november/december 2017

BROADEN
YOU R TOUC H
REPERTOIRE
B E C O M E A M O R E V E R S AT I L E
AND EFFECTIVE PRACTITIONER
WITH THIS RECEPTIVE APPROACH
By Robyn Scherr and Kate Mackinnon

+
The
Brachial
Plexus &
Thoracic Outlet
Syndrome
p 60

An Interview with Dolores Krieger Yoga & Massage On-Demand Massage Firms
 WHATS INSIDE? NOVEMBER/DECEMBER 2017

FEATURES
60
THE BRACHIAL PLEXUS
AND THORACIC
OUTLET SYNDROME
Understanding the complex relationship
between the brachial plexus and
TOS can sharpen your anatomy
skills, boost your critical thinking
skills, and benefit your clients.
By Joseph E. Muscolino, DC

70
THE UNION OF YOGA
AND MASSAGE
From integrated health to growing
your practice, read lessons from
a massage educator and yoga
instructor about the potential symbiotic
benefits of yoga and bodywork.
By Cindy Williams

52
74
THE LESSONS OF
COMPASSION
Massage & Bodywork sits down
with Therapeutic Touch developer
Dolores Krieger, a trailblazer in

BROADEN YOUR TOUCH introducing complementary health to

traditional medicine practitioners.

REPERTOIRE By Karrie Osborn

How often do you bring your assumptions about a clients 80

condition to the table? What difference would it make if you let HOW ON-DEMAND
MASSAGE FIRMS CAN
the clients body guide you instead? These authors suggest
WORK FOR YOU
ipping your predispositions and observing the outcomes. Consumer demand for massage is
By Robyn Scherr and Kate Mackinnon at an all-time highand thats good
news for you. Learn how you can
partner with these firms and enjoy
the career exibility you deserve.
By Brandon Twyford

ABMP MEMBER PROFILE: Ashley Allday 112 Cover photo at Esalen by Doug Ellis Photography.
 NOVEMBER/DECEMBER 2017 94

24
28 COLUMNS
THIS ISSUE BEST PRACTICES TECHNIQUE
8 Editors Note 20 BUSINESS SIDE 84 SCIENCE OF NERVES
10 Contributors Signs of Change
Let These Half-Baked Ideas Inspire You
13 Mind of an MT By Whitney Lowe
By Les Sweeney
15 On the Web
17 Speak Your Mind 24 SAVVY SELF-CARE 88 MYOSKELETAL ALIGNMENT
19 News Notes Connect with Community TECHNIQUES
99 Happenings By Jennie Hastings Crick in the Neck
101 New Products By Erik Dalton, PhD
26 TABLE LESSONS
105 Display Showcase 90 ENERGY WORK
Whos Assessing Whom?
108 Classifieds & Education Resource Listing What is Really Yours?
By Douglas Nelson
110 ABMP & You
By Cyndi Dale
111 10- and 20-Year Members 28 MINDFUL MONEY
112 ABMP Member Profile: Ashley Allday Be Your Own Hero 94 MYOFASCIAL TECHNIQUES
By Jennie Hastings Working with the Vagus Nerve
By Til Luchau
31 HEART OF BODYWORK
The Right to Refuse a Client
By Laura Allen

34
17 EDUCATION
34 CLASSROOM TO CLIENT
Creating Connection
By Cindy Williams
36 PATHOLOGY PERSPECTIVES
Polymyalgia Rheumatica and Giant Cell Arteritis
By Ruth Werner
41 FUNCTIONAL ANATOMY
Pelvic Girdle Suspension System
By Christy Cael
44 SOMATIC RESEARCH
Real-World Massage Research
By Jerrilyn Cambron, DC, PhD
 MIND OF AN MT

To the Moon and Back

By Susan Coffey

I never thought I would become a massage therapist. It wasnt even an

option in my mind. I more or less fell into it through a random chain of events.

I was 38 years old when I enrolled in massage school. At
the time, I was working at a private psychiatric hospital. I
was a single mom with three kids who had begun a journey of
self-discovery. In the process, I found reiki. Before long, I was
surrounded by smart, introspective, wine-drinking artists who,
ultimately, set me on a life-changing path.
The fi rst time I walked into the Muscular Therapy
Institute in Cambridge, Massachusetts, I felt like I was home.
I didnt have any rational thoughts on why I felt this way. I
just did. And for the next two years, I became immersed in
a community of like-minded people who would become as
important to me as my birth family. It is rare, I think, to fi nd
an educational setting and a career that carries with it a true
sense of belonging. What I didnt know was that my life would
forever change, and I was about to embark on a journey that
would stretch my sense of self to places I never imagined.
EVERY TWIST AND TURN
Years have passed16 to be exact. I am not the same person
I was then. My life has changed not once, but countless
times. Thats the way life is. Children grow up and begin
their own lives. They have children. I am now Nana. Parents
get older and oftentimes require care before they pass on
from this life. I am no longer a daughter. Relationships
end. I am no longer a wife. And we learn to be alone.
Relationships begin, and we start over. People come and
go. We navigate through this life knowing that change is
inevitable, and its somehow easier with less resistance.
Throughout the 16 years of change, massage has been
my constant. Without a crystal ball, I couldnt have known
that massage therapy would shift and mold perfectly into my
life at every corner. My sweet massage career was right there
to weather every twist and turn. Part time, full time, self-
employed, employee, subcontractorI have worked in every
capacity. I have taught, mentored, and managed a student
clinic. I have practiced reiki, hot stone massage, prenatal
massage, relaxation massage, sports massage, myofascial
release, oncology massage, and hospice massage. And still,
there are literally thousands of other possibilities left to learn.
The field of massage is an endless reservoir for the
insatiable learner. It allows us to explore new modalities,
to continuously grow and learn, and to defi ne and
redefi ne ourselves whenever we feel complacent or when
our responsibilities require a new course of action. My
journey has changed direction many times since it began.
I am blessed. I have loved my job, in all of its forms, every
day. Who knows what the future holds? In this amazing,
boundless field, anything is possible and all of it is beautiful.
If you are just graduating from massage school, thank your
lucky stars. For you are only beginning a journey that allows
you freedom and creativity and endless ways to explore who
you are and who you will become. And if you, like me, have
been around for a minute, keep dreaming, keep growing, and
take this beautiful career to the moon and back.
Susan Coffey has a private practice in Watertown,
Massachusetts, and also works for Care Dimensions (formerly
Hospice North Shore). She teaches continuing education
classes, including hospice massage, and all levels of reiki. Visit
www.susancoffeylmt.com to learn more about her work.
Have your own insights or inspiration to share for Mind
of an MT? Email editor@abmp.com.

ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 13
 ON THE WEB

BLOG POSTS

www.abmp.com/updates/blog

HOW MUCH DOES A MASSAGE

THERAPIST EARN?
Get a sense of the overall income profile
of the profession and see how you WEBINARS
compare in this blog post from ABMP www.abmp.com/ce
President Les Sweeney, as he discusses
the results of an ABMP member survey. WITH ABMP, YOUR
WEBINAR CE IS FREE!

ADVICE FROM THE PROS #8: Choose from more than

BEN BENJAMIN, PhD 140 webinars on demand
Ben Benjamin, PhD, coauthor of The Ethics in the ABMP Education
Center, including:
of Touch, draws on his more than 50 years of
experience to give business tips and advice
The Art and Science of
on practice management and marketing in a Good Nights Sleep
this edition of ABMPs Advice from the Pros. with Anne Williams.
Approximately 60 million
Americans dont get the sleep
they need to feel refreshed.
If this is you, you know the
negative impact that lack of
sleep can have on your massage
practice. Join ABMP Director
of Education Anne Williams
for an exploration of the art and
science of a good nights sleep.

Social Trigger Points: Massage

Therapists Guide to Marketing
Online with Stephanie Beck.
Stephanie Beck shares the best
strategies to utilize exciting
content for your social trigger
points like Facebook, Google+,
Twitter, YouTube, Pinterest,
and LinkedIn to help you
M&B ONLINE
understand the differences
www.massageandbodyworkdigital.com between informational
and promotional sharing,
Read senior editor Karrie Osborns interview with complementary medicine pioneer and how they play a role
Dolores Krieger on page 74, then visit page 115 of the digital edition of this issue in getting new clients.
for scientific research on the effects of Kriegers Therapeutic Touch modality.

ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 15
 SPEAK YOUR MIND
What is your least favorite
office policy to enforce?
FROM FACEBOOK
My 24-hour cancellation policy. The
client must cancel at least 24 hours in
advance to avoid paying full-service price.
The responses I get are either OK, I
totally understand or Um, no, that
makes no sense. I let all clients know
of this policy at their fi rst booking.
NICOLE BEARD
I have a four-hour cancellation policy and
use online software now. A credit card
is required to book the appointment. I
got tired of that struggle. I guess now
my biggest problem is if you come late,
I still end on time. Sometimes, I will
split the difference (10 minutes late,
I will go 5 over), but only once.
BECKY MX
Looks like the resistance to the
cancellation policy is an industry thing.
I think its because the vast majority of
the population doesnt take us seriously.
They think of massage as fun self-care
instead of the health care it really is. Its
cumulative. You dont exercise once and
thats it. You dont eat a salad once and
call it a diet. Dont get me started.
GINGER MAGGRETT
Upcoming What is your favorite client
Topics education resource?
Publication Date: Jan/Feb 2018
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 17
Enforcing the cancellation policy is
the toughest. I ask for 24-hour notice
as well, but am very lenient about it. If
I can fi ll the spot, I dont sweat it. The
no calls/no shows who want to rebook
later without reimbursing me for lost
revenue are the ones I struggle with.
LIZ BARNARD
For some reason, nobody ever wants to
fi ll out the new client intake. They think
its a waste of time and nobody looks at
it, anyway. We have to explain to them FROM TWITTER
that its necessary to help us treat them.
LORI DUDLEY I hate enforcing my cancellation policy. No
one likes paying for a missed appointment,
I would have to say for me, its saying no but I have to enforce it because this is my
to folks with contraindications. I explain livelihood.
my reasoning and I will still get Aw, come @EMERGEMASSAGE
on. It will be fi ne. No, its not. I do not
want what they have, nor do I want to
make things worse. Its difficult turning
folks away, as I want to help everyone.
DENICE GRAY
What is your vision of an Email your responses to
ultimate massage experience? darren@abmp.com. Your
Publication Date: Mar/Apr 2018 submission can be as short as
youd like and up to 250 words.
 NEWS NOTES
compiled by Brandon Twyford
ABMP Associate Editor | brandon@abmp.com

Massage Therapy Foundation

Honors ABMPs Leslie Young
Massage & Bodywork Editor-in-Chief and ABMP Vice
President Communication Leslie A. Young, PhD,
received the 2017 Massage Therapy Foundation (MTF)
John Balletto Distinguished Service Award this autumn.
MTF President and Massage & Bodywork columnist
Jerrilyn Cambron, DC, announced the award at the
MTFs annual donor reception in September.
Young began volunteering for the foundation in 2006
and served on the Board of Trustees from 2008 to 2016, and
chaired the Development Committee during that time. Shes
currently on the Governance Committee and the Advisory
Council, but has also served on the Conference Planning and
Community Service Granting Committees.
Im deeply honored to accept this award, simply for
supporting a foundation and a mission I love so much,
Young says. Ill do my best to continue to uphold the
legacy of dedication exhibited by the foundations past president John Balletto. The
foundations mission to support research, community service, and education projects
that forward the massage and bodywork professions is crucial. Americans Prefer
For more information about the Massage Therapy Foundation, Drug-Free Pain
visit www.massagetherapyfoundation.org.
Management Options
Over Opioids
Data collected for the Gallup-Palmer
NCBTMB Announces New Spa College of Chiropractic Annual Study
Management Certificate of Americans reveal that 78 percent of
Americans prefer to try other ways to
The National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) address their physical pain before they take
announced a partnership with the American College of Healthcare Sciences (ACHS) pain medication prescribed by a doctor.
to introduce the professions first Spa Management Specialty Certificate Program. In addition, 44 percent of Americans
The program offers massage therapists who are looking to grow their careers an see prescription painkillers as a crisis or
opportunity to obtain specialty training in spa management positions. very serious problem in their local area,
We are thrilled to partner with ACHS to create yet another career pathway for all and 55 percent of those who know about
massage therapists, bodyworkers, spa managers, and even spa owners with an interest in the problem place a lot of blame on the
furthering their success, says Donna Sarvello, NCBTMB vice president of educational pharmaceutical industry encouraging doctors
support. By achieving this Specialty Certificate, therapists are empowered with an to use opioids. Fifty-three percent place a
industry-recognized credential to separate themselves from the pack. NCBTMB is proud lot of blame on doctors overprescribing
to continue fulfilling its mission of defining and advancing newer, higher standards for painkillers to their patients.
therapists involved in this rewarding sector. The report states these data could be a
The program has two key components: sign of a future where patients and health-
1. A
 CHS Certificate in Holistic Spa Management (five courses totaling nine semester care professionals alike favor drug-free
credit hours of undergraduate credit through the Distance Education Accrediting treatment options before relying on opioids.
Commission) The findings are encouraging for massage
2. NCBTMB Specialty Exam (available online) therapists, who offer drug-free methods of
For more information about the Specialty Certificate in Spa Management, visit pain relief.
www.ncbtmb.org/specialty-certificates/specialty-certificate-spa-management. Download the full research brief at
http://news.gallup.com/reports/218495/s.aspx.

ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 19
best practices BUSINESS SIDE

Find Your Own Creative Recipe

for a Successful Practice
Let These Half-Baked Ideas Inspire You
By Les Sweeney

Author note: Hello, readers!Kristin Coverly herewith

a bit of sad news;this will be Les Sweeneys last Business
Side columnas a regular contributor. After coauthoring
30 columnswith him,Illbecome a solo writer and
hesback to focusing on his day jobbeing president of
ABMP.Even thoughwellmiss him and his incredible
wit, charm, pop culture references,and sound business
advice, dont worryyou havent seen the last ofhim yet.
Were pretty sure hell chime in from time to time as a
guest coauthor on future columns.
As this is his last formalcolumn, he kept the
keyboard to himself to share one last irreverent take on
business.Enjoy!

Ive been writing this business column

for the past five years with my friend,

colleague, massage therapist, and

inspiration, Kristin Coverly, and its been

a lot of fun. However, as we all know, there

are few guarantees in lifeone of which

is that all good things come to an end. Im

not going anywhere, but youll only get my

wisdom(?) on occasion, which means more

Kristin, which means a better column.

20 massage & bodywork november/december 2017


One of my favorite things to talk
about with therapists is how to generate
and sustain a healthy practice. But, to be
honest, there are only so many ways to get
from A to B. Our job is to help stimulate,
motivate, and indoctrinate you, our beloved
readers, with ideas to make your practice
more successful and fulfilling. But when we
come down to it, success in business is made
up of attracting new clients and keeping
your current ones. And there are only so
many ways of achieving that, right? Well,
Im going to spend a little time this issue
trying to break that mold, and focus on
unconventional means to achieve your goals.
One of my favorite podcasts used to have
a segment they called Half-Baked Ideas
outside-the-box suggestions to make life
more interesting, with the understanding
that these things may not be quite ready for
prime time. So, consider this my swan song,
and my half-baked ideas column. After
you read it, you may celebrate my departure!
UNIQUE (AND POSSIBLY TERRIBLE)
WAYS TO FIND NEW CLIENTS
Go to a Bar
Typically, professional decorum and
contraindications suggest keeping
massage and alcohol separate. But what
about marketing massage? Were not
suggesting you set up your table at the
end of the bar, but if youre a person who
enjoys an occasional pint and sets foot in
an establishment, why not reach out to
potential clients there? Take a stack of
business cards to your next happy hour
after all, we know those patrons arent afraid
to use some of their disposable income.
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 21
Go to a Funeral
Bear with me here. Im not suggesting
replicating Will Ferrells performance
in Wedding Crashers (well, not exactly, at
least). And Im not suggesting you actually
go to a funeral. But providing support and
relief to your clients is your mantra, right?
Volunteering your services to clients in
their time of need is wholly consistent with
why we chose to practice massage. Showing
your support to grieving clients is not only
a heartfelt gesture that will be appreciated,
but it may help build the client-therapist
trust that can lead to a lifelong client.
Go to a Wedding
OK, more traditional, but only if youre Perhaps youve heard of this. The kids
invited. Offer the bride and groom a
free massage, or crazy discounts for the
wedding party. Everyone is happy and
celebrating! Dont be afraid to leverage
that joy into a little subtle prospecting.
Go to Jail
Just kidding. Wanted to see how far
youd follow here. However
Partner with a Bail Bondsman
Look, people make mistakes. And those
people undoubtedly are going to
be stressed, right? Partner with a
lawyer and offer a discount after
they meet with the lawyer (the
lawyer can screen them for you).
Have the attorney give out your
discount card. Speaking of which
Partner with a Divorce Attorney
Talk about stress! Same concept.
This is one of the most difficult
times in someones life. An
arrangement with an attorney
could give you an opportunity to provide
support for someone in a tough time.
Or, just do like every mobile phone
carrier and/or mattress store and
Shutterstock.com
Be a Sign-Spinner
Stand on the corner for hours at a time
spinning a sign with your latest promotion.
And while youre at it, schedule yourself
for a massageyour delts will need it!
WAYS TO COMMUNICATE
WITH CLIENTS
Text Them
all really seem to enjoy it. Heres how
it works: you type a message into your
phone. Were not sure what happens after
that, but the other person somehow knows
what you wrote. Seriously, make sure
when you sign up a new client that you
get their mobile phone number and get
permission to send them text messages.
Then, set up a weekly Openings message
group where you blast out open session
times and get your calendar all filled up.
Call Them
As mentioned,
this is a half-
baked idea
column. But what
if you actually
went old school
and picked up
the phone and
spoke to another
person? OK,
sit down, and
read that last
sentence again. This is a bit out there, but
the strategy of calling people to (a) check on
their welfare and (b) politely ask for their
business has actually been used quite often
since 1876. Dont be afraid to go old school.

Write a Letter
If you think phone calls are retro, how about
going back to 1860 and the Pony Express?
One way would be for you to buy a horse
and deliver a letter yourself; interesting,
but overall probably not terribly efficient.
Horses eat a lot, and after they eat but
what about sending a handwritten thank-you
card or invitation to book? I recently got a
handwritten thank-you card from a company
Shutterstock.com
I ordered swim trunks from! The card is
still on my desk, because, its awesome, and
makes me like the company even more.
Be Like McDonalds
Bet you werent expecting that one, huh? I
dont mean give out Happy Meals, or create
a hamburger that looks like you sat on it. I
mean, offer some gimmick that gets people
to come back. How many times in our adult
lives has McDonalds offered that Monopoly
game? Why? Because people love Monopoly
and burgers that look like you sat on them.
You, instead, can come up with a scavenger
hunt game, or some type of collect
all 7 promotion, and deliver awesome
massage instead of chicken nuggets.
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 23
Use Technology
First, a comment, which some of you may
not like: if you are not using scheduling
software, or your free ABMP website,
or a smartphone to help manage your
practice, please stop reading this, roll up
the magazine, and swat yourself with it.
Why are you reading this article about
helping your business when you have these
tools sitting right in front of you? Why?
OK, where were
wewell, we already
talked about texting, but
what about social media?
Are you on Twitter? Its
a good way to pick up
savvy clientstake a more
unconventional stance and
become the personality
on Twitter that shares
goofy videos, funny stuff,
opinions, and also shoot
out tips, self-help info, and
session offers. Get your
clients Twitter handles
and follow them, and ask
them to follow you back.
Facebook is a more obvious target (which
weve discussed before)try Twitter as an
additional strategy.
Another idea could be to hire a
receptionist servicemake your bones on
the phone. Make sure theres a live person
who can book sessions on your behalf.
WAYS TO DELIVER THE GOODS
Just a reminder, dear readerthis
is the half-baked ideas edition.
Not all of these may work (maybe
none of them will, who knows).
Give Free Time
My favorite massage therapist occasionally
offers extra time, and while in many cases
it is not taken advantage of, it fosters
loyalty. At the beginning of a session, ask,
BUSINESS SIDE
Whats your schedule? I was thinking
Id like to add another 20 minutes today,
if youre able to stay a bit longer.
Add Something
Another one of my favorite massage
therapists brings me a bottle of water
for each session. Thats a nice touch.
Change It Up
If you have the ability to do this, ask
your client if they would prefer you
come to their home or office for this
session. Not something youd want to
do regularly, but they may enjoy it, and
again, its another level of service.
Buy the Massage
If youre feeling particularly generous,
tell your client, This ones on
me. Or give them a free session
coupon to give to someone elseit
might gain you another client.
Some of these ideas are close to fully
baked (perhaps just a bit al dente), while
others might need to go directly to the
garbageits up to you to decide what to
do with them. My intent is to challenge
your assumptions and standard line of
thinking. A favorite line around here has
become, Inertia is the strongest force in
the universe. Who said it? I did! The worst
thing we can do in lifewhether in your
practice, relationships, diet, you name itis
to get in a rut. Dont be afraid to be creative
and recognize that not all ideas will work.
But you gotta go for it!
See you around.
Les Sweeney, BCTMB, is ABMPs president.
Contact him at les@abmp.com and read his
occasional blog posts on www.abmp.com.
best practices SAVVY SELF-CARE

Connect with Community

By Jennie Hastings

Author note: This will be my

last Savvy Self-Care column.
It has been a great learning
experience to share these ideas
with you. I am looking forward
to reading what is to come in
this column in the future. Please
find me in the Mindful Money
column. I'm looking forward to
continuing this journey together.

Self-care is the practice of maintaining ones body, mind, and spirit in a way that

promotes wellness. As massage therapists and bodyworkers, most of us realize we need to

take good care of ourselves so we can take good care of our clients. Though we are interested in

taking care of ourselves, hardly anybody wants to be an island of self-reliance. I have found that

some of the most effective self-care I can do for myself comes from engaging in community.

