held, she will not relax and let you perform the joint mobilisation. Exactly how the stabilisation hand is positioned will vary depending upon the level and exact joint mobilisation that is being done. As a general rule, it will be placed on the opposite side from the treatment hand and under the centre of weight of the head so that the head is comfortably balanced in the hand (Figure 4). When placing the stabilisation hand on the clients head, be careful to place your thumb and index finger around the ear; do not cup over the clients ear, and be sure to not place any pressure on the clients temporomandibular joint. 4 Steps to perform joint mobilisation of the neck (see Figure 4)
It is critically important to emphasize that joint mobilizations never involve any type of fast thrust. If a fast thrust is done, the therapist is no longer performing a joint mobilization, but rather is performing an osseous adjustment that is only within the scope of practice of chiropractors and osteopaths.
1. Comfortably and securely, place clients head in your stabilisation hand. 2. Place treatment hand contact on the facet at the desired vertebral level. 3. With stabilisation hand, move the clients head and upper cervical spine around the treatment hand contact until the end of passive range of motion is reached (at
Figure 4 demonstrates right lateral flexion joint mobilisation of the neck at the C5-C6 level. The therapists left hand is the stabilisation hand and supports and moves the clients head and upper neck around the contact point of the treatment hand (therapists right hand) on the right facet of C6. Once this position is reached, the treatment hand pushes the facet of C6 to the left (red arrow) and/or the stabilisation hand further moves the clients head and neck around the contact of the treatment hand (green arrow).
technique, the benefits to your clients will be great. I strongly recommend that you add this powerful and effective tool to your practice!
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The first day will cover body mechanics for deep tissue work, muscle palpation assessment, orthopedic assessment testing of the lumbar spine, and stretching for the lower back and pelvis. The second day focuses on advanced stretching (CR, AC, and CRAC stretching), assessment of the sacroiliac joint, and how to safely perform joint mobilisation.
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Warming Up
By Art Riggs
Dear Art, Ive been taught that I need to warm the body before starting a massage. How much time is sufficient so I can get to work? Time Urgency Dear Time Urgency, Actually, your question brings up a crucial issue: a warm-up is not something to do before you begin real work. Warm-ups are, indeed, work and require a definite therapeutic focus, albeit with more emphasis on evaluation. A broad and general warm-up is certainly beneficial, as long as it doesnt entice you to cut corners in the body of your massage because you lost time with preliminaries. Time management is crucial for a smooth session. Even five minutes of superfluous preliminary work may have more downsides than benefits because of lost opportunities for concentrated focus in the core of your session. Thats why I try to educate my clients on the benefits of longer sessions. Lets look at the main reasons for doing a warm-up: Introducing yourself. Particularly with new clients, this can be a good way to introduce yourself to the whole body, rather than an isolated part, and to prospect for areas of hidden tension. However, some therapists arent clear with their intention. This doesnt accomplish much in getting to know each other and can seem like superficial conversation at a cocktail party: Nice weather were having. So are you a Taurus? Calming your client. We want to release the client from the emotional stresses of life before performing deep work. This is certainly a worthwhile goal, but may not always be necessary. By starting your work with a slow and focused intention on the shoulders or other core areas of holding, you may initiate an even deeper relaxation and leave more time for detailed work. Preparing for later work. While this is a worthy strategy, many therapists spend an inordinate amount of time working on relaxed superficial layers that cover
Photograph by Art
Warming Up
evaluation soft hat to begin, and then abruptly rolling up your sleeves and putting on your hard hat after the introduction. Whats your prelude? Make Your Warm-Up Pleasing and Effective Most everyone I ask seems to feel they can tell how good a massage will be in the first minute or two after they feel the therapists touch. The most important thing is to have a clear purpose in your strokes. A stroke (even a gentle energy stroke) without intention is an empty gesture (or like a day without chocolate). As the saying goes, You never get a second chance to make a first impression. Ive had fantastic warm-ups as the therapist tunes into my body rhythms, slow down to say hello to pockets of tension, and actually lays the groundwork for later. Conversely, Ive had therapists performing a choreographed routine that, like a limp handshake, only demonstrates a lack of focus and contact, and a waste of time. Here are some suggestions to add substance to your warm-up: Apply pressure from your body weight and core, rather than through peripheral muscular effort. Linger at areas of holding and begin the first stage of release. When moving any part of the body, move joint and muscular restrictions to their end range of easy motion and wait a bit to give a message of release, rather than just testing or jostling in the middle range of joint motion. Sink quickly through layers of superficial ease until you encounter deeper layers that resist your efforts. This will not only begin to free tension in the first couple of minutes, but will tell you where to plan work for efficient management of your time. Dont feel obliged to perform an extensive warm-up with every client. Undue emphasis is sometimes placed on an overcautious approach to working both with the bodys energy and more deeply with specific tight areas. We dont want to get a running start from across the room, but we also dont want to tiptoe or hesitate. A photographer, explaining how he composes photographs and what to include in the foreground, background, and main focus, once told me, With every consideration, I ask myself, Does this add to, or detract from, what Im trying to convey? These are wise words for many things, and especially for a bodywork session.
Join Art Riggs for a unique experience in Deep Tissue Massage Workshop Sydney, October 2012
More details will be available at www.terrarosa.com.au
rotate and side bend. If any of these movements becomes impeded, SIJ dysfunction can occur. In other words, the sacrum gets stuck!
Ideally, during hip flexion the innominate on the same side rotates in a posterior and inferior direction (using the posterior superior iliac spine as the reference), moving the ischial tuberosity anteriorly and reducing hamstring strain. If however, the innominate is fixed in anterior rotation, the ischium will not move anteriorly during hip flexion and this will increase stress at the origin of the hamstrings.
Over time, unilateral muscle tightness can produce rotational forces in the innominates, and this is particularly true of athletes overtraining with unilateral load-
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ing as in kicking or throwing (Ross 2000). For example, a tight rectus femoris could produce anteriorinferior rotation force on the anterior superior iliac spine, while a tight biceps femoris could produce posterior-inferior rotational force at the ischial tuberosity and sacrum. Mobilising the SIJ can reduce asymmetry in the tilts of innomates and therefore reduce stress on the biceps femoris (Cibulka et al 1986). SIJ dysfunction has also been associated with hamstring spasm (Dowling 2004). Joint Influences We are all familiar with the terms agonist and antagonist in relation to muscle pairing based on opposing functions. What is not often remembered however, is that during contraction of agonist muscles, the antagonists do no behave passively, but are actively inhibited by the central nervous system. This is Sherringtons principle of reciprocal innervations (Day et al 1984). This mechanism is thought to be partly mediated by joint receptors, which form arthrokinetic reflex (AKR) circuits that can inhibit or facilitate muscle tone (Makofsky et al 2007). In other words, by mobilising a joint in a particular way for a specific effect, we can help switch on or off a muscle group by influencing reflexes generated from within the joint capsule. In relation to chronic hamstring pain, for example, a tightened anterior hip capsule would facilitate the iliopsoas muscle while inhibiting the gluteus maximus through the arthrokinetic reflex (Yerys et al 2002). Muscle wasting of the gluteals is often visible when tightness is present in the iliopsoas. Since gluteus
Picture from Primal Pictures. Used with permisiion
maximus is a prime mover in hip extension, its inhibition places undue loads on its hamstring synergists making them more prone to injury. Mobilisations performed on the anterior hip capsule have been shown to significantly increase gluteus maximus strength (Yerys et al 2002), and muscle weakness may therefore be influenced by inhibition related to capsular hypomobility of the underlying joint. In other words, the gluteus maximus is inhibited each time the hip extends against its restrictive barrier of motion. When there are joint restrictions, mechanoreceptor inputs to the CNS can cause active weakening (or inhibition) of muscles whose action could take the joint beyond its restrictive barrier. Therefore, trying to strengthen a muscle that is being inhibited before mobilising the joint may be counterproductive. It is more beneficial to lengthen the chronically contracted myofascial units and mobilise the associated joint, prior to
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About the Author Stephanie Panayi is a Rolfing practitioner. Her practice is located in Melbourne, Australia. You can contact here at: [email protected]
This article is an abridged version of an article by the author published in the July 2010 issue of the Journal of Bodywork and Movement Therapies titled The need for lumbarpelvic assessment in the resolution of chronic hamstring strain .
