Massage Professionals Article Archive

by Nicole Cutler, L.Ac.

Similar to the hygienic ritual required of surgeons, massage therapists find themselves washing their hands repeatedly throughout the day. With the rising popularity of hand sanitizers, some therapists are opting to rub an alcohol-based gel between their hands in lieu of scrubbing with soap and water. While hand sanitizers have revolutionized how we practice infection control, it may not always be the best choice for massage therapists.

Bodyworkers' hands function as their primary tools. Because their tools are reused on each and every client, keeping their hands free of pathogens is a prerequisite to being a responsible therapist. Bodyworkers must wash their hands:

· Before and after eating
· Before and after using the restroom
· Before and after each interaction with a client

That adds up to a significant amount of time at the sink as well as consumption of a lot of soap and water. In an attempt to minimize the cost and time of frequent hand washing, some therapists are choosing a quick spritz of hand sanitizer instead. Before choosing one method of hand cleansing over the other, make sure you know why washing with soap and water remains the standard procedure.

Hand Sanitizer Pros and Cons
Alcohol kills most pathogens. Thus, hand sanitizer's high alcohol content will eliminate many types of bacteria and viruses. Alcohol has even proven effective against some dangerous forms of bacteria, like methicillin-resistant staphylococcus aureus (MRSA), which can cause the deadly and frightening flesh-eating bacteria.

Hand sanitizer is especially convenient due to its ease-of-use, portability and non-reliance on water. However, many are not aware of its limitations:

· Hand sanitizer must have a minimum of 60 percent alcohol concentration to be effective. Some discount sanitizers and do-it-yourself preparations contain a lower concentration of alcohol. According to Scott Reynolds, a specialist in infection control at the James H. Quillen Veterans Affairs Medical Center in Mountain Home, TN, hand sanitizer with an insufficient concentration of alcohol appears to mobilize bacteria, spreading them around the hand instead of killing them.

· At least a dime-sized dollop should be scrubbed all over the hands for 30 seconds. If the sanitizer dries in less time, one likely did not use enough and should repeat the process.

· Any breaks in the skin (including hangnails) can be aggravated by alcohol-based hand sanitizer with burning, itching or rash development.

· While non-alcohol sanitizers are available, claims of their effectiveness are not as reliable as the alcohol-based gels.

· Hand sanitizers do not effectively clean the hands when they are exposed to bodily fluids, especially blood or fecal matter.

· Some individuals are sensitive to alcohol and will develop contact dermatitis from hand sanitizers.

Soap and Water
An integral element to any massage therapist's routine, washing with soap and water remains the best way to cleanse hands of dirt, germs and other harmful substances. Just like hand sanitizers, hand washing also has demonstrated the ability to prevent the spread of MRSA. However, the following steps must be adhered to for optimal hand washing effectiveness:

· Use warm water - not cold.

· Use soap and work it into a thick lather. Research shows that both regular and anti-bacterial soaps are equally effective.

· Rub hands with lather for at least 30 seconds covering every surface, including fingertips, beneath the nails and the base of the wrists.

· Rinse hands thoroughly.

· Dry hands with a towel.

Soap is an emulsifying agent, which means it is capable of dispersing oil in water. When people wash their hands, dirt and germs trapped in the natural oils of the skin are lifted and suspended in water. Body fluids or a massage lubricant could easily trap pathogens on a therapist's hands. Thus, the old fashioned approach of hand washing is preferred by most health professionals because it physically removes such substances.

When it comes to efficiency, there is actually very little time difference between properly cleansing the hands with hand sanitizers vs. soap and water washing. Since half a minute is required for either cleansing method, only hand washing's requirement of water (for lathering and rinsing) and a towel (for drying) make hand sanitizers more "convenient." On the other hand, soap and water is better at removing bodily fluids from the hands than hand sanitizer.

At first thought, bodyworkers may think that hand sanitizers save them time during their requisite hand cleansing. However, further investigation shows that this assumption is not accurate. In addition, hand sanitizers may kill most types of bacteria and viruses but they are not sufficient for removing body fluids from the hands. Thus, the old-fashioned approach using water, soap and a towel remains the preferred way for massage therapists to achieve clean, hygienic hands.

