Prepared for the Australian Association of Massage Therapists, April 2004
Massage is often the first recourse for people with sore and aching muscles, and massage has been practised with these problems in mind for thousands of years. Few working practitioners confine themselves to these problems today, however. The range of problems considered tractable to the various forms of massage is vast; examples include general and specific tension associated with stress, neck and back problems, postural problems, sporting injuries, digestive problems, headaches, and the pursuit of enhanced well being.
All forms of massage use manual techniques applied to the surface of the body. The general goal is reduction of tension held in the muscles and fascia (or a redistribution of tension, according to principles that vary between different forms of massage), and that, among other effects, blood flow will be enhanced and the state of mind improved.
The deep belief of any bodywork technique is that improvement in health will follow this kind of physical intervention. In this note, I wish to argue for an addition to your present techniques – specific stretching exercises – and will support this with reference to a branch of philosophy, called supervenience theory.
The term ‘supervenience’ describes the relationship between ‘global properties’ of all complex systems and the ‘subvening’ (or smaller, comprising) parts. By ‘global’ we mean large-scale properties or functions. For example, talking about a patient, the term could mean the capacity to place a hand on the back between the shoulder blades. By ‘subvening,’ we mean the comprising systems, or their parts. In this example, this could include the skeletal system, the circulatory system, the nervous system and so on. In oriental systems the skeletal system would be part of the explanation, but so too would the meridian systems, and that mysterious substance ch’i.
The only relation between levels in complex systems can be stated simply: there can be no change at any level without a change at an underlying level. Specifically, bringing about change to a supervening property (or function) entails a change to either the properties of one or more of the subvening parts, or a change to the relationship between these parts. As far as anyone has observed, the supervenient relation is always found when complex systems are observed. Until recently, however, this relation was thought to be too general to be any practical use.
For all practitioners, supervenience is the fundamental relation that underlies the interventions that occur in clinics every day. Within these relations, a smaller set of relations is found – cause and effect, or symptom and cause.
Very few problems treated by massage are single cause problems, such as when a patient presents to hospital with a broken bone, for example. The vast majority of general health problems are multi-causal; accordingly, a real problem for the practitioner is ‘what is the relationship between the causes identified in the system?’ Do they interact (assuming two causes) in such a way that they add to each other making the condition worse, or do they perhaps balance each other with no net effect, or does the presence of one cause render the other possible cause inactive?
Back pain can help illustrate the problem. The anatomically-short leg is an accepted cause of low back pain (through the asymmetrical stresses imposed on the spine through pelvic obliquity; see Laughlin, 1998, p 157ff. for a detailed analysis) but having one leg shorter than the other may be an aggregating (additive) or a countervailing (making neutral) cause of middle back pain, and similarly for neck pain – depending on (for example) which is the patient’s dominant arm. The point is that a shorter leg may cause one problem (back pain), yet may help neck pain.
Consider a patient with a shorter right leg and whose spine has adapted in a subtle ‘S’ shape in the plane between the shoulders, as would be seen from behind (see Travell & Simons, 1992, p. 54, or Laughlin 1998, p. 172). Other things being equal, this patient will carry the left shoulder on the outside of a right-facing thoracic concavity, and the muscles of the thoracic spine are usually more developed on the outside of this curve, as a necessary adaptation to the effects of gravity – more work is done by these muscles to hold the body straight. This can explain why a right-handed patient can have more tension on the left thoracic spine.
If this patient is left-handed, the shorter right leg may be an aggregating cause for middle back pain (tension from two causes being experienced at the same point), but if the patient is right-handed, the same phenomenon may cancel the first cause – and the patient who otherwise might be expected to have neck pain (through right-arm dominance) is pain free!
Too often, however, obvious cause(s) for a patient’s problem cannot be found. Does this reduce you to treating symptoms – in fact, to giving the sort of treatment that other branches of medicine are sometimes criticised for? Not at all. The most useful aspect flowing from the supervenient relation is that if we cannot locate cause(s) for which we have treatment, we do not need to know the precise cause or causes of the problem to know that beneficial intervention is still possible.
We choose a function or functions which we know are out of the normal range (or out of balance, if doing left/right comparisons within an individual) and prescribe techniques that we know are likely to improve the function, being confident that if sufficient change is provoked in the patient then other supervenient properties – like pain or dysfunction – will also be altered. This is where stretching exercises come into their own.
Suppose that you have a patient with low back pain on one side, but there is no evidence of a leg-length difference or significant asymmetry in lifestyle. We know from the symmetry of the skeleton in the coronal plane that certain functions deriving from this plane should also be symmetrical. In every case of back pain I have come across in more than twenty years of practice, this has not been the case – and this observation is independent of whether the patient is flexible or inflexible compared to the normal population.
Accordingly, we test certain functions, using specific parts of exercises: left/right rotation, left/right lateral flexion, left/right hip flexion, and left/right hip extension. In all cases treated so far, these four simple tests reveal characteristic asymmetrical patterns.
We treat the tighter of the patterns with specific exercises and we find that the problem resolves itself as the patient acquires functional symmetry. The practitioner does not need to know which structures are involved, or why. Instead, the power of the supervenient relation is exemplified. The practitioner begins by identifying deficient function, which will be a suitable supervenient property of the system, chosen with respect to general knowledge of the system, and will prescribe a range of techniques known to improve the particular function. If treatment is successful, improvement in function leads to improvement of the original condition – here, decrease in pain, another supervenient property of the system.
In conclusion, appropriate stretches should be used with your clients, and taught to them at the conclusion of the treatment. You will need to know which ones, and how to teach them properly! Because your treatments will be longer-lasting and more effective if you do, your reputation will be enhanced. Your client base will increase, because word-of-mouth advertising is still by far the best, and certainly it’s the cheapest! And your practise will improve because you will not be seeing the same clients week after week with little or no change: when you show them the right stretching exercise, they start to take responsibility for their own problems and, as we all know, until that happens no real change is possible.
Laughlin, K., 1995. Overcome neck & back pain. Simon & Schuster, 3rd edition, revised, 1998.
Travell, J.G. and Simons, D.G., Volume1, 1983; Volume II, 1992. Myofascial pain and Dysfunction: The Trigger Point Manual. Williams & Wilkins, Baltimore.
Kit is the author of Overcome Neck & Back Pain, and the presenter of the national workshops of the same name, as well as the originator of the Posture & Flexibility* system. His PhD (ANU) research examined the relationship between information generated in different disciplinary frameworks. [* Former name of Stretch Therapy.]