Manual therapies

Alexander technique

Alexander technique

• “Every man, woman and child holds the possibility of physical perfection; it rests with each of us to attain it by personal understanding and effort. “

• FM Alexander

Definition

• The Alexander technique is an educational and therapeutic method of encouraging an individual to expend a minimum of effort to achieve the maximum efficient use of muscles and movement with the aim of relieving pain and improving posture and overall health.

• Put more simply, it is a practical method for finding out what habits of body use a person has and how best he or she can promote the most beneficial actions and prevent the most harmful actions.

Theory

• 1. End gaining and the means whereby: Alexander used the term ‘end gaining’ to describe the tendency to follow some course of action almost automatically without first thinking through one’s intended actions carefully. He called the opposite process of waiting, thinking and assessing the most appropriate activity the ‘means whereby’.

Theory

• 2. Faculty sensory appreciation: with this term Alexander acknowledged the presence of habits of proprioception or feeling underlying habitual actions. This can result in a feeling of uneasiness during the correction of a long-standing incorrect posture because it represents a change from what has been regarded as normal behaviour in the past.

Theory • 3. Inhibition: the third idea is linked to the second.

It represents a natural self-control of unwanted and inappropriate reactions without any sense of suppressing spontaneity. When Alexander discovered a way of integrating these concepts he found the solution to his problems. By recognising the strength of his old habits and the inappropriateness of end gaining, he was forced to consider the ‘means whereby’ he could secure the necessary improvements in posture. To do this he had to overcome the faulty sensory perception of how his body should be. This he did by inhibiting his end-gaining behaviour.

Practice

• The technique involves a process of psychophysical re-education that engages both mind and body.

• This learning process is best achieved through a series of one-to-one lessons with a qualified teacher who, using very gentle non-manipulative touch, gives the pupil the necessary new experiences.

• Modern practitioners recommend up to an hour to enable changes to be made.

Practice

• In group classes the emphasis is more on experiment and observation.

• Pupils are also encouraged to observe the thought processes and tensions associated with their activities in daily life.

• As the principles are assimilated, the pupil begins to develop the tools necessary to make his or her own discoveries and can continue to learn independently.

• Alexander technique may not be effective for everyone. Most teachers consider that 20–40 lessons are required.

Feldenkreis method

Feldenkreis method

• A technique similar to the Alexander technique has been developed by Moshe Feldenkrais (1904–1984) in Israel over a 40-year period.

• The Feldenkreis method (FM) is viewed as an educational system for the development of self-awareness, which relies on the body as the learning instrument.

Feldenkreis method

• It deals with the question of how to enable the individual to reorganise and recall forgotten movement patterns.

• Unlike other complementary and alternative manual and touch modalities, FM is not aimed at curing or healing a client but rather at bringing about a change in his or her awareness, self-image and attitude towards the self, and taking responsibility for his or her wellbeing.

Bowen technique

Bowen technique

• The Bowen technique involves a gentle, rolling motion, with very light touches. The practitioner stimulates sets of points, often with pauses between sets.

• Bowen therapy was pioneered by Tom Bowen of Victoria, Australia (1916–82) in the 1950s. It has been suggested that the Bowen technique may introduce specific harmonic frequencies to the body systems.

Bowen technique

• The Bowen technique is not a form of massage, although it does claim to release areas of built-up stress in the muscles, and clients usually experience profound relaxation after a session.

• A typical session takes place over 30–45 minutes, with occasional 2- to 5-minute breaks during the session to allow the body to respond to the treatment.

• The Bowen technique has been used to treat back pain, neck pain, frozen shoulder, tennis elbow, repetitive strain injury and other musculoskeletal disorders.

Chiropractic

Chiropractic

• Chiropractic is gaining in popularity and in the USA its practitioners are third in number to physicians and dentists.

• The discipline is the most popular example of complementary and alternative medicine (CAM) in the country, with as many as one in three patients with lower back pain being treated in this way.

Definition

• Chiropractic (chieri, meaning hand, and praktikos, meaning performed) is a complementary discipline that focuses on the spine as being integrally involved in maintaining health, providing primacy to the nervous system as the primary coordination for function and thus health in the body.

Definition

• Maintenance of optimal neurophysical balance in the body is accomplished by correcting structural or biomechanical abnormalities or disrelationships through the use of manipulation and adjustment.

• Chiropractors specialise in the diagnosis, treatment and prevention of biomechanical disorders of the musculoskeletal system, particularly those involving the spine and their effects on the nervous system.

History

• Although manipulation dates back to ancient times, its popularity in modern times is attributed to Daniel David Palmer (1845–1913), a selfeducated scientist from Iowa.