References:

http://biology.about.com/od/microbiology/a/handsanitizers.htm, Hand Sanitizers vs. Soap and Water, Regina Bailey, Retrieved November 21, 2009, about.com, 2009.

http://public-healthcare-issues.suite101.com/article.cfm/soap_vs_hand_sanitizer_which_kills_germs_best, Soap vs. Hand Sanitizer: Which Kills Germs Best, Tammie Burak, Retrieved November 21, 2009, Suite101.net, November 2009.

http://safety.lovetoknow.com/Hand_Sanitizer_Dangers, Hand Sanitizer Dangers, Retrieved November 21, 2009, LoveToKnow Corp., 2009.
http://www.massagemag.com/News/massage-news.php?id=6133, Handwashing Combats MRSA, Retrieved November 22, 2009, Massage Magazine, 2009.

http://www.nytimes.com/2006/03/21/health/21cons.html, Hand Sanitizers, Good or Bad? , Deborah Franklin, Retrieved November 21, 2009, The New York Times Company, March 2006.

http://www.wisegeek.com/how-does-hand-sanitizer-work.htm, How Does Hand Sanitizer Work?, Tricia Ellis-Christensen, Retrieved November 22, Conjecture Corporation, 2009.

by Nicole Cutler, L.Ac.

As healthcare professionals who navigate through their medium using touch, massage therapists are susceptible to the strengths and weaknesses of their own palpatory skills. A practitioner with a sensitive and responsive touch can adjust his or her applications accordingly, while one lacking these skills can make a faulty assessment, deliver a mediocre massage or even inflict accidental pain. While developing the ability to interpret what is felt underneath one's hands is a valued massage therapy skill, it is also one of the more obscure concepts to teach.

Although it is of major importance, memorizing a map of human anatomical structures is not enough preparation for learning how and where to apply bodywork. Because people come in all shapes and sizes, you can not simply superimpose any given diagram of anatomical landmarks on a client to locate the structure or muscle group being searched for. Most experts agree that there are several components to mastering palpation - including combining the imaginative mind and drawing from the therapist's knowledge of anatomy.

According to Leon Chaitow, ND, DO, "Palpation cannot be learned by reading or listening; it can only be learned by palpation." He also says that an open mind is vital to the task of learning palpatory literacy - practitioners with the greatest degree of rigidity, in terms of their training, often have the hardest time allowing themselves to feel new feelings and sense new sensations.

In accordance to John Upledger, DO, OMM, the developer of CranioSacral Therapy, "Learning to trust your hands is not an easy task. You must learn to shut off your conscious, critical mind while you palpate for subtle changes in the body you are examining. You must adopt an attitude so that you may temporarily accept without question those perceptions which come into your brain from your hands. After you have developed your palpatory skill, you can criticize what you have felt with your hands. If you criticize before you learn to palpate, you will never learn to palpate."

Each tissue has a different tactile sensation. Since a practitioner's fingers can literally only contact the skin, sensing the structures underneath is akin to trying to recognize types of food while blindfolded and wearing winter gloves. Below are some exercises devised by Mary Ann Foster, massage therapist and movement educator, to help develop a bodyworker's palpation skills of skin, superficial fascia, deep fascia, tendons, ligaments and muscle.

To explore the skin and superficial fascia:

1. Lightly stretch the top layer of skin in one direction without compressing or sliding it. Release and sense how it recoils.

2. Press the skin into the superficial fascia, which should feel thick, spongy and springy. Gently explore kneading this layer, much like a cat would paw a pillow.

3. Lift and roll the skin and superficial fascia in several areas, noting variances in their thickness.

To explore the deep fascia:

4. Compress the skin and superficial fascia, then slide them over the deep fascia underneath, which feels slick, like slipping on ice.

5. Palpate deep fascia in various parts of the body, noticing variances in texture and elasticity.

6. Contrast moving across deep fascia over bone and muscle.

7. Pin the deep fascia against its underlying muscle or bone. Stretch it to end range and hold until you feel it yield, then stretch a bit further.

To explore tendons and ligaments:

8. Palpate the tendons above the wrist, which will feel like slippery cords. Follow the tendon up the arm, noting what the transition from tendon to muscle feels like. One is fibrous and ropy, the other meaty and substantial.

9. Palpate the patellar tendon above the knee. Differentiate muscle from tendon by contracting and relaxing the quadriceps as you palpate.

10. Run your finger across collateral ligaments of the knee or wrist. Notice how the ligaments feel different from tendons.

To explore muscle tissue:

11. With a partner, explore tracing different muscles. Follow along the fibers and fascicles from one end of a limb to the other.

12. Contrast palpating muscles along and across the fibers.

13. Explore squeezing round muscles like the deltoid and triceps, pressing into muscles over bones like the infraspinatus, and lifting the edges of flat muscles like the latissimus dorsi.