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Michelanglo, Atlas Captive, 1520. Seen statically, this captive figure is endlessly straining against the adhesive forces in the marble. But imagine the marble in motion and you have an inspiring symbol of fascial plasticity, the body emerging to freedom.
not have this option for straightening out the fascia network. Instead, the body goes through fascial unwinding, a process that can take several years in severe cases. Fascial unwinding has several definitions. In a recent survey paper, it is defined as a type of indirect myofascial release technique (Minasny, 2009). In other circles, fascial unwinding refers to spontaneous movements (for example, see http://www.youtube.com/ watch?v=1QM-8_DwArU). Fascial unwinding is closely related to pandiculation (stretching and yawning); Ber-
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Fascial Unwinding
tolucci (2011) discusses the role of pandiculation in maintaining the myofascial system. A model of a biological system is a simplification: the model characterizes selected aspects of a complex physical system. A model can be used for understanding and teaching, as well as for formulating testable research hypotheses. Tensegrity and viscoelasticity are two wellestablished models for biological systems. Ingber, Heidemann, Lamoureux and Buxbaum (2000) debate the strengths and weaknesses of tensegrity and viscoelasticity for modeling at the cellular level. Myers (2001) provides a popular and accessible presentation of tensegrity and its use to model bones (under compression) and fascia (under tension). The bodys ground substance can be modeled as a viscoelastic liquid. Viscoelastic liquids countertwist. This cancelation of torsional forces have marvelous properties: if you pull on them sudmoves the fascia network from a higher energy state denly, they are tremendously strong, like a solid, but left to a lower energy state. on their own, they flow around like a liquid. To experience this for yourself, use this goop recipe to make a Fascial unwinding can be facilitated in two ways: viscoelastic liquid out of a mixture of water, white 1. Place the body into a position that aligns a twist school glue, and borax. and countertwist along a straight axis. Applying Here is a description of the elements of the proposed force along this unwinding axis helps to bridge the model for fascial unwinding. adhesion that separates twist and countertwist*. The fascia network naturally tends to a configuration 2. Reduce adhesive forces, by breaking up scar tissue that minimizes energy. An idealized initial state is or by increasing circulation to reduce the viscosity used as a reference. In the initial state, the fascia netof the ground substance. work is straight, meaning that torsional forces in the Fascial unwinding axes have a fractal organization. fascia network are at a minimum. Thus the initial This arises because the fascia network has a fractal state is the configuration of lowest energy. structure. (Fractal means that a zoomed-in view of a Injury can introduce torsional forces into the fascia small region of fascia looks similar to a zoomed-out network. When a torsional force is introduced, this view of a large region of fascia.) During self unwindnecessarily introduces an equal and opposite couning the perceived locations of several small unwindtertorsion elsewhere in the fascia network. A toring axes can be used to find larger-scale axes along sional force applied to some part of the fascia netwhich fascia needs to unwind. work causes twisting in that part of the network. The amount of twist the angle of rotation depends on Positive feedback assists the process of fascial unwinding, with the effect that successful unwinding the torsional stiffness of the affected fascia. Even facilitates further unwinding. When unwinding sucsmall angles of twist are damaging in many parts of ceeds, this reduces torsional forces in some part of the body; the body compensates by increasing torthe fascia network. I hypothesize that a reduction in sional stiffness of affected fascia and/or by distributtorsional forces triggers a local reduction in the vising the torsional force to other parts of the fascia netcosity of the ground substance. The less-viscous work. ground substance allows fascia to move more easily, Adhesive forces can prevent a twist and countertwist further decreasing the local strain on the fascia, trigfrom meeting and cancelling out. Thus the adhesive * Applying force along an unwinding axis usually has the effect forces hold the fascia network in a higher energy of straightening the axis. However, in some cases the unwindstate. Fascial unwinding is the process of overcoming adhesions to bring together and cancel a twist and
ing axis stays bent or curved. For example, fascia can unwind along an axis that curves around skull bones: muscular force can put tension along this curving axis because the skull bones act as a brace.
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Fascial Unwinding
gering further reduction in ground-substance viscosity. Also, less viscous ground substance allows fluid circulation to improve, thereby encouraging further reduction of viscosity. Various investigations could be undertaken to refine this model. One problem is to study how the body reacts to torsion. My hypothesis is that high torsional force triggers an increase in local torsional stiffness (for example, an increase in the viscosity of the ground substance, or a stiffening of the fascia). Such increase in torsional stiffness is advantageous because it reduces the angle of twist for a given torsional force, thereby reducing the degree to which the torsional force impacts mechanical performance of the affected body part. The entire fascia network responds to a local injury, so a torsional force can be distributed to body parts that are far from the site of injury. It would be interesting to model injuries and how they introduce torsional forces into a fascia network. An impact injury could create scar tissue and adhesions that cause long-term displacement of fascia, thus giving rise to torsional and countertorsional forces elsewhere in the fascia network. Alternatively, long-term asymmetrical body use might introduce imbalances and twists. Another possibility is that localized proprioception reversals can cause incorrect reflexive responses, increasing torsional forces instead of reducing them. (Eye movement exercises can be used to correct proprioception problems in the head and neck. The stability of vision is discussed by Harris (1965): in situations where vision information disagrees with the position sense, the disagreement is resolved by changes in the position sense.)
The gyroscope analogy. When you push on a spinning gyroscope it responds by moving in a direction that is at a right angle to the direction of your push. Picture from: http://www.i -am-a-i.org (used with permission).
tion cost while meeting stated load-bearing requirements (Rhode-Barbarigos, Schmidt, Ali and Smith, 2009). Computer simulation offers the opportunity to study how localized damage in a tensegrity structure causes a gradual, system-wide degradation of function.
Physical realizations or computer simulation could be used to see whether this model of fascial unwinding can give rise to spontaneous movements as the modeled fascia network undergoes self unwinding to return to a lower energy state. If successful, this could offer a mechanical explanation for the spontaneous movements people exhibit during fascial unwinding. I conjecture that smooth, flowing types of spontaneous movement are due to the body aligning itself along a shifting axis of fascial unwinding. In contrast, fast oscillatory moveComputer simulation can be used to investigate the be- ments arise when the body is improperly aligned along an axis; the oscillation calms down when alignment is havior of the model. I propose simulating a tensegrity model that has been extended to include adhesive forces corrected by a manual practitioner or by the patient as well as tension and compression forces. A single scale during self unwinding. Oscillatory movements can also can be used for model elements that are under compres- arise when the body oscillates between several possible sion (these represent bone) and fractal structure can be unwinding axes; in this case unwinding is unsuccessful and the oscillatory movements can repeat indefinitely. used for model elements that are under tension (these represent fascia). Torsional forces and adhesions can be I conclude with personal observations about self unintroduced during the simulation. It would be interest- winding. Fascial unwinding is mostly sub-conscious and ing to develop measures for characterizing a tensegrity reflexive, but I can consciously take actions to assist unstructure in terms of its structural buffering capacity: winding. Helpful feedback is provided by the amount of how much adhesion and twisting can the tensegrity spontaneous body movement: if I succeed in lining structure tolerate, while still maintaining a specified things up correctly, the external body movement stops. level of functionality? Related work includes the study This reminds me of balancing a spinning basketball on of tensegrity and adhesions at the cellular level my finger: if I do this correctly, my hand and the ball are (Stamenovic 2006), tensegrity models of biomechanics stable, whereas if I do it incorrectly my hand and the (Levin 2002 and 2006), and engineering methods for ball wobble around. designing tensegrity structures that minimize construc-
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Fascial Unwinding
For many months, I found it difficult to react properly to my sensations of the shifting axes of fascial unwinding: an axis moves in an unexpected direction when I (internally) apply a force in a direction that is perpendicular to the axis. This unexpected response suddenly struck me as familiar when I recalled an earlier experience in which I was holding a spinning bicycle wheel with one hand on each end of the axle. This inspired me to take the front wheel off of a bicycle and use it for more gyroscope practice. I found that the reflexive movement patterns I developed using the bicycle wheel were transferable to the movement patterns I needed during self unwinding. This gyroscope analogy seems puzzling because fascia cannot possibly spin fast enough to act like a traditional gyroscope. The effect might be explained as follows. Imagine looking along the length of a horizontal axis of fascial unwinding: imagine that this section of fascia is under clockwise torsion, so that it needs to unwind clockwise around the horizontal axis in order to reduce torsional forces. (Since torsion and countertorsion are counterbalanced, there is some other part of the axis where fascia is under counterclockwise torsion. For this example, focus on the part of the unwinding axis that is experiencing clockwise torsional forces.) Now imagine trying to make a fine adjustment in body position to keep this unwinding axis properly lined up. Continuous small adjustments are needed as unwinding occurs, because the axis location shifts in response to asymmetries such as an anisotropic extracellular matrix. Imagine applying a force that pushes on this section of the unwinding axis from the right; the expectation is that this force from the right will move the unwinding axis toward the left. But because the fascia is under clockwise torsion, the tangential force from the surrounding extracellular matrix may cause the unwinding axis to move upwards rather than toward the left. This might explain the apparently gyroscopic nature of fascial unwinding. In summary, during self unwinding I have found it helpful to envision the goal of overcoming adhesive forces to cancel a fascial twist and countertwist. Formal diagnosis is difficult in a case like mine because current medical imaging techniques are limited in their ability to capture fascia. I have heard a prediction that within 2-5 years the rapid advances in ultrasound elastography may make it possible to detect small local changes in fascial stiffness (R. Schleip, personal communication, Dec. 2010). Such imaging would revolutionize the diagnostic capabilities for fascial unwinding patients. However, treatment will likely continue to be centered around manual therapy. References