• He founded that the nervous system was the ultimate control mechanism of the body and that even minor misalignments of the spine, which he termed subluxations, could significantly impact on a person’s health.

History • In the closing years of the 19th century, Palmer

produced his theory of musculoskeletal effects on the central nervous system and developed the first manipulative techniques to relieve them.

• Palmer is reputed to have opened his own school in the 1890s; some texts quote 1895 and others 3 years later.

• The profession celebrated its centenary in 1995 so the earlier date would seem to be the more appropriate!

• Daniel’s son, Bartlett Joshua (1882–1961), promoted chiropractic enthusiastically, helped by a number of his father’s contemporaries and his own students.

Theory. There are four aspects of chiropractic philosophy:

• 1. The importance of the nervous system: 31 different pairs of spinal nerves travel through openings in the vertebrae to and from the brain. If one of the vertebrae is partly displaced from its correct position, it can cause an impingement and pressure, or irritate the surrounding nerves. As a result, essential nerve messages are distorted, causing damage to the surrounding tissues.

Theory. There are four aspects of chiropractic philosophy:

• 2. The body’s inherent ability to heal itself: this is embodied in the phrase vis medicatrix naturae.

• 3. The effect of subluxation or joint dysfunction: such abnormalities are believed to interfere with the ability of the neuromuscular system to act in an optimal fashion, in turn contributing to the presence of disease.

• 4. The identification and treatment of subluxations.

Practice Examination

• As spinal manipulation is of such importance to the chiropractor, examination of this area of the body is of particular interest, following an initial history-taking.

The acronym PARTS (steps of examination):

• Pain: pain and tenderness are identified using observation, palpation and percussion.

• Asymmetry: this may be identified by palpation, radiograph analysis or observation of gait.

• Range of motion: this includes assessment of different types of motion, including stability of joints using palpation and radiographs.

• Tissue characteristics: these include tone, texture and temperature abnormalities; a range of diagnostic techniques may be employed.

• Special procedures: EMG, ultrasonography and kinesiology may be considered to augment information obtained from previous tests.

Treatment

• Procedures used during chiropractic treatment may include gentle massage, ultrasonic treatment and adjustment.

Treatment

• The chiropractic adjustment (often also called manipulation) to joints in the spine or extraspinal regions entails placement of the practitioner’s hands on appropriate contact points.

• This is followed by positioning of the joint, during which the patient may feel tension of the muscles and ligaments; a popping sound may occur.

Treatment

• A short sharp thrust may then be delivered. Chiropractors use different parts of the hand to direct the thrust, depending on the joint being adjusted, e.g. the middle or base of the index finger may be used to adjust the neck whereas an area of the wrist bone may be used to adjust the lumbar spine. In cases of injury an indirect thrust may be used.

Treatment

• The joint to be manipulated may be gently stretched over a pad or wedge-shaped block until realignment is accomplished.

• A typical course of treatment for uncomplicated cases may involve six sessions over a 2- to 3-week period.

Massage

Massage • Although remedial massage

has its own methods and procedures, at its simplest it may be considered as being the age-old response to a painful stimulus, i.e. rubbing the bit that hurts!

• It is used in physical therapy, sports medicine, nursing, and as an adjunct to chiropractic, osteopathy and naturopathy.

The aims of massage are to:

• relieve pain and reduce swelling

• relax the muscles

• encourage the healing process after strain and sprain injuries.

Contrary to popular opinion, it cannot prevent loss of muscle strength or reduce fat deposits.

Definition • Massage is the systematic manipulation of

body tissues, performed primarily (but not exclusively) with the hands for therapeutic effect on the nervous and muscular systems, and on systemic circulation.

• The primary characteristics of massage are touch and movement.

• It may be performed in association with another therapy or alone.

History

• Massage is reputed to have been used more than 3000 years ago by the Chinese.

• Later, the Greek physician Hippocrates used friction in the treatment of sprains and dislocations, and kneading to treat constipation.

History • Early in the nineteenth century, Per Henrik Ling

(1776–1839) of Stockholm devised a system of massage to treat ailments involving joints and muscles. Ling believed that vigorous massage could bring about healing by improving the circulation of the blood and lymph. In the past 20–30 years complementary therapists have adapted Swedish massage so as to place greater emphasis on the psychological and spiritual aspects of the treatment.

• The benefits of massage are now described more in terms such as ‘calmness’ or ‘wholeness’ than of loosening stiff joints or improving blood flow.

