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1.  Spacial Medicine

2.  The Puzzle Of Perfect Posture

3.  What Happens When You Stretch

4.  A New Look at Lactic Acid

5.  Why is Popping Your Neck Harmful?

6.  Scar-Tissue Massage

 

 


Spatial Medicine


byTom
Meyers

www.anatomytrains.com

 

Osteopaths and chiropractors, yoga and Alexander teachers, Feldenkrais workers, Pilates and dance teachers, martial artists, somatically-oriented psychotherapists, athletic trainers and coaches, bodyworkers of all stripes, and most especially the teachers of movement to children – all these and more labor in the vineyard of “Spatial Medicine’.

 

All Spatial Medicine practitioners seek what we could call ‘KQ’ – increased Kinesthetic Intelligence. We are accustomed to measuring IQ, and we are warming to the idea of EQ – Emotional Intelligence. But KQ – the intelligence of the moving body – has yet to be measured or mapped, with the result that, especially in our body-alienating culture, much of our KQ is wasted.

 

In Spatial Medicine, nothing is added but information; nothing is taken away but strain. We do not mean to imply that Material Medicine - nutrition or drugs - have no effect on structure – sometimes they very much can and do. And the practice of Temporal Medicine – e.g. psychotherapy – can sometimes affect posture, as when a mental or emotional burden is relieved, and the body straightens in response.

But Spatial Medicine is working from a different premise from either of the other two: get the spatial order of the elements right, and you will contribute to health. Align the bones, free the glued fabric, balance muscle tonus – and watch the changes to chemical and mental health, as well as seeing the structure and movement itself improve. All the therapists working in the fields above can attest to stacks of anecdotal evidence for the kinds of mental, spiritual, and physiological changes that proceed from interventions to the structure and movement of the client / patient.

 

There are two major approaches within Spatial Medicine – the biomechanical and the perceptual. The biomechanical in turn has two major divisions: one uses leverage, usually applied with the hand or other part of the body, or (as in yoga) using the recipient’s own body to exert leverage on another part, in order to change the length or apposition of body tissues. Chiropractors and osteopaths claim to be manipulating bones, whereas in actuality HVLA thrusts change peri-articular tissues – muscles and ligaments close to the joint; the bones themselves do not change.

Structural Integration workers play with the guy-wires that hold the bones – lengthening and freeing the fascial planes that surround the skeleton and help determine its overall shape.

 

The second major approach to Spatial Medicine, the perceptual, involves the training and/or re-training of the muscles – (the contractile units within structural biomechanical tissues). Correcting adverse muscle tone, and creating a balanced tonus around the skeleton and within the fascial fabric, obviously contributes to spatial health.

There are too many systems of exercise to catalogue here – from the gentle to the strenuous, and from the most generalized to the therapeutically specific. The general populace is so kinesthetically deprived that nearly any form of exercise is better than none, but different people require different applications, and who needs what is only now beginning to be studied.

 

Pilates, Alexander, Gyrotonics, Feldenkrais, Yoga and Yoga Therapy, Callanetics, Nautilus, Aikido, Tai Chi, karate and the rest of the martial arts – the list is endless – but all seek to balance the body in terms of muscular tone, counting on this ‘fix’ to work its magic on the other biomechanical tissues listed above. Often it works, sometimes manipulative help is needed. In any case, muscle exercise and toning has a salutary effect on physiology and mentality even if the specific biomechnical intent is not realized.

Hand in hand with the biomechanical goes the perceptual aspect of Spatial Medicine. We often mis-perceive our own bodies. We miss signals that are there; we augment signals that are relatively meaningless, we ignore signals until the body breaks down.

 

Over the next century, I strongly believe that Spatial Medicine – whatever it comes to be called – will flower and bloom. As KQ grows, so will our sophistication and reliance on our balanced body. As we live longer, healthy functioning of our frame will be ever more necessary.

 

Spatial Medicine involves expanding our understanding of somatic maturational development – in other words, it is an anthropological study that includes both our physical and social evolution. It is the key to a whole new field of healing and growth in the human condition. Material Medicine – allopathy, our current medical system - has made great strides, and many refinements are still to come, but its major creative period is behind it. Temporal Medicine – psychology – is temporarily a bit stalled and diverted into chemistry, but has more discoveries left in it. But Spatial Medicine is just beginning to find its feet and its voice – a toddler, in other words, compared to the others. But like most toddlers, it has great potential and a great future if it is raised up properly.




The Puzzle of Perfect Posture   
B y E r i k D a l t o n   

SEPTEMBER/OCTOBER 2006 • MASSAGE & BODYWORK 99

No therapeutic approach to pain management is satisfactory until body posture is generally improved. Whatever the cause of the client’s problem, special focus should always be given to posture. Overall body alignment may seem time consuming and is therefore frequently neglected because both therapist and client are often content with immediate symptom alleviation.

In recent years, however, the manual therapy community has been blessed with scientific advances spearheaded by researchers such as J. Gordon Zink (Common Compensatory Pattern)1 and Vladimir Janda (Upper and Lower Crossed Syndromes)2 which has sparked renewed interest in the neuromyofascial formation of commonly seen postural patterns. As a result, practical new structural balancing approaches have surfaced that not only save time but also offer more satisfying long-lasting results. By integrating these new strategies, the demands for structurally-trained pain therapists increases as chronic sufferers find relief from long-standing musculoskeletal ailments. This ultimately sets these bodyworkers apart in the eyes of clients and referral sources.

For today’s touch therapist to gain a basic understanding of how distorted postural patterns lead to chronic head, neck and back pain, the concept of perfect posture must first be defined. Simply put, perfect posture is a condition where body mass is evenly distributed and balance is evenly maintained during standing and locomotion, i.e., “body mass is evenly dispersed in relation to gravity over a given base of support.” Since our bodies are eloquently designed to react to any shift in center of gravity through sophisticated somatic mechanisms, if the normal function of any part of the mind/body system becomes overstressed, a vicious cycle of pain and dysfunction begins. Structural alignment pain therapists seek to restore normal mobility to all components of the somatic system by correcting postural imbalances to minimize compressional loading from gravitational exposure.

Each of us is affected by the mysterious and potentially stressful force of gravity. If, for a moment, we assume that posture is the result of the dynamic interaction of two groups of forces acting on the human body—the environmental force of gravity on one hand and the strength of the individual on the other—then posture could be considered as the ideal expression of balance between these two groups of forces. Therefore, any deterioration of posture indicates that the individual is losing ground in the contest with gravity’s unrelenting power.

 

Proprioceptive Influence on Posture

Postural homeostatic lessons are learned early in life by the central nervous system (CNS). Visual and proprioceptive input continually supplies the toddler with the  necessary information for growth and development. Normally, as a child progresses into adolescence, compressive forces on spinal intervertebral discs and facet

joints are beautifully balanced through ligamentous tension allowing minimal energy expenditure from postural muscles. However, structural or functional body stressors (tension, trauma, genetics, etc.), may prevent achievement of optimum posture. Faulty posture from physical occurrences such as leg length discrepancies, cranial imbalances, and scoliosis alters the body’s center of gravity which requires mechanical adjustments (compensations) leading to muscle, fascial and osseous adaptations.

