Friday, June 28, 2013

Practical Massage and Corrective Exercises

Erik Dalton recently pointed out a 1916 book by a Norwegian Masseur Hartvig Nissen who was as an instructor for the Harvard University Summer School, teaching massage therapy and Swedish Gymnastics.

Hartvig may as well be the Father of Swedish Massage as he was probably the one who introduced The "Swedish Movement" in the US. In the History section of his book, he described the Ling's school as:

The principal studies for graduation are : Anatomy, Physiology, Pathology, Chemistry, Hygiene, Diagnosis, Principles of the Movement Treatment, and the use of exercises for general and local development. 

It was not, however, until after the middle of the nineteenth century that massage became really known and was considered by the medical profession as a scientific and valuable remedy in the treatment of diseases. 

In the United States massage was hardly known when I arrived here in the early eighties.

I opened an institute, "The Swedish Health Institute for the Treatment of Chronic Diseases by Swedish Movements and Massage," in Washington, where the foreign diplomats assembled for treatment well known to them, and they soon brought scores of the great men and women of the United States to the institute, and gradually the physicians of the city came to inquire into the mode of treatment and send their patients there. 

In March, 1888, I read a paper before the Clinical Society of Maryland, on "Swedish Movement and Massage Treatment," which appeared in several medical journals, resulting in numerous letters from medical men who wanted to know more about it, and urging me to write a manual and also give instructions on the subject, and in 1889 my book, "Swedish Movement and Massage Treatment," was published.

Swedish movements and massage are based on plain physiological laws, and have nothing in common with " magnetism," nor is it " regular gymnastics," nor " rubbing"

I think most of the current massage myths still come from the 19th century, as he wrote:

For instance, in a case of synovitis or glandular enlargement or sprains, etc., the manipulations should always be directed centripetally — toward the heart ; but in case of insomnia, or very painful neuralgia, the manipulation should be directed downward, from the shoulder toward the fingers, ...

Certainly current Swedish massage has other influences, as the movement he described is all in English such as centripetal stroking, kneading, and circular friction. The term petrissage, effluerage, tapotement are not found in his manuals.

It is a delightful reading, he also has written a few other similar books (Hartvig is the Leon Chaitow of 19th century):

Here are some other  interesting books:

  • Complete Course in Massage, Swedish Movement and Mechanical Therapeutics. With a subtitle based on the teachings of Peter Henrik Ling, founder of the Royal Central Gymnastic Institute, Stockholm, Sweden and supplemented by original discoveries and teachings. A practical course in manual treatment as applicable to surgery and medicine. Written by James Gwalia, published in Canada in 1911. In this book, the usual terms petrissage, effluerage, tapotement can be found under kinds of movement (page 6)

The nomenclature adopted in the description of the manipulations is that which isgenerally recognised both in Europe and America ; and although the use of foreignwords may be open to objection, still, it seems preferable to retain them, as they constitute a kind of volapuk among practitioners of the method throughout theworld, 

Effleurage, petrissage, tapotement, vibration, and massage a friction are the names given to these manipulations,

Digital kneading, instead of petrissage

Palmar stroking, instead of effluerage

Ulnar percussion, instead of tapotement

Homo elasticus: The catapult effect of throwing

Humans are the only species that are able to throw objects incredibly fast and with great accuracy. Darwin noted that the unique throwing abilities of humans, which were made possible when bipedalism emancipated the arms, enabled foragers to hunt effectively using projectiles.

Researchers from George Washington University and Harvard University, led by Neil Roach investigated when, how and why humans evolved the ability to generate high-speed throws. Their study was published in the June edition of Nature.

Using experimental studies of humans throwing projectiles the authors showed that our throwing capabilities largely result from several derived anatomical features that enable the storing and releasing energy in the tendons and ligaments crossing the shoulder. This energy is used to catapult the arm forward, creating the fastest motion the human body can produce, and resulting in very rapid throws.

The authors showed that this ability to store energy in the shoulder is made possible by three critical changes in our upper bodies that occurred during human evolution:
 1. the expansion of the waist,
 2. a lower positioning of the shoulders on the torso, and
 3. the twisting of the humerus.

 All of these key evolutionary changes first appear together approximately 2 million years ago in the species Homo erectus.

