RMT · Shoulder and Upper Arm, Elbow, Wrist and Hand, Spine, Thorax and Abdomen, Pelvis, Hip and Thigh, Knee and Lower Leg and the Ankle and Foot. Orthopedic Physical Assessment with

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VOLUME 9 ISSUE 1

Anvil CentreNew Westminster

KEYNOTE SPEAKERSInternationally Recognized Speakers

BREAK-OUT PRESENTERSPanels, Workshops and Seminars

LEGAL MATTERSFive things NOT to do...

Featured Articles

Manual Therapy ConferenceApril 16-18

M a t t e r s

An Interdisciplinary Approach to the Science and Practice

Home Study CE Programs Approvedby the CMTBC for 10 PD/A4 CEC’s

Human Gross Anatomy CD-ROM SeriesModules 1-7These modules contain a thorough and comprehensive review of Anatomy and Regional Orthopedic Pathology of the Shoulder and Upper Arm, Elbow, Wrist and Hand, Spine, Thorax and Abdomen, Pelvis, Hip and Thigh, Knee and Lower Leg and the Ankle and Foot.

Orthopedic Physical Assessment with Special Tests ShoulderModules 1-4These modules contain a review of all Movements, Special Tests for Anterior Glenohumeral Instability, Posterior Glenohumeral Instability, Inferior Glenohumeral Instability, and Impingement Syndrome.

Orthopedic Physical Assessment with Special Tests ShoulderModules 5-9These modules contain a review of the Special Tests for Labral Tears of the Glenohumeral Joint, Scapular Stability, Acromioclavicular and Sternoclavicular Joints, Muscle and Tendon Pathology, Thoracic Outlet Syndrome and Joint Play Movements of the Shoulder.

Orthopedic Physical Assessment with Special Tests Pelvis and HipModules 1-5These modules contain a review of all Movements of the Pelvis, Special Tests for Neurological Involvement, Sacroilliac Joint Dysfunction, Leg Length, Selected Movements for the Hip, and Special Tests for Hip Pathology, Anteriorlateral Rotary Instability and Posterolateral Rotary Instability.

Orthopedic Physical Assessment with Special Tests KneeModules 1-5These modules contain a review of all Movements of the Knee and Special Tests for One-Plane Medial Instability, One Plane Posterior Instability, Anterolateral Rotary Instability and Posterolateral Rotary Instability.

Orthopedic Physical Assessment with Special Tests Lower Leg, Ankle & FootModules 1-5These modules contain a review of all Movements of the Lower Leg, Ankle and Foot, Special Tests for Neutral Position of the Talus, Ligamentous Instability and Joint Play Movements.

CDPRICE:$297$197

To Register Go To: www.sesonlinece.com/cmtbc or call Toll Free at 1-888-738-8147

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CONTENTS

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From The Desk

Break-out Presenters

Classified

Professional Education Series

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Legal Advice

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RMTBC

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RMT MATTERS | VOL 9 ISSUE 1 - rmtbc.ca 3

Keynote Speakers

RMTBCAnvil Centre, New Westminster, BC

April 16 - 18, 2016

M T 2 0 1 6RMTBC Conference

RESEARCH & LEGAL

$70

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$70

RMTBC

FROM THE DESK

We have all heard of Dr. Google and the resultant fact that Internet research brings us more knowledgeable and enquiring patients. The

good doctor also offers a plethora of inaccurate, incorrect, and just plain misleading information we need to dispel. But one question we should be asking ourselves is ‘does Dr. Google raise our own educational bar?’ Because

of Dr. Google and the like (chat rooms, internet research, Facebook pages, special interest groups, Twitter’s speed of information), do RMTs need to increase their own educational credentials to maintain not only educational superiority but also professional credibility?

If you take a close look at today’s patient, you will find the answer.

First today’s patient is far better equipped with information and questions than ever before. How many RMTs have had patients show up with a sheaf of papers printed out from the Internet on their particular ailment and what an RMT should be doing to address or alleviate it? Information (and misinformation) is so readily available through the Internet; it is rare that a patient has not done any research on their particular ailment.Plus today’s patient, prior to an appointment with you, has likely spoken to another family member, friend, or health care provider about what’s bothering them. They may have visited a health care website that has ideas or suggestions on ways to address their physical impairment or resulting pain.

And today’s patient also comes, oftentimes, with a personal Twitter or Facebook page, and may have reached out to others about their own ailments or limitations. There is no shortage of opinion out there when you ask for it.

In fact, today’s patients, according to a survey of RMTs with more than five years experience, have more complex health care issues. Eighty-one percent of RMTs surveyed state that their patient populations understand more about their own health care needs today than previously, and 54 per cent of those patients ask more about health care news and research than ever before.

But there’s something you may not know about today’s patient. More and more, they are coming to an RMT for help. The proportion of individuals who seek an RMT for help has grown in the past six years, according to our survey done in March 2014. A full 81 percent more British Columbians visited an RMT in 2014 than in 2008. That translates into this fact: 67 percent of residents have visited an RMT in their life, second to physiotherapists and more than chiropractors, acupuncturists and TCM practitioners. Looking only at the last five years, 52 percent of residents have visited an RMT compared to only 50 percent of residents visiting a physiotherapist. The need for our particular type of effective therapy is on the rise.

There’s more. The average number of visits to RMTs is up, and most patients (just over half) see an RMT for muscle pain, followed closely by neck and shoulder pain, and then back pain. A quarter of residents seek RMT treatment for stress. Ninety-one percent of residents are favourable toward RMTs, including 56 percent who claim to be very favourable.

So what should we do with this information? As we rise in popularity amongst a much more knowledgeable and inquisitive patient base, should we maintain the status quo regarding our own credentials or is now the time to raise the bar?

Eighty-six percent of RMTs would support RMT education in a public institution and 83 percent of those would do so for the advancement of the profession. Eighty-five percent of us believe that a B.Sc. in massage therapy would advance the profession.

Now is the time to raise the bar. More than ever before, today’s RMT must match today’s patient with increased knowledge, advanced education, and continued credibility. It is the most effective way to hold our position as the health care provider of choice amongst our patient base. Our patients look to us for the answers; now RMTs must find those answers in a university degree program.

By Anne Horng, RMT

RMT Registered Massage Therapists’ Association of British Columbia

www.rmtbc.ca

EditingScantone Jones, Jessica ter Wolbeek, Brenda Locke, Anne Horng & Mike Reoch

Artistic DirectionRachelle Paradis, Dave DeWitt

Content ContributorsAnne Horng, Corey Van’t Haaff

Registered Massage Therapists’ Association of British Columbia

Suite 180, Airport Square 1200 West 73rd Avenue Vancouver, BC V6P 6G5 P: 604.873.4467F: 604.873.6211T: 1.888.413.4467 [email protected] www.rmtbc.ca

RMT Matters is published three times a year for Registered Massage Therapists (RMTs). This publication intends to provide a voice for RMTs and to act as a source for the latest research plus a vehicle for the general population to understand and respect the valuable work of RMTs. Funding is provided by RMTBC and through advertising revenue.

