free CPD/CE directly to your inbox every week.
In this week’s Knowledge Nibble we discuss why massage must be followed by movement.
If you would like to read the transcript for this post then please click on the reference below.
We are going to think about why massage must be followed by movement. First of all, let’s have a think about what we are trying to achieve with massage and range of movement. So when we go along and we first initially have a session with a patient or whether it’s something that we are doing on an ongoing basis or whether these may be weekly sessions or they might even be as distant as six monthly sessions, let’s just have a little think about what we are trying to achieve in those sessions when we are hands on with the patient.
There are lots of things that we could be saying that we want to try and do, and I’ve not made any secret of the fact that there is quite an argument in the literature and in the human world about what manual therapists actually do and what their value is. But all of that aside, there is definitely this element that we consider and I believe this is one of the most important elements, and how we use massage and range of movement in rehab. This is the element that I believe is the main benefit of massage or any hands-on technique.
The fact is that when we have the patient with us and we have our hands on them, we have the capacity to reduce their pain and we can quite significantly within a session reduce pain. For those of you that have any sort of neck pain, muscle pain or compensatory pain, you know how painful it is when you have muscle problems or compensatory problems. Anybody that has any sort of ongoing neck problem or back problem, you know how that feels. It’s very, very, very debilitating. With our hands-on treatments, we have the capacity within that session to massively reduce that. And then what we need to do is use that window of opportunity to then promote some more movement – that is really what I’m discussing today. How and why we need to follow that up. That hands-on treatment – why we need to follow that up with movement if we want to get the best out of it.
We are going to reduce pain and that is with the pain gate theory. If you bang your leg or hit your toe, the first thing you want to do is rub it. That is one of the reasons why that is the case because when you rub it, you can override that painful stimulus. You can actually (in layman’s terms) feel the rub, which is a nice feeling and a comforting feeling and you feel that rather than you feel the pain. That is one of the ways in which massage and any sort of hands-on treatment can reduce that pain through the pain gate theory. If you don’t know that much about the pain gate theory, conduct research on it just so that you understand how we are trying to affect that with any hands-on treatments that we give.
When we reduce pain, we can reduce tone. A lot of the discomfort will come from muscles being in spasm and being in high tone, and that will also reduce range of movement. If a muscle is shortened and it’s hypertonic, the range of movement will be reduced and it’s a bit of a downward spiral. You don’t move very much and you have got more pain and then you get more tone, so we want to try and break that cycle. So if we can reduce the pain, we can reduce that feedback and we can reduce the tone in that muscle, which is really quite a significant outcome of massage. Therefore, we can increase the range of movement. If we would use that tone and effectively allow that muscle to lengthen, we can increase the range of movement and that is why you can see quite dramatic changes in an animal. If you have an animal come in and it’s very stiff and it has a very reduced range of movement and then you treat them, they walk away much better, much straighter and with much longer stride length. And it’s like, wow, that’s really impressive and that is great. If I can do that as a therapist then I’m happy.
What we need to think about is how we can have more carry over from our treatment and how we can actually use that to benefit them long term. That increase in range of movement and then we are going to increase confidence so the animal is going to feel better. You are going to put your hands on and you are going to take away the pain or you are going to reduce it massively.
You are then going to be able to increase the range of movement and increase confidence because you are going to move those joints, limbs and spine into positions where they haven’t been moved into for a long time. The animal is then going to feel more confident about that. It’s going to think ‘yes, I can do that and it actually feels quite nice to sort of mobilise and sort of stretch through there’. Increasing the confidence for the animal in turn is going to increase their wellbeing. So if we go back to a few previous knowledge nibbles where we have discussed pain, fear and pain sensitization, those topics are all linked and related to this. If we can increase their confidence and if we can make them feel better, they are then going to be able to move better and they are going to reduce that hypersensitivity to pain. We can then hopefully move forward in a good direction with this.
We need to use it or lose it, and that is sort of a term that’s thrown about quite a lot, but you really do need to use it or lose it. If you go along and you treat a patient and you increase this range of movement which is really beneficial, and you get them much straighter, moving beautifully, much more comfortable, much more sort of stretched out, but then that’s it. Tomorrow and then next day, nobody does anything with the animal. The benefits of what you have been able to bring about with your treatment will diminish quite quickly over the next few days. What we really need to do is work on increasing that. Once we have got this range of movement, we need to use it. We need to keep using it so that we can keep that movement there and keep all the benefits going for much longer, so that is why it’s really important that we use movement to do that.
We are going to think about two types of movements starting with mobilisation. Mobilisation is the action of making something movable or capable of movement. An animal or a young animal has a huge range of movement and capability of movement, but through pain, changing proprioception, guarding, perhaps overwork or under work, or lots of different things as they start to age, they will start to lose their range of movement in certain joints. This is not always the case, but with animals we are working with, they will have lost range of movement and that’s through various reasons. That is something that we need to tackle.
