Massage Therapy Journal Spring 2024

Spring 2024

JOURNAL

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Massage Therapy Journal Vol. 63 No. 1 Contents

FEATURES

14 MASSAGE FOR SHOULDER AND BACK PAIN

20 THE ROLE OF THE SI JOINT IN HIP AND LOW-BACK PAIN When working with clients managing low-back and hip pain, making sure you assess for sacroiliac joint involvement is important. By George Russell

26 ORTHOPEDIC

62 MASSAGE FOR THE LEGS, KNEES AND FEET Massage therapy for the lower body can help with so much more than just pain.

MASSAGE TECHNIQUES FOR THE LOWER BODY new CE Explore how to perform specific assessments and develop personalized massage session plans that are based on what your clients need. By Rob Kelly

Massage therapy can offer some relief for the millions of people who suffer from back and shoulder pain. By David Malone

Kamil Macniak / Shutterstock.com

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DEPARTMENTS 6

LETTER FROM THE PRESIDENT The Strength Of Community

JOURNAL

Massage Therapy Journal® | Official Publication of the American Massage Therapy Association® Spring 2024 Vol. 63 No. 1

9

CLIENT TEAROUT Massage for Pain Relief, Range of Motion and Edema Post Surgery: What the Research Tells Us

ISSN: 0895-0814 USPS 0010-218 Cover credit: Deemerwha studio / Shutterstock.com

Michelle Vallet Publications Manager AMTA BOARD OF DIRECTORS (effective March 1, 2024) Kimberly Kane Santos President Christine Bailor-Goodlander Immediate Past President

Jaime Bernardo, Jr. Director Heber J. Blackner Director Cindy E. Farrar Director Donald Goodale Director Richard A. Greely Director Robert C. Jantsch Director

Jane Horton Johnson Director Cheryl L. Siniakin, Ph.D. Director Lee Stang Director LaDonna Ward Director

Valerio Pardi / Shutterstock.com

EDITORIAL REVIEW OPERATIONAL COMMITTEE Jacqueline Herbach, LMSW, LMT President, Momentum Massage, Jane Neumann, BS, LMT, NCTMB Private Practice

12

ADVOCACY Advocacy Year in Review

Fitness, & Mind New York City Steve Jurch, MA, ATC, LMT Director of Allied Health Training at the Community College of Baltimore County

AMTA Illinois Chapter Communication Chair

Jessica Libero, LMT, NCTMB Connecticut and New York Licensed Reiki Practitioner Martha Brown Menard, Ph.D., CMT

70 SOOTHE

Refresh Your Relationship to Your Digital Devices: Why A Digital Detox is Good for Your Physical and Mental Health

Publication Management SPARK Publications sparkpublications.com

Project Manager: Jaclyn Yepsen Creative Director: Larry Preslar

Massage Therapy Journal is published quarterly by the American Massage Therapy Association (address below). Periodicals postage paid at Evanston, Illinois, and additional mailing offices. POSTMASTER: Send address changes to Massage Therapy Journal , 500 Davis St., Suite 900, Evanston, IL 60201-4695. SUBSCRIPTIONS: All subscription matters and notice of change of address should be sent to: Massage Therapy Journal Subscriptions, AMTA, 500 Davis St., Suite 900, Evanston, IL 60201-4695 (877-905-2700). Subscription rates: U.S. and Canada, $25 for one year (four issues); $45 for two years (eight issues). Foreign, $70 for one year; $120 for two years; available on a limited basis. Contact AMTA Member Experience, 500 Davis St., Suite 900, Evanston, IL 60201-4695. Phone: 847-864-0123 info@amtamassage.org EDITORIAL COPY: Queries should be sent to Michelle Vallet via email: mtj@amtamassage.org . Visit amtamassage.org/mtj for writer guidelines. Information contained in Massage Therapy Journal does not necessarily reflect the opinions or beliefs of AMTA and/or the staff of Massage Therapy Journal . ADVERTISING: Contact the AMTA sales team at Smithbucklin to learn more about advertising and exhibitor opportunities: (301) 215-6710 Ext.130 or hbrown@smithbucklin.com. Copyright © 2024 American Massage Therapy Association MTJ-024