History • In contrast to the vigorous and standardised

treatment recommended by Ling, current massage techniques are more gentle, calming, flowing and intuitive. Ling’s Swedish system was popular at European spa towns in the nineteenth century, when it was used in conjunction with hydrotherapy. It was taken to the USA in 1854 by Dr George Taylor and his brother Dr Charles Taylor.

• Others later extended the treatment to relieve deformities of arthritis and to re-educate muscles after paralysis.

Theory

• Massage involves two main components: touch and pressure.

• Attaining a balance between the two is an important skill.

Practice

• The most commonly used therapeutic massage is known as Swedish massage, although many other variants exist, including deep-tissue massage (used to release chronic patterns of muscular tension), sports massage (similar to both Swedish and deep-tissue massage) and acupressure.

Practice

• Craniosacral massage is designed to deal with cranial and spinal imbalance. Treatment often involves several different procedures and may last between 15 and 90 min. It starts with the case history, although this is usually relatively short compared with other complementary therapies. The patient is ideally treated unclothed on a specially designed massage couch. This normally incorporates soft but firm padding and a hole for the face.

A variety of strokes are used: • Effleurage is a deep stroking movement in

the direction of the venous flow that relaxes muscles, improves circulation to the small surface blood vessels and is thought to increase the flow of blood towards the heart.

• Pétrissage is a compression procedure that includes kneading, squeezing and friction; it is useful in stretching scar tissue, muscles and tendons so that movement is easier.

A variety of strokes are used: • Friction or rubbing is carried out with a slow

elliptical or circular movement to increase blood flow and muscle movement.

• Tapotement or percussion uses the sides of the hands to strike the surface of the skin in rapid succession to improve circulation.

• Vibration or shaking is used on the extremities and is said to lower muscle tone.

A variety of strokes are used:

• Massage practitioners who treat sports injuries and musculoskeletal disorders may incorporate techniques derived from physiotherapy, osteopathy and chiropractic. These include deep massage, passive and active stretching, and muscle energy techniques (in which the patient moves against resistance from the practitioner).

Massage of the joints • Stiff and swollen joints can be cured by massage

combined with mechanical movements. • Massage is, however, not recommended in serious

inflammatory cases of the joints and in tubercular joints.

• Sprains and bruises can be cured by massage. • In these cases, affected parts should first be bathed

with hot water for 15–30 min. • Next the massage should be done for a few minutes. • Gentle stroking and kneading are recommended on

and around the injured tissues. • Fractures can also be treated through massage.

Massaging the nerves

• Massage benefits many nerve problems. In cases of acute inflammation of the nerves, massage should be done carefully.

• Light and gentle stroking is recommended.

• Deep pressure should not be used on swollen nerves because it will increase the inflammation.

• All that is needed is a gentle tapotement or beating of the nerve.

Abdominal massage

• This form of massage is beneficial in constipation.

• It stimulates peristalsis of the small intestines, tones up the muscles of the abdomen walls, and mechanically eliminates the contents of both the large and the small intestines.

Chest massage

• Chest massage is helpful in many ways.

• It strengthens the chest muscles, increases circulation and tones up the nervous system of the chest, heart and lungs.

• It is especially recommended in weakness of the lungs, palpitation and organic heart disorders.

• Bust and mammary glands can be developed by proper massage.

Massage of the back

• The purpose of massage of the back is to stimulate the nerves and circulation for treating backache and rheumatic afflictions of the back muscles, and for soothing the nervous system.

• The patient is made to lie down with the arms at the sides.

Massage of the throat

• This helps to overcome headache, sore throat and catarrh of the throat.

Anxiety

• There is some good evidence from RCTs that massage can reduce anxiety in the short term in psychiatric patients who are children or adolescents, 83 and in palliative care.

• In one study of cancer patients suffering from pain, 60% of the respondents reported a reduction in pain after a 30-minute massage.

Anxiety

• Massage has been beneficial in intensive care after cardiac surgery, although some concerns about its effect on critically ill patients have been expressed.

• Long-term elderly hospital patients are reported to have responded to massage with a reduction in anxiety, tension and heart rate.

Premenstrual syndrome

• Massage therapy may be an effective long-term aid for pain reduction and water retention, and a short-term aid for decreasing anxiety and improving mood for women with premenstrual dysphoric disorder.

Low back pain

• An RCT with four parts sought to compare the effectiveness of massage therapy with other interventions for the treatment of low back pain.

• The massage provided a benefit to patients in excess of the other interventions.

• AIDS There is some evidence that massage may improve the immune function and quality of life of AIDS patients.

Massage for children

• A critical review of the use of massage therapy in children concluded that there was insufficient evidence to support its use without qualification.

• None the less it is used in both neonates and older children with a variety of medical conditions.