© 2016 RMTBC. No part of this publication may be duplicated or reproduced in any manner without the prior written permission of the RMTBC. All efforts have been made to ensure the accuracy of information in this publication; however, the RMTBC accepts no responsibility for errors or omissions.


Additional ContributersEyal Lederman, Sandra Hilton, Walt Fritz, Ravensara Travillian, Rob Hemsworth, Angela Mackenzie, Brian Fulton, Christopher A. Moyer, Susan Chapelle,Cory Blickentaff, Nikita Vizniak & Scott Nicoll

M a t t e r s

RMTBCM a n u a l T h e r a p y C o n f e r e n c e An Interd isc ip l inary Approach to the Science and Pract ice

R M T B C C o n f e r e n c e , A p r i l 1 6 - 1 8 , 2 0 1 6Anvil Centre, New Westminster, BC MT2016.com

RMTBC

Professional Education Series

April 16 - 18, 2016

Emphasis on Evidence-based Techniques

We are expecting a diverse audience of health care professionals mainly from the manual disciplines.

Participants will increase their understanding of various therapies by learning the most recent developments in the field.

In recent years, the RMTBC has hosted extremely successful conference events with attendees and speakers alike lauding the importance and relativity of these including our sold-out 3rd International Fascial Research Congress hosted in 2012 and a Pain Management Conference in 2014.

Advertorial cont....

The 2016 Manual Therapy Conference continues the commitment of presenting the very latest and best research and information possible.

We are pleased to invite you to the latest RMTBC conference. We will continue to proactively present continuing education that ensures you are constantly up to date on the cutting edge of research, practice, science & techniques.

There will be two days (Apr. 16-17) of Internationally known speakers and practitioners addressing the science and practice of manual therapy using safe and effective manipulative and/or movement therapies followed by one day (Apr. 18) of intensive workshops.

Presentations at this year’s event Manual Therapy: an Interdisciplinary Approach to the Science and Practice will address the science and practice of manual therapy using safe and effective manipulative and or movement therapies. Emphasis will be on evidence-based techniques. Sound science will underpin theoretical constructs. You can expect to increase your understanding of various therapies by learning of the most recent developments in the field.

Confirmed as Keynotes and Post Conference Workshop Facilitators:

• Eyal Lederman, PhD, DO• Sandy Hilton, DPT, MS• Walt Fritz, PT• Ravensara Travillian, PhD, NA-C, LMP

There will be two exciting panel discussions:

Pelvic Floor Health: an Interdisciplinary Approach to Assessment, Diagnosis, and Treatment, moderated by Holly Henry, RMT and Chair of RMTBC’s PPG Women’s Health, will address aspects of Pelvic Health.

The closing panel, moderated by Bodhi Haraldsson, RMT and RMTBC’s Director of Research, is titled “Contemporary Manual Therapy within the Biopsychosocial Model.”

Afternoons will feature concurrent breakout groups showcasing a number of presenters including: Corey Blickenstaff, PT, MS, OCS, Nikita Vizniak, DC, Chair of Physical Medicine at the Boucher Institute of Naturopathic Medicine, Christopher A. Moyer, PhD, Rob Hemsworth, B.P.E, B.Ed., RMT, MRSC, Angela Mackenzie, RMT, Brian Fulton, RMT, Dr. John Sloan and Damian John, BA, RMT.

Prices as follows: early member $425, regular member $475, non-members $550 and workshops $250. Workshop seats are available only to conference attendees.

REGISTRATION IS OPENmt2016.ca

Sound Science will Underpin Theoretical Constructs

7

Increase your Understandingof the Various Therapies by Learning most recent Developments

processes can be seen in various musculoskeletal and pain conditions. Recovery by repair is seen in conditions such as acute spinal and disc injuries, joint / capsular-ligamentous sprains / strains, muscle tears, etc. Recovery by adaptation is expected in chronic such as post-immobilization conditions, long-term contractures after injury and surgery, stiff phase of frozen shoulder, and recovery in central nervous system damage such as stroke and traumatic head injuries. Symptomatic-related recovery probably plays an important role in recuperation from chronic conditions such as low back and neck pain, and improvements in painful tendinopathies and other unexplained local and regional whiplash-associated pain conditions.

The management in a Process Approach aims to identify the dominant processes which underpin the individual’s recovery. Once identified, environments that support these innate recovery processes are explored with the patient. These environments contain physical, psychological, cognitive, behavioural, and social dimensions. They include: hands-on support, exploring movement that would be beneficial for recovery, psychological support, working with cognitions, raising awareness to avoidance and recovery behaviour, as well as exploring social and physical environments that assist recuperation. A Process Approach takes a different therapeutic vector from the traditional Structural Model. In Process Approach the management is aimed directly at supporting the recovery processes rather than indirectly through influencing biomechanics, structure/anatomy or posture as proposed by the Structural Model. A Process Approach is informed by and developed from biopsychosocial sciences and evidence-based medicine.

MT2016KEYNOTE SPEAKERS

The innate capacity of the body/person for self-recovery and healing is a key concept and the basis for manual therapy management for a broad range of conditions. It is believed that the ability of a person to recover their health and functionality is determined by the viability of these self-healing/recovery processes. Failure in these systems is seen as an obstacle for recovery and therefore the role of manual therapy is to support these innate self-recovery processes. Usually, the focus of the management is to identify and remove the obstacles which may impede self-healing. It is believed that these obstacles can arise from faults, misalignments, or imbalances within the body’s structure. By removing these structural obstacles, damaging stresses can be minimized and physiology improved. When achieved, this idealized structural state would help self-healing, prevent the development of pathology, and support health and well-being. It could also reduce the energy costs to

the system; energy that can be ‘utilized elsewhere’ for self-healing. This form of care is the basis of the Structural Model in manual therapy. This model is often used to rationalize the cause of the patient’s complaint as well as to justify the clinical management. However, research findings in the last

three decades have challenged the plausibility of the Structural Model and imply that the role of manual therapy in supporting health and recovery needs to be reconsidered. In response to these findings an alternative management called a Process Approach is proposed.

In the last decade I have proposed an alternative basis for manual therapy based on direct support for self-healing called a Process Approach. This approach shares the view that the body/person has the capacity for self-healing but aims to directly support the processes associated with recovery: namely, repair, adaptation and alleviation of symptoms. The relative dominance of these

However, research

findings in the last

three decades have

challenged the

plausibility of the

Structural Model...

