2016 January-February PDF

january/february 2016
Enjoy Massage & Bodyworks

NEW, LARGER SIZE!
Lymph
Recent scientific
breakthroughs will
change how we look
at the lymphatic system
Insurance Code Changes

Breastfeeding
& Bodywork
History Lesson!
THE EVOLUTION OF MASSAGE
NEW COLUMNS
> Mindful Money p. 30
> Science of Nerves p. 98
> The Story of Massage p. 119
TIPS FOR TODAY
6 Must-Dos to Increase Your Massage Revenue

By Brandon Twyford
ABMP Associate Editor | brandon@abmp.com
elenaray.photoshelter.com
Short of raising rates, what can massage therapists do to maximize their practices
revenue? Here are some simple ideas that can put a little extra cash in your pocket.
20 massage & bodywork january/february 2016

If youre
looking to
beef up your
1. SET UP ONLINE
BOOKING/SCHEDULING
schedule,
be sure to
5. START A BLOG AND INCREASE
YOUR PRESENCE ON SOCIAL MEDIA
Are your clients able to view your schedule Take advantage of the free avenues you have
and book their own appointments
online, at any timeeven late at night
ask every to promote your practice online. Blogging
and other social media channels provide
or on weekends? They should be. Set up
your own free account at MassageBook
client you the perfect opportunities for you to get
your name out there and attract new clients
(www.massagebook.com/abmp), where
ABMP members get special enhanced
see when without having to spend a penny. Financial
gains from blogging and social media
practice management features at no
additional charge. Anything that makes
theyd like to can be less immediate and less tangible
than the other topics weve discussed
it easier for your customers to find you
and book an appointment can result in
rebook. Give here, but a positive online reputation
pays off in a big way in the long run.
more bookings and more revenue.
them the Many times, when people think about
starting a blog, their initial thoughts
2. opportunity are, But I dont have anything new or

interesting to say. Thats simply not true.
while theyre
BUILD A CUSTOM WEBSITE
Each of us has a unique background, and
A professional website for your practice
we all bring something slightly different
is no longer optionalits mandatory.
You get a free, fully hosted website as still in awe of to the table. Creating a blog and making
frequent posts that insert you into the
part of your ABMP membershipuse it!
Its easy to do, even if youre a beginner. their session. current conversation around the massage
and bodywork profession will give
ABMPs Website Builder (www.abmp.
clients a personal insight into you and
com/members/site) guides you through
what makes your practice different. The
building your own custom website, using
more your voice comes through in your
4.
professionally designed templates and
online presence, the more likely clients
prewritten content. Your website can
are to trust you with their wellness.
be up and running in about an hour. ADD RETAIL ITEMS
6.
Are you faithful to a brand? Do you have
3.
any favorite products you consider superior
to others on the market? Youre the perfect WRITE OFF BUSINESS EXPENSES
ASK CLIENTS TO REBOOK
spokesperson alreadywhy not make a little Did you know you might be able to claim
BEFORE THEY LEAVE
extra cash for it? When youre passionate tax deductions for continuing education,
How do you get clients to rebook? Just
about a product, selling its benefits to others massage supplies, and business mileage?
ask! This is sometimes a sticking point for
is easy. Reach out to those brands you love Keep receipts for everything you buy
massage therapists who often prefer to let
and ask for wholesale pricing on the items related to your practice. Come tax time,
their hands do the talking and shy away
you want to sell. Eventually, you can even speak with an accountant to see what
from behavior they may consider pushy. But
add them to the online storefront on your legitimate deductions you can make.
sometimes, word-of-mouth marketing and
custom website. Theyll sell themselves (ABMP members get discounts on tax
customer referrals arent enough. If youre
without you ever having to make an in- preparation services from H&R Block;
looking to beef up your schedule, be sure to
person sale, but you still get commission! log in to www.abmp.com and click on
ask every client you see when theyd like to
Discounts to learn more). The savings
rebook. Give them the opportunity while
you are entitled to may surprise you.
theyre still in awe of their session. You
might be surprised how easily many clients
say yes and start to check their calendars.
Check out ABMPs latest news and blog posts. Available at www.abmp.com. 21
education FUNCTIONAL ANATOMY
Deltoid
By Christy Cael
The deltoid muscle is a large, superficial

structure that covers the lateral shoulder.
The muscle originates at the lateral one-third
of the clavicle anteriorly, the acromion process
laterally, and the spine of the scapula posteriorly.
It begins where the trapezius muscle ends,
Deltoid
but with clear delineation provided by the
bony landmarks. The thick fibers of the deltoid
converge to a single point halfway down the
lateral side of the humerus and insert on the
deltoid tuberosity. The muscle is named for the
triangular shape it forms on the shoulder.
The deltoid is a prime mover for nearly all movements
of the shoulder. Its multipennate fiber arrangement,
large cross-sectional area, and broad attachment points
create excellent leverage on the glenohumeral joint. The
deltoid also plays an important role in stabilizing the
shoulder by wrapping itself around the glenohumeral
joint and holding it together. When all fibers of the
deltoid work together, it is a powerful abductor. The
supraspinatus stabilizes the head of the humerus as the
deltoid abducts the shoulder and prevents impingement
of the humeral head on the acromion process. This
tandem action provides the smooth and powerful
DELTOID
movement of the shoulder necessary for lifting and Attachments
reaching both above and below shoulder height. O rigin: Lateral one-third of the clavicle,
The anterior fibers of the deltoid work with the acromion process, and spine of the scapula
pectoralis major to flex, horizontally adduct, and Insertion: Deltoid tuberosity of the humerus
internally rotate the humerus. This is a powerful Actions
combination, and these muscles are utilized in pushing,
Abducts the shoulder (all fibers)
reaching, and initiating throwing movements. As a result
F lexes, internally rotates, and horizontally
of this association with the pectoralis major, as well as the
adducts the shoulder (anterior fibers)
fact that most activities of daily living utilize movements
E xtends, externally rotates, and horizontally
in front of the body, the anterior fibers of the deltoid
abducts the shoulder (posterior fibers)
are often overdeveloped and the posterior fibers are
typically underdeveloped. The anterior deltoid frequently Innervation
adheres to the pectoralis major where the muscles overlap Axillary nerve
at the anterior shoulder. This pattern contributes to C56
mechanical dysfunction, soft-tissue impingement, and
pain in the glenohumeral joint and associated structures.
FUNCTIONAL ANATOMY
The posterior fibers of the deltoid are antagonists

to the anterior fibers in all motions except abduction.
These fibers horizontally abduct and externally rotate the
shoulder. They also work with the latissimus dorsi and
teres major to extend the shoulder, with the pectoralis
major contributing to this motion from overhead, flexed
positions. Functionally, these movements are critical for
pulling and overhand throwing motions. Effective and
efficient movement of the glenohumeral joint depends
on proper coordination and development of all fibers of
the deltoid and the muscles of the rotator cuff.
Christy Cael is a licensed massage therapist, certified strength

and conditioning specialist, and instructor at the Bodymechanics
School of Myotherapy & Massage in Olympia, Washington. Her
private practice focuses on injury treatment, biomechanical analysis,
craniosacral therapy, and massage for clients with neurological issues.
She is the author of Functional Anatomy: Musculoskeletal Anatomy,
Palpating the Deltoid Kinesiology, and Palpation for Manual Therapists (Lippincott Williams
Positioning: client supine with arm at side. & Wilkins, 2009). Contact her at functionalbook@hotmail.com.
1. Locate the clavicle and follow it laterally to the acromion, then

Editors note: The Client Homework element in Functional Anatomy
posteriorly to the spine of the scapula. is intended as a take-home resource for clients experiencing
2. From here, palpate inferiorly along the muscle belly with the issues with the profiled muscle. The stretches identified in
Functional Anatomy should not be performed within massage
palm of your hand.
sessions or progressed by massage therapists, in order to
3. Continue palpating the muscle belly as it converges about comply with state laws and maintain scope of practice.
halfway down the lateral humerus.
4. Gently resist as the client abducts the shoulder to ensure
proper location.
Client HomeworkRows
1. S
it or stand with your eyes forward and your
spine straight.
2. Reach forward and grasp the handle (or handles) with
both hands.
3. Pull back by bending your elbows and pinching your
shoulder blades together.
4. Keep your hands evenly spaced through the entire
movement as you pull toward your chest.
5. Gradually return to the original position, then repeat.

education SOMATIC RESEARCH
Massage Therapy for Multiple Sclerosis

By Jerrilyn Cambron
Multiple sclerosis (MS) is each massage session, the subject

completed a brief questionnaire to
a disease of the central
determine the degree of similarity
nervous system. The between each treatment. The
massage therapist also completed
most common symptoms
a brief questionnaire defining the
are overwhelming fatigue, duration of treatment and observed
changes in the subjects. On a weekly
visual disturbances, altered
basis, the subjects completed a
sensation, and difficulties three-question health assessment
to log any stressors that may have
with mobility. Approximately
aggravated their MS symptoms.
2.3 million people are Based on these measures, there
were no reported differences in
affected by MS worldwide.1
the massage technique or duration.
Exact figures are difficult There were also no changes in self-
reported health status throughout
to calculate because MS
the study between the two groups.
symptoms can be nearly Subjects also completed three
previously used massage, and therefore had
other outcome measures at the start of
invisible and MS is not a disease with some experience with this form of care.
the study, the end of four weeks, and the
Subjects were initially randomized
mandatory government reporting. end of eight weeks. First, a six-minute
to one of two groups. Group 1 received
walk test (6MWT) was completed to
Treatment of MS is frequently sought 45-minute whole-body Swedish massages
determine exercise capacity as a measure
through disease-modifying medications twice a week for four weeks. Prior to the
of leg function. Second, the Hamburg
along with other medications for symptom start of the study, the massage therapists
Quality of Life Questionnaire in Multiple
relief. Massage therapy is one of the practiced the standardized massage
Sclerosis (HAQUAMS) survey was
most commonly used complementary routine, and the routine was then posted
used to measure different aspects of
and alternative medicine treatments. at the head of the massage table during
physical, mental, emotional, and social
However, very little is known about the the study as a reminder for the therapists.
health. Finally, the Expanded Disability
benefits of massage therapy for MS. The four weeks of massage sessions were
Status Scale (EDSS) was used to collect
In a 2014 study, Brittany Schroeder followed by four weeks of twice weekly
and measure the level of disability.
and a team of researchers evaluated the rest (no care) as a comparative control.
effects of massage therapy on quality of life Group 2 started with four weeks of rest
and leg function in individuals with MS.2 two times a week, and then received twice THE FINDINGS
Twenty-four Canadian subjects who had a weekly massage therapy during the second No statistically significant changes were
moderate disability score (between 3.5 and four weeks (weeks five through eight). found in the 6MWT, HAQUAMS, or EDSS
7.0 out of 10 on the Expanded Disability The crossover of patients from massage measures due to massage treatment when
Status Scale) enrolled in the study. Potential therapy to no care or from no care to compared to rest. However, the subjects in
subjects were excluded due to chest pain massage therapy allowed data to be collected group 1 who had worse disease severity had
(unstable angina) or heart attack during from all 24 subjects in the no care and the significantly better walking distances on the
the previous month, high blood pressure, massage care situations. In other words, 6MWT and also better HAQUAMS scores
or inability to attend regular massage subjects served as their own control. after four weeks of massage, demonstrating
appointments. Eighteen of the 24 subjects Several outcome measures were collected that massage may be of more benefit to MS
within this study. Immediately after

subjects with more severe symptoms. No expressions of feelings.4 Of the 300 found that massage improved their sleep
other differences in treatment were noted. reflexology sessions, 245 audiotapes were and increased their energy levels.
The majority of the subjects written available for assessment. Transcripts were More research is needed to better
comments were favorable, with 18 of the 24 explored for common themes and were understand which symptoms might
subjects including positive statements and reread for specific issues and perspectives. be improved by massage, particularly
only three including negative statements. These items were clustered in areas of at different stages of the disorder.
Positive comments included that the benefit commonality. Two raters reviewed the People with MS may express concerns
of massage lasted several hours to several transcripts for themes, and differing about life issues during a treatment session,
weeks and that massage helped with sleep views were discussed and agreed upon. highlighting the need for therapists to know
and increased energy levels the next day. The researchers found there were when and how to refer to other health-care
Overall, there were no significant four common themes discussed by the professionals or social-service agencies.
differences between massage and rest, subjects during the treatment sessions. All clients are differentparticularly
although there were many positive written The common themes surrounded their clients with MSdue to the nature of the
comments about the effects of massage worries and concerns regarding: (1) disorder. Talk to your clients with MS
treatment. Perhaps the study limitation physical health and treatment, such as and their health-care teams to determine
of a small number of subjects did not symptoms of fatigue, pain, bladder and the best course of treatment.
allow for statistical significance to be bowel problems, diagnosis experiences,
discovered. Larger sample sizes typically treatment, and interactions with health
Notes
allow for a more robust data analysis and professionals; (2) psychological concerns,
1. National Multiple Sclerosis Society, Multiple
should be considered in future trials. such as worry, anxiety, depression, anger, Sclerosis FAQs, accessed November
Also, the subjects MS may not have been frustration, future, body image, isolation, 2015, www.nationalmssociety.org.
severe enough to demonstrate significant and loss issues; (3) home and family, such as
2. B. Schroeder, J. Doig, and K. Premkumar, The Effects
improvement over time when compared to relationships, financial issues, and domestic
of Massage Therapy on Multiple Sclerosis Patients
no treatment. There were pre/post changes activities; and (4) work and leisure, such Quality of Life and Leg Function, Evidence-Based
in the massage group in subjects with more as sick leave, part-time, work stresses, Complementary and Alternative Medicine (May 8, 2014).
advanced MS, so perhaps a higher degree retirement reaction from colleagues, and
3. P. A. Mackereth et al., Reflexology and Progressive
of severity of MS is needed in order to see effects on social and leisure activities.
Muscle Relaxation Training for People with Multiple
a significant change in subjects outcomes. Study limitations may narrow the Sclerosis: A Crossover Trial, Complementary Therapies
Finally, there was no justification as to why application of these results. For example, in Clinical Practice 15, no. 1 (February 2009): 1421.
the treatment schedule of two 45-minute the comments made by these clients
4. P. A. Mackereth et al., What Do People Talk
massage treatments per week for four may be different from what other clients
About During Reflexology? Analysis of Worries and
weeks was chosen. A different schedule experience. Also, the themes found by the Concerns Expressed During Sessions for Patients
of care might have had a greater effect. researchers may be different from what with Multiple Sclerosis, Complementary Therapies
In a related study led by P. A. other researchers would find in the data. in Clinical Practice 15, no. 2 (May 2009): 8590.
Mackereth, 50 subjects with MS in the
United Kingdom were randomized to
CONCLUSIONS Jerrilyn Cambron, DC, PhD, MPH, LMT, is
either progressive muscle relaxation or
In a small-scale study focused on subjects an educator at the National University of Health
reflexology for six sessions of treatment.3
with MS, massage therapy did not affect Sciences and president of the Massage Therapy
After the six sessions, subjects crossed
quality of life, walking, or disability when Foundation. Contact her at jcambron@nuhs.edu.
over to the other group for six sessions of
compared to rest. However, improvements
the opposite form of care. Several types of
in walking after massage were noted
outcome measures demonstrated positive
by subjects who had more severe cases
effects for both treatments, with limited
of MS. Some subjects with MS also
differences between the groups. However,
some of the most interesting data came
from the conversations during the care.
To collect data on the conversations For more information about massage therapy and
during care, subjects in both groups MS, please read the January/February 2012 issue
were audiotaped and the conversations of Massage & Bodywork magazine, available
were transcribed to assess the verbal at www.massageandbodyworkdigital.com.
The lymphatics are closely
and universally connected with
the spinal cord and all other
nerves, long or short, universal
or separate, and all drink from
the waters of the brain.
A. T. Still, 18991

