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"The Critical Role of Orthopedic Massage in Sports Medicine" by James Waslaski International Author and Lecturer
In 1998 I had the opportunity to teach at the Olympic Training Center in Australia about the vital role of orthopedic massage for Olympic caliber athletes. I was delighted to find that the entire staff at the Olympic Training Center attended my workshop with open minds. We were surrounded by physiotherapists, orthopedic physicians, osteopaths, chiropractors, sports psychologists, nutritionists, and sports massage therapists. Much to my delight they all left their credentials out the door and came together with the best interest of the athlete in mind. The entire staff had frequently met to teach each other how to best integrate all the varying disciplines, in order to optimize athletic performance, and how to best prevent and rehabilitate sports injuries. This was quite unlike what I had experienced throughout the United States where it was not uncommon to experience "turf wars" between various medical experts as a result of egos, differences in training, and competition to work with world class athletes. This began my passionate journey to go back to other countries and try to blend as many disciplines as possible to build a large tool box and enhance everyone's ability to treat complicated sports injury conditions.
In this desperate journey to build a large tool box, I was fortunate to have many mentors including chiropractors from Florida, osteopaths from Scotland, leading physiotherapists from Australia, top sports massage therapists from the United States, sports psychologists, orthopedic surgeons, and many other experts in the field of chronic pain and sports injuries. However, many of these experts had a major difference of opinion on how to best treat complicated sports injuries, which often allowed the athlete to slip through the cracks and stay injured in our traditional sports medicine system. Through my own frustration I have found a way to blend as many disciplines as possible and build a great referral team of open minded medical experts that have the client's best interest in mind.
In this particular article I intend to talk about two of the pieces I was able to add to the tool box of all medical experts in order to treat conditions that often fall through the cracks in our current sports medicine system. After years of being challenged on my sometimes controversial opinions, my trademarks seem to be a unique technique to immediately release complicated frozen shoulders and hip capsules, and the highly controversial use of hot and cold therapies.
Through feedback from around the world, and an intense self study of anatomy and pathology, I was able to discover the missing link for immediate release of complicated frozen shoulders and this work was adapted to releasing frozen hip joints. After being challenged with many clients with difficult frozen shoulders, also termed adhesive capsulitis, I was viewing the human dissection tapes by Lippincot, Williams and Wilkens and observed that at the articulating cartilage of ball and socket joints was a thick layer of fascia. Due to repetitive movements in the shoulder and hip joints certain muscle groups become strong and short while opposing muscle groups become overstretched and weak. This tension and imbalance around the joints sets up a neuromuscular response attempting to restore balance, but also creates tension in the joint. This eventually leads not only to joint degeneration and resulting arthritis as the cartilage wears down, but also the resultant discomfort limits range of motion causing a formation of adhesions in the joint capsule itself. The articulating fascia acts as superglue and literally glues the humerus to the scapula or the head of the femur to the ilium. Repeated forceful movements to free up the glued joint lays down fibroblasts and progressively deeper adhesions until there is a bone on bone end feel to the ball and socket joint.
The deep fascial adhesions however can be melted much like you would melt jello. In almost a miraculous discovery I was able to use the head of the humerus in the shoulder to melt the fascia (or superglue) using very gentle movements. Theory has it that heat, pressure, and gentle stretch facilitates myofascial warming and myofascial release. But the muscles would rebel by tightening around the joint if even mild discomfort was created during the technique. Therefore we need to do a dance between muscle imbalances, joint capsule melting and pain free release of sprains and strains around the shoulder and hip joints. Over the past five years we have been able to release thousands of complicated frozen shoulders in literally one session. Most of our clients have undergone intense physical therapy for at least one year with little benefit to the adhesion inside the capsule. Some clients were actually on a program to strengthen the already tight muscles further restricting movement in the joint. Other clients were actually scheduled for what I classify as a "barbaric" surgical release where they put you under anesthesia and actually rip the capsule free tearing all the surrounding supportive structures in the process. I have seen many of these patients post-surgically and their condition is actually worse following this procedure as a result of all the scar tissue from this overly aggressive technique.
