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The structural components in the human body include the bones, connective tissue, cartilage, tendons, ligaments, muscles, fat and the various components of the nervous system. Structural integration helps the body shift back into proper structural and functional alignment in two ways: It removes tensions and restrictions in areas that have been held tight, and it balances the myofascial relationships throughout the body. When restricted fascia is released and repositioned, the body returns to its optimal structural position. Orthopedic massage stands apart from dozens of other massage modalities because it is not really a technique. "Orthopedic" refers to the locomotor system as it is used in conventional medicine; that is, the bones, joints, muscles and other connective tissues-those parts of the body that allow us to move.

Power and synergy

I use a multidisciplinary approach to restore structural balance and address soft-tissue dysfunction, pain and injuries. Following a comprehensive assessment, I match the physiology of the tissue injury to a modality that treats that body component.

I value orthopedic massage because I can focus on the structural balance of the entire body-or simply address a specific clinical condition. I like to encourage other practitioners to add these treatments into a spa session or a relaxation massage.

As I've already mentioned, we don't subscribe to one modality to address all conditions. I believe in the synergistic healing power that results from combining multiple modalities. All of my protocols use functional assessment, myofascial release, neuromuscular therapy, scar-tissue mobilization, myoskeletal alignment, joint-capsule release, proprioceptive neuromuscular facilitation (PNF) stretching and strengthening. I have repeatedly seen how the impact of using a multidisciplinary approach is far more powerful than if just one modality is used.

When combined with specific home-care protocols, the use of multiple modalities results in long-lasting or permanent structural integration, enhanced movement, and restoration of pain-free range of motion. I'll talk more about incorporating specific modalities in a future article. But for now, I want to mention that we concentrate on lengthening shortened muscle groups around each joint, strengthening weak muscle groups, and increasing joint space throughout the entire body, thereby eliminating myofascial pain patterns, neuromuscular pain patterns and the skeletal imbalances that result from soft-tissue imbalance.

I encourage other practitioners to integrate as many advanced massage disciplines as possible into each session, and to remain focused on the whole person. Naturally, practitioners should pay attention to any changes in the client's breathing, to emotional guarding, and to the client's pain threshold. What's more, the practitioner should perform this work so that it remains pain-free for the client. I should mention here that orthopedic massage is also incredibly easy on the practitioner's body and easy to perform, compared to the energy it may take to do a series of relaxation massages.

Orthopedic massage incorporates therapeutic assessment tools that are used by other health-care practitioners, such as physical therapists and physicians. By the same token, orthopedic- and sports-massage practitioners need to respect any medical contraindications that arise in the client and be willing to work in tandem with other health-care professionals who are treating the client.

The process illustrated

During the first session, the client provides a clinical history and I do a functional assessment using range-of-motion tests to determine the exact cause or pathology of each musculoskeletal complaint. In this way I am able to match the appropriate bodywork technique to the underlying pathology of each condition.

Let's use a complicated shoulder problem to illustrate this process. I begin by evaluating the degree of flexion, extension, abduction, adduction, horizontal abduction, horizontal adduction, and medial and lateral rotation, to determine which muscle groups are tight. Finally, I assess the client's passive range of motion for what I call the "endfeel" of the above movements.

For example, if the end feel in the shoulder is bone-on-bone-like, in abduction and lateral rotation, when it should be leathery, I begin to think about conditions such as adhesive capsulitis or frozen shoulders, and a technique that facilitates the release in frozen shoulders that involves jointcapsule work. (See Figure 1.)

I assess the client's resisted range of motion to determine if there is muscle strain and exactly which muscle-tendon unit is involved, taking precautions here by testing with minimal resistance and then slowly increasing the resistance to fully recruit the muscle fibers. (See Figure 2.)

Next, I manipulate and move the soft tissues to reduce or eliminate pain and dysfunction, always with the intent of improving the condition that brought the client in to see me. I focus on balancing every muscle group around each joint in the body, which involves lengthening shortened muscles, and then stimulating and strengthening weak opposing muscle groups.

