Exploring Palliative Care I Have a Full Schedule. Now What?

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JANUARY/FEBRUARY 2024

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36
A LIFE FREE OF HEAD PAIN
The suboccipitals are a testament
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sequenced techniques designed
to release tension while
considering the broader context
of upper-crossed syndrome
and forward-head posture.
By Erik Dalton, PhD

46
PALPATING THE ANTERIOR
HIP FLEXOR MUSCLES
Discerning the “hills and valleys” of
the hip flexor musculature can save
time and energy and facilitate the
job of muscle palpation.
By Dr. Joe Muscolino

56
DANCING THROUGH LIFE
Judith Aston has been a force in
the world of movement for more
than six decades. The founder
of Aston Kinetics talks teaching,
movement, life, and weaving it all
together.
By Karrie Osborn

62
RENAL FAILURE, DIALYSIS,
AND KIDNEY TRANSPLANTS
When things go wrong with the
kidneys, significant problems
can develop. Massage therapy
can substantially help limit the
pain and some of the other issues
that can result from chronic
kidney disease, dialysis, and renal

36
transplant.
By Ruth Werner

ABMP members earn FREE CE hours by reading this issue! 3

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 JANUARY/FEBRUARY 2024

THIS ISSUE
9 Editor’s Note
11 Speak Your Mind
12 ABMP Legislative Advocacy
14 ABMP Profession Update
17 Your Magazine Is CE
19 Black Massage Therapist
Conference
21 Knead to Know
23 Faces of Bodywork
84 ABMP Member Benefits CRITICAL THINKING
86 ABMP Continuing Education
70 ANATOMY FOR TOUCH
87 10-, 20-, and 30-Year Members
The First Millimeters of
88 Savvy Self-Care Every Massage
By Nicole Trombley
and Rachelle Clauson

74 MASSAGE THERAPY
AS HEALTH CARE
Palliative Care
By Cal Cates

TECHNIQUE 76 TABLE LESSONS

Finding That Sweet Spot

24
24 THE REBEL MT
By Douglas Nelson
Under Pressure
By Allison Denney
ESSENTIAL SKILLS
26 CLINICAL EXPLORATIONS
78 PRESSURE POINTS
Ankle Sprains
OF BUSINESS
By Whitney Lowe
Using Artificial Intelligence
30 THE SOMATIC EDGE in Your Massage Business
The Brain in Bodywork By Allissa Haines
By Til Luchau
80 BACK TO BASICS
and Jeffrey Bramhall
Guiding Your Client’s
Wellness Path Through
Treatment Planning

Massage & Bodywork (ISSN 1544-8827; USPS 005-245) is

74 83 By Cindy Williams

83 HEART OF BODYWORK
a bimonthly magazine published by Associated Bodywork & The Careless Therapist
Massage Professionals Inc., 25188 Genesee Trail Road, Suite
200, Golden CO 80401. Periodicals rate postage paid at Golden, By Laura Allen
Colorado, and additional offices.
POSTMASTER: Send address changes to ABMP, 25188 Genesee
Trail Road, Suite 200, Golden CO 80401.

88

ABMP members earn FREE CE hours by reading this issue! 5

 Tom Myers’
Anatomy Trains
Structural Integration

“Continual
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Join Anatomy Trains author Tom Myers in California
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ATSI Part 1 Intensive: Structural Essentials starts February 5, 2024
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Email: info@anatomytrains.com Phone: 207-563-7121
 Massage & Bodywork promotes professionalism among practitioners, stimulates
healthy dialogue, and expands the knowledge of those in the field to advance
their success—while remaining mindful of the breadth of bodywork backgrounds,
beliefs, and modalities.

EDITORIAL DESIGN & PRODUCTION

Darren Buford Amy Klein
Editor-in-Chief Art Director
darren@abmp.com amy@abmp.com

Karrie Osborn Amy Rowe

Senior Editor, Education Graphic Designer
and Project Management amyr@abmp.com
karrie@abmp.com
ADVERTISING
Scott Kaniewski Angie Parris-Raney
Editor, Online and Director
Digital Strategy angie@abmp.com
scott@abmp.com
Mandy Norris
Jennifer Anderson Coordinator
Contributing Editor amanda@abmp.com
jena@abmp.com

Erica Buehler
Associate Editor
erica@abmp.com

Enviro/Tech inks, which Massage & Bodywork has printed with since 2002, have a renewable resource content of 25.3%, which is much higher than the published
7% minimum soy content required for soy inks. Enviro/Tech inks include pine, linseed, and other vegetable or seed oils.

ABMP
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Vol. #39, Issue #1 January/February 2024. All rights reserved © 2024.

SUBSCRIPTIONS
Annual subscription rate in the United States and Canada is $26 for one year (US funds). To subscribe, call 800-458-2267.
WEBSITES
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No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording, or by any information storage and retrieval system, without specific written permission from ABMP. The
views expressed herein are those of the authors, and not necessarily of the publisher or its advertisers. Publisher cannot be responsible
for any unsolicited articles or materials, or the return of such items. The editorial and advertising content in Massage & Bodywork is for
educational purposes only and is not intended as comprehensive modality training or medical advice. Massage & Bodywork encourages
practitioners and massage therapy clients to consult a qualified professional for individual diagnostic and health-care needs.

ABMP members earn FREE CE hours by reading this issue! 7

 ARE YOU
CERTIFIED YET?
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 EDITOR’S NOTE

Accountability Buddy
Three years ago, I wrote an Editor’s Note to jump-start my new
year with some resolutions—10, in fact. I believe I did a darn good
job of upholding my end of the bargain with myself and achieving
those items throughout the year, many of which required some
sustained frequency.
Most people fail in their New Year’s resolutions within the first or
second week. That’s why you see the gym packed January 1–7, then
fewer and fewer people January 8–31. I wonder if much of that failure
comes down to how people set an intention but have no real path for
manifesting it.
Enter the accountability buddy.
The first time I heard this term was when speaking with Massage
& Bodywork columnist Ruth Werner. She mentioned to me that she
and fellow M&B columnist Whitney Lowe were “accountability
buddies.”
“What’s that?” I asked.
“Well, we get together and check in on the progress of each other’s
projects,” Ruth said.
So, what does this person actually do? Are there rules to being an
accountability buddy? And what makes a good accountability buddy?
Essentially, this person helps hold you up to the standards you set
for yourself, whether that’s improving your marketing, learning a new
technique, hiring your first employee, or redesigning your space.
According to Ruth, the rules she and Whitney abide by
are (1) no scolding, (2) provide lots of support, and (3) changes If you’re going to set
of plans and directions are good. They meet biweekly. and accomplish goals
As far as what to look for in an accountability buddy, Ruth says, “Find someone
with a similar level of experience who has similar (but not identical) goals. Talk about
in the new year, you
those goals and why they’re important. Work together to establish action items that may need to first put
take the highest priority. Share resources. Reflect progress. Listen well.” pen to paper, then
Why am I bringing this up, and why is this pertinent to 2024? Well, if you’re
going to set and accomplish goals in the new year, you may need to first put pen to
find someone to hold
paper, then find someone to hold you accountable, to up the peer pressure a bit. you accountable.
I’m lucky to have a couple of people in my life who hold me accountable to
goals and intentions. Nothing as formal as what Ruth and Whitney have, but that’s
something I’d like to change and lean into in the coming year.
Here at ABMP and M&B, we like to see ourselves as a tool for your accountability
buddy meetings. We hope you see each magazine that arrives in the mailbox as a
chance to reignite your passion for learning, garner some new techniques to try in
your practice, and get soft skills that improve your non-touch toolbox. (PS: There are
a ton of ABMP member benefits online to up the ante in 2024.)
As you get around to 2023 reflection and 2024 planning, email me your goals for
2024. I’m curious about what you want to attain and just how you’ll do it, and maybe,
just maybe, we’ll become accountability buddies in the process.

DARREN BUFORD
Editor-in-Chief
darren@abmp.com

ABMP members earn FREE CE hours by reading this issue! 9

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 SPEAK YOUR MIND
What’s Inspiring
Your Practice in 2024?
FACEBOOK/ABMPPAGE
Being able to incorporate a truly
holistic knowledge base into dealing
with pain. So, thinking about the
whole musculoskeletal structure and
myofascia, thinking about hormones
and overall biochemistry, and thinking
how everything is connected in order to
get the best outcomes for my patients.
ELIZABETH PLANT
I fi nd myself continually inspired by
industry leaders, most of whom are
columnists in Massage & Bodywork magazine
and instructors who lead courses in the
extensive ABMP CE library. Integrative
bodywork with an emphasis on nervous
system regulation, client education, and
self-care are cornerstones to my approach
as a manual therapy practitioner. That
being said, ego tells me I’d like to be as big
of a name or as successful as them in my
time. However, what I fi nd more rewarding
than success in that sense is being able to
provide services that facilitate positive,
embodied, visceral experiences. I want to
help create a lasting impact in more lives
this year than I did in 2023, while staying
true to my passion and profession.
ANDREW DEGROAT
JESSICA RUSCELLO/UNSPLASH
INSTAGRAM/@ABMPMASSAGE
Stillness. Reflexology, craniosacral,
myofascial . . . Is there anything more
rare, precious, or sacred than stillness?
KIRBYCLARK.MMT
As a trauma survivor, I understand how
trauma can be stored in the body and
manifest itself in many ways. Therapeutic
massage can help. My plan is to continue
my professional course and incorporate
more trauma-informed bodywork, along
with always being the catalyst for my
clients’ own healing journeys—teaching
them how to breathe properly, things
to do in between sessions, and more.
PURPLECATERPILLARMASSAGE
Empowering our clients to take
charge of their wellness!
OAKESSENTIALSWELLNESS
Encouraging the client community to
embrace the idea that discomfort and illness
does not victimize them—it amplifies our
ability and courage to curate lifestyle choices
that manage and create more opportunities,
wherever we exist on our life canvas.
EMILYINLYMPHETHERBODY
Showing my clients the wonders of massage
therapy and the healing process behind
it. Introducing cupping therapy to more
and more people, showing them that
bodywork is for everyone, not just athletes!
CAMPOS_CUPPING_MASSAGE
Contrast therapy! I’ve curated a session with
contrast therapy on the hands, belly, and
face/neck. It’s my most requested session!
THESANDRAWEBER
ABMP members earn FREE CE hours by reading this issue! 11
It has always been my prayer before
each day to focus on doing the best I
can with what I have. In 2024, I want to
further educate myself so I can continue
to empower my clients to be their best
solution outside of our sessions.
JWISEMAN_WELLNESS
The sigh of relief from my clients
and silly, happy smiles when they
leave their treatment sessions! It’s
that magic that keeps me inspired.
MAUDIFIT
Reminding people to take care of
their bodies and minds by blending
medical massage and spa treatments.
Educating them on how to take care of
themselves after a session mentally and
physically. Everything is connected!
DVALLEYLUXURYSPA
Our founders have a lofty goal for 2024.
They want to enhance the inspired and
ignite passion in those who have been
feeling like they’re in a slump. Our
inspiration stems from a deep need to
increase professionalism, expertise,
connection, and education for LMTs and
the public. It’s going to be a great year!
MASSAGEMASTERYINSTITUTE
 ABMP LEGISLATIVE ADVOCACY

Human Trafficking: A Hot-Button

Issue in Massage Policy
By Lance Hostetter

Legislatures across the country are returning to

work in January. In the November/December 2023
issue of Massage & Bodywork (“Policy Issues Facing
Massage Therapy in 2024,” page 16), I outlined
key issues expected across the country—continued
momentum for the Interstate Massage Compact,
licensing bills in Minnesota and Kansas, and
potential changes to licensing requirements (both
continuing education and examination). However,
I didn’t cover the continued focus by legislatures
to stop human trafficking and illicit massage.
In 2023, many states (and some localities)
continued to push for establishment licensure despite
most states already requiring occupational licensure.
In most cases, ABMP sees establishment licensure as
unnecessary and overly burdensome. In some cases
though, ABMP supports establishment licensure with
some consideration (exempting sole practitioners, in
place of occupational licensing in states without it).
Human trafficking and illicit sex business are
major issues, but hardworking, law-abiding massage
professionals should not be punished, nor should
lawmakers create policies that inflate the incorrect
assumptions about the profession. Instead, lawmakers
need to work with the massage industry to help solve
these issues that reach far beyond the profession. confusion, and devalue the legitimacy of a massage
Human trafficking is a societal issue that can be therapy license.
found in many industries, from marijuana to massage There’s also the idea that individuals performing
to house cleaning to the illegal drug market. nontherapeutic massage would line up in earnest to
Yet, public policy is routinely introduced that receive a registration. Individuals who operate illicit
focuses primarily on human trafficking in massage. sex businesses typically do not hire licensed massage
Take, for example, Ohio House Bill 255 (HB 255), therapists. In fact, many do not hire employees at
which would create a nontherapeutic massage all. Work may be forced labor, and “employees”
definition and registration. While the intentions of may be the victims of human trafficking. These
the bill’s sponsors are good, it is highly unlikely the businesses will likely not allow their employees to
bill would successfully curb illicit sex practices and sign up as nontherapeutic massage therapists. In
human trafficking in Ohio. Instead, HB 255 would these scenarios, businesses may make more of an
likely lead to unintended consequences, create public effort to remain hidden to evade law enforcement.

12 massage & bodywork january/february 2024


If individuals engaging in illicit activity are not self-
identifying now, a registry will not be a tool that
encourages them to do so.
As well-intentioned as some policy proposals may be,
creating different classes or definitions of massage devalues
the profession and confuses the public. HB 255 defines
nontherapeutic massage as “massage techniques that do
not constitute massage therapy because they are performed
for other reasons than treatment of disorders of the human
body,” which is nonspecific. This places massage therapists
and the public in a precarious situation that could lead to
public safety issues.
Furthermore, nontherapeutic massage registration may
devalue a massage license. Under Ohio’s potential policy,
a nontherapeutic massage therapist requires no education,
while licensed massage therapists, by contrast, require at
least 600 hours of formal education in massage techniques,
anatomy, physiology, ethics, safety, and sanitation.
Would the public understand the difference between
these two credentials? Probably not. This means the
Ohio massage therapy license is in jeopardy of suffering
depreciating value. This could also create market
competition and threaten the bottom line of licensed
massage therapists. Additionally, with a zero-educational
COTTONBRO/PEXELS
pathway, this could put massage therapy schools in
jeopardy of a potential decrease in student enrollment.
ABMP members earn FREE CE hours by reading this issue! 13
ABMP Government
Relations Director
Lance Hostetter
Lawmakers need to work
with the massage industry to
help solve issues that reach
far beyond the profession.
The point here? States and localities across the
country are grappling with serious issues of human
trafficking and illicit sex businesses. There’s no doubt
about that. Pushing forward legislation that harms
the massage profession, creates public confusion, and
opens the door for unintended consequences does
nothing to help solve those issues. That’s why ABMP
will continue to advocate against policies like Ohio’s
HB 255, and instead work to support policies that
help solve these problems.
Most importantly, we hope you will continue to
elevate your voice when troubling policies like this
one are brought forward.
Lance Hostetter is the ABMP director of government
relations. To contact ABMP government relations, email
gr@abmp.com.
 ABMP PROFESSION UPDATE

Massage
School
Programs
at Risk After
Amendment
of “150%” Rule
Despite efforts by Associated Bodywork &
Massage Professionals (ABMP) to advocate
for changes to the US Department of
Education’s (ED) Gainful Employment
rules in June 2023, final rules were
released on October 31 that could greatly
impact clock-hour programs in states
with minimum clock-hour requirements
for licensure or certification, including
massage therapy. The new rule is flawed
and, if not changed, will cause devastating
collateral damage to schools, instructors, hours by up to 50 percent and students would still be
students, and the public. ABMP explains eligible for financial aid through Title IV. For example,
the new rule below and outlines potential if a state has a massage therapy minimum requirement
advocacy steps schools may wish to of 500 hours, a school in that state could offer a massage
pursue to work for a different result. program up to 750 hours (150 percent of the minimum)
and remain eligible to offer federal financial aid.
As of July 1, 2024, for a massage program to remain
EXPLANATION OF THE NEW RULE Title IV-eligible, program length must be exactly what the
Educational programs that are clock- state requires. Schools cannot deviate from this number,
hour-based, such as massage therapy, or the entire program becomes ineligible for Title IV
have historically had a rule for financial funding. In essence, the new rule amends the 150 percent
aid called the “150% Rule.” This allowed rule to 100 percent.
programs to offer more education than The ED’s reasoning for this change is based on the
their state’s minimum requirements and premise of saving the US taxpayer money. The ED believes
remain eligible to offer students federal that when a state arrives at a minimum number of required
financial aid. Essentially, if a state had education hours, the state has made a reasonable judgment ANDREA PIACQUADIO/PEXELS

a minimum-hour requirement for a about how many hours it takes to be trained and ready to
program, then a school could offer a work in a profession. Therefore, in the ED’s reasoning,
program that exceeded the minimum Title IV-financed hours in addition to that foundation
result in an unnecessary taxpayer financial burden.

14 massage & bodywork january/february 2024

WHAT WILL HAPPEN TO CLOCK-HOUR
PROGRAMS
There is no legacy clause—all massage schools across the
country with Title IV funding must align their hours
to their state minimum hours by July 1, 2024 (ABMP
believes this affects approximately 350 programs across
the US). This change is for students who start on or after
July 1, 2024. Students who start before July 1, 2024, will
remain in a program that exceeds state minimum hours
and remain eligible for Title IV funding. Schools will
have a transition period where some students in massage
programs will be subject to different hour requirements.
WHAT ARE MY SCHOOL’S OPTIONS?
If your state currently requires fewer than 600 education
hours, encourage your state legislators and regulators to
increase the required hours for licensure to the Entry
Level Analysis Project (ELAP) recommendation
of “approximately 625 hours” necessary to prepare students
for entry into the profession. (While “approximately”
has not been defined, certainly somewhere in the range
of 600–650 hours would qualify.) Currently, 23 states
require fewer than 600 hours for licensure. We can
work together to advocate for reasonable, defensible
increases to meet the ELAP recommendations across
the country. In doing so, massage programs will be
able to maintain quality curriculum offerings, while
states will align with massage profession standards.
Schools can begin the process to adjust their program
hours so they are fully compliant by July 1, 2024. If you
take this route, we recommend starting very soon because
July 2024 is only seven months away—there’s not a lot
of time to complete the various steps needed to adjust
program lengths. If a school’s current program consists
of more than 650 education hours, another downside is
that its future graduates will have a less robust massage
education.
Schools can also decide not to make changes and pull
their massage program out of Title IV funding.
WHAT ELSE CAN BE DONE?
Although the rule is final, communicating with members
of Congress can’t hurt to apply some level of pressure
on the ED. ABMP has learned of some efforts to fight
this through legislation and will share any action
steps identified to aid in supporting the effort.
ABMP members earn FREE CE hours by reading this issue! 15
If you have questions, reach
out to gr@abmp.com. For
resources and how to get
involved, visit abmp.com/
updates/legislative-updates/
massage-school-programs-
risk-across-country.
At a minimum, notifying your local representative
and senators explaining the impact of the rule change is
an appropriate first step. ABMP has created an advocacy
template to use in reaching out to your elected federal
government officials.
If you are in a state that has a high number of
educational hours, ABMP urges you to advocate
for schools in states that have fewer required hours.
Ultimately, this affects the entire profession, from barriers
to entry to licensure by endorsement processes to mobility
complications. In addition, you may wish to send a copy
of your correspondence to US Representative Lloyd
Smucker, a Republican who sits on the House Ways and
Means Committee and the Budget Committee. He is
an advocate for regulatory relief from rules that hamper
small businesses. He has introduced an amendment that, if
passed, would stop the ED from enforcing elimination of
the 150 percent standard.
ABMP intends to advocate for reconsideration of the
rule change at the federal level as well as work with states
now requiring fewer than 600 hours to seek changes
to their education requirements. ABMP’s Government
Relations team will be working with our partners and state
and federal leaders to find solutions that work for schools
and students.
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 YOUR MAGAZINE IS CE

Earn up to 3
Free CE Hours
with Each Issue
For years, members of Associated
Bodywork & Massage Professionals (ABMP)
have told us how much they value Massage
& Bodywork magazine. From keeping their
entire library of magazines to reference
before and after sessions to sharing each
issue with colleagues, members have valued
Massage & Bodywork as a long-trusted
resource in the profession. But did you

know your magazine is also a pathway
to earn up to three free CE hours?
LEARN AND EARN
Massage & Bodywork promotes
professionalism among practitioners and
stimulates healthy dialogue about the field
while remaining mindful of the breadth
of bodywork backgrounds, beliefs, and
modalities. ABMP members can earn
free CE by reading each issue of the
magazine and then taking a short quiz
about the material they read. It’s that easy.
Nonmembers can also earn up to three CE
hours with each issue for a nominal fee.
ABMP has always promoted Massage
& Bodywork as an educational tool for the
critical thinker. And since 2017, we’ve stood
behind and supported that claim by offering
CE hours with each issue.
Already filled with some of the biggest
thinkers in the profession, Massage &
Bodywork takes readers on a somatic journey.
With authors like Erik Dalton, Cal Cates,
Allison Denney, Whitney Lowe, and Ruth
Werner, the content in each issue is rich
with diverse, out-of-the-box thinking.
24,668
Total number of CE certificates
earned for M&B CE courses to date
“I love the ability to use the amazing
information in these magazines to gain
some CE (hours). I learn so much this way.”
— ABMP Member
From techniques and contraindications
to looking at anatomy through a different
lens to implementing best practices and
After the CE for each issue is
finding innovative ways to build client lists,
approved by the NCBTMB, the
there’s something for everyone in each issue.
Whether you’re preparing to see your first magazine will be
paid client or you’ve been seeing clients for posted to the ABMP
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ABMP members earn FREE CE hours by reading this issue! 17