L. Bertolucci (2011) Pandiculation: Nature's way of maintaining the functional integrity of the myofascial system? Journal of Bodywork and Movement Therapies, Vol. 15, No. 3, pp. 268280, July 2011. A. Boser and D. Lesondak (2009) Helping clients understand their fascial network. Yearbook of Structural Integration, International Association of Structural Integrators (IASI), pp. 7880. Available from the collection of articles at http:// www.somatics.de C.S. Harris (1965) Perceptual adaptation to inverted, reversed, and displaced vision. Psychological Review, Vol. 72, No. 6, pp. 419444, Nov. 1965. D. Ingber, S. Heidemann, P. Lamoureux and R. Buxbaum (2000) Opposing views on tensegrity as a structural framework for understanding cell mechanics. Journal of Applied Physiology, Vol. 89, No. 4, pp. 16631678. H. Langevin and P. Huijing (2009) Communication about fascia: History, pitfalls, and recommendations. International Journal of Therapeutic Massage & Bodywork, Vol. 2, No. 4, pp. 38, Dec. 2009. S. Levin (2002) The tensegrity-truss as a model for spine mechanics: biotensegrity. Journal of Mechanics in Medicine and Biology Vol. 2, No. 3-4, pp. 375388. S. Levin (2006) Tensegrity: the new biomechanics, a chapter in Textbook of Musculoskeletal Medicine, M. Hutson and R. Ellis editors; available at http://www.biotensegrity.com/ tensegrity_new_biomechanics.php B. Minasny (2009) Understanding the process of fascial unwinding. International Journal of Therapeutic Massage & Bodywork, Vol. 2, No. 3. T. Myers (2001) Anatomy Trains : Myofascial meridians for manual and movement therapists, Elsevier. L. Rhode-Barbarigos, E. Schmidt, N. Bel Hadj Ali and I.F.C. Smith (2009) Comparing two design strategies for tensegrity structures. EG-ICE Workshop: Intelligent Computing in Engineering (ICE09), Berlin, July 2009. R. Schleip (2003) Fascial plasticity a new neurobiological explanation, Parts 1 and 2, Journal of Bodywork and Movement Therapies, Vol. 7, No. 1 and 2, January 2003, . D. Stamenovic (2006) Cells as tensegrity structures: architectural basis of the cytoskeleton. FME Transactions, Vol. 34, No. 2, pp. 5764.
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their risk of bruising. This fact doesnt prohibit Myofascial Vacuum Cupping but it is wise to be aware of the potential adverse reactions and to be conservative in your application of the technique. Are there specific Principles of Application of Myofascial Vacuum Cupping to limiting adverse tissue reaction?
Cupping has the potential to significantly bruise tissue I believe that MVC should be applied by a skilled practi- and this is to be avoided in the style of cupping we are tioner and certain contra-Indications apply in exactly advancing. the same way as direct hands-on treatment. How can you maximize the effectiveness of the Examples of absolute contra-Indications to MVC are: treatment and limit adverse tissue reaction? Skins lesions, skin fragility, Myofascial attachment sites to bone. History of Vascular disease eg Previous incidents of Deep vein thrombosis Varicose veins Examples of Relative Contra-Indications are: We suggest that there are 4 Vital Signs to adhere to, that will minimise bruising, they are 1. Watch and monitor the colour of the tissue being treated and do not allow the tissue to become a red/ purple colour keep it to a pink colour. As soon as the colour changes to a red/purple remove the cup.
The release of Relaxin and other hormones during preg- 2. Dont leave the cups on for more than 2 minutes nancy, to allow the connective tissue in the pelvis to initially. elongate and allow the child to move through the birth 3. Be aware of your patients skin type: Fair skin will canal, may also cause the general fascia structure to bruise more easily than olive skin change with less external force than the tissue in nonpregnancy mode. It is therefore wise, as with any tech4. Monitor the degree of Vacuum inside the cup by nique during pregnancy, to be conservative and watch watching the degree of Skin raise within the vacuum the tissue carefully to ensure adverse reaction doesnt cup to ensure it is not excessive. occur As a guide only draw the skin approximately of the Patients taking specific medications, e.g. Blood thinning way up to the 1st treatment line on the cup medications like Asprin and Warfarin may increase
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1. Apply cream or oil to the above region, begin superior to the crest of the Illium 2. Place a Size 1. (45mm) cup on the left side in the center of the Ilio-costalis / Longissimus Muscles and the Superficial Thoraco-lumbar fascia just below the target tissue. Avoid contact with the Spinous Processes and the Iliac crest.
Sliding cupping
3. Monitor the level of Skin raise and stop at a point 3/4 Sliding Cupping can also be used. The steps are s the way up to the first cup line. Monitor also the Skin Colour. Ask the patient How does it feel? The re1. Apply cream or oil to the above region sponse we want is A mild Stretching feeling Begin just below, inferior, to the target tissue and place 4. Place and secure a cup at the same place on the right a 45mm cup on the center of the Longissimus / Thoraco -lumbar Fascia. Again avoid contact with the Spinous 5. Remove the 1st cup and place it superior to the origiProcesses nal position of the 1st cup (i.e. Still on the Left Longissimus) 2. Use Full Pump Stroke or stop at a point of skin raise 3/4 s the way up to the first cup line 6. Remove the 2nd cup and place it superior to the original position of the 2nd cup (i.e. Still on the Right Long- Leave the cup in place and Remove Pump and Monitor issimus) the Skin Colour. ASK & OBSERVE 7. Continue this leap frog method until you reach the level above the target tissue. Remove cups and repeat the same process, steps 1 to 7, twice more. 3. Move the cup by sliding it slowly superiorly all the way through the Target tissue and back down again. Apply a zig-zag motion as the cup is moved to activate as many mechano-receptors as possible for improved treatment effectiveness If the Resistance within the cup is INSUFFICIENT Increase the level of Vacuum until the first onset of resistance is felt.
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This new DVD by Robert Granter will show you an efficient use of Vacuum Cupping for the Soft Tissue Therapist. The cupping technique is anatomically specific myofascial mobilisation. Unlike traditional cupping methods which can usually create bruise on the skin, these new and innovative techniques are anatomically based for myofascial mobilization. It can be integrated into your massage treatment and reduce excessive stress on the therapist's body. Available from www.terrarosa.com.au
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Get em back
In our office, we have a comprehensive one-page intake form that patients fill out in the waiting room. Underneath is a laminated fee schedule outlining our fees, possible initial reactions to treatment, and the names and pictures of our practitioners. We are building credibility. Your intake interview outlines what they can expect from you. Holding eye contact, actively listening, asking clarifying questions...all demonstrate your interest in them. I screen potential associates by acting as patient in a mock intake. Most practitioners quickly scan the intake form and encourage me to get on the table. She/he often doesnt take the time to listen and really assess my needs before trying some intervention. My point is: Your intake process is an opportunity to make a positive, lasting impression and to build trust. Treatment. Treatment is more than the techniques you will apply. Its using verbal and kinaesthetic communication. Its honouring the persons responsiveness, and your biomechanics. Its an opportunity to describe your findings (cause), how this problem has manifested in the body (effect), and what your plan of action is (remedy). Use treatment as an opportunity to educate, to draw awareness to movement or postural patterns that are causing harm, and to discuss and apply interventions that can prevent further entrenchment. Address the primary problem, with some attention to secondary problems. Stay focused. Get some positive results, even if minimal in that first session together to instil the patients confidence in your work. Evaluate. Re-check the findings you observed during the assessment process. Evaluate postural assessment, range-of-motion, muscle testing, palpation, ortho/ neuro tests, numeric pain scale or pain/disability questionnaires. How have things changed, and by how much? What hasn't? Reinforce the session outcomes in the mind of the patient, stressing the benefits your interventions have induced. Encourage the patient to modify attitude and behaviour to reinforce the changes. Plan together how the things that havent changed can be approached in a future treatment. Report of Findings. An ROF summarizes what you have been saying during the whole process - cause, effect and remedy. In our office, we use a variety of teaching aids to get our points across, such as a comprehensive spine model with nerves, muscles and shoulder/pelvic girdles, cranium with painted facial/ cranial muscles, trigger point and anatomy charts, and analogies or word-pictures. Incorporate visual, auditory and kinaesthetic means of helping patients understand their condition. Educated patients feel empowered and make better health care decisions. Add further value by giving your new patient a small bag of Epsom salts with instructions on how to use, and a glass of water after their treatment. "Wow" them with service above and beyond their previous experiences. Reconnect. Call first-timers next day to check their response to treatment, and to offer guidance if the person is having a reaction or needs clarification on a remedial exercise prescribed. How many times have you heard someone say I went to XYZ therapist and I was sore for three days afterward!? How many people never seek bodywork again because the practitioner did not follow up to assess an unfavourable reaction? Over a longer term, reconnect with patients via regular mailings . Newsletters, birthday cards or monthly tipbased e-mails are all ways to stay in their perceptual field and reinforce that your care is an important aspect of their health care. Practitioners ask "Isn't that pushy?" Nope. When I call, my patients to offer an open appointment, they say I'm glad you called. I need an appointment." Or "I should have been in earlier but I was so busy.... In this era of mass interruption, disstress and technology overload, people will be glad you were thinking of them and offered a little reprieve from the world. If you want to know what patients/clients really think, administer a short survey. Let your existing patients know you want to provide the best care, and you would appreciate them taking a few moments to respond. Survey everyone it will only take a few moments. Use 13 x 10 cm (5 x 4-inch) cards and a shoe box with a slot cut out for returned cards, to protect peoples anonymity. Here are several sample questions: We strive for excellence in providing your massage therapy. Please help us grow by completing the following questions as completely and as accurately as possible. Feel free to write additional comments on the back of the card. 1 - unsatisfactory 2 - poor 3 - satisfactory 4 - good 5 - excellent Availability - Did you get an appointment when you needed to? 1 2 3 4 5 Environment - How are the temperature, lighting, sound/noise levels? 1 2 3 4 5
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Quality - How pleased are you with the therapy/ service you are receiving? 1 2 3 4 5 What do you really value, and always expect from us?