I have also found that one of the leading causes of SI joint pain is because of adhesions in the ball and socket joint of the hip capsule. At about 10 degrees of hip extension the ilium is forced into flexion on the involved side because the femur is superglued into the socket. This puts stress on the SI joint and results in sprains and strains in that area. In this case adjustments will not have any type of lasting effect. Yet the simple addition by chiropractors and osteopaths in releasing the joint capsule will eliminate the underlying cause of the SI joint dysfunction immediately, and when the muscle groups around the hip are balanced back out the patient will remain pain free. In my practice, I have found joint capsule adhesions in over 50% of my patients with low back pain including young children.
Finally we need to address the difference between hot and cold therapies. Through my intense collaboration with Performance Health, we have discovered a way to treat both the cause of musculoskeletal pain, and the resultant symptom. This goes back to the fascial adhesions throughout the body. The entire body is surrounded by progressively deeper layers of connective tissue called fascia. We compare this to jello. As we heat up jello or fascia it becomes more liquid in state and more accessible. When I approached Performance Health about an all natural heating ointment to be used in conjunction with a cooling application like Biofreeze, they needed an in depth explanation.
Let me use the forearm and wrist as an example to differentiate the use of hot and cold therapy. Most of my clients with carpal tunnel or tendinitis of the elbow are people who use the wrist flexors over and over each day. Without proper daily stretching the flexors of the forearm get stronger and tighter over time putting increased stress on the attachments of the wrist and elbow. The symptoms mostly show up at the joints because there is more joint tension as the muscle groups feeding that joint get tighter over time. As tension builds the fascia shortens and thickens and trigger points form in opposing muscle groups. The tension in the wrist results in "symptoms" like inflammation and joint arthritis as the articulating bones begin to wear out cartilage. We told Perry Isenberg from Performance Health that we feel Biofreeze is indeed the best product in our industry for treating the "symptoms" of joint inflammation and resultant joint arthritis. However, we also suggested a tremendous growing need to have an all natural heating product to melt the connective tissue surrounding the tight muscle groups feeding each joint. This will result in deeper and faster pain free release of taut bands and trigger points feeding the tight tendons that cause joint degeneration. I am grateful that Performance Health did not see this as a conflict to Biofreeze. Instead they put the patient's best interest first and decided to revolutionize our industry by finally having synergistic products to treat both the cause and the symptoms of musculoskeletal pain throughout the body. The new product is called Prossage Heat. After about two years of changing the all natural ingredients, based of feedback from practitioners in my seminars worldwide, we have the perfect heating ointment with the perfect glide for fast, deep, pain free soft tissue release.
Published in: FCA Journal Jan/ Feb '04 Issue CAM Magazine (England) March/ April '04 Issue Massage Message (FSMTA) Spring /04 Issue
"Orthopedic Massage vs. Medical Massage: Are We Using the Correct Terminology? "
By James Waslaski
Author and lecturer James Waslaski is the past chair of the AMTA National Sports Massage Education Council. He currently teaches orthopedic massage nationally and internationally, and has produced a videotape series on orthopedic conditions and sports injuries. James is the recipient of the 1999 International Achievement Award for educating medical practitioners worldwide on integrated pain-free healing.
Several weeks ago, after discussing my mother's "medical" condition with her surgeon, I realized how vital it is for our profession to establish the differences between medical and orthopedic massage. My mother had a critical medical condition called a dissecting aortic aneurysm, in which she exhibited low back pain symptoms, similar to someone with a tight iliopsoas. The medical doctor expected kidney problems, but - through divine intervention - an MRI discovered the massive aneurysm near the bifurcation of the femoral arteries, and it was ready to burst. I thank God each day that she did not go to someone minimally trained in medical or orthopedic massage, because an attempt to release her iliopsoas would have ruptured the aneurysm, and she likely would have died on the massage table.
However, a year prior to discovering the aneurysm, my mother had an "orthopedic" condition called iliotibial band friction syndrome that presented as lateral right-knee pain; through the release of the gluteus maximus, the TFL, and other tight muscles around the knee, surgery was avoided, and she is pain-free one year later, thanks to proper stretching techniques.