A Process Approach in manual therapy: beyond the Structural Approach

Eyal Lederman DO, PhD

RMT MATTERS | VOL 9 ISSUE 1 - rmtbc.ca8

Are you

comfortable with

someone telling

you that they

have genital

pain?

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The estimated impact of back pain is that over 80 percent of people will experience some form in their lifetime. Pain experienced in the pelvis is more challenging to estimate as many people report pain from mid-thigh to pubic area as “back”, “hip”, “leg”, “belly”, or “bottom” when they are experiencing pain in the high groin, the genitals, or with the functions of the pelvis. Cultural limitations also affect how people in pain will communicate their pain and how the health professionals react or hear their complaints. As a provider, are you comfortable with someone telling you that they have genital pain? Understanding the possible causes and treatments of pelvic pain will help you negotiate those moments. Knowing which professionals to refer to is also important.

Complex back and pelvic pain conditions often require a team approach including the person in pain and a host of health professionals. One of the biggest challenges is getting a person in pain to a health professional who can screen them adequately and provide the appropriate referral for treatment. The team approach for pelvic pain includes urologists, gynecologists, sexual therapists/counselors, massage therapists, physiotherapists and more. As a physical therapist (physiotherapist) I can evaluate internally and work to restore the deep pelvic muscles and sensory awareness and I do. But the bulk of my treatment is in restoring the accuracy of sensation and movement (motor control) and importantly involves reconceptualizing pain. Those components are available for all health professionals.

Massage therapists can be one of the first providers to find out about pelvic pain, and as such are a valuable member of the health care team with a role to play in providing relief and referral as needed. Despite the complexity of pelvic and back pain, there is hope and help. Individuals with challenges in the hip, low back, belly, genital region, and any combination of those can find relief with careful assessment and treatment aimed at restoring function.

Where does treatment for pelvic conditions start? The first step is to understand that the nerves that supply the pelvic floor and control bowel, bladder and sexual function in men and women involve the thoracic and lumbar spine and the autonomic nervous system. Manual therapy techniques that are purposefully non-pain-provoking and that encourage movement can be an important tool for reducing the pain response and returning confidence in movement.

I am glad for the opportunity to explore NeuroDynamic principles for the pelvic nerves and gentle manual therapy options in my workshop at the Manual Therapy Conference. I am happy to share the hope of relief from pelvic pain!

Sandra Hilton PT, DPT, MS

Restoring function following back and pelvic pain


Keynote Speakers, cont...

Looking behind the fascia curtain

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What made a physical therapist with a few decades of experience using myofascial release as a primary treatment modality, who once believed that most pain and emotional trauma was held in the restricted fascia, turn away from these views? When outcomes seemed good, why change? Easy, I looked behind the curtain.

The number of modalities available to massage therapists and manual therapists is nearly endless, with each professing to hold the key to pain and movement dysfunction. Most seem to have unique science that explains their views, as well as equally unique targets for intervention, so how can all be correct? How many parallel universes must exist if so many modalities can accurately claim to be the most effective? And how many target tissues can be the source of pain? When we touch a patient, can we really be doing all of the unique things that we are told we are doing?

In the book and movie, The Wizard of Oz, the Wizard held great power over Dorothy and made her believe he was the “Great and Powerful Oz.” Using this great power, he manipulated Dorothy to do his bidding with promises

of returning her to her home. But in the end, he was just a normal guy with no special powers. The curtain, and all that went along with the magical powers, was just a ruse. It took Toto to pull back the curtain and allow Dorothy a peek behind it to get her to see that she already had the power to return home.

My own therapeutic curtain of beliefs was knocked down nearly a decade ago and even though I initially resisted, I have never looked back with regret. In my life, the role of Toto was played by science, and the science-informed folks who showed me the flaws in my thinking and education. Who was my Wizard of Oz? Not one person, but

it was more a metaphor for those who taught me wonderfully effective hands-on treatment, but with factually incorrect explanations. “It took only a few scientific papers to allow me to see perspectives opposite from mine, from alternate views on poor posture and skeletal asymmetry, to the commonness of “bulging” discs, these and more gave me new insights out of the rather closed world of MFR in which I trained. But incorporating this information into my practice and teachings required that I become more informed about other views and explanations of how change occurs through manual therapy. Which is how I ended up presenting to you.”

I hope to share this journey back from Oz, one in which science and research made me understand more about what was happening under my hands, made me be more honest with my patients, and in the end allowed me to continue with real outcomes that can be plausibly explained. It wasn’t a simple journey, but it is one that all should consider.

When outcomes

seemed good,

why change?

Walt Fritz, PT



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Massage therapy has tremendous potential for relieving suffering in populations who have experienced trauma, such as military veterans and refugees. While the exact mechanisms by which massage therapy reduces anxiety and depression remain to be better understood, its positive effects on those conditions are strongly supported in the literature. As Christopher Moyer observed in 2008, the scientific consensus is that massage therapy’s effects on anxiety and depression are the most solid and well-established effects in massage research.

In that context, then, massage therapy provides an avenue to reducing the burden of illness

and improving the quality of life in people whose anxiety or depression compounds the effects of other conditions that they cope with on a daily basis. For example, using sophisticated statistical analyses, Matthew Jakupcak’s team demonstrated that, in a population of veterans in the Pacific Northwest, the symptoms of depression and anxiety sensitivity heightened the effect of post-traumatic stress disorder (PTSD) on physical symptoms that this population experienced.

M. Van Ommeren’s team carried out a study in 2002 among Bhutanese refugees living in United

Nations-sponsored refugee camps in Nepal. They compared symptoms among refugees who had been tortured and those who had not been, and found that the number of PTSD symptoms experienced by those survivors was a consistent indicator of the physical symptoms present. Andrea Niles’ team performed a more specific study, linking the severity of anxiety and depressive

Massage therapy’s potential for reducing physical symptoms by addressing underlying depression and anxiety

Jakupcak M, Osborne T, Michael S, Cook J, Albrizio P, McFall M. Anxiety sensitivity and depression: mechanisms for understanding somatic complaints in veterans with posttraumatic stress disorder. J Trauma Stress. 2006 Aug;19(4):471-9.Moyer CA. Affective massage therapy. Int J Ther Massage Bodywork. 2008 Dec 15;1(2):3-5.Niles AN, Dour HJ, Stanton AL, Roy-Byrne PP, Stein MB, Sullivan G, Sherbourne CD, Rose RD, Craske MG. Anxiety and depressive symptoms and medical illness among adults with anxiety disorders. J Psychosom Res. 2015 Feb;78(2):109-15.Van Ommeren M, Sharma B, Sharma GK, Komproe I, Cardeña E, de Jong JT. The relationship between somatic and PTSD symptoms among Bhutanese refugee torture survivors: examination of comorbidity with anxiety and depression. J Trauma Stress. 2002 Oct;15(5):415-21.


symptoms to specific medical conditions, including serious conditions that carry the risk of increased mortality, such as asthma, heart disease, and ulcers. They conclude that, “These findings add to a growing body of research linking anxiety disorders with physical health problems and indicate that anxiety and depressive symptoms deserve greater attention in their association with disease.”

