• BY 
• James Ivaska & Douglas Nelson, LMT, BCTMB
  


• ​Understanding anatomy of the hip joint is integral to understanding musculoskeletal dysfunction because of its influences not only at the pelvic girdle but above and below the pelvis as well.The ball-and-socket joint of the hip, or the acetabulofemoral, joint allows for a wide range of movement, which makes possible important daily activities such as walking, squatting, running and jumping.

Actions at the hip joint include extension, flexion, adduction, abduction, internal rotation, external rotation, horizontal adduction and horizontal abduction. Combinations of these movements propel us through the world every day.
Weight bearing is another important role the hip joint provides for the system. Unlike other ball-and-socket joints like the glenohumeral joint or shoulder joint, the hip joint is often, throughout the day, placed in a weight-bearing capacity.
Therefore, the hip joint not only provides mobility for the body, but stability as well. Strong capsular ligaments and complex muscle activation allow the hip to carry our weight as we move through space.
Forces are applied to the acetabulofemoral joint from our body weight (forces from above, downward) as well as the ground reaction force (forces from below, upward). In the complex system that is human bipedalism, the hip plays a starring role.
Full MobilityGiven the architecture and functional importance of the hip joint, full mobility is essential.
If the mobility in the hip is limited, that limitation in range of motion has to be compensated for elsewhere. In one recent study published in the International Journal of Sports Physical Therapy, “Passive hip range of motion is reduced in active subjects with chronic low back pain compared to controls,” loss of hip extension was shown to correlate with the presence of chronic low-back pain.
What the hips cannot do, the low back will try to make up for, leading to musculoskeletal pain and dysfunction. While the low back may be hypertonic and tender to touch, the larger question is why. Range-of-motion testing of the hip may reveal that the low back is doing too much. In that case, treatment focused only on the low back is not likely to be successful, no matter what the intervention.
Compensation for restricted hip mobility can also spread down the kinetic chain, as exemplified by a study published in Knee Surgery, Sports Traumatology, Arthroscopy, “Restriction in hip internal rotation is associated with an increased risk of ACL injury,” which showed loss of internal rotation of the hip was correlated with knee injuries, specifically to the anterior cruciate ligament (ACL).
Decreased strength or lowered hip mobility around the hip is bound to disturb normal gait patterns, likely leading to altered biomechanics and thus possible dysfunction throughout the kinetic chain—and complaints from head to toe.
Seeking BalanceIdentifying decreases in range of motion can be an important tool for massage therapists to help determine possible sources of pain. To test range of motion, the client should wear comfortable, loose-fitting clothes.
The therapist needs to be aware of both quantitative and qualitative criteria during passive range of motion testing, assessing not only how far (quantitative), but also paying attention to how the body responds to the movement (qualitative), especially at the end of range, called end feel.
If the end feel is flexible and elastic, the restriction is probably soft-tissue in nature. If the end feel feels excessively hard, as if you are hitting a wall you cannot push past, that is a possible sign of intrajoint pathology, such as arthritic changes.
Deep knowledge of functional anatomy is a prerequisite for fully utilizing range-of-motion testing. When testing any plane of movement, you are length-testing muscles that do the opposite action. For instance, testing internal rotation of the hip is length-testing the muscles that create external rotation. Obviously, it is important to know what those muscles are and then have the skill set to address each of them precisely and thoroughly.
Furthermore, it is important to note that excessive range in any plane is not necessarily beneficial, especially if it is in one plane of movement only. These asymmetries are often problematic, often more so than symmetrical restrictions. Therapists are likely to discover that after increasing flexibility in a restricted plane, the opposite plane—which was previously hyperflexible—will now decrease in range. The body tends to seek balance.
Range-of-Motion TestsInternal and external rotation can be tested in both supine and prone positions. To test internal rotation from the supine position, use the 90/90 position, which means the client’s knee is bent at 90 degrees and the hip is flexed to 90 degrees as well.
Taking the foot and lower leg laterally allows the acetabulofemoral joint to rotate internally. The hip should be able to rotate internally approximately 40 degrees. This can be measured with a goniometer or estimated visually.

Testing internal rotation in the prone positionTo test internal rotation in the prone position, the knee is again flexed to 90 degrees so the foot is above the knee. The foot is then moved laterally again so the femoral head can rotate internally within the acetabulum. The therapist should place one hand on the pelvis or sacrum.
The end of range is revealed when the pelvis or sacrum begins to rise, signifying the end of independent motion of the femur relative to the pelvis.
External rotation can be done in both supine and prone positions as well and involves the opposite motion with the femur. In the supine position, employ the same 90/90 position of the hip and the knee. To test external rotation, take the lower leg and foot medially, rotating the femur externally. The ideal range of motion for external rotation is approximately 60 degrees.
To test external rotation in the prone position, the knee is again flexed to 90 degrees so the foot is above the knee. The lower leg and foot is then moved medially, rotating the femoral head externally within the acetabulum. Monitoring the pelvis with one hand, the end of range is revealed when the pelvis or sacrum begins to rise.

Testing flexion of the hip.Testing flexion of the hip is accomplished with the client supine. With the knee above the hip, bring the knee as far toward the chest as is comfortable for the client. Flexion should be approximately 40 degrees from the starting position.
Hip flexion is not usually limited; if it is the therapist should be aware of a hard end feel, because limited flexion and hard feel may be indicative of hip joint pathologies. When flexion is limited past the 90-degree starting position, the other leg will often be lifted off the table (the knee will bend), being pulled by rotation of the pelvis as a whole.

