AMTA NATIONAL CONVENTION October 19-22, 2011 Pelvic Stabilization The Key to Structural Integration The Cutting Edge in Orthopedic Massage and Pain Management Training James Waslaski, LMT Author and International Lecturer www.orthomassage.net A Unique Multidisciplinary Approach to Chronic Pain and Sports Injuries 1
Instructor Biography James Waslaski, LMT James Waslaski worked 20 years as a paramedic, and in a trauma center, while teaching emergency medical courses, and studied pre med in college prior to his massage training in Florida. James served as Professional Relations Chair for Florida and received the 1998 FSMTA outstanding state service award. He also served as AMTA Sports Massage Education Council Chair from 1993 1997 receiving the AMTA National Officer Award. He is a self published author and international lecturer who has pioneered deep pain free orthopedic massage, pain management, sports injury, and sports enhancement treatments. His unique structural and multidisciplinary bodywork approach has been taught throughout the United States, Ireland, London, Scotland, Canada, Costa Rica, Puerto Rico, Greece, Australia, and the Caribbean. His seminars are being requested now in New Zealand, South Africa, Amsterdam, Holland, Italy, Egypt, Russia, and Dubai. James was the 1999 recipient of the FSMTA International Achievement Award. James has presented at state, national and international massage conventions, as well as chiropractic conventions, osteopathic conventions, the college of sports medicine, the University of South Wales, the Olympic training center in Australia, and the osteopathic and manipulative massage therapy convention in London. His audience consists of Massage Therapists, Physical Therapists, Occupational Therapists, Athletic Trainers, Osteopaths, Chiropractors, Nurses, and Physicians. He has worked with collegiate, professional and Olympic athletes, including the 1996 Olympic Games and the New York Yankees, and has published articles, books, manuals, and a series of DVDs on sports injuries, chronic pain, and complicated orthopedic conditions. James has also produced a powerful motivational audio series, highlighting success strategies of leaders in the wellness industry, to help guide massage therapists to their true spiritual blueprint for success. James book has been released since September 30, 2011, Clinical Massage Therapy A structural Approach to Pain Management with hopes to bridge the gap between all health care providers throughout the world. James was inducted in 2008 into The Massage Hall of Fame. www.orthomassage.net The Center for Pain Management PO Box 822141 North Richland Hills, Texas 76182 (800)643 5543 NCBTMB APPROVED PROVIDOR No. 049978-00 CE Broker 50-1075 Copyright 1996-2011 James Waslaski. All rights reserved. No part of this handout may be reproduced, in any manner whatsoever, without prior written permission of James Waslaski. This handout does not offer medical advice and is not intended as a replacement for appropriate health care and treatment. For such advice consult a licensed physician. The author shall not be liable or responsible for any loss, injury, or damage allegedly arising from information in this manual. 2
The Twelve-Step Approach Assessment, Treatment, and Rehabilitation It is vital that the following twelve steps are not used as a cookbook approach to therapy. Each step is dependent on the client s individual response to the preceding step. You do not progress to the next step until each area of tension is appropriately released. It is critical to apply specific work to release specific structures and also critical to differentiate between soft tissue problems due to myofascial restrictions, versus trigger point tension, or strained muscle fibers since the specific release techniques for each will vary greatly. The goal is to maintain structure, posture, movement and balance. As you put this twelvestep program into use, you will realize that soft tissue balancing is the missing link to long term pain free musculoskeletal alignment. *Precaution note- do not work on a client with a recent injury (acute condition). Twelve Steps: 1. Client History 2. Assess Active Range of Motion 3. Assess Passive Range of Motion 4. Assess Resisted Range of Motion 5. Area Preparation 6. Myofascial Release 7. Trigger Point Therapy 8. Cross Fiber or Multidirectional Friction 9. Pain Free Movement 10. Eccentric Scar Tissue Alignment (Pain Free) 11. Stretching (Pain Free) 12. Strengthening (Pain Free) Pelvic Stabilization Pelvic stabilization techniques should be a routine part of a massage protocol, prior to dealing with chronic pain in any other area of the