24 massage & bodywork november/december 2017


Whether youre new in town or looking to meet like-minded people in your area,
following are a few resources to help you find a community you can connect with.
City-Data Forums: www.city-data.com/forum
WHAT IS COMMUNITY AND
HOW DO WE FIND IT?
I would define community as a group
of people who are deeply connected. A
community can be a family, a neighborhood,
or a group of people who come together
because they share a common interest.
The unique connection you share with
your community does not necessarily mean
you love the other members, although you
might. The connection is that you are all
drawn together by something you recognize
are bigger than your individual selves.
A like-minded community can fill us
up like nothing else. When we relax into
our connection with other people, we take
the focus off our individual self and place
it on the collective whole. From this place
of perspective, our individual challenges
do not seem like such a big deal. We laugh
and smile. We serve others, which provides
a special energetic charge to our beings.
We feel purposeful and appreciated. And
we learn to receive kindness and help from
others who are also offering their own
special gifts.
WHAT COMMUNITIES DO
YOU BELONG TO?
When I look at my life, I honor my
family, yoga, dance, friend, and work
communities. In all of these groups,
there is an element of love that brings
us together. I also identify a few places
that could use more love, or perhaps
areas where I need to make a decision to
move on. Take a moment and consider
the communities you are a part of and
discover what it is that binds you together.
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 25
Finding Community
Meetup: www.meetup.com
Nextdoor: www.nextdoor.com
Are you part of a community that lights
you up when you think about it? If so,
wonderful! This is the kind of connection
that is great for everybody. You get to look
forward to this connection and feel the
emotion it stirs in your heart even when you
are busy doing other things. You know you
are in a nourishing community when you
think the other people in it are amazing and
you find yourself thinking of nice things you
can do for them.
Chances are you might also be part of a
community that is not fulfilling. If so, what
is it that binds you together? Is it necessary
that you stay in this community? I know
some people struggle with their connection
to family. Other people, like me, have a hard
time moving on from friendships that are no
longer beneficial. Maybe you find yourself
part of a community that you did not
choose. If you discover that the only energy
connecting you to a group of people is guilt,
fear, or some other negative emotion, simply
notice that. Bringing it to your awareness
can help shift you into more of a connection
with this community or help you walk away.
YOUR BEST SELF THROUGH
COMMUNITY
My friend Natalie recently joined a
community yard-work group in her
neighborhood. She and 30 other people
descended on a neighbors yard one
Saturday morning. She said that with so
many hands, they transformed the way
it looked before lunch. Natalie said it felt
like participating in an old-fashioned barn
raising. I noticed the light in her eyes as
she described these neighbors getting
together to help each other. I know the
idea is that at some point all the people she
helps with their yards will come to hers.
But from my point of view, it seems she
gained something already, regardless of
when, or whether, the favor is returned.
In a nourishing community, giving
and receiving is reciprocal. People can
offer their talents and receive the talents of
others. No one has to do it all by themselves.
Members of a community inspire and
anchor each other while holding a special
focus. This does not mean that being part
of a nourishing community will always be
blissful and fun. On the contrary, it can
sometimes mean slogging through some
tough times. But the sense of connection in
community is sustaining and something we
all need.
Sometimes the best self-care will be to
bring your best self to a community you
are connected to by love. You may doubt
that your contribution will be important,
but it is. Realizing your own value through
contribution is perhaps the most nourishing
thing you can doits a win-win for
everybody. May you find the sense of
belonging in community that fills you up
with love and light.
Jennie Hastings is a board-certified massage
therapist, writer, and yoga teacher. She is the
author ofThe Inspired Massage Therapist(Massage
Blossom Books, 2012). Hastings believes having
a career in massage and bodywork means having
infinite possibilities, and she is always exploring
new ways to evolve her practice. You can find
more from her atwww.jenniehastingsyoga.com.
best practices TABLE LESSONS
Whos Assessing Whom?
By Douglas Nelson
You could certainly tell who was the
mostexperienced, my client said. It was
interesting to perceive the distinct differences
in abilities between the therapists.
Im sure my eyes widened a bit at her statement. I was
immediately lost in thought, thinking about the impact and
gravity of her statement. Allow me to explain the context.
Ms. J. was a previous client participant in an advanced-level
course I was teaching. She had returned for a follow-up session
after her initial participation. In these courses, six therapists and I
see clients who have predefined, specific issues. In almost all cases,
I have never met the clients; my only contact with them is a phone
interview to make reasonably sure their problem is relevant to our
training. This makes the context of the session as real as possible.
Many of these clients have never had massage therapy, and I have
no idea where the direction of the session might go. As a group, we
interview, create assessment strategies, and problem-solve our way
to a viable strategy, which is then executed. In itssimplest form,
we gather information, interpret the meaning of that information,
and then respond. If the response is positive and what we expect,
we are on the correct path. If not, we redirect. This is the hallmark
of great problem-solving, no matter what the discipline.
How do we gather information? In our field, there are three
primary avenues. First, we ask questions. Voltaire said you should
judge a person by their questions rather than their answers. In
medicine, it is often stated that 90 percent of diagnoses can be done
with only a detailed case history. In the field of massage therapy,
asking pertinent questions can immensely influence treatment
outcomes. Second, what we observe is an essential aspect of gathering
information. We observe the clients posture, movement patterns,
26 massage & bodywork november/december 2017
and body language. These observations are
then combined with the case history for
possible connections. Third, we palpate.
What is the quality of the tissue? How does
the tissue respond to intervention? From our
first training in massage school to advanced
approaches in the field, the value of accurate
and thorough assessment is stressed as
essential to producing desired outcomes.
That is what makes Ms. J.s statement
so powerful. Whos assessing whom?
While we therapists are concentrating
on our listening, observational, and
palpatory skills, our clients are doing
the same to us.The assessment highway
has two lanes. When she articulated
her ability to discern differences in
therapists, my brain flashed back to her
session during the training. Lets take
each of the three avenues of information
gathering, but from her perspective.
LISTENING
I remember watching Ms. J. as she
listened to the questions from my group
of therapists. Watching her micro- and
macrofacial expressions, she was reacting
to the question and the questioner. If the
question seemed irrelevant or too vague,
her expression revealed the disconnect.
Questions that surprised and intrigued her
were revealed in her body language and
showed a connection with the therapist
who asked such an insightful question.
In our speech, in
our body language,
in our touchwhat
impressions are we
giving them?
OBSERVATION
I paid close attention to Ms J.s reaction to
the group; she was observing us (including
me) closely. In fact, following her comment
about the varying level of experience and
abilities between therapists in the group, she
also commented on how fully engaged some
therapists were. How did she determine full
engagement? I thought back to watching her
eyes when she was lying supine on the table
while one therapist was treating her. She
was glancing around the room, observing
the other attending therapists who were not
presently treating her. If those therapists
were distracted or not paying attention to
what the treating therapist was doing, she
registered that as lack of engagement.
PALPATION
This aspect of her experience at the
training was absolutelyintriguing.
I had to ask: How is it that you
determined one therapist was more
experienced or competent than another?
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 27
The quality of their touch, she replied. Some therapists,
from the initial contact, put their hands on me with complete
authority; I felt a clarity about what they were feeling and why. It
just put me at ease, like they knew what they were doing and were
fully in charge. Other therapists seemed tentative, which might
be a lack of confidence. The difference was quite noticeable.
I processed Ms. J.s statements as we shared a moment of silence.
So much of the focus of training in the field of massage therapy
is centered around the therapists assessment and subsequent
response. Far less discussed is the reality that as we are assessing
the people who grace our treatment table, they are assessing us
as well. In our speech, in our body language, in our touchwhat
impressions are we giving them? Whos assessing whom?
Douglas Nelson is the founder and principal instructor for Precision
Neuromuscular Therapy Seminars, president of the 16-therapist clinic
BodyWork Associates in Champaign, Illinois, and president-elect of the
Massage Therapy Foundation. His clinic, seminars, and research endeavors
explore the science behind this work. Visit www.nmtmidwest.com, or email
him at doug@nmtmidwest.com.
best practices MINDFUL MONEY

Be Your Own Hero

By Jennie Hastings

The Mindful Money journey is about becoming

aware of how money is linked to our life energy

and learning how to use that energy consciously.

It is about learning to direct our financial resources toward

things we truly value and not waste them on things that

are not aligned with our lives. It is about being willing

to face our fears of not having or being enough, and

learning how to make peace with the material world from

a place of self-knowledge and love. It is about realizing

that it is not important how much money we have, but

how we feel about our livesthat numbers are arbitrary

and peace of mind and contentment indicate success.

It is not usually easy to take responsibility for our financial lives.

We must push through layers of thought and emotion we inherited,
and face dark places within ourselves filled with doubt and fear.
Because of these challenges in facing the reality of our financial
situations, it is easy to put it off in the hope that someone else will
save us. Maybe we are hoping we will marry rich, or perhaps we are
waiting to inherit something. Maybe we have our hopes pinned on
the book we are still thinking about writing to become a bestseller.

28 massage & bodywork november/december 2017

 Money Mantra
You do not have to become your own money hero and fix all your finances
at once. The most important first step is your willingness to be your own
savior. Say to yourself, From this day forward, I take charge of my own
financial future. I am no longer waiting for anyone else to fix things for
me. I will do what I can, with what I have, to be mindful of my money and
make decisions that support what I value most in life. I promise this kind
of willingness, accompanied by small actions, will never let you down.

Some of us might spend years,
even decades, postponing taking full
responsibility for our financial lives.
Every time the issue rears its head, we
push dealing with it to the future and
continue with our unconscious money
habits. Each month finds us a little deeper
in debt, ignoring the penalty fees or the
unpaid tax bill, and telling ourselves that
one day some kind of miracle will arrive
and everything will be taken care of.
CALL TO ACTION
If this sounds familiar to you, I have
a call to action I hope you can hear: it
is time to be your own hero. will gain the strength to look at what is
What does being your own financial
hero look like? We often think of heroes
as arriving from the heavens and fixing
everything in one fell swoop. But we are
massage therapists and bodyworkers. If
anybody knows that true healing usually
comes not in quick fixes but in slow,
steady steps toward progress, it is us. So
being your own financial hero does not
mean you fix everything overnight.
On the contrary, being your own
financial hero means you commit to taking
the small steps toward money mindfulness
we have been covering in this column. You
can begin by becoming more conscious
of your income and spending by opening
your bank account online every day and
noticing what is coming in and what is
going out. As you work with this practice,
you will begin to notice that some of the
things you spend your money on feel good,
and some feel not so good. This is where
value comes in. As you begin to recognize
what you value and what you do not value,
your spending habits will begin to shift.
From this place of consciousness you
truly necessary to live your life, and what
is actually draining you. You will gain a
realistic perspective on what it takes to live
your life fully and begin looking for ways
to support it financially. It is much easier to
ask for a raise, or increase your rates, when
you are coming from a place of realistic
understanding rather than from feelings.
THE GREATEST OBSTACLE
I think most of you will find, as I have
found, that the greatest obstacle to money
mindfulness is not money, but yourself. If I
am nervous, anxious, or fearful about taking
responsibility for anything, it will plague me
to no end. As soon as I take a deep breath,
ask someone to hold my hand if necessary,
and face whatever it is that is causing my
fear, it quickly loses its power over me. With
money, I realized that it was an energy I was
avoiding, and one I assumed had negative
properties; and as soon as I learned to
embrace it, respect it, even love it, it began
to be attracted to me and love me back.
So dont wait for a hero to come and
save you. Dont wait to win the lottery or
for your app to be bought by Google before
you start taking the small steps needed to
become more conscious of your money.
Learning to become mindful of money is
necessary no matter how much money you
have, and good money habits developed now
will pay off for the rest of your life.
Jennie Hastings, LMT, BCTMB, has studied
money in the therapeutic process from every angle:
as a client, patient, and practitioner. She is the
author ofThe Inspired Massage Therapist(Massage
Blossom Books, 2012). Hastings believes having
a career in massage and bodywork means having
infinite possibilities, and she is always exploring
new ways to evolve her practice. You can find
more from her atwww.jenniehastingsyoga.com.

ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 29
best practices
The Right to Refuse a Client
By Laura Allen
Practitioners in private practice
have right of refusal. They can
refuse to work with a prospective
client, and they can discontinue
working with a client they cannot form
a therapeutic alliance with, or lack
the training or physical capabilities to
work with. If you work for someone,
your employer may not support your
freedom to turn away an undesirable
clientyet another reason to
choose your employer carefully.
JUDGMENT CALLS
Your regular client spent the
afternoon doing yard work and is
uncharacteristically dirty and sweaty.
You have worked with a couple on
an outcall basis several times. While
youre alone with the husband, he
makes suggestive remarks.
You weigh 100 pounds. Your prospective
client weighs twice that and requests
deep work. You dont think you can
give them the massage they want.
Reasons (outside contraindications) not
to work with a client include poor hygiene,
inappropriate sexual behavior, or a physical
mismatch. (Granted, a small massage
therapist can, with good body mechanics,
handle working with any size client; its
up to you to set your physical boundaries.)
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 31
HEART OF BODYWORK
Be aware of your own
limitations. You may
want to limit the number
of clients you see with
special difficulties.
Regarding the sweaty
client, most practitioners
dont mind an occasionally
grimy client. Those who
do should make their
policies clear up front by
spelling out on an intake
form that the therapist can
refuse to work, or terminate
work, with someone because of
poor hygiene or inappropriate
sexual behavior or comments.
In the case of the husband
who made inappropriate remarks, it
depends on your prior relationship and
degree of offensiveness of the remarks. If a
client makes obviously offensive remarks,
end the session and decline to make
another appointment. If youre unclear
about the intent, you can give a warning
that you will not continue working with
him unless he stops being suggestive. Laura Allen is the massage division director of
If he had never been inappropriate Soothing Touch. A licensed massage therapist,
before, you could say, I only work with she is an accomplished author and educator.
clients who respect me. Ill end the massage Contact her at educatedheart@gmail.com.
if you make any more inappropriate
remarks. If he continues, end the massage Editors Note: In 2017, we are delighted to print
and let him know you wont work with excerpts from Nina McIntoshs The Educated
him again. You might lose the wifes Heart, 4th edition. Nina was a longtime Massage
business also, but theres never a good & Bodywork columnist. Prior to her death, she
reason to work with a disrespectful client. handed her work over to Laura Allen, who created
When deciding not to take on a new 2016 edition (adapted with permission
someone who taxes your physical from Lippincott Williams & Wilkins). Mari Gayatri
capabilities, be straightforward about Steins illustrations enrich each edition of the
your reasons: I cant do justice to text; she passed away on March 2, 2017.
someone with your particular needs. May
I give you the names of practitioners
who would be more appropriate?
education CLASSROOM TO CLIENT
Creating Connection
Effective Approaches to Ensure
Your Clients Feel Heard
By Cindy Williams
There is more to an exceptional massage
experience than well-executed hands-on skills.
In 2014, I conducted a series of interviews across the
country with massage consumers to gain a firsthand
understanding of what clients want from massage
sessions. While clients definitely want to receive massage
from a well-trained, technically skilled therapist, they
choose whether to continue as a regular client for more
expansive reasons. One of the primary complaints clients
reported in these interviews was that many massage
therapists dont listen to their needs and dont create
an individualized experience based on what is asked
for. Clients want to be heard and responded to based
on what they say. In short, they want connection.
WHAT IS CONNECTION?
Merriam-Websters Learners Dictionary defines connection as A Active listening is a skill. The more you practice, the better you
situation in which two or more things have the same cause, origin,
or goal.1 You must communicate effectively, authentically, and
with curiosity in order to determine what caused a client to come
to you, as well as what their goals are. This information can then
be applied to the massage experience in several ways so the client
feels heard. From the first moment we meet a new client, to the
massage session and beyond, creating and maintaining connection
is simple when a few basic communication skills are applied.
34 massage & bodywork november/december 2017
HOW TO CONNECT
Following are simple ways to let your client know you care about why
they are coming to see you and how you can help them reach their
session goals.
Make a Pre-Session Phone Call
Its helpful to make a reminder call about your upcoming client
appointments, because it reduces the number of cancellations and no-
shows. However, the pre-session call can also be a great time to find
out why your client is coming to see you. For first-time clients, ask
them if they are seeking relaxation and stress relief, or if they have a
specific pain or injury they want to have addressed (it might be both).
Whatever their needs are, respond with empathy, saying things
like, I understand how tiring stress and/or pain can be, so I look
forward to providing you some relief, or, Thank you for letting
me know ahead of time so I can have some [warm towels, warm rice
bags, pain relief cream, etc.] ready to go to make the session even
more effective, or, I have some great techniques to address neck
pain, so Im sure I can help. Reflect back what you hear them say.
If you are calling a repeat client, you can ask how theyve
been feeling since the last session. Ask, How is your shoulder
feeling? Have you felt any improvements, or is it still hurting?
The simple act of remembering what was addressed at the last
session proves to your client that you were paying attention.
You dont have to go into elaborate detail, but you can
begin communicating that you care about their needs.
Listen Actively
become. A few valuable suggestions made in a Forbes magazine
article are particularly appropriate for massage therapists:2
1. Face the speaker and maintain eye contact. Avoid engaging in
any other activity, such as resetting the room or warming a
rice bag, while your client is reporting their current status.
2. Try to picture what the speaker is saying. For massage
therapists, this is especially helpful as you determine
how to approach the clients area of pain or stress.

3. Try to feel what the speaker is feeling.
Essentially, put yourself in their shoes.
This is the cornerstone of empathy,
and it will go a long way in helping a
client feel heard and connected with.
The information you gather through
active listening will help you plan the
session, as well as negotiate the time you
spend on each part of the body. If your
client complains of neck pain, you might
suggest 15 minutes of the hour be spent
there. Its essential to tell a client what your
plan is so they can tell you if they prefer a
different plan. They might prefer you spend
the entire session on their upper body only.
As previously mentioned, when I
conducted the consumer interviews and
asked about their not-so-positive massage
experiences, many individuals reported
that they didnt feel the massage therapist
listened to them. One consumer summed
it up by saying, She just did what she
did. In other words, the session was a
routine rather than a response. Stagnant
routines do not create connection.
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 35
From the first moment with a new
client, to the massage session and
beyond, creating and maintaining
connection is simple when a few basic
communication skills are applied.
Request Feedback
Even though requesting feedback is taught
as an entry-level skill, some therapists dont
practice it. Excellent therapists check in
both during and after the session to ensure
clients feel comfortable and safe, and
needs are addressed. You arent required to
constantly engage your client in feedback
during a session (they probably also want
to quietly relax). You do, however, create a
greater sense of connection when you are
applying the right amount of depth and
spending the right amount of time based on
your clients response. One of my favorite
questions occurs directly after working
on an area of concern. Does this area
feel complete, or would you like for me to
spend more time here? This is one simple
example of how to truly customize a session.
Follow Up
Lastly, make a follow-up call. Even if
you only leave a message, a brief call
asking how your client feels the next
day will show you care. Another idea is
to send an email a week or two after the
session that links to an article offering
education specific to their challenge. You
can find many article ideas for clients at
www.bodysensemagazinedigital.com.
WHY CONNECT?
People like to talk about what matters
to them. Even folks who are quiet and
shy still want to tell their story to an
authentically curious and caring person,
especially when pain and stress is the
problem. If they believe you are willing
and able to offer support, they will likely
feel safety and comfort, and be more
receptive to your hands-on work. Our
work as massage therapists is as much
about relationship building as it is about
applying the appropriate techniques.
I received wise words from a teacher
many years ago that stuck with me. He said,
Treat each client as if what they are saying
to you is the most important thing you will
hear all day. It goes a long way. Your clients
will keep coming back, and you will find
that you are more effective when youve
been present enough to hear them. Then,
the common goal can be reached.
Notes
1. Merriam-Websters Learners Dictionary,
accessed September 2017, www.
learnersdictionary.com/definition/connection.
2. Dianne Schilling, 10 Steps to Effective Listening,
Forbes, November 9, 2012, accessed September 2017,
www.forbes.com/sites/womensmedia/2012/11/09/10-
steps-to-effective-listening/#d15a1cb38918.
Since 2000, Cindy Williams, LMT, has been
actively involved in the massage profession as
a practitioner, school administrator, instructor,
curriculum developer, and mentor. She maintains
a private practice as a massage and yoga
instructor. Contact her at cindy@abmp.com.
education
Polymyalgia Rheumatica
and Giant Cell Arteritis
Common, Dangerous, Treatable
By Ruth Werner
Have you ever had any senior
clients who came to you for help
with shoulder pain, hip pain, or a
headache?
Have they ever been slow to respond
to massage, or even become worse?
Have you considered that their
situation may be more complicated than
it appears, and that without appropriate
treatment, they may be at risk for
blindness, stroke, or aneurysm?
Polymyalgia rheumatica is among
the most common types of inflammatory
joint pain seen in older people. It is often
accompanied by another condition,
giant cell arteritis, which can lead to
irreversible vision changes and worse.
In this column, well take a look at these
two fairly common, poorly understood,
potentially dangerous, but highly treatable
conditions that affect older adults.
DEFINITIONS: WHAT ARE THEY?
Polymyalgia rheumatica (PMR): its a
complicated name. Its etymology suggests
that it means multiple muscle pains
and problems with flow of the humors,
although modern usage applies the word
rheumatism to nonspecific joint problems.
And the leading symptoms of PMR do
indeed look like muscle painalthough, as
we will see, the problems begin elsewhere.
Giant cell arteritis (GCA) refers to
inflammation and abnormally large white
blood cells found in the lining of affected
medium and large arteries. It used to be
36 massage & bodywork november/december 2017
PATHOLOGY PERSPECTIVES
called temporal arteritis because it
was frequently found in the temporal
artery, but tissue studies reveal it
affects many other arteries as well.
What is the link between PMR
and GCA? These two conditions
are autoimmune problems, and
they often occur together. Statistics
vary, but most specialists agree that
1520 percent of all people who have PMR
also develop GCA, and of those who have
GCA, it appears that about 50 percent of
them have also had PMR. Further, studies average concentration of cases in Northern
of people with PMR often reveal the same Europe, especially Scandinavia.
subtle tissue changes that are seen with PMR and GCA are rare in people
GCA, but they are asymptomatic. These under 50. The average age at onset is
correlations have led some researchers about 72. Women develop these conditions
to propose that the two conditions exist about twice as frequently as men.
on a continuum, with PMR on the mild It is difficult to pin down how many
end and GCA on the more severe end. people in this country have PMR or GCA.
However, it is important to point out Some estimates suggest they are diagnosed
that a person can experience one without about 47,000 times each year, and about
the other, and it is possible that a person 1.6 million people currently live with
can have symptoms of both conditions one or both of these challenges. Three
simultaneously, or in reverse order. features make these conditions a topic that
massage therapists should know about:
Early symptoms include shoulder and
WHO IS AT RISK? hip pain, and possible headaches
PMR and GCA have some extremely all of which may prompt affected
reliable demographic distributions. They people to seek massage.
are seen in Caucasians far more often Both PMR and GCA respond well to
than in other races, and their global medical intervention, so individuals
incidence demonstrates a higher-than- should pursue this quickly (and
Specialists believe
that polymyalgia
rheumatica and giant ????? Giant Cell Arteritis
Polymyalgia Rheumatica
cell arteritis are related,
but the nature of their
connection is not clear.
less severe more severe