Testing the length of the hip abductors.In testing hip adduction, you are testing the length of the hip abductors. With the person in side-lying position, have the shoulders, hips and knee all in a straight line. Supporting the knee with your hand, lower the leg with one hand while monitoring the movement of the pelvis with the other hand. When you sense with your superior hand the pelvic crest being pulled inferiorly, this is the end of range of motion. Optimal range is that the tested knee will travel halfway to the table.

Length-testing the adductors.To test abduction, you are length testing the adductors of the hip. With the client supine, abduct the leg while monitoring the opposite anterior superior iliac spine (ASIS). The moment the ASIS dips inferiorly reveals the end of range. Two helpful hints are: Don’t move too slowly, as speed makes the end of range easier to recognize; and keep the leg in a neutral position.

Extension is measured prone with the knee flexed and the foot above the knee.Extension is measured prone with the knee flexed and the foot above the knee. The therapist lifts the femur from the knee toward the ceiling while monitoring any movement in the pelvis and sacrum. The acetabulofemoral joint should extend 30 degrees before the sacrum and pelvis begin to move. If the person experiences back pain while doing this, consider the psoas muscle as a possible source.
Hip extension restrictions are commonly overlooked and often unnoticed by the client, yet it may be one of the first signs of hip restriction. This plane is often limited for people who spend a lot of time sitting.
Finding that the hip is restricted in extension is important, but it would be helpful to know exactly which muscles are causing that restriction. To discover which muscles may be causing hip extension restrictions, you may employ a modification of the Thomas Test.
With the client in supine position, have the knee on the untested side bent and that foot resting on the table. Raise the straight leg on the side you are testing to about 50 degrees. With your superior hand, monitor the inferior surface of the ASIS.
As you lower the leg, monitor any movement of the ASIS. Full range is accomplished when the leg makes it all the way to the table with no movement in the ASIS. Muscles to suspect if the ASIS is pulled inferiorly are the iliacus, rectus femoris and tensor fascia lata.

To discover which muscles may be causing hip extension restrictions, you may employ a modification of the Thomas Test.These specific range-of-motion tests can provide clues as to possible reasons for your clients’ presenting symptoms. While range of motion is important, full range is not the answer to every problem. The authors have seen many clients with full range and significant discomfort. In the complex world of musculoskeletal pain, range is but one criterion—but one worth considering as a possible source of your client’s pain.
About the Authors:Douglas Nelson, BCTMB, LMT, is celebrating his 43rd year in clinical practice and is the current president of the Massage Therapy Foundation (MTF). His articles for this publication include “Geriatric Massage: Why Touch is so Important as We Age.”
James Ivaska started his career as a massage therapist after receiving his master’s degree in kinesiology. He is the owner of Muscular Health Center in Alexandria, Virginia and teaches for Precision Neuromuscular Therapy Seminars.
​

• BY
• Joy Stephenson-Laws
  


• ​With shutdowns and shelter-in-place orders throughout the nation, many of us stayed inside and fired up Netflix.Now, we’re a nation of less-fit people than we might have been earlier this year, even if we have gone back to work. That needs to change — and you can get in shape, quickly, with regular activity.