body. The goal will be to assure that each client achieves a balance between five basic muscle groups. This means each muscle group has the ability to release to the full range of motion on both the left and the right sides. Deep pelvic contractions can cause distortions throughout the entire body. This is why pelvic stabilization is the key to structural balance. *Note- it is imperative to place a bolster under the client s hips or use a Body Cushion, when prone, during pelvic stabilization. This allows the ilium to rotate posteriorly and helps lengthen the entire spinal column to open up facet joints and help relieve vertebral compression of the spine. *Precautions: Be gentle and non-aggressive with your work. Assume the client could have conditions including bulging or herniated discs, sacroiliac (SI) joint pain or dysfunction, etc. High velocity chiropractic manipulation to the SI joint on someone with a sprain or a tear at the SI joint is not advised. Client History: Ask the client when, where and how the problem began. Have them describe the area of pain and what makes it better or worse. Assess Active Range of Motion (ROM): As you work through the specific order for releasing the muscle groups ask the client to perform each of the six primary single plane movements of the hip joint, with zero discomfort. Determine if the range of motion is normal. If the ROM is less than average, identify which muscle groups are restricted and therefore preventing normal movement. Hip Joint Single Plane Movements: Flexion 90 (knee extended) Iliacus, Psoas Rectus Femoris Sartorius Tensor Fasciae Latae 3
Flexion 120 (knee flexed) Iliacus Psoas Rectus Femoris Sartorius Tensor Fasciae Latae Extension 35-45 Biceps Femoris (long head) Gluteus Maximus Semimembranosus Semitendinosus Medial/ Internal Rotation 30-45 Lateral/ External Rotation 60 Adductor Brevis Adductor Longus, Magnus Gluteus Medius Gluteus Minimus, Tensor Fascia Latae Gemellus Inferior, Superior Gluteus Maximus Obturator Externus, Internus Piriformis, Quadratus Femoris, Sartorius Adduction 30 Abduction 45 (pelvis stationary) 4
Adductor Brevis Adductor Longus Adductor Magnus Gracilis Pectineus Gluteus Maximus Gluteus Medius Gluteus Minimus Sartorius Tensor Fascia Latae Assess Passive Range of Motion (ROM): Gently test the end feel of the above movements. All movements should be soft and leathery except for extension which will feel more ligamentous and abrupt. Assess Resisted Range of Motion (ROM): The client attempts each of the hip joint single plane movements while the therapist applies reverse resistance. If the client experiences pain or discomfort, ask them to point to the specific spot. This is most likely a muscle strain. This area will be worked last. 1. Psoas Major and Iliacus (Iliopsoas) The psoas major attach to the transverse processes of lumbar vertebrae 1-5 and the intervertebral discs above each of these vertebrae. The iliacus attach to the iliac fossa. Both insert on the lesser trochanter of the femur. Together they are called the iliopsoas and they are strong hip flexors and low back stabilizers. Restricted, dense connective tissue where the iliacus and psoas major join on the inside rim of the iliac crest can be a major cause of pain in the lower back. Tight psoas major muscles compress the lumbar spine downward and forward onto the nerve roots causing pain and can also herniate and rupture the lumbar discs. Tight iliacus muscles can rotate the ilium anteriorly because they are directly attached to the ilium. Think about the psoas major for lumbar compression, bulging and herniated discs, nerve compression and excessive lumbar lordosis. Think about iliacus for anterior pelvic tilt and sacroiliac (SI) joint pain. Typically, the client s dominant side will have more anterior ilium rotation, which will also elevate the iliac crest on that side. This causes stress between the articulation of the sacrum and the ilium, which can cause sacroiliac (SI) joint pain to occur. The sacrum can be pulled onto the vertebrae, which are then pulled onto the nerve roots, causing low back pain. Imbalance in these two muscle groups in the pelvis can affect the entire body and must be corrected first before any other orthopedic massage is performed. Assess Active Range of Motion (ROM): The client is prone with their knee bent 90, or less than 90 if they have tight quadriceps. Ask them to lift their leg up off the table and explain to them this is to be performed with zero discomfort. Tell them to only lift their leg to where it is comfortable. Normal range of motion is 35-45. If they can not achieve this then the hip flexors; psoas and iliacus are contracted and