Although cognitive learning is essential, the ability to listen to what our hands are telling us is a vital component of delivering an effective massage. By developing palpation skills and carefully listening to a client's tissue with attentive hands, bodyworkers can transform into masters of their profession. As thinking and sensing merge together, the art and science of palpation takes full form - leading to a stronger and more therapeutic connection for both practitioner and client.

Recommended Study:
Anatomy Review for Professionals
Cranial-Sacral Fundamentals

References:

Adkins, Garry, NCTMB, Improving Palpation, Massage Today, May 2006.

Benjamin, Ben, PhD, Let's Talk About Palpation, Massage Today, February 2001.

Foster, Mary Ann, Listening Hands and Tissue Palpation, Massage & Bodywork, August/September 2006.

by Linda Fehrs, LMT

Shingles is a viral infection causing a painful rash. Known also as herpes zoster, it is caused by the varicella-zoster virus, which is also responsible for chickenpox. While chickenpox is, for the most part, considered a children's disease, shingles reserves itself for those quite a bit older, usually (but not limited to) people over 50.

Anyone who has had chickenpox is susceptible to getting shingles. Overall, only about 20 percent of those who contract chickenpox as children will eventually get shingles. The majority of those who develop shingles are adults over 50, the incidence increasing as one gets older, but there have been some children and even newborn infants who have been diagnosed with shingles. It is thought to follow a lessening of effectiveness in the immune system.

Causes
After having chickenpox, the virus causing it may not be completely eliminated by the immune system, remaining dormant in nerve cell bodies. Usually this causes no problems. Many years later, when the body's immune system become less effective, or in persons with compromised immune systems (such as those with HIV/AIDS, organ transplant patients or those receiving cancer treatment), the virus can reactivate in the form of shingles. It will erupt along the affected nerve and produce blistery lesions on the body. No one know exactly why this happens, but it seems to be triggered when the immune system becomes weakened as a result of stress, fatigue, certain medications, medical treatments or other illness.

Symptoms
The first symptoms of shingles are not always obvious. There may be a general malaise combined with pain, burning, tingling, numbness (paresthesia) or extreme sensitivity (hyperesthesia) along certain parts of the body. The sufferer can also have swollen lymph nodes, an upset stomach and chills. A case of shingles can, at first, be misdiagnosed as pain from an ulcer, heart attack, migraine headaches, appendicitis or even a lower back problem, which is why someone in the very early stages might come to a massage therapist for relief in the first place. In rare cases a person may have pain, but no rash. This form of shingles is more difficult to diagnose.

The first symptoms may last anywhere from a few days to a few weeks before being followed by the definitive rash, evolving into tiny clear blisters on a red base, along with a slight fever and fatigue. The rash will usually appear on the trunk of the body, the neck or back depending on the nerves affected. The pattern of the rash follows dermatome lines, areas of the body innervated by individual spinal nerves. Most commonly affected nerves are those emanating from T3, T4 as well as the ophthalmic branch of the trigeminal nerve. The stripe or belt-like rash makes it fairly distinct visually from contact dermatitis, which may have irregular patterns or cover wider areas of skin.

Note: If shingles appears on the face, especially near the eyes, it needs prompt medical attention, even if the outbreak seems mild. If left untreated it can scar the cornea and lead to blindness.

Post Shingles Pain
About twenty percent of those who get shingles also experience post-shingle pain, or post-herpetic neuralgia (PHN). PHN is diagnosed when the pain lasts a month or longer after the blisters have healed. In some people, PHN may last for six months. For others it may last up to a year.

There is no clear-cut cause of PHN, but it may be brought about by an autoimmune disorder, or perhaps pain-inhibiting connections that are destroyed by infection. Without a definitive cause, effective treatment for the pain is hard to come by.

Prevention and Treatment
Not everyone who has had chickenpox will get shingles. One of the best ways to lessen your chances is to keep your immune system strong.

There are two vaccines on the market that may help prevent shingles - the chickenpox (varicella) vaccine and the shingles (varicella zoster) vaccine. The chickenpox vaccine was developed in Japan in 1974, but only became available in the United States in 1995, and is now a routine childhood immunization. The shingles vaccine is recommended for adults aged 60 and older, and is given as a single injection. Neither vaccine guarantees that you won't get shingles, but it should lessen the severity of an outbreak and reduce the length of time you have it. It also reduces the risk of postherpetic neuralgia.