In my own anecdotal experience providing massage therapy in the Refugee Clinic in Seattle, the topic of the intractability of severe depression among our clients, the relative ineffectiveness of prescription medication against that depression, and our providers’ sense of frustration and helplessness at not having anything better to offer was a frequent subject of discussion. In fact, the search for a more effective and culturally appropriate treatment was one of the reasons they made the decision to expand their treatment options to include massage therapy, a decision which was very well received by the patients treated at the Clinic, who made full use of the massage therapy service.

A research question naturally suggests itself then: can trauma survivors’ physical symptoms and suffering be reduced, and the quality of life enhanced, by using massage therapy to address the underlying depression and anxiety that is exacerbating their physical complaints? The previous work on the topic suggests that this is a very plausible hypothesis, consistent with the existing body of knowledge on anxiety, depression, PTSD, and massage therapy, and that it promises to be a very fruitful area of research, with the potential of significant improvement to quality of life and reduction of physical illness burden in multiple populations living with the effects of trauma, and the anxiety and depression that exacerbate those effects.

...this is a

very plausible

hypothesis,

consistent with

the existing

body of

knowledge...


Ravensara S. Travillian, Ph.D., NA-C, LMP

BREAK-OUT SPEAKERS

Health-Related Quality of Life (HRQOL) Measures and Patient-Centred Healthcare

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Shifting Healthcare Paradigm

Evolving healthcare trends are challenging health professionals to use evidence-based practices (EBP) that demonstrate intervention effectiveness and efficiency. Accordingly, assessment practices deemed (1) evidence-based, (2) standardized, and (3) centralized are essential to EBP for supporting clinical decision-making through accuracy of measurement outcomes and health status identification (Fawcett, 2007). Standardized means measurement tools that are designed for a specific purpose in a given population. Detailed instructions are provided regarding administration and scoring, interpretation of scores, and results of reliability and validity. Centralized means listening to client needs and responding by emphasizing a client-centered healthcare process. The International Classification of Functioning, Disability, and Health (ICF) is the World Health Organization (WHO) international framework for measuring health and disability (WHO, 2002). Accordingly, health-related quality of life (HRQOL) is a concept that embraces the spirit of the WHO definition of health by providing a comprehensive patient-centred approach to measuring the impact of a disease and its treatment on different domains (physical, mental, and social well-being) of daily life and health experience. Assessing HRQOL extends outcome measurement and enhances treatment decision-making, efficacy evaluation, and interpretation of outcomes (Geyh, 2007). As RMTs, are we utilizing HRQOL measures in practice?

Stakeholder Mandate

Professional mandates now reflect this evidence-based assessment trend across all levels of health care. For example, the World Health Organization (WHO, 2002) values ‘insider’ perspectives of people with disability. Provincially, the British Columbia Ministry of Health (BCMOH; 2015) strives to deliver effective health care by shifting from provider-focused approaches to more ‘patient-centred’ ones…requiring understanding of and responsiveness to patient needs, values, and preferences as the primary drivers of daily practice at all levels. Additionally, provincial insurers [WorkSafeBC (WCB-BC) and the Insurance Corporation of British Columbia (ICBC)] increasingly request

Rob Hemsworth, B.P.E., B.Ed., RMT, MRSC

Framing the Problem

Proliferation in the development of standardized assessment (SA) resources (databases) has tried to address EBA/EBP demand by informing clinical knowledge (Kania, 2009; Russek, 1997). However, standardized assessment uptake remains challenging across health disciplines, as clinical practises remain fixated on assessment of function at the impairment level (WHO, 2001). This evidence-to-practice gap (Bland, 2013; Salbach, 2011; Swinkles, 2011) justifies the need to conduct research inquiry into HRQOL measurement practice behaviours of massage therapists to enable practise comparisons with similar professions.As RMTs, are we accessing and utilizing resources that enable HRQOL measures in practice?

Role of Research

Increasingly, theory-informed research is being conducted to measure and explain health-related behaviors in health care. For example, the theory of planned behavior (TPB) proposes a model to explain how human action is guided (Ajzen, 1991) and has explained health professional behavior in disciplines similar to our own. As RMTs, you will have an opportunity to participate in an upcoming research project that will investigate RMT intentions to perform HRQOL measures in practise. Doing so will enable the development of strategies (resource development and access) to address practise barriers and increase HRQOL behaviour.

This is your chance to have a voice in research and facilitate a meaningful change in how we think and practise as RMTs. I look forward to hearing from all of you!

As RMTs, should we support massage therapy research to advance professional knowledge and skill?

For references please go to page 31.

professional provision of reliable ‘subjective’ reports in the form of self-report measures (Matheson, 2006). Professionally, the Registered Massage Therapists’ Association of BC’s (RMTBC, 2016) research vision is to advance the science and practices of massage therapy through the use of high quality research in massage therapy education, practices and professional development. Thus, as a regulated healthcare profession in British Columbia (HPA, 2016), RMTs have a responsibility to deliver health services that demonstrate safety, efficiency, and effectiveness. As RMTs, do we feel obligated to utilize HRQOL measures in practice?

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Why study fascial anatomy?

Break-out Speakers, cont...

Angela Mackenzie, RMT

endofascial fibres and interfascial planes could cause anomalous tension, and given the many mechanoreceptors imbedded within the fascia, altered proprioceptive afferents could then result in non-physiologic movements at joints.Such movements could cause inflammation within a joint of a malfunctioning myofascial unit or pain along a myofascial sequence.

These are some of the symptoms our patients describe when they point to their joints and areas of pain, stiffness, numbness, and weakness. As massage therapists we are asked to evaluate and create a treatment plan to resolve these symptoms using a manual technique.

The assessment process used in Fascial Manipulation® is characterized by an analytic procedure that results in a personalized treatment plan for each patient.

Using movement and palpatory tests as a guide, therapists can determine which fasciae are involved in any given dysfunction.

The manual technique involves a deep friction over specific points on the deep muscular fascia that are always at a distance from the actual site of pain. In this way, the technique can be applied safely, even during the acute phase of dysfunction.