If a joint’s mechanical behavior is altered, flexibility and range of motion suffers. The increase in mechanoreceptor stimulation from chronically locked joints results in neuroreflexive muscular changes, i.e., protective muscle guarding. Long-standing over-activation of abnormal joint reflexes causes changes in spinal cord memory that eventually “burns a groove” in the CNS as the brain and cord are unknowingly saturated with a constant stream of inappropriate proprioceptive information. Regrettably, the brain comes to rely on this faulty information about where it is in space to determine how to establish perfect posture. The brain simply forgets what its alignment should be.

Many of us have experienced the distress of standing in a three-way mirror trying on a suit or dress when suddenly a shocking profile appears. We ask ourselves where, when and how did this protruding belly, slumped shouldered and accompanying forward head posture develop? The silent progression of aberrant postures is all part of the reflexogenic relationship between muscles and joints.

Gravity and Tensegrity

Some humans appear genetically blessed with optimal posture—where muscles are not actively working as restraining tissues, ligamentous tension is perfectly balanced against compressive and tensegrity forces—and normal everyday activities such as standing and walking require minimal energy expenditure. Buttressed by a dynamic anti-gravity tensegrity system, tensional and compressive forces are evenly dispersed through the entire organism. The ligamentous pelvic bowl is a key structure and part of an eloquent myofascial web designed to transmit forces from above and below during locomotion. When working properly, trunk stabilizers such as transversus abdominis, thoracolumbar fascia, multifidus, and pelvic/respiratory diaphragms form a perfect antigravity pump that lifts the thorax with each step. In the presence of normal spinal curves, the body’s bony framework is effectively supported and moved by this remarkably elastic myofascial network.  As the person walks or runs, the antigravity springing mechanism decompresses intravertebral discs and facet joints allowing lubricating synovial fluids (metabolic substrates) to be sucked in.

Gluteus medius and minimus are excellent examples of the power generated by tensegrity muscles. Regrettably, they are possibly the least appreciated and most important of all of the body’s antigravity structures. When firing in proper order (during the stance phase), these primary hip abductors must elevate the contralateral ilium to allow the leg to swing through preventing the foot from dragging the ground.

Wasted Energy

Ideally, during the static act of standing, postural muscles are in a state of normal tonus and not actively contracting. In reality, however, most people have less-than-perfect postural balance and as a result, active muscular contraction is required to redistribute body mass and effectively hold it in place. Muscles are now working against gravity and performing the job of ligaments as they are forced to stabilize the spine. If a person’s homeostatic threshold has been violated, tonic postural muscles tighten and shorten while their phasic antagonists become overstretched and weak. Asymmetric patterns develop and soon the antigravity function of the body’s myofascial system collapses sending warning alarms to deep intrinsic structures such as spinal ligaments, joint capsules, and intervertebral discs to brace against the onslaught of overbearing compressional loads.

Because locomotion requires the controlled loss and regaining of balance, movement of any body part with respect to the rest of the body shifts its centerline of gravity, causing an inevitable change in overall balance. Muscle and ligamentous tension is maintained by negative feedback from sensory receptors located in joint capsules, ligaments, fascia, and intervertebral discs. Structural asymmetries increase sensory information to the CNS which is then interpreted and reflected in predictable asymmetrical postural patterns such as Vladimir Janda’s upper crossed syndrome. An enormous amount of information can be gleaned by manually and visually assessing for these postural irregularities. Observation of posture provides the clinician with the first and most important clues to the client’s overall physical, emotional and psychological condition.

Compensation

For the body to sail smoothly through life, it must have the ability to repair, regulate and protect itself. Humans possess a complex self-regulatory mechanism that allows for adjustments to environmental stresses while maintaining homeostasis in all systems—myofascial, skeletal, nervous, circulatory, endocrine, etc. These compensatory mechanisms work to keep the body in balance regardless of what works upon it or what happens around it. Although innate compensation is obviously a much needed protective device for repairing worn out parts and maintaining bodily homeostasis, its role in maintaining posture is often confusing as overlapping strain patterns accumulate.

In simple terms, compensation is the counter-balancing of any defect of bodily structure or function. Compensated postures are the result of an individual’s homeostatic mechanism working smoothly even though they exist within a body exhibiting less that ideal posture. Fortunately, this neurologically hard-wired compensatory mechanism allows the person to operate as efficiently as possible in less than perfect circumstances.

Most clients entering our workplace are compensated in one way or another. In the early stages, the individual with structural compensation appears to function normally despite some occasional aches and pains. When physical injury occurs, local myofascial structures tighten (splinting reflex) allowing the body to compensate and continue on its journey—safely, healthfully and productively. Regrettably, as time passes, these compensations accumulate and integrate into myofascial, osseous and visceral systems. Repeated traumatic physical episodes also leave emotional scarring that buries deep within our self-regulating energy system. Micro or macro traumas never leave the body but infiltrate and integrate into every cell and system of the organism. In time, these compensations surface and are visually reflected in every step taken.

Decompensation

When an individual’s homeostatic thresholds are overwhelmed, decompensation occurs. The most destructive postural adaptations occur at the four transitional zones -   cervicocranial, cervicothoracic, thoracolumbar, and lumbosacral). These critical cross-over junctions are areas where anatomical structural changes create the greatest potential for neuromyoskeletal dysfunction. By developing acute visual and palpatory skills, therapists can quickly become proficient in monitoring and correcting regional zone asymmetry in clients.  Many find that assessing and correcting transitional zone decompensations alone produces surprisingly dramatic postural improvement and helps attune therapists to the visual art of unraveling complex strain patterns.

Because of an accumulated history of genetic, traumatic, and habitual processes requiring compensations—in the real world—few clients actually present with ideal posture.

The Battle between Intrinsics and Extrinsics

Deep intrinsic postural muscles such as the iliopsoas, quadratus, transversus abdominis, and multifidus contain more slow-twitch fibers and prefer burning oxygen for fuel (oxidative metabolism). These tonic muscles have a higher capillary density than extrinsics (rectus abdominis, rhomboids, lower trapezius, gluteals, etc.) and are better designed to withstand sustained compressional loads during normal activities such as standing and walking.

Since tonic (postural) muscles have more high-density slow-twitch fibers, they react to functional disturbances by shortening and tightening. Problems appear when the muscle shortening process compresses and twists spinal joints. In the presence of joint dysfunction, the muscle spindles’ gamma system can neurologically weaken the transversospinalis and erector spinae muscles creating scoliotic patterns. As deep intrinsic muscles become spasmodic, their fascial bags react by forming contractures. This leads to a loss of oxygen fuel causing muscle fatigue and eventual collapse of the body’s antigravity system.

The compressive load must then shift to the extrinsic (phasic) muscles. Phasic shoulder girdle muscles such as the rhomboids, lower trapezius, posterior rotator cuff, serratus anterior, and triceps brachii are usually the first to respond. Since these tissues contain a greater number of fast-twitch fibers, they are dynamic and emit bursts of energy. However, their reliance on glucose for fuel (glycolytic metabolism) causes them to fatigue easily. As the supply of glucose diminishes, the extrinsics “give-out” and reluctantly shift the load back to the already overworked and exhausted intrinsics. Many aberrant postural patterns entering our practices belong to bodies screaming out for help—either because they are in an intrinsic or extrinsic stage of collapse.

