Warm Hydrotherapy for Chronic Injury Pain
October 9, 2009 by whymassagetherapy
Filed under Hydrotherapy
The use of warm hydrotherapy, also known in therapeutic massage as deep moist heat, is an excellent way to control and alleviate the pain and achiness associated with chronic injuries.
Most of us have experienced at one point or another the nagging achiness that comes with a chronic injury. Deep, moist heat is an excellent way to help control this pain as a part of homecare, and is also used pre-massage treatment to prepare and warm up the tissues.
Often when an injury has been long-standing, previously damaged muscle fibres have been replaced with tough collagen fibres, aka scar tissue, which reinforce and strengthen a muscle that has been damaged. Collagen fibres do not have the blood vessels that muscle has, and this avascular quality means that decreased blood flow in this tissue interrupts or decrease cell metabolism, oxygen delivery and metabolic waste removal. While scar tissue development is a normal part of the healing process, when collagen fibres are laid down, the muscle becomes more inelastic – unable to elongate and then return to its original length. This affects not only the comfort of the client, but also the power and strength of the affected muscle.
The goals, therefore of deep moist heat in the form of a hydrocollator or thermaphore are:
- to warm up an area by increasing blood flow
- increase the delivery of oxygen and nutrients to muscle cells, and speeding up metabolic processes. This decreases pain and achiness.
- the heat itself will decrease the viscosity of the “ground substance” in muscle tissue, allowing the massage therapist to break down any scar tissue and realign the affected muscle fibres with those of the surrounding tissue
Contraindications for using heat:
- uncontrolled high blood pressure
- diabetes or any conditions with neuropathies or altered sensation – the client won’t be able to tell if the application is too hot, and tissue could be damaged
- any condition where tissue is fragile or circulation has been compromised (i.e. immediately after a cast is removed) – the circulation may be too impaired for extreme heat, so mild applications can be used until the condition of the tissue improves
- tissue is broken (i.e. a cut, or skin condition such as psoriasis – the tissue is likely already inflamed – heat will make it worse, and infection can be introduced)
- metal implants – pins, plates, rods, wire – these will heat up quickly and can really injure a client
- heat sources should NEVER be placed over major arteries or over the heart
How to use heat properly
You may have never heard of a thermaphore or a hydrocollator, but if you have used a gel pack or grain-filled bag you can heat in the microwave, these same principles apply:
- heat should only be left on for 20 minutes maximum – any longer and the tissue can get very congested and be even more painful. You can take it off and use it on another area, or reapply after an hour or so.
- For hygiene and to prevent burns, the heat source should always be wrapped in a clean towel. For a gel pack (I boil mine on the stove in a cooking pot), I wrap a clean, damp dishcloth around it when it is hot, then a thicker cloth over top. I get the benefit of the moisture that way.
- it is a good idea to do any stretching that needs to be done after a heat application – you muscles will be much more pliable and stretch more easily.
- use caution if you have taken any analgesics (pain killers), your perception of heat and pain may be off and you could get burned.
- NEVER lie on a heat source – in the case of a gel pack, hydrocollator or grain-filled bag, it could burst from your weight and you could get seriously burned.
The use of heat in this manner is a great way to control pain from a chronic injury, as well as prepare the muscles in the area for stretching.
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How Does Lactic Acid Affect Muscles?
September 17, 2009 by whymassagetherapy
Filed under FAQ
Lactic acid buildup is often blamed for post workout muscle fatigue and pain, but just how true are these claims, and how exactly does lactic acid affect muscles, fitness and performance?
First of all, let’s get familiar with the basics of the chemical process of energy production in muscle.
In aerobic metabolism, the oxygen that is required by cells to create energy is obtained via respiration. The “energy” that is produced is ATP, or adenosine triphosphate, which is a molecule that is created and stored in all body cells and provides chemical energy for cellular function. ATP provides the energy required for a muscle to contract, and is also necessary for the operation of the muscle’s calcium pump, which is involved in the sliding filament mechanism responsible for muscle contraction.
