November 04, 2005
Eight Tests for Anterior Knee Pain |
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Anterior knee pain is a common complaint presented to bodyworkers. Learn how to perform eight orthopedic knee tests to determine when a referral to another healthcare professional is warranted.
As recognition of massage therapy’s importance within health care increases, so does the demand for educated and skilled practitioners. The widespread acceptance of therapeutic massage as a viable pain-relieving option leads many sufferers to see a massage therapist before visiting their physician. Since some orthopedic conditions can be aggravated by therapeutic massage, identification of and referral for these conditions is a testament to a therapist’s competency.
Anterior knee pain presents an ideal opportunity for employing condition differentiation skills. The body’s initial weight-bearing joint is stabilized most by ligaments, making the knee highly susceptible to injury. Using client history, observatory, palpatory and manual resistive testing skills, a therapist can confidently isolate injuries conflicting with massage and avoid manipulating a knee requiring medical attention.
Adding some simple orthopedic tests to a massage therapist’s evaluation can greatly enhance their assessment skills. The descriptions of specialized manual resistive tests for anterior knee pain is not intended to teach diagnosis, but rather, to help a therapist identify possible conditions requiring a referral to another healthcare professional; such as a physician, orthopedist, chiropractor or physical therapist.
A massage therapist increases his/her value exponentially, by knowing when to refer out. According to Benny Vaughn’s video, Functional Assessment Skills for Massage Therapists, “Knowing when NOT TO is just as important as knowing when TO.” Following a knee injury, a foot blue in color and cool to the touch is indicative of a dislocation. Signifying a serious injury to the foot’s blood vessels, this condition should be considered an emergency and professional help must be sought immediately.
When addressing anterior knee pain, the following injured structures mandate additional professional evaluation:
• Cruciate Ligaments -The cruciate ligaments stabilize the knee by crossing over each other in an X formation, from the upper to lower leg. Located in the center of the knee joint, the anterior cruciate ligament (ACL) is the major stabilizing ligament of the knee, connecting the femur to the tibia. The ACL prevents anterior displacement of the tibia, which would cause a knee to buckle. Of the four major ligaments of the knee, the ACL injury is the most common knee ligament injury.
The posterior cruciate ligament (PCL) also connects the femur to the tibia. The PCL prevents posterior displacement of the tibia. While this ligament is stronger than the ACL, and less frequently injured, it is still important to test for when faced with mysterious knee pain.
• Collateral Ligaments - The collateral ligaments are the ligaments on either side of the knee joint. On the outer aspect of the knee is the lateral collateral ligament (LCL), and on the inner aspect is the medial collateral ligament (MCL). The LCL stretches from a tubercle on the femur’s lateral condyle to the lateral surface of the head of the fibula, while the MCL connects the femur’s medial epicondyle to the medial tibial condyle. At its midpoint, the fibers of the MCL are firmly attached to the medial meniscus. Damage to the collateral ligaments typically involves significant force, such as a blow to the side of the knee during contact sports or a bad fall.
• Meniscus - There are two C-shaped pieces of cartilage in the knee joint, the lateral meniscus and the medial meniscus. Knee stabilization, joint lubrication and shock absorption are the three primary functions of the menisci.
• Chondromalacia patella - Patello-femoral syndrome indicates pain between the femur and patella. The patella is designed to glide smoothly over the femur, however, poor alignment causes inflammation and pain, indicating chondromalacia patella. Chondromalacia patella is the most common source of chronic knee pain, causing pathological changes and possibly leading to deterioration of the articular surface of the patella.
Manual resistive tests can give the massage therapist a substantial amount of information regarding the functioning of these knee components. A painful response from a client indicates a serious injury, necessitating a referral, as does a positive indication for any of the following tests described by Vaughn:
1. Lachman Test - The Lachman Test stresses the ACL to detect anterior tibial displacement. Performed with the client supine, the therapist grasps the distal portion of the thigh and the proximal portion of the lower leg to create anterior-posterior shifting. This shifting at the knee joint is from pulling the proximal tibia anteriorly, then pushing it posteriorly. Make certain there is a slight bit of flexion in the knee to create some hamstring slack, as hamstring tension can interfere with this test. A positive test is assumed when the movement feels “mushy” (soft endpoint), has a gapping sensation, or when excessive glide is noted. A positive test suggests ACL damage and requires a referral.
