Category — Soft Tissue Techniques

In past blogs I have referred to soft tissue therapy as a “dance” between doing something, assessing (assessing tissue quality, movement, mobility, etc), and then doing something else or something different.

This concept has become even more apparent as I have been working with the Anatomy Links thought process over the past few months.  I find myself working on one thing much less as I am constantly moving to check other areas that are part of the “link” that I am trying to treat/affect.  This is in stark contrast to what is taught in massage therapy school where if something feels “tight” or the client says that it is “tender” you just keep working on it until something happens (that elusive something).  Unfortunately, that something doesn’t always happen and you typically find yourself wasting treatment time on one structure or, at worst, irritating things more and getting a negative outcome.

Following the assessment process, I try and key in on areas that I think are important to work on or at least areas that I want to have an affect on.  From there, I put together a plan of attack, thinking about other things that affect those areas (bones, muscles, fascia, skin, nerves, etc).  Those “key” areas serve as a standard for me to check my work against to make sure I am moving in the right direction – Is tissue quality improving? Does the client report less pain/tenderness? Can we get better range of motion?

Rather than beating an area to death.  I make contact with it, work on it for a minute or two, and then start to move on to some of the “links” that interact with it.  Again, I work for a little bit, go back and check the key area, work a little more, move to another link, etc.  This “dance” goes on for the entire treatment period.  In doing this, I find that I have much faster results and positive outcomes.

Instead of just banging away on one area for 20 minutes hoping to make something happen, try and connect the dots to other areas and see what sort of result can be achieved when they are treated.  Or, as Willem says,

If you do not get the answer you are looking for in a short amount of time, rephrase your question and ask again.

Patrick
patrick@optimumsportsperformance.com

When Anatomylinks.com became available I was extremely eager to check it out, as Willem Kramer has been a huge influence on me.  After several months of poking around on the website, here is my review!

Who

Willem Kramer is a Dutch trained physical therapist, licensed massage therapist and Certified Strength and Conditioning Specialist.  For those that don’t know, it is because of Willem that I attended massage school in the first place.  A few years ago Willem was working for the Arizona Diamondbacks as their manual therapist and I happened to be hanging out in the training room watching him work magic on a few players.  I was intrigued by what he was doing and started asking him questions about were I could learn the type of soft tissue therapy he does.  He told me that I should just go to massage therapy school, get a massage license, and then start putting together ideas on how to treat people based on my knowledge of anatomy.  I was sold!  Two weeks later I signed up for massage therapy school.

Hopefully more people will hear about Willem in the future, as he is one of the smartest people I have had the opportunity to speak to and learn from.  His knowledge of anatomy is top notch and the way he applies this knowledge in his manual therapy approach is very unique.  You can hear more from Willem in his interview with Carson Boddicker on the Sports Rehab Expert Podcast.

What

First and foremost, Anatomy links is not the same as Anatomy Trains.  Anatomy Trains is a great product and Tom Myers is someone I have a lot of respect for.  While Anatomy Trains looks at the fascial system Anatomy Links goes beyond that.

The Anatomy Links approach honors the statement “Everything attaches to everything”.  With this in mind, Willem shows us the possible connections for one single structure, which he refers to as an Anatomical Unit.  While most people think in terms of muscles, bones, and joints, Willem challenges us to open up our minds and and consider everything else as well: skin, fascia (superficial and deep), tendons, ligaments, nerves, and blood vessels. 

I am going to be totally honest when I say it is overwhelming to think like this.  I told Willem after the first few weeks of using the site that I felt like a quarterback who’s playbook went from 12 plays to 50 plays overnight.  Willem is honest and says that it takes time to consider all of this.  At his clinic in the Netherlands, Veel Beter Fysiotherapy, clinicians are asked to sign a minimum of a 3 year contract in order to immerse themselves in the system and take the appropriate amount of time to think about all the possible links.

Willem has a number of examples on his website.  Here is one example showing you what the Anatomy Links screen looks like and the information contained in each column:

Most people will watch this video and wonder where to go from here.  I know I did!  This is where the vast number of possibilities start to come into play.  I’ll give a simplified explanation of how I use the information contained in this site by using the above example of the Fibula.

If we determine that the Fibula is something that needs to be treated (perhaps in a situation of ankle sprains, restricted ankle mobility, or problems with the proximal tibiofibular joint) we would type “Fibula” in the search box at the top and get the above page with the column on the far left giving us a detailed anatomy of the structure in question, the Anatomical Unit.  In the middle column we see all the things that make up the structure we are looking at – arteries, bones, deep fascia, joint capsules, ligaments, muscles, and nerves.  In the case of the fibula, there are 51 structures that are part of this anatomical unit.  By selecting one of the tabs in the middle column, the column on the right will give us the structures contained in that specific category.  It is in the right column where we look at the links to the Anatomical Unit (in this case the fibula).  These are the structures that we want to evaluate and if necessary treat in order to get a favorable response in the Anatomical Unit that is determined to be dysfunctional.  Furthermore, rather than limiting ourselves to the right hand column, we can click on each one of the structures in this column making them the new anatomical unit (left column) and creating a new list of connections that need to be evaluated. 