tight and need to be released. Assess Passive Range of Motion (ROM): The client is prone with their knee bent 90. Place one hand under their knee. Place the other hand on their hip to stabilize it as the ilium must stay on the table. Move one of these fingers over the SI joint, inferior of the iliac crest, to assess if the ilium is moving with extension. The client s lower leg can rest across your forearm. Gently lift their leg only to the restrictive barrier, pain free, and assess the end feel of the hip joint. It should feel soft and leathery. If it feels like a bone on bone end feel, the hip needs joint capsule work. Assess Passive Psoas ROM Hip Joint Capsule Work: The joint capsule work is one of James Waslaski s unique trademark techniques. An imbalance of the muscles around the hip joint can set up a neuromuscular response attempting to restore balance. This also creates tension in the joint, which eventually leads to joint 5
degeneration and arthritis, as the cartilage wears down. The resultant discomfort also limits range of motion causing a formation of adhesions in the joint capsule itself. Adhesions in the hip capsule are more predominant in the anterior capsule due to excessive or prolonged hip flexion. The articulating fascia acts as superglue and limits range of motion in the hip. These deep fascial adhesions however can be melted much like you would melt jello. The head of the femur can be used as a massage tool to melt the fascia or superglue in the hip joint capsule using very gentle, pain free movements. Heat, pressure, and gentle stretch facilitates myofascial warming and myofascial release. Perform joint capsule work if any ROM end feel feels like bone on bone. The client is supine with one hip flexed 90, their knee is bent. Having the hip flexed 90 is important, as this allows the plunging to be performed straight down toward the table, so that the lumbar spine is not compromised. Place both hands around their thigh. Their lower leg can rest on your forearm, which becomes a lever to facilitate the stretch. Gently move and rock their leg to make sure they are fully relaxed. Push down on the thigh gently, so that the femur goes into the hip socket, rotate it into lateral rotation and then pull it out. Contact, rotate, decompress. This is a plunging type of technique, cartilage on cartilage, to warm and melt the joint capsule adhesions. Tell the client to visualize the joint capsule softening, releasing, and letting go. Ask the client if this is uncomfortable. It usually is not, as you are taking the pressure off the hip joint by shortening the fascial adhesions. This must be performed pain free as even minor muscle tension prevents joint capsule work, as muscles will splint the area in response to discomfort. Repeat the plunging several times, warming up the fascia inside the hip. Then plunge once into the joint capsule, make contact, rotate it laterally to the restriction, and then give a deep capsular stretch. Back off the stretch, return to neutral, and then pull back out of the joint capsule. Watch the ilium; if it moves with the femur, you are not stretching the joint capsule. Joint Capsule Plunging Joint Capsule Lateral Rotation, Stretch Watch the client s facial expressions and look for any changes in their breathing to indicate discomfort. Making your plunges non-synchronized, and stretching the capsule when the client least expects it prevents them from guarding or helping during this work. Next, repeat this sequence, rotating and stretching the femur medially. On joint capsule work, lateral rotation usually moves freely on most clients. Performing capsule work laterally first is to gain a sense of trust with clients who have had a painful iliopsoas or manipulation experience. Medial rotation is usually more adhesive due to prolonged shortening of lateral hip rotators and this is where your focus of therapy should be. Plunge and rotate the femur several times, then plunge once into the joint capsule, make contact, rotate it medially to the restriction, and then give a deep capsular stretch. Back off the stretch, return to neutral and then pull back out. Repeat this sequence again, if needed. You must rotate the hip both ways, as there could be multiple adhesions in different directions. Start with lateral rotation. Medial rotation is usually more adhesive and restricted; therefore work it second. Iliacus Release: To perform the iliacus release, the client is supine with their hip flexed 90. Always get the client s permission before you treat this area. Use a visual aid, if needed, to explain where you are going to be working. Lay their bent leg over your leg so their muscles are shortened and completely relaxed. Palpate the ASIS (anterior superior iliac spine) and to make sure the client is completely relaxed, perform a positional release by gently moving or rocking their leg. Have the client take a deep breath and 6
