July 26, 1989


Integrating diagnosis and treatment for massage

How does the practitioner integrate diagnostic processes (such as leg-length testing and assessment of patterns of functional flexibility) into a treatment?

The question of how the practitioner can incorporate diagnostic techniques (assessment of structural and functional considerations deemed relevant to the patient’s problem) into a standard massage treatment is not an easy one to answer. This question give rise to two additional questions: what are the expectations of the patient, and how may they be changed for the patient’s ultimate benefit?

What is the reason for treatment?

The first question may be reworded: for what ostensible reason is the patient coming to see you? The reasons are many and varied, but chief among them are stress management, neck, middle or lower back pain, optimisation of well-being, or some specific musculoskeletal problem. If stress management is the reason, then the practitioner can explain during the treatment that the tension that is being explicitly dealt with in the massage session is in fact the body’s most fundamental reaction to stress. Accordingly, any one of the orthodox approaches to reducing stress is then a natural subject to which the conversations can turn. So, for example, one might talk about relaxation techniques (usually a more gentle term to use than meditation, the use of which can alarm some patients), or the use of stretching exercises to change tension patterns. It is a perfectly reasonable matter, then, to offer to teach the patient a number of such exercise at the conclusion of the session. One could shorten the actual massage part of the session by 10 or 15 minutes explicitly for this purpose. If the use of the exercises by the patient makes a difference to this very common problem, you can be sure the patient will ask you for additional stretching exercises at a future consultation. Over time, one may devote the entire hour to stretching exercises if the patient so wishes.

The Japanese Ambassador

There are patients, however, who only wish their symptoms to be dealt with. For example, when the Japanese ambassador first came to me for treatment, he said that the time he spent in my clinic was the only time in his working week that he could completely escape business and political considerations. Of course, under these sorts of circumstances, one is happy to enter into an explicit treatment of symptoms. As time went by, however, he informed me of a shoulder problem that had been troubling him for many years. So, in line with the model outlined above, I spent some time with him at the end of the treatment (still within the treatment hour) working on his shoulder problem with specific stretching exercises. The fact is that I had worked on his shoulder with massage and shiatsu techniques meant that the stretches were even more effective than they would have been if done on their own. In time the problem resolved.

Neck or back pain

One of the most common reasons for a patient to come to a massage practitioner is for the treatment of the neck or back pain. The practitioner needs to realise that a patient has a specific idea of what it is they want from you, but often lacks the language or concepts with which to articulate their concerns. In the case of neck and back pain, during the taking of the patient history before the massage commences, the practitioner can float the idea of doing a structural and functional analysis some time in the future as a means of making concrete some possible causes of their problem. The initial consultation then proceeds as normal, with a standard massage being performed. During the massage, the practitioner is gaining a much clearer idea of where the patient hold tension, and possibly where the patient lacks strength as well. For example, in the case of neck pain, levator scapulae can explicitly palpated and its tension in relation to surrounding tissues assessed. In the case of back pain, erector spinae (or even quadratus lumborum, If the practitioner is sufficiently skilled) may be palpated, assessed and treated. Comparisons of left/right development of muscles articulating the spine can be made.

Talking about future sessions

At the end of the treatment, keeping these considerations in mind, one may suggest that a future treatment sessions be devoted to a structural and functional analysis, in order to move the treatment away from symptomatic to an understanding of underlying cause. This will entail the possible uncovering of underlying causes such as structural leg-length difference and a comparison of left/right patterns of flexibility. Following this, you might say, certain stretching exercises will be indicated, and offer to spend a future sessions doing practising these.

Specific conditions

If the patient is coming to see you for a specific musculoskeletal problem, it is an easy matter for the practitioner to suggest stretching or strengthening exercises as the patient’s homework, and be certain that this course of action is very likely to yield much faster results than simply being treated by massage. This is because dysfunctional patterns of flexibility or dysfunctional motor patterns are the main reason for these kinds of problems. The vast majority of musculoskeletal problems (including, of course, neck and back problems) may be said to be the result of inefficient biomechanics, but so saying does not indicate specific treatment directions. To move beyond a mere description of the problem (even though ‘biomechanical’ does has a nice scientific ring about it!) to a treatment of its cause(s) requires that some analytical process be used. As I have published elsewhere, one such specific and repeatable process is the assessment of physical functions in terms of insufficient flexibility or lack of strength. This relatively simple analysis yields specific treatment recommendations: stretching exercises for areas that testing reveals to be tight in comparison with what is ‘normal’ for that patient and strengthening exercises for areas shown to be weak. This latter assessment will require an understanding of which muscles need to be activated and how strong they need to be in relation to other muscles.

Going beyond a ‘condition’ or ‘problem’

There is a further consideration in recommending specific stretching and strengthening exercises, and that is the notion of empowerment. Far too many practitioners – deliberately or inadvertently – disempower their patients. That is, from the very first consultation, an atmosphere can be created wherein the practitioner and the patient both regard the patient as the more-or-less passive recipient of the treatment being practised. In other words, the practitioner is put forward implicitly as the fount of wisdom, and the patient the vessel. Apart from being patronising, a great deal of recent research in medical anthropology suggests strongly that the likelihood of successful resolution of any problem is lessened considerably if the patient is not actively involved in his or her treatment.