Through this system, we may start at the ankle with the distal tibiofibular joint and end up working all the way up to the lumbar spine when our assessment is comprehensive and honors the links found to be dysfunctional.  The way that we get to the lumbar spine can be through any one of the links that are affecting the anatomical unit – bones, joints, muscles, skin, fascia, nerves, blood vessels, etc.

If this seems overwhelming, don’t worry…it is!  Like I stated earlier, grasping this system in its entirety will not happen overnight.  That being said, you can easily begin to use the system and start considering various links to the Anatomical Unit you are trying to affect/treat and as you get better at putting things together and connecting the dots, more options will open up for you. 

One way to simplify things is through the “settings” tab at the top right of the page, which allows you to control the structures that show up in the middle column.  For example, if you want to start simple and only look at bones and muscles, you can unselect everything else, making only those two structures viewable, and allowing you to build your links from there.

Currently, the Anatomy Links site is complete through the lower extremity.  Willem is working on adding in connections for the upper extremity and torso but I am not certain when this will be complete as it is an enormous task to try and put all this stuff into the system.

Why

I cannot recommend the Anatomy Links system enough as it has opened up my mind to different ideas and strategies when working on clients.  I find myself thinking about people that I work on and looking through the site and considering new connections that I may not have previously considered. 

Many have heard the term Regional Interdependence, which in a nutshell tells us that the pain or dysfunction you are experiencing in one area may be created by or related too dysfunction in a region of the body remote to the location of the current complaint.  Anatomy Links takes this concept to the next level tying together all of the systems of the body, not just the musculoskeletal system.

I highly suggest checking out the Anatomy Links site as Willem has several other tutorials explaining how to use the site besides the one posted here.  The site also has a blog section were Willem occasionally writes ideas and concepts to consider.  Willem’s personal blog also has additional articles that reflect his Anatomy Links thought process.

I hope you take the time to investigate the Anatomy Links site and consider the vast possibilities in your treatment approach.  Hopefully we will hear more from Willem Kramer in the future, as I believe that he has a lot to offer the industry.

Patrick
patrick@optimumsportsperformance.com

“What gets measured, gets managed” was a quote that Jon Torine, Head Strength Coach for the Colts, used during his lecture at the NSCA National Conference to emphasize the importance of using objective testing in the training process.

Basically, if something is important, you need to measure it.  Determine what is important to you – deadlifts, squats, cleans, bench press, movement tests, 10yrd dash, vertical jump, etc.  If you measure it, you will attempt to manage and improve upon it.  If something goes unmeasured, you have less chance of knowing if you are making progress or not.  Making it difficult to sustain a well developed training system.

I thought about this quote today as I rolled into the facility to do some soft tissue work on my first client.  I was thinking to myself how most massage therapists are in a rush to get people on the table and “do work”. 

If we aren’t measuring anything, how do we know if we are being effective?  How do we know that we are getting what we want from our treatment?  Are we only relying on subjective information provided from our clients, “Yes, that feels a little bit better.”  Or are we actually making some improvements in how things work – Do they function better?  Move better? Walk better?  Has joint mobility and end feel improved?  Was there a change in the soft tissue texture and pliability?

“What gets measured, gets managed.”

Take some time out of your treatment session to assess things and see what you can improve on.  If you measure something, it will help you put together a treatment plan and hopefully yield favorable results when the session comes to an end.  Additionally, if the results were less than favorable you at least have somethings to think about for next time and you will be sure not to repeat the same approach.

Don’t think of your soft tissue/massage work as 60min. of just rubbing lotion on people.  Rather, consider it a dance between some manual work, re-test/evaluate, work again, and repeat.  Each time, trying to manage that which has been measured.

Patrick
patrick@optimumsportsperformance.com

A question that I commonly get asked is, “How do I go about choosing a soft tissue therapist to refer my clients to?”

My last two blog articles were on the topic of going about obtaining a massage licensure.  For some people, this may not be an option as they want to focus on being a great trainer or strength coach rather than “serving to many masters”.  This is something I can certainly appreciate, as picking one thing and really trying to own it will always help you more professionally than trying to do everything.  That being said, if you are not planning on doing the soft tissue work yourself, the next best thing is to partner up with a good therapist!

Having a soft tissue therapist in your network can be an incredibly valuable tool, as they can be instrumental in helping your clients enhance mobility, so that you can then go in and fine tune the movements you are trying to develop.  Additionally, the better you educate the therapist on what you do, your goals and philosophy on training, the more they will be inclined to refer their clients to you for training, as they will realize that you can’t have one (soft tissue work) without the other (training).  You really need both to be effective, in my opinion. 

With so much information out there about different techniques (Active Release, Myofascial Release, Rolfing, Neuromuscular Therapy, “Sports Massage”, etc), knowing who to select can be a daunting task.  So, here is a little cheat-cheat of what to look for in a therapist to ensure that you can find a professional that will prove to be a good referral for your clientele.