Orthopedic massage involves therapeutic assessment, manipulation and movement of locomotor soft tissue to reduce pain and dysfunction. Restoring structural balance throughout the body allows us to focus on both prevention and rehabilitation of musculoskeletal dysfunctions. I hope for this to be one of many articles on the differences between orthopedic and medical massage so that there is more consistency within the profession on the use of the terms. It is my strong opinion that misusing the term "medical massage" will build a wall between massage therapists and other health care professionals who spend many years studying medical conditions that are quite different from orthopedic conditions. After spending almost 20 years in a trauma center, I have seen thousands of medical and orthopedic conditions. As massage therapists, there are several potential dilemmas we face when we claim to perform medical massage. For example:
A client presents in your clinic with left shoulder pain. Have you been trained well enough in your "medical massage" classes to know that if your client is sweating profusely, or experiencing mild shortness of breath or an irregular pulse, he or she could actually be having a heart attack?
Is the client you are treating for thoracic outlet because he or she presented with left-sided weakness actually having a mild stroke?
Does the type of cancer your client has tend to spread with the massage modality you are trained to use?
Is the pain in your client's right leg following his or her surgery actually a blood clot? As you attempt to eliminate that "pain," are you instead releasing the clot into the lungs or brain, which can cause a massive stroke or pulmonary edema? The list of potential medical complications goes on and on.
I am concerned about organizations that claim to "certify" massage therapists in medical massage in as few as three days. Doctors - especially chiropractors - frequently ask me how a massage therapist with as little as 300-500 hours of training can become certified in assessing and treating medical conditions in one weekend. I tell them that many educators and therapists in our industry misuse the term "medical massage" because it is the current "buzz word." In other words, it sells seminars and sounds very clinical when used in practice and on business cards. But there are longer, more comprehensive massage programs out there that train students in medical settings and discuss the signs and symptoms of various medical conditions, and if you are already trained as a nurse, doctor, or in another medical specialty, you can see the big picture much more clearly.
In my opinion, orthopedic massage is much more appropriate when we are treating musculoskeletal pain conditions or sports injuries. Its objectives are to restore structural balance in the muscle groups throughout the body, and decompress arthritic or painful joints. Muscle groups shorten, due to prolonged poor posture or repetitive motions, and shortened muscle groups need to be stretched out or they will pull bones onto nerves and blood vessels, and cause or contribute to all sorts of orthopedic conditions. I believe that conditions like joint arthritis are symptoms that result from tight muscles around a joint; thus, thoracic outlet and carpal tunnel syndrome are actually orthopedic conditions.
In thoracic outlet, our goal is to lengthen short muscle groups, such as the anterior and posterior scalenes, the pectoralis minor, and any supporting muscles that compress nerves in the neck and shoulder and cause weakness and radiating pain into the arm or hand. Carpal tunnel can often be effectively treated by lengthening the pronator teres and the flexors of the wrist, and assuring the carpal bones are in alignment. Achilles tendonitis would be best addressed by lengthening the gastrocnemius and soleus muscles. In my opinion, it is truly orthopedic massage when we work to restore range-of-motion, balance out muscle groups surrounding the joints to treat pain, and work to prevent and rehabilitate injuries that involve muscles, bones, tendons and ligaments. Orthopedic massage is also great for performance enhancement.
However, medical conditions can mask and/or complicate orthopedic conditions. For example, a woman in her third trimester of pregnancy may have excessive swelling in her wrists, adding to the tight muscles and tendons in the wrist area requiring medical assistance, perhaps also requiring the use of a diuretic (if not contraindicated) or lymphatic drainage to reduce inflammation. There are functional assessment tests that can determine most orthopedic conditions and outline a treatment plan using multiple modalities. These assessment skills better align you with other orthopedic experts, including orthopedic surgeons, chiropractors, physical therapists and osteopaths.
I also believe that combining multiple disciplines allows better results. One patient may respond better to CranioSacral Therapy, while another requires lymphatic drainage, and the next needs a combination of myofascial release, neuromuscular therapy and stretching. (I will touch more on a multidisciplinary approach in a future article.) Lastly, patients need to be actively involved in their own treatment by perhaps changing the ergonomics of the work environment, watching their posture, using good body mechanics, and doing specific stretches and exercises between treatments.
I would briefly like to address one other concern about the current state of the massage profession. I came from Florida and trained with many of the leaders in our industry. I also took college courses in pathology, biomechanics, anatomy and physiology, then took years of workshops to prevent "tunnel vision" into any one discipline from occurring. In Florida, the base training starts at 500-600 hours and becomes more advanced.