18 massage & bodywork january/february 2024
 BLACK MASSAGE THERAPIST CONFERENCE
Inaugural Black Massage
Therapist Conference
By Davonna Willis
Editor’s note: The first Black
Massage Therapist Conference
was held October 14 in
Charlotte, North Carolina.
The event was rich with
tradition, support, learning,
and encouragement, and ABMP
was proud to be a sponsor in
attendance. What follows is
conference president Davonna
Willis’s account of the event.
The excitement was so high the weekend
of the event that it was palpable. There were
about 80 people in attendance, including
attendees, sponsors, and vendors. One
attendee traveled from Alaska, and two came from Canada,
so the conference is now international! It was amazing.
A FEW MEMORABLE MOMENTS
At one point, a massage student who recently graduated
stopped me in the hallway to tell me how grateful he
was to be sponsored by one of our “Sponsor a Student”
promotions. He was also grateful for his first massage
therapy conference being the Black Massage Therapist
Conference.
During the conference, a massage therapist who had
been following me online approached me because she
related to my journey; both of us grew up in housing
projects in New York City, had similar academic journeys,
and excelled, despite the odds. She was overwhelmed with
emotion and began to cry.
I also had the opportunity to see some massage
therapists who I networked with online and met them Note
in person for the first time. Their attendance at this 1. Oluwakemi Balogun and Ann Blair Kennedy,
conference showed how much they support me, the “Equity, Diversity, and Inclusion in the
mission, and the vision of the conference. Massage Therapy Profession,” International
Journal of Therapeutic Massage & Bodywork
13, no. 3 (August 2020): 1–5, www.ncbi.nlm.
nih.gov/pmc/articles/PMC7454234.
THE FUTURE IS BRIGHT
I see the number of conference attendees growing
every year, and I hope we continue to spread globally. Davonna Willis is a respected health
My hope is that the sponsorships, vendors, and school and wellness practitioner, an acclaimed
involvement also grow. I would like for the sponsors entrepreneur, and educator. She is a passionate
and vendors to see how this niche market is just as advocate for her clients and students. She has
important as the other massage conferences. If they can a master’s in health education and bachelor’s
put their resources toward professional development in athletic training and has more than 20 years
and business growth, both parties will benefit greatly. of experience in the health and wellness field.
I would like to see more massage corporations and You can check out 4 Nineteen’s education and
franchises get involved by sponsoring the conference and training classes at 4nineteeneducation.com.
sponsoring their Black employees to attend; according to
the 2019 US Bureau of Labor Statistics, only 8.8 percent of
massage therapists are Black.1 For more information, go to
blackmassagetherapist.com.
ABMP members earn FREE CE hours by reading this issue! 19
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20 massage & bodywork january/february 2024

 KNEAD TO KNOW

ABMP Launches Customizable

MBLEx Prep Curriculum
The recently launched MBLEx Curriculum is now
available for participating schools that want to offer
students a deeper understanding of how to think
critically and what it takes to pass the MBLEx.

This three-part prep course is easily adaptable

for instructors to fit into current curricula based
on their school’s needs and is free to ABMP
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engage students in deeper learning and critical-thinking skills.
Most Common
The MBLEx Prep Curriculum offers students program-long Website Mistakes
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tools they need to be successful learners. The curriculum is highly Websites are an incredible tool for
customizable, meaning instructors can fit lessons into established recruiting new massage clients. A
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incorporates ABMP Exam Coach and ABMP Five-Minute Muscles in to this episode of Business or
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Naprapathy most-common-website-mistakes-
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nə-ˈprap-ə-thē haines
NOUN
With influences from osteopathy and chiropractic, this
system of treatment uses soft-tissue manipulation to
release tension and balance energy flows in the body.
The practitioner uses palpation to explore the tissue,
looking for rigid, contracted areas of the body, then
begins repetitive, rhythmic thrusts to gently stretch
the contracted connective tissues. Sessions usually last
30 minutes, focusing mainly on the ligaments near the
spinal column. Diet, exercise, and postural adjustments
help improve circulatory and nervous system function.

definition from massagetherapy.com

ABMP members earn FREE CE hours by reading this issue! 21

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22 massage & bodywork january/february 2024

 FACES OF BODYWORK
Heather Massage & Bodywork: Can
you share the journey that
Topoly brought you to where you
are today? Why massage?
• Cuyahoga Falls, Ohio
Heather Topoly: I never
• Stark State College chose massage; it chose me.
I am a veteran of the US Navy
• Owner, Restorative
and served in the reserves for
Massage & Wellness
nine years. I have always been
Center, a nine- interested in the medical field.
therapist facility In the military, I was trained
as a combat corpsman; after I
got out, I became a nationally
registered EMT. After having
three children, I went back to
school to pursue a career as
a physical therapy assistant
(PTA). During that training, I
needed rotator cuff surgery
from a car accident. I was
receiving massage from a PTA
but noticed a huge difference
when the massage therapist
worked on me. I literally had
no interest in doing massage,
but thought I would study it
to help my PT patients. About
halfway through the first
semester of massage school,
I fell in love with it. I became
licensed in January 2010 and
continue to love what I do.
M&B: You offer an interesting
array of modalities. Tell us
how this tapestry wove
together over the years.
HT: I find massage to be a
puzzle, and I like when clients
leave feeling better. I intertwine
everything I have learned over
the past 15 years based on what
is needed at that moment.
ABMP members earn FREE CE hours by reading this issue! 23
Read more about
Heather and
her massage
journey at abmp.
com/updates/
blog-posts/
faces-bodywork-
heather-topoly.
I have worked in a wide range
of massage businesses,
including chiropractic, PT
clinics, corporate, and hospice.
I have spent seven years of
my career in hospice and
working in hospitals such as
the Cleveland Clinic. I found
hospice to be very rewarding,
and it changed my perspective
on life. I am trained in Reiki
II, Craniosacral 3, trigger
point, medical massage,
and some myofascial work.
The majority of my sessions
are therapeutic and clinical,
with a side of energy work.
 TECHNIQUE
THE REBEL MT
By Allison Denney

Is pressure a good thing? Is it a

bad thing? Can good pressure be
bad? Can bad pressure be good? Oh,
how I love a deeply metaphysical
question. Especially if that question
symbolizes what it’s like to work
with other humans for a living.
These quandaries are perplexing,
with layers, twists, and turns that
signal any good, thought-provoking
concept. I have answers to these
questions, but first, I want to
direct your attention to tennis.

CONSIDER THE
(METAPHORICAL) ANGLE
Coco Gauff won the US Open
women’s tennis championship in
September. She was asked how she
handled the pressure of performing
at such a high level, and her answer
was exquisite. “I realize, in a way, it’s
pressure, but it’s not,” she said. “I

Under Pressure
mean, there are people struggling to
feed their families, people who don’t know where
their next meal is going to come from, people
Implementing Perspective who have to pay their bills. That’s real pressure,
that’s real hardship, that’s real life. I’m in a very

Can Alter Results, privileged position, I’m getting paid to do what

Knowledge, and Technique
KEY POINT
• Whether it’s pressure-filled moments
during our first years as practicing
bodyworkers or the question of how much
pressure a client wants during a session,
gaining perspective is a handy tool.
I love and getting support to do what I love.
That’s something that I don’t take for granted.”
I love this answer for many reasons. Mainly,
I appreciate that it speaks to perspective.
Whether we are talking about the pressure-
filled moments during our first years as
practicing bodyworkers, when the weight of
all the newness becomes particularly heavy, or
we are highlighting the question of how much
pressure a client wants implemented during a
session, gaining perspective is a handy tool.
It’s not a groundbreaking science that requires
an advanced course to understand; it’s a basic
truth that most of us know but might have
forgotten somewhere along the way. It’s too easy
to get caught up in the details and forget the
foundations we can lean on to make progress.

24 massage & bodywork january/february 2024

 THE PRINCIPLES OF PRESSURE
Making decisions about how much pressure to apply to
soft-tissue issues—a trigger point, an old scar, a recent
injury, a tense muscle, a weak muscle—requires us to
understand the difference between good pressure and
bad pressure. This is a “pressure-filled” responsibility
in and of itself; and recognizing we are fortunate to
be in this position because what we do for a living is,
well, awesome, can alleviate some of that. But also, as
the implementor of pressure, getting to know when
the pressure you apply tips from good to bad simply
requires the understanding of basic principles.
As the implementor of pressure, getting
to know when the pressure you apply
tips from good to bad simply requires
the understanding of basic principles.
Principle No. 1
Check in with your client. I know, I know. Duh,
right? But to be clear, this is never a yes/no question.
Ask pointedly if they want more or less pressure and
if the direction of your pressure is accurate or if it
should shift a bit. Your client is your best guide.
Principle No. 2
Check in with your client. Again? Yes, again.
Pressure on the back can feel completely different
from pressure on the shins. And pressure with your
thumbs can feel worlds apart from pressure with your
elbows. Never assume all pressure is the same.
Principle No. 3
Have your client check in with themselves. Give them
some guidance toward changing their perspective.
Once the session is over, have a conversation about
how their muscles responded. Send them a text
later that day or the next day or even the following
week. Stay in communication with them. Offer
a few reminders to drop in and feel how things
might have shifted internally. This offers a lot of
information you can both use moving forward.
MAKING ADJUSTMENTS
You probably already know these principles. If you
don’t, get familiar with them and begin harnessing their
power today. If they’re already on your radar but you still
crumble a little under the weight of it all, you need to put
them into practice. This is all about getting your client
to shift their perspective and helping us gain perspective
at the same time. As Big Bird likes to say, asking
questions is a good way to find things out.
Pressure is whatever we make it out to be. For
your clients, the pressure on a sore or tense muscle
can be eye-opening. Being in a session and feeling
the work is one thing—stepping back into their
usual routines and being able to observe their
tissues is another. And for ourselves, the pressure
to know everything about anatomy, how it might
go sideways, and what we can do to help can also
be bewildering. Pressure is about perspective, and
perspective takes time to understand. Be patient
with the understanding, with your clients, and with
yourself. Like Gauff, we are so lucky to be doing what we
love for a living.
Allison Denney is a certified massage therapist and
certified YouTuber. You can find her massage tutorials
at YouTube.com/RebelMassage. She is also passionate
about creating products that are kind, simple, and
productive for therapists to use in their practices.
Her products, along with access to her blog and CE
opportunities, can be found at rebelmassage.com.
WATCH VIDEO
“FROZEN SHOULDER! — NEW
THERAPEUTIC TECHNIQUES”
ABMP members earn FREE CE hours by reading this issue! 25
 TECHNIQUE
CLINICAL EXPLORATIONS
By Whitney Lowe
Ankle Sprains
A Rehabilitation Road Map
Ankle sprains are among the most common
injuries encountered in both athletic and
general populations, affecting millions
globally every year. This pervasive injury
can significantly impact an individual’s daily
activities, athletic performance, and quality
of life. The nature of an ankle sprain, often
resulting from a sudden twist or misstep,
can lead to varying degrees of ligament
damage, pain, and functional impairment.
The ankle is a complex structure,
stabilized by an intricate network of
ligaments, tendons, and muscles, all working
together to facilitate movement and bear the
body’s weight. Massage therapists can play
an important role in treating this condition
and helping clients return to activity.
Let’s explore the key aspects of anatomy,
biomechanics, assessment, and treatment for
these common soft-tissue disorders.
ANATOMY
The ankle region is a complex structure,
incorporating bones, joints, and soft tissues
that work together to allow locomotion.
They provide strength, stability, and
flexibility essential for daily activities and
dynamic movements. Let’s delve deeper
into ankle sprains, starting with the bones.
The ankle comprises multiple joints,
with four main bones playing key roles
in ankle function: the tibia, fibula, talus,
and calcaneus (Image 1). The tibia bears
the brunt of the body’s weight, while the
fibula is a support and attachment point
for muscles. Together, they rest upon the
talus, which in turn transfers force to the
calcaneus below. This arrangement creates
26 massage & bodywork january/february 2024
Fibula
Syndesmosis joint Tibia
Talocrural joint
Talus
Subtalar joint
1
Bones and joints
that make up the
ankle complex.
Image courtesy
of Complete Calcaneus
Anatomy.
KEY POINTS
a stable yet adaptable foundation for
•Ankle sprains typically occur in one
efficient movement and shock absorption. of three areas—lateral, medial, or
Three main joints form the ankle syndesmosis.
complex: the talocrural, subtalar, and
• Massage therapy is a core
distal tibiofibular joints (Image 1). The
component for treating ankle
talocrural joint is where the tibia and sprains and is used with other
fibula meet the talus. The subtalar joint treatments used by other providers,
lies between the talus and calcaneus, such as laser therapy, ultrasound,
and the distal tibiofibular joint connects microcurrent, and electrical
the lower ends of the tibia and fibula. stimulation.
Ligaments play a crucial role in
ankle stability, spanning these joints.
The ankle ligaments are grouped into
three categories: lateral, medial, and syndesmotic. The
lateral ligaments, consisting of the anterior talofibular
ligament (ATFL), posterior talofibular ligament (PTFL),
and calcaneofibular ligament (CFL), work synergistically
to prevent foot inversion and offer lateral stability (Image
2). On the medial side, four ligaments make up the deltoid
ligament complex
(Image 3) and are referred to as the deltoid ligament;
they resist eversion. The syndesmotic ligaments, running
between the distal ends of the tibia and fibula, provide
stability and protection against forces attempting to
separate these bones (Image 3).
 Syndesmosis ligaments

ATFL
Deltoid ligament group
PTFL

2
CFL

The lateral and

syndesmotic ankle
ligaments (right foot).
Image courtesy of Lateral ligaments
Complete Anatomy.

3
The medial ankle ligaments
(right foot). Image courtesy of
Complete Anatomy.

Numerous muscles and tendons play vital roles in the

ankle’s structure and function, contributing to movement
and stability. The Achilles tendon, the largest in the body,
connects the calf muscles to the calcaneus, enabling the
powerful plantar flexion needed for propulsion. The
fibularis (peroneal) tendons, crucial for eversion and
stabilization, run along the ankle’s outer side, helping us
navigate uneven terrains. Internally, the tibialis anterior,
tibialis posterior, and flexor hallucis longus tendons assist
in various movements, support the arch, and contribute to
overall stability.
The ankle’s structure is designed for stability and
flexibility and is crucial for bearing weight and executing
various movements. A thorough understanding of this
anatomy is paramount for practitioners to accurately assess
and treat ankle sprains.
BIOMECHANICS
Anatomy helps us understand structure, but it is
also imperative that we understand the mechanical
function of these ligaments and joints. The primary
movements of the ankle are dorsiflexion and plantar
flexion, both occurring at the talocrural joint.
Typically, the ankle can move about 20 degrees in
dorsiflexion and up to 50 degrees in plantar flexion.
The ankle complex also enables inversion and eversion
movements, predominantly occurring at the subtalar
joint. Inversion involves raising the foot’s medial edge
and turning the sole inward, while eversion entails lifting
the lateral edge and turning the sole outward. These
movements are essential for navigating uneven surfaces
and maintaining stability during dynamic activities.
Understanding ankle
biomechanics will direct your
treatment and rehabilitation.
The ankle distributes forces in specific
patterns during various activities. For
instance, walking begins with a heel strike,
transitioning forces through the ankle as
the foot flattens and the body’s weight
moves forward. The forces peak during
push-off, demanding substantial plantar
flexion strength and stability. Running
intensifies these forces, requiring enhanced
shock absorption upon landing and more
powerful propulsion during push-off.
Ligaments and tendons in the ankle play
pivotal roles in joint stabilization, while
muscles manage the force production.
Ankle sprains can lead to pain and
instability, significantly impacting smooth
and efficient movement. Therefore,
understanding ankle biomechanics will
direct your treatment and rehabilitation.

ABMP members earn FREE CE hours by reading this issue! 27

ANKLE SPRAINS DEFINED
A sprain refers to the tensile (pulling)
stress injury of a ligament, thus, it’s an
overstretching or tear in one or more of
the ligaments connecting the ankle joints.
Sprains are usually graded in one of three
levels: first-degree (mild), second-degree
(moderate), or third-degree (severe).
Ankle sprains typically occur in one of
three areas—lateral, medial, or syndesmosis,
all of which have ligaments we previously
identified. Grasping the intricacies of
each type will help you deliver effective
treatment and aid optimal recovery.
Lateral Ankle Sprains
These are the most frequently occurring
ankle sprains, generally caused by
excessive inversion or a combination
of inversion and plantar flexion. Such
movements can put undue stress on the
lateral ligaments, potentially leading
to injury. The involved ligaments here
are the ATFL, PTFL, and CFL.
The ATFL, being the most vulnerable,
is usually the first to get injured due to its
relative weakness and its susceptibility to
stress during inversion and plantar flexion.
The CFL comes next in vulnerability, as
it provides stability in both neutral and
dorsiflexed positions. The PTFL, being
the most robust of the three, is infrequently
injured. Symptoms of a lateral ankle sprain
may range from pain, swelling, and bruising
to instability, with severity depending on
the sprain’s grade.
Medial Ankle Sprains
These sprains are rarer and typically
involve the deltoid ligament complex, often
resulting from an outward turning of the
foot or a traumatic force to the outer part
of the ankle. Given the deltoid ligament’s
strength, a considerable force is usually
required to cause a medial ankle sprain.
28 massage & bodywork january/february 2024
4
Friction applied to the
anterior talofibular
ligament.
The deltoid
ligament group
provides extensive
support to the
ankle’s medial side, and injuries here may
occur alongside fractures or other more
severe injuries. Symptoms can include pain,
swelling, and tenderness along the inner
ankle, dependent on the extent of ligament
damage.
Syndesmosis Sprains
Also referred to as high ankle sprains,
these affect the syndesmosis joint
above the commonly injured lateral
and medial ligament groups. While
less common, they tend to be more
severe and require longer recovery.
High ankle sprains usually stem from
rotational forces or a forceful widening of
the ankle, such as from a planted foot and a
twisting body, or an impact that forces the
ankle into dorsiflexion and eversion. These
incidents can disrupt the syndesmosis joint,
potentially resulting in instability between
the tibia and fibula.
Symptoms may include pain during
dorsiflexion or when compressing the sides
of the lower leg, as well as tenderness along
the syndesmosis. Given the potential for
long-term instability resulting from these
injuries, thorough evaluation and careful
management are imperative.
ASSESSING ANKLE SPRAINS
Conducting a detailed soft-tissue assessment
will help you clarify the specifics of the
sprain and develop an effective treatment
plan. It’s important not to underestimate the
role of assessment in injury evaluation. Even
with a diagnosis, your treatment will be far
more efficient and direct if you know what
tissues are involved and how. The process
does not need to be time intensive; just a
few quick evaluation methods can pinpoint
where and how you need to apply your care.
Using various assessment techniques
not only aids in identifying the affected
ligaments, but it also sheds light on the
ankle’s overall health so you can customize
the intervention.
The evaluation process begins with
history-taking and involves collecting
detailed information about the injury’s
occurrence, the pain’s characteristics, and
any prior injuries to the area. In particular,
you will want to explore the injury
mechanics—was there a twisting motion, a
direct blow, or an awkward landing? These
details offer insights into which ligaments
may be compromised.

