Massage Therapy Journal Summer 2024

Summer 2024

JOURNAL

Massage Benefits from Birth to End of Life

The Whole

Life Issue

MASSAGE FOR · Infants · Middle Age Injuries · Palliative Care

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Massage Therapy Journal Vol. 63 No. 2 Contents

FEATURES

14 MASSAGE FOR THE PEDIATRIC AND INFANT POPULATION Recent research continues to build on what we know about how massage can benefit both infants and pediatric clients. By David Malone

22 INJURIES OF MIDDLE AGE: THE SHOULDERS An aging cohort of affluent baby boomers is extending “middle age” indefinitely, and this population is showing up in clinical settings with a set of problems very well suited to massage therapy. By George Russell

30 MASSAGE THERAPY AND STRETCHING TECHNIQUES FOR TECH NECK SYNDROME new CE Learn how massage therapy and stretching protocols can help clients and massage therapists manage symptoms of “tech neck” syndrome. By Jessica Crow

62 THE ROLE OF

MASSAGE THERAPY IN PALLIATIVE CARE What research is telling us about the benefits massage therapy may offer to clients who are facing serious, chronic illness.

Kamil Macniak / Shutterstock.com

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DEPARTMENTS 6

LETTER FROM THE PRESIDENT Career Changes, Career Constants

JOURNAL

Massage Therapy Journal® | Official Publication of the American Massage Therapy Association® Summer 2024 Vol. 63 No. 2 ISSN: 0895-0814 USPS 0010-218 Cover credit: Pixel-Shot / Shutterstock.com / Photo illustration by SPARK Publications Michelle Vallet Publications Manager AMTA BOARD OF DIRECTORS (effective March 1, 2024) Kimberly Kane Santos President Christine Bailor-Goodlander Immediate Past President Cindy E. Farrar President Elect

9

SHAREABLE RESEARCH Massage for Middle-Aged and Older Clients

Jaime Bernardo, Jr. Director Heber J. Blackner Director Donald Goodale Director Rick Greely Director Robert C. Jantsch Director

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

Lisa F. Young / Africa Studio / Shutterstock.com

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

12

ADVOCACY Advocacy 101 for Massage Therapists

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

72

SOOTHE 5 Quick Exercises for Self-Care Between Massage Sessions

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 . ADVE RTISING: 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

Lio putra / Shutterstock.com

76

TOOLS OF THE TRADE 5 Ideas to Keep Your Summer Marketing Efforts Hot

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Medical Massage Certification ARE YOU CERTIFIED YET?

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1 Medical Massage Practitioners™ are the most highly compensated in the industry. 2 the number of hospitals offering massage increased by 1/3 in just two years. source: american Hospital association 3 Your largest competitors (franchises and day spas) generally do not participate in Medical Massage. 4 Medical Massage Practitioners™ are not limited to working in a doctor's office or hospital, but can practice in their own office or even a home based outcall practice. 5 Helping their clients get well with physician prescribed massage therapy is a source of tremendous personal satisfaction for lMts.

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6 • Massage Therapy Journal

Letter from the

President

Career Changes, Career Constants Hola, AMTA Peeps I hope this message finds you well and planning to do something cool with your summer! I am particularly excited about this issue

Now, working with people facing the end of their life took some time for me. It wasn’t until about 10 years ago after facing a significant loss of my own that I got serious and knew the time had come for me to engage with this client demographic. So, I approached a local hospital with an inpatient hospice care facility to inquire about incorporating gentle touch with their patients. Over the next year, we negotiated a contract, and let me tell you that the work I do at the hospice house is incredibly different than the work I do in my office. And while I enjoy working with different populations, I can honestly say that the hospice work is truly a gift. I found myself needing to go further, and in 2020 I completed an End-of-Life Doula course. I can’t begin to tell you how much this learning has enhanced my hospice work. As you can see, my practice has evolved and shifted and changed over the years. But in that evolution are some constants, too. The constancy of the AMTA community. The continual personal growth achieved through continuing education. The continuous growth of the massage profession, advanced by research and the passion of massage therapists like you. Speaking of passion, community and education—I hope to see you all at the 2024 AMTA National Convention, September 12–14 in Tampa, Florida. Register today! Until then, I’m going to grab a blanket, fill a basket with snacks and head to a nearby park for a lovely picnic. It takes ALL of us! Kim