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76

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6 • Massage Therapy Journal

Letter from the

President

The Strength of Community Hello AMTA Peeps,

I hope as I write my first letter to you in Massage Therapy Journal that you are well and looking forward to Spring! The season of renewal is approaching, and as you settle deeper into the new year, I’m settling into the role of being your 2024–2025 AMTA President. I am humbled and honored to have your trust. We All Rise Spring is always a very active time for AMTA. Our new fiscal year begins March 1. Chapter volunteers are buzzing around as they prepare for elections and local annual meetings. Of course, that’s all in addition to caring for the clients who understand the benefits of massage therapy and keep us busy year-round. When I think back on the start of my career as a massage therapist—like the first day I walked into class at my massage school or the first AMTA event I attended as a massage student—it never feels like it was too long ago. But, then I do the math and realize I’ve been in this profession for 20 years … WOW! That is 20 years of AMTA community. That is 20 years of watching our profession grow alongside our association. I have witnessed firsthand the continual raising up of AMTA and AMTA members over the years. So, as I look toward this upcoming year as your President, here are some words that will help guide me: enlightenment, collaboration, productiveness, inspiration and allyship. AMTA is your association, our association, and the National Board is committed to continuing our mission of lifting up both the entire profession and members. I encourage you all to settle into this upcoming season by renewing your commitment to your practice, your profession and, maybe most importantly, yourself. You are an integral part of this community, a community

that was, is and will continue to be built and reinforced by the passion every AMTA member brings to the massage profession, a profession we know helps people be their best selves. Remember, there is no better place to feel and experience this community than our National Convention. This year, we’ll gather September 12–14 in Tampa, FL. I hope to see and meet some of you there. Or, connect with local massage therapists at one of your Chapter events. In the meantime, I’d like to encourage you to take a few moments as we move through this lively season … a moment to celebrate the positive impact we as an association have on the massage profession. A moment to appreciate one another. And above all, a moment to recognize that you matter! committed to continuing our mission of lifting up both the entire profession and members.” “AMTA is your association, our association, and the National Board is

ENGAGE WITH AMTA AMTA’S local chapters are a great place to start getting involved. Find yours at amtamassage.org/ chapters.

It takes ALL of us! In heartfelt service, Kim

P.S. Here’s a fun fact: On the way to my office, I pass the factory where those little colorful marshmallow Peeps are produced!

Kim Kane Santos AMTA President

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Spring 2024 • 9

Massage for Pain Relief, Range of Motion and Edema Post Surgery: What the Research Tells Us As the nation ages, so will the number of clients you see who need help managing painful joints. The source may be arthritis or injury or postoperative healing, and you might find the role of massage therapy is broadened to include not only pain but other symptoms, like edema and range of motion.

Valerio Pardi / Shutterstock.com

Share this research with clients and colleagues by visiting amtamassage.org/mtj.

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10 • Massage Therapy Journal

Massage After Knee Arthroplasty Researchers wanted to know how manual lymphatic drainage and Kinesio Taping might benefit lower extremity edema and pain, and improve function for patients undergoing total knee arthroplasty. Controlling some of these early symptoms can be critical for long term outcomes. The Study. Participants included 45 female patients with unilateral total knee arthroplasty who were assigned to either an additional postoperative manual lymphatic drainage massage with exercises, additional Kinesio Taping session with exercises or exercise only. Each group was comprised of 15 people. Lower limb circumference, range of motion, pain level and knee osteoarthritis score were all compared among the three study groups. The Results. Both the manual lymphatic drainage and Kinesio Taping groups had reduced edema and lower pain levels when compared to the exercise only group on postoperative day four, and these results continued until two weeks postoperatively but diminished by week six. “Additional manual lymphatic drainage or Kinesio Taping applications to standard exercises were both effective on early-stage lower extremity edema and pain levels,” researchers noted. “Clinicians might implement one of these applications to the standard rehabilitation programs to control pain and edema following total knee arthroplasty.”

Massage After Laparoscopic Surgery After laparoscopic surgery, shoulder pain is common. Researchers focused on how massage therapy and transcutaneous electrical nerve stimulation (TENS) may benefit routine treatment and increase pain relief. The Study. Participants included 138 patients who underwent laparoscopic cholecystectomy who were randomly divided into three groups: massage plus conventional pharmacological treatment, TENS and conventional pharmacological treatment, and conventional pharmacological treatment. Both massage and TENS were performed three consecutive times after patients regained consciousness in the inpatient wards, and intensity of shoulder pain was evaluated using a visual analog scale before and after each 20-minute treatment. The Results. For all three measured times, both massage and TENS showed a significant reduction in shoulder pain intensity when compared to the control group. “This study’s findings suggest that massage and TENS techniques could reduce post-laparoscopic shoulder pain,” researchers add.