the hoped-for benefits of massage
may delay their seeking help from
a primary care provider).
GCA in particular is associated with some
serious complications that appropriate
treatment can preventa delay in
treatment can lead to permanent damage.
ETIOLOGY: WHAT HAPPENS?
PMR and GCA have been painstakingly
studied for many years, and we still dont
completely understand how these conditions
come about. It is clear they both involve
inappropriate immune system activity,
perhaps in reaction to a common viral
trigger. They appear to have a predictable
chemical profile with consistently high
levels of a pro-inflammatory cytokine
called IL-6. Further, IL-6 levels appear to
correlate with the severity of symptoms,
and this finding may help in the
development of more treatment options.
PMR
In PMR, the inappropriate immune system
activity appears to begin in the synovia
of the proximal limb joints: shoulders and
hips, and sometimes the neck. Inflammation
may affect the joint linings, bursae, and
synovial sheaths in the area. The individual
often interprets this as muscle pain and
weakness, but strength tests and muscle
biopsies are normal. And here is more
good news: the inflammation of joint
capsules in the shoulders and hips is non-
erosiveno permanent damage accrues.
In rare cases, PMR may cause some
swelling in distal tissues of the arms or legs,
but this is the exception rather than the rule.
Untreated PMR may persist for many
months, up to a couple of years. At that
time, it may spontaneously resolve with no
lasting consequences, but about one-fifth
of people with PMR also develop GCA.
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 37
Diagnostic Criteria
for PMR and GCA
PMR and GCA have some diagnostic
criteria in common, and many patients
GCA who have markers for one condition
In GCA, we see the accumulation of
may have subtler markers for the other.
abnormal white blood cells that proliferate
in the lining of medium and large arteries.
Symptom or Sign PMR GCA
These are the giant cells found in tissue
biopsies. We dont know why this occurs,
Age is 50 years
but the result of this type of vasculitis is a or older
risk for obstruction of the artery, and tissues
downstream of the damaged vessel may High erythrocyte
degenerate and die. sedimentation
Arteries that branch off the carotid are rate (a marker for
inflammation)
the most commonly affected by GCA. This
condition is not limited to the arteries that Pain for more
than 1 month in
supply the head, however; it can also affect 2 or more of the
the subclavian artery, and it may weaken the shoulder, neck, or
pelvic girdle
ascending arch of the aorta.
1 hour or more of
morning stiffness
SIGNS AND SYMPTOMS
New headache,
scalp, or jaw pain
PMR
Signs and symptoms of PMR look as if Abnormality of
the temporal
someone engaged in a lot of unusual activity artery, including
one day, and then woke up the next feeling tenderness
and decreased
terribly stiff and sore. Pain centers in the pulsation
lower neck, shoulders, and hips. It is worse
after rest and in the morning, and it can Positive biopsy of
make activities of daily livingincluding temporal artery
getting out of bed or standing up from using
the toiletextremely difficult. Rapid response
About half of all patients report a sudden to steroidal anti-
inflammatories
onset, but the other half experience a
slower development of symptoms. Pain may
begin on one side, but eventually becomes
bilateral.
About one-third of all PMR patients
also have unexplained fever, cough, sore Low-grade fever, weight loss, and
throat, and other subtle signs that might depression may also develop. And any visual
suggest low-grade vasculitis. In some changesdizziness, difficulty focusing,
cases, pain spreads to affect the upper arms double vision or cloudy vision, or any loss
and thighs, and, in rare versions, patients of balance or coordinationneed to be
may experience substantial swelling in referred to a doctor immediately: damage
the extremities, with pitting edema. to the optic nerve is irreversible, and
permanent blindness is a real possibility.
One final observation about PMR and
GCA GCA is that their onset appears to occur
GCA is usually identified by long-lasting most often in the spring and summer,
headache that is accompanied by scalp and falls off in the autumn and winter.
tenderness and jaw pain. Inflammation of
the throat and the tongue are common.
 Consequences of Long-Term Steroid Use
Steroids work
PMR and GCA respond so well to oral corticosteroids (specifically
prednisone or prednisolone) that this treatment is often used as
a diagnostic confirmation. Left untreated, PMR-related pain may
persist for months or years, and GCA can lead to life-threatening
complications. But with appropriate steroid use, the period of
pain and risk can be reduced to a matter of days; these are truly
miraculous drugs for this situation.
But theres a catch
A person with PMR or CGA is typically treated with steroids for
many months, and sometimes years. Primary care physicians must
slowly taper off doses to allow the body to return to full function
this may take a long time. And the longer steroid treatment lasts,
the higher the risk for adverse events.
Here is a short list of adverse events associated with steroidal anti-
inflammatories that are particularly relevant to massage therapists:
Increased bruising and slowed wound healing
Myopathy (muscle wasting)
Bone thinning and vertebral collapse (especially since most
patients are middle-aged and elderly Caucasian womenexactly
the same group most at risk for osteoporosis)
Avascular necrosis (the head of the femur degenerates due to
poor blood supply)
Steroid-induced diabetes
High blood pressure
Extreme mood swings
Increased vulnerability to infections
How do massage therapists make appropriate accommodations
for these risks? It is impossible to fully catalog all the possibilities.
But lets be sure that when we gather information, we find out
both what medications our clients use and what side effects those
medications may be causing. Then, we can be sure to offer the
pressure, positioning, and type of massage therapy that is most
likely to magnify the benefits of our work, while minimizing the risks.
38 massage & bodywork november/december 2017
This is not universally accurate, but a
client who reports these symptoms in
the spring or summer, and who doesnt
get relief from massage, is a good person
to refer to a primary care physician.
See the Diagnostic Criteria for PMR
and GCA, page 37 for more details.
COMORBIDITIES, COMPLICATIONS,
AND DIFFERENTIALS
PMR and GCA are conditions with a
well-recognized etiology and a predictably
positive response to treatment with steroidal
anti-inflammatories. But they can resemble
many other conditions, and they can be
comorbid with other conditions as well.
And to have a successful outcome, other
confusing overlapping problems must
be ruled out, or identified and treated
separately. This allows for treatment before
complications develop, which is important.
Comorbidities
Consider a female client who is Caucasian
and middle-aged. Can you think of
conditions that are common in this
population that present with achy joints and/
or headaches? Of course you can: the short
list includes osteoporosis, osteoarthritis,
fibromyalgia, hypothyroidism, and
depression, among othersany of which can
be confused with or comorbid with PMR
and GCA. The challenge is that treatment
strategies for these overlapping conditions
are very different, and unless all the issues
are addressed, the person is likely to be
stuck in a painful state.
Complications
Sometimes complications of diseases are also
their signs and symptoms. This is the case
for GCA, which, as weve discussed, can
lead to headaches and scalp pain; jaw, throat,
and tongue inflammation; low fever; and
general malaise. GCA is also associated with
distal edema and Raynauds phenomenon
(a condition that is discussed in the March/
 PATHOLOGY PERSPECTIVES

April 2017 edition of Pathology Perspectives
Raynauds Syndrome, page 40).
But in addition to these, GCA has some
potentially disabling complications. It can
lead to blindness if the nerves that supply
the eye are deprived of blood flow, and this
vision loss is permanent. Other obstructions
in cranial arteries might lead to mild or
severe stroke. And weakness in arterial walls
can cause the inner layers of the ascending
thoracic aorta to split: this is called a
dissecting aneurysm. This allows blood
between layers to accumulate and thicken,
and when fragments break loose, they can
cause ischemic damage wherever they land.
Increased mortality due to cardiovascular
events is a known consequence of GCA.
Differential Diagnoses
A few conditions can present similarly to
PMR or GCA, and they may only be found
when the typical treatments (low or high
doses of steroidal anti-inflammatories)
dont work well. Among the conditions
that may be revealed this way, we find
hypothyroidism, amyloidosis, rheumatoid
arthritis, and various types of cancer.
IMPLICATIONS FOR
MASSAGE THERAPY
PMR affects up to 1.6 million people in
the United States, and it rises in frequency
as people age. It usually presents like a
musculoskeletal problemit could easily
be mistaken for signs of arthritis, muscle
fatigue, fibromyalgia, headache, or several
other common complaints for which people
seek massage. It is entirely likely that a
senior client may come to a trusted massage
therapist, complaining of new shoulder or
hip pain: I must have really overdone it at
my job/in the garden/on the golf course/
playing with grandkids, and so on.
But this pain is unlikely to be addressed
successfully with massage therapy or
bodywork. Indeed, massage may make this
worse, and that is an important piece of
information. If the joint-related aches and
pains dont improve with massage, and if
they continue to worsenespecially if they
begin to include headaches, scalp pain,
jaw or tongue pain, or vision changesit
is absolutely vital that the person see a
specialist as soon as possible. Any further
delay may lead to irreversible changes in
vision, and a substantial risk of stroke,
aneurysm, or other complications.
What if a person has already been
diagnosed and is currently treating their
condition? Clients who have been diagnosed
with either PMR or GCA are likely to take
prednisone or prednisolone to manage their
symptoms, and steroidal anti-inflammatory
use presents further concerns for massage
therapists. These drugs are extremely
effective for the management of both
conditions, but they are typically used for
several months, or maybe years. The side
effects of prednisone and prednisolone
involve issues that impact bodywork
choices, including easy bruising and an
increased risk of diabetes and osteoporosis.
See Consequences of Long-Term Steroid
Use for more on this topic. This doesnt
mean we cant work with clients who are
in treatment for PMR or GCA, but we do
have to make appropriate adjustments.
Do you have clients who are over 50? Do
they ever ask for your help with shoulder or
hip pain or headachesespecially with new
and worsening symptoms? If the answers
are yes, then PMR and GCA need to be
on your radarand now they are.
Ruth Werner, BCTMB, is a former massage
therapist, a writer, and an NCBTMB-approved
provider of continuing education. She wrote A
Massage Therapists Guide to Pathology (Lippincott
Williams & Wilkins, 2016), now in its sixth edition,
which is used in massage schools worldwide.
Werner is available at www.ruthwerner.com.

Resources
Cimmino, M. A. et al. A Seasonal Pattern in the Onset of Polymyalgia Rheumatica. Annals of the Rheumatic Diseases 49 (1990): 5213.
Clifford, A., and G. Hoffman. Polymyalgia Rheumatica and Giant Cell Arteritis. The Cleveland Clinic Foundation. June 2014. Accessed
September 2017. www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/rheumatology/polymyalgia-rheumatica-and-giant-cell-
arteritis/.
Giant Cell Arteritis. Johns Hopkins Vasculitis Center. Accessed September 2017. www.hopkinsvasculitis.org/types-vasculitis/giant-cell-arteritis/.
How Many People Per Year are Diagnosed with Polymyalgia Rheumatica? Zocdoc. Accessed September 2017. www.zocdoc.com/
answers/21939/how-many-people-per-year-are-diagnosed-with-polymyalgia-rheumatica.
Polymyalgia Rheumatica. Vasculitis Foundation. Last updated September 2012. Accessed September 2017. www.vasculitisfoundation.org/
education/forms/polymyalgia-rheumatica/.
Questions and Answers About Polymyalgia Rheumatica and Giant Cell Arteritis. National Institute of Arthritis and Musculoskeletal and Skin
Diseases (NIAMS). May 2016. Accessed September 2017. www.niams.nih.gov/Health_Info/Polymyalgia/default.asp.
Saad, E. Polymyalgia Rheumatica. Medscape. Last updated September 19, 2016. Accessed September 2017. http://emedicine.medscape.com/
article/330815-overview#showall.

ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 39
education FUNCTIONAL ANATOMY

Pelvic Girdle Suspension

System Pubic
Anterior
sacrococcygeal
By Christy Cael symphysis ligament
Anterior The iliolumbar
longitudinal ligament stabilizes
The human body uses various systems ligament the pelvic
girdle and its
Anterior connection to the
to absorb impact and cope with uneven lumbar spine.
sacroiliac
ligament
surfaces while maintaining a stable base The inguinal
Sacrotuberous ligament is the
of support. Anatomical structures in the foot, ligament inferior margin of
the aponeurosis
Sacrospinous of the external
knee, pelvis, and spine all work in tandem to oblique muscle and
ligament
superior border of
distribute forces and prevent wear and tear on the femoral triangle.
Pubofemoral
the body as it interfaces with other objects ligament
The iliofemoral
ligament helps
such as the groundduring gait. Much like maintain optimal
Obturator contact between the
membrane femoral head and
the suspension of a car, an assembly of rigid acetabulum, limiting
medial rotation and
links and optimally mobile joints function as a extension of hip.

kinematic chain to manage forces and movement

The posterior
sacroiliac ligaments
in, and through, weight-bearing structures.
surround and
Iliolumbar
stabilize the sacrum.
Focusing on the pelvic girdle, parallels can be made ligament
They work as part
between the springs, shock absorbers, and linkages of of a large network
a cars suspension and the bones, joints, and ligaments of thick, strong
ligaments located in Iliofemoral
functioning as a kinematic chain in this region. The ligament
the pelvic region.
anterior pelvic girdle is formed by the pubic symphysis, a
cartilaginous joint uniting where the two pubic rami join Sacrospinous
at the midline. Posteriorly, the pelvic girdle consists of The sacrotuberous ligament
two large, stable synovial joints where the large right and ligament stabilizes
left ilia join the centrally suspended sacrum. The weight the sacrum inferiorly
of the torso and upper body descends through the spine, and provides
muscle attachment
pelvic girdle, and then laterally through the femoral neck
points on the
on each side, and finally through the lower extremities. posterior pelvis.

Posterior sacrococcygeal The ischiofemoral ligament spirals

ligaments anchor and stabilize around the posterior coxal joint and
the small, delicate coccyx. assists the iliofemoral ligament in
limiting medial rotation of the hip.

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FUNCTIONAL ANATOMY

MECHANICS OF THE PELVIC GIRDLE
Distribution of weight in the pelvic girdle
primarily occurs in the posterior region.
The sacrum is suspended between the
two large ilia by the posterior sacroiliac
ligaments, and symmetrical tension in these
ligaments is key to maintaining alignment
and stability in the pelvic girdle. A complex
network of ligaments, including the
sacroiliac, sacrotuberous, and sacrospinal
ligaments, maintains the position of the
sacrum, much like springs maintain the
position and equal tension on the fabric
at the center of a trampoline. Balanced
tension in this ligamentous network
maintains optimal deflection (the degree
to which a structural element is displaced
under a load) and spring rate (the change
in force exerted divided by the change
in deflection) in the pelvic girdle. The
resulting mechanical alteration of forces
helps decrease impact on the soft tissues
and articulating surfaces further up the
kinematic chain, particularly in the spine.
Slight mobility provided anteriorly
by the cartilaginous disc at the pubic
symphysis, in conjunction with the two
sacroiliac joints located posteriorly,
accommodates forces generated with the
asymmetrical weight transfer and rotational
motion of the sacrum during gait. It also
assists in maintaining a relatively constant
torso and head position, allowing the
eyes to remain level with the horizon, by
minimizing body lean as weight shifts from excessive compression. Asymmetrical force
one foot to the other. The combination distribution due to leg-length discrepancy,
of posterior stability and slight anterior functional scoliosis, or other chronic use
mobility makes the pelvic girdle an efficient patterns can prove equally challenging.
and effective suspension system capable of Encouraging optimal postural alignment
both intense, and subtle, force distribution and functional mobility, maintaining
at the center of the body. symmetric stability both statically
(ligamentous) and dynamically (muscle
tension patterns), and effective activation of
DYSFUNCTION core muscles all help support the function
Proper function of the pelvic girdle of the pelvic girdle suspension system.
suspension system relies on a balance
between rigidity and mobility. Excessive
joint mobility due to ligament injury or Christy Cael is a licensed massage therapist
general hypermobility may lead to chronic and certified strength and conditioning specialist.
misalignment and excessive wear on joint Her private practice focuses on injury treatment,
surfaces. Reduced mobility decreases biomechanical analysis, craniosacral therapy, and
the efficacy of the suspension system, massage for clients with neurological issues. She is
transferring potentially harmful forces the author ofFunctional Anatomy: Musculoskeletal
further up the kinematic chain. Trauma and Anatomy, Kinesiology, and Palpation for Manual
chronic degeneration to the intervertebral Therapists(Lippincott Williams & Wilkins, 2009).
discs and other essential structures may Contact her at christy_cael@hotmail.com.
result as they are forced to cope with
Client Homework: Pelvic Tilts
1. Lie on your back with your knees bent and feet flat on the floor.
2. Press your low back flat into the floor by tightening your abdominal muscles.
3. Make sure your glutes and hamstrings stay relaxed. Breathe normally.
4. Relax your abdominals and let the curve in your back return.
5. Practice flattening and restoring the curve by tightening
and relaxing your abdominal muscles.

Editors note: The Client Homework element in Functional Anatomy is intended as a take-
home resource for clients experiencing issues with the profiled muscle. The stretches identified
Resources
in Functional Anatomy should not be performed within massage sessions or progressed by
Alderink, Gordon J. The Sacroiliac Joint:
massage therapists, in order to comply with state laws and maintain scope of practice.
Review of Anatomy, Mechanics, and
Function. Journal of Orthopaedic & Sports
Physical Therapy 13, no. 2 (1991): 7184.
Suspension (vehicle). Accessed
September 2017. https://en.wikipedia.
org/wiki/Suspension_(vehicle).
Uhthoff, Hans K. Current Concepts
of External Fixation of Fractures.
Berlin, Germany: Springer Science
& Business Media, 2012.

42 massage & bodywork november/december 2017

education SOMATIC RESEARCH

Real-World Massage Research

and Massage Therapist Involvement
By Jerrilyn Cambron, DC, PhD

Back pain is a condition on which a

lot of massage therapy research has

been conducted, and for good reason.

Back pain is the leading cause of years lost

to disability1 and one of the top reasons

people seek out massage therapy. A recent

study in Pain Medicine highlights real-world

massage therapy for chronic low-back pain

and found outcomes beneficial for study

participants.2 The study was conducted at

the University of Kentucky and examined

massage therapy for pain with disability

and health-related quality of life in primary

care patients with chronic low-back pain.

44 massage & bodywork november/december 2017

 The study is important for the massage
therapy field because unlike earlier large-
scale research studies, this one used
community practicing massage therapists
who developed individualized treatment
plans for study participants assigned to
them. The whole study was set up to
reflect the way real chronic low-back pain
patients would access massage therapy in
most parts of the country. Several Central
Kentucky family and internal medicine
primary care providers participated in
the research and their referrals were
how patients entered the study.
Primary care providers referred patients
with chronic low-back pain to the study if
they thought massage would be beneficial.
Once enrolled, patients were matched
with community massage therapists who
practiced close to either where they lived
or worked. Patients were allowed to access
up to 10 complimentary one-hour massage
sessions over 12 weeks (massage therapists
were compensated by the study team). All
aspects of the massage sessions occurred
as typical in the massage field after the
initial patient-to-therapist match by study
personnel. Patients scheduled with the
massage therapist per their availability
and the treatment plan, and they attended
sessions in their therapists clinic. Therapists
documented each treatment session with
a study-provided SOAP notes template
that they submitted to study personnel.
Details of the community practicing
massage therapists were reported prior
to the publication of the study results
in the open-access International Journal
of Therapeutic Massage and Bodywork.3
I sat down with Niki Munk, PhD, LMT,
co-lead author on the study, at the Alliance
for Massage Therapy Education conference
back in July to talk about the study, its
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 45
importance to the field, and the various
ways massage therapists can contribute
to, or be involved in, massage research.
JERRILYN CAMBRON: The buzz
word for this study is real world. What
does real world mean and why is
this study considered real world?
NIKI MUNK: Real world essentially means
what it implies: as it happens or occurs in
the real world, in real applications. The
words pragmatic and effectiveness are related
research terms that indicate, along with real
world, that the research does not seek to
examine interventions or make observations
in controlled settings. Our study design was
real world from several perspectives. We
had a very open inclusion criteria, which
allowed for medically complex participants
who are often excluded from research or
controlled studies. For example, we did not
have an upper age limit for participants,
which allowed us to include much older
participants who, up to that point, had been
excluded from large clinical trials examining
massage for back pain. We also allowed
chronic low-back pain patients with co-
morbidities such as diabetes, hypertension,
depression, and obesity to participate, as
well as patients who were on scheduled
medications such as opioids. Essentially,
the participants in this study reflect the real
world: complex individuals who massage
therapists work with every day in a variety
of practice settings, all across the country.
JC: And the treatments provided
by the community massage
therapists were real world too?
NM: Yes. Therapists were allowed to
develop and apply individualized treatment
plans within their scope of practice and
skill set to meet the needs of each study
participant within the study parameters
of 10 one-hour sessions within 12 weeks.
There were two non-real-world study
aspects related to the massage therapists,
though. First, only those who were decision-
makers for their practice environment could
be study therapists, and second, therapists
had to be at least five years out of their
foundation massage training program.
JC: Why were these non-real-
world study parameters needed?
NM: The decision-maker parameter
simply became a necessity for logistical
reasons. The study budget was only able
to compensate massage therapists $25 for
each completed massage session. Because
study therapists were asked to provide all
the needed massage materials, schedule the
appointments, and provide study-related
treatment documentation that became
study data (study treatment notes did not
remain with the therapist at the end of the
study), these were individual decisions that
the therapist had to weigh with regard to
their client load, the study parameters and
compensation policy, their schedule, and
what they were willing to do. Environments
in which therapists are paid on a percentage
split of the charged amount would have
 Passing the Torch
There is much more Niki Munk,
PhD, LMT, could talk about related
to the chronic low-back pain
study, massage therapy research
in general, research education,
and research implications for the
massage fieldand she will. I am
pleased to share that authorship of
this Somatic Research column will
transfer to Munk beginning with
the January/February 2018 issue.
During my four years on the job,
I have enjoyed covering various
topics in the column, and I look
forward to watching the continued
discussion in the years ahead.
Dr. Munk and I have actually
known each other for quite some
time, and it is my pleasure to
have Somatic Research in her
capable hands. In the next issue,
she will pick up the conversation
started here about the outcomes
of the real-world massage for
chronic low-back pain study
and discuss potential practice
implications of the studys results.
For now, I encourage readers
interested in learning more about
becoming involved in massage
research to consider if further
education is of interest to them,
and if so, explore the various
program options at your local
or not-so-local universities.
The field needs more
practitioners trained in research,
and who knows, maybe a future
Massage & Bodywork Somatic
Research column will report on a
research study conducted by you!
46 massage & bodywork november/december 2017
required contact and negotiation with
multiple decision-makers, which was just
beyond this studys management capacity.
With regard to the five years post-
foundation education requirement: again,
from the logistical side of things, we needed
to work with therapists who had had time
to build a reliable practice environment and
who wouldnt be using their work with the
research study as a way to build a clientele.
In addition, the five-year experience
expectation allowed for study therapists
to accumulate more treatment experience
and additional education the logic being
that these therapists would have more tools
to address the complex cases that people
with chronic low-back pain present.
JC: You are a trained and licensed
massage therapist and a researcher.
Which were you for this study?
NM: I actually had a couple of separate,
but related, roles on this study. When
the study was first being designed for
the initial National Institutes of Health
(NIH) grant submission over 10 years
ago, I consulted with the studys principal
investigator (William Elder, PhD) on the
study design. I was a doctoral student at the
time, focused on completing my research
training, so was not actually involved in
the multiple subsequent grant revisions,
funding procurement, or start of the study.
Another, even more experienced community
massage therapist (Katie Stewart, who
also happened to be one of my massage
therapy instructors) was the studys primary
massage field consultant and served as the
massage liaison for the study duration. I
officially joined the research team as the
studys program manager four years after
my initial consulting role and after having
completed my doctoral training. The study
had commenced about two years prior,
and, in addition to my coordinating and
management role, I served the study as
another massage field liaison and statistician
due to the statistics emphasis with my
doctoral training. After the study was
complete, I organized and analyzed the data
and was a key contributor to the results
dissemination process. These later roles
earned me an investigator and co-lead-
author role with Elder, who served as the
studys principal investigator. Ultimately,
while I am a licensed massage therapist in
Kentucky, I did not provide treatments for
any of the study participants. I served on the
study in a research capacity, but with a deep
knowledge of the massage field context and

