ipsbcollegemassageresearch

Massage research is an important way to promote an understanding of what bodywork therapists actually do and the results that can be achieved.


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Carpet Cleaner to Healer- The Power of Touch Intention

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“I didn’t want to be a massage therapist; I wanted to be a healer.” Those words said by Skip Kanester, Instructor of Tui Na at IPSB College, made Oscar Arce perk up. For 26 years Oscar Arce ran his own carpet cleaning business. When the economy took a downturn and the trend increased to use laminate instead of carpet for flooring, Oscar pondered other career paths. He started taking classes at the International Professional School of Bodywork (IPSB College) but often wondered, “What the heck am I doing in massage school? I have an interest in massage but is this the career change for me?”

Upon hearing Skip’s words, Oscar’s focus became how he could be an agent of change in someone’s healing process. He was drawn to the Eastern modalities of healing touch. Tui Na, one of the oldest recorded forms of bodywork is considered the physical medicine of the traditional Chinese system of healing. As Skip Kanester explains, “if someone’s goal is to be a healer, as opposed to a therapeutic bodyworker, a traditional source system like Tui Na and traditional Chinese medicine (TCM) is a great place to start one’s studies.” In addition to Tui Na, Oscar studied Jin Shin Acutouch with Barbara Clark. Barbara had developed Jin Shin Acutouch after studying and practicing Jin Shin Jyutsu® for many years. She integrated her experiential knowledge of Jin Shin Jyutsu® with an in-depth understanding of ancient Asian healing theories to create Jin Shin Acutouch. Jin Shin Acutouch means “Compassionate Spirit Penetrating through Touch”.

During this time, Oscar’s wife, Laura had been suffering from extreme pre-menopause symptoms of having her menses every two weeks. She was in the hospital five different times. The doctor’s had a hard time keeping her red blood cell count up. In addition, she was diagnosed with Celiac Sprue, an autoimmune dis-ease that damages the lining of the small intestine and prevents it from absorbing parts of food that are important for staying healthy. Oscar took all the information he had learned while studying at IPSB and began to apply this knowledge to his wife’s symptoms. Each day he blended a smoothie for her of beet, kale, chia and berries, which he learned in the Food as Medicine class at IPSB, with Chance Billmeyer. Within three weeks her RBC was up to 12.5. A normal red blood cell count is between 12 to 14 points. Laura’s count had been down to 6.2.

With her blood count stabilized, Oscar combined the tools he learned in Tui Na with Jin Shin Acutouch to help Laura’s body regulate hormone levels and stabilize her menstrual cycle. Through Oscar’s continued intention to be an agent of healing for his wife, they were able to uncover a long line of food allergies and deal with each through his eastern touch therapies and Nambudripad’s Allergy Elimination Technique (NAET).

Today, Laura has none of her presenting symptoms and has through Oscar’s intention to be an agent of healing, developed a balanced and healthy lifestyle. From a hunch that massage school might be a place to explore a career path, to understanding the power of touch in the healing process, Oscar now has a new career objective of opening a clinic which will focus on helping clients eliminate food allergies. And it all started with the words “I wanted to be a healer.”


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EXPANSIONAL BALANCE AND “THE LINE”

By  Edward W. Maupin, Ph.D.

Ida RolfI was quite inspired when I finished my classes with Dr. Rolf in 1968.  As a psychologist I felt I had acquired a way to communicate with the core consciousness of a person through the body.  Nine years earlier, in graduate school, I had had a ‘beginner’s enlightenment’ using a Zen Buddhist meditation.  I discovered a point of witnessing from which I could observe the contents of my mind without attachment.  For the next three months I could return to that state. One of my great discoveries was that my body is me in the realest sense, and that it is extremely intelligent and creative.  The body seemed to me to be the key to authenticity and to developing consciousness.  I decided I wanted to practice a psychotherapy that focused on the body.  I worked with Mary Whitehouse, the pioneer of “Authentic Movement,” and later, when I lived at Esalen Institute in Big Sur, I had access to other pioneers in body techniques.  It was when I underwent the 10 sessions with Dr. Rolf that I found myself back in the state of ‘witness.’  Frankly, it was the pain that made it necessary, but in witnessing I discovered much else.  I asked her to train me. Four months later in January 1968, I audited her first class and ‘practitioned’ six months later in her second.

I emerged, grateful for what I had received, but aware I didn’t know much.  I could execute the ten sessions as a recipe, but I couldn’t ‘see’ structure.  She told us to keep following the recipe until we knew what we were doing.  Fortunately my hands were better than my eyes (though heavy in the style of those days), and my clients and I sometimes had profound realizations of awareness and being.

Still, I knew I didn’t understand the movement part.  If structure and function were two aspects of the same thing, the function part was a bit skimpy for me.  The key seemed to be to know more about movement.

I also felt the touch needed more refinement, but what I learned about that has been published elsewhere  (“The Mirror of Awareness,” IASI yearbook, 2008).  Here I want to describe what I learned about movement.

‘The Line’ – and ‘Expansional Balance’

When speaking of movement, Dr. Rolf emphasized ‘The Line.’  The centers of gravity of each body segment should, most efficiently, align in a vertical column.  Again and again she emphasized this as the fundamental concept of integrated structure.  She sometimes talked about the balance of segments on this ‘Line’ as if it were a static concept.  That blocky boy, the so-fiercely defended ‘little boy logo,’ expresses this static quality.

But she also spoke of ‘The Line’ in a more dynamic way, as a polarity expanding in two directions.  She said the reflexive downward thrust of the feet against the ground could be translated into an upward thrust of the head, provided the pelvis, diaphragm and shoulders are not interfering, but are balanced on ‘the line.’

Communicating the full feeling of this dynamic expansion would have taken the skills of a dance teacher, which Ida was not.  I remember awkward scenes of our class sitting rigidly ‘keeping our heads up and our waistlines back,’ lest she chide us for our lapses.  Once she had us standing in a chorus line attempting to swing our knees forward from the 12th rib.  (This doesn’t do justice to the Patterning movements she also taught and which Judith Aston so effectively elaborated.”)  But more developed movement work was definitely needed.

Six years later I met Michael Nebadon (known then as Oscar Aguado), an Argentine jazz dancer.  He had had moments of such inspiring freedom in his dance career in New York that he had “retired to find the true sources of movement.”  He spoke of open expansion so extreme that the ordinary sense of self was transcended.  To him the body naturally expands “omnidirectionally” in response to gravity.  I thought this seemed a lot like Dr. Rolf’s ‘Line’ – only more clearly three dimensional.  He called it “Expansional Balance.”

Now he was teaching students how to find their expansion in small steps by meticulously centering each joint across its functional planes.  In this way, the body sense shifts from outer tension to the center of the joint so that open expansion can take place out through it.  One can then feel connection between adjacent joints until there comes to be an open, integrated state of the entire body.  It sounded like a good strategy for structural bodywork.

In movement classes he often started with the arms, balancing each joint, opening the horizontal polarity from spine through fingertips and beyond. With the arms extended, we developed the ‘pelvic extension down through into the feet and related it to the balance front to back of the lumbar, and up through the neck and head, the ‘upper pole.’

My ‘Line’ was taking on much clearer form in these classes, and I was learning to feel structure from the inside.  Balancing joints across their functional planes became part of my bodywork strategy – still following the recipe.

rolfer“Four Parts of Expansional Balance”

It seemed to me that “omnidirectional expansion in gravity” needed to be broken down into practical parts.  Based on a variety of sources, I decided there must be four parts: a lower extension from pelvis through feet, a front-back balance across the torso, a horizontal expansion of the arms, and (finally) an upper extension of the neck and head.  Of course the upper extension is the other end of the lower extension, two ends of the same dynamic ‘Line,’ but in practice the two seemed to develop separately.

These ‘Four Parts of Expansional Balance’ can be stated as movement directives:

“Find the Pelvic Extension,”

“Relate it to the Lumbar Balance,”

“Find the Horizontal Polarity,”

“Find the Upper Pole.”

It was obvious to me that everything we do in the Rolf work can be seen as pursuing one or more of these goals.  Various details shifted, though, and my emphases changed.

1. Pelvic Extension

Like many fellow Rolf practitioners, I eventually came to feel that Dr. Rolf was excessively biased in favor of a lengthened lumbar spine.  The illustrations in her book are extreme in this regard.  I faithfully kept my ‘tail under and waistline back’ for many years, until I discovered I needed more lumbar curve to avoid back pain

Look at how Dr. Rolf coached the “Pelvic Lift”, that basic movement of pelvic extension:  “Just turn your tail under. . . .Now lift up. . . . Now let your waistline come down in the back.” (She said the exact words were very important.)

What did she mean by ‘waistline?’  I’ve heard she once said it referred to the whole back of the lumbar.  But she also used it for the front of the spine at L5.  Many of Ida’s pelvic lifts emphasized this ‘sacral hinge.’

Michael’s concept of “Pelvic Extension” implied a subtly different sense of opening downward from the anterior lower lumbar through the center of the pelvic bowl through the feet into the ground.  Less turning the tail under was involved.  The upward extension involved a separation of forces, down and up, at the lumbar hinge.  The body can thus unroll all the way from the feet up through the diaphragm and all the way to the head.  The arms can be open and balanced out across the horizontal plane, and the head can come up effortlessly.

2.  The Lumbar Balance

Michael was finding the functional balance of joints, and the torso was no exception.  Each hinge of the spine involved three layers: the anterior abdomenal wall, the anterior spine (psoas) and posterior spine (spinal erectors, etc.).  The anterior spine needs to be brought into relation with the posterior, and for this the abdominal wall needs to participate in the proper way.  The overly-dominant rectus is only part of the picture.  Rectus needs to lift into each hinge (L1, L3 and L5) and for this it needs the transversus and obliques to be strong.  The Rolf method is pretty good at releasing tissue, but not so good at strengthening it.  Something else is needed.  I began teaching an exercise of lifting the rectus with ‘fire breathing’ and with tutoring the 3 lumbar hinges in bench work.  This gives much more feeling of support in the abdominal wall.  Contacting the iliopsoas in this context can be a lot less confrontational.

3.  The Horizontal Polarity.

Work with the arms and shoulders became much more important for me.  Dr. Rolf’s initial arm work sought primarily to balance the shoulder girdle across the coronal plane.  Not much happened with the rest of the arms until the integration sessions.  With Expansional Balance it became clear the arms and hands have an immense impact on the rest of the body.  As a result I worked with them earlier and more often in my sessions.  (I’m aware that many other practitioners have come to focus earlier and much more on arms as well.)

My recent work with walking (“Five-Awareness Walking”) has made the hands and arms seem more important still.  Keeping the hands open and sensing has all kinds of effects, such as lightening the step, unifying the body, and even helping to organize the feet.  It appears that we are quadrupeds even in our upright posture.  The large area of the neocortex that registers sensation from the hands is within a synapse or two of four fifths of the cortex, I have read.  What a massive role it must play in our coordination!  The hands especially seem to feed energy to the core, and when they are withdrawn from being in the world (for example, in the way elderly people often withdraw from contact through the hands and feet), the effects are obvious.

Greater attention to the counter-rotation of shoulders and hips in walking also reveals a lot about rotations in the torso.

4.  The Upper Pole

For the upper pole to extend effortlessly, the hinging of the cranium on the atlas is crucial.  The cue from the Alexander Technique – “Neck free to come forward and up” – is worth contemplating.  There are essential reflexes in the neck such that, when the head tilts backward, the neck tends to plunge forward at the thoracic hinge, and when the head hinges forward on the atlas (chin in) the thoracic hinge tends to release upward.  The head has come ‘forward and up.’  But of course, the neck must be free to allow the atlantean hinge to function, and the front of the anterior neck and upper chest must be free to respond.  We can help with that.

These were the ways, some large and some small, in which Michael Nebadon’s concept of ‘expansional balance’ modified my practice of the ten series and of integrated movement.  After six years in practice I finally knew what I was doing, somewhat.

In the End

In the end I want to say something about how Dr. Rolf seemed to me.  Whatever “improvements” I feel I have found, I never forget that I am following in the footsteps of a great teacher.

She was a very spiritual, loving being.  Compassion was behind it all: we knew “mama knows best” and mama wanted the best for us.  Sometimes I felt a profound spiritual presence in her touch.  She had very little interest in the subjective experience of the person under her hands.  She was very precise, but it was the precision of a surgeon. She was a material scientist, not a psychologist.  That left much to develop in the touch communication.  Nevertheless, hers was a vast compassion transmitted by a formidable intellect.  To this day I carry an impression of her spirit and hear words that seem to come from her memory.

esalen


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The Benefits of Using Side-Lying Positioning

Carole Osborne, November 13, 2013
Most massage therapists have had clients they knew could benefit from a different approach—and finding a different approach doesn’t always have to mean adding a new technique to your massage therapy toolbox. Whether it’s adding a new piece of equipment, changing the lotions and oils you use or doing more focused work on a specific area, finding a way to meet your client’s individual needs during a massage session is an integral part of providing the best service you can.
Another approach you can add to how you work with clients is different positioning. Not only will incorporating side-lying positioning into your practice help you better work with some of your existing clients—like elderly and frail clients, clients who are pregnant or recovering from surgery, or those with implanted medical equipment, for example—you’ll also be able to reach out to new client demographics.
Read on to learn more about the basics of incorporating side-lying position into your practice, the benefits this positioning off ers both you and your clients, as well as ways using this positioning can help you boost your business.

Why Bother?

Learning to position your clients in a new way might seem daunting. Or, perhaps you’ve already tried the side-lying position and had trouble adjusting. There is a great deal to be gained, however, from learning to work with clients in this position, including comfort, accessibility, safety and effectiveness. Additionally, having an alternate way to position people can open up new client markets to you. Following are a few of the benefits you’ll see:
Comfort. The familiar sniffing and snorting for clearer breathing as our clients rise from a prone position might seem like an unavoidable side effect of a back massage. Side-lying positioning, however, eliminates much of this discomfort—which is especially important for those with colds, allergies, or respiratory compromise or disease.
Propping securely on the side, rather than prone, also avoids the uncomfortable pressure on sensitive
or enlarged breasts, anterior surgical or medical equipment sites, as well as gestating bellies. There is less pressing into the table or face cradle for those with delicate skin, and soft, stable support for the potentially fragile bones and inflexible joints of the aging, injured or those with considerable postural deviation.
Using strategically placed pillows and specially designed bolsters greatly improves prone positioning for many clients. However, face down may still be problematic for those with severe lumbar and pelvic pain. Prone positioning shortens posterior musculature, and compresses and anteriorly displaces the lumbar vertebrae and lumbosacral junction.
For most pregnant women, prone positioning also rotates and strains the problematic pelvic joints, and increases strain on the uterine ligaments, some of the very causes of many women’s back discomfort. Deep posterior pressure may further aggravate these structures rather than relieve pain. Instead of potentially worsening clients’ pain, execute a well-organized sidelying position, and the position will facilitate your session rather than hamper it.
Remember, too, that the joint neutral positioning achievable on the side often improves effectiveness with chronic back pain because you’re able to address the multidimensional nature of pain.
You will need to modify your prone and supine techniques for the side-lying client, though doing so opens up other possibilities that will provide great benefit. For example, you might choose to include stretches and other passive and active movements aimed at helping dysfunctional joints and soft tissue. Or, facilitate normalization of nerve function and myofascial organization in painful areas with trigger point, structural integration, Swedish and cross-fiber treatment protocols.
 
