When we were studying at the Northern Institute of Massage the then principal, Eddie Caldwell, would often be asked by new students what the difference was and if the Institute taught them. His answer was yes they ran courses for different types of massage but would add “do you know, at the end of the day it’s all skin rubbing”. Now this isn’t strictly true. There are differences, and they don’t just involve rubbing of the skin. But Mr Caldwell’s down-to-earth approach always manages to put things into perspective.

Massage, although an ancient art, is constantly being updated as variations in procedure or new therapeutic techniques are added to the toolbox. Unfortunately these new techniques are often padded out, inflated and given a new name in order to create a whole new therapy. It might be cynical to suggest that the reason for this is for marketing purposes or to sound more scientific and to distance themselves from the word ‘massage’. It’s hard not to think, when meeting such a therapist, ‘get over yourself you are a masseur!’

On the positive side, even if these techniques don’t justify the creation of a whole new therapeutic modality or proprietary brand, they can be useful tools to have at your disposal as a therapist.

Multiple types of massage can be used to treat a patient in the clinic. The skill is deciding what mix of techniques is best suited to an individual patient’s needs. A patient suffering from stress needs a different form of massage to someone with a frozen shoulder. These in turn requires a different treatment plan to an athlete who wants to improve performance. In some ways there are as many different types of massage as there are patients.

So, bearing this in mind, we can define the different types of massage recognising that each represents just one string to the therapist’s bow.

Remedial Massage

remedial : adjective
giving or intended as a remedy or cure. Example ‘remedial surgery’
Remedial masseurs are trained to recognise and treat musculoskeletal conditions such as back pain, stiff neck and shoulders, sciatica and knee injuries. A typical treatment may include massage, mobilisations, tractions, rehabilitation exercises/stretches, postural assessment and a mixture of the techniques described below used for therapeutic effect.

Swedish Massage

The classic massage. A straightforward, no frills but very effective massage for general aches and pains. Also an excellent stress buster. It usually incorporates the neck, shoulders, back and legs.  The term isn’t recognised in Sweden. Not surprisingly they just call it massage. The popularisation of this type of massage is often wrongly accredited to Peter Henry Ling, a Swedish gymnastics teacher in the 1800s. In actual fact, it was Dutch practitioner Johan Georg Mezger who which developed ‘Swedish massage’ as we know it today, and adopted  French names like ‘effleurage’ and ‘petrissage’ to denote the basic strokes that we perform.

Sports Massage

A form of massage geared towards amateur and professional sports people. One of the oldest recorded forms of massage dating from early martial arts in the far east to the ancient Greek and Roman games. Homer writes in the poem The Odyssey of Greek soldiers being rubbed with oils to aid their recovery and regain strength on return from battle.

Deep Tissue Massage

Deep tissue massage is a type of massage aimed at the deeper tissue structures of the muscle and fascia. The term is often used to distance the therapist from the lightweight ‘beauty therapy massage’. A bit unfair to beauty therapists many of whom can give a perfectly decent massage. Getting through the layers of muscle is more subtle than you might imagine and requires persistence and coaxing as well as firm pressure. Just digging in demonstrates inexperience or a lack of training. Many people like a deep massage as the pain produces large amounts of endorphins (the body’s own painkiller) that gives a natural high. However, overdoing it can cause the muscle to react badly causing more tightness than before.

Soft Tissue Release

Soft tissue release (or STR massage) is a technique of assisted stretching of muscle fibres, tendon and fascia. STR involves repeatedly and quickly stretching small areas of the soft tissue. Precise pressure is applied to part of the muscle which is then moved to achieve a very specific stretch. An interesting and popular form of therapy, especially useful if adhesions are present in the tissue.

Trigger Point Therapy

A trigger point (TrP) is a small area of muscle that is exquisitely painful and tender to pressure. When pressed it produces a recognisable and reproducible pattern of referred pain away from the site of the trigger point. We use TrP therapy to get rid of these nasty little blighters.

Neuromuscular Massage

As well as TrP release this also includes the very effective Muscle Energy Techniques (MET) and Positional Release. Neuromuscular techniques are a recommended and powerful skill set for any Remedial masseur.

Lymphatic Massage

A type of massage which encourages the natural drainage of the lymph, which carries waste products away from the tissues.

Myofascial Release

Fascia is a thin, tough, elastic type of connective tissue that wraps most structures within the human body, including muscle. Fascia supports and protects these structures. All types of massage will involve treating the fascia to some degree, it fact it would be hard not to! Myofascial techniques claim to isolate and release fascial tension by using gentle sustained pressure on the tissue.

Although it is a useful exercise to define the different types of massage, I have never understood a therapist defining or limiting themselves to a specific skill set. This would be like a carpenter limiting themselves to just using a hammer. As long as a therapist has taken the time to study and train in the therapy and as long as it is covered by their insurance and recognised by their professional body then there is no reason why a therapist shouldn’t expand their repertoire. The availability of high quality courses makes acquiring new skills and learning new types of massage a natural part of Continuous Professional Development.

The post What is the difference between the various types of massage? appeared first on The Muscle Clinic | Remedial and Sports Massage Plymouth.

Ok, that was easy enough but now we have answered that question let’s take a closer look at what we actually mean by massage being an art and a science.

Art in this context could be defined as: the application of human creativity and imagination using practical and personal skills. Science is the pursuit of knowledge and the exploration of the world based on evidence.

Put simply science teaches to ‘know’ and art teaches to ‘do’.

The Art of Massage

The art of massage involves more than the practical skill of a well developed sense of touch and may involve the following:

Thinking intuitively

Being intuitive is not an excuse for woolly mindedness or delusional thinking. It is a practical way of making sense of a complicated and immediate situation. An instinctive strategy for dealing with novelty in an urgent and complex world. This may involve carrying out tasks and making decisions partially below the threshold of conscious awareness – this is very different from performing a task mechanically or mindlessly. It is a natural and very human ability that comes with experience. If you have ever learnt a musical instrument you will remember how at first you needed to concentrate hard on every note. Eventually you can play automatically without immediate focal awareness of individual notes. It could be argued that the tune has just been memorised but that doesn’t explain how experienced musicians can jam and play skillful variations in real time. Making clinical decisions intuitively, on the fly, is akin to this creative musical process.

“Therapists must be able to think along multiple lines and often think on different levels at the same time.”
Jones & Rivett (2004)

Pattern recognition

Finding relationships between signs and symptoms, joining the dots and seeing the big picture is an essential skill for any therapist. And just as importantly, recognising when a relationship doesn’t exist and interpreting the meaning of the relationship correctly.

Seeing patterns is a natural and extremely useful function of the brain, the downside to this is that we have a tendency to find patterns in random data that aren’t there. It even has a name – Apophenia is the spontaneous perception of connections and meaning in unrelated phenomena and figures prominently in conspiracy theories, pseudoscience and the misinterpretation of statistics and scientific data.