with an eye for what was meaningful within
the work from a massage field standpoint.
JC: Why were you able to have such
a significant role on a prominent and
federally funded massage therapy
research study? program I am affiliated with is in health
NM: Part of it was that I happened to be
in the right place at the right time and
had a basis of knowledge that aligned with
study needs. I was already enmeshed in the
research environment at the University of
Kentucky during my doctoral training and
met Elder at a local research conference.
Elder happened to be interested in
complementary therapies for chronic pain
populations and be a researcher in family
medicine. The rest of the story actually
has a lot of other twists and turns, but
the bottom line is that I had the training
and skills that meshed with and filled a
gap in the research team at the time, and
I was able to take the opportunity when
it presented itself. While the roles were
different, the same can be said for the
several community massage therapists who
worked on the study as well; there was
an opportunity to be involved in a large,
NIH-funded study, they recognized and
accepted the opportunity, and fulfilled the
study requirements. They were valuable
members of the study team and reliable in
their completion of the necessary tasks.
JC: Are you still conducting research?
NM: Yes! I am in fact still conducting
research, and I am building a massage
therapy research program at Indiana
University (IU) on the Indiana University
Purdue University Indianapolis campus.
I have been at IU for four years now and
have developed a cadre of local community
therapists who provide the massage
treatments examined in my various research
studies for chronic pain conditions. In
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 47
my professor role at the university, I also
train undergraduate to doctoral students
in research, aging, and theory building.
Ive had a handful of undergraduate
students cross my path who were also
massage therapists, and working with
them has been great! The IU doctoral
and rehabilitation sciencesa field with
a logical alignment to massage therapy.
It is my hope that eventually I will train
massage therapists interested in becoming
researchers in my lab while they earn
their PhD in health and rehabilitation.
Our field needs more research, and
ideally, future massage research will be
conducted by professionals in our field like
other applied disciplines such as nursing,
physical therapy, medicine, etc. This is a
little challenging right now because there
are only a few trained massage therapist
researchers in positions that make them
eligible for, and capable to conduct, large-
scale research studies and build research
programs, which takes oh-so-much time.
Many of the leading massage therapy
researchers are from other disciplines,
like medicine or nursing, but there are a
few of us out here, and hopefully there
will be more in the coming years.
JC: It seems like another way the chronic
low-back pain study is real world is that it
provides an example of several ways massage
therapists can be a part of research with the
appropriate training and/or experience.
NM: Sure. Research involvement can
include roles as a consultant, liaison,
therapist, coordinator, research assistant,
investigator, or lead investigator with the
right experience and training. The studys
progression from conception to completion
was concurrent with my development
as a massage-therapist-turned-research
professional. There are all manner of
ways in which massage therapists can get
SOMATIC RESEARCH
involved with, or train for, various roles
in research. In certain cases, particularly
for doctoral training, there is even the
potential for funding support. Interested
potential students just have to inquire about
student support or the potential for research
or teaching assistantships associated
with doctoral programs of interest.
That was actually a surprise to me when
I was looking into getting my doctorate.
The program in which I received my
training only admitted students who the
program could support, which means
my tuition was paid and I was paid a
stipend for the research assistance work I
provided during my training. It was a win-
win situation, and now I am developing
massage-focused research programs of
my own at a research-focused institution
and looking forward to training future
massage therapist researchers.
Notes
1. US Burden of Disease Collaborators, The State of
US Health, 19902010: Burden of Diseases, Injuries,
and Risk Factors, JAMA 310, no. 6 (August 14, 2013):
591608; Christopher J. L. Murray et al., Disability-
Adjusted Life Years (DALYs) for 291 Diseases and
Injuries in 21 Regions, 19902010: A Systematic
Analysis for the Global Burden of Disease Study 2010,
Lancet 380, no. 9859 (December 15, 2012): 2,197223.
2. William G. Elder et al., RealWorld Massage
Therapy Produces Meaningful Effectiveness Signal
for Primary Care Patients with Chronic Low Back
Pain: Results of a Repeated Measures Cohort
Study, Pain Medicine 18 (2017): 1,394405.
3. Niki Munk et al., Intersection of Massage Practice
and Research: Community Massage Therapists as
Research Personnel on an NIH-Funded Effectiveness
Study, International Journal of Therapeutic Massage
& Bodywork 7, no. 2 (June 2014): 1019.
Jerrilyn Cambron, DC, PhD, MPH,
LMT, is dean of the College of Allied Health
Sciences and Distance Education at the
National University of Health Sciences and
president of the Massage Therapy Foundation.
Contact her at jcambron@nuhs.edu.
 EDUCATION INSPIRATION
Erik Dalton
Founder of the Freedom From Pain Institute
Q&A
Who is Erik Dalton, the bodyworker? My college years were
devoted to psychology and drumming in a rock n roll band, but
after attending an Ida Rolf presentation at the Esalen Institute, I
was hooked on bodywork. There is nothing more exhilarating than
the ability to help people using only your hands. Thats why, in
1998, I introduced the first state and nationally approved home-
study course, Myoskeletal Alignment Techniques (MAT). To
my pleasant surprise, the program was immediately successful,
and students quickly demanded more. In response, I decided
to organize all Id learned through years of study and practice into a
full training curriculum, licensed by the Oklahoma Board of Private
Vocational Schools and named the Freedom From Pain Institute.
Whats new with the Freedom From Pain Institute? With the
completion of our new Art of MAT five-piece home-study and
e-learning course, were thrilled to offer the long-awaited Master
Myoskeletal Therapist (MMT) certification, which includes a teachers-
in-training program. Currently, we have nine highly skilled instructors
conducting live MAT workshops internationally, and in late November,
Ill teach my 18th annual Pain Management in Paradise retreat in
SPECIAL ADVERTISING SECTION
San Jose, Costa Rica. Weve also been doing a lot of filming for our
upcoming online technique-only subscription service with special
guests Paul Kelly, Nick Cress, Michelle Mokracek, and James Waslaski.
What are you most proud of in your career? My greatest joy has
come from working with and learning from clients for the past 38 years.
No teachers, books, or research conferences can take the place of the
things Ive learned in my full-time bodywork practice. I love teaching
and am proud of my three textbooks and numerous technique videos,
but my deepest satisfaction comes from getting to know people
and helping them resolve their chronic pain and injury problems.
I would like to see
more young educators,
especially women, rise up
through the ranks.
Whats your primary concern relative to todays massage
therapy profession? I would like to see more young educators,
especially women, rise up through the ranks. Also, although I really
like communicating and keeping up with my bodywork friends on
social media and sharing new relevant research, I fear we may
be sacrificing expression of our personal clinical findings for fear
of evidence-based rebuttal. Its exciting to see a trend toward
science-based methodology, but the pendulum must not swing
so far as to impede fresh, creative clinical ideas from bright young
minds. On a positive note, Im very impressed with the hands-on
skill set Im seeing recently in my MAT workshops, which tells me
massage schools may be doing a better job in basic curriculum.
What are you most excited about? What inspires you? Im most
excited about spending more time at my Costa Rica home, working on
a new book, hiking with my wife and spoiled dogs, and upgrading my
snorkeling skills. Ive set up a video studio on my terrace, so when I run
across an unusual client case I can quickly get it on film. There just isnt
enough time in the day to list all the things Im passionate about when
it comes to touch therapy. Thats the wonderful thing about this work
never a dull moment. Just when you think youve seen it all, boom!
sponsored by
 EDUCATION INSPIRATION
Cyndi Dale
Author, Intuitive, and Healer
Q&A
How do you define your career to those who dont know Cyndi
Dale?Officially, I perform client sessions as an intuitive consultant and
energy healer. Im also an author and I love teaching. When working
with a client, I use my intuitive gifts to perceive whats happening in
the subtle energy realms affecting a client. You see, everything is
made of energy, which is simply information that vibrates. There are
two types of energy. Physical energy is obvious. Subtle energy, which
is the lattice upon which physical energies organize, is psychic, or
difficult to perceive. My task is to figure out what subtle energies are
creating problems and what solutions might be effective. When Im
not interacting with clients, I teach people how to develop their own
skills in the energetic arena, which is also the subject of my books.
Whats your most important gift? From an energetic perspective,
Im mainly visual or clairvoyant, and have been since I was a child.
I could perceive these psychic or subtle energies with my eyes.
Sometimes, I still can, although mostly I view them internally. In
my client work, I might visualize a picture from a clients history, a
possible future, or see through the veil to discover whats really
happening in a current situation. I tell my clients we have to take
the practical steps necessary to assure the optimum future.
SPECIAL ADVERTISING SECTION
How do you define being intuitive to the uninitiated? Basically,
intuition is the bridge between the physical and the subtle worlds.
We can easily perceive physical reality with our five senses. Most
of reality, however, is unapparent. For instance, we only see
something like .00035 percent of light on a linear scale. How can
we see, hear, feel, or become aware of the difficult to perceive,
which are the subtle or psychic energies that actually create
physical reality? We have to use our intuition. Formally, there are
at least 11 forms of intuition, which can be organized as empathic,
verbal, and visual capabilities. We are all intuitive, we just have
to learn how to recognize our intuitive styles and trust them.
I love to see people
become all of themselves.
What do you love most about mentoring others? I love to see
people become all of themselves. There is so much talent and beauty
packed inside each of us; weve only to unlock it. That process
usually involves becoming educated about our intuitive or spiritual
abilities and then learning how to use them. This authentication
process isnt age-related. Not long ago, I worked with a 10-year-
old boy who had been getting visions of the future. The accuracy
frightened him. I showed him how to contain the gift and then
control it. What an amazing ability! Recently I interacted with an
80-year-old woman who has been hearing angelic words in her
head for years. Now shes writing a book of spiritual insights. We
all have surprises inside, and I get to witness them unfolding.
Youre known internationally and teach across the globe.
Whats your secret to creating work/life balance? First of all,
I believe in work/life balance. I think our world is lopsided, with
work occupying the number one spot. But time for connection,
joy, rest, learning, and even silliness allows us to bring more to
our career, not less. So Im structured in my approach to life.
In the end, I think the key is boundaries. I dont answer
clients questions unless Im in a session. I keep my
private time my private time. We have to set parameters
and boundaries or our personal lives disappear.
sponsored by
CYNDI DALE
AUTHOR INTUITIVE HEALER
 Photo by Doug Ellis Photography.

52 massage & bodywork november/december 2017

Broaden
Your Touch How much information are your

hands capable of receiving?

Repertoire
Broadening your touch repertoire

to include a receptive approach

will make you a more versatile

Let the Body Lead the Way and effective practitioner.

As bodyworkers, we know how

By Robyn Scherr and Kate Mackinnon
important and powerful touch is in peoples
lives. We are all born with an incredibly
sophisticated neural network that helps
us understand and use signals that come
in through the largest organ in our
bodies, our skin. Not only that, our entire
nervous systemincluding our brainis
constantly learning from and changing
itself in response to those signals. This
is the very definition of neuroplasticity.
Touch informs us and forms us.
Its easy to remember that our clients
receive input through the quality, depth,
speed, and intentionality of our touch.
But we can overlook that just the act of
our touching them gives us input as well;
we receive information we often dont
recognize, or that we ignore or dismiss
because we dont know its value. We can
forget how powerfully touch informs us
and rely on technique alone. Recognizing
a broader spectrum of input from our
touch is one of the cornerstones of good

ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 53
therapeutic presence, as it helps us hone
in on the most helpful engagement.
Lets explore how to expand your
palpatory sense, learning what information
the client is showing us when we touch
with the least amount of disturbance or
invasiveness, keeping our hands relaxed
and alert to receive the most input possible.
This noninvasive approach will make any
bodywork modality more effective.
TRADITIONAL PALPATION AND
THE FIX-IT MENTALITY
We are trained to palpate within a
medical model. We are taught how to
feel for certain qualities such as a tense,
tight area that could mean scar tissue,
a soft boggy feel representing swelling,
heat for inflammation, or the hard end-
feel of a braced joint. All these ways of
palpating provide useful information.
Note that all are in search of discovering
specific pieces of information. We go in,
literally, with a plan and an idea of what
we will find. This is a model of being the
expert in the room, looking for whats
wrong and devising a plan to remedy it.
We carry that mentality into the session.
As bodyworkers, many of us are trained
with the following way of approaching our
business: greet the client, listen to their
concerns, settle them on the table, do an
assessment in a way thats comfortable and
familiar to the therapist, and then set about
remediating the stuck places, or whats been
deemed wrong. Hopefully there is a check-
in along the way: gauging comfort for the
client, and how well their body is accepting
the changes the therapist is trying to bring
about by measuring against the initial
assessment. This approach can create good
change for our clients; however, we only
54 massage & bodywork november/december 2017
get what were looking for, and that means
we can only find what we already know.
We also limit avenues for change to
those that address the problem weve
identified. Whether light touch or deep the compensations. When we take away
tissue, the focus is on seeking out and
doing. The major downside of looking for
problems is that it is easy to override the
clients system because we have an agenda.
The opposite of that would be to touch
with the intention of finding out what
information can come into our hands,
instead of what our hands can go in and
find. What we find may be surprising, like
noticing a sore knee is actually helped most
by releasing the opposite shoulder rather
than working on a tight set of quads. We
may also find whats going right in the body
and learn that bolstering whats going right
rather than trying to find and fix whats
going wrong may be just whats needed.
As much as we focus on pain and
dysfunction in bodywork, we know that if
our client can come to us, and even most
of the time when the client is unable to
come to us and we go to them, theres more
going right in the body than going wrong.
This is true even for clients who are ill, but
a simple example of this would be a client
complaining of neck pain. Perhaps we
find that their neck and torso are stiff and
resistant to touch, but their feet are very
open to being worked, and that the client
begins to relax and enjoy touch at their feet.
This client may be best served by working
the feet thoroughly, and then expanding
work into other areas of the body that can
also experience these calming, pleasurable
sensations. You may be surprised that their
neck releases without any work there at all.
Its good to remind ourselves that when
we focus on whats wrong, we are aligned
with the part of the client that wants to
change (see Cultivating Neutrality: Grow
Your Therapeutic Presence, Massage &
Bodywork, November/December 2014).
We have no room to see how the pattern is
serving the client and whether it is in their
best interest to go in with the intention of
correcting back to normal or proper
alignment. In sessions like these, often
clients bodies either resist or give in.
There is greater likelihood of missing the
source of the issue, and only changing
compensations that are working for the
client, weve done them a disservice. And
as we are sure youve seen, often those
compensations come right back, and were
left with a client who says, It felt better
for a bit, and then started hurting again.
When you can keep your hands
curious and open to new information,
outcomes improve. This openness can
be especially useful with clients who
dont improve despite all your orthopedic
tests or amazing protocols of wonderful
techniques. If outcomes are baffling or
less than ideal, consider taking in more
information and following what you
find, rather than coming up with a plan
and attempting to fix whats wrong.
A PALPATION MODEL
Craniosacral therapy (CST) is based
in noninvasive touch, so it provides an
effective model for this session approach.
In the CST paradigm, we become a
mirror for our clients, so clients can feel
themselves more than our intervention.
This can be especially important for folks
who are already in sensory overload. And
since many people in acute and chronic
pain are in sensory overload, this can be
a large percentage of the clients you see.
As in other forms of bodywork, trust
is vital for the CST practitioner: first we
must trust that the clients body is smart
and communicating with us. Then, we
must trust the communication our hands
are receiving and be willing to respond
to that. This trust develops over time,
as we build a library of sensation and
track treatment outcomes. Assessment
becomes taking a baseline, to borrow a
concept from Emilie Conrads Continuum
Movement method. Its asking, What is
happening in this body right now?, rather
than measuring against a set of standards.
Evaluation and the treatment become more
of a conversation (sometimes including
words, sometimes silent) than executing
a plan. Assessment is repeated at the
close of the session, not to see how the
plan worked, but to notice what this new
moments baseline is, providing feedback
to both the client and practitioner.
For those of us who are trained to
do to our clients and accustomed to
crafting and executing a plan, this can
be a challenge! But its a challenge worth
exploring. It leaves us open to finding
out more information without being
limited by what we already know. With
this expansive awareness, our touch can
be more sensitive and flexible to meet the
needs of clients at each moment in time.
When we are palpating from a place
of allowing information to come into our
hands, we are able to identify more clearly
when there is something novel or different
from what were used to feeling. In a recent
multihands session (where a client has more
than one therapist in a session), we were
with a new client who reported having
several abdominal surgeries in the last year.
She told us she had a high pain threshold
and made light of the surgeries as if they
were not all that significant. On assessment,
we noted her abdomen was relaxed, without
much fascial tightness. This itself was
interesting, because usually with abdominal
surgeries there is a lot of tightness and many
directions of pull. Given our clients ease on
the table and her lighthearted tone (and the
fact that CST is performed with clothes on),
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 55
When we are
it might have been easy not to appreciate
just how extensive these surgeries were.
palpating from a
As we stayed with the tissue, we
noticed that in addition to that uncanny
ease of motion, there was something
place of allowing
else we couldnt quite identify in a large
section along the midline. With a few information to
general inquiries about her surgeries and
no answer to what we were feeling, we
continued working in silence for several
come into our
minutes. The client then suddenly said,
Well, they took out so much scar tissue
and so much of my skin they did have to
hands, we are
use pig skin to close the wound in the last
surgery. All of a sudden what we were able to identify
feeling made sense, and we were able
to treat that area with more precision.
Much of the rest of the session involved
more clearly
the client feeling beyond her own tissue
and into that new skin, incorporating it
into the felt sense of her body. And, as a
when there is
bonus, our hands now know what pig skin
feels like in a human body, increasing something novel
our felt-sense library of knowledge!
A MODEL IN ACTION
or different from
As CST practitioners, we are accustomed
to encouraging our clients body awareness
and their experience of touch and internal
what were used
sensation. We recognize that its the clients
body that makes helpful change, more to feeling.
than any technique we can employ, so its
useful to engage them in the process. We
will often ask, What are you aware of
right now? as a prompt. Clients report
that, over time, they become more aware
of their bodies. Their treatments are more
effective, too, because theyre now better
equipped to respond to their bodies needs.
When we started working together
in multihands sessions, we began to ask
each other the same question: What
are you aware of? We each perform
an assessment and settle in to work.
Asking each other to state what were
noticing in the tissues deepens our skill
level, because we need to think through
the nuances of what were feeling.
Sometimes its easy to feel through
the clients body to each others hands,
and sometimes the connection between
our hands is not so clear. This is one way
to discover where the body is struggling,
to focus on an area that is difficult to
palpate through. Other times, we notice
that while our hands are in the right place,
its the specificity of our touch that needs
to change. Perhaps theyre connected in
with the tissue fairly globally, and honing
in on a specific structure helps expedite
the change the body wants. It can also be
the other way around: sometimes one of
us is too focused on a structure or tissue
type, and a more global approach is better.
If the client has good body awareness,
they will often track all of this with us.
Over the years, this type of questioning
has become well ingrained in our practices,
so that even when we may be touching
with significant depth or pressure, our
clients remain relaxed and receptive.
We dont create a guarding response in
our clients because we are not imposing
ourselves, but rather responding accurately
to their needs for that depth of pressure.
Recently, a client asked why she could
not feel much in an area where our hands
were. Although we could feel change in
the tissues, it was not something the client
could track. By deepening the palpation
by a couple of grams, and therefore
applying a little more drag, the client
was able to feel what was happening.
And while our work showed signs of
LEARN MORE
Continuum Movement www.continuummovement.com
Healing From the Core www.healingfromthecore.com
Upledger Institute International www.upledger.com
56 massage & bodywork november/december 2017
being effective before she participated,
it was more effective, and more specific,
once she was involved in the process.
THE THERAPISTS FELT SENSE
To palpate with accuracy, we must allow
ourselves to be moved by the clients tissues.
Otherwise, we are just feeling where their
tissues meet our own restrictions. So we
need to be very aware of our own body. We
need to be able to notice where we may be
holding tension or have discomfort, and how
much presence we have in any one area. For
example, when something does not feel good
in our own body, it is easy to simply ignore
that area and have no presence there at all.
If we are distracted from our own body
sensation or preoccupied with discomfort
or effort, we will convey this through our
touch. The equivalent would be putting
on ear mufflers and babbling aloud when
we are trying to listen to a certain sound
someone is making. And sometimes, when
we are learning a new skill or unsure of
what we are feeling, we can have a tendency
to put in too much effort, just with our
intention. Even if were employing very light
touch, this can feel invasive to the client.
So, we can see that it is not just light
touch alone that is needed to be noninvasive;
we also need to consider our sense of our
own body, and our intention, as we work.
The more awareness we have, and the more
comfort and ease we can create in our own
bodies, the more potential we create for
clients to feel themselves. We are essentially
being role models for them. Becoming
the role models we want to be for our
clients may involve unlearning a lot of the
lessons we get around touch early in life.
TOUCH AS FIRST LANGUAGE
When we are born, we are unable to talk to
communicate our needs. Fortunately, most
of us can cry very loudly to get attention
when we are distressed! Words spoken or
sung to calm us can be helpful, but the
real support comes from being held and
touched in a way that meets our needs.
Touch is our primary sense for well-being.
Babies and toddlers respond to touch.
When touch does not feel good to them,
they communicate by recoiling. They
respond to touch that meets them by
meeting it in return, and often showing the
person touching them just what they want
(leaning in for a tighter hug, extending
the spine to request a lift up, taking away
one hand but leaving another in place).
Touching a child noninvasively allows for
more conversation to happen between
caregiver and child. There is a respect for
the childs boundaries and body integrity.
Unfortunately, all too often, babies
and young children are not respected in
regard to touch. Children instead learn
to put up with or submit to touch
that does not feel good. This begins
the process of being educated out of
this innate understanding we are born
with around the language of touch.
We adults have, by and large, been
taught to submit to discomfort for our
own good. We learn early that our bodies
are not completely our own, and that
we must ignore or override distressing
sensations. This translates easily to the
massage table, which can lead to poor
communication and poor outcomes. You
may feel this in sessions with your clients,
when they tighten to resist your touch
or go limp, giving in to pressure. One
of our goals as bodyworkers is to ensure
that coming generations dont have this
hurdle (see sidebar on page 57). Imagine
how much more effective your work will be
when your touch meets your clients needs,
and doesnt elicit guarding or collapse.
Recently co-author Mackinnon was
working with a longtime client who had
an acute injury to her left knee after
tripping on a sidewalk the week before.
It had been resolving, and then she went
to see a doctor who carried out routine Compassionate Touch for Children
orthopedic tests to diagnose the problem. We work every day to help our clients gain a healthy awareness
This flared up all her pain and she went
back to using crutches again for a few of their bodies and a healthy relationship with touch. And
days. When she came in, the knee was were working toward the day when children arent educated
clearly swollen, and the client was in a out of their natural awareness of nurturing touch.
good amount of pain. Mackinnon started
out by employing her physical therapist How can we raise new generations that arent dissociated from
skills and palpated the medial ligament in a their bodies? One way is to introduce the idea of healthy touch in
traditional, medical manner. It was painful
school, teaching children to recognize touch that is nurturing and
with very little pressure. That alone told
the therapist she was going to gain little helpful, and how to avoid touch that isnt. There are easy ways to
information with this kind of touch. talk about touch, and bringing Compassionate Touch safely into
Instead, she then put her hands on
schools is one way. One of the basic ground rules around touch in
the front and back of the clients knee
and listened. She was able to feel the schools is that permission is always given for touch from both people,
many structures that were affected by either verbally or by a simple gesture like putting out your hand for
the clients accident and found that global
a shake, or bending down and opening your arms to invite a hug.
inflammation was the most pressing issue.
As Mackinnons hands remained on the Children can also be taught how to use Compassionate Touch
knee, she could feel small movements take with one another. For example, when a student falls and hurts their
place under her hands and see movement
knee, their friend can say, Please, may I touch you? And if their
along the lines of pull down to the ankle
as the body accessed its own self-healing friend answers yes, they can then put their hands on their friends
capacity. The inflammation began to hurt knee and think kind, loving thoughts. Susan Cottas book I
resolve and the client reported less pain.
Can Show You I Care: Compassionate Touch for Children (North
As Mackinnons hands continued to
cradle the knee, the client recalled that Atlantic Books, 2003) is a great resource for children and schools,
this knee had been badly injured before. and also for touch therapists. We use the book in our offices.
She was also able to see how the doctors
Students and teachers alike have found Compassionate Touch
exam had exacerbated the pain. She was
due to see another doctor later that day to be a very effective way of increasing pro-social behaviors in
for more tests, and then was scheduled the classroom, and its an important component of any social and
to travel for several days. She was able to
emotional learning curriculum.
reflect on the timing of this and see that she
would be better off postponing her doctors
appointment, which was likely to aggravate
her symptoms for a bit, until after her travel.

ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 57

Amplify Your
Bodywork Skills
Join like-minded colleagues at Esalen
in Big Sur, California (January 1214,
2018), as educators Robyn Scherr and
Kate Mackinnon help you attune your
palpation to clients needs.
Noninvasive Palpation: Amplify
Your Bodywork Skills will teach you
how to palpate the tissues, fluids,
and frequencies of the bodyin its
various densitieswith ease and
specificity. Imagine how effective your
will work be when you can track and
respond to inflammation, strain, and
metabolic processes accurately, and
without force. Noninvasive palpation
makes any bodywork modality
more effective, enjoyable, and more
comfortable for clients. Theres no
more precise and sensitive instrument
than well-trained hands.
Lecture, gentle proprioceptive
movement, and sensory exploration
will be balanced with plenty of practice
time at the table. For more information
visit http://bit.ly/2xAXNBF.
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 59
FELT SENSE AND
THERAPEUTIC PRESENCE
The most useful practice we have found
to enhance our awareness and increase
our therapeutic presence is Suzanne
Scurlock-Duranas Healing From the
Core curriculum. In its essence, it helps
us assess ourselves (take a baseline) by
noticing how much of our bodies we are
able to access through our felt sense, and
then gently bring awareness and presence
to places that may feel stuck or absent.
This is a constant exploration, different
every time we practice, and we find it vital
for our ability to palpate accurately. It
requires getting really comfortable with
curiosity and that place of not knowing. It treatment. During sessions, periodically
helps keep us in check when were tempted
to think we have a solution to a clients
problem. By staying grounded and aware in
our own bodies, we are better facilitators
and empower our clients own self-discovery.
NONINVASIVE PALPATION
We think the best way to develop
noninvasive bodywork skills is to practice
with peers who are also interested in
honing their own felt sense. Set up
a trade where the purpose is more
about discovery than treatment.
You may wish to review the various
touch receptors as preparation. It can be
useful to remind yourself of the different
inputs our skin can register (light and
steady, light and fleeting, deep and steady,
deep and fleeting, direction, temperature,
etc.). But remember that nothing in the body
acts in isolation. Our felt sense is always a
blend of every input thats coming from our
insides, our sense organs, and our skin.
A relaxed, steady hand that uses only its
natural weight will help you avoid giving
distracting input to yourself and your
partner. Often light touch therapists
stiffen their hands, arms, and shoulders to
achieve that sense of lightness, a not-quite
touching. And deep touch therapists
stiffen or compress their joints to press. We
propose learning what it feels like to simply
place your relaxed hands on your partner,
and then becoming more aware of yourself.
To start, place your hands somewhere
on your partners body (abdomens are a
great place to start exploring), notice what
happens in your body for some time, then
notice your partner. How deep into the
body is your awareness? Without changing
your hands at all, can you feel more into the
depths of the body? More to the surface?
Can you identify soft tissue, bone, fluid,
movement? This exploration alone will
increase the accuracy of your assessments.
You can then take this curiosity into
take a moment to explore whats in your
current awareness. Notice where in the
body youre most engaged. Ask yourself,
What is happening as I employ this
techniquein my own body, in my
clients body, directly under my hands,
and throughout my clients body?
We have found that when clients
are touched with relaxed, alert, curious
respect, they relax more easily on the table,
are more receptive to techniques when
theyre needed, and have more capacity
for change. This process is educational
to the client and helps them come back
into a healthy communication with their
bodies and with touch. They are able
to take more ownership of their health
and well-being, and be better advocates
for themselves. Its also much easier on
our bodies, as we can remain relaxed
and at ease, even at great depths.
Robyn Scherr and Kate Mackinnon are
both diplomate-certified in craniosacral therapy.
Find out more at www.robynscherr.com and
www.kmackinnon.com.
 The Brachial Plexus
and Thoracic
Outlet Syndrome The brachial plexus of nerves and
Understanding Signs and Symptoms the subclavian/axillary artery and
By Joseph E. Muscolino, DC vein comprise a neurovascular

bundle that is often compressed

in the lower neck/upper thoracic

1
Thoracic outlet syndrome is the name given region, causing a condition known
to a set of neurovascular compression
syndromes that affect the brachial plexus of as thoracic outlet syndrome (TOS).
nerves and/or the subclavian/axillary artery
and vein where they outlet from the thorax
into the upper extremity. Note the presence There are actually four different forms
of a cervical rib on the models left side. of TOS, each named for the region where
Images courtesy Joseph E. Muscolino. the compression occurs (Image 1). One
Illustrations by Giovanni Rimasti. Photography is called anterior scalene syndrome because
by Yanik Chauvin and Joseph E. Muscolino.
the neurovascular contents are entrapped
and compressed between the anterior and
middle scalene muscles. The second is
called costoclavicular syndrome because the
Middle scalene
C5 entrapment/compression occurs between
C6
Anterior scalene
C7
the first rib (cost is Latin for rib) and
C3 the clavicle. The third is called pectoralis
Brachial plexus C8
trunks T1 minor syndrome because the entrapment/
compression occurs between the pectoralis
C6 minor and the rib cage. The fourth type
Cervical
rib of TOS occurs due to the presence of a
Subclavian genetic anomaly that creates what is called
artery
a cervical rib, which is a formation of bone
Musculocutaneous nerve off the seventh cervical vertebra (C7).
Median nerve The first three types of TOSanterior
Ulnar nerve scalene, costoclavicular, and pectoralis
minor syndromesare caused by soft-
tissue postural dysfunction and will
1st rib
Axillary nerve respond well to manual and movement
Radial nerve Subclavius
therapy care. Therefore, the emphasis for
anyone in the field of bodywork should
Brachial plexus be placed on these forms of TOS. The
cords
fourth typecervical rib TOSbeing due
to a relatively rare bony anomaly (which
occurs in approximately 12 percent of
Axillary artery
and vein the population) is not readily treatable
with manual and movement therapy and is
therefore of less importance to bodyworkers.
Pectoralis minor

60 massage & bodywork november/december 2017

 Brachial Plexus Tree

2
This image is an anatomically correct, yet artistic, rendering of the brachial plexus of nerves, providing a visual touchstone for learning the structures. Leaves represent the muscles
innervated by the branches of the brachial plexus; indicates that muscle is innervated by two different nerve branches. Please see Tables 2 and 3 for a listing of the muscles
corresponding to the abbreviations used in this image.
 Cervical Rib: True Thoracic Outlet Syndrome?
Interestingly, the cervical rib version of TOS is often referred to in medical literature as true TOS, which implies
that the other forms of TOS are in some way false. Terming cervical rib TOS as true occurs because of the
undue emphasis the medical establishment places on skeletal structure, as well as the lack of importance it
places on soft-tissue dysfunction (the cause of the other three types of TOS). But it should be stated that all
four forms of TOS can cause the signs and symptoms of TOS and, therefore, are all true forms of TOS.

SIGNS AND SYMPTOMS OF TOS
A full awareness of the signs and symptoms
of TOS cannot be understood without
a somewhat in-depth knowledge of the
brachial plexus; however, the major concepts
can be addressed and understood. Before
moving forward with this discussion, it is
worth noting that symptoms, by definition,
are subjective in that they must be reported
by the client. For example, only the client
can state if they are experiencing pain.
Signs, on the other hand, are objective
in that they can be measured by the
therapist. For example, the strength of
the clients pulse is a sign that can be
felt and reported by the therapist.
Neural Symptoms
Almost all peripheral spinal nerves are
mixed in that they carry both sensory and
motor neurons (the only exception is the
C1 nerve root, which is only sensory). In
this sense, they can be likened to two-
lane north-south highways comprising
a northbound lane that carries sensory
information gathered in the periphery
up to the central nervous system, and
a southbound lane that carries motor
information down from the central
nervous system to the periphery. TOS
usually involves peripheral nerve
compression; therefore, the two major
types of neural signs/symptoms result
from sensory compression and motor
compression. And, given that the brachial
plexus of nerves travel to/from the upper
extremity, these signs and symptoms
would manifest in the upper extremityin
other words, the arm, forearm, and/or
hand. Most often, upper extremity nerve
compression is experienced in the hand.
Compression of a sensory neuron can
cause irritation of the neuron, creating
aberrant sensory impulses resulting in
increased sensation, termed hyperesthesia.
Examples include hypersensitivity to
touch, a feeling of tingling even when
no stimulus is being applied to the skin,
or burning or shooting pain. When the
compression is greater, it can begin to
obstruct axonal flow within the sensory
neuron, resulting in diminished ability of
the neuron to carry impulses. This, in turn,
results in diminished sensation, termed
hypesthesia. This is often experienced as
pins and needles, instead of a full sensation
of touch, when pressure is applied to the
skin. If the axonal flow is entirely blocked,
numbness can result. Any altered sensation,
whether it is hyperesthesia or hypesthesia,
can be termed paresthesia. Because
paresthesia, is by definition, something
the client feels, it is a subjective symptom
and must be reported by the client.
Given that motor neurons are
responsible for directing muscle contraction,
compression of a motor neuron would
affect muscle function. If the motor neuron
is irritated and creates aberrant nerve
impulses, then muscle twitching (termed
fasciculation) can occur. If the compression is
greater, then obstruction of the axonal flow
could result in the inability of the neuron
to direct its muscle fibers to contract. This
would result in weakness, and, perhaps in
time, atrophy of the associated musculature.
Arterial Symptoms
Arterial blood is delivered to the upper
extremity via the subclavian artery, which,
as it travels distally, becomes the axillary
artery, then the brachial artery, and then
divides into the radial and ulnar arteries,
which enter the hand. The various types
of TOS can potentially compress the
subclavian artery or axillary artery pathway
of arterial delivery into the upper extremity.
This would decrease the delivery of
oxygenated arterial blood to all the tissues
and cells of the upper extremity, distal to
the point of compression. In light-skinned
individuals, the skins pallor might become
cyanotic (bluish) and is often noticed in
the hand. Decreased arterial flow can be
objectively measured by feeling for the
strength of the clients radial pulse at the
wrist (it should be emphasized that it is
the strength of the pulse, not the rate
of the pulse, that is assessed). As we will
see later in this article, palpating for the
strength of the radial pulse is the primary
means by which TOS is assessed.
Venous Symptoms
Venous blood is drained from the upper
extremity by veins that are similarly named
to the arteries. TOS can compress the
subclavian and/or axillary vein, which
would result in decreased venous return
and cause pooling of fluidin other
words, swellingin the extremities. As
with neural and arterial compression, this
will usually be noticed in the hands.
ORTHOPEDIC ASSESSMENT OF TOS
Given that there are three different forms of
soft-tissue dysfunctional TOS, there are also
three different orthopedic assessment tests.
I like to describe the fundamental concept of

62 massage & bodywork november/december 2017

 3A
3B
orthopedic assessment as stress and assess.
If we believe a structure is unhealthy and
causing the client to experience the signs or
symptoms of a condition, then the goal of
our assessment test is to increase the stress
on that structure to see if it reproduces or
increases the clients characteristic pattern
of signs and symptoms. To do this, we need
to understand the underlying mechanics
of the condition we are assessing. With
anterior scalene syndrome, the underlying
mechanism is tight anterior/middle
scalene musculature; with costoclavicular
syndrome, the underlying mechanism
is a decreased costoclavicular space
between the clavicle and first rib; and with
pectoralis minor syndrome, the underlying
mechanism is a tight pectoralis minor.
Each of these cases results in compression
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Orthopedic assessment
tests for TOS. 3A:
Adsons test for anterior
scalene syndrome.
3B: Edens test
for costoclavicular
syndrome. 3C: Wrights
test for pectoralis
minor syndrome. 3D:
Alternate Wrights test
position for pectoralis
minor syndrome.
3C
on the brachial plexus of nerves (or the
subclavian/axillary artery or vein).
Therefore, our orthopedic assessment
tests for these conditions involve increasing
the physical stress on the structures
involved. For whom would we perform these
TOS orthopedic assessment tests? Most
often, it would be for any client who presents
with upper extremity paresthesia or motor
dysfunction. The most common symptom
of TOS is tingling or numbness in the hand.
The three orthopedic assessment tests for
TOS are Adsons, Edens, and Wrights.
Adsons Test
Adsons test for anterior scalene syndrome
places a tension stress on the scalene
musculature by stretching it, thereby pulling
it taut and hard against the neurovascular
contents. Given that the anterior/middle
scalenes are flexors of the neck in the sagittal
plane, lateral flexors in the frontal plane,
and contralateral rotators in the transverse
plane, they would be stretched by asking
the client to move the neck into extension,
lateral flexion to the opposite side, and
rotation to the same side (Image 3A).
It should be noted that if the
client is experiencing TOS due to the
presence of a cervical rib, then because
the compression caused by the cervical
rib occurs at the scalene musculature,
Adsons test would usually show positive.
Therefore, Adsons test assesses TOS due
3D
to both anterior scalene syndrome and
a cervical rib. Cervical ribs can often be
palpated, but definitive assessment of a
cervical rib would be made by X-ray.
Edens Test
Edens test for costoclavicular syndrome
is performed by asking the client to
assume a posture that stresses the body by
decreasing the costoclavicular space. This
is accomplished by asking the client to
push their chest out and pull their shoulder
girdles back, as if standing at attention in
front of a commanding military officer
(Image 3B). This pushes the first rib
anteriorly against the clavicle as the clavicle
is pulled posteriorly against the first rib.
Wrights Test
Wrights test for pectoralis minor syndrome
stresses the pectoralis minor by stretching
it. Because the pectoralis minor is a
protractor and depressor of the scapula,
the clients scapula is brought back into
retraction and elevation, using the clients
arm as the contact (Image 3C). This tautens
and hardens the pectoralis minor, as it is
pulled posteriorly against the neurovascular
contents. There is an alternative position
for Wrights test that involves stretching
and tethering the brachial plexus of nerves
around the pectoralis minor by simply
bringing the arm into abduction with
the elbow joint flexed to approximately

(A) Anterior view
90 degrees (Image 3D); this version of
Wrights test is usually not as sensitive as
the first version presented in Image 3C.
In each case, the therapist assesses the
strength of the radial pulse. The concept is
that because the brachial plexus structures
lie next to the subclavian/axillary artery,
then if the pulse strength is decreased due
to arterial compression, we can extrapolate
that the brachial plexus nerve structures
must also be compressed. If the strength
of the pulse decreases during the test, the
test is considered positive. The test is also
considered positive if the client reports
the reproduction of their characteristic
paresthesia pattern in the upper extremity.
Adsons, Edens, and Wrights tests are
performed to determine which form of
TOS the client is experiencing. Once the
client is assessed as positive for TOS, it can
then be helpful to determine which nerve
is being compressed. This can be done
by comparing the location of the clients
paresthesia with a map of the sensory
innervation of the brachial plexus nerves
(Image 4). Note: this innervation pattern
64 massage & bodywork november/december 2017
(B) Posterior view
should not be confused with a sensory
dermatomal map by spinal nerve root.
Determining the specific brachial
plexus nerve that is being compressed
can also be done by performing a series
of orthopedic assessment tests known as
brachial plexus tension tests (BPTTs).
There is one BPTT for each of the
brachial plexus terminal branches that
enter the hand: the median, ulnar, and
radial nerves. Following the concept of
stress and assess, each test is performed
by stressing the nerve by stretching it.
Stretching a nerve is performed in a similar
manner to stretching a muscle; our goal is
to make it longer, and this is accomplished
by knowing which side of each joint it
crosses from the neck down to the fingers,
and then moving these joints to increase
the length of the nerve. Images 5AC
demonstrate the three BPTTs. In each case,
the test would be considered positive if it
recreates the clients characteristic pattern
of upper extremity paresthesia. It is worth
noting that these BPTTs are essentially
identical to the positions used when
performing nerve mobilization treatment.
4
Sensory innervation patterns of the terminal
and preterminal branches of the brachial
plexus. A: Anterior view. B: Posterior view.
THE BRACHIAL PLEXUS
Although TOS can involve
neural, arterial, and/
or venous compression,
because nerve tissue is
more sensitive to pressure,
signs and symptoms of
neural compression are,
by far, most common. As
mentioned previously, a full
understanding of the signs and symptoms
of TOS requires a fundamental knowledge
of the brachial plexus of nerves. It is
only by knowing the sensory and motor
innervation patterns of the structures of the
brachial plexus that a full understanding
of the clients signs and symptoms can be
appreciated and correlated with the TOS
nerve compression that is occurring.
Unfortunately, most students and
therapists are exposed to the brachial plexus
as an exercise to memorize for an exam and
then forget the details, without long-term
understanding of its structure, its function,
and its relationship to TOS. I have learned
and forgotten the structure of the brachial
plexus more times than I can count. After
all, there are roots, trunks, divisions,
cords, preterminal branches, and terminal
branches. Remembering in what order these
structures occur, as well as how they diverge
and converge, their exact names, and what
they innervate, can be a daunting task. One
of the reasons so many therapists, myself
included, struggle with truly learning the
brachial plexus is that most all figures drawn
for the brachial plexus are static and more
closely resemble a metropolitan subway
grid map than the brachial plexus itself.
 Brachial plexus tension tests
(BPTTs). 5A: Median nerve. 5B:
Radial nerve. 5C: Ulnar nerve.
Causes of Thoracic
Outlet Syndrome
The immediate causes of the
various types of thoracic outlet
syndrome (TOS) are clear. Anterior
scalene syndrome is caused
by tight anterior/middle scalene
musculature. Costoclavicular
syndrome is caused by either
a posturally collapsed clavicle
or elevated first rib decreasing
the costoclavicular space. And
pectoralis minor syndrome is caused
by a tight (or perhaps hypertrophied)
pectoralis minor. But the larger
question might be why these
conditions exist in the first place.
Often, two or all three of these types
of TOS occur together as part of a
larger postural dysfunctional pattern
known as upper-crossed syndrome.
Upper-crossed syndrome involves
hyperkyphosis (hyperflexion) of the
upper thoracic spine, protracted
shoulder girdles, and medially
rotated arms at the glenohumeral
joints. It also usually involves a
hypolordotic lower cervical spine
along with a hyperlordotic head
and upper cervical spine, and
a forward-head posture. When
upper-crossed syndrome is
present, it is usually necessary
to address this larger postural
dysfunctional pattern for any lasting
relief from TOS to be attained.
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5A 5B
So, for the purpose of this feature, I
had an illustration drawn of the brachial
plexus that is anatomically correct in its
labeling, but is artistically drawn as a tree
(Image 2). After all, the different named
parts of the brachial plexus are described
as roots, trunks, divisions, cords, and
branches. Having an illustration that
gives expression to the named parts of
the plexus and visually does so as parts of
a tree can offer the therapist a powerful 5C
image, a visual touchstone that can be a
major step forward toward truly learning
and remembering the structural and
functional intricacies of the brachial plexus. TABLE 1
To further aid in learning the structure Brachial Plexus Structures
of the brachial plexus, I have created a
teaching video at http://bit.ly/ABMP-BP Roots C5, C6, C7, C8, T1
that utilizes this brachial plexus illustration.
Given how full and complicated the
brachial plexus as a whole is, it is helpful to
approach it a few structures at a time. For
Trunks Superior, Middle, Inferior
this reason, we will build up our illustration
beginning literally from the ground up.
S uperior Anterior, Superior
STRUCTURES OF THE Posterior, Middle Anterior, Middle
Divisions
BRACHIAL PLEXUS Posterior, Inferior Anterior, and
The structures of the brachial plexus, Inferior Posterior
in order, are: roots, trunks, divisions,
cords, and branches. More specifically,
the branches at the ends of the cords Cords L ateral, Medial, Posterior
are terminal branches; there are also
preterminal branches that arise along the
course of the brachial plexus from the roots (Terminal): Musculocutaneous,
to the cords. The structures can be seen in Branches
Axillary, Median, Radial, Ulnar
Image 6 and are listed in Table 1. Note: only
terminal branches are shown and described
in Image 6 and Table 1; preterminal
branches are shown in Image 2 and Table 3.
 6
The main structural components of the brachial
plexus of nerves: roots, trunks, divisions,
cords, and (terminal) branches.

7
The cords of the brachial plexus are named
for their relative position to the axillary artery.

Roots
There are five nerve roots that contribute to
create the brachial plexus. They are the C5,
C6, C7, C8, and T1 nerve roots (Image 6).
Joseph Muscolino is offering his Digital Clinical Orthopedic Manual Therapy
streaming subscription service at a deep discount to ABMP members. This
service contains all his video content, plus new content uploaded each week.
For more information, visit his website at www.learnmuscles.com/abmp.

Trunks
The five nerve roots of the brachial
plexus create the three trunks of the
brachial plexus. They are the superior,
middle, and inferior trunks.

Divisions
Each of the three trunks of the brachial
8
plexus then divides to create an anterior
and posterior division. Hence, there The ulnar, median, and musculocutaneous nerves form
are six divisions of the brachial plexus: a characteristic M shape around the axillary artery.
superior anterior, superior posterior, (Note: this image is oriented 180 degrees differently to
middle anterior, middle posterior, inferior Images 6 and 7.)
anterior, and inferior posterior divisions.

Cords
The six divisions of the brachial plexus
then converge to form the three cords.
They are the lateral, medial, and posterior
cords. It should be pointed out that
the cords are named for their relative
positions to the axillary artery (Image 7).

Terminal Branches
The three cords of the brachial plexus then
diverge to form the five terminal branches.
They are the musculocutaneous, axillary,
median, radial, and ulnar nerves.
In a cadaver lab, anatomists look to
identify the cords and terminal branches
of the brachial plexus by locating the
characteristic M shape of the ulnar,
median, and musculocutaneous nerves
around the axillary artery. The outer legs
of the M are formed by the medial cord
giving rise to the ulnar nerve and the lateral
cord giving rise to the musculocutaneous
nerve. The inner legs of the M are formed
by the medial and lateral cords contributing
to the median nerve (Image 8). Once
these cords and branches are located and
identified, the other (posterior) cord and
other two terminal (radial and axillary)
branches are located by looking posterior to
the axillary artery. Thus, this M shape is the landmark for locating all three cords and all
five terminal branches of the brachial plexus.
Motor Innervations of the Terminal Branches
Each of the five terminal branch nerves of the brachial plexus divides to form motor
neurons that innervate muscles of the upper extremity. In Image 9, each of the muscles
that is innervated by a terminal branch is represented by a leaf of that branch. Note:
Image 9 also shows that each of the five terminal branches also has a sensory innervation
component; for more detail on these sensory innervations, please see Image 4.
Motor Innervations of the Preterminal Branches
The five terminal branches of the brachial plexus are named terminal because they branch
from the ends of the cords. However, there are also 11 other preterminal branches that
emanate from the brachial plexus before the ends of the cords, either from roots, trunks,
or along the length of the cords. These preterminal branches are shown in Image 2. Leaves
indicating what muscle(s) is/are innervated by each preterminal branch (or whether it is
sensory) are also indicated in this image (for more detail on these sensory innervations, please

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 TABLE 2
Muscle Innervations of the Terminal Branches

Authors note: The abbreviation listed after each name

corresponds to the abbreviation used in Image 9 (as well as
Image 2).