2. The Drawer Tests - The Anterior Drawer Test stresses the ACL and will detect its weakness. Performed with the client supine, the knee is flexed at a 45-degree angle with the foot flat on the table. By sitting on or just past the foot, the therapist stabilizes the leg to prevent its movement. The therapist grasps the proximal portion of the tibia with both hands and yanks towards him/herself.
The Posterior Drawer Test is performed immediately following the Anterior Drawer Test’s forward tibia yank. The Posterior Drawer Test stresses the PCL, and is done by pushing the tibia back towards the client’s thigh. Positive Drawer Tests occur when the movement feels mushy (soft endpoint), has a gapping sensation or when excessive movement (anteriorly or posteriorly) is noted. A positive test suggests ACL or PCL damage and requires a referral.
3. Valgus Stress Test - The Valgus Stress Test puts pressure on the medial collateral ligament. The client lays supine with extended legs. While supporting the thigh and stabilizing the leg with a firm distal leg grasp, the therapist applies pressure to the lateral aspect of the knee by pushing medially. The knee is slightly flexed to avoid tightened hamstring muscles, which are capable of interfering with the accuracy of this test. The creation of pain or a widened joint space indicates a positive test and requires referral for further evaluation.
4. Varus Stress Test - The Varus Stress Test puts pressure on the lateral collateral ligament. Positioning is identical to the Valgus Stress Test except pressure is applied to the medial aspect of the knee by pushing laterally. The creation of pain or a widened joint space indicates a positive test and requires referral for further evaluation.
5. Apley Compression Test - The Apley Compression Test puts pressure on the meniscal cartilage. The client lies prone with the leg at a 90-degree angle to the thigh. The therapist grasps the plantar side of the foot and pushes down into the table. If there is no response, this test can be exaggerated by adding internal and external rotation of the tibia to the downward compression. Because compression traps the meniscus, pain indicates possible meniscal cartilage involvement. When rotation is added to the compression, pain can indicate injury to the meniscus, knee ligaments or both.
6. Apley Distraction Test - The Apley Distraction Test puts traction on the tibia, decompressing any pressure on the meniscus. The client lies prone with the leg at a 90-degree angle to the thigh. The therapist stabilizes the thigh by using the weight of their leg to prevent movement. Hold the ankle with both hands and pull straight up towards the ceiling, relieving any pressure on the meniscus.
If the Apley Compression Test elicits pain, and the Apley Distraction Test provides pain relief, then the likelihood of meniscal injury is high. If the reverse is true, where pain exists on distraction but not compression, then the collateral ligaments may be injured. In either case, a positive finding suggesting meniscal injury or collateral ligament injury necessitates a referral.
7. Patellofemoral Compression Test - The Patellofemoral Compression Test puts pressure on the patella. The client sits on the table with the lower legs hanging over the side. The therapist compresses the patella while the client flexes and extends his/her leg within a 35-degree range. The flexion and extension can be done actively (by the client), or passively (by the therapist). A positive test elicits pain or discomfort, indicating patello-femoral syndrome and a subsequent referral.
8. Clarke’s Sign - Clarke’s Sign is a test designed to identify the presence of chondromalacia patella and can only be done once. A positive test will cause a significant amount of discomfort or pain, and most clients will not allow for its repeat. The patient lies prone. With the web of the hand the therapist presses the patella down towards the feet in an inferior direction. The client is then asked to contract the quadriceps muscle as the therapist continues applying force. The test is positive if the patient cannot complete the contraction without pain, or has a great deal of apprehension about tightening their quads. A positive Clarke’s sign requires a referral; however, quadriceps, hamstring and adductor massage may reduce the pain in the meantime.
Incorporating these manual resistive tests into a massage therapist’s skill set requires practice. It is highly recommended to rehearse new maneuvers on uninjured volunteers before using them in a therapeutic setting. While the descriptions provided act as a guide, live training or repeated video viewing (such as Vaughn’s video) provides complimentary visual support. As a therapist’s comfort level for performing the preceding tests rises, so will his/her confidence in safely working with anterior knee pain.