Lymph in
the Brain
New Scientific Paradigms About the Brain,
Cerebrospinal Fluid Dynamics, Lymph,
and Their Applications for Manual Therapy
By Bruno Chikly, MD, DO, and Alaya Chikly
R
throughout his life. In 1741, he described G. Schwalbe injected Berlin Blue dye
the expansion and contraction of the into the most external cerebrospinal
brain, and its production of an extremely spaces (the subarachnoid space or SAS)
refined substance, a highly gifted juice, of dogs and found that he could follow
which he called the spirituous essence, the dye from the central nervous system
the spirituous fluid, that was present in (CNS) into the lymph nodes of the neck.
CSF.4 He said this refined fluid traveled Schwalbe made the very first statement
throughout the entire body and was that the lymphatic pathways are the
returned to the blood by lymph.5 major pathways, outside of the CNS, for
In his description, Swedenborg may have CSF reabsorption.7 However, it was not
made the first connection between CSF clear exactly what pathway the blue dye
and the lymphatic system. He also stated, took to get from the CSF to the nodes
for the first time, that CSF is secreted by in the neck. A little later, in 1872, H.
Recent scientific breakthroughs in
the blood vessels in the brain, a concept Quincke demonstrated that the CSF
how we look at the lymph system that has just recently been confirmed by could leave the CNS through little
scientific investigations, as we will discuss spaces surrounding the cranial and spinal
and the circulation of cerebral
later. A man ahead of his time, Swedenborg nerves.8 Numerous researchers have
spinal fluid are causing gradual likely had an influence on the development demonstrated these pathways and shown
of cranial osteopathy, potentially influencing that some constituents of the CSF drain
shifts in massage therapy.
W. G. Sutherland (18731954), the into lymph nodes in the neck (cervical
Lets look briefly at the historical originator of cranial osteopathy, which is lymph nodes), using the lymph pathways
journey of our ongoing understanding of the foundation of craniosacral therapy. to exit the CNS.9 T. Brinker, and others,
fluid dynamics, unveil some of the newest For more than 100 years, the classical showed that at least 50 percent of CSF is
and most exciting discoveries concerning understanding of the physiology of CSF reabsorbed through the lymphatics rather
the circulation of lymph and cerebrospinal has remained unchallenged, until recently. than the veins.10
fluid (CSF), and then offer some effective Today, these three pillars of the
manual therapy techniques for lymph The Old Model: The Three Falling physiology of CSF are losing their ground
drainage that can help facilitate the Pillars of CSF Physiology as fundamental principles. Even though this
natural exchanges between these fluids. If you understand a little about CSF is what most physiology and neurobiology
physiology, you know it has traditionally books still describe today, recent research
NEW AND OLD CSF HYDRODYNAMICS been based on three main points that shows there is now little convincing
The lymphatic system was discovered experts universally accepted as the evidence to support this exact model.11
somewhat late in history, 2 but the unquestioned truth:
identification of CSF came even later. In Production. Since 1919, schools have taught The New Scientific Model
ancient times, Hippocrates and Galen that CSF is mainly formed by the choroid With the three main pillars of conventional
recognized fluids in the brain, but even plexi inside the brain ventricles; it then CSF physiologyproduction, circulation,
at the time of French philosopher and circulates within the ventricular system, and reabsorptionbeing critically
scientist Ren Descartes (15961650), the eventually to be passively absorbed into challenged, a reformulation of this old
brain was still considered to be merely the venous sinuses, and/or into the lymph theory may change applications in research,
a hydraulic pump moving fluid through system.6 as well as applications to manual treatments.
the nerves to animate the muscles. Circulation. In the classical model, it was Lets look at the changes in conventional
The scientific discovery of CSF is also believed that CSF flows unilaterally thinking regarding CSF physiology.
attributed to Swedish scientist, philosopher, (from the lateral ventricles to the third and Production. Today, researchers are
and visionary Emanuel Swedenborg fourth ventricles), eventually reaching the finding that choroid plexi most likely have
(16881772).3 His career was exceptionally spaces around the brain. only a small role in CSF secretion; the
prolifiche wrote approximately 40,000 Reabsorption. The old CSF model major source of CSF production is in all
pages on scientific and mystical topics attributed the fluids reabsorption only probability the capillaries of the brains
to the veins and lymphatics. In 1869, cerebral tissue,12 echoing the innovative

LYMPH IN THE BRAIN
concept of Swedenborg, who said: CSF is
1
secreted by the blood vessels in the brain.
Part of that evidence came in 1969,
when T. H. Milhorat removed the
choroid plexi from both lateral ventricles The lymphatic system
(choroid plexectomy) in a human subject from the classical
and in monkeys, and found no changes perspective (left). Recent
in the volume of CSF secretion, or in its research shows a new
composition, contradicting conventional model integrating the
knowledge.13 Even after a total choroid central nervous system
plexectomy, the CSF still secreted at the (right). UVA Health.
rate of approximately 1 liter per day.14
Circulation. In the classical model,
we should obviously see CSF flowing
inside the ventricles, which is opposite Additionally, the CNS requires fast
through the different cavities of the
to the direction given by the classical communication pathways for circulation
ventricular system. However, when
model.17 J. D. Fenstermacher led a study of immune-competent cells and
M. Klarica and a team of researchers
that also showed that marked tritium stimulation of the immune system.
inserted a cannula inside the aqueduct of
passes through the ventricular wall of the This, too, remained misunderstood
Sylvius in numerous cats, they did not see
brain (ependymal), confirming that the without our latest findings of a lymph
any net flow of CSF via the cannula for
ventricular wall is not impermeable.18 system presence in the brain.
more than three hours. This data added
Reabsorption. Under normal CSF
to their suspicion of a faulty classical
pressure, marked tritium (3H water) is LYMPH & GLYMPH: THE
model, and made these scientists wonder
reabsorbed into the brain capillaries GLIOVASCULAR CLEARANCE SYSTEM
whether CSF really circulated.15
around the ventricles (periventricular Now, lets look within the brain itselfnot
The old model described CSF
capillaries), suggesting that CSF just the pathways of the cerebrospinal fluid.
flowing unidirectionally within the
bulk water is produced, as well as In 2012, researchers demonstrated that
brain ventricles and surrounding the
absorbed, into the brain tissue.19 tracers injected into the ventricular CSF
brain tissue. Large molecules have
If the CSF is not mainly produced of mice entered the parenchyma of the
been used in the past to study CSF
by the choroid plexi, but locally in every brain, and were transported into a small
physiology, and this may have caused
aspect of the brain tissue (parenchyma), space between the brain capillaries and the
numerous misconceptions about CSF
it is also reabsorbed in the same places, astrocytes surrounding them.20 Astrocytes
circulation. In these older experiments,
everywhere within the brain. In fact, cover approximately 99 percent of all
the injection of macromolecules into
CSF components can be found in spaces cerebral capillaries (see Image 2, page 50).
the ventricular spaces to define the
around major cranial and extra-cranial This is a very slow clearance pathway in
circulation of CSF gave the wrong
nerves (perineural lymphatic pathways), the CNS, present in most mammals, that
impression that the walls of the ventricles
such as the olfactory nerves, the optic facilitates the removal of CNS interstitial
were impermeable, and that CSF is
nerves, and the auditory nerves, as well as fluid, as well as waste products, including
transported in a linear manner from the
other cranial and/or spinal nerves. Once amyloid beta proteins that accumulate in
lateral ventricles to the third and fourth
recognized, these areas can be stimulated pathologies such as Alzheimers disease.
ventricles, then into the subarachnoid
by a trained manual therapist to facilitate The function of the glymphatic system
spaces and all the brain cisterns.16
reabsorption into the lymph pathways. is lymphatic-like in the brain, but the fluid
Recently, the injection of marked
Today we know that in the case of within the system is not lymph fluid, as
tritium (3H water) into the CSF system
hemorrhage or infection, large proteins it is not located inside the CNS lymph
demonstrated water distribution in
can accumulate in the central nervous
the ventricles in almost all possible
system (CNS), and the brain needs to
directions, including a retrograde path
be cleaned and drained. Previously,
what system was truly responsible for
this important function was a mystery.
2 vessels. It is another newly discovered slow
pathway for drainage of CSF components.
There is much new evidence describing
the essential function of sleep in activating
this glymphatic pathway that helps to
maintain metabolic homeostasis. It seems
Astrocytic that the clearance of potentially neurotoxic
endfeet waste products is increased during sleep
by the expansion of these extracellular
spaces in the brain (a 60 percent increase
Tight junction in the glymphatic pathways).21 An
alternative important function of the
Venule glymphatic system may be to transport
small lipid molecules in the CNS.22
Arteriole
CNS endothelial cell LYMPH IN THE BRAIN PROVEN
Nucleus of endothelial cell Still, glymphatic pathways are not
Pericyte Basal lamina
lymphatic pathways. For decades,
researchers tried to understand the
Astrocytic endfeet. They cover approximately 99 percent of all blood capillaries in the brain. In the brain, there is a mechanisms directing the entrance and
little space between the astrocytes endfeet covering and the external aspect of the blood capillaries (see the yellow exit of immune cells in the CNS and finally
area in Image 3). This space constitutes the glymphatic system (gliovascular clearance system, or glymphatic did so in 2015. Two separate teams of
clearance pathway). Quaghebeur Jrgen.
researchers, one team at the University of
3
Virginia23 and one team at the University
of Helsinki24 in Finland, independently
found typical lymph vessels in the brain.
These vessels, which line the dural
sinuses in the brain, carry lymphatic fluid
(and immune cells) toward deep nodes
of the neck (cervical lymph nodes). We
Perivascular can postulate that manual activation of
astrocyte the lymph flow in the numerous nodes
endfeet
of the neck may stimulate drainage
of CNS fluid and waste products, and
facilitate transportation of immune cells/
antigen-presenting cells to the nodes.
Until now, no lymph vessels had
been officially found in the brain itself,
Blood
so manual lymphatic techniques could
not be appropriately applied to this
region. With the discovery of lymph
vessels in the meninges (the cover of the
CNS capillary endothelium
brain), manual lymphatic techniques can
Basement membrane now be applied to the dura matter, the
} Glymphatic system
external and thicker layer of the brain.
The glymphatic system (in yellow) is located between the basement membrane of the central nervous systems blood
capillaries and the astrocytes layer. Quaghebeur Jrgen.