Please list 3 reasons why you would refer someone to our office?
Thank you for helping us provide better care! Jane Doe, DRM
Id recommend doing this survey every six to 12 months to check how well youre meeting the needs of your patients. This is worth repeating. Add value to your services at first meeting by providing above and beyond what they expect. Take the time during the case history to listen and empathize. Do a thorough assessment to really understand their problem and explain to them the cause, effect and remedy. Make sure to address their primary problem in the first session, even if this is not the root cause, so they feel you are listening and want to help. Send them home with Epsom salts and simple, effective remedial exercises. Create a healing, nurturing, relaxing or rehabilitative experience. Do the things that go above and beyond your hands-on work to add value to your services. This excerpt is reprinted from Massage Therapist Practice: Start. Sustain. Succeed. Available from Terra Rosa http://www.terrarosa.com.au/book/ massage_therapist_practice.htm
Don Dillon, RMT is the author of Massage Therapist Practice: Start. Sustain. Succeed. and the self-study workbook Charting Skills for Massage Therapists. Don has lectured in seven Canadian provinces and over 60 of his articles have appeared in massage industry publications in Canada, the United States and Australia. Don is the recipient of several awards from the Ontario Massage Therapist Association, and is one of the founding members of Massage Therapy Radio www.massagetherapyradio.com. His website, www.MTCoach.com, provides a variety of resources for massage therapists.
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Pandiculation:
An organic way to maintain musculoskeletal health
By Luiz Fernando Bertolucci, MD
Summary Pandiculation is the involuntary stretching of the soft tissues, which occurs in most animals and is associated with transitions between cyclic biological behaviours, especially the sleep-wake rhythm. Yawning is considered a special case of pandiculation. When, as often happens, yawning occurs simultaneously with pandiculation in other body regions, the combined behaviour is referred to as the stretch-yawning syndrome (SYS). Although today it is possible to trace the main neural pathways responsible for the expression of the SYS, its intimate biological meanings are still poorly understood. In the First International Congress on Yawning, held in Paris in 2010, different hypotheses were presented about the main possible SYSs mechanisms and purposes (summarized in the book: The Mystery of Yawning in Physiology and Disease, edited by Dr O. Walusinski), ranging from ethological to neurophysiological perspectives. This article explores the hypothesis that the SYS has an auto-regulatory role in our locomotor system: to maintain the animals ability to express coordinated and integrated movement by regularly restoring and resetting the structural and functional equilibrium of the myofascial system. The ideas presented here initially arose from clinical observations during the practice of a manual therapy called Muscular Repositioning (MR) (Bertolucci, 2008; Bertolucci and Kozasa, 2010a; Bertolucci, 2010b). These observations were supplemented by a review of the literature on the subject. A possible link between MR and SYS is presented: The neural reexes characteristically evoked through MR are reminiscent of SYS,
which both suggests that MR might stimulate parts of the SYS reaction, and also points to one of MRs possible mechanisms of action. Pandiculation: determining and maintaining musculoskeletal structure and function Pandiculation is an old and almost ubiquitous behaviour that occurs in similar form and circumstances across a wide spectrum of species (Baenninger, 1997). The regularity and vigour of pandiculatory movements suggest that they might be physiologically signicant. Walusinki noted that according to Darwins concepts, the cost of a behaviour with high metabolic demand is likely to be outweighed by some adaptive benet (Walusinski, 2006). Indeed, the phylogeny and ontogeny of pandiculation reveal its likely role in the development and maintenance of motor function, in both its structural and neural aspects. Fraser (1989a), in connection with ultrasound foetal studies on sheep, refers to foetal pandiculation as a mechanism that inuences functional determination of the moving parts of the musculoskeletal system and contributes to articular
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development and maintenance. He also identied a bodily care and self-maintenance function of pandiculation, which restores muscle homeostasis in poultry, dogs, cats and horses, among other animals (Fraser, 1989a). In human, pandiculation is also ontogenetically precocious, starting as early as 12 weeks of gestation (de Vries et al., 1982). It has been associated with the development of motor neural circuitry (Lagercrantz and Ringsted, 2001; Marder and Rehm, 2005; Briscoe and Wilkinson, 2004) and associated musculoskeletal effectors (de Vries et al., 1982; Walusinski et al.,2005). In fact, individual muscles are differentiated only after the establishment of their neural connections (Sadler, 1995), based on their specic motor actions. Such mechanical-structural coupling is not conned to soft tissues; it can be extended to bone (Wolff, 1986), joint surface shapes (Kapandji, 1987) and virtually every tissue under mechanical stress (Moore, 2003; Silver et al., 2003). In summary of the above, repetitive motion gradually determines shape and composition of moving structures, as well as their associated neural control pathways. The precociousness and stability of pandiculation suggest its contribution to such development. SYS and arousal: restoration of postural tonus The SYS has been associated with the maintenance of arousal and attention; i.e., it sets and maintains the central nervous and locomotor systems so that the animal is able to perceive environmental stimuli and respond to them with appropriate motor actions (Baenninger, 1997; Walusinski, 2006; Askenasy, 1989). It has been shown that rats stereotypical yawning, including trunk stretching (SYS), can be triggered by
stimulation of the paraventricular nucleus (PVN) of the hypothalamus via electrical or chemical means (SatoSuzuki et al., 1998). The fact that animals most often awaken immediately following REM sleep (which is characterized by muscle atonia), led Walusinski (2006) to postulate an opposing relationship between REM sleep and SYS. Apparently, SYS restores to the myofascial system the elevated level of tonus required for activity in gravity: because in sleep the myofascia is slack and relaxed, the body segments must be reassembled upon awakening before the organism can move properly in the eld of gravity. SYS: compensatory response to stiffness The SYS has a similar and stereotyped phenotype along the evolutionary scale, having remained virtually unchanged. Yawning starts with a long and deep inhale, reaches a peak, and concludes with a short exhale. Respiratory, mouth, neck and upper spine muscles engage in co-contraction, simultaneously stiffening the joints and stretching the myofascial tissues (Walusinski, 2006). The few references to body pandiculation in the existing literature describe it as a series of coordinated actions that unfold sequentially, building up soft tissue contractile tension to a peak, at which point the joints of the limbs and trunk are maximally extended or, alternatively, the trunk is arched in exion (Fraser, 1989b). After the peak, the soft tissue tension level plummets, yielding a sense of pleasure and well-being. The patterns of full body pandiculation are, in general, similar to the ones used in striding and righting behaviours (Fraser, 1989b) i.e., they emulate ordinary functional movements while pandiculation of limited bodily regions seem to be a corrective response to the stiffness induced by temporary positional stress or im-
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limb (and related musculature) to an original (homeostatic) state (Fraser, 1989a, 1989b). In fact, SYS has much in common with other homeostatic functions, as discussed below. Emotional motor system and SYS Human movement involves the concerted activity of all parts of the motor system. Voluntary movement involves the so-called cortico-spinal tract (connection between cerebral cortex and spinal nerves), which is modulated, by information from lower motor regions (basal ganglia, thalamus, midbrain, cerebellum, spinal cord). Such modulation allows voluntary movements to be smooth, precise and well coordinated (Kandel et al., 2000) and is mainly unconscious and automatic (Jacobs and Horak, 2007; Guyton and Hall, 2006; Takakusaki et al., 2003).