Athletics and Posture

The issues of faulty posture are often magnified in athletic clients. Imbalances such as short-leg syndromes resulting from a tilted innominate or pronated foot can dramatically reduce speed, strength, coordination and endurance. Moreover, an athlete’s joints are often subjected to abnormal mechanical stresses. Alterations in joint function caused by capsular restriction or loss of joint play either inhibit or facilitate muscles that cross the misaligned joint.3

Muscle imbalances occur as the length-tension relationship surrounding a given joint is disrupted. Therefore, when treating muscle imbalances in athletes, the primary goal is restoration of length, strength, and control of muscle function. Many of today’s exercise programs address length and strength, but few deal with the issues of motor control. Any successful exercise program must focus on restoring proper central nervous system control.

Muscle firing order sequencing is of particular concern to today’s sports therapist. The following Myoskeletal approach has proved successful in restoring muscle balance, reducing nociception and improving proprioception in competing athletes and the general population as well:

·         Lengthen short, hypertonic muscles, and their enveloping fascia;

·         Strengthen weak, inhibited muscles through specific hands-on spindle techniques and Thera Band retraining exercises;

·         Correct aberrant hip hyperextension, hip abduction, shoulder abduction, and neck flexion firing order patterns;

·         Restore proprioceptive motor balance (mini trampolines, yoga, etc.); and

·         Maintain a good aerobic exercise program.

 

Electromyographic studies have repeatedly demonstrated how alterations in the proper sequence of muscle activation (firing order) adversely affect speed and coordination in competing athletes. Clinically, it has been found that in some athletes, inhibition of dynamic extrinsic muscles—commonly due to joint dysfunction—may be so great, that attempting to strengthen the inhibited muscles through resistance training may only serve to further intensify the inhibition.4

This is a vital piece of information for the sports therapist. The bottom line is to first create myofascial balance and restore proper joint function before recommending strengthening exercises. Once muscle balance, posture, and pain-free movement have improved, the client can resume resistance retraining and aerobic exercises.

Moving Forward

Because muscle contraction requires energy, postural imbalances drain energy in proportion to the magnitude of the imbalance. This is wasted energy, energy unavailable for its original purposes. Energy drains dramatically affect the limbic system—the highest cortical level regulating muscle tone. As whole-body tension builds, therapists begin to see energy-draining symptoms reflected in conditions such as fibromyalgia, chronic fatigue syndrome and digestive or hormonal disorders. It has long been known that psychological factors play a large part in creating distorted postures through selective tightening of specific muscle groups. The word “uptight” is an expression commonly used to denote that feeling of tightness, stiffness and fatigue. The power mantra: Poor posture is always perpetuated as tight muscles become tighter—weak muscles become weaker—and CNS motor control becomes disrupted. If not properly assessed and corrected, this commonly seen postural progression leads to agonizing, self-perpetuating pain/spasm/pain cycles.

 Erik Dalton, PhD, originator of the Myoskeletal Alignment Techniques and founder of the Freedom From Pain Institute, shares a broad therapeutic background in Rolfing and manipulative osteopathy in his innovative pain-management workshops. Visit www.erikdalton.com to view additional Myoskeletal Alignment Technique articles and new products and to register for a free monthly technique newsletter. Call 800-709-5054 for more information.

Notes

1. G.J. Zink,“Respiratory and Circulatory Care:The Conceptual Model,” Osteopathic Annals (1997):

108-112.

2.V. Janda,“Evaluations of Muscular Imbalance.” Rehabilitation of the Spine 2nd edition ed Craig

Liebenson (Lippincott,Williams & Wilkins, 2006), 203.

3.V. Janda,“Muscle Weakness and Inhibition in Back Pain Syndromes,” In Modern Manual Therapy of

the Vertebral Column ed. Gregory P. Grieve (Churchill-Livingstone, 1986), 197.

4. F.P. Kendall and E.K. McCreary, Muscle Testing and Function (Williams & Wilkins, 1983).


 

 

                     What Happens When You Stretch

                                                                                                 from www.runtheplanet.com

The stretching of a muscle fiber begins with the sarcomere,  the basic unit of contraction in the muscle fiber. As the sarcomere contracts, the area of overlap between the thick and
thin myofilaments increases. As it stretches, this area of overlap decreases, allowing the muscle fiber to elongate. Once the muscle fiber is at its maximum resting length (all the sarcomeres are fully stretched), additional stretching places force on the surrounding connective tissue.  As the tension increases, the collagen fibers in the connective tissue align themselves along the same line of force as the tension. Hence when you stretch, the muscle fiber is pulled out to its full length sarcomere by sarcomere, and then the connective tissue takes up the remaining slack. When this occurs, it helps to realign any disorganized fibers in the direction of the tension. This realignment is what helps to rehabilitate scarred tissue back to health.

When a muscle is stretched, some of its fibers lengthen, but other fibers may remain at rest. The current length of the entire muscle depends upon the number of stretched fibers (similar to the way that the total strength of a contracting muscle depends on the number of recruited fibers contracting). According to SynerStretch you should think of "little pockets of fibers distributed throughout the muscle body stretching, and other fibers simply going along for the ride". The more fibers that are stretched, the greater the length developed by the stretched muscle.

Proprioceptors

The nerve endings that relay all the information about the musculoskeletal system to the central nervous system are called proprioceptors. Proprioceptors (also called mechanoreceptors) are the source of all proprioception: the perception of one's own body position and movement. The proprioceptors detect any changes in physical displacement (movement or position) and any changes in tension, or force, within the body. They are found in all nerve endings of the joints, muscles, and tendons. The proprioceptors related to stretching are located in the tendons and in the muscle fibers.

There are two kinds of muscle fibers: intrafusal muscle fibers and extrafusal muscle fibers. Extrafusal fibers are the ones that contain myofibrils and are what is usually meant when we talk about muscle fibers. Intrafusal fibers are also called muscle spindles and lie parallel to the extrafusal fibers. Muscle spindles, or stretch receptors, are the primary proprioceptors in the muscle. Another proprioceptor that comes into play during stretching is located in the tendon near the end of the muscle fiber and is called the golgi tendon organ. A third type of proprioceptor, called a pacinian corpuscle, is located close to the golgi tendon organ and is responsible for detecting changes in movement and pressure within the body.

When the extrafusal fibers of a muscle lengthen, so do the intrafusal fibers (muscle spindles). The muscle spindle contains two different types of fibers (or stretch receptors) which are sensitive to the change in muscle length and the rate of change in muscle length. When muscles contract it places tension on the tendons where the golgi tendon organ is located. The golgi tendon organ is sensitive to the change in tension and the rate of change of the tension.

The Stretch Reflex

When the muscle is stretched, so is the muscle spindle. The muscle spindle records the change in length (and how fast) and sends signals to the spine which convey this information. This triggers the stretch reflex (also called the myotatic reflex) which attempts to resist the change in muscle length by causing the stretched muscle to contract. The more sudden the change in muscle length, the stronger the muscle contractions will be (plyometric, or "jump", training is based on this fact). This basic function of the muscle spindle helps to maintain muscle tone and to protect the body from injury.

One of the reasons for holding a stretch for a prolonged period of time is that as you hold the muscle in a stretched position, the muscle spindle habituates (becomes accustomed to the new length) and reduces its signaling. Gradually, you can train your stretch receptors to allow greater lengthening of the muscles.

Some sources suggest that with extensive training, the stretch reflex of certain muscles can be controlled so that there is little or no reflex contraction in response to a sudden stretch. While this type of control provides the opportunity for the greatest gains in flexibility, it also provides the greatest risk of injury if used improperly. Only consummate professional athletes and dancers at the top of their sport (or art) are believed to actually possess this level of muscular control.