LYMPH IN THE BRAIN
Your patient had better the brain, the practitioner needs to start To be able to palpate the lymphatic flow
at the clavicles (supraclavicular nodes) requires time and dedication. Nevertheless,
save his life and money and work his way up to the numerous it is an effort that is worthwhile because
by passing you by as a nodes of the neck (approximately 300). it is a doorway to the fluid body, an
Once the neck sequence is complete, inner realm that holds great potential.
failure, until you are by some techniques can address the cerebral However, this does not make the
knowledge qualified to deal interstitial fluid, and then the area lymphatic flow easily palpable in all cases.
of cranial (and spinal) nerves can be This type of training, as with many
with the lymphatics. specifically addressed. As an example, other professional manual techniques,
A. T. Still, 189925
lymphatic drainage of the sciatic nerve requires time and dedicated effort.
(an advanced training of LDT) can
DRAIN YOUR BRAIN
be very efficient. In the few minutes it Direction of the Lymph Flow
The use of very specific manual techniques
takes to accomplish the protocol, the Advanced LDT practitioners use
to activate the lymphatic flow began, as far
client can be completely released, or Manual Lymphatic Mapping to
as we know, at the beginning of the 20th
freed enough to lie down calmly on the manually assess the specific direction
century26 when traditional osteopaths C.
therapeutic table so other complementary of the lymphatic flow and find areas of
E. Miller (1920) and F. P. Millard (1922)
approaches can be easily used. fluid retention, edemas, or fibrosis.
first documented specialized techniques
Lets now look at the specific rhythm, Heightened palpation skills enable
to work on the lymphatic system.27
direction, depth, and quality of the lymph practitioners to discern normal flow
There are scientific descriptions of the
flow as part of the LDT protocol. from disturbed or pathological flow
lymphatic rhythm in humans, but very few
patterns. A practitioner is then able to
practitioners are working at stimulating
The Lymphatic Rhythm support the client in self-correction,
lymph circulation in a direct and precise
The lymphatic rhythm in humans was allowing the intelligence of the body to
manner with this rhythm. Lymph Drainage
scientifically described by A. Engeset and express its own ability to heal itself.
Therapy (LDT) was developed to manually
W. Olszewski more than 30 years ago.29 In cases of fluid obstruction, these
attune to the specific rhythm, the direction,
The main vessels of the human lymphatic tools are very important in order to find
the depth, and the quality of the lymph
system (lymphatic collectors) present two the most accurate alternate lymphatic
flow, consistent with these recent scientific
or three layers of spiral muscles that have pathways in different areas of the body. At
discoveries. LDT teaches practitioners how
peristaltic (wavelike) contractions controlled the beginning of a manual therapy session,
to work with lymph and interstitial fluid on
by the autonomic nervous system.30 an initial assessment of the areas of fluid
skin and mucosa, muscles, fascia, tendons,
Contrary to what is sometimes taught, stagnation can be made with a trained hand.
the chambers of the eyes, periosteum,
the lymphatic system is not a passive system The therapist can then determine the areas
most viscera, the dura, and the pia.28
only stimulated by respirationand lymph that need the most work, and perform that
LDT explains how to manually map the
doesnt need to be forcefully pushed with work. They can then manually recheck
lymphatic pathways with the hands (Manual
our fingers. The intrinsic motility of the if the lymph flow has been efficiently
Lymphatic Mapping), how to identify
lymph fluid is generated by the contraction and noninvasively rerouted. Verifying
precise areas of the body where there is fluid
of little muscular units located in the the results can help the practitioner
stagnation or fibrosis, and how to find the
collector vessels between two valves. These select an effective treatment protocol.
most appropriate pathways for drainage.
contractile units, called lymphangions or
LDT approaches are gentle techniques
little lymphatic hearts, were discovered Depth and Pressure
that work through the interstitial and
long ago, but were not recognized by the The LDT touch is gentle, relaxed, and
lymphatic systems of the body to activate
scientific community until recently.31 flowing. A rhythmic, loving hand is always
the bodys circulatory and immune systems.
LDT practitioners learn how to required. This ensures a noninvasive,
The work is typically done from
apply the right pressure and attune to respectful touch throughout every
proximal (the location where the fluid ends
the deep rhythm of the lymph. Then the treatment.
up), to distal (away from this location). To
right pressure and proper rhythm can The hand surrenders to the movement
stimulate CSF circulation and drainage of
be applied in synchrony with the whole and depths of the waters of the body. The
system, attuning to and supporting the depth is determined by whether you are in
specific lymphatic rhythm of each client. superficial lymph, deep interstitial fluid,
intracellular fluid, superficial (epifascial)
Our vision and understanding
circulation, or lymph circulation below the
fascia, muscles, intercostal spaces, viscera, or
of lymphatics has profoundly
periosteum. Each has a special quality that
is palpable. As you become more attuned expanded, giving us entry into
deeper levels of healing, which
to the fluid dynamics of the body, you are
better able to read and discern the signs of
both pathologic and healthy tissue. This
gives the practitioner an important skill that
heightens the effectiveness of his treatment.
now includes the brain.
It can clearly indicate and direct attention to
the areas of the body that are pathological,
which can easily be overlooked. The stimulation of lymph flow through AN OPPORTUNITY FOR
The ideal pressure has been calculated, the lymphatic nodes also activates the DEEPER HEALING
and has been suggested to be no more immune system, increasing the production It is so exciting that the classical models
than 33 millimeters of mercury per square of lymphocytes by about 30 percent. of CSF physiology and the lymphatic
centimeter.32 The standard pressure used Lymphocytes are important in anatomy in the CNS have both been
is often similar to the pressure applied sustaining a healthy immune system, and dramatically updated with recent
in craniosacral work. This pressure there are two main types: B cells and T research. Our vision and understanding
can change in different areas of the cells. The B cells make antibodies that can of lymphatics has profoundly expanded,
body and in different conditions. handle toxins and aggressive bacteria, while giving us entry into deeper levels of
the T cells attack body cells themselves. healing, which now includes the brain.
Quality Lymphocytes are often present at sites This new scientific evidence also
An assessment of lymph quality is of chronic inflammation, so a 30 percent opens the way for new manual techniques
another important element of LDT. increase can certainly be a great advantage to arise that are more consistent with
Lymph is usually watery, but it can also to sustaining or reinstating health. this evidence, giving the practitioners
be quite viscous in cases of chronic LDT can help with reabsorption and work a higher level of credibility and
lymph retention, such as those caused by cleansing of some constituents of CSF acceptance in the health-care field.
allergies, fibromyalgia, chronic fatigue through the perineural lymphatic pathways. The new scientific findings
syndrome, chronic inflammation, leaky This has become more important as our concerning the CNS, lymph, and the
gut syndrome, etc. Recognizing the environment and food become increasingly glymphatic system reveal far-reaching
quality of lymph can bring a deeper more toxic and our bodies are being and exciting benefits for the lymphatic
awareness of the conditions a client may challenged more than ever. LDT is a system and its manual treatment.
be challenged with, or suffering from. valuable tool that can sustain a balance of We are in awe at the new potential that
Emotions can also affect the natural health as it deeply cleanses overloaded tissue. has opened to us. These new models, along
fluidity in lymph. When we are unable to One of the benefits of manual LDT is with more precise anatomical maps, will be
process our emotions, they are unable to its gentleness and noninvasiveness, which able to take our awareness and attention to
flow. This can have a direct effect on our gives the client an opportunity to deeply much more refined levels. The world of our
lymph, creating a feeling of fatigue and rest and receive. The touch itself stimulates inner fluid dynamics is wide open.
physical heaviness. A treatment can help the parasympathetic system, opening the
the client release emotional duress and possibilities for deeper healing. As the hand Notes
stress, and return to a calmer and more becomes more trained in the realm of fluid 1. A. T. Still, Philosophy of Osteopathy (1899): 105.
balanced state of being. We are becoming dynamics, it is able to address a number 2. G. Aselli, De Lactibus Seu Lactis Venis,
more aware of the direct relationship of potential systems and pathologies, Quarto Vasorum Mesaraicorum Genere Novo
between our emotions and our fluida true beginning with inflammation, chronic pain, Inventa, Dissertatio Mediolan (1627).
physical expression of our emotional body. swelling, and/or detoxification. It can also be 3. S. Hajdu, A Note from History: Discovery of
seen as a very effective preventive approach. the Cerebrospinal Fluid, Annals of Clinical
Application of LDT to the CNS and Laboratory Science 33, no. 3 (2003).
A 1994 study showed LDT has a real
influence on CNS, and can reduce
intracranial pressure dramatically.33

LYMPH IN THE BRAIN
26. B. Chikly, Manual Techniques: Addressing the

4. E. Swedenborg, The Brain, Considered Blockage in Cats: Effects on Cerebrospinal Lymphatic System: Origins and Development,
Anatomically, Physiologically and Philosophically, Fluid Pressure and the Size of Brain Ventricles, Journal of the American Osteopathic Association
Vol. 1 (London: James Speirs, 1882). Neuroscience 158, no. 4 (2009): 13971405. 105, no. 10 (October 2005): 45764.
5. E. Swedenborg, The Economy of the Animal Kingdom, 16. N. Striki et al., Effect of Active Transport on 27. C. E. Miller, Osteopathic Treatment of Acute
Considered Anatomically, Physiologically and Distribution and Concentration Gradients of Infections by Means of the Lymphatics, Journal of the
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Neuroscience Letters 169, no. 12 (March 1994): F. P. Millard, Applied Anatomy of the Lymphatics
6. W. E. Dandy, Experimental Hydrocephalus,
15962; A. Vladi, M. Klarica, and M. Bulat, (Kirksville, MO: The Journal Printing Company, 1922).
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Dynamics of Distribution of 3H-inulin Between
7. G. Schwalbe, Der Arachnoidalraum Ein 28. B. Chikly, Silent Waves: Theory and Practice of
the Cerebrospinal Fluid Compartments, Brain
Lympharaum Und Sein Zusammenhang Mir Den Lymph Drainage Therapy, an Osteopathic Lymphatic
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17. M. Bulat and M. Klarica, Recent Insights Into a New
8. H. Quincke, Zur Physiologie der 29. A. Engeset et al., Twenty-Four Hour Variation in Flow
Hydrodynamics of the Cerebrospinal Fluid, Brain
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18. J. D. Fenstermacher and T. Kaye, Drug Diffusion W. L. Olszewski and A. Engeset, Characteristics
9. B. Chikly, Is Human Cerebrospinal Fluid Reabsorbed Within the Brain, Annals of the New York Academy of of Lymph Flow in Lower Limbs Under Normal
by Lymph? Lymph Drainage Therapy and Manual Sciences 531 (1988): 2939; L. B. Flexner, The Water Conditions, Progress in Lymphology XII (1990): 213.
Drainage of the Central Nervous System, American of the Cerebrospinal Fluid: Variations of Its Rate of
Academy of Osteopathy 8, no. 2 (1998): 2834. 30. D. C. Zawieja, Contractile Physiology of Lymphatics,
Flow with Variation of Ventricular Pressure, American
Lymphatic Research and Biology 7, no. 2 (2009):
10. T. Brinker, M. Boker, and M. Foldi, Manual Journal of Physiology 106, no. 1 (1933): 17074.
8796.
Lymphatic Drainage of the Head and the Neck 19. M. Bulat and M. Klarica, Fluid Filtration and
for Treatment of Increased Intracranial Pressure, 31. H. Mislin and D. Rathenow, Beeinflussung Des
Reabsorption Across Microvascular Walls:
Progress in Lymphology XIV, ed. M. H. Witte and Spontanrhythmik Der Isolierten Mesenterialen
Control by Oncotic or Osmotic Pressure?
C.L. Witte, in Lymphology 27 (1994): 61417. Lymphgefsse (Lymphangion) Durch
Periodicum Biologorum 107, no. 2 (2005): 14752;
Diverse Pharmaka, Helvetica Physiologica
11. B. Chikly and J. Quaghebeur, Reassessing M. Bulat et al., Transventricular and Transpial
et Pharmacologica Acta 19 (1961): 87.
Cerebrospinal Fluid (CSF) Hydrodynamics: A Absorption of Cerebrospinal Fluid into Cerebral
Literature Review Presenting a Novel Hypothesis Microvessels, Collegium Antropologicum 32, 32. J. Asdonk, Lymphdrainage Und Molekularmassage,
for CSF Physiology, Journal of Bodywork & Supplement 1 (January 2008): 4350. Physikalische und Rehabilitative Medizin, Heft 10 (1967).
Movement Therapies 17, no. 3 (2013), DOI: 20. J. J. Iliff et al., A Paravascular Pathway Facilitates 33. T. Brinker, M. Boker, and M. Foldi, Manual
10.1016/j.jbmt.2013.02.002: 34454. CSF Flow Through the Brain Parenchyma and Lymphatic Drainage of the Head and the Neck
12. D. Orekovi et al., Fluid Perfusion as a the Clearance of Interstitial Solutes, Including for Treatment of Increased Intracranial Pressure,
Method of Cerebrospinal Fluid Formation Rate- Amyloid , Science Translational Medicine Progress in Lymphology XIV, in Lymphology 27,
Critical Appraisal, Collegium Antropologicum 4, no. 147 (August 2012): 147ra111. eds. C. L. Witte and M. H. Witte (1994): 61417.
32 Suppl 1 (January 2008): 1337. 21. L. Xie et al., Sleep Drives Metabolite
13. T. H. Milhorat, Choroid Plexus and Cerebrospinal Clearance From the Adult Brain, Science Bruno Chikly, MD, DO, LMT, is course
Fluid Production, Science 166 (1969): 151416; 342, no. 6156 (October 2013): 3737. developer and teacher at the Chikly Health
M. K. Hammock and T. H. Milhorat, 1973: Recent 22. V. Rangroo Thrane et al., Paravascular Institute. He is an osteopath and medical school
Studies on the Formation of Cerebrospinal Fluid, Microcirculation Facilitates Rapid Lipid graduate from Paris, France, where he received
Developmental Medicine and Child Neurology Transport and Astrocyte Signaling in the the Medal of the Medical Faculty of Paris VI for his
Supplement (1973): 2734; T. H. Milhorat, Structure Brain, Scientific Reports 3 (2013): 2582. thesis on the lymphatic system. An international
and Function of the Choroid Plexus and Other Sites
23. A. Louveau et al., Structural and Functional seminar leader, lecturer, and writer, Chikly is the
of Cerebrospinal Fluid Formation, International
Features of Central Nervous System Lymphatic author of Silent Waves: Theory and Practice of
Review of Cytology 47 (1976): 22588.
Vessels, Nature 523, no. 7560 (July 2015): 33741. Lymph Drainage Therapy (IHH Inc., 2005), the
14. G. Tamburrini et al., The Role of Endoscopic Choroid
24. A. Aspelund et al., A Dural Lymphatic Vascular first extensive book on the lymphatic system
Plexus Coagulation in the Surgical Management
System that Drains Brain Interstitial Fluid and and lymphedema published in North America. In
of Bilateral Choroid Plexuses Hyperplasia, Childs
Macromolecules, Journal of Experimental addition to his innovative contributions to the field
Nervous System 22, no. 6 (June 2006): 6058.
Medicine 212, no. 7 (June 2015): 9919. of health, he has now developed and expanded
15. D. Orekovi, M. Klarica, and M.Vuki, Does
25. A. T. Still, Philosophy of Osteopathy (1899): 105. his work into neuroscience with his hands-on Brain
the Secretion and Circulation of the Cerebrospinal
Therapy curriculum. Alaya Chikly, LMT, co-teaches
Fluid Really Exist? Medical Hypotheses 56,
no. 5 (May 2001): 62224; M. Klarica et al., with him and is the developer of Heart Centered
New Experimental Model of Acute Aqueductal Therapy. Both live in Scottsdale, Arizona. For
more information, visit www.chiklyinstitute.com.
Can Massage
Targeting
LymphaticBy Sandy Fritz
Function Be
Justified?
The massage therapy

profession is moving toward
an understanding of the
importance of evidence-
informed practice, a process
that allows us to make
statements about the benefits
and risks of massage based
on objective criteria and not
just anecdotal reports. Lets
take this premise and apply
it toward understanding the
evidence behind various
forms of lymphatic work.
STARTING WITH THE RESEARCH also inconclusive. This means that other to open like flaps, allowing interstitial fluid
When we think of evidence for an forms of evidence need to be used to justify to enter the lymph capillaries. The moment
evidence-informed practice, we most often massage benefits related to the lymphatic interstitial fluid enters a lymph capillary
think of scientific research studies. Yes, system. a flap valve prevents it from returning to
these are evidence, but the information is Expert opinion consensus is the primary the interstitial space. Lymph capillaries
only as good as the studys design. Going type of evidence that currently supports join to form larger lymph vessels that
a step further, its important to look at the manual movement of tissue fluid and resemble veins but have thinner, more
both meta-analysis and systematic reviews lymph. The foundation for this type of transparent walls. Like veins, they have
when evaluating evidence to weed out evidence needs to be based on known valves to prevent backflow. The large vessels
poor research studies and seek common anatomy and physiology, changes that continue to merge and eventually become
conclusions from higher quality ones. occur with pathology, and the ability to two main ducts called the right lymphatic
In relation to lymphatic techniques, support normal function based on logical duct and the thoracic duct (left lymphatic
I found three systematic reviews and a approaches that mimic normal function. duct) (Image 1). The right lymphatic duct
meta-analysis of randomized controlled When making statements related to the drains the upper right half of the body and
trials (RCTs) related to manual lymphatic possibility of massage therapy, performed in empties into the right subclavian vein. The
drainage (MLD): a specific way, with the intent to influence thoracic duct drains the rest of the body
1. Systematic Review of Efficacy for Manual lymphatic movement in the body, we need to and empties into the left subclavian vein.
Lymphatic Drainage Techniques in Sports provide a logical explanation or rationale (a The lymph nodes play an active part in
Medicine and Rehabilitation: An Evidence- justification) and to explain to clients that the immune defenses of the body by filtering
Based Practice Approach, by G. Vairo et although the methods appear to be clinically out and destroying foreign substances and
al., published in The Journal of Manual & effective, research, as yet, is unable to prove microorganisms. Interstitial fluid comes
Manipulative Therapy in 2009.1 the outcomes. from blood plasma that seeps through
2. Effects of Manual Lymphatic Drainage Lets use our evidence to explore the capillaries. Interstitial fluid becomes lymph
on Breast Cancer-Related Lymphedema: possibility that massage can influence the when it moves into the lymph capillaries,
A Systematic Review and Meta-Analysis of lymphatic system in a beneficial manner which are tiny, open-ended channels
Randomized Controlled Trials, by T. W. and create a justification process for that located in tissue spaces throughout the
Huang et al., published in the World Journal possibility. body. Lymph contains proteins and other
of Surgical Oncology in 2013.2 cell by-products, as well as pathogens
3. Conservative Interventions for Preventing JUSTIFICATION STEP 1 and cell debris. As lymph travels through
Clinically Detectable Upper-Limb UNDERSTAND NORMAL FUNCTION lymph vessels, it is filtered by lymph
Lymphoedema in Patients Who Are At OF THE LYMPHATIC SYSTEM nodes that remove the pathogens and cell
Risk of Developing Lymphoedema After The lymphatic system includes the spleen; debris, before traveling to the bloodstream
Breast Cancer Therapy, by M. M. Stuiver thymus; lymph nodes and lymph nodules; and once again becoming plasma.
et al., published in the Cochrane Database the lymph capillaries, vessels, trunks, Lymphatic circulation is separated into
of Systematic Reviews, 2015.3 and ducts; and lymph and lymphocytes. two layers:
4. Manual Lymphatic Drainage for It is a one-way system that begins in The superficial circulation, which
Lymphedema Following Breast Cancer the tissues and ends when it reaches constitutes 6070 percent of lymph
Treatment, by J. Ezzo et al., published the blood vessels. The system helps the circulation, is located just under the skin
in the Cochrane Database of Systematic body maintain homeostasis by collecting in the junction between the superficial
Reviews, 2015.4 accumulated tissue fluid around the cells fascia and the dermis. The superficial
and returning it to the bloodstream. circulation is not stimulated directly
While results varied, none of these The lymphatic system is an open- by exercise but is influenced by the
reviews offered conclusive support for ended system, beginning in the interstitial stretching and pulling of the skin and
manual lymphatic drainage, and individual spaces. The fluid located around the cells superficial fascia during movement.
studies justifying the use of massage for is called interstitial fluid. As fluid pressure Deep muscular and visceral circulation,
lymphatic movement are few in number and increases between the cells, the cells move below the fascia, is activated by muscular
apart, pulling on the microfilaments that contraction, peristalsis, and respiration.
connect the endothelial cells of the lymph
capillaries to tissue cells. The pull on the
microfilaments causes the lymph capillaries