When the body is no longer able to obtain oxygen from aerobic metabolism, the energy is obtained by a process known as anaerobic cellular metabolism. Activities such as weight lifting, sprinting, or prolonged maximum output activities achieve oxygen deficit quite quickly, where more oxygen is required for cellular reactions than is available. Lactic acid is a metabolic by-product of anaerobic processes.
During anaerobic activities, energy is produced in one of two ways, the first of which involves a reaction between the creatine phosphate that is stored in muscle cells, and adenosine diphosphate (ADP). The creatine phosphate gives its phosphate molecule to adenosine disphosphate, making it “triphosphate”; therefore, the by-products of this reaction are creatine and ATP. The energy produced from this reaction is enough to last about 15 to 20 seconds, or a 100 metre sprint, then it needs to be replenished.
The second process by which anaerobic metabolism occurs is known as glycolysis – the breakdown of glycogen, which is stored energy in muscle. (glycol = sugar or glucose; lysis = splitting). ATP is a by-product of glycolysis, as is pyruvic acid. If there is still not enough available oxygen to produce more ATP in conjunction with pyruvic acid, then the pyruvic acid is converted to lactic acid and is released into the blood stream.
And this is how it happens…
Maximum contraction of a muscle during quick bursts of power, or maximal sustained effort, increases lactic acid production in muscle because blood vessels are compressed and oxygen can’t be delivered to the cells – the aerobic, energy producing pathway is insufficient to allow oxygen to fuel the reaction. As a result, an anaerobic energy production is used, and ATP and pyruvic acid are produced. The pyruvic acid is then converted to lactic acid – therefore, during an oxygen deficit, lactic acid will be the primary by-product of glucose metabolism within a cell.
When lactic acid is released from the muscle cells into the bloodstream, it is taken to the liver usually within 30 minutes of cessation of activity. In the liver it is reconverted to pyruvic acid and released into the bloodstream for further use by muscles, or it is converted to glycogen or carbon dioxide via aerobic metabolism. It is important to note at this point that lactic acid is not necessarily the “bad guy” it has been made out to be, as it still plays an important role in energy production when sufficient oxygen becomes available again.
When large amounts of glucose are used in sustained anaerobic activity, lactic acid accumulates and is alleged to contribute to muscle soreness. The buildup of lactic acid increases muscle cell acidity (hence the burning feeling in muscle) and makes ATP production more difficult. ATP is also required for the sodium-potassium pump which maintains cellular homeostasis. In the absence of ATP, the sodium-potassium pump is unable to correct any ionic (sodium, potassium etc) imbalances in the cell environment, and muscle becomes unresponsive to stimuli.
And don’t forget that the calcium pump, used in muscle contraction, requires ATP to operate. When a deficit of ATP occurs, the muscle fibres are unable to release the “cross bridges” which are created during contraction.
As a result, in either one of the two above case scenarios, the muscle may not be able to relax, resulting in cramping and spasm.
How Can Massage Therapy Assist with Lactic Acid removal?
Ok, so maybe you don’t really care about how this all transpires, and that’s fine. Here is what you need to know about lactic acid if you are a fitness enthusiast:
The claim that lactic acid causes muscle pain has been disproven, as mentioned in the article Lactic Acid Does More Than Cause Fatigue , though it is known to cause fatigue. If this is the case, then my (educated) guess is that muscle pain is caused by micro-tearing and inflammation of muscle fibres due to over-exertion.
There is also some debate concerning the degree of assistance that massage therapy can lend to the removal of lactic acid from muscle. However, as mentioned in my previous article, Massage Therapy, Fitness and Optimal Performance , massage therapy has both a mechanical and chemical effect on the body, and I believe for these reasons, it can have a positive influence on the removal of lactic acid from muscle tissue.
Mechanically, the stretching, manipulation and kneading of tissue will assist in “unhooking” the cross bridge created during contraction and relieve some cramping and spasm. Increasing circulation by this mechanical effect will assist in oxygen delivery and waste removal to and from muscle respectively. In addition, the chemical effects of massage, causing increased blood vessel permeability, will also assist in the process. And, also, don’t forget about the release of endorphins as a benefit of massage, which can help alleviate pain.