References 1. Guney-Deniz H, Kinikli G, Aylar S, Sevinç C, Canlar A, Yüksel I. “Manual lymphatic drainage and Kinesin Taping applications reduce early-stage lower extremity edema and pain following total knee arthroplasty.” Physiother Theory Pract. 2023 Aug 3;39(8):1582–1590. 2. Mottahedi M, Shamsi M, Babani S, Goli S, Rizevandi P. “Comparing the effect of transcutaneous electrical nerve stimulation and massage therapy on post laparoscopic shoulder pain: a randomized clinical trial.” BMC Musculoskelet Disord. 2023 Sep 28;24(1):764.

WANT MORE INFORMATION? For more information on some of the research being done on the benefits of massage therapy, browse the Research section of AMTA’s website at amtamassage.org/research.

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12 • Massage Therapy Journal

Advocate Advancing the Massage Therapy Profession Advocacy

Year in Review

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A MTA advocates for issues that matter to massage therapists across the country at the federal, state and local levels of government. Through our advocacy work, we strive to enhance the reputation and acceptance of massage therapy and the crucial role of professional massage therapists in health and wellness. From championing massage licensure to advancing legislation on massage for pain, and helping veterans gain better access to massage— here are just a few of AMTA’s important efforts on behalf of the massage therapy profession in 2023! therapists in all 50 states across the country. Legal recognition of massage therapy and clearly defined requirements will help advance the profession as well as protect the health and safety of massage consumers. Kansas and Minnesota, two of the remaining unlicensed states, continued to be a top priority for AMTA in 2023. • AMTA advocated in Kansas for the passage of Senate Bill 305, which would establish a massage therapy board under the healing arts in the state. This bill includes language that would allow all current massage therapists to easily obtain a state license. Unfortunately, the bill ran out of time during a very busy legislative AMTA Continues to Champion Massage Licensure in All 50 States AMTA is committed to helping champion licensure for massage

Check out AMTA’s 2023 top advocacy efforts on behalf of the massage therapy profession

session. AMTA continues to work with key leadership in Kansas who support this bill. • AMTA worked with Minnesota on Senate File 967 and House File 973, which were companion bills to establish state licensure for massage therapists as well as Asian bodywork therapists. These bills were held up due to other priorities in the legislature, and were deferred until this year. AMTA continues to make strides on this effort by building our stakeholder support and communicating the value of licensure for massage therapists in the state. AMTA Helps Advance Massage for Pain for pain management. We provided input for bills related to the study of alternative treatments for chronic pain, removing barriers to non-opioid pain management, and requiring insurers to cover alternative treatment options. Two important examples of these pain management bills include: 1. Senate Bill 1272 in Massachusetts would direct the Massachusetts Department of Health to develop and publish an educational pamphlet regarding non-opioid alternatives for the treatment of pain, including non pharmacological therapies. AMTA submitted a letter to the Joint Committee on Mental Management Legislation AMTA monitored 145 bills during the 2023 legislative session related to non-pharmacological approaches

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Spring 2024 • 13

Health, Substance Use and Recovery in support of this legislation. SB 1272 is still active and continues to move through the Senate. 2. New Hampshire House Bill 66 , which was enacted into law in April 2023, helps establish a committee to study non-pharmacological treatment options for patients with chronic pain.

Education (ED) released proposed regulations to establish safeguards to protect students from unaffordable debt or insufficient earnings from career training programs. AMTA submitted comments to the ED on the proposed rules. On October 10, 2023, the ED released its final rule on Financial Value Transparency and Gainful Employment. In addition, on October 31, 2023, ED released landscape within our massage therapy profession, most significantly the elimination of the 150% rule. You can view AMTA’s stance on the 150% rule at amtamassage.org/schools-fundingatrisk. AMTA will closely monitor the implementation of the final rule, while continuing to advocate for massage therapy students and graduates. AMTA Advocates for U.S. Veterans to Gain Better Access to Massage Therapy AMTA was invited to submit a statement on the benefits of massage for military and veteran populations at the Senate Veterans Affairs Committee hearing on the Department of Veterans Affairs research program. In addition, we issued a press release in honor of Veterans Day in November 2023. The press release, featuring the latest research on how massage therapy can help military veterans with chronic pain and mental health issues, reached millions of consumers across the country. AMTA also met with the Veterans Health Administration to support better funding and access to massage therapy for veterans. We continue to collaborate with veteran researchers and work with our members directly on regional issues affecting veterans. AMTA has also been an ongoing member of the stakeholder coalition: Friends of Veterans to help endorse access to complementary and integrative health services for veterans, including massage therapy. its final rule on Financial Responsibility, Administrative Capability, Certification Procedures, Ability To Benefit (ATB). This will have a substantial impact on the educational

AMTA Advocates for the Regulation of Massage Therapy in Utah and Alabama • In Utah, the “Massage Therapy

