Ira Zunin, MD, MBA, MPH

Ira Zunin, MD, MPH, MBA offers a global, strategic perspective as to why he has made a priority of forming partnerships with insurers and employers to advance his integrative practice model for disabling pain: “We know we can spend a decade in the legislature trying to fight for one small thing. This is an opportunity to solve big problems which big payers know they have and create a lot of latitude for integrative medicine.”

Zunin’s base is his Manakai O Malama integrative center on the island of Oahu. Since it’s founding in 2002, the clinic has had over 100,000 patient visits to its array of practitioners. (See “Clinical Services” in the table). In 2005, the Zunin’s team partnered with Hawaii Medical Services Association (HMSA), the island’s Blue Cross Blue Shield carrier, and two workman’s compensation firms for an integrative pain pilot that targets a costly, disabled population .

Hawaii Blues Plan funded the pilot

“We viewed this as a chance to study a comprehensive biopsychosocial intervention,” states Zunin, an Integrator adviser.

Hawaii Blues Plan funded the pilot

“We viewed this as a chance to study a comprehensive biopsychosocial intervention,” states Zunin, an Integrator adviser. The program is family, community and group-based. Zunin adds that the approach particularly sought to “interrupt the pattern of social isolation” often found in such a population. Group process might shift the “pattern of suffering.” Working with families might increase positive secondary gains. The emphasis was on mind-body strategies which might reduce “pain-related depression that can contribute to suffering.”

Among the complementary and alternative
components included are the use of Feldenkrais and Yoga, humor, acupuncture in a
group-delivery model, and diverse mind-body therapies including a
program with elements of the mind-body stress reduction programs
developed by Jon Kabat-Zinn, PhD.

Outcomes: anxiety, disability, opiate use down

Zunin reports that “the outcomes have been great.” Among those found were:

• Quality of life Scores for the 33 who completed all of the 12 weeks improved on all standardized, subjective measures, with particular advances in diminishing anxiety.

• Disability Of the 64% who had been disabled or partially disabled in the prior 12 months, 85% returned to gainful activity or were cleared to work. 100% of those who returned to gainful activity were still “gainfully engaged” at one-year follow-up.

• Opiate use Of the 79% who had been under high level opiate analgesics during the 12 months prior, 97% had reductions in use of 25% or more, 81% of 50% or more and 50% had 100% reductions on high level opiate use. At one year follow-up, 100% of those who substantially-reduced opiates remained off of them.

Zunin, reports that these positive outcomes have led to a discussions
with HMSA to make the program a covered benefit, and with the Veteran’s
Administration about expanding the program and offering it to vets.

The carrot and stick values of the group intervention

Zunin believes that the group-method of service delivery was a significant factor in achieving these positive outcomes. “The thing about pain and extreme obesity is that they are socially isolating. So, on one side” – what Zunin called the “carrot” – “you are interrupting this pattern.” He adds that he felt that acupuncture in a group model can particularly help: “There is something energetic that occurs as a group.”

Then Zunin explains how he believes that group-focused treatment also has a “stick” dimension to it. Reflects Zunin: “The other side of the group ethic is the stick. In this population, you typically have people who have learned to manipulate one provider after another. They spot that manipulation in each other and whomp each other for it when it comes up.” In short, the counseling from a fellow-patient may be much more direct and to the point than that from the patient’s doctor.

Zunin described plans for modifying the program from lessons learned in this round. First, Zunin anticipates screening all participants at the first 4 weeks. This would give a chance to “graduate” some of the quick responders and to remove some from the program who are clearly not engaged. In both cases, costs would be saved. Zunin also anticipates producing the three 4-week sessions as “chapters” with more of a thematic continuity.

Zunin, who founded the Hawaii State Consortium for Integrative Health Care, continues to believe that pilots such as this, which analyze outcomes of whole systems of care, in partnership with insurers or other payers is the way to transform the system. Says Zunin: “The contribution I would like to see to our shared field is to lighten the path to rapid change.”

For another article on Zunin’s work, please see (Zunin on CAM-IM Clinical Services in Healthy Living “Age Targeted” Communities, April 24, 2006).

Comment: Zunin’s comments about the value of the group reminded me of the astonishingly positive outcomes of the group-focused programs delivered to Chrysler employees onsite (Chrysler Expands Group-Focused Integrative Pain Partnership with Henry Ford Health System CAM Group, July 23, 2007; and Chrysler’s Health Leaders on Their Integrative Health Pilot Projects, February 26, 2008). Zunin agreed that there may be something in the individualized nature of the experience of pain which makes it particularly susceptible to group mind-body interventions.

To the extent that this may be true, our health professional educational programs must begin to train professionals to participate in and help lead these group interventions. The training in delivering such programs is essentially, as the fundamental, economic law of clinical decision-making seems to be that practitioners of all stripes are most likely to recommend services that they, themselves are equipped to provide.

Kudos to Zunin for having the vision to put this together and see it through this round. I agree with his strategic sense that these kinds of projects are the best way to light the path to quicker uptake of integrative practices.

According to a U.S. Department of Health and Human Services
survey, there were 34.5 million people over the age of 65 in 1999,
representing about 12.7 percent of the U.S. population. By 2030,
that number will grow to 20 percent, or about 70 million people. Yet
as large as it is, the elderly population experiences an alarming
number of health problems that are often inadequately treated, such
as arthritis, depression, pain, constipation, stress and loneliness.

The suicide rate among people over 65 is higher than any other
group, and is considered a major public health problem by the
National Institute of Mental Health. Yet a case study conducted by a
nurse consultant for Beverly Health and Rehabilitation Services, Inc.
in 1997 found that seniors who received massage therapy experienced a
tremendous improvement in mood and anxiety levels.

Chinese massage and acupuncture can help with all of these
ailments and more. Massage and acupuncture increase the circulation
of blood and lymphatic fluids, reduce muscular tension, relieve pain,
and release endorphins. Improved circulation brings fresh oxygen to
body tissues, which eliminates waste products from inside the body
and enhances recovery from diseases. And the bond that can be forged
between practitioner and patient can serve to relieve loneliness and
depression.

For more information on how Oriental medicine can help the
elderly, please call (800) 729-0941.

Physicians and healers of all forms and from all cultures have used hands-on manipulation throughout history as an integral part of health care practice. In the former Soviet countries, Germany, Japan, and China, massage has continued uninterrupted as massage therapists today work alongside doctors as part of the health care team.

In modern Germany massage therapy is covered by national health insurance. In China it is fully integrated into the health care system, where the hospitals have massage wards. In one Shanghai hospital the massage department covers two floors.

In this country, the medical use of massage began to diminish in the early part of this century with the evolution of pharmaceutical, surgical, and technological medicine. It reached a nadir in the 1930s, 40s, and 50s because it was considered too time intensive for the modern physician. Massage therapy duties were gradually handed over to aides, who eventually became the physical therapists of the modern era.

The professionalization of massage therapy in the United States began in 1943 when the graduating class of the College of Swedish Massage in Chicago decided to band together and form an association with twenty-nine charter members. What they created was destined to become the American Massage Therapy Association (AMTA).

In the 1960s, while modern medicine continued its march toward higher technology and drugs and away from physician contact with patients, such concepts as holistic health, self-improvement, and optimal health experienced a rebirth. The 1970s brought even greater interest in health promotion and a new openness to massage.

This was followed by explosive growth in the varieties of massage and bodywork available, and today there are now over eighty different varieties. The term “bodywork” evolved as a generic term for referring to this broadening field. It is now loosely used to incorporate massage and other forms of manipulation.

In the survey of alternative medicine that was published in The New England Journal of Medicine in January 1993,¹ massage therapy ranked third among the most frequently used forms of alternative health care. According to Elliot Greene, president of the AMTA, there are now an estimated fifty thousand massage therapists of various kinds in the United States, and the AMTA may be the fastest-growing organization of health care providers m the country. At this writing it has over eighteen thousand members and its rolls have more than doubled in the last three years.

Education

There are myriad programs of education and training for the many different forms of massage and bodywork. For the massage therapy field, the AMTA has been successful in establishing standards that are incorporated in many state licensing laws. Fifty-eight training programs are currently accredited or approved by the AMTA-affiliated Commission on Massage Training Accreditation/Approval, which requires at least five hundred hours of classroom instruction. The curriculum includes three hundred hours of massage theory and technique, one hundred hours of anatomy and physiology, and one hundred hours of additional required courses including first aid and cardiopulmonary resuscitation (CPR). There are of course many other training programs that do not meet all of these standards.

Training in other forms of bodywork is much less uniform and there are no licensing laws for bodywork methods as such. Many bodyworkers are also massage therapists, but this is not required for most bodywork traditions. The various associations described later in this chapter all have their own unique standards for training.

While there are a wide variety of forms of massage therapy and bodywork, all with their own theoretical or philosophical perspectives, there are certain basic principles they all tend to; hold in common.

Circulation of Blood. Perhaps the most basic principle in this field is that improved blood circulation is beneficial for virtually all health conditions. Tension in the muscles and other soft tissues can impair circulation, resulting in a deficient supply of nutrients and inadequate removal of wastes or toxins from the tissues of the body. This in turn can lead to illness, structural and functional problems, or slower healing. Recognition of the importance of blood circulation is implicit in all forms of massage and bodywork.

Elliot Greene describes the process as one of breaking up the scarring that had occurred in her muscles and connective tissue or fascia between the muscles, vertebra, and ribs, all of which had become stuck together. Blood flow through the area was restored and the depression that had been palpable in her spine gradually began to diminish. The full range of motion of the spine returned.

Movement of Lymphatic Fluid. The lymph system is almost as extensive as that of the blood. The circulation of lymphatic fluid plays a key role in ridding the body of wastes, toxins, and pathogens. The lymph system also benefits from massage, particularly in conditions where lymphatic flow is impaired by injury or surgery (e.g., in postmastectomy women).

Release of Toxins. Chronic tension or trauma to the soft tissues of the body can result in the buildup of toxic by-products of normal metabolism. Hands-on techniques help move the toxins through the body’s normal pathways of release and elimination.

Release of Tension. Chronic muscular tension as a result of high stress lifestyles, trauma, or injury can accumulate and impair the body’s structure and function. Psychological well-being is also affected. Release of tension allows greater relaxation, which has important physiological and psychological benefits.

Structure and Function Are Interdependent. The musculoskeletal structure of the body affects function and function affects structure. Both can be adversely altered by stress or trauma. Massage therapy and bodywork can help restore healthy structure and function, thereby allowing better circulation, greater ease of movement, wider range of movement, more flexibility, and the release of chronic patterns of tension.

Enhancement of All Bodily Systems. All bodily systems are affected by better circulation and more harmonious functioning of the soft tissue and musculature. Internal organ systems as well as the nervous system, the immune system, and other systems can benefit. There can be an overall improvement in the quality of life and physical health.

Mind/Body Integration. Mind and body have a reciprocal relationship. Soma (body) affects psyche (mind) and vice versa. Hence there can be somatopsychic effects, in which the conditions of the body affect the mind and emotions, and there can be psychosomatic effects, in which psychological or emotional conditions affect the body. Change in one domain may cause change in the other. A habit or fixed pattern in one may also impede change in the other and require special attention. Often psychotherapy and massage or bodywork complement each other.

Reduction of Stress. Stress is increasingly believed to induce illness, and perhaps 80 to 90 percent of all disease is stress induced. Massage therapy is an effective non-drug method for reducing stress and promoting relaxation.

Energy. Many modalities in this tradition work with the flow of energy through the body as a means to promote healing. Energy can be directed or encouraged to move through and around the body in such ways as to have impact on the physical structure and function of the body as well as on emotional well-being. This work may involve hands-on contact or may be done with no contact with the physical body.

According to Joanna Chieppa, R.M.T., a faculty member at Heartwood Institute in Garberville, California, and an energy healing practitioner in Sonoma County, “It is important for people to develop an awareness that the flow of energy in and around the body is just as important to well-being as the flow of blood, the flow of breath, the flow of cerebral spinal fluid— that it is essential for the health of body, mind, and spirit.”²

For this chapter, the sections on varieties and techniques are combined. As stated earlier, there are over eighty different types of massage therapy and bodywork. Many are variations on each other, often developed by a practitioner who is trained in one particular approach and then goes on to develop his or her own variety, with its own new “brand name.”

Most varieties can be broken down into the following five broad categories:

Traditional European Massage

Contemporary Western Massage

Structural/Functional/Movement Integration

Oriental Methods

Energetic Methods (Non-oriental)

The majority of activity in this field is oriented toward the traditional European and contemporary Western forms of massage simply because there are such large numbers of practitioners of these methods.

Traditional European Massage

Traditional European massage includes methods based on conventional Western concepts of anatomy and physiology and soft tissue manipulation. There are five basic kinds of soft tissue manipulation techniques: effleurage (long flowing or gliding strokes, usually toward the heart, tracing the outer contours of the body), petrissage (strokes that lift, roll, or knead the tissue), friction (circular strokes), vibration, and tapotement (percussion or tapping).

Traditional European massage was brought to the United States by two doctors from New York who were brothers— Charles and George Taylor—who studied in Sweden and introduced Americans to Swedish techniques in the 1850s. After the Civil War, the first Swedish clinics opened in Boston and Washington, the latter frequented by U. S. Grant.

Swedish Massage. Swedish massage is by far the most predominant example of traditional European massage and it is the most commonly used method in the United States. It was developed by Per Henrik Ling in Sweden in the 1830s and uses a system of long gliding strokes, kneading, and friction techniques on the more superficial layers of muscles. It usually goes in the direction of blood flow toward the heart because there is an emphasis on stimulating the circulation of the blood through the soft tissues of the body. Swedish can be a relatively vigorous form of massage, sometimes with a great deal of joint movement included.