To learn more about the physiology behind this topic, please refer to my source noted below:
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What are the Causes of Low Back Pain
August 16, 2009 by whymassagetherapy
Filed under FAQ
Low back pain is one of the most common conditions treated by massage therapists. I have been asked by countless clients “what are the causes of low back pain?”, and I am afraid to say that there is no simple answer. The causes of low back pain are many, and it is important for clients to understand this, as appropriate treatment approaches differ as much as the causes themselves.
So common is low back pain that I decided to do a little research and try to get some statistics on it.
Here is what I found:
Back pain statistics from the Workers Compensation Board of British Columbia
So, that’s all fine and well, but while “back strain” appears to be the most common cause of low back pain, and quite a generic term, there are other causes of low back pain. It is very important to identify the cause and contributing factors to low back pain for successful treatment, otherwise clients may just end up wasting time and money.
Falling into each of these 4 broad categories, which I am going to name as causes for low back pain, are several different conditions which I have seen in my practice.
Low back pain cause – Muscle fatigue or strain
Also referred to as a “pulled muscle”, this happens when muscles are overused or is weak. Muscles can also be torn from an injury, and of course, the more serious the damage, the longer it will take to heal …
This is also the primary participant in “soft tissue injuries” – the effects of which insurance companies have lead people to believe are minimal. The reality is that soft tissue injury, and the chronic inflammation which may accompany the more severe injuries, often take longer to heal than the ballpark figure in the insurance tables. However, I digress …
Pain can also be caused by an imbalance of muscle development, or a lack of “extensibility” or “stretch” of the muscles. This is very easy to see, for example, in athletes who may overuse and overdevelop one muscle group. This muscle imbalance is stressful for the body and may cause pain and spasm in the opposing muscle group as the body tries to maintain homeostasis. This lack of balance can lead to “mechanical dysfunction” of the joints of the back (see below). Muscle imbalance, can, however, be treated at home if you know what to do.
Low back pain cause – Joint and bone dysfunction
This type of back pain is often referred to as “mechanical back pain” or “mechanical joint dysfunction” when referring specifically to the joints. What this means is that a joint is not able to move as it is meant to, either from injury to the bone or joint, or hypertonicity of the surrounding muscles (hyper meaning ‘too much’, tone means the amount of tension in the muscle). Unfortunately, this can lead to several other issues and can be a self-perpetuating cycle if left untreated, often causing seemingly unrelated problems.
Of course, bones and joints can also be affected by fractures, breaks, arthritis and a multitude of other conditions which is well beyond the scope of massage therapy to diagnose and in some cases, treat. Massage therapy can, however, be used to alleviate symptoms and assist in recovery.
Low back pain cause – neurological
Low back pain from a neurological source can be a result of a variety of triggers, all of which are related to either the intervertebral disc, spinal cord, or the “nerve roots” as they exit the spinal cord. This type of pain can be excruciating and very debilitating, as anyone with a “slipped disc” will tell you. (this is a bit of a misnomer, and will be addressed in upcoming articles). This type of low back pain usually presents as symptoms in the area which the affected nerve root supplies, so the location of the symptoms is really dependent on the nerve root “level” where the injury or restriction happened. (and often the level of the injury is determined by the presentation of symptoms.) Pain which occurs in one area but originates from dysfunction in another area is called “referred” or “referral” pain.
Low Back Pain – Neurological from Bulging, or Herniated, Disc
Low back pain cause – visceral referral
In some cases pain can be a result of a dysfunction or infection of an internal organ. This happens because the “nociceptors” (pain receptors) of an organ are irritated and the pain is either felt in the skin or tissue which is superficial to (or just above) the organ, or in a classic “referral pattern”. Pain caused by visceral dysfunction can be quite severe. A classic example is low back pain in the lumbar area which may wrap around a persons front, or extend down the sides of the thighs and into the groin. This is a referral pattern of the kidneys, and should never be ignored.
Remember, most low back pain is a result of muscle weakness or imbalance. However, if you are not aware of any activity or cause of the pain, the pain is severe, or if the pain has been present for any length of time, I would urge you to see a physician immediately to rule out anything more serious than a muscular cause for the pain. You may also want to check out more information I have found on WebMD.