on their exhale go in using your finger pads, very slowly. Do not go in too far or too fast toward the psoas. Lead with your little finger, with your hand at a slight angle. Come back to the iliacus and pin the fascia directly onto the inside of the ilium. Then lift, and lengthen the fascia superior toward the same shoulder and pin it there (pin and stretch). You want to create an upward traction on the fascia. Now, while keeping your finger pads on the iliacus, place your other hand under the client s knee. Help the client drop their heel down onto the table and allow them to actively drag their heel toward hip extension. As they engage their extensors (hamstrings and glutes), they inhibit their hip flexors. This is called reciprocal inhibition. Repeat the above procedure several times, going in a little deeper onto the iliacus, sweeping, scooping, pinning and stretching the connective tissue upward each time. This will melt the fascia so you can gently isolate and deactivate any tight bands and trigger points in the iliacus. *Note- you must continually check in with the client, are they guarding? Watch their face, voice tonality, and breathing. What is their comfort or discomfort level? The iliacus release must be performed pain free. Iliacus Release Hand Placement Close-up of Same Hand Placement Psoas Release: Tight psoas can create compression and rotation of the lumbar spine. The client is in the same position as the iliacus release. On their exhale, go in using your finger pads, very slowly toward the psoas, at a 45 toward the spine. To find the psoas have the client attempt to bring their knee toward their chest. The psoas will pop up under your fingers. Gently pin it down with the fingerpads, not the fingertips, as they can be painful. Give it a gentle stretch by passively moving the client s hip into extension. Gently move and rock their knee on your knee toward extension. Repeat this psoas pin and stretch several times. These are very subtle movements. Then, go to the end of the table. Grasp the client s ankle, lean back and give a gentle stretch and traction to their hip, knee, and ankle for 5 seconds. Release very slowly. *Precaution note: be cautious when pressing directly downward on the psoas, as there could be an underlying medical condition. If you ever feel a massive pulsation in this area, consider the possibility of an aneurysm, or you may be pressing on the wrong structure. Immediately reposition your hand. Iliacus and Psoas Stretch: The client is prone with their knee bent 90. Place one hand under their knee. Place the other hand on their hip pulling the hip inferiorly and laterally and then stabilize it. The ilium must stay on the table. The hand on the hip can also determine if the ilium is moving with extension, indicating a joint capsule problem. Their lower leg can rest across your forearm. Remind them to do nothing that is uncomfortable. Then, ask them to gently press their knee into the table with 20% force for 5-10 seconds, as you provide resistance. They relax, take a deep breath, and on their exhale they lift their leg up, only to where they are comfortable, while you assist the stretch for about 2 seconds. Keep the leg at this new height, put your knee under their leg as a restrictive barrier, and repeat this contract-relax, contract-antagonist with active assisted stretching 2-3 times. Do not stretch past a pain free end feel. Next, ask the client to actively lift their leg up several times, only to where they are comfortable, for neuromuscular re-education. *Note- to isolate the psoas, have the client move their leg into 30 abduction and perform the stretch. To isolate the iliacus, have the client keep their leg adducted (knees closer together) during the stretch. 7