Think, too, of clients who have health conditions or medical treatments that limit their positioning during amassage therapy session. Side-lying position can help you remain effective while also avoiding undesirable and painful pressure on a pacemaker, ostomy bag, chemotherapy port, radiation burn or healing surgical scar, to name a few.
In addition to these physical comfort advantages, side-lying is often more emotionally comforting. Remember that stress and negative feelings often create or accompany physical pain. Side-lying position, more closely than any other, recreates the fetal position that many find reassuring and restful, and can encourage useful and compassionate communication between you and your client, unhampered by the confines of a face cradle.
Patients recovering from heart, breast, abdominal, eye or oral surgeries, as well as pregnant women, are often uneasy about, and most have been advised by their doctors, to avoid anterior pressure. So, when you’re limited to prone and supine, you may be missing opportunities to work with clients who need alternative positioning.
Effectiveness and accessibility. By providing more physical and emotional comfort in your positioning, your work might just become more effective too. You can also adapt and augment your technique repertoire to optimize the increased access that side-lying positioning creates, particularly to hips, shoulders and spine.
Resolving some clients’ issues requires working on structures that are easier to reach from the side: quadratus lumborum, tensor fascia latae, and ITT and thigh adductors, for example. Side-lying position allows you to interact with these soft tissues and associated joints with more ease, accuracy and stability. You will also be able to explore more unique and multidimensional movements when stretching and rocking spine, pelvic and pectoral girdle tissues. Athletes in particular can find this positioning beneficial.
Safety. Both the customary massage positions of face up (supine) or face down (prone) are problematic in some circumstances. With some clients, lying on their back for an extended period results in a drop in blood pressure. Clients most likely to experience this supine hypotensive syndrome are pregnant, have certain heart and lung diseases or compromise, or are overweight.
Typically they feel uneasy, dizzy, weak, nauseated, short of breath or generally uncomfortable if pressure drops due to compression of the vena cava. Others, however, feel no signs but may still be experiencing lower blood pressure. Doctors generally recommend a lateral recumbent position with these patients to maximize their blood circulation and oxygenation.
With no specific research data confirming or negating any type of positioning for prenatal massage therapy, I rely on nursing and obstetrical studies that show correlations between increased intrauterine pressure and complications. How relevant this is to the practice of massage therapy depends on many factors, including: fetal and maternal size, structure, amount of pressure used, duration of treatment, known risk factors, as well as other considerations. Potential danger to any mother and/or baby is enough to make me conservative in my use of prone positioning during pregnancy, however.

Side-lying Fundamentals

Alignment. Fortunately, there are many options on how to get your client comfortably on their side: pillows, specially designed support systems or a combination of both. A few principles for achieving a jointneutral arrangement and some tried-and-true steps to follow to get there will have your clients happily side-lying in no time.

Proper client alignment includes the following:

  • Spine paralleling table length and near the back edge
  • Space for the pectoral girdle
  • Support under the hip and belly, especially important with a gestating or obese belly
  • Firm and high supports under the ceiling-side leg to level off that hip, knee and foot
  • Often, too, you’ll use comfort supports under the arm, lumbar spine and rib cage, as well as custom provisions for medical equipment, extreme kyphosis or other postural deviations

Availabe equipment for practicing massage in side-lying equipment has both advantages and disadvantages, and client comfort varies with all. Experiment and identify what works for you and, if you use this position frequently, try to develop at least two reliable methods to get your clients to side-lying position.

For example, most clients find the firm stability of the Side Lying Positioning System comfortable and reassuring. Alternatively, the most petite or thin clients might prefer only softer pillows.

Whatever equipment you choose, be ready to make adjustments for individual client needs. For example, clients with pelvic instability at the symphysis pubis often are more comfortable with supports between their legs of sufficient height to level the hip with the entire leg.

Additionally, clients who are living with cancer may appreciate rolled towels to make soft channels of cushioning on top of pillows for maximum “float” and fine-tuning of limb comfort. Practitioners of structural integration, too, often adopt a less-is-more propping attitude.

Draping. Securing the covering sheet for working on the back is relatively straightforward. Maximize access to the entire back with an L-shaped arrangement along the underwear line and the lateral side of the torso.

Anchor this by tucking under the tableside gluteals and thigh. Gaining access to the entire leg and hip is a bit more complex, but I have refined a U-shaped drape and the steps to get there that you can count on:

  • Reach across the table for the opposite corner of cover sheet
  • Slip that corner between the ceiling-side knee and its supports, from posterior to anterior
  • Alternate pulling a U-shape up the lateral thigh and sliding the sheet gently along the medial thigh
  • Tuck the sheet end into the U at the lateral pelvis
  • Secure the drape under gluteals and thigh against the table

Therapist comfort. Some therapists are discouraged from regularly side-laying their clients because the positioning hurts their body. You need to remember your own alignment and consider working with a table adjusted to a higher height so you can efficiently shift weight in the more horizontally directed line of force that side-lying requires.

Positioning Yourself to Open New Markets

Being able to position your clients in ways different than simply prone and supine can help bring a wider variety of clients to your practice or help you more clearly focus your marketing efforts so you can reach the clients you’re interested in working with regularly.

First, however, you need to equip yourself well and then practice repeatedly to develop ease and grace in the steps of side-lying set-up, draping and client turning on the table. One way to do that is to recognize your current clients who might benefi t from the fresh perspective and novel approach this additional position provides.

Most therapists, for example, have a long-term client whose progress has plateaued. Getting a new angle on your work with that client might solve those stagnations, and give you needed experience and confidence in lateral recumbent work.

Then, point out the unique benefi ts of your sidelying positioning option when marketing your practice’s services. Some potential employment sites and locations to market your side-lying advantage to include:

  • Retirement and skilled care facilities
  • Radiation and other out-patient oncology treatment facilities
  • Oral and cosmetic surgical facilities
  • Midwifery and obstetrical practices
  • Health and athletic clubs
  • Professional and school sports teams
  • Chronic pain or back pain treatment centers
  • Treatment centers for PTSD and other mental health conditions

When thinking of special populations you might reach, start from your own natural interests. As the population ages, do you fi nd yourself more interested in working with older clients? Are you an avid athlete who would like to reach more clients like yourself with the benefits of massage therapy? When you develop markets that naturally correspond with your own interests, finding and marketing to these client demographics becomes less difficult.

Learning and actively using side-lying positioning gives you one more way to work with a wide variety of clients, from maternity clients to clients facing health problems to athletes. Soon, you’ll find clients and health care providers are eager to schedule with you and you’ll quickly become the go-to therapist in your area!


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 Is
 Tui 
Na 
Effective
 for 
Relieving 
Low
 Back 
Pain?



Taylor 
Jump

Research 
Case 
Report

IPSB

 Spring
 2010

Abstract

Objective: 
This 
study 
is 
designed
 to 
determine 
if 
Tui 
Na
 massage
 can
 be
 effective 
in
 relieving 
low
 back
 pain.

Methods:
 A 
54
 year 
old
 full‐time 
mother 
and
 house wife
 recently
 twisted 
and 
injured
 her
 low
 back 
and
 her left 
knee
 from
 a 
serious 
fall. 
She 
cannot
 put 
all 
of
 her
 weight 
on 
the
 injured
 leg. 
Five
 sessions, 
60
 minutes each, 
of 
Tui 
Na 
massage 
were 
performed
 once 
a 
week 
for 
5 
weeks
 to 
address 
acupoints
 commonly
 used 
in acupuncture 
for 
low
 back 
pain. 
Range 
of
 motion 
of 
flexion 
of
 the 
upper 
torso 
was
 measured, 
and
 the
 client 
kept 
track 
of 
how
 often
 back 
pain 
occurred,
 what
 activity 
aggravated
 it, 
and
 pain 
level.

Results:
 Pain
 frequency 
and
 intensity 
decreased 
during 
the
 course 
of 
the 
study. 
Flexion 
of 
the
 spinal column increased.

Conclusion: 
Tui
 Na 
was 
shown
 to
 be 
an 
effective 
treatment 
for 
LBP.

Keywords: 
Low 
back
 pain,
 acupoints, Tui 
Na.

Introduction

This
 study
 is 
designed
 to 
determine 
if 
Tui 
Na
 massage 
will 
be 
effective
 in
 relieving
 low
 back 
pain. 

Low back pain
 (LBP) 
is 
described
 as, 
“Pain 
in 
the
 low
 back 
area 
that 
can 
relate 
to 
problems 
with 
the
 lumbar
 spine,
 the 
discs 
between
 the
 vertebrae, 
the
 ligaments 
around
 the
 spine 
and 
discs,
 the
 spinal
 cord 
and
 nerves, muscles 
of 
the
 low
 back,
 internal 
organs 
of 
the 
pelvis 
and 
abdomen, 
or 
the
 skin 
covering 
the
 lumbar 
area” (Medicinenet,
 2002). 

It 
is 
for 
this 
broad
 definition
 that
 approximately 
31
million
 Americans 
experience
 some form
 of 
LBP
 at
 any 
given 
time 
(American 
Chiropractic 
Association, 
2010).

 Deyo, 
Mirza, 
&
Martin 
(2006) produced
 a 
study
 in 
which
 they
 found 
that 
at 
least 
25%
 of 
the
 31,044
 participants 
in 
the
 study
 had
 LBP. Many
 symptoms
 of 
LBP 
include, 
but 
are
 not 
limited
 to, 
pain
 while
 bending 
over, 
stiffness
 of 
the 
back,
 and pain 
down
 the 
leg 
(WebMD, 
2008). 
The
 client 
in 
this 
particular
 study
 injured 
her 
back 
from a 
fall 
and experienced 
pain 
while
 bending 
over 
or 
sitting 
for 
prolonged
 periods 
of 
time.

Rostocki’s 
(2010)
 review
 of 
the 
literature 
found
 that
 there 
are
 over
 50 
different 
treatments
 for 
LBP. 
A
 few different 
treatments 
include
 chiropractic 
manipulation,
 spinal 
decompression, 
acupuncture, electrotherapy,
 transcendental 
meditation, 
and
 hypnotherapy.
 
Few
 of
 the
 50
 treatments, 
like
 those
 listed, actually 
have
 scientific 
evidence 
supporting
 the 
effectiveness 
of
 the
 treatment.
 Surgery
 and
 medication are
 the 
most
 common
 forms 
of
 western
 intervention 
for 
low
 back
 pain
 treatment, 
but
 surgery 
is 
often viewed
 as
 a 
last 
resort 
treatment 
even 
by
 medical 
practitioners. 
Only
 50%
 of 
surgeries
 are
 viewed
 as successful, 
and
 many
 who
 undergo 
surgery 
wish
 they 
had
 not
 received
 the
 surgery 
at 
all.

As 
for 
alternatives
 to
 these 
treatments,
 options
 vary, 
but 
popular 
forms
 are
 massage
 and
 yoga. 
Massage has 
been 
recently 
implemented
 in 
western 
medical 
practice 
and 
has 
proven 
effective 
at 
relieving 
LBP (Furlan, 
Imamura, 
Dryden, 
& 
Irvin, 
2010; 
Cherkin, 
Sherman, 
Deyo, &
 Shekelle, 
2003). 
In 
all 
of 
the
 literature reviewed
 massage 
techniques
 included
 trigger 
point
 therapy,
 Swedish 
massage,
 and
 deep
 tissue
techniques.

Traditional 
Chinese 
Medicine 
(TCM)
 has
 been
 around
 for
 approximately
 4000
 years 
and
 has 
many different 
branches 
and 
applications
 (Mercati, 
1997). 
One
 of 
the 
most
 common
 TCM 
treatments 
is acupuncture. 
Acupuncture 
has
 been
 used
 to 
treat 
many
 different 
disorders 
such 
as 
anxiety, 
frozen shoulder, 
anorexia, 
constipation, 
and
 of 
course,
 LBP
 (Braverman,
 2010).
 Acupuncture
 has
 been
s hown
 to
 have
 significant
 effects
 on 
low
 back
 pain
 as 
opposed
 to
 no
 treatment
 at 
all 
(Furlan, 
Van
 Tulder, 
Cherkin,
  & Tsukayama,
 2005; 
Brinkhaus, 
Witt,
 Jenna,
 Linde, 
& 
Streng, 
2006).

Tui 
Na 
is 
closely
 associated
 with 
acupuncture. 
Instead
 of 
using
 needles, 
the 
therapist 
uses 
thumbs
 and elbows 
to 
affect 
acupoints. 
Common
 techniques 
include
 rolling, 
press
 rubbing,
 chafing,
 kneading, 
and finger 
springing
 (Helm,
 2009). 
There 
is 
very 
little 
research 
which
 includes 
Tui
 Na 
massage
 in
 the 
English language. 
This
 study
 is 
meant
 to 
add 
to 
the
 research 
done
 on
 Tui 
Na 
and 
low
 back 
pain.
 The 
particular massage 
performed 
in 
this 
study 
addressed 
acupoints 
commonly 
used
 in
 acupuncture 
for 
LBP.

The 
client
 filled 
out
 a
 daily 
journal
 recording 
date, 
pain
 level, 
and
 the
 activity 
that
 aggravated 
the
 back. 
The therapist 
also 
used
 a 
goniometer
 to 
measure
 range
 of 
motion 
(ROM)
 of 
low
 back 
flexion.

Methods

Client 
Profile

A 
54
 year
 old 
full‐time 
mother 
and
 house wife
 recently 
injured
 her 
low
 back
 and
 her
 left 
knee
 from
 a serious 
fall. 
The
 client
 twisted 
her 
back
 from
 the 
fall 
and
 now
 almost
 every
 day
 when 
she
 wakes 
up
 she
 has 
to 
stretch 
her
 low 
back 
in 
order 
to 
even 
rise 
out 
of 
bed.
 The
 pain
 is 
continuous
 throughout 
the 
day and
 many 
of 
her 
daily 
activities 
have 
become 
monumental 
tasks 
because 
of
 the
 pain
 she
 endures. Retrieving 
a 
1
lb. 
box 
of
 sugar 
from
 the
 bottom
 shelf 
causes 
excruciating 
pain. 
She
 experiences 
stabbing pain 
whenever 
she
 tries 
to 
stand
 up 
too 
fast 
or 
sometimes
 even
 while
 she’s 
sitting.
 The
 client
 has
 pointed to 
her
 low 
back 
area,
 specifically 
the 
quadratus
 lumborum
 muscle, 
iliac 
crest, 
and
 sacrum
 on
 both 
sides 
as the 
area
 of 
the
 stabbing 
pain.

She
 also 
experiences 
tightness 
in 
her 
right
 knee
 from
 the 
fall, 
but
 explains 
that 
the 
pain
 is 
bearable. 
This tightness 
is 
felt 
in 
the 
hamstring 
of 
her 
right 
leg. 
She
 cannot
 put
 all 
of
 her 
weight
 on
 that 
leg 
so 
she
 walks with 
a 
slight 
limp.

Pain 
medication 
has 
become
 a
 daily 
occurrence 
for 
this 
client, 
although 
none 
are 
prescribed
 (Motrin 
and Aleve 
are
 the
 preferred 
choices). 
Since 
the
 fall 
she 
has 
been 
through 
physical 
therapy, 
electrical
 stimulation 
and 
other 
forms
 of 
massage
 (Swedish).
 The
 physical
 therapy 
definitely 
helped
 to 
improve
 her mobility 
immediately
 after
 the
 fall, 
but
 neither 
of 
the 
other 
therapies 
have
 helped 
her 
at 
all. 
The
 client
 also experiences 
neck
 and
 shoulder 
pain
 and
 occasionally 
the
 right
 arm
 goes
 numb
 and
 limits 
day‐ to‐day activity.

She
 is
 allergic 
to 
grasses 
and
 pollen
 as 
well 
as 
the 
smell 
of 
eucalyptus.
 The
 pain 
in 
her 
back
 is 
increased when
 she 
is
 exposed 
to 
the 
smells 
as 
she
 begins 
to 
sneeze 
excessively.

She 
has
 had
 abdominal 
surgery, 
a
 hysterectomy,
 and
 two 
caesarean
 sections. 
The
 abdominal 
surgery, performed
 in 
2003, 
was
 to 
disconnect
 her 
small 
intestine
 that 
managed 
to 
attach 
to 
her 
bladder. 
The
 first caesarean 
was
 performed
 in
 1984. 
The 
hysterectomy 
was 
performed
 during 
her
 second
 caesarean
 surgery in 
1986. 
She
 does 
not 
feel 
any 
discomfort 
from
 previous
 surgeries 
and 
has
 been
 cleared 
by
 her
 medical physician
 to 
receive 
massage.

Her 
goal 
during
 this
 study
 was 
to 
no 
longer 
deal 
with 
daily 
low
 back 
pain.
 She
 wanted
 to 
be
 able
 to 
bend over, 
sit 
down, 
and 
lie
 down
 without
 having 
to 
worry 
about
 excruciating 
pain.

Treatment 
Protocol

Five
 sessions, 
60 
minutes 
each, 
of
 Tui 
Na 
massage 
were
 performed
 once 
a 
week
 for 
5
 weeks. 

The
 techniques 
used 
were 
as 
follows:

Prone:

1) 
1 
minute
 Palpate 
for 
Ash i
points.

2)
 15
 minutes
 Tui
 Na
 rolling
 on
 quadratus 
lumborum, 
sacrum,
 gluteal 
muscles,
 ham strings 
and
 calves.