Components of the Stretch Reflex

The stretch reflex has both a dynamic component and a static component. The static component of the stretch reflex persists as long as the muscle is being stretched. The dynamic component of the stretch reflex (which can be very powerful) lasts for only a moment and is in response to the initial sudden increase in muscle length. The reason that the stretch reflex has two components is because there are actually two kinds of intrafusal muscle fibers: nuclear chain fibers, which are responsible for the static component; and nuclear bag fibers, which are responsible for the dynamic component.

Nuclear chain fibers are long and thin, and lengthen steadily when stretched. When these fibers are stretched, the stretch reflex nerves increase their firing rates (signaling) as their length steadily increases. This is the static component of the stretch reflex.

Nuclear bag fibers bulge out at the middle, where they are the most elastic. The stretch-sensing nerve ending for these fibers is wrapped around this middle area, which lengthens rapidly when the fiber is stretched. The outer-middle areas, in contrast, act like they are filled with viscous fluid; they resist fast stretching, then gradually extend under prolonged tension. So, when a fast stretch is demanded of these fibers, the middle takes most of the stretch at first; then, as the outer-middle parts extend, the middle can shorten somewhat. So the nerve that senses stretching in these fibers fires rapidly with the onset of a fast stretch, then slows as the middle section of the fiber is allowed to shorten again. This is the dynamic component of the stretch reflex: a strong signal to contract at the onset of a rapid increase in muscle length, followed by slightly "higher than normal" signaling which gradually decreases as the rate of change of the muscle length decreases.

The Lengthening Reaction

When muscles contract (possibly due to the stretch reflex), they produce tension at the point where the muscle is connected to the tendon, where the golgi tendon organ is located. The golgi tendon organ records the change in tension, and the rate of change of the tension, and sends signals to the spine to convey this information. When this tension exceeds a certain threshold, it triggers the lengthening reaction which inhibits the muscles from contracting and causes them to relax. Other names for this reflex are the inverse myotatic reflex, autogenic inhibition, and the clasped-knife reflex. This basic function of the golgi tendon organ helps to protect the muscles, tendons, and ligaments from injury. The lengthening reaction is possible only because the signaling of golgi tendon organ to the spinal cord is powerful enough to overcome the signaling of the muscle spindles telling the muscle to contract.

Another reason for holding a stretch for a prolonged period of time is to allow this lengthening reaction to occur, thus helping the stretched muscles to relax. It is easier to stretch, or lengthen, a muscle when it is not trying to contract.

Reciprocal Inhibition

When an agonist contracts, in order to cause the desired motion, it usually forces the antagonists to relax. This phenomenon is called reciprocal inhibition because the antagonists are inhibited from contracting. This is sometimes called reciprocal innervation but that term is really a misnomer since it is the agonists which inhibit (relax) the antagonists. The antagonists do not actually innervate (cause the contraction of) the agonists.

Such inhibition of the antagonistic muscles is not necessarily required. In fact, co-contraction can occur. When you perform a sit-up, one would normally assume that the stomach muscles inhibit the contraction of the muscles in the lumbar, or lower, region of the back. In this particular instance however, the back muscles (spinal erectors) also contract. This is one reason why sit-ups are good for strengthening the back as well as the stomach.

When stretching, it is easier to stretch a muscle that is relaxed than to stretch a muscle that is contracting. By taking advantage of the situations when reciprocal inhibition does occur, you can get a more effective stretch by inducing the antagonists to relax during the stretch due to the contraction of the agonists. You also want to relax any muscles used as synergists by the muscle you are trying to stretch. For example, when you stretch your calf, you want to contract the shin muscles (the antagonists of the calf) by flexing your foot. However, the hamstrings use the calf as a synergist so you want to also relax the hamstrings by contracting the quadricep (i.e., keeping your leg straight).

 

 

A New Look at Lactic Acid
Dispelling the Myths

 

By:  Shirley Vanderbilt

 

Sometimes a “truth” is not what it seems.  Take lactic acid.  For years, many massage therapists have been taught that lactic acid can and should be flushed from the muscles of athletes after intense activity.  This truism has been passed on to clients who have also accepted it as fact.  Both therapist and client thus have established and perpetuated a mutual belief system that purging lactic acid is not only necessary, but also efficiently accomplished with the assistance of massage.  Some beliefs die hard.  This one and others related to lactic acid have been holding their own, not only in some massage schools and practices, but also in the community at large, despite emerging research to the contrary.  Pass the word.  There’s no need to mess with Mother Nature.

 

TERMINOLOGY

 

Adenosine triphosphate (ATP)  A compound present in muscle cells for energy storage.  When split by an enzyme, energy is produced. 

Glycolysis  Series of reactions converting glucose into pyruvic acid and releasing energy in the form of ATP. 

Krebs Cycle  Complicated series of reactions involving metabolism of pyruvic acid and liberation of energy.  Main pathway of terminal oxidation whereby carbohydrates, proteins and fats are utilized. 

Mitochondria  Cell organelle containing enzymes for aerobic stages of cell respiration; site of most ATP synthesis.      

pH  Potential of hydrogen.  A value expression of the acidity or alkalinity of a substance. 

Pyruvic acid  Intermediate product in metabolism of carbohydrates, fats and amino acids.  Plays an important role in the Krebs cycle. 

 

Taber’s Cyclopedic Medical Dictionary

 

            Lactate accumulated from intense exercise actually fuels the body, according to Dr. Owen Anderson, exercise physiologist and editor of Running Research News.  In a recent interview from his office in Michigan, Anderson explained the facts. 

            Lactic acid levels will return to homeostasis quickly post-exercise without any “hands-on” assistance.  “Muscles don’t need help from massage in removing lactate,” said Anderson.  “Massage will probably have the biggest effect on venous blood,” and by the time massage is administered, lactate has already left the muscle.  This is not to say massage isn’t beneficial to the athlete.  “Massage is good for relaxing,” said Anderson, “and provides help increasing flexibility of muscles.” 

            Whitney Lowe, owner and director of Orthopedic Massage Education and Research Institute and author of Functional Assessment in Massage Therapy concurs with Anderson’s statements. 

            “Lactic acid is a natural by-product of any muscular activity.  There are elevated levels of lactic acid in muscle tissues after exercise, but that is going to subside either with time or with any type of movement activity, even just walking around the room.” 

            In addition, lactic acid does not cause muscle soreness, fatigue or the “burn” of intensive exercise, noted Anderson.  His comments and those of Lowe are backed by valid scientific research.  Several studies conducted in the 1980s by exercise physiologist Dr. George A. Brooks ushered in a new perspective on this supposed “demon.”  Brooks noted that lactic acid is a key substance for providing energy, disposing dietary carbohydrate, producing blood glucose and liver glycogen and promoting survival in stress situations.1/ 

 

Nature’s Magic Tricks 

            Just as the body’s intelligence keeps our hearts pumping and our intestines digesting without any intervention on our part, in like manner it maintains the chemical process of glycolysis to provide energy on a 24-hour basis.  In Anderson’s book, Lactate Lift-off, he writes, “Glycolysis is actually a series of 10 different chemical reactions…that break down glucose, the simple six-carbon sugar which is your body’s most important source of carbohydrate fuel, into something called pyruvic acid.”2/  From pyruvic acid, with the help of the enzyme lactate dehydrogenase, we get lactic acid.  But it’s not quite that simple. 