Hyperemia caused by the deep friction could modify the extracellular matrix and restore gliding. Active joint movement and muscle recruitment is improved and symptoms are resolved.

My experience using Fascial Manipulation® method in my practice is that it provides me with a comprehensive understanding of fascia and a process with which I can be more effective and timely with symptom resolution and improved function for my patients.

Angela Mackenzie’s references are on p. 31.

As an RMT since 1995, I recognize the clinical importance of fascia in pathology and manipulative treatment.

For the last six years, my studies have been with Luigi Stecco, an Italian physiotherapist and founder of Fascial Manipulation® method, and other healthcare professionals, including his two children, Prof. Carla Stecco and Dr. Antonio Stecco. Prof. Carla Stecco has more than 60 indexed papers about fascial anatomy including extensive anatomical dissections of unembalmed bodies carried out in collaboration with the Anatomy Department at Rene Decartes University in Paris and the Anatomy Department of the Padova University (Italy). Furthermore, Prof. C. Stecco recently published a ‘Functional Atlas of the Human Fascial System’, with dissections that examine the complex organization of the

human fascial system in detail. Biomechanical studies analyzing the histologic components, fibre arrangement and innervation, have provided a working hypothesis for the direct involvement of fascia in proprioception and peripheral motor coordination.

Luigi Stecco has dedicated 40 years to the study of fascia and has developed a biomechanical model that can help clinicians understand the complexity of the fascial system, but more specifically, sees the deep muscular fascia as:

• Coordinating elements for motor units (grouped together in myofascial units)

• Uniting elements between unidirectional myofascial units (myofascial sequences), and

• Connecting elements between body joints through myofascial expansions and retinancula (myofascial diagonals and spirals).

This biomechanical model, together with the anatomical research, has resulted in some important clinical considerations concerning the role of the deep fascia in myofascial dysfunctions.

Any impediment to gliding between the

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The placebo effect in manual therapy

Placebo effect is a term that conjures up all sorts of images. As a result there is certainly no shortage of terms to describe the phenomenon. The short list includes terms like non-specific effects, contextual effects, and psychosocial factors; and there are a dozen or more other terms in the literature as well. While the term placebo effect carries a lot of excess baggage, it is still the most widely used Medical Subject heading (MeSH) term to describe the phenomenon in research literature; so let’s put semantics aside for a moment while we examine this phenomenon. Why should a massage therapist be curious about the placebo effect? The reason is that we now know that the placebo effect comes into play in virtually every medical encounter, up to and including surgery. In the manual therapy professions

two major reports have identified the ubiquitous presence of placebo effects: Bialosky’s 2011 report, “Placebo response to manual therapy: something out of nothing?” looked at 94 research papers on manual therapy, and Bronfort’s 2010 paper entitled, “Effectiveness of manual therapies: the UK evidence report” looked at 49 relevant systematic

reviews, 16 evidence-based clinical guidelines, plus 46 random control trials. Both papers found strong evidence of placebo effects in manual therapy, and both endorsed an ethical approach to managing the placebo effect in clinical practice. So, having learned that the placebo effect plays a role in most medical treatments, what is your reaction to this information? Hopefully you will be curious to learn more about what has been discovered, and how some of the principles can be ethically incorporated into your practice, to the end of improving clinical outcomes for your clients. The full explanation of this subject involves about 300 pages of information, and it is covered in my recent book on the subject. The short explanation is that you need to learn to manage ever-present psychosocial cues such as expectancy, conditioning, and meaning as they emerge in the clinical environment.

As a concept, expectancy seems simple enough, but we must remember that this involves not simply the client’s expectations, but ours as well. In the history of clinical trials, it was recognized very early on that studies needed to be double-blinded. This was because researcher’s expectations were affecting outcomes. Managing realistic expectations is tricky business, but research suggests that we should err on the side of positive, particularly with expectations that we project to our clients.

Conditioning has been extremely well studied in both animal models and human clinical trials. There is little doubt that previous conditioning can affect clinical outcomes, and a therapist would be wise to take conditioning factors into consideration with each and every client. This comes into play with words that you use, the modality you choose, with remedial exercises, and even with homecare. It is far more productive to build upon previous positive conditioning, than to push uphill against negative conditioning.

Finally there is the incredibly complex subject of ‘meaning’. As a result, I devote a good portion of the book to this topic. Meaning involves things like trust, the clinical environment, receiving adequate explanation of the pathology, client certainty as well as their motivation and desire, and your active listening skills. As far the image that you project is concerned, meaning involves your professionalism, your confidence, your own belief system, the enthusiasm put forth, your perceived competence, and possibly even your sense of humour. For the client, meaning may also involve their own feeling of control, their anxiety levels, the inner narrative that they tell themselves, and eventually an acceptance of the mysteries of healing.

As you can see, this is a very large and complex subject. Since any one of these factors or cues has a potential to affect clinical outcomes, it would behoove us to better understand them so that we can effectively manage the factors that affect clinical outcomes. If, as practitioners, we are not knowledgeable about the placebo effect and the many factors involved, we run the risk of doing a disservice to our clients by inadvertently triggering a nocebo response. As therapists, this is the last thing that we want to do.

Brian Fulton’s references are on p. 31

Brian Fulton, RMT

Why should

a massage

therapist be

curious about

the placebo

effect?

MT2016


A short history of two paradoxical careers

Dreyer, N. E., Cutshall, S. M., Huebner, M., Foss, D. M., Lovely, J. K., Bauer, B. A., & Cima, R. R. (2015). Effect of massage therapy on pain, anxiety, relaxation, and tension after colorectal surgery: A randomized study. Complement Ther Clin Pract, 21(3), 154-159. doi:10.1016/j. ctcp.2015.06.004Frankel, R. M., & Sherman, H. B. (2015). The secret of the care of the patient is in knowing and applying the evidence about effective clinical communication. Oral Dis, 21(8), 919-926. doi:10.1111/odi.12250Major, B., Rattazzi, L., Brod, S., Pilipovic, I., Leposavic, G., & D’Acquisto, F. (2015). Massage-like stroking boosts the immune system in mice. Sci Rep, 5, 10913. doi:10.1038/ srep10913Turan, N., & Atabek Ast, T. (2016). The Effect of Abdominal Massage on Constipation and Quality of Life. Gastroenterol Nurs, 39(1), 48-59. doi:10.1097/ SGA.0000000000000202Vahedian-Azimi, A., Ebadi, A., Asghari Jafarabadi, M., Saadat, S., & Ahmadi, F. (2014). Effect of Massage Therapy on Vital Signs and GCS Scores of ICU Patients: A Randomized Controlled Clinical Trial. Trauma Mon, 19(3), e17031. doi:10.5812/traumamon.17031

My education in Manual Therapy was as comprehensive as it could be in two years, despite little evidence or science for an in-depth cellular level understanding of a mechanism. I learned to palpate, and I learned science from Dr. Gila Strauch who taught me not to settle for a weak understanding if it was possible to know more.