of Massage Therapy Journal because I feel like it encompasses my massage career journey. When I think about when I first started massage to now— all the research that we currently have continually showing the benefits of massage—I’m amazed. Truly, massage has a place throughout our life. Massage Through the Ages One of my very first continuing education courses after graduating from Health Options Institute was pre- and post-natal massage, and I soon found myself working with this client population. Having gone through pregnancy a few times myself, I really felt I could relate and wished that I would have had massage available to me during that time in my life. From there, I enrolled in an infant massage course, and then another one. Then, I was hosting “mommy and me massage” sessions. I found this very rewarding and enjoyed gathering with new mamas and their tiny little babies. I was fascinated how the infants would calm as they received intentional touch. The senior population, too, has always been a constant within my practice. My heart is filled with joy to work with and meet the needs of aging clients. My very first massage client was a young 60-year-old woman. She’s received massage from me almost weekly throughout the years, and we continue our sessions to this day! In our early days of working together, she would tell me after every session: “That was the best massage I ever had!” These days, she assures me: “I don’t think I would be able to get around if I didn’t have my massages.”

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

Fun Fact: National Donut Day is June 3rd. YUM!

Kim Kane Santos AMTA President

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Technique Tuesday DALTON’S Sign up now for articles and technique demonstration videos delivered to your inbox without subscription fees.

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Summer 2024 • 9

Shareable Research

Massage for Middle-Aged and Older Clients For many, middle age is a time when new health conditions can start to appear, whether acute or chronic. From symptoms of menopause to increased stress to skin conditions, aging bodies are sometimes in need of deeper, more frequent care. More recently, the benefits of integrative health care approaches, including massage therapy, are showing themselves to be very effective in helping manage some of the conditions that frequently arise in the middle years of life.

Lisa F. Young / Africa Studio / Shutterstock.com

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

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10 • Massage Therapy Journal

Aromatherapy Massage + Stress and Pruritus in Older Women

Aromatherapy Massage + Menopausal Symptoms Women experience a variety of physical and psychological symptoms around menopause and postmenopause. Researchers wanted to know what effects of aromatherapy massage with peppermint and lemon essential oil would have on menopausal symptoms. The Study. A total of 63 menopausal women were enrolled in this 2023 double-blinded, randomized, placebo-controlled clinical trial. Participants were randomly assigned to one of three groups: Menta peppermint, Citrus lemon or placebo. Essential oils in the aromatherapy therapy massage groups were diluted with 1.5 percent sweet almond oil, and pure sweet almond oil was used in the placebo group. Each participant received a hand and arm massage with the selected oil for 30 minutes twice a week for four weeks. Menopausal symptoms were assessed before and after each session using the Menopause Symptoms Rating Scale. The Results. Researchers found there were statistically significant differences between the essential oil groups and placebo. Overall, the peppermint essential oil was more effective than lemon. Both peppermint and lemon were effective for somatic symptoms, though only lemon oil proved effective for psychological symptoms. “The study found that aromatherapy massage with peppermint and lemon essential oil effectively reduced menopause symptoms,” researchers noted. “Peppermint essential oil was more effective than lemon essential oil in reducing menopausal symptoms.”

A decrease in skin elasticity and thickness that decreases the skin’s ability to retain moisture means pruritus is a common disease among older adults. Researchers asked: What are the effects of aromatherapy massage on pruritus and stress in older women? The Study. This 2023 nonequivalence, pre-post, quasi-experimental study comprised 64 women who were divided between an intervention and control group. By the end, five participants dropped out, leaving 59 to be included in analysis. The aromatherapy massage intervention included a blend of three essential oils: 1 mL of lavender, 0.25 mL of Roman chamomile and 0.25 mL of sandalwood diluted to 1.5 percent with a sweet almond carrier oil. The control group received massage with 0.25 percent sandalwood oil. Outcome measures included the degree, area and frequency of pruritus and its impact on everyday life using the Pruritus Score Scale. Skin hydration was also measured using a moisture-measuring module sensor and skin pH was measured using a Howskin device. The Perceived Stress Scale measured stress. The Results. Researchers found a significant difference between the intervention and control groups regarding both relief of pruritus and stress levels, and no adverse effects were noted. “Aromatherapy massage can be an effective intervention to decrease pruritus and stress in older women,” researchers concluded. “Further studies with larger samples that include men are required to confirm the generalizability of these results.”

References 1. Doner S, Tuzmen H, Duran B, Sunar F. “The effect of aromatherapy massage with lemon and peppermint essential oil on menopausal symptoms: A double-blinded, randomized placebo controlled clinical trial.” Explore (NY). 2023 Sep 13:S1550–8307. 2. Shim MS, Je NJ, Lee DY. “Aromatherapy massage for relief of pruritus and stress in older women.” Altern Ther Health Med. 2023 Mar;29(2):36–41.