Roach, N.T., Venkadesan, M., Rainbow, M.J., Lieberman, D.E. 2013. Elastic energy storage in the shoulder and the evolution of high-speed throwing in Homo. Nature.

Friday, June 21, 2013

Massage and Body Image

Body image or the conscious sense of our body, is our perception of and beliefs about our own body’s appearance. Or simply the feeling we have of our own body. Constructed by the brain from past experience and present sensations, the body image is a mental representation of our physical appearance, and is a fundamental aspect of self-awareness and self-identity. Body image depends on our internal ‘body maps’ that are modulated by somatic and proprioceptive input.

The term “body image” was introduced in 1935 by Paul Schilder, an Austrian American neurologist, which refers to the mental pictures we have of our bodies or the way our bodies appear to us. It is the set of beliefs we hold about ourselves. The topic of body image is covered extensively in recent popular books: The Body has A Mind of Its Own by Sandra and Matthew Blakeslee and The Brain that Changes Itself by Norman Doidge. Distorted body image Body image can be disrupted in people with pain disorders, and the disruption can have profound physical and psychological effects. For example, body image distortion is implicated in people with eating disorders (such as anorexia nervosa). Anorexics experience their bodies as fat even when they are on the edge of starvation.

Body image can be distorted in people suffering from chronic pain, as complex regional pain syndrome, phantom limb pain, and back pain. Pain is commonly experienced as projected into the body. People say “My back is killing me!”, but not “My pain is killing me.” However people having phantom limb pain show that we don't need a body part or even pain receptors to feel pain. The only factor that controls this pain is our body image. Physician VS Ramachandran said that pain is an opinion on the organism's state of health rather than a mere reflexive response to injury. The brain gathers evidence from many sources before triggering pain. Pain, like the body image, is a construct of our brain. Therefore he successfully used a mirror box to modify a body image and eliminate the phantom and its pain.

Dr. Lorimer Mosely, a scientist from Australia, have demonstrated visual distortions of the body image in patients suffering from chronic pain can significantly affect their perception of painful sensations. People with CRPS and phantom limb pain, were shown to have decreased tactile acuity and distorted body image for the affected limb. CRPS and phantom limb pain patients tend to perceive the painful or phantom limb as being bigger than it really is. Lorimer also tested to use the mirror box to make chronic pain in a real limb disappear. He asked his patients to simply imagine moving their painful limbs, without executing the movements, in order to activate brain networks for movement. The patients also looked at pictures of hands, to determine whether they were the left or right, until they could identify them quickly and accurately. They were shown hands in various positions and asked to imagine them for fifteen minutes, three times a day. After practicing the visualization exercises they did the mirror therapy, and with twelve weeks of therapy, pain had diminished in some and had disappeared in half. Lorimer also demonstrated that people with chronic back pain has disrupted body image. The patients were unable to clearly delineate the outline of their trunk and stated that they could not ‘‘find it”. This finding raises the possibility that training body image or tactile acuity may help patients in chronic spinal pain.

Massage is well known to make people feel more relaxed and better about themselves. While there are many evidences that suggest positive effects of massage on psychological health, several studies now showed the positive effects of massage on body image. Researchers have started to investigate massage as a way of improving body image. Thomas Pruzinsky in his book Body Image: A Handbook of Theory, Research, and Clinical Practice, writes that massage therapy is a somatic approach that is helpful in positively affecting body image “by helping the client reconnect to the body in a very concrete manner.” Dr. Marcia Hutchinson, author of the book Transforming Body Image, suggested that since body image is a product of the imagination, it can also be changed using the imagination. Hutchinson describes an exercise called “imaginal massage” in which you visualize a massage occurring allowing the hands of the massage therapist to transfer healing to your bodymind allowing acceptance of your body.

A study conducted by the Department of Nursing, Wonkwang Health Science College in South Korea evaluated the effect of massage on abdominal fat, waist circumference and body image of post-menopausal women. The participants received a full body massage once a week and massaged their own abdomens twice a day during a six week experiment. Half the group received massages with grapeseed oil. The other half received an aromatherapy massage with a blend of essential oils. Both groups felt better and improved body image after the treatment, but the group receiving aromatherapy massage showed significant changes across all areas – body image, waist circumference and abdominal fat.