Visual examination can reveal
signs of swelling, bruising, and skin
color changes, while palpation aids in
identifying areas of tenderness and
evaluating ligament integrity. The
subsequent physical examination,
including range of motion and
resistance testing, should help narrow
down the affected ligaments and
their contribution to the pain. For
example, during both active and passive
movements, any motion that further
stretches the ligament is likely painful.
This assessment will also help you
differentiate ankle sprains from other
soft-tissue injuries.
In addition to these techniques,
special orthopedic tests can provide
further insights. Tests such as the
anterior drawer test, targeting the
ATFL, and the talar tilt test, focusing on
the CFL, can be instrumental in confirming
the presence and gauging the severity of
ligament injuries.
TREATMENT STRATEGIES
Crafting an effective treatment plan for
an ankle sprain should evolve directly
from the information gathered during
the assessment process. A multifaceted
approach is most effective in treating ankle
sprains and combines immediate care
strategies, manual therapy, rehabilitative
exercises, and advanced treatment options
when necessary. Massage therapy is a core
component for treating sprains. It can be
used with other treatments used by other
providers, such as laser therapy, ultrasound,
microcurrent, and electrical stimulation.
RICE Protocol
The rest, ice, compression, and elevation
(RICE) protocol is the widely accepted
initial protocol for the acute phase of
ankle sprains. The acute injury stage
covers the first 48–72 hours after injury.
In the early stages, immediately after
the injury, ice has analgesic effects and
reduces initial swelling. However, research
indicates that prolonged use of ice can
interfere with, and slow, healing. Rest,
compression, and elevation are necessary
to start the healing process. Nonsteroidal
anti-inflammatory drugs (NSAIDs) are
often used at this stage. Practitioners
should avoid treating the region if it is
still in an acute inflammatory phase.
Manual and Massage Therapy
Massage or soft-tissue treatments are
core, indispensable components of
any ankle sprain treatment regimen,
offering a range of benefits. These
begin after the acute phase.
Post-strain discomfort is often a result of
excess fluid in the area that presses on nerve
endings and fills the interstitial spaces.
Light massage will reduce this swelling.
Gentle stroking in a proximal direction
aids lymphatic drainage in the area, which
reduces excess tissue fluid and decreases
pain.
Swelling can persist for several weeks
post-injury. Do not wait until the visible
swelling is gone or you will miss the
ideal window of opportunity for injury
rehabilitation. Massage techniques can be
delivered in moderation, even if chronic
swelling persists. Just use caution and work
within your client’s tolerance.
As the swelling begins to subside, deep
transverse friction at the injury site will
aid in repairing ligament tissue damage,
in part by stimulating fibroblast activity.
In addition, deep transverse friction plays
a role in mobilizing the ligament and
preventing it from adhering to adjacent
tissues. This friction is typically performed
in a direction that is perpendicular to the
direction of the ligament’s fibers (Image 4).
In addition to the foot, the lower leg
muscles are treated, especially if they are in
a protective spasm following the injury. For
example, after an inversion sprain, there is
usually tightness in the peroneal muscles—
the muscles are likely to become hypertonic.
ABMP members earn FREE CE hours by reading this issue! 29
CLINICAL EXPLORATIONS
Not everyone experiences the same rate of
injury healing. Someone with scar tissue
from an older injury could take longer to
regain proper functional movement than
someone with a recent sprain.
It is essential to achieve early
mobilization in the area for the most
beneficial healing. But because passive
movement runs the risk of overstretching
the damaged tissue, active movement is
preferable, especially in the early stages.
The client is unlikely to perform movements
that hurt too much, so active movement is
self-limiting and not likely to cause further
damage. It is helpful to stretch muscles that
might also be in protective spasm. Leave
stretching for the later recovery stage to
develop healthy and functional movement.
Finally, rehabilitative exercise is a
cornerstone of ligament sprain recovery. A
pivotal aspect of preventing further sprains
and ensuring safe ligament healing involves
enhancing proprioceptive awareness and
strengthening the surrounding muscles.
This is typically conducted in physical
therapy sessions, using tools like a wobble
board.
CONCLUSION
Ankle sprains are among the more
frequently seen injuries in the massage
clinic. Massage has a core role in
their treatment. We can significantly
contribute to our client’s recovery
by making our care as informed and
efficient as possible. Not only will the
client return to function quicker, but
they will also endure less pain.
Whitney Lowe is the developer and
instructor of one of the profession’s most
popular orthopedic massage training
programs. His text and programs have
been used by professionals and schools
for almost 30 years. Learn more at
academyofclinicalmassage.com.
 TECHNIQUE
THE SOMATIC EDGE
By Til Luchau and Jeffrey Bramhall

The Brain in Bodywork

Your client’s brain is an always-on
Unlocking the Power of prediction machine. That’s not to say
that it’s always whirring away generating
Predictive Coding weather reports or stock forecasts during
their bodywork session (at least, we hope
it isn’t). Instead, your client’s brain is busy
predicting every detail of their bodywork
experience—from how your touch feels
to them to how comfortable they are on
your table to their sense of the session’s
overall helpfulness (or lack of it).
Retina The concept of predictive coding
suggests your client’s actual in-the-
moment sensory information plays only
a minor role in their brain’s formation
of its perceptions and impressions about
Fovea
centralis your work. The majority of our internal
experience, predictive coding says, is
shaped by matching tiny snippets of in-the-
Blind spot moment sensory data (the pressure of your
touch, for example), with past experiences
(have I felt something like this before?),
contextual cues (in a place or relationship
like this?), all flavored by autonomic
predispositions (did I come in feeling

1 Your brain “predicts” much of what you see with your eyes. The pinpoint-sized fovea centralis is
the only portion of the retina that sends detailed information to your brain. This tiny field of vision,
about the size of a dime held at arm’s length, is all the brain needs to extrapolate (or predict) the
clarity with which you “see” your entire visual field.
relaxed and safe, or on-alert and watchful?).
Visual perception provides a fascinating
example of how prediction forms our
perceptive experience. Your eye sends
detailed information to your brain from
just a tiny portion of your retinal field—as
a result, your brain “sees” only a very small
area (it’s about the size of a dime held at
arm’s length) with any clarity. But this bit
KEY POINTS of detailed vision (relayed from the eye’s
• A client’s sensations and experience in a session pinpoint-size fovea centralis, to be precise) is
likely have more to do with their brain’s sensory all your brain needs to extrapolate or predict
predictions than about what we actually do with our the subjective clarity with which you “see”
hands. your entire visual field (Image 1). The brain
• We can use this principle to help shift our clients’ accomplishes this by “remembering” the
habitual tension, pain, or movement challenges by details of what it saw or expected to see in
working with them to help their brains discover new other visual areas, and then reassembling
experiences and update its predictions. these into the prediction that we experience
as our central and peripheral fields of vision.

30 massage & bodywork january/february 2024

 What’s more, the brain also predicts the sensory Interventions that actively involve the
information it expects in your retinal blind spot—the client can even more powerfully disrupt and
portion of your visual field where the optic nerve exits rewire habitual sensory predictions. Inviting
and where there are zero light-sensitive cells. If our your client to slowly and actively explore
brains didn’t do visual predicting as well
as they do, we wouldn’t be able to drive
a car, find our keys, or read an article.
In his book The Body Keeps the Score,
When the brain fails to update
psychiatrist and trauma researcher Bessel its predictions, those attempts
van der Kolk writes, “The most important
job of the brain is to ensure our survival . at preparatory protection
. . everything else is secondary.”1 Though based on our past can become
he was writing about the brain and trauma,
the concept applies to predictive coding self-perpetuating and self-
as well. Predictions are our brain’s way of
preparing us for what might happen next,
fulfilling sources of real pain
so we can be ready to keep ourselves safe. in our present-day lives.
Chronic pain may be an example of
this preparation going tragically wrong.
In her book How Emotions Are Made, neuroscientist the range of motion that doesn’t cause them
Lisa Feldman Barrett makes the case that chronic pain pain, within the safe context of your hands-
may result from our brain’s (predicted) present-day on work, helps add new, nonthreatening
sensory predictions based on past injury or stress.2 options to their repertoire of movement
When the brain fails to update its predictions, those predictions. A practice example: Clients
attempts at preparatory protection based on our often respond well to the invitation to gently
past can become self-perpetuating and self-fulfilling “explore the corners” (the places they don’t
sources of real pain in our present-day lives. usually go) of their usual movement range.
Each time a client goes into one of these
new kinesthetic “corners” with curiosity
HOW YOU CAN USE IT and attention, the experience refines their
As bodyworkers, we can use these ideas to introduce a proprioceptive awareness and provides
sense of possibility and relief to our clients. For example, more possibilities for safety and ease.
clients with shoulder pain will often feel better when a Following are a few more ways to bring
practitioner gently, skillfully, and patiently moves them the power of predictive coding into your
through a pain-free range of motion—you can think of this treatment room.
as disrupting their brain’s prediction habits. The clients’
brain now has a new piece of information about their Pre-Session: Your Assessment
shoulder movement—that it is possible to move without Can Also Be a Treatment
pain. When this learning is integrated, this new possibility When a client tells you about a
becomes part of the set of expectations that inform their movement limitation during your intake
ongoing shoulder experience. This may be one reason conversation, ask them to demonstrate
why clients report significant improvements in their pain, the limited movement. Often, they will
kinesiophobia, and guarding as a result of the “simple” move quickly as they show it to you. If we
interventions we typically perform as hands-on therapists. invite them to slow down and describe
the sense of limitation using sensory

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32 massage & bodywork january/february 2024
 THE SOMATIC EDGE

language (bony, muscular, sharp, dull, etc.), not only

can we get intuitive clues about how to “get hold” of
that limitation, but their experience itself will often
change because of their exploration and description.

During Session: Recruit Your Client as a Partner

A client’s feedback and active participation during your
work can give you clarity on what has been effective so far
and what still needs to be done. Something as simple as
drawing a client’s attention to a side-to-side comparison
of proprioceptive sensation (“What difference do you
feel between this and that?”) can enrich and refine their
felt experience and help them take on new information.

Post-Session: Integrate the Changes

This could be the most important tool in your toolbox.
Save a few minutes at the end of a session to help your
client register and integrate their new experiences. This
could mean returning to any movements discussed
during your intake conversation or suggesting a
slow walk around your treatment room, letting
whatever has changed come to light.
In each of these cases, we draw our client’s attention to
how they feel right here and now. This attention causes the
brain to update its predictions based on new information.
These updated predictions can then become part of
what our client experiences as available and possible.
BRINGING IT TOGETHER
Predictive coding gives us a framework to understand one
way that our work offers the benefits it does. It also invites
us to bring our clients on board as active participants
in the work we do together. By shifting our orientation
from doing things to our clients in order to change them
toward working together with them to shift their habitual
predictive coding, we help our clients feel empowered
and at ease in the felt experience of their lives.
Notes
1. Bessel A. Van der Kolk, The Body Keeps the Score:
Brain, Mind and Body in the Healing of Trauma
(New York, NY: Penguin Books, 2015).
Til Luchau is the author of Advanced
Myofascial Techniques (Handspring
Publishing), a Certified Advanced Rolfer,
and a member of the Advanced-Trainings.
com faculty, which offers online learning and
in-person seminars throughout the US and
abroad. He and Whitney Lowe cohost the
ABMP-sponsored The Thinking Practitioner
podcast. He invites questions or comments
via info@advanced-trainings.com and
Advanced-Trainings’ Facebook page.
Jeff Bramhall developed and practices
nervous system-centered bodywork at
Just Breathe Manual Therapy in Arlington,
Massachusetts, and is certified in advanced
myofascial techniques. He is on the faculty of
the Massage School in Boston, where he finds
great joy in introducing our profession to the
next generation of therapists. Reach out to
him at jeff@justbreathemanualtherapy.com.

2. Lisa Feldman Barrett, How Emotions Are Made: The

Secret Life of the Brain (Boston: Mariner Books, 2018).

ABMP members earn FREE CE hours by reading this issue! 33

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 The Suboccipitals:
Small Muscles,
Big Impact
ee of Head Pai
Fr n
L ife
A

By Erik Dalton, PhD

36 massage & bodywork january/february 2024

A
mong the intricate tapestry of bones,
muscles, tendons, ligaments, and fascia exist
eight structures that have long captivated
the attention of massage therapists and
bodyworkers. At the juncture where the spine meets
the skull, the suboccipital muscles play a pivotal role
in our daily lives. Along with the inner ear’s vestibular
system, they help keep our gaze level with the horizon
while facilitating the fine-tuned movements that
allow us to nod “yes” to life—or look at the stars.
The suboccipitals are a testament to the
sophisticated design of our anatomy and the delicate
interplay between structure and function. Their
location, intimately close to vital neurological
pathways, means that disturbances here can reverberate
throughout the body. Therefore, part of the fascination
of the suboccipitals lies in the stories they tell our hands
about a client’s life. When we touch these muscles, we
glean insights into how this person sits at their desk,
cradles their phone, or stands in conversation with a
group of friends. The suboccipitals help us understand
the burdens a person carries, both physically and
metaphorically.
Let’s delve deeper into the mystique of the
suboccipitals to better understand these small muscles
and their huge importance to a life free of head pain.

KEY POINTS
• The suboccipital muscles play a unique role in
head-righting reflexes because of their high density
of muscle spindles.
• Releasing tension in tight suboccipitals and creating
the opportunity for proper atlas and axis alignment
becomes an important goal when clients report head
and neck pain.

ABMP members earn FREE CE hours by reading this issue! 37


SUBOCCIPITAL ANATOMY
AND PHYSIOLOGY
Most massage therapists know that the
suboccipital muscles reside at the base of
the skull, where they orchestrate delicate
movements of the head and help stabilize
the atlanto-occipital (OA) and atlantoaxial
(AA) joints (Image 1). These paired muscles
are the rectus capitis posterior major, rectus
capitis posterior minor, obliquus capitis
superior, and obliquus capitis inferior.
Rectus capitis posterior major originates
from the spinous process of the axis and
inserts into the lateral part of the inferior
nuchal line of the occipital bone. It assists
in extending the head at the OA joint and
ipsilateral head rotation.
Rectus capitis posterior minor originates
from the posterior tubercle of the atlas and
inserts into the medial part of the inferior
nuchal line of the occipital bone and the
neighboring part of the occipital bone
below this line. It helps in extending the
head at the OA joint and assists in ipsilateral
rotation of the head.
Obliquus capitis superior originates
from the transverse process of the atlas and
inserts into the lateral portion of the inferior
nuchal line of the occipital bone. Obliquus
capitis superior assists in extending the head
at the OA joint and lateral head flexion.
Obliquus capitis inferior originates
from the spinous process of the axis and
passes laterally, slanting upward to insert
on the transverse process of the atlas. It
is the most laterally placed among the
suboccipital muscles and the only “capitis”
muscle that does not attach to the skull.
The obliquus capitis inferior muscles
function in rotation at the AA joint.
In an optimal head and neck position,
the ear (external auditory meatus) generally
aligns vertically over the shoulder’s
38 massage & bodywork january/february 2024
Rectus capitis
posterior major
1
Rectus capitis Obliquus capitis
posterior minor superior
The suboccipitals
orchestrate delicate
movements of the
head and contain
a high density of
muscle spindle
proprioceptors.
Obliquus capitis
inferior
acromion, and
the cervical spine
assumes a natural
lordotic curve that properly distributes
the head’s weight across the cervical
vertebrae. Unfortunately, modern
lifestyles of people hunched over
computers or smartphones promote
forward-head postures (Image 2).
A forward-head posture causes an
anterior shift of the head out of neutral
alignment. The lower cervical vertebrae
flex forward, causing the upper cervical
segments to hyperextend. This posture
has several negative consequences,
including stress on facet joints and
intervertebral discs, a compressed chest
cavity and reduced lung capacity, neural
2
impingement, and the altered position At right, we see an optimal head position
with the external auditory meatus aligned
of the shoulder girdle. vertically over the shoulder’s acromion. At
The suboccipital muscles experience left, we see a forward-head posture, which
causes an anterior shift of the head, placing
excessive strain. As the head moves
excessive strain on the suboccipitals and
forward relative to the spine, the other structures.
chin juts out. The head feels heavier
to the structures responsible for
supporting it because the head’s center of
gravity has shifted (Image 3). Now, the
posterior neck muscles must work harder
to keep the eyes level. Sustained isometric
contraction in the suboccipital muscles
causes joint compression and, over time,
may cause damage to the articular
3
cartilage of the OA condyles. We’ll
find that a forward-head posture is a
primary contributor to the suboccipital- As the head moves forward relative to the
related conditions we discuss here. spine, it feels heavier to the structures
responsible for supporting it because the
head’s center of gravity has shifted.
THE SUBOCCIPITALS AND DIZZINESS
Spin on a dance floor or step onto the
tilting deck of a sailboat and imagine
what would happen to your body if head-
righting reflexes didn’t help you maintain
your equilibrium. When the head moves or
changes its orientation relative to gravity,
the suboccipitals and the vestibular system
of the inner ear work in tandem to provide
accurate feedback to the brain. Head-
righting reflexes are crucial for maintaining
the head’s orientation in space and keeping
the eyes on a horizontal plane irrespective
of the body’s position. A level head and
stable visual field are essential for accurately
judging distances and throwing objects or
engaging in the complex motor movements
used to participate in daily activities.
The suboccipital muscles play a unique
role in head-righting reflexes because
of their high density of muscle spindles.
Massage therapists will remember these
sensory receptors located within muscle
fibers are sensitive to changes in muscle
length and velocity (the rate at which
muscle length changes). They are integral
to balance, coordination, and the body’s
innate sense of self in space. The dense
concentration of muscle spindles in the
suboccipitals (compared to other muscles of
similar size) suggests a highly specialized
role in proprioception and the fine-tuning
of head movements.
Researchers found that chronic forward-
head posture results in functional and
structural changes in the suboccipital
muscles. Except for obliquus capitis inferior,
which acts in head rotation, the suboccipitals
undergo the most significant shortening of
the occipital extensors. These changes in
length influence the binding action between
actin and myosin filaments, reducing the
ability of these muscles to generate force
(strength) and resist fatigue (endurance).
Over time, the rectus capitis posterior major
and minor muscles atrophy, causing adipose
cells to accumulate within the muscle tissue
(myosteatosis). When adipose replaces muscle
tissue, it reduces the density of muscle
spindles, resulting in inaccurate positional
signaling to the brain.
Cervicogenic pain often relates to
hypertension or spasms in the muscles
that create the suboccipital triangles.
Altered proprioception in the
suboccipitals disrupts the normal function
of head-righting reflexes, causing dizziness
and issues with balance and coordination.
When the brain gets confusing signals
about the head and body position, it may
splint the cervical spine with protective
muscle spasms, contributing to neck pain
and headache.
THE SUBOCCIPITALS AND
CERVICOGENIC HEADACHES
4
Cervicogenic headache is a general term for The obliquus capitis superior muscles
head pain originating from cervical spine form the superior borders of each
suboccipital triangle. The obliquus
disorders. Cervicogenic pain often relates capitis inferior muscles form the inferior
to hypertension or spasms in the muscles borders, and the rectus capitis posterior
major forms the medial borders.
that create the suboccipital triangles.
The suboccipital triangles are formed
on either side of the upper cervical spine
by the arrangement of three suboccipital
muscles (Image 4). The obliquus capitis
superior muscles form the superior borders
of each triangle. The obliquus capitis
inferior muscles form the inferior borders,
and the rectus capitis posterior major
forms the medial borders. The suboccipital
triangles act as a space for the passage of
the vertebral arteries and the suboccipital
nerves. The suboccipital nerves are motor
nerves that don’t produce pain sensations.
However, several nerves that exit the upper
5
cervical complex travel near the suboccipital
triangles, where tight or spasming Tight or spasming suboccipital
muscles can compress the greater
suboccipital muscles might compress them, occipital nerve, causing pain. The nerve
causing headache pain. originates from the C2 spinal nerve root
and passes the suboccipital triangle
For example, occipital neuralgia is a near its apex before continuing up to
neuropathic pain syndrome characterized innervate the skull.
by sudden and severe stabbing pain in
the distribution area of the occipital
nerves. The etiology of occipital neuralgia
ABMP members earn FREE CE hours by reading this issue! 39
is multifactorial and may include
inflammation of the occipital nerves
because of rheumatoid arthritis, diabetes,
direct trauma, or other causes. However,
compression of the nerves by tight muscles
in the neck is often a factor (Image 5).
Consider that the greater occipital nerve
originates from the C2 spinal nerve root.
It emerges between the atlas and axis and
ascends upward. As it travels, it pierces
the semispinalis capitis muscle and then
crosses the suboccipital triangle near its
apex. After passing the triangle, the nerve
continues upward to innervate the scalp up
to the vertex of the skull. Tight or spasming
suboccipital muscles can compress the
nerve, causing pain.
Hypertonicity or spasm in the muscles
of the suboccipital triangle may also lead
to minor compression of the vertebral
artery, reducing blood flow to the brain and
resulting in lightheadedness and dizziness.
Another type of cervicogenic condition
is stomach sleeper’s headache. It occurs
because stomach sleepers typically turn
their head to one side to breathe. As we’ve
discussed, the obliquus capitis inferior
muscles arise from the spinous processes
of the axis and insert on the transverse
processes of the atlas. The primary function
of the obliquus capitis inferior muscles
is head-on-neck rotation. With stomach
sleeping, one obliquus capitis inferior muscle
remains shortened while the other remains
lengthened for a prolonged period.
Ideally, the atlas vertebra rotates with
the head, but with a shortened obliquus
capitis inferior, the atlas drags the axis with
it. So, when the stomach-sleeping client
rises from bed and attempts to rotate their
head to neutral, the affected obliquus capitis
inferior muscle spasms, fixing the atlas on
the axis. If a person forces their head to
rotate, the joint jamming moves down the
chain to C3, causing the brain to splint the
area with protective muscle guarding and
amplifying pain.
40 massage & bodywork january/february 2024
SPINAL MENINGES
• Dura mater
• Arachnoid
• Pia mater
Spinal nerve
Spinal cord
Posterior
longitudinal
ligament
6
The dura mater is the
THE SUBOCCIPITALS AND DURAL TORSION outermost, thickest, and
toughest layer of the
The dura mater (dura) is the outermost, thickest, and meninges—a membrane
toughest layer of the meninges. Massage therapists that covers and protects
will remember that the meninges are three layers the brain and spinal cord
(you’ll recognize the
of membrane that cover and protect the brain and meninges as the white
spinal cord and separate them from their bony covering over the yellow
nerves). Tension in the
cases, the skull and vertebral column (Image 6). rectus capitis posterior
Superiorly, the spinal dura attaches to the major and minor translates
directly to drag on the dura.
circumference of the foramen magnum and the posterior
longitudinal ligament. The foramen magnum is the large,
oval-shaped opening in the skull’s occipital bone. The
spinal cord passes through the foramen magnum as it exits
the cranial cavity. The posterior longitudinal ligament
connects and stabilizes the bones of the spinal column. It
runs adjacent to the spinal cord almost the entire length of
the spine from the axis to the sacrum.
Inferiorly, the spinal dura extends below the spinal cord
termination to end at S2, becoming a thin cord known
as the coccygeal ligament anchoring the dural sac to the
sacral periosteum.
Several anatomical asymmetries can place excessive
tension on the dura, including scoliosis, hyperkyphosis,
hyperlordosis, or a sacrum that’s rotated, tilted, shifted
anteriorly, or shifted posteriorly. As you’ve probably
guessed, alterations in the alignment and kinematics of
the OA and AA joints and the muscles that cross them can
overstretch and torque the dura.
For example, a forward-head posture causes notable
hypertonicities in the rectus capitis posterior major and
minor. Interestingly, these muscles form a myodural bridge
or specific soft-tissue connection to the posterior atlanto-
 occipital membrane and the dura mater. As a
result, tension in the rectus capitis posterior
major and minor translates directly to drag
on the dura. Consider how asymmetries
at both the top and bottom of the spinal
column create multiple points of tension,
torque, or drag that amplify an overstretch
on the dura. Several things can happen:
• An overstretch of the dura can alter the
intensity and frequency of nerve signals to
and from the brain.
• When the dura is under stress, some of
its cells release chemicals that heighten
pain perception and increase tissue
inflammation.
• Overstretched dura may compress
branches of the trigeminal and upper
cervical nerves, leading to referred pain in
areas these nerves supply.
• The dura plays a role in the containment of
cerebrospinal fluid (CSF), so compression
can interfere with CSF dynamics.
Releasing tension in tight suboccipitals
and creating the opportunity for proper
atlas and axis alignment becomes an
important goal when clients report head and
neck pain.
MICHELA RAVASIO/STOCKSY
A HOLISTIC APPROACH TO
SUBOCCIPITAL DYSFUNCTION
Most massage therapists know that those with a
forward-head posture may be suffering from a
common muscle imbalance problem called upper
crossed syndrome (UCS). In the late 1980s, famed
neurologist and researcher Vladimir Janda, MD, and
his team at Charles University in Prague, found that
when stressed, some muscles tighten and become
neurologically facilitated (tight), while others become
weak and inhibited. They also found that these muscle
imbalances formed a predictable forward-head carriage.
In an upper cross pattern, the upper trapezius and
levator scapula are tight and the neck flexors (anterior
scalene, longus capitis, longus colli) are inhibited. Tight
pectorals are accompanied by inhibited rhomboids and
serratus anterior muscles. Along with a hypertonic upper
trapezius and levator scapula, a client with a forward-head
posture and contracted suboccipitals is likely to exhibit
a hypertonic splenius capitis, semispinalis capitis, and
splenius cervicis.
Our session outcomes won’t be effective if we work
exhaustively on the suboccipitals, ignoring the other
muscles involved in an upper cross pattern. For this reason,
myoskeletal alignment technique (MAT) takes a holistic
approach to the cervical region.
One of the systems MAT employs is the use of
thoughtfully crafted routines. In manual therapy, a
routine is a series of carefully chosen
techniques delivered to body regions
in a specific sequence to achieve
defined outcomes. MAT routines
take the guesswork out of treating
many conditions because they
integrate massage with movement
strategies like graded exposure
stretching, nerve gliding, and nerve
tensioning, creating a comprehensive
and inclusive treatment protocol.
The repeated application of a
particular routine often corrects the
core biomechanical issues at play in a
particular musculoskeletal pathology,
resulting in significant improvements
for clients with moderate to severe
symptoms. When a client requires
additional specialized methods,
MAT uses orthopedic assessment
to help therapists choose targeted
techniques.
ABMP members earn FREE CE hours by reading this issue! 41