Did you know that not being active can actually harm your health in the same way that being active can enhance it? Many people may be tempted to say something along the lines of, “Yes, I know that being more active is good for me, but if I slack off, I will just stay in the same condition I am now. So, no harm if I decide to spend more time watching television.”
But research continues to show, in a very stark way, that physical inactivity is not only harmful to your health (the WHO says inactivity is the fourth leading risk factor for global mortality) but that it can quickly undo whatever health benefits you may have gained from previous physical activities.
It also may be tempting for you to believe that if you don’t have a weight issue, you are in the clear and don’t need as much — or any — physical activity to stay healthy. The truth is that not being physically active increases everyone’s risk of dying from a preventable disease.
This includes an increased chance of developing diabetes, heart disease, stroke, depression and certain cancers, to name a few. In fact, someone who is mostly sedentary has an up to 30% increased risk of death compared to people who move regularly.
Deconditioning HappensRemember the expression about something taking years to build and only a second to break? Whoever came up with it could just as easily have been talking about how quickly we can lose the benefits of having an active lifestyle. How quickly? While some changes are almost immediately noticeable, the general research consensus is that within two weeks of decreasing physical activity, negative changes can be seen across a variety of health measurements.
According to the well-respected Cleveland Clinic, cutting back on physical activity can take a toll on muscle mass and increase body fat in just two weeks. These changes can increase the risk of developing type 2 diabetes, heart disease and other chronic conditions.
Other physiological changes that research has identified include:
• A rise in blood pressure among a group of pre-hypertensive men who were using exercise as a way to lower their blood pressure
• Blood sugar levels remaining elevated after a meal after only three days of being sedentary
• Decrease in metabolic rate, which can result in weight gain and changes in body composition
• The heart losing the efficiency it built up with exercise and physical activity – it can start losing its ability to handle extra blood flow by up to five percent in 24 hours, and resting heartbeat also starts increasing by up to four to 15 beats per minute within a month of reducing physical activity
• Cholesterol levels may increase
• The body’s ability to effectively use oxygen (technically known as VO2 max) declines so drastically that most of the aerobic capacity gained over the previous two or three months is lost within two to four weeks.
How quickly anyone will see these declines will depend on how active they were before going inactive, their age (the older someone is, the quicker the decline), and why the person is taking a break. Everyone is unique, but everyone who becomes sedentary or reduces previous activity levels will experience these types of negative changes.
You Can Bounce Back and Get in ShapeFaced with this information, it’s quite possible that your clients may simply throw up their hands and say, “Why bother? Pass me the chips, please.” But before they give up on getting in shape, make sure they know that the good news is that they can start to reverse the damage of inactivity pretty quickly.
In fact, research indicates some markers will return to where they were in about the same amount of time a person was inactive. Others may take a little longer to get back to where they were before they hit the couch. Again, factors such as age play a role.
Cardiovascular function, for example, returns to where it was within two weeks. Body fat, waist circumference and insulin sensitivity also come back fairly quickly. Regaining muscle mass and VO2 max capacity, however, could take twice as long as the time someone was inactive to get back to where they were (but they do return). And the younger someone is, the quicker they can get in shape and return to where they were.
The Role Nutrition PlaysThis should almost go without saying, but good nutrition goes hand-in-hand with being active. Neither alone will promote good health; if someone is not giving their body what it needs, no amount of exercise will make up for nutritional deficiencies and no amount of healthy eating will make up for, or negate, a sedentary lifestyle.
What kind of diet is best? Research continues to indicate that a primarily plant-based diet that includes a wide variety of fresh fruits and vegetables is best. Some foods that are great for getting the nutrition needed for a healthy, active lifestyle are spinach, pumpkin seeds, yogurt, avocados, dark chocolate and bananas for magnesium; nuts, lima beans, broccoli, sweet potatoes and tomatoes for potassium; lamb, pumpkin seeds, mushrooms, chicken and chickpeas for zinc; and wheat-bran cereals, whole-grain products and shellfish for copper.
It’s also important that meals are prepared at home as much as possible to be able to better control what is in (and not in) each meal and also to have better portion control.
You might also consider including routine, comprehensive nutrient tests as part of your active, healthy lifestyle. If someone is nutritionally unbalanced (meaning they have too much or too little of a specific nutrient), this may increase their risk of developing cardiovascular issues and other conditions that could make it difficult to perform physically. If the test reveals an imbalance, a competent health care professional can help with making the necessary dietary changes or recommend quality supplements you can take.
Get in Shape NowStart back slowly by setting realistic goals and not overdoing it at the beginning — getting active is not an all-or-nothing endeavor. See how easy it is to increase your activity levels with things you do every day, such as walking when you talk on the phone, or parking at the far end of a parking lot or taking the stairs.
To get in shape without turning it into an unpleasant grind, do something you enjoy versus something you think you should be doing. Consider getting a training app to track your progress and give you motivation. And remember to fuel your body with the food and supplementation it craves.
About the AuthorJoy Stephenson-Laws is the founder of Proactive Health Labs, a national nonprofit health information company that provides education and tools needed to achieve optimal health. Her most recent book is “Minerals – The Forgotten Nutrient: Your Secret Weapon for Getting and Staying Healthy,” available through Amazon, iTunes and bookstores. Her articles for MASSAGE Magazine include “Dr. Google Will See You Now — But That Might Not Be Best” and “Mineral Research That Does Not Lie.”
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• BY
• Melinda Roland, PT
  


• ​Concussion, traumatic brain injury and post-concussion syndrome have been in the news for several years now, as professional and school-age athletes alike suffer from these injury-caused conditions.The Centers for Disease Control and Prevention (CDC) reports that “from 2006 to 2014, the number of TBI-related emergency department visits, hospitalizations and deaths increased by 53%.”