Practice Amendments,” a sunset review provision, was passed over in the Business and Labor Interim Committee on August 9, 2023. This inaction threatened to deregulate massage therapy in the state. AMTA’s grassroots efforts led to more than 1,300 members, volunteers and concerned citizens sending messages to state legislators, advocating for allowing the Utah Board of Massage Therapy to continue. As a result, the Massage Therapy Practice Act Amendments were unanimously passed out of committee, extending the next sunset date to July of 2034—a huge win for the profession! • In Alabama, HB 192 was introduced as a standard Sunset Legislation for the Alabama Board of Massage Therapy. A board’s sunset puts an end date in the statute, which requires the legislature to review the board for efficacy, necessity and transparency. In a surprising and unprecedented act, HB 192 was amended to reduce licensing and penalty fees, as well as make changes to the original Massage Therapy Practice Act. Despite the Board’s attempts to correct the issues raised in the 2023 Sunset Audit Report, the Committee determined that allowing the current Board of Massage Therapy to terminate in 2024 was the best course of action. AMTA will continue to advocate for the state regulation of massage therapy in Alabama, and will offer input and guidance to the Alabama legislature as they consider language to reconstitute the Board in 2024. AMTA Submits Comments on Department of Education Rules Recently, the U.S. Department of

LEARN MORE Read more about AMTA’s advocacy efforts and how you can get involved at amtamassage.org/ advocacy.

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14 • Massage Therapy Journal

Massage for Shoulder and Back Pain

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Spring 2024 • 15

Massage therapy can offer some relief for the millions of people who suffer from back and shoulder pain. By David Malone B ack and shoulder pain are two of the most common types of pain a massage therapist is likely to see on a daily basis. Back pain is especially common, with some estimates suggesting as many as 80 percent of the population will experience a back problem at some point in their lives, according to the American Chiropractic Association.

Albina Gavrilovic / shutterstock.com

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16 • Massage Therapy Journal

Additionally, the Georgetown University Health Policy Institute suggests roughly 83 million days of work are lost each year due to back pain, making this condition one of the leading causes of work-loss days. Shoulder pain, although less common than back pain, is still one of the most common regional pain syndromes. According to one study 1 , population surveys show that shoulder pain affects between 18 to 26 percent of adults at any point in time. With so many people experiencing upper body pain, massage therapists have a real opportunity to help clients find some real relief.

says Alicia Durrence, owner and massage therapist at Southern Charm Massage.

Understanding the lower, middle and upper back regions can help massage therapists better pinpoint where pain is occurring: 1. The low back includes the lumbar spine (composed of five vertebrae). 2. The middle back, also called the thoracic spine, is made up of 12 vertebrae and provides support for the majority of your body’s weight. 3. The upper back is part of the cervical spine, which includes the neck, and is composed of seven vertebrae. Each area of the back also includes and is surrounded by various structures, including intervertebral discs, the spinal cord, nerves, muscles, tendons and ligaments, according to the Cleveland Clinic. Because each part of the back serves a different function and supports a different part of the body, the cause and source of pain can be vastly different for each area. For example, pain in the upper back and neck may intersect. “There are layers of muscles throughout our neck and back, many of which are involved in the same activities, like bending, lifting and turning,” says Brandilyn Jobe, LMT. “When tense, over-contracted muscles pull on their attachment sites and the surrounding muscles often over-contract as well.” The shoulder is the most flexible joint in the human body, as well as one of the most complex, which means deciphering the source or cause of pain can be tricky. “Shoulder pain is usually a complex puzzle caused by held tension, repetitive motion, or strain/injury due to some form of over-extension or imbalance in the muscles that provide rotation, adduction and abduction, flexion, and extension of the humerus,” says Dede Dancing, LMT, BCTMB. “Sometimes the biceps tendon is part of the puzzle. Sometimes nerves of the brachial plexus are trapped or compressed by tight scalenes, pectoralis minor or by bones being pulled too Svitlana Hulko / shutterstock.com

Common Types and Causes of Back and Shoulder Pain

The causes of back and shoulder pain are as numerous as the people experiencing it. “I see a lot of back pain from sports injuries, degenerative joint disease, car accidents, bulging and herniated discs, falls, pregnancy, and from sitting too much for work,”

The upper back is part of the cervical spine, which includes the neck, and is composed of seven vertebrae.