In contrast to voluntary movement, there is a wide range of instinctive motor behaviours that are automatic and can be executed without the intervention by the cortical centres. Instinctive behaviours evolved to guarantee the continuity of the organisms lineages, to maintain internal homeostasis, and to insure successful breeding (Dentona et al., 2009). They are mediated primarily by the limbic system and include those lifesupporting activities (e.g., feeding, self-defense, sex) collectively named emotional behaviours (Guyton and For the conguration of the ECM to be physiologically Hall, 2006; Kandel et al., 2000). In experimental aniappropriate, the mechanical input that stimulates it mal models, stimulation of limbic structures, notably must rst be appropriate. For example, a long striding the hypothalamus and the amygdala, has elicited varimovement will remain possible only to the extent it is ous emotional behaviours (Kandel et al., 2000,Guyton sufficiently expressed, because only such expression will and Hall, 2006) even in the absence of the cerebral stimulate a supportive ECM conguration (Kjr, 2004; cortex. Experimentally, animals without cortical funcKjr et al., 2009, Heinemeier et al., 2007). But, most of tion can feed themselves, express rage and ght, and the time, animals are not expressing their optimal quali- have sexual intercourse (Magoun and Ranson, 1938; ties of movement, such as running at maximum speeds Smith, 1939; Guyton and Hall, 2006), which shows that and attaining maximum range of movement (ROM) in the limbic system can produce such behaviours in the the joints. Whats more, sleep imposes a regular period absence of cortical participation. of immobilization, to which the ECM turnover will acIn fact, the limbic system sends diffuse and innumerable commodate. This suggests a continual tendency to tie projections to the medulla. It is a system unto itself, able up the animals entire structure by the creation of abto produce motor activity independent of the voluntarily normal ECM links (adhesions). driven cortico-spinal system. Holtstege describes it as Pandiculation, with its specic and vigorous muscle ac- the emotional motor system because limbically regutivity, might be a means to compensate for the mechani- lated behaviours depend on the emotional state of the cal signals delivered by rest periods and sub-optimal animal. The functions governed by the limbic system movements. Fraser mentions, in connection with his include different types of involuntary movements assostudies of pandiculation among various species, that it ciated with olfaction and eating, such as licking, chewmight be considered a feedback from stiffness, and pos- ing, and swallowing; clonic and rhythmical movements sibly be triggered by extended periods of immobility in (e.g., locomotion, shivering); sexual function; vocalizaasymmetrical positions. He concludes that if the body tion, laughing, and crying; and defense reexes, among tends to stiffen, pandiculation can serve to restore the others (Guyton and Hall, 2006; Holstege, 1992). In-
mobility. Such stiffness is related to the molecular composition and dynamics of the extracellular matrix (ECM). In fact, during physiological turnover metabolism, ECM components are continuously being replaced, depending on the mechanical stresses acting on them; i.e., movement is crucial to the maintenance of the appropriate form and function of the ECM (Kjr et al., 2005, 2006, 2009; Tomiosso et al., 2005). For example, dense tissue is deposited in response to the mechanical need for tensional resistance, while areolar tissue is renewed where gliding is required. Without mechanical input, the ECM would be laid down amorphously and its conguration would not meet physiological requirements.
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deed, in laboratory animals various stereotyped behaviors have been reproduced with electrical or chemical stimulation of mesencephalic nuclei, particularly the PVN (paraventricular nucleus) of the hypothalamus. Chewing, licking, lordosis in females, penile erection, and grooming have been observed (Argiolas et al., 2000; De Wied, 1999; Vergoni et al., 1998). The SYS is among these behaviors produced by the limbic system, and its phylogenic longevity suggests an adaptive function. That the SYS is mediated by the PVN suggests that the SYS might serve some general homeostatic function, which functions are carried out autonomously by the emotional motor system. In human, the workings of the emotional motor system are illustrated by the involuntary movements of patients with voluntary motor pathway lesions. For instance, when hemiplegic patients yawn, they have been observed to raise involuntarily an otherwise plegic arm (Graham, 1982; Tpper et al., 2003; Stewart, 1921) (Omam et al., 1989). Similarly, patients with voluntary facial palsy show facial movements while laughing (Hopf et al., 1992; Tpper et al., 1995; Chernev et al., 2009), and patients incapable of voluntarily opening their mouths do indeed open them while yawning (Askenasy, 1989). Taken together, the experimental and clinical observations summarized above illustrate that automatic (emotional) motor behaviours can express their patterns independent of the voluntary motor system. Such automatisms may be interfered with, because normal adult human motor behaviour includes the inhibition of instinctual drives (Smith, 1992). In fact, yawning has negative social connotations in most cultures and religious traditions, and the SYS behaviour has been observed to decrease as the person ages (Walusinski et al., 2010). Based on the above, one can speculate that cultural conditioning inhibits the SYS in humans. Given the likely homeostatic function of SYS, any such inhibition might contribute to the high incidence of human musculoskeletal disorders. Pandiculation versus ordinary stretching: automatic versus volitional motor actions If we attend to our interoceptive sensations, our experience tells us that pandiculation and SYS exhibit peculiar motor recruitment. If one yawns on purpose, ones internal sensations are quite different from those elicited by a spontaneous yawn. Similarly, the sensations produced by spontaneous pandiculation are different from those that accompany either volitional pandiculation or volitional soft tissue stretching. The
patterns of volitional stretching are cognitively established and the action purposely performed. They often involve relaxation of the muscles through a diminution of their actions: the subject muscle is elongated passively, as a result of either gravity or the activity of opposing muscles. By contrast, the patterns of pandiculation are automatic. Through intense and involuntary deep muscle co -contractions, the soft tissues actively elongate themselves against the bony structures as the joints are stiffened. Each movement within the pattern emerges in sequence, apparently from the recruitment of a mosaic of reexes, the sequence of which can neither be anticipated nor purposely performed. Just as a spontaneous yawn feels quite different from a deliberate imitation of one, spontaneous pandiculation feels quite different from a voluntary pandiculation-like stretch. Because the voluntary and emotional motor systems have discrete neural pathways, pandiculations distinctive internal sensations might be attributable to the motor unit recruitment sequences dedicated to automatic movement patterns. Indeed, the contrast between interoceptive experiences during automatic versus volitional motor actions has been documented (Hommel, 2009). Whats more, operation of the hierarchically higher volitional system can inhibit that of the
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lower automatic system; this inhibition can disrupt the characteristic spontaneity of the SYS in favor of a cognitively directed stretch. Automatic arm abduction during yawning in hemiplegic shows the non-volitional nature of SYS: the patients did not show any arm movement when they imitated a yawn (Tpper et al., 2003). In other words, voluntarily imitation of the automatic motor pattern (via the cortico-spinal system) will not reproduce immediately the instinctive patterns originated in the limbic system (via the emotional motor system). Moreover, if the motor patterns are discrete, their physiological effects should be discrete, as well.
Picture from: Wikimedia commons.