Taking an holistic approach

Few words will have science fundamentalists frothing at the mouth more than ‘holistic’. The holistic approach is often sneered at as hippy, new age nonsense. This is because science traditionally reduces and dissects the world to study it (we will look at why this is a useful thing to do later). An holistic view means recognising that natural systems should be regarded as a whole and not just as a collection of individual parts. The workings of biological systems are dependent in large measure upon the total setting in which they occur.
Few medical conditions are simple and straightforward and most involve the interplay of very many factors including physiological, psychological and socio-economic that require multifaceted solutions. Scientists are now beginning to investigate how our emotional state can affect our immune system and modern pain management models recognise that the patient’s fears, attitudes and beliefs are just as important factors as tissue damage. Research has demonstrated that for some patients just imagining movement of a painful joint can cause inflammation in that joint!

Empathy and communication skills

The ability to understand and share the feelings of another person is an art in itself. It’s often the case that those people who think they are good at this aren’t. Empathy is different from sympathy. Feeling pity and sorrow for someone else’s pain and misfortune isn’t necessarily helpful and may be viewed as patronising behaviour. Sympathy may be a driving force in wanting to help someone but empathy enables us to understand how we may best accomplish this. This is one advantage we have as masseurs. We get to spend time with people and can empathise and treat them as individuals. Therapists need strong verbal and nonverbal communication skills. Patients begin healing the moment they feel they are being listened to and understood.

A sense of salience

Recognising what is relevant and important. A new therapist may ask every question and carry out every measurement and every test in the book. An experienced therapist will know when it is expedient to cut corners and avoid an information overload. But we have to be careful. The risk here is that we have a tendency to see what we believe. If we make an early assumption about a patient’s condition we may only carry out tests and ask questions that confirm our beliefs rather than challenge them. This is the complacency of experience.

Use creative thinking

Creative thinking involves learning to generate and apply new ideas. Seeing existing situations in a new way, identifying alternative explanations and finding novel solutions to an individual’s unique problems. Eddie Caldwell from the Northern Institute of Massage needed to get creative when one of his elderly patients needed to carry out exercises on the vastus medialis as part of her knee rehabilitation. She wasn’t a member of a gym nor did she own any weights. The solution had to involve things she would have around the home. An oven glove hung over the leg with a tin of beans in each pocket did the job perfectly.

Being open minded

“Your assumptions are your windows on the world. Scrub them off every once in a while, or the light won’t come in.” Isaac Asimov

Open-mindedness engenders a willingness to question current thinking and practice, to be receptive to emerging possibilities, to share ideas and to consider differing perspectives. Therapists need to be willing to revise firmly held views on the basis of evidence.

The Science of Massage

The science of massage involves a logical and analytical approach that could involve the following:

Quantifying and measuring

Much of science involves taking measurements. Massage therapists can record Range of Movement (ROM) using an instrument called a goniometer. Comparing these measurements to normal ranges has to be done with caution as what is normal for one person may not be for another. Measuring ROM is useful to monitor changes over time, to demonstrate improvement to a patient and also as evidence if conducting research and compiling case studies. To some degree pain can be quantified using numerical scales. Again this is useful to compare changes over time but has limited value when making comparisons between different patients as pain is subjective.

Care has to be taken when quantifying and recording data that the emphasis doesn’t shift from looking, thinking and understanding to depending on tables of measurements. We are health workers not accountants.

Taking a reductionist approach

Reductionism is the belief that the world can be explained by breaking it down into smaller component parts. It does not mean we are simplifying things: on the contrary the closer we look at something the more detail we see. Most special tests we use in the clinic aim to isolate specific body tissues in order to assess them, and whenever we study the physiology of the human body in close detail we are taking a reductionist approach. Reductionism gives us high definition whereas an holistic approach may allow us to see the interconnectedness between things but we will lose the detail. Being able to switch between the two ways of examining the world is a useful ability.

Using critical thinking skills

If being open minded is part of the art of massage then doubting and questioning everything we know and learn is part of the science of massage.

Doubt is the origin of wisdom

…or as G.P. Ann Robinson suggests “keep your skepticism wrapped around you like a cloak”. Critical thinking involves interpreting, analysing, evaluating, reasoning. This includes appraising, questioning and testing rather than just accepting new ideas. Being skeptical is not the same as being cynical! We may have our reservations about some techniques we come across but should be willing to give them a go. In this case we apply the “do no harm” rule. Some techniques may be dropped after a trial period if they prove to be ineffective, others may be excluded if we believe the risks outweigh the benefits such as spinal manipulation and ‘neck cracking’.

Being familiar with latest research

There is an increasing amount of research being carried out on the musculoskeletal system and on the various methods of treatment for the associated injuries and conditions. However care has to be taken. The scientific method is robust but it is still a human being who implements and interprets the research. All research will be flawed or limited to some degree (see a brief discussion of this in the notes below). It is a good idea to pool the evidence from lots of different trials and case studies. Luckily for us the Cochrane network carries out systematic reviews of health care research and is recognised as the highest standard in evidence-based health care resources.

Monitoring effectiveness

This can be as simple as getting feedback from patients or using measurements as described above.
One way to monitor the success (or non-success) of a technique is to compile case studies. It is important to record the failures as well as the successes.

Using evidence based practice

EBP is an approach to making quality decisions and providing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic.

Keep training up-to-date

This involves not only learning new skills but also revisiting and revising old ones. Acquiring knowledge and being able to use and act on that knowledge as part of lifelong learning is important for any therapist.
Continuing Professional Development (CPD) refers to the process of tracking and documenting the skills, knowledge and experience that are gained both formally and informally as we work, beyond any initial training.

In conclusion, analytical thought and creativity are two sides of the same coin. It is unnecessary to place these disciplines into separate silos.

Most geniuses, from Da Vinci to Einstein seem to have been highly creative as well as logical and analytical. Research on Einstein’s brain (preserved in two jars apparently) has shown he had a very high degree of interconnectedness between areas of the brain associated with logic and creativity. Few of us fall into this category but it does suggest that massage therapists and other healthcare workers should develop this crossover thinking and find the balance between logic and intuition, science and art, in order to provide the best treatment for their patients.

Notes, References and Further Reading

Main Image: HEALTH, 2009, Get Color. Album cover detail.