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Spring 2024 • 17

A Common Shoulder Condition: Osteoarthritis According to the Arthritis Foundation, shoulder osteoarthritis is a degenerative joint disease where cartilage and joint tissue gradually break down. Friction in the joint leads to pain, which slowly reduces mobility and function. Although less common than hip or knee osteoarthritis, it’s estimated that one in three people over the age of 60 are dealing with some degree of shoulder osteoarthritis. There are two types of shoulder osteoarthritis: primary and secondary. Primary shoulder osteoarthritis has no known cause, but is thought to be related to age, genes and sex, as it’s generally seen in people over 50 and women are affected more often than men. Alternatively, secondary shoulder osteoarthritis has a cause, such as previous injury, infection or rotator cuff tears. Common symptoms clients with shoulder osteoarthritis may be trying to manage include pain, reduced range of motion and crepitus.

tightly together with imbalances in one or more of the muscle groups already mentioned.” Overuse is one of the most common sources of shoulder pain. Other sources include post-surgery pain, frozen shoulder, and fascial/scar adhesions around the

shoulder capsule and collarbone. Massage for Back Pain: Updates in Research

The benefits of massage therapy for back pain are well-studied, and results have long shown the promise of massage, especially as alternatives to pharmacological interventions become an important part of combatting the opioid epidemic. In recent years, numerous studies investigating the effects of massage therapy on back pain have continued to build on the existing knowledge base. One such study 2 explored the effect of lumbar myofascial release with electrotherapy on the elastic modulus of lumbar fascia and pain in patients with non-specific low-back pain. The purpose of the study was to compare the effect of lumbar myofascial release and electrotherapy on clinical outcomes of non specific low-back pain and elastic modulus of lumbar myofascial tissue. Low-back pain severity and elastic modulus of the lumbar myofascial tissue were assessed before and after treatment. The study found improvements in the outcome measures, which suggests that lumbar myofascial release may be effective in reducing non-specific low-back pain. “Data suggest that the elastic modulus of lumbar fascia and the severity of low-back pain are directly linked,” researchers noted. “Decreasing the elastic modulus after myofascial release can directly affect reducing low-back pain.” Another study 3 focused on the effect of massage force on relieving non-specific low-back pain. The study enrolled 56 female patients with non-specific low back pain at a single medical center. For each patient, a massage therapist performed a 30-minute (20-minute general

session and 10-minute focal session) massage session using a special instrument with a force sensor inserted. During the 10-minute focal session, the patients were split into two groups, a high force group (≥2 kg) and a low force group (≤1 kg). Pain intensity using the visual analog scale was the primary outcome measured. The study concluded high force massage exerted superior effects on pain relief in female patients with non-specific low-back pain when compared to low force massage. These results align with how some massage therapists we talked with describe the work they do with clients with low-back pain. “The techniques I use—effleurage, petrissage, friction and compression—don’t vary much from client to client, but the pressure, speed and direction of movement do,” Jobe explains. For Jobe, a typical massage session with a client experiencing back pain starts with warming the tissue using Swedish massage, myofascial release or a warm compress and identifying any tension or trigger points. Once areas that may benefit from attention are identified, she moves to massage techniques like petrissage, friction and compression.

DEEPER DIVE For more information on the promise massage therapy is showing in providing pain relief and reducing the need for opioids, see AMTA’s resource “Massage as an Alternative to Opioids,” available at amtamassage.org.

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18 • Massage Therapy Journal

The Pain Problem: The Role of Integrative Therapies

“I gradually increase the pressure, change the direction of my strokes, and add movement until I feel a difference in the muscle tissue,” Jobe adds. After identifying tight spots and trigger points, Durrence will also use deeper pressure and active and passive stretching to release tension. Massage for Shoulder Pain: Updates in Research A January 2022 study 4 sought to determine the effectiveness of proprioceptive neuromuscular facilitation and myofascial release techniques

Both treatment methods were performed three times a week for four weeks. Pain severity was assessed by visual analog scale, range of motion using a goniometer, muscle strength by digital hand dynamometer, quality of life by Nottingham health profile, functionality by arm, shoulder and hand problems questionnaire, and disability by shoulder pain and disability index. The study concluded that the combined application of proprioceptive neuromuscular facilitation and myofascial release had a more acute and cumulative positive effect on all of the measured outcomes. Additionally, myofascial release was found to be more effective in increasing flexion, external and internal rotation range of motion, and flexion and abduction muscle strength after the first session. Another study 5 compared the effects pharmacological treatment alone for shoulder pain after laparoscopic surgery. The intensity of shoulder pain was evaluated using a visual analog scale before and after each 20-minute treatment. Finding ways to deal with chronic pain that don’t require—or at the very least reduce the need for—opioids has been one of the cornerstones in helping people with addiction, as well as preventing addiction. Learn more about what some leading experts are saying about the role of massage therapy in pain management in “Promising Approaches to Pain Relief,” available at amtamassage.org/mtj . of massage therapy in tandem with pharmacological treatment versus

The middle back, also called the

thoracic spine, is made up of 12 vertebrae and provides support for the majority of your body’s weight.