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What is muscular atrophy, and what causes denervation and disuse atrophy?
July 16, 2009 by whymassagetherapy
Filed under Anatomy
What does atrophy mean, and what causes atrophy of a muscle?
The definition of Atrophy, according to Human Anatomy and Physiology (8th Edition)
Atrophy of a muscle can occur in 2 ways – from disuse or denervation.
Disuse atrophy will occur when a person is unable to use a muscle for any number of reasons. It is very common when a limb has been cast from a break or fracture, or a person has been on bed rest for a extended length of time. Once a person is mobile again, or a cast has been removed, the client should undergo a rehabilitation process designed to challenge and strengthen the involved structures. Assuming that the atrophy was only caused by lack of use, the patient will eventually regain strength and normal size of the muscle.
Denervation atrophy occurs when the nerve supply to a muscle is interrupted and the muscle no longer receives signals or stimulus from the nervous system. This type of atrophy can occur from injury to the central nervous system, as in a spinal cord injury, or in the peripheral nervous system, such as a broken bone which damages surrounding nerve. Damage doesn’t necessarily mean a complete severing of the nerve, in which case nerve tissue is not known to regenerate. Damage will occur in varying degrees of severity, and may be a result of compression (impingement), crushing or partial tearing. If this is the case, with proper care and rehabilitation the injury will heal and muscle strength can be regained.
Why is this important to a Massage Therapist?
Massage therapists are specialists in treating the dysfunctions of the musculoskeletal system, and understanding the anatomy of the involved structures is key to providing a successful treatment. Odds are that you will see quite a few conditions throughout your career that will either cause, or have the potential to cause, muscle atrophy. Conditions such as chronic Thoracic Outlet Syndrome or Carpal Tunnel Syndrome may cause denervation atrophy due to impingement or compression of the ulnar nerve root and median nerve respectively, and can be successfully resolved once the underlying cause of the compression has been addressed.
Atrophied tissue is very fragile, and deep techniques are contraindicated until the condition of the tissue improves. Initially, the primary goal of treatment for atrophied tissue is to increase circulation and to stimulate the nerves – this can be accomplished by gentle dry brushing, followed up by light stimulating techniques such as stroking, effleurage or c-scooping. Great care must be taken if there has been crushing or tearing of the nerve, as any local techniques which apply pressure or traction can disrupt the healing of the injury.
It is highly recommended that you consult with the client’s physician, physiotherapist or chiropractor to verify the cause of atrophy, and that you work under his or her supervision and guidance if the atrophy is caused by denervation.
© Copyright 2009
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My first massage therapy treatment – is it normal to be sore?
May 25, 2009 by whymassagetherapy
Filed under FAQ
A frequent question that I hear from new clients is “My (Aunt Betty) had a massage, and she was so sore she could hardly move the next day. Will I be sore, too?”
We have all heard horror stories about the therapist who had bone-crushing pressure and didn’t listen when asked to back off. I’ve heard another client of mine tell me that when she asked her (previous) therapist to lighten up, the response was “I’m not using a lot of pressure, and it has to hurt to work.”
I’m hear to tell you that this is NOT the case – and that massage can be very effective when applied with moderate pressure. It takes intuition, experience and time to learn just how much pressure the tissue (and a client) can take, and this amount of time varies from therapist to therapist. I’d also like to add that your massage therapist should never brush off indications of pain – as a massage therapist myself I wouldn’t go to someone else who seemed to have no regard for my pain tolerance.
Does Massage Therapy “have” to hurt?
Let me put it this way – it is normal, especially if you’ve never had a therapeutic massage before, for muscles to feel a little stiff or sore after a treatment. I think of it much the same as working out, after all, muscle tissue is being manipulated and worked, so a little discomfort is not unusual. If a person has never been to the gym before, it is not a good idea to ask him or her to leg press 100lbs, any more than it is wise for a massage therapist to put all of his or her weight behind their elbow as they perform muscle stripping on the back of a new client. Either way you look at it, if you’ve never had a treatment before, you have NO idea how your body will react or how much pressure is “enough”, and the therapist really has NO idea what “deep” means to a client. Depth of pressure is very subjective, and pain is a subjective response – what hurts to client A might feel great to client B – there is just no way to tell.