When we think about mobilisations, we can think about three different types of mobilizations. I use the word mobilisation. I’m not saying ‘stretching’ or ‘gliding’ and different terms that you can use. All I want to think about is the big term here which is mobilisation, which is all about making something able to move again. We use that as a broad term. There are a lot of different techniques within this, but just your general techniques or your general ways we can think about mobilisation. First of all, if we look at this dog over here on the right-hand side, this is a passive range of movement that I’m doing here with the joint. There is no input from the animal. I’m just moving the joint through a range of movement and that is a passive range of movement.
Moving onto active assisted range of movement or system active range of movement. This horse on the left-hand side is showing an active assisted range of movement. I am using a bait (carrot) here to ask this animal to move into particular movements. This is very valuable because they just stop using a certain range of movement and they stop using certain actions because previously it has brought about pain, or again, they have lost some proprioception there.
He just was not using this range of movement. So we soften them and we make them feel better and then we say ‘Come here, you can come here. Now you can move this way’ and they think, ‘Oh yeah, I can move that way’. And actually it feels quite nice. So we are using a bait and we are actively assisting them into a position and into a shape that they haven’t done for a while.
This horse is actually on stability pods as well so this was being done for stability exercise as well. It is really interesting that there are these ranges of movements and that they are there but they just are not using them.
It is very important to actively assist them into those shapes. This horse here in the middle is going over a pole and is showing an active range of movement. This is whereby we use some sort of prop like a pole, cavaletti or step or something like that to increase their range of movement. We can use water for this as well for those of you that do hydrotherapy. So this is an active range of movement and that has the added benefit of increase in strength as well.
Finally, we are just going to think about strength. What I am going to discuss is counter-intuitive, but it is a good way to think about this and it is something that I would much prefer people to approach it from this angle. If a muscle is hypertonic (tight and it spasms). We come along and we think ‘Let’s rub that through with some massage and let’s stretch it. Let’s effectively stretch it and lengthened it by pulling it’. That doesn’t really happen and it doesn’t work like that. When a muscle is hypertonic, it is normally normally weak and needs to be strengthened. If a muscle is weak, it will often be higher in tone. Because it’s weak, it’s contracting and it’s trying to be shorter than it is.
For example, let’s think about back muscles. In this case with animals, we are thinking about multifidus which is a deep stabilising muscle. If that muscle is weak or switched off, then there is going to be too much movement there and the brain is going to say ‘Whoa, there is too much movement. The spine isn’t being stabilised. I need to do something about this’. The global muscles will then become very tight and very hypertonic. You can use your massage to rub through and you can stretch those muscles, but unless we switch on the other muscles and unless we switch back on multifidus and we strengthen that, we are not going to be able to allow those other muscles to relax because they are doing the job of that stabiliser muscle. This example is a balance issue. But actually with the muscles themselves, if they are stretched and they are long, they will very often be tight.
Or it is a bit of a chicken and an egg situation. If they are tight because there is an underlying pain problem and they are guarding, through that hypertonic situation, they become weak because they are not functioning as they should. They are not using a full range of movement and they are just becoming weaker and weaker so they become tighter and tighter. So that is a slightly counter-intuitive way to think about it, but we don’t want to be stretching them and just pulling them because they might lengthen slightly as we are pulling it, but it’s not going to maintain that stretch. If we can train those muscles to be stronger, and when they are stronger and they are doing their job properly, then they can actually relax. We want strength and flexibility. We want them to be strong but flexible and we want them to be strong in a full range of movement. We don’t want them to be just strong when they are being very short. We want them strong when they are in a lengthened position as well. The strength of that muscle is very important. In the long term, if you want to reduce tonicity in a muscle, you need to strengthen it and you need to strengthen its antagonist because you need to get this balance right. The only way we can do that is through exercise.
It’s just a different approach and different way to think about it. In summary, what we want to do is we want to reduce pain (I always come back to that source). The first thing we want to do is reduce pain and we want to increase confidence. We then want to mobilise (whether that is manually or through active or both). Once we have increased the confidence and we have reduced the pain, we want to say ‘Let’s move here. Let’s move here. You haven’t done this for a while. Let’s start using this range of movement that you have just lost and forgotten about’. In those positions, we want to start strengthening so that we can continue to reduce tone and reduce pain etc.
Your action this week is to review your current approach to treatment. Are you sending your clients away with movements to do with their animal at home with the aim of maintaining range of movement – the new range of movement that you have just managed to get for them through your hands-on treatment? Are you sending them away with exercises that are going to help to maintain that and to help reduce pain and reduce tone through increase in strength?