Discussion: Limitations in research

• The observer effect in science recognises that any observation will affect the system being observed. Think of measuring the pressure of a car tyre, impossible to do without letting out some air. In physics the observer effect can be minimised to make it almost insignificant but in biology and particularly medicine it is difficult to isolate the subject from the observation technique.
• We like to think of science as being objective but the way we decide if the result of our research is significant is by using an arbitrary statistical figure! As a general rule, the significance level is arbitrarily set to 0.05 (5%)
• There is a difference between recognising the limitations of research and flawed or fabricated data. If researchers or their sponsors have a vested interest in the results then this is almost certainly going to introduce bias. Researchers should always declare potential conflict of interest that might introduce bias. For most researchers a positive, significant or interesting result is normally going to be the preferred outcome and this could potentially introduce a subconscious bias; researchers are human after all. In surveys asking about the falsification of data, admission rates were 14.12% for falsification, and up to 72% for other questionable research practices. Sadly this is a conservative estimate of the true prevalence of scientific misconduct. Believing in research can be an act of faith and we are more likely to trust the research if it supports our own world view.
• Different research is often contradictory, this is only to be expected and is a normal part of the scientific process. This is why we have to pool the results from many different trials. But until an adequate consensus is reached we are left trusting our instincts and making educated guesses.
• In some cases, even when the evidence from research is overwhelming and when a rational consensus has been reached it may be dangerously ignored by policy makers. This is hardly the fault of science but it places a huge collective responsibility on all researchers to get it right as poor research that is uncovered, and it always is eventually, will very quickly be held up as counter evidence and other valid researchers will be guilty by association.
• Sometimes the basic premise of the research is flawed. For example, a good deal of research on back pain and the efficacy of different treatments and techniques is flawed even before the research begins. Back pain is not a medical condition or disease it is a symptom. In the same way as a cough is a sign that can be caused by a many medical conditions from colds and allergies to cancer. A technique that helps with back pain caused by a prolapsed disc may not help with back pain caused by a tight psoas or tight quadratus lumborum or any of the multitude of other causes of back pain. Lumping together all these conditions makes the results from the research at best worthless and at worst misleading.
• The reductionism of science works well for the physical sciences but in medicine it often takes the research so far out of context that it becomes meaningless.
• Research can be limited by sample size and selection, duration and location amongst other factors.
• After the research is complete the statistical analysis and interpretation of the results is often flawed and research can be overblown both by researchers and the press.

Despite all these limitations and flaws, science is still a very powerful tool and the best we have but perhaps its pedestal should be a little shorter.

References

1. Definition of science
   http://sciencecouncil.org/about-us/our-definition-of-science/
2. Moseley G.L (2004), Imagined movements cause pain and swelling in a patient with complex regional pain syndrome. Neurology 62. 1644
3. Price D.D (2000) Psychological Mechanisms of Pain and Analgesia Vol. 15. Seattle, IASP Press 223
4. The corpus callosum of Albert Einstein‘s brain: another clue to his high intelligence https://academic.oup.com/brain/article-lookup/doi/10.1093/brain/awt252
5. Explain Pain, Lorimer, Moseley, David, Butler. Noigroup Publications ISBN 978-0-9873426-6-9
6. Association between socioeconomic status and pain, function and pain catastrophizing at presentation for total knee arthroplasty http://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-015-0475-8
7. Dangers of neck manipulations. https://youtu.be/ezKnjah7nwI
8. How Many Scientists Fabricate and Falsify Research? A Systematic Review and Meta-Analysis of Survey Data http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0005738
9. Open mindedness in health care http://www.transformnursing.eu/working-definitions/open-mindedness.aspx
10. Ann Robinson https://www.theguardian.com/profile/annrobinson
11. How We Know What isn’t So: Fallibility of Human Reason in Everyday Life, Thomas Gilovich, Free Press ISBN 0029117062
12. Bad Science, Ben Goldacre, 4th Estate ISBN 978-0-00-728487-0
13. How expert nurses use intuition http://journals.lww.com/ajnonline/Citation/1987/01000/How_Expert_Nurses_Use_Intuition.12.aspx
14. Intuition and rational decision-making in professional thinking: a false dichotomy? http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2648.1996.02413.x/full
15. Intuition in the context of discovery http://www.sciencedirect.com/science/article/pii/001002859090004N
16. One source of medical research http://www.mayo.edu/research?_ga=1.262747401.463349823.1485550355
17. The organism: A holistic approach to biology derived from pathological data in man. Goldstein, Kurt Salt Lake City, UT, US: American Book Publishing The organism: A holistic approach to biology derived from pathological data in man.(1939). x 539 pp. http://dx.doi.org/10.1037/10021-000
18. Pattern recognition Eysenck, Michael W.; Keane, Mark T. (2003). Cognitive Psychology: A Student’s Handbook (4th ed.). Hove; Philadelphia; New York: Taylor & Francis. ISBN 9780863775512
19. What is evidence based practice http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021 http://www.csp.org.uk/professional-union/practice/evidence-base/evidence-based-practice/what-evidence-based-practice
20. Critical and creative thinking http://www.australiancurriculum.edu.au/generalcapabilities/critical-and-creative-thinking/introduction/introduction
21. History of massage http://www.naturalhealers.com/massage-therapy/history/ 
22. Stepping out of silos – art and science http://www.artsprofessional.co.uk/magazine/268/article/stepping-out-silos

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It is commonly thought that osteoarthritis is due to wear and tear as we age – but this isn’t inevitable and is far from the full story. There are several factors thought to increase the risk of developing the condition including genetics and having a joint injury in the past, especially if it was overused before it was given enough time to heal. Recent studies suggest osteoarthritis may be caused by activation of a chain reaction in the bodies defence mechanism causing low grade chronic inflammation.

Regular massage therapy can lead to improvements in the sypmtoms of osteoarthritis

Recent studies on the effects of massage for arthritis symptoms have shown regular use of massage therapy led to improvements in pain, stiffness, range of motion, hand grip strength and overall function of the joints.
Arthritis Foundation

Osteoarthritis is made worse by being big and heavy

It isn’t so much about how big you are and more about how much fat you are carrying. Interestingly, the loss of body fat is more closely related to symptom relief than the loss of body weight, it has been suggested that there may be a metabolic link to body fat as opposed to just excessive strain on the joint.
British Medical Journal 

Massage therapy is useful in the treatment of osteoarthritis of the knee

Massage therapy is efficacious in the treatment of OA of the knee, with beneficial effects persisting for weeks following treatment cessation. Massage therapy seems to be well tolerated by people with painful OA of the knee.
Journal of the American Medical Association – internal medicine

X-rays are the best way to diagnose osteoarthritis

In fact x-rays aren’t especially useful in diagnosing osteoarthritis and can be misleading. The severity of the symptoms may be totally unrelated to how the joint appears on x-ray. The majority of people over 40 show some signs of osteoarthritis (seven out of ten people over the age of seventy show signs) although most don’t develop symptoms. On the other hand some people have a perfectly normal x-ray but suffer excruciating symptoms.