In Texas (where I now live), a person can be a practicing and certified massage therapist with 300 hours. I recently attended a great insurance billing seminar here in Texas; what frustrated me, however, was that many of the attendees had only 300 hours of training. Even if these therapists learned to use the insurance billing codes properly, it is unlikely that after only 300 hours of training, they could ethically support their treatment and billing claims without additional training. I also see claims to "certify" these therapists in medical massage without administering a written and practical exam. No wonder the medical community looks down on us!
I hope I have put a bit of fear into massage therapists that may still have a long way to go to understand that all medical conditions do not fall under plain and simple treatment protocols learned in a basic medical massage training program. As a profession, I suggest we work to distinguish medical conditions from orthopedic conditions to better align ourselves with other medical experts.
I look forward to seeing how the National Certification Board for Therapeutic Massage and Bodywork defines an advanced-level therapist, once it moves to a higher level of certification, and is confident that the process includes a large panel of experts in role delineation and item-writing processes. I also hope that more schools and educators can agree on whether we should call our work clinical massage, orthopedic massage or simply an all-inclusive term like medical massage.
Author and lecturer James Waslaski is the past chair of the AMTA National Sports Massage Education Council. He currently teaches orthopedic massage nationally and internationally, and has produced a videotape series on orthopedic conditions and sports injuries. James is also the recipient of the 1999 International Achievement Award for educating medical practitioners worldwide on integrated pain-free healing.
I disagree with the segment recently shown on national television claiming that massage can cause more harm than good ("Setting the Records Straight: Massage Gets a Bad Rap in National Report," www.massagetoday.com/archives/2004/06/02.html). Statements like these are usually based on turf wars in the health care profession. If there were substantial truth to these accusations, I would not be traveling 40 weekends a year teaching orthopedic massage!
My first article, "Medical Massage vs. Orthopedic Massage" (Feb. 2004, www.massagetoday.com/archives/2004/02/03.html), was intended to bring leaders of advanced massage disciplines together to create a unified definition of "medical" massage; now, it has become a mission to set a unified standard for medical massage "certification."
The best short definition I gathered from medical massage therapists is: "Medical massage is performed with the intent of improving conditions or pathologies that have been diagnosed by a physician; a wide variety of modalities or procedures are utilized to focus the treatment based on the diagnosed condition." I was determined to prove that advanced disciplines, such as neuromuscular therapy, CranioSacral Therapy (CST), myofascial release, lymphatic drainage, massage for cancer patients, orthopedic massage, etc., fall under medical massage disciplines, and certification in many of these disciplines usually requires a minimum of 100 hours of training.
Interestingly, when I teach orthopedic massage, it is a blend of many of these disciplines, and I believe that orthopedic massage is an advanced discipline of medical massage. It involves therapeutic assessment, manipulation, and movement of the locomotor soft tissues to reduce or eliminate pain or dysfunction. A unique multidisciplinary approach is utilized to restore structural balance throughout the body, which allows focus on prevention and rehabilitation of musculoskeletal dysfunctions, chronic pain and sports injuries. Primary modalities include functional assessment, myofascial release, neuromuscular therapy, scar tissue mobilization techniques, neuromuscular re-education, PNF stretching, strengthening, and specific client home-care protocols.
I encourage participants to be cross-trained in as many advanced disciplines as possible, and constantly research which discipline works best in each particular situation. I firmly believe that disciplines such as lymphatic drainage, CST, myoskeletal alignment, energy work,etc., may be better modalities than orthopedic massage for a percentage of patients; therefore, they are a critical part of the toolbox for elite-level medical massage practitioners.
Still, I question whether fewer than 100 hours of medical massage training without an internship and written and practical exam, can properly prepare therapists for the vast array of medical complications that could be made worse by improperly applied massage. For example, one massage instructor recently challenged my February article claiming that a patient with an aneurysm (like that of my mother) would be pale and too weak to get onto the massage table. My mother's aneurysm was leaking and ready to burst, but she did not have pale skin, diaphoresis or weakness. Other than slight kidney pain (often diagnosed as back pain) and small traces of blood in her urine, she had no other symptoms. Some therapists do not complete a thorough medical history, which is why an internship and direct medical training with a doctor is beneficial. In Canada, for example, many therapists spend two years in a hospital setting, following 2,000 hours of initial massage training to intern in neurology, cardiac physiology, etc.