Massage for children

• Benefits include improved mood (less crying and salivation), increased sleep and reduced pain in children with juvenile rheumatoid arthritis.

• Supporters believe that massage has a positive effect on behaviour, concentration and children’s respect for each other.

Osteopathy (osteopathic manipulative medicine)

• The name ‘osteopathy’ stems from the Latin words osteon and pathos, which translates to ‘suffering of the bone’.

• This name has caused con-fusion in the sense that it makes people believe that an osteopath treats only conditions of the bones.

Osteopathy (osteopathic manipulative medicine)

Osteopathy (osteopathic manipulative medicine)

• However, the name was chosen because its founder, Dr Andrew Still, recognised that a well-balanced, properly functioning body relies on both the muscular and the skeletal systems of an individual being healthy and well.

• The World Health Organization recognises the osteopathic concept of somatic dysfunction as being scientifically proven.

Definition

• Osteopathy is a medical discipline that is based primarily on the manual diagnosis and treatment of impaired function resulting from loss of movement.

• Its philosophy has an emphasis on internal relationships of structure and function, with an appreciation of the body’s ability to heal itself.

• It uses a wide range of techniques to treat musculoskeletal problems and other functional disorders of the body.

History

• Osteopathy was developed in the USA in the 1870s by an American frontier doctor, Andrew Taylor Still (1828–1917).

• Still used his extensive knowledge of anatomy and physiology to develop a method to diagnose and treat the body through palpation and manipulation.

• He founded the American School of Osteopathy at Kirksville, Missouri in 1892.

Theory

• The philosophy of osteopathic medicine is based on the idea that the human body constitutes an ecologically and biologically unified whole.

• Body systems are united through the neuroendocrine and circulatory systems.

Theory

• In the study of health and disease, therefore, no single part of the body can be considered autonomous.

• Osteopaths believe that the problems of health and the treatment of disease can be rationally considered only through the study of the whole person in relation to both internal and external environments.

The following key principles are involved:

• The body comprises interrelated organs and systems, and functions as a whole unit; disease results from an imbalance in overall health.

• The body has an ability to heal itself and may be assisted in this function by the practitioner; disease represents a breakdown in this capability.

The following key principles are involved:

• The body is much more than the sum of its individual parts; nothing exists in isolation and the totality must be considered, e.g. dysfunction in the musculoskeletal system frequently contributes to pain, poor circulation and changes in function leading to constipation, headache, fatigue.

• Treatment is based on the three basic principles of body unity, selfregulation and the interrelationship of structure and function, as stated above.

Practice • Osteopathic treatment is purely and

solely based on manual techniques, which are used to adjust and correct mechanical problems in the whole body.

• The osteopath does not prescribe any medicines, nor does he or she use any invasive techniques (injections, surgery, etc.), although in the USA the scope of treatment may be wider than this.

• Diagnostic techniques are as for chiropractic and may include radiology.

• The aim is not to treat the illness itself but to stimulate the patient’s natural healing processes.

There are four phases to treatment:

• 1. Detection of changes in muscles and tissues (by palpation)

• 2. Observation of any body asymmetry (e.g. leg length), posture and respiratory function

• 3. Testing of mobility and sensitivity • 4. Application of treatment. • Usually, a patient will be asked to be passive

during this phase. However, at times there are some techniques for which the patient must actively participate in the movements.

Examples of the direct and indirect

techniques employed by osteopaths: • Counterstrain techniques achieve release of restriction

by placing the affected joint or muscle in a position of comfort, while applying a counter-stretch to the antagonists of the tight muscles.

• Functional techniques involve gentle mobilisation of joints so that barriers to normal movement are identified until a way is found through the restriction.

• Osteopathic manipulations are carried out using minimum force levels in order to maximise safety and minimise patient discomfort; manipulation is not the mainstay of most osteopathic treatments.

• A treatment session lasts approximately half an hour.

Craniosacral techniques

are very gentle release techniques particularly suited to young children and physically frail individuals;

this therapy was evolved by the Swiss practitioner William Garner Sutherland (1873–1954) and depends on the suggestion that cranial sutures have the ability to move slightly and their manipulation is thought to improve the circulation of cerebrospinal fluid, which in turn may relieve certain local symptoms.

Visceral techniques

are used in the management of conditions affecting internal organs and involve gentle and rhythmical stretching of the visceral areas.

Apart from low back pain, other conditions treated by osteopathy are similar to those addressed by chiropractors and include neck and shoulder pain, sports injuries, repetitive strain disorders and headache.

Visceral techniques

In addition, practitioners also treat arthritis; although they cannot affect disease pathology or progression, they claim to be able to treat secondary symptoms such as pain from associated muscle spasm.