Massage can lead to reduction in pain for people with arthritis

Regular massage of muscles and joints, can lead to a significant reduction in pain for people with arthritis, according to Tiffany Field, PhD, director of the Touch Research Institute at the University of Miami School of Medicine.
Arthritis Foundation

Bats and sloths are the only known animals that do not develop arthritis

It has often been quoted that bats and sloths are the only known animals that do not develop arthritis – the reason being that they don’t put as much pressure on their joints because they hang upside-down. Nice theory, but not true – bats have been found with arthritis of the knee and carpal joints.

Osteoarthritis causes nodes on the finger joints

Bony enlargement on the end joints of the fingers (Heberden nodes) or on the middle joint of the fingers (Bouchard nodes) are a sign of osteoarthritis of the hand.

Joints are like the bearings on a car which wear out the more you use them

Cartilage in the joints isn’t inert; it is living tissue capable of regeneration. Recent research showed that running significantly reduced arthritis and hip replacement risk. The benefits of exercise include lower body fat and stronger muscles protecting the joint (studies have shown that people with weak thigh muscles are more likely to develop osteoarthritis).

Osteoarthritis pain usually worsens through the day

Osteoarthritis pain tends to get worse through the day whereas other types of arthritis tend to be worse in the morning or remain the same during the day.
However, osteoarthritis can cause stiffness in the morning but this usually lasts for less than half an hour.

Cracking your knuckles can cause arthritis

Doctor Donald Unger cracked the knuckles of his left hand every day for more than sixty years, but he did not crack the knuckles of his right hand. He did not develop arthritis or other ailments in either hand. This earned him the 2009 Ig-Nobel Prize in Medicine, a parody of the Nobel Prize. Researchers from the Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA, carried out a study – “Knuckle Cracking and Hand Osteoarthritis” – published in the Journal of the American Board of Family Medicine (April 2011 issue). This did not show any link between knuckle cracking and osteoarthritis. If cracking is accompanied by pain, there could be underlying abnormalities of the structures of the joint, such as loose cartilage or injured ligaments. No one knows for certain what causes joints to crack but the most likely theory involves cavitation within the joint— where small cavities of partial vacuum form in the synovial fluid and then rapidly collapse, producing a sharp sound.

High heeled shoes can increase your risk of osteoarthritis

Although no type of shoe can prevent osteoarthritis some types are better than others. Flip flops and tennis shoes with flexible soles can ease the symptoms of OA and high heels can make it worse.
MedicineNet

Cod liver oil ‘lubricates’ the joints

It’s not true that cod liver oil ‘lubricates’ the joints, but they have been found to help relieve pain and inflammation if you suffer from rheumatoid arthritis. They are also showing some promise in people who suffer from osteoarthritis.

Further reading and references

‘Medical Conditions and Massage Therapy – A Decision Tree Approach’
Tracy Walton

‘Massage for Orthopedic Conditions’
Thomas Hendrickson

‘Rheumatology and Orthopaedics’
Coote, Haslam

‘Osteoarthritis results from inflammatory process, not just wear and tear, study suggests’
Stanford School of Medicine

‘Effects of running and walking on osteoarthritis and hip replacement risk’
Life Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA.

‘Why Don’t Most Runners Get Knee Osteoarthritis?’
American College of Sports Medicine

‘Change in body mass index during middle age affects risk of total knee arthoplasty due to osteoarthritis: A 19-year prospective study of 1003 women’
NIHR Musculoskeletal Biomedical Research Unit, Nuffield Orthopaedic Centre, Windmill Rd., University of Oxford

A Meta-Analysis of Massage Therapy Research
A meta-analysis was conducted of studies that used random assignment to test the effectiveness of Massage Therapy. Mean effect sizes were calculated from 37 studies for 9 dependent variables. Single applications of MT reduced state anxiety, blood pressure, and heart rate but not negative mood, immediate assessment of pain, and cortisol level. Multiple applications reduced delayed assessment of pain. Reductions of trait anxiety and depression were Massage Therapy’s largest effects, with a course of treatment providing benefits similar in magnitude to those of psychotherapy.
American Psychology Association

Cortisol Decreases and Serotonin and Dopamine Increase Following Massage Therapy
In this article the positive effects of massage therapy on biochemistry are reviewed including decreased levels of cortisol and increased levels of serotonin and dopamine.
Department of Pharmacology, Duke University Medical School, Durham, North Carolina, USA
Correspondence: TIFFANY FIELD, Touch Research Institutes, University of Miami School of Medicine
International Journal of NeuroScience

Diseases in Free-Ranging Bats from Germany
BMC Veterinary Research

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A DVT is a blood clot that has formed in a deep vein, more often than not in the legs or pelvis.

Recognising the symptoms of DVT are important for any massage therapist as the condition can lead to serious complications including pulmonary embolism, where the blood clot breaks loose and travels to the lungs, a situation that is potentially fatal.

So what are the signs and symptoms of Deep Vein Thrombosis?

Unfortunately, in up to half the cases there may be no signs at all. But the following should make us alert:

• Pain in one or both legs
• Pitting edema. This is swelling that when pressed with a finger leaves an indentation for a few seconds when released.
• Redness and warm to the touch.
• Tenderness along path of deep veins
• Engorged veins at the surface of the skin
• Recent long haul plane flight
• Period of immobilisation such as a stay in hospital or leg in a cast
• Recent major surgery
• Trauma or minor leg injuries
• Active cancer or treatment within 6 months
• Recent Venous Catheters in the neck, chest or groin
• Inflammatory Bowel Disease e.g. Crohns
• History of DVT
• Blood group other than type O doubles the risk
• Age over 40
• Smoker
• Overweight
• Oral contraceptives or Hormonal Replacement Therapy
• Pregnancy or postnatal (6 weeks)

Although passive dorsiflexion of the foot can elicit pain (Homan’s Sign) this cannot reliably confirm or exclude the condition. There are many other conditions that have symptoms similar to DVT including muscle strains and special diagnostic tests are required in order to confirm DVT and may include a D-dimer blood test and Doppler ultrasound.

So when should we refer a patient?

There is a useful scoring system we can use to assess the probability of DVT called the Wells Score. Questions are answered and points allocated accordingly. Wells scores can be categorized as high if greater than two, moderate if one or two, and low if less than one, with likelihoods of 53%, 17%, and 5% respectively.