My new treatment for muscle strains does not create additional inflammation or add new scar tissue to the injured area. The initial client-history review and functional assessment are starting points, invariably changing over the course of treatment.

Evaluation is an ongoing process, and as the client changes, I continue to pair the appropriate modality with the exact underlying condition at any given time. Even after making that determination in each session, I remain in the present moment with the client, paying close attention to breathing and any guardedness or apprehension. Sometimes an emotional release may be a part of the healing process, and our presence and caring is critical at that time.

Benefits of orthopedic massage

Clients who benefit from orthopedic massage suffer from musculoskeletal dysfunctions, chronic pain and sports injuries. Examples of upperextremity conditions include severe thoracic-outlet syndrome, frozen-shoulder problems, rotator-cuff injuries, bicipital tendinitis, and shoulderimpingement problems. Orthopedic massage will also relieve carpal-tunnel syndrome, tendinitis, nerve entrapments and progressive joint arthritis, among others.

The majority of my clients are flexed throughout the body, and have shoulders that are in a forward position and that are anteriorly rotated because of trauma, poor posture, or a history of using repetitive movements or positions. Their anterior muscles (pectoralis major, pectoralis minor, and subscapularis) have become tight and contracted, while the opposing muscles (rhomboids, middle trapezius, infaspinatus, and teres minor) have become weak and inhibited. The resulting joint imbalance triggers a neuromuscular response to restore balance, which can create additional tension in the joint.

As the articulating cartilage moves in a tight and unbalanced or restricted joint, progressive joint degeneration-a condition commonly known as joint arthritis-develops. The associated discomfort further limits range of motion, and may lead to a formation of adhesions in the joint capsule itself. The articulating fascia acts as "super glue," literally gluing the scapula to the fascia of the humerus. These fascial adhesions usually accumulate in the inferior and medial shoulder capsule from limited lateral rotation and abduction, creating a condition known as frozen shoulder, or adhesive capsulitis.

However, these deep fascial adhesions can be mobilized by applying heat, pressure, gentle movement and pain-free, slow-velocity stretching, using the head of the humerus to massage the fascia that glues it against the scapula to help facilitate myofascial warming and myofascial release. (See Figure 3.)

This action, in conjunction with pain-free softtissue balancing, releases the frozen shoulder, oftentimes in as little as one session. Although some people in the health-care industry are skeptical about the feasibility of releasing long-term frozen shoulders, orthopedic-massage practitioners have witnessed the release of frozen shoulders multiple times, in cases where the participants had previously been diagnosed with adhesive capsulitis by their physicians. The same approach has proven highly successful in releasing adhesive capsulitis of the hip, as part of a dynamic pelvic stabilization protocol for treating low back pain, SI joint pain, bulging discs and sciatica.

In all cases, the healing process requires the practitioner to employ a multidisciplinary approach to orthopedic massage, using an assessment method that will subsequently define the treatment plan. Both the assessment and the treatment will allow the practitioner to address the cause and the symptom of the condition(s), and to teach the client how to use custom-designed self-care stretching-andstrengthening protocols at home. (See Figure 4.) Ultimately, athletes will perform at optimal levels, and clients will live pain-free.

1. Cyriax, J., M.D., Cyriax clinical reasoning in orthopedic medicine (ETGOM, 2005). 2. Travell, J., M.D., Simon, D., Myofascial Pain and Dysfunction (Lippincott Williams & Wilkins, 1999). 3. Gracer, R.L., M.D., Overview of Orthopedic Medicine (www.gracermedicalgroup.com). 4. Dalton, E., Ph.D., Myoskeletal Alignment Techniques (Freedom From Pain Institute, 2005). 5. Mattes, A., Active Isolated Stretching (Aaron Mattes Therapy, 1995). 6. Lowe, Whitney, Orthopedic Assessment in Massage Therapy, Daviau Scott, 2006 7. Ida Rolf, Rolfing: Reestablishing the Natural Alignment and Structural Integration of the Human Body for Vitality and Well-Being, Healing Arts Press; 1989, Vermont