Oil is usually used, which facilitates the stroking and kneading of the body, thereby stimulating metabolism and circulation. Its active and passive movements of the joints promote general relaxation, improve circulation and range of motion, and relieve muscle tension. Swedish massage is often given as a complete, full body technique, though sometimes only a part of the body is worked on.

Contemporary Western Massage

This includes methods based primarily on modern Western concepts of human function, anatomy, and physiology, using a wide variety of manipulative techniques. These may include broad applications for personal growth, emotional release, and balance of mind-body-spirit in addition to traditional applications. These approaches go beyond the original framework or intention of Swedish massage. They include Esalen or Swedish/Esalen, neuromuscular massage, deep tissue massage, sports massage, and manual lymph drainage. Most of these are American techniques developed from the late 1960s onward, though the latter was developed in the 1920s.

Esalen and Swedish/Esalen. Esalen massage is a modern variation that was developed at the famous growth center, Esalen Institute in Big Sur, California. Its focus is not so much on relieving muscle tension or increasing circulation as it is on creating deeper states of relaxation, beneficial states of consciousness, and general well-being. Whereas Swedish is more brisk and focuses on the body, Esalen is more slow, rhythmic, and hypnotic and focuses on the mind/body as a whole.

Esalen massage is not widely taught as a pure form. Rather, a marriage of sorts has been formed by the integration of Swedish and Esalen as a way of incorporating the strengths of each. Many massage therapists describe their method as Swedish/Esalen, and this hybrid is commonly taught in massage schools.

Neuromuscular Massage. This is a form of deep massage that applies concentrated finger pressure specifically to individual muscles. This is a very detailed approach, used to increase blood flow and to release trigger points, intense knots of muscle tension that refer pain to other parts of the body (they become trigger points when they seem to trigger a pain pattern). This form of massage helps to break the cycle of spasm and pain and is often used in pain control. Trigger point massage and myotherapy are varieties of neuromuscular massage.

Deep Tissue Massage. This approach is used to release chronic patterns of muscular tension using slow strokes, direct pressure, or friction. Often the movements are directed across the grain of the muscles (cross-fiber) using the fingers, thumbs, or elbows. This is applied with greater pressure and at deeper layers of the muscle than Swedish massage and that is why it is called deep tissue.

It is also more specific. For example, in the case of someone with a sore shoulder, the practitioner may focus on the trapezius and the rhomboid underneath, trying to work in all the layers of muscle that might be involved. Deep tissue massage lends itself to being more focused on a problem area.

Sports Massage. This uses techniques similar to Swedish and deep tissue but more specifically adapted to deal with the needs of athletes and the effects of athletic performance on the body. Sports massage is used before or after events, as part of an athlete’s training regimen, and to promote healing from injuries.

As Elliot Greene explains, the problem with severe spasm is that it cuts off its own circulation and becomes a self-reinforcing syndrome. This is another case of opening up the flow of blood and lymph through the area, releasing adhesions, and using deep transverse friction to encourage the unhealed part of the muscle to heal.

Manual Lymph Drainage Massage. This approach improves the flow of lymph rhythmic strokes. It is used primarily in conditions characterized by poor lymph flow, such as edema.

Structural/Functional/ Movement Integration

These approaches organize and integrate the body in relationship to gravity through manipulating the soft tissues, and/or through correcting inappropriate patterns of movement. These are methods that bring about more balanced use of the body and nervous system, creating greater integration and more ease of movement.

This category of approaches is interesting in that some do not even involve the practitioner touching the client. There is no clear line of demarcation between where the bodywork therapies end and the movement therapies begin. Furthermore, many practitioners use multiple techniques that integrate massage, deeper tissue work, and movement all in the same session with a client.

These approaches work on the body structure and how it moves. The most common approaches include Rolfing, Hellerwork, the Rosen Method, the Trager approach, the Feldenkrais Method, the Alexander Technique, and Ortho-Bionomy.

Rolfing. Rolfing is the most established method in this category. There are over eight hundred Rolfers practicing in twenty-seven countries, with about seven hundred in the United States.

Rolfing is a trademarked approach within the generic field of structural integration. It was developed by Ida Rolf, Ph.D., a biophysicist who earned her doctorate in the 1920s. She began doing her form of bodywork in the 1940s and 50s. Her clientele included Georgia O’Keeffe and Buckminster Fuller and she worked with other pioneers in the bodywork field. In the 1960s she began teaching at Esalen Institute. She formed the Rolf Institute of Structural Integration in Boulder, Colorado, in 1972.

Rolfing involves a form of deep tissue work for reordering the body so as to bring its major segments—head, shoulder, thorax, pelvis, and legs—into a finer vertical alignment. The technique loosens or releases adhesions in the fascia, the flexible tissue that envelops our muscles and muscle groups. The fascia is supposed to move easily and allow easy articulation or movement of muscles or muscle groups past each other. However, trauma such as injury or chronic stress can cause stuck points or adhesions, in which the fascia is in a sense frozen, not allowing full freedom of movement.

The Rolfer works to restore this freedom of movement, resulting in a more balanced, vertical alignment of the body and often a lengthening or expansion of the body’s trunk. Rolfing usually takes place over a series of ten organized sessions dealing with different areas of the body.

Hellerwork. This approach was founded by Joseph Heller in 1979. A former Rolfer, Heller developed a method that, along with structural reintegration, incorporates a movement reeducation process with exercises that teach stress-free methods for performing everyday movements such as standing, walking, bending, sitting, and reaching. (Since he left the Rolf Institute, Rolfing has also incorporated movement in its work.) Heller’s approach often includes video feedback to show clients how they move.

Hellerwork takes place in a series of eleven sessions. Each session includes about an hour of bodywork and a half hour of movement education. There are over 160 certified Hellerwork practitioners in twenty-three states and seven foreign countries.

Rosen Method. Marion Rosen began her career in the 1930s and is still actively teaching her technique today. She founded her training program in 1972. The Rosen Method sees the body’s tensions as indications of unexpressed feelings or other repressed or suppressed aspects of the self. The result of such holding patterns, which may be very subtle, can be lifelong patterns of tension or organic malfunction.

The Rosen Method uses gentle, nonintrusive touch and verbal exchange between practitioner and client to help draw the client’s attention to areas of holding. This serves to help the client become fully aware of how the patterns of tension are associated with emotional or unconscious material. This awareness itself is the key that allows the tension or holding patterns to be released. Often the tightness softens and the area that was being held begins to move easily with the breath.

In the words of Marion Rosen, “This work is about transformation, from the person we think we are to the person we really are.”

Trager. The Trager approach is a system of movement reeducation or psychophysical integration developed by Milton Trager, M.D. It uses gentle, noninvasive movements to help release deep-seated physical and mental patterns and in turn allow deeper relaxation, increased physical mobility, and better mental clarity.

A session is one to one and a half hours. The practitioner moves the client’s trunk and limbs in a gentle, rhythmic way so that the person experiences new sensations of freedom of movement. The practitioner’s concern is fostering a sense of freedom and lightness.

After the hands-on portion of the session, the client is given instruction in the use of Mentastics, a system of movement sequences developed by Trager for the purpose of re-creating and enhancing the sense of lightness and ease of movement initiated on the table. The benefits of the Trager approach are cumulative, though there is no set series of sessions.

Feldenkrais Method. This approach was developed by Moshe Feldenkrais, a Russian-born Israeli educator. It uses physical movement to focus learning on the juncture of thought and action. It is known for its ability to improve posture and flexibility and alleviate muscular tension and pain.

It works with the nervous system’s capacity for change and learning new patterns for moving, feeling, and thinking. The method involves two applications: Awareness Through Movement (ATM) and Functional Integration (FI). ATM consists of verbally directed, pleasurable, and effortless exercise lessons involving highly sophisticated movement sequences. FI is a one-on-one process that involves the use of specific skilled touch and passive movement. It is known for its ability to address serious muscular and neurological problems and improve human functioning.

The Alexander Technique. This is an approach to psychophysical reeducation. It was developed by the Australian actor F. M. Alexander and works with unconscious patterns of thinking and the resultant movements or postures that become set in the musculature. Such patterns can be made conscious so the student can then become aware of how he/she moves and can make the choice to change patterns, allowing more balance, grace, and ease of movement, thereby reducing and eliminating chronic tension or distortion in the musculoskeletal system. The relationships among the head, neck, and back are of particular importance.

The Alexander Technique is taught in private half-hour to hour lessons. The teacher works with the student to observe and change mind/body habits that interfere with optimal functioning. The teacher uses both verbal and hands-on guidance to help the student experience new ways of moving and embodying him- or herself. It is not a fixed series of treatments or exercises, but often a series of several lessons is recommended. Training to become a teacher takes three years (sixteen hundred hours).

Ortho-Bionomy. Ortho-Bionomy was developed in the 1970s by the bodyworker Arthur Lincoln Pauls. This approach uses gentle, relaxing movements and postures to help the body release tensions and muscular holding patterns. No force or pressure from the practitioner is used. Its goal is a restoration of structural alignment and balance.

Oriental Methods

Oriental methods are based on the principles of Chinese medicine and the flow of energy or chi through the meridians. The geography of the acupuncture meridians is relied upon to determine points of applying the techniques and the ultimate goal is restoration of harmony or balance in the flow of chi. These forms may also be used in concert with herbs and acupuncture.

Pressure is applied by finger or thumb tips to predetermined points rather than by the sweeping broad strokes of Western style massage. Strong pressure or very light pressure may be applied. There are over a dozen varieties of oriental massage and bodywork therapy, but the most common forms in this country are acupressure, shiatsu, Jin Shin Jyutsu, and Jin Shin Do® Bodymind Acupressure^tm;.

Acupressure and Shiatsu. These are similar varieties of finger pressure massage. They are both based on applying pressure to a pattern of specific points that correspond with the acupuncture points. Pressure is applied with the thumb, finger, and palm rather than needles.

The goal is the efficient and balanced flow of chi through the meridians. It is believed that where there is tension being held in the musculature, the flow of chi is impaired through those areas, which can lead to chronic problems not only in the musculature but in the associated organs. Stretching and movement are also sometimes used.

Acupressure is the more generic term used for this approach and shiatsu is the Japanese version.

Jin Shin Jyutsu. This approach comes from an ancient Japanese healing tradition that uses touch to restore the internal flow of energy through the body by releasing energetic blockages. A session lasts about an hour and the client is fully clothed, lying on a table. The practitioner uses pulse diagnosis to identify energy blocks and then gently holds or touches a specific combination of two of twenty-six acupuncture points to allow release of the blockage.

As it is practiced in the United States the holding uses less pressure than other forms of acupressure or shiatsu and there is no application of massage-like movements to specific points. Rather the touch is very light and works to balance the flow of energy.

Jin Shin Do® Bodymind Acupressure^tm;. This approach was developed by California psychotherapist lone Marsaa Teeguarden. It applies stronger acupressure on the points and for a longer period of time than does Jin Shin Jyutsu. It focuses on the deep release of armoring (muscular tension of physical or emotional origins) through gentle yet deep finger pressure.

Jin Shin Do© incorporates Taoist breathing techniques, oriental acupuncture theory, Japanese finger pressure technique (sometimes holding points for as much as one to three minutes), and Reichian segmental theory (an understanding of how tensions in different parts of the body affect each other as well as particular feelings or emotions).

Energetic Methods (Non-oriental)

In a sense, all the oriental methods described above are also energetic methods in that they are working with energy according to principles of Chinese medicine and view the human being as an energy system. However, there are other energetic methods that are not based on Chinese principles. The most prominent of these are Therapeutic Touch, polarity therapy, and Reiki.

Therapeutic Touch. This method is unique in that it was born and reached its maturation within the context of conventional Western medicine. It was developed in the 1970s by Dolores Krieger, Ph.D., R.N., a professor at New York University, and Dora Kunz, a natural healer. It is a contemporary interpretation of several ancient healing traditions.

It is based on the principle that the human energy field extends beyond the skin and the practitioner can use the hands as sensors to locate problems in it that correspond with problems in the physical body. Disease is seen as a condition of energy imbalance or blocked energy flow. Assessment is done by passing the hands over the body from head to toe at about two to four inches above the surface.

The practitioner then serves as a conduit for universal energy, consciously and actively transferring energy into the recipient. The hands are used to direct and focus the energy, sometimes in rhythmical, sweeping motions. The method is initially taught “off body,” meaning the practitioner’s hands do not touch the physical body, though later with experience some physical touch may take place.

Since it is not necessary to touch the physical body (what is being touched is the energy field or energy body), this method can be applied in situations where the patient may not be able to tolerate contact (e.g., in postsurgical patients or burn victims). Sessions last up to thirty minutes and can be done sitting or lying down fully clothed.

Therapeutic Touch is currently taught in over eighty universities and thirty countries and is practiced by twenty to thirty thousand health care professionals in the United States and around the world.

Polarity Therapy. This is a form of energy work that was developed by Randolph Stone, a chiropractor, osteopath, and naturopath in the mid-1920s. The practitioner uses subtle touch or holding on specific points to harmonize the flow of energy through the body and also to enhance the body’s structural balance.

It is based on the principle that every cell has both negative and positive poles and the body is gently manipulated to enhance the energy flow. Emotional tension or physical pain are released as the flow of energy becomes more properly balanced. Polarity therapy is often given in a series of four sessions and may be accompanied by guidelines for diet and exercise.