1. Active cancer (treatment within last 6 months or palliative): +1 point
2. Calf swelling ≥ 3 cm compared to asymptomatic calf (measured 10 cm below tibial tuberosity): +1 point
3. Swollen unilateral superficial veins (non-varicose, in symptomatic leg): +1 point
4. Unilateral pitting edema (in symptomatic leg): +1 point
5. Previous documented DVT: +1 point
6. Swelling of entire leg: +1 point
7. Localized tenderness along the deep venous system: +1 point
8. Paralysis, or recent cast immobilization of lower extremities: +1 point
9. Recently bedridden ≥ 3 days, or major surgery requiring regional or general anaesthetic in the past 12 weeks: +1 point
10. Alternative diagnosis at least as likely e.g Bakers cyst or muscle damage: −2 points

Image Credit: Wikimedia Commons

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Recent research suggests that the amount of benefit from a massage treatment was more than that achieved by joint mobilization, relaxation, physical therapy, self-care education or acupuncture. (see further reading and research below).

Most back pain is actually muscular or ligamentous in origin rather than skeletal, therefore vertebral manipulation or invasive surgical procedures (with the risk of adverse effects) is rarely necessary.

About 19 out of 20 cases of acute low back pain are classed by doctors as non-specific. It is called non-specific because it is usually not clear what is actually causing the pain. In the vast majority of cases it is not due to a serious disease or serious back problem, but the pain itself can be very severe and is debilitating as it hinders movement, strength and flexibility. It is only natural that we want to know the exact cause of the pain and it can be frustrating both for the doctor and the patient not to have a clear cut reason for it.

 Surprisingly x-rays and other scans are not always helpful in this situation and may be misleading:

• More than a third of people without back pain would show some signs of disc ‘abnormality’ such as bulging, herniated disc or degeneration. It would be tempting to identify a similar abnormality in a back pain sufferer as the cause of their symptoms  when it may be a red herring and not the cause of their pain at all.

• It works the other way too.  There may be internal disc disruption (IDD), which may cause pain, without any anatomical distortion, so in this case the scans appear normal.

• Also, the technical jargon you will see on scan reports can sound alarming, when in fact the scan is just showing results that are perfectly normal for your age. This can cause unnecessary worry that may hinder recovery.

Acute low back pain that isn’t associated with any kind of trauma is not normally something that requires a doctor’s visit and will normally improve with the help of massage and other conservative treatments.

We will discuss these and other self-help measures later but first we need to exclude other conditions that do require examination by a doctor and further tests would be strongly advised.

See a doctor if you have any of the following:

• Loss of bladder or bowel control or an inability to pass urine.
• Numbness around your genitals, buttocks or back passage.
• Muscle weakness in the legs or feet.
• Pain that is worse at night or is constant pain that isn’t relieved at all by lying down.
• Fever or unexplained weight loss.
• Swelling or bruising in the back.
• Recent trauma such as a fall or car crash.
• Any other unusual symptom that has appeared around the same time as your back pain.

If you are in any doubt whatsoever see your doctor for a checkup and advice.

What is the cause of non-specific low back pain?

Just because low back pain is described as non specific by a doctor doesn’t mean you are imagining it or that the pain and disruption associated with it isn’t severe. Muscular pain is by far the most common type of back pain.  A professionally trained remedial massage therapist should be able to identify the tissues involved. It might also be necessary to look further afield than the back for the problem as many muscles refer pain to this area.

So who are the chief culprits; what tissues are commonly responsible for low back pain?

The paraspinal muscles are a muscle group on either side of the spine. They enable us to twist and bend as well as provide support for the spine and they are very powerful. A sudden unexpected twisting movement especially when lifting a weight can injure these muscles.

Quadratus lumborum muscles can cause pain in the sacroiliac joint, hips and buttocks and may easily be mistaken for arthritis of the spine, sciatica or disc problems.

Research suggests that gluteus medius is one of the main culprits for causing low back pain and hip problems. Weak gluteus medius or an altered reflex response of the gluteus medius muscle is associated with reduced hip stability which can also cause low back pain..

The piriformis muscle is notorious for causing low back and buttock pain. It can also irritate the sciatic nerve causing shooting pain down the leg mimicking sciatica caused by a bulging or herniated disc.

The iliopsoas muscle group is hidden deep inside the body and is a common source of low back pain. These muscles are large and powerful but unlike the hamstring and quads they are little known to the general public. The iliopsoas are difficult to reach and require a trained therapist using a variety of techniques to release them.

The serratus posterior inferior muscle connects the lower ribs to four vertebrae in the low back. The function of this muscle is unknown, it was originally thought to help with respiration but this is now in doubt. It is one of the muscles that aches and is stiff when you have slept on a mattress that is too soft. The pain from this muscle can be mistaken for kidney pain.

Abdominal muscles frequently refer pain to the back. Too many sit-ups, a chronic cough or emotional stress can provoke these muscles and set off referred pain in the mid and low back.

The ligaments are strong fibrous bands that hold the vertebrae together, stabilize the spine, and protect the discs. The ligaments are supplied with many nerves and are very sensitive. The pain is usually well localised and can be sharp in certain movements.

It would be wrong to look at the muscles in isolation. The functions of these muscles overlap and interact in one interconnected myofascial system. Generally more than one muscle will be involved and although the dysfunction will vary from person to person there are recognisable patterns of muscle imbalance. A remedial massage therapist will, as part of the treatment process, carry out a musculoskeletal assessment; identifying weakness, tightness or inappropriate recruitment of muscle.

How does massage help low back pain?

In the past, you would have been advised to rest until the pain eases. We now know that this was incorrect. The evidence from many research trials and case studies is that you are likely to recover much more quickly if you get moving again as soon as possible. Also, you are less likely to develop persistent (chronic) back pain if you keep active rather than resting or lying flat. Shuffling slowly around the house is better than taking to your bed. This is easier said than done. When a muscle becomes irritated or traumatised from being overstretched or misused it can lock up and may present as a gripping spasm that can be worse with active motion making it difficult to return to your daily routine. Massage works to relieve low back pain by releasing tightness, stiffness, spasms and restrictions in the muscle tissue. By overcoming this inertia and breaking the pain barrier you can start to follow the good advice and get moving again.

Current remedial massage theory also suggests:

• Remedial massage and rehabilitation exercises and mobilisations will improve muscle tone and balance, reducing the physical stress placed on bones and joints.

• Massage helps to free adhesions and break down scar tissue. As a result, it can help to restore range of motion to a stiff back.  Massage can help increase joint mobility by reducing any thickening of the connective tissue and helping to release restrictions in the fascia.

• There is some evidence to suggest that massage has an anti-inflammatory effect on tissue (although further research needs to be carried out in this area).

• A deep tissue massage reduces pain by the release of endorphins (endorphins are also known to elevate the mood).

• Reduces ischemia (ischemia is a reduction in the flow of blood to body parts, often marked by pain and tissue dysfunction)

• Massage stimulates the parasympathetic nervous system, helping promote relaxation and the reduction of stress.

• Passive mobilisations increase flexibility and can reset the muscle length of hypertonic, shortened muscle. Research has shown that mobilisation used as a therapy can produce significant mechanical and neurophysiological effects. The explanations of these effects – the mechanism of mobilisation – is still relatively unknown, especially in regards to the spine, and is subject to further research.