The effects are serious and can be long-lasting. One therapy that has shown promise for treatment is CranioSacral Therapy as developed by John Upledger, DOO, OMM (1932–2012).
CranioSacral Therapy is a gentle, noninvasive manual therapy that detects and modifies restrictions in the craniosacral system as well as strain patterns throughout the body. Of course, it is essential to remember that neither massage therapists nor CranioSacral therapists diagnose or treat; however, the therapist may be in a place to address such a condition if on a medical team or the recipient of a referral.
What is Concussion?Concussion is considered a mild traumatic brain injury, and is a complex pathophysiological process affecting the brain that may or may not involve a loss of consciousness. Traumatic brain injury is defined as “a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury,” according to the CDC.
Concussion can also occur via biomechanical forces taken in elsewhere in the body, such as a hard fall on the sacrum, a hard hit to the body, or the forceful movement of the head without any direct contact with an object, such as in a whiplash injury. The forces generated are transmitted to the head and brain as well as the entire body, causing the brain to move, often violently, within the cranial vault, with ensuing injury.
What is Post-Concussion Syndrome?Post-concussion syndrome describes a group of three or more symptoms that persist after a concussion, sometimes for months or years. Common complaints include headache, cervical pain, photophobia and visual dysfunction, noise sensitivity and tinnitus, dizziness, balance and coordination problems, and fatigue.
In addition, such cognitive changes as memory impairment, especially short-term memory, difficulty concentrating, confusion, fogginess, and such behavioral changes as anxiety, irritability and depression, as well as insomnia, are often seen in post-concussion syndrome.
Some symptoms, such as cognitive and behavioral changes and sensitivities to noise, may not develop for days or weeks after the injury occurs. The strongest and most consistent predictor of slower recovery from concussion was greater severity of a person’s acute and subacute symptoms following injury.1
There are many causes of post-concussion syndrome symptomatology. Impact can cause structural damage to the brain or interruption of neural communication.
“Immediately after biomechanical injury to the brain, abrupt, indiscriminate release of neurotransmitters and unchecked ionic fluxes occur … These ionic shifts lead to acute and subacute changes in cellular physiology. The resulting energy crisis is a likely mechanism for post-concussive vulnerability, making the brain less able to respond adequately to a second injury and potentially leading to longer-lasting deficits.”2
Delicate structures responsible for vision or balance can be affected. Resultant cervical dysfunction can create similar long-lasting symptoms. The interconnectedness of connective tissue and structure forms a matrix through which strain patterns can be transmitted throughout the body and the brain in all directions.
Cranial AnatomyThe craniosacral system consists of the meningeal membranes, including the dural membranes surrounding the brain and spinal cord, the osseous and fascial structures to which the meningeal membranes attach, the non-osseous connective tissue structures which are intimately related to the meningeal membranes, the cerebrospinal fluid the ventricles and all the structures related to the production, resorption of the cerebrospinal fluid, the meninges and the craniosacral system glia cells.
The brain and spinal cord are covered and protected by layers of tissue called the meninges. The anatomy of the craniosacral system includes the cranial vault, which is lined with the two-layered dura mater, an endosteal layer firmly attached to the inner surface of the skull and an inner meningeal layer.
In some areas, the dural meningeal layer reflects inward and forms partitions, creating the quadrilateral space that houses the brain. The dural tissue or membrane forms a vertical partition that separates and contains the left and right hemispheres of the cerebrum (falx cerebri) and the cerebellum (falx cerebelli). The dura that forms the posterior horizontal partition (tentorium cerebelli) acts as a mezzanine floor of sorts, with the occipital and temporal lobes above and the cerebellum below.
“The falx sits like a mohawk hairstyle between the brain’s two halves and is stiffer than the rest of the brain, like leather versus gelatin. Watching reproductions of the recorded impacts and additional simulations, the researchers saw that hits to the side of the head could produce vibrations in the falx, due to its stiffness. Those could then propagate down to the corpus callosum, creating the kind of tissue strain that is often implicated in concussion.”3
The authors went on to further describe C-shape waves produced in the falx by simulated strikes that moved the head toward the shoulder and S-waves from those that caused the head to turn. CranioSacral Therapy approaches this kind of membranous strain gently and effectively.
The second layer of the meninges is the arachnoid layer, which follows and attaches directly to the dural layer. The innermost meningeal layer, the pia mater, follows the brain contours like shrink wrap. With firm attachments at the foramen magnum and at C2 and C3 segments of the cervical spine, the dural tissue continues caudally to form a tube that surrounds the spinal cord, tethered only by ligaments, until anchoring at the second sacral segment, exiting out of the sacral canal and blending with the periosteum of the coccyx. The dura mater accompanies the spinal nerves as they exit the intervertebral foramina, forming dural sleeves that attach on the vertebral bodies.
The cushioning cerebral spinal fluid is located between the arachnoid and pia mater in the sub-arachnoid space. The cerebral spinal fluid surrounds, protects, nourishes and cleanses the brain and spinal cord. It flows within the dural system, around and throughout the brain, where the flow is regulated by glial cells, around the spinal cord to the dural sleeves, and it is affected by dural tension.
The deepest layer of the meninges, the pia mater, is firmly connected to the dura mater of the craniosacral system via the arachnoid layer. The innermost surface of the pia mater also has a direct connection to the brain itself. It directly adheres to the brain’s matrix of glial cells via glial end-feet that form a membrane layer, called the outer glial limiting membrane.