3)
 2 
minutes 
place 
fire
 cups
 on 
Ashi
 Points

4) 
5
 minutes 
grasping 
low
 back, 
gluteal 
muscles, 
and
 legs,
 UB
40, 
UB
39, 
GB
30, 
K
10, 
K
3.

5) 
2 
minutes
 moderate 
kneading 
back
 and 
thighs.

6) 
5
 minutes 
press 
rub 
UB
23, 
UB
25,
 Du
3, 
Du
4, 
Ashi 
Points, 
UB
40,
 UB
39, 
K10,
 K
3

7) 
1 
minute
 remove
 fire 
cups

8) 
10
 minutes 
rolling
 low
 back,
 gluteal
 muscles, 
and 
hamstrings.

9) 
3 
minutes 
grasping 
cupped
 areas

10) 
2 
minutes 
pok
 on 
low
 back
 and
 legs

Supine:

11) 
10 
minutes
 rolling 
quadriceps

12)
 5 
minutes 
passive 
movement 
of 
hip
 joint 
w/ 
traction.

Measurement 
Tools

The 
practitioner
 used
 a
 goniometer
 to 
measure 
flexion 
of 
the
 upper
 torso 
in 
relation 
to 
a
 vertical
 wall (range
 of 
motion). 
The 
client
 filled
 out 
a 
continuous
 journal 
indicating 
how 
often
 back
 pain 
occurred,
 what activity 
aggravated 
it, 
and
 pain
 level.

Pain 
Scale

0
  


No
Pain

1‐2 




Mild 
Pain

3‐5 




Moderate
 Pain

6‐8
 



Severe 
Pain

9‐10 


Excruciating
 pain

Results

The
 treatment
 protocol 
was
 to
 meet 
with 
the
 client 
once 
a 
week 
for 
5 
weeks
 the
 same
 day 
and
 time
 every
week. 
ROM
 tests 
were
 performed
 before 
and 
after 
each
 treatment.

Baseline 
week: 
The
 client 
reported 
5 
incidents 
of 
pain 
rating
10, 
mostly
 when
 sleeping 
and
 getting
 dressed
throughout
 the
 week. 
She 
experienced 
moderate
 discomfort 
doing 
daily 
tasks, 
bending
 over,
 cooking, walking ,
 etc. 

ROM:
 16°.

Session 
1:
 The
 client 
showed
 up 
with
 great
 excitement. 
She
 had 
experienced 
5 
instances
 that
 day
 in
 which
she
 had
 to 
stop 
what
 she
 was
 doing 
because
 of
 the
 pain. 
There
 was
 a
lot 
of
 stagnation
 in 
the 
right
 hip
 and
right 
leg.
 Before 
ROM:
 18°

/

After 
ROM:

 92°.
 During
 the 
following
 week
 the 
client 
experienced
 many
incidents 
of 
pain, 
mostly 
in 
the 
morning 
while
 getting 
out
 of 
bed
 and
 getting 
ready
 for
 the
 day.

 Shaving
proved
 very
 difficult 
and 
was
 reported 
as 
the
 only 
10
 throughout 
the 
week. 
Putting 
on 
socks
 often
produced
 a 
9
 on 
the 
pain
 scale.
 The
 client 
often
 reported
 a
 pain 
rating 
of 
8‐9 
(6 
times). 
No 
pain 
in
 left 
knee
all 
week.
 
She
 took
 3
 aspirin 
during 
the
 week.

Session 
2: 

The
 client
 showed
 up 
with 
very
 minimal 
energy. 
She 
had
 done 
a 
lot
 of 
gardening 
before
 showing 
up 
for 
the 
massage. 
She 
experienced
 3
 instances 
during
 the
 day
 in
 which
 the
 pain
 caused
 her 
to
 stop 
what
 she
 was
 doing.
 She
 has 
decreased
 tightness
 in
 right 
leg 
and
 right 
hip,
 very
 sensitive 
points
 in
 left 
hip 
and
 her 
low
b ack.
 Before 
ROM:

 52°

/

After 
ROM:

 76°.
 The
 following
 week
 the 
client
 spent
 a 
lot
 of 
time 
gardening, 
which 
she
 hadn’t
 been
 able 
to 
do 
before. 
Throughout 
the 
week 
client 
reported
 regular
pain 
ratings 
of 
7‐9
 (6
 times),
 usually 
when
 getting
 out
 of 
bed
 and
 putting
 on
 socks. 
Sleeping 
was
 the 
only
incident
 of 
10
 on 
the
 pain
 scale.
 She
 took
 2
 aspirin 
throughout
 the
 week.

Session 
3: 
The
 client
 showed
 up 
in 
a 
lot 
of 
pain,
 and
 had
 increased
 amounts
 of 
tightness
 all 
over.
 Two
 days
before
 treatment
 she
s pent
 6 
hours
 shopping
 and
 walking
 around
 the 
mall. 
She
 explained 
that
 yesterday
she 
was 
very
 sore.
 She 
had
 areas 
of 
tightness
 in 
her
 UB39,
 UB40,
 and
 K10
 points.
 
Bl
37 
point
 was
 also
 very tender
 for
 the
 client.
 
Before 
ROM:

 65°

/

After 
ROM:
 
72°.

 The
 following
 week
 the
 client
 experienced 
a 
pain
rating
 of
 7 
(5 
times), 
usually 
while
 getting 
out
 of 
bed
 and 
getting
 dressed;
 getting
 dressed 
produced
 pain of
 10.
 Took
 1 
aspirin 
all 
week
 and
 had
 2 
days 
of 
no 
pain 
incidents
 at 
all.

Session
 4: 

Treatment
 was
 postponed
 by
 3
 days, 
but
 the
 client
 continued
 to 
fill 
out
 record
 of
 pain
 incidents.
 The
 client 
showed
 up
 in 
good
 spirits. 
In
particular 
UB
39,
 UB40
 and 
K10
 on 
the
 right
 leg
 were
 still
very 
stagnant,
 but
 far 
less 
sensitive.
 
Since 
past
 areas 
of 
pain
 were
 no 
longer
 sensitive, 
the
 therapist
 spent
what 
time
 was 
left 
of 
the
 session 
on 
areas 
not
 worked
 on
 before.
 The
 therapist 
worked
 on 
the
 liver
meridian 
of 
both
 legs
 for 
a 
few 
minutes 
and
 found
 areas 
of 
extreme 
tenderness.
 Before
 ROM:

 80°

/

After
 ROM:
 
82°.
 The
 client
 reported
 1 
incident 
of
 pain
 rating
 10 
and 
1 
incident 
of
 pain
 rating 
8
 throughout
 the
following 
week. 
No
 aspirin 
was 
used
 and 
she 
reported 
3 
days 
of
 no
 pain.
 
Putting
 on
 socks
 produced
 pain
rating
 of 
10.
 Waking 
up
 and
 getting 
out
 of 
bed
 became
 much
 easier 
and
 she
 no
 longer
 worried
 about
twisting 
in 
the 
wrong
 direction.

Session
 5: 

The
 client
 had
 increased
 energy 
and 
felt
 as 
good
 as 
she 
had
 felt 
before
 her
 injury.
 The
 client
 was
able
 to
 bend 
over 
before
 session 
and
 not
 feel 
any
 pain, 
but 
fel t
“normal” 
tightness
 in 
hamstrings
 while
bending 
over. 
The 
therapist 
found
 more
 tenderness 
in 
the
 liver 
meridian.
 
Before 
ROM:

 84°

/

 After 
ROM:

 86°. 
The
 client
 stopped
 recording 
journal,
 but
 no
 longer
 felt 
pain
 on
 a 
regular
 basis. 
Once
 throughout
 the
week 
the 
client 
experienced
 pain
 putting 
on 
socks,
 pain 
rating 
10,
 but
 no
 other 
incidents
 throughout
 the
week.

tuina_img1

Discussion
 and
 Conclusion

The
 graphs 
above
 chart 
the
 progress 
of 
the
 client. 
Figure
 1
 shows
 the 
number
 of 
times
 the
 client
 reported
pain
 throughout
 the 
week.
 As
 can
 be 
seen
 the
 number
 of
 times
 she 
reported
 pain
 decreased
 as
 the 
weeks
went 
on. 
Week 
4, 
however,
 shows
 an 
increase 
in
 numbers,
 but 
it 
may
 be
 attributed
 to 
the
 excess 
walking
she 
did 
that 
week.

Figure
 2 
tracks 
the 
client’s 
most 
frequently 
reported
 pain
 rating. 
Week
 one
 the
 client
 reported 
more
 10s
 than 
any
 other 
number.
 
This 
chart 
shows
 a 
steady 
decrease
 in 
how
 much
 pain
 was
 felt 
by
 the
 client.

 Even
though 
Figure 
1 
shows 
an 
increase 
in 
the
 number 
of
 times 
the
 client
 experienced
 pain, 
Figure 
2
 shows
 that
 the 
pain
 intensity
 decreased
 as 
the
 study
 progressed.

Figure
 3 
shows
 the
 amount
 of 
spinal 
flexion
 the 
client 
was
 able
 to 
perform
 before 
and 
after
 treatment.

 As
can
 be 
seen
 the
 client’s 
flexion
 before 
treatment
 steadily 
increased, 
but
 seemed
 to
 begin 
to 
level 
off
 towards
 the 
end 
of 
week 
six.
 
The
 flexion 
measured 
after 
treatment
 seemed
 to 
remain 
around 
the 
same.

 This 
study
 cannot
 conclude 
why
 the
 flexion 
after 
session
 1 
is 
greater 
than
 the
 other 
weeks,
 but
 the
 ROM
 seemed
 to 
level 
off 
at 
the
 end
 of 
treatment.

Tui 
Na
 has 
proven
 to 
be
 an 
effective 
treatment
 for 
LBP.
 It 
has 
improved
 the 
client’s 
mobility 
and
 decreased
 the 
amount
 of 
pain 
the 
client 
endures
 with 
day‐to‐day
 activities. 
The 
client
 has
 continued
 to
 report 
increased
 mobility 
even 
after
 the
 treatment 
has
 stopped. 
It 
is 
possible 
that 
this 
weekly
 treatment
 has
 provided 
the 
client 
with 
long
 lasting 
pain
 relief,
 but 
only 
a
 continued
 study 
would 
be 
able
 to
 draw
 conclusions 
about
 which
 this
 study
 can 
only 
speculate. 

Tui 
Na
 has
 also 
proved
 itself 
as 
a 
safe
 alternative
 to
 any 
sort 
of
 invasive
 treatment
 such
 as 
surgery. 
Only
 a
 continued
 study
 could
 tell 
if
 the
 treatment 
will
 continue
 to
 produce
 long
 term
 effects.

It 
is
 also 
possible 
that 
with
 the
 client
 recording 
and
 cataloguing 
the 
information
 throughout 
the
 study
 that 
it 
has 
increased
 her 
inner 
sense
 and
 knowledge 
of 
her
 own
 body.
 It 
has,
 in
 the
 therapist’s 
view,
 provided
 her
 with 
a 
knowledge 
that 
she 
would 
not
 have
 otherwise 
had.
 The
 recording 
of 
daily
 information
has
 in 
a 
sense 
provided 
the
 therapist 
with 
a 
much
 more
 detailed
 look
 into 
what
 was
 really
 going 
on 
every
day.
 It 
provided 
information 
to 
the
 therapist 
that
 he
 may
 not
 have
 been
 able 
to 
obtain
 otherwise,
 very
specific 
information 
which 
in 
turn 
allowed
 the
 therapist 
to 
focus
 on 
exactly 
where 
areas of 
pain 
and
discomfort 
were 
located. 

As
 a
 side
 note
 the
 therapist 
reports 
that 
providing 
the
 client 
with
 recording
materials, 
such
 as 
a 
journal, 
to 
catalog
 progress 
may
 complement
 the
 healing
 process 
for
 the
 client.

Having
 the
 client 
record
 daily 
activities 
did
 give
 better
 feedback
 for
 the
 therapist 
to 
review
 and
 use
 to
design 
future
 session 
protocols.

Bibliography

Back
 Pain
 Facts 
& 
Statistics. 
(2010). 
American
 chiropractic 
association.
 Retrieved
(2010, 
May
 13)

Braverman,
S.E. 
(n.d.). 
Medical 
acupuncture 
review: 
safety,
 efficacy, 
and
 treatment
 practices.
 Medical
 Acupuncture
 A 
Journal
 for 
Physicians
 by 
Physicians,
 15(3).

Brinkhaus,
 B., 
Witt, 
C.M.,
 Jenna, 
S., 
Linde, 
K.,
 & 
Streng,
 A. 
(2006). 
Acupuncture 
in 
patients 
with
 low
 back
 pain.
 Archives 
of 
Internal 
Medicine,
166(4).

Carter,
 B. 
(2004). 
Acupuncture 
statistics. 
Brian
 Carter’s 
Pulse
 of 
Oriental
 Medicine.

Cherkin,
 D.C.,
 Sherman,
 K.J., 
Deyo,
 R.A., 
& 
Shekelle, 
P.G.
 (2003).
 A 
Review
 of
 the
 evidence
 for 
the
 effectiveness, 
safety, 
and
 cost 
of 
acupuncture,
 massage
 therapy,
 and
s pinal
 manipulation
 for
back
 pain.
American 
College 
of
 Physicians,
 138(11).

Deyo, 
R.A., 
Mirza,
 S.A., 
& 
Martin, 
B.I. 
(2006).
 Back
 pain
 prevalence 
and
 visit 
rates: 
estimates
 from
 national 
us
surveys, 
2002.
 Lippincott 
Williams
 & 
Wilkins, 
31(23).

Furlan, 
A.D.,
 Imamura, 
M.,
 Dryden,
 T., 
Irvin, 
E.
 Massage 
for 
low‐back 
pain.
 Cochrane
 Database
 of
 Systematic
 Reviews
 2008,
 Issue 
4.

Furlan,
 A.D., 
van
 Tulder, 
M.W.,
 Cherkin, 
D.,
 Tsukayama,
 H., 
Lao,
 L., 
Koes,
 B.W.,
 Berman,
 B.M.
 Acupuncture
and
 dry 
needling 
for 
low 
back
 pain.
 Cochrane
 Database 
of 
Systematic 
Reviews
 2005,
 Issue
 1.

Helm,
 B. 
(2009). 
Tui 
na 
structural
 disorders 
therapy 
treatments. 
San
 Diego,
 CA:
 Taoist 
Sanctuary.
 Medicinenet.com
 (2002). 
Retrieved
 from
 http://www.medterms.com/script/main/art.asp?articlekey=20587
(2010,
May
14)

Rakel, 
D.
P., 
& 
Faass, 
N.
 (2006). 
Complementary 
medicine 
in
 clinical
 practice.
 Sudbury,
 MA:
 Jones
and
 Bartlett
Publishers.

Rostocki, 
A. 
(2006,
 May 
10). 
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May
1)

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Somato-Emotional Integration Reduces Frequency and Intensity of Tension-type Headaches and Alleviates Low Back Pain in a Female Subject

Casie L. Bennett June 23, 2008

Research Case Report
Case Report Supervisors: Jack Baker & Joanne Odenthal Clinical Supervisor: Carole Osborne-Sheets

The author wishes to acknowledge Carole Osborne-Sheets for masterminding the Somato-Emotional Integration Modality that was used in this study. She also wishes to show appreciation for the efforts of Jack Baker and Joanne Odenthal for their tireless guidance and much needed assistance with the creation and completion of this study.

Abstract

Objective: This study investigated the efficacy of a specific massage therapy procedure on alleviating the frequency, intensity and duration of tension-type headaches and the chronic low back pain of a test subject.

Methods: The subject reported experiencing 5+ headaches per week and almost daily lower back pain for the previous six months. Frequency, intensity and duration of headaches and back pain was recorded in a daily pain journal for a baseline period of two weeks prior to the five weeks of massage treatment. Manual therapy was administered once weekly; each session lasted sixty minutes and consisted of a structured protocol directed toward integration of the physical body and the conscious mind.

Results: During baseline, the headache frequency was established at an average of 5.6 incidences per week and low back pain occurred at an average rate of 3 days per week. After the first week of treatment headache incidence was reduced to and remained at an average of 1.5 incidences per weeks and back pain decreased to an average of 1 incident per week. During the treatment period there was a decrease in the intensity of headaches from a level 7 to a level 2 and the use of NSAID pharmacological intervention decreased from 4 pills per week to 0.