References:
Functional Assessment Skills for Massage Therapists. Writ. Benny Vaughn. Benny Vaughn Associates. 1997.
www.kneeguru.co.uk
www.medicinenet.com
www.orthopedics.about.com
Posted by Nicole at 11:07 AM
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How to Integrate Chakra Theory into Bodywork |
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Understanding the chakra system provides multi-dimensional insight into the human condition, and can increase the therapeutic value of massage. In addition to a brief summary of this system, a chakra clearing technique to encourage healing is described.
Chakras are energy centers, where wheels of light spin within each human being. Indian yogic traditions perceive chakras as locations where personalities interface and energetic exchanges are continually processed. Individuals spiritually, emotionally and physically aware of their own energy, are more likely to be attuned to chakra functioning. An example of this energetic exchange can be experienced when one feels threatened. This feeling of helplessness typically manifests as physical discomfort in the solar plexus, where the chakra related to power is located. Another physical manifestation of a chakra’s energetics occurs when feelings of love materialize as warmth in the chest, at the level of the heart chakra.
The seven major chakras in the body are located in the trunk and head, while several minor chakras are located in the hands, feet and joints. Chakras metabolize energy from the environment at different frequencies. The lower chakras absorb denser energies and the upper chakras digest higher/faster vibrations. Color is representative of this scale, as the lower chakras attract reds and oranges, while the upper chakras retain blues and violets. The lower a chakra is located, the more tangible its vibration, as evidenced by a dense and intense feeling, such as sexuality. A more ethereal quality is characteristic of the upper chakras, which focus on such traits as wisdom and thought.
Disease typically results from a blockage or suppression of energy in any given chakra. A blocked energy center reduces the circulation in that physical location, causing slight localized vaso-constriction. This decrease in blood flow weakens tissue, priming the affected area for injury or disease. This mechanism translates emotions, thoughts and beliefs into physical manifestations. Systemic opening and clearing of chakras maintains circulation and renews the blood supply, encouraging a return to health.
The centers of our palms contain minor chakras, capable of sensing and transmitting energy. Practice enhances chakras’ sensitivity and effectiveness. Although it is possible to sense energy early in your practice, the more these vortexes are utilized, the sharper your energy manipulative skills become. Additionally, the hand vortex’s connection to the heart chakra explains the hand’s capability of expressing heartfelt compassion.
According to Ralph Napolitano, author of the Institute for Integrative Healthcare Studies’ Healing Energy and Touch continuing education course for massage therapists, working from the heart chakra during a healing session allows both therapist and client to be more effective. This enhancement is due to the heart chakra’s role as a point of balance for the entire body.
Chakra Levels
The seven major chakras each correspond to different levels of existence. The first three chakras are the most basic, primarily corresponding with the gross, physical world. It is within chakras associated with the physical plane, where the majority of society operates. Accessed in the astral plane, the fourth chakra (heart chakra) maintains symmetry and balance. The last three chakras bring us to higher, more spiritual realms of consciousness. A hierarchical progression ascends to the crown chakra, considered the height of spiritual enlightenment and attainment. Many aspire to move up this ladder of consciousness to guide their personal development.
When energy flows freely through balanced and open chakras, health and well-being flourish. A blocked or inhibited chakra impacts all levels of existence, affecting the individual’s body, mind and spirit.
First Chakra (Root Chakra)
Muladhara, the first chakra, is the root of our being, and is responsible for our physical existence.
• Color = fiery red
• Element = earth
• Sense = smell
• Body Parts = spinal column, bone, teeth and nails
• Glands = adrenal glands
• Location = base of the coccyx
The root chakra provides life force to the adrenal glands, which controls our fight or flight response. Energy from this chakra is also responsible for maintaining the nervous and circulatory systems. Physical symptoms that can emerge when this chakra is blocked include; constipation, hemorrhoids, obesity, sciatica, arthritis, knee trouble, anorexia and suicidal tendencies.
The first chakra is concerned with survival, keeping us rooted in the present moment, and heightening our awareness of possible threats to our existence. The primary role of the root chakra centers on the protective nature of our sense of smell, as it alerts us to anything noxious or toxic.