As Elliot Greene states, “It is very common that someone will come in for one reason, and then they will discover another whole dimension to the problem or to themselves that they want to explore.”

Reiki. This is the Japanese word for “universal life force energy.” It is an ancient approach in which the practitioner is a kind of healer in the sense that he or she serves as a conduit for healing energy coming from the universe.

The Reiki energy enters the practitioner through the top of the head and exits through the hands, being directed into the body or energy field of the recipient. Reiki is another very subtle form of healing and may be done through clothing and without any physical contact between practitioner and client.

While all the above energetic methods appear to operate on different principles than most other varieties of massage therapy and bodywork, they nonetheless have an important and growing role.

Other Approaches

Integrative Methods. There are other approaches and combinations of approaches that do not fit neatly into any of the above categories. Many massage therapists and bodyworkers use combinations of approaches that could be called integrative massage or integrative bodywork.

CranioSacral Therapy^tm;. This approach was named in 1977 by John Upledger, D.O., and Ernest Retzlaff, Ph.D., to distinguish it from Sutherland’s cranial osteopathy. According to Upledger, “CranioSacral Therapy is not osteopathy. Sutherland’s approach was bone-oriented and you make bony corrections. This is soft tissue-oriented, fluid-oriented, membrane-oriented, and energy-oriented. It’s much more subtle than any other kind of cranial work I know of.”³

Palpation (touch by the practitioner) is used both to observe and treat dysfunctions in the craniosacral system, which includes the head, spinal column, and sacrum in one continuous membranous sheath. This system has its own pulse for circulating the cerebrospinal fluid (six to twelve cycles per minute) and the practitioner can feel the rate, amplitude, symmetry, and quality of the rhythm—somewhat analogous to pulse diagnosis in Ayurveda and Chinese medicine. Corrective pressure of only about five grams (the weight of a nickel) is applied to various areas to promote the re-establishment of a normal, symmetrical pattern of pulsation throughout the system. This in turn allows more efficient functioning of the entire nervous system throughout the body.

Upledger reports success in treating chronic pain, chronic brain dysfunctions when there is no structural problem involved, endogenous depression, migraines, learning disabilities, dyslexia, hyperkinesis, spasticity in cerebral palsy, strabismus (cross-eyes), Ménière’s disease (vertigo), and many other conditions.

Reflexology. This approach involves the manual stimulation of reflex points on the ears, hands, and feet. Similar methods resembling shiatsu and acupressure have also been practiced in China for thousands of years. Thumb pressure is applied to specific points that correspond somatotopically to specific areas or organs of the body.

Reflexology was introduced to this country by William Fitzgerald, who termed it “zone therapy,” in the early 1900s. One of the contemporary explanations for how it works is that compression by specific touch techniques affects a system of points and areas that are thought to “reflex” through neurological pathways to distant parts of the body. The pressure on these reflex points (also called “cuteneo-organ reflex points”) is used to relieve stress and tension, to improve blood supply, to promote the unblocking of nerve impulses, and to help restore homeostasis or balance in the body.⁴

Zero Balancing. This is a painless, hands-on method of aligning body energy with body structure. It is done through clothes and involves the practitioner in using gentle pressure at key areas of the skeleton in order to balance the energy body with the structural body.

The theory holds that each of us has an unseen energy body that exists like a glove surrounding the physical body. When injury or trauma occurs, healing of these two bodies does not necessarily occur simultaneously. “Balancing” refers to balancing the relationship between energy and structure. Zero Balancing seeks to bridge the gap between those methods that work with structure and those working with energy.

Prior to the advent of pharmaceutical medicine earlier in this century, references to massage therapy and research were not uncommon in the mainstream medical literature. There were over six hundred articles in various journals such as the Journal of the American Medical Association, British Medical Journal, and others from 1813 to 1939. A great deal of research was also conducted in Eastern Bloc countries and China. In this country after World War I, there was a precipitous decline in focus on this field as drugs and other allopathic interventions gained the foreground.

With the renewed interest in natural forms of treatment, research activity in massage and bodywork has again gained momentum. Studies have documented benefits for amputations, arthritis, cerebral palsy, cerebral vascular accident, fibrositis syndrome, menstrual cramps, paraplegia/quadriplegia, scoliosis, acute and chronic pain, acute and chronic inflammation, chronic lymphedema, nausea, muscle spasm, soft tissue dysfunctions, grand mal epileptic seizures, anxiety, depression, insomnia, and psychoemotional stress, which may aggravate significant mental illness. Following are a few examples of recent studies.

Massage in the Elderly. A controlled study showed massage therapy produced relaxation in eighteen elderly subjects. This study demonstrated physiological signs of relaxation in terms of decreased blood pressure and heart rate and increased skin temperature.⁵

Spinal Pain. A study of the combination of various types of massage in fifty-two patients with traumatically induced spinal pain led to significant reductions in acute and chronic pain and increased muscle flexibility and tone. This study also found massage to be extremely cost-effective in comparison with other pain therapies, with cost savings ranging from 15 to 50 percent.⁶

Pain Control. Massage has also been shown to stimulate the body’s ability to control pain naturally. One study showed that massage stimulates the brain to produce endorphins, chemicals that control pain.⁷

Lymphedema. Lymph drainage massage has been found to be more effective than mechanized methods or diuretic drugs to control lymphedema (a form of swelling) caused by radical mastectomy. It can be expected that using massage to control lymphedema will significantly lower treatment costs. This is based on a study comparing massage with the use of sleeve-like pressure cuffs often worn by women with lymphedema.⁸

Inflammatory Bowel Disease. A study found that massage therapy can have a powerful effect on psychoemotional distress in patients with chronic inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease. Stress can worsen the symptoms of these conditions, which can lead to great pain, bleeding, and hospitalization or death. Massage therapy was effective in reducing the frequency of episodes of pain and disability in these patients.⁹

Therapeutic Touch and Wound Healing. A controlled trial examined the effects of Therapeutic Touch on healing identical surgically inflicted minor wounds in the shoulders of forty-four male college students. Twenty-three received Therapeutic Touch treatments and twenty-one did not. Neither group was aware of the purpose of the experiment and those treated were not aware they were being treated. After eight days, the treated group’s wounds had shrunk an average of 93.5 percent compared to 67.3 percent for those untreated. After sixteen days the figures were 99.3 percent and 90.9 percent.¹⁰

Reflexology and PMS. A controlled clinical study of thirty-eight women with premenstrual syndrome examined the effects of a thirty-minute reflexology treatment weekly for eight weeks. Those receiving the treatment were treated by ear, hand, and foot reflexology. Those in the control group were given placebo or sham reflexology. Based on a daily diary that monitored the severity of thirty-eight premenstrual symptoms, the treated group had a 46-percent reduction, which was a significantly greater reduction than the 19-percent reduction of the control group.

Unlike some of the hormone-altering drugs and antidepressant medications that are often used, the treatment produced no side effects. The researchers concluded that reflexology might work by softening adrenocortical reactivity to stress, which is known to exacerbate symptoms in PMS.¹¹

Touch Research Institute, University of Miami

The most comprehensive program of massage-related research is the University of Miami’s Touch Research Institute. Created in 1991 by the school of medicine, it is the world’s first center for basic and applied research in the use of touch in human health and development. Directed by Tiffany Field, Ph.D., a professor of psychology, pediatrics, and psychiatry, the TRI has a multidisciplinary staff of forty scientists from the fields of medicine, biology, and psychology and another thirty visiting scientists from other universities participating in collaborative studies.

A plethora of studies have demonstrated impressive benefits for integrating massage therapy into medical care. In one study, premature infants treated with daily massage therapy gained 47 percent more weight per day and had shorter hospital stays by six days than those that were not massaged, resulting in cost savings of approximately $3000 per infant.¹²

A study of the effects of massage therapy on HIV patients found that those who received a massage five times a week for one month had higher numbers of natural killer (NK) cells, which were also more potent. They also had less anxiety and lower serotonin (stress hormone) levels.¹³

A third study involved giving massage therapy to fifty-two hospitalized depressed and adjustment disordered children and adolescents. A separate comparison group viewed relaxation videotapes. Those receiving the massage therapy were less depressed and anxious and had lower saliva cortisol levels, which is an indicator of less depression.¹⁴

Following is a list of other applications of massage therapy currently being studied at TRI:

• Newborns of cocaine-addicted mothers

• HlV-exposed newborns

• Infants of depressed mothers

• Infant colic

• Infant sleep disorders

• Infants with cancer

• Preschool children

• Neglected children

• Abused children

• Autistic children

• Posttraumatic stress disorder after Hurricane Andrew

• Pediatric skin disorders

• Asthma

• Diabetes

• Juvenile rheumatoid arthritis

• Depressed teenage mothers

• Teenage mothers’ childbirth labor

• Eating disorders

• Job performance/stress

• Pregnancy

• Hypertension

• HIV and improved immune function

• Spinal cord injuries

• Fibromyalgia syndrome

• Rape and spouse abuse

• Couples’ sex therapy

• Volunteer foster grandparents

• Arthritis

• Chronic fatigue syndrome

Bodywork Research

Little research has been conducted on the various forms of bodywork. One exception is Rolfing, for which several studies have found interesting effects.

In one controlled study, forty-eight participants were randomly assigned to either the experimental group (Rolfing) or a control group (no Rolfing). A significant decrease in anxiety was found in those who received the treatment over a five-week period. The researchers explained these findings in terms of the theory that the Rolfing caused a release of emotional tension that had been stored up in the muscles, which in turn resulted in lower anxiety scores on a psychological test of state anxiety.¹⁵

Other studies of Rolfing have found improvements in muscular efficiency,¹⁶ reductions in anxiety,¹⁷ decrease in pelvic tilt, and increase in vagal tone (amplitude of respiratory sinus arrhythmia, a heart rate function that corresponds with reduced stress in the body).¹⁸

Massage therapy and bodywork obviously have a very broad, diverse range of applications. Essentially, they can support any health condition that would benefit from greater blood circulation and the release of tension. Psychological conditions also are affected beneficially, as the physiological changes that occur with these kinds of intervention help harmonize and rebalance the nervous and hormonal systems.

There is great potential in using massage to reduce cumulative traumatic disorders in the workplace. For example, chicken cutters in chicken processing plants often develop carpal tunnel problems. Several companies in the chicken processing industry in Virginia have developed worksite massage programs that have shown impressive reductions in these problems. The most frequently used techniques include cross-fiber, deep tissue, and Swedish, concentrated on those muscle groups that are chronically stressed in the work (hands, arms, shoulders, and back). The programs also teach self-massage techniques and the results include better morale and reduced absenteeism.

Contraindications to massage or bodywork are few and may include transmittable skin diseases, unhealed wounds, postoperative conditions, and blood clots. In many cases, of course, such therapy can avoid problem areas in the body, assuming the practitioner is aware of the condition.

Many people wonder about whether massage or bodywork could cause a cancer to metastasize. According to Elliot Greene, “This is an area where research is needed to define the risk. Practitioners are generally taught to err on the side of conservatism. For example, massage is not recommended for someone immediately after chemotherapy or radiation treatment.

“Physiologically, it is not easy to metastasize a tumor from simple pressure and studies have shown that the body has a number of layers of defenses to prevent that from happening simply from touch. It is known, however, that certain kinds of chemotherapies in particular make the tissue fragile for a couple of days and massage immediately after such therapies might irritate the tissues. If there was any danger of metastasizing, it would be more likely to happen closer to the treatment. A conservative response would be to use much lighter forms of massage.”¹⁹

In fact, massage therapy is increasingly being incorporated into complementary cancer therapy programs. At the Cancer Support and Education Center in Menlo Park, California, it has been an integral part of a program that resulted in significant improvement in quality of life, even for patients with metastatic disease.²⁰

The ability of massage to reduce anxiety, depression, and stress is a logical counter to the strain a cancer patient must deal with in facing a life-threatening condition and traumatic treatment.

Hands-on therapies naturally foster a kind of intimacy between the practitioner and patient. In many of the approaches, the recipient partially or fully disrobes and lies on a table (though they are draped with a sheet and are never fully exposed), which further contributes to the intimacy and vulnerability that may be felt when using this tradition. Normal boundaries of social interaction are crossed. Hence there is a special need for sensitivity and regard for the client on the part of the practitioner that matches and perhaps even exceeds that of many doctor-patient relationships.

There is a wide range of attitudes among practitioners about how they view their role. Some think of themselves as healers or therapists, working with the whole person through the body. Certain approaches (e.g., the Rosen Method) are explicitly focused on engaging the person on the emotional level and working with emotional issues in the context of the body with subtle verbal suggestions. Others may take a more mechanistic approach toward working with the body. They may not wish to engage the client on the emotional level at all but rather concentrate on physical techniques. Some see themselves as facilitators, some as educators.

There is wide variation among practitioners, even within the specific approaches, as to how much verbal exchange takes place and the degree to which the practitioner is available for emotional or psychological support. Finally, some approaches require a series of sessions over a period of time (e.g., Rolfing, Hellerwork), which naturally fosters a therapeutic relationship and requires communication, instruction, and feedback. On the other hand, many European or Western forms of massage are complete in themselves as one session and do not really require any communication between practitioner and client. It is not unusual to experience an entire massage without a word being spoken.

The subjective experience of the client is generally the most important way of evaluating personal results. However, sometimes the change process naturally causes temporary discomfort, which needs to be accepted, so that expectations of feeling good may not always be appropriate.

Practitioners of the various methods can often also give the client feedback based on what they feel through their hands and what they see with their eyes.

Some modalities, particularly those of structural/functional/movement integration, use visual feedback in the form of having clients look at themselves in mirrors or even taking “before and after” photographs. The photographic record is particularly common in Rolfing and Hellerwork as a way of following progress over time.