An  in-depth interviews study conducted by Mary Bredin in UK explored the experiences of breast loss in mastectomy with particular focus on body image issues in three women. A pilot study also investigated a massage intervention as a means of helping them adjust to living with their changed body image. The study showed that the availability of a body-centered therapy such as massage might help with certain aspects of life adjustment.

The Touch Research Institute in Miami studied the effect of massage on people with eating disorders including bulimia (overeating and vomiting) and anorexia. Body image dissatisfaction contributes to the development and maintenance of  these eating disorders. Adolescents with bulimia who received one month of twice weekly massages plus their standard daily group therapy treatment (versus adolescents with bulimia who only received the standard group therapy) had  fewer symptoms of depression,  lower anxiety levels, and lower stress hormone levels (urinary cortisol levels). Their eating habits also improved, and their 
body image was less distorted. In another study on adolescents with anorexia at the same hospital the mas- 
saged women (versus the standard group therapy control women) reported lower anxiety levels and had lower  stress hormone levels.Over the five-week treatment period, they also reported decreases in body dissatisfaction on the Eating Disorder Inventory and showed increased dopamine and norepinephrine levels.  

Massage may improve body image by decreasing negative body image and increasing positive body image. A positive body image accepts the body and respects it by attending to its needs and engaging in healthy behaviours. In a qualitative study, many college women with a positive body image indicated that they regularly received massages to take care of, appreciate, and pamper their body, showing that they view massage as pleasurable. Massage treatment could function as a positive feedback cycle, by not only lessening negative feelings about the body through increasing body acceptance, but also by associating emergent positive feelings with the body and partaking in a behaviour that honours and relaxes the body. Massage could also improve body image by reducing women’s objectification of their body. A woman with a negative body image often views her body as an object to be evaluated. Women in western cultures learn to survey their bodies through the eyes of their culture to avoid negative judgment. A woman can feel that her body brings unhappiness and shame because it is perceived as not measuring up to society’s ideals. A woman who receives a massage, can let her body becomes a vehicle for the experience of pleasure. Women who hold a negative body image may avoid massage due to shame or embarrassment.

A study conducted by scientists from Bridgewater State University, MA, USA looked at the effect of massage on state body image. The study recruited forty-nine female university students; they were randomly assigned to either a massage condition or a control condition. It was hypothesized that participants in the massage condition would report improved state body image following the intervention when compared to participants in the control condition. As predicted, participants in the massage condition reported a more favourable state body image than participants in the control condition post-manipulation. Certain body image evaluations were moderately associated with views that massage is pleasurable, with the link between Body Areas Satisfaction and viewing massage as pleasurable reaching significance.

In this study, it is conclusive that the female university students reported feeling better about themselves and their bodies after having massage. Meanwhile the control group, who did not receive massage, showed no change in their attitudes. A woman’s negative view of her body can make the body seem untouchable and grotesque. Massage can be a vehicle to have a positive experience the body could potentially break through these negative body image attitudes. Nevertheless, a woman who holds negative thoughts about her body may be less apt to seek out massage therapy. This attitude will need to be addressed for massage to be a viable therapeutic option. In addition to relaxation and a shift in focus from the body as an object, regular massage could help change negative thoughts about the body as the body becomes associated with the good feelings that it brings through the massage experience.


Bredin M. Mastectomy, body image and therapeutic massage: a qualitative study of women's experience. J Adv Nurs. 1999 May;29(5):1113-20.

Cash TF, Pruzinsky T. Body Image: A Handbook of Theory, Research, and Clinical Practice. Guilford Press, 2004.

Dunigan BJ, King TK, Morse BJ.A preliminary examination of the effect of massage on state body image. Body Image . 2011 8(4):411-4.

Field T, Schanberg S, Kuhn C, Field T, Fierro K, Henteleff T, Mueller C, Yando R, Shaw S, Burman I. Bulimic adolescents benefit from massage therapy. Adolescence. 1998 Fall;33(131):555-63.

Hart S, Field T, Hernandez-Reif M, Nearing G, Shaw S, Schanberg S, Kuhn C. Anorexia nervosa symptoms are reduced by massage therapy.Eat Disord. 2001 Winter;9(4):289-99.