Coracobrachialis (Cb)
Musculocutaneous
Biceps Brachii (BB)
Nerve
Brachialis (Brach)

Deltoid (Del)
Axillary Nerve
Teres Minor (TMin)

Pronator Teres (PrT)

Pronator Quadratus (PrQ)
Flexor Carpi Radialis (FCR)
Palmaris Longus (PL)
Flexor Digitorum Superficialis (FDS)
Median Nerve Flexor Digitorum Profundus (FDP)
Flexor Pollicis Longus (FPL)
Abductor Pollicis Brevis (APB)
Flexor Pollicis Brevis (FPB)
Opponens Pollicis (OP)
Lumbricals Manus (LM)
Triceps Brachii (TrB)
Anconeus (Anc)
Brachioradialis (Brrad)
Supinator (Sup)
Extensor Carpi Radialis Longus (ECRL)
Extensor Carpi Radialis Brevis (ECRB)
Radial Nerve Extensor Carpi Ulnaris (ECU)
Extensor Digitorum (ED)
Extensor Digiti Minimi (EDM)
Abductor Pollicis Longus (APL)
Extensor Pollicis Brevis (EPB)
Extensor Pollicis Longus (EPL)
Extensor Indicis (EI)
Flexor Carpi Ulnaris (FCU)
Flexor Digitorum Profundus (FDP)
Flexor Pollicis Brevis (FPB)
Opponens Pollicis (OP)
Abductor Digiti Minimi Manus (ADMM)
9 Flexor Digiti Minimi Manus (FDMM)
Ulnar Nerve
Opponens Digiti Minimi (ODM)
The brachial plexus illustration seen in Image 6 now has leaves added to the tree. Each leaf represents
Palmaris Brevis (PB)
a specific muscle that is innervated by the terminal branch from which it emanates (sensory innervation
Adductor Pollicis (AdP)
is also indicated); indicates that muscle is innervated by two different nerve branches. See Table 2
Lumbricals Manus (LM)
for a listing of these muscles corresponding to the abbreviations used in this image.
Palmar Interossei (PI)
Dorsal Interossei Manus (DIM)

68 massage & bodywork november/december 2017

 see Image 4). Thus Image 2 gives us the full nerve branch is being compressed and,
expression of the structure and innervation therefore, direct our manual therapy
TABLE 3 patterns of the brachial plexus of nerves. assessment and treatment. Image 4
Muscle Innervations of the Preterminal illustrates the sensory innervation pattern of
Branches Importance of Motor Innervation the peripheral nerves of the brachial plexus.
The specific muscles innervated by the
Authors note: The abbreviation listed after each
terminal and preterminal branches of BRACHIAL PLEXUS AND ITS
name corresponds to the abbreviation used in
Image 2. the brachial plexus have been described RELATIONSHIP TO THORACIC
in Images 2 and 9, and listed in Tables 2 OUTLET SYNDROME
and 3. Knowing these motor innervations Although knowing anatomy for anatomys
Long Thoracic of the brachial plexus nerves can help us sake is wonderful, ultimately, its importance
Serratus Anterior (SA)
Nerve understand how TOS nerve compression lies in our ability to marry together the
Rhomboid Major (RMaj)
can affect muscular function and assist underlying science of anatomy with our
Dorsal Scapular
Rhomboid Minor (RMin)
us in finding and treating our clients hands-on manual therapy assessment
Nerve
Levator Scapulae (LevSc)
dysfunctional patterns. Most commonly, and treatment techniques. By first
TOS will result in compression of learning anatomy (structure), physiology
Subclavian Nerve Subclavius (Subcl) median, radial, or ulnar nerves. Assessing (function) can be figured out. By then
the presence of TOS can then be understanding function, altered function
Suprascapular Infraspinatus (Infra) correlated with motor dysfunction in the (pathophysiology) can be figured out.
Nerve Supraspinatus (Supra) innervation patterns of these nerves. Armed with an understanding of the
mechanics of pathophysiology, our hands-
Medial Pectoral Pectoralis Minor (PMin)
Nerve
The following motor innervation on assessment and treatment tools can
Pectoralis Major (PMaj)
generalizations can be made: then be determined. In essence, a deeper
Lateral Pectoral Pectoralis Minor (PMin) The musculocutaneous nerve innervates knowledge of anatomy allows for the critical
Nerve Pectoralis Major (PMaj) the muscles of the anterior arm. reasoning skills that then allow for creative
The median nerve innervates the application of our hands-on manual and
Upper Teres Major (TMaj)
Subscapular muscles of the anterior forearm movement therapy techniques.
Subscapularis (Subsc)
Nerve and the intrinsic muscles of the
Lower thenar eminence of the hand. Joseph E. Muscolino, DC, has been a manual
Subscapular Subscapularis (Subsc) The ulnar nerve innervates the intrinsic and movement therapy educator for more than
Nerve
muscles of the hypothenar eminence 30 years. He is the author of multiple textbooks,
Thoracodorsal
Latissimus Dorsi (Lat) and central compartment of the hand. includingThe Muscular System Manual: The
Nerve
And the radial nerve innervates the Skeletal Muscles of the Human Body(Elsevier,
Medial posterior muscles of the arm and forearm. 2017);The Muscle and Bone Palpation Manual with
Antebrachial Sensory only
Cutaneous Nerve Trigger Points, Referral Patterns, and Stretching
Authors note: slight exceptions to these (Elsevier, 2016); andKinesiology: The Skeletal
Medial Brachial
Sensory only
rules exist (see Image 2 for the detailed System and Muscle Function(Elsevier, 2017).
Cutaneous Nerve
muscle innervations), but they are a good He is also the author of 12 DVDs on manual
starting point to learning motor innervation and movement therapy and teaches continuing
patterns of the upper extremity. education workshops around the world, including a
certification in Clinical Orthopedic Manual Therapy
Importance of Sensory Innervation (COMT), and has created Digital COMT, a video
Knowledge of the sensory innervation streaming subscription service for manual and
patterns of the branches of the brachial movement therapists, with new content added
plexus is also extremely important. If a each and every week. Visitwww.learnmuscles.
client presents with any type of paresthesia comfor more information or reach him directly
(e.g., pain, tingling, numbness) in the upper atjoseph.e.muscolino@gmail.com.
extremity, the location of the paresthesia
can direct us toward which brachial plexus

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The Union
of Yoga &
Massage
By Cindy Williams
At Associated Bodywork & Massage
Professionals (ABMP), we talk a lot
about yoga. We recommend yoga
poses to keep your body moving and
pain-free as part of self-care, we
partner with national yoga studio
franchises to bring you yoga class
discounts, and we recognize that many
massage therapists practice yoga,
and even teach it. So do your clients.
The 2016 Yoga in America Study
conducted by Yoga Journal and the Yoga
Alliance illuminates the rise of yoga
awareness nationwide, and practitioners
understanding of the profound effects yoga
practices have on the body, mind, and spirit.1
70 massage & bodywork november/december 2017
Results from this study raise important
questions. Should there be a stronger union
between the worlds of yoga and massage
therapy? Would developing purposeful
partnerships support the well-being of our
clients in a more holistic fashion and deepen
the healing effects of our work? Would these
partnerships aid the success of massage
practices, as well as increase yoga class sizes
and individualized yoga sessions? Arent
we, after all, supporting the same people?
Lets ponder these questions by starting
with the facts.
WHO IS PRACTICING
YOGA AND WHY?
The 2016 Yoga in America Study
aimed to understand who is practicing
yoga, why they practice yoga, and how
people view yoga in general. Survey
participants were yoga practitioners,
nonpractitioners, instructors, and studio
owners, and findings were compared to
the previous survey conducted in 2012.
The study found that individuals who
practice yoga regularly (once or more
per week) increased from approximately
20 million in 2012 to nearly 37 million
in 2016. Thats an increase of almost 50
percent in just four years! Within this
growth are practitioners over the age
of 50, now making up about 38 percent
of all yogis and yoginis nationwide.
Why has yoga become so popular?
Reasons cited for committing to a regular
yoga practice include stress relief, flexibility,
injury recovery, pain management, and
overall fitness/wellness. Cyclists, runners,
weight lifters, climbers, and other athletes
rave about how yoga complements
their chosen sport and improves overall
performance, not only because of its
physical benefits, but because regular
practice increases mental clarity. Last,
but not least, yoga simply feels good.
Do any of these benefits sound familiar?
WHO IS RECEIVING
MASSAGE AND WHY?
In 2017, ABMP conducted its biennial
survey on consumer use and views
of massage therapy in the United
States. The study concluded that
approximately 55 million Americans
received at least one massage in 2016.
When asked about the primary
reasons for seeking out massage therapy,
respondents put relaxation, stress relief,
relief of sore and stiff muscles, injury
recovery, and pain relief at the top of
the list. Survey conclusions also support
that, similar to yoga, clients return
because it feels good and supports
their overall sense of well-being.
It seems clear that yoga instructors
and massage therapists have target
markets in common and the means to
meet the needs of a large and growing
population of people who care about their
health. I see a symbiotic relationship
that benefits clients, yoga practitioners,
yoga instructors, and massage therapists.
So where do we go from here?
INSIDE OUT, OUTSIDE IN
One of the beautiful aspects of the
relationship between yoga and massage
therapy is that, while the goals are often
the same, the approaches are quite
different. Partnering and referring to
each other could definitely offer depth to
our common clients healing journeys.
Generally speaking, the application of
massage involves a trained massage therapist
sensing, palpating, and manipulating
soft tissues that are restricted, ischemic,
and posturally compromised due to
physical, mental, and emotional demands
placed on the client. While there can
certainly be active aspects to the massage
session and within different modalities,
the most common approaches involve a
client passively receiving the work. We
attempt, within scope, to offer clients
exercises to utilize between sessions
to help our work stick and to involve
them in reaching their health goals.
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Yoga, in contrast, primarily involves a
trained yoga instructor verbally guiding
students on how to move their own bodies
in an effort to sense, feel, and manipulate
their soft tissues that are restricted,
ischemic, and posturally compromised due
to physical, mental, and emotional demands
placed on them. Being a yoga instructor,
I can attest to the number of practitioners
who come up after class wanting advice on
how to best address specific pains and tight,
sore muscles. Since yoga instructors can
recommend yoga postures and practices
that are specific to a students needs, they
are an excellent resource for us to offer to
our clients and, in turn, we are an excellent
resource for yoga instructors to refer for
hands-on assessment and treatment of those
specific pains and tight, sore muscles.2
This opens up a whole new world of
marketing and a spirit of cooperation with
yoga instructors. They are your people.
NEED FRESH MARKETING
IDEAS? THINK YOGA
There are myriad ways to work
together with yoga studios and
instructors to reach more potential
clients. Networking is the key.
Take Classes and Get Educated
Just as there are many modalities to choose
from in the world of massage and bodywork,
there are diverse approaches to yoga. Each
approach has unique benefits, and some
focus on special needs and populations.
Take a variety of classes at different studios.
Stay after class to talk with the instructors
about the styles they teach, and share with
them the work you do. If there is a class
that would benefit your client, such as a
prenatal yoga class or a class for seniors, the
instructor will likely be open to you auditing

My Experience
Using Yoga and
Massage to Heal
When I experienced a traumatic
injury in 2008, I was only a month
shy of completing my training to
become a restorative yoga instructor.
For five months postinjury, I couldnt
bear weight on either of my feet and
was unable to move my spine for
six weeks while in a back brace. I
was able to receive weekly, modified
massages during the time I was
mostly immobile, which provided
a sense of circulation and mobility.
72 massage & bodywork november/december 2017
Massages were soothing and spirit-
lifting! When my surgeon approved
the removal of the brace, restorative
yoga offered me an option to move
my body without bearing weight on
my feet and gently introduced healthy
movement back to my immobilized
spine. Being an active woman, I had
experienced grief after the injury. The
inspiring messages interwoven with
the gentle, restorative movement
helped to heal my body, mind, and
spirit, and I remain grateful to this
day that massage and gentle yoga
combined assisted me through
a very difficult experience.
the class so you have a better
understanding of the purpose and
approach. Offer to trade a massage
for a one-on-one yoga session so
they can experience your work.
Get Acquainted with
Studio Owners
Schedule informational interviews
with studio owners to learn more
about the styles of yoga they offer.
Often, yoga studios will have
community nights where they
provide a free class to thank their
regular students and market to
new prospects. In many cases, they
invite vendors, such as health-
food providers, jewelry artists,
musicians, and massage therapists.
Ive seen schools market their
massage and bodywork programs
at studio events like these. Building
relationships with local yoga
studios is a simple and effective way to
create community and build your network.
Add Massage Space in Yoga Studios
I have yet to practice in a yoga studio that
offers massage, but it would make a lot of
sense. I practice yoga at home before every
massage I receive so that my body is warm
and ready for the work, and the therapist can
more easily feel restrictions and patterns.
How wonderful would it be to go straight
from yoga class, to shower, to massage table?
This would require a studio with showers
and a space that is dedicated to massage,
but I have seen studios where it would be
possible. Its an idea worth investigating.
Get Involved in Community Events
The world of yoga is rich in community.
Its one of the many things this industry
does well. Spring and summer bring a
regular schedule of outdoor yoga classes
in nearly all parts of the country. Music
festivals geared toward a new-age-minded
population incorporate vendors similarly
mentioned above. Local kirtans do the same
any time of year. Community events are a
great way to connect with yoga practitioners
and instructors, and give them a firsthand
experience of your work (pun intended!).
Looking back at the 2016 Yoga in
America Study, we see that over half of
yoga practitioners who were surveyed
reported donating time to community
service activities. Consider partnering
with a yoga studio to sponsor and
donate time to a community service
activity that you organize. Partnerships
built on service run deep.
A contemporary approach to marketing,
called lifestyle marketing, suggests that
consumers prefer to align with businesses
that align with their values, activities,
opinions, and aspirations. Attending events
that draw health-conscious individuals and
involving yourself in community service
activities where you can meet prospective
clients with similar interests are invaluable.
START THE CONVERSATION
Its important when you start the
conversation that you have a foundation
to build on. Following is a small list
of common yoga styles taught in
mainstream yoga classes in America and
their specialized benefits. I recommend
trying them all! Talk to each instructor,
meet practitioners in the classes, and
experience the benefits for yourself.
Hatha Yoga
Although hatha yoga is a very broad term
that encompasses many styles, it is defined
as the active, physical practice of asana,
or postures, designed to awaken and
strengthen the body in connection with
the breath. Historically, it is designed to
prepare the practitioner for the meditative
aspect of yoga. Todays hatha yoga classes
are gentle, slower-paced classes that
are great for beginners and helpful for
correcting common postural habits.
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 73
Vinyasa Yoga
Vinyasa is a vigorous practice designed
to increase heart rate, muscle tone, and
range of motion. It is supportive for clients
who cant perform high-impact exercise,
but want to build heat, detoxify through
sweat, strengthen weak areas, and stretch
shortened areas. Its a perfect complement
to other forms of exercise, in addition to
offering a total-body workout on its own.
Yin Yoga and Restorative Yoga
Both yin and restorative yoga styles are
very slow-paced and include postures that
are held for long periods of time. There
are, however, differences between them.
Yin focuses on taking the student
to the edge of their range of motion
in a gentle, supported fashion, and
then allowing the connective tissue to
unwind and release. People with chronic
tension in the hips, psoas, neck, and
lower, middle, and upper back benefit
significantly from this approach.
Restorative yoga poses are completely
surrendering and restful. Participants
are supported with bolsters and guided
through body-centered meditations to
calm the nervous system and consciously
unlock tension patterns, such as releasing
a clenched jaw, opening pectoral muscles
that hold shoulders forward, and dropping
those shoulders that unconsciously
creep up when stress creeps in.
Both are great options for clients who
suffer from high stress and anxiety or
chronic pain, or are recovering from an
injury that limits them from an active yoga
practice.
Prenatal Yoga
Prenatal yoga is essentially hatha yoga with
modifications. It is gentle and aims to assist
with the physical changes that occur with
pregnancy. Research has shown that prenatal
yoga improves sleep and reduces anxiety, as
well as increases strength, flexibility, and
endurance of muscles needed for childbirth.
Senior Yoga
Senior yoga is also a modified form of hatha
yoga. Modifications include holding poses
for short periods of time, making very slow
transitions, and using props like blocks,
straps, or chairs for support. Poses that
place body weight on weaker joints, such
as wrists, are avoided. The idea behind
senior yoga is to keep individuals active
when they might otherwise be sedentary.
Studies have shown that senior yoga
reduces the effects of diabetes, arthritis,
hypertension, and chronic pain. It also
elevates mood and improves sleep.
COMING FULL CIRCLE
Should there be a stronger union between
the worlds of yoga and massage therapy?
Would developing purposeful partnerships
support the well-being of our clients in
a more holistic fashion and deepen the
healing effects of our work? Would these
partnerships aid the success of massage
practices, as well as increase yoga class sizes
and individualized yoga sessions? Arent
we, after all, supporting the same people?
I say yes.
Notes
1. Yoga Alliance, 2016 Yoga in America Study, January
13, 2016, accessed September 2017,
www.yogaalliance.org/2016yogainamericastudy.
2. This is a broad characterization of massage and yoga
in general. There are certainly active aspects to some
styles of massage therapy, and passive aspects to
some styles of yoga. We have focused on the broader
definitions of these terms for the purposes of this article.
Since 2000, Cindy Williams, LMT, has been
actively involved in the massage profession as
a practitioner, school administrator, instructor,
curriculum developer, and mentor. She maintains a
private practice as a massage and yoga instructor.
Contact her at cynthialynn@massagetherapy.com.
Dolores
Krieger

74 massage & bodywork november/december 2017

 By Karrie Osborn

Lessons of Compassion
An Interview with the Developer of Therapeutic Touch

Her mornings begin with a wander through the pristine

Montana forest that surrounds her mountain home. There,
she breathes in the language and lessons of nature. The quiet
gives you some idea of what peace must be likeits such a
wonderful background to think and reflect and write. This is
the retirement backdrop for Dolores (Dee) Krieger, PhD, RN,
cofounder of Therapeutic Touch and matriarch of a community
of touch practitioners who span the globe.
Witty and thoughtful, fiery and bold, at 96, Krieger shows no signs of slowing down.
In fact, retirement has given her new clarity. What I like is that while, yes, there are some
little things like senior moments, your mind starts to acquire other abilities and a different
perspective on life. Obviously, youre seeing life differently, but it also helps you to open
yourself more to other kinds of relationships. And its that relationship with nature that helps
fuel her each day.
If you were to go out my front door, you have 34 million acres of national forest. On my
land, there are grizzliesthey are so interestingmountain lions, lynx, fox; its fascinating,
the life that continues to persist, she says of the forest that envelops her.
Every morning, I take my wheelie and go into the backwoods. (Kriegers wheelie is an
all-terrain walker that helps her nearly 100-year-old frame maneuver through the forest
brush.) I do a 20- to 30-minute stint and get my heart going. After my wheelie, I stay out
and get some sun. Thats where I sit and get my peace. Its so refreshing, and I have plenty of
Photo by Bob Paulus.

company with the animals, she laughs.

Then its time to sit in her sun-drenched study and write, and think, and write and
figure out how to fit it all into her day.

Compassion is a power
with its own sphere of
influence; a realm engaged
by fine energy patterns that
play out as behaviors, such
as aspiration, empathy,
and the fulfillment of a
need to heal Compassion
is a highly humanand
humanefunction.
Dolores Krieger, keynote address,
Therapeutic Touch International
Associations Fourth International
Congress, April 2017
For more information, go to
www.therapeutictouch.org.
76 massage & bodywork november/december 2017
A Path of Compassion
Since her early teens, Krieger has been
interested in healing. I think probably
it was very much how your readers come
to know their own ability in massage and
bodywork. As a child, and as an adolescent
in particular, when someone had a problem,
my hands would automatically go to the
place they hurt. Probably the first person
I worked on was my mother, who had
problems with her knees. My initial urge
to help people came from my hands.
And those hands have continued to paint
the broad brush of her work ever since.
Compassion, which is fundamental
to the Therapeutic Touch modality she
created, was most likely learned as a
child. I was very sick as a kid and almost
died a couple of times. Underweight,
bedridden, and often without family by
her side, she learned about caring and
compassion from those who attended to
her during her frequent hospital stays.
And it was there that she also found her
motivation to be well. From the hospital
window I could see the school kids running
around outside; I was determined to run
around, too. My motivation was to be like
them. And she met her goal. I turned out
to be a pretty good track star, especially in
long distance; nobody could ever catch me.
In the Meantime, There
Were My Hands
Krieger once told People magazine,
Touching permeates almost every
phase of nursing. I believe in my
hands before anything else.
Knowing that she wanted to be
involved in helping and healing people,
Krieger says her original career choice
was physical therapy. But, without
the money to go to college, Temple
Universitys offer of two years college
credit for those who enrolled in the nursing
program was how Krieger planned her
segue into a physical therapy path.
However, I wasnt into nursing more
than six weeks before I realized it was
what I really wanted to do. Her new
path led her to earn her masters degree
and doctorate in nursing and eventually
to teach at New York University (NYU)
School of Nursing, where she was a
professor until her retirement in 1997.
It was during this journey that Krieger
would cross paths with the woman who
would ultimately change her life.
Dee and DoraThe Nurse
and the Clairvoyant
Krieger speaks lovingly of her Therapeutic
Touch partner, Dora Kunz, who passed in
1999.
I dont know anybody who wasnt her
friend. She was absolutely fascinating. A
world traveler, a friend to Nobel Peace Prize
and Pulitzer Prize winners, and a person
unique unto herself, Kunz became the
teacher, and Krieger became the student.
Krieger describes her partner as a
world-class clairvoyant, the fifth generation
in her family to have the ability, and a
woman of tremendous compassion. She met
her mentor at a meditation lecture Kunz was
holding. Intrigued by the presenter and the
material, Krieger pondered how she could
determine whether what Kunz was saying
was legitimate. The best way to know
was to apply what shes suggesting to my
life, and then know how my life changes.
It was probably the best way I could learn
at that time. So, I became her student.
Over time, part of her role as student
was to drive Kunz to the various medical
conferences and lectures Kunz attended,
largely because no one else would (I was
the only one willing to drive her, because
she would see things on the road no one else
could, Krieger says, making the experience
harrowing, to say the least). Krieger says it
was at one of these conferences, where Kunz
was brought in to explain subtle energy,
Dolores Krieger (left) and Dora Kunz, co-developers of
Therapeutic Touch, in their earlier years.
 What is Therapeutic Touch?
According to the Therapeutic Touch International Association,
this therapy incorporates the intentional and compassionate
use of universal energy to promote balance and well-being. It
is a consciously directed process of energy exchange during
which the practitioner uses the hands as a focus to facilitate the
process. The University of Maryland Medical Center describes
it as a technique based on the theory that the body, mind, and
emotions form a complex energy field. A balanced energy field
is indicated by good health, while illness represents imbalance.
Developed by Dolores (Dee) Krieger, PhD, RN, and Dora
Kunz, a natural healer, the modality was first taught to graduate
nursing school students, but then expanded across the country,
largely through the grassroots efforts of professional nurses.
A Therapeutic Touch treatment is individualized for each
clothed client/patient, and is typically less than 30 minutes.
Dora Kunz, shown here with a Therapeutic Touch student,
was described as a woman of tremendous compassion.

that the two women watched the work of
lay healer Oskar Estebani. At the time,
healers of this type were thought to possess
a God-given gift. She says most of it had a
religious tonality to it and it was felt only
people of certain faiths, or certain sects,
could heal. Kunz and Krieger had already
found influence from Christian healer
Kathryn Kuhlman, and became fascinated
witnessing the slant of Estebanis work.
The two women eventually invited
him to gatherings at the Pumpkin Hollow
Retreat in New York to learn more about
his healing processes. It was from there
that the nonsecular Therapeutic Touch was
born. One time after a session was over,
and we saw Mr. Estebani off, Dora and I
were sitting on the lawn, having a few quiet
minutes in the shade, talking about what had
gone on. Dora told me, I think I understand
how he is able to heal. And I said, Dora,
do you think you understand it enough to
be able to teach it? She thought about it
for a moment and said, Yes, I think I do.
It was the late 1960s, an era of
enlightenment, where people began to
think about health care differently, and
Therapeutic Touch quickly filled a niche
in the medical community. With my
medical connections, I initially got about
50 doctors and nurses together who wanted
to learn to heal, Krieger says. That was a
catalyst. With her knowledge of curriculum
development, and Kunzs ability to connect
with people, Krieger says the two were able
to quickly bring the modality to the nursing
community. Initially called Frontiers in
Nursing, Krieger was able to get the work
accredited at the graduate level at NYU.
Acceptance grew, nurses were taking
the work they learned into the patients
hospital rooms, and the dean of the
college was pleased with the demand.
We were accepted by the medical
community, Krieger says. It all began
to mesh together. We were the only ones
at the time to have the support of both
the medical community and academe.
By the early 1970s, Kunz was ready
to follow her next passion, and moved
out of state to lead the Theosophical
Society. Krieger was left to shepherd the
healing paradigm they had constructed
together. I thought, theres too much
good happening out of this to not keep
it going. It was then that the work took
its new nameTherapeutic Touch. an interview with her, and then put her
Kunz remained active with the
association when she could, and would
attend the Therapeutic Touch conferences
each year. She was still very much
part of it and we remained good friends
until her death, Krieger says.
Today, Therapeutic Touch has been
taught at more than 70 medical centers
and health agencies in the United States,
and to people in health professions
in 107 countries. More than 250,000
health professionals have been trained
in Therapeutic Touch worldwide.
Historical Importance
If you dont know the history of Therapeutic
Touch, then you dont know that Krieger
and Kunz were key players in opening the
door of complementary and alternative
health practices to the traditional medical
community. For a nursing community
hungry to reclaim its roots of personalized
patient care, Therapeutic Touch was a
breath of fresh air. But its developers had
to defend their work all along the way.
One of the first challenges came
in the mid-70s when Krieger says the
National Enquirer used deception to gain
on its cover in a sensational story. It was
heartbreaking, she recalls. They were
trying to discredit the therapy, but some
good came out of it. Because I was the
only one at that time who had both the
medical community and academia as
my sponsor, other people on the leading
edge of this whole New Age push got in
touch with me. And Therapeutic Touch

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 The 5 Phases of
Therapeutic Touch
1. Centering. This phase involves bringing
the body, mind, and emotions to a
quiet, focused state of consciousness,
and opening yourself to find an inner
sense of equilibrium to connect with the
inner core of wholeness and stillness.
2. A ssessing. By holding your hands 26
inches away from the clients body while
moving them from the head to the feet in a
rhythmical, symmetrical manner, youll pick
up sensory cues such as warmth, coolness,
static, blockage, pulling, and tingling.
3. I ntervention. Called clearing or unruffling,
this process facilitates the symmetrical flow
of energy through the field. This is achieved
by using hand movements from the midline,
while continuing to move in a rhythmical
and symmetrical manner from head to toe.
4. B
 alance, Rebalance. Here you project,
direct, and modulate energy and assist to
reestablish order in the system. Treatment
is accomplished by moving the hands to
the areas that seem to need attention;
energy may be transferred where there is
a deficit, or energy may be mobilized or
repatterned from areas of congestion.
5. E
 valuation, Closure. When youre no longer
getting that sense of imbalance or change of
patterns, the treatment is finished. Reassessing
the field continuously during the treatment
to determine balance and elicit feedback
from the individual are cues as to when to
end the Therapeutic Touch treatment.