The first chakra is a slow vibrating chakra. The sound it resonates with is similar to the hum of a motor or the deep buzzing of a bumblebee. The root chakra’s will to live embodies the spirit of vitality, enthusiasm and joy.
Second Chakra (Sacral Center)
Svadhisthana, the second chakra, is referred to as the seat of sex, passion and the water world.
• Color = orange
• Element = water
• Sense = taste
• Body Parts = pelvic girdle, reproductive organs, kidneys, bladder, blood, lymph, digestive fluid and semen
• Glands = ovaries, prostate and testicles
• Location = located about 2 inches below the navel
The second chakra represents the life force of reproductive organs and their related hormones. During gestation, the second chakra helps feed the developing fetus its own life energy. The sacral center also fosters emotional expression. An opening of this chakra is joined by an increased receptivity to the emotional and sensual aspects of life.
The sacral center is related to deep breathing, and according to Chinese medicine, is governed by the kidneys. Blockage or dysfunction of this chakra can result in illnesses related to the kidneys, bladder, sex organs and the lower back.
Third Chakra (Solar Plexus)
Manipura, the third chakra, is tied to power, mastery and the ego. Often referred to as the navel center, the terms spleen, stomach and liver chakra are also occasionally referenced.
• Color = yellow to gold
• Element = fire
• Sense = smell
• Body Parts = lower back, abdomen, digestive system, stomach, liver, spleen and gallbladder
• Glands = pancreas and liver (because of their gland-like properties and functions)
• Location = 8th thoracic vertebrae, about 2 inches above the navel
The third chakra relates to the digestive organs. Dysfunction of this chakra can lead to digestive imbalances, ulcers, diabetes, hypoglycemia, liver problems and cholesterol disorders.
Anger and violence are also attributed to this chakra. The inability to express passion creates pent up frustration, which evolves into anger. This power center houses assertion and strength, propelling us to accomplish what we set forth to do.
Fourth Chakra (Heart Center)
Anahata, the fourth chakra, is based on devotion, selflessness and awakening to unity.
• Color = green, pink and gold
• Element = air
• Sense = touch
• Body Part = heart, lungs, arms and hands
• Glands = thymus gland
• Location = 1st thoracic vertebrae
The central theme of the heart chakra is love, particularly compassion and unconditional devotion. Congestion within this chakra can be indicative of heart disease, high blood pressure, asthma and lung disease.
Healing work originates from the fourth chakra. This chakra opens us to the concept of unity of all things and all people. As the center point of seven chakras, the fourth represents balance between physical and non-physical existence. Development of consciousness by progressing from the third to fourth chakra often accompanies a crisis. This major transformation from lower, self-oriented chakras, to higher, unity-based chakras, underlies the escalation from a selfish ego to spiritual guidance. The fourth chakra’s deeper, higher meaning and connectedness of all things creates the basis for a balanced and healthful existence.
Fifth Chakra (Throat Center)
Vishuddha, the fifth chakra, is rooted in communication and the expression of oneself in the world.
• Color = pale blue, greenish blue and silver
• Element = ether
• Sense = hearing
• Body Parts = larynx, neck, shoulders, arms and ears
• Glands = thyroid and parathyroid
• Location = 3rd cervical vertebrae
The fifth chakra is closely associated with speech, sound and hearing. Problems related to the throat chakra include disorders of the thyroid and parathyroid, stiff neck, hearing impairments, tinnitus, colds, tonsillitis, laryngitis and tumors/cancer of the larynx. Blockages in this chakra may occur in conjunction with difficulty in self-expression and communicating one’s true inner feelings.
Sixth Chakra (Third Eye)
Ajna, the sixth chakra, rests on the principles of knowledge and wisdom.
• Color = indigo, yellow and violet
• Element = light
• Sense = governs all senses, including extra sensory perception
• Body Parts = eyes, central nervous system and mid-brain
• Glands = pituitary gland
• Location = between the eyebrows
This chakra controls concentration, consciousness, intuition, extra-sensory perception and paranormal experiences. The third eye houses our ability to visualize and comprehend concepts. Energy blockages of this chakra physically manifest in the form of such divergent illnesses as sinus problems, cataracts and major endocrine imbalances.