Hutchinson MG. Transforming Body Image: Learning to Love the Body You Have. The Crossing Press, 1985.

Kim HJ. Effect of aromatherapy massage on abdominal fat and body image in post-menopausal women. Taehan Kanho Hakhoe Chi. 2007 Jun;37(4):603-12. [Article in Korean] 

Lotze M, Moseley GL. Role of distorted body image in pain. Curr Rheumatol Rep. 2007 Dec;9(6):488-96.

Moseley GL. I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008 Nov 15;140(1):239-43.

Wood-Barcalow, N. L., Tylka, T. L., & Augustus- Horvath, C. L. (2010). ’But I like my body’: Positive body image characteristics and a holistic model for young-adult women. Body Image, 7, 106–116.

Wednesday, June 12, 2013

A Journey in Fascia Wonderland

This article is based on Robert Schlep’s talk at the 3rd World Fascia Congress in Vancouver 2012 titled: Alice in Wonderland- Getting curioser and curioser.

The scientific world and the clinician world rarely meet, and the fascia congress is one of the important events that tried to make scientists and manual therapists meet and started to talk to each other. Most manual therapists or bodyworkers choose to be in the complementary and alternative groups. The field is usually dominated by different schools, where the teachers or charismatic founders are regarded as the ‘knowledge’ authority. (Whitney Lowe called this The Sage on the Stage). The teachers are quite skilful but sometimes the concepts they proposed stretch a bit beyond from the scientific reality. For example Dr. Andrew Taylor Still, the founder of Osteopathy, and Dr. Ida Rolf, the founder of Rolfing. They have very profound clinical knowledge, and they tried to explain what they are doing based on their knowledge at that time. Myofascial release was thought to be able to change the state of the ground substance from gel to sol, or able to loosen the cross links of the collagen fibre. But most of these theories or hypotheses came from their own intuition without solid scientific proof.

The first fascia congress held in Boston, in 2007, and covered by the prestigious Science magazine with an article titled “Cell Biology Meets Rolfing”. The article described the opportunity but also the challenges of how scientists and clinician can meet and talk to each other. The two groups reach out to each other, with a hope to provide fruitful exchanges of ideas and experiences. Clinicians such as Schleip have travelled from the ‘alternative world’ to the scientific world by doing a PhD degree in fascia biology. Meanwhile scientists such as Tom Findley, a medical researcher, travelled to the clinician world by studying Rolfing for several years. Robert compared himself as Alice in Wonderland, he has travelled in the Scientific Wonderland, and came back telling stories about strange scientists he met to his fellow clinicians.

Robert gave three specific examples of what he as a clinician had been able to learn from the scientific world. 

(1) Fluid dynamics
Water constitutes around 68% of the fascial tissuesvolume . Fascia regulates the flow of fluid in the extracellular matrix, and fluid flow can causes fascial remodelling. A study conducted by Schleip and co-workers at the University of Ulm (Figure 1) showed that, in an in vitro study using fascia from animal, that during the tissue loading (fascia stretch) water is extruded from the tissue and this tends to contribute to a temporary decrease in tissue stiffness (i.e. tissue softening) immediately after the stretch. The findings also found that that after the stretch, the stiffness of the tissue increases and it also regains a gradual rehydration. This phenomenon is due to the behaviour of the ground substance in the extracellular matrix which prevented from absorbing fluid by tension that fibroblast cells put on extracellular matrix fibres. When this tension is relaxed, the extracellular matrix can absorb fluid rapidly.

The implication is that when Robert applied pressure through his elbow to the thoracolumbar fascia, he now paid more attention to the fluid dynamics, rather than only trying to melt the tissue or breaking up the fibrous tissues, or stimulating the mechanoreceptors. Now Robert works more gently and more slowly. We should now thinking not only about stimulating the mechanoreceptors or golgi tendon organ, but be aware of how the fluid moves.

Another research by Melody Swartz (from Lausanne, Switzerland) described how subtle change in fluid shear on cell culture has a profound change in the fibroblasts. Fibroblasts are most responsive to the detection of fluid shear - i.e. to the slow motions of the water around them - as sensed through their antenna-like cilia (soft tentacle). It is indicated that a large portion of the impact of collagen stretch is less due to the direct effect of transmission of that stretch to the cell membrane, but rather to the sensation of the fluid shear which is induced by the collagen fibre reorientation which is then sensed by the hair-like cilia.