Opening Neck Stretch
Trap Hook
Cervical Decompression
42 massage & bodywork january/february 2024
I’ll share eight techniques from the much
longer MAT cervical routine for this article.
Incorporate these methods into your neck
massage to bring greater focus to the OA and AA
joints and the suboccipital muscles. Use these
techniques to prevent dysfunction in healthy
necks and as a treatment for clients who exhibit
upper cross syndrome or forward-head postures.
8 MAT TECHNIQUES FOR
THE CERVICAL REGION
Opening Neck Stretch
This technique softens the posterior and
lateral cervical soft tissue. First, stand on the
client’s right with your left hand on the client’s
forehead and your right hand draped over and
around the client’s lateral neck. Establish a
counterforce as your right hand (and extended
arm) gently pulls the soft tissue of the client’s
neck anteriorly. At the same time, your left
hand resists the client’s right head rotation.
As you continue this rhythmic maneuver, curl
your fingers to hook the suboccipitals and pull
them anteriorly to work across their fibers.
Repeat this stretch on the opposite side.
Trap Hook
This technique helps release a hypertonic
upper trapezius. Cradle the client’s head with
your right hand and gently move it into right
side bending and rotation. Use your left hand
in a soft fist to hook the upper traps and drag
the tissue laterally as you continue to move
the client’s head into right side bending and
rotation. Make two to three passes and then
repeat this technique on the opposite side.
Cervical Decompression
This maneuver tractions the client’s neck
to decompress the cervical joints. Lift the
client’s head to slide your right forearm under
the client’s neck with your palm up. Use
your left hand to brace the client’s forehead.
Pronate your forearm using your radius to
hook the tissue while continuing to brace
the client’s forehead. Return your arm to the
starting position by supinating your forearm
and repeat this movement for two minutes.
Move to the client’s left side and repeat the
technique for an additional two minutes.
OA Chin Tuck
This procedure mobilizes the OA joint and
stretches the suboccipitals. Standing at the
head of the therapy table, slide your right
hand under the client’s head to cradle their
head. Use your left hand to brace the client’s
forehead. Ask the client to tuck their chin to
their chest. With your elbows extended and your
hands fixed, step to your left foot and apply a
gentle two-second overpressure that places a
stretch on the suboccipitals and encourages the
occipital condyles to glide posteriorly. Work
within the client’s comfort zone and repeat the
chin tuck three or four times. Reverse your
hand position, step onto your right foot, and OA Chin Tuck
repeat the technique three or four times.

Atlas-Axis Technique
This technique stretches the obliquus capitis
inferior and frees the AA joint. With your left
hand, lift the client’s head to flex their neck
to 45 degrees and stabilize their head in this
position with your right hand on their forehead.
Visualize a pole running straight through the
client’s head and neck. Maintain this 45-degree
position throughout this technique because
it ligamentously locks C2 through C7 and
allows you to isolate atlas-axis rotation.
Slowly rotate the client’s head to the right
and back to the left. If the client’s movement is
restricted in right rotation, turn their head until
you meet their first restrictive barrier, then back
Atlas-Axis Technique
off slightly. Ask the client to turn their head
gently to left rotation against your resistance to
a count of five and then relax. Take their head
back into right rotation to the next restrictive
barrier, back off slightly, and repeat this process
up to five times. If the client’s movement is
restricted in left rotation, turn their head to the
left and repeat the appropriate steps above from
that position.

Suboccipital Release No. 1

This rhythmic, soothing technique releases the
suboccipital muscles. With your curled finger
pads, grasp the lateral suboccipital muscles on
both sides of the client’s neck. As you step onto
your left foot, your fingers pull superiorly on
the suboccipitals on the left. As you step onto
your right foot, your fingers pull superiorly on Suboccipital Release No. 1

the suboccipitals on the right. Repeat this back-

and-forth movement for two minutes or longer.

ABMP members earn FREE CE hours by reading this issue! 43

 resources
Chu, E. C. P., F. S. Lo, and A. Bhaumik.
“Plausible Impact of Forward
Head Posture on Upper Cervical
Spine Stability.” Journal of Family
Medicine and Primary Care 9,
no. 5 (May 31, 2020): 2517–20.
https://pubmed.ncbi.nlm.nih.
gov/32754534.
Comerford, M. J., and S. L. Mottram.
“Movement and Stability
Dysfunction—Contemporary
Developments.” Manual Therapy
6, no. 1 (February 2001): 15–26.
https://pubmed.ncbi.nlm.nih.
gov/11243905.
Enix, D. E., F., Scali, and M. E. Pontell.
“The Cervical Myodural Bridge: A
Review of Literature and Clinical
Implications.” The Journal of the
Canadian Chiropractic Association
58, no. 2 (June 2014): 184–92.
https://pubmed.ncbi.nlm.nih.
gov/24932022.
Hallgren, R. C., et al. “Forward
Head Posture and Activation of
Rectus Capitis Posterior Muscles.”
Journal of Osteopathic Medicine
117, no. 1 (January 2017): 24–31.
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https://pubmed.ncbi.nlm.nih.
gov/28055084.
Karwacki, G. M., and J. F.
Schneider. “Normal Ossification
Patterns of Atlas and Axis: A
CT Study.” American Journal
of Neuroradiology 33, no.
10 (November 2012): 1882–7.
https://pubmed.ncbi.nlm.nih.
gov/22576894.
Khayatzadeh S., et al. “Cervical
Spine Muscle-Tendon Unit
Length Differences Between
Neutral and Forward Head
Postures: Biomechanical
Study Using Human Cadaveric
Specimens.” Physical Therapy
97, no. 7 (July 2017): 756–66.
https://pubmed.ncbi.nlm.nih.
gov/28444241.
McPartland, J. M., R. R. Brodeur,
and R. C Hallgren. “Chronic
Neck Pain, Standing Balance,
and Suboccipital Muscle
Atrophy—A Pilot Study.” Journal
of Manipulative Physiotherapy 20,
no. 1 (January 1997): 24–9. https://
pubmed.ncbi.nlm.nih.gov/9004119.
january/february 2024
Offiah, C. E., and E. Day. “The 2010): 7–12. https://pubmed.ncbi.
Craniocervical Junction: nlm.nih.gov/20173531.
Embryology, Anatomy,
Sung, Y-H. “Upper Cervical Spine
Biomechanics and Imaging
Dysfunction and Dizziness.”
in Blunt Trauma.” Insights Into
Journal of Exercise Rehabilitation
Imaging 8, no. 1 (February 2017):
16, no. 5 (October 2020): 385–91.
29–47. www.ncbi.nlm.nih.gov/pmc/
www.ncbi.nlm.nih.gov/pmc/
articles/PMC5265194.
articles/PMC7609854.
Peng, B., et al. “Cervical
Sung, Y-H. “Suboccipital Muscles,
Proprioception Impairment in
Forward Head Posture, and
Neck Pain-Pathophysiology,
Cervicogenic Dizziness.” Medicina
Clinical Evaluation, and
58, no. 12 (December 2022): 1791.
Management: A Narrative Review.”
https://pubmed.ncbi.nlm.nih.
Pain and Therapy 10, no. 1 (June
gov/36556992.
2021): 143–64. www.ncbi.nlm.nih.
gov/pmc/articles/PMC8119582. Swartz, E. E., R. T. Floyd, and M.
Cendoma. “Cervical Spine
Pettorossi V. E., and M. Schieppati.
Functional Anatomy and the
“Neck Proprioception Shapes
Biomechanics of Injury Due to
Body Orientation and Perception
Compressive Loading.” Journal of
of Motion.” Frontiers in Human
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Neuroscience 8 (November 2014):
September 2005): 155–61. www.
895. https://pubmed.ncbi.nlm.nih.
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THOMAS CHAUKE/PEXELS
gov/25414660.
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Steinmetz, M. P., T. E. Mroz, and E. C.
Benzel. “Craniovertebral Junction:
Biomechanical Considerations.”
Neurosurgery 66, no. 3 (March
 Suboccipital Release No. 2
Move the client into a sidelying position to
better access and release the suboccipital
muscles. Grasp around the client’s head
so your thumbs meet at the base of the
client’s skull on the suboccipital muscles.
Massage along the occipital ridge, making WATCH VIDEO
several passes with your thumbs. When “UNILATERAL NECK
you palpate areas of particular tension, STRETCH ”
compress the tight tissue with your
thumbs and ask the client to flex their head
forward. Follow this movement with your
thumbs to stretch and release the tissue.

Pillowcase Decompression MAT offers a holistic, comprehensive

Suboccipital Release No. 2
Pillowcase Decompression
This technique creates space between
the vertebrae, relieving pressure on the
intervertebral discs and promoting proper
cervical alignment. Fold a pillowcase
into a narrow strip and ask the client
to lift their head so you can place it
under their mid-neck to maintain their
cervical lordosis. Hold the pillowcase
strip with both hands close to the client’s
head, just above their ears, so your
thumbs rest between their brows.
Drop your body weight back to apply
gentle traction to the cervical spine. Avoid
intense pressure or jerking the pillowcase.
Lean back slightly until you feel the client’s
first restrictive barrier. Ask the client to
shrug their shoulders toward their ears
while you continue holding to a count
of five. Relax and have the client relax.
Reengage the pillowcase and lean back,
applying light traction to the client’s second
restrictive barrier, and repeat the shoulder
shrugging process. Repeat the sequence a
third time to complete the technique.
PULLING IT ALL TOGETHER
We’ve plunged into the world of the
suboccipitals and explored the delicate
interplay between the structures of the
upper cervical spine. We’ve examined
the far-reaching consequences of
suboccipital imbalance and hypertonicity
related to proprioception, head-righting
reflexes, occipital neuralgia, stomach
sleeper’s headache, and dural tension.
solution, incorporating thoughtfully
sequenced techniques designed to
release tension in the suboccipitals while
considering the broader context of upper
cross syndrome and forward-head posture.
These eight fundamental techniques
come from a longer MAT cervical routine.
These methods promote proper atlas and
axis alignment, reduce tension, and improve
cervical function.
Digital devices will continue to
dominate our lives and inform the
stories the suboccipitals tell our hands.
By staying informed and integrating
effective techniques into our neck
treatment, we can empower clients
to find relief and make choices to
improve their postural habits.
Erik Dalton, PhD, is the executive
director of the Freedom from Pain Institute.
Educated in massage, osteopathy, and
Rolfing, he has maintained a practice
in Oklahoma City, Oklahoma, for
more than three decades. For more
information, visit erikdalton.com.

ABMP members earn FREE CE hours by reading this issue! 45

 PALPATING THE
ANTERIOR HIP
Think Hills and Valleys
By Dr. Joe Muscolino

KEY POINT
• The beauty of applying the hill and
valley approach to palpation of the hip
flexor musculature is that the hip flexor
muscles form an alternating contour of
hill, valley, hill, valley, etc.

46 massage & bodywork january/february 2024


W
When teaching muscle palpation, there
is often a rubric that is followed. We
begin by learning the attachments of the
target muscle so we know where to place
our palpating fingers. We then ask the
client to contract the muscle so it hardens,
thereby becoming more easily palpable.
And if we can find a joint action of the
target muscle that is different from the
joint actions of adjacent musculature, our
target muscle will be the only muscle that
contracts and becomes hard, soft tissue
amidst a sea of soft, soft tissues. This way,
we can not only palpate it, but palpate
and discern it from adjacent musculature.
Once found, we can palpate the entirety
of the muscle so we can then assess it.
Finding the Difference
When we ask the client to
contract the target muscle by
doing one of its joint actions
(given that most muscles
have more than one joint
action), the art of muscle
palpation is determining
which action to choose.
Or, perhaps better put,
which oblique-plane joint
function to choose, given
that muscle function does
not always fall neatly into
cardinal-plane joint actions.
For our example, when
palpating the hip flexor
muscles, given that all hip
flexors do hip joint flexion,
it is not useful to ask the
client to try to do hip flexion
because all the hip flexors
will likely engage, making it
difficult to discern our target
muscle from the adjacent
musculature. What we need
is to have the target muscle
be the only hard, soft tissue,
amidst a sea of soft, soft
tissues. Having the target
muscle and the adjacent
muscles all contract will not
accomplish this. Therefore,
we need to find a difference
between our target muscle
and the adjacent muscles. For
this reason, we ask for medial
rotation when palpating the
tensor fasciae latae (TFL),
for knee extension when
palpating the rectus femoris,
and for trunk flexion when
palpating the psoas major,
to cite a few examples. The
art of muscle palpation when
asking the client to engage
the target muscle is learning
how to choose the best
joint action/oblique-plane
function of the target muscle
that is most different from
the adjacent musculature.
 Psoas minor

Psoas major

Piriformis Iliacus

Inguinal ligament

Gluteus medius

Tensor fasciae
latae (TFL)
Gluteus minimus
Sartorius

Pectineus
Rectus femoris
Adductor longus

Adductor brevis

Gracilis

Adductor magnus
Iliotibial band
(ITB)

1A
Hip flexor muscles
of the anterior thigh.
Anterior view.

Patella

Tibial
tuberosity

Sartorius
Pes anserine
tendon Gracilis

Semitendinosus

48 massage & bodywork january/february 2024

 PALPATION OF THE HIP FLEXORS
This rubric is effective and can be used
for any muscle in the body. It requires
knowing the attachments and actions of
the target muscle as well as the attachments
and actions of the adjacent musculature. If
we apply this rubric to flexor musculature
of the anterior hip joint, we can work our
way from the tensor fasciae latae (TFL)
laterally to the adductor magnus medially
(Image 1A and 1B). With the client WATCH, LEARN, AND EARN CE
“PALPATING THE HIP FLEXORS”
supine,1 and palpating immediately distal
WITH DR. JOE MUSCOLINO
to the inguinal ligament, we can carry
out this palpation approach as follows.

TFL
Find the anterior superior iliac spine
(ASIS) and drop immediately distal and
slightly lateral. Now ask the client to
medially rotate the thigh at the hip joint

Iliacus

Anterior superior
iliac spine (ASIS) Sacrum

Psoas minor

Psoas major

Sartorius

Pubic symphysis
Adductor longus

1B Adductor brevis
Hip muscles of Gracilis
the right thigh.
Medial view Adductor magnus
(proximal thigh Semitendinosus
only). Semimembranosus
Rectus femoris

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 2 Palpation of the tensor fasciae latae.
4 Palpation of the sartorius.
and then gently flex the thigh at the hip
joint. The TFL will engage and pop, and
we can discern it from the nearby rectus
femoris of the quadriceps femoris group
as well as the nearby sartorius (Image 2).
Rectus Femoris
Staying close and parallel to the inguinal
ligament, drop immediately medial to
the TFL and you should be on the rectus
femoris. To confirm this, ask the client
to extend the leg at the knee joint. This
will engage the rectus femoris, but not
the nearby TFL or sartorius (Image 3).
Sartorius
Drop immediately medial to the rectus
femoris and you should be on the
sartorius. To confirm, ask the client to
laterally rotate and abduct the thigh
50 massage & bodywork january/february 2024
3 Palpation of the rectus femoris.
5 Palpation of the psoas major femoral belly.
at the hip joint, and slightly flex the
leg at the knee joint. The sartorius
will engage and pop, but the adjacent
muscles will remain relaxed (Image 4).
Iliacus
Now, drop immediately medial to the
sartorius and you should be on the iliacus.
The iliacus is challenging to have its
engagement isolated (because its joint
actions are essentially identical to those
of the adjacent muscles), so I like to
continue palpating medially until I find
the psoas major, then return laterally,
and whatever is between the psoas major
and sartorius will be the iliacus.
Psoas Major
To find the psoas major, look for the first
tissue that is medial to the sartorius and
engages with gentle flexion of the trunk
at the spinal joints (Image 5). The psoas
major is the only hip flexor that crosses
the spinal joints, so this joint action should
yield an isolated engagement of the psoas
major. Once found, return laterally for
the iliacus as previously mentioned.
Pectineus
Drop immediately medial off the psoas
major and you will be on the pectineus.
Similar to the iliacus, the pectineus
is challenging to have its engagement
isolated, so I like to continue palpating
medially until I find the adductor longus,
then return laterally. Whatever is
between the adductor longus and psoas
major will be the pectineus (Image 6).
 6 Palpation of the pectineus. 7 Palpation of the adductor longus.

8 Palpation of the gracilis. 9 Palpation of the adductor magnus.

Adductor Longus
The adductor longus has the most easily
palpable proximal tendon of all the hip
flexors and is usually clearly palpable even
when it is relaxed. Once located, return
laterally for the pectineus. But if we did
want to engage it to make it contract and
pop, then we ask the client to gently adduct
the thigh at the hip joint (Image 7).
Adductor Brevis
The adductor brevis is the most challenging
and variable of the hip flexors. It can be
wholly deep to the adductor longus, and
therefore not discernible from the more
superficial adductor longus. And sometimes,
there is some superficial exposure of
the adductor brevis on the lateral side of
the adductor longus, between it and the
pectineus. But most often, there is a small
amount of superficial exposure of the
adductor brevis lateral (and at this point,
it could be said to be posterior) to the
adductor longus. However, because the
longus and brevis share all the same joint
actions, it’s not possible to find a different
joint action to discern between them.
Gracilis
Whether it is the adductor longus or brevis,
drop immediately medial (posterior), and
you should be on the gracilis. To discern the
gracilis, ask the client to flex the leg at the
knee joint and only the gracilis will engage,
given that the adjacent muscle on each side
does not cross the knee joint and, therefore,
will not engage with knee flexion (Image 8).
Adductor Magnus
Once the gracilis has been found, we
drop immediately posterior off it and
will be on the adductor magnus. To
engage it, ask the client to extend the
thigh at the hip joint and the adductor
magnus will engage (the anterior head of
the adductor magnus is a hip flexor, but
its posterior head does hip extension),
but the gracilis will not (Image 9).
Medial Hamstrings
Locate the medial hamstrings
(semitendinosus and semimembranosus)
by asking the client to flex the leg at
the knee joint. This will engage the
hamstrings but not the adductor magnus.
Given that the exercise in this article is
to palpate and discern the hip flexors,
we are locating the medial hamstrings
only as a means of locating the posterior
border of the adductor magnus.