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

Advocacy Advancing the Massage Therapy Profession

Advocacy 101 for Massage Therapists

ViDI Studio / shutterstock.com

A MTA is the only nonprofit organization in the country that represents massage therapists. As such, we have a duty and obligation to give back, and one of the most significant ways we can do that is through our government relations and advocacy efforts. Learn more about what advocacy is, as well as why our AMTA Government Relations team does this work on behalf of massage therapists at the federal, state and local levels. What is Advocacy? Advocacy is the act of publicly supporting or recommending a particular cause, issue or policy. Advocacy efforts can include lobbying, organizing campaigns, raising awareness to influence decision makers and public opinion, and supporting issues and legislation to help create positive change. What does the AMTA Government Relations Team do? The AMTA Government Relations team helps influence public policy and legislation that impact the massage therapy profession at the local, state and federal levels. These efforts involve building relationships with policymakers, monitoring legislation and regulatory developments, and advocating for policies that elevate, expand and strengthen the massage profession. What are the Goals of AMTA’s Advocacy and Government Relations Work? Through our award-winning advocacy and government relations 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 in every state to advancing legislation on massage for pain to helping veterans gain better access to massage therapy—AMTA advocates for issues that matter most to massage therapists across the country! How Does This Work Happen? By working with other organizations and associations, AMTA can make the most of our resources and maximize our impact in areas that are beneficial for our members and the massage profession. AMTA meets with key legislators, legislative staff, federal agencies and key stakeholder groups so we can share the latest research, build relationships and better represent the massage therapy profession as the experts in the industry. Forging these connections ensures our public statements to agencies and legislative committees are taken seriously, and our recommendations are considered for inclusion in legislation and regulations related to massage. Where Does this Work Happen? AMTA encourages local, state and federal levels of government, including Services (CMS) and the National Center for Complementary and Integrative Health (NCCIH), to promote the benefits of massage therapy and increase the expansion, acceptance and visibility of it as an important part of health care. government agencies such as the Centers for Medicare and Medicaid

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Summer 2024 • 13

AMTA’s Advocacy Work Wins Awards

We work with the health care community, including medical associations and partner organizations such as the American Medical

Association, U.S. Pain Foundation, Alliance to Advance Comprehensive Integrative Pain Management, and Voices for Non-Opioid Choices, where our goals and interests overlap. AMTA encourages private and public health insurance plans to cover massage therapy as a non pharmacological treatment for managing pain and health conditions. In addition, we encourage medical practitioners and providers to prescribe the use of massage therapy as an effective tool for health and wellness. AMTA educates and engages our

AMTA was recently recognized for our Massage Therapy for Pain Management Integrated Communications and Advocacy campaign with a Hermes Gold Award and an APEX Award of Excellence in 2023.

Visit the QR code to learn more about AMTA’s award-winning advocacy efforts and how you can get involved.

• Massage therapy for pain management (as an alternative to opioid use) is now a recognized supplemental benefit in Medicare Advantage plans. • Massage therapy is now a covered benefit for our nation’s veterans and active duty personnel. • The NCCIH supports the value of massage therapy for both acute and chronic pain, including low back pain, neck and shoulder pain, and side effects associated with certain cancers, as well as HIV/ AIDS and fibromyalgia. • Massage therapy is now endorsed by the American College of Physicians and The Joint Commission. • At the state level, AMTA monitored 145 bills during the 2023 legislative session related to non-pharmacological approaches 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 non-pharmacological approaches, including massage therapy. The significant number of bills and activity indicates we are making great strides in this arena.

members, consumers, and the general public on state and federal legislation and our advocacy efforts, so they

can lend their voices and support for important bills related to advancing the massage therapy profession.

We remain committed to seeking out opportunities for supporting sound research and the creation of standards. Research and standards drive policy

change by providing the necessary evidence and insights to inform decision-making. This helps ensure that policies are well-informed, effective, and address the underlying issues they aim to solve. Why Massage Therapists are an Important Part of Advocacy • As a massage therapist, your voice is important— your experience and expertise can have a powerful impact on lawmakers who rely on subject-matter experts. • Your involvement as a massage therapist can elevate the entire massage community. • Your advocacy grows the awareness and visibility of the massage therapy profession.

In addition, AMTA continues to work to promote responsible and inclusive massage therapy licensing and portability across all 50 states and territories, as well as to protect and support massage therapy schools and students.