Seventh Chakra (Crown Chakra)
Sahasrara, the seventh chakra, is considered to be the gateway to everything beyond the material world.
• Color = violet, white and gold
• Element = thought
• Body Part = cerebral cortex and the entire nervous system
• Gland = pineal gland
• Location = top of the head
The crown chakra is a wheel propelling the search for deep inner truth. The opening of this chakra allows one to enter into the highest state of consciousness. Activation of this center influences the balance between the right and left hemispheres of the brain, facilitating the integration of our physical self with our eternal self. Inhibition of energy flow at the seventh chakra may manifest as a cerebral dysfunction.
Clearing the Chakras
Regular clearing and harmonizing of the chakras cumulatively resolves old issues and memories, resulting in feeling more centered, grounded and energized.
Clearing chakras can be done alone or with a partner. In her book Energy Medicine, Donna Eden recommends spending about three to nine minutes per chakra when performing the following chakra clearing techniques:
1. Lie on your back.
2. Shake the hands to clear any excess energy from them.
3. Beginning with the root chakra, place one or both hands about four inches above the chakra. Make slow counterclockwise circles, slightly less or equal to the width of the body.
4. After completing this counterclockwise motion, shake off the hands and reverse the circling direction.
5. When complete, shake the hands of excess energy.
6. Move up to the next chakra and begin with a counterclockwise direction, as in step 3.
7. Repeat this procedure for each chakra, ending at the crown.
8. Note: At the crown there is a difference in this procedure between men and women.
• Men: Begin clearing with a clockwise motion; end with a counterclockwise motion.
• Women: Begin with a counterclockwise motion; end with a clockwise motion.
As the chakras horizontally traverse the body, energy enters the anterior plane and exits out the posterior. The counterclockwise motion stirs up toxic energies and drives any toxicity out, while the clockwise motion feeds and re-harmonizes to energize that chakra. While performing these circles, add chakra-related colors and visualize chakra clearing/balancing to enhance your work.
In the Integrative Massage: Spirit video offered as a course component by the Institute for Integrative Healthcare Studies, Jenny Wilmer demonstrates balancing and harmonizing neighboring chakras by using guided imagery and chakra colors. This process provides a sense of the chakras feeding one another, evoking gratitude from recipients. Opening, clearing, connecting and increasing the communication among the chakras can be a profound healing experience.
Chakra Integration
The more theories a practitioner integrates into their perception of healing, the greater the opportunity for generating advanced therapeutic prospects. An understanding of the chakra system adds yet another layer of comprehending a client’s complexities. Advanced medical knowledge is not required to apply this simple chakra clearing technique, which can have potentially life changing benefits.
Recommended Study
Healing Energy and Touch, Integrative Massage: Spirit
References:
Angelo, Jack. Hands-on Healing: A Practical Guide to Channeling Your Healing Energies, Healing Arts Press, 1997.
Eden, Donna. Energy Medicine, Tarcher/Putnam Publishers, 1998.
Gerber, Richard. Vibrational Medicine, Third Edition, Bear and Company, 2001.
Krieger, Dolores. Therapeutic Touch Inner Workbook, Bear and Company, 1997.
Napolitano, Ralph. Healing Energy and Touch, Natural Wellness, 2000.
Integrative Massage: Spirit. Writ. Sean Riehl and Jenny Wilmer. Real Bodywork. 2004.
Posted by Nicole at 10:52 AM
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News Report on Massage for Pain |
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A new, national survey conducted by an independent research firm, spotlights massage’s popular opinion rise in therapeutic effectiveness. These poll results are valuable additions to a massage therapist’s promotional material for consumer marketing and education.
Massage Scores For Pain Relief
CBS News
Daniel J. DeNoon (WebMD)
© 2005, WebMD Inc. All rights reserved.
Oct. 26, 2005 - For the treatment of pain, Americans rate massage as highly as medications, a new survey shows.
Conducted by an independent research firm, the annual survey is the ninth commissioned by the American Massage Therapy Association (AMTA).
It shows that one in five U.S. adults got a therapeutic massage in the last year. Three-fourths of them would recommend it to others — one reason for the body therapy's growing popularity.