This idea can be illustrated as follow: imagine how much the hairy tip of a painter's brush would bend if you move it at a steady speed through a fluid medium. Or imagine moving a finger through yoghurt. Both the speed as well as the viscosity of the fluid medium will influence the amount of shear. The clinical implication is that if you move very slowly at a constant speed through a dense tissue area (e.g. with the therapist's knuckle or a foam roll), then the tiny cilia of the fibroblasts will be bent only very gently by the resulting fluid shear, and this seems to stimulate them to produce an enzyme (MMP-1) which starts to break down excessive collagen in the next few hours.

(2) A tool for evaluating the stiffness of tissue
Most palpation that we do is subjective, and therapists cannot remember how ‘stiff’ is the tissue before and after treatment (or even a week after treatment). Therapists should have a more objective tool to measure the therapeutic response. Robert suggested Myoton Pro, a tool recently developed to measure the tissue stiffness. The quantitative digital measurement provided by this ‘myometer’ proved to be reliable and useful for assessing biomechanical properties of myofascial tissues. This tool works by creating a constant pre-load of the soft tissue via a movable indentation probe, which is then rapidly released and the tissue response (damping oscillation) of the tissue is measured. This kind of tool could provide a more objective measurement on the effectiveness of our treatment.

(3) Innervations of the lumbar fascia
Prof. Siegfried Mense, in his lab. in Heidelberg, Germany, showed that the thoracolumbar fascia is densely innervated. Another recent study also from Heidelberg led by Jonas Tesarz et al. (2011), and published in Neuroscience journal, quantified the amount of innervation of the thoracolumbar fascia (TLF). Using calcitonin gene-related peptide (CGRP) and substance P (SP)-containing free nerve endings, they quantified the amount of nerve endings in the TLF of rat. They showed that the TLF is a densely innervated tissue with marked differences in the distribution of the nerve endings over the fascial layers (Figure 2). 
Figure 2. The distribution of CGRP and Substance P (SP)-immunoreactive nerve fibers in the Thoracolumbar Fascia (redrawn from Tesarz et al., 2011).
(a) Mean nerve fibre length of CGRP and SP. Almost all fibres were found in the outer layer of the fascia and the subcutaneous tissue. The middle layer was free of SP-positive fibres.
(b) Distribution of CGRP and SP-containing receptive free nerve endings expressed as percent of the total number of CGRP- or SP-containing fibres in each fascia layer. SP-containing free nerve endings were restricted to the outer layer of the thoracolumbar fascia and the subcutaneous connective tissue while CGRP-containing free nerve endings were also found in the inner layer of the thoracolumbar fascia.

They distinguished three layers:
(1) outer layer (transversely oriented collagen fibers adjacent to the subcutaneous tissue),
(2) middle layer (massive collagen fiber bundles oriented obliquely to the animal's long axis), and
(3) inner layer (loose connective tissue covering the paraspinal muscles).
It is the subcutaneous tissue and the outer layer that showed a particularly dense innervation with sensory fibres. SP-positive free nerve endings-which are assumed to be nociceptive-were exclusively found in these layers.
Because of its dense sensory innervation, including nociceptive fibres, the TLF may play an important role in lower back pain. Most of the myofascial pain may come from the superficial layer. This suggests that it may be most effective to work more superficially, stimulating proprioceptive nerve endings and reaching to the nociceptor. For many years Robert taught his students to work deeper for more profound change, but now based on this new finding, he often works more superficially to be more effective. 

In addition, Robert also suggested three areas of consideration that scientists can learn from therapists:

(1) The influence of sympathetic activation on and fascial tonicity
Vladimir Janda, suggested a close relationship between the autonomic nervous system (ANS) and fascial tonicity, implying that sympathetic activation may lead to an increased cellular contraction within fascial tissues. However it was not until recent findings that suggests that sympathetic activation induces an increased TGF-β1 expression; and- since this cytokine is known as the most potent stimulator of myofibroblasts contraction- that this may also lead towards an increased fascial contractility.
Figure 3 illustrates a possible two-way interaction between ANS activation and fascial tonicity. Besides the influence of the ANS on cellular contractility in fascia, this diagram also emphasizes the potential influence of therapeutic fascial stimulation on ANS tuning. Stimulation of non-nociceptive mechanosensory free nerve endings can influence ANS tuning. In addition, stimulation of Ruffini corpuscles- which are reportedly particularly sensitive to slow shear application - tends to inhibit sympathetic activation.