The importance of stretching to the maintenance of musculoskeletal health is well-known. In humans, each of the myriad of physical tness regimens that include stretching has its own rationale; and although all muscle groups should be stretched, different regimens address particular problems and are intended to compensate for various patterns of muscle shortness or consequent joint mobility restriction. But how do animals in the wild maintain musculoskeletal health? They perform no voluntary stretching and still maintain their motor capabilities. Might SYS be responsible? If so, and if it were possible to stimulate SYS, might SYS be employed to achieve therapeutic goals?
linked to the perception of positive affects (Esch and Stefano, 2004). Such positive affect states are closely related to ancient limbic brain regions common among humans and other mammals (Burgdorf and Panksepp, 2006; Vincent, 1994; Cabanac, 1992). The instinctive behaviours, contributing as they do to the maintenance of the internal milieu, can be considered homeostatic drives (Sherwood, 2010), a category within which pandiculation may also be included. Not only has pandiculation been associated with pleasure and wellbeing (Fraser, 1989a; Sauer and Sauer, 1967; Russel and Fernandez-Doz, 1997; Walusinski, 2006; Steward, Various somatic practices encourage the SYS because of 1921), but it also shares with the other homeostatic its apparent homeostatic effects, e.g., Hanna Somatics, drives involvement of the PVN nucleus of the hypothalamus. Homeostasis is maintained chiey by the parasymJoyexing, Eutonia (Hanna, 2004; Johnson, 2002; Vishnivetz, 1995). In Eutonia, the SYS is observed to be pathetic division of the autonomic nervous system (Recordati and Bellini, 2004), and increased parasymevoked by certain attentional states and forms of mechanical stimulation. Similarly, the specic mechanical pathetic activity has been detected during SYS (Askenasy and Askenasy, 1996). Whats more, the frestimulation of Muscle Repositioning might also stimulate the SYS. (see section on responses induced by MR, quency of SYS is correlated with degrees of health or convalescence: Fraser (Fraser, 1989b) notes that below). pandiculation is absent in animals with some systemic Pleasure and health illnesses, but returns as the animal recovers. Similarly, in recovering hemiplegic patients, SYS and synkinesias Ancient biological behaviours associated with the maincharacteristically re-emerge (Tpper et al., 2003; tenance of homeostasis are directed through interocepHwang et al., 2005) in advance of voluntary limb movetion the sensory experience reective of the physioments. logical condition (Craig, 2003). Sensory experiences of displeasure and pleasure dene the affective qualities of However, excessive pandiculation is associated with stimuli, which inuence an animals behaviour (Guyton certain diseases and the use of certain drugs (Askenasy, and Hall, 2006; Bozarth, 1994). The positive effects of 1989). This suggests a possible distinction between pleasurable experiences support many life-supporting complete (and successful) and an incomplete (and unbehaviours: satisfaction of hunger and thirst, sexual in- successful) pandiculation. Perhaps the former, having tercourse, and vesicle and bowel evacuation are examfullled its purpose, physiologically recurs; while the ples of instinctive behaviours that, once accomplished, latter, seeking completion, pathologically repeats. Conreward the animal with an experience of pleasure, which sider, for example, the palpable frustration that accombiologically reinforces their expression. panies the interruption of a yawn or sneeze! Preservation of health (salutogenesis) is intimately
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the hypothalamus and midbrain periaqueductal gray (PAG) (Ulrich and Azrin, 1962; Shaikh and Siegel, 1994). Muscle Repositioning: assisting pandiculation? Like pandiculation, MRs manual local loading of the myofascial system integrates body parts, apparently by inducing co-contraction of opposing muscle groups (Bertolucci, 2008; Bertolucci and Kozasa2010a, Bertolucci, 2010b), at the same time as it evokes a measurable rise in tonic muscle activity indicative of an overall increase in load. The clients subjective experience is similar to that evoked by pandiculation, which suggests a common element among pandiculation, yoga and martial arts and MR. The pandiculation connection: yoga and martial In pandiculation, muscle activation begins locally and spreads to neighbouring areas until it reaches a peak of arts distribution and intensity; i.e., joints progressively The downward dog position, like many yoga asanas, is stiffen through a chain of reexes, in which neighboring reminiscent of an animal pandiculation position segments are sequentially engaged to form an ever(Iyengar, 1979). In fact, some say yoga is derived from larger block that eventually encompasses the entire automatic and spontaneous actions of sages deep in body. Following the peak, the tissues release. MR inmeditation, and that yoga should be practiced spontane- duces a similar progressive engagement of body segously (Muni, 1994). Eastern martial arts might also have ments. The inclusion of each segment increases the a connection with pandiculation. Qi Gong, for instance, overall tension within the block until, following the requires the body to be fortied with automatic peak, the practitioner feels an abrupt soft tissue release. (involuntary) tonus in the deep postural muscles at the The progressive segmental engagement is paralleled by same time the supercial muscles associated with volan increasing involuntary tonic muscle activity observuntary activity are relaxed. Under these conditions, the able both by palpation and by electromyography body is integrated as a whole and all its parts relate with (Bertolucci, 2008; Bertolucci and Kozasa, 2010a; Berone another in movement (see http:// tolucci, 2010b). Let us imagine how it might be that MR www.caiwenyu.com.br/09_Fotos_p_ing.htm). These and pandiculation would evoke similar muscle activity. conditions cannot be produced by voluntary motor action, but emerge spontaneously with appropriate states The author hypothesizes that the manual forces applied during MR maneuvers mimic internal forces, and thereof attention in which mechanosensing is enhanced. A person in such state could take advantage of elastic po- fore induce mechanoreceptor afferents, similar to those characteristic of pandiculation. In the clinical setting, tential energy stored in the body when performing a recipients of MR treatments have exhibited spontaneblow. This characteristic of Qi Gong suggests a tensegrity-based mode of action with a high pre-stress level. In ous pandiculation-like movements (see videos at http:// musclerepositioning.blogspot.com/), and have defact, potentiation of performance has already been scribed their subjective experiences during MR as simishown in prestretched muscles, due to their ability to lar to their experiences during pandiculation. Some clistore potential elastic energy (Bosco et al., 2008; Etents also report having resumed the habit of pandiculattema et al., 1990; Ishikawa et al., 2006). Elements of martial arts training forms are often described in terms ing in the morning, to which they attribute a greater sense of bodily well-being along with relief from muscusuggestive of animal pandiculatory patterns (Johnson, 2002). This invites reection upon the fact that decorti- loskeletal symptoms. These observations support the hypothesis of a similarity between MR and pandiculacated cats and dogs do exhibit instinctual behaviours, tion. Perhaps MR is a blend of myofascial release and such as eating, copulating and ghting (Argyle, 1988); assisted pandiculation, with the soft tissue release i.e., that basic life-supporting behaviours can happen evoked by a combination of the practitioners manual without cortical participation. In fact, ghting appears input and the internally generated forces of tonic to be a largely reexive behaviour, the expression of pandiculation-like reactions. This combination of forces which is associated with subcortical structures such as
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Askenasy, J.J., Askenasy, N., 1996. Inhibition of muscle sympathetic nerve activity during yawning. Clinical Autonomic Research 6, 237239. doi:10.1007/BF02291140. Baenninger, R., 1997. On yawning and its functions. Psychonomic Bulletin and Review 4 (2), 198-207. Bertolini, A., Gessa, G.L., 1981. Behavioral effects of ACTH and MSH peptides. Journal of Endocrinological Investigation 4, 241-251. Bertolucci, L.F., 2008. Muscle Repositioning: A new verifiable approach to neuro-myofascial release?. Journal of Bodywork and Movement Therapies 12, 213-224. Bertolucci, L.F., 2010b. Muscle Repositioning: combining subjective and objective feedbacks in the teaching and practice of a reflex-based myofascial release technique. International Journal of Therapeutic Massage and Bodywork 3 (1), 26-35. Bertolucci, L.F., Kozasa, E.H., 2010a. Sustained manual loading of the fascial system can evoke tonic reactions: preliminary results. International Journal of Therapeutic Massage and Bodywork 3 (1), 12-14. Bosco, C., Komi, P.V., Ito, A., 2008. Prestretch potentiation of human skeletal muscle during ballistic movement. Acta Physiologica Scandinavica 111 (2), 135-140. Bozarth, M.A., 1994. Pleasure systems in the brain. In: Warburton, D.M. (Ed.), Pleasure: The politics and the reality. John Wiley & Sons, New York, pp. 5-14. Briscoe, J., Wilkinson, D.G., 2004. Establishing neuronal circuitry: hox genes make the connection. Genes and Development 18(14), 16431648. Burgdorf, J., Panksepp, J., 2006. The neurobiology of positive emotions. Neuroscience Biobehavioral Reviews 30 (2), 173-187. Cabanac, M., 1992. Pleasure: the common currency. Journal of Theoretical Biology 155 (2), 173-200. Chernev, I., Petrea, R.E., Reynolds, M.S., Wang, F., 2009. The classical type of Foix-Chavany-Marie syndrome: assessment and treatment of dysphagia. The Internet Journal of Neurology 11 (1). Chiquet, M., Gelman, L., Lutz, R., Maier, S., 2009. From mechanotransduction to extracellular matrix gene expression in fibroblasts. Biochimica and Biophysica Acta 1793 (5), 911-920. Craig, A.D., 2003. Interoception: the sense of the physiological condition of the body. Current Opinion in Neurobiology 13 (4), 500-505. de Vries, J.I., Visser, G.H., Prechtl, H.F., 1982. The emergence of fetal behavior: I. Qualitative Aspects Early Human Development 7 (4), 301322. De Wied, D., 1999. Behavioral pharmacology of neuropeptides related to melanocortins and the neurohypophyseal hormones. European Journal of Pharmacology 375 (1-3), 1e11.
might produce a greater effect in the soft tissues than either manual input or pandiculation alone.