ABMP members earn FREE CE hours by reading this issue! 51

 Inguinal ligament

Sar torius
ae Latae
sci
Fa Psoa

r
so

sM
Ten

ajor
R e ct u s
Fe m o r i s ac

Ili
us

Add

Pe c

uc
tor ngus
i n e us
HILL AND VALLEY APPROACH

Lo
As I hope this rubric shows, we can use joint

Ad
B r ev i s
duct
actions as a means of palpation to locate
or

a c ili s
and discern our target muscle. Indeed,

Magnu r
Adducto
s

Gr
this is how muscle palpation is classically
taught and I wholly approve of this

no n o s u s
approach and use it as my default guideline

sus
i
with palpation assessment. However,

nd
ite
Se m b

ra
em
Se mim this approach can be costly timewise, so
10 I would like to offer the possibility of a
The muscles different approach to muscle palpation.
of hip joint When possible, if a target muscle can be
flexion have a palpated and discerned simply by knowing
contour that
resembles
its location and using its contour to be
hills and confident that we are on it, it saves time
valleys. and energy and facilitates the job of muscle
palpation. This contour approach to muscle
palpation can be used when palpating the
hip flexor musculature, and when used here,
Inguinal ligament I like to call it the hill and valley approach.
Instead of spending time asking the client
sci
ae Latae
Sar torius
to engage the target muscles, we can
Fa
simply discern each hip flexor muscle by
r
so
Ten

R e ct u s
its contour: If the contour is rounded and
Fe m o r i s
prominent, it is a hill; if it is flat and sits
recessed between two hills, it is a valley.
The beauty of applying the hill and
valley approach to palpation of the hip flexor
musculature is that the hip flexor muscles
form an alternating contour of hill, valley,
hill, valley, etc. We begin with the TFL,
which has a rounded contour and is clearly a
hill. We drop immediately medial off it and
the rectus femoris sits in a valley between
11A the rounded hills of the TFL on the lateral
side and the sartorius on the medial side.
Couplets of
two hills with From the hill of the sartorius, we drop
the valley medially off it, and we have the valley of the
between. iliacus, which sits between the hills of the
TFL and
sartorius on the lateral side and the psoas
sartorius with
the rectus major on the medial side. The psoas major is
femoris another hill, and immediately medial to it is
between. the valley of the pectineus that sits between
the hills of the psoas major on its lateral side

52 massage & bodywork january/february 2024

 Inguinal ligament

Sar torius

Psoa

sM
When possible, if a

ajor
ac

Ili
us

target muscle can

be palpated and
discerned simply
by knowing its
location and then
using its contour
11B to be confident
Sartorius
and psoas that we are on it,
major with
the iliacus
this saves time
between.
and energy and
facilitates the job of
muscle palpation.

and the adductor longus on its medial side.

The adductor brevis is variable but often sits
as a valley between the hills of the adductor
longus on its lateral side and the gracilis
on its medial (posterior) side. The gracilis Inguinal ligament

is a hill, and immediately posterior to it is

the adductor magnus, which is a valley that
sits between the hills of the gracilis on its Psoa

sM
anterior side and the medial hamstrings that

ajor
sit on its posterior side.
So, we have TFL (hill), rectus femoris Add

Pe c

uc
(valley), sartorius (hill), iliacus (valley), psoas

tor ngus
i n e us
t

Lo
major (hill), pectineus (valley), adductor
longus (hill), adductor brevis (valley),
gracilis (hill), adductor magnus (valley),
and medial hamstrings (hill again) as the
posterior border of the adductor magnus
(Image 10).
Or, looking at these muscles as couplets
of two hills with a valley between, we have
TFL and sartorius as hills, with the rectus
femoris as the valley between them (Image
11A); sartorius and psoas major as the hills,
with the iliacus as the valley between them
11C
Psoas major
(Image 11B); psoas major and adductor and adductor
longus as the hills, with the pectineus as the longus with
valley between them (Image 11C); adductor the pectineus
longus and gracilis as the hills, with the between.

ABMP members earn FREE CE hours by reading this issue! 53

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 Inguinal ligament

adductor brevis as the valley between

them (Image 11D); and gracilis and medial
Add
hamstring muscles as the hills, with the
adductor magnus as the valley between

uc
tor ngus
them (Image 11E).

Lo
When it comes to the rubric of having

Ad
B r ev i s
duct
the client engage the target muscle to locate
or

a c ili s
it versus simply using the contour approach,

Gr
I recommend new practitioners work
with the engagement approach because it
is confirmation that you are, in fact, on
the target muscle. But once you are more
experienced, simply having the knowledge
of the location and contour of the target
11D musculature is often enough to know with
Adductor confidence that you have located it. With
longus and either approach, once located, the target
gracilis with muscle can then be assessed.
the adductor
brevis
Note
between.
1. Images 2–9 demonstrate the client lying on
the table supine with their right thigh on the
table and their (lower) leg hanging off the
Inguinal ligament
table. Ideally, their left hip and knee joints
should be flexed with the left foot on the table
so the pelvis is stabilized. However, this was
not done for the sake of the camera view. The
palpation protocol for these muscles could
also be done with the client lying supine
with both lower extremities on the table.

Dr. Joe Muscolino has been a manual and

movement therapy educator for more than 35
years. He has created several online streaming
a c ili s

subscription platforms for manual therapy

Magnu r
Adducto
s

Gr

continuing education, including LearnMuscles

Continuing Education with more than 3,300
no n o s u s

video lessons and more than 320 hours of

sus
i
nd

ite
Se m b
NCBTMB credit. He has also created Massage
ra

em
Se mim Therapy—Master Online Curriculum, a full

11E online curriculum for massage therapy

schools. He is the author of multiple textbooks
Gracilis
and medial with Elsevier and has authored more than
hamstrings 90 articles. For more information on any of
with the Dr. Joe’s content, visit learnmuscles.com.
adductor To contact Dr. Joe directly, you can reach
magnus
him at joseph.e.muscolino@gmail.com.  
between.

ABMP members earn FREE CE hours by reading this issue! 55

 Dancing
Through Life

KEY POINT
• Rather than enforce physical
symmetry, Aston Kinetics
(which trains people in
movement, bodywork, fitness,
and ergonomics) seeks to
recognize the asymmetries
natural to a person’s body.

56 massage & bodywork january/february 2024

AN INTERVIEW WITH MOVEMENT EXPERT JUDITH ASTON
By Karrie Osborn
W
ith the spirit of a dancer, the
vision of an artist, the intuition
of a healer, and the curiosity of
a lifelong learner, Judith Aston has been a
mighty force in the world of movement for
more than six decades. She’s worked and
studied with legends like Moshe Feldenkrais
and Ida Rolf, and she’s trained many of
today’s biggest names in the profession.
Yet her sparkle shines brightest when
she talks about the unique complexity of
movement within each individual and how
that has fueled her journey in the field
of movement and movement therapies.
MOVEMENT IS LIFE
As the founder of the movement training
known as Aston Kinetics, Aston’s system
“aims to treat a person’s physical body
as something that is unique to them.
Rather than enforce physical symmetry,
Aston Kinetics seeks to recognize the
asymmetries that are natural to a person’s
body . . . and ensure that the entire
body is in sync with itself”1—a concept
Aston describes as achieving neutrality.
“I see all movement as the opportunity
to dance through life,” she says, “whether
it is the dance of doing Rolfing moves
or the opportunity to coach athletes
to run faster. This is not ‘dance’ in a
stylized way, but the ability to use the
forces of gravity and ground reaction
for efficiency, ease, and strength.”
Part of what makes Aston such an
insightful movement educator is her ability
to interpret, identify, mimic, and rethink
the movements she sees in front of her. It’s a
skill she remembers having as early as when
she was 5, recalling an interaction with her
mother. “One day, my mother asked, ‘What
is this envelope? Who brought this?’ I said,
‘A woman dropped that by. I don’t know
who she was, but she walks like this.’” Aston
proceeded to imitate how the woman walked
and moved and her mother immediately
knew who her daughter was talking about.
The ability to break down movement
into this kind of detail has helped Aston see
things most can’t—points of weakness or
conflict, and areas of strain and pain buried
in the motions. It’s something she brings
into her workshops to help others develop
their abilities to see within the movement.
“It has to do with the energy, the strength,
the tone, the lack of tone, the speed; it’s
something that’s always been easy for
me to read,” she says. And it’s something
profound when she teaches it to others.
THE DANCER’S SPIRIT
If movement is Aston’s poetry, then dance
is certainly her language. Ask Aston
about dance or her dance background,
and she lights up. She can’t help but
“dance” when she teaches; when she
speaks, her body moves lyrically to
explain a point, share an emotion, paint a
picture. It can be hypnotizing to watch.
“I begged from probably age 5 until
I was 7 . . . ‘Could I please study dance?’
But it wasn’t in the budget, and it wasn’t in
the time frame.” Finally, after two years
of persistence, Aston started lessons at the
local dance studio down the street from
ABMP members earn FREE CE hours by reading this issue! 57
 her home. There, she learned a variety of
dance techniques: tap, ballet, tarantella,
modern, Broadway, etc. She loved them
all—the rules of each, the somatic mantra
of each, and the movement of each ‘What do you do to neutralize yourself
captivated her imagination. By high school, from always rotating to the left around
Aston was advancing her own as-yet-to- the track? The oval you run in, you’re
be-realized “experiment” in movement always leaning around the curve to the left,
when she melded her interest in modern meaning your right leg is crossing more
dance with water ballet. “I don’t even like over your left at that point. And I think
to have my head under water very much, I see that in your walk.’” She asked the
but that was interesting,” she says. right-handed tennis players what they did
Dance followed Aston to college, to neutralize their repetitive movement
when she was encouraged by others to patterns. Baffled responses were the
“You Have to Teach”
transfer to UCLA and study modern norm. It didn’t take long, however, for the
Others recognized something
dance. Aston completed her undergraduate athletes (and their coaches and trainers) to
special in Judith Aston through
degree in dance at UCLA in 1963 quickly see Aston’s abilities to further their
each part of her journey,
and her graduate degree in 1965. proficiencies and neutralize the impact
including Moshe Feldenkrais,
Today, Aston’s dance history is of their sport. So, they accepted a little
who encouraged her to pursue
obvious in both her posture and stance. ballroom dance instruction along the way.
her work early on. But it was
But it’s not only how she carries her It was early epiphanies like this that
a high school teacher who
body in space—dance also carries a laid a foundation for Aston’s thinking.
originally inspired this journey.
history that is woven within all that “I explained to them why you need to
Aston teaches. When she teaches, it’s neutralize, because that pattern will age you
“Mrs. Marti Walker set me on my
obvious that dance is an important quickly and take you out of the competition
path,” Aston says. In high school,
“partner” for her in the classroom. sooner than you would need to. So, the
Walker needed a student aide
things that came later from all those early,
to help with her blind students,
early days, I still work with,” she says.
and Aston was invited to assist
OUT OF THE BOX
one class period a day, from her
Aston has always seen the world differently
sophomore to senior years.
from others. While still in college, Aston CREATIVE SPACE
was hired by the president of Long Beach It was the mid ’60s, and with her master’s
When Walker later asked Aston
Community College to create and teach degree in hand, Aston was ready for new
what she wanted to do in her
classes for the physical education and adventures. She was referred by one
career, the then-16-year-old said,
theater departments. Working with the of her professors to Kairos, a growth
“Oh, that’s easy. I want to travel all
theater department was easy; working center in Southern California born
around the world,” Aston told her.
with the athletes was a little trickier. out of the human potential movement.
It was a life-changing moment
“The athletes were required to take Similar to the Esalen Institute in Big
when Walker explained to the
one class with me, which meant they Sur, thinkers of the time would come and
young Aston that she could do
learned ballroom dance, folk dance, etc. visit these locations in workshop-style.
that, but she also had a higher
They hated all of that. But then I would Aston describes the Esalen and Kairos
calling. What did Walker have
go out and watch their sport—I watched experiences in the 1960s as fluid, thriving
in mind for her young mentee?
the golf team, I watched the track team, environments. “You had very famous
“You were born to teach. You
I watched the baseball team. And I would people in their fields move to be close
have to teach.” And so, at 16, the
ask them questions. I’d ask the runners, to these gurus who were coming in, or
path had prophetically been set.
the gurus who were there full time. You
“She was my guide,” Aston says.
had people who were retired specialists
coming for their own selves to take the
workshops and have these experiences.

58 massage & bodywork january/february 2024

It was so fascinating. There were true
traditional massage trainings there, but
there were so many other things happening
with the maharishi coming and Fritz
Perls [the founder of Gestalt therapy]
. . . It was a new experience for me.”
At Kairos, Aston was invited to come
teach movement. “They invited me to
come be the ‘movement lady’ on the
weekends, maybe once or twice a month.”
When an early Gestalt therapist was so
taken with Aston’s abilities that he asked
her to attend every one of his workshops
at Kairos, she agreed. “OK, but obviously
I’m not a psychiatrist or a psychologist,”
she told him. “I know, you’re a dancer. But
your creativity and intuition for what you
just did is pretty astounding,” he said.
A PATH BORN FROM PAIN
It was during this time that Aston unwittingly found
her segue into the world of bodywork, after two auto
accidents left her with debilitating pain. The first
accident was in 1966. “The light turned, I stopped,
but the car behind me did not.” She managed to
avoid colliding with an oncoming 18-wheeler, but the
resulting impact left her with no feeling or movement
in her legs. “They took me to the hospital, and for
24 hours, I couldn’t move. It was so frightening.”
Eventually sensation returned, and then movement
followed, but Aston describes her health during that
time as “terribly compromised.” She worked hard on her
recovery but was impacted by a second accident a year
later. With it came a new layer of pain and eventually
frustration with a medical team that dismissed it.
“I was in excruciating pain for most of every day;
it would wake me up at night. I told the [doctors] this
was not something I could do for the rest of my career,”
Aston recalls. A battery of tests was administered, and
ABMP members earn FREE CE hours by reading this issue! 59
 LISTEN NOW
EP 254 – “SEEING THE HUMAN BODY WITH
JUDITH ASTON”
the doctors said they couldn’t find any reason for her
pain. Their theory? “We believe it’s in your mind.”
A psychiatrist friend whose classes Aston assisted with
reassured her that her pain was real. “He said, ‘They don’t
understand soft-tissue injuries, but Ida Rolf does. And
she is coming to Esalen . . . You should see her. She could
help you.’” Aston was not familiar with the bodywork
community, but she was willing to try anything for relief.
Aston called her friends at Esalen to see if she could get in
to see Dr. Rolf during her visit. “Don’t bother coming” was
their advice; the grande dame’s schedule was already full.
“Well, I’m coming anyway,” she told them. Without an
appointment or an invitation, Aston was determined to see
this woman with the magic hands. “So, I sat on Dr. Rolf’s
doorstep at the [Esalen] baths for two days, and every time
she would open the door, she would give me a stink eye.”
But tenacity was something Aston was quite adept at.
‘I HAVE TO TRAIN YOU’
The story of the meeting between Ida Rolf and Judith
Aston is part of bodywork history. On day two of sitting
on that doorstep, Dr. Rolf finally acknowledged Aston.
“What are you doing on my doorstep?” Rolf
asked. “I’m waiting for a cancellation,” Aston said.
“Oh,” Dr. Rolf replied, as she closed the door and left
for lunch. Fate prevailed, and Aston finally got her
chance to get on Dr. Rolf’s table the following day.
The experience, Aston says, was life-changing. At the
end of the hour, Aston stood up and immediately felt
a difference. “I knew this was hope on the horizon.”
Even being completely unfamiliar with the work just
administered to her, Aston believed in the giver. “Dr.
Rolf was very sure of the success of her work. She was a
biochemist; she knew physics; she knew the arts. She had
unbelievable skill sets.” Deep down, Aston knew she was
right where she was supposed to be. And Dr. Rolf did too.
“At the end of that session, I picked up my things to
leave, and [Dr. Rolf] said, ‘Wait a minute. I understand you
create movement programs for leaders? Could you create
a movement program for my work?’” Aston was excited
about the offer; this was something she had done for
many others, but she didn’t fully understand the request
being made. After Dr. Rolf said, “I have to train you in
this work so you will know what to create,” Aston began
60 massage & bodywork january/february 2024
to see the path ahead. The timing was not
ideal, but what Aston refers to as Dr. Rolf’s
“triple Taurus look” prompted Aston to
cancel a long-awaited (and nonrefundable)
trip to Europe so she could return to Big
Sur in six weeks and start training with Dr.
Rolf in anticipation of the project ahead.
“Massage and bodywork was not
something I was familiar with. But I
was familiar with problem-solving and
movement, and that’s what she was
asking for. And she was asking for my
expertise.” Assured she was making the
right decision, Aston stopped on her way
home from Esalen and signed up to be a
student at the Pomona School of Massage,
a requirement if she was going to undertake
the six-week training with Dr. Rolf.
And when the six weeks of training
were complete, Aston knew she had
something to offer. “I knew from both
directions, looking from her view and my
view. I knew I could teach her students how
to see bodies. I could teach her students
how to use their body mechanics. And
I could teach the practitioners and the
clients how to do certain movements
so they would sustain the work. I had
those three gifts in mind when I watched
what happened those first six weeks.”
Aston went on to create three courses
for Dr. Rolf that became required training
for Rolfing students starting in 1971. Aston
remembers this time with great fondness,
both in the relationship with Dr. Rolf and
the creativity that was being spawned.
Aston delivered these classes until 1977,
when a parting of philosophies brought
the relationship to an end. And while the
history is tangled by some, and not clear in
the memory of others, Aston remembers
like it was yesterday. It was a painful
parting of the ways, she says, but she will
always treasure her time working with Dr.
Rolf. From pain came renewed purpose.
CHOSEN TO DO SOMETHING
DIFFERENT
“I just had to let happen what happened;
I had to let that go,” she says of the
dissolution of the Rolf partnership. “But
it was amazing, because in all the pain A LEGACY OF MOVEMENT
that happened, it became very clear that Aston has worked with Olympic athletes, professional
I was chosen to do something different dancers, and leaders from massage, bodywork, yoga, and
with all this knowledge that had come to Pilates communities. She helped create foundational
me from all these years I’d helped people movement instruction that has impacted thousands, and
create their own programs. I was supposed she was part of the human potential movement in its most
to clearly take this to the next step.” exciting and pivotal time. With all that history, what
Her inspiration drove her to a frenetic is it that she’s most proud of in her journey? Helping
pace, and she soon began designing people get to an “easier, less stressed, more aligned” way
products—most notably, ergonomic devices of being. Using bodywork, movement, and ergonomic
for sitting and laying. She had over 200 principles to help others find their somatic neutrality has
product designs and five patents by the time been most meaningful for Aston. Helping people find
it was all said and done. Call it guides or their own dance is the gift she receives in return.
inner intelligence, Aston says everywhere
she looked she saw ways she could help Note
people find their “best available neutral,” 1. Aston Kinetics, Judith Aston-Linderoth. www.astonkinetics.com/
so she started creating products that would judith-aston.
help them sit better, work better, and live
better. “I couldn’t stop creating products.” Karrie Osborn is senior editor at Massage & Bodywork
The Aston paradigm continued to evolve magazine. She has written about and supported the massage
in this new creative space, and she began and bodywork community for the past 25 years and is a vocal
expanding her thinking around stillness and advocate for the health benefits of all hands-on therapies.
motion. Her following grew, the demand
for her work grew, and her legacy began
to take shape. In addition to her work with
athletes, she continued to develop movement
programs for seniors and infants, yoga
Teaching Massage Therapists and Bodyworkers
and Pilates instructors, and anyone who
How can a massage therapist benefit from Aston’s work? Three courses
wanted more personalized instruction for
are specifically designed for massage and bodywork practitioners.
healthy aging. She ventures to guess that
• A ston Postural Assessment: The Art of Seeing the Fascial Body
she’s taught tens of thousands of students
See and understand the body’s relationship to all its segments and how
since the early 1960s and has hopes of
to problem solve the sequencing of the session to the client’s pattern.
teaching many more. (See “Teaching
• A ston Movement: The Art of Moving the Fascial Body
Massage Therapists and Bodyworkers.”)
Build skills from seeing alignment in stance to improving overall body
Now 82, Aston continues to teach
alignment and function.
year-round along with her husband, Brian
• A ston Fascial Integration: The Art of Feeling the Fascial Body
Linderoth. And it’s safe to say that she is far
Learn how deep and superficial patterns are connected and how to
from done.
match the details of the postural assessment with palpation assessment
in order to design a specific session for the client’s pattern.

Learn more at astonkinetics.com.

ABMP members earn FREE CE hours by reading this issue! 61

 Renal Failure, Dialysis,
and Kidney Transplants

Is There a Role for Massage Therapy?

By
Ruth
Werner

62 massage & bodywork january/february 2024

 Take a moment and turn your
attention inward to your two fist-
sized kidneys located on either
side of your anterior spine, from
about T11 to L2 or 3. You might
remember your right kidney is a bit
lower than your left. The kidneys
are in the retroperitoneal space.
They are protected by thick layers
of muscle and a bit of lumbodorsal
fascia, but because they are only
partially shielded by the rib cage,
Kidneys are hardworking organs. They
kidneys can be injured with a sharp filter our entire blood volume over 30
times every day. But that’s not all—they
blow to the torso where the 12th
also help us maintain an appropriate pH
rib emerges from the spine. In balance in the blood, they secrete hormones
to maintain healthy blood pressure and
boxing, a “kidney punch” is illegal.
blood volume, and they help maintain bone
density through the production of vitamin
D. And, amazingly, we have about twice as
much kidney function as we need, so we can
give one away if necessary.
But when things go wrong with the
kidneys, big problems can develop, and that
is the focus of this article: the progression
from chronic kidney disease to renal failure
to dialysis to renal transplant—and what
those situations mean for decisions about
massage therapy. Because diabetes is a
major contributing factor to chronic kidney
KEY POINT
disease, this piece is closely connected to
• The benefits massage therapy two articles in the November/December
has to offer this population 2023 issue of Massage & Bodywork,
are substantial: Our work may
“Deconstructing Diabetes” and “Diabetes
help with pain, fatigue, muscle
cramping, sleep quality, and Complications.”
much more.