These direct and significant connections provide a plausible mechanism by which trauma to boney structures lined with dura, as well as connective tissue strain from throughout the body, can be communicated deep into the glial matrix that makes up the brain and supports its vulnerable structures.
Treatment of Post-Concussion SyndromeTypically, management of post-concussion syndrome involves symptomatic treatment. Medication, physical therapy, and vestibular and vision therapy are traditionally used to diminish complaints and restore function.
However, clinically, we see significant and far-reaching results regularly in the treatment of post-concussion syndrome when the rehabilitation approach includes CranioSacral Therapy. In addition to being an effective treatment approach for boney, connective tissue, visceral, neural and meningeal stress, CranioSacral Therapy can enhance standard therapies by calming the sympathetic nervous system, allowing other therapies to be better tolerated.
CranioSacral Therapy mobilizes sutural restrictions and effects changes in mobility of structures that are within or are influenced by the CSS, as well as the important dural tissues that connect to them. It facilitates the correction of boney and connective tissue dysfunction and strain, and improves cerebral spinal fluid flow.
It does so by using light-touch mobilization techniques that require a high degree of palpatory specificity and sensitivity. As a result, CranioSacral Therapy effectively treats strain patterns in the connective tissue network of the body, brain and spinal cord, enhancing function and easing symptoms.
Myriad structures are lined with dural tissue, and thus can be considered as both an origin of symptoms and as a focus for treatment. For example, all cranial bones, the nasal bones, and the orbit of the eye are lined with dura.
Cranial nerves for vision, hearing and balance, among others, travel through dural tissue or through mobile boney structures with profound connections to dura, and thus can be directly influenced by dural tension. The jugular foramen, the opening through which three important cranial nerves (vagus, spinal accessory and glossopharyngeal) must pass, is surrounded by a ring of dural tissue.
CN X, the vagus nerve, is a primary parasympathetic nerve. Relieving dural strain can improve its function and be important in restoring the autonomic flexibility so often compromised after concussion.
The myodural bridge consists of three deep suboccipital muscles that provide direct connection of C1 to dura. The eyeball itself has a dural investment directly attached to its sclera. The optic nerves, responsible for vision, is ensheathed in all three meningeal layers, and the olfactory nerves, responsible for smell, are ensheathed by the pia mater layer. The three motor nerves for the eye must traverse the tentorium cerebelli and are directly affected by abnormal tension in this tissue layer, creating visual issues like eye teaming and tracking difficulty. These are just a few specific examples.
Because of the anatomical attachments and the continuity of fascia, CranioSacral Therapy treatment of involved structures can produce far-reaching effects, which we have seen clinically and in our research.
One study was conducted in 2014 and 2015 with ex-NFL football players with diagnosis of post-concussion syndrome, to determine if specific manual therapy techniques could provide an intervention that would diminish long-term symptoms in professional athletes with histories of concussion.
Upledger CranioSacral Therapy, along with Jean-Pierre Barral, DO, MRO(F), RPT’s Visceral Manipulation and neuromeningeal techniques, applied to these patients with post-concussion syndrome provided significant results for future concussion recovery. Statistically significant, positive changes in cervical range of motion, memory, physical reaction time, quality of life, headache, pain levels and duration of sleep were documented up to three months after the intervention.4
The Missing PieceThese initial outcomes were inspiring and showed real promise for viable treatment options for traumatic brain injury, concussion, and the secondary compensatory dysfunctions that occur following traumatic brain injury.
Changes in the continuity of fascia, restrictions in mobility of cranial structures, sutural restrictions, extensive dural connections (meninges attached to bone, neural and visual structures and to the glial matrix of the brain) provide a mechanism whereby trauma can be communicated. CranioSacral Therapy addresses these structures and dysfunction directly, providing a mechanism whereby correction of such strain patterns is possible, facilitating reduction in symptoms, a greater functional ease and enhanced quality of life.
According to a statement from the Concussion Alliance, “Craniosacral Therapy [is] … one of the most effective treatments that we’ve found for persistent post-concussion symptoms.”
CranioSacral Therapy is an important tool in the evaluation and treatment of the structural, vascular and neurologic tissue changes in concussion and post-concussion syndrome that occur throughout the body, brain and spinal cord. It is not a substitute for traditional therapies and re-education; it is the piece that is missing.
[OEx] Read “Pro Football Players Testify to CranioSacral Therapy’s Ability to Address Concussion and CTE” at massagemag.com/current-issue and learn what former NFL running back Ricky Williams has to say about this technique.
About the Author:Mentored by John Upledger, DOO, OMM, Melinda Roland, PT, LAc, OMD, Dipl-Ac, CST-D, has taught CranioSacral Therapy internationally since 1988. She has been lead therapist and research director in the Upledger Institute International concussion programs. Her husband’s traumatic brain injury in 1999 significantly impacted her family. Roland credits his improbable return to his profession as an orthopedic surgeon 11 years later to his treatments with CranioSacral Therapy. She wrote this article on behalf of Upledger Institute International.
Footnotes
1. Iverson GL, Gardner AJ, Terry DP, et al.Predictors of clinical recovery from concussion: a systematic review. British Journal of Sports Medicine. 2017; 51:941-948.
2. Christopher, C, Hovda, D. “The neurometabolic cascade of concussion,” Journal of Athletic Training. 2001; vol 36(3)Jul-Sept.
3. Stanford University. “Role of a deep brain structure in concussion,” ScienceDaily. 2019; March 12). Retrieved Aug. 16, 2019, from sciencedaily.com/releases/2019/03/190312151206.htm.
4. Wetzler, R, Fryer-Deitz, A. “Craniosacral therapy and visceral manipulation: a new treatment intervention for concussion recovery,” Medical Acupuncture. 2017; vol 29, 4.
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• BY 
• Joe Yoon
  