Some of the movement integration therapies also use videotape to help observe changes in function, posture, and range of motion.

These modalities tend to be highly complementary to all other medical traditions. They can enhance the effectiveness of other forms of treatment by inducing relaxation, promoting circulation, and their other common benefits. They can also help patients tolerate more invasive approaches and handle the side effects of other treatments.

Costs tend to be higher in urban areas. Generally, the cost of massage therapy will range from $30 to $60 for an hour and will be somewhat lower in less urban environments. Cost of other more specialized modalities may be higher. Rolfing, for example, averages around $75 to $80 for a ninety-minute session and is ordinarily done in a series of ten sessions spaced at least a week

It should be noted that practitioners of many health care disciplines often learn some massage therapy techniques during the course of their training without necessarily having any of the following credentials. Thus they may practice massage therapy (and facilitate insurance coverage) under another kind of license or credential such as nursing, chiropractic, or the like.

The AMTA has recently begun to discourage practitioners from using initials after their names, feeling this may be confusing to the public because there is no standardization and such initials tend to mimic academic degrees. Instead the AMTA encourages practitioners to spell out what their credential is. In some states the use of initials is controlled (such as licensed massage therapist, L.M.T.), but in many states it is meaningless.

The most common titles for massage therapists are as follows:

Nationally Certified in Therapeutic Massage and Bodywork. This title designates the person has completed the requirements for and passed the National Certification Board for Therapeutic Massage and Bodywork (N.C.B.T.M.B.). This is the leading national certification exam.

Massage Practitioner (M.P.). This title is often used by practitioners whose training is less extensive than that required for certification by schools or by the AMTA as a massage therapist.

Certified Massage Therapist (C.M.T.). This is a voluntary, professional, non-governmental certification from organizations that can attest to the therapist’s competency. This is granted by many massage therapy schools, which may or may not meet AMTA standards for training. Thus the quality of this credential depends on the quality of the certifier and its standards. (For example, even a person who has only taken an eight-hour course can claim to be certified.)

Registered Massage Therapist (R.M.T.). This is a form of voluntary licensing for the use of a specific professional title. Rarely used in the United States, some Canadian provinces use this to designate government licensing. At one time it also designated a special credential for members of the AMTA who had advanced training in therapeutic massage and passed a special exam, but this usage has been discontinued.

Licensed Massage Therapist (L.M.T.). This refers to occupational licensing by a state or local government. Nineteen states have licensing laws requiring massage therapists to meet minimum standards of training. The basic requirement is usually five hundred hours of classroom training with instructors present, followed by a written and practical exam. The following states have licensing laws: Arkansas, Connecticut, Delaware, Florida, Hawaii, Iowa, Louisiana, Maine, Nebraska, New Hampshire, New Mexico, New York, North Dakota, Ohio, Oregon, Rhode Island, Tennessee, Texas, Utah, and Washington, D.C.

In states that do not require licensing, a good credential to seek is graduation from an AMTA-accredited program that meets the five hundred-hour standard. There are many schools of massage therapy and bodywork that require fewer hours of training (often one hundred to two hundred hours), so the extent of training is an important question in choosing a practitioner.

The American Massage Therapy Association is the predominant organization for massage therapists with over eighteen thousand members, representing all fifty states, D.C., the Virgin Islands, and several foreign countries. Membership is a good indication of professional preparation. It requires one of the following:

1. Graduation from a training program approved by the Commission on Massage Training Accreditation/Approval. This is an accreditation agency commissioned by the AMTA. This assures the practitioner has completed a program of a minimum of six months duration with five hundred in-class hours of training. There are currently fifty-eight massage therapy schools accredited by COMTAA. Subjects include anatomy and physiology, massage techniques, and practical training.

2. Holding a state license that meets AMTA certification standards.

3. Passing an AMTA membership entrance examination.

4. Passing the National Certification Examination for Therapeutic Massage and Bodywork. Six states have adopted this exam, developed by the AMTA, as their licensing exam. It is anticipated that eventually all the states that license massage will adopt this exam and the number of such states is expected to increase.

In early 1994 this exam was accredited by the National Commission for Certifying Agencies, a major independent agency that evaluates professional certification programs according to stringent standards.

Membership in the AMTA also requires six hours of continuing education every two years.

The AMTA publishes a membership registry for use by its members and provides referrals to local practitioners. Address: 820 Davis St., Suite 100, Evanston, IL 60201-4444, phone (708) 864-0123.

Other Forms of Bodywork or Energy Work


Finding a competent practitioner of the other forms of bodywork or energy work is essentially a matter of asking whether they are certified by the particular professional association for the method being used. Some practitioners integrate multiple methods, but if they are not certified in any one, their preparation is dubious. It is best to work with someone who has completed training and thereby has achieved a standard of expertise in at least one method.

Following are the professional associations for the most common forms of bodywork and energy work.

Rolf Institute of Structural Integration. The training is typically twelve months long for basic certification. A Certified Advanced Rolfer is one who has practiced at least five years and has taken an additional six weeks training. A list of certified practitioners is available. Address: 205 Canyon Blvd., Boulder, CO 80302, phone (800) 530-8875.

Hellerwork, Inc. Training is a 1,250-hour program leading to certification as a Hellerwork practitioner. Trainings are offered internationally. Address: 406 Berry St., Mt. Shasta, CA 96067, phone (800) 392-3900 or (916) 926-2500.

Rosen Method Professional Association. Certification training is two years plus an eighteen-month internship. Certified practitioners must also hold a state-approved massage certificate. A directory of practitioners is available from the association. Address: 2550 Shattuck Ave., Box 49, Berkeley, CA 94704, phone (510) 644-4166.

The Trager Institute. Training for Trager practitioners takes a minimum of 269 hours usually over at least six months. A list of certified practitioners is available. Address: 33 Millwood St., Mill Valley, CA 94941, phone (415) 388-2688, FAX (415) 388-2710.

The Feldenkrais Guild. Only people trained by Moshe Feldenkrais or graduates of guild accredited training programs are eligible to be members of the guild. Practitioner members are qualified teachers of Awareness Through Movement and Functional Integration. Associate members are qualified teachers of Awareness Through Movement. The professional training program spans 160 days over three and a half years. The guild publishes a directory of certified practitioners. Address: 3611 SW Hood Avenue Suite 100, Portland, OR 97201, phone (800) 775-2118 or (503) 221-6612, FAX (503) 221-6616.

North American Society of Teachers of the Alexander Technique (NASTAT) formed in 1987 to educate the public about the Alexander Technique, to establish and maintain standards for certification of teachers and teacher training courses in the United States, and to ensure that the educational principles of the Alexander Technique are upheld. It publishes a directory of certified teachers. Training to become a teacher takes three years (sixteen hundred hours). Address: P.O. Box 112484, Tacoma, WA 98411-2484, phone (800) 473-0620 or (206) 627-3766.

Nurse Healers Professional Associates, Inc., provides information about Therapeutic Touch and training for health care providers. The length of trainings varies and there is no formal certification. Address: P.O. Box 444, Allison Park, PA 15101, phone (412) 355-8476.

Jin Shin Jyutsu, Inc., is an organization for practitioners who have completed a five-day training course in this method. Practitioners are encouraged to repeat the basic training several times, but there is no formal certification. There is also an advanced course. Address: 8719 E. San Alberta, Scottsdale, AZ 85258, phone (602) 998-9331.

Jin Shin Do® Foundation for Bodymind Acupressure^tm; is a network of authorized teachers and registered practitioners who have received standardized training in this approach. Registered practitioners have 250 hours of training plus practical experience. A directory of registered practitioners and authorized teachers is available from the foundation. Address: 366 California Ave., Suite 16, Palo Alto, CA 94306, or P.O. Box 1097, Felton, CA 95018, or call J.S.D.F. in Palo Alto, CA at (415) 328-1811.

American Oriental Bodywork Therapy Association (AOBTA) is an educational and certifying organization for practitioners of a variety of forms of oriental bodywork. Associate members have at least 150 hours of training with a certified instructor and a hundred hours of practice. Certified practitioners have completed five hundred hours of such training and passed a certification exam. AOBTA has about eight hundred members and publishes a membership directory. Address: 6801 Jericho Turnpike, Syosset, NY 11791, phone (516) 364-5533.

Associated Bodywork and Massage Professionals (ABMP) provides professional support and legislative advocacy for massage therapists and bodyworkers. Membership is of two levels: practitioner level requires a hundred hours of training. Professional level requires five hundred hours or state licenser or registration. ABMP also publishes Massage and Bodywork Quarterly. Address: 28677 Buffalo Park Rd., Evergreen CO 80439, phone (303) 674-8478.

The Upledger Institute, Inc., is an educational and clinical resource and training center for manipulative therapies such as CranioSacral Therapy, visceral manipulation, and other holistically oriented approaches used by bodyworkers. Founded by John Upledger, D.O., it conducts training nationally and internationally. It also produces several instructional publications and a directory of alumni of its trainings. Address: 11211 Prosperity Farms Rd., Palm Beach Gardens, FL 33410, phone (800) 233-5880.

American Academy of Reflexology conducts training in ear, hand, and foot reflexology and can provide referrals to certified practitioners. Address: 606 E. Magnolia Blvd., Suite B. Burbank, CA 91501, phone (818) 841-7741.

International Institute of Reflexology conducts two-day trainings nationally and internationally and a certification exam in the Ingham Method of reflexology. They also can provide referrals to trained practitioners. Address: 5650 First Avenue North, P.O. Box 12642, St. Petersburg, FL 33733, phone (813) 343-4811.

Zero Balancing Association offers training in this method, a fifty-hour basic course, and an eighteen-month certification program. Address: P.O. Box 1727, Capitola, CA 95010, phone (408) 476-0665.

Nothing in this book should be considered as medical advice for dealing with a given problem. You should consult your health care professional for individual guidance with specific medical problems.

Prior to the advent of pharmaceutical medicine earlier in this century, references to massage therapy and research were not uncommon in the mainstream medical literature. There were over six hundred articles in various journals such as the Journal of the American Medical Association, British Medical Journal, and others from 1813 to 1939. A great deal of research was also conducted in Eastern Bloc countries and China. In this country after World War I, there was a precipitous decline in focus on this field as drugs and other allopathic interventions gained the foreground.

With the renewed interest in natural forms of treatment, research activity in massage and bodywork has again gained momentum. Studies have documented benefits for amputations, arthritis, cerebral palsy, cerebral vascular accident, fibrositis syndrome, menstrual cramps, paraplegia/quadriplegia, scoliosis, acute and chronic pain, acute and chronic inflammation, chronic lymphedema, nausea, muscle spasm, soft tissue dysfunctions, grand mal epileptic seizures, anxiety, depression, insomnia, and psychoemotional stress, which may aggravate significant mental illness. Following are a few examples of recent studies.

Massage in the Elderly. A controlled study showed massage therapy produced relaxation in eighteen elderly subjects. This study demonstrated physiological signs of relaxation in terms of decreased blood pressure and heart rate and increased skin temperature.⁵

Spinal Pain. A study of the combination of various types of massage in fifty-two patients with traumatically induced spinal pain led to significant reductions in acute and chronic pain and increased muscle flexibility and tone. This study also found massage to be extremely cost-effective in comparison with other pain therapies, with cost savings ranging from 15 to 50 percent.⁶

Pain Control. Massage has also been shown to stimulate the body’s ability to control pain naturally. One study showed that massage stimulates the brain to produce endorphins, chemicals that control pain.⁷

Lymphedema. Lymph drainage massage has been found to be more effective than mechanized methods or diuretic drugs to control lymphedema (a form of swelling) caused by radical mastectomy. It can be expected that using massage to control lymphedema will significantly lower treatment costs. This is based on a study comparing massage with the use of sleeve-like pressure cuffs often worn by women with lymphedema.⁸

Inflammatory Bowel Disease. A study found that massage therapy can have a powerful effect on psychoemotional distress in patients with chronic inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease. Stress can worsen the symptoms of these conditions, which can lead to great pain, bleeding, and hospitalization or death. Massage therapy was effective in reducing the frequency of episodes of pain and disability in these patients.⁹

Therapeutic Touch and Wound Healing. A controlled trial examined the effects of Therapeutic Touch on healing identical surgically inflicted minor wounds in the shoulders of forty-four male college students. Twenty-three received Therapeutic Touch treatments and twenty-one did not. Neither group was aware of the purpose of the experiment and those treated were not aware they were being treated. After eight days, the treated group’s wounds had shrunk an average of 93.5 percent compared to 67.3 percent for those untreated. After sixteen days the figures were 99.3 percent and 90.9 percent.¹⁰

Reflexology and PMS. A controlled clinical study of thirty-eight women with premenstrual syndrome examined the effects of a thirty-minute reflexology treatment weekly for eight weeks. Those receiving the treatment were treated by ear, hand, and foot reflexology. Those in the control group were given placebo or sham reflexology. Based on a daily diary that monitored the severity of thirty-eight premenstrual symptoms, the treated group had a 46-percent reduction, which was a significantly greater reduction than the 19-percent reduction of the control group.

Unlike some of the hormone-altering drugs and antidepressant medications that are often used, the treatment produced no side effects. The researchers concluded that reflexology might work by softening adrenocortical reactivity to stress, which is known to exacerbate symptoms in PMS.¹¹

Touch Research Institute, University of Miami

The most comprehensive program of massage-related research is the University of Miami’s Touch Research Institute. Created in 1991 by the school of medicine, it is the world’s first center for basic and applied research in the use of touch in human health and development. Directed by Tiffany Field, Ph.D., a professor of psychology, pediatrics, and psychiatry, the TRI has a multidisciplinary staff of forty scientists from the fields of medicine, biology, and psychology and another thirty visiting scientists from other universities participating in collaborative studies.