CAN MASSAGE TARGETING LYMPHATIC FUNCTION BE JUSTIFIED?
Parotid nodes
Facial nodes Occipital nodes
Deep cervical nodes Superficial

cervical nodes
Right lymphatic duct Popliteal in an increase in fluid movement into the
Thoracic duct nodes
Subclavicular node interstitial spaces. This may be one cause of
Axillary nodes the delayed onset of muscle soreness when
there is an increase in physical activity.
Mammary plexus With injury, increased blood flow to an
injured area and the release of vasodilators,
Cubital nodes which are part of the inflammatory
response, can also contribute to edema.
The more severe condition of
Plantar
Superficial inguinal nodes plexus lymphedema occurs with an increase
in tissue fluid caused by inflammation
Palmar plexus or obstruction by scar tissue, parasites,
or trauma. Lymphedema can be life
threatening because the interstitial fluid
is contaminated, injuries to the skin
do not heal, and even small abrasions
and sores can become infected.
The lymphatic system:
The movement of lymph is known as lymphatic drainage. The JUSTIFICATION STEP 3
principal lymph vessels
lymphatic system does not have a central pump like the heart, so UNDERSTAND CURRENT METHODS
and nodes. Fritz, Sandy.
various factors assist the transport of lymph through the lymphatic FOR LYMPHATIC TREATMENT
Mosbys Essential
vessels. During inhalation, the thoracic duct is squeezed, which Methods used to support lymph drainage
Sciences for Therapeutic
pushes fluid forward and creates a vacuum in the duct. During include medication (diuretics) and
Massage: Anatomy,
exhalation, fluid is pulled from the lymphatics into the thoracic duct decongestive therapy. The primary medical
Physiology, Biomechanics,
to fill the partial vacuum. The main mechanism of opening lymph treatment for generalized edema is the
and Pathology, 4th
capillary vessels (called collectors) is from the pull of the skin and cautious use of diuretics to remove the
ed. Elsevier, 2013.
fascia during movement. Movement of lymph fluid in the lymph fluid. Complete/complex decongestive
vessels is assisted by the pressure exerted by the compression of therapy (CDT) is an intensive program
skeletal muscles against the vessels during physical movement and that combines bandages, compression
by changes in internal pressure during respiration. Major lymph garments, external pumping sleeves that
plexuses are found on the soles and the palms, possibly because the rhythmically compress the area, manual
rhythmic pumping of walking and grasping facilitates lymphatic flow. lymphatic drainage, exercise, and self-care.
The lymph vessels themselves may have an intrinsic pumping action. MLD methods use a gentle technique
designed to move the skin in specific
JUSTIFICATION STEP 2UNDERSTAND WHAT directions based on the underlying structure
HAPPENS WHEN FUNCTION IS NOT NORMAL and physiology of the lymphatic system.
When the influx of fluid into the tissue is more than can be The intent of the various interventions is
drained by the lymphatic system, edema occurs. Simple edema draining lymph already in the lymph vessels
can be related to variations in fluid and salt intake or hormonal (collectors) and stimulating the formation of
changes. Common causes of edema are congestive heart failure, lymph by increasing the flow of interstitial
kidney disease, liver disease, and medications, including steroids, fluid to the lymphatic capillaries (initial
hormones, and chemotherapy for cancer, which may cause edema lymphatics). The working hypothesis
as a side effect. Localized edema occurs with inflammation for manual methods is to support more
and lymphatic obstruction, and scar tissue and muscle tension normal fluid flow by creating spaces in the
can cause obstructive edema by restricting lymph vessels. tissues and then massaging fluid into these
Additionally, both a lack of movement and an increase in exercise spaces by external tissue compression.
can result in edema. A decrease in movement interrupts the normal
pumping action of fluid, while an increase in exercise can strain the
lymph system by causing blood capillary permeability, resulting
There are different types of MLD
techniques, including those advanced
by Emil Vodder, Albert Leduc, Bruno
Chikly, the Fldi College, Judith Casley-
Smith, and Jos Maria Pereira de Godoy.
Contraindications and Cautions Most of the methods have a foundation
for Lymphatic Drainage Massage based on the work by Vodder and the
If the area in question is swollen, hot, red, Dr. Vodder Akademie in Austria.
and painful, refer the client to a medical There is a long history of manual
professional. If inflammation is present, methods in osteopathic medicine that
massage the area only after the reason for target the lymphatic system. Taylor Still,
the condition has been determined. Here are DO, proposed the initial principles of
additional cautions and contraindications: manual lymphatic drainage techniques
Undiagnosed persistent edema with the advent of osteopathic manipulative
should initiate a referral. techniques in the late 1800s. The
Edematous tissues have poor osteopathic medical profession has
oxygenation and reduced function, designed a set of osteopathic manipulative
and they heal slowly after injury. techniques, called lymphatic pump
Chronic edema results in chronic inflammation techniques, to enhance the flow of
and fibrosis, which makes the edematous lymph through the lymphatic system.
tissue coarse, thicker, and less flexible.
Massage may lower blood pressure. If the JUSTIFICATION STEP 4EVALUATE
client has low blood pressure, the client CURRENT INTERVENTIONS IN
may become dizzy upon standing. RELATION TO MASSAGE THERAPY
The fourth step in the justification
process is to evaluate currently used
lymphatic interventions in relation to the
application of massage therapy. During this
evaluation, indications, contraindications,
and cautions are identified, and contrasts
Assessment of Fluid Imbalance and comparisons are drawn between
The following information and suggested massage the methods used and massage.
applications may be beneficial for the lymphatic system in Scope of practice is an important
general, and for occasional nonpathologic simple edema: consideration here. Much of what is being
1. Ask the client if the tissue feels taut, distended, fat, or stiff. If used for lymph-related treatments is part of
the answer is no, palpate to confirm that edema is not present the osteopathic medicine scope of practice,
and then proceed with general massage. If the answer is including the prescription of medications.
yes, ask for the history and screen for potential referral. There is specific advanced training in
2. Look for decreased muscle definition, bruising, tissue decongestive therapy, and these methods are
distention, and changes in color. If any of these are found, often used by physical therapists and nurses.
palpate. The massage-like skin stretching
3. Palpate for increased muscle tone, specifically tissue tautness used in MLD and the rhythmic rocking
and an increase in fluid (pitting edema) or venous congestion. If and compression used in the osteopathic
these are noted, observe and palpate for signs of inflammation. approach are also part of therapeutic
Palpate for heat and observe for redness. Ask about pain. massage. The management of simple
edema as part of a general massage seems
to be within scope of practice; however, if
pathology does exist, focused treatment by a

massage therapist without direct supervision fascial layer, which contains 6070 percent of
by a physician, nurse, or physical therapist the lymphatic circulation in the extremities. Not
may be outside an MTs scope of practice. much pressure is required to contact the area.
If too much pressure is applied, the capillaries
JUSTIFICATION STEP 5 are pressed closed; this nullifies any effect on
ANSWER THE QUESTION the more superficial vessels. Generally, light
The fifth step is to answer the question we pressure is indicated initially, which increases
began with: Can massage targeting general to a moderate level (including kneading,
fluid movement and lymphatic function compression, and gliding) during repeated
be justified? application to the area to reach the deep
If massage does indeed affect the lymphatic vessels. The technique then returns
movement of fluid (including lymph) in to lighter pressure over the area. Rhythmic,
the body, then somehow massage would gentle, passive, and active joint movement
need to mimic the natural mechanism and rhythmic muscle contraction reproduce
of fluid and lymph movement. the way the body normally pumps lymph,
The pressure and tissue movement especially in the deep lymphatic circulation.
provided by massage mimics the tissue During massage, the practitioner can
sliding and compressive forces of movement stimulate this process by using rhythmic
and respiration, and can move the skin compression with enough depth to compress
to open the lymph capillaries, allowing the muscle tissue in general with rhythmic
interstitial fluid to flow into lymph vessels. pumping of the thorax including the abdomen.
Simple muscle tension and connective The client helps the process by breathing slowly
tissue stiffness puts pressure on the lymph and deeply, which stimulates lymph flow.
vessels and may block them, interfering with The depth of pressure, speed and frequency,
efficient drainage. Massage may normalize direction, rhythm, duration, and drag are
this muscle tension and increase connective adjusted to support the lymphatic system and
tissue pliability. As the muscles relax and the fluid flow in general:
tissues soften, the lymph vessels open and Depth of pressure. This pressure
drainage becomes more efficient. Massage is just enough to move the skin. The
therapists should work on the areas of lymphatics are located mostly in superficial
muscle and connective tension first, using tissues, in the outer 0.3 millimeters of
appropriate massage methods such as gliding the skin, and surface edema occurs in
and kneading with moderate pressure, and those superficial tissues, not in the deep tissue. Because lymph
then finish the area with skin drag methods. capillary plexuses are present on the bottoms of the feet, rhythmic
Moving the skin moves the lymphatics. compression on the soles may also enhance lymph flow.
Stretching the lymphatics longitudinally, Speed and frequency. The greater the amount of fluid in the
horizontally, and diagonally stimulates them tissue, the slower the massage movements. Massage strokes are
to contract. The pressure gradient from repeated at a rate of approximately 10 per minute in an area, the
high pressure to low pressure is supported approximate rate at which the peripheral lymphatics contract.
by creating low-pressure areas in the vessels Direction. The lymph is moved toward the closest cluster of lymph Direction of strokes for
facilitating lymphatic flow.
proximal to the area to be drained. Massage nodes, which are located in the neck, axilla, and groin for the most part
Fritz, Sandy. Mosbys
that uses light pressure to drag the skin (Image 2). Massage near nodes first, and then move fluid toward them, Essential Sciences for
has the potential to increase superficial working proximally from the swollen area toward the nodes. Massage Therapeutic Massage:
uptake of interstitial fluid into the lymphatic the unaffected side first, then the obstructed side. For instance, if the Anatomy, Physiology,
capillaries. The focus of the initial pressure right arm is swollen because of scar tissue from a muscle tear, massage Biomechanics, and
and finishing strokes is in the dermis, just Pathology, 4th ed.
Elsevier, 2013.
below the surface layer of skin, and the
layer of tissue just beneath the skin and
above the muscles. This is the superficial
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17 Orthopedic Massage $180 $144
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Resources 7 Massage & TMJ $75 $60
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Taradaj, J. et al. Comparison of Efficacy of the Intermittent Pneumatic Compression with a
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Rhythmic pumping of chest. Fritz, Sandy. Mosbys Fundamentals Rhythmic pumping of abdomen. Fritz, Sandy. Mosbys
of Therapeutic Massage, 5th ed. Elsevier, 2013. Fundamentals of Therapeutic Massage, 5th ed. Elsevier, 2013.
Lymph nodes Begin End

Lymph nodes
Rhythmic passive and active joint movement. Fritz, Sandy. Mosbys Short, pumping strokes move distally. Fritz, Sandy. Mosbys
Fundamentals of Therapeutic Massage, 5th ed. Elsevier, 2013. Fundamentals of Therapeutic Massage, 5th ed. Elsevier, 2013.
The following sequence combines various methods to support Generalized pumping protocol (Total time: 10 minutes)
fluid movement in the body. Little, if any, lubricant is used, so the Begin the massage session by slow skin-stroking on the
skin can be easily moved. The approach is slow and methodical. The anterior cervical area above the clavicles. (60 seconds)
pumping protocol is performed in primarily the supine position, but Place both hands on the anterior surface of the thoracic cage just
can be modified for side lying and can be done with clients clothed. below the clavicles and apply a firm but gentle rhythmic pumping
The massage protocol must be done on skin and can be done in all action on the thorax (Image 3). Repeat this procedure four or five
positions. Each section of the process can be used separately and times.
is easily combined into general therapeutic massage application. As the client exhales completely, allow your hands to passively
follow the movements of the thorax. When the client starts to
inhale, resist the movement of the thorax with counter pressure
for 57 seconds. Repeat this procedure four or five times.