The advancements in massage therapy research and standards. • AMTA’s advocacy work helped lead to the

How are AMTA’s Advocacy Efforts Creating Change for Massage Therapists? The expansion, recognition and

introduction of S. 2922, the Advancing Research for Chronic Pain Act. This crucial legislation will fund new research to better understand pain conditions and inform interventions for improving care and reducing associated costs.

ONYXprj / Alexandr III / FeelplusCreator / Voodoodot / shutterstock.com acceptance of massage therapy in the integrative health care community.

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14 • Massage Therapy Journal

Massage for the Pediatric and Infant Population Recent research continues to build on what we know about how massage can benefit both infants and pediatric clients. By David Malone

Dmitry Naumov / shutterstock.com

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Summer 2024 • 15

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16 • Massage Therapy Journal

Y ou know from your own practice that one of the greatest assets of massage therapy is its versatility. Massage research continues to advance the profession by highlighting how massage impacts both the physical and mental well-being of your clients, with several studies suggesting massage can help relieve symptoms of acute and chronic health conditions and alleviate stress and anxiety, for example.

• relaxation • growth and development support • alleviation of gastrointestinal issues and aids in digestion

• emotional well-being support • reduced pain and discomfort

• enhanced sleep quality • improved circulation • strengthens bond between parent and child (parent-led massage) Similar to your adult clients, working with infant and pediatric clients requires you to tailor every session to meet the unique needs of the child, both in the goals of the work you do together and in how you interact with the child. For example, massage therapists should be prepared to accommodate child-specific needs and differences, such as a decreased attention span, and more delicate skin and musculature. “In pediatric massage, the pressure applied is much lighter compared to adults,” Allen explains. “The techniques are gentler and more suited to a child’s delicate skin and developing musculature.” Additionally, the duration of a massage session for a child will typically be shorter. Infants can quickly become bored and overstimulated during a massage, and overstimulation can end up negating many of the benefits a massage may offer younger children, like improved relaxation and sleep. Intake for pediatric clients will also look a little different. Your pediatric clients may have health concerns that are unique to them, so consider adding questions around social and emotional health (being sure to respect scope of practice), as well as ADHD, autism and other sensory processing disorders. Remember, too, that parents should be present throughout the intake and massage session. Not only can the parent provide helpful feedback, but they can also put the child at ease and provide a real sense of security. Pediatric and Infant Massage for Sleep One of the most studied potential benefits of pediatric and infant massage is the potential for

In recent years, more research is showing massage therapy may provide a host of benefits for infant and pediatric clients.

So often, people assume the primary benefits of massage belong to adults. But that isn’t really true. In recent years, more research is showing massage therapy may provide a host of benefits for infant and pediatric clients, too. “Massage therapy for pediatric and infant clients offers significant benefits for various conditions, including sleep issues, autism, eczema, weight gain, anxiety and pain management,” says Tina Allen, LMT, CPMMT, CPMT, CIMT, founder and director, Liddle Kidz Foundation. According to Allen, some of the overarching benefits of pediatric massage include:

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Summer 2024 • 17

Infant Massage for Eczema According to nationaleczema.org, eczema is an inflammatory skin condition that causes dry, itchy skin, rashes, scaly patches, blisters and skin infections. Infants are particularly prone to eczema because their skin barrier is more fragile than adults. According to the Cleveland Clinic, eczema

improved sleep. “Massage therapy can enhance sleep quality in children by promoting relaxation, improving the production of melatonin and reducing the levels of stress hormones,” Allen says. “This effect facilitates deeper and more restful sleep, which is crucial for overall health and development.” One study 1 explored the effects of massage therapy and white noise application on the sleep quality and duration of premature infants. The study was conducted in a randomized controlled experimental design with three groups of premature infants ranging in gestational age from 28 to 37 weeks. The study included 120 premature infants evenly divided among a massage therapy group, a white noise group and a control group. Researchers noted an increase in sleep duration and sleep efficiency for premature infants in the massage group, as well as a decrease in both the number of awakenings and wakefulness after sleep onset scores. Sleep duration also increased for infants in the white noise group, though only by roughly two hours compared to the more than five-hour increase for infants in the massage group. An early systematic review 2 evaluated non-pharmacological interventions for sleep promotion in hospitalized children and adolescents of all ages. The analysis investigated 10 trials comprising a total of 528 participants ages three to 22, eight of which investigated behavioral interventions such as massage therapy, touch therapy and bedtime stories. Results from one of the studies included for analysis found 87 percent of participants felt they slept better following massage, with 92 percent of parents reporting they wanted their child to receive a massage again. Additionally, researchers noted that evidence from some single studies indicated that sleep efficiency may increase and the percentage of nighttime wakefulness may decrease more over a five‐day period following a massage than usual care. “Improved relaxation often leads to better sleep patterns,” Allen confirms. “This is especially important for infants and children, as quality sleep is crucial for healthy development.”