Cranial osteopathy has a particular reputation for treating children with conditions such as infantile colic, constant crying and behavioural problems.

Reflexology

Reflexology

• The word ‘reflexology’ comprises ‘reflex’, in this case meaning one part reflecting another part, and ‘ology’, meaning study of.

• Put together, we get the study of how one part reflects another.

• However, the discipline involves much more than simply a study of parts.

• Reflexology is the most popular complementary discipline in Denmark.

Definition

• Reflexology may be defined as ‘the scientific theory that maps out the reflexes on the feet and hands to all the organs and the rest of the body’.

• It involves the application of pressure to reflex areas of the hands or feet to produce specific effects in other parts of the body.

Reflexology map; each of the shaded areas represents different

areas of the body or organs.

History • A pictograph in the tomb of Ankhmahar, a

physician of particularly high esteem, discovered at Saqqara in 1979, revealed that the ancient Egyptians were aware of the benefits of foot and hand reflexology.

• The pictograph, dating back to around 2500 BC, shows a therapist working on a patient’s foot and a second therapist working on another patient’s hand.

History • Reflexology is also said to have been

practised in Chinese and North American Indian cultures.

• Willam Fitzgerald (1872–1942), observed that applying pressure to specific areas of hands and feet caused an anaesthetising effect on other areas of the body and was useful in the treat-ment of pain.

• He divided the body into five longitudinal zones on each side of the body.

History • These terminated in the toes and fingers.

Fitzgerald suggested that a direct link existed between the areas and organs within each of the zones.

• This idea was developed by Eunice Ingham (1879–1974), who charted reflex areas in the foot that appeared to correspond to areas of the entire body. refinements.

Theory

• It is suggested that, when the reflexes are stimulated, the body’s natural electric energy works along the nervous system and meridian lines to clear any blockages on those lines and in the corresponding zones.

• A treatment seems to break up deposits (felt as gritty areas under the skin) that may interfere with the natural flow of the body’s energy.

Practice

Practice

• Reflexologists do not seek to diagnose medical conditions, nor do they prescribe medicines, although the topical use of oils or herbal preparations is often recommended.

• Dietary advice may also be given. Most reflexologists work on the feet, although the hands may also be involved.

• A treatment session lasts around 40 min. Practitioners usually advise their patients that the effects of a treatment may last up to a week.

Practice

The need for further treatment will vary according to the severity of the condition and the patient. The following benefits are possible:

• Improved urination

• Improved digestion

• Heightened sense of energy

• Reduction in pain.

Rolfing

• When the body gets working appropriately the force of gravity can flow through then, spontaneously, the body heals itself.

• Dr Ida P Rolf

Rolfing

Definition

• Rolfing is a comprehensive system of hands-on, connective tissue manipulation and movement education that releases stress patterns in the human organism.

• As with other similar techniques (e.g. Feldenkrais), rolfing seeks to organise and integrate the body in relation to gravity by manipulating the soft tissues or by correcting inappropriate patterns of movement.

• The final goal is that the client can move and function with greater freedom, and effortlessly maintain a more upright posture.

History

• Rolfing is the creation of Dr Ida Rolf, a biochemist and physiologist who established the Rolf Institute for Structural Integration in 1970.

• She believed that, for optimum health, the body must be in alignment with gravity: any deviation from the norm requires extra energy for movement and imposes unnecessary strain on the muscles.

• She contended that, as the muscles work to compensate for failing efficiency over the passing years, the fascia surrounding them tend to bunch up and harden, creating even more strain.

• Ultimately, she said, the cumulative stress can interfere with normal breathing and impair circulation, digestion and the nervous system.

Theory

• The deep massage techniques employed in rolfing seek to loosen and relax the fascia – the membranes that surround the muscles.

• Rolfers believe that the fascia toughen and thicken over time, subtly contorting the body and throwing it out of healthy alignment.

Practice • To break up knots in the fascia and ‘reset’

the muscles, rolfers apply slow, sliding pressure with their knuckles, thumbs, fingers, elbows and knees.

• The treatments are not mild and relaxing – indeed, they can cause a degree of pain.

• However, practitioners view this temporary discomfort as a sign that the treatment is achieving the changes necessary to bring the body back into proper alignment.

Practice • During each session, the rolfer will

concentrate on a different set of muscles, starting with those nearest the surface and moving on to those deep within the body.

• To maximise the benefits of treatment, the therapist may also teach selfhelp exercises known as movement integration.

• Sessions usually last 60–90 min. • The basic sequence of rolfing consists of 10

sessions through which a new structural order and a more efficient movement pattern are developed.

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