2. T. W. Huang et al., Effects of Manual

Place both hands on the surface of the abdomen on either side of
Lymphatic Drainage on Breast Cancer-Related
the umbilicus and apply a firm but gentle rhythmic pumping action
Lymphedema: A Systematic Review and Meta-
toward the thorax (Image 4). Repeat this procedure four or five Analysis of Randomized Controlled Trials, World
times. Journal of Surgical Oncology 14 (2013).
Apply a pumping, rhythmic compression on the soles of the feet and
3. M. M. Stuiver et al., Conservative Interventions
palms of the hands.
for Preventing Clinically Detectable Upper-Limb
Rhythmically rock the body, beginning at the feet, and passively Lymphoedema in Patients Who Are At Risk of
move the joints throughout the massage session (Image 5). Developing Lymphoedema After Breast Cancer
Therapy, Cochrane Database of Systematic
Massage protocol (Total time: 30 minutes) Reviews (February 2015), accessed December
The massage application consists of a combination of short, 2015, www.ncbi.nlm.nih.gov/pubmed/25677413.
light, pumping, gliding strokes, beginning close to the torso 4. J. Ezzo et al., Manual Lymphatic Drainage
at the node clusters and directed toward the torso. for Lymphedema Following Breast Cancer
The strokes methodically move distally (Image 6). The stroke Treatment, Cochrane Database of Systematic
does not slip, but rather drags the tissue to bind. The phase of Reviews (May 2015), accessed December 2015,
applying pressure and drag must be longer than the phase of www.ncbi.nlm.nih.gov/pubmed/25994425.
pressure and drag release. The releasing phase cannot be too short,
because the lymph needs time to drain from the distal segment. Sandy Fritz is the owner and head educator of
Therefore, the optimum duration of the pressure and drag phase the Health Enrichment Center School of Therapeutic
is 67 seconds; for the release phase, it is about 5 seconds. Massage in Lapeer, Michigan. In massage practice
This pattern is followed by long, surface, gliding strokes and for more than 35 years and actively involved in
kneading with a bit more pressure to influence deeper lymph the global advancement of massage therapy, Fritz
vessels. The direction is toward the drainage points. is passionate about training the next generation
Repeat in each body segment and limb. of instructors and leaders. She is the author of
Mosbys Fundamentals of Therapeutic Massage
Repeat generalized pumping protocol (Total time: 10 minutes) (Mosby, 2012) and Mosbys Essential Sciences
To end the session, repeat the same steps as in the opening pumping for Therapeutic Massage (Mosby, 2012) and
protocol. many other textbooks published by Elsevier.
Visit www.sandyfritz.info for more details.
CONCLUSION
If massage does
This is an example of how to justify massage adapted to specifically
target fluid movement when research evidence is inconclusive or
does not exist. Each step of the suggested protocol is based on
mimicking normal function. Obviously, all fluid is movednot
just lymph. Also, the connective tissue structures and nervous
indeed affect the
system are stimulated as well. Regardless of how specific an
outcome we intend, massage is just too general and broad in
movement of fluid
approach and effects to make a specific type of claim.
However, by using critical thinking and offering full disclosure
(including lymph)
during the clients informed consent process, you can safely and
ethically offer an adapted massage that is safe for your clients
in the body, then
lymphatic issues.
somehow massage
Notes
1. Giampietro Vairo et al., Systematic Review of Efficacy for Manual Lymphatic Drainage would need to
Techniques in Sports Medicine and Rehabilitation: An Evidence-Based Practice
Approach, The Journal of Manual & Manipulative Therapy 17, no. 3 (2009): e80e89. mimic the natural
mechanism of
fluid and lymph
movement.
By Wolfgang Luckmann
When a clients lymphatic system

is already overburdened because
of poor circulation, lymphedema,
or lymph node removal, traditional
massage is contraindicated.
Because traditional massage releases histamines from the mast
cells, it causes a dilation of the capillary sphincters and therefore
vasodilation, otherwise known as active hyperemia. In addition, more
capillary pressure is created and therefore more capillary filtration
occurs during massage, which is desirable in a healthy circulatory and
lymphatic system, but not in a system that is already compromised.
How, then, do we safely and effectively work with clients with
pre-existing edematic conditions or those at risk of lymphedema? The
answer may well lie in an integrated and global holistic approach.
According to
traditional Chinese EDEMA SEEN FROM TWO partnership with the stomach, is responsible
medicine (TCM), there PERSPECTIVES for the transportation of nutrients.
are two ways to view In traditional Chinese medicine (TCM), Whereas the stomach physically ripens
the nature of edema: the nature of edema is viewed as either and rots the food, the spleen is concerned
Yang edema is being short and abrupt (yang edema) with absorption and distribution of
short and abrupt in its or slow and insidious (yin edema) in its nutritious essences to all systems of the
cause and effect. cause and effect. As a result, a massage body. The metabolizing and breaking
Yin edema is slow therapists plan of treatment should have down of food into nutrients is essential;
and insidious in its
both short- and long-term goals.1 otherwise food stagnates in the stomach
cause and effect.
The most common type of edema found and intestines and turns into a damp
in the massage therapy clinic, however, is slush. When there is a deficiency in this
yin edema, which takes weeks or months process, TCM refers to it as dampness.
to progress. It starts at the top of the feet Another function of the spleen is
and ankles, slowly creeps up the legs, and sprinkling, or moisturizing all the
settles in the waist. Yin edema is systemic systems of the body as it sends fluids
1 Contracting or pumping manipulations on the

spleen help move spleen qi.
and is caused by a combination of a toxic
and excessive diet, lack of
exercise or regular sustained
movement, poor breathing
upward to the lungs. The spleen assists the
stomach in sending the turbid or toxic
liquids into the intestines and ultimately
the bowels. While the spleen physically
habits, stress, pathologies controls the nourishment of muscles and
of the organs, or trauma flesh, it also controls blood and lymph.
to a persons physiological In TCM, clients with diabetes,
systems caused by surgery. fibromyalgia, and chronic fatigue have
Whether your consistently weak spleens or weak spleen
understanding of edema is qi. Their digestion is sluggish and
from a Western or Eastern stagnated, and their overall circulation
perspective, the principal of blood, lymph, and body fluids is
organs of elimination slow and impaired. These clients will
heavily involved in the complain of overall pain, diarrhea,
lymphatic system include irritable bowel syndrome, and fatigue.
the liver, kidneys, spleen, Emotionally, from the TCM
and intestines. But, in perspective, the spleen is responsible for
TCM, special emphasis is negative worry and obsessive thinking. It
given to the spleen. This also helps absorb information and logically
leads to the question: Why categorizes it, as in reading a book or
single out the spleen? listening to a lecture. Muddled thinking
and so-called fibro fog are believed to be
THE SPLEENS the result of weak and stagnant spleen qi.
IMPORTANCE Movement is essential in helping
The spleen is the largest these clients feel better. During a session,
lymphatic organ and the therapist can gently pump the
2 Apply local acupressure on the Stomach 25 has the same filtering clients spleen like an accordion for a
point for better digestion and metabolism function as lymph nodes. minimum of 2 minutes (Image 1). The
within the spleen and intestines. The pressure It also produces white blood cells called result is an amazing resurgence of qi.
used is equal to the weight of a coin. T-lymphocytes, which are an important
part of the immune system. In TCM,
the spleen is an Earth element and, in

A GLOBAL APPROACH TO LYMPHATIC DRAINAGE MASSAGE
Pumping or contracting the spleen is LET THE EMOTIONS DRAW A MAP

followed by acupressure on the stomach When the emotional functions of the
and spleen meridians, locally and distally, organs involved in lymphatic function
to move stagnant qi (Image 2). If there is are revealed, Selyes General Adaptation
sensitivity on the points, the therapist Syndrome and the long-lasting effects of
with pressure not exceeding the weight of stress on the whole body make perfect
a coingently rotates counterclockwise sense. The liver is in charge of anger;
3
(right to left as viewed by the therapist) the spleen and stomach (partners
until the sensitivity is gone. This disperses in the 24-hour circadian rhythm
the stagnant qi. Then the therapist reverses of qi) handle worry, concern,
the rotational flow and moves clockwise and obsessive thinking; and the
K3
(left to right) to tonify or strengthen the kidneys oversee fear and fright. (inside of foot)
qi in the organ. The rotation of fingers or When these emotions are excessive,
thumbs on acupressure points is based on stress is generated on multiple
ancient TCM principles of acupuncture organ and physiological systems.
for propagating and enhancing qi flow. A comprehensive body-mind
As part of a comprehensive body- approach is then necessary.
mind approach, the next step is to address As an experienced TCM
distal points (found on the limbs) of the therapist, my first question to the
spleen, stomach, kidneys, and liver to client, after finding out what has
create an abundant flow of qi that pushes brought him or her to my clinic,
the circulatory system. Through the use is: What emotion rules your life or
of certain key points, named Golden what emotion has lately been taking Position of the distal Golden Point Kidney 3,
Points by some master acupuncturists over your life? The answer can vary for edema, urination, calming of nerves, and
strengthening of willpower.
in ancient China (gold, because of greatly, but in TCM, it can be
their high value in healing), a cluster principally narrowed down to
of issues are successfully addressed.2 four main categories: fear, anger,
This could include balancing excessive worry, and joy. It is only when
emotions like anger, fear, worry, sadness, there is an excess or deficiency of
and hysteria. Over time, these emotions these four emotions that health
can turn toxic as they become deeply issues emerge. The answer to
embedded in the psychological makeup my question can then lead me to
of the client. One only has to read Hans a formula of acupressure points
Selyes research on the effects of stress on that address the clients ailments
the human body3 and mind to understand successfully and economically.
the importance of finding that balance. Overall, the guiding goals in
In his theory of General Adaptation selecting all these acupressure
Syndrome, Selye showed that the body has points are increasing circulation
a general response to demands made by and lymph flow; detoxifying
stress that are either positive or negative. the lymphatic system and
He proved that the syndrome induced chronic negative emotions; Golden Point Spleen 6, where the liver, spleen,
hormonal autonomic responses, which,
when left unchecked, can lead to ulcers,
high blood pressure, arteriosclerosis,
calming inflammation,
both myofascial and organ-related;
and boosting the immune system.
and kidney channels cross. Pressure to this
point calms the mind, increases circulation
and energy, and regulates metabolism. 4
arthritis, kidney disease, and allergic A typical distal acupressure protocol for
reactions. Such a complex reaction, yin edema starts at the feet and legsall
therefore, has to be treated with a set of distal to the organs involved in edemaand
acupressure points that address multiple progresses to the hands and arms. Also,
physiological and organ systems. by selecting mainly the Golden Points,
most of the guiding goals will be addressed

with these points. Thus, one can select Kidney
1 and Kidney 3 (Image 3) for energizing and
centering; Spleen 6 (Image 4) and Stomach 36
(Image 5) for increasing circulation, immune
system enhancement, detoxification, and
metabolism; Large Intestine 4 for calming
and strengthening the immune system, and
anti-inflammation; and Urinary Bladder 23 for
energizing all the organs (especially the kidneys
and bladder), calming, and anti-inflammation.
The kidneys are of paramount importance in
this equation, because they provide energy
for longevity and are ultimately connected to
the well-being of all physiological systems.
When doing acupressure, take note of these
guiding principles: If the points are sensitive
to the touch, rotate with a finger pad or thumb
pad counterclockwise for a minute or two, or
5
Apply distal acupressure on Stomach 36 (on the tibialis anterior). This is the
Master Point for the digestive system and a point beneficial for calming and until the sensitivity is diminished substantially.
boosting the immune system. After going through all points from the feet to
the arms, address the same points again, but this
time rotate clockwise to increase energy to the
channels and organs to which they are affiliated.
Lastly, with the client in a prone position,
the therapist can pump the clients feet up
and down (Image 6). This exercise is aimed at
contracting and stretching the soleus muscle.
Compared to other lower extremity muscles,
the soleus often acts as a second heart pump and
provides most intramuscular pressure. According
to Simon and Travell, Its pumping action
increases the venous flow of blood from the
feet and legs ... The soleus provides a major
pumping action to return blood from the lower
limb toward the heart.4 This prevents venous
blood from accumulating over time in the lower
limbs as the result of prolonged inactivity.
ADD ESSENTIAL OILS TO THE MIX

When dealing with lymphatic issues, essential
oils can be an ally. Research has established that
acupressure and essential oils activate both the
central nervous system and endocrine system by
releasing hormones like endorphins, encephalins,
dopamine, serotonin, etc.5 This means that
6
Pump the clients soleus both acupressure and essential oils deepen and
muscle up and down on
a sagittal plane for better
lengthen the effect of any lymphatic drainage
venous blood return.

massage done on the skin and fascia by A good protocol to follow, then, would the mixture lightly with long stripping
directly affecting physiological systems that be to use lavender and chamomile for strokes, starting proximally to the major
aid in getting rid of edema and edematous pain and inflammation; grapefruit for lymph nodes and then working distally.
conditions. Because we are directly tapping detoxifying the lymphatic flow; cypress Because of the complex and chronic
into the clients physiological systems, both for increasing general circulation; and issues inherent in clients with lymphatic
acupressure and essential oils prolong the peppermint for boosting the immune disorders, a multilevel approach consisting
effects of lymphatic drainage massage. system. These oils can be applied in layers of essential oils, acupressure, and lymphatic
When choosing essential oils, therapists by using two drops each on the acupressure drainage massage is necessary for
should make selections based on the guiding point after applying a general massage successfully treating the client holistically.
goals for choosing acupressure points. oil first, like jojoba oil, which can act as Try applying these principles to help edema-
Depending on what health issues are most a carrier oil; do not place the pure oils ridden clients regain their health.
important to address, the therapist may directly on the skin. Alternatively, therapists
choose a variety of oils. In massage therapy, can mix these oils in an 8-ounce bottle Notes
its usually inflammation accompanied containing jojoba oil or any other carrier 1. Miriam Lee, Insights of a Senior Acupuncturist
by pain that gets addressed first. oil. The therapist can either select one each (Boulder: Blue Poppy Press, 1992).
of the previously mentioned oils or several 2. Yu Hui-chan and Han Fu-ru, Golden Needle Wang
oils of each category. A typical formula for Le-Ting (Boulder: Blue Poppy Press, 1997).
a lymphatic session would look like this: 3. Hans Selye, Stress and Distress, Science
1416 drops each of lavender, grapefruit, 122 (October 1955): 62531.
cypress, and peppermint. If, however, the
4. Janet Travell and David Simon, Myofascial
emphasis is on anti-inflammation and pain Pain and Dysfunction: The Trigger Point
control, then the therapist could choose a ManualThe Lower Extremities (Baltimore:
combination of 1416 drops each of lavender Williams and Wilkins, 1992): 42932.
and chamomile, 810 drops of cypress and
5. Kurt Schnaubelt, Advanced Aromatherapy:
peppermint, and 56 drops of grapefruit. The Science of Essential Oil Therapy
The application with the essential (Rochester, VT: Healing Arts Press, 1998).
oils alone can be one of simply rubbing
them on the site of pain and/or the
Wolfgang Luckmann is an acupuncture
acupressure points by rotating the finger
physician and massage therapist who teaches
of application counterclockwise with
7
workshops all across the countrymost are
Utilize lymphatic massage, with essential very light pressure for about a minute
based in traditional Chinese medicine and
oils, toward the two thoracic ducts. (Image 7). If premixed with a carrier
Ayurvedic philosophy. In 2015, he was inducted
oil, then the therapist again applies
into the Massage Therapy Hall of Fame. For more
information, visit www.wolfgangluckmann.com.
Resources
Flaws, B. Sticking to the PointA Step-by-Step Approach to TCM Acupuncture Therapy. 2nd ed. Boulder: Blue Poppy
Press, 2007.
Hui-chan, Y., and H. Fu-ru. Golden Needle Wang Le-Ting. Boulder: Blue Poppy Press, 1997.
Jwing-Ming, Y. Chinese QiGong Massage. Jamaica Plain, MA: YMAA Publications Center, 1992.
Kasseroller, R. Compendium for Dr. Vodders Manual Lymphatic Drainage. Heidelberg, Germany: Heidelberg and Haug
Press, 1998.
Lawless, J. B. The Illustrated Encyclopedia of Essential Oils. New York: Noble Books, 1995.
Lee, M. Insights of a Senior Acupuncturist. Boulder: Blue Poppy Press, 1992.
Travell, J., and D. Simon. Myofascial Pain and Dysfunction: The Trigger Point ManualThe Lower Extremities. Baltimore:
Williams and Wilkins, 1992.
Schnaubelt, K. Advanced Aromatherapy: The Science of Essential Oil Therapy. Rochester, VT: Healing Arts Press, 1998.
Selye, H. Stress and Distress. Science 122 (October 1955): 62931.
Shutes, J., and C. Weaver. Aromatherapy for Bodyworkers. Upper Saddle River, NJ: Prentice Hall Health, 2008.
Breastfeeding Bodywork
&
Overcoming Nursing Challenges
Through Infant Massage
Those of us familiar with infant massage may be