According to the Cleveland Clinic, eczema affects an estimated 15 to 20 percent of infants under the age of two.

affects an estimated 15 to 20 percent of infants under the age of two. Skin irritants and allergens, an immune system reaction and genetics can all trigger infant eczema. A 2023 study 3 explored the influence of mother-performed infant massage (MPIM) on infantile eczema, quality of life, growth and maternal mental state. This randomized controlled trial included 66 full-term infants with eczema who were randomly divided into an eczema control group (EC) and an eczema with MPIM group (EM). Healthy full-term infants were also included in a control group.

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18 • Massage Therapy Journal

The mothers in the EC group received routine care instructions, while the mothers in the EM group received routine care instruction and guidance for providing massage. The control group received no specific instruction. Data were collected at baseline and at the end of 2- and 5-months of intervention. Mothers were assessed for anxiety and depression at the same time intervals. The study found the scores of eczema area severity index and infantile dermatitis quality of life index were significantly lower in the EM group than the EC group. The EM group also had a lower relapse rate in infants with eczema, along with significantly lower scores on the self-rating anxiety scale and self-rating depression scale in the mothers. Additionally, no adverse reactions were reported following MPIM. “MPIM could effectively promote the remission of infantile eczema and reduce its relapse, along with relieving maternal anxiety and depression mood,” researchers noted. Parent-Led Massage: Benefits for Both The benefits of parent-led massage are wide ranging—not just for the child, but also for the parent provider. “There are the usual reasons for parent-led massage, like relieving colic, improving sleep, relieving teething pain, helping the baby process their daily stress, to name a few,” says Barbara Jazzo,

a licensed massage therapist who teaches parents how to provide infant massages to their children. “But I feel the most important reason is for parents to bond with their child. Having a parent’s hands on their baby is a very intimate action.” This intimacy allows parents to begin to relate to their baby’s cues so they learn what conveys discomfort, hunger or tiredness, for example. The main goal of an infant massage is to relax the baby, so Jazzo suggests using long strokes. For some areas of the body, circular strokes may also work. “The difference between infant and older child massage is both the amount of pressure and the number of strokes,” Jazzo explains. “A person may use less pressure with an infant, and perhaps fewer strokes.” Jazzo begins her introductory class on parent led massage by asking participants why they are interested in massage for their child. Having an idea of parents’ goals helps her better understand what parents are hoping to learn. For many parents, pressure is a primary concern. So, Jazzo typically starts by talking about appropriate amounts of pressure when working with children. Too much, as is the top concern for many parents, is not good, but neither is too little. “Too light is tickling and can overstimulate the baby,” Jazzo explains. The first strokes Jazzo teaches focus on the legs and the arms. Massage techniques for the stomach, chest and face might also be covered during the introductory session, as well as what

The benefits of parent-led massage are wide ranging— not just for the child, but also for the parent provider.

Vitalinka / shutterstock.com

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Summer 2024 • 19

kind of oil to use, contraindications and exercises parents can do with their baby. Allen has seen the benefits of parent-led massage first-hand while working with a family whose baby was born with a serious cardiac condition. “Rather than me working directly with the baby, I thought it would be more beneficial if I taught the mother how to perform the massage,” Allen says. “Initially, she was hesitant, worried about the delicate health of her child. I decided my role was to support and guide her.” Allen visited the family’s home three times, helping the mother gain confidence, demonstrating how gentle touch can be safe and beneficial, and emphasizing the importance of a mother’s touch in healing and bonding. On the third visit, Allen noticed a significant change in the mother, who had become more confident and finally began massaging her baby and forming a stronger connection. The baby also seemed to relax and respond positively to the mother’s touch. “Now, at 16, this child is a testament to the power of touch therapy and the bond between a mother and her child,” Allen says. “It seemed evident that the massage therapy, administered lovingly by his mother, had a significant role in his survival and ongoing well-being.” Parent-led Massage: What Does the Science Say? A feasibility study 4 examined the effects of a physical and occupational therapy-led and parent administered massage program aimed at improving parent mental health and infant development in extremely preterm infants. Parents in the study attended weekly hands-on education sessions with a primary therapist while in the hospital, and received bi-weekly support emails for 12 months post-discharge. Researchers measured parent anxiety, depression and massage competence at baseline, upon discharge from the hospital, less than four months post discharge, and then again at 12 months post-discharge. Results showed that the parents met or exceeded all feasibility targets at both baseline and discharge, with parent-rated feasibility and acceptability scores remaining high at all points in time.