ABMP members earn FREE CE hours by reading this issue! 63

 Nephron
Efferent
arteriol

Afferent
arteriol

Glomerular
capsule

1 Kidney
Fluid passes Renal pelvis
from blood to
the nephron at
the glomerular
capsule. Filtration
occurs in the Renal
renal cortex and cortex
medulla, and the
newly formed
urine collects in
the renal pelvis
Nephron loop
before it exits via
the ureter to the Medulla
urinary bladder.

Urine flows into

renal papilla

To fully grasp the importance of renal
failure, we need to do a brief review of
kidney structure and function. You may
remember that the main functional unit
of the kidney is the nephron, a delicate
epithelial duct that connects with a blood
capillary in the renal cortex at a junction
called the glomerular capsule. Each nephron
extends a long loop down into the renal
medulla and then comes back into the
cortex. Nephrons eventually drain into the
renal pelvis (Image 1).
Plasma from the cardiovascular system
is forced by blood pressure to cross from the
capillary to the nephron at the glomerular
capsule. As that fluid travels along the
long and convoluted nephron, much of it is
reabsorbed into the bloodstream, and the
remainders—mainly water, salts, excess
hormones, drug leftovers, and other wastes,
travel into the renal pelvis, down the
ureters, into the urinary bladder, and finally
out of the body; this is urine.
An amazing amount of fluid passes through healthy
kidneys; a normal glomerular filtration rate (GFR) is 120
mL per minute, which means we process nearly 180 liters of
fluid every 24 hours. We need this high volume of turnover
to stay healthy and to prevent the accumulation of toxins
and waste products in the bloodstream.
But the kidneys are vulnerable to a few problems.
Bacteria from the urinary tract may travel up the ureters to
cause kidney infections, or pyelonephritis. Polycystic kidney
disease is a genetic disorder that causes cysts to grow, and
they interfere with function. And imbalances between
water and mineral levels can promote the growth of sharp
crystals within the kidneys that excoriate the ureters as they
travel downward; these are kidney stones. But the focus of
this article is on what happens when chronic wear and tear
affects the delicate kidney tissues and eventually leads to
renal failure.
CHRONIC RENAL FAILURE
Renal failure describes a situation where the kidneys
cannot keep up with a person’s needs. It can have a sudden
onset or be the result of some kind of trauma, which
would be acute renal failure. But silently progressive
chronic renal failure is much more common, and it’s

64 massage & bodywork january/february 2024

The Continuum of Renal Failure
Stage GFR Extent of damage
I 90–120 mL/minute Damage is minor, no symptoms may be present
II 60–89 mL/minute Mild reduction in function, subtle symptoms
may be noticed
III 30–59 mL/minute Chronic kidney disease is diagnosed at this time
IV 15–29 mL/minute Severe reduction in function, dialysis may be
recommended
V Less than 15 mL/ End-stage renal disease, unsustainable loss of
minute function
something massage therapists are more
likely to encounter in their practice.
Chronic kidney disease occurs on a
continuum, determined by the GFR
(see “The Continuum of Renal Failure”).
Early stages are often silent, and many
people may not know they are at risk. In
later stages, we see the consequences of
a low filtration rate: retention of fluid,
accumulation of toxins and excessive
minerals, and the loss of important renal
hormones—this is the transition from
chronic kidney disease to renal failure.
Advanced renal failure can affect many
organ systems. Damaged kidneys lead to
decreased urine output, edema in the lungs
and in the extremities from salt and water
retention, arrhythmia from potassium
retention, anemia, and bone thinning
related to the suppression of important
hormones. Rashes and skin discoloration
appear from retention of toxins in the blood.
Failing kidneys can cause easy bruising and
bleeding, muscle weakness, and cramps.
Fatigue, headaches, peripheral neuropathy,
tremors, seizures, and changes in mental
and emotional states are the result of toxins
that cross the blood-brain barrier.
Given how serious chronic kidney
disease is, it’s shocking to learn how
many people in this country have it.
About 14 percent of Americans (about 37
million) are affected, and that number is
growing by some 8 percent per year. More
than 800,000 people are in late-stage
renal failure, and about 130,000 people are
diagnosed with a new case every year.1
The consequences of untreated kidney
disease are not evenly distributed throughout
society. Compared to White Americans, Black
Americans are 4.2 times more likely to develop
renal failure, Hispanic Americans are 2.3 times
more likely, Native Americans are 1.9 times more likely, and
Asian Americans are 1.5 times more likely to end up with
late-stage renal disease.2 This may reflect the consequences
of socioeconomic standing and systemic barriers to health
care based on race and ethnicity more than on any specific
genetic predisposition to kidney disease.
Only two treatments for chronic renal failure are
available: dialysis and kidney transplant.
Dialysis
Kidneys can go through a lot, but when they go from a
GFR of 180 mL per minute to 30 mL per minute, it’s time
to look for external help. This is where hemodialysis and
peritoneal dialysis come in (see “Kidney Heroes,” page 66).
Hemodialysis is typically offered in an outpatient
clinic and requires a minimum of three sessions per week,
each lasting 3–5 hours. A home version of hemodialysis
is available; this one is used more frequently for shorter
periods.
Peritoneal dialysis is an alternative to hemodialysis and
can be done at home rather than in a clinic. This process
uses the capillaries of the peritoneum to filter blood with
a dialysis solution. A permanent catheter is inserted in the
peritoneum. During a session, the dialysis solution flows
into the peritoneal cavity, where it absorbs waste and excess
fluid from the body, which takes 60–90 minutes. Then it is
drained out of the body. This must be done four times each
day, and it can be done during sleep.
Dialysis is an intervention that can prolong the lives of
people with end-stage renal failure, but it can have some
serious side effects and complications. With hemodialysis,
the person may develop an infection or a blockage in the
affected blood vessels, or the needle may become dislodged
during treatment. With peritoneal dialysis, the person
may develop skin infections, peritonitis, and weakened
ABMP members earn FREE CE hours by reading this issue! 65
 Arterial
pressure
monitor
Blood
pump Heparin pump to
Dialyser inflow
prevent clotting
pressure monitor

Fresh
dialysing
solution
Blood
removed Venous
for dialysis pressure
monitor

Filtered
blood return Automatic
clamp
Used
Air trap and dialysing
air detector solution

In hemodialysis,
blood is removed
Kidney Heroes
from the body, The idea of an external machine to filter blood has
put through a a fascinating history. The first doctor to explore this
filter, and then
returned. possibility was Dutch physician Willem Kolff. His
work was interrupted by the Nazi invasion of the
Netherlands, during which he illegally sheltered
a Jewish colleague and his son. After many
failures, he eventually constructed a machine
with improvised parts that worked for patients
with acute renal failure. He came to the US in the
late 1940s and continued to refine his invention.
However, dialysis was not considered a long-term
solution for people with chronic disease until
a solution was found for repeated blood vessel
damage. This was accomplished by Dr. Belding
Scribner with the invention of a shunt, which
allowed repeated access to the vascular system.
Scribner opened the first outpatient dialysis center
in 1962. The process of choosing who would be
given access to this lifesaving intervention led to
the formation of the first bioethics committee,
a practice that continues to impact health-care
accessibility to this day.
Kolff went on to pave the way for the first renal
transplant in 1954 and was involved in the creation
of the first heart-lung machine, the first artificial
heart, and many other innovations in medicine. He
died in 2009 at age 97.
The etymology of the term dialysis comes from the
Greek dia/luein, which means “to split apart and
set free.” For renal failure patients, this “splitting
apart” can happen in two ways: as hemodialysis or
peritoneal dialysis.
The process of hemodialysis is complex, but a
simplified description looks like this: Blood is
removed from the body and passed through a
machine that puts it through a filter. At one end of
this filter, the blood is forced into many tiny, hollow,
semipermeable tubes that resemble capillaries.
Dialysis solution passes in the opposite direction,
outside these tubules. Waste is sucked out of the
blood-carrying vessels and into the dialysis fluid,
which is extracted and discarded. The filtered
blood re-enters the cardiovascular system.

66 massage & bodywork january/february 2024

abdominal muscles and
hernia. Since a major The accommodations for
ingredient of the dialysis
solution is dextrose, they clients with renal disease
may also absorb a lot of or renal failure must be led
sugar and have weight
gain—which doesn’t help by their tolerance—some
factors like diabetes or
high blood pressure that
days they may be too tired
contribute to renal failure. to receive massage—and by
Any kind of dialysis
may also involve their physical resilience.
severe fatigue, painful
muscle cramps, and the
accumulation of aluminum in the bloodstream,
which might need to be treated with chelation
therapy. (For context, aluminum poisoning is
less of a problem than it used to be, but people
who have been on dialysis for a long time may
be at risk.) These problems can be addressed, capacity. If a recipient’s kidneys are free from infection,
but for most people, dialysis is a stop-gap necrosis, or other problems, they are left in place and the
measure while they wait for the prospect of new kidney is connected to the urinary bladder in the
receiving a donated kidney. The mortality pelvis. A kidney from a deceased donor typically lasts 10–
rate for people on dialysis is sobering—the 15 years, and from a living donor, that time is 15–20 years.
five-year survival rate is about 35 percent.3 However, those numbers can vary, and kidney transplant
protocols are always under development for better access
and survival rates.
Kidney Transplants
Kidney transplants work better and longer than
dialysis to treat renal failure. However, they DOES MASSAGE HAVE A ROLE
are complex and not always successful. And the IN KIDNEY DISEASE?
longer a person is on dialysis, the weaker and Considering how common chronic kidney disease is
less capable they are of receiving a transplant. and how severe it can become, there is surprisingly
At this time, about 90,000 people in the US little reliable information about massage therapy in
are on the waiting list for a new kidney, and about this context. A couple of reviews have looked at manual
25,000 transplant surgeries are performed each therapies to help improve sleep for this population, and
year. The average amount of time on the kidney they found mixed results. A handful of small studies
donor waiting list is just short of two years, but looked at massage during dialysis sessions for fatigue
that is a national average, and actual times vary and between-session muscle cramping, with more
depending on location and availability. That said, consistently positive results. But the idea of massage
Black patients on average wait a year longer than therapy as part of a whole-person coping strategy during
others to receive a new organ. The costs of kidney a very challenging time has not been researched.
transplants are also daunting, and one factor in Given all this, is massage therapy appropriate for
selecting who receives a new organ is whether someone with chronic kidney disease? The answer is, it
they can afford the thousands of dollars per depends. To figure out what it depends on, let’s put this
month it costs to use antirejection drugs.4 decision through a critical-thinking process.
A new kidney can come from a deceased organ • Identify the key question: What does the client want
donor or from a carefully matched live donor who that massage therapy might help them achieve?
is healthy enough to lose half of their filtering

ABMP members earn FREE CE hours by reading this issue! 67


RESOURCES
Association of American Medical Colleges. “How Our Organ
Transplant System Fails People of Color.” Accessed October 12,
2023. www.aamc.org/news/how-our-organ-transplant-system-
fails-people-color.
American Kidney Fund. “Deceased Donor Kidney Transplants.”
Accessed October 12, 2023. www.kidneyfund.org/kidney-
donation-and-transplant/deceased-donor-kidney-transplants.
American Kidney Fund. “Quick Kidney Disease Facts and Stats.”
Accessed October 6, 2023. www.kidneyfund.org/all-about-
kidneys/quick-kidney-disease-facts-and-stats.
Centers for Disease Control and Prevention. “Chronic Kidney Disease
in the United States, 2023.” Accessed October 9, 2023. cdc.gov/
kidneydisease/publications-resources/ckd-national-facts.html.
Çeçen, S., and D. Lafcı. “The Effect of Hand and Foot Massage on
Fatigue in Hemodialysis Patients: A Randomized Controlled Trial.”
Complementary Therapies in Clinical Practice 43, (May 2021):
101344. https://doi.org/10.1016/j.ctcp.2021.101344.
Chu, S. W. F. et al. “Manipulative and Body-Based Methods in
Chronic Kidney Disease Patients: A Systematic Review of
Randomized Controlled Trials.” Complementary Therapies in
Clinical Practice 48, (August 2022): 101593. https://doi.org/10.1016/j.
ctcp.2022.101593.
Chuang, P-H. et al. “Blood Aluminum Levels in Patients with
Hemodialysis and Peritoneal Dialysis.” International Journal of
Environmental Research and Public Health 19, no. 7 (2022): 3885.
https://doi.org/10.3390/ijerph19073885.
Cleveland Clinic. “Dialysis.” Accessed October 6, 2023. https://
my.clevelandclinic.org/health/treatments/14618-dialysis.
Davita Kidney Care. “The History of Dialysis.” Accessed October 10,
2023. www.davita.com/treatment-services/dialysis/the-history-of-
dialysis.
Habibzadeh, H. et al. “Effects of Foot Massage on Severity of Fatigue
and Quality of Life in Hemodialysis Patients: A Randomized
Controlled Trial.” International Journal of Community Based
Nursing and Midwifery 8, no. 2 (2020): 92–102. https://doi.
org/10.30476/IJCBNM.2020.81662.0.
Home Dialysis Central. “Kidney Disease and
Massage.” Accessed September 6, 2023. https://
forums.homedialysis.org/t/kidney-disease-and-
massage/2745.
Lai, M-Y. et al. “Fever with Acute Renal
Failure Due to Body Massage-Induced
Rhabdomyolysis.” Nephrology Dialysis
Transplantation 21, no. 1 (2006): 233–4. https://
doi.org/10.1093/ndt/gfi158.
68 massage & bodywork january/february 2024
Lazarus, E. R. et al. “The Effects of an Olive-Oil Massage
on Hemodialysis Patients Suffering from Fatigue
at a Hemodialysis Unit in Southern India—A
Randomized Controlled Trial.” Journal of
Complementary and Integrative Medicine
18, no. 2 (2020): 397–403. https://doi.
org/10.1515/jcim-2019-0338.
Mastnardo, B. S. et al. “Intradialytic
Massage for Leg Cramps Among
Hemodialysis Patients: A Pilot
Randomized Controlled Trial.”
International Journal of Therapeutic
Massage & Bodywork 9, no. 2 (2016):
3–8. https://doi.org/10.3822/ijtmb.
v9i2.305.
National Foundation for Transplants.
“Get Informed.” Accessed October
12, 2023. https://transplants.org/get-
informed.
National Institute of Diabetes and
Digestive and Kidney Diseases.
“Explaining Your Kidney Test Results: A
Tool for Clinical Use.” Accessed October 12,
2023. www.niddk.nih.gov/health-information/
professionals/advanced-search/explain-kidney-test-results.
National Institute of Diabetes and Digestive and Kidney Diseases.
“Hemodialysis.” Accessed October 10, 2023. www.niddk.nih.gov/
health-information/kidney-disease/kidney-failure/hemodialysis.
National Institute of Diabetes and Digestive and Kidney Diseases.
“Kidney Disease Statistics for the United States.” Accessed
October 9, 2023. niddk.nih.gov/health-information/health-
statistics/kidney-disease.
National Institute of Diabetes and Digestive and Kidney Diseases.
“Kidney Transplant.” Accessed October 5, 2023. www.niddk.nih.
gov/health-information/kidney-disease/kidney-failure/kidney-
transplant.
National Kidney Foundation. “How Your Kidneys Work.” Accessed
October 5, 2023. www.kidney.org/kidneydisease/howkidneyswrk.
National Kidney Foundation. “Transplants For All: Saving Lives, One
Kidney at a Time.” Accessed October 12, 2023. www.kidney.org/
newsletter/transplants-all-saving-lives-one-kidney-time.
Stanford Medicine. “Kidney Failure Symptoms.” Accessed September
6, 2023. https://stanfordhealthcare.org/medical-conditions/liver-
kidneys-and-urinary-system/kidney-failure/symptoms.html.
The Kidney Failure Risk Equation. “Facts & Figures of Chronic Kidney
Disease.” Accessed October 5, 2023. http://kidneyfailurerisk.com.
University of California, San Francisco, “The Kidney Project,” accessed
October 12, 2023, https://pharm.ucsf.edu/kidney/need/statistics.
• Identify the variables that must inform
that question: How severe is their disease?
What treatments are they using? What
symptoms and side effects are bothering
them? What daily activities do they
tolerate well? What activities make
them feel better? Worse? (There are
a lot of other possible questions,
but these provide a good start.)
• Look for assumptions about this
situation: What have you missed?
Are you focused on treating the
kidney problem rather than the
reason the client came to see you?
• Find what others have done in
similar situations: Look at the
research, consult with peers, and if
appropriate, reach out to the client’s
medical providers with specific
questions about goals and safety.
• Plan and execute the session: Use
what you’ve learned to work with
your client. Consider the risks, benefits,
and appropriate accommodations.
• Evaluate the results: How will you
determine if your work is successful?
What will you do differently next
time you work together?
RISKS, BENEFITS, AND
ACCOMMODATIONS
We know people with chronic kidney
disease have a hard time managing fluid
flow, and we can surmise that to challenge
that with deep, fast, draining strokes is
probably not a good idea. Other risks that
inform our work include bone thinning,
skin rashes, itching that thoughtless
massage might make worse, and general
malaise that is not appropriate for rigorous
bodywork. Organ transplant recipients
often have complex health situations,
and they use tissue-rejection drugs that
make them vulnerable to infections.
The benefits that massage therapy has
to offer this population are substantial: Our
work may help with pain, fatigue, muscle
cramping, sleep quality, and much more.
In a recent episode of the podcast “I Have a
Client Who . . .” (Episode 377), I spoke about
doing massage for a person undergoing
dialysis. As long as the work is gentle
and doesn’t challenge the client’s general
energy levels, there is no reason to withhold
LISTEN NOW
treatment.
EP 377 – “DIALYSIS:
The accommodations for clients with ‘I HAVE A CLIENT
renal disease or renal failure must be led WHO . . .’ PATHOLOGY
CONVERSATIONS WITH
by their tolerance—some days they may be
RUTH WERNER”
too tired to receive massage—and by their
physical resilience. Obviously, the access site
is a local caution, and it may be best to offer
shorter sessions while you and your client
evaluate how things go for them. Finally,
let’s bear in mind that clients with renal
failure may seek massage for other issues—
2. American Kidney Fund, “Quick Kidney Disease
musculoskeletal injuries, for instance.
Facts and Stats,” accessed October 6, 2023,
And while we must accommodate for their
www.kidneyfund.org/all-about-kidneys/
limitations, their kidney disease might not quick-kidney-disease-facts-and-stats.
be the centerpiece of their goals.
3. University of California, San Francisco, “The
Clients who have received transplanted
Kidney Project,” accessed October 12, 2023,
kidneys may have extensive scar tissue and a
https://pharm.ucsf.edu/kidney/need/statistics.
new organ in their pelvis. Also, these clients
4. National Foundation for Transplants, “Get
use immune-suppressant drugs, so they
Informed,” accessed October 12, 2023,
require us to be especially careful about
https://transplants.org/get-informed.
infection risk along with whatever other
challenges they have.
People with chronic kidney disease, Ruth Werner is a former massage
those with renal failure, those who use therapist, a writer, and an NCBTMB-
dialysis, and those who have received a approved continuing education provider.
transplant all need us to adapt our work to She wrote A Massage Therapist’s Guide to
their needs. But knowledgeable massage Pathology (available at booksofdiscovery.
therapists can offer safe, educated, and com), now in its seventh edition, which
caring touch in ways that might help with is used in massage schools worldwide.
pain, stress, fatigue, and much more. Werner is available at ruthwerner.com.
Notes
1. National Institute of Diabetes and Digestive
and Kidney Diseases, “Kidney Disease
Statistics for the United States,” accessed
October 9, 2023, www.niddk.nih.gov/health-
information/health-statistics/kidney-disease.
ABMP members earn FREE CE hours by reading this issue! 69
 critical thinking | Anatomy for Touch

The First
Millimeters of
Every Massage
Giving Skin the Attention
It Deserves
By Nicole Trombley and Rachelle Clauson

Skin is the first thing we touch in every massage, even if

our intentions and pressure run deeper. Though skin is a
mere 1–3 millimeters thick in most areas,1 it’s the largest
organ in the human body and
accounts for 15 percent of our
body weight. Richly supplied KEY POINT
with lymph and blood networks • While our work often

1
and packed with sensory nerve Skin reflected. After carefully separating the
revolves around deeper skin ligaments that connect the dermis to the
endings, skin serves as a key tissues, special attention underlying layers, we can examine both sides
player in the immune system should be paid to the of the skin. On the superficial side, we see the
protective epidermis on the left. Full of sensory
and easily ranks as one of the skin, the first responder
nerve endings, it’s the first tissue we touch.
body’s most sensitive organs. to our touch. On the deep side, we get a good view of the
thicker, tougher, deep surface of the dermis,
But perhaps more importantly, with its undulating texture exposed as it is
the skin is the canvas upon which reflected from the bubbly adipose lobules of
we paint our strokes, the first the subcutaneous tissue on the right. Image
courtesy of AnatomySCAPES.com.
responder to our touch, and the primary vehicle for our
clients’ experience of relaxation. If we fail to consider how
we attend to those first few millimeters of touch in the
skin, we might be missing out on one of the most accessible
ways to positively affect our clients’ health and well-being. Hairy Skin
Let’s explore the skin’s rich anatomy as we consider how to Hairy skin covers 90 percent of the body.2 In some areas,
make the most of every inch. the hair is coarse and obvious, but in others, it is so fine
that it’s barely visible. Body hair can sometimes seem
like it gets in the way of bodywork, but when we look at
TWO TYPES OF SKIN the anatomy, hair plays an important role in our sense
Regardless of age, ethnicity, pigmentation, or of touch due to the sensory nerves that wrap around
lifestyle factors, skin on every body comprises each hair follicle. Like a cat’s whiskers, the hair extends
two types that are consistently found in the same beyond the surface of the skin and mechanically relays
specific regions: hairy skin and glabrous skin. any movement—from a breeze, a wandering ladybug, or a
light massage stroke—directly to the sensory nerve at its
root. Even if the skin itself is not touched, the nerve fires,
providing very subtle information about the environment.