New Africa / shutterstock.com

in patients with subacromial impingement syndrome. The study measured the effectiveness of the interventions in terms of pain, range of motion, muscle strength, quality of life, functionality and disability. The study divided 30 patients into two groups, a proprioceptive neuromuscular facilitation group and a proprioceptive neuromuscular facilitation combined with myofascial release group.

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Spring 2024 • 19

The study’s findings showed a significant reduction in pain, suggesting that massage therapy could help reduce post-laparoscopic shoulder pain. Real Results: Success Stories of Massage Therapy for Pain Relief Back in January of 2018, Durrence had a 38-year-old pediatric occupational therapist client come in with an L1 compression fracture after a fall. The client had a kyphoplasty―a procedure for treating vertebral compression fractures that uses an inflated balloon to restore bone height followed by an injection of bone cement into the vertebral body―performed two months after the fall. Her back was now in complete spasm after being bedridden for weeks and from the strain of the surgery. “I knew that I didn’t want to put direct hard pressure on the area, so in collaboration with the client I came up with some techniques that would release the muscles from one side while having her move the opposite side,” Durrence says. “Five and a half years later, she works full-time with minimal pain while maintaining the results with monthly massage, yoga and some Pilates.” Jobe works with a lot of clients who need help managing back pain during pregnancy. “Many seek my help to alleviate lower back

The low back includes the lumbar spine (composed of five vertebrae).

Atsock Productions / shutterstock.com

pain during pregnancy. The hormonal changes, fluid retention and shifts in their center of gravity often make pregnancy an exceptionally uncomfortable experience,” she says. “Numerous clients have shared that their weekly massages are the only time they find any physical comfort during their pregnancy. Many have also expressed that they only sleep well after their massage sessions.”

References 1. Linaker CH, Walker. “Bone K. Shoulder disorders and occupation.” Best Pract Res Clin Rheumatol. 2015 Jun;29(3):405-23 2. Tamartash H, Bahrpeyma F, Mokhtari Dizaji M. “Comparative effect of lumbar myofascial release with electrotherapy on the elastic modulus of lumbar fascia and pain in patients with non-specific low back pain.” J Bodyw Mov Ther. 2022 Jan;29:174-179. 3. Chen PC, Wei L, Huang CY, Chang FH, Lin YN. “The Effect of Massage Force on Relieving Nonspecific Low Back Pain: A Randomized Controlled Trial.” Int J Environ Res Public Health. 4. Çelik MS, Sönmezer E, Acar M. “Effectiveness of proprioceptive neuromuscular facilitation and myofascial release techniques in patients with subacromial impingement syndrome.” Somatosens Mot Res. 2022 Jun Dec;39(2-4):97-105. 5. Mottahedi M, Shamsi M, Babani SF, Goli S, Rizevandi P. “Comparing the effect of transcutaneous electrical nerve stimulation and massage therapy on post laparoscopic shoulder pain: a randomized clinical trial.” BMC Musculoskelet Disord. 2023 Sep 28;24(1):764.

DEEPER DIVE For more in-depth content on how massage therapy can relieve low-back pain, consider AMTA’s continuing education course “Lower Back Pain and the Role of Massage Therapy,” available at amtamassage.org/learn.

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20 • Massage Therapy Journal

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Spring 2024 • 21

The Role of the SI Joint in Hip and Low-Back Pain When working with clients managing low-back and hip pain, making sure you assess for sacroiliac joint involvement is important. By George Russell

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22 • Massage Therapy Journal

T he hip and the lumbar spine are intimately pain. But there’s another joint in between the two—the sacroiliac joint (SI)—that can play an important part in both dysfunction and helping a client get relief. connected, and I always work on them both when a client has trouble with either hip or low-back

Considering the pelvic region more broadly and thinking of the SI joint as the link between the leg and the spine can give us clarity around both what might be causing a client’s issues as well as how we can bring them some relief. Massage and the SI Joint: Relieving Hip and Low-Back Pain To better understand the role SI joint dysfunction plays in pain, as well as how massage therapy can help reduce symptoms, let’s review some basic structures in the pelvic region and how they function, starting with the ilium. Consider the ilium the scapula of your leg. Like the shoulder blade, the ilium’s main movement is to turn around its own center like a wheel, allowing your leg to rise and fall. In the shoulder, this motion is called the “upward and downward rotation of the shoulder blade.” When talking about the ilium, we refer to this motion as the “flexion and extension of the SI joint.” Flexion occurs when one ilium spins toward a tucked pelvis, helping you lift your knee higher. Extension is when the ilium spins the other way and arches, causing the leg and torso to lock together so a person can balance on one leg. Now, it’s true that the the SI joint doesn’t move much, but its ability and freedom to move are important. If the hip and SI joint aren’t flexing well, which is common in clients with hip and low-back issues, tucking the whole pelvis to get the knee into the air becomes necessary, which puts strain on the low back and can lead to lumbar spine problems. That’s why keeping the hip—and the SI joint—working well is so critical. Amazing, right? So what does that mean for massage therapists? You can help your clients so much by addressing SI joint dysfunction during a massage session. SI joint motion is often discussed as only passive because, with the exception of the pelvic floor muscles, there are no muscles that pass directly from the pelvis to the sacrum. But that’s not really true. The stabilizing pelvic floor and several hip joint