• ​If I had to guess, the reason most people start a fitness program is because they want to get slim enough to fit into the jeans they wore five years ago, or because they want to gain muscle so they look better at the beach. There’s nothing wrong with that! But what if you want to move with greater ease and feel better doing the things you do daily?

Like carrying bags of groceries up the stairs in one trip. Like squatting and bending down to pick up your toddler’s toys after playtime.
For us massage therapists, getting in shape could mean the movements we perform every day in sessions with clients are stronger and our bodies become more resilient to wear and tear. This is what the fitness industry calls functional fitness.
What is Functional Fitness?The Mayo Clinic defines functional fitness training this way: “Functional fitness exercises train your muscles to work together and prepare them for daily tasks by simulating common movements you might do at home, at work or in sports. While using various muscles in the upper and lower body at the same time, functional fitness exercises also emphasize core stability.”
You may have even engaged in functional fitness exercises before without necessarily realizing it — many of them are staples in gym routines and workout classes. Typical functional fitness exercises include squats, split squats, lunges and deadlifts for the lower body. Moves that involve pulling and pushing, like push-ups and pull-ups, are the functional fitness exercises best for the upper body.
All of these functional fitness movements can be made more difficult by using equipment like dumbbells, bands, kettlebells and medicine balls. And all of them work multiple body parts instead of isolating a single body part at a time. That’s one of the reasons they work so well to improve your quality of life.
Save Time, Feel BetterI’m a big advocate of functional fitness training. Let me just sum up all the advantages it offers. Function fitness training:
• Saves time. Because functional fitness training focuses on multiple muscle groups at one time, you can achieve more in a shorter amount of time.
• Reduces the risk of injuries. As you’re engaging all those different muscles at the same time, you’re training your body to move more efficiently. That can lessen the likelihood you’ll injure yourself during the movements you make on a day-to-day basis.
• Is convenient. Functional training can be a lot easier on your schedule than a traditional workout. Since many of these movements can be done without access to the gym, you can do it anywhere, anytime. Now there is no excuse for missing your workout.
• Makes you feel better. When you incorporate functional fitness into your life, you develop strength, stability, mobility and endurance, and you do it efficiently. These changes will help you get through your daily activities with ease (and may help you slide back into those old jeans and look good on the beach, to boot!).
Get Moving!Here are some of my favorite functional fitness moves.

Split squat, step 1
Split squat, step 2
Split SquatThe effort you make while doing this exercise is primarily concentrated in the front of the leg. However, being in that position also makes the other parts of the body work a little harder to control balance and stability, so you get much more benefit from the move than first meets the eye. Avoid bouncing when you do the squat.
Stand straight and place one leg a few feet behind the other, toe on the floor, heel up. Place your hands on your hips and bend your back knee until it almost reaches the floor. Pause for a few seconds, then rise back up. Do one set of 10 reps.

Deadlift, step 1
Single-Leg Deadlift
Deadlift, step 2If the word deadlift conjures up images of giant-size Olympic powerlifters, consider that anyone can do it (and benefit from it); it’s all about the amount of weight you’re deadlifting. If you’re a beginner, you can use body weight and concentrate on technique and balance. To advance, add in dumbbells in weight increments that align with your improving strength.
Stand straight with your arms at your side, feet hip-width apart. Bend the knee of one leg slightly as you raise the other behind you, and bend at the hips as if to touch something (with both hands) about a foot off the ground. Slowly straighten back up. Do one set of 10 reps.

Push-up, step 1
Push-up, step 2
Push-UpPush-ups are probably the best overall upper-body exercise—but they can be difficult, so don’t feel bad if it takes you a while to work up to doing any number of reps. And there are ways to make the movement easier, such as performing them on your knees or doing them on a bench. Just know that, with practice, you will improve. And it’s worth the effort, since push-ups do more than just strengthen the arms: They engage the core as well.
Get down on your hands and knees, then slide forward until you are balanced on your hands and toes (in the plank position). Your arms should be shoulder-width apart and your fingers splayed. Bend your elbows at a 45-degree angle and lower your body down to an inch or two above the floor, keeping your back flat. Tighten your abdominal muscles and push up with your arms to return to the plank position. Do one set of 10 reps.
World’s Second Greatest Stretch
Stretch, step 1Even though this is titled a stretch, this is an amazing overall dynamic movement that works every part of your body. It will help your mobility and stability at the same time!

Stretch, step 2Stand in a wide-leg position, bend down, place both hands on the floor, and walk them out until your body and arms are both straight. In one continuous move, push your hips up and reach your right hand toward your left foot, then come back to the start, bring your right foot forward, bend at the knee, rotate your torso and reach your right hand up toward the sky. Come back to the start and walk your hands back to standing wide-leg position. Switch sides. Do 10 reps.

Stretch, step 3
Stretch, step 4
Stretch, step 5
Stretch, step 6From “Better Stretching,” by Joe Yoon. Copyright © 2020 by the author, reprinted with permission of St. Martin’s Publishing Group.
About the AuthorJoe Yoon is a massage therapist, personal trainer and founder of Joe Therapy, a company that provides massage therapy at his clinic in Orlando, Florida, and through which he teaches stretching and self-massage techniques online. He wrote “Better Stretching: 9 Minutes a Day to Greater Flexibility, Less Pain and Enhanced Performance,” which will be released in early 2020. Joe is also a MASSAGE Magazine All-Star (massagemag.com/all-stars), one of a group of innovative therapists and teachers who are educating the magazine’s community of massage therapists in our print magazine, on our social media channels and on our website. 