Massage Therapy school felt like a battleground. How could we manipulate systems we could not palpate? Where my fingers could not reach, I had great difficulty evaluating differences in anatomical textures. As a practising therapist, I consistently developed and challenged various hypotheses on cellular level mechanisms. I felt if I could have understood what effect manual therapy had on connective tissues, I would better be able to assist people in feeling well after treatment.

Dr. Geoffrey Bove, DC, PhD and I met at a research conference on connective tissue in Amsterdam. He critically questioned my assertion that therapy had some effect on the connective tissue system. Reviewing the literature on scars and adhesions, it was clear that the science for treating a scar or adhesion with manual therapy was weak at best. For seven years, we have worked together studying the effect of manual therapy in animal models. The development of new models, proper controls, assessment of variables, and very little literature relevant to the field have made the science interesting and extremely challenging, not to mention expensive.

Together we have attempted to ascertain any changes that could come about by manually manipulating an animal model of adhesions. We have looked at nerve injuries and the possible effect of manual therapy on regeneration. We have done assays on inflammation, macrophages, and biomarkers of various sorts and made seven years of observations, including some unpleasant bowel function experiments. We are currently funded by the National Institute of General Medical Science, but began with pilot projects with funding from the Rotary and Registered Massage Therapists’ Association of British Columbia.

The side effect of working in science as a manual therapist is that asserting my philosophy did not go very far in a neuroscience lab. I have had my belief

systems challenged, and almost to a fault must now assess if the thoughts exiting Broca’s area while palpating and manipulating tissue should be spoken out loud regarding the workings of manual therapy.

We believe that people seem to feel better when movement is induced in tissue. We understand that exercise is essential, but not often used as a control group in manual therapy studies. We know that paying attention to patients is good for their well-being (Frankel & Sherman, 2015). We appreciate that palpation can distinguish structures somewhat accurately with good knowledge of anatomy. People seem to do better after surgery with decreased pain, anxiety, and tension with manual therapy (Dreyer et al., 2015). We know that people are better able to defecate with massage (Turan & Atabek Ast, 2016), maybe that small fact is enough.

My time in labs working with scientists has been instrumental in evaluating the paradoxical philosophies of my careers in both politics and manual therapy. I am heartened by the move towards a desire for better science and evidence-based treatments in all fields. I feel excited by the public awareness that popular science communicators are bringing to the world. In our future, perhaps, there is hope that a dose of scientific skepticism may better lead us to a collaborative and prevention-focused health system.

Susan Chapelle, RMT


MT2016



Why manual therapy needs modern psychology?

In the dozen-plus years I have spent working closely with manual therapists, I have seen that they tend to be very knowledgeable in key content areas such as anatomy, physiology, and pathology. This is to be expected given the nature of their work. But I have also noticed that, generally, manual therapists are significantly less knowledgeable about psychology, the science that seeks to understand behaviour and mental processes and apply that knowledge to further human well-being.

There are probably several reasons for this. A main reason is that the curricula of manual therapy training programs devote little time to psychology as a core subject. Another reason, I believe, is that psychology lends itself to being underestimated. Nearly everyone believes themselves to know something about human behaviour, and nearly everyone can say something about historical figures such as Freud or Jung and the ideas they had, long ago, about how the mind might work. As such it is easy for a person to convince themselves that they ‘know’ some psychology without realizing that they may know nothing about the ways in which modern psychology, using modern scientific methods, is advancing our understanding of how the experience of pain is mediated by the social environment, how emotions alter cognitive processes, or how the principles of operant conditioning can powerfully influence the effectiveness of health interventions, all of which have direct relevance to manual therapy.

Modern psychology is not a handful of thought-provoking ideas generated exclusively by some European men 100 years ago. Rather, it is a rich and expanding domain of knowledge, grounded in scientific data, that is advancing how we understand human health, social interactions and relationships, thought processes, and development. Applied to the manual therapy profession, it has great potential to help us better understand treatment processes and outcomes, and to promote interprofessionalism between manual therapy and related health care and health-

promoting professions. An increased understanding and appreciation of modern psychology will also serve to strengthen critical thinking skills within manual therapy, which will lessen the pernicious influence of pseudoscience that is sometimes tolerated or even encouraged within the profession.

The further advancement of manual therapy research is also sure to depend on modern psychology; already many of the most highly-cited research articles examining massage therapy are in journals with a focus on psychology or the closely related field of neuroscience, and this trend is

likely to continue or even increase. Many of the methodological challenges that arise in

manual therapy research are ones that have previously arisen in psychological research, especially in the subfield of psychotherapy research; manual therapy research need not and should not attempt to ‘reinvent the wheel’ but should profit from the advances already made in that well-developed clinical field.

Finally, I believe manual therapy may have the most to offer humanity by extending itself, carefully and professionally, into the treatment of anxiety and depressive disorders. Large-scale examinations of massage therapy research indicate that this form of treatment can be quite effective in reducing anxiety and depression. These are common conditions with well-documented detrimental impacts on individuals, families, and communities, and their

impact on the economy – in the form of absenteeism, unemployment,

and increased health care utilization – is substantial. Effective treatment

options that have the potential to complement, extend, or in rare cases even

replace current first-line treatments such as medication and psychotherapy, are needed. Manual therapy is a form of treatment for anxiety and depression with great potential to be effective, and well tolerated, and to have a minimum of detrimental side effects.

Christopher A. Moyer, Ph.D.

...manual

therapy

may have

the most to

offer humanity

by extending

itself...into the

treatment of

anxiety and

depressive

disorders

MT2016


What is edge work?

Edge work is an approach for people in pain to expand un-restrained and confident movement. The edge is defined as the place or circumstance in which the first signs of protective behaviours become apparent or felt and may include changes in breathing, sensation of tension, or feelings of unease, to name just a few. As the name implies, this edge is where the work gets done.

The work that is done is consistent with the Cognitive Behavioral Therapy concept of the “Behavioral Experiment”. (1) I have long considered that my role as a physical therapist is best described as that of a context architect (2) where I provide a setting and scenario where the patient is most likely to come to the desired outcome themselves. With this in mind, the edge is a place where beliefs and behaviours are challenged and changed. Because this occurs at the edge, at the beginning of noticeable change, the subtleties of change are more easily noticed.