There are several theories that provide an explanation for the mechanism of action that makes massage and neuromuscular techniques effective in releasing tight muscle.  Massage involves two types of response. A mechanical response as a result of pressure and movement as the soft tissues are manipulated, and reflex responses in which the nerves respond to stimulation.

Massage can break the pain-spasm-pain cycle in low back pain and there are well documented physiological principles that explain these effects including spinal inhibition, descending inhibition (Gate Control Theory) and trigger point inhibition. A remedial masseur has a toolbox of powerful and effective techniques to treat soft tissue in the low back. These include Deep Tissue Massage, Trigger Point Therapy, Positional release, Muscle Energy Techniques, tractions, passive joint movements and harmonic mobilisations, stretches and exercises. We will discuss these principles and techniques and the research evidence that support them in a future article.

Further Reading and Research

Professor Goldstone supervised a study  of low back pain led by Elizabeth Dodd at Bradford University and Chris Caldwell at the Northern Institute published in 2003

A further low back pain study by Barbara Heron and Jean Kay, of the Massage Research Advisory Group (2008), involved practitioners from the Northern Institute in the practical work undertaken by the study.

http://summaries.cochrane.org/CD001929/massage-for-low-back-pain
Research report on benefits and efficacy of massage for low back pain.

http://archinte.jamanetwork.com/article.aspx?articleid=647957
Research report  conclusion: Therapeutic massage was effective for persistent low back pain, apparently providing long-lasting benefits. Massage might be an effective alternative to conventional medical care for persistent back pain.

http://informahealthcare.com/doi/abs/10.3109/00207450109149744
Research Conclusions: Massage therapy is effective in reducing pain, stress hormones and symptoms associated with chronic low back pain.

http://www.nejm.org/doi/pdf/10.1056/NEJM199407143310201
On MRI examination of the lumbar spine many people have disc bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery MRI of bulges or protrusions in people with low back pain may frequently be incidental

http://www.ncbi.nlm.nih.gov/pubmed/23427384
Lumbar tender point deep tissue massage combined with lumbar traction produced better improvement in pressure pain threshold, muscle hardness and pain intensity in patients with chronic nonspecific low back pain than with lumbar traction alone.

http://www.ncbi.nlm.nih.gov/pubmed/21424336
Altered hip muscle activation in patients with chronic nonspecific low back pain. Healthy controls showed a significantly higher maximum amplitude of the gluteus medius muscle in comparison to patients with nonspecific low back pain. Patients showed an altered reflex response of the gluteus medius muscle which could be associated with reduced hip stability.

http://iospress.metapress.com/content/9d9lpeb7y6x76qqa/
Certain muscle impairment patterns could contribute to chronic LBP, but probably not by changing the degree of lumbar lordosis as has been previously suggested with Lower Crossed Syndrome.

http://www.ncbi.nlm.nih.gov/pubmed/21328304
High quality evidence suggests that there is no clinically relevant difference between spinal manipulation and other interventions for reducing pain and improving function in patients with chronic low-back pain.

http://onlinelibrary.wiley.com/doi/10.1002/ca.1039/abstract
We suggest that the serratus posterior muscles function primarily in proprioception.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3373767/
Neural structural/functional and physiological correlates of massage therapy in response to physical stress.

http://www.sciencedirect.com/science/article/pii/0306362389902000
Increase of plasma β-endorphins in connective tissue massage.

http://www.physio-pedia.com/Manual_Therapy_Techniques_For_The_Lumbar_Spine
Mobilisations primarily consist of passive movements which can be classified as physiological or accessory. The purpose is to provide short term pain relief and to restore pain-free, functional movements by achieving full range at the joint.

Manual massage is a long established and effective therapy used for the relief of pain, swelling, muscle spasm and restricted movement. Latterly, various mechanical methods have appeared to complement the traditional manual techniques. Both manual and mechanical techniques are described systematically, together with a review of indications for use in sports medicine.

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The symptoms include:

• Pain on the anterior aspect (front) of the knee.
• Tends to affect active people especially those who also sit at a desk for long periods.
• May occur in one or both knees.
• Pain is often described as aching. It can be quite severe and may be intermittent.
• Stiffness after a long period sat down, referred to as ‘moviegoers sign’.
• Difficulty walking down stairs.
• Clicking and grinding noise on movement (crepitation).
• Not normally associated with swelling or bruising.
• Knee stiffness but normal range of movement and no locking.
• Pain may be elicited by carrying out squat exercises.
• Often coincides with a step-up in training, especially starting hill running.

There is no real agreement on the definition and classification of this condition. There is debate as to what tissues are involved and what the main cause is. The most widely accepted theory suggests that the symptoms are the result of excessive joint stress due to abnormal movement of the knee-cap but it is likely to involve more than this. At the muscle clinic we commonly find patterns of muscle imbalance and dysfunction associated with Runners Knee that extend beyond the knee joint.

The knee-cap, or patella, is a free bone that ‘floats’ above the end of the thigh bone (femur). It is stabilised and held in position by the thigh muscles (quadriceps). The underside of the patella has a grooved surface that aligns with a guiding track on the femur; the patella glides along this track when the knee bends. If for any reason the patella is derailed from this track, even by a small amount, it doesn’t glide along as it should and it causes the symptoms associated with Runners Knee.

What causes the patella not to track properly?

The quadriceps, as the name suggests, consists of four muscles. An imbalance in these muscles can pull the patella slightly out of alignment as they contract causing the patella to track incorrectly.
The body is a complex structure and reducing it to individual components often leads to an oversimplification of the problem – a mistake even professional researchers make.

The leg bone’s connected to the knee bone,
The knee bone’s connected to the thigh bone,
The thigh bone’s connected to the hip bone,
Now shake dem skeleton bones!

The old children’s song is true; the entire body is connected and any treatment must recognise this. Just massaging the knee and leg isn’t going to solve this problem. Faulty hip mechanics are recognised as being linked to this condition although it is unclear if this is a cause or an effect of runners knee. There is growing evidence to support the association of gluteal muscle weakness in individuals with runners knee and the effectiveness of gluteal strengthening when treating the condition. The gluteus medius is one of the main stabilisers of the hip. When it’s under-active the opposite quadratus lumborum (QL) becomes overactive, often causing low back pain and stiffness. If the gluteus medius is weak, the tensor fascia lata (TFL) will also substitute, causing it to become short, tight and painful to touch. The other areas that may need working on include the iliotibial band, the iliopsoas and possibly the piriformis.

Muscles are very gregarious and like to join in the party! Sometimes the original problem can resolve but still leave traces in the misbehaviour of other muscles.