By Grace Burnham
surprised by the powerful impact this gentle therapy

may also have for infants with breastfeeding
challenges. By addressing an infants soft-
tissue restrictions that may negatively impact
breastfeeding, bodyworkers are in a unique
position to work through the underlying causes of
a difficult nursing relationship, and thus potentially
improve the quality of life for these tiniest clients.
MUSCULOSKELETAL CAUSES OF DIFFICULT BREASTFEEDING
Breastfeeding requires complex muscle movements of an infants jaw, mouth, neck,
and upper torso, where the muscles of the throat and esophagus have to engage to
facilitate swallowing. These movements all need to happen in a tiny person whose body
is just getting accustomed to breathing air. Fortunately, most breastfeeding duos
mother and infantget along just fine and are able to nurse without assistance.
Still, even although the movements involved in breastfeeding are instinctual, some infants
struggle to breastfeed because of musculoskeletal issues. Injuries sustained during birth or
shortly after, and other developmental or health issues, can lead to difficulty breastfeeding.
Infants must be able to lift and rotate their heads in order to successfully maneuver
to the breast, adjust the head into a comfortable position, and achieve a proper latch
onto the nipple. Infants with neck injuries or torticollisa condition involving
inflammation and an inability to move the neckoften develop a preference for one
side or nursing position. When this happens, it can prevent the breast from draining
effectively, causing discomfort, inflammation, and sometimes infection for the mother.
While positioning the infant in his preferred position during feeding can help, this
is an imperfect solution. Eventually, an infants difficulty turning his head will cause
difficulty in other areas and make breastfeeding more complicated than necessary.

Soft-tissue
therapy can
dramatically
improve
a difficult
breastfeeding
relationship
for even
the smallest
infants.
BREASTFEEDING & BODY WORK
Almost 75% of all moms

produce more milk in their
right breast, whether they when an infant has difficulty breastfeeding. The skills to assess and treat a
are right- or left-handed. Massage and physical therapists primarily breastfeeding infant stem from a solid
www.health-foundations.com/blog/2013/11/ trained in soft-tissue treatments should be understanding of muscle anatomy that
19/15-cool-facts-about-breastfeeding on the front line in correcting these issues. every therapist should have, along with
Breast milk and maintaining a an understanding of the movements
breastfeeding relationship are beneficial involved in breastfeeding. The therapist
to the health of the breastfeeding mother also needs an understanding of behaviors
and infant, so if issues with feeding can be and physiology specific to infants. Just
corrected by a soft-tissue therapist, these as therapists do not need to know the
therapies should be presented to parents rules of the sport to treat a professional
as an option. A therapist should, of course, athlete as long as they understand the
have an informed consent conversation movements and their effect on the players
with the parents, including risks and body, a therapist can successfully treat
benefits of treatment and explanation of the the effects of the movements involved in
An infant also needs to be able to open
therapists experience with this condition, breastfeeding even if the therapist never
his small mouth wide enough to surround
before applying a preferred modality to learns the more complicated physiology of
the nipple and then use his tongue to move
an infant presenting for the services. breastfeeding and breast milk production.
milk from the breast while massaging
For example, Joans 3-month-
the it with his lower jaw. This requires
old infant was born with the assistance CONCLUSION
movement and coordination of the mouth,
of forceps and was unable to turn his By learning the movements necessary
temporomandibular joint, and muscles
head to the right. He was also unable to for successful breastfeeding, massage
of the tongue. Without this necessary
extend his head. The family pediatrician therapists can closely translate the therapies
skill, an infant may not be able to latch on
suggested encouraging him to turn to his they perform on adults to infants with
appropriately and breastfeed efficiently
nonpreferred side during breastfeeding, breastfeeding challenges. Soft-tissue
enough for his needs. When an infant is
suggested a watch-and-wait approach, therapy can dramatically improve a difficult
unable to remove the needed amount of
and recommended muscle-release surgery breastfeeding relationship for even the
milk from the breast, the breast will reduce
if there was no improvement. Joan was smallest infants. While gentle therapies
the amount of milk it produces over time,
also experiencing difficulty breastfeeding such as craniosacral and Bowenwork are
lowering the supply or ending production
because her infant chose to face the left often promoted for infants, with skill
altogether if the mother does not take an
side with his chin tucked in, creating breast and experience any soft-tissue therapy
alternative approach to stimulating the
preference and a shallow latch. Joan had performed on adults can be modified for
breast, such as pumping or hand expression.
discomfort when nursing and had multiple infants, who, after all, have the same soft-
This drop in production and its effects on an
cases of plugged ducts and mastitis. tissue systems as adults. Myofascial release
infant can be difficult for a parent struggling
Joan saw a lactation consultant who, and trigger point therapy, for example,
to maintain a feeding relationship without
after evaluation, recommended bodywork can safely and successfully be used to
the use of alternative feeding products
for the infant. The massage therapist treat infants as young as 3 months old.
or equipmentmost commonly, breast
assessed the infant and discovered a Because professional bodyworkers are in
pumps, bottles, and supplements formula.
reduced range of motion when rotating a unique position to treat the underlying
An infant may also be able to move
the head to the right and when extending causes of a difficult nursing relationship,
enough milk from the breast to meet his
the neck, consistent with the diagnosis of parents and health-care providers alike
needs, but may latch on in a way that injures
torticollis. The therapist also discovered should recognize the value of soft-
the nipple, discouraging the mother from
trigger points on the sternocleidomastoid tissue therapy for breastfeeding.
continuing the breastfeeding relationship.
and capitis muscles, also known as the
suboccipital muscle group. The therapist Grace Burnham, LMT, BCTMB,is a graduate of
MASSAGE THERAPY MAY
proceeded to use trigger point therapy the NorthwestSchool ofMassage in Washington.
IMPROVE BREASTFEEDING
to treat the infant, gently releasing and Her practice is based in Tempe,Arizona,and
In the absence of other health
stretching each restriction, resulting focuses on injury treatment, massage during the
complications, soft-tissue restrictions due
in an increased range of motion and an childbearing year, and infants with breastfeeding
to injury or unknown causes should be
improved breastfeeding relationship. challenges. Burnham can be contacted through
considered as primary contributing factors
her website www.azfamilymassage.com.
NEW
technique SCIENCE OF NERVES
The Long and Winding Nerve

Challenges Involving the Long Thoracic Nerve
By Whitney Lowe
Do you recall sitting in a classroom

and thinking that one or two Long thoracic nerve
students were getting the lions
1
share of attention when others Brachial plexus
had things to contribute as well?
It seems the world of soft-tissue The long thoracic nerve
(LTN) in relation to the
pain and injury problems shares this brachial plexus. Image
courtesy 3D4Medicals
metaphor. Take nerve entrapment,
Essential Anatomy 5
for example. As soon as you say application.
the phrase upper extremity nerve

ANATOMICAL BACKGROUND to the serratus anterior, the common
entrapment, most peoples minds
The LTN originates from nerve roots pattern of scapular winging is present.
immediately jump to carpal tunnel at the lower cervical vertebrae, usually The serratus anterior has another
between C5 and C7. Once the nerve root important role: upward rotation of
syndrome. But there are numerous
fibers exit the cervical vertebrae, they the scapula. The movement of upward
other nerve compression syndromes blend together to form the main trunk of rotation is a key component of proper
the LTN. The nerve then passes between scapulothoracic mechanics. Later in this
that also cause significant pain or
the anterior and middle scalene muscles column, I will highlight why this role of the
dysfunction in the upper extremity. immediately adjacent to the other major serratus anterior is so important and what
fibers of the brachial plexus (Image 1). happens when muscle weakness from nerve
In this newly focused column, my goal
After passing between the scalene impingement affects shoulder biomechanics.
is to shed light on current pain science, as
muscles, the nerve courses between
well as a host of nerve-related disorders
the clavicle and first rib. It continues
that go undetected or misidentified on a PATHOLOGY
down the lateral aspect of the rib cage
regular basis. Massage therapists often Damage or dysfunction can occur with the
to its termination at multiple points
admit to limited focus on the neurological LTN from either excessive compression
along the serratus anterior muscle.
system in their basic education. Yet, or tension, although compression injuries
This nerves pathway is quite long, and
neurological sensation is a foundational are most common. There are several
consequently, there are multiple locations
and critical component of every clients locations where compression injuries
along its path where it is susceptible
experience. In this first installment, I are likely to occur. Compression could
to compression or traction injury.
turn attention to problems involving affect LTN roots at the cervical spine
The primary function of the LTN is
the long thoracic nerve (LTN). This is a from herniated discs, bone spurs, tumors,
motor innervation to the serratus anterior
tissue many massage practitioners may or other obstructions. Moving distally
muscle, which has several key functions.
not be familiar with, but it plays a key from the nerve root, the next location
The major function of serratus anterior
role in upper extremity biomechanics of potential compression is between the
is to hold the scapula firmly against the
and numerous pain complaints. anterior and middle scalene muscles.
thoracic rib cage. Accordingly, when
The brachial plexus courses between
there is an interruption of motor stimulus
the anterior and middle scalene muscles

Dorsal scapular nerve
between the scapula and humerus called the
scapulo-humeral rhythm. This coordinated
Long thoracic nerve pattern is such that for every three degrees
of abduction, two degrees occur at the
2
Proximity of the LTN
glenohumeral joint and one occurs at
the scapulothoracic articulation. This
coordinated movement allows the shoulder
to the dorsal scapular to abduct as fully as possible. The upward
nerve. Their close rotation of the scapula helps make a greater
proximity sometimes range of motion than would be possible
allows for a connecting with just glenohumeral abduction alone.
branch between In a situation of LTN compression,
them. Image courtesy
weakness of the serratus anterior means
3D4Medicals Essential
Anatomy 5 application. that full upward rotation of the scapula does
not occur during abduction. Consequently,
range of motion in abduction is diminished.
as this large nerve bundle exits the neck or postural strain from a challenging
However, when the scapula does not move
region. The LTN is directly adjacent to workstation or occupational activity.
in full upward rotation, the lateral edge of
the major nerve bundles that comprise There are also reports of LTN injury
the humeral head is more likely to contact
the brachial plexus. Often, when there is resulting from surgeries in which the
the underside of the acromion process
brachial plexus compression, the LTN patient was placed in a position on the
during abduction, leading to shoulder
can be compressed, but symptoms from surgical table for hours at a time.3 Surgery
impingement and potential damage to soft
other nerves likely dominate, so LTN can also be implicated in LTN damage
tissues in the subacromial region, including
compression may go undetected. from direct trauma of the nerve during
the bursa, supraspinatus, or joint capsule.
Other causes of nerve compression in the surgical procedure. There are reports
this region include falls or blows directly of LTN injury from mastectomy, first rib
on top of the shoulder, especially those resection to treat thoracic outlet syndrome, SYMPTOMS OF LTN PATHOLOGY
that may include clavicular fracture.1 cardiac surgery, and even spinal fusion Because the LTN is primarily a motor
You see injuries like these in football. surgery to treat scoliosis.4 In addition to nerve, it does not have many sensory
Heavy straps such as those in backpacks, the more common causes of nerve injury fibers. Thus, the usual indicators of
knapsacks, shoulder bags, or even bra described above, some anatomical variations nerve compression, such as sharp pain or
straps can also compress the nerve. If can contribute to LTN pathology. An paresthesia, are not always present or may
you are a massage therapist who carries anatomical anomaly can occur in which be diminished. Those with LTN injury may
your table around with a strap over your there is a connecting branch between the report weakness in the shoulder along with
shoulder, this is something to consider. dorsal scapular nerve and the long thoracic pain sensations. Keep in mind shoulder pain
Rapid tensile loading on the nerve can nerve (Image 2). When a connection exists can result from impingement problems that
also cause damage and dysfunction. The between two nerves, each is less mobile are directly caused by the biomechanical
rapid stretch of the nerve is most common and more susceptible to tension injury.5 dysfunction. Attempting to address shoulder
in sudden lateral flexion movements of the impingement and not recognizing the
cervical region, such as those that happen in contribution of LTN involvement can lead
DYSFUNCTIONAL BIOMECHANICS
contact sports or in lateral whiplash injuries to poor results and continual problems.
As noted earlier, the LTN is the motor
from automobile accidents.2 There are also Sometimes people describe weakness
supply nerve for the serratus anterior
some associations of LTN injury with sports with various shoulder motions. The
muscle. The serratus anteriors function is to
activities that have a strong single-arm weakness might be accompanied with
hold the scapula firmly against the thoracic
dominance, such as bowling, tennis, or golf. pain, but could also occur without any
rib cage and contribute to upward rotation
LTN injuries are most frequently pain or sensory deficit. The client may
of the scapula. However, this function
associated with an activity. However, also describe some difficulty performing
should not be oversimplified because it plays
nerve compression can occur from activities overhead, as these motions
a key role in scapulothoracic mechanics.
inactivity if the body is in a position that usually involve a significant degree of
When the shoulder is moved in
compresses the nerve for long periods, scapular upward rotation to complete.
abduction, there is a coordinated movement
such as awkward sleeping positions
Whitney Lowes
orthopedic massage
TREATMENT STRATEGIES
As with any nerve compression or tension injury, the key factor
for success is reducing the mechanical load. That means getting
pressure off the nerve if it is a compression problem, or relieving the
excess tensile stress if it is a nerve traction injury. A thorough client
Go beyond history is extremely important in identifying the primary causative
the surface! factors that may have led to nerve compression or tension injury.
Keep in mind that, especially with compression injuries, the
longer the force has been applied to the nerve, the slower and longer
the healing time. Symptom relief may take many months or even a
year or longer.6 During the healing process, the person should avoid
aggravating activities like carrying heavy loads on the affected side.
Dive into training that takes you When compression occurs from external forces such as
to new depths of learning heavy shoulder straps, removing the offending activity may
be sufficient for healing. However, in many cases, there still
Online Training & Certification may be soft-tissue involvement that can benefit from massage.
There are a few key areas that are important to address to make
sure the nerve has the greatest potential for proper healing.
Personalized instruction from Whitney Lowe
If LTN compression is occurring between the anterior and
Interactive & dynamic learning activities middle scalene muscles, it is often hypertonicity or taut bands within
these muscles that are compressing the nerve. In these cases, the
Extensive video library with ongoing access key treatment goal is to reduce muscle tightness to prevent further
compression. However, diving in with deep pressure on these muscles
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when they may already be tight can be counterproductive and cause
Free CE sample courses more irritation to the nervous system. Light, gentle pressure in this
case can be even more effective in helping restore proper tone.
...the best course Ive taken in 30 years of CE. Begin with the client in a supine position. Turn the clients
head slightly to the opposite side and, if possible, laterally flex
...one of the very best teachers Ive had in the business. the head toward the affected side. This position will slightly
...what an incredibly useful & accessible course! shorten the scalene muscles and reduce any stretch tension
perceived by the muscle. Place the fingertips of one hand near
the superior portion of the muscle and the fingertips of the
Workshops: GA, DE, TX, CT, CA, ID other hand near the inferior portion of the muscle near the
clavicle and first rib (Image 3). Apply a gentle pulling force,
separating your two hands, and hold for about 2 minutes.
ABMP Member Specials After holding this position, very slowly and gradually let go
Visit us at: of the pulling force. Slowly releasing this force allows the brain
www.acmspecials.com to adapt to a different sensation coming from the muscles and
save on courses, books, workshops is more likely to have a longer lasting effect. After pressure is
released, take the clients head, then slowly and gently move it
back and forth in slight flexion and lateral flexion toward the
Training excellence affected side, trying to keep from overstretching the muscles
in science-based clinical that have just been treated. These gentle and easy movement
massage for over 2 decades. patterns help retrain the neuromuscular pattern perceived by
the brain. If youre not forcibly stretching the muscle, the brain
does not have to perceive any potential tissue damage and will
not cause as much reactive resistance to the movement.
A similar technique can be applied to the muscles on the top of
Academy of clinical massage the shoulder along the path of the long thoracic nerve. Place one
hand near the base of the neck and the other hand near the distal
www.academyofclinicalmassage.com
866-744-8456