Among those who actually had a massage in the past year, 28 percent say massage therapy gives them "the greatest relief from pain." Another 28 percent say medication gives them the greatest relief. Chiropractic comes in third at 11 percent, followed by 8 percent who got the most pain relief from physical therapy, 3 percent who said acupuncture was best for their pain, and 1 percent whose pain best responded to biofeedback.
Survey Findings
The survey, conducted by Opinion Research Corp. International in Princeton, N.J., surveyed a national sample of 1,014 U.S. adults. The poll has a margin of error of plus or minus 3 percent. It found that:
• 90 percent of Americans feel massage is good for a person's health.
• 93 percent agree with the statement that massage can be effective for pain relief.
• Use of massage in people age 65 and older has tripled from 4 percent in 1997 to 15 percent in 2005.
• 22 percent of Americans had a massage in the past year; 34 percent had a massage in the last five years.
• 73 percent of those who had a massage would recommend it to a person they know.
• 46 percent of respondents at some time had a massage to relieve pain.
• Among respondents who discussed massage with their health care provider, 57 percent said this health professional strongly recommended massage or encouraged them to get a massage.
Whole-Body Approach To Pain
Massaging sore muscles obviously reduces pain. But massage is really meant as a whole-body approach, says AMTA vice president and licensed massage therapist M.K. Brennan, RN, LMBT.
"One of the things about massage that helps pain is that it goes down to the heart of where people feel their pain," Brennan tells WebMD. "There is the overall sense of well-being one can get from the massage approach. And the stress responses in the body associated with pain, such as elevated cortisol, are reduced through massage."
For these reasons, massage can be used to treat many different kinds of pain, says Tiffany Field, PhD, director of the Touch Research Institute at the University of Miami School of Medicine.
"Basically we have found massage to be effective in chronic pain syndromes in arthritis and diabetes; in depressive disorders such as ones that involve addiction like eating disorders; in chronic fatigue and fibromyalgia and other autoimmune disorders — HIV-associated diseases, too," Field told WebMD in a June 29 interview. "We have looked at the A-to-Z of medical conditions, and we have not found a single condition massage has not been effective for."
Brennan says all trained massage therapists learn the same basic techniques. As they go on to advanced training, massage therapists may specialize in one or more specific kinds of massage. There are more than 200 of these techniques, according to the Massage.com web site.
Qualifications For Therapists
Brennan recommends that a person seeking therapeutic massage look for a well-trained professional. Most states, she says, require that massage therapists be licensed or registered. And the AMTA web site maintains a referral list of massage therapists who meet certain standards:
• Graduate from a minimum 500 in-class-hour massage therapy training program, or
• Pass the National Certification Examination in therapeutic massage and bodywork, or
• Possess a current AMTA-accepted license to practice, and
• Earn continuing education credit, and
• Uphold the AMTA Code of Ethics.
"If you are looking for someone dealing with chronic or acute pain issues, you may want to look for someone who does sports massage, neuromuscular massage therapy, orthopedic massage, or someone who does craniosacral work or uses strain/counterstrain techniques," Brennan says. "But any list like this leaves out some qualified professionals. The best thing to do is to find a qualified massage therapist and talk with him or her about what you want massage for, be it relaxation or pain relief. Then ask what is their experience in addressing that issue."
Brennan says weekly massage is most effective but admits that not everyone has the time or money to get massage therapy that often.
Field, however, has a solution. Though there's no replacement for a qualified massage professional, she recommends that families learn basic massage techniques.
"In our studies, we try with adults to get them two 20-minute massages a week," she says. "With kids, we use parents as therapists so they can give their children massages every night, 10 minutes before bedtime. We say this because most of the children in our studies have chronic illnesses and can really benefit from a daily dose of massage."
Sources: 2005 Massage Therapy Consumer Survey, Opinion Research Corp. International, Princeton, N.J., conducted Aug. 11-14, 2005. M.K. Brennan, RN, LMBT, vice president, American Massage Therapy Association. Tiffany Field, PhD, director, Touch Research Institute, University of Miami School of Medicine.
Reviewed by Louise Chang, MD
Posted by Nicole at 10:42 AM
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