Conclusion: The somato-emotional integration massage therapy techniques used in this study have the potential to be a functional, non-pharmacological intervention for reducing the incidence of tension headaches and chronic low back pain.

Key Words: Somato-Emotional Integration, tension headache, chronic back pain, emotional release, massage, body-mind.

 

Introduction

Throughout time touch has been implemented in an effort to comfort, heal and to relieve pain. Touch triggers both metabolic and chemical changes in the body that promote healing (Davis, 1991). Many researchers have discovered that massage therapy shows promising results with regards to chronic pain management (Tsao, 2007). Nearly a quarter of all adult Americans (twenty four percent) had a massage at least once in the last 12 months, and more than a third (thirty four percent) have received a massage in the last five years, according to a survey sponsored by the American Massage Therapy Association® While use of massage is growing, the reasons people are turning to massage therapy are also expanding. More and more, people recognize massage as an important element of their overall health and wellness. There is a clear trend in America today: more people than ever are turning to massage therapy for pain relief. Nearly one-third of adult Americans say they’ve used massage therapy at least one time for pain relief. Of the people who had at least one massage in the last five years, 30 percent report that they did so for health conditions such as pain management, injury rehabilitation, migraine control, or overall wellness (2007 Massage therapy consumer fact sheet).

Emotional tensions are often the main source of physical tension (Kurtz, 1990). Traditionally, emotional release has been achieved through the practice of psychotherapy. In Western civilization, psychologists have predominantly used talk therapy to help their patients release emotional distress. However, some psychotherapists are turning to alternative therapies to complement talk therapy and possibly enhance the overall therapeutic result (Collinge, 2005).

Somatic authors have observed that many of the most important discoveries in psychology have increased relevance when grounded in the experience of the body (Maupin, 2000). Emotional reality and biological ground are the same and cannot, in any way, be separated or distinguished (Keleman, 1985). Our thoughts and feelings influence the body via two mechanisms: the nervous system and the circulatory system. These are the pathways of communication between the brain and the rest of the body (Collinge, 1996). Over two thousand studies regarding mind-body medicine have been published in the last twenty five years. These studies demonstrate through the use of measurable diagnostic tests, that mind-body interactions are real and can be measured (Jacobs, 2001). As Collinge notes, this fact is being recognized in the medical establishment. As evidence he quotes Dr. Kolk, director of the TraumaCenter in Boston: “Current research concludes that traumatic experiences involve the whole person’s emotions and feelings (mind, body and spirit). It is believed that traumatic experience is evidenced at the biochemical/neuromuscular levels and that treatment must integrate cognitive- based narrative therapy (psychotherapy/counseling) with somatic body memory treatment” (Collinge, 2005).

Through the process of receiving massage, many clients discover unconscious tensions, recall memories of past events, or release suppressed emotions (Davis, 1991). Emotional trauma sustained in accidents, loss of loved ones, violent natural or interpersonal experiences and repeated abuse or deprivation often profoundly impact the body’s soft tissue. Through mindful and respectful bodywork, a client is allowed to express these deeply rooted emotions and in doing so, the client’s current stresses and their associated psychological traumas can melt from the body’s soft tissues with a resulting sense of relief and resolution (Osborne-Sheets, 1990).

The clients physical body responds to mind/body therapy rapidly by manifesting positive changes in his or her mood, pain level, or other physiological body functions (Collinge, 1996).

Somato-Emotional Integration is a bodywork modality that promotes body awareness through deep tissue sculpting and various other massage therapy techniques with the intention of interfering with the client’s long held physical and intellectual defenses, thereby allowing deeply rooted emotions to emerge from the body. Through massage techniques, awareness, breath work and guided imagery, Somato-Emotional body work promotes integration of the client’s physical, emotional and intellectual experience of her being (Osborne-Sheets, 1990)

One of the areas where massage has proven effective is in treating chronic pain, and two chronic pain conditions are addressed in study: tension headaches and low back pain. Chronic pain is a serious health condition that approximately fifty million Americans live with daily (Menard & Piltch, 2008). Chronic pain is characterized by pain that continues a month or more beyond the usual recovery period for its cause, or pain that goes on for months or years because of a chronic condition (Goodrich-Dunn, & Greene, 2004). Often, no initial cause for the pain is identifiable. When there is no obvious physical injury, muscle tightness due to stress, anxiety and/or depression is often believed to be the source of the pain (Goodrich-Dunn, & Greene, 2004). Chronic pain is a major cause of absenteeism in the workplace.

One common chronic condition is tension headaches. Tension headaches are defined as headaches that are triggered by mechanical stresses that initiate central nervous system changes in serotonin levels and blood vessel dilation (Werner, 2005). Any kind of ongoing mental or physical stress can change postural and movement patterns, which will lead to muscle spasm. These sustained muscle contractions are often the culprit behind chronic tension headaches (Werner, 2005). Since chronically constricted muscles may reflect chronically constricted emotions (Osborne-Sheets, 1990), it is reasonable to assume that somato-emotional bodywork could provide relief from tension headaches. It has been observed that relaxing from the inside out, rather than from the outside in seems to be important to headache prevention and relief (On the Mark, 1996).

The most common type of chronic pain is back pain (Menard & Piltch, 2008). Massage therapy has been shown to effectively reduced the symptoms of chronic lower back pain (Field, Hernandez-Reif, Krasnegor, & Theakston, 2001). Interventions such as relaxation techniques, stress reduction and conflict management have all been used to help alleviate back pain in direct patient care-givers with great success (Williams, 2007). Therefore, low back pain that has no obvious physical cause may be relieved through somato-emotional bodywork.

Researchers have identified how the ways that we cope with emotions and stressful situations can influence our physical health (Collinge,1996). There is growing evidence that massage and other forms of bodywork beneficially complement traditional medicine. A rising number of conventional healthcare companies now offer complementary alternative medicine to their subscribers (Vanderbilt, 2006). Although there have been many studies done to support the relevance of massage therapy, most have focused on the efficacy of massage for treating medical conditions (Moyer, 2004). Virtually no scientifically based research has studied Somato-Emotional Integration as a specific modality. More research is needed to explore the full potential of psychologically based bodywork.

The objective of this study was to determine if a specific massage therapy program could have beneficial effects on the frequency and intensity of tension headaches and chronic low back pain. A two-week measurement period prior to treatment was used to establish baseline measures. Following the baseline period, a five week treatment program that incorporated somato-emotional body awareness techniques and full-body therapeutic massage was initiated. Post session measurements continued for one week following the treatment program.

Methods

Profile of the client: A thirty year old, married mother of two had been experiencing at least four tension headaches episodes per week for the past six months. She had also been experiencing chronic pain in her lower back. A visit with her regular physician determined that the subject’s pain was not the result of any physical ailments. The subject reported occasional use of over the counter non-steroidal anti-inflammatory drugs (NSAID) in conjunction with a microwaveable heating pad and stretching exercises to alleviate her lower back pain as recommended by her physician. She was instructed to continue with pharmacological treatment as necessary, but not to begin new pharmacological intervention related to headaches or the back pain during the course of this study. It is interesting to note that the client was a body worker who had a very strong body-awareness and was able to give the practitioner very anatomically specific feedback throughout the course of this study.

Study Overview: The eight-week study consisted of baseline headache and back pain measures recorded during the first two weeks, followed by once weekly, one-hour Somato- Emotional Integration, massage therapy sessions for the remaining five weeks of the study. Beginning two weeks prior to the first session and continuing one week beyond the final session, a daily log book was completed by the subject each evening before retiring for sleep and each morning upon waking. The logbook recorded the frequency and intensity of the day’s headaches, as well as the frequency, intensity and location of the day’s back pain. The duration of the subjects sleep hours and any pain related interruptions of the subject’s sleep patterns were also noted. In addition, the subject made note of any pharmacological intervention that was used to alleviate pain on the occasions that she resorted to using them. Headache and backache intensity was determined by the subject drawing a mark along a visual analog scale ranging from 0-10 centimeters, with descriptors at each end. The left side (or zero station) indicating no pain and at the right side (or ten station) indicating the worst possible pain. The distance from the zero point to the subjects mark was measured in centimeters. The subject noted the location of her back pain by drawing mark that corresponded with her own body on a pain diagram that consists of two sketches of the human body, both in anatomical position, one prone and one supine.

Treatment Plan: In this study, the client received a total of five, one-hour Somato- Emotional Integration sessions. The bodywork sessions were conducted once a week for five weeks consecutively and were separated by at least 120 hours and no more than 168 hours. Manual therapy and guided imagery and breath work was conducted by a Holistic Health Practitioner with over 1800 hours of combined classroom time and clinical treatment experience. A one-hour treatment protocol was designed and typically consisted of four distinct phases within the sixty-minute time frame. The descriptions of each phase are as follows. (Note: The subject’s position on the table varied according to the changing needs of the client.)

Each session begins with greetings and a preliminary intake that consists of verbal interaction as well as visual observations. The therapist orients the client to the procedures and obtains permission to touch. At this stage the frame of mind that the client is in is defined as “Ordinary Awareness.” This term is used to describe a person who is behaving as they normally would, in an outwardly oriented, goal directed manner. Their awareness is usually narrowly focused and ruled by habits and routines in space and time (Barstow & Johanson, n.d.).

The second phase of the session begins with breathing exercises and light effleurage as the parasympathetic nervous system are stimulated and the client settles into a more relaxed state and begins to have more body awareness. The massage therapist makes contact over the heart chakra, and may lead the client in a breathing meditation. At this point the client is entering what is referred to as the “Witness State,” which is defined as the client experiencing a mindful consciousness that can simply stand back and observe the inner experience without being caught up in it (Barstow & Johanson, n.d.).

During the third phase, which constitutes the bulk of the session, the client is usually completely in witness state. At this time the massage therapist incorporates bodywork techniques such as deep tissue compressions, sensory repatterning, and passive joint movements as she sees fit, directed by the emotional and physical cues expressed by the client. The massage therapist listens attentively and asks open ended questions to promote the client’s thought process and possible emotional release. The therapist may also use visualizations, past incident processing or body part dialogue as a tool to further explore an area of interest in the clients body. During this phase the therapist may observe the client express his/her “Inner Child,” a state of consciousness in which the client is aware of their current adult status and at the same time is experiencing the memories, feelings, thought modes and speech patterns of childhood (Barstow & Johanson, n.d.). During this phase the client is most likely to experience emotional processing or what is known as “riding the rapids,” a state of consciousness characterized by the loss of mindfulness, uncontrollable emotional release, spontaneous movements and tensions, waves of memory and feeling, and the use of tension and posture to control the flow of feeling (Barstow & Johanson, n.d.). The massage therapist is present as a non-judgmental support system, to assist with the client’s processing and to keep the client safe on the table.

The last phase of a somato-emotional session is closure. The client is told that their time has come to an end, and the massage therapist will check-in to be certain that the client is ready to move on from the subject matter that they were working with. Closing the session involves making tactile contact with the whole of the body with the intention of grounding the client and helping the client return to ordinary awareness. This contact may include effleurage, palm presses, passive movement or zone therapy reflexology on the feet with an emphasis on bringing the client’s attention back to the present and their awareness and their breath back throughout their entire body from head to toe. Finally the therapist will make contact with the three centers (head, heart and lower abdomen) in a final act of integrating the entire body. When the bodywork session is complete, the client is left alone to get up off the table and to dress. Once they are ready, the massage therapist discusses any revelations that occurred during the session. The client is often asked what they would like to remember from the day’s work and to speak it aloud. Then the massage therapist will repeat that back to the client in order to solidify the memory. Finally, pleasantries and goodbyes are exchanged and the client leaves. The massage therapist then documents the client’s progress using a Somato-Emotional Integration specific log, in order to record what occurred before, during and after each session.

Report of Client Visits

Session 1: The client arrived reporting pain and discomfort in the gluteal region due to increased physical fitness training. After the initial greetings and touching-in described in phases one and two, the practitioner focused on releasing the muscles in the gluteal region using a combination of deep tissue compressions and passive joint movements. During the course of these compressions the subject experienced visual images that she connected to a source of emotional stress in her life, in addition to muscular release in the area. While processing the manifestation of stress in the gluteal region, the client’s shoulders became tight and her right shoulder became noticeably elevated. The client confirmed that she was experiencing pain in that area. After treating both shoulders with deep tissue compressions and skin rolling, the client reported that the discomfort was moving down her arms, so the therapist continued the deep tissue work down each of the subject’s arms and out to the ends of her finger tips. As a result, the client noticed a searing pain in her IT band near where her hand was laying at her side. In this area the therapist used deep tissue compress-and-follow style strokes combined with gentle rocking of the hips to release the IT band beginning at the greater trochanter and ending just lateral to the knee. This resulted in a strong physical release down the entire right side of her body accompanied by vivid, colorful imagery. This was the end of the bodywork processing segment of this session. The practitioner then proceeded with closure as described in the last phase of the treatment plan, and the practitioner prompted the client to verbalize the connections that she had made during the session before leaving.

Session 2: The client arrived reporting that she had a stiff neck after sleeping poorly the previous night. After the initial greetings and touching-in described in phases one and two, the practitioner began with passive joint movement of the head and neck, followed by traction applied at the occipital ridge. After applying Shiatsu compressions along the sagittal suture of the skull, the therapist used deep tissue compressions to release the frontalis muscle of the forehead as well as the masseter muscle of the jaw. While working in both of these locations the client experienced intense emotional release consisting of clenching of her hands followed by loud sighing and vocalizations of anger and frustration. The client noticed that the anger seemed to be “trying to escape” down her neck toward her right arm and so the therapist skin-rolled down the right side of the neck, across the shoulder and down the right arm, resulting in yet another loud sigh and a visualization of the anger leaving her body. In order to maintain balance in the client’s body, the same pattern was performed on her left side. At this juncture, the client reported a heaviness that had settled in the area over her heart. As a response to this observation, the practitioner responded by addressing the pectoral muscles. The therapist released both sides of the client’s chest using deep tissue compressions and skin rolling techniques. While doing so, the client’s lips began to quiver and several tears escaped as she talked about the feelings that were coming to the surface as a result of work in that area. Work on the pectoral muscles led to a feeling of tension in the client’s abdominal muscles. The therapist performed a few circulatory style effleurage strokes in a clockwise direction over the subject’s abdominal area, followed by several deep Shiatsu style compressions, combined with deep breathing to further enhance the release of the muscles in the area. This was the end of the bodywork processing segment of this session. The practitioner then proceeded with closure as described in the last phase of the treatment plan, and the practitioner prompted the client to verbalize the connections that she had made during the session before leaving.

Session 3: The client arrived reporting tension in her lower back and shoulder girdle. After the initial greetings and touching-in described in phases one and two, the practitioner began with passive joint movement of the hips and traction of the legs. This was followed by passive joint movement at the shoulder joints and traction of the arms, and finally with passive joint movement of the neck followed by traction at the head. The client noticed that she was clenching her teeth together and she requested that further attention be paid to her jaw muscles. The therapist complied to her request by performing deep tissue compressions in the muscles that were displaying obvious tension, and by guiding the client in a few stretching exercises that consisted of opening the jaw wide and moving the mandible from side to side. As the client moved her jaw, she was compelled to make throat-clearing noises and to cough repeatedly. As she did so, the client visualized images of symbols that she connected to events that had been causing her grief in her life. The client experienced a tightening of her gluteal muscles and noticed that her back had begun to ache again as she thought about the stressful events. The subject was then asked to move into the prone position on the table, where the therapist focused on the gluteal muscles using deep tissue compressions and rhythmic rocking motions to facilitate release. After completing both sides of the body, the therapist followed up with deep tissue compressions into the sacro-iliac joints. The work in this location was accompanied by loud sighs and exclamations of relief. Next, at the client’s request, the therapist concentrated on releasing both the right and left quadratus lumborum muscles. The softening of these muscles led to a feeling of tension in the area of the thoracic vertebrae. The therapist responded to this observation by first skin rolling the entire back and then using deep tissue compressions to work down the client’s erector muscles from cervical vertebra seven to the iliac crest. The sudden release of muscular tension in this area led the client into a fit of child-like giggles. When the giggles subsided, she reported feeling “warm and safe.” The practitioner then proceeded with closure as described in the last phase of the treatment plan, and the practitioner prompted the client to verbalize the connections that she had made during the session before leaving.