70 massage & bodywork january/february 2024

 No matter how deep your
focus, remember you are
always touching highly
Glabrous Skin
Glabrous skin covers approximately 10
perceptive skin.
percent of the body. It’s smooth and
non-hairy and, therefore, can’t rely on
the movement of hair to sense the world around it. But
the good news is that it doesn’t have to; glabrous skin
is densely packed with a much higher concentration of
sensory nerve endings than hairy skin, which helps with
proprioception and coordination. Located in the regions
that we use for discriminative touch—including the
fingertips, palms, soles of the feet, and lips—glabrous
skin’s higher concentration of nerve endings provides
needed sensitivity for object recognition, texture
discrimination, and sensory-motor feedback. As a result,
your clients can perceive your work in these areas with
incredible detail. Nuanced touch with varied pressures,
speeds, and contact surface area, varying textures of
lotions, oils, and butters, or the use of hot towels can
all evoke fine-tuned sensations in these regions. This
might explain why so many clients often say, “Why

does that feel so good on my hands and feet?”
SKIMMING THE SURFACE: EPIDERMIS
Hairy or not, all skin is organized in two distinct parts:
the more superficial epidermis and the deeper dermis.
The outermost layer of skin is the epidermis. It’s what
you touch first on your clients and what you touch
with first (remembering that your skin as the therapist
is also part of this story). Over most of the body, the
epidermis is barely as thick as a sheet of paper, yet it
serves as an almost impenetrable barrier that protects
us from invading microorganisms, dehydration, and
damaging ultraviolet (UV) light, as well as from the
first impact from any bump, scratch, or cut. Made of
layers of tightly packed cells, the epidermis is avascular
and is filled with the tough protein, keratin.
2
Skin and subcutis. After partially dissecting the skin from
the subcutaneous tissues beneath, the skin is tractioned,
giving us a view of the many collagenous retinacula
cutis (skin ligaments) that connect the two tissue layers.
Because of these firm connections, skin can translate
our touch deeper as we push, pull, and stretch the skin
with every massage stroke. To learn more about the skin
ligament connections, see Massage & Bodywork, January/
February 2023, “Skin Ligaments,” page 70. Image courtesy
of AnatomySCAPES.com.
The protective epidermis may keep the dangers of
the world out, but it lets in your massage touch and is
where the initial perception of your massage begins. The
epidermis is rich in different types of nerve endings:
Merkel’s cells that can sense the slightest distortion
of pressure; thermoreceptors that sense changes in
temperature; and nociceptors that can sense potentially
damaging stimuli are all residents of the epidermis.
Remarkably, this incredibly thin part of the skin’s surface
serves as the sensing, feeling bridge that connects your
touch to your client’s underlying tissues and is your first
opportunity to promote relaxation and well-being.

ABMP members earn FREE CE hours by reading this issue! 71

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with physicians.
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Webinars: Learn why research matters, how to write a case report & more!
Research posters: Be inspired by the work your peers are sharing.
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72 massage & bodywork january/february 2024


DIVING DEEPER: DERMIS
Just beneath the epidermis lies the busy, 1–4 millimeters
where the real action happens in the skin, the dermis. This
thicker, highly vascular, and lymph-rich dermis serves
as the lifeline to the paper-thin, avascular epidermis by
keeping it nourished and physically anchored to the body.
The deepest part of the dermis is densely packed with
strong collagen fibers and stretchy elastic fibers that allow
the skin to be stretched and compressed with resiliency as we
move, touch, and are touched. Every deep compression, skin
rolling, or shearing massage stroke relies on the resilience of
the dermis. Nestled among the interwoven collagen fibers,
we find specialized sensory mechanoreceptors, including
Ruffini corpuscles, which perceive skin stretch, and Pacinian
corpuscles, which detect vibration, texture, and pressure.
Connecting strokes that soothe, push, and pull the skin
activate these nerves. No matter how deep your focus,
remember you are always touching highly perceptive skin!
WHY WE CARE
As massage therapists, our primary focus often revolves
around the deeper tissues—the muscles, fasciae, tendons,
and joints. It’s easy to forget about the skin itself, aside
from how much lotion or oil is needed to get the glide
or grip we want. However, the skin is an integral part
of every massage, influencing the overall impact on our
client’s experience. Skin deserves our attention.
AnatomySCAPES Meets Rebel Massage
AnatomySCAPES is joining forces with
Rebel Massage therapist Allison Denney for
“Journey into the MATRIX: the Fascial System.”
This multidimensional learning experience
includes three full days in the dissection lab,
in the classroom, and at the massage tables.
Join them February 27–29, 2024, in San Diego
and start developing the “X-ray vision” that
comes from seeing real fascia anatomy. Go to
anatomyscapes.com/MATRIX to apply today.
ABMP members earn FREE CE hours by reading this issue! 73
ANATOMY FOR TOUCH
Let’s Explore
Check out the authors’ additional
resources at abmp.com/anatomy.
Notes
1. Skin thickness varies over the surface of the body, as well as from
person to person, ranging from less than 1 mm on the eyelids
to up to 5 mm on the upper back. Skin thickness changes
as we age, reaching maximum thickness at around age 20
and thinning over time as we continue to age. Environmental
factors such as sun exposure and smoking create damage and
accelerate the thinning of the skin. (Pawlina 2023, Wong 2015).
2. Amanda Zimmerman, Lijun Bai, and David D. Ginty,
“The Gentle Touch Receptors of Mammalian Skin,”
Science 346, no. 6212 (November 21, 2014): 950–54,
https://doi.org/10.1126/science.1254229.
Nicole Trombley and Rachelle Clauson, massage
therapists, authors, teachers, and co-directors of
AnatomySCAPES, lead you beneath the surface in their
highly interactive Dissection Lab Workshops and online
continuing education courses for hands-on professionals.
They help you discover what real anatomy looks and feels
like, and how it moves and relates to its surroundings. Find
out more about the skin in their fascia-focused online
courses “Skin: The Epidermis” and “Skin: The Dermis.” ABMP
members save 20 percent at anatomyscapes.com/ABMP.
RESOURCES
Lyman, M. Remarkable Life of Skin: An Intimate Journey
Across Our Surface. S. L.: Black Swan, 2020.
Pawlina, W. Histology: A Text and Atlas. Lippincott Williams &
Wilkins, 2023.
Wong, R. et al. “The Dynamic Anatomy and Patterning of
Skin.” Experimental Dermatology 25, no. 2 (February
2016): 92–8. https://doi.org/10.1111/exd.12832.
Zimmerman, A., Ling B., and D. D. Ginty. “The Gentle Touch
Receptors of Mammalian Skin.” Science 346, no. 6212 (November
21, 2014): 950–4. https://doi.org/10.1126/science.1254229.
WATCH VIDEO
“SKIN: THE FIRST
MILLIMETERS OF
EVERY MASSAGE”
 critical thinking | Massage Therapy as Health Care
Palliative Care: A Step in
a Similar Direction for MTs
By Cal Cates
KEY POINT
• Palliative care is an added
layer of support for people
living with chronic or serious
illness. It enhances people’s
care by offering quality of
life for them and their family.
And your touch can make a
difference in all their lives.
74 massage & bodywork january/february 2024
The most common reason
people become massage
therapists is the desire to
help people. Other top
reasons are the flexible
hours, the variety of clients,
and the uniqueness of each
session.
What if I told you none
of that has to change when
you expand your massage
therapy skills into the
palliative care space? You
could ease the suffering
of your fellow humans in
a variety of settings. You
could continue to have
flexibility in how and
where you work. You could
expand your work in your
community, work in people’s
homes, or in hospitals and
clinics. And you could make
a measurable difference in
the lives of people living
with chronic and serious
illnesses.
This is what it’s like to
be a massage therapist with
palliative care skills. The
way I look at it, palliative
care is like chocolate.
Everything goes with chocolate, right? Most
massage therapists are surprised to learn
that their brand, technique, and approach to
massage therapy already work with palliative
care. It’s simply a way to grow what you do
and the kind of support you can offer.
Palliative care is an added layer of
support for people living with chronic
or serious illness. (It’s not hospice. We’ll
address that another time.) Palliative care
enhances a person’s current care by focusing
on quality of life for them and their family.1
Isn’t that what you do already?
You are not the only health-care
provider that your clients see. Most of your
clients get some care from someone else,
whether it’s primary care, chiropractic care,
or physical therapy. Your work enhances
that care, even if you never hear about it or
don’t think about it.
BUILDING AWARENESS
There are millions of people in the US who
aren’t benefiting from palliative care, in
large part because they don’t know it exists
or what it could do for them. Still, others are
simply exhausted by the idea of “one more
doctor’s appointment.” But what if they
could start their palliative journey with you?
People living with diabetes, lung disease,
chronic kidney disease, heart disease,
cancer, dementia, depression, anxiety, or
other mental health challenges, or people
recovering from a stroke may find their
way to your table and could benefit from
the skills of a palliative-trained massage
therapist.
Palliative care is not a new path. It’s a
broader path. With the right training, you
can invite many people into a type of care
they never imagined, with little (if any)
change to the techniques you already use
in your massage practice. When people are
diagnosed with a serious illness, they report
DANIE FRANKO/UNSPLASH
a marked decrease in satisfaction with the

kind of care they receive. Most negative
health-care experiences are due to a mix of:
• discrimination
• lack of empathy
• poor communication/listening skills
• frustration/anxiety navigating and dealing
with the health-care system
• disregard for the individual’s mental health
and overall well-being.2
“Just being nicer” to those clients
won’t change this, but a palliative care
perspective and related skills could make all
the difference. By learning some essential
pieces of information about these diseases
and some specialized communication
and collaboration skills, your treatment
space could become an important site of
compassionate care for people living with
serious illness, and you and any therapists
who work with you could change the daily
experience of illness for people and their
families.
GROWTH IN PALLIATIVE CARE
Palliative care was officially recognized as
a specialty area of practice in 2006, but the
imperative for all care providers to have
a working knowledge of the foundational
skills that differentiate palliative care from
what’s often called curative treatment has
become clear in recent years. The nation’s
palliative care organizations agree that
“equipping all clinicians with foundational
palliative care competencies (serious illness
communication, illness trajectory and
symptom management, collaborative care,
and psychosocial/spiritual care, to name
a few) is essential to address the complex
Most massage
therapists are surprised
to learn that their
brand, technique, and
approach to massage
therapy already work
with palliative care.
needs of the growing number of adults
living with chronic, progressive, or life-
threatening serious illness.”3 When these
organizations make these assertions, they’re
talking about doctors, social workers,
nurses . . . and us. We are clinicians. I know
they’re talking about us because they’re
talking about anyone who provides any
kind of care for “the growing number of
adults living with chronic, progressive, or
life-threatening serious illness.” It’s time to
start noticing that people living with these
conditions are already our clients and our
clients’ loved ones.
We’ve all heard about the workforce
shortage in health care, and the conversation
about this shortage is shifting. The first
thing that needs to happen is a move away
from the idea that doctors are always the
first point of contact for people living with
illness. People are often diagnosed by a
doctor, but then many other care team
members join together (in the same location
or not) to provide the care they receive
related to that illness. Currently, massage
therapists are not a very big part of that
equation in reality or in the minds of health-
care decision-makers, but we can be part of
the solution to the workforce shortage. It’s
on us to show up to meet this need.
ABMP members earn FREE CE hours by reading this issue! 75
Notes
1. National Institute on Aging, “What Are Palliative
Care and Hospice Care?” accessed November
24, 2023, www.nia.nih.gov/health/what-are-
palliative-care-and-hospice-care.
2. Massachusetts Coalition for Serious Illness
Care, “2020–2021 Public Experience Research
Findings,” accessed November 24, 2023, www.
maseriouscare.org/sites/g/files/csphws2336/
files/2021-12/MCSIC-2020-2021-Public-
Experience-Research-Findings.pdf.
3. Brook A. Calton et al., “An Interprofessional
Primary Palliative Care Curriculum for Health
Care Trainees and Practicing Clinicians,”
Palliative Medicine Reports 3, no. 1 (2022):
80–6, www.liebertpub.com/doi/full/10.1089/
pmr.2021.0074.
Cal Cates is an educator, writer, and speaker
on topics ranging from massage therapy in the
hospital setting to end-of-life care and massage
therapy policy and regulation. A founding director
of the Society for Oncology Massage from 2007–
2014 and current executive director and founder
of Healwell, Cates works within and beyond the
massage therapy community to elevate the level
of practice and integration of massage overall and
in health care specifically. Cates also is the co-
creator of the podcasts Massage Therapy Without
Borders and Interdisciplinary.
Check out Healwell’s new podcast,
The Rub, where hosts Cal Cates and
Corey Rivera explore issues related to
palliative care and massage therapy,
health care and massage therapy, and
all things clinical massage therapy.
Find it wherever you get your podcasts.
 critical thinking | Table Lessons

Finding That Sweet Spot

So You Have a Full Schedule—Now What?
By Douglas Nelson

“This was so inspiring,” a therapist said following

one of my seminars. “I have been feeling in a rut
lately, where I have been doing the same work with
the same clients and feeling unchallenged. It has
made me question whether I should think about
a different profession or a change of scenery.”
Inquiring further, I discovered this therapist
has a full practice that’s booked out for weeks.
Looking from the outside, her practice is
a resounding success. She shared with me
that she had raised her prices in an effort to
lighten her schedule, but her clients happily
pay whatever she asks. I can see why, since
she’s an excellent therapist with a wonderful
presence. With a full schedule and clients who
appreciate her, why does she feel stifled?
I’ve seen this many times in my clinic and with
therapists across the country. As an employer,
I see it as an ominous warning sign, one that
could torpedo an excellent practice and cause
the therapist to leave the profession. For new
therapists, a full schedule seems like the goal of
all the work put into building a practice. It is,
but there is a shadow side you may want to guard
against. If it doesn’t challenge you, it doesn’t
change you.
In the beginning of your career, everything is
new. Each person on your schedule is a challenge
and you learn and grow in
adapting your newfound skills
to produce results and an
experience that clients appreciate. KEY POINT
News flash: People generally • Consider employing
love massage! Therefore, over new techniques and
time, the clients who might strategies with clients in
order to remain fresh and
mentally invigorated.
IVAN SAMKOV/PEXELS

76 massage & bodywork january/february 2024


have initially come for a specific issue are likely to come
for more general maintenance sessions. Adding to the
experience is the relationship between therapist and client,
as we get to know people in a personal way through the
context of massage therapy. Clients look forward to their
experience and enjoy the regular connection.
Quite often, there is a sweet spot in your career when
you have regular clients and still have time to see new
people who present with challenges that push your skills.
The clients who present with difficult musculoskeletal
issues are the clients who teach you the most. When your
go-to strategy doesn’t work, that’s when the learning
begins. When you successfully address a client’s presenting
needs, it’s wonderful for them, but you haven’t learned
anything new. I recently heard an interview with the late
Kobe Bryant, discussing his learning strategy when he was
a freshman in high school. Observing his peers, he noticed
that everyone tended to play to their strengths. Since they
played so often, he decided to only play to his weaknesses.
If he didn’t dribble well with his left hand, he played games
where that’s all he did. Over time, well, we all know how
successful of a professional he became.
A few days before writing this, I had my own
experience with a limitation leading to creativity and
learning. I fell off my bike and sprained my left wrist. The
only movement that hurt was ulnar deviation. After a day
of rest, I worried how I would see a full schedule of clients
the next day. At that point I decided to explore seeing
clients without ulnar deviating my left wrist. The day was
a rich exploration of keeping my wrist in a neutral position,
which I did. Really, keeping it in a neutral position is where
it should be anyway, so now I’m probably using better
mechanics than before the injury. Several clients that day
remarked on how locked-in and focused I seemed to be.
Little did they know why. It was a great day in the clinic.
This experience matches what experts tell us about
falling into a rut when creativity is lacking. It’s paradoxical,
but limitations spark creativity, not the removal of
constraints. This is one reason I love shorter sessions,
It’s paradoxical, but
limitations spark
creativity, not the
removal of constraints.
where time constraints force me to analyze and address
issues quickly. It’s also why I’m vigilant about leaving
spaces in my schedule for new clients who present with
difficult problems that push my skills to the limit and
beyond. Those clients are my learning laboratory, and I
cherish the opportunity to learn and develop my skills.
I’ve seen several therapists respond to feeling in a
rut by learning a completely different approach, which
they are excited about. Unfortunately, in many cases,
their regular clients aren’t as excited about the change.
This is understandable since these clients often want the
predictable and reproducible experience they have come
to know. Consider employing these new strategies with
new clients, or slowly introducing them, if appropriate,
to regular clients. Creating a practice that is rewarding
for therapist and client alike is often a difficult dance, but
one that should be carefully designed to have a long and
rewarding career.
Douglas Nelson is the founder and principal instructor
for Precision Neuromuscular Therapy Seminars, president
of the 20-therapist clinic BodyWork Associates in
Champaign, Illinois, and past president of the Massage
Therapy Foundation. His clinic, seminars, and research
endeavors explore the science behind this work. Visit
pnmt.org or email him at doug@pnmt.org.
ABMP members earn FREE CE hours by reading this issue! 77
 essential skills | Pressure Points of Business

Using Artificial Intelligence

in Your Massage Business
By Allissa Haines

There’s a lot of chatter in the world about artificial

intelligence (AI) programs. The AI programs
relevant to massage therapists include writing
tools that offer the ability to assist in creating
content for almost every part of our businesses.
I want to emphasize the important words in that
previous sentence: tools and assist. AI does not eliminate
the need for thought and discretion in the message you put
out into the world. But it can make creating those messages
much easier. AI does not remove the uniqueness of your
business, but it can help you be consistent in the tone and
style of your messaging to attract the best clients for you.
There are new programs frequently popping up and
increasing integrations of AI into existing social media and
content creation tools. We’re going to cover the popular
and easy-to-use program ChatGPT (chat.openai.com) and
its simple uses in your business.

LETTING AI WORK FOR YOU

ChatGPT has been available since late 2022. Since, it’s KEY POINT
become a commonly used tool for all kinds of businesses. • Artificial intelligence can
There is a free version that can likely do everything you be used by massage
need for small CHATGPT IN ACTION therapists to aid in
business use. Maybe you can write a business communications
I’ve found AI is most useful in creating and polishing decent blog post or email and marketing, but it
written content. Many business owners don’t have newsletter, but you aren’t should be used wisely and
with a sharp eye for editing.
experience writing marketing copy like email content or confident in grammar
social media posts, and most of us have no experience with or spelling. You can task
branding or creating a consistent message and feel for our ChatGPT with something
business. But these are important marketing tasks that can like: “Check the grammar and spelling of the following
determine if our business attracts the right new clients or article and correct any errors.” Then, paste your content
lets them slip by. in, submit the prompt, and let the program generate a
ChatGPT solves that lack of experience issue. corrected version.
Give the program a clear and specific prompt, and it I sometimes worry that my content is boring or that I SHANTANU KUMAR/UNSPLASH
will complete the task. Let’s dive into some examples haven’t written it in the best tone for my brand. I can ask
of using ChatGPT in a massage business. ChatGPT to “rewrite the following article in a fun and
personable tone,” and like magic, my article is much more
entertaining to read.