A plethora of studies have demonstrated impressive benefits for integrating massage therapy into medical care. In one study, premature infants treated with daily massage therapy gained 47 percent more weight per day and had shorter hospital stays by six days than those that were not massaged, resulting in cost savings of approximately $3000 per infant.¹²

A study of the effects of massage therapy on HIV patients found that those who received a massage five times a week for one month had higher numbers of natural killer (NK) cells, which were also more potent. They also had less anxiety and lower serotonin (stress hormone) levels.¹³

A third study involved giving massage therapy to fifty-two hospitalized depressed and adjustment disordered children and adolescents. A separate comparison group viewed relaxation videotapes. Those receiving the massage therapy were less depressed and anxious and had lower saliva cortisol levels, which is an indicator of less depression.¹⁴

Following is a list of other applications of massage therapy currently being studied at TRI:

• Newborns of cocaine-addicted mothers
  
• HlV-exposed newborns
  
• Infants of depressed mothers
  
• Infant colic
  
• Infant sleep disorders
  
• Infants with cancer
  
• Preschool children
  
• Neglected children
  
• Abused children
  
• Autistic children
  
• Posttraumatic stress disorder after Hurricane Andrew
  
• Pediatric skin disorders
  
• Asthma
  
• Diabetes
  
• Juvenile rheumatoid arthritis
  
• Depressed teenage mothers
  
• Teenage mothers’ childbirth labor
  
• Eating disorders
  
• Job performance/stress
  
• Pregnancy
  
• Hypertension
  
• HIV and improved immune function
  
• Spinal cord injuries
  
• Fibromyalgia syndrome
  
• Rape and spouse abuse
  
• Couples’ sex therapy
  
• Volunteer foster grandparents
  
• Arthritis
  
• Chronic fatigue syndrome
  

Bodywork Research

Little research has been conducted on the various forms of bodywork. One exception is Rolfing, for which several studies have found interesting effects.

In one controlled study, forty-eight participants were randomly assigned to either the experimental group (Rolfing) or a control group (no Rolfing). A significant decrease in anxiety was found in those who received the treatment over a five-week period. The researchers explained these findings in terms of the theory that the Rolfing caused a release of emotional tension that had been stored up in the muscles, which in turn resulted in lower anxiety scores on a psychological test of state anxiety.¹⁵

Other studies of Rolfing have found improvements in muscular efficiency,¹⁶ reductions in anxiety,¹⁷ decrease in pelvic tilt, and increase in vagal tone (amplitude of respiratory sinus arrhythmia, a heart rate function that corresponds with reduced stress in the body).¹⁸

Massage therapy and bodywork obviously have a very broad, diverse range of applications. Essentially, they can support any health condition that would benefit from greater blood circulation and the release of tension. Psychological conditions also are affected beneficially, as the physiological changes that occur with these kinds of intervention help harmonize and rebalance the nervous and hormonal systems.

There is great potential in using massage to reduce cumulative traumatic disorders in the workplace. For example, chicken cutters in chicken processing plants often develop carpal tunnel problems. Several companies in the chicken processing industry in Virginia have developed worksite massage programs that have shown impressive reductions in these problems. The most frequently used techniques include cross-fiber, deep tissue, and Swedish, concentrated on those muscle groups that are chronically stressed in the work (hands, arms, shoulders, and back). The programs also teach self-massage techniques and the results include better morale and reduced absenteeism.

Contraindications to massage or bodywork are few and may include transmittable skin diseases, unhealed wounds, postoperative conditions, and blood clots. In many cases, of course, such therapy can avoid problem areas in the body, assuming the practitioner is aware of the condition.

Many people wonder about whether massage or bodywork could cause a cancer to metastasize. According to Elliot Greene, “This is an area where research is needed to define the risk. Practitioners are generally taught to err on the side of conservatism. For example, massage is not recommended for someone immediately after chemotherapy or radiation treatment.

“Physiologically, it is not easy to metastasize a tumor from simple pressure and studies have shown that the body has a number of layers of defenses to prevent that from happening simply from touch. It is known, however, that certain kinds of chemotherapies in particular make the tissue fragile for a couple of days and massage immediately after such therapies might irritate the tissues. If there was any danger of metastasizing, it would be more likely to happen closer to the treatment. A conservative response would be to use much lighter forms of massage.”¹⁹

In fact, massage therapy is increasingly being incorporated into complementary cancer therapy programs. At the Cancer Support and Education Center in Menlo Park, California, it has been an integral part of a program that resulted in significant improvement in quality of life, even for patients with metastatic disease.²⁰

The ability of massage to reduce anxiety, depression, and stress is a logical counter to the strain a cancer patient must deal with in facing a life-threatening condition and traumatic treatment.

Hands-on therapies naturally foster a kind of intimacy between the practitioner and patient. In many of the approaches, the recipient partially or fully disrobes and lies on a table (though they are draped with a sheet and are never fully exposed), which further contributes to the intimacy and vulnerability that may be felt when using this tradition. Normal boundaries of social interaction are crossed. Hence there is a special need for sensitivity and regard for the client on the part of the practitioner that matches and perhaps even exceeds that of many doctor-patient relationships.

There is a wide range of attitudes among practitioners about how they view their role. Some think of themselves as healers or therapists, working with the whole person through the body. Certain approaches (e.g., the Rosen Method) are explicitly focused on engaging the person on the emotional level and working with emotional issues in the context of the body with subtle verbal suggestions. Others may take a more mechanistic approach toward working with the body. They may not wish to engage the client on the emotional level at all but rather concentrate on physical techniques. Some see themselves as facilitators, some as educators.

There is wide variation among practitioners, even within the specific approaches, as to how much verbal exchange takes place and the degree to which the practitioner is available for emotional or psychological support. Finally, some approaches require a series of sessions over a period of time (e.g., Rolfing, Hellerwork), which naturally fosters a therapeutic relationship and requires communication, instruction, and feedback. On the other hand, many European or Western forms of massage are complete in themselves as one session and do not really require any communication between practitioner and client. It is not unusual to experience an entire massage without a word being spoken.

The subjective experience of the client is generally the most important way of evaluating personal results. However, sometimes the change process naturally causes temporary discomfort, which needs to be accepted, so that expectations of feeling good may not always be appropriate.

Practitioners of the various methods can often also give the client feedback based on what they feel through their hands and what they see with their eyes.

Some modalities, particularly those of structural/functional/movement integration, use visual feedback in the form of having clients look at themselves in mirrors or even taking “before and after” photographs. The photographic record is particularly common in Rolfing and Hellerwork as a way of following progress over time.

Some of the movement integration therapies also use videotape to help observe changes in function, posture, and range of motion.

These modalities tend to be highly complementary to all other medical traditions. They can enhance the effectiveness of other forms of treatment by inducing relaxation, promoting circulation, and their other common benefits. They can also help patients tolerate more invasive approaches and handle the side effects of other treatments.

Costs tend to be higher in urban areas. Generally, the cost of massage therapy will range from $30 to $60 for an hour and will be somewhat lower in less urban environments. Cost of other more specialized modalities may be higher. Rolfing, for example, averages around $75 to $80 for a ninety-minute session and is ordinarily done in a series of ten sessions spaced at least a week apart.

Other modalities tend to fall within these ranges. Most insurance companies do not cover massage and bodywork, although such coverage is much more likely if it is prescribed by a physician. Massage therapy is more likely to be covered than the other methods, although a physician’s prescription and the licenser of the practitioner may help increase the chances.

Nothing in this book should be considered as medical advice for dealing with a given problem. You should consult your health care professional for individual guidance with specific medical problems.

For this chapter, the sections on varieties and techniques are combined. As stated earlier, there are over eighty different types of massage therapy and bodywork. Many are variations on each other, often developed by a practitioner who is trained in one particular approach and then goes on to develop his or her own variety, with its own new “brand name.”

Most varieties can be broken down into the following five broad categories:

Traditional European Massage

Contemporary Western Massage

Structural/Functional/Movement Integration

Oriental Methods

Energetic Methods (Non-oriental)

The majority of activity in this field is oriented toward the traditional European and contemporary Western forms of massage simply because there are such large numbers of practitioners of these methods.

Traditional European Massage

Traditional European massage includes methods based on conventional Western concepts of anatomy and physiology and soft tissue manipulation. There are five basic kinds of soft tissue manipulation techniques: effleurage (long flowing or gliding strokes, usually toward the heart, tracing the outer contours of the body), petrissage (strokes that lift, roll, or knead the tissue), friction (circular strokes), vibration, and tapotement (percussion or tapping).

Traditional European massage was brought to the United States by two doctors from New York who were brothers— Charles and George Taylor—who studied in Sweden and introduced Americans to Swedish techniques in the 1850s. After the Civil War, the first Swedish clinics opened in Boston and Washington, the latter frequented by U. S. Grant.

Swedish Massage. Swedish massage is by far the most predominant example of traditional European massage and it is the most commonly used method in the United States. It was developed by Per Henrik Ling in Sweden in the 1830s and uses a system of long gliding strokes, kneading, and friction techniques on the more superficial layers of muscles. It usually goes in the direction of blood flow toward the heart because there is an emphasis on stimulating the circulation of the blood through the soft tissues of the body. Swedish can be a relatively vigorous form of massage, sometimes with a great deal of joint movement included.

Oil is usually used, which facilitates the stroking and kneading of the body, thereby stimulating metabolism and circulation. Its active and passive movements of the joints promote general relaxation, improve circulation and range of motion, and relieve muscle tension. Swedish massage is often given as a complete, full body technique, though sometimes only a part of the body is worked on.

Contemporary Western Massage


This includes methods based primarily on modern Western concepts of human function, anatomy, and physiology, using a wide variety of manipulative techniques. These may include broad applications for personal growth, emotional release, and balance of mind-body-spirit in addition to traditional applications. These approaches go beyond the original framework or intention of Swedish massage. They include Esalen or Swedish/Esalen, neuromuscular massage, deep tissue massage, sports massage, and manual lymph drainage. Most of these are American techniques developed from the late 1960s onward, though the latter was developed in the 1920s.

Esalen and Swedish/Esalen. Esalen massage is a modern variation that was developed at the famous growth center, Esalen Institute in Big Sur, California. Its focus is not so much on relieving muscle tension or increasing circulation as it is on creating deeper states of relaxation, beneficial states of consciousness, and general well-being. Whereas Swedish is more brisk and focuses on the body, Esalen is more slow, rhythmic, and hypnotic and focuses on the mind/body as a whole.

Esalen massage is not widely taught as a pure form. Rather, a marriage of sorts has been formed by the integration of Swedish and Esalen as a way of incorporating the strengths of each. Many massage therapists describe their method as Swedish/Esalen, and this hybrid is commonly taught in massage schools.

Neuromuscular Massage. This is a form of deep massage that applies concentrated finger pressure specifically to individual muscles. This is a very detailed approach, used to increase blood flow and to release trigger points, intense knots of muscle tension that refer pain to other parts of the body (they become trigger points when they seem to trigger a pain pattern). This form of massage helps to break the cycle of spasm and pain and is often used in pain control. Trigger point massage and myotherapy are varieties of neuromuscular massage.

Deep Tissue Massage. This approach is used to release chronic patterns of muscular tension using slow strokes, direct pressure, or friction. Often the movements are directed across the grain of the muscles (cross-fiber) using the fingers, thumbs, or elbows. This is applied with greater pressure and at deeper layers of the muscle than Swedish massage and that is why it is called deep tissue.

It is also more specific. For example, in the case of someone with a sore shoulder, the practitioner may focus on the trapezius and the rhomboid underneath, trying to work in all the layers of muscle that might be involved. Deep tissue massage lends itself to being more focused on a problem area.

Sports Massage. This uses techniques similar to Swedish and deep tissue but more specifically adapted to deal with the needs of athletes and the effects of athletic performance on the body. Sports massage is used before or after events, as part of an athlete’s training regimen, and to promote healing from injuries.

As Elliot Greene explains, the problem with severe spasm is that it cuts off its own circulation and becomes a self-reinforcing syndrome. This is another case of opening up the flow of blood and lymph through the area, releasing adhesions, and using deep transverse friction to encourage the unhealed part of the muscle to heal.

Manual Lymph Drainage Massage. This approach improves the flow of lymph rhythmic strokes. It is used primarily in conditions characterized by poor lymph flow, such as edema.

Structural / Functional / Movement Integration


These approaches organize and integrate the body in relationship to gravity through manipulating the soft tissues, and/or through correcting inappropriate patterns of movement. These are methods that bring about more balanced use of the body and nervous system, creating greater integration and more ease of movement.

This category of approaches is interesting in that some do not even involve the practitioner touching the client. There is no clear line of demarcation between where the bodywork therapies end and the movement therapies begin. Furthermore, many practitioners use multiple techniques that integrate massage, deeper tissue work, and movement all in the same session with a client.

These approaches work on the body structure and how it moves. The most common approaches include Rolfing, Hellerwork, the Rosen Method, the Trager approach, the Feldenkrais Method, the Alexander Technique, and Ortho-Bionomy.

Rolfing. Rolfing is the most established method in this category. There are over eight hundred Rolfers practicing in twenty-seven countries, with about seven hundred in the United States.