Here, we’ll discuss why considering if a client’s SI joint is involved in their hip or low-back pain is important, as well as strategies massage therapists can use to help their clients improve stability and mobility, as well as relieve pain.

Flexion occurs when one ilium spins toward a tucked pelvis, helping you lift your knee higher. Extension is when the ilium spins the other way and arches, causing the leg and torso to lock together so a person can balance on one leg.

A Broader Perspective: Making the SI Joint Connection Before the 20th century, anatomists assumed that the sacrum and pelvis operated as a single bone. Now we know that the SI joint does indeed move and its dysfunctions create significant problems, not only pain but also alignment. When thinking through how I can help a client experiencing pain related to the SI joint— as well how I can address pain in the whole pelvic region—I like to think of the ilia as the “Mousketeer Ears” of the pelvis and, further, a part of a person’s leg. Think of it this way: I picture the sacrum at the end of the spine as a fishtail and the ilia as the start of the client’s leg, all the way up to the iliac crest and anterior superior iliac spine. You might be wondering: How is that helpful?

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Spring 2024 • 23

TRY IT FOR YOURSELF: Assessing and Releasing the Sacroiliac Joint Try these following techniques with clients you suspect may have issues with their sacroiliac joint (SI). You can easily assess and work on the SI joint in a side-lying position.

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With your hand tucked under the ASIS, release the SI joint by reaching around the client’s pelvis as far as you can and drawing the pelvis over your hand toward you. It will be easier for the client to let go if you bring their pelvis toward your hand than if you push your hand into their pelvis/iliacus.

Facing the client lying on their side with their hips and knees at 90 degrees, tuck your hand or knuckles under the anterior superior iliac spine and you’ll find the iliacus. If the person is overweight or pregnant, they’ll always need iliacus work, and side-lying may be the only way to get to that muscle.

muscles, for example the glutes and piriformis, influence the motion of the sacrum. When they are asymmetrical, the pelvis twists and wreaks havoc on a person’s gait and stability, among other things. But of all the muscles that impact the SI joint, the most influential is the iliacus. Its fibers attach to the inner groin, angle across the fulcrum of the pubic bone, and connect via powerful fibers to the whole inside of the ilium. Stand behind the client’s pelvis. Use your hand on the posterior superior iliac spine, knee or greater trochanter to slide one leg back and forth along the other leg like a piston. The top leg rests along the other the whole time. This maneuver mobilizes both sides at once because the other leg and pelvis are pinned to the table. You’re also automatically mobilizing both sides of the lumbar and thoracic spine and ribcage.

When your torso stays still and you stand on one leg, the iliacus flexes and externally rotates your thigh to create an action similar to if you were to step one leg onto the seat of a chair that’s in front and to the side of you. But when you stand on both legs, a tight iliacus tilts to the same side ilium anteriorly ,

Of all the muscles that impact the SI joint, the most influential is the iliacus . Its fibers attach to the inner groin, angle across the fulcrum of the pubic bone, and connect via powerful fibers to the whole inside of the ilium.