• By 
• Andrea Winzer, MSc, LMT, BCTMB

As massage therapists, we witness the healing power of touch every day. Massage research is providing a view into the why behind that power.Across the many modalities we practice, our skilled therapeutic touch facilitates stress relief and relaxation, lowers anxiety and depression, reduces pain, supports skeletal and muscular realignment, and promotes overall improved well-being.
These beneficial outcomes create the foundation for the effectiveness of massage and bodywork — but have you ever wondered why it works the way it does, what the science is behind it?
Awareness of the mind-body connection is increasingly finding its way into the fields of medicine and integrative health care. Supported by modern neuroscience techniques, scientific research has increased efforts to demystify the benefits of touch and explore how the connection between the skin and the nervous system works and influences our bodies.
As we take a closer look at the results of massage research, we discover that the effects of massage on the body are truly more than skin deep. In fact, much deeper.
[Read “These are the 6 Types of Research that will Benefit Your Massage Practice.”]
Massage Research: Skin-Nervous System ConnectionThere is a close connection between the skin and the brain that begins at the earliest stages of embryonic development.1 After conception, the fertilized egg (the zygote) makes its way to the uterus, where it implants itself into the uterine lining, the endometrium. The fertilized egg then undergoes a series of cell differentiations, and in week three after conception, three distinct germ layers are formed: the ectoderm, the mesoderm and the endoderm.
The endoderm, the internal layer, develops into the epithelial lining of the digestive tract and forms organs such as the stomach, colon, liver, pancreas, bladder and lungs. The mesoderm, the middle layer, develops into bone, muscle, connective tissue, kidneys, gonads and the circulatory system.
The ectoderm, the outermost germ layer, develops into the skin, brain, spinal cord, and peripheral nervous system. Simplified, we can therefore say that the skin is the outermost part of the brain, and the brain is the innermost part of the skin.
As the largest organ, the skin covers approximately 22 square feet (2 m2) in an adult and accounts for about 16% of total body weight. Highly innervated, it contains millions of sensory receptors that gather information from the outside environment and transmit these impulses to the central nervous system (brain and spinal cord) for processing via the peripheral nervous system.
The role of the brain includes reception, processing and transmission of this environmental information from sensory organs inside the skin to the systems of the whole body.
This close developmental link between the skin and the brain explains why a significant relationship between skin-to-skin contact and activities in the nervous system can be observed throughout our lives, influencing neurological processes such as brain development and function, hormonal balance, mood and behavior.2
Skin-to-skin contact right after birth has been shown to increase physiologic stability, promote psycho-emotional well-being, and support structural and functional brain development in infants.3 Massage research studies conducted by Allan Schore, PhD, a neurobiologist from the University of California, Los Angeles, demonstrate that touch is an essential element in the maturation process of vital brain structures, such as the amygdala.4
This part of the limbic system is involved in emotional learning, memory modulation and the activation of the sympathetic nervous system, and is activated through postpartum skin-to-skin contact during its critical developmental period over the first two months after birth.
Massage Research: Psychological Health & BondingNumerous massage research studies conducted by Tiffany Field, PhD, at the Touch Research Institute at the University of Miami School of Medicine have also brought awareness to the positive effects of touch on infant development.
In one study on tactile/kinesthetic stimulation effects on preterm neonates, published in Pediatrics, Field, et al., observed premature infants who received 15-minute massages three times a day. In comparison to other infants who were left alone in their incubators, babies receiving touch therapy showed a 47% increased weight gain as well as a faster maturation of their nervous system (measured based on activity levels and responsiveness).
Altogether, premature infants treated with touch therapy were discharged from the hospital an average of six days earlier than infants who did not receive massage treatments.
James Prescott, PhD, a neuropsychologist and health science administrator at the National Institute of Child Health and Human Development in Washington, D.C., demonstrated in his studies that touch and motion are the most important senses affecting normal brain development and can be considered critical for the proper integration, connection and activation of those areas of the brain involved in psychological health and bonding.5
In addition to influencing the development of brain structures and metabolism, early life skin-to-skin contact has also been shown to create a foundation for peaceful behavioral expressions. After analyzing anthropological data from 49 primitive cultures, Prescott was able to conclude that societies in which babies were carried on their mothers’ bodies throughout the first year of their lives showed significantly less violence than groups that had not adopted this intimate level of care.6
In addition, the researcher was able to observe an association between longer duration of breastfeeding (more than two-and-a-half years) and very low or non-existing occurrences of suicide in these primitive cultures. Prescott concluded that during the sensitive time of brain formation in infants, skin-to-skin contact is a necessary factor for healthy neurological development and consequently protection against depression and violence.7
Massage Research: The Third Brain?Through touch, we induce nerve and hormonal signals that are transmitted via the skin to the brain’s cognitive and emotional processing center. A massage research study by Field, et al., published in the International Journal of Neuroscience, demonstrates that following massage therapy, the parasympathetic nervous system is stimulated. Levels of stress hormones, including adrenaline, noradrenalin and cortisol are lowered, which leads to a decrease of stress, anxiety and feelings of overwhelm.8
In addition, neurotransmitters like serotonin and dopamine are boosted, promoting improved mood, increased vitality, and an overall feeling of well-being. Another hormone that is activated through skin-to-skin contact is oxytocin, the hormone responsible for bonding, creating trust and strengthening relationships.
The connection between skin-to-skin contact and activity of the brain and nervous system has a strong impact on our mental health and the development of a healthy relationship with ourselves and others.