Rolfing is a trademarked approach within the generic field of structural integration. It was developed by Ida Rolf, Ph.D., a biophysicist who earned her doctorate in the 1920s. She began doing her form of bodywork in the 1940s and 50s. Her clientele included Georgia O’Keeffe and Buckminster Fuller and she worked with other pioneers in the bodywork field. In the 1960s she began teaching at Esalen Institute. She formed the Rolf Institute of Structural Integration in Boulder, Colorado, in 1972.

Rolfing involves a form of deep tissue work for reordering the body so as to bring its major segments—head, shoulder, thorax, pelvis, and legs—into a finer vertical alignment. The technique loosens or releases adhesions in the fascia, the flexible tissue that envelops our muscles and muscle groups. The fascia is supposed to move easily and allow easy articulation or movement of muscles or muscle groups past each other. However, trauma such as injury or chronic stress can cause stuck points or adhesions, in which the fascia is in a sense frozen, not allowing full freedom of movement.

The Rolfer works to restore this freedom of movement, resulting in a more balanced, vertical alignment of the body and often a lengthening or expansion of the body’s trunk. Rolfing usually takes place over a series of ten organized sessions dealing with different areas of the body.

Hellerwork. This approach was founded by Joseph Heller in 1979. A former Rolfer, Heller developed a method that, along with structural reintegration, incorporates a movement reeducation process with exercises that teach stress-free methods for performing everyday movements such as standing, walking, bending, sitting, and reaching. (Since he left the Rolf Institute, Rolfing has also incorporated movement in its work.) Heller’s approach often includes video feedback to show clients how they move.

Hellerwork takes place in a series of eleven sessions. Each session includes about an hour of bodywork and a half hour of movement education. There are over 160 certified Hellerwork practitioners in twenty-three states and seven foreign countries.

Rosen Method. Marion Rosen began her career in the 1930s and is still actively teaching her technique today. She founded her training program in 1972. The Rosen Method sees the body’s tensions as indications of unexpressed feelings or other repressed or suppressed aspects of the self. The result of such holding patterns, which may be very subtle, can be lifelong patterns of tension or organic malfunction.

The Rosen Method uses gentle, nonintrusive touch and verbal exchange between practitioner and client to help draw the client’s attention to areas of holding. This serves to help the client become fully aware of how the patterns of tension are associated with emotional or unconscious material. This awareness itself is the key that allows the tension or holding patterns to be released. Often the tightness softens and the area that was being held begins to move easily with the breath.

In the words of Marion Rosen, “This work is about transformation, from the person we think we are to the person we really are.”

Trager. The Trager approach is a system of movement reeducation or psychophysical integration developed by Milton Trager, M.D. It uses gentle, noninvasive movements to help release deep-seated physical and mental patterns and in turn allow deeper relaxation, increased physical mobility, and better mental clarity.

A session is one to one and a half hours. The practitioner moves the client’s trunk and limbs in a gentle, rhythmic way so that the person experiences new sensations of freedom of movement. The practitioner’s concern is fostering a sense of freedom and lightness.

After the hands-on portion of the session, the client is given instruction in the use of Mentastics, a system of movement sequences developed by Trager for the purpose of re-creating and enhancing the sense of lightness and ease of movement initiated on the table. The benefits of the Trager approach are cumulative, though there is no set series of sessions.

Feldenkrais Method. This approach was developed by Moshe Feldenkrais, a Russian-born Israeli educator. It uses physical movement to focus learning on the juncture of thought and action. It is known for its ability to improve posture and flexibility and alleviate muscular tension and pain.

It works with the nervous system’s capacity for change and learning new patterns for moving, feeling, and thinking. The method involves two applications: Awareness Through Movement (ATM) and Functional Integration (FI). ATM consists of verbally directed, pleasurable, and effortless exercise lessons involving highly sophisticated movement sequences. FI is a one-on-one process that involves the use of specific skilled touch and passive movement. It is known for its ability to address serious muscular and neurological problems and improve human functioning.

The Alexander Technique. This is an approach to psychophysical reeducation. It was developed by the Australian actor F. M. Alexander and works with unconscious patterns of thinking and the resultant movements or postures that become set in the musculature. Such patterns can be made conscious so the student can then become aware of how he/she moves and can make the choice to change patterns, allowing more balance, grace, and ease of movement, thereby reducing and eliminating chronic tension or distortion in the musculoskeletal system. The relationships among the head, neck, and back are of particular importance.

The Alexander Technique is taught in private half-hour to hour lessons. The teacher works with the student to observe and change mind/body habits that interfere with optimal functioning. The teacher uses both verbal and hands-on guidance to help the student experience new ways of moving and embodying him- or herself. It is not a fixed series of treatments or exercises, but often a series of several lessons is recommended. Training to become a teacher takes three years (sixteen hundred hours).

Ortho-Bionomy. Ortho-Bionomy was developed in the 1970s by the bodyworker Arthur Lincoln Pauls. This approach uses gentle, relaxing movements and postures to help the body release tensions and muscular holding patterns. No force or pressure from the practitioner is used. Its goal is a restoration of structural alignment and balance.

Oriental Methods


Oriental methods are based on the principles of Chinese medicine and the flow of energy or chi through the meridians. The geography of the acupuncture meridians is relied upon to determine points of applying the techniques and the ultimate goal is restoration of harmony or balance in the flow of chi. These forms may also be used in concert with herbs and acupuncture.

Pressure is applied by finger or thumb tips to predetermined points rather than by the sweeping broad strokes of Western style massage. Strong pressure or very light pressure may be applied. There are over a dozen varieties of oriental massage and bodywork therapy, but the most common forms in this country are acupressure, shiatsu, Jin Shin Jyutsu, and Jin Shin Do® Bodymind Acupressure^tm.

Acupressure and Shiatsu. These are similar varieties of finger pressure massage. They are both based on applying pressure to a pattern of specific points that correspond with the acupuncture points. Pressure is applied with the thumb, finger, and palm rather than needles.

The goal is the efficient and balanced flow of chi through the meridians. It is believed that where there is tension being held in the musculature, the flow of chi is impaired through those areas, which can lead to chronic problems not only in the musculature but in the associated organs. Stretching and movement are also sometimes used.

Acupressure is the more generic term used for this approach and shiatsu is the Japanese version.

Jin Shin Jyutsu. This approach comes from an ancient Japanese healing tradition that uses touch to restore the internal flow of energy through the body by releasing energetic blockages. A session lasts about an hour and the client is fully clothed, lying on a table. The practitioner uses pulse diagnosis to identify energy blocks and then gently holds or touches a specific combination of two of twenty-six acupuncture points to allow release of the blockage.

As it is practiced in the United States the holding uses less pressure than other forms of acupressure or shiatsu and there is no application of massage-like movements to specific points. Rather the touch is very light and works to balance the flow of energy.

Jin Shin Do® Bodymind Acupressure^tm;. This approach was developed by California psychotherapist lone Marsaa Teeguarden. It applies stronger acupressure on the points and for a longer period of time than does Jin Shin Jyutsu. It focuses on the deep release of armoring (muscular tension of physical or emotional origins) through gentle yet deep finger pressure.

Jin Shin Do© incorporates Taoist breathing techniques, oriental acupuncture theory, Japanese finger pressure technique (sometimes holding points for as much as one to three minutes), and Reichian segmental theory (an understanding of how tensions in different parts of the body affect each other as well as particular feelings or emotions).

Energetic Methods (Non-oriental)


In a sense, all the oriental methods described above are also energetic methods in that they are working with energy according to principles of Chinese medicine and view the human being as an energy system. However, there are other energetic methods that are not based on Chinese principles. The most prominent of these are Therapeutic Touch, polarity therapy, and Reiki.

Therapeutic Touch. This method is unique in that it was born and reached its maturation within the context of conventional Western medicine. It was developed in the 1970s by Dolores Krieger, Ph.D., R.N., a professor at New York University, and Dora Kunz, a natural healer. It is a contemporary interpretation of several ancient healing traditions.

It is based on the principle that the human energy field extends beyond the skin and the practitioner can use the hands as sensors to locate problems in it that correspond with problems in the physical body. Disease is seen as a condition of energy imbalance or blocked energy flow. Assessment is done by passing the hands over the body from head to toe at about two to four inches above the surface.

The practitioner then serves as a conduit for universal energy, consciously and actively transferring energy into the recipient. The hands are used to direct and focus the energy, sometimes in rhythmical, sweeping motions. The method is initially taught “off body,” meaning the practitioner’s hands do not touch the physical body, though later with experience some physical touch may take place.

Since it is not necessary to touch the physical body (what is being touched is the energy field or energy body), this method can be applied in situations where the patient may not be able to tolerate contact (e.g., in postsurgical patients or burn victims). Sessions last up to thirty minutes and can be done sitting or lying down fully clothed.

Therapeutic Touch is currently taught in over eighty universities and thirty countries and is practiced by twenty to thirty thousand health care professionals in the United States and around the world.

Polarity Therapy. This is a form of energy work that was developed by Randolph Stone, a chiropractor, osteopath, and naturopath in the mid-1920s. The practitioner uses subtle touch or holding on specific points to harmonize the flow of energy through the body and also to enhance the body’s structural balance.

It is based on the principle that every cell has both negative and positive poles and the body is gently manipulated to enhance the energy flow. Emotional tension or physical pain are released as the flow of energy becomes more properly balanced. Polarity therapy is often given in a series of four sessions and may be accompanied by guidelines for diet and exercise.

As Elliot Greene states, “It is very common that someone will come in for one reason, and then they will discover another whole dimension to the problem or to themselves that they want to explore.”

Reiki. This is the Japanese word for “universal life force energy.” It is an ancient approach in which the practitioner is a kind of healer in the sense that he or she serves as a conduit for healing energy coming from the universe.

The Reiki energy enters the practitioner through the top of the head and exits through the hands, being directed into the body or energy field of the recipient. Reiki is another very subtle form of healing and may be done through clothing and without any physical contact between practitioner and client.

While all the above energetic methods appear to operate on different principles than most other varieties of massage therapy and bodywork, they nonetheless have an important and growing role.

Other Approaches


Integrative Methods. There are other approaches and combinations of approaches that do not fit neatly into any of the above categories. Many massage therapists and bodyworkers use combinations of approaches that could be called integrative massage or integrative bodywork.

CranioSacral Therapy^tm. This approach was named in 1977 by John Upledger, D.O., and Ernest Retzlaff, Ph.D., to distinguish it from Sutherland’s cranial osteopathy. According to Upledger, “CranioSacral Therapy is not osteopathy. Sutherland’s approach was bone-oriented and you make bony corrections. This is soft tissue-oriented, fluid-oriented, membrane-oriented, and energy-oriented. It’s much more subtle than any other kind of cranial work I know of.”³

Palpation (touch by the practitioner) is used both to observe and treat dysfunctions in the craniosacral system, which includes the head, spinal column, and sacrum in one continuous membranous sheath. This system has its own pulse for circulating the cerebrospinal fluid (six to twelve cycles per minute) and the practitioner can feel the rate, amplitude, symmetry, and quality of the rhythm—somewhat analogous to pulse diagnosis in Ayurveda and Chinese medicine. Corrective pressure of only about five grams (the weight of a nickel) is applied to various areas to promote the re-establishment of a normal, symmetrical pattern of pulsation throughout the system. This in turn allows more efficient functioning of the entire nervous system throughout the body.

Upledger reports success in treating chronic pain, chronic brain dysfunctions when there is no structural problem involved, endogenous depression, migraines, learning disabilities, dyslexia, hyperkinesis, spasticity in cerebral palsy, strabismus (cross-eyes), Ménière’s disease (vertigo), and many other conditions.

Reflexology. This approach involves the manual stimulation of reflex points on the ears, hands, and feet. Similar methods resembling shiatsu and acupressure have also been practiced in China for thousands of years. Thumb pressure is applied to specific points that correspond somatotopically to specific areas or organs of the body.

Reflexology was introduced to this country by William Fitzgerald, who termed it “zone therapy,” in the early 1900s. One of the contemporary explanations for how it works is that compression by specific touch techniques affects a system of points and areas that are thought to “reflex” through neurological pathways to distant parts of the body. The pressure on these reflex points (also called “cuteneo-organ reflex points”) is used to relieve stress and tension, to improve blood supply, to promote the unblocking of nerve impulses, and to help restore homeostasis or balance in the body.

Zero Balancing. This is a painless, hands-on method of aligning body energy with body structure. It is done through clothes and involves the practitioner in using gentle pressure at key areas of the skeleton in order to balance the energy body with the structural body.

The theory holds that each of us has an unseen energy body that exists like a glove surrounding the physical body. When injury or trauma occurs, healing of these two bodies does not necessarily occur simultaneously. “Balancing” refers to balancing the relationship between energy and structure. Zero Balancing seeks to bridge the gap between those methods that work with structure and those working with energy.

Nothing in this book should be considered as medical advice for dealing with a given problem. You should consult your health care professional for individual guidance with specific medical problems.

The developer of Functional Technique, Harold V. Hoover DO used the term ‘dynamic neutral’ to describe what it was that was being achieved as disturbed tissues were positioned in a state of ‘ease’.¹

As we examine the mechanisms of what is taking place when tissues are placed in a balanced state the terms ‘ease’ and ‘bind’ will frequently be used to describe the extremes of restriction and freedom of movement.

It was Lawrence Jones DO who first developed an approach to joint and soft tissue dysfunction which he termed ‘Strain and Counterstrain’ (SCS).²

Walther Describes Jones Discovery³

‘Jones’ initial observation of the efficacy of counterstrain was with a patient who was unresponsive to treatment. The patient had been unable to sleep because of pain. Jones attempted to find a comfortable position for the patient to aid him in sleeping. After twenty minutes of trial and error, a position was finally achieved in which the patient’s pain was relieved. Leaving the patient in this position for a short time, Jones was astonished when the patient came out of the position and was able to stand comfortably erect. The relief of pain was lasting and the patient made an uneventful recovery.’