            The process of glycolysis converts each glucose molecule into two pyruvic acid molecules, releasing energy in the form of adenosine triphosphate (ATP).  From there, pyruvic acid enters the mitochondria, where more ATP is produced through the Krebs cycle.3/  “In addition to ‘handling’ the pyruvic acid produced from glucose,” states Anderson, “the Krebs cycle also metabolizes fats; over all, it furnishes more than 90% of the energy you need to exercise in a sustained manner.” 

            As exercise intensity increases, glycolysis speeds up and pyruvic acid is produced at an increasing rate.  When it can no longer be processed through the Krebs cycle as quickly as it is generated, some of the pyruvic acid is converted to lactic acid, which rapidly dissociates into a lactate anion and a free hydrogen ion (H+).  Lactate can then be quickly transported from the muscle into the blood, where it is circulated throughout the body.  If an excessive amount of pyruvic acid were allowed to build up, glycolysis would come to a halt, thus blocking energy production.  The conversion to lactic acid allows the body to continue its exertion of energy.  Once the lactate enters other tissues, it can be converted to pyruvate, which is processed by the Krebs cycle into ATP for even more energy.  Lactate can also be converted by the liver and other tissues into glucose, boosting depleted stores of glycogen needed for future activity.5,6,7/ 

            Although the focus here is to examine excessive lactic acid accumulation during intensive activity, it’s important to clarify that lactic acid production is a normal and continuous part of the body’s energy cycle.  According to Anderson, lactate is produced even at rest and “…its concentrations can rise rather dramatically whenever you take in a carbohydrate-containing meal.”  Lactate plays an important role in processing carbohydrate and facilitating its availability to the lever and muscles.8/ 

Lactic acid reaches excessive levels when the body can no longer clear it as quickly as it is being produced.  “When you begin a moderate to difficult workout,” states Anderson, “lactate levels in your blood initially rise, simply because glycolysis is working away to provide quite a bit of the energy you require.”  At this point, there is minimal blood and oxygen flow to the muscles.  This limits the breakdown of pyruvate in the Krebs cycle and increases its conversion to lactate.  With continued activity, heart rate increases and oxygen becomes more readily available to the muscle cells, allowing pyruvate and lactate to be oxidized for energy.  The entry and exit rates of lactate then become stabilized and will remain so even with gradually intensified activity.” 

“However,” states Anderson, “once you get up to a point (actually a speed) at which glycolysis is tearing along so fast that your leg muscles have problems converting most of the pyruvate and lactate being formed to carbon dioxide and water, the lactate-spilling process may accelerate so much that lactate levels in the blood may really begin to lift off.”  This can be a result of oxygen debt inside the muscle cell, inadequate concentrations of enzymes necessary for oxidation at high rates or a lack of sufficient cell-mitochondria, where the Krebs cycle takes place.  The point at which this occurs is referred to as the lactate threshold (LT).  According to Anderson, the LT is simply an indicator of how effectively your tissues utilize lactate as an energy source.  For athletes, a high LT means increased endurance – the longer the athlete can perform before reaching this point, the longer lactate production and extraction is kept in balance and energy is maintained.” 

At the completion of exercise, lactate levels will return to normal within 30-60 minutes, being quickly converted back to pyruvate or glucose.11/  Research supports the claim that active recovery (light exercise) is the most effective approach to speed up this procedes,12,13/ and that massage is no more effective than passive rest.14   This does not discount other potential benefits of massage in sports recovery.  A study by Monederno and Donne showed that while active recovery proved best in removing lactic acid, a combined approach (active recovery and massage) did increase recovery rate during short intervals between maximal efforts and was most efficient for maintaining maximal performance time in subsequent performance.  Recovery rate was determined by blood lactate levels and heart rate during recovery, and performance times in tests of maximal efforts.15/ 

For post-exercise recovery, Anderson recommends a cool-down of about 10 minutes or running a few miles followed by stretching and strengthening exercises, nutrition (carbohy-drates) to restock energy and a good night’s sleep.  Improving the body’s ability to break down pyruvate, use oxygen and extract lactate from the muscle during activity will raise the LT and increase an athlete’s endurance.  This can be accomplished with proper training, such as methods recommended in Lactate Lift-off.16/  An effective training approach can increase the supply of mitochondria, enzymes and capillaries needed to enhance the body’s ability to rapidly use lactate as an energy source.17/ 

 

Soreness, Fatigue and the ‘Burn’

            Is lactic acid to blame?  “There has been a strong suggestion,” said Lowe, “that delayed onset muscle soreness (DOMS) occurring 12-24 hours after exercise is caused by excess levels of lactic acid, but the onset of soreness does not at all coincide with the levels of lactic acid.  This is still a very rampant misconception.” 

            Anderson indicates that there are two likely causes of muscle soreness:  tears in the muscle associated with the stress of exercise and free radical attack on the muscle membranes.  According to physician Dr. Gabe Mirkin, “Next-day muscle soreness is caused by damage to the muscle fibers themselves.  Muscle biopsies taken on the day after exercising show bleeding and disruption of the z-band filaments that hold the fibers together as they slide over each other during a contraction.”  Mirkin suggests ceasing exercise when muscles start to burn and hurt as this is likely an indication that DOMS will occur.18/ 

            The free hydrogen ions produced in dissociation of lactic acid can present a problem.  Biscarbonate buffers H+ to maintain homeostasis in pH, but increase of H+ during intensive exercise can overwhelm the buffering system, resulting in acidity (low pH) of muscle and blood.  If the pH goes to below 7.00, the athlete may experience nausea, headache, dizziness and pain in the muscles.  But with cessation of exercise the pH, like lactate, returns to normal.19/  “The muscle will slow down if there is a great enough lowering of pH,” said Anderson. “and this may cause fatigue.”  He notes there can be a lowering of pH in muscles even while sedentary.  “We don’t know if it can cause burn,” he added, “but burn is the nervous system’s way of telling you you’re exercising at too high intensity and you need to cut back.  There is nothing wrong.  It’s just a message.” 

            Heavy legs or fatigue can occur in an all-out sprint, said Anderson, but if it occurs at the 20-mile point in a marathon, it’s a sign the muscles are running out of energy.  To combat these problems, Anderson emphasizes the importance of training.  “If you are really strong," he said, “you have less stress and damage.” 

 

So What About Massage

            Although the effectiveness of massage to flush out lactic acid after exercise has been disproven, there are benefits to validate its use in sports.  “In my own experience,” said Keith Grant, head of Sports and Deep Tissue Massage Department at McKinnon Institute, “I’ve seen that massage is effective.  How our body reacts to things depends on both the state our body is in (state of memory), as well as the input.”  Grant combines his knowledge as a scientist with personal experience as a massage instructor and runner to support his conclusions. 

            Pointing to a study by Tiitus and Shoemaker (1995) in which effleurage did not increase local blood flow, Grant said, “This is a mechanistic way of looking at what’s going on.”  The difficulty, he noted, in interpreting research results comes from looking for direct, mechanical effects.  “Clinically, we see a different story,” he said.  “Through our techniques we work with the nervous system to relax muscles, but that’s not a direct mechanical effect.  “I believe the effects of massage also involve the neurological and emotional.  My reason for that is the neurological side controls the current (base) state of the muscle activation.  The emotional controls the chemical messengers that affect the immune system.  What seems likely is massage acts as a new input to a system with a memory.  Massage stimulates the mechanoreceptors and can gate off pain receptors.  It floods the body with new sensory input.  We are using the nervous system to reset the muscle to greater relaxation. 