Figure 3. Proposed interaction between the autonomic nervous system and fascial tonicity. Sympathetic activation tends to activate TGF-β1 expression (as well as probably other cytokines) in the body, which has a stimulatory effect on myofibroblast contraction, thereby leading to an increase of fascial stiffness. In addition, shifts in the autonomic nervous system state can induce changes in pH, which affects myofibroblast contraction as well. Skilful therapeutic stimulation of mechanoreceptors in fascia - particularly of Ruffini or free nerve endings - can induce changes in the autonomic nervous system. Redrawn from Schleip et al. (2012).

(2) The Rhythmic oscillations of fascial tissues
When connective tissue cells were put together in a cell culture medium with a collagen grid, they tend to show periodic oscillations. In particular, it has been shown that they expressed rhythmic calcium oscillations which were accompanied by contractions of the cells. A study by Follonier et al. (2010) demonstrated that myofibroblasts tend to oscillate in such an environment in synchronicity, when they were in close contact with each other (Fig. 4). The observed oscillations had a mean period length of 100 second. It is an intriguing question whether this very slow rhythm observed in these cell cultures - with one cycle taking more than one and a half minutes- could be related to the so-called “long tide” oscillations in biodynamic craniosacral therapy. The so-called “breath of life” has a deep and slow rhythmic impulse expressed about once every 100 seconds. This needs to be tested in real-world, whether myofibroblasts can express this behaviour, and related to the "breath of life". Or this is just a palpatory illusion of the therapist.

Figure 4. Myofibroblasts expressed rhythmic calcium oscillations. The graph on the left showed recording of fluorescence activity of five individual cells, which were previously stained with Flura-2. The analysis revealed a common peak around 99 ± 32 seconds of the cells, as well as asecond maximumof 221 ± 21 s. Graphics based on Follonier et al. (201 0).

(3) Fascia research networking
Finally, scientists should collaborate more following the network properties of the connective tissues. Competition in the scientific world is very strong (sometimes can be ruthless), researchers compete to publish first, therefore they usually never share their findings or data. This is also instigated by competition for funding. Scientists should be more open to their work and collaborate more, without the fear of other people trying to steal their ideas. They should imitate the network tissues they are working on by forming a network of exchange of information.


Follonier, C.L., Buscemi, L.,Godbout, C., et al., 20 I 0.A new lock step mechanism of matrix remodeling based on subcellular contractile events. J. Cell Sci. 123, 1751-1760.

Schleip R, Duerselen L, Vleeming A, Naylor IL, Lehmann-Horn F, Zorn A, Jaeger H, Klingler W. Strain hardening of fascia: static stretching of dense fibrous connective tissues can induce a temporary stiffness increase accompanied by enhanced matrix hydration. J Bodyw Mov Ther. 2012 Jan;16(1):94-100. doi: 10.1016/j.jbmt.2011.09.003.

Tesarz J, Hoheisel U, Wiedenhöfer B, Mense S. Sensory innervation of the thoracolumbar fascia in rats and humans. Neuroscience. 2011 Oct 27;194:302-8. doi: 10.1016/j.neuroscience.

Schleip, R., Jager, H., Klinger, W. 2012. Fascia is Alive. In: Fascia: The Tensional Network of the Human Body. Churchill Livingstone.

Originally published in Terra Rosa E-magazine No. 12, June 2013. 

Watch Robert Schleip's lecture 

Pseudoscience and Pseudoskeptic

Early knowledge on massage therapy has been mostly based on what therapists observed or experienced. As with other health disciplines, early therapists present their hypothesis based on what they believed is happening. Nothing scientific, but some become myths that are still being passed on. For example, massage can expel toxins out of the body. It turns out some of these myths are completely wrong.