In his article “Epidermis as the ‘Third Brain?’” Japanese researcher Mitsuhiro Denda, PhD, introduces the idea that the epidermis (the outermost layer of skin), which forms the interface between the body and the environment, could be considered the “third brain” (next to the digestive tract as the “second brain”), as it contains multiple environmental sensors and a sensory information-processing system, and generates a variety of hormones and neurotransmitters with the potential to influence whole-body states and emotions.9
The Role of Epidermal KeratinocytesDenda points out the role of epidermal keratinocytes, the major cell type of the epidermis that originate in the deepest layer of the epidermis (the stratum basale) and move up to the final barrier layer of the skin (the stratum corneum) during their differentiation process. According to the author, keratinocytes have been shown to contain sensors of mechanical input, temperature and chemical stimuli, as well as a series of neurotransmitter receptors which play an important role in the central nervous system and the brain.
In addition, all components of the hypothalamic-pituitary-adrenal (HPA) axis, an interactive neuroendocrine unit that describes the functional connection between the hypothalamus, the pituitary gland (both located in the brain), and the adrenal glands (on top of the kidneys) can be found in epidermal keratinocytes.
The HPA axis is considered a key player in maintaining homeostasis and the body’s response to stress through the production and secretion of cortisol. Locating this system inside the epidermis supports Denda’s hypothesis that the skin plays a significant role in adapting whole-body physiology as well as emotional responses to changes in the environment.
A study on the effect of massage on the hypothalamic-pituitary-adrenal (HPA) axis and immune function in healthy individuals was conducted by Mark Rapaport et al. During a five-week survey with young adults who received either weekly or twice-weekly treatments of Swedish or light touch massage, the research team recorded and compared the respective increase or decrease of oxytocin (bonding hormone), cortisol (stress hormone) and adrenal corticotropin (stress hormone) levels, among other parameters.10
Individuals who received weekly massages didn’t show a significant response, but individuals who received massage twice a week showed response patterns with increased oxytocin levels and decreased levels of cortisol as well as adrenal corticotropin hormones. These findings show that frequent massage treatments have an effect on the hypothalamic-pituitary-adrenal (HPA) axis and can contribute to facilitating well-being and decreased stress levels.
New ApproachesBased on the growing body of scientific evidence for the physiological connection between the skin and the nervous system, and in further consequence emotional and mental health, new approaches are being explored by combining different treatment modalities that can create holistic therapy approaches.
One example within the field of medicine is the developing subspecies of psychodermatology, a novel approach that merges psychiatry and dermatology and their respective focuses on treating mental processes manifested internally and skin diseases manifested externally. Mohammed Jafferany, MD, et al., observed in a research study that in a typical dermatology practice, 30 to 40% of patients experience psychological problems in relation to their dermatological symptoms.11
Claudia Aguirre, PhD, a neuroscientist who specializes on the connection between psychology and the skin, suggests in her article “The Brain-Skin-Connection” that touch therapy provided by massage and bodywork therapists as well as estheticians could bridge the gap between these individual medical specialties by offering patients integrative mind-body therapies that restore the cellular balance between the skin, nervous system and immune system.12
More Massage Research is NeededOver the last decades, scientific research and the application of newly developed neuroscience techniques has brought many exciting discoveries and a deeper understanding regarding the brain-skin connection, yet there is still much we do not know.
Further studies and research are required to acquire additional knowledge about the effects of touch on the body and potential integrative treatment modalities that could utilize the strong relation between the skin and the nervous system to effectively and safely support people in their healing.
About the Author:Andrea Winzer, M.Sc., LMT, BCTMB, holds a master’s degree in ecology and is a board certified massage and bodywork therapist. She practices CranioSacral Therapy and offers a variety of holistic treatment modalities with a focus on the integration of body-mind-spirit, release of physical and emotional trauma from the body, and supporting mental health therapies through trauma-sensitive bodywork. She wrote this article on behalf of the Massage Therapy Foundation.
What the MTF Does for You: The Massage Therapy Foundation is a 501(c)3 providing support to the massage therapy profession. Since 1990, MTF has provided over $1 million in research grants studying the science behind therapeutic massage.MTF founded and publishes an open-access, peer-reviewed scientific journal and provides many educational resources for massage therapists, educators and students. MTF also provides community service grants to populations in need of therapeutic massage who would otherwise lack access.
References
1. Encyclopedia Britannica.
2. Harvard Medical School Newsletter: Recognizing the Mind-Skin Connection. October 2006.
3. Phillips R., MD, IBCLC, FAAP, Uninterrupted Skin-to-Skin Contact Immediately After Birth. NAINR, 2013; 13(2):67-72.
4. Schore A. Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health J. 2001; 22:7-66.
5. Prescott J. Body pleasure and the origins of violence. Bull Atomic Sci. 1975: 10-20.
6. Prescott J. Cross-cultural studies of violence, in aggressive behavior: current progress in pre-clinical and clinical research. Los Angeles, CA: University of California, 1974.
7. Field T., Schanberg S., Scafidi F., Bauer C., Vega-Lahr N., Garcia R., Nystrom J., Kuhn C. Tactile/kinesthetic Stimulation Effects on Preterm Neonates. Pediatrics. 1986 May; 77(5):654-8.
8. Field T., Hernandez-Reif M., Diego M., Schanberg S., Kuhn C. Cortisol Decreases and Serotonin and Dopamine Increase Following Massage Therapy. Int J Neurosci. 2005 Oct;115(10):1397-413.
9. Denda M. Epidermis as the “Third Brain?”. Dermatologica Sinica 33 (2015) 70-73
10. Rapaport M., Schettler P., Bresee C. A Preliminary Study of the Effects of Repeated Massage on Hypothalamic-Pituitary-Adrenal and Immune Function in Healthy Individuals: A Study of Mechanisms of Action and Dosage. J Altern Complement Med. 2012. Aug; 18(8): 789-97.
11. Jafferany M, Vander Stoep A, Dumitrescu A, et al: The knowledge, awareness, and practice patterns of dermatologists toward psychocutaneous disorders: results of a survey study. Int J Dermatol. 2010; 49:784-789.
12. Aguirre C. The Brain Skin Connection.
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