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Spotting Sacroiliac Joint Dysfunction According to Veritas Health’s Spine-health , these are some of the most common symptoms of sacroiliac joint dysfunction. I’ve added some information specific to the work massage therapists do: • Lower back pain in the region of the PSIS or along the edge of the sacrum that feels dull, aching and can range from mild to severe. Typically, lower back pain related to sacroiliac joint dysfunction occurs on one side, but in some cases may be felt on both sides. Remember, the location of the pain isn’t always the location of the problem. For example, if there is fixity in one SI joint, the other side may hurt because it needs to move more to compensate. • Pain that spreads to the hips, buttocks and/or groin. One of the most common areas to feel SI joint pain is in the buttocks and upper back or side of the thigh. Again, pain is typically contained to one side, but may be felt on both sides in some cases. Often, SI-based pain will be more acute during walking, whereas lumbar disc pain will be more acute while sitting. • Sciatic-like pain in the buttocks and/or backs of the thighs that feels hot, sharp and stabbing. Numbness and tingling may also be present, and the symptoms may mirror sciatica, but rarely extend below the knee. • Stiffness and reduced range of motion in the lower back, hips, pelvis and groin that may make movements such as walking up stairs or bending at the waist more difficult. • Worsened pain when added pressure is put on the sacroiliac joint, such as when climbing stairs, running or jogging, and lying or putting weight on one side. • Instability in the pelvis and/or lower back that can cause the pelvis to feel like it will buckle or give way when standing, walking or moving from standing to sitting. arching and locking that side of the low back while leaving the opposite side in a tucked position, which often destabilizes it and can lead to both hip and low-back problems. Releasing the iliacus nearly always helps the SI joint, low back and hips. But there’s more. It’s easy to understand that tense muscles lock joints. But the opposite is also true! If a joint locks up, the muscle has no other option but to shorten when the client gets off the table. When you release the muscle and the joint, the client will stay supple, open and strong. The next time a client complains about low-back pain, think about the SI joint. Your client’s low back and hips will thank you.

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26 • Massage Therapy Journal

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Spring 2024 • 27

AMTA Continuing Education Orthopedic Massage Techniques for the Lower Body Explore how to perform specific assessments and

develop personalized massage session plans that are based on what your clients need. By Rob Kelly

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28 • Massage Therapy Journal

AMTA Continuing Education

What is Orthopedic Massage Therapy? Orthopedics is a branch of medicine that focuses on the diagnosis, treatment and prevention of conditions and injuries that affect the musculoskeletal system. Orthopedic massage therapy (OMT) is therefore a type of massage therapy that involves the use of a variety of techniques to help decrease or manage pain, increase range of motion and encourage the healing process. Massage therapists who wish to offer OMT should be well educated in musculoskeletal anatomy and physiology. For instance, having knowledge of where the joints are, their respective ranges of motion and how they function will be of great importance in helping clients with these conditions. Similarly, understanding where the muscles are located, where their attachment sites are and the movement patterns or actions of each muscle is crucial; this extensive knowledge and understanding of how the body moves and functions is at the core of a well-trained orthopedic massage therapist. In the workplace, these therapists are likely seeing clients who have conditions that include chronic pain, injuries and postural imbalances. As a result, massage therapists who use orthopedic massage techniques with clients will often need to work with other health care professionals, such as chiropractors and physical therapists, who are part of the client’s broad health care team. During an orthopedic massage session, the massage therapist commonly performs an assessment of posture, movement patterns and areas of tension or pain for each client. Specific orthopedic assessments are also used to gain more precise information on a client’s specific condition. Based on the results of the assessments, the therapist will then develop a tailored massage session plan that may include a combination of approaches to address the client’s condition. This course takes a deep look at the anatomy of the joints, muscles and nerves. Based on this knowledge, specific orthopedic assessments can help assess specific conditions to determine if massage therapy can help. The therapist must

then utilize a variety of massage techniques to help with conditions clients may encounter. We will discuss orthopedic conditions and the differential diagnoses later in this course. Massage therapists should not use the differential diagnosis to diagnose their clients. Instead, they should use it to educate themselves on possible diagnoses that their clients may have received from a physician. Joints of the body, also known as articulations, are areas where two or more bones come together. They provide the necessary flexibility and movement required for various activities. Joints are organized based on their structure and the types of movements they allow. The main classifications of joints include: Structural classification organizes joints based on the type of connective tissue that holds the bones together and whether it has a joint cavity present. There are three types: 1. Fibrous Joints: A type of joint where the bones are held together by dense fibrous connective tissue. These joints allow very little to no movement. Examples include sutures in the skull and gomphosis, where the teeth articulate with either the mandible or maxilla. Another example is a syndemosis, a type of immoveable joint where bones are joined by connective tissue, such as the tibiofibular joint. 2. Cartilaginous Joints: As the name implies, these joints are connected by cartilage. These joints allow limited movement. Two subtypes are present in the body: • Synchondroses: These joints are linked by hyaline cartilage. Some examples are the epiphyseal plate in growing bones, the first sternocostal joint and the spheno-occipital synchondrosis. • Symphyses: These joints are connected by fibrocartilage. Some examples are the pubic symphysis, manubriosternal joints and the intervertebral joints. Joints, Movement and Terminology: Structural Classifications of Joints

DISCLAIMER As a reminder, before practicing any new modalities or techniques, check with your state’s massage therapy regulatory authority to ensure they are within the state’s defined scope of practice for massage therapy.

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