Every individual will present with a slightly different pattern of muscle dysfunction and it is important to differentiate between a variety of other related conditions that present with knee pain such as iliotibial band syndrome (ITBS), bursitis, plica syndromes, Sinding Larsen’s disease and Osgood Schlatter’s disease. Successful treatment of Runners Knee involves a thorough examination and assessment followed by an entire treatment protocol involving the release of tight muscle, and strengthening of weak muscle. Mobilisations, tractions, massage, stretches and exercises will be an important part of the treatment.

Self Help

• Reduce intensity of training.
• Avoid running over hilly terrain until the condition clears up.
• If you work at a desk ensure you get adequate breaks and don’t miss an opportunity to stand up, stretch and move around.
• Stretch your calf, thigh and hamstring of the affected leg.
• The runner may also want to experiment with slightly reducing their stride length.

Research and further reading

The Role of Hip Muscle Function in the Treatment of Patellofemoral Pain Syndrome

Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome

Gluteal muscle activity and patellofemoral pain syndrome: a systematic review

Patellofemoral pain syndrome : Clinical and pathophysiological considerations

A retrospective case-control analysis of 2002 running injuries

Patello-femoral syndrome

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We are all aware that poor posture causes neck and shoulder pain, but what are the processes involved?

The fact is we are designed to be hunter gatherers. In the natural state we would spend a good deal of the time standing, walking, running and generally moving about but in the modern world we spend much of our time sat at a desk, driving a car or slumped in front of the TV. Even if we don’t work at a desk, many of us have jobs that involve us looking down or maintaining the same bent over posture for hours on end (including masseurs I might add). Poor posture can also have a psychological root. Poor self esteem, anxiety and depression can result in this postural pattern. Negative emotions are expressed through flexion of the spine – the desire to curl up into a protective ball. Tall people who don’t wish to stand out from the crowd can also develop the slumped forward head posture. Maintaining the same posture causes unrelenting pressure on the same muscle groups and causes muscle fatigue. Naturally under these circumstances we slump forward, develop rounded shoulders and what is called a forward head posture.

Ask a friend to stand up face forward. Stand to their side and imagine a line drawn vertically downward from their ear. This line should pass directly down from the ear through the shoulder, hip and ankle, but it is possible that the line passes in front of them and the head appears forward of the centre of gravity.  When the head is nicely balanced on the neck and shoulders it doesn’t take much effort to hold it in place. The light work of a few ligaments and muscles will maintain stability.  The weight of the average human head is around 5kg but in forward head posture due to a fulcrum effect it can have an apparent weight of more than 15kg. Think of the extra strain involved in holding the head up in this situation. Although the head is forward of the centre of gravity the eyes still want to be horizontal so the head, as well as being forward, also needs to tilt upward. This sets off a cascade of events that, in the long term, can cause a great deal of pain and discomfort.

The typical slumped posture with rounded shoulders and forward head is easily recognisable in modern society and, when maintained persistently, the knock on effects can be very widespread and debilitating. It is the soft tissues that suffer first.

• The muscles of the neck and upper back (including the upper trapezius and neck extensors) are in a sustained isometric contraction and become short and tight. The muscles of the chest (pectorals) also become short and tight. Causing generalised aching and more localised trigger points in the muscle.
• The muscles in the front of the neck, the deep neck flexors, are stretched and become weak and inhibited. A number of mid-back muscles (lower trapezius and rhomboids) plus the serratus anterior muscles are also stretched and become weak and inhibited.
• The shoulder muscles (deltoids) roll forward and develop an abnormal torsion.
• A number of ligaments (nuchal ligament) will be placed under excessive stress.
• The normal curve of the upper back becomes exaggerated (thoracic kyphosis).
• The shoulder blades (scapulae) rotate downwards
• The vital capacity of the lungs is decreased with a diminished thoracic cavity.
• The joints of the cervical spine can become partially compressed and the cartilage is exposed to repeated trauma. This compression could potentially lead to nerve root pressure.
• There is a decreased range of movement of the neck and shoulder.
• Tension where the muscle tendons join the back of the skull (occiput) can initiate headaches.
• Chronic pain and discomfort can result in general irritability and poor sleep patterns.
• There is mixed evidence to suggest that compression of the space above and below the collar bone (clavicle) caused by forward head posture could compress the nerve supply and blood flow into the arm (thoracic outlet syndrome) causing numbness and tingling.
• There is mixed evidence to suggest that a forward head posture can also cause temporomandibular joint (jaw) problems.
• There is mixed evidence to suggest a forward head posture and rounded shoulders may help to create or exacerbate impingement syndrome where the tendons of the rotator cuff in the shoulder become irritated and inflamed as they pass through the subacromial space, the passage beneath the collarbone. This can result in pain, weakness and loss of movement at the shoulder.

This list is long enough but unfortunately it doesn’t stop here. Muscles that are chronically contracted disrupt the symmetry of balanced forces acting on the body. This disruption cannot be maintained indefinitely – the body seeks out stability. Changes in one part of the body lead to adaptive changes in other distant parts of the body. The patient may present with widespread problems such as low back, hip or knee dysfunction as well as shoulder and neck pain.The problem escalates as muscles designed to move bones are now given the task of stabilisation and the body sacrifices flexibility for stability. The body finds a new stable state, albeit a noxious one. The body’s natural healing process stalls. In a sense it is stuck in a rut of chronic pain and requires a gentle nudge to reset the balance.  Given the opportunity the body will heal itself but sometimes just needs a push in the right direction.

The process of rehabilitation involves awareness and education as much as remedial massage. Massage attempts to break the pain-spasm-pain cycle long enough to initiate self healing and repair.

The massage treatment will also attempt to stretch short tight muscle and activate weak inhibited muscle. Once the body has been prepared for repair the original cause, poor posture, will need to be addressed. The Muscle Clinic offer advice on lifestyle and work changes that can be introduced and we have found that a physical fitness and education system such as Pilates works very well for rebalancing the body. We can recommend Body Care Pilates  in Plymouth, Devon. Mixed ability and one-to-one classes are available. Ideal for beginners as well as the more experienced.

In a later article we will discuss in greater depth the Pain-Spasm-Pain cycle and how massage can break this pattern, giving the tissue some much needed breathing space and allows the body to initiate the repair process.