The position of ‘ease’ which Jones found for this patient was an exaggeration of the position in which spasm was holding him, which provided Jones with an insight into the mechanisms involved.
Many hospitalised patients have been treated for their current pain and discomfort, without leaving their beds, using these methods.⁴

SCS requires verbal feedback from the patient as to pain in a ‘tender’ point, being palpated by the operator as a monitor while a position of ease is sought.

Where there is a language barrier, or someone has lost the ability to speak, or is too young to cooperate a need exists for a method which allowed the operator to achieve the same ends without words, in which the operator determines a position of ease by means of palpation alone, assessing for a state of ‘ease’ in the tissues.

1. Exaggeration of Distortion

This is an element of SCS methodology.

Consider the example of someone bent forward in psoas spasm/’lumbago’ in considerable discomfort or pain. The person would be posturally distorted – bent into flexion,together with rotation and sidebending.

Any attempt to straighten towards a more physiologically normal posture, pushing through the ‘barrier of resistance’ would produce pain.

However moving the area away from the restriction barrier (in this case bending forwards more), increasing the degree of distortion displayed would normally be easy and painless. After 60 to 90 seconds in such a position of ease, a slow return to neutral will commonly leave the patient somewhat or completely relieved of pain and spasm.

2. Replication of Position of Strain.

This is another element of SCS methodology.

If as someone bending they slip or their load shifts they might remain locked into a distorted position as in example 1.

If, as SCS suggests, the position of ease equals the position of strain – then they need return to flexion in slow motion until tenderness vanishes from the monitor/tender point and/or a sense of ‘ease’ is perceived in the hypertonic tissues. By adding ‘fine-tuning’ positioning to the position of ease achieved by flexion, greater reduction in pain can usually be achieved. This position is held for 60 to 90 seconds before slowly returning to neutral at which time a some resolution of hypertonicity and pain should be felt.

The position of strain is often an exact duplication of the position of exaggeration of distortion – as in example 1.

Limited Value

These two elements of SCS are described as examples only, since it is not a frequent occurrence to have patients describe precisely in which way there symptoms developed. Nor is obvious spasm such as torticollis or ‘lumbago’ the norm. Ways other than ‘exaggerated distortion’ and ‘replication of position of strain’ are needed to enable identification of positions of ease.

3. Jones’ Tender Points⁵

Through years of clinical experience Jones compiled lists of tender point areas relating to strain of most of the joints and muscles of the body. These ‘proven'(by clinical experience) points are usually found in tissues shortened at the time of strain, rather than those which were stretched.

New points are periodically reported – for example recent sacral foramen points relating to sacroiliac strains.⁶

Jones provided directions for achieving ease tender points being palpated involving maintenance of pressure on the tender point, or periodically probing it, as a position is achieved in which:
a/ there is no additional pain, and

b/ the monitor point pain reduces by at least 75%.

This is then held for an appropriate length of time (90 seconds according to Jones, however there ways of reducing this).

The person with acute low back pain, locked in flexion,will have a tender point in the abdominal muscles short at the time of strain (when the patient was in flexion). The position which removes tenderness from this will, as in previous examples, require flexion and probably some rotation and/or side-bending.

The problem with Jones’ formulaic approach is that the mechanics of the particular strain with which the operator is confronted may not always coincide with Jones’ guidelines. An operator relying on Jones’ formulae may find difficulty in handling a situation in which the prescription fails to produce results. It is suggested that a reliance on palpation skills and other positional release variations offers a more rounded approach to dealing with strain and pain.

4. Goodheart’s Approach^7,8

George Goodheart D.C. (the developer of Applied Kinesiology) has described an almost universally applicable formula which relies more on the individual features displayed by the patient, and less on rigid formulae as used in Jones’ approach.

Goodheart suggests that a tender point be sought in the tissues opposite those ‘working’ when pain or restriction is noted. If pain or restriction is reported or is apparent on any given movement, the antagonist muscles to those operating at the time pain is noted will be those that house the tender point(s).

In examples 1 and 2, of a person locked in forward bending with acute pain and spasm, using Goodheart’s approach, pain and restriction would be experienced as the person moved into extension from their position of enforced flexion.

Irrespective of where the pain is noted when trying to straighten from this position, the tender point would be sought (and subsequently treated by being taken to a state of ease) in the muscles opposite those working when pain was experienced – i.e. it would lie in the flexor muscles (probably psoas) in this example.

Tender points which are going to be used as ‘monitors’ during the positioning phase of this approach are not sought in the muscles opposite those where pain is noted, but in the muscles opposite those which are actively moving the patient or area when pain or restriction is noted.
Goodheart has added various refinement which reduce the amount of time the position of ease needs to be maintained, from 90 seconds to 30 seconds.

5. Functional Technique^9,10

Osteopathic functional technique ignores pain as its guide to the position of ease and relies instead on a reduction in palpated tone in stressed (hypertonic/spasm) tissues as the body (or part) is being positioned or fine-tuned in relation to all available directions of movement in a given region.

One hand palpates the affected tissues (moulded to them, without invasive pressure). This ‘listening’ hand assesses changes in tone as the operator’s other hand guides the patient or part through a sequence of positions which are aimed at enhancing ‘ease’ and reducing ‘bind’.

A sequence of evaluations is carried out, each involving different directions of movement (flexion/extension, rotation right and left, sidebending right and left etc) with each evaluation starting at the point of maximum ease discovered during the previous evaluation, or at the combined position of ease of a number of previous evaluations. In this way one position of ease is ‘stacked’ on to another until all directions of movement have been assessed for ease.

Were the same patient with low back problems(examples 1, 2) being treated using Functional Technique the tense tissues in the low back would be palpated. A sequence of flexion/extension, sidebending and rotation in each direction, translation right and left, translation anterior and posterior, and compression/ distraction, would be painlessly attempted, involving all available directions of movement of the area, until a position of maximum ease is arrived at and held for 30 to 90 seconds. This produces a release of hypertonicity and reduction in pain.

The precise sequence in which the various directions of motion are evaluated is irrelevant, as long as all possibilities are included. Only very limited range of motion would be available in some directions during this assessment and the whole procedure would be performed very slowly.

The position of palpated maximum ease (reduced tone) in the distressed tissues should correspond with the position which would have been found were pain being used as a guide, as in either Jones’ or Goodheart’s approach, or using the more basic ‘exaggeration of distortion’ or ‘replication of position of strain’.

6. Any Painful Point as a Starting Place for SCS.

All areas which palpate as painful are responding to, or are associated with, some degree of imbalance, dysfunction or reflexive activity which may well involve acute or chronic strain (see March, April and June articles in this series).

We might therefore consider that any painful point found during soft tissue evaluation, massage or palpation, including a search for trigger points, could be treated by positional release, whether we know what strain produced them or not, and whether the problem is acute or chronic.

The response to positional release of a chronically fibrosed area will be less dramatic than from tissues held in simple spasm or hypertonicity. Nevertheless, even in chronic settings, a degree of release and ease can be produced, allowing for easier access to the deeper fibrosis.

Treatment of painful tissue using positional release, is possible whether using reducing levels of pain in the palpated point as a guide or whether the concept of assessing a reduction in tone in the tissues is being used (as in example 5 above).

Anything from 20 to 60 seconds are suggested for holding the painless position of ease.

7. Facilitated Positional Release (FPR)¹¹

This involves the positioning of the distressed area into the direction of its greatest freedom of movement starting from a position of ‘neutral’.

The seated patient’s sagittal posture would be modified to take the body or the part (neck for example) into a more ‘neutral’ position – a balance between flexion and extension – following which an application of a facilitating force would be introduced. No pain monitor is used but rather a palpating/ listening hand is applied (as in Functional technique) which senses for changes in tone in distressed tissues as positioning is performed. The final ‘crowding’ of the tissues, to encourage a ‘slackening’ of local tension, is the facilitating aspect of the process. ‘Crowding’ might involve compression applied through the long axis of a limb, or directly downwards through the spine via cranially applied pressure.

The position of ease is usually suggested at just 5 seconds.

8. Induration Technique¹²

Marsh Morrison DC suggested very light palpation, using extremely light touch, as a means of the feeling a ‘drag’ sensation (see March issue of JACM) alongside the spine (as lateral as the tips of the transverse processes). Drag results from hydrosis, the physiological response to increased sympathetic activity, an invariable factor in skin overlying trigger and other forms of reflexively active myofascial areas. Once drag is noted pressure into the tissues normally identifies pain.

The operator stands on the side of the prone patient opposite the side in which pain has been discovered in paraspinal tissues.The point is held by firm thumb pressure while, with the soft thenar eminence of the other hand, the tip of the spinous process most adjacent to the pain-point is very gently eased towards the pain (ounces of pressure only) crowding and slackening the tissues being palpated, until pain reduces by at least 75%.

Somewhere within an arc involving a half circle, an angle of push towards the pain will be found to abolish the pain,lessening any palpated tension. This is held for 20 seconds after which the next point is treated. A full spinal treatment is possible using this extremely gentle approach which incorporates the same principles as SCS and Functional technique.

9. Integrated Neuromuscular Inhibition Technique¹³

INIT involves using the position of ease as part of a sequence which commences with the location of a tender/pain/trigger point, followed by application of ischemic compression (this is optional and is avoided if pain is too intense or the patient too fragile or sensitive) followed by the introduction of positional release (as in number 6 above).After an appropriate length of time during which the tissues are held in ‘ease’ the patient is asked to introduce an isometric contraction into the affected tissues for 7 to 10 seconds after which these are stretched (or they may be stretched at the same time as the contraction – if fibrotic tissue calls for such attention).

10. Fascial Release

Soft tissues are gently moved towards the direction of their greatest ease until ‘release’ occurs. The process is repeated until there exists symmetry of motion in all directions of possible motion.

11. Cranial Methods (applicable anywhere on the body)¹⁴

Restricted structures/tissues are taken towards their direction of greatest ease of motion, at which time this position is held until there is a sense of an attempt by them to return towards the direction from which they have come. This is gently resisted for a short time. Subsequently the barrier usually retreats and the tissues can be taken into greater ease in previously restricted directions, and the process is repeated.

Summary

All methods require positioning to be performed slowly without introducing any additional pain to the patient.

In all variations a slow return to neutral is advised following the holding of the position of ease.

Most of the positional release methods involve movement towards ease, away from bind, using a slackening or crowding of dysfunctional tissues in order to facilitate muscle spindle resetting and improved function.

Despite the gentleness of the methods there is almost always a reaction involving stiffness and possibly discomfort on the day following treatment, as tissues adjust to new their situation and adaptation processes accommodate to these changes.

References

1. Hoover H Collected Papers Academy of Applied Osteopathy Year Book 1969

2. Jones L Strain and Counterstrain Academy of Applied Osteopathy Colorado Springs 1981

3. Walther D Applied Kinesiology Synopsis Systems DC Pueblo Colorado 1988

4. Schwartz H The Use of Counterstrain in an acutely ill in-hospital population J. American Osteopathic Association 86(7)pp433-442 1986

5. Jones L op cit

6. Ramirez M et al Low Back Pain – Diagnosis by six newly discovered sacral tender points and treatment with counterstrain technique J American Osteopathic Association 89(7) pp905-913 1989

7. Goodheart G Applied Kinesiology Workshop Procedure Manual 21st Edition (Detroit – privately published) 1984

8. Walther D Applied Kinesiology Synopsis Systems DC Pueblo Colorado 1988

9. Hoover H op cit

10. Bowles C Functional Technique – a modern perspective J American Osteopathic Association 80(3)pp326-331 1981

11. Schiowitz S Facilitated Positional Release J American Osteopathic Association 90(2)pp145-156 1990

12. Morrison M Lecture Notes presentation/seminar Research Society for Naturopathy, London 1969

13. Chaitow L Integrated Neuromuscular Inhibition Technique British Journal of Osteopathy Vol13 1994 p17-20

14. Upledger J & Vredevoogd J Craniosacral Therapy Eastland Press Seattle 1983

Leon Chaitow DO, former editor of JACM, practices at The Hale Clinic London (0171-631-0156). He teaches widely in the UK, Europe and the USA, and is author of major textbooks including ‘Soft tissue Manipulation’ . He is a senior lecturer on the University of Westminster’s MA in Therapeutic Bodywork course.

Take the simple action of a firm dragging action of a digit or the thumb across an area of skin, in which hyperaemia is produced – a ‘red reaction’.

It is fascinating to go back through the history of bodywork and to find how many ways this simple method has been utilised.

Many researchers and clinicians have described an assortment of responses in the form of such ‘lines’, variously coloured from red to white and even blue-black, after application of local skin dragging friction, with a finger or probe.

In the early days of osteopathy in the 19th Century the phenomenon was already in use.

Carl McConnell D.O.stated the following in 1899:

‘I begin at the first dorsal and examine the spinal column down to the sacrum by placing my middle fingers over the spinous processes and standing directly back of the patient draw the flat surfaces of these two fingers over the spinous processes from the upper dorsal to the sacrum in such a manner that the spines of the vertebrae pass tightly between the two fingers; thus leaving a red streak where the cutaneous vessels press upon the spines of the vertebrae. In this manner slight deviations of the vertebrae laterally can be told with the greatest accuracy by observing the red line. When a vertebra or section of vertebrae are too posterior a heavy red streak is noticed and when a vertebra or section of vertebrae are too anterior the streak is not so noticeable’.