SCIENCE OF NERVES
3
Treatment of
4
Treatment of
scalene muscles shoulder muscles
to reduce LTN to reduce LTN
compression. compression.
5
Serratus anterior
6
Serratus anterior
treatment treatment
(direction 1). (direction 2).
3. J. G. Skedros et al., Complex Scapular Winging

end of the clavicle. Slightly laterally flex CONCLUSION Following Total Shoulder Arthroplasty in a
the clients head toward the affected side. When you begin to explore the anatomy of Patient with Ehlers-Danlos Syndrome, Case
Apply a traction force to the skin with the nervous system, it is clear there are many Reports in Orthopedics (2015): 680252.
your hands, gently pulling them apart more locations where nerves are vulnerable
4. A. I. Tsirikos and K. Al-Hourani, Transient Long
(Image 4). Hold this for about 2 minutes. to excessive compression or tension than Thoracic Nerve Injury During Posterior Spinal
At the end of that period, very slowly and most of us realize. While stories of carpal Fusion for Adolescent Idiopathic Scoliosis:
gently let go and once again move the neck tunnel, thoracic outlet, or nerve root A Report of Two Cases, Indian Journal of
and shoulder slowly and easily within a compression dominate most of the focus Orthopaedics 47, no. 6 (2013): 62123.
comfortable range of motion to help re- of nerve compression problems, there is 5. P. Shilal et al., Aberrant Dual Origin of the
encourage safe and pain-free movement. a whole host of other disorders involving Dorsal Scapular Nerve and Its Communication
There can be bind and restriction in other nerve tissues throughout the body. with Long Thoracic Nerve: An Unusual Variation
the lower portions of the long thoracic Massage therapists are ideally positioned to of the Brachial Plexus, Journal of Clinical and
nerve as well. These restrictions can be help address these complaints, and future Diagnostic Research 9, no. 6 (2015): AD0102.
addressed with the client in a side-lying versions of this column will focus on these 6. M. Pecina, A. Markiewitz, and J. Krmpotic-Nemanic,
position. Have the client hold one arm fascinating issues. For a full list of references Tunnel Syndromes: Peripheral Nerve Compression
across the front of the body and use the and some additional information on long Syndromes (Boca Raton, FL: CRC Press, 2001).
other hand to keep the drape in place so the thoracic nerve injury, visit our blog at
lateral aspect of the rib cage is accessible. www.academyofclinicalmassage.com.
Whitney Lowe is the developer and instructor
With one or both hands, push the
of one of the profession's most popular orthopedic
surface layer of skin across the lateral
Notes massage training programs. His texts and
rib cage and hold this position for a few
1. K. E. Keenan and J. G. Skedros, A Patient programs have been used by professionals
moments (Image 5). Then, slowly let go with Clavicle Fracture and Recurrent Scapular and schools for almost 30 years. Learn more
and push in a slightly different direction Winging with Spontaneous Resolutions, Case at www.academyofclinicalmassage.com.
(Image 6). Pushing and pulling the skin Reports in Orthopedics (2012): 603726.
perpendicular to the direction of the
2. N. Omar, F. Alvi, and M. S. Srinivasan, An Unusual
nerve can help to mobilize the nerve Presentation of Whiplash Injury: Long Thoracic
and make sure it is not being entrapped, and Spinal Accessory Nerve Injury, European
bound, or restricted by adjacent tissues. Spine Journal 16, supplement 3 (2007): 27577.
technique MYOSKELETAL ALIGNMENT TECHNIQUES
An Alternate Approach to Tennis Elbow

Articular Stretching for Neural Mobilization
By Erik Dalton
Humeroulnar
hinge joint the area with protective
A primary part of being human
spasm, resulting in
is the ability to use our hands in radial nerve symptoms
that resemble lateral
1
extraordinary ways. This effective
epicondylalgia, or
and skillful hand use requires stable tennis elbow.
The humeroulnar Famed hand surgeon
and painless movement of all upper is the only true Emanuel Kaplan, MD,
extremity joints, including the elbows. elbow hinge joint. was the first to suspect
Adapted from
radial nerve denervation
Since the elbow bends and straightens Dreamstime.
as a possible cause for
much like a basic door hinge, it is some epicondylalgia
cases. In dissection
referred to as a hinge joint (Image 1).
studies, he noted
However, the interaction of the elbow constriction of the radial nerve by adhesions
to the capsule of the radiohumeral joint
with the forearm and wrist is far from
and the short extensor muscle of the wrist.1
basic. When this complex interaction is A study published in Manual Therapy
Journal found that a significant percentage
fully understood, its easy to see how
of double-blind subjects presenting with
dysfunctional elbow mechanics could tennis elbow demonstrated a favorable
response to articular stretching techniques
be a major contributor to forearm and
to restore optimal extension, pronation,
hand pain. and supination.2 A similar study on
EPICONDYLALGIA
While the humeral and ulnar bones flex
2
The elbow's radial
computer users found immediate reduction
in lateral elbow pain after radial nerve
mobilization.3 The researchers concluded
head smoothly that mobilization with movement appears
and extend similar to a door hinge, the
rotates around the to be a promising alternative treatment
humeral and radial articulations are much
ulnar bone. Adapted for clients with tennis elbow. But why?
more complex. Shaped like a contoured from McGraw-Hill
knob with a cup at the end, the elbows Education with
radial head smoothly rotates around the permission. TENDINOSIS OR NERVE PAIN?
ulnar bone, causing the radiohumeral and Most of us who treat athletes are keenly
radioulnar joints to efficiently turn the aware that repetitive gripping can strain
palm up (supination) or down (pronation) elbow tendons, leading to palpable
(Image 2). Sportsand occupations that maladaptions in tendon structure. During
involve repetitive lifting, forceful forearm clinical examination of tennis elbow,
maneuvers, and recurrent vibrationmay, clients often report tenderness over
in time, damage the elbows extensor the common forearm extensor tendon
tendons and degrade the joints articular insertion at the lateral epicondyle. Pain
cartilage. In the presence of altered joint is reproduced with resisted wrist and
mechanics, the brain may decide to layer

middle finger extension and with gripping
activities. Ive had success treating this
tendinopathy using crossfiber frictioning
and eccentric strengthening exercises.
However, Ive had better results when the
treatment included articular stretching
routines to help calm hyperexcited
mechanoreceptors, reduce protective muscle
guarding, and remove tension on strained
fibers and compressed nerve tunnels.
Try incorporating the myoskeletal
3 With the elbow pinned to the clients side, articular stretching techniques for elbow
the forearm is rotated to the first supination supination, pronation, and extension
barrier. The client gently pronates the arm shown in Images 3, 4, and 5 prior to
against resistance to a count of five and assessing and treating soft-tissue lesions.
relaxes. I supinate to the next restrictive barrier If your state laws allow home retraining
and repeat until full supination is reached. advice, teach the radial nerve mobilization
stretch shown in Image 6. You may find
4
The forearm is rotated to the first pronation that many chronic elbow and forearm
barrier and the client gently supinates against problems soon disappear as full mobility
resistance to a count of five and relaxes. is restored to motion-restricted joints
I rotate to the next restrictive barrier and and associated soft tissues.
repeat until full pronation is achieved.
Notes
1. E. B. Kaplan, Treatment of Tennis Elbow by
Denervation, Journal of Bone and Joint Surgery:
6
American Volume 41, no. A(1) (January 1959): 14751.
2. J. H. Abbott, C. E. Patla, and R. H. Jensen,

The Initial Effects of an Elbow Mobilization
with Movement Technique on Grip Strength in
The client extends Subjects with Lateral Epicondylalgia, Manual
the elbow and curls Therapy 6, no. 3 (August 2001): 16369.
the fingers around
the thumb. She 3. V. Arumugam, S. Selvam, and J. C. MacDermid,
5 The clients elbow is extended

to the first restrictive
barrier. The client gently
flexes the biceps to a count
internally rotates
the arm, retracts
the scapula, and
left sidebends her
Radial Nerve Mobilization Reduces Lateral Elbow Pain
and Provides Short-Term Relief in Computer Users,
Open Orthopaedics Journal 8 (October 2014): 36871.
head. To enhance
of five and relaxes, and I the nerve flossing Erik Dalton is the executive director of
bring her elbow to the first stretch, she slowly the Freedom from Pain Institute. Educated
extension restriction barrier. abducts her arm in massage, osteopathy, and Rolfing, Dalton
Repeat until full elbow and reaches toward
the floor. Repeat has maintained a practice in Oklahoma City,
extension is achieved. Oklahoma, for more than three decades. For
daily. Adapted from
Dreamstime. more information, visit www.erikdalton.com.
technique ENERGY WORK
Chakras
A Cultural Look at These Energetic Bodies
By Cyndi Dale
My newest book is an exploration Grays Anatomy to track the flow of fluids. or chakras. This is only one of the chakras
It would not occur to them to mock many names, as they appear in different
of all aspects of the chakras and
someone who had heard from Spirit in a forms in cultures around the world. Yet
like-minded organs, including dream. They trusted their spiritual senses no matter how such descriptions differ,
as much asif not more thantheir chakras are defined in the same way: as a
the science, spirituality, and history
physical ones, and their understanding system of subtle energy transformers
of these stellar centers; practices of the human body, mind, and soul similar to the common electrical devices
reflected this advanced consciousness. that control electrical energyoperating
involving them; and hundreds of
Our ancestors believed there were within a network of systems that compose
pages featuring energy systems energy bodies associated with their our energetic anatomy. In other words,
physical bodiessubtler dimensions of they constitute a vital part of us that
from various cultures across time.
the miraculous gift of life. East Indian can and does influence both subtleor
A few years ago, Llewellyn, the culture called these energy bodies cakras psychicenergy and physical energy.
publisher of my book The Complete Book of
Chakra Healing (2009), asked me to gather
THE THREE MAIN FUNCTIONS
into a single volume as much material as
OF THE CHAKRAS
possible on chakras, the energy bodies
All chakras or similar energy bodies
that constitute the heart of our subtle
perform three vital functions:
energy anatomy. I immersed myself in
1. P
hysical processing: Many chakras have a
the assignment and Im pleased to report
bodily location, including an attachment
its as complete as such a book can be,
to a nerve plexus and/or endocrine
given that it is more than 1,150 pages.
gland, and they all manage a certain
Now Im excited to share my wisdom
part of the body. They can also be
from this book, Llewellyns Complete Book
described as colors and sounds, which
of Chakras (Llewellyn Publications, 2016),
are related to the vibratory bands they
and this article showcases a set of excerpts
operate within and emanate, so they
from the manuscript. I include a brief
relate to our physical senses as well.
introduction to the chakras and their three
2. Psychological processing: Each chakra
main functions; a summary snapshot of
interacts withand creates
the science of chakras; a brief description
psychological constructs that affect our
of their place within the subtle energetic
well-being. This processing takes place
constellation; and an overview of one of
in the realm of beliefs and feelings.
the dozens of energetic systems featured
3. S
piritual processing: Each chakra
in the bookalong with an exercise you
contributes to our spiritual well-being
can use to explore this Yorubic system.
and development, adding a layer of
consciousness to our maturing sense
MEET YOUR CHAKRAS
Thousands of years ago, our ancestors
didnt have machines to substantiate
someones claim that they felt sick. They
didnt look up sketches of the body in