References 1. Düken ME, Yayan EH. “The effects of massage therapy and white noise application on premature infants’ sleep.” Explore (NY). 2023 Sep 12:S1550-8307 2. Kudchadkar SR, Berger J, Patel R, Barnes S, Twose C, Walker T, Mitchell R, Song J, Anton B, Punjabi NM. “Non-pharmacological interventions for sleep promotion in hospitalized children.” Cochrane Database Syst Rev . 2022 Jun 15;6. 3. Lin L, Yu L, Zhang S, Liu J, Xiong Y. “The positive effect of mother performed infant massage on infantile eczema and maternal mental state: A randomized controlled trial.” Front Public Health . 2023 Jan 11:10. 4. Geary O, Grealish A, Bright AM. “The effectiveness of mother-led infant massage on symptoms of maternal postnatal depression: A systematic review.” PLoS One . 2023 Dec 13:18. The review comprised eight studies with a total of 521 women with maternal postnatal depression. Researchers noted that all eight studies reported a reduction in postnatal depression in women participating in infant massage. In addition, women who used infant massage achieved improved mother-infant interactions and improved self-efficacy. Mother-led Infant Massage for Postpartum Depression Postpartum depression, according to the Mayo Clinic, is a condition new moms experience that commonly includes severe mood swings, crying spells, severe anxiety, difficulty bonding with their baby, loss of appetite, anger, thoughts of suicide and difficulty sleeping. Untreated, postpartum depression can last from three to six months or longer. According to Postpartumdepression.org, about one in 10 women will experience the condition, with some studies reporting the incidence as frequent as one in 7. Of the women who experience postpartum depression, nearly 50 percent go undiagnosed by their health care provider. Additionally, younger mothers (aged 25 or younger) are 7 percent more likely to develop postpartum depression than all other age groups. While there are numerous treatment options for postpartum depression, a recent systematic review 4 explored the effectiveness of mother-led infant massage on symptoms of maternal postnatal depression.

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22 • Massage Therapy Journal

The Shoulders INJURIES OF MIDDLE AGE

Andrey_Popov / Ground Picture / lialeonteva / shutterstock.com

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Summer 2024 • 23

An aging cohort of affluent baby boomers is extending “middle age” indefinitely, and this population is showing up in clinical settings with a set of problems very well suited to massage therapy.

By George Russell

A mong the dilemmas of middle age is the balance between accepting limitation and soldiering on aggressively—the latter, at least in part, being a manifestation At the musculoskeletal level, a cardinal issue contributing to middle-aged injuries is that fascia shrink-wraps to match a person’s habits. The body lays down scaffolding, in the form of fascia, to match long-held patterns of movement and posture. In this sense, fascia is your history—like the fibrous rings of a tree—but it’s also your destiny because tightly woven fascia makes forming new habits difficult. Most of the problems people present with in middle age have to do with a loss of the subtle gliding movement that maintains proper joint position and mobility. Frozen shoulder, of many Americans’, and especially the baby boomers’, obsession with “more.”

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24 • Massage Therapy Journal

effects of this change. One of the many fabulous things about estrogen is that it keeps our tissues hydrated and supple. Frozen shoulder is an extreme example of this challenge, appearing most often in peri- and post-menopause. Here, we’ll focus on the shoulders, and, in particular, the roll-and-glide mechanics of a ball and socket joint, as well as the impact of scapular mobility and placement on issues in the shoulder.

Pepermpron / shutterstock.com

Roll and Glide: Movement Basics The hips and shoulders are ball and socket joints. Think of them being shaped like a mortar and pestle. When you lift your arm, your humeral head rolls up toward the edge of the socket. But unless it also glides back toward the center of the joint, the humeral head ends up pressing against the front structures of the shoulder, and this area is where almost all injuries of the shoulder begin. Reminder: Whichever way the end of the bone (the elbow) moves, the humeral head must glide in an equal and opposite way to maintain a healthy joint. For example, elbow up, humeral head down. Problems in the shoulder or hip almost always involve disruption of the glide function. So, what muscles create the gliding action? The internal and external rotators. In the shoulder, that’s the rotator cuff. That’s why almost all shoulder problems involve trigger points, functional weakness and mechanical disadvantage of the rotator cuff. I’ve always thought that the rotator cuff should be renamed the “stability cuff.”