• Education -  University education is not everything and many therapist that you will encounter may have nothing more than a diploma from a massage college and a professional licensure (always ensure that they have a professional licensure to protect yourself and your clients!).  By education, I mean, what do they read?  What do they study?  Talk shop with the therapist and get a feel for what they know with regard to anatomy and physiology.  I have found a few massage therapists that are more educated on the body than those who hold degrees in chiropractic or physical therapy because their commitment to continuing education has allowed them to surpass those in other fields who have gotten lazy since obtaining their degrees.
• Do they workout? - While they may not be as educated as you on exercise programming (remember that whole bit about owning your craft?) you do want to know if they exercise and train themselves.  Many masssage therapists that I have run into do very little resistance training and stick with things like yoga or pilates, if they do anything at all.  I am not trying to bash on yoga or pilates, but those that are devout followers of these types of exercise typically don’t believe in strength training (of course there are always exceptions to the rule) and usually will not be open to understanding what it is you try and do for your clients in the weightroom.  Talk to the therapist and get a feel for how much they understand training.  You may additionally want to invite them down for an assessment so that they can get a feel for what you do and how your skills will be a good blend with their skills.
• Get a session - Try out a few therapists and see what their treatment is like.  One thing I always like to find out is what happens during the first session, is there an evaluation that takes place?  What is their intake paper work like?  Do they ask you a lot of questions about any pain you have been feeling, any injuries you have sustained or any surgeries you have gone through?  Do they put you through an assessment to determine a treatment plan?  If so, what does that assessment consist of?  You would be amazed at how many therapists just get you on the table and start working!  That would be like having someone show up for a first training session and you just start working them out.  That doesn’t happen (or at least it shouldn’t)!  You need to ask questions, perform some assessments, and get a general feel for what the individual is capable of so that appropriate training progressions are chosen.  During the session, ask a lot of questions.  What are you doing now?  Why are you doing it?  What is the goal of what you are trying to do?  How does this affect my problem?  Asking questions willl help you get a grasp of whether or not the therapist will be someone you can, or should, refer too.  If I am refering my clients out, I want to be able to communicate to the therapist what I am feeling, what I think is going on, and what my training goals are.  They should be able to be an active participant in the conversation and not just go by what I am saying.  I want them to tell me what they found in their evaluation, what they their course of action is going to be, and any recommendations they have for me regarding exercise progressions based on what they feel or how the client responds to treatment.  Basically, I need the conversation to be a two way street, where we can talk shop and discuss the client to ensure that the best possible outcome is achieved.  Another good option is to ask if you can attend one of your clients sessions so that you can see how they work and what takes place during treatment.
• What is in their tool box and do they know when to use the hammer or the wrench? - I know that things like ART are all the rage right now, but honestly, it doesn’t really matter what letters are after their name.  A good knowledgeable therapist will always be a good knowledgeable therapists, and treatment techniques should be dicated based on what the client needs at the time and not what was learned in this past weekends continuing education course.  Therapists should have a tool box of options and know when to use those tools – when ART would be a better choice over some other technique, and vice versa.  This part comes down to how well the therapists has developed their thought process and application of that which they have learned.  I have seen people get really amazing results with incredibly gentle/superficial techniques and I have seen people get amazing results with really agressive techniques.  Techniques are just that, techniques.  They don’t tell you when to do something, they just tell you how to do it.  The later will get you inconsistent results at best (since not everyone will fit into the mold of any one technique), while the former will allow you to choose wisely based on what you feel, what the client reports, and information gained during the assessment process, ultimately leading to better treatment outcomes.
• Crystals, hot stones, and fancy creams and lotions…………RUN!!!! -  There is nothing wrong with spa services and treatments.  However, this is not something that I would consider to be essential for your training/athletic clientele.  While this stuff may feel good and help you to relax, when you need more clinical based treatments in order to enhance movement, decrease pain, or improve function this is not the way to go.  Aside from the fact that these sessions can be extremely expensive, the overall goal of them is to pamper the client, not deliver a therapy session that is specific to the functional needs of the individual.  So, if you find yourself walking into an establishment that turns out to offer more spa oriented treatments, be polite, say hello, slip them your business card and perhaps pick up a gift certificate for your significant other.

Hopefully these ideas will help you in making a worthwhile selection for yourself and your clients.  If anyone has any other ideas that have helped them select a soft tissue therapist feel free to leave them in the comments section!

Patrick
patrick@optimumsportsperformance.com

Sports Rehab Expert Porcast #3 is up and contains a great interview with Physical Therapist Phil Plisky.  Joe Heiler talks about some SFMA specifics and Charlie Weingroff gives us some great information regaring the cervical spine and core function.  Wrapping up the podcast, I speak a little bit about the importance of the skin and some basic skin assessments and treatment options available in your manual therapy sessions.

ENJOY!

Patrick
patrick@optimumsportsperformance.com