Session 4: The client arrived and expressed a need for release in the area of her hamstrings. After the initial greetings and touching-in described in phases one and two, the practitioner began the fourth session with the subject in the prone position on the table. The therapist started with Thai- style palm presses up the subject’s legs and over her entire back. Next, she combined passive stretching of the quadriceps with deep compressions into the gluteal muscles to achieve release. The therapist then focused on the hamstrings using deep tissue compressions combined with breathing exercises and a brief body-part dialogue. The client made several emotional connections, linking the tension in her hamstrings to the pain in her low back. Work on the client’s hamstrings led to a feeling of achiness in her left IT band. The therapist once again addressed the IT band with deep tissue compressions and the rhythmic rocking of the hips. Again, the client experienced vivid imagery and a rush of emotion as the therapist reached the end of the compression, just lateral to the knee. At this time the client reported a feeling that her quadriceps were “stuck to the table.” The practitioner asked the client to move into the supine position, and then addressed the subject’s thighs by rhythmically rolling the quadriceps back and forth across the femur before finishing with deep tissue compressions into the bellies of the muscles. The practitioner then proceeded with closure as described in the last phase of the treatment plan, and the practitioner prompted the client to verbalize the connections that she had made during the session before leaving.

Session 5: The client arrived and reported that at that time, she was not experiencing pain or stiffness in any particular region of her body. After the initial greetings and touching-in described in phases one and two, the practitioner began with guided imagery and a breathing meditation with the intention of bringing the subject’s awareness to the areas of her body that were in need of attention. During this time the client visualized many images that led her to new revelations about how her body was being affected by her current life situations. The new connections that she made brought tears to her eyes and a full body shudder. These exercises led the client to express a need for more work on her head, neck and jaw. With the subject in the supine position on the table, the therapist began with deep tissue compressions into the upper trapezius on both sides of the body. Continuing with deep tissue compressions, the therapist addressed the attachments of the levator scapula, the sternocleidomastoid and the scalene muscles. Next, the therapist used deep compressions to release the muscle attachments at the occipital ridge. In this area, the client experienced images that affected her profoundly. As she spoke about her thoughts and feelings regarding these images, her voice took on a very strong and assertive quality. The therapist then performed passive stretching of the subject’s neck muscles before employing passive joint movement of the head and neck, after which the client reported a feeling of floating. While massaging the muscles of the face, the temporalis muscle and the masseter both triggered emotional release in the form of a large sighs and groaning. The therapist completed the work with a circulatory-style scalp massage and gentle stroking of the subject’s hair. The practitioner then proceeded with closure as described in the last phase of the treatment plan, and the practitioner prompted the client to verbalize the connections that she had made during the session before leaving.

Results/Discussion

Headache, experienced almost daily prior to manual therapy, was reduced to an average of 1.5 incidences per week after the first week of treatment. The reduction in headache frequency was maintained through the course of treatment. The intensity of the headaches that the subject experienced was reduced from an average intensity level of 7 prior to treatment to an average intensity level of 2 after the first session and continuing on throughout the following five weeks. These results represent a remarkable change in the subject’s life, gifting her with substantially more productive hours in each week.

The average number of days that the subject reported back pain that was severe enough to interfere with her daily activities was reduced from an average number of 3 incidences per week before treatment to an average of 1 incidence per week after the first week of treatment. Over- the-counter medications are commonly used to treat tension headaches as well as low back pain. During the course of this study, the subject decreased her consumption of over-the-counter analgesic medications by 100%. Prior to receiving somato-emotional bodywork sessions, the subject ingested an average of 6 NSAID tablets per week to help alleviate her pain. In the 5 weeks that followed the first session, the subject did not need to use any sort of pharmacological intervention.

It should be noted that the subject suffered from a head cold during the final week of treatment. The headaches that were reported during that week could have been a result of the virus that she had contracted as opposed to tension. Since the subject did not specify what type of headaches she had that week, all three headaches were included in and calculated into the totals for that week. If they had not been included, the average number representing the reduction in headache pain would have been dramatically lower.

The somato-emotional integration bodywork treatment protocol used in this study was successful in reducing pain associated with tension headaches and the subject’s low back pain. However, components other than massage could be responsible for or may have contributed to the overall effect. For example, the subject was following a regular regimen of specific stretches each morning, as directed by her regular physician in an attempt to alleviate low back tension. This may have contributed to the success of this study in the area of chronic low back pain. It would prove interesting to stage a case study based solely on the effects of stretching on chronic low back pain. The subject in this study observed a meaningful reduction in headache and low back pain frequency and intensity. These findings suggest that a larger, more thorough study that includes a non-headache control group is warranted. Further investigation into the role of somato-emotional integration therapy for alleviating other types of chronic pain is called for as well.

The results of this study suggest that somato-emotional integration therapy is effective at reducing the frequency and intensity of tension headaches in this subject. The reduction in headache frequency and intensity was noted during the first week of treatment, which suggests that SEI therapy may exhibit an effect with as few as one or two treatments. The results of this study also suggest that somato-emotional integration therapy is effective at reducing the occurrence of chronic low back pain.

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Case Study Bibliography

2007 Massage therapy consumer fact sheet: Wellness drives Americans’ growing use of massage therapy. Retrieved April 24, 2008, from http://www.amtamassage.org/media/consumersurveyfactsheet.html

Barstow, C. & Johnson, G.(n.d.) Glossary of hakomi therapy terms. Retrieved April 24, 2008, from http://www.hakomiinstitute.com/Forum/Issue13/Front.doc

Chandler, C., Moraska, A., & Quinn, C. (2002) Massage therapy and frequency of chronic tension headaches. American Journal of Public Health, 92(10), 1657-1661. Retrieved April 30, 2008, from Academic Search Premier database.

Collinge,W., Sabo,S. & Wentworth, R. (2005) Integrating complementary therapies into community mental health practice: An exploration. Journal of Alternative and complementary medicine, 11(3), 569-574.

Collinge, W. (1996). Mind/body medicine: The dance of soma and psyche. In The American holistic health associations complete guide to alternative medicine. Warner Books. Retrieved May 12, 2008, from http://www.healthy.net/scr/article.asp?Id1949

Davis, P. K. (1991). The power of touch. Carson, CA: Hay House, Inc.

Dychtwald, K. (1977). Bodymind. New York: Pantheon Books.

Field, T., Hernandez-Reif, M., Krasnegor, J., & Theakston, H. (2001) Lower back pain is reduced and range of motion increased after massage therapy. International Journal of Neuroscience,106(3/4), 131. Retrieved April 24, 2008, from Academic Search Premier database (00207454)

Goodrich-Dunn, B. & Greene, E. (2004). The psychology of the body. Philadelphia: Lippincott, Williams & Wikins.

Hannum, J., Moyer, C. & Rounds, J. (2004) A meta-analysis of massage therapy research. Psychological Bulletin, 130(1), 3-18.

Jacobs, G. D. (2001). The physiology of mind-body interactions: the stress response and the relaxation response. Journal of Alternative Complementary Medicine, 7(1), 83-92. Retrieved April 24, 2008, from PubMed database (11822639)

Keleman, S. (1985). Emotional Anatomy. Berkeley, CA: Center Press.
Kurtz, R. (1990). Body-centered psychotherapy: The hakomi method. Mendocino, CA:

LifeRythm.
Maupin, E. (2000). Body epiphany: the somatic viewpoint in bodywork. San Diego: Maupin.

Menard, M. B. & Piltch, C. (2008) Massage soothes chronic pain. Massage Therapy Journal, 47(1), 153-155.

On the mark. (1996). Prevention, 48(1), 24. Retrieved April 30, 2008 from Academic Search Premier database. (0032-8006)

Osborne-Sheets, C. (1990). Deep tissue sculpting. San Diego: Body Therapy Associates.
Tsao, J.C.I. (2007). Effectiveness of massage therapy for chronic, non-malignant pain: A review.

Advance Access Publication, eCAM, 4(2),165–179.
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mental health practice. Massage & Bodywork, Feb./Mar. 140-143.
Werner, R. (2005). The massage therapist’s guide to pathology (3rd ed.) Philadelphia: Lippincott,

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Williams, M.(2007). Managing physical stress can lead to less emotional stress. [Electronic version]. ONS Connect, March 2007, 24.


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Impact of NMT in the treatment of postural misalignment and chronic hip, low back, and knee pain

Caylon Ellis

Research Case Report
Bodywork Modality Supervisor: Jack Baker June 23, 2008

Abstract

Objectives: The intent of this study was to explore the possible relationship between the use of Neuromuscular Therapy (NMT) to bring about structural changes in the body to improve postural alignment and the subsequent reduction in chronic hip, low back, and knee pain.

Methods: The subject reported twenty years of chronic hip pain with low back and knee pain developing within the past four years. Frequency and duration of pain were recorded in a daily journal for a baseline period of one month before treatment and during treatment. Pre- and post- treatment PSIS/ASIS discrepancy was recorded to track anterior pelvic tilt, and before and after pictures documented postural changes. NMT was administered for five sessions over four weeks. Each session led up to the anterior pelvic tilt correction.

Results: PSIS/ASIS discrepancy decreased over the length of treatment, and either decreased or stayed the same after each session. Significant changes in posture were visible after treatment. Pain experienced by the client was reduced over the course of treatment and after each session.

Conclusions: These findings suggest that NMT can effect structural changes and postural re- alignment which corresponded to a reduction in chronic hip, low back, and knee pain.

Key Words: Neuromuscular therapy, chronic pain, low back pain, anterior pelvic tilt, postural misalignment, clinical massage, trigger point therapy

Introduction

The intent of this study was to explore the possible relationship between the use of Neuromuscular Therapy (NMT) to bring about structural changes in the body to improve postural alignment and the subsequent reduction in chronic hip, low back, and knee pain in one client.

Congress has declared 2000-2010 as the Decade of Pain Control and Research (American Pain Society [APS], 2008). In 2005, the National Pain Care Policy Act became the first proactive pain care legislation introduced to Congress (APS, 2008). This bill reflects a nationally recognized need to increase resources for people who suffer from pain.

Reflecting a need to expand resources for pain, there has been an increasing trend toward the use of therapeutic massage for pain relief. Massage for pain management is now recommended by health care providers, and is even provided by several hospitals (Gatlin & Schulmeister, 2007). As massage becomes more mainstream, people with low back pain commonly turn to massage therapy for relief (Melancon & Miller, 2005). In fact, more people seek alternative therapy for low back pain than any other condition (Cherkin, Sherman, Deyo, Shekelle, 2003).

A survey commissioned by the American Massage Therapy Association found that medication and therapeutic massage tied as the favored type of pain relief (AMTA, 2005). In this same study, 93% of the respondents were in accordance that massage therapy is an effective method to reduce pain (AMTA, 2005). It is worthwhile to examine existing studies and conduct further research to determine the validity of such a widespread belief.

NMT is a specific type of massage that is dedicated to pain management. It is defined by the Associated Bodywork & Massage Professionals as a, “comprehensive program of soft-tissue manipulation [that] balances the body’s central nervous system with the musculoskeletal system . . . the goal is to help relieve the pain and dysfunction by understanding and alleviating the underlying cause . . . to locate and release spasms and hypercontraction in the tissue, eliminate trigger points that cause referred pain . . . and restore postural alignment, proper biomechanics, and flexibility to the tissues” (ABMP, 2007). In America, NMT grew out of a collaboration of ideas from pioneers such as Travell & Simons, Raymond Nimmo, Paul St. John, and Judith DeLaney (DeLaney, 2008). Dr. Travell provided a strong foundation with her myofascial pain and trigger point (TP) research (Travell & Simons, 1983), which was further explored and developed by Raymond Nimmo from the 1950s to the 1980s (Cohen & Gibbons, 1998). While Travell primarily used injections to treat TPs, Nimmo developed a method he called Receptor- Tonus Technique to deactivate TPs using a mechanical technique of applying force (Cohen & Gibbons, 1998). Inspired by one of Nimmo’s seminars, Paul St. John attended massage school, brought the concepts of TPs and NMT into the massage world, and developed NMT St. John method (DeLaney, 2008). Judith DeLaney taught the St. John method and after five years branched off with her own style called NMT American version (DeLaney, 2008). Although the methods used in these different styles may vary, one of the common goals shared by all styles of NMT is to reduce pain by finding and deactivating TPs.

Trigger points are one of six principles NMT aims to address (Baker, 2003). According to Travell and Simons (1983) a myofascial trigger point is a, “hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle’s fascia, that is painful on compression and that can give rise to characteristic referred pain, tenderness, and autonomic phenomena.” The source of referred pain is the TP, but the pain is actually felt somewhere else, often remotely, in the body (Travell & Simons, 1983). TPs commonly develop within ischemic tissue, another principle of NMT, which is an irritated area of constricted blood that prevents oxygen and nutrients from entering and metabolic waste products from exiting (Baker, 2003). The other four principles are lesions (tears in muscles or connective tissue), nerve compression and entrapment, postural distortion, and biomechanical dysfunction (Baker, 2003). The focus of this case study will be on NMT’s ability to bring about structural changes to correct postural distortions and to locate and deactivate any TPs that have developed in ischemic tissue, causing pain to the low back, knee and hips.

Postural distortion and biomechanical dysfunction are the “root causes of discomfort, pain and predisposition to injury,” from NMT’s perspective (Baker, 2003). According to Davis’ Law, muscles that are shortened become hypertonic and possibly stronger, and muscles that are longer lose tonus, become weak, and cause pain (Baker, 2003). If posture becomes distorted, a pattern of shortened and lengthened muscles develops in the body. Travell and Simons (1992) acknowledge that distortions in the lower girdle (structural imbalances) can also cause postural misalignments and pain in the upper body. Following this logic, one can see the link between structural imbalances in the pelvic girdle and postural misalignment, and their ability to cause a shortening of musculature in the low back extensors and hip flexors and the possibility of it leading to chronic pain in the low back, hip, and knee. The goal of NMT is therefore to induce structural changes in an area, reversing an anterior tilt to the pelvis for example, to bring about overall postural alignment and a reduction of pain.

A case study of a 15-year-old girl with asymmetrical hip rotation and pain in the right knee for eight months without injury, found a connection between pelvic asymmetry and patellofemoral pain (Cibulka & Threlkeld-Watkins, 2005). This study suggests the potential of a postural distortion in one area of the body to cause ischemia and TPs to develop in the tissue and radiate pain to other areas. In another study that examined 150 people with apparent leg-length difference, pelvic asymmetry, and lateral curvature of the spine (all postural distortions), 55 complained of lumbosacral pain, and almost half of them had pain radiating down the leg (Timgren & Soinila, 2006). In this same study, people with improved alignment had a statistically significant (P<.01) correlation with an improvement of condition, referring to a reduction of pain (Timgren & Soinila, 2006). It was also noted in Timgren and Soinila (2006) that, “none of the patients with relapsing asymmetry showed improved condition.” Although the treatment used in this study was not NMT, it would be interesting to see if massage in the form of NMT could effect these same structural and postural changes and reduction of pain.

The impact of proper body alignment and pain prevention is also indicated in a discussion of nonpharmacologic methods to alleviate pain for cancer patients that stressed the importance of patient positioning to maintain alignment and prevent pain (Gatlin & Schulmeister, 2007). Another study found that increased thoracic kyphosis (hunchback posture) is correlated with increased multi-segmental spinal loads from T2 to L5, which is connected to dysfunction and pain (Briggs, van Dieen, Wrigley, Greig, Phillips, Lo, et al., 2007). Although the aforementioned studies have found or suggested positive correlations between postural misalignments and pain, the possibility of using massage in the form of NMT to effect postural changes, thus reduce pain, has rarely been rigorously explored and documented. The studies that have been done are general in nature and focus on massage’s ability to reduce pain without making the connection to postural imbalances and NMT.

There is evidence to show that massage therapy in general reduces pain and is superior to some techniques such as relaxation therapy, acupuncture, placebo treatments, sham laser therapy, exercise, progressive muscle relaxation, and self-care educational materials (Cherkin et al., 2003; Hernandez-Reif, Field, Krasnegor, Theakston, 2001; Tsao, 2007). Other studies contradict the efficacy of massage in reducing pain and found that massage therapy was not any more effective than techniques such as corsets, exercise, spinal manipulation, and transcutaneous electrical nerve stimulation (TENS) (Tsao, 2007; Vernon, Humphreys, Hagino, 2007). In another study, evidence supporting the efficacy of massage was not convincing enough because it was not based on enough rigorous clinical trials (Melancon & Miller, 2005). Within one review, massage was found to be more effective for treating low back pain than relaxation therapy, acupuncture, sham laser, and self-education, and less effective than spinal manipulation and TENS (Chou & Huffman, 2007). None of the trials examined in Chou and Huffman described the types of massage used, and they only tracked results during or up to one month after treatment. These results therefore reflect short-term effects of massage. The inconsistency in results and data and a lack of long-term studies translates to the need for more rigorous research.