Much more recently, Marshall Hoag D.O. writes as follows regarding examination of the spinal area using skin friction:

‘With firm but moderate pressure the pads of the fingers are repeatedly rubbed over the surface of the skin, preferably with extensive longitudinal strokes along the paraspinal area. The blunt end of an instrument or of a pen may be used to apply friction, since the purpose is simply to detect colour change, but care must be taken to avoid abrading the skin. The appearance of less intense and rapidly fading colour in certain areas as compared with the general reaction is ascribed to increased vasoconstriction in that area, indicating a disturbance in autonomic reflex activity. The significance of this red reaction and other evidence of altered reflex activity in relation to (osteopathic) lesions has been examined in research. Others give significance to an increased degree of erythema or a prolonged lingering of the red line response’.

John Upledger D.O. writes of this phenomenon:

‘Skin texture changes produced by a facilitated segment [localised areas of hyper-irritability in the soft tissues involving neural sensitisation to long term stress] are palpable as you lightly drag your fingers over the nearby paravertebral area of the back. I usually do skin drag evaluation moving from the top of the neck to the sacral area in one motion. Where your fingertips drag on the skin you will probably find a facilitated segment. After several repetitions, with increased force, the affected area will appear redder than nearby areas. This is the ‘red reflex’. Muscles and connective tissues at this level will:

1. have a ‘shotty’ feel (like BBs under the skin);
   
2. be more tender to palpation;
   
3. be tight, and tend to restrict vertebral motion; and
   
4. exhibit tenderness of the spinous processes when tapped by fingers or a rubber hammer’.
   

Roger Newman Turner N.D., D.O. describes the research of another osteopath/naturopath, Keith Lamont N.D., D.O., who first described the ‘black line’ phenomenon:

‘It is a common observation of osteopaths who use a spinal meter, to detect the most active lesions, that pressure on either side of the spine with a hemispherical probe of approximately 0.5 cm diameter, will, in some patients, illicit a dark blue or black line. The pressure of the probe is usually very light since it is intended to register variations in skin resistance, but it has a pinching-off effect on the arterioles and venules of the capillary network beneath the skin. Local engorgement of the capillary bed with deoxygenated venous blood causes the appearance of the line which slowly fades as the circulation returns.’

This is considered to relate to a nutrient deficit in those patients in whom this sign is seen:
Keith Lamont, who first drew attention to the Black Line Phenomenon, has found that administration of vitamin E, bioflavonoid complex and homoeopathic ferum phosphate will correct this deficiency.

Bertrand DeJarnette D.C. the developer of sacrocranial technique, writes extensively on the subject of the ‘red reaction’-

He describes how he initially makes assessments of patients (partly based on blood pressure readings) into various categories, during which process he has them treated in order to alter the relative oxygenation levels which are assumed on the basis of these categories. None of these methods are pertinent to this survey of skin reactions, but are a necessary preamble to his descriptions, which would be confusing otherwise. In a ‘type 1’ patient, who has received the appropriate preliminary attention as outlined (‘carbon dioxide elimination technic’):

‘Sit or stand immediately behind the patient facing the patient’s back. Have the patient bend slightly forward. Be sure the light is even on the patient’s back to avoid shadows. Place the index and middle fingers of your right hand upon the 7th cervical vertebra, having the two fingers about an inch lateral from the spine of the 7th cervical vertebra. Keep the fingers evenly spaced as you go down the spine, so each line is as straight as possible. For the ‘Type 1’ patient (normal BP after appropriate techniques) use a light touch. To produce an even pressure of both fingers on the back they may be fortified by placing the fingers of the left hand over them. As you go down the spine, your pressure will be just hard enough to cause the fingers to dent the skin.

Now draw your fingers down the spine very quickly ending at the coccyx. Step back and watch the reaction. A red line will usually appear all the way down the spine. This soon starts to fade and the fading is what you must watch. The area that appears Reddest as this fading starts, is the major [lesion] for this patient and should be marked with a skin pencil. You will often notice on this type of patient that the major area is much wider than any other area of your lines down the back. This is caused by tissue infiltration’.

The ‘Type 2’ category patient will have slightly high blood pressure after DeJarnette’s preliminary treatment. After adopting the same starting position:

‘Making a firm pressure, draw fingers down the spine, with a fairly slow motion. You should be able to count to 15 while drawing the fingers from the 7th cervical to the coccyx, by counting steadily. With a good light on the back, the results should show a line which becomes red, some portions brighter and some very faintly coloured. Now watch the lines fade. The area which shows the Whitest is marked as the major [lesions] for this is the most anaemic spinal muscle area. It will be paler than any portion of skin on the patient’s body.’

Moving next to the final category which interests us in this survey, (patients with high blood pressure) DeJarnette asks that you adopt the same start position and then:
‘Making heavy pressure, come down the spine slowly, counting 20 as you go from 7th cervical to coccyx. Now watch the reaction. The line that shows the Whitest is the major [lesion]. In this type the blood pressure is over 180 (systolic) the whitest area shows a waxy, pale colour and may persist for several minutes.’

Professor Irvin Korr, writing of his years of osteopathic research described how this red reflex phenomenon was shown to correspond well with areas of lowered electrical resistance, which themselves correspond accurately to regions of lowered pain threshold and areas of cutaneous and deep tenderness.

He cautions:

‘You must not look for perfect correspondence between the skin resistance (or the red reflex) and the distribution of deeper pathologic disturbance, because an area of skin which is segmentally related to a particular muscle does not necessarily overlie that muscle. With the latissimus dorsi, for example, the myofascial disturbance might be over the hip but the reflex manifestations would be in much higher dermatomes because this muscle has its innervation from the cervical part of the cord.’

By use of a mechanical instrument which quantified the pressure applied at a constant speed, followed by measurement of the duration of the redness resulting from the action of the frictional stimulator on the skin, Korr could detect areas of intense vasoconstriction which corresponded well with dysfunction elicited by manual clinical examination.

It could be said that the opportunity to ‘feel’ the tissues was being ignored during all these ‘strokes’, and ‘drawing’ of the fingers down the spinal musculature.

This thought was not lost on Marsh Morrison D.C. who describes his views as follows:

‘Run your fingers longitudinally down alongside the dorsal and lumbar vertebrae (anywhere from the spinous processes extending laterally up to two inches) and stop at any spot of tissue which seems ‘harder’ or different from normal tissue. These thickened areas, stringy ligaments, bunched muscle bounds, all represent indurated tissue; they are usually protective and indicate irritation and dysfunction. Once these indurated areas are palpated press down and almost always they will be sensitive, indicating a need for treatment.’

Morrison used a technique for easing such contractions similar to that later described by Lawrence Jones D.O. in his Strain/ counterstrain system.

Osteopathic researchers, Doctors, Cox, Gorbis, Dick and Rogers, writing in 1983 (regarding their work on identification of palpable musculoskeletal findings in coronary artery disease describe their use of the ‘red reflex’ as part of their examination procedures (other methods included range of motion testing of spinal segments and ribs, assessment of local pain on palpation, and altered soft tissue texture). In this study the most sensitive parameters, which were found to be significant predictors for coronary stenosis, were limitation in range of motion and altered soft tissue texture.

‘Red reflex’ cutaneous stimulation was applied digitally in both paraspinal areas [T4 and T9-11] simultaneously briskly stroking the skin in a caudad direction. Patients were divided arbitrarily into three groups.

• a/ Grade 1 – erythema of the spinal tissues lasting less than 15 seconds after cutaneous stimulation.
  
• b/ Grade 2 – erythema persisting for 15 to 30 seconds after stimulation
  
• c/ Grade 3 – erythema persisting longer than 30 seconds after stimulation.
  

In this context the Grade 3 – maintained erythema – is seen to represent the most dysfunctional response.

Making Sense of the Red Reaction

Clearly there is a good deal to learn from and about the simple procedure of stroking the paraspinal muscles. Whether or not DeJarnette’s preliminary methods are validated does not alter the possible wisdom of his subsequent observations, employing as it does variable pressures and looking as it does at the fading of redness, rather than the initial red reaction itself, for evidence of altered function.

Similarly, Lamont’s nutritional observations would need verification, something which does not alter the fact that some patients demonstrate this unusual ‘black streak’. As with so much in palpation there is little question of ‘something’ being ‘felt’ or observed. It is the interpretation of what it means that excites debate.

The simpler observations of Upledger, Hoag, Morrison and McConnell are readily applicable, and should be tested against known dysfunction to assess the usefulness of these methods during assessment.

The research of Cox et al indicates that one musculoskeletal assessment method alone is probably not sufficiently reliable to be diagnostic, however when for example tissue texture, changes in range of motion, pain and the ‘red reaction’ are all used, a finding of the presence of several of these is a good indication of underlying dysfunction which may involve the process of facilitation.

A Simpler Use for the Reaction

A less complex use of the red reaction is to go back a century to McConnell’s method, described earlier in this special topic note, in order to highlight spinal deviations. By creating erythema paraspinally you can stand back and visualise the general contours of the spine as well as any local deviations in the pattern created by application of your firm digital strokes.

Question:

How do you know whether your palpating fingers or thumbs are applying equal pressure bilaterally during such assessments, or when palpating elsewhere, bilaterally?

A useful guide to the uniformity of pressure can be obtained by comparing the relative blanching of your nail beds; are they equally white, pink, red?

References

1. McConnell C The Practice of Osteopathy 1899

2. Hoag M Osteopathic Medicine McGraw Hill, 1969.

3 Upledger J. Vredevoogd W. Craniosacral Therapy, Eastland Press, Seattle 1983

4. Newman Turner R Naturopathic Medicine Thorsons, Wellingborough UK, 1984

5. DeJarnette B Reflex Pain (Nebraska,1934)

6. Korr I The Physiological Basis of Osteopathic Medicine, Postgraduate Institute of Osteopathic Medicine and Surgery, N.Y. 1970

7. Morrison M Lecture Notes, London 1969

8. Cox, Gorbis, Dick and Rogers Journal American Osteopathic Association vol.82 No.11 1983

Since the normal excursion of the straight leg into abduction is around 45º it is possible, by testing both legs in the manner described, to quickly evaluate whether they are both tight and short, or whether one is and the other is not. Even if both are tight and short one set of muscles may be more restricted than the other and this is the one to treat first, possibly using one of the various Muscle Energy Techniques (MET) which this article will describe.

Practice

It is suggested that before using MET clinically you practice performing palpation exercises for ‘ease’ and ‘bind’ on many muscles, until you are comfortable with your skill in palpating changes in tone. Subsequent articles in this series will explore assessment methods for shortness in specific muscles in greater detail.

Different Starting Points for MET

In order to use MET successfully the identification of the first sign of the barrier of resistance – where bind is first noted – is necessary – either as the starting point for MET in treating acute conditions, or as a marker when a starting point short of the barrier is selected in treatment of chronic conditions.

Goodridge continues his beginners exercise in MET application as follows:

‘By individually abducting the legs of the supine patient the operator compares the arc on one side with the arc produced on the opposite side. For example, if the abducted right femur reaches resistance sooner than the left, then restriction of abduction exists on the right. To reduce this restriction, the patient’s limb is positioned in that arc of movement, where resistance is first perceived, and at this point the operator employs MET to lessen the sense of resistance, and increase the range of movement.’¹

How is MET Used?

The following exercises in MET variations include the key features emphasised by some of the leading contributors to MET methodology.

Post Isometric Relaxation (PIR).

Having established the barrier of resistance where, in Goodridge’s words, ‘resistance is first perceived’:

• The patient/model is asked to use no more than 20% of their available strength to try to take the leg gently back towards the table, i.e. to adduct the leg, against your firm, unyielding resistance.
  

  
  

• In this example they are trying to pull the limb away from the barrier, while you hold it at the barrier.
  

  
  

• The patient/model should be using (contracting) the agonist, the muscle(s) which requires to be released because its shortness is preventing a full range of movement. In this example it is the inner thigh muscles, adductors and medial hamstrings which need releasing and which therefore are asked to contract during MET.
  

  
  

• As the patient holds the light contraction they are commonly asked to hold their breath.
  

  
  

• The isometric contraction should be introduced slowly and resisted without any jerking, wobbling or bouncing.
  

  
  

• Maintaining the resistance to the contraction should produce no strain in the operator.
  

  
  

• The contraction should be held for at least 7, and ideally 10, seconds – the time it is thought necessary for the ‘load’ on the Golgi tendon organs to become active and to neurologically influence the intrafusal fibres of the muscle spindles which inhibits muscle tone, so providing the opportunity for the area (muscle, joint) to be taken to a new resting length/resistance barrier without effort, or to stretch it through the barrier of resistance, if this is appropriate (see below).²
  

  
  

• The instruction is given, ‘Now let your breath go and release your effort, slowly and completely’ – while you maintain the limb (in this example) at the same barrier.
  

  
  

• The patient/model is asked to breathe in and out once more and to completely relax, and as they exhale you gently guide the limb to the point where you now sense a resistance barrier/bind.
  You should almost always have created an increased range, by a significant degree.
  

  
  

• After Post Isometric Relaxation (PIR) a refractory or latency period of anything from 15 to 30 seconds exists during which the muscle can be taken to its new resting length (where ‘bind’ begins) , or it can be tretched more easily than would have been the case before the contraction.³
  

What Alternative MET Methods are There?

You could repeat the exercise precisely as described above, working from the resistance barrier. This is Lewit’s PIR method and is ideal for releasing tone, for relaxing spasm, in acute conditions.⁴

Janda’s Approach for Chronic/Fibrotic Tissues⁵