Benefits of Acupressure
During an outbreak of shingles, the pain is usually so intense that the last thing a person will want is for a massage therapist or anyone else to touch them. An alternative to traditional Western style massage is acupressure. Acupressure, which uses the theory of Traditional Chinese Medicine (TCM), considers shingles to be caused by a combination of both excess and deficiency in the body. It is also explained by the presence of pathogenic damp, heat and wind. Among other things, a practitioner of TCM would look at where the lesions are and how they manifest on the body in determining which points to treat. Working on the Triple Heater (TH) and Spleen (SP) meridians can help to boost the immune system. Dampness in the body can be treated using SP9 and SP6, while SP10 and LI11 (Large Intestine) can be used to cool the blood and treat skin problems.

The massage therapist is cautioned to keep clear of any rash suspected to be shingles. While shingles itself it is not considered contagious, a person who comes in contact with the fluid from a blister can contract chickenpox if they have not had it before or not been vaccinated against it.

Home Remedies Ease Symptoms
Treatment for shingles is mainly palliative. The doctor may prescribe such things as corticosteroids, narcotic pain relievers or other prescription drugs to ease the pain and itching, but with mild to moderate outbreaks there are also a few simple things you can do at home to ease the symptoms.

· Take an anti-inflammatory drug, such as aspirin or ibuprophen.
· Taking an antihistamine such as diphenhydramine (Benadryl for example) or using a non-prescription ointment containing at least one percent hydrocortisone can reduce the itching.
· Use cool water compresses to help soothe the pain and reduce the chance of skin infection. Adding 1 ounce of vinegar to 32 ounces of water will help its effectiveness.
· Topical lotions containing calamine may offer comfort and can be used on the rash and blisters.
· Take a cool bath. Add a small amount of baking soda, uncooked oatmeal or colloidal oatmeal (Aveeno) to the water to relieve itching and pain.

In most people, shingles will last anywhere from three to five weeks. The good news is that most people will only have one outbreak of this painful condition. Only about 10 percent of those who get shingles will develop it a second time.

Perhaps the best way a massage therapist can help with shingles is in the area of prevention. Stress has been shown to be one of the major factors in getting shingles. Massage can help reduce overall stress as well as help keep the immune system in good working order. Getting a regular massage may also help to reduce the symptoms by making the body better able to fight off the virus if it does flare up.

Recommended Study:
Advanced Anatomy & Pathology
Infectious Disease: HIV/AIDS
Shiatsu Anma Therapy

Resources:

Marley, Joyce. "Acupuncture Treatment of Shingles." 24 April 2007. Acupuncture Services of Central New York. 3 Sep 2009 http://www.acupuncture-services.com/health-az/shingles/acupuncture-treatment-for-shingles.

Mayo Clinic Staff, "Shingles." MayoClinic.com. 21 May 2008. Mayo Clinic, Mayo Foundation for Medical Education and Research. 3 Sep 2009 http://www.mayoclinic.com/health/shingles/DS00098.

"Shingles - Symptoms, Treatment and Prevention." Health Encyclopedia - Diseases and Conditions. 1 April 2009. The HealthCentralNetwork, Inc. 3 Sep 2009 http://www.healthscout.com/ency/68/138/main.html.

Werner, Ruth. A Massage Therapist's Guide to Pathology. 4th ed.. Baltimore : Lippincott Williams & Wilkins, 2009. Print.

Werner, Ruth. "Comforting Clients with Postherpetic Neuralgia." massagetherapy.com. July 2006. Associated Bodywork and Massage Professionals. 3 Sep 2009 http://www.massagetherapy.com/articles/index.php/article_id/1194/Comforting-Clients-with-Postherpetic-Neuralgia.

by Nicole Cutler, L.Ac.

A knee that goes beyond its normal limits will typically illicit pain, and could possibly set up the joint for a future of subsequently related injuries. A client with a current knee hyperextension or a history of such a problem requires that his or her attending massage therapist be aware of several anatomical and physiological facts. When addressing a hyperextended knee, bodyworkers are most useful to their clients when they know what type of activities could exacerbate the knee's instability and which muscles benefit most from circulatory massage.

Most people are aware of how easily the knee can be injured from twisting. However, fewer realize that straightening the knee beyond a straight line is another type of misalignment that can pave the way for more serious knee injuries. Over time, knee hyperextension can:

· Strain or tear ligaments

· Degenerate local cartilage (including the meniscus)

· Cause arthritis of the knee joint or kneecap

· Fracture the tibia

In many of the body's joints, ligaments and tendons play a major role in preventing excessive motion. If those tissues become too loose, the joint can move in ways that cause damage or set the stage for injury. Known as a hypermobile joint, the knee is particularly vulnerable to this problem. Experts agree that keeping the knee stable requires balancing the knee-extending strength of the quadriceps with the knee-flexing strength of the hamstrings and other knee-flexing muscles.

Anatomy