Conclusion The concept of myofascial force transmission (Huijing and Jaspers, 2005) assumes the presence of ECM links among musculoskeletal components, which links unite those components into an integrated system; i.e., the fascia itself is assumed to play an integrative role. Integrated movement both requires and stimulates appropriate matrix connections. However, animals engage in a great deal of non-optimal movement, of which immobilization (e.g., during sleep), trauma and bad postural habits are among the causes. Should normal activities generate both good and bad mechanical signals to the ECM, the bad signals would need to be countermanded by good ones for the animal to maintain full movement capabilities throughout life. Pandiculation might provide one source of good signals by (i) breaking bad connections while stimulating better ones, and (ii) resetting postural muscle tonus to produce integrated movement, which movement is a further source of good mechanical signals. In short, pandiculation might be a form of neuro-myofascial hygiene. If this be true, might we encourage pandiculation to enhance general health? This would require a reassessment of the cultural stigma against yawning and pandiculation, as well as further investigation of therapeutic approaches, such as Muscle Repositioning, that seem to stimulate it. References
Argiolas, A., Melis, M.R., Murgia, S., Schioth, H.B., 2000. ACTH- and Dentona, D.A., McKinleyc, M.J., Farrell, M., Egan, G.F., 2009. The alpha-MSH-induced grooming, stretching, yawning and penile erecrole of primordial emotions in the evolutionary origin of conscioustion in male rats: site of action in the brain and role of melanocortin ness. Consciousness and Cognition 18 (2), 500-514. receptors. Brain Research Bulletin 51 (5), 425-431. Argyle, M., 1988. Bodily Communication. Routledge, New York. Askenasy, J.J., 1989. Is yawing an arousal defense reflex? The Journal of Psychology 123 (6), 609-621. Esch, T., Stefano, G.B., 2004. The neurobiology of pleasure, reward processes, addiction and their health implications. Neuroendocrinology Letters 4 (25), 235-251. Fraser, A.F., 1989a. Pandiculation: the comparative phenomenon of
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systematic stretching. Applied Animal Behaviour Science 23, 263-268. Kjr, M., Magnusson, P., Krogsgaard, M., Boysen Mller, J., Olesen, J., Heinemeier, K., Hansen, M., Haraldsson, B., Koskinen, S., EsFraser, A.F., 1989b. The phenomenon of pandiculation in the kinetic marck, B., Langberg, H., 2006. Extracellular matrix adaptation of behaviour of the sheep fetus. Applied Animal Behaviour Science 24 tendon and skeletal muscle to exercise. Journal of Anatomy 208 (4), (2), 169-182. 445-450. Graham, M., 1982. Assoctiated reactions in the hemiplegic arm. Scandinavian Journal of Rehabilitation Medicine 14 (3), 117-120. Guyton, A.C., Hall, J.E., 2006. Textbook of Medical Physiology. Elsevier, Philadelphia. Lagercrantz, H., Ringstedt, T., 2001. Organization of the neuronal circuits in the central nervous system during development. Acta Paediatrica 90 (7), 707-715. Lehmann, H.E., 1979. Yawning: a homeostatic reflex and its psychological significance. Bulletin of the Menninger Clinic 43(2), 123-136.
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during yawning in patients with pyramidal tract lesions: further evidence for the existence of an independent emotional motor system. European Journal of Neurology 10 (5), 495-499. Ulrich, R.E., Azrin, N.H., 1962. Reflexive fighting in response to aversive stimulation1 Journal of Experimental Analysis of Behavior. October 5 (4), 511-520. Urba-Holmgren, R., Gonzalez, R.M., Holmgren, B., 1977. Is yawning cholinergic response? Nature 267 (5608), 261-262. Vergoni, A.V., Bertolini, A., Mutulis, F., Wikberg, J.E., Schith, H.B., 1998. Differential influence of a selective melanocortin MC4 receptor antagonist (HS014) on melanocortin-induced behavioural effects in rats. European Journal of Pharmacology 362 (2-3), 95-101. Vincent, J.D., 1994. Biology of pleasure. Presse Mdicale 23 (40), 1871 -1876. Vishnivetz, B., 1995. Educao do corpo para o ser. Editora Summus, So Paulo. Walshe, F.M.R., 1923. On certain tonic or postural reflexes in hemiplegia with special reference to the so called "associated movements. Brain 46, 1-37. Walusinski, O., 2006. Yawning: unsuspected avenue for a better understanding of arousal and interoception. Medical Hypotheses 67 (1), 6-14. Walusinski, O., Kurjak, A., Andonotopo, W., Azumendi, G., 2005. Fetal yawning assessed by 3D and 4D sonography. The Ultrasound Review of Obstetrics and Gynecology 5 (3), 210-217. Walusinski, O., Meenakshisundaram, R., Thirumalaikolundusubramanian, P., Diwakar, S., Dhanalakshmi, G., 2010. Yawning: Comparative Study of Knowledge and Beliefs, Popular and Medica. In the Mystery of Yawning in Physiology and Disease. Available at. http:// www.baillement.com/recherche/beliefs_knowledge.pdf. Wolff, J., 1986. The Law of Bone Remodelling. Springer-Verlag, Berlin.
About the Author Luiz Fernando Bertolucci is a physiatrist and cofounder of Ncleo Anthropos, Integrative Medicine group at UNIFESP (So Paulo Federal University). He is also a Certified Advanced Rolfer; Rolf Institute of Structural Integration and Associao Brasileira de Rolfing faculty. Email: [email protected]. Or visit his blog site http:// musclerepositioning.blogspot.com/ This article builds on part of an earlier publication: Bertolucci LF. Pandiculation: nature's way of maintaining the functional integrity of the myofascial system? J Bodyw Mov Ther 2011 Jul; 15(3):268-80.
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reflexive response to injury. The brain gathers evidence from many sources before triggering pain. Pain, like the body image, is a construct of our brain. Therefore he successfully used a mirror box to modify a body image and eliminate the phantom and its pain. Dr. Lorimer Mosely, a scientist from Australia, have demonstrated visual distortions of the body image in patients suffering from chronic pain can significantly affect their perception of painful sensations. People with CRPS and phantom limb pain, were shown to have decreased tactile acuity and distorted body image for the affected limb. CRPS and phantom limb pain patients tend to perceive the painful or phantom limb as being bigger than it really is. Lorimer also tested to use the mirror box to make chronic pain in a real limb disappear. He asked his patients to simply imagine moving their painful limbs, without executing the movements, in order to activate brain networks for movement. The patients also looked at pictures of hands, to determine whether they were the left or right, until they could identify them quickly and accurately. They were shown hands in various positions and asked to imagine them for fifteen minutes, three times a day. After practicing the visualization exercises they did the mirror therapy, and with twelve weeks of therapy, pain had diminished in some and had
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Body Image
day during a six week experiment. Half the group received massages with grapeseed oil. The other half received an aromatherapy massage with a blend of essential oils. Both groups felt better and improved body image after the treatment, but the group receiving aromatherapy massage showed significant changes across all areas body image, waist circumference and abdominal fat. Massage may improve body image by decreasing negative body image and increasing positive body image. A positive body image accepts the body and respects it by attending to its needs and engaging in healthy behaviours. In a qualitative study, many college women with a positive body image indicated that they regularly received massages to take care of, appreciate, and pamper their body, showing that they view massage as pleasurable. Massage treatment could function as a positive feedback cycle, by not only lessening negative feelings about the body through increasing body acceptance, but also by associating emergent positive feelings with the body and partaking in a behaviour that honours and relaxes the body. Massage could also improve body image by reducing womens objectification of their body. A woman with a negative body image often views her body as an object to be evaluated. Women in western cultures learn to survey their bodies through the eyes of their culture to avoid negative judgment. A woman can feel that her body brings unhappiness and shame because it is perceived as not measuring up to societys ideals. A woman who receives a massage, can let her body becomes a vehicle for the experience of pleasure. Women who hold a negative body image may avoid massage due to shame or embarrassment. A study conducted by scientists from Bridgewater State University, MA, USA looked at the effect of massage on state body image. The study recruited forty-nine female university students; they were randomly assigned to either a massage condition or a control condition. It was hypothesized that participants in the massage condition would report improved state body image following the intervention when compared to participants in the control condition. As predicted, participants in the massage condition reported a more favourable state body image than participants in the control condition post-manipulation. Certain body image evaluations were moderately associated with views that massage is pleasurable, with the link between Body Areas Satisfaction and viewing massage as pleasurable reaching significance.
disappeared in half. Lorimer also demonstrated that people with chronic back pain has disrupted body image. The patients were unable to clearly delineate the outline of their trunk and stated that they could not find it. This finding raises the possibility that training body image or tactile acuity may help patients in chronic spinal pain Massage and Body Image Massage is well known to make people feel more relaxed and better about themselves. While there are many evidences that suggest positive effects of massage on psychological health, little is known about the effects of massage on body image. Researchers have started to investigate massage as a way of improving body image. Thomas Pruzinsky in his book Body Image: A Handbook of Theory, Research, and Clinical Practice, writes that massage therapy is a somatic approach that is helpful in positively affecting body image by helping the client reconnect to the body in a very concrete manner. Dr. Marcia Hutchinson, author of the book Transforming Body Image, suggests that since body image is a product of the imagination, it can also be changed using the imagination. Hutchinson describes an exercise called imaginal massage in which you visualize a massage occurring allowing the hands of the massage therapist to transfer healing to your bodymind allowing acceptance of your body. A study conducted by the Department of Nursing, Wonkwang Health Science College in South Korea evaluated the effect of massage on abdominal fat, waist circumference and body image of post-menopausal women. The participants received a full body massage once a week and massaged their own abdomens twice a
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Body Image
In this study, it is conclusive that the female university students reported feeling better about themselves and their bodies after having massage. Meanwhile the control group, who did not receive massage, showed no change in their attitudes.