It didn’t take me long to learn that the size of the client has absolutely no bearing on how much pressure he or she can take. I have been able to use deep pressure effectively and painlessly with some very small women, and much less pressure with some very muscular and burly men. My approach is now this – when I first start treating a new client, I use broad, firm pressure, and resist the urge to “go deeper” even at their request. What I tell them before they get on the table is that the first treatment I will be very moderate because I’m not sure of how they will react – they may feel great in the days following the treatment, in which case next time I will go deeper. (here’s a question to consider – does the saying “the customer is always right” apply in this scenario?) If my client feels not so great in the days following a treatment, then I know I need to do something different and will adapt subsequent treatments to suit my client.
In a nutshell, what I would tell a client is that while some discomfort is normal, your request to a therapist to lessen the pressure should never be ignored or brushed off. You are paying for a treatment, and you always have the right to stop or modify what is happening (an FYI in case your therapist doesn’t tell you this.) If you are a therapist, especially a new one, take the time to listen to your client and his or her muscle tissue – not everyone is created the same, and it does take time to learn how much is “enough”. Also, be sure to advise your client of any possible side effects or risks associated with the treatment (informed verbal consent), and let him or her decide what is right for their body.
Massage Therapy, Fitness and Optimal Performance
May 11, 2009 by whymassagetherapy
Filed under Treatments
Massage therapy is often used as an adjunct to a fitness routine to assist in achieving peak athletic performance. There are a variety of ways in which massage therapy is used to promote optimal fitness – massage therapy is not all just about spas and “fluff”. Massage can be used to increase the suppleness of muscle, aid in recovery after exertion, assist in fluid removal in the presence of injury or inflammation (from non-infectious origins) or control pain through the release of endorphins.
Massage therapy affects muscles in 2 ways: mechanically and chemically. Mechanically, it is the kneading, stretching and compression of the tissue which stimulates the smooth muscle of the blood vessels and increases blood flow to and from the area. (due to an increase in histamine – see below). Manual manipulation of the tissue will also literally break adhesions and scar tissue, regardless of whether techniques are applied with or against the muscle fibre. This decrease in inelastic scar tissue will allow muscles to contract and elongate as they should, and will increase muscle performance.
At a chemical level, massage therapy can cause the release of “endorphins”, neurotransmitters that reduce the perception of pain, and increase a feeling of wellbeing. Increased permeability of the blood vessels is caused by release of histamine in response to mechanical stimulation – this increase in blood flow leads to “hyperemia”, redness which is often visible after a massage.
The application of therapeutic massage plays a role in event preparation as well as recovery and maintenance, though the goals and application will be different depending on the timing of the treatment in relation to the activity.
Pre-event, the purpose of massage is to “wake-up” and warm-up the muscles, ensuring that they are ready for physical demands to be placed on them. During a pre-event treatment, the movements of the therapist are quick, stimulating the nerves in the area and increasing the ability of a muscle to react to stimuli. Circulation to the muscle is also increased and with it oxygen delivery to the muscle cells, causing a subsequent increase in cellular metabolism and improved functionality. Increased blood flow also warms up the muscle, allowing for greater pre-event stretching, imperative to optimizing performance and reducing injury due to muscle strain.
Post-event massage is much slower, encouraging the body to relax after exertion. Massage therapy at this stage is utilized to assist the body in removing metabolic waste, relaxing and stretching the fatigued muscle. This is done by increasing the circulation and pliability of the muscle tissue. The increased removal of metabolic waste such as lactic acid will decrease recovery time and soreness in the days following an event.
Massage therapy used as a maintenance tool will assist an athlete in maintaining optimal muscle health. During maintenance treatments, the therapist will assess the condition of tissue and establish a treatment plan in conjunction with the goals and condition of the client. It is during these treatments that muscle imbalances are often identified; adhesions and scar tissue are broken down (thus increasing muscle functionality) via manipulation, stretching and breaking down of tissue. Circulation is increased, assisting in oxygen delivery and metabolic waste removal.