78 massage & bodywork november/december 2017

took off. Soon, Krieger began teaching the work
across the country, then around the world.
In 1998, Therapeutic Touch again was challenged,
this time by the famous case of Emily Rosa, the 9-year-
old girl whose 4th grade science project on Therapeutic
Touch made it into the Journal of the American Medical
Association.
How does Krieger address the naysayers and the
people she says treat her with suspicion and distaste?
The first thing you do is develop a sense of humor,
she says. That is a requirement. But she also tries to
dialog with people, in their terms. What youll find,
she says, is that there is a tremendous amount you can
Dolores Krieger demonstrates the therapy she helped create. Photo by Bob Paulus.
align with. I have worked on a lot of people who are
skeptics, and I have never turned anyone away, ever.
While not everyone welcomed Krieger with open
arms, she says the early acceptance from her colleagues
was something she hadnt expected. Surprise hardly power; it is what continues, its our soul. This is
encompasses what my feelings were at the time, where it pushes you. And its in this way, by working
Krieger says. First of all, particularly with the National through your heart chakra, she says, that youre
Enquirer interest, my own career was at stake, but I able to bring through you the prana, the energy.
was determined. What we were doing, Dora and I, I The process, she says, is transpersonal healing.
learned how helpful it was. We werent causing any
miracles, but we had many instances of people walking
out of a hospital who werent expected to, and other A Future to Unfold
instances of people dying peacefully who were originally As a consultant for the Therapeutic Touch International
very unhappy and ready to die a miserable death. Association today, Krieger continues to forward-think
about the work she helped create. Her most recent
musings, and subject of her next book, revolve around
Compassion and Energy Medicine what happens within the healer during the healing act.
Integral to Therapeutic Touch, and certainly integral If you look back, healing has a history that
to her own journey, Krieger says compassion is an predates civilization. In all that time, healing has been
important part of our humanity. There is a neurological inarticulate. There is very little in the literature about
effect on the person who is enacting compassion. That what goes on in the healer. Understanding that the
surge of emotion coming from compassion, thats act of Therapeutic Touch extends beyond the outside
the lodestar the healer follows. Without compassion, experience is important, she says. That interior
you dont have Therapeutic Touch; you have merely experience is forcing peoples consciousness toward
a manipulation, so to speak, a power play. Krieger transformation in a way that is at the frontier of where
says just as massage and bodywork require grounded were goingin a good wayas human beings.
therapists who need to approach their work mindfully, The future, Krieger says, is one filled with
the same is true for Therapeutic Touch practitioners. opportunities to utilize Therapeutic Touch and she
Sustained centering is where you stay throughout feels confident her work will continue to find its value
the entire session. You try to be mindful and aware of and legacy long after shes gone. Its at the extreme
the shifts in consciousness. The 5 Phases of Therapeutic opposite end to high tech; as such, Therapeutic Touch
Touch are really just shifts in consciousness, she says. will have a great deal to offer even if it only helps
With time and training, awareness and intuition people remember to be compassionate.
sharpen for the Therapeutic Touch practitioner. You
begin to realize youre in a very different state. And Karrie Osborn is an award-winning author and senior
its not only that youre in an altered state, but youre editor for Massage & Bodywork and ABMP. Contact her
being urged on by the psychic force of compassion. at karrie@abmp.com.
We call it the inner self, some might call it higher

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 How On-Demand Massage Firms
can work for you By Brandon Twyford

80 massage & bodywork november/december 2017

P
Part of the appeal of a career in massage
therapy is the flexibility of being able to choose
your own schedule and determine your own
availability. The catch is that you are then
responsible for finding and retaining your own
clients. For consumers, part of the hurdle
in receiving a massage for the first time is
finding a quality, vetted therapist they can trust
and whose availability matches their own.
Enter the rise of on-demand massage. Billed as Uber for
massage, on-demand massage companies match qualified
therapists with consumers seeking a great massage. Through an
app, a website, or a phone call, consumers can find exactly the
service they want, when they want it, and receive the work in the
comfort of their own home. We talked to three on-demand massage
companiesRubzy, Soothe, and Zeelto learn more about what
a massage therapist might expect from working with them.
Like other partnerships an independent massage therapist might
enter, theres likely to be a trade-off between gaining access to
potential new clients and paying a fee for gaining that access. Other
than that, its difficult to think of a major drawback to working
with an on-demand massage company. MTs gain access to a much
wider client pool than they could ever find on their own and can fill
holes in their schedule with vetted and qualified clients. They pay
a fee to the company for the increased business, but its business
they wouldnt have found otherwise. Most MTs are happy with the
trade-off, as evidenced by the rapid growth in popularity of these
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services. Soothes Director of Marketplace Operations Jeff Bishop
says, Therapists can create their own availability for the times and
days that work for them, and they earn 23 times more than they
would working at a traditional day spa or even a private practice
because of the accessibility to new (and returning) clientele.
Lets take a closer look at what sort of therapist might benefit
from working with an on-demand massage company and what to
expect from the partnership.
PRELIMINARY CONSIDERATIONS
What sort of massage therapist would most benefit from working
with an on-demand massage company? Newer therapists who are
still working on building their client list will find the increased
pool of available clients highly valuable. Mobile massage therapists
who already have the equipment needed for in-home or in-office
massages can easily make the switch to working with an on-demand
massage company. However, if they already have a robust client
list, theyll need to consider whether the increased number of
sessions are worth the cost of commission. Soothes Bishop says
it also helps to know the area in which you live or work, so youre
comfortable getting to appointments, and so youll better know
how to gauge your last-minute availability for pop-up sessions.
Eva Carey, national community director for Zeel, says,
Zeel is the perfect solution for a massage therapist looking for
extra appointments and also for a massage therapist interested
in designing their own schedule. Because of the volume and
diversity of available appointments, therapists are better able
to balance their work and lives using the Zeel platform.
Speaking about Rubzys status as a brand-new company
still building its therapist and client list, owner Chris Raschko
says, Since Rubzy is such a new and unique revolution in the
massage industry, the ideal therapist is absolutely anyone with
Offering services through Rubzy, Soothe,
or Zeel can end up being the best of
both worlds for a massage therapist.
a massage license. However, we have
a top-notch review system, and the
therapists who perform the best (on-
time, courteous, professional, etc.)
will remain the most in demand.
OTHER CONSIDERATIONS
One thing to keep in mind is the time and
cost associated with the travel to and from
appointments. When you consider how
much youll make for a session with Zeel or
Soothe, you should factor in your commute
time and associated costs. If you are offered
to perform a one-hour session on the other
side of town and must drive an hour or
more roundtrip, remember youre only
getting paid for the one hour of service.
82 massage & bodywork november/december 2017
Rubzy, however, allows you to set a flat rate
you charge for travel and the maximum
distance you are willing to travel. (Note:
you may be able to deduct your mileage on
your taxes, so check with your accountant.)
Therapists should also be aware of
the physical labor involved in carrying
a table and supplies up and down
stairs, in and out of their cars, etc., and
consider whether theyre up for it. Raschko says that with Rubzy, both
GETTING STARTED
Therapists working with Rubzy, Soothe, or
Zeel must be licensed and insured massage
therapists with reliable transportation and
their own suppliestable, chair, linens,
oils/lotions, etc. Of course, each company
also expects their therapists to be punctual,
exhibit solid time management skills, and
be able to deliver high-quality service.
Zeel offers consumers a massage
membership program that includes a
professional massage table and linens
that the consumer gets to keep at home.
When a Zeel therapist massages a
consumer who is part of the membership
program, the therapist does not have to
worry about providing these items.
clients and therapists are in charge of
the process. Customers can finally
choose the exact therapist they want by
viewing massage therapists profiles,
and massage therapists can confirm
or deny any customer, Raschko says.
Even if you currently have your own
practice or work somewhere else, you
can easily earn extra income by selecting
the hours youre available, he adds.
Rubzy does all the marketing for
youwe attract the customers to our
network, and they book with you.
There are no start-up fees associated
with joining any of these three on-demand
massage platforms. In addition, since
therapists working for Rubzy, Soothe, or
Zeel are independent contractors, there
are no restrictions on how many on-
demand platforms therapists can work
fortherapists are free to work with
whomever they want, whenever they want.
SAFETY FIRST
A concern for many mobile MTs, not just
those working with on-demand massage
companies, is safety. When you get a call
from a client who found your information
on Yelp or Google, it can be difficult to
fully ascertain the quality of the client,
even with a thorough interview or intake
process. Soothe offers a check-in, check-out
process, and a GPS location monitoring
system to ensure therapists always feel in
touch and protected. Theres even a 24-
hour US-based concierge team to support
therapists with appointment-related issues
parking, client not answering the door, etc.
Zeel also has safety processes in place.
Our process is designed to safeguard
the massage therapist, Carey says.
Any customer booking on the Zeel
platform is required to verify their ID
and mobile phone number through our
security partners before they can book
a first massage. Our safeguard process
for massage therapists is best-in-class.
Rubzy is a bit different in that its
business model aims to cut out the middle
man, and as such, third-party monitoring
isnt offered; but thats a trade-off many
MTs will accept, since it means they get
to keep more of their massage feeup to
95 percent of it, according to Raschko.
That said, Rubzy does implement a two-
way review system where therapists can
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rate the quality of clients, which Raschko
says will quickly and effectively build a
community of trust. Thats already a step
up in safety from getting a random phone
call from a stranger who found your number
online. Rubzy also allows you to specify
whether you only accept appointments at
your place of business, or whether youre
willing to travel to a customers location.
THE FUTURE
Rubzy is the new kid on the block, but
Raschko says theyve had no problem
finding therapists who want to partner
with them. In just three weeks of
operation, we have had a lot of massage
therapists signing up, he says.
Bishop says Soothe is currently
in over 55 markets around the United
States, Canada, the United Kingdom,
and Australia, and grew five-fold in
2017. In 2018, Soothe plans to expand
into many resort markets throughout
the United States, while continuing
its international expansion.
Zeel likewise plans to continue growing
and expanding. Carey says, Zeels mission
is to Power Massage Everywhere, and
were going to continue doing so with our
rapid expansion and new lines of business.
In many ways, it appears that offering
services through Rubzy, Soothe, or
Zeel can end up being the best of both
worlds for a massage therapist. For
many, the arrangement ends up a sort
of hybrid between being completely
independent versus working as a
structured employee. With no additional
financial commitment required beyond
standard massage equipment, insurance
costs, and licensing fees, and the ability
to accept or decline any session, the
partnership seems worthy of consideration
for most massage therapists.
Brandon Twyford is associate editor and award-
winning writer for Massage & Bodywork and ABMP.
Contact him at brandon@abmp.com.
technique SCIENCE OF NERVES

Signs of Change
Understanding Clients Pain
By Whitney Lowe

This is an exciting time to be in the massage

profession, thanks to research that is shedding

new light on various facets of our work. In this

column, Ill explore a fascinating shift in our understanding

of our clients pain complaints. Pain is the most common

reason people seek the care of a massage therapist,

and the more we understand pain, the better we can

participate in a comprehensive solution to address it.

Many in the health-care professions today were taught a

relatively simple, and decidedly mechanistic, physiological
explanation for how pain is perceived and transmitted in
the body. This model actually goes back to the time of the
philosopher Rene Descartes in the 17th century. Descartess
philosophy has carried through to form the philosophical
foundation of our perspective of the body. When you hear the
term Cartesian in relation to mathematical or scientific ideas,
that means to some extent it follows Descartess influence.
Our understanding of pain transmission has, of course,
evolved since the time of Descartes, but there is a great
deal of similarity between his original ideas and those of

1 This image from Descartes shows the pathways for pain signals.
our recent training. Yet, much of the body as a machine
philosophy (i.e., the mechanistic view of the body) continues.
Descartes suggested that when there is a noxious stimulus,
like getting too close to a fire, a pain stimulus traveled from
the contact point along a pathway of pain fibers to the brain
(Image 1). Based on this idea, the predominant methods
of pain management involved trying to block pain fibers
before they got to the brain. This idea has continued to
influence modern pain management to a significant degree.

84 massage & bodywork november/december 2017

 It is helpful to think about pain as an
More recent neuroscience has modified
alarm that is generated by our body,
these ideas, but many are still taught
that the body has pain receptors that,
just like the alarm system that may
once stimulated, send a pain signal to the
brain. However, there arent any actual
be protecting a home.
pain receptors, so to speak. But, before
we get into the finer details of how pain
interpretation actually works, lets explore a
simple example to see why that idea doesnt
pan out.

HOW THE BRAIN PRIORITIZES PAIN
If you were crossing the street in a quiet
neighborhood with no traffic and suddenly
sprained your ankle while in the middle of
the road, theres a good chance you would
feel pain right away and then calmly limp
to the side of the road. If, however, you
were crossing a very busy street when you
sprained your ankle and also noticed a large
bus bearing down on you, your reaction
would be quite different. Most likely you
would sprint to safety on the side of the road
first. Only then would you begin to feel pain
in your ankle. If there were pain receptors
in your ankle, they would send pain signals
to the brain immediately in either instance.
In the second scenario, the ankle pain may
have kept you from focusing on the more
important survival task of the moment
getting out of the way of the oncoming bus!
We now recognize that pain is far
more complex than previously thought.
Pain signals do involve sensory receptors
connected to nerve fibers that go to the
brain. The sensory receptors responsible
for sending information about a noxious
stimulus, like when you sprain your ankle,
are called nociceptors. They are sensitive to
chemical, mechanical, and thermal stimuli.
But pain isnt felt until the brain receives
those signals and interprets the input as
pain. This activity happens instantaneously,
and it isnt under conscious control.
It is helpful to think about pain as an
alarm that is generated by our body, just like
the alarm system that may be protecting a
home. Multiple sensors around the house
detect motion or sound and the system
determines which ones are minor (like a
leaf falling in front of the door) and which
ones are important (someone breaking
into the house). The alarm signal doesnt
go off with every sensor change, only with
the ones that are indicative of a potential
threat. Just like that alarm system for your
house, the nociceptors send many signals to
the brain, but the alarm (pain) isnt set off
until that information is processed and it is
determined that a significant threat exists.
Therefore, we now talk about pain
being an output of the brain and not a
pain signal that is coming from the
periphery and traveling to the brain. It is
very much like the other senses we have.
For our hearing, sound waves are captured
by the eardrum, but it is not conceived of
as a recognizable sound until the brain
organizes the information received from
the sensory receptors in our ear. The
idea that pain is an output of the brain
should not be confused with dismissive
statements that are often given to patients
whose pain is still a mystery to their
health-care provider. In some cases, when
a health-care professional has not been
able to identify a clear biological cause
of pain, the patient or client may be told
the pain is psychosomatic or all in their
head. That is not what is being implied
by stating pain is an output of the brain.
Pain can come from many factors, and
pain without obvious tissue damage is just
as real as pain felt by the person who has
an observable injury. It is common to find
people who have very little or no apparent
tissue damage, but a great deal of pain.
Conversely, it is also easy to find people
who have significant tissue damage, but
no pain (or pain that comes on much later
than the initial tissue insult). Examples
include highly competitive athletes or
soldiers who were severely injured but did
not feel pain because there was something
more important that their brain was
focused on (winning the competition in
the athletic example or staying alive on the
battlefield). Both of these situations produce
a clinical conundrum that is difficult
to explain with the former Cartesian

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model of pain receptors sending pain
signals from the periphery to the brain.
So how do pain signals actually work?
NERVES AND PAIN
To fully grasp how pain sensations are
produced, it is helpful to review some basic
principles of neuroanatomy. Not all massage
therapists are taught these details about
the nervous system in their basic training,
so this is a great opportunity to polish
your understanding of these concepts.
Nerve fibers are classified according
to their diameter. There are four primary
types of nerves that play a major role in
our experience of pain. They are named
with letters from our alphabet as well as the
Greek alphabet. These four primary types of
nerve fibers and their key characteristics are:
Fiber Type
Myelinated Primary Responsibility
Name
Proprioception: muscle
A (alpha) Yes spindle and golgi tendon
organ
A (beta) Yes Mechanoreception
Thinly
Free nerve endings and
A (delta) nociceptors for touch and
myelinated
pressure, cold receptors
Non- Nociceptors and warmth
C the notion of pain receptors in the periphery
myelinated receptors
When a nerve fiber is myelinated, that
means it is covered by a myelin sheath
(Image 2). The myelin sheath helps the
nerve impulse travel along the length
of the nerve at a much faster rate. The
rate of signal transmission plays a crucial
role in pain perception and also how that
sensation can be magnified or diminished.
Nerves that carry nociceptive signals
are primarily the A and C fibers, although
there is some indication that nociceptive
input can travel along the A fibers in some
cases. Often when you have an acute injury,
you feel a sudden, sharp, and strong pain
first that is followed by a more persistent,
86 massage & bodywork november/december 2017
Myelin
sheath
2
Myelin sheath surrounding a nerve fiber. Image courtesy Wikipedia.
dull, aching pain afterward. The strong and
sharp pain is mostly from A fiber signals,
which arrive at the brain before the slower,
non-myelinated nociceptive signals from
the C fibers. The C fibers are responsible
for the latent dull, aching pain that comes
on after the immediate pain from an injury.
There is also an indication that C fiber
nociceptive signals are mainly responsible
for many of the chronic-pain complaints
that persist for long periods of time.1
In 1965, two researchers, Ronald
Melzack and Patrick Wall, published a paper
outlining a new theory of pain modulation
that emphasized an expanded role for the
central nervous system and de-emphasized
and the idea they were sending pain
signals to the brain. This theory has come
to be known as the gate control theory of pain.
While it has been modified from its original
presentation, there is still strong evidence
to support the idea that signal transmission
and the experience of pain can be modified
in the way they originally described it. Lets
take a look at how that works.
THE GATE THEORY OF PAIN
Nociceptive signals are sent from specialized
sensory receptors in the periphery of the
body. Once those sensory receptors are
activated, they send a message primarily
along the A and C fibers. But the body is
also getting sensory information from other
receptors simultaneously. Proprioceptive
signals about the bodys position in space
and signals about joint position from
mechanoreceptors are traveling on the
much faster A and A nerve fibers. They
get to processing stations in the spinal
cord and central nervous system faster
than the nociceptive signals traveling
on the A and C fibers (Image 3).
The gate theory suggests there is a
neurological gate (not truly a mechanical
gate, but a metaphorical one) in the spinal
cord that closes down to limit the amount
of information being sent to the brain for
processing. When the proprioceptive signals
arrive at the gate first, the gate shuts down
to the slower-traveling nociceptive signals.
With fewer nociceptive signals getting
through, there is decreased pain sensation.
The benefit of mechanoreceptors and
proprioceptors outpacing the nociceptive
signals means that the most important
stimulus is perceived by the brain first,
as in the example of the person with the
sprained ankle sprinting to the sidewalk to
avoid a bus. This mechanism also explains

Proprioceptive
signal from
periphery
Nociceptive
signal
from periphery
3 Schematic representation of the gate control theory. Mediclip image copyright (1998)
Williams & Wilkins. All rights reserved.
why rubbing a painful body area reduces
the pain experienced in that moment.
Massage therapists should take note
that some of the positive effects of massage
related to pain management may very well
be attributed to mechanisms described by
the gate theory. We have yet to research
this fully, but certain techniques like
active engagement methods, where there is
simultaneous massage along with concentric
or eccentric muscle engagement, may be
capitalizing on the pain-gating process. It
is likely that proprioceptive information
coming from the massage technique,
along with the joint movement and muscle
contraction, closes the gate on nociceptive
signals and thereby decreases pain.
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 87
Nociceptive signal is
inhibited when it reaches
the central nervous system
because proprioceptive
signal arrived first.
NEW DEVELOPMENTS IN OUR
UNDERSTANDING OF PAIN
Our current understanding of pain-signal
transmission also sheds some interesting
light on pain experiences our clients present
to us. When nociceptive signals reach the
central nervous system, they travel through
the spinal cord and then ascend through
the lower, mid, and upper portions of the
brain until they are fully processed. As they
travel through these different sections,
the intensity of the signals can be altered.
Various factors can cause pain signals
to be amplified; this is called ascending
facilitation. Think of it as turning up the
volume on the nociceptive signals that are
arriving. Ascending facilitation can create
two characteristic clinical experiences:
hyperalgesia and allodynia. Hyperalgesia
is when something is much more painful
than it ordinarily should be. Allodynia is
when something is painful that shouldnt
be (like when a client reports that gently
stroking the skin is painful). Obviously, our
SCIENCE OF NERVES
goals of pain treatment are to decrease any
ascending facilitation that may be occurring.
There is a corresponding process that
turns down the volume on nociceptive
signals and is very helpful for decreasing
the clients pain experience. When various
pleasurable sensations (like massage) are
experienced, the upper portions of the brain
can send signals to the lower sections and
block a certain amount of nociceptive input,
decreasing the persons sensations of pain.
This process is called descending inhibition
(or descending modulation). There is some
research that now suggests this may be one
of the most important benefits of massage
when it comes to pain management.2
There are fascinating new developments
in our understanding of how pain is
experienced and the various strategies we
can use to help manage our clients pain.
The more we understand about the pain
process, the better we will be at adapting
our massage treatment to take the best
advantage of how pain transmission occurs
in the body. In upcoming installments,
we will further explore some of these
important concepts about how to use this
new research to best help our clients.
Notes
1. D. Butler and G. L. Moseley, Explain Pain Supercharged
(Adelaide, Australia: Noigroup Publications, 2017).
2. A. D. Vigotsky and R. P. Bruhns, The Role of
Descending Modulation in Manual Therapy
and Its Analgesic Implications: A Narrative
Review, Pain Research and Treatment
(2015), doi:10.1155/2015/292805.
Whitney Lowe is the developer and instructor
of one of the professions most popular orthopedic
massage training programs. His texts and
programs have been used by professionals
and schools for almost 30 years. Learn more
at www.academyofclinicalmassage.com.
technique MYOSKELETAL ALIGNMENT TECHNIQUES

Crick in the Neck 2

From Pathology to Pain Compressed disc

By Erik Dalton, PhD

Bulging disc

A crick in the neck is a common complaint among Herniated disc

clients seeking manual therapy. This informal umbrella

term can refer to symptoms that range from general cervical

stiffness to complete immobility and unrelenting pain. Disc degeneration

When assessing cricks, therapists trained in myoskeletal
alignment techniques (MAT) engage the clients nervous
system through active and passive movements, observing
for range-of-motion limitations and local or referred pain
patterns (Image 1). Some clients might report general neck
stiffness, whereas others may experience radiating pain
that limits their ability to rotate the head in one or more
directions. A thorough history intake usually reveals helpful
clues to possible neck crick etiology, but not always.
and bone spurring
Degenerative joint disease may or may not cause pain.
During the intake process, you may learn that many chronic
pain clients carry a diagnosis of osteoarthritis and degenerative
disc disease, and are convinced these abnormalities are responsible
for their pain (Image 2). Although these medical terms do sound
scary, they are, in fact, part of the normal aging progression of
the human spine and, depending on how the brain perceives
the threat, may or may not be actual pain generators.
Its not unusual for clients diagnosed with a degenerating
spine to tie the pathology to the pain, but this kind of mental
connection often causes much unneeded worry and stress.
When working with these clients, it is best not to dramatize,
catastrophize, or blame their pain on the pathology. The therapist
must try to avoid words or graphic images that may trigger
fear and possibly induce the nocebo effect. The opposite of the
placebo effect, the nocebo effect occurs when negative beliefs
and expectations influence a situation in a negative way.
This is not to say therapists should avoid the study of orthopedic
terminology. In my opinion, the more the therapist knows, the
safer the client and the practitioner. Without an understanding

1
of terminology, its difficult to visualize how neck cricks due
to a degenerating spine can progress from protective muscle
spasm to painand even more difficult to learn to derail the
crick in its early stages. So, from one professional to another,
The therapists
left thumb and lets discuss a common example of how a simple neck crick might
fingers palpate progress from a spasm, to degeneration, to full-blown pain.
each cervical
vertebra while the
right hand flexes,
STAGE 1: MECHANICAL COMPRESSION
extends, rotates,
and sidebends the The client begins noticing neck stiffness and loss of range of motion,
clients head and but no pain. As joint, ligament, and deep spinal groove muscles
neck, examining for lose their ability to perform normal smooth gliding movements,
motion restrictions.