A systematic review on massage studies from 2007 only found one trial that directly compared different massage techniques (Chou & Huffman, 2007). In this trial, cited in two reviews, acupressure/pressure point massage was found to be superior to Swedish massage with regards to pain relief, which indicates that certain techniques or modalities may be more effective than others when it comes to relieving pain (Chou & Huffman, 2007; Tsao, 2007). Given the previous explanation of NMT as a therapy that addresses the underlying causes of chronic pain, there is a need to further examine its effects on the treatment of postural misalignment by bringing about structural changes, and long-term pain relief. Treating pain without taking underlying issues into account will not result in long-term healing.

TP therapy has shown significant results in the reduction of pain in the head, neck, and shoulders (DeLaney, Leong, Watkins, Brodie, 2002; Eisensmith, 2007). It seems logical to assume this type of therapy would be just as effective on other areas of the body, which this study sets out to examine. TP therapy has also been found to be safe and noninvasive (Delaney et al., 2002). In one study that used Swedish, Deep Tissue, and TP therapy to treat people with pain all over the body, unexpected positive side-effects such as improvement in mood, digestion, and respiration more than doubled negative side-effects such as bruising, headache, fatigue, and soreness (Cambron, Dexheimer, Coe, Swenson, 2007). In a study examining the effects of manual therapies on chronic mechanical neck pain, spinal manipulation or mobilization was found to be superior to massage (Vernon et al., 2007). It was specifically stated, however, that none of the trials in this study included TP therapy. It is valuable to observe the possibility that NMT and TP therapy could be more effective than other massage modalities in reducing pain. In a study that was previously discussed, acupuncture massage was found to be superior to Swedish/classical massage (Chou & Huffman, 2007; Tsao, 2007). Although the study fails to provide a description of acupuncture massage, the results suggest that different types of massage have different effects. Not many modalities besides Swedish have been evaluated and compared.

NMT is indicated for this study because structural and postural changes have been shown to be made in the body using NMT following repeated sessions (Hamm, 2006). This study examined the treatment of linked pathologies and found positive results in the reduction of pain, improved ROM, improved sleep, and changes in posture (Hamm, 2006). This study also concluded that more research is needed for, “massage’s potential for simultaneous beneficial influence on multiple systems and processes in the treatment of pain and dysfunction…” (Hamm, 2006). NMT was combined with other techniques in this study, so it is difficult to determine the efficacy of NMT alone in treating pain. Based on the statistical findings in the aforementioned research and overall lack of studies examining specific types of massage, the current study aims to demonstrate that NMT addresses the underlying causes of pain by effecting structural changes, which leads to postural re-alignment and long-term relief from chronic pain.

Methods

Client Profile

A 60 year old male business owner and father has been suffering from chronic hip pain for the past twenty years. He has also developed chronic low back and knee pain within the past four years. The low back starts out stiff every morning and the pain level is usually mild but occasionally severe. The pain lessens throughout the day unless aggravating activities cause it to persist. He experiences sporadic stabbing pains in his left hip that are severe and only last a few seconds, and moderate achy pains that radiate down the leg and can last for days. He experiences mild stiffness in the left knee that can last from hours to days and occurs a few times a month. The client also reports moderate to severe pain in his left shoulder that can last from hours to days that limits his mobility. One to two times a year, pain in the left shoulder is severe and the client cannot turn his head at all. Although the client occasionally uses ibuprofen for aches and pains, he is not currently taking any prescription drugs for pain management. He is currently taking Levoxyl for low thyroid, Advair for asthma, baby aspirin, glucosamine, and fish oil. He has never experienced any major health problems or surgeries that would contraindicate massage.

When the client was eight years old he was diagnosed with Legg-Calvé-Perthes Disease in his left hip. It is a degenerative disease of the hip joint where ischemia and osteonecrosis (bone death) of the femur cause the ball of the hip to collapse and become flat (National Osteonecrosis Foundation, 2000). The client spent three years on crutches and one year with lifts in his shoes. He has never received any physical therapy, chiropractic, or any other treatments to address structural and postural imbalances resulting from changing walking patterns to protect the affected joint. A side effect of this disease that often occurs later in life is osteoarthritis of the hip, along with knee and back pain (NONF, 2000). Other repetitive motions have also contributed to the client’s experience of pain in the low back, hip, and knee. For the past 35 years, work related repetitive activities have included driving for at least 6 hours a day, carrying a 20 pound tank around with the left arm, and crawling through attics. Massage in the form of NMT is indicated to address structural and postural imbalances that have most likely initially developed from Legg-Calvé-Perthes Disease and have been exacerbated over the years by the aforementioned repetitive activities.

Baseline Postural Assessment

A month before treatment began, an assessment of posture was conducted by examining the client from four different positions in front of a plumb line. Gait was examined and range of motion tests exposed several structural imbalances and postural misalignments in the client’s body. The client walks with both feet turned out (laterally rotated) and kicks the left hip out with every step. The head juts forward, and both shoulders have a slight medial rotation. The left shoulder is slightly elevated, causing the right arm to appear longer. There is an overall rotation of the torso to the left, accompanied by exaggerated kyphotic thoracic and lordotic lumbar curves. The left iliac crest appears to be slightly lower than the right. An anterior pelvic tilt is indicated by a discrepancy of 2 1⁄4 inches between the posterior superior iliac spine (PSIS) and the anterior superior iliac spine (ASIS). The right foot appears to have a higher arch and the left medial malleolus is slightly lower. When the client is laying supine, the left leg appears slightly longer.

Treatment Plan

A treatment plan consisting of five sessions over four weeks was designed to address the client’s areas of chronic pain. Two sessions were conducted in the first week, followed by a session every week for the duration of the treatment. The client did not expect to have his pain completely disappear after five bodywork sessions, and merely expressed a desire to experience a reduction in the frequency of pain.

A postural assessment revealed that an anterior pelvic tilt is the chief causative factor of postural misalignment in the body. The sessions were strategically designed to release the muscles holding the pelvis in an anterior tilt to facilitate the anterior correction at the end of each session. Chronically contracted and short muscles in this posture are hip flexors and low back extensors, and they must be treated and stretched. Following this logic, the deep lateral rotators, adductors and iliopsoas were addressed first. The distance between the PSIS and ASIS was measured immediately before and after each session to track any changes from the anterior pelvic correction. This study could be improved by using more exact methods to measure PSIS/ASIS discrepancy. In this study, the bony landmarks were palpated and marked with a dot. The distance between the dots was measured with a cloth tape measure. The measurements were somewhat accurate but could benefit from being more exact with specialized calibration tools.

The pelvic tilt was also measured by tracking the discrepancy between the left and right medial malleoli before and after each session. All of the treatment techniques and choices for session design were based on the NMT manual by Jack Baker, personal consultation with Jack Baker, and 1230 hours of combined classroom training and clinical experience with 120 hours of specialized training in NMT.

Treatment Protocol

Session 1. Lateral hip, adductors sidelying, anterior correction

  1. Place client in sidelying position with top leg straight and bottom leg bent for cross-fiber

    examination of gluteus medius & minimus from greater trochanter to iliac crest.

  2. Cross-fiber and with-fiber tensor fascial latae from iliac crest to greater trochanter.
  3. With both legs bent, deep tissue compress and follow down IT band from greater trochanter

    to tibia.

  4. Use thumbs and fingertips to examine edges of IT band on the lateral knee and up at the

    greater trochanter.

  5. Adjust client so bottom leg is straight and top leg is bent forward at the knee and supported

    with a pillow. On the bottom leg, bone clean along ischium and ischiopubic ramus for origin

    of adductor magnus.

  6. Cross-fiber adductor muscle bellies down length of the adductor compartment.
  7. Sink & melt on adductor tubercle insertion of adductor magnus on medial knee.
  8. Finish with gentle cross and with-fiber circulatory strokes along adductor compartment.
  9. Have client turn to other side and repeat steps 2-9 above.
  1. Client supine: pelvic rocking (client’s knees up and feet together, allows knees to open and rock on angle parallel with femurs, pushing with one hand on left ASIS and pulling with right hand around iliac crest and vice versa) until it gets easier and goes farther.
  2. SI Joint Decompression: Client sidelying: heel of hand on gluteus medius and TFL, press straight down and hold on wing of ilium. Repeat on other side.
  3. Hip Hiking: Client supine: With client’s knees up and feet flat, have client alternate hiking hips until it begins to feel easier for the client.
  4. Traction: With outside hand on top of foot and inside hand under the heel, gently “whip” leg so that knee and thigh bounce on table.
  5. Hip rotation: Drape client to prepare for passive movement. Keeping knee at a 90 degree angle, start with thigh across the body, pushing the foot away and directing the whole leg back to the lateral side. Direct leg back toward the midline, keeping the 90 degree angle at the knee and pulling the foot toward you.
  6. Anterior Rotation Correction: Check for alignment of medial malleoli, start and end with the leg that appears longer. Have client clasp hands behind the knee, pulling leg toward the face with both hands. Hook outside hand under ASIS, and with other hand on ischial tuberosity, lean onto client’s leg with shoulder and prompt them to push into your shoulder.
  7. Repeat step 15, alternating legs until balance is reached (L & R medial malleoli are aligned).
  8. Wrap up session with bone cleaning along occipital ridge from mastoid process to midline,

    apply gentle traction to neck, bounce hooked into mastoid process and release.

Session 2: Adductors supine, iliacus, psoas, anterior correction

  1. Client supine: Touching in, prompting deep breathing, and gentle rocking to mobilize area.
  2. Client supine: Have client flex and laterally rotate hip, and support thigh with cushions.

    Follow adductor longus down to attachment on pubic bone. Move laterally, bone cleaning along superior pubic ramus. Move down along bone for adductor longus, brevis, and gracilis.

  3. Use pincer palpation and cross-fiber examination for adductors brevis and longus on the upper third to upper half of adductor compartment.
  4. With cream, cross-fiber belly of adductor magnus down to adductor tubercle
  5. Finish work in adductor compartment with general circulatory strokes
  6. Repeat steps 2-6 on opposite leg.
  7. Iliacus: Enter at ASIS and sink and melt, sculpting downward inside the bowl toward the

    pubic bone and then, secondly, back toward the sacroiliac joint.

  8. Psoas: Instruct client to flex knees and rotate to one side so the knees rest to that side of the

    table. Enter half way between the belly button and ASIS, and do some gentle counter clockwise circles to encourage organs to move aside. Gradually sink medially to touch psoas (confirm contact by having client lift knee to feel it engage). Use cross and with-fiber strokes to treat psoas from level of ASIS down to inguinal ligament.

  9. Psoas: Contact edge of psoas at level of ASIS and cross and with-fiber up toward T12.
  10. Anchor into the psoas at level of ASIS and have client slowly extend the limb. Use cross-

    fiber as the muscle lengthens beneath your touch, following muscle up toward T12.

  11. Flex the client’s knee and hip to place foot against the inside of the outside of the opposite

    outstretched leg. Laterally rotate hip and rest knee against your abdomen. Palpate iliopsoas

    tendon inferior to inguinal ligament. Sink and melt, treating attachment with cross-fiber.

  12. Repeat 7-11 on opposite leg.

13. Repeat steps 10-17 from session 1 for anterior correction and wrap up.

Session 3: Quads, knee, calf, ankle, anterior correction

  1. Client supine: Touching in, prompting deep breathing, and gentle rocking to mobilize area.
  2. Apply cream, examine medial, inferior, and lateral aspects of the ASIS for TPs.
  3. With heel of hand, press just inferior to ASIS, and rock lateral side of leg while compressed

    inferior to ASIS.

  4. Use flat palpation inferior to AIIS and down length of rectus femoris, examining for TPs.
  5. Displace rectus femoris and palpate and examine vastus intermedius for TPs.
  6. Cross-fiber examination of muscle belly of vastus lateralis and lateral aspect of patella.
  7. Cross-fiber examination of vastus medialis & sartorius.
  8. Treat around the patella. Support patella with one hand and bone clean with the other hand.

    Give special attention to the oblique fibers of vastus medialis near the knee.

  9. Cross-fiber tibialis anterior and peroneals with cream.
  10. With client’s knee bent, hook fingertips into middle of calf and pull away from each other,

    cross-fibering gastrocnemius and soleus.

  11. Cradling heel in palm of one hand, mobilize the foot with the other hand, taking it through

    flexion, extension, inversion, and eversion.

  12. Repeat steps 2-11 on opposite leg.
  13. Repeat steps 10-17 from session 1 for anterior correction and wrap up.

Session 4: Gluteus maximus, lateral rotators, hamstrings, anterior correction

  1. Client prone: Touching in, prompting deep breathing, and torso rock to mobilize area.
  2. Over sheet, compressions around iliac crest, sacral attachments, and into sacrotuberous

    ligament, and gluteal tuberosity.

  3. Drape client to expose gluteus maximus. Examine gluteus maximus for TPs using cross-

    fiber movements in an arc pattern from the iliac crest to the greater trochanter, with arcs

    getting wider.

  4. Repeat the arc pattern working with the direction of the gluteus muscle fibers.
  5. Grasp the skin and muscle belly and roll the tissue in all directions.
  6. Compress through the gluteus maximus to cross-fiber piriformis.
  7. Continue to work piriformis but with a different vector. Face client’s feet and bone clean

    attachment on superior aspect of the greater trochanter.

  8. Cross-fiber examination of lateral rotators inferior to piriformis, working from trochanter

    medially toward ischium.

  9. Anchor into piriformis and lateral rotators and stretch the muscles by pulling leg toward you.
  10. Compression/bone cleaning on ischial tuberosity.
  11. Cross-fiber TP examination of hamstring muscle bellies.
  12. Flex the knee and bone clean proximal third of tibia.
  13. Bone clean around medial and lateral epicondyles of the femur.
  14. General broad cross-fiber circulatory strokes on hamstrings and fanning around the knee.
  15. Repeat steps 10-17 from session 1 for anterior correction and wrap up.

Session 5: Low Back, anterior correction

1. Client prone: Touching in, prompting deep breathing, and torso rock to mobilize area. 8

  1. Spread cream on back with effleurage strokes.
  2. Bone clean along spinous processes from T1-sacrum.
  3. General circulatory back work (broad cross-fiber) on erector spinae.
  4. Thumb press down lateral edge of erector spinae.
  5. Sculpt inferior aspect of 12th rib from medial to lateral. Continue bone cleaning and

    examining for TPs between ribs 12, 11, 10, & 9.

  6. Repeat thumb press along lateral edge of erector spinae.
  7. Examine for TPs in quadratus lumborum by moving out into soft tissue below the 12th rib

    and press into transverse processes.

  8. Sculpt iliac crest medial to lateral examining for TPs, then from lateral to medial and

    compression into iliolumbar ligament.

  9. Sculpt lateral free edge of QL and examine for TPs.
  10. Thumb press down lateral edge of erector spinae and examine for TPs in the lumbar area.
  11. Deep with-fiber strokes down length of erector spinae, in the middle of the bundle, and back.
  12. Wring across lower back and repeat steps 3-12 on other side.
  13. Transverse friction on sacrum and area of SI joint.
  14. Compressions into: gluteal tuberosity, ischial tuberosity, sacrotuberous ligament, lateral

    border of sacrum, and into gluteus medius on both sides.

  15. Repeat steps 10-17 from session 1 for anterior correction and wrap up.

Report of Clinical Visits

Session 1: No trigger points (TPs) were uncovered during the session, but the adductor attachments on the ischium and adductor tubercle were very tender. The gluteus medius was hypertonic.

Session 2: Client reported pain before the session that was concentrated in the middle of the low back and the left shoulder was stiff. Crawling in attics and carrying a tank the previous day aggravated the low back and shoulder. Several TPs were found in the right psoas and referred to the right costal area, and right and left thighs. TPs were found in the right adductor belly and referred to the medial/anterior portion of the same knee. A TP on the left side of the occipital ridge referred to the left knee and thigh. Several tender points presented in the psoas, adductors and knee on the left side. After the session, the client’s arms extended further over his head, and his legs were basically the same length.