78 massage & bodywork january/february 2024

 If you have a hard time composing
your thoughts in full sentences, you
can give the program bullet points
and request it to form the ideas into a
marketing email to clients. ChatGPT
will then create a fully formed message.
Here’s a fun example: At a family event,
my cousin mentioned how hard he found
it to write an email to his clients about
increasing the price of his services. We
tasked ChatGPT to write an email in a
friendly tone to announce the increase in
pricing for his service.
Boom. In 30 seconds, we had solid
email copy that needed only a few
edits to be perfect. Then, just for fun,
we asked ChatGPT to rewrite the
email in iambic pentameter. (He did
not use that one, of course, but it was
fun to read that version aloud!)
Need to fire a client but can’t
find the words? I asked ChatGPT to
“compose a clear and kind email firing
a massage client because they are
often late or miss appointments. Use
200 words or less,” and the program
did just that. Read it for yourself:
Subject: Important Update Regarding
Your Massage Appointments
Dear [Client’s Name],
I hope this email finds you well. I want to
express my appreciation for your ongoing
support of our massage therapy services. It
has been a pleasure working with you.
However, I wanted to address a recurring
issue that has been affecting the quality of our
sessions. Over the past few months, there have
been instances of appointments being missed or
running significantly late [sic]. As you know,
punctuality is crucial for ensuring a relaxed
and effective massage experience for all clients.
To maintain the high standards we set for our
services and respect the time of other clients,
we regretfully must part ways with clients who
repeatedly miss or arrive late for appointments
[sic]. In light of this, we believe it would be best
for you to seek massage services elsewhere.
Please understand that this decision is not taken
lightly, and we genuinely hope you find a more
suitable place for your massage needs. We wish
you all the best in your future endeavors.
Thank you for your understanding,
and if you have any questions or need
recommendations for other massage therapists,
please do not hesitate to reach out.
Sincerely,
[Your Name]
[Your Massage Therapy Clinic]
I would certainly make some edits to
this email, but it’s a good foundation for a
professional and clear email when dealing
with a difficult situation.
If you find it challenging to come
up with an email, blog content, or social
media posts, you can use ChatGPT as
an idea generator. I asked, “What are
the FAQs of massage clients?” and it
gave me a list of common questions
that was a great launching pad for
multiple blog or social posts.
But with using AI comes great
responsibility on behalf of the user. AI is not
perfect. It can make factual errors, attribute
quotes incorrectly, or write in a perspective
that does not match your beliefs.
For this reason, you should not depend
on AI to create full articles or health
information from scratch. “Make a list of
10 ways to treat frozen shoulder” is a great
starting point that will provide ideas to
include in your own article. “Write a blog
post about curing frozen shoulder through
ABMP members earn FREE CE hours by reading this issue! 79
massage” is likely to result in a factually
incorrect article that violates a massage
therapist’s scope of practice. Use this tool
wisely and with a sharp eye for editing.
Likewise, information pasted into AI
programs is not private. Data entered into
ChatGPT can be used to train the program
for future use. There is a setting to opt out
of sharing your history and content, but it is
wise to assume everything you put in could
be seen and stored.
When I first started using AI
programs in my business, it felt very
strange. I doubted it would be a useful
tool and thought it would be an oversized,
complicated program. But after just a
little practice, I realized AI is much like
a calculator; it simplifies the complicated
work I could probably do on my own, but
saves me so much time and energy.
Give it a try, and see how AI can serve
your business!
Allissa Haines is a practicing massage
therapist and host of Business or Pressure
on The ABMP Podcast Network. She builds
websites and cultivates a community of
massage therapists at deepbreathdigital.com.
WATCH VIDEO
“HOW TO USE CHATGPT”
 essential skills | Back to Basics
Guiding Your Client’s Wellness
Path Through Treatment Planning
Many massage therapists run their
practices on a session-by-session
schedule. After a client receives their
massage session, the practitioner
rebooks for the next session only.
While this might be sufficient,
it’s worth asking yourself, “Is this
approach in the best interest of
both my client and my practice?”
A good way to determine the
answer is to consider goals. What are
the reasons this client has come to
you; what are their goals? And what
are your goals as a practitioner? Is
your aim to offer clients one special
experience of relaxation? Or is it to
be a guide along a personalized path
of long-term wellness? If you’re in
for the long haul, treatment planning
creates the map.
SESSION PLANNING VS.
TREATMENT PLANNING
It’s possible that when you were in school,
the focus was primarily on session planning.
This involves asking your client what
their needs and session goals are, then
breaking down how you will spend the time
addressing those needs during that session.
Treatment planning entails much more.
While it still involves asking your client
about their needs, it calls for establishing
long-term goals (with short-term goals
along the way) that can potentially create a
dramatic change in their quality of life. It
requires an investment from both parties.
The practitioner must invest extra time
and research into determining potential
root causes of the client’s experience, then
design a path that progressively molds the
body into the desired new state. The client
80 massage & bodywork january/february 2024
By Cindy Williams
In the case of treatment planning,
find out where the client wants to
go (i.e., how they want to feel and
what they want to be capable of
doing), then look at where they are
(i.e., how they feel and what they are
capable of doing). During the client
interview, write down the answers
to these questions to assist you in
providing a written treatment plan.
From there, make a list of
necessities for the journey. This will
vary depending on the extent of the
trip. A person who wants to hike a
10,000-foot peak along an eight-mile
trail would certainly need more time,
food, water, and gear than someone
who wants to hike three
miles to an overlook.
As you work with your
KEY POINT
client to chart their
• While treatment planning path, be realistic about
still involves asking your
must invest time and the distance between
client about their needs,
money into the process, it calls for establishing their goal and their
then commit to taking long-term goals that starting point. Consider
part in the journey can potentially create a their age, physical
through in-session dramatic change in their constitution, level of
feedback and consistent quality of life. investment financially
at-home self-care. and logistically (how
This isn’t to say that much time they can
a single session can’t create change or that dedicate to sessions and self-care), and
a practitioner won’t attempt to determine genuine mental and emotional willingness
root causes and educate a client on how they to take part in the therapeutic process.
can help themselves between sessions. But, There’s no exact formula for developing
as with any substantial goal, a long-term, a personalized treatment plan; each client
dedicated commitment is imperative. And so is unique. It’s important to be honest
is a plan! with them and ask them to be honest
with you. For example, if they don’t think
they will commit to multiple self-care
CHARTING THE PATH recommendations, provide one that will
To prepare for a journey, first determine make the greatest impact. Or, if they
your destination. Then, look at where you don’t have the financial means to pay for
are so you can find the most efficient path. two 60-minute sessions per week, try two

30-minute sessions per week. Additionally,
if their goal over one month is to be able
to walk three miles without stopping
but they currently can’t walk a half mile,
recommend a more realistic time frame.
Gathering as much information and being
as clear and straightforward with each
other as possible will result in an effective
planning process as a therapeutic team.
DEVELOPING A PERSONALIZED
ROAD MAP
A personalized road map plots out the
precise route to the end goal. While there
are fine details I won’t cover here, following
is a basic overview of this process.
Identify the Client’s Goals
Start with the health history form.
Be sure there is a line item that asks
what their goals are for your work
together. Then, in the client interview,
obtain as many details as possible.
For example, if they say they want relief
from neck pain, ask how it affects their daily
life and what activities this concern hinders.
When do they most notice the concern, and
what exacerbates it? Perhaps they experience
the most pain while driving when they turn
their head to see in their periphery. So, the
goal could be to increase cervical range of
motion while reducing pain so they feel
safer engaging in this activity.
Assess
Next, assess where they are so you
have a sense of the distance between
their present state and the goal. This
is done subjectively and objectively.
• Subjective—this is what the client tells
you they are experiencing. It includes
physical sensations as well as mental
and emotional states of being. Ask
the client how they feel about what
As you work with
your client to chart
their path, be
realistic about the
distance between
their goal and their
starting point.
they are experiencing. These are all
parts of the whole and will affect the
pace and type of approach you use.
• Objective—this is a measurable
observation and is done through multiple
assessment methods: palpation, posture,
range of motion, pain, and functional
limitations. Also observe how their
nervous system responds to their thoughts
and feelings about their condition by
noting their demeanor, such as facial
expressions and body language.
Set Specific Goals
Even though you determined what
their goals are, your job as the educated
professional is to set more specific goals
at short intervals to get them there. Use
the SMART goal model—in other words,
each goal should be specific, measurable,
attainable/achievable, realistic/relevant,
and time-bound.1 Goals are best set and
reviewed for progress in 3–4 session
intervals. Then, depending on whether
the treatment approach is working,
you will keep doing what you are doing
or pivot to a different approach.
Determine the Approach
This will vary depending on the type
of work you perform and your client’s
needs. Options to consider are:
• Tissue manipulation—gliding, torsion,
shearing, elongating, oscillating,
and/or percussive forces
• Joint movement—passive, active, resistive
ABMP members earn FREE CE hours by reading this issue! 81
• Static methods—static compression,
myofascial release, energy work, etc.
• Hot/cold therapy
• Variations of application—pace, depth,
rhythm, etc.
• Record and track—every session must be
documented and tracked for progress.
GUIDING THE PATH
When you take the time to guide a client’s
path by recommending and developing
an individualized treatment plan, you
show investment in them and their well-
being. This goes a long way in gaining
their trust, respect, and willingness to
engage in their health. It also encourages
your client to be invested, which increases
the chances of creating change.
A perk of incorporating treatment
planning into your practice is more
consistency of client booking, which
guarantees a fuller schedule and better
financial outlook. Most importantly, you
make a significant difference in your clients’
journeys.
Note
1. George Doran, Arthur Miller, and James
Cunningham, “There’s a S.M.A.R.T. Way to Write
Management Goals and Objectives,” Journal of
Management Review 70, (1981): 35–6, https://
community.mis.temple.edu/mis0855002fall2015/
files/2015/10/S.M.A.R.T-Way-Management-
Review.pdf.
Since 2000, Cindy Williams, LMT, has been
actively involved in the massage profession
as a practitioner, school administrator,
instructor, curriculum developer, and
mentor. In addition to maintaining a part-
time massage and bodywork practice and
teaching yoga, she is a freelance content writer
and educational consultant. Contact her at
massagetherapyfortwayne@gmail.com.
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essential skills | Heart of Bodywork

The Careless Therapist

By Laura Allen

The Oxford Dictionary defines careless as “not

giving sufficient thought or attention to avoiding
harm or errors.” Synonyms include inattentive,
negligent, absentminded, and forgetful.
We’ve all been guilty of carelessness at one time or
another: grabbing a hot pan without thinking, running out
of gas because you forgot to fill up, or forgetting to make
brownies for your kid’s school bake sale. When it comes
to the practice of massage, being habitually careless can
cost you clients, subsequently affecting your business and
income, and it may harm your reputation. Following are a
few examples of client comments about a careless therapist.

“She gives a good massage, but she runs late all

the time.”
KEY POINT
“Some kind of smell in the office was • Carelessness can
overwhelming. It gave me a headache.” negatively impact
your business and
“She keeps her cat at the office. There was cat your reputation.
hair on the blanket.”

“He constantly reschedules my appointments.” If you’re an employee, chronic lateness or constantly

Other issues, such as careless draping, can be even
more serious and may result in disciplinary action.
It’s enough to make a client think about switching
therapists for someone who’s more on the ball. Put yourself
in the client’s place. Don’t you get aggravated when you
have an appointment with someone and they’re running
late? If you got on the examination table at your doctor’s
office and there was cat hair on it, what would you think?
Many people are sensitive to smells, to the point that it
causes them headaches or respiratory issues. Just because
you find an essential oil pleasant doesn’t mean your clients
will. Beware of diffusing oils in the office.
Anyone can have an occasional emergency requiring
an appointment to be rescheduled, but when it happens
chronically, that’s usually the therapist’s lack of planning
and organization. Clients deserve better, and if they don’t
get it, they’ll eventually tire of it and go elsewhere. If it
happens to be their first appointment when you’re late or
when they find cat hair on the blanket, they will likely
never return . . . and they’ll tell their neighbors. They may
even leave a negative review of your business online. You
only get one chance to make a good first impression.
asking for appointments to be rescheduled is likely going
to result in termination. If you’re self-employed, take a
good self-inventory. Why are you always late? If you’re
scheduling your first appointment at 8:00 a.m. when you’re
not a morning person, change your work hours. Set a
regular day off during weekdays and schedule anything
you need to do, such as going to the dentist or another
non-emergency medical appointment or getting your own
massage, on that day so you don’t have to call clients to
reschedule.
Ethical behavior includes providing the highest quality
of care to those who seek our services. While carelessness
is different from intentional ethics violations, quality of
care should not suffer due to carelessness either.
Laura Allen has been a licensed massage therapist since
1999 and an approved provider of continuing education
since 2000. She is the author of Nina McIntosh’s The
Educated Heart, now in its fifth edition, and numerous
other books. Allen lives in the mountains of western North
Carolina with her husband and their two rescue dogs.

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 MEMBER BENEFIT: ABMP FIVE-MINUTE MUSCLES

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“Upper-Extremity Conditions,” and
“Lower-Extremity Conditions.”
2. Skin Cancer: Beyond the Basics
Ruth Werner
Strengthen your identification
skills and learn the details of each
major type of skin cancer.
Sidelying Techniques Series
Allison Denney
Learn client positioning, draping,
and targeted techniques and
stretches in the sidelying position
in this three-course series covering
the shoulder, back, and hip.
4. Hygiene: Critical Updates
for Massage Therapists
Ruth Werner
Review standard and universal
precautions, identify updated
practices, including sanitation
and air quality, and take an in-
depth look at pathogens.
for Back Pain Series
Ann and Lynn Teachworth
Discover essential hands-on
approaches and embodiment
practices for lower-back and upper-
back pain in this two-course series.
NEWLY ADDED CE COURSES
 Palpating the Hip Flexors
Dr. Joe Muscolino
 Protect Your Practice: Public
Health and Contagious
Diseases—Two-Course Series
Ruth Werner

86 massage & bodywork january/february 2024

 LOYAL ABMP MEMBERS

Andrea Richardson Theresa Cipolla Joyce Kahakalau Catherine Reichenbach

30 years Margie Kaiser Monica Reineck
Steven Romey Florence Claypoole
Clemente Allamby
Carolyn Ida Sadowski Jennifer Cohon Catherine Kannenberg Michele
Phillip Bordonaro
Jacqueline Sarkis Brigitte Collins Michael Kistler Renee-Vyverman
Thalia Cunningham
Melinda Scott Aleta Confessore Vicki Klepper Heike Rentel
Denise Daniels
Jennifer Share Jenni Lyn Cooper Mary Knapp Jonnie Renteria
Jerome Davre
Tanya Sowards Sheena Creed Sally Koester Jenny Beth Ribaudo
Elaina Fields
Steffani Szana Ashley Daggett Debbie Koki James Riddell
Jeffery Flint
Juliana Tacey Monica Dain Ilke Lander Joy Riggs
Jeanne Gibson
Michael Talbot Diane D’Arcangelis Michael Larios Maria Robles
Marty Hale
Patricia Tallman Nancy Davis Teresa Lawvor Miller Sarah Roe
Jeffrey Longin
Jana Tift Catherine Degraaf Brad Lecraw Sarah Rood
Harini Oken
Edward Torres Jennifer DiBonaventura Sung Lee Bruno Rowell
Dawn Smith
Natalie Trudeau Julia Dinter Corinne Leemann Phornvipar
Cara Theriault
Mary Van Nuland Donene Marie Disco Kristen Lefebvre Ruangsakvichit
Robert True
Lisa Walters Gregorio Dominguez Stephanie Linge Janet Sacco
Mary Wheeler
Kathryn Weymouth Jessica Donachy Rosemary Shiu Ching John Santos
Maurizia Zanin
Michael Wilemaitis Donna Donato Low Zachary Schlotthauer
Tammy Lea Wise Kaia Drezner Kayla Machniak Vickey Schmadeka
20 years Kimberly Wollschlager Katherine Driban Jesse Magana Yanin Schneider
Mariah Achey-Pramick Stacy Yankura Kathleen Duval Stephanie Marshall Lindsay Schroeder
Margaret Adams Amy Yaple Traci Dyer Dolores Matel Nicole Scorse
Connie Alexander Carol Einwalter Margaret McCollum Roojjaravee
Nichelle Alicea Jennifer Elting Naomi McGehee Seedarunpon
N. Todd Billig
10 years April Epps Tilanda McMillan Jonathan Shwartzer
Jennifer Adams
Barbara Branny Alma Ervin Lauret Meier Quinn Silverleaf
Kathryn Alexander
Joy E. Brody Laurie Eudy Christine Meredith Anna Smith
Kahleah Alkire
Justin Canfield Anna Everhard Katherine Elizabeth Jessi Spierings
Kathy Arendt
J Michael Clark Dianne Filip Miller Tammy Springman
Lisa Arroniz
Valerie de Haas Naomi Finochio Renee Mink Cory Stanchfield
Molly Arvin
Annette Elsea Steve Foerst Kyohko Miyazawa Francisca Steevensz
Lashawnda Ausbon
Chris Estrem Sherry Joell Mina Moghadam Kelley Steger
Laurel Ayers
Kristina Falciano Fogg-Arnold Matthew Moller Kelly Stewart
Benita Babeckis
Marie Free Cyndi Fonseca Erica Morgan Lauren Swick
Nichol Bauer
Barbara Frydryk Kelsey Anne Morrison Johnny Tea
Amanda Baxter
Linda Garofallou Foster-Goodrich Bridget Mueggenborg Susan Thomas
Michele Belcher
Andrea Gordon Kellie Gale Christine Mullin Linda Tipton
Sarah Berckman
Hede Griem Veronica Garcoveanu Kevin Myers Minna Tolvanen
Diane Bergstedt
Malia Grimes Kelly Gauthier Paula Nettesheim Dennis
Modesta Best
Eileen Haggerty Wislar Chadamas Geddes Jennifer Nogas Lauren Turner
Anett Betancourt
Traci Doran Hawkins Jeanne Geisler Tomasz Nowakowski Stefanie Verity
Sharon Bevins
Adam Horkavy Christopher Gengarelli Hisako Oba Janice Vick
Elizabeth Bies
Alyson Hurlbutt Michele Good Michael O’Brien Danguole Vilkiene
Melanie Blair
Andrei Kazlouski Gail Gregorich Lesa O’Connor Maria Villafuerte
Tami Boardman
Lisa Klossner Karri Grenier Erica Olsen Dianna Waters
Barbara Boling
Carol Leas Michael Miles Hahn Melissa Olson Amy Webb
David Bradford
Catherine Leduc Linda Hanson Brooke Oyadomari Andy Whitman
Cynthia Bradley
Melissa Lucier Jennifer Harmon Blakely Parent Geneva Wilson
Amy Braida
Bonnie Madison Jami Helmig Lauramy Paris Vicky Wilson
Lynnette Brewer
Donald Martinez Ann Hibbard Angela Parker Genelyn Winningham
Sonia Brixey Fernandez
Connie Merrill Leanna Hirsh Dan Pawloski Alisha Wiskirchen
Diane Burciaga
Marco Munoz James Horn Gilberto Pena Jr Jacquelyn Wolniewicz
Jane Burke
Vincent Nalli Stasia Humphreys Tavia Pensinger Hannah Woltman
Carol Canton
Elysse O’Connor Lee Hutchison Camille Percy Anna Marie Wood
Teri Capaldi
Melissa Paluzzi Candice Isphording Anne-Therese Peterson Wendy Woods
Deborah Capone
Sally Ann Parent Kathlyn Jackson Hanni Peterson Ying Yu Xuan
Chelsea Carpenter
Wendy Peloquin Keriann Jamerson Katerina Plskova Michiko Yamagata
Anna Carter
Natalie Pope Zoyamarie Jilbere Jacquelyn Poe Ashley Yeager Dresch
Robert Cesarz
Mary Radewahn Shantell Johnson Danielle Powell Theresa Youngblood
Ronald Chaney
Bryn Rath Jenny Jones Jacqueline Rager HongXia Zeng
Eduardo Chavarria

ABMP members earn FREE CE hours by reading this issue! 87

Savvy Self-Care
The Physiological Sigh:
Our Built-In Adaptogen
By Heath and Nicole Reed
T
he benefits of adaptogens are
nothing short of a wonder drug:
diminishing stress, enhancing
hormonal and immunological efficiency,
reducing inflammation, and even
preventing age-related diseases. One
of the most profound and intriguing
features of adaptogens is their customized
responsiveness and individual healing
prowess. Adaptogens seem to have an
intelligence of their own, inspiring our
physiology to upgrade and more gracefully
respond to the inevitable stressors and
changes around us. We are amazed at the
intelligence transmitted through a plant,
flower, herb, vegetable, mushroom, spice,
or even a conscious breath that can provide
WATCH VIDEO
the perfect nudge toward physiological and
“THE
PHYSIOLOGICAL psychological equilibrium. Adaptogens
SIGH” remind us that food is medicine, or poison,
depending on our choices, and that small
behavioral shifts, like a few mindful
physiological sighs, can be the perfect assist
to feeling more aligned and less stressed.
Read more about adaptogens at abmp.com/updates/blog-posts/savvy-self-care-evolutionary-benefits-adaptogens
88 massage & bodywork january/february 2024
THE METHOD
A new favorite adaptogenic practice in
the Reed household is the “physiological
sigh,” a breathing practice to help soften
the blows of small and large doses of
everyday stressors. This is a modern
spin on ancient pranayama practices.
Breathe in deeply through your nose.
When you think you’ve reached the top of
your in-breath, pull in a short, staccato-
like breath. Without holding your breath,
purse your lips and slowly exhale all the
breath from your lungs with an even and
steady flow. Repeat at least three times
to feel yourself return to balance.
Heath and Nicole Reed are co-founders
of Living Metta (living “loving kindness”), a
continuing education company committed
to sharing feel-good therapies to give and
receive. They also host CE healing retreats in
Thailand. Discover more at livingmetta.com.
 Committed to a
Culture of Care

Proud sponsor of
Massage Heights franchisees are
passionate about creating positive
work environments that value and
inspire their staff. We have career
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validation of their unique talents.

Positions available in California,

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Visit our website to learn more

about our Culture.
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Retreat and franchisees are not acting as an agent of MHF or its affiliates. ©2023. SWG IP, LLC. All Rights Reserved.
now hiring massage therapists

A CAREER DESIGNED
with you in mind
The Career Advancement Program is
designed to recognize, reward, and uplift
the best Massage Therapists within an
Elements Massage® studio. Elevated status
comes with benefits such as a higher
commission rate, access to CEU courses
& unique career growth opportunities.

To apply, text Improve Lives to 97211

or visit ElementsMassage.com/careers
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employment by Elements Therapeutic Massage, LLC. (“ETM”). ETM is not involved in, and is not responsible for, employment and personnel matters and decisions
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