88 massage & bodywork november/december 2017

 3
To help correct a forward-
head carriage, the therapists
extended fingers apply light C7
T1 sustained pressure as the
client slowly extends their head.
specialized sensory receptors called
mechanoreceptors are triggered. Their job is to
alert the spinal cord of possible mechanical
malfunction. The spinal cord reacts by
recruiting head and neck righting reflexes
that are often able to restore temporary
gravitational balance by pulling the head
and spine back into vertical alignment.
STAGE 2: CHRONIC SYSTEMIC
INFLAMMATION
The clients neck crick symptoms escalate
as prolonged stiffness increases joint
compression, resulting in disc compression,
articular cartilage degradation, and
possible nerve root impingement. Although
inflammation is a natural and vital part
of the injury repair process, prolonged
exposure irritates surrounding soft tissues
and hyperexcites chemical receptors called
chemoreceptors. Together, the upregulated
chemical and mechanical receptors
bombard the spinal cord with warnings of
excessive chemical and mechanical duress.
STAGE 3: BRAIN ALERTED TO
POSSIBLE TISSUE DAMAGE
In this progression, the combined
mechanoreceptive and chemoreceptive
stimuli become too much for the spinal
cord reflexes to handle. Specialized danger-
signaling receptors called nociceptors are
recruited to fast-track information to the
brain, warning of the possibility of tissue
damage. The brain quickly interprets the
nociceptive informationbased on factors
such as prior experiences, expectations, and
moodand passes that assessment along
in several ways. The brain may choose to
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ignore the situation for the time being, lock
up the area with protective muscle guarding,
or trigger a pain response to persuade
the person to do something about it.
If the individual continues with their
old patterns of overuse and abuse, the neck
and shoulders may become sensitized to the
pain. Prolonged exposure to the painful
neck crick can trigger a host of unwanted
4
To help correct a left sidebending and right
symptoms, including sympathetic spasm rotation musculofascial restriction, the
in neighboring tissues. MAT therapists therapists hands create a gentle counterforce.
apply graded exposure stretches, nerve The client elevates their right shoulder against
mobilization, and manual tractioning the therapists resistance to a count of five, then
techniques (Images 3, 4, and 5) in a relaxes. Working with the nervous system, the
therapist engages the new right rotation barrier.
controlled, comfortable manner to convince
the brain that it is now safe to move stiff
necks in directions that were once locked up.
These MAT techniques are fantastic for
clients suffering sensory motor amnesia,
where habitual inefficient movement
patterns have caused the brain to forget
how to completely relax certain parts of
the body, such as the neck and shoulders.
By progressively introducing stretch to
areas that have been problematic in the
past, the nervous system begins associating
the new movement with safety instead
of pain. The subsequent reduction in
pain, increased efficiency of movement,
and improved function are the desired
outcomes of any bodywork strategy.
Erik Dalton is the executive director of
the Freedom From Pain Institute. Educated
in massage, osteopathy, and Rolfing, he
has maintained a practice in Oklahoma City,
Oklahoma, for more than three decades. For
5
more information, visit www.erikdalton.com. The therapists fingers and thumb secure each
vertebral segment beginning at C3, while their
right hand assesses for rotation restrictions in
each individual vertebral segment.
technique
What Is Really Yours?
Identifying Absorbed Energy
By Cyndi Dale
Most negative or destructive
psychic information-energy
stored in your body or psyche
isnt your own. I believe that more
than 80 percent of all life problems,
in fact, are caused by energies
not our own. Our own information
doesnt harm us. You might have
beliefs that are wrong, feelings that
are repressed, or issues that indicate
misunderstandings, but these are
ultimately challenges to work through,
as each presents an opportunity for
understanding and growth. Others
information-energy, however`, causes
real damage, for several reasons. restrict, and help rather than hurt.
90 massage & bodywork november/december 2017
ENERGY WORK
From a scientific perspective, all
information-energy is frequency- or
vibration-based. The energy that makes
a chair a chair runs on certain bands, or
vibrations. The energy of your ears runs
on its own unique set of frequencies
frequencies that are different than the
energies of your kidneys. Harmonics are
the full set of vibrations that make up who
we are. Personal energies will match our
harmonics, or personal vibrations. We
can fail to release or recognize personal
vibrations, such as feelings and ideas, or
we can misplace them inside or outside
our body. Unreleased, unrecognized, or
misplaced vibrations will cause blocks,
misperceptions, holes, muddy spots, rips,
tears, and congestion in our energetic fields.
In turn, those energetic problems will create
physical, emotional, mental, and spiritual
challenges. If we shift our misunderstood
or misplaced energies, however, they will
heal rather than harm, instruct rather than
THE EFFECTS OF ABSORBED ENERGY
Energy internalized from others wont
match our own frequencies and will
always harm us. Imagine that your face
is burned, and surgeons graft skin from
your thighs onto your face. The frequency
Energy internalized from others wont match
our own frequencies and will always harm us.

of your own skin will match that of your

facial skin, and this transplanted skin
has a good chance of taking. Now,
think what might happen if you undergo
heart surgery, and the surgeon leaves an
instrument in your body. The metal tool
doesnt synchronize with your physical
tissue, and results in all sorts of problems!
As close or desirable as the energetic match
might be, others energies are not your
own. They will not take and will cause
problems. These psychic toxinsothers
energies that you acquire psychically
can transform into physical energies.
In addition to creating negative physical
effects, absorbed energy can also adversely
affect your personality and spirituality.
When we internalize information that isnt
relevant to us, we become someone we are
not. Psychic energy can carry all sorts of
information, including instructions about
careers, money, ideas, feelings, emotional
states, attitudes, prejudices, religious
ideals, body-image standards, and more.
What if a 10-year-old girl internalizes

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 relax
Obtaining CE hours
is more convenient the cultures model of the perfect body?
Well, many of them do, which is one of
than ever! the reasons so many girls in our culture
experience anorexia. Certainly there is a
genetic predisposition to alcoholism, which
involves inheriting the inability to produce
a certain liver enzyme necessary to fully
break down alcohol. The template for
1. Purchase alcoholism, however, is a family matter and
is energetically passed from parent to child.
2. Test Online If you chronically experience an issue that
or On Paper never seems to change, no matter how much
you work on it, you may have internalized or
3. Receive Your been imprisoned by a psychically transferred
Certificate energy that is affecting your integrity.

LIVING IN INTEGRITY WITH YOURSELF

Why do we psychically absorb ideas that
conflict with our spiritual wisdom? The
psychic is designed to enable survival,
and we innately believe that the key to
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92 massage & bodywork november/december 2017


voices, ideas, pictures, sensations, images,
orders, or visitations that are unwelcome at
best and dangerous at worst. Even laypeople
are adversely affected by unwanted psychic
instructions. Just about every person who
comes to see me is experiencing the negative
effects of others psychic information.
Typical scenarios are:
H  ating your professionbecause
youve accepted someone elses idea of
what type of work you should do.
N  ot having enough moneybecause
you are living out someone elses
poverty mentality or religious beliefs
about the virtue of being poor.
P  hysical maladiesbecause of
energies inherited from the family.
Depressionbecause you are
repressing parts of your real self.
A  nxietybecause youve accepted
familial fears of the future.
R  elationship problemsbecause you
keep dating or marrying people who
remind you of a family member.
D  issatisfactionbecause if you are living
for others, you arent living as yourself.
O  ppressionbecause parts of your
self are being repressed by another.
These and other issues can be caused
by any number of problems for which its
important to see a licensed professional.
In addition, the origin of some of your
problems may be psychic energies that are
not yours. Running your life on others
concepts will keep you from integrating the
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ENERGY WORK
various parts of yourself needed to live a full,
happy life. It can also cloud your perceptions
so much that you dont even know who you
really are, which not only affects your life,
but also can keep you from becoming full of
the spirit that you are.
Its time to separate the wheat from the
Cyndi Dale is accepting a
chaff, the useful from the useless, and the
limited number of students
helpful from the harmful. And its time to
for her apprenticeship
put up boundaries so the harmful can never
program February
enter again.
22October 28, 2018:
Develop Your Magical,
Mysterious, and Miraculous
This column is excerpted from Cyndi Dales
Spiritual Gifts. Massage &
The Intuition Guidebook: How to Safely and Wisely
Bodywork readers can use
Use Your Sixth Sense (Deeper Well Publishing,
code CDABMP to receive
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technique
Working with the Vagus Nerve
By Til Luchau
The vagus nerve is an extremely
interesting structure. Much more
than just a passive wire or cable, its
afferent (sensory) and efferent (motor)
neurons work together to actively
regulate a long list of processes that
span the boundary between the brain
and body, biology and psychology,
and health and dysfunction. And,
since we can stimulate the vagus
nerve with the right kinds of touch,
could hands-on work beneficially
affect the vaguss function?
THE INFLUENTIAL VAGUS NERVE
Some of the many ways the vagus (or cranial
nerve X) actively influences our well-being
include:
Stress Resilience and Recovery
When your vagus nerve senses stress
hormones like cortisol and adrenaline, the
motor neurons in its wide-reaching branches
(Image 1) release neurotransmitters like
acetylcholine (which was originally called
Vagusstoff, or vagus-substance) and
hormones like oxytocin, which dampen
the sympathetic activation and help you
recover more quickly from stress.
94 massage & bodywork november/december 2017
MYOFASCIAL TECHNIQUES
Inammatory and Immune Control
The vagus inhibits inflammation
by releasing anti-inflammatory
1
neurotransmitters when it Lung
detects inflammatory markers
like cytokines or tumor necrosis Heart
factor (TNF).1 When unchecked,
these are involved in autoimmune
conditions (such as rheumatoid Liver
arthritis), chronic pain, and more. Stomach
Mood Regulation
The vagus is the major communicator
between the brain and the enteric Kidney
Large
nervous systemthe rich neurology Intestine
of your viscera. Your guts, with
more than 100 million neurons, 30
neurotransmitters, and 95 percent Small
Intestine
of your bodys serotonin, send large
quantities of information to the brain
via the vagus nerves afferent fibers; this
sets the mood or emotional backdrop
The vagus nerve (yellow) is the bodys main
for our brains mental processes.2 Vagal tone
parasympathetic (rest and repair) structure. As the
(a measure of the vaguss responsiveness primary pathway between the brain and visceras
and its effects on the heart) has been rich neuronal network (the enteric nervous system),
correlated with organ-based conditions like it plays a crucial role in mood regulation, immune
function, heart rate, and stress recovery. Redrawn
heart disease and diabetes, as well as better
from De Witt; courtesy Advanced-Trainings.com.
emotional regulation and less anxiousness.
VAGAL STIMULATION everyone responds to VNS; there are clear
Vagal nerve stimulation (VNS) involves risks (including infection); and the long-
implanting a pacemaker-like device to excite term side effects of VNS are unknown.3
the vagus via an electrode wrapped around Of course, there are other, less invasive
it in the neck. Though somewhat drastic- and less risky ways to elicit the vagus nerves
sounding, VNS has long been approved beneficial effects. These include controlled
for treating a list of conditions including breathing (especially longer exhalation);
epilepsy, headaches, and treatment-resistant meditation; moving and relaxing the tongue,
depression, and is being studied for use as well as singing, humming, and speaking
in an even broader range of complaints, (since the tongue and larynx are innervated
including anxiety disorders, Alzheimers, by the vagus); animated conversation (since
migraines, fibromyalgia, obesity, and
tinnitus. VNS might offer welcome options,
especially in difficult cases. However, not
 Watch Til Luchaus technique videos and read his past
articles in Massage & Bodyworks digital edition, available at
www.massageandbodyworkdigital.com, www.abmp.com,
Vagus Nerve and on Advanced-Trainings.coms Facebook page.
Technique
facial expression has a two-way relationship to vagal
function) 4; improving gut health; exercise and rest;
and, especially, reducing sources of physical, mental,
and social stress.
But as hands-on practitioners, with our pragmatic
perspective, our question is often, So how can I
touch it, and in what way, that might help?
THE VAGUS IN YOUR EAR
The ear is the only place where the vagus nerve
reaches the surface of the body (via its auricular
branch, Image 2). In fact, transcutaneous (skin)
stimulation of this particular branch of the vagus
is being studied as a treatment for numerous
vagal-modulated conditions, and already has
European clearance for treating epilepsy,
depression, migraines, and chronic pain.5
In our Advanced Myofascial Techniques series
at Advanced-Trainings.com, we use several different
ear techniques for working with conditions like
temporomandibular joint (TMJ) pain (since the
vagus nerve can be a powerful pain modulator, via
its calming and neuroimmune effects), as well as for
migraines and headaches.
2
Green: vagus nerve (X)auricular branch. Violet: mandibular nerve (V3)
auriculotemporal branch. Orange: lesser occipital nerve (C2) and greater
auricular nerve (C2, C3). Courtesy Primal Pictures, used by permission.
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 95
The Vagus Nerve Technique
Purpose
Increase vagal nerve activity through gentle
stimulation of sensation.
Indications
Migraines and other headaches
Temporomandibular joint (TMJ) pain and
temporomandibular joint dysfunction
Stress, anxiousness, or sympathetic autonomic
nervous system arousal
Perhaps palliative in a wide array of conditions
mediated by the vagus nerve, such as tinnitus,
mood issues, digestive issues, immune function
and autoimmune conditions, pain, and others
Instructions
Use gentle touch, pressure, or light traction on
the ears concha (deepest bowl), ear canal, and
the scalp just behind the ears, to gently stimulate
sensation in the ears vagus-innervated areas.
For migraine or TMJ pain, look for areas of
sensitivity, and for active movements of the jaw,
eyes, and face that evoke, relieve, or relate to the
pain felt.
Movement Cues
Let your exhale be even slower, fuller, and longer.
Let your tongue rest in your mouth.
Lets hum a little tune and meanwhile,
let your neck and jaw stay relaxed.
For migraines: Look left and right with your eyes.
For TMJ pain: Gently, slide your jaw away from your
ear.
For More Learning
TMJ and Migraines in the Advanced Myofascial
Techniques series of workshops and video courses.
Advanced Myofascial Techniques (Handspring
Publishing, 2016), Vol. 2, Chapters 15, 18.

Helix Cymba
Antihelix
Concha
Tragus
Antitragus
3 Lobule
The ear is the only place the vagus nerve reaches the surface of the body, via the auricular
branch of the vagus nerve (dark green) and the ear structures it innervates (the concha and
external auditory meatus; transparent green). Courtesy Primal Pictures, used by permission.
White dots: facial nerve (VII): cutaneous fibers. Courtesy Advanced-Trainings.com.
The Vagus Nerve Technique
The vaguss auricular branch is made
up of afferent neurons, which means
that stimulating sensation in the vagal-
innervated parts of the ear (Image 3) excites
greater vagal nerve activity. Since in most
cases our aim is also to calm and reassure
the clients nervous system, a gentle,
confident, and sensitive touch (Image 4) is
usually most effective, with one study (of
infants vagal reactions to massage) showing
that moderate pressure yielded greater
vagal effects than light touch.6 Since some
clients may not be accustomed to having
their ears included in bodywork, be sure
to ask permission first, and explain your
purpose for proposing this technique.
Could manual therapy with the ears
be used to evoke some of the vaguss many
beneficial effects? Clearly, touch wouldnt be
expected to have the same effects as direct,
longer-duration electrical stimulation; and
though a few small studies have shown
that hands-on work can measurably affect
vagus tone,7 other results have been limited
or mixed, and so a definitive answer
would require more investigation. But,
understanding more about the vagus nerve
can certainly stimulate our therapeutic
imagination and creativity. Practitioners
have long known that careful work with the
ears, as well as relieving specific complaints
ABMP members earn FREE CE at www.abmp.com/ce by reading Massage & Bodywork magazine 97
like headaches and TMJ pain, can be
extremely calming, perhaps because of the
vagus nerves power to soothe and relax both
our body and mind.
An extended version of this article,
including full references, links, and a
bibliography, is available at www.a-t.tv/
workingwiththevagusnerve.
Notes
1. S. L. Oke and K. J. Tracey, From CNI-1493 to
the Immunological Homunculus: Physiology of
the Inflammatory Reflex, Journal of Leukocyte
Biology 83, no. 3 (March 2008): 51217.
2. Adam Hadhazy, Think Twice: How the Guts
Second Brain Influences Mood and Well-
Being, Scientific American, February 12,
2010, accessed September 2017, www.
scientificamerican.com/article/gut-second-brain.
3. National Institute of Mental Health, Brain Stimulation
Therapies, 2016, accessed September 2017,
www.nimh.nih.gov/health/topics/brain-stimulation-
therapies/brain-stimulation-therapies.shtml.
4. K. M. Gothard, The Amygdalo-Motor Pathways
and the Control of Facial Expressions,
Frontiers in Neuroscience 8, no. 43 (2014).
5. R. H. Howland, Vagus Nerve Stimulation,
Current Behavioral Neuroscience
Reports 1, no. 2 (2014): 6473.
MYOFASCIAL TECHNIQUES
4
The Vagus Nerve Technique involves stimulating the
vagus nerves auricular branches via moderate pressure,
gentle traction, and active movement. Courtesy Advanced-
Trainings.com.
5
Gentle touch on the scalps vagus nerve-innervated zone,
just behind the ear, where the auricular branch emerges
from the cranial vault through a small hole in the temporal
bone. Courtesy Advanced-Trainings.com.
6. Tiffany Field et al., Moderate Versus Light
Pressure Massage Therapy Leads to Greater
Weight Gain in Preterm Infants, Infant Behavior
and Development 29, no. 4 (2006): 57478.
7. J. Cottingham, S. Porges, and K. Richmond, Shifts
in Pelvic Inclination Angle and Parasympathetic
Tone Produced by Rolfing Soft Tissue Manipulation,
Physical Therapy 68, no. 9 (September 1988):
136470; J. Cottingham and J. Maitland, A Three
Paradigm Treatment Model Using Soft Tissue
Mobilization and Guided Movement-Awareness
Techniques for a Patient with Chronic Low Back
Pain: A Case Study, Journal of Orthopedic Sports
Physical Therapy 26, no. 3 (1997): 15467.
Til Luchau is the author of Advanced Myofascial
Techniques (Handspring Publishing, 2016), a
Certified Advanced Rolfer, and a member of the
Advanced-Trainings.com faculty, which offers
online learning and in-person seminars throughout
the USA and abroad. He invites questions or
comments via info@advanced-trainings.com and
Advanced-Trainings.coms Facebook page.

The Research Behind
Therapeutic Touch
By Karrie Osborn
According to Dolores Krieger, PhD, RN, cofounder of
Therapeutic Touch, the most important studies about
this modality she helped develop come from Gloria
Gronowicz, PhD, a professor at the University of
Connecticut Health Centers Department of Surgery.
Krieger says Gronowiczs 2008 study1 developed
bench criteria for Therapeutic Touch. Krieger says this
cell biologist showed how you can monitor Therapeutic
Touch within a laboratory setting. The objective of the
2008 research was to assess the effect of Therapeutic
Touch on the proliferation of normal human cells in
culture compared to sham and no treatment. The study
found that a specific pattern of Therapeutic Touch
produced a significant increase in proliferation of
fibro-blasts, osteoblasts, and tenocytes in culture.
In a more recent study from Gronowicz2, researchers
found that while Therapeutic Touch did not significantly
decrease the primary tumor size in a breast cancer
model in mice, it did significantly decrease metastasis.
digita
l
extra
Researchers said this human biofield therapy also
significantly downregulated specific lymphocytes,
macrophages, and serum cytokines induced by cancer.
This study is the first to show modulation of immune
function by human biofield therapies with possible
positive outcomes in breast cancer progression. Human
biofield therapy along with standard allopathic care
may have beneficial effects on cancer subjects.
This research suggests that Therapeutic Touch can have
significant effects on immune function.
Notes
1. G. Gronowicz et al., Therapeutic Touch Stimulates the
Proliferation of Human Cells in Culture, Journal of Alternative
and Complementary Medicine 3, April 14, 2008, accessed
October 2017, www.ncbi.nlm.nih.gov/pubmed/18370579.
2. G. Gronowicz et al., Therapeutic Touch Has Significant Effects
on Mouse Breast Cancer Metastasis and Immune Responses
but Not Primary Tumor Size, Evidence Based Complementary
and Alternative Medicine, May 31, 2015, accessed October
2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC4465772.
Karrie Osborn is senior editor at ABMP.