            “In my observation, fatigued muscles tend to remain hypertonic and shortened.  When we cajole specific muscles to relax and lengthen via mechanical and neurological input, we reduce their metabolic activity.  When the muscle relaxes, it’s not using energy as much, not metabolizing as fast, not producing waste products and because it’s more relaxed, it’s not compressed and not exerting pressure on surrounding tissues.  This means circulation is better.  It’s not because we’re pushing fluid around.  It’s because we’ve put the body in a more optimum state, so the body naturally increases circulation on it’s own.  By massaging muscles and adding input to the nervous system, we are facilitating the body in recovering faster from exercise.  It’s not the massage that’s doing the healing, it’s the person’s body.” 

            In a British study of boxers, massage was reported to have a significantly positive effect on perception of recovery, giving scientific credence of its benefits as a recovery strategy.  According to the authors, their results support arguments by some researchers that “the benefits of massage (in sports recovery) are more psychological than physiological.”20/  Grant takes that a step farther.  “As a trained scientist, I use what I observe and what I know about physiology to come with a hypothesis.  From my own experience in running, when you exert to the point of substantial fatigue, you come back feeling more fragile, in an emotionally vulnerable spot.  To have the sense that someone is nurturing, in a sense taking care of you, is a very psychologically emotional thing.  In supporting the person, we improve their immune function and their ability to heal, by influencing the chemical environment of their body.  It has to do with psychoneuroimmunology, the whole chemical homeostasis of their body – neurochemicals and the relationship between mood, or feelings, and the immune system. 

            “There is some evidence that following heavy exercise, both L-glutamine (an amino acid manufactured by the body) and the immune system take a dip.  I look at the healing effect of massage as, in some way, counteracting that dip.  When you provide support it has a positive effect on immune function.  If the person doesn’t feel supported and nurtured, it will have a negative effect on the chemical environment, opening them more to catching colds, not healing as fast and decreasing their ability to train.  It ties into the whole emotional state of a person.  The athlete has to stay health in order to continue training.  With massage, they can train harder because they are able to recover faster.” 

 

Facts and Myths 

            Remember the old theory about the earth being flat?  The more we learn, the more we realize how much we don’t know.  That’s why research in massage is so important.  “These concepts and ideas are firmly entrenched in our early training, and in the medical profession, said Lowe.  “Things that have been disproved continue to persist.  It takes a long time to trickle down.  If we say there is no research that supports massage works for inflammation, there may not be research – or it may not be true.  We don’t really know yet and we need to investigate that further.  This lactic acid concept illustrates the perpetuation of misinformation that can happen if we don’t have the research base.  When we are looking for credibility with others in health care, they want to know on what we base our opinions.  A lot is passed along on hearsay, not on scientific information.  What we need to keep our eyes on is how to reduce that as much as possible so we do have accurate information.” 

 

Reference

1/   Vannatta, Dan, “Lactic Acid:  Friend or Foe?”

       http://sportsmedicine.about.com/library/weekly/oo053101a.htm.

2/   Anderson, Owen, Lactate Lift-off (Lansing, Mich: SSS Publishing, 1998),16.

3/   Vannatta.

4/   Anderson, 16

5/  Vannatta

6/   Anderson, 16-24

7/   Grant, Keith, “Lactating Mythers.”

       www.mckinnanmassage.com/articles/lactating_mythers.html.

8/   Anderson, 20-21

9/   Ibid., 25-26

10/  Ibid., 26-30

11/  Grant.

12/  Ibid.

13/  Vannatta.

14/  Hemmings, B., Smith, M., Graydon, G. and Dyson, R., “Effects of massage on physiological

       restoration, perceived recovery, and repeated sports performance.”  British Journal of Sports

       Medicine34 (2000): 113.

15/  Monedero, J. and Donne, B., “Effect of recovery interventions on lactate removal and subsequent performance,” International J. of Sports Medicine 21,B (Nov. 2000):593-597. 

16/  Anderson, 30-35.

17/  Grant.

18/  Mirkin, Gabe.  “What causes muscle soreness?”  Report #6386. 

       www.drmirkin.com/archive/6386.html. 

19/  Grant.

20/  Hemmings, 113







Why Popping Your Neck is Harmful

SUMMARY: If you often crack or pop your neck yourself, it probably means that the joints are hypermobile. The ligaments are a bit lax so the joints move a little more than they should. In response, the muscles tighten up to stabilize the joints. This makes your neck feel tight and makes you want to crack it. When you do that, the muscles are momentarily stretched, they relax somewhat, and you feel better for a while. But when you crack your neck you also stretch the loose ligaments further which makes the muscles tighten up again. It’s a vicious cycle.

(Hypermobility should not be confused with clinical instability
.)

What’s the Real Problem and What Can You Do About It? 
      
The scenario goes something like this: You’re under a lot of stress and your neck feels tight. This morning you drove all over town meeting with clients. You were late for a meeting and the client left before you could get there. The next client stood you up. Now you’re back at the office staring at your computer screen. Your company just upgraded and you can’t get the program to do what it’s suppose to do. Your neck feels like it’s in a vice. Without giving it much thought you put one hand on the back of your head, cup your chin in the palm of the other hand, and twist sharply. Your neck emits popping sounds like a string of firecrackers on Chinese New Year. You twist in the other directions, hearing and feeling another series of cracks. Aaahh … that’s better! But soon the stress mounts again, tension builds, and you find yourself twisting your neck again. Each time the results are less satisfying. By the end of the day you feel like you’ve been through the ringer, and so does your neck.

If you are a chronic neck cracker you are probably doing more harm than good. What happens when someone repeatedly manipulates his or her neck? In order to understand how this can be harmful, it first helps to have some knowledge of normal joint function. Here are the fundamentals:

1. Joints move. Okay, you knew that already. The point is that your spine is made up of many vertebrae, each of which articulates (forms joints with) the vertebra above and the vertebra below. The joints in the spine do not have as great a range of motion as do the larger and more mobile joints of the shoulders, elbows, hips, and knees, but because there are 24 moveable segments in the spine, the combined motion of these joints allows us to bend forward and touch our toes (some of us, anyway), look over our shoulders to back the car out of the driveway, and perform nearly all of our daily activities. Without spinal motion people would look like the Tin Man before he found his oil can. Joints move.

2. Normal joints have normal motion. This may sound like another no-brainer, but neck-crackers have a problem with normal joint motion. There are four phases of motion: active, passive, paraphysiologic - where the “pop” occurs during manipulation - and sprain - where ligaments are injured.
Active motion is the range in which a person can move a joint unaided. For example, wave your index finger up and down. That’s the active range of your second metacarpophalangeal joint (the big knuckle). Now use the fingers of your other hand to move the index finger up and down passively. The passive range of motion should be greater than the active range. Joint mobilization, a treatment used by physical therapists and less commonly by chiropractors, is movement within the passive range of motion.

3. Why joints pop. Movement through the paraphysiologic zone, the Twilight Zone of joint motion, occurs when the passive range is exceeded but before actual damage can occur. Paraphysiologic motion involves the “play” of a joint, not just further passive motion. This springiness you feel in your knuckle when you gently tug on a finger or push the finger backward to the endrange of passive motion is there because the ligaments have a little give built into them. In the paraphysiologic zone the surfaces of each bone - which don’t actually quite touch in a normal joint - move apart slightly further. A sudden and quite temporary vacuum occurs which is just as suddenly filled by gas which has been, up until that moment, saturated in the joint fluid. A popping or cracking noise is produced. This exchange of gas and fluid is called cavitation. It is similar to popping your cheek with your finger; when you push your fingertip out of your mouth quickly, air rushes in to the space suddenly created and makes a pop!