States of mind

So we might say that one could have a process reason for recommending stretching or strengthening exercises (that your analysis has yielded an understanding of specific biomechanical problems in the patient’s system) and a psychological reason. This latter reason is simply (and very importantly) the creation of an optimistic state of mind in the patient, and the passing on of specific tools for the patient to use to resolve his or the problem. This gives the control of the problem largely to the patient – in my view an essential first step up for full, permanent resolution of the problem. Until the patient takes responsibility for his or her own problem, the problem is likely to recur regardless of how effective your treatment is. And please do not be like the practitioner I worked with once who, by the afternoon of the second day of a workshop could see how effective the techniques are, and, accordingly, was terrified about his patients getting better and no longer needing to come to see him! Embrace success, and be assured that if you can actually help someone’s problems, they will tell everyone they know, and there is no doubt at all that word-of-mouth advertising is the best.

Integration of treatment elements

If the practitioner embraces an analytic protocol as, for example, outlined in the book Overcome neck & back pain, the structural and functional analysis will take about 30 minutes in total. Assuming a treatment hour, the remainder of the time can be used in the teaching what the analysis reveals to be the most likely significant two or three exercises. At a future consultation, you will be able to concentrate on whichever muscles the analysis has revealed to be excessively tight, in addition to the massage process that you usually use. At the conclusion of the massage, spend 10 minutes reviewing the previously-taught exercises with the patient. Experience has shown that no matter how well these exercises are taught the first time, reviewing them a week or a couple of weeks later will reveal practise errors; we are all human, after all, and patients (and practitioners) alter the form of an exercise to make it more comfortable, and often avoid the target area as a result.

Progressing the intensity of the exercises

I have found that once the pain of the initial problem has receded, it is usually necessary to teach some strengthening exercises in order that the patient returned to full normal (or, desirable) function. We might say that in order for rehabilitation to be considered complete, the patient must move beyond the pre-injury state of fitness that led to the initial problem. In respect of neck pain, the anterior neck muscles usually need strengthening. Any tendency to carry the head forward of the ideal position will also need to be corrected, and this usually requires the strengthening of muscles in the lower abdominal area. In addition, it will be necessary to check the flexibility of the hip flexors, iliopsoas and rectus femoris, in particular. This is because the research has shown that an anterior pelvic tilt can be the main cause of the forward-head posture.

Unstable exercises

If lower back pain is the initial consultation problem, it is usually necessary to teach effective strengthening exercises for particular muscle groups once the pain has settled down. Without wanting to preempt your testing procedures, experience has shown that the lower abdominal muscles, transversus abdominis, and the relationship between the strengths of the internal and external obliques usually needs attention. Recent work I have done with Paul Chek confirms the claim that strengthening exercises are most efficiently done using an exercise ball. All of the abdominal strength the exercises in my book Overcome neck & back pain can be done this way. I believe the usefulness of the exercise ball lies in the elicitation of some primitive reflex arcs, which in turn reactivate the righting and tilting reflexes. The reason this is important is that life, and inefficient exercise patterns, tends to worsen existing imbalances and frequently strengthens the upper abdominals preferentially. As these attach to the ribs, increasing their strength without attention to how the body uses the other abdominal muscles can actually worsen one’s posture. Exercising over the Swiss ball, an extremely unstable environment (especially for those people who have never done any strengthening exercises before) wakes up the fundamental reflexes and allows the patient to re-establish desirable patterns. I am happy to report here that results come extremely quickly, especially with patients to have no experience with exercise.

In conclusion

Speaking generally, massage practitioners are uniquely poised to take advantage of recent breakthroughs in rehabilitation medicine techniques. Because of the physical basis of the massage practice, many practitioners already have a deep intuitive understanding of how the parts of the body work together. To make massage practitioners the preeminent rehabilitation practitioners in the new millennium, all that is needed in my view is to acquire an effective understanding of efficient stretching and strengthening exercise techniques in addition to the specific massage modality one uses.

It is no accident that massage practitioners are very often the first recourse in people’s daily life problems. This is because massage therapy has a very low incidence of unwanted side effects and because the treatment is with friendly and supportive. The atmosphere created in the treatment facilitates a deep exploration of the causes of any particular problem – psychological and emotional as well as physical. It is also no accident that massage practitioners form the bulk of those who attend my workshops – and others who teach similar techniques – and are among the most open minded of practitioners, too.

As an aside, it is for this reason that I’m somewhat concerned to see the trend in massage therapy going towards more and more formal qualifications. This is not to say that there are not specific areas of knowledge that are essential to good, and safe, practice. My concern is that as the focus in massage goes towards the academic style of learning, the foundation of good practice – exquisitely sensitive sense of touch and an understanding of how to change the state of the tissue underneath one’s hands – may be lost. I urge practitioners to maintain the tactile foundation of their practice and augment it with knowledge that can be explicitly and efficiently applied in your practice, and the experiential learning of stretching and strengthening exercises is one of the most grounding and effective ways of achieving this.

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