Session 3: He was experiencing pain in his low back since the morning, achy pain in his left shoulder, and pain ranging from 0-4 from a pulled right adductor. Bone cleaning on the left patella caused his left foot to twitch and “stretchy” feelings were felt in his whole leg. There was no tenderness in his right patella. A lot of tenderness was present in his left calf, tibialis anterior, and peroneals. After the massage, the tender spots were less tender, his medial malleoli lined up evenly after the anterior correction, and there was a decrease in the PSIS/ASIS discrepancy.

Session 4: Client reported pain concentrated on the right side of the low back and stiff ankles. Low back pain was exacerbated by lifting heavy boxes earlier in the week. Before treatment, the malleoli were almost even. During treatment, the right hamstring was riddled with tender points and TPs in the left and right ischial tuberosities, left piriformis, left gluteus maximus, and right hamstring all referred to the right knee. The right knee started hurting toward the middle of the session. The left and right medial malleoli lined up and the PSIS/ASIS discrepancy decreased.

Session 5: The client stated that “nothing hurt” before the session. The left malleolus was just slightly lower before the session. During the session, the piriformis was a little tight, but tender points on the back were much less sensitive than usual. The medial malleoli lined up after the anterior pelvic correction and the tender points eased up as they were revisited. No TPs were uncovered.

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Results

Daily Log Book

Table 1: Client Post-Massage Feedback

A daily log book was kept by the client one month before treatment to provide a baseline for his experience of pain. In the baseline period, the client reported having a stiff back and legs every morning and sporadic problems with his left knee, left shoulder, and neck. He completed the Brief Pain Inventory form which described his average pain as a 2. He also completed the Oswestry Low Back Pain Scale and his score was 28%. After the five sessions, his average pain dropped to a 1 and his Oswestry score dropped to 2%. Overall, the client did not report a high intensity level of pain. It is probable that pain was under-reported because he is accustomed to living with pain on a daily basis.

The day after massage for the first three sessions, the client’s back was “not as stiff as usual” and he slept really well the night after the session. Throughout the week, he stated that his back was stiff “but not as bad as usual.” By the third session, the client reported that he “felt really good” the night of the session, his back “felt good” in the morning, and he also slept well the night after the session. After the fourth session, the client started to notice stiffness in his shoulders. Before the final session, no pain was felt by the client. After the final session, the client slept well, “felt good” and was not “stiff and sore” for three days in a row. Spending an entire day at Disneyland on the fourth day re-aggravated some of his pain. Even after Disneyland, the client reported being stiff sometimes but not everyday.

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Structural Changes

The correction of the anterior pelvic tilt was measured by the change in inches between the PSIS and ASIS. A smaller distance indicates a correction in the anterior tilt. During the baseline, the distance on both sides of the body was 2.25 inches, indicating approximately a 15 degree difference between the two points. For a male, the distance should be within 5 degrees. From baseline to session five, there was a general decline in the PSIS/ASIS discrepancy. More specifically, the distance either stayed the same or decreased after each session. The iliac crests also lined up from left to right after treatment.

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Postural Changes

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Before treatment, the plumb line fell slightly to the right of the nose and to the left of the belly button. The left shoulder was elevated so the right arm appeared longer. After treatment, the line was lined up with the nose but still left of the belly button and the arms were about even.

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In the before picture, the anterior pelvic tilt is quite apparent, accompanied by an exaggerated kyphotic thoracic and lumbar lordotic curve, with the head jutting forward. The plumb line is in alignment with the ankle, knee and hip, but falls in front of the elbow and shoulder and behind the ear. This suggests a slight rotation to the left in the upper torso. In the after picture, the client clearly exhibits a more erect posture. The line now falls slightly behind the knee and hip, but is in line with the shoulder and elbow. The anterior tilt has been corrected somewhat, but there is still a slight rotational component to the upper torso.

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Before, the line falls slightly left of the midline, and a rotation of the upper torso to the left is apparent. A hunching forward of the head and shoulders is also noticeable. After, the head and shoulders are pulled back more, but the line falls slightly to the right of the head which indicates the presence of a slight rotation.

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Before, the line falls behind every joint and behind the ear. The lordotic lumbar curve is quite pronounced. After, the plumb line is almost in perfect alignment with every joint and falls just slightly behind the ear. The lumbar curve is also less exaggerated.

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The client’s range of motion has clearly improved, especially throughout the thoracic spine. In the after picture his hands are folded on the floor and there is more space in the lumbar region. This position caused a lot of pain before treatment, and after he could hold the position longer.

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Right lateral flexion improved as a result of treatment. In the before picture his fingertips fell above his knee and they reached the bottom of his knee after treatment. The client’s ability to move his neck more independently is also more apparent in the after picture.

Left lateral flexion also improved. The fingertips fall to the middle of the knee compared to a few inches above the knee in the before picture. The neck also laterally flexes more.

Discussion

It is interesting to note that when the client made post-session comments about specific parts of the body, he noticed how range of motion increased and muscle tension decreased in his shoulders, neck, and arms. These areas of the body, however, were never directly addressed during the five sessions, excluding less than five minutes of bone cleaning on the occipital ridge and neck traction during each session wrap up. These subjective comments and objective observations of increased range of motion and reduction of tender points highlight the interconnectedness of the body and support Travell & Simons’ acknowledgement that lower girdle distortions can cause pain in the upper body (1992). This study demonstrates that correcting lower girdle distortions can also provide pain relief in the upper body without working directly on those muscles.

Although the client felt considerable relief in his upper girdle, he also became more aware of pain in his shoulders after the fourth session. It is likely that the pain in the shoulders was always present, but it took a back seat to the hip flexors and extensor that were screaming out in pain and therefore went unnoticed. The iliopsoas (chronically shortened) and hamstrings (chronically lengthened) contained the most TPs out of all the muscles addressed during treatment. Once these muscles were released and TPs were deactivated, pain from other muscles probably became more apparent to the client. The muscles in the shoulders and neck have most likely accumulated TPs from being held in a contracted (shortened) or over-stretched (lengthened) state for so long. The short muscles need to be released and stretched, and the long muscles (the ones screaming out in pain) need to be relieved and strengthened. It is important to address TPs in these areas after addressing the underlying factor, in this case the anterior pelvic tilt. Correcting the anterior pelvic tilt releases tension and makes it possible for shortened and lengthened muscles to return to a balanced state. Treating muscles and deactivating TPs in the upper girdle and neck would most likely provide more long-term pain relief. Although substantial changes were made in just four weeks, it would be beneficial to extend treatment beyond five sessions. Future research to determine the length of pain reduction and maintenance of postural alignment after the cessation of treatment would be interesting to explore.

This is the first known study to examine the effects of NMT alone (without intervening factors such as nutritional advising, stretching, changing aggravating activities or other massage techniques) on bringing about structural changes in the body to address postural misalignment and reduce chronic hip, low back, and knee pain. The results of this study suggest a positive relationship between postural re-alignment effected by NMT and a reduction in chronic hip, low back, and knee pain. The structural and postural changes resulting from NMT correlated with a reduction in pain both immediately after the sessions and over the course of treatment. Postural re-alignment was clearly visible from the before and after pictures. These findings suggest that NMT can effect structural changes and postural re-alignment which corresponded to a reduction in pain in this case study. As expected based on existing literature, research, and previous experience with clients, NMT’s perspective that postural distortions and biomechanical dysfunction are “the root causes of discomfort [and] pain” holds true (Baker, 2003).

Acknowledgments

The author wishes to thank Jack Baker for generously contributing to the planning of the session design, providing the training for the treatment techniques, and for all of his editing brilliance.

 

References

American Massage Therapy Association. (2005). 2005 Massage Therapy Consumer Survey Fact Sheet. Retrieved April 27, 2008 from http://www.amtamassage.org/pdf/05consurvey.pdf

American Pain Society. (2008). A Summary of the Provisions of HR1020. Retrieved May 4, 2008 from http://www.ampainsoc.org/advocacy/monitor/

Associated Bodywork & Massage Professionals. (2007). Types of Massage and Bodywork Defined. Retrieved May 4, 2008 from http://www.massagetherapy.com/glossary/index.php#N

Baker, J. (2003). Intro to NMT. (Self-published.)

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CranioSacral Therapy Reduces Chronic Back Pain and Improves Structural Balance

Abby McKenna

Research Case Report June 29, 2009

The author wishes to acknowledge Dorothy Mahrie for her guidance and helpful advice given throughout this case report project.

Abstract
Objective: This study investigated the effects of CranioSacral Therapy (CST) on structural imbalance and the reduction of chronic pain.

Method: A 23 year old male experiencing chronic pain from the mid-back shooting up the spine, and radiating out through the upper girdle region. Five CST sessions were given once a week for five weeks, each treatment lasted for 1 hour. Each bodywork session began with three initial check-in phases to determine where to begin the specific CST holds. The client recorded his pain daily on a number scale and the practitioner measured his structural alignment.

Results: The client experienced a significant reduction in pain following the first session, and stayed at that level throughout the rest of the treatments. There was no measurable change in the clients physical structure, although many of the inner structures shifted and aligned to create ease.

Conclusion: This case study has shown that Craniosacral Therapy improves inner body awareness, decreases chronic pain, and creates a feeling of balance and alignment throughout one’s being.

Key Words: CranioSacral Therapy, Chronic Back Pain, Alignment, Upledger, Osteopathy

Introduction

Chronic pain has been defined by the International Association for the Study of Pain (IASP) as continuous or recurrent pain that persists for longer than the normal time of healing, generally about three months (Merskey, 1994). Chronic pain can range from mild tissue irritation to intense suffering and disability affecting an individual’s entire body, psyche and life. The perception of pain often persists long after the injured tissue has healed. This can cause compensatory patterns that continue to maintain the sensation of pain, eventually leading to abnormal somatic and visceral changes that frequently mask the primary cause of the chronic pain (Wanveer, 2006).

An estimated two-thirds of American adults suffer from back pain — a condition almost as prevalent as the common cold. When the pain lingers, making it hard to get comfortable or do simple activities, this is chronic pain. Acute or Chronic, the causes of back pain are sometimes unknown (Deyo, 2007). Precipitating factors that can cause back pain include mechanical problems, such as the way the spine moves or the way you feel when your spine moves a certain way. Spasms, muscle tension, and ruptured or herniated discs can cause chronic pain. Injuries can cause back pain and muscle strains or ligament sprains; they can occur from twisting or lifting improperly. Acquired conditions and diseases such as arthritis, osteoarthritis, scoliosis, also lead to chronic back pain. Although the many causes of back pain are usually physical, emotional stress can play a role in how severe pain is and how long it lasts. Most back pain, acute or chronic, is treated with a wide range of medications available over the counter, or by a doctor’s prescription. In more extreme cases corsets and braces are used, injections of anesthetic or steroid medications are used and sometimes even surgery is needed (NIAMS, 2005).

Webster’s Dictionary defines alignment as an “arrangement in a straight line.” When referring to the body we look at the way the bones fit in relationship to one another. Ideal alignment creates an easy feeling throughout the musculoskeletal system. A balanced posture is one in which positioning is centered and relaxed for all the joints of the body. With joints in non-awkward positions, muscles relax, and unnecessary tension can be released. Tension can lead to pain, discomfort, lack of range of motion along with other uncomfortable situations. The mid-line is an imaginary line down the center of the body which provides a reference for viewing the positions of the ears, shoulders, spine, hips, knees, ankles, feet, and the very specific cranial bones. Looking to the midline shows one the relationship between theses structures, and gives information on where imbalances exist. When all is in line with the midline, alignment is improved and therefore tension is reduced and systems flow freely on the straight line known as alignment.

Craniosacral therapy (CST) is a gentle, non-invasive, hands-on alternative medicine procedure for evaluating and enhancing the body’s own natural healing mechanism. The focus of this work is on the craniosacral system, a physiological system which consists of the membranes and cerebrospinal fluid that surround the brain and spinal cord. This system extends from the bones of the skull, face and mouth, which make up the cranium, down the spine to the sacrum and coccyx, our tail bone (Mahrie, 2004). The craniosacral system is a very important system in our body and directly influences the performance of the brain and spinal cord, having a direct affect on the central nervous system. Imbalances or restrictions anywhere in this system could cause any number of sensory, motor or neurological challenges. Balancing the craniosacral system frees the movement of the cerebrospinal fluid, improving brain and spinal cord function along with improvement of the other body systems (Mahrie, 2004). CST has addressed many symptoms, such as musculoskeletal imbalance, myofascial dysfunction, chronic fatigue, immune system dysfunction, autonomic nervous system dysfunction, elevated heart rate, high blood pressure, endocrine system dysfunction, stress, anxiety, brain and spinal cord injuries, sleep difficulties and chronic neck and back pain (Wanveer, 2006).

Wanveer (a LMT specializing in Craniosacral therapy) explains chronic pain and how it relates to the brain and spinal cord, showing that there is a need for balance of this system. In this article, Wanveer shows that CranioSacral Therapy can be used to identify and help the body change core patterns contributing to chronic pain. Describing that with chronic pain the sensitivity does not decrease, thus abnormal changes in the structure and function of the tissue innervated by the area of the affected spinal cord neurons maintain the sensation of chronic pain (Wanveer, 2006).

Tan et al. (2007) provides a review on the efficacy of selected Complementary Alternative Medicine (CAM) modalities in the management of chronic pain, reported pain relief from the use of some modalities. Massage therapy was found to be useful for pain relief in numerous chronic pain conditions, particularly low back pain and shoulder pain. The use of Cranial Electrotherapy Stimulation (CES) was tested showing that there is considerable promise as both a complementary modality to other forms of therapeutic interventions to treat particular types of pain. CST and the CV-4 technique were examined for tension-type headaches. Patients who received the CST treatments reported less pain intensity, however additional large scale trials were recommended.

Upledger (1977) examined statistical analysis from 50 craniosacral examinations on 25 schoolchildren to help determine cranial rhythmic impulse, showing how its motion may display dysfunction/damage and whether cranial osteopathic treatment can bring any change to dysfunction. He also examined a collection of photographic evidence supporting the craniosacral examination. A systematic review of 33 studies by Green et al (1999) showed that only seven were based on the effectiveness of the treatment. No other systematic review was found, and relevant, reliable primary data research based on the effectiveness of craniosacral treatment was not found either. Research into clinically measurable patient outcomes after craniosacral therapy treatments is still lacking (Green et al 1999).

The objective of this study is to determine if Craniosacral Therapy (CST) can improve structural alignment to reduce chronic back pain. In CST, the practitioner is taught to be a therapeutic facilitator, not deciding what must be done, rather following the lead of the body. Practitioners are taught that the client’s body has within it the wisdom to solve its own problems. Primarily, all that is asked of the CST practitioner is a supportive presence that offers assistance in the forms of light touch, energy and intention (Upledger, 1996). This study’s treatment protocol is established around this point of view, beginning with three initial check-in phases to determine where to begin treatment on the body. Measurements are made objectively by the practitioner before and after each session using a ruler and a level to assess the clients structure, measuring the structural alignment of the client’s shoulder girdle where the chronic pain begins. The subjective measurement of pain is recorded by the client every day during the study to track changes in the intensity of his chronic pain.

Methods

Profile of Client: A 23 year old male bodywork practitioner and student has been experiencing chronic pain from the mid-back, shooting up the spine and radiating out through the upper girdle region (shoulders). Client has a history of rotator cuff tears and dislocations in both right and left shoulders due to many falls and crashes throughout childhood. He broke metatarsal bones of the right foot twice, once in 1999 and again in 2005. He has had rhinoplasty to improve breathing, and his wisdom teeth have been removed. The client does not currently take prescription medications however, he does smoke 2 cigarettes a day, consumes alcohol 2-3 times a week and often self medicates with THC.

The client feels as though he can not stand up straight, and after measuring using a plumb line, this was confirmed. This initial structural assessment using the plumb line revealed that the client has a prominent kyphotic thoracic curve and lordotic cervical curve. His right shoulder is significantly higher than the left, his clavicles do not line up. When lifting arms over his head the shooting pain from the mid-back up the spine increases. Client experiences slightly less than moderate pain on a consistent basis.

The client recently sought chiropractic work, and discovered from x-rays that two cervical vertebrae were fused. He has not returned to the chiropractor since, believing the treatment did not help aside from the x-rays. He has tried acupuncture, physical therapy, osteopathy, and many types of massage and bodywork. Currently, he is receiving massage two to three times a month, and feels that these sessions help relieve pain and discomfort for a short time. He was instructed not to receive other massage and bodywork while involved in this study.