Some of massage teachers then become the ‘authorities’ and start to develop their own modalities and schools, and frequently used pseudoscience to describe what they are doing. Pseudoscience is a claim, belief, or practice which is presented as scientific, but does not adhere to a valid scientific method. It lacks supporting evidence or plausibility, cannot be reliably tested, or otherwise lacks scientific status ( 

A typical example is linking a modality with quantum physics, the authority would quote something about the efficacy of the technique is due to the reduction in entropy, engaging fractal structure, based on relativity, uncertainty principle, and so on that all sound scientific but got no scientific grounds at all. Pseudoscience holds back the progress in massage therapy.

However many great researchers have contributed to the better understanding of what is happening with massage. Much research has been conducted for the past 20 years to show the efficacy of massage through clinical trials and also trying to figure out the mechanisms on what’s happening. For example, in the field of fascia research there has been tremendous research on the basic understanding on the anatomy and physiology of fascia.

But, there are another group of people who claimed they understand science and started to discredit massage therapy research. E.g. massage has no benefit at all except for relaxation, most research studies on the efficacy were flawed, fascia research is overrated and of no use, stretching is no use, palpation is just an illusion, etc. 
Unfortunately many therapists buy into those arguments, some believed they liked to be challenged, and encouraged critical thinking as they dare to disagree. However most of this ‘critical thinking’ is just another presentation of a biased view.

What seems to be a skeptic turn out to be pseudoskeptic, which usually made negative claims without bearing the burden of proof of those claims. Pseudoskepticism (or pseudoscepticism) refers to arguments which use scientific-sounding language to disparage or refute given beliefs, theories, or claims, but which in fact fail to follow the precepts of conventional scientific principles. What you can see directly is that pseudoskepticism usually involves "negative hypotheses" - theoretical assertions that some belief, theory, or claim is factually wrong - without satisfying the burden of proof that such negative theoretical assertions would require. Some of the characteristics include double standards in the application of criticism, tendency to discredit, rather than investigate, and suggesting that unconvincing evidence is grounds for completely dismissing a claim. (

Pseudoskepticism is related to pseudoscience as both advocate poor scientific reasoning. They are impediment to growth and progress. Some like to be challenged, however one should also understand that doesn’t mean it follows any scientific principle. 

Critical thinking? All they do is just criticize and offer nothingI appreciate much more researchers who are doing actual research and trying to figure out what's happening rather.

Just as much of it needs science, massage is more as an art as well. Joe Muscolino said “Be open-minded, but don‘t be so open that your brains fall out”.

A quote from Zhiangzu illustrates this:
Life is finite, but knowledge is infinite. To pursue the infinite with the finite, how dangerous that is! To believe that one truly knows, how extremely more dangerous that is

Originally published in Terra Rosa E-magazine No. 12, June 2013. 

Fascia and Reflexology

Fascia, as we all now know, is a seamless web of connective tissue that covers, connects, and holds the muscles, organs, and skeletal structures in our body. Fascia envelopes every structure in the body, each nerve, bone, muscle, organ of the body is surrounded by fascia.  Fascia can be found superficially and deep within our body. Superficially, a layer of fascia can be found just under the skin sandwiched between two layers of a honeycomb-like structure that contains fat tissue (See Figure 1). Deeper within the body, fascial planes wrap around the muscles (Muscolino, 2012).

Figure 1. Cross-section from the skin to musculature, showing fascial membranes and rtetinacula cutis fibres. Illustration by Giovanni Rimasti, modelled from an illustration by Luigi Stecco. (From Muscolino, 2012, Used with permission).

Generally fascia is distinguished into superficial and deep fascia. The superficial fascia is located just underneath the skin. According to the Stecco studies, the superficial fascia is a bilaminar membranous layer rich in elastic fibres lying within two layers of what is called the “retinacula cutis”. The superficial fascia together with the superficial and deep retinacula cutis layers is commonly known as the hypodermis.  Deep fascia is a tough dense connective tissue below the superficial fascia, and it envelops the underlying muscles that are deep to the skin or envelops periosteum of the bone in regions. For a more thorough explanation on the different layers of fascia, read Joe Muscolino’s article Fascial Structure (originally published in the Massage Therapy Journal of the American Massage Therapy Association).