Photo by Mark Hanson

You don’t need me to tell you that massaging the shoulder muscles—from the biceps to the spine—helps immensely with any shoulder problem. ... As a massage therapist, you are already working on all of this.

labral tears, supraspinatus fraying and rupture, acromial impingement, bursitis, arthritis—these are all injuries that have separate features, but what they have in common is a loss of glide in the shoulder joint and the resultant limitations to healthy movement. Additionally, the fascia dehydrates and becomes stiffer as we age. Its capacity to absorb stress decreases and the cells that rebuild injured tissue become fewer. If you’ve gone through menopause—and all of the problems of middle age it can cause—you probably experienced the

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Summer 2024 • 25

Hips, Shoulders and the Symptom Cascade

shoulder problem. Remember that the arms are like wings. The shoulder muscle attaches to the skull, C1 through T12, and because the latissimus dorsi’s tendon is the tough, diamond-shaped thoracolumbar fascia, you could even say that each arm starts at the opposite iliac crest. As a massage therapist, you are already working on all of this, of course, but awareness, intention and sequencing are important and change how the client takes in your work. The fundamental issue is posture-based joint stress. Restrictions in shoulder movement generally start with limitations in gliding, a small but crucial movement. Joint limitation cannot be fixed by pushing the arm at end range. If you can restore glide—then release fascial restriction and tension in overworked muscles—your client’s healthy range of motion, and your success rate, will increase dramatically. Fascial techniques are immensely helpful. In truth, though, fascia and muscle are often intertwined. Fascia surrounds each muscle and also surrounds all the individual structures of muscles, even into the muscle cells themselves, which have a cytoskeleton, or fibers that separate and connect the parts of the cell.

In a way, humans are like dogs standing on their hind legs. When our simian ancestors stood up on two legs, the hips and the shoulders evolved in very different ways. We have traded stability for mobility in both sets of joints, but most of all in the shoulder. The shoulder adapted to maximize range of motion and dexterity, and the hip for stability with motion. Both joints switched orientation by 90 degrees. The benefits of being able to stand on two legs and to move our arms around are obvious. But most hip and shoulder problems also stem from our evolution. Gravity tends to take the hips forward in space, which may include an overarched low back. In less flexible people, that tends to be accompanied by hamstring shortness. In people with more flexibility, psoas spasm. An overarched lower back position pushes the femoral head forward against the front of the acetabulum, labrum and front capsule and ligaments, which can lead to groin pain, limited range of motion and psoas spasm. Ultimately there could be a labral tear, arthritis and complications to the low back and sacroiliac joint regions. What about the shoulder? These postural asymmetries put stresses on the shoulders by destabilizing and displacing them. Think about it this way: Forward shifted and/ or forward-tilting hips lead to a backward tilting ribcage. The chest ends up collapsed and the neck compressed with the head forward. Gravity then draws the humeral heads forward. The symptom cascade for shoulders is quite similar to the hips: labral and biceps tendon damage, limited motion, rotator cuff strain, and pain and/or arthritis. The Benefits of Massage for Shoulder Problems You don’t need me to tell you that massaging By the time many people reach middle age, they’ve been in this type of position for a long time.

Fascia surrounds each muscle and also surrounds all the individual structures of muscles, even into the muscle cells themselves, which have a cytoskeleton, or fibers that separate and connect the parts of the cell.

Muscle Fiber

Myofibril

Muscle

Actin

Fascia

Blood Vessels

the shoulder muscles—from the biceps to the spine—helps immensely with any

Sarcomere

Myosins

Designua / shutterstock.com

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26 • Massage Therapy Journal

Supine Position

Massage Protocols for Restoring Glide to the Shoulder Joint Here are two ways to mobilize the shoulder, working with the client in a supine position: With the client’s arm on the table : 1. Find their humeral head, just beyond the tip of the acromion. If you come in with the palms of your hands from the side, you can be sure you’re on the humerus and not on the acromion or collarbone. 2. Test the gliding micromovement of the shoulder by springing down just a bit. This is a very small movement. If you do both sides at once, you’re more likely to feel where there is more or less movement. 3. Start by pressing straight down toward the table, then make your way around to the top of the joint, stopping frequently to push the humerus toward the center of the joint. The shoulder is almost never restricted except in the quarter of the circle between A-P and S-I. 4. Once you’ve found the spot that feels most restricted to you, continue to spring down gently, as you would with those cabinets that you have to push slightly shut to open. Use low pressure and repeat until you feel some play come into the shoulder. With the client’s arm at 90 degrees: 1. Lift the supine client’s arm until it’s perpendicular to the table. 2. Interlace your fingers around the top of the humerus and very gently draw the humerus away from the midline of the body. 3. Repeat that gesture several times while