4. The bad news for “self-manipulators.” If you are a chronic neck-popper, you are very likely stretching the ligaments which support and stabilize your neck joints. Stretched ligaments result in a condition called hypermobility in which the joints lose their natural springy end play. To someone skilled at feeling joint motion, like a chiropractor, this loss of springiness can be detected. It is sometimes jokingly referred to as “floppy disc syndrome,” although the discs in the neck are not directly affected. As the ligaments become more lax, the small muscles that connect one vertebra to the next become tight. They have to work harder to make up for the loss of stability due to the lax ligaments. This makes your neck feel tight. As the muscle tension builds and your neck becomes more and more uncomfortable, you feel the urge to manipulate your neck. CRACK! The muscles are stretched, they relax, and you feel some relief. Of course, this manipulation also stretched those already loose ligaments, and the vicious cycle starts over again.

Hypermobility can be congenital (i.e., hereditary) or acquired. Teens tend to have hypermobile spinal joints. This is normal and will usually resolve as the skeleton and supporting tissues finish growing. However, if neck cracking becomes a habit, then the problem can continue into adulthood. Clinical evidence suggests that hypermobile spinal joints become arthritic at a faster rate than normal joints. Hypermobility can also result from injuries such as whiplash, or it can be self-inflicted. Some popping in the back or neck occurs spontaneously with movement and may be normal.

Treatment: Chiropractors treat hypermobility with strengthening exercises. If the ligaments are weak and the muscles have to work harder, they will be less tense if they are stronger. Strong muscles don’t have to work as hard as weak muscles, so there is less tension. Hypermobility is also treated with spinal adjustments, a form of manipulation. Although this would seem to be contradictory, sometimes hypermobility can be a compensation for restricted or fixated joints elsewhere in the spine. The adjustments are given only to these joints, not the hypermobile ones.

Of course, the best thing to do is to STOP POPPING YOUR NECK. That’s it. Just don’t do it. Most people who “go cold turkey” will feel worse for a time. But even if no other treatment is given, you will probably feel much better after two or three weeks.





 

Scar-Tissue Massage

 

This technique effectively reduces adhesions in the scar-tissue matrix, resulting in accelerated return to full muscle function and freer range of motion.  Research on wound healing supports the efficacy of scar-tissue massage, and points toward the benefits of the inclusion of this technique in post-injury and post-surgical situations.

 

By:  Chuck LaFrano

 

Scar-tissue formation, while absolutely necessary to the healing process, can be a significant impediment to the recovery and rehabilitation of injured muscle tissue.  Effective scar-tissue massage can speed up the time it takes the body to regain function after surgery or injury.  Additionally it enables the body to regain pre-injury range of motion not otherwise attainable.  Scar-tissue massage is also gaining recognition as an asset in reducing health-care costs.1/ 

            Scar tissue can inhibit range of motion by adhering the connective tissue of the wounded and adjacent structures together.  This often affects associated joints and presents a formidable barrier to attaining comfortable body function and useful range of motion.  Circulation problems can be caused by reflexive muscle tightness in the wound area, and the resulting reduction in movement interferes with blood circulation, allowing waste to become trapped in the dense collagen network, and blocking out nutrients.  Add to this the adhesion and circulation problems in referred areas due to the pain reflex response, and scar tissue can indeed be considered a significant clinical problem.  Research supports the use of scar-tissue massage in resolving these functional problems. 

            “Analysis of various disorders resulting from abnormal deposition of collagen indicates that it is not the volume or amount of collagen that accumulates in the tissue lesion, but rather the physical properties (maturation, polymerization) of the collagenous matrix that are responsible for the dysfunction of the affected tissue organ,” write M. Chvapil and C. F. Koopman.  “Once collagen is stabilized, it is more resistant to degradation by tissue collagenases.  The dense, rigid scar of mature collagen binds less water.”2/  When collagen binds less water it is more dense and thick, therefore the movement and action of collagenase to and through the tissue is impeded. 

            Newer scars are more malleable and more easily affected by scar-tissue massage, although any scar can be worked on for greater function.  Optimally, best results come from beginning work on scar tissue eight to 16 days after injury or surgery, at which point the scar is in the maturation/remodeling phase.3/ 

            Inhibition of free, or at least reasonably functional, range of motion is a particularly insidious problem with scar tissue.  To have full range of motion, the muscles must be able to slide in relation to each other in order to be independent in their motion.  Scarred muscles adhere to and pull adjacent connective tissue and muscle with them when they contract or lengthen.  Thus one of the functions of connective tissue, to provide a sliding surface for the muscles, is inhabited.  This function is apparent in the separation of muscles by intermuscular septa and into fascicles (fiber bundles).  Since every muscle fiber is surrounded by connective tissue, conceivably any motor unit could need to slide in relation to adjacent motor units for dexterity and graceful movement. 

            Scar tissue can bind muscle and connective tissue together so that they cannot move independently but must pull on each other when muscles move.  If the injury or the surgical cut is deep, scar tissue can bind many layers of muscle and connective tissue, causing varying degrees of limited movement and pain.  A physiological problem connected with scar tissue is that the collagen fiber network is reticular in orientation, meaning it goes in all directions and so has limited range of motion in any one direction.  Consequently, the surrounding area’s flexibility and circulation are affected.  If the collagen network is large and extensive, functional movement may be decreased.  The advantage of treating scar tissue is that no matter how tough and thick it is, it maintains some pliability.  Collagenase is always present in connective tissue.  All scars can be loosened to some degree, and usually to a great degree.  Scar-tissue massage allows the scar’s collagen fibers to increase movement in a greater and more comfortable range. 

            Scar tissue is connective tissue, which has the ability to arrange its fibers in a variety of ways in response to the pressures it is under.  When connective tissue is stretched, like elastic, its fibers recoil to their original state.  However, the fibers incorporate some of the stretch, lengthening the fiber net.  If the stretch is applied slowly, steadily and repetitively, the increase in the elastic quality can be effectively controlled.  “The permanent changes result from the breaking intermolecular and intramolecular bonds between collagen molecules, fibers and cross links,” write A. J. Grodin and R. I. Cantu.4/ 

“All connective tissue seeks metabolic homeostasis—the tendency of chemical reactions involved in cellular metabolism to occur in a manner that leads most efficiently to stability of the cells’ metabolism—equal to the outside stresses applied to it.  Carefully controlled stresses may positively change the metabolic and physical homeostasis of the tissue.  For example, collagen production is less haphazard, more organized and laid down in a quality and direction more suited to optimal tissue function.”5/ 

            It is evident that in many cases full use of areas of the body, especially limbs, can be impeded by nerves and muscles bound up by the fibers of scar tissue.  Scar-tissue massage is a simple solution to achieve freer movement.  But like most tissue injuries, every scar carries its own special circumstances and skilled, individualized adaptation of technique is required.  Effectively worked, the reticular fibrous network of this tissue can be coaxed into functional movement. 

 

Case histories

            The following two client case histories show the benefits of scar-tissue massage. 