A significant layer of fat in the superficial fascia is distinctive to human, compensating for the lack of thick body hair, and plays an important role in heat insulation. The superficial fascia also conveys blood, lymphatic vessels and nerves to and from the skin and often promotes movement (gliding) between the skin and underlying structures.  It will be mostly affected by light touch techniques (e.g. lymphatic drainage therapy, Bowen therapy, myofascial release). By contrast, the deep fasciae in the limbs and back are typically dense connective tissue sheets that have large numbers of closely packed collagen fibres (Benjamin, 2009). The deep fascia in contrast to the superficial fascia has a robust, multilayer collagen fibre structure and relatively fewer elastic fibres. The deep fascia is responsible for mechanical function of force transmission and a possible proprioceptive role which is due to the large numbers of embedded mechanoreceptors. It is more probable that this layer can be affected by deep massage techniques, such as deep tissue work or friction concentrated in limited areas.

In most parts of the body, the superficial fascia is an elastic connective tissue layer surrounded above and below by adipose tissue. However at the palm and sole of the foot, the skin is tightly bound to the underlying tissues to prevent or restrict movement (Figure 2) . If movements were allowed to occur here within fascial planes, then the hands or feet would not been able to have a firm grip. The retinacula of the retinacula cutis layers in the palms and soles are much thicker. They bind the superficial fascia to the deep fascia and adipose tissue is sparse beneath the skin. It is even absent at the finger creases on the palmar sides of the interphalangeal joints, so that the skin immediately covers fascial tendon sheaths (Benjamin, 2009). See also Figure 2 and Figure 3 of Mike Benjamin’s article The fascia of the limbs and back . (The article also provides a thorough anatomical view of the fascia of the hands and feet) Pavan et al. (2011) studied the mechanical properties of the plantar aponeurosis.

Figure 2. A dissection view of the plantar aponeurosis  (Photo by Carla Stecco, Used with permission).

According to Julie Day, a physiotherapist working with the Stecco group in Italy: “The fact that the superficial fascia and the deep fascia almost fuse together in the soles of the feet and the palms of the hand could be an explanation for why working deeply in these areas, as in reflexology, can affect areas that are distant from the area we work on.” Julie who presented Fascial Manipulation at the AAMT conference said that she had often used plantar reflexology in the past and but, at that time, had not found any plausible anatomical explanations for its effectiveness. Reflexology is a relatively easy technique to learn and it can either be incorporated within a massage session or as a specific session apart.

The general belief in reflexology is that each part of the body is interconnected through the nervous system to the hands and feet. Stimulating specific reflex points in the feet is believed to be able to bring relieve to poorly functioning areas of the body. However there is no evidence of such connections between certain parts of the feet and hands and the various organs in the body.

According to Dr. Ida Rolf in “Rolfing and Physical Reality”: "The meridian points and reflex points in the feet are most likely end-points of myofascial strain, the result of imbalance which transmits its difficulty in compensating pattern through the body to the surface. Fascial planes may be the route of mechanical transmission of pain." She also mentioned "Foot reflexes are peaks of strains. They are nothing mystical; they are where strain goes in the foot. If you are relieving strain above the reflex points (for example in the ankle and shin) you will relieve those points of strain in the sole of the foot. When a weight goes down and dies in some place, it becomes a reflex point." And "I think that many if not all reflex points in the foot are simply points where gravitational strain inserts and comes together. They are the end of the line we call balance"

So next time we work on reflexology think of the connective tissue!

Mike Benjamin. The fascia of the limbs and back – a review. J Anat. 2009 January; 214(1): 1–18. doi:  10.1111/j.1469-7580.2008.01011.x
Julie Day. What’s New in Fascial Anatomy. Terra Rosa E-magazine No. 8, July 2011.
Joe Muscolino. Fascial Structure. Massage Therapy Journal, Spring 2012.
Pavan PG, Stecco C, Darwish S, Natali AN, De Caro R.  Investigation of the mechanical properties of the plantar aponeurosis. Surg Radiol Anat. 2011 Dec;33(10):905-11. doi: 10.1007/s00276-011-0873-z. 
Ida Rolf. Rolfing and Physical Reality. Edited by Rosemary Feitis. Healing Arts  Press, 1978, 1990.

Originally published in Terra Rosa E-magazine No. 12, June 2013.