of self. Every chakra also serves as a limited definition brings us to the doorstep
meridians in traditional Chinese medicine
channel for a specific psychic ability. of the chakras, but doesnt invite us into the
and nadis in traditional Indian medicine.
room. For that, we have to pass through
Among the thousands of meridians and
the gate of quantum physics, the study of
WHAT DOES SCIENCE SAY? hundreds of thousands of nadis, there
the subatomic ingredients that compose
Science explains chakras in many different are 14 main meridians and 14 main
the universe. Quantum physics explains the
ways. The most basic level is biological. nadis. This has led some to theorize
weirdness of the chakrastheir ability to
Chakras interact with our nervous system, that meridians and nadis are equivalent;
transcend time and space, alert us to psychic
and each chakra is associated with an others insist they are different systems.
information, and evolve us spiritually.
endocrine gland. Chakras are therefore Also associated with the chakras are
Quantum physics also explains
involved with our electromagnetic energetic fields, which include the human
why subtle energy structures such as
functions and our biochemistryaspects auric field. Every auric layer is partnered
chakras connect us to one another
of us that control everything from with a chakra, and together they exchange
across distances. According to quantum
our bodily functions to our moods. energy inside and outside of the body.
theory, a particle can sense the activity
Another scientific perspective involves However, there are thousands, if not
of another particle close to it or millions
electromagnetic fields, which are composed millions, of other energetic fields that affect
of light-years away.2 The nature of this
of all the different speeds and wavelengths our chakras. These include the seven rays,
interconnectivity has led quantum
of light. We are actually a collection made famous by several esoteric circles.
physicists to call all of reality nonlocal, or
of oscillating fields of lightas are our We are truly made of field upon field
unbound within time and space, rather
chakras. Chakras express the magnificence of oscillating energy, our own swirling
than local, or only located in one place.
of this fact, each operating on a differently dramas interacting with those of others.
The ultimate implication of nonlocality
colored band of frequencies. This is one of And while the famous chakra
is that everyone and everything is
the reasons most experts typically perceive might like to portray itself as a solo
inseparable. We exist within an ocean
the seven in-body chakras as particular act, there are dozens of other subtle
of oneness. There is no distinction
colorsrainbow colors, in fact. The lowest energy bodies composing the self.
between communicator and recipient.
in-body chakra is red and the highest is These often function as various planes
We play a dualistic role of observing our
white. The other colors of the rainbow lie of reality as well as energetic fields.
own actions and participating in them.
in between. For this reason, chakras are Ultimately, the message of the chakra
And a vortexone of the definitions
often referred to as a rainbow bridge. is this: we are each a mini-universe, a
of a chakrahas a nonlocal origin and
Then there is the aspect of sound. beautifully choreographed composite of
expression, even though it can be, at
Most ancient cultures also ascribed sounds subtle structures. Whether we call them
one level, located in time and space.3
to the chakras. In fact, there are often bodies, energy layers, channels, tubules, or
Because of nonlocality, a chakra
several sounds associated with each one. any other name, each constellation points
can be both here and everywhere at the
In the Hindu tradition, the chakra tones us toward the heavens, our birthplace.
same time. Nonlocality also explains
are called bija or seed sounds, and the
why some chakra systems present
50 sounds within the Sanskrit language
dozens, if not hundreds, of chakras. FEATURED CHAKRA SYSTEM:
are spread out among all seven chakras.
THE YORUBA CHAKRA SYSTEM
Some of these sounds are the seed, or
Peel back the layers of time and travel
core, tones of the chakras, while others CHAKRAS AS PART OF A
deep into the African continent, and
are sounds associated with the petals that GREATER FAMILY
you will meet the practitioners of the
make up the lotus shapes of the chakras.1 As powerful and transformative as they
Yoruba religion, originally developed
So far, weve been explaining the science are, chakras function within an even
among the people of Nigeria and
of chakras through the lens of classical greater subtle anatomy. One partner
Benin. Yoruba religious principles also
physics, which explains that energy is set is the energy channels, or riverways
apply to a medicine as comprehensive
the force that makes things happen. This of subtle energy. These are known as
as Ayurveda, with philosophies and body. Each of the orisha areas relates to
systems that include the chakras. one of the standard Hindu chakras.
Making use of chakras is part of the Following is a description of the
medicine of the Yorubic people. The various orishas, with each orishas
Yorubic healing system is rooted in the name paired with a chakra.
Ifa Corpus, a religious text revealed to the
mystic Orunmilla more than 4,000 years Obatala orisha: First chakra
ago. This system is still practiced widely Obatala is a creature of human form.
on the African continent, the Caribbean, White with purity, he cures illness and
and South America, having traveled there deformities. This orisha manages the
with African slaves. But Yoruba medicine brain, bones, and white fluids of the body.
originates from traditions even older
than the Ifa Corpus. Archeologists track We are each a Elegba orisha: Second chakra
it to the migration of the East African The messenger of the orishas, Elegba holds
population across the trans-African route mini-universe, ashe for his brethren and negotiates between
from the mid-Nileor Egyptto the the negative and positive forces in the
mid-Niger between 2,000 and 500 BCE.
This area had long been settled,
a beautifully body. This orisha governs the sympathetic
and parasympathetic nervous systems.
perhaps from as long ago as 65,000
BCE, by people from many cultures, choreographed Ogun orisha: Third chakra
among them people who referred to The ruler of iron, Ogun clears paths,
themselves as the Yoruba. They were composite of specifically in relation to blockages in
an ancient, cultured, and mystical the body. Ogun runs the heart, kidney,
people who brought their knowledge
into Egypt. However, their medicine
subtle structures. adrenal glands, tendons, and sinews.
and beliefs are also steeped in Egyptian Yemoja orisha: Fourth chakra
philosophy, including the knowledge As the mother of waters, Yemoja
of herbs, divination, ritual, demonic represents sexuality and nurturing.
release, and, most importantly, magic.4 She is the protective energy of the
The Egyptian, and therefore Yoruba, feminine. She manages the womb,
medical systems include the knowledge of liver, breasts, and buttocks.
extremely human in their characteristics.
two creative principles and four elements.
Overall, despite their mixed traits, they
The soul and body are not considered Oshun orisha: Fifth chakra
are considered helpful and might inhabit
distinct in these systems; rather, we are one Oshun symbolizes clarity and feminine
the bodies of their worshipers, who often
being in two aspects. These systems also motion. With the power to heal with
invoke them during dance and other rituals.
include an understanding of pathological cool water, she assists with childbearing
The counterbalance is negative forces
toxins and the importance of the brain, and fertility. Oshun is charged with the
called ajogun, which can cause everything
spinal cord, and central nervous system, circulatory and elimination systems,
from accidents to depression. It is often
in addition to other bodily systems. digestive organs, and female pubic hair.
necessary to free oneself of the ajogun to
The ancient Egyptians even used light
attain health and well-being and promote
therapeutically, such as to bleach the skin. Shango orisha: Sixth chakra
the flow of ashe, a vital life energy.
The name of the primary Yoruba god Kingly and virile, Shango represents
The primary orishas were considered
is Olodumare, who is similar to Brahma of the fire and lightning of a warrior. He
angelic beings that also emanated into the
Hinduism, respected but not approached can also transform base substances into
physical body. The seven major orishas
daily. Instead, humans turn to orishas, valuable elements. Shango runs the male
were each to be internalized in a specific
beings that intercede between the worlds reproductive system, bone marrow, and ashe.
area of the body, thus opening the body
of humanity and divinity. These are
to the One, or Olodumare, and the free
similar to Catholic saints, and many are
flow of ashe. Another goal was to free a
person from any ajoguns locked in the

ENERGY WORK
Oya orisha: Seventh chakra

The guardian of the cemetery, winds of
Exercise: Clearing Your Orishas
change, and progression, Oya is usually
found with Shango, who allows the old
With Poetry
to die so they can initiate rebirth. The How can you safely employ a bit of this ancient knowledge
area served includes the lungs, bronchial for yourself? Start by closing your eyes and breathing deeply
passages, and mucous membranes.5
before selecting a specific challenge. Ask the Divine to give
What I've learned in writing this you a spiritual healing guide for this process.
bookthis timeis that no matter the Ask that this healer assess your ori, the spiritual soul of
culture, chakras are portrayed as essential
components of our being. They enable your being, next revealing which orisha is most affected
us to be fully human. They invite us to by the causes of your situation. What natural law has been
be divine. And they create within our broken? What is this ailment or challenge trying to teach
soul a space in which to be both.
you? When you feel ready to shift your consciousness, ask
the healer to help you remember, write, or find a poem in the
Notes
1. Chakra Vortex of Light, Sounds of the Chakras, next couple of daysa poem that will both reveal your issue
accessed November 2015, http://home.
to you and reflect the necessary and transformational truth.
comcast.net/~chakra_system/sound.html.
Thank this being and the Divine for this personalized help
2. Robert Nadeau and Menas Kafatos, The Non-Local
Universe (New York: Oxford University Press, 2001): 4. and return to your day.
3. F. David Peat, Non-Locality in Nature and
Cognition, accessed November 2015, www.
fdavidpeat.com/bibliography/essays/nat-cog.htm.
4. Femi Fani-Kayode, This Day Live, Who are

The Yoruba People? (III), accessed November
2015, www.thisdaylive.com/articles/who-
are-the-yoruba-people-iii-/149801.
5. Tariq Sawandi, East West School of Planetary

Herbology, Yorubic Medicine: The Art of Divine
Herbology, accessed November 2015, www.
planetherbs.com/theory/yorubic-medicine-
the-art-of-divine-herbology.html.
Cyndi Dale is an internationally renowned

author, speaker, and intuitive consultant. Her books
include Llewellyns Complete Book of Chakras
(Llewellyn Publications, 2016), The Subtle Body: An
Encyclopedia of Your Energetic Anatomy (Sounds
True, 2009), The Complete Book of Chakra Healing
(Llewellyn Publications, 2009), and Advanced
Chakra Healing (Crossing Press, 2005). To learn
more about Dale and her products, services,
and classes, please visit www.cyndidale.com.
technique MYOFASCIAL TECHNIQUES
Sequencing Your Techniques

A Three-Phase Approach to Bodywork
By Til Luchau
Knowing how to do a technique

is important. Perhaps even more
important is knowing when to use
it. This means not only knowing
techniques to address the condition at
hand, but also how to sequence these
tools into a cohesive whole, with a
1 2
coherent beginning, middle, and end.
One way to accomplish this is to follow a

Preparation, differentiation, and integration as a The three-dimensional self-similarity of Romanesco
sequence or protocol (such as those we teach
repeating cycle that applies a single technique (large broccoli is one of the many examples from nature that
in our Advanced Myofascial Techniques
triangle) as well as to a session or series (smaller illustrates how smaller units (e.g., techniques) make
videos and trainings). But, just as techniques
triangles), each of which is composed of smaller up similarly patterned larger units (sessions), which
are not all that is required for good hands-
versions of the same beginning-middle-end cycle. in turn make up the whole (a series of sessions).
on work, recipes and routines also have their
Image courtesy Advanced-Trainings.com. Smaller
limits. At some point in their professional
Koch snowflake images used under CC BY-SA 3.0.
development, many practitioners look to
move beyond the scripts and routines that
originally helped them learn and apply
structural integration lineage. One way a working phase (in our method, this
their work. Different contexts, styles,
her 10-session series can be understood is is usually differentiating one structure
and methods call for different ways of
as a three-phase progression of preparation from another); and an easing out
sequencing the tools we choose. Here are
(the theme of the first three sessions), phaseintegrating the learning and
some general principles that can guide
differentiation (sessions four through seven), changes with the rest of the body, with
your technique selection and sequencing,
and integration (the final three sessions).2 other sessions, and ones daily life.
whatever your context or method.
Without trying to replicate Rolfs This same beginning-middle-end
recipe, we can respectfully adapt her general rhythm applies to the session as a whole,
PREPARATION, DIFFERENTIATION, principles of preparation, differentiation, where the first techniques are preparatory
AND INTEGRATION and integration to inform any approach. (e.g., Preparing the Neck for Deep Work,
Ida P. Rolf, PhD, the originator of This progression can be applied to all scales Massage & Bodywork, January/February
Rolfing structural integration, taught the and levels of our workfrom an individual 2009, page 124), the middle techniques focus
sequencing of her work via a recipe of 10 technique, to a session, to a series of sessions on differentiation (e.g., Working with the
basic sessions that progressively addressed (Image 1). This micro/macro repetition can Scalenes, Massage & Bodywork, January/
the body in its entirety.1 The logic of be compared to a self-similar fractal-like February 2011, page 108), and the last
her original 10-session series has been design, where the same patterns are visible techniques are integrative, emphasizing the
analyzed, reinterpreted, and hotly debated at all scales of magnification whole rather than the parts (e.g., Working
among various schools that continue her (Image 2). Each technique needs an
easing into phase (i.e., preparation);

Watch Til Luchaus technique videos and read his past
articles in Massage & Bodyworks digital edition, available at
www.massageandbodywork.com, www.abmp.com, and on
Advanced-Trainings.coms Facebook page. Anterior Neck/Shoulder
Differentiation Technique
The proportion of time, techniques,
3
with Bone, Massage & Bodywork November/ or sessions spent in each phase
December 2013, page 114). It also applies of the preparation-differentiation-
to a series of sessions, where the efficacy integration cycle can be adjusted
of later sessions depends on the extent of to the context or condition being
preparation early on, and successful long- addressed. Image 3: a cautious
term change for the client hinges on the approach, appropriate for complex
integration occurring in later sessions. or less predictable conditions, such
HOW MUCH IS ENOUGH?

Although there is much more to be
4 as hot whiplash or intervertebral disk
issues. In comparison to a typical
approach (Image 4), a bold, direct
approach (Image 5) with minimal
said about the topic, the preparation-
preparation may be effective for
differentiation-integration sequence
stubborn conditions, especially when
provides a simple but useful conceptual
5
there is good client/practitioner
framework for strategizing sessions. The
rapport and you are familiar with
proportion of time, techniques, or sessions
your clients post-session responses
you spend in each of these phases can
to previous work. Images courtesy
be adjusted, depending on the stability,
Advanced-Trainings.com.
fragility, responsiveness, or stubbornness
of the issues being addressed. In complex,
unstable, or less-predictable conditions, our faculty and alumni of our in-person trainings),
just a few clear concepts to integrate, and
such as spinal disc issues, hot whiplash, or I should clarify that this work is not Rolfing (which
practitioner exhaustion and burnout. is trademarked by the Rolf Institute of Structural
symptomatic scoliosis, a cautious approach
It is almost always beneficial to slow Integration) per se, because we are focusing on
(Image 3), devoting proportionally more
down and spend more time with fewer techniques to address specific conditions, rather than
time to preparation and integration than
techniques, rather than rushing through as on integration of the entire body in the field of gravity,
in a typical progression (Image 4), allows
many as possible in the allotted time. Try which is one aim of Rolfing structural integration.
time to observe your clients response to
cooking your sessions with just one or
the work and, if necessary, course-correct
two spices, instead of every seasoning in the Editors note: An expanded version of this
before aggravating the condition. In other
cabinet. Or, let the sessions you compose column will appear in Til Luchaus upcoming
cases, where the body or symptoms seem
have the spare beauty and spaciousness of book, Advanced Myofascial Techniques,
slow to respond, a bolder, more direct
a string quartet, rather than always going Vol. 2, to be published early 2016 and
approach might be appropriate (Image
for the lushness of the full orchestra. The available at Advanced-Trainings.com.
5). Even in slow-to-respond conditions,
effectiveness and satisfaction you and
results are usually greater when the
your client get from your work depends Til Luchau is a member of the Advanced-
preparation-phase functions of assessment,
less on how much you can fit in, and more Trainings.com faculty, which offers distance
rapport, relaxation, and peripheral mobility
on the art of leaving things out. learning and in-person seminars throughout
have been thoroughly addressed.
North America and abroad. He is a Certified
Whatever sequencing protocols you
Advanced Rolfer and originator of the Advanced
choose, the adage less is more holds true. Notes
Myofascial Techniques approach. Contact
Whether it is from trying to give clients 1. Ida P. Rolf, Rolfing: Reestablishing the Natural
him via info@advanced-trainings.com and
their moneys worth, prioritization and Alignment and Structural Integration of the
Human Body for Vitality and Well-Being Advanced-Trainings.coms Facebook page.
time management challenges, or fear of
(Rochester, VT: Healing Arts Press, 1989).
leaving something out, it is common for
therapists to do more than is necessary. 2. Even though we draw inspiration from Rolfs
Good intentions often result in working the sequencing principles in our Advanced Myofascial
client past the point of maximum benefit, Techniques work (and even though many Rolfers
and structural integration practitioners are among
diluting the educational value of having

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