            A 42-year-old lawyer, who plays soccer on weekends, tears an Achilles tendon completely in half about three inches from the heel.  Ten days after surgery he began receiving scar-tissue massage.  Since the would was so fresh, the massage began with gently moving the skin over the underlying tissue to develop independence of the superficial fascia.  As the skin became free of the repaired tendon, the massage went slowly deeper into the underlying layers.  The goal of the deeper work was to feel for the integrity of the collagen fiber network, and continue to influence the fibers’ orientation.  This protocol continued twice weekly for four weeks.  At that point the Achilles tendon could be stretched into dorsiflexion.  Massage treatments were changed to once a week, slowly increasing independence in the tendon sheath and surrounding connective tissue.  After three months the client resumed jogging, and at five-and-a-half months post-injury the client was playing soccer at full speed, cutting and pivoting without holding back.  The client’s post-operative prognosis was nine to 12 months to regain full functional use of the Achilles tendon excluding participation in sports.  This occurred four years ago.  Today the client remains active in sports and has had no Achilles tendon problems since. 

            The second case involves a 52-year-old woman who fell on Thanksgiving Day 1996.  The client fell forward, breading her fall with her hands, and broke bones in both the forearms, requiring the radius in her left arm to be pinned twice and a rod was inserted.  She had two surgeries 10 days apart.  She wore cast for two months, and required 16 weeks of physical therapy post-surgery.  The client stopped treatment at that point due to lack of insurance coverage. 

            Upon completion of treatment the client could not close her fist, could not drive a car, and could not sleep through the night because of the pain.  Even light pressure or movement on her shoulders was extremely uncomfortable.  Pre-treatment assessment for massage revealed permeating scar tissue networks throughout the shoulder girdles, rib cage, neck and left forearm. 

            Her massage program began with slowly and gently moving the shoulder girdles, assessing for areas of more movement and independence between shoulders and rib cage.  (Freedom of movement of the rib cage is crucial for sustained change in the range of motion for the shoulders, arms and neck.)  After only two scar-tissue massage sessions, the client reported her first full night’s sleep since her fall.  Treatments began in April 1997 and stopped in February 1998.  There were numerous lapses in treatment, due to financial constraints.  In all, the client had 26 treatments of 45 minutes each.  Currently, the client reports less pain, the ability to drive a car and sleep through the night, full range of motion in her left hand, and increased power in her grasp.  The client returned to work January 12, 1998.  The remaining scar tissue in her left forearm is extensive due the fact that one pin inserted during surgery had to be removed and reinserted.  A significant amount of tissue is bound up in scar tissue in that area, which would require further intensive sessions to release. 

            These two cases required different use of the scar-tissue massage techniques.  The pressures and rate at which tissue was manipulated, and the levels of movement explored, were quite varied.  The application of individualized techniques is of primary importance to the effectiveness of this kind of massage. 

 

On collagen

            My personal experience indicates that moving the scar-adhered area along the lines of the fascial planes induces the scar-modeling mechanisms to organize the scar tissue along those lines of movement.  This observation is supported by H. P. Ehrlich and T. M. Krummel in an article in Would Repair and Regeneration:

            “The arrangement of collagen fibers is by the resident cells, but they are influenced by the chemical composition of the collagen in terms of quantity and quality, as well as the physical forces generated at the healing site as a consequence of its anatomical location.”6/ 

            Scar-tissue massage works by applying controlled physical forces to the healing site.  Effective scar-tissue massage also normalizes and balances the chemical composition of the connective tissue matrix and the interstitial fluid, and improves the function of muscle, connective tissue and nerves. 

            “The roles of the intra-articular and extra-articular contractures in restricting joint motion following prolonged immobilization were studied by the manipulation of previously immobilized rats.  The extra-articular pericapsular and the capsular structures resisted most motion.  Intra-articularly, manipulation tore the proliferative connective tissue in a plane different from the original joint cleft.  The new cleft was lined on either side by fibro-fatty tissue that, with time, came to resemble a synovial membrane (the membrane lining the capsule of a joint),” write W. F. Enneking and M. Horowitz.  “The adhesions not disrupted by the manipulation were not affected by the resumption of motion.”7/   The scar tissue matrix, and indeed all connective tissue, respond to pressure and movement.  In their absence, the matrix will revert to its simplest state:  fibro-fatty connective tissue. 

            Massage to the scar increases fluid, independent movement of the adjacent tissue, improves muscle function through increased circulation of nutrients and removal of metabolites, and increases range of motion by influencing the effectiveness of the way the wound-healing mechanisms remodel the scar.  The less movement connective tissue has, the thicker and denser it becomes, and the pain associated with scar-tissue problems usually discourages movement.  A 1972 study of knee immobilization reported that, soon after movement resumes, the connective tissue at the site of movement responds by developing a synovial membrane, which is the variation of connective tissue most conducive to movement.8/  Scar-tissue massage uses the inherent responsiveness of connective tissue to control scar-tissue remodeling.  Further, Ehrlich and Krummel’s work suggests that manipulating the scar changes the nature of the scar tissue’s anatomical location from immobility toward synovial-quality independence of movement. 

            “Although soluble collagen can self-polymerize into filamentous fibrils under physiologic conditions (in this case, those in the would-healing process), the organization of these fibrils into fibers requires cellular intervention,” the study concludes.  “The cellular organization of collagen fibers is important in terms of scar volume, stability and strength … Although collagen covalent cross-links have been shown to correlate and increasing wound-breaking strength [the amount of physical stress the scar tissue matrix can withstand before tearing itself], the amount of collagen deposited, as well as its degree of organization [the alignment of the collagen fibers in the scar tissue matrix, referring in particular to how they function:  How much pressure they can withstand vis-à-vis how much movement they allow], may be of greater importance.”9/ 

            The response of the local fibroblasts is largely predicted on local tissue chemistry and pressures.  My experience indicates that both chemistry and pressures can be effectively influenced by massage techniques.  Scar-tissue massage applies pressure along the planes of movement in the surrounding tissue (fascial planes), thereby influencing the fibers’ degree of organization. 

 

Footnotes

1.      1.        Witte, M. B., Barbul, A. “General Principles of Wound Healing,” 1997, The Surgical Clinics of North America, 77, (3), pp. 509-528.

2.      2.        Chvapil, M.,; Koopman, C.F. “Scar Formation:  Physiology and Pathological States,” 1984, The Otolaryngologic Clinics of North America, 17, (2), pp. 267-268.

3.      3.        Witte, M. B.; Barbul, A., p. 516.

4.      4.        Grodin, A. J.; Cantu, R. Myofascial Manipulation Theory and Clinical Application, 1992, Aspen Series in Physical Therapy, p. 31. 

5.      5.        Ibid, p. 34.

6.      6.        Ehrlich, H. P.; Krummel, T. M. “Regulation of Would healing From a Connective Tissue Perspective,” 1996, Would Repair and Regeneration, 4, (2), p. 204. 

7.      7.        Enneking, W.F.; Horowitz, M. “The Intra-Articular Effects of Immobilization on the Human Knee,” 1972, Journal of Bone and Joint Surgery American 54-A, (5), p. 983.

8.      8.        Ibid. 

9.      9.        Ehrlich, H.P.; Krummel, T.M., p. 205. 

 

Chuck LaFranco has taught at the Wellness and Massage Training Institute in Woodridge, Illinois, since 1989.  He was also director of the massage department at the Heartland Health and Fitness Retreat, and head of the massage team for the Chicago Bears for six seasons.  In addition to his private massage practice, he works in a chiropractic clinic.  He lives in the Chicago area.

 

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