The client’s desired outcome for this treatment is to feel a straightening in the spine; he would like to lessen the degree of kyphosis in the thoracic region and lordosis in the cervical area. The client feels that with balance in that area, the pain will decrease. He would also like to feel a reduction in the shooting pain from mid-back out to the shoulders.

Treatment Plan: To begin each session, there is an initial intake of how the client is feeling today, a check in of how much pain has been experienced on this day and throughout the past week. Next, the therapist measures alignment — tools for measurement and the procedure are described in the assessment tools section. Next, the client lies supine on the table fully clothed with relaxation music playing. The therapist begins with three initial check-in phases to determine where to begin treatment on the body.

First phase, vector searching, where the therapist looks and feels for energetic misalignments in the structure of the body, feeling for vectors from the feet to the cranium, and then from the cranium to the feet, not yet placing hands on the body. Energetic vectors should be in alignment with the midline of the body. When vectors go off in directions off of the midline this shows imbalances from the energetic body to the physical body. Looking for vectors to show misalignment will help the therapist to determine where to begin the session.

Second phase, feeling through the body for relations of certain areas and systems. The therapist’s position for this phase is having her hands supine cradling the occiput. The therapist is feeling through the body for relationships between certain bones, muscles, the brain and spinal cord, specifically the cranium and pelvis relation, occiput and sacrum relation, specific cranial bones, movement, or lack of movement throughout. The therapist is also checking for the balance of the inter-cranial membranes, horizontally and vertically. Feeling for these key check-in points and how they relate helps to bring focus to those areas that are not in alignment. The therapist facilitates a neutral space where the body feels comfort and can then find balance and begin to align.

Third phase: feeling for the flow, listening to the body. The therapist in this phase has one hand supine under the sacrum and the other hand supine under the occiput. In this position the therapist can feel the flow of the Cerebrospinal Fluid (CSF), which is the core of our being. CSF is always producing fluid that runs along our brain and spinal cord, constantly pulsating an exchange of information throughout our bodies. In this same phase, the therapist can also feel the craniosacral rhythm (CSR) which is its own unique rhythm in the body. When feeling the CSR, the therapist will gain more information about the flexion and extension of the sacrum, and therefore a better understanding of the relationship of many of the bones that were mentioned in phase two.

After sorting and becoming aware of the information given in these three phases, the therapist then proceeds to the place of the body where they feel a need for more focus. More focus and attention to certain areas, along with hand position, will create comfort and support for the body to begin to unwind and restore itself to a state of balance and flow. Specific hand positions are performed upon the discovery of where the body directs the therapist.

Assessment Tools: The client will record on a 1 to 10 visual analog scale (VAS) the intensity of his pain every day. This charting began one week prior to bodywork sessions and continues throughout the five week study, including days with treatment. On the scale, the left end of the line indicates no pain at all, and the right end indicates worst possible pain. There has been a chart created with the specific amount of scales needed, the start date, dates of treatment, and end date have been indicated. The average of each week was then graphed on a chart to show change.

Using a level and a ruler as tools, the practitioner will determine the differences in shoulder height to measure and record the clients structural alignment. Before and after each session, the therapist uses a level and a ruler to measure the distance from the level to the clavicle. The end of the level is focused at the sternoclavicular notch, and is level (bubble in the middle of center line), the measurements with a ruler are made from the level to the clavicle from this focus point. This will show the differences in alignment of the clavicles, and therefore shoulder alignment.

Report of Client Visits

Session 1: The client arrived reporting a number three on the pain scale, feeling less pain than recorded the week earlier. During the three initial check-in phases, described in the treatment plan, a plethora of information was obtained. The practitioner found vectors branching out to the left, the right shoulder was significantly higher than the left. When feeling from the occiput down through the body she found that the sacrum and occiput were also elevated on the right. The CSF seemed to be flowing at a wonderful pace up until T-5 where it then takes slow circular motions to make its way through the cervical region, and into the cranium.

Once this information was obtained, the practitioner continued to more focused hand positioning. First, she began with the left hand supine under the sacrum and the right supine under the T-5 to T-6 region. The sacrum shifted from a tilting up to the right position to a more balanced, even rocking of flexion and extension (head-to-toe movement). The CSF then began to flow more freely up to the point of T-5, where the flow seemed stuck. The practitioner continued up the spine with the right hand supine under T-4, 3, 2 and left hand resting, (no more than 5 grams of pressure) on the sternum with fingers branching out toward the clavicles. Finding a blockage with this hold, the awareness of the practitioner began to open, and lead her on to a new area.

The practitioner’s attention was drawn to the arms: they may be forming the blockage in the sternum and T-4-2 area. First, the left arm was held allowing for an unwinding of the humerus in its socket. Having the right hand supine under T-1, and the left hand and arm supporting the clients left arm, the humerus went through slow internal movements that occasionally branched out to look physical. The practitioner then moved to the right arm using the same hand positioning as the left, yet opposite. The right arm began much bigger movements than the left, going in circles, flexing down, extending up, and unrolling. After this the shoulders had significantly relaxed and lowered down to the table.

Next, the therapist at the head of the table held both hands supine between scapulas with arms close together so the client could then rest his head on her forearms comfortably. This allowed the shoulders to open laterally and release to the table even more. This position also gave a connection into the cervical vertebrae and the cranium. The next hold was the left hand under the occiput and the right supine under C-7 and T-1 the head began to unwind rolling from left to right to left again. During this hold the practitioner and the client both felt a large pressure which then turned into an immense pain shooting down the arm. The pain got stronger and more intense, the client was asked to stay with that pain and feel it, and he did. He breathed deeply, and stayed with the pain and eventually, after quite a few minutes, the pain subsided. The practitioner then held the occiput to feel new balances and let the neck unwind a little more, finding that everything felt a lot more centered and flowing, with much less pressure and torque throughout the left side.

The session ended with the balancing position of one hand on the sacrum and the other on the occipital bone to balance and clear the core. Client reported feeling much loser and more expanded after the session.

Session 2: The client arrived reporting a number three on the pain scale, feeling much less pain following the first session. During the three check-in phases the practitioner obtained much information about the same area of blockage discovered in the first session. This area began at the bottom right rib cage, went to the left heart center, then back to the right stopping behind the sternum to turn at an angle to the left shoulder, and then back right into the cranium shifting back upward to the left to the center of the sphenoid bone. Finding this vector and flow of CSF lead the practitioner to a wonderful starting point. She was drawn to the lungs, feeling that both the right and left lobes where turning in towards the heart, perhaps causing the zigzaging feeling throughout the upper girdle, and into the cranium.

The practitioner first placed hands on the sacrum and T-12, feeling the lower body, hips and legs and their connection into the torso. This flow felt wonderful, and she moved onto the zigzag above, beginning at the bottom right lung, one hand under the rib cage, the other on top. Being drawn into this lung, the practitioner and client noticed movement, the lung began to shift and roll down and away from the midline that it had been hugging. This brought attention to the liver, which was also being affected by the roll to the midline. The liver then shifted in this hold along with the bottom of the right lung. The diaphragm was also being affected by the lungs and their roll into the midline, making breathing a challenge for the client. The client and practitioner placed focus on the diaphragm and its relation to the lungs, and it too shifted, moving towards the table and down toward the feet, making room. The practitioner then moved her top hand to the top of the lung just under the top of the left scapula. This allowed the lung to completely unroll, and open up.

Next the left lung drew her in, and felt much different than the right, with much more of a roll to the midline almost suffocating the heart and its circulation. When tuning in to the bottom of the left lung, with one hand under the rib cage and the other on top, the lung shifted and rolled out and down, similar to the right side. As this was happening, the client began to go deeper into an altered state, almost asleep and snoring but could still hear the practitioners words. The lung began to pull the practitioner deeper as well. In this deep space was silence, heavy breathe from the client, and much space holding from the practitioner, leading to a big spontaneous breathe releasing tension in the lung and heart area. After this release the client still in an altered state, the practitioner moved to the thoracic inlet hold, one hand under C-7 through T-2 the other hand with index finger and thumb at the sternoclavicular joints. This structure felt much more open and movable than before, the right clavicle shifted slightly up then down, and the clients breathing pattern changed dramatically. Finding this movement was satisfying and showed that the respiratory system was much involved in the restriction of the upper girdle.

To end the session the practitioner allowed the neck to unwind, connecting the new respiratory flow into the cranium. Finally, a hold for the balancing of movement between the viscerocranium and the neurocranium created space between those two areas, and they found their relation to the midline.

Session 3: The client arrived reporting a number four on the pain scale; feeling a little fatigue today. During the initial check-in phases, the practitioner found a vector going from the mid-back around T-12 up to the right shoulder, the right shoulder is higher than the left. The CSF flow maintained the same pattern, feeling like a roll to the right. The occiput, sacrum, scapulas and spheniod bones made the same upward movement to the right.

The practitioner started with the right hand supine under the sacrum, and the left under T-12 and the lower part of the rib cage. The sacrum rocked up and down, and right to left a few times with a big connection into the ribs, rolling from right to left and slightly down. She then moved to the right rib cage, one hand on behind and the other in front, allowing space for the rib cage to shift down and slightly out away from it’s close hug to the spine. This lead the practitioner to the right arm which felt locked into the shoulder girdle. She lead the arm to it’s vector and it began to unwind and release finding its place of stillness and comfort.

Next, the therapist at the head of the table held both hands supine between scapulas with arms close together so the client could then rest his head on her forearms comfortably. This allowed the shoulders to open laterally, and release to the table even more. This position also gave a connection into the cervical vertebrae and the cranium. She then held the occiput to allow the neck to unwind, during which she was draw to the cranial bones, mainly the sphenoid bone. Feeling a torsion and twist to the left, the right wing of the bone felt much higher and very stuck between the other cranial bones. This being the case the practitioner then held and released the temporal bones, parietals and frontal, opening space for the sphenoid to move more freely. Lastly, holding space for the viscerocranium and nuerocranium, which involves holding the sphenoid to separate the neurocranium, and the zygoma bones as the viscerocranium, allowing for separation between these two structures gave her and the client a balanced feeling in the cranium.

Session 4: The client arrived reporting a four on the pain scale feeling much better since the previous session. He is feeling a lot more open in the upper girdle region where the pain resides, and he has noticed a large connection between the right side of the neck and his right arm. This wonderful piece of awareness brought by the client gave the practitioner a sense that CST creates body awareness. In the check-in phases the practitioner noticed the vector to the right not feeling as strong as before. During the feeling of CSF, she found the flow to be more of a turn and roll to the right, rather than the ridged flow as in the prior sessions. The client agreed on this information feeling a much less rigid flow himself.

The practitioner began with one hand supine under the sacrum, and the other under the mid-back around T-12 and the last rib area. This allowed the sacrum to shift into a neutral place and guided the practitioner to where the flow rolls to the right. This started the next position being at the T-12 area, and the other hand at C-7 T-1, allowing the roll to move left quite a bit.

Next, she moved to the neck, allowing it to unwind in big, slow movements, left to right for about 15 minutes. These shifts gave the client great relief, and created connection for the practitioner into the cranium, mainly the cranial membranes feeling them in the same roll-to-the-right pattern. The client found a connection into his rib cage, around to T-11-12 area, feeling that this area was very stuck and painful; when his neck moved to the right the sensation increased. Following this information the practitioner moved one hand to that thoracic area and the other to the occiput. The ribs then rolled out and up and back down as the occiput followed the movements, this lead to a still point and large release, a subtle, silent pop and click into relaxation.

Moving to the cranium, she held the cranial membranes; first the tentorium to balance it with the new flow coming up the spine, and then the falx cerebri. These structures also felt as if they rolled to the right. This hold allowed the membranes to match the rib cage and spine feeling much more balanced. The practitioner ended holding the sacrum and occiput, feeling much less of a roll to the right, and a great balance between all the structures.

Session 5: The client arrived reporting a six on the pain scale, the week was long and he was feeling tired. The past few days had brought him awareness and pain to the right lower portion of the rib cage however, on this day it felt better. In the check-in phases the practitioner noticed a new feeling, the right shoulder seemed relaxed and lower and the left pressing down. The cranial bones and sacrum felt pressed downward on the left feeling, as did the vector. In the flow phase the CSF felt still like a roll to the right, but not as intense as the past sessions. The check-ins lead the practitioner to the cranium, but before going right to the skull, the thoracic outlet felt a need for release. She held this position for quite some time feeling a great opening across the chest.

Then, she began the cranial work. She started with holding the occiput and sphenoid, feeling them shift left to right and down to the left quite a few times, sometimes even moving towards each other. Eventually, the two bones went into a flexion and extension pattern to begin to match the sacrum in the same pattern. She then felt a connection into the left arm/side body, rib cage area. The client agreed with this connection. Feeling like the left side wanted to come up to meet the right side, she went to the arm and put it into its vector, held space for that and a stillness occurred and then let her go.

She was then draw back to the cranium, first releasing the parietal bones and then the temporal bones and tentorium membrane. Holding the temporals and then the temporal ear pull, when thumbs are inserted into the ear at the auditory meatus. This allowed for a wonderful horizontal release in the skull connecting down to the shoulders/scapulas and pelvis. After much release and balance of the larger bones of the skull she was drawn to the inner structures of the ethmoid and vomer bones, feeling their pressure on the sphenoid, creating some of the downward pressure on the left side. The practitioner held the vomer and ethmoid and then the vomer and atlanto-occipital area, finding a great drop of the vomer down and back in the roof of the mouth. Creating lots of space and allowing the left side to open and feel more free.

Again, holding the viscerocranium and nuerocranium to feel the relation between these structures after much of the cranium had released. She and the client felt a wonderful balance between these two areas with much relief in the surrounding, inner structures. To finish the cranium work she held interlocked fingers of both hands over the midline of the frontal bone. Allowing for midline alignment of the cranial bones, brain and membrane system. When this aligned and balanced, the client felt a great connection to his thoracic area, feeling clarity and alignment throughout his structure.

Results, Discussion and Conclusion

After receiving Craniosacral Therapy once a week for five weeks, chronic pain has been slightly reduced. An average rate of pain on a weekly basis (as shown in figure 1) was taken from the clients records, recorded on a visual analog scale daily throughout the bodywork sessions.

cranio_img1

The pain was recorded starting the week before session one and ending after the last session was completed. The client reported the largest change following the first session. With a baseline average of 6.3 for the week prior to treatment, a significant decrease after session 1 brought the clients report to a four, and then in the second week, and a 3.8 for the third. The average increased at week four, and then back to a decrease following the fifth session. After much consideration of daily activities and everyday habits, the practitioner believes that everyday movements may be causing the majority of the pain and structural imbalances. Further acknowledgement and awareness to shift these habits may have an impact in the reduction of pain in the future. The client reported feeling much less pain and discomfort than before the bodywork sessions.

The measurement of structural alignment did not show a significant change, however, this does not mean that nothing changed at all. The height of the left and right clavicles did not show a measurable change (as shown in figure 2).

cranio_img2

In craniosacral therapy, the outside structural changes are so subtle that a large visual change is challenging to see through physical measurement. The subtle shifts on the inside are what made the client report feeling more aligned and balanced. The shifts in the inner structures, such as the organs, the brain, membranes of the brain and dural tube surrounding the spinal cord, created a balance throughout the body. As explained in the report of client sessions, many of the sessions lead the practitioner into the organs and membrane systems rather than to the outside structures of bone and muscle. CST deals with the energetic vectors and their alignment to the physical being. In the treatment protocol the practitioner begins by looking for the energetic vectors of the body, vectors cannot be measured with a ruler. By assisting the body into it’s energetic vector and allowing it to feel comfort and release held patterns, the client will feel a result of relief and balance. Creating alignment of the inner-most structures, though not visually measurable on the outside, things did shift and result in comfort on the inside projecting out.

These results show that CST can reduce chronic pain and improve the alignment of the inner structures of the body. How does the inner structure affects the outer physical structural alignment? This question needs further investigation. The practitioner may have needed pictures to see physical changes in the shoulder girdle of this client. Or, perhaps a better tool for measurement of this particular structure.

This case study has shown that Craniosacral Therapy improves inner body awareness, decreases chronic pain and creates a wonderful feeling of balance and alignment throughout one’s being. By holding a space of neutral energy, the practitioner was able to facilitate a comfortable space for the body to unwind and realign it’s inner structures, thus, reflecting out to the client’s outside physical movements, and an improved overall well-being.

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