Regardless of fitness level, massage therapy can help a fitness enthusiast or athlete achieve his or her performance goals by promoting and maintaining muscle health.
© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.
Carpal Tunnel Syndrome, Massage Therapy and Surgery Prevention
May 8, 2009 by whymassagetherapy
Filed under Treatments
Carpal tunnel syndrome is a compression of the median nerve as it passes through the carpal tunnel of the wrist. Caught early enough, carpal tunnel syndrome, or CTS, doesn’t have to progress to the point where it is debilitating or affects activities of daily living. The incidence of surgery, which involves cutting the carpal tunnel ligament (aka flexor retinaculum) could very well be reduced if massage therapy was used more frequently as an early intervention.
Symptoms of Carpal Tunnel Syndrome:
The median nerve is not the only structure that passes through the carpal tunnel – the muscles of the anterior forearm (the forearm and wrist flexors) also figure prominently in CTS. In early stages there is often numbness, tingling or “pins and needles” in the lateral 31/2 digits of the hand (thumb through to 1/2 of the ring finger). There could also be pain and local inflammation or swelling over the wrist on the palmar surface of the heel of the hand. In later or more chronic stages, there could be atrophy of the thenar emminence (muscles which move the thumb), or trophic skin changes in the same area, such as redness, dry or scaly skin. At this stage, there may also be altered sensation in the forearm and axilla (armpit).
In conjunction with the muscle wasting, there may also be difficulty in activities which require fine motor control (i.e. picking up car keys, buttoning a shirt). It is not unusual for people with more severe or chronic cases of CTS to wake at night from pain, which is relieved by moving or elevating the limb.
Who is at risk for Carpal Tunnel Syndrome?
CTS often affects people whose activities of daily living (either work or hobbies) involve repetitive motion of the fingers and hands. (Think of a data entry clerk, a musician, a massage therapist or someone who knits a lot). Repetitive motion causes “hypertonicity” of the muscles of the forearm, and as they pass through the carpal tunnel, the larger size of the tendons impinge the nerve. Left long term, the muscles are unable to function as they should and they become weak.
Injuries to the wrist, with displacement of the carpal bones, may also compress the median nerve or cause swelling of the tendons that pass through the carpal tunnel; edema during late stages of pregnancy or during illness may also narrow the tunnel, compressing the median nerve.
How can massage therapy help prevent and treat carpal tunnel syndrome?
Massage therapy can provide valuable assistance to someone suffering from CTS, either as a stand-alone treatment, or in conjunction with other modalities. Massage can also assist in prevention of the syndrome; when treatment is started early enough, muscle hypertonicity is decreased, and edema can be reduced.
Treatment will depend on the actual cause and stage of presentation of the condition. For example, in a case where repetitive stress is the cause, the therapist will attempt to decrease hypertonicity and myofascial trigger points of the brachium, ante-brachium, all of which are proximal to the site of compression. This can be achieved by doing deep work to the muscles of the arm and forearm, as well as stretching of the forearm flexors.
If the structures in the carpal tunnel are impinged due to thickening or scarring of the flexor retinaculum, friction therapy to break down the tissue can be invaluable, if painful, to reduce compression.
Manual lymph drainage can assist in the reduction of fluid build up post treatment.
The therapist may also stretch the carpal ligament and palmar tissue & fascia, reducing compression of the structures, and finish with a cold hydrotherapy application on the site to reduce any inflammation.
Outside of surgery, there is no “cure” for carpal tunnel syndrome which results from hypertonicity of the forearm flexors. If CTS is caused by a repetitive stress injury (RSI), then maintenance will be necessary. Maintenance in this case will involve a program of stretching, hydrotherapy, massage therapy and possibly a wrist brace. The use of ergonomically correct keyboards for those whose work involves a lot of typing can also be useful.
Depending on the severity of the condition, a treatment plan may involve a few weeks of treatments 2 times per week, in addition to a homecare plan to reinforce the effects of the treatment. As hypertonicity of the forearm flexors is reduced, the frequency of the treatment is reduced to once a week for several weeks.If you have questions concerning the treatment plan, your massage therapist should be more than willing to discuss it with you.
© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.