Iliacus and Psoas Stretch Re-assess Active ROM: Reassess the range of motion of the psoas and iliacus. You may need to repeat the iliacus release and stretch and joint capsule work several times to achieve optimum results. 2. Quadratus Lumborum (QL) and Erector Spinae The QL originates on the posterior iliac crest and inserts on the 12th rib and the transverse processes of L1- L4. Its actions are to unilaterally elevate, or hike the hip and laterally flex the vertebral column. The QL are usually dominant side tight with the other side over stretched. The erector spinae is a group of muscles that run from the sacrum to the occiput along the spine. They extend and laterally flex the vertebral column and can create SI joint symptoms if they are not balanced. Assess Passive ROM: The client is prone. Make sure they are straight on the table. Perform a visual posture assessment of the client. Do they have a low shoulder or the appearance of a shorter leg while lying on the table? Palpate the QL and erectors with your thumbs coming off the iliac crest superiorly. Assess which iliac crest is elevated. This will indicate which side is contracted and short. This is the side you will release; regardless of what side the client reports the pain. Remember, pain is an unreliable sign of where the problem is. For those therapists with advanced palpation skills, palpate the PSIS (posterior, superior, iliac spine) and assess which side is elevated. Equally balancing the QL and erectors insures that the lumbar spine is not unilaterally out of balance and compressed on one side. Palpate Iliac Crests Myofascial Release: With the client prone and your hands on their back, start with gentle rocking motions to relax them. Next, perform myofascial spreading of the QL and the erector spinae, at a 45 angle up and out, moving toward the upper back. Repeat this several times. Have the client move into a side lying position. Provide support under their neck and upper bent leg so they are comfortable. This allows their muscles to be as relaxed as possible before you begin. Have them place their arm over their head and keep their spine in alignment; not rolled forward or backward. Perform myofascial release with your forearm, up the erectors, to lift and lengthen them. With your other hand, stabilize the client s hip and pull downward toward the foot of the table. Forearm Myofascial Release 8
Tendinosis of the Elbow; Muscle-Tendon Strain without Inflammation. Clinical Features and Findings of Histological, Immunohistochemical, and Electron Microscopy Studies. Investigation performed at Nirschl Orthopedic Sports Medicine Clinic, Arlington; Arlington Hospital, Arlington and Georgetown University Medical Center, Washington, DC Barry S. Krashaar, MD and Robert P. Nirschl MD, MS Tendinosis vs. Tendinitis Tendinitis- Acute tendon injuries such as laceration of the flexor tendons of the fingers are traumatic in nature and have associated inflammation. Tendinosis- Chronic overuse injuries are the result of multiple microtraumatic events that cause disruption of the internal structure of the tendon and degeneration of the cells and matrix, which fail to mature into normal tendon; at times such injuries result in tendinosis. There is an absence of acute inflammatory cells in tendinosis. Tendinosis-Tendon Strain without Inflammation Examinations of specimens from patients who have tennis elbow serve as a model for investigation of other areas where tendinosis has been reported. Other areas include the rotator cuff, Achilles tendon, patellar ligament, the adductors of the hip, the triceps, the flexors and extensors of the elbow, and the plantar fascia. Tendinosis or Tendinitis? While the terms epicondylitis and tendinitis commonly are used to describe tennis elbow, histopathological studies have demonstrated that tennis elbow is not an inflammatory condition. It is a fibroblastic and vascular response called angiofibroblastic degeneration, now more commonly called tendinosis. Thus, proper treatment depends on a correct understanding of the nature of the injury and goals of therapeutic intervention. Tendinosis is incompletely understood. Although the term tendinitis is used frequently and indiscriminately, histopathological studies have shown that specimens of tendon obtained from areas of chronic overuse do not contain large numbers of macrophages, lymphocytes, or neutrophils. Rather tendinosis appears to be characterized by the presence of dense populations of fibroblasts, vascular hyperplasia, & disorganized collagen. It is not sure why tendinosis is painful, given the absence of acute inflammatory cells, nor is it known why the collagen fails to mature. Tendinosis Treatment Hypothesis By Author and International Lecturer, James Waslaski Based on this research study it is not known why dysfunctional collagen fibers fail to heal. It is my firm belief, based on many years of tendon pain treatments, that functional collagen or fibroblast formation is only possible when the underlying cause of tendinosis conditions are addressed prior to addressing the resultant microtraumatic symptoms.we must restore normal muscle resting length to antagonistic muscle groups prior to treating the resulting tendon pain and we must be less aggressive and more specific in our approach to the working on the resultant strained fibers. 9