There are different types of experiments that can be run at the edge. One may simply move up to and away from the edge repeatedly while paying attention to any change that occurs, looking for an expansion of unguarded movement. Another is to add something new to the situation at the edge. This is a bit like cheating because we want to add a new input of which we likely already have a non-threatening opinion. For example, once at the edge one could simply add a dose of diaphragmatic breathing. Another good option might be to add support or manual input at this point, all the while monitoring with keen awareness for changes and markers of an expansion of unguarded movement. These are just a couple of the myriad possible options.

Just as there are markers of the edge, there are also markers of expansion that show up in the manner of movement and contents of the patient’s narrative. For example, a simple increase in range of motion may occur, or ease with an action like squatting to pick something up from the floor. But also, the person may start to describe their ability and confidence in the motion differently. Again, we want to provide a context in which narratives that are consistent with self-efficacy are promoted.

Approaching painful movement in this manner gives us a means to interact with our patients

in a way that preserves their autonomy and therefore fosters self-efficacy. In the course of the experimentation, they guide the movement, they come to any changes of their own accord, and so the change is truly theirs. I’ve told students for years that it is always best if the patient feet that the change was their idea. They have ownership of it and it will have more meaning for them.

I look forward to presenting this approach in more detail along with some specific examples of how to apply it during the RMTBC conference in April.

(1) Vlaeyen, J. W. S., S. J. Morley, et al. (2012). Pain-Related Fear:Exposure-Based Treatment of Chronic Pain. Seattle, IASP.(2) Blickenstaff, C. (2011) Therapist as ‘contextual architect’. J Man Manip Ther. Nov;19(4):238

Cory Blickentaff, PT, MS, OCS


Photo: istock

MT2016



Buying an IASTM instrument is like buying a new car – research must be done! You have to “test drive” these instruments to determine which one fits your treatment approach, your hand size, and your budget. It has to be practical, affordable, and effective.

With the largest known IASTM instrument collection in the world, we have definitely “test driven” enough tools to come up with these rules from choosing the right IASTM instrument for you.

Simple and quick overview of the basics of choosing the right Instrument Assisted Soft Tissue Mobilization (IASTM) tool for you

Rule #1: Ensure the instrument is suitable for the type of IASTM you want to perform

Every IASTM instrument is designed differently and every design dictates the efficacy of your treatment protocol.

Choosing the right design is like choosing whether you want a sports car or a mini van. There’s no right or wrong, it all depends on what you need it for – zipping around the country side at 100 km/h or packing up soccer balls and the kids to drive them to soccer practise.

Rule #2: ‘All-in-one instruments’ can work for you

All-in-one tools are best suited for soft tissue mobilization/neurological stimulation.

Generally, more organic shapes tend to better fit body parts and offer a larger number of treatment edges.

However, it is important to ensure you have safe and effective biomechanics during your treatment application.

Rule #3: Watch out for cheap materials

Plastics, Jade, Ivory, “training tools” all fall under the category of cheap materials.

Nikita Vizniak, DC

Photo: Nikita Vizniak,

MT2016



Although they can still give some result, they cannot provide the efficacy that a precision-made stainless steel instrument can provide. This is because the materials cannot provide the same feedback, durability and consistency of application.

Rule #4: Treatment edges count! Not all stainless steel IASTM instruments are made the same

More treatment edges and variability of bevels results in more treatment options.

– Single bevels give better penetration but are generally used in one direction– Double bevels give slightly less penetration but can be used in both directions.

Many of the lower quality instrument sets sold by companies offer one or two treatment edges per tool; this greatly limits the usefulness of the instrument. More edges and variability give you more options for different regions & different sized patients. Some instruments are less than ~10% efficient based on this measure.

Vizniak cont...

Photo: Nikita Vizniak..

Vizniak cont...


Rule #5: There’s no guarantee that your hands will be saved when using IASTM instruments

Choose instruments that are designed for your hands, are ambidextrous in nature (right & left usability), and give better treatment options. There are a lot of companies that sell IASTM instruments and they all state that their products help save your hands. Unfortunately, this isn’t necessarily true.

To truly save your hands, choose techniques and instruments that have been ergonomically designed and can be used either right or left handed (i.e. have not neglected the importance of your hands). The most important instrument in your practice is YOU!

Break-out Speakers, cont... MT2016

All photos: Nikita Vizniak

Vizniak cont...


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5 Things NOT to Do... When You Are the Subject of a Complaint to the College

As members of a self-regulating profession, RMTs are privileged to administer their own professional regulatory process, just as with all professions regulated under the BC Health Professions Act. The legislation makes it clear, however, that the primary role of the College is to protect the public, not to protect you. The College protects the public – your Association protects you. This is an important distinction that you need to be aware of in all of your dealings with the College. They are not your regulatory friend, and nor should they be. The College has a number of roles to fulfill, but their most important is to ensure that Massage Therapy services are provided to the public by only those qualified to do so and only in a manner that puts the interests of the patient first. We are all health care consumers at one time or another in our lives and we would not want it any other way.

This relationship has a number of ramifications for you as a member of the College. Arguably one of the most important, however, is the fact that they have the ability to affect if and how you

practise massage therapy if you become the subject of a complaint to the College. One of the most stressful situations you are likely to find yourself in is when someone makes a complaint against you in your professional capacity. You may be one of the lucky ones and never become the subject of a complaint during your professional working life. If, however, you are not one of those, there are a number of things you should NOT do once you get the letter from the College advising you that a complaint has been made against you.

1. Do NOT attempt to contact the complainant. In my practice I have acted for a number of health care professionals who, upon receipt of the letter from the College advising that they are the subject of a complaint, have decided that the best thing they could do to contact the complainant. Their belief is that it was all a misunderstanding and that by contacting the complainant they could work things out. Do not do that. A complainant is very unlikely to want to speak or otherwise communicate with you once they have decided to make a complaint. In fact, you are likely the last person they wish to speak with. Contacting them will only make it worse. They will not likely even respond to you but you can be sure they will advise the College that you have attempted to contact them. This admonition also applies to anyone you believe to be a witness with respect to the complaint. Do not contact

them before speaking with a lawyer.

2. Do NOT contact the College without first speaking with a lawyer. You may believe the complaint that has been made against you is relatively minor. You may even be correct in your assessment. You may believe that by contacting the College you can work it all out, as it was just a misunderstanding. That is very unlikely. Contacting the College will result in the College taking notes about what you tell them. Those notes will form part of any investigation record they may create. Remember – they are not your friend in this process, and nor should they be. Do not make the mistake of believing this process is an informal one that can be resolved with a phone call or two. That is very unlikely to be the case. As a member of the RMTBC you have access to complimentary legal advice in certain situations, and a complaint to the College about you is one of those situations. Use this to find out if you need a lawyer or not. You do not need to respond to the College immediately. Neither, of course, should you delay. Once you receive the notice, contact the RMTBC and ask to speak to a lawyer about your situation. You will have a much better understanding of any potential risk that you may face and what your best options are for proceeding to the next step.