I am blessed to be able to teach with some of the leading educators in the industry. Most recently, I taught with Dr. Erik Dalton (the founder of Myoskeletal Alignment Techniques) in Costa Rica, and was impressed with the emphasis he placed on assessing the cervical spine prior to beginning any treatments. He is highly concerned about the possibility of compromising the vertebral arteries during therapy and about pressing into the soft spot at the base of the skull when treating the suboccipital muscles. In another seminar, Dr. Dalton and I taught together with David Kent, a specialist in neuromuscular therapy and practice-building. He also emphasized the same precautions, as well as the importance of conducting a thorough assessment prior to treatment. He also stressed the need to refer some patients out to avoid complications from certain treatment protocols.
I am determined to point out those educators that mislead students into taking their courses, stating they will "certify" therapists in medical massage in as few as three days. One Texas chiropractor claims to grant a "certification" in medical massage if you take his six-hour continuing education course. Is it ethical to give a certification without a unified examination? Many of the therapists entering these courses have as few as 300 hours of massage training, with no medical background; most have only 500 hours of massage training. I think the word "certification" is misleading. I do not think a massage therapist with little medical background and training should be certified in medical massage without an intense clinical internship, or at least proof that the therapist can competently perform the skills he or she has learned.
I do not certify anyone in orthopedic massage for this exact reason; in fact, I am waiting for the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) to create "advanced certification" in massage before I set the standards to certify people in orthopedic massage. Then I will require a written and practical exam, and at least one year of experience in treating orthopedic conditions, prior to granting orthopedic massage certification.
Sure, I could probably sell more courses if I told people they would be "certified" after two weekends and a five-day intensive course. But we need to attest to the competency of the learned skills of our students to avoid complications when new therapists apply advanced skills. There are so many incredible advanced disciplines that we see as specialties of medical massage. I know many of those specialties usually require a minimum of 100 hours to be recognized as practitioners of that work. People excel much faster in seminars if they are already certified in other disciplines. But only a small percentage of our students come into the advanced courses with adequate prior training.
I look back on my many years in a hospital setting as a gift to what I now bring to orthopedic massage. It is also the reason I reference medical massage, but do not generically call my work "medical massage". Little did I know how valuable that type of hands-on learning would be in professional debates within the industry.
My intense medical background tells me we may be in a danger zone, unless we come together as a profession, clearly define medical massage and determine how it relates to the many advanced disciplines in our rapidly advancing profession. This will lead to a unified standard in our industry, and consistency among the true experts in the various advanced disciplines of massage. Then we can finally have a true certification in medical massage, and it will attest to the competency of those well-deserved advanced therapists.
"The Role of Orthopedic Massage in True Health and Well Being" by James Waslaski
My role is to teach medical practitioners throughout the world how to correct or eliminate musculoskeletal pain throughout the body, by bringing the body back into balance structurally. But as I travel about 40 week-ends per year presenting seminars to massage therapists, physical therapists, chiropractors, doctors, etc., it seems that the clients with complicated pain conditions continue to challenge and teach me. After spending almost 20 years in a medical trauma center seeing patients with severe medical and orthopedic conditions, I have come to question where the patient's true healing comes from. Experience has taught me that just balancing out the structure, and restoring pain free function to the body can sometimes lead to only limited success.
My trademark is a technique that aids in the immediate release of patients with frozen shoulder problems. However, experience has shown me that in many of the clients with long term frozen shoulders there is a large percentage that have an emotional release along with the soft tissue release. Early in my career I was not quite sure how to support my clients through this sometimes unexpected part of their healing process. But a lot happens when you stay focused and always provide a loving and supportive environment for healing to occur. Sometimes just compassionate touch and being a good listener can be the emotional support that starts the true healing process.