Research and further reading:

Body Care Pilates
http://www.body-care-pilates.co.uk/

Muscle Clinic Blog Post
How Does Stress Cause Neck and Shoulder Pain

Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks.
http://www.ncbi.nlm.nih.gov/pubmed/20097090

Influence of forward head posture on scapular upward rotators during isometric shoulder flexion.
http://www.ncbi.nlm.nih.gov/pubmed/20850044

Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement.
http://www.ncbi.nlm.nih.gov/pubmed/15773565

Relationship of Forward Head Posture and Cervical Backward Bending to Neck Pain
http://www.ingentaconnect.com/content/maney/jmt/1995/00000003/00000003/art00003

Trigger Points in the Suboccipital Muscles and Forward Head Posture in Tension-Type Headache
http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2006.00288.x/abstract;jsessionid=A9F3071F2B639573397446292320E150.d04t04?deniedAccessCustomisedMessage=&userIsAuthenticated=false

Reliability of measuring forward head posture in a clinical setting.
http://europepmc.org/abstract/MED/8472080

Thoracic outlet syndrome
http://www.ncbi.nlm.nih.gov/pubmed/7808947

Body posture evaluations in subjects with internal temporomandibular joint derangement.
http://www.ncbi.nlm.nih.gov/pubmed/19891257

Global body posture evaluation in patients with temporomandibular joint disorder.

http://www.ncbi.nlm.nih.gov/pubmed/19142549

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There is an interesting moment in the BBC News 24 countdown sequence. The tension builds as the drums beat and the pips match the time signal. Images of various correspondents, working both home and abroad, are flashed across the screen until we see John Simpson talking to camera in a war zone. An explosion occurs behind him and John, the consummate professional, continues to speak to camera. His body does react however. In fact all the people around him react in the same way. His head drops down and his shoulders rise up as he ducks.

The body is well designed to protect vulnerable areas. The major nerves and blood vessels in the arms and legs run down the inner surface of the limbs. The femoral artery for example runs down the less exposed inner thigh. But one area of the body is very vulnerable and not well protected at all – the neck. The instinctive reaction of John Simpson is designed to make the body a smaller target but also designed to protect the exposed neck and throat. The shoulders rise up as the head drops down and the back stoops. This instinctive reaction lasts just a second or two before his posture returns to normal.

We moved house recently, apparently one of the most stressful things you can do in normal life and whenever I took time to notice I found my shoulders were nearly up to my ears with the stress. Now Plymouth is hardly a war zone, so what is happening here? The body finds it difficult to distinguish between instantaneous fight or flight situations and the insidious stress we feel in our everyday lives and the physical reactions can be remarkably similar.

How Does Stress Cause Neck and Shoulder Pain? Holding the shoulders in this raised position causes the neck and shoulder muscles to become shortened and tight. The muscles become strained particularly at the tendons where they join the area of bone at the back of the skull called the occiput. The associated discomfort, the aching shoulders and a sore neck, will be familiar to most of us. The hyperventilation and ‘chest breathing’ associated with stress exacerbate the situation still further as a band of tightness around the chest develops.
Under normal circumstances after the stress is resolved, the tension in the muscles dissipates relatively quickly; a good night out with friends, a relaxing holiday or a massage is usually sufficient to relax the muscles. In a later article we will look at the cascade of events that can lead to chronic neck and shoulder pain and even injury.

Interestingly, although stress and tight muscles can lead to headaches, latest research suggests that tension headaches may be caused or at least prolonged by taking too many painkillers over a period of time. Some people are trapped in a “vicious cycle” of taking medication for pain relief, which then causes even more headaches. The warning came as part of the National Institute for Health and Clinical Excellence’s (NICE) first guidelines for treating headaches.

In light of this research it becomes a matter of some urgency to find an alternative to taking pain killers for headaches. Fortunately, plenty of research has been done to investigate the effect of massage therapy on chronic non-migraine headaches and stress.

Research and further reading

1m Britons have Headaches from Overusing Painkillers
Article and video in The Guardian: Experts say pills people take to relieve headaches and migraines may be making things much worse

Neck movement and muscle activity characteristics in female office workers with neck pain.

Massage Therapy and Frequency of Chronic Tension Headaches
Compared with baseline values, headache frequency was significantly reduced within the first week of the massage protocol.
Conclusion – The muscle-specific massage therapy technique used in this study has the potential to be a functional, non-pharmacological intervention for reducing the incidence of chronic tension headache.

Massage Therapy for Stress Management: Implications for Nursing Practice
Research suggests massage has a direct relationship with positive health outcomes and patients’ perceptions of stress and anxiety were significantly reduced.

Research for Evaluation of Stress Change via Thermotherapy and Massage.
Jeong I, Jun S, Park S, Jung S, Shin T, Yoon H.
Department of Biomedical Engineering, Yonsei University, Wonju, Kangwon, 220-840, Korea. decem31@chol.com
The physiological changes of subjects before and after treatment were compared, the present research was able to prove that thermotherapy and massage treatment induces physiological change of patients thus relieves stress.

Physiological and clinical changes after therapeutic massage of the neck and shoulders
Sefton JM, Yarar C, Carpenter DM, Berry JW.
Neuromechanics Research Laboratory, Department of Kinesiology, Auburn University, Auburn, AL 36849-5323, USA. jmsefton@auburn.edu

This study investigated the influence of a standardized clinical neck/shoulder therapeutic massage intervention on physiological measures assessing α-motoneurone pool excitability, muscle activity; and the clinical measure of range of motion (ROM) compared to a light touch and control intervention. Flexor carpi radialis (FCR) α-motoneurone pool excitability (Hoffmann reflex), electromyography (EMG) signal amplitude of the upper trapezius during maximal muscle activity, and cervical ROM were used to assess possible physiological changes and clinical effects of therapeutic massage.
The intervention produced increases in cervical range of movement in all directions assessed. Therapeutic massage of the neck/shoulders reduced the α-motoneurone pool excitability of the flexor carpi radialis after therapeutic massage. Moreover, decreases in the normalized EMG amplitude during MVIC of the upper trapezius muscle; and demonstrated increases in cervical ROM in all directions assessed occurred after therapeutic massage.

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What is Remedial Massage?

Remedial Massage is a form of Deep Tissue Massage – a clinical treatment that also integrates techniques not normally associated with other forms of massage.
Ordinarily, Remedial Massage tends to be deeper and much more targeted; although the long, slow and gentle strokes associated with a classic massage may be used to relax the patient and prepare the area to be worked on.
After an examination and assessment, the therapist will identify which tissues and areas of the body are dysfunctional. They will then focus a variety of practical techniques towards resolving the problem. Reduction of muscle tension and release of soft tissue in one area will often produce favourable changes in the body’s overall alignment and balance.

Getting beneath the skin

There is no quick answer to how Remedial Massage works. A short paragraph listing the benefits of massage doesn’t really satisfy the curious or answer the question. We hope to get ‘beneath the skin’ and explain in greater detail, without getting too technical, what is happening when various Remedial Massage procedures are applied. Latest research has produced some surprising results that may turn some of our current theories on their head and suggest that massage works in some surprising and unexpected ways. We will look in some detail at the causes and development of painful conditions such as chronic neck and shoulder pain and explain how Remedial Massage can be of help.

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