Kim HJ. Effect of aromatherapy massage on abdominal fat and body image in post-menopausal women. Taehan Kanho Hakhoe Chi. 2007 Jun;37(4):603-12. [Article in Korean]
Lotze M, Moseley GL. Role of distorted body image in A womans negative view of her body can make the body pain. Curr Rheumatol Rep. 2007 Dec;9(6):488-96. seem untouchable and grotesque. Massage can be a vehicle to have a positive experience the body could poten- Moseley GL. I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. tially break through these negative body image attiPain. 2008 Nov 15;140(1):239-43. tudes. Nevertheless, a woman who holds negative thoughts about her body may be less apt to seek out Wood-Barcalow, N. L., Tylka, T. L., & Augustusmassage therapy. This attitude will need to be addressed Horvath, C. L. (2010). But I like my body: Positive for massage to be a viable therapeutic option. body image characteristics and a holistic model for In addition to relaxation and a shift in focus from the body as an object, regular massage could help change negative thoughts about the body as the body becomes associated with the good feelings that it brings through the massage experience. young-adult women. Body Image, 7, 106116.
References Cash TF, Pruzinsky T. Body Image: A Handbook of Theory, Research, and Clinical Practice. Guilford Press, 2004. Dunigan BJ, King TK, Morse BJ.A preliminary examination of the effect of massage on state body image. Body Image . 2011 8(4):411-4. Hutchinson MG. Transforming Body Image: Learning to Love the Body You Have. The Crossing Press, 1985.
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Research Highlights
Relaxed muscles behave like springs Australian researchers have discovered an entirely new aspect of human muscle behaviour. Professor Simon Gandevia, of Neuroscience Research Australia and the University of New South Wales, and colleagues, report their findings in the Journal of Physiology. Gandevia and team have discovered that when human muscles are completely relaxed, the muscle fibres don't just shorten, but behave like springs that resist joint motion. Although this sounds paradoxical, it means that at rest, muscles are under no tension whatsoever. "Just imagine a coil of rope or wire that had become so low in tension [or slack] that it buckled," says Gandevia. At short lengths most muscle fascicles (bundles of muscle cells) are slack. As the muscle is lengthened the slack is progressively taken up, first in some fascicles then in others. The increase in muscle length is due partly to increases in the length of muscle fascicles but most of the increase in muscle length occurs in the tendons. Sensory innervation of the thoracolumbar fascia There has been a debate on the role of the fascia as a potential source of pain in the low back because the lack of data on the sensory innervation of the thoracolumbar fascia (TLF). A recent study from Germany provided a quantitative evaluation of calcitonin generelated peptide (CGRP) and substance P (SP)containing free nerve endings in the rat TLF. A preliminary non-quantitative evaluation was also performed in specimens of the human TLF. Their data show that the thoracolumbar fascia is a densely innervated tissue with marked differences in the distribution of the nerve endings over the fascial layers. In the rat, they distinguished three layers: (1) Outer layer (transversely oriented collagen fibers adjacent to the subcutaneous tissue), (2) middle layer (massive collagen fiber bundles oriented obliquely to the animal's long axis), and (3) inner layer (loose connective tissue covering the paraspinal muscles). The subcutaneous tissue and the outer layer showed a particularly dense innervation with sensory fibres. Because of its dense sensory innervation, including presumably nociceptive fibres, the TLF may play an important role in low back pain. The effect of massage on pain management for thoracic surgery patients Thoracic surgery patients undergo long procedures and commonly have postoperative back, neck, and shoulder pain. A study published in the June issue of International Journal of Therapeutic Massage & Bodywork looked at the effectiveness and feasibility of massage therapy delivered in the postoperative thoracic surgery setting. The study was with patients who received massage in the postoperative setting had pain scores evaluated pre and post massage on a rating scale of 0 to 10 (0 = no pain, 10 = worst possible pain). In total, 160 patients completed the pilot study and received massage therapy that was individualized. Patients receiving massage therapy had significantly decreased pain scores after massage, and patients' comments were very favourable. Patients and staff were highly satisfied with having massage therapy available, and no major barriers to implementing massage therapy were identified. Effects of massage on pain in patients with metastatic bone pain Patients with metastatic cancers, such as bone metastases, are more likely to report pain, compared to patients without metastatic cancer. Their cancer pain results in substantial morbidity and disrupted quality of life in 34-45% of cancer patients. A study from Department of Nursing, Chang Gung University of Science and Technology, Taiwan published in the Journal Pain July 2011 conducted a randomized clinical trial to study the effects of massage on pain, mood status, relaxation, and sleep in patients with metastatic bone pain. Massage therapy appears to have positive effects in patients with cancer; however, the benefits of MT, specifically in patients with metastatic bone pain, remains unknown. In the study with 72 Taiwanese cancer patients , massage was shown to have beneficial withinor between-subjects effects on pain, mood, muscle relaxation, and sleep quality. Results also demonstrated that massage resulted in a linear trend of improvements in mood and relaxation over time. More importantly, the reduction in pain with massage was both statistically and clinically significant, and the massagerelated effects on relaxation were sustained for at least 16-18hours post intervention. Furthermore, massagerelated effects on sleep were associated with within-
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Research Highlights
The authors addressed the benefits of pre-exercise muscle stretching, which have been recently questioned folEffects of infant massage on HIV-infected moth- lowing reports of significant post-stretch reductions in force and power production. However, there ers and their infants are many methodological issues and equivocal findings A study from Arizona State University was conducted to have prevented a clear consensus being reached. The authors conducted a systematic review for randomdetermine the feasibility of implementing an infant ized or quasi-randomized controlled trials and intervenmassage intervention and to evaluate the preliminary tion-based trials published in peer-reviewed scientific effects of infant massage on HIV-infected journals examining the effect of an acute static stretch mothers and their infants. The study was published in intervention on maximal muscular performance. the July issue of J Spec Pediatr Nurs. From 106 good studies they found: In the study, two-group, randomized controlled pilot Clear evidence indicating that short-duration acute study, intervention group mothers were taught to perstatic stretch (less than 30 seconds) has no detrimental form infant massage daily for 10 weeks. The results effect, with overwhelming evidence that stretch durashowed that Infant massage training had a positive im- tions of 30-45 seconds also imparted no significant efpact on maternal depression, parental distress, and in- fect. However a significant reduction likely to occur fant growth along with facilitating more optimal parent- with stretches greater than 60 sec. child interactions. The authors concluded that infant This strong evidence was independent of performance massage, a quick, easy, and inexpensive intervention, is task, contraction mode or muscle group. feasible in a clinic setting and may benefit human immunodeficiency virus-infected mothers and their inThe authors concluded that the detrimental effects of fants. static stretch are mainly limited to longer durations subjects effects. The Effect of Static Stretching on Muscle Performance Kay & Blazevich, scientists from Western Australia recently reviewed the Effect of Static Stretching on Maximal Muscle Performance, it was published in Medicine Science of Sports & Exercises Journal July 2011. (60 s) which may not be typically used during preexercise routines in clinical, healthy or athletic populations. Shorter durations of stretch (<60 s) can be performed in a pre-exercise routine without compromising maximal muscle performance.
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Byron Barth, L.Ac., Dipl. O.M., MSTOM, is the author of the DVD The Art of Zen Shiatsu. He is a practicing Zen Shiatsu therapist and licensed Acupuncturist. He has been instructing Zen Shiatsu for over a decade and is on faculty at Pacific College of Oriental Medicine in San Diego, California. He is nationally certified in Chinese Herbology, Acupuncture and Oriental Medicine (NCCAOM). Other licenses include Holistic Health Practitioner and NCBTMB for Massage.
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