So let me start this article with the physical or mechanical component for frozen shoulders, and then let me move to the even more important emotional and spiritual components of this revolutionary technique. The physiology in a frozen shoulder, often termed adhesive capsulitis, is when the client is unable to move the shoulder through full pain free range of motion, especially into flexion, abduction, and external rotation. Sometimes this occurs following a minor injury such as a rotator cuff injury, or bursitis, or bicipital tendinitis. Sometimes the clients just wake up with a frozen shoulder without any specific physical trauma. There is almost a super gluing inside the ball and socket joint of the shoulder and there is an abrupt bone on bone end feel from adhesions inside the joint. Orthopedic massage can balance out the muscle groups around the shoulder, reduce the scar tissue in the injured areas, eliminate trigger points ant correct the soft tissue component. This is done using disciplines including functional assessment, myofascial release, neuromuscular therapy, frictioning to areas of scar tissue, p.n.f. stretching, etc. The work must be very systematic, applied pain free, and focused on structural integration. However, surgical intervention involves putting the patient to sleep under anesthesia, and ripping the shoulder capsule free, often tearing all of the surrounding soft tissues. In my opinion this procedure is barbaric and most clients get worse post surgically due to all the resulting scar tissue.
Here is the divine intervention or spiritual part of this condition. After struggling several years with complicated frozen shoulders, I had a dream or vision where I could literally see a picture of the adhesive capsule inside the shoulder. It appeared as glue inside the ball and socket joint. Based on that vision I was able to find a human dissection of the shoulder to match the same picture from the dream. It showed fascia or connective tissue inside the joint that acts as superglue following prolonged poor postures or minor musculoskeletal injuries in the shoulder area. Based on the vision my thought was to use the humerus as a massage tool to gently melt the adhesions gluing the humerus to the scapula. Myofascial experts teach that a combination of heat, pressure, and gentle stretch will melt and mobilize the connective tissue called fascia. So why not use gentle movements of the humerus to melt the adhesions gluing it to the scapula. Or even use the head of the femur to release it from the ilium of the hip. This technique to the best of my knowledge was not taught anywhere else in the world, but has proven incredibly effective in releasing thousands of frozen shoulders and hip dysfunctions, usually in only one session. Many of our clients have had a frozen shoulder, or hip and back pain for as long as 30 years, and have been through years of intense rehabilitation. Since I was not taught this technique in my thousands of hours of training, I credit the vision that led to this technique as coming from a higher power, a sort of spiritually guided process.
Next came the emotional piece that was so vital to true healing of many clients. One of my clients was left for dead after intense physical trauma to her shoulder. However, she survived and many years ago when this technique was applied, she had an associated emotional release. She was crying and re-living the actual trauma that led to her living so many years with a frozen shoulder. I believe the emotional trauma was locked into the connective tissue and became stored in that connective tissue for years until she felt safe to allow release both mentally and physically. Fortunately, following the shoulder release, the therapists attending my seminar simply surrounded her with love, safe touch, and prayer to facilitate her body's potential to heal itself. Seeing her several years later, she still had total wellness in her body, mind and spirit.
Many other experiences like this have taught me the importance of presence in my work. It also reminds me that we are not the one performing the healing; rather we are there to facilitate the body's potential to heal itself. As a result of my presence; always coming from a safe and loving place, more and more of my clients feel safe and supported in their healing process, especially in cases with frozen shoulders and frozen hip capsules.
Many clients with frozen shoulders do not have an associated emotional release, but the therapist has to stay focused and rely on intuition to guide them while applying techniques that correct structure and posture. I remember a tough truck driver from Texas that lost his wife and child in a head on collision. When I treated his thoracic outlet, cervical sprain and strain, and frozen shoulder condition, he broke down feeling guilty to have survived. But he finally allowed me to facilitate his body's potential to heal completely.
There is also a huge nutritional aspect we feel may contribute to adhesive capsulitis in diabetics. We are looking into the effect of better regulation of insulin and glucose as that may contribute to capsule adhesions, and whether increased calcium supplements that are sometimes prescribed for diabetics, may actually increase the adhesions in the joint and potentially develop calcium deposits making adhesive hips and shoulders common in severe diabetics.
I have been blessed to have had many mentors such as leading osteopaths, orthopedic surgeons, psychologists, advanced massage educators, and spiritual advisors. Our staff prides themselves as consistent life long learners with a spiritual purpose. We cannot separate physical health, emotional health and spiritual health if we hope to facilitate true health and well being in the lives of our clients.
by James Waslaski
Published in: Health and Well Being Magazine Spring '04 Issue
The Center for Pain Management PO Box 822141 N. Richland Hills, TX 76182 1-800-643-5543 Business Hours are 9:00am - 5:00pm CST Monday through Friday allison@orthomassage.net