Continuies on page 29

Legal Mattersby Scott NicollPanorama Legal LLP. [email protected]

LEGAL & RESEARCH

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3. Do NOT answer questions or provide documents to the College, police, or anyone else about the complaint without first talking to a lawyer. There will never be an instance where you are required to respond to questions from the College or the police without first seeking legal advice. If your complaint has first involved the police, as some do, do not answer their questions or otherwise provide any information without first speaking to a lawyer. This is very important. If the first contact with anyone about the complaint is from the College, the same principle applies. Do not provide any information without first understanding the legal and professional ramifications of you doing so.

4. Do NOT destroy or otherwise alter or amend any documents or communications of any kind that may relate to the subject matter of the complaint. In many instances, the facts involved in the complaint will be determined at least in part from the written record relating to the incident or incidents giving rise to the complaint. It is crucial that you protect any

record of the facts or events relating to the subject matter of the complaint. Do not rely on others (such as clinic owners or colleagues, etc.) to do this for you. Do it yourself and make sure it is stored in a location that you have access to.

5. Do NOT discuss the subject matter or the fact of the complaint with anyone other than your lawyer. This particularly includes anyone you believe may be a witness. This does not, however, include your spouse, as communications between you and your spouse are privileged, as long as you or your spouse do not repeat those communications to others. If the College believes it necessary, they will perform an investigation into the circumstances of the complaint. They will interview the complainant, you, and any witnesses. In my experience the College investigators will ask how others learned about the fact of the complaint and what they were told. The less you say, the better. It avoids any misunderstandings or confusion about the facts or events. It also gives you time to discuss it with your lawyer before you

repeat anything to anyone else.

The process of dealing with a complaint about you to the College is stressful. It is often time-consuming and it is always something you would rather not be burdened with. Once the complaint is made, however, you should try not to do those things that will only make it more difficult and more stressful to deal with. To that end, I hope these points will assist you…should you ever need to refer them.

For more information, please contact Practice Resource Support at the RMTBC or Scott Nicoll directly at Panorama Legal, LLP.

LEGAL & RESEARCH

29RMT MATTERS | VOL 9 ISSUE 1 - rmtbc.ca

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31

Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179- 211. doi:10.1016/0749-5978(91)90020-TBritish Columbia Ministry of Health (BCMOH). (2016, February 11). The British Columbia Patient-Centred

Care Framework. Retrieved from htt://www.health.gov.bc.ca/library/publications/year/2015_a/pt-centred-care- framework.pdfBland, M. D., Sturmoski, A., Whitson, M., Harris, H., Connor, L. T., Fucetola, R., Lang, C. E. (2013). Clinician adherence

to a standardized assessment battery across settings and disciplines in a poststroke rehabilitation population. Archives of Physical Medicine and Rehabilitation, 94(6), 1048. doi:10.1016/j.apmr.2013.02.004Fawcett, A. J. L. (2007). Principles of assessment and outcome measurement for occupational therapists and

physiotherapists: Theory, skills and application (1. Aufl.; 1 ed.). Hoboken, NJ; Chichester, West Sussex, England: John Wiley & Sons.Geyh, S., Cieza, A., Kollerits, B., Grimby, G., Stucki, G., Sahlgrenska akademin, Göteborgs universitet. (2007). Content comparison of health-related quality of life measures used in stroke based on the international classification

of functioning, disability and health (ICF): A systematic review. Quality of Life Research, 16(5), 833-851. doi:10.1007/s11136-007-9174-8Salbach, N. M., Guilcher, S. J. T., & Jaglal, S. B. (2011). Physical therapists’ perceptions and use of standardized

assessments of walking ability post-stroke. Journal of Rehabilitation Medicine, 43(6), 543-549. doi:10.2340/16501977-0820Swinkels, R. A. H. M., van Peppen, R. P. S., Wittink, H., Custers, J. W. H., & Beurskens, A. J. H. M. (2011). Current use

and barriers and facilitators for implementation of standardised measures in physical therapy in the Netherlands. BMC Musculoskeletal Disorders, 12(1), 106-106. doi:10.1186/1471-2474-12-106World Health Organization (WHO). (2016, February 11). International Classification of Functioning, Disability, and

Heatlh. Retrieved from htt://www.who.int/classifications/icf/en/

References from Rob Hemsworth

1. Stecco C, Porzionato A, Macchi V, Tiengo C, Parenti A, Aldegheri R, et al. Histological characteristics of

the deep fascia of the upper limb. Ital J Anat Embryol 2006; 1112: 05-1102. Stecco C, Gagey O, Macchi V, Porzionato A, De Caro R, Aldegheri R, et al. Tendinous muscular

insertions onto the deep fascia of the upper limb. First part: anatomical study. Morphologie 2007; 91292: 29-37 3. Stecco C, Gagey O, Belloni A, Pozzuoli A, Porzionato A, Macchi V, et al. Anatomy of the deep fascia of

the upper limb. Second part: study of innervation. Morphologie 2007; 91292: 38-43 4. Stecco C, Porzionato A, Macchi V, Stecco A, Vigato E, Parenti A, et al. The expansions of the pectoral

girdle muscles onto the brachial fascia: morphological aspects and spatial disposition. Cells Tissues Organs 2008; 1883: 320-329 5. Stecco C, Macchi V, Porzionato A, Morra A, Delmas V, De caro R. The ankle retinacula: morphological

evidence of the proprioceptive role of the fascial system. Cells Tissues Organs 2010; 192(3):200-10. doi: 10.1159/000290225. 6. Pedrelli A, Stecco C, Day JA. Treating patellar tendinopathy with Fascial Manipulation. J Bodyw Mov Ther 2009; 73-80 7. Stecco C. Functional Atlas of the Human Fascial System, 2014, Elesevier

References from Angela Mackenzie

Brody, H. (2000). The Placebo Response. New York, New York. Harper CollinsJonas WB, Crawford C, Colloca L et. al. To what extent are surgery and invasive procedures effective beyond a

placebo response? A systematic review with meta-analysis of randomised, sham controlled trials. BMJ Open. 2015 Dec. 11;5(12):e009655. doi: 10.1136/bmjopen-2015-009655.Fulton, B. (2015) Placebo Effect in Manual Therapy: Improving clinical outcomes. Edinburgh, Handspring Publishing

References from Brian Fulton

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Documents

RMT · Shoulder and Upper Arm, Elbow, Wrist and Hand, Spine, Thorax and Abdomen, Pelvis, Hip and Thigh, Knee and Lower Leg and the Ankle and Foot. Orthopedic Physical Assessment with