moving slowly a quarter of the way around the circle of the humeral head until you are drawing the top of the humerus toward the client’s foot. How to Work the Muscles Around the Joint Once the joint’s gliding motion is improved as much as possible, work on the muscles around the joint. Whenever you work on muscles, you are also working on fascia, which is the gristle of the muscle between the skin and the muscle, around the muscle and marbled through the muscle. The rotator cuff may be a good place to start, especially since it’s what generates the necessary glide in the shoulder to maintain proper mechanics and relieve the symptoms of almost all shoulder dysfunction. From the rotator cuff, move to the deltoid muscle, which crosses close to the joint so may yield pain upon palpation. That pain is usually coming from the joint itself rather than from the deltoid. By the same token, working the deltoid allows you to affect the joint directly, which may help greatly. Now, work the scapular stabilizers from the skull to the bottom of the ribcage. Don’t forget serratus anterior, which is well accessed in a side lying position. In slim/flexible clients, you can get all the way up to rib one or two going through the armpit and moving medially along the rib with the client in side-lying. The fibers run directly along the ribs as opposed to the intercostals, which run in between the ribs and do not move the shoulder. The upper trapezius and levator tend to be very tense compensators when there are shoulder

Photos courtesy of Mark Hanson, Wellness Stock Shop

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Summer 2024 • 27

Quick reminder protocol to balance the muscles around the shoulder: 1. Start with the rotator cuff. This group of muscles generates the glide in the shoulder that is necessary to maintain proper mechanics.

problems because when you can’t lift your arm you compensate by lifting your shoulder blade to get your arm over your head. But in my experience, the upper trapezius is not usually a direct cause of problems in the glenohumeral joint. Pectoralis minor can get tense from poor posture, when the chest is caved in and arm placement is in front instead of to the side. Releasing this muscle will bring the shoulders more onto the back than the front, which is crucial for shoulder health. Pectoralis major crosses the front of the shoulder and can be tight in people with hypermobile shoulders, especially because this muscle provides some support across the front of the joint (remember that when the shoulder loses its glide, it’s almost always somewhere in the quarter circle between S-I and L-M). On the other hand, a humerus stuck forward mimics tight pectorals major, so if you see the upper humerus forward, you will make faster progress if you release the humerus back and down. The latissimus dorsi are the back of the armpit. Below the armpit, they angle sharply in toward the bottom of the thoracic spine and the thoracolumbar fascia. Make sure you release them all the way down. This work is easily done in side-lying position, where you can put the heel of your hand on the low outside of the muscle and push its mass toward the thoracolumbar spine. Working the Scapula The shoulder blade moves in many directions, but it’s important to understand that early anatomists, working on a static, dead body, applied the x/y/z axis of science when describing scapular motion instead of looking at the main movements of the scapula in real life. Elevation and depression do occur in the scapulothoracic articulation, but they’re not the main motions by any means. The common real-life movements are upward and downward rotation (when lifting and lowering the arm), and protraction/retraction (when reaching forward and when drawing the arm back to stabilize it, like when you lift).

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2. Move to the deltoids. Palpation may yield pain, as this muscle crosses close to the joint.

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3. Then, work the scapular stabilizers from the skull to the bottom of the ribcage, including pectorals minor and serratus anterior. 4. Finish with the pectorals and latissimus dorsi , double checking that the lat, pectorals and trapezius are balanced with each other.

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VectorMine / shutterstock.com

Elevation, depression and anterior tilt (the “transom-window” action of the pectoralis minor) don’t occur frequently in concerted motion, although they do help stabilize and add detail to complex movements, as well as being involved in compensations to poor posture lower in the body and problems with the glenohumoral (true shoulder) joint. Mobilizing the scapula is something almost all massage therapists do brilliantly. Make sure, though, that you include upward and downward rotation in your sequence, spinning the scapula in both directions as if it were a wheel. Retraining the scapula is essential for proper humeral placement, since it is the socket, and retraining the ribs and spine may also be necessary since they support and tether the scapula. In most shoulder injuries, the hips are not seated properly and lead to a lack of support for the shoulder, forcing the muscles to work at bad angles. Massage therapists can help clients effectively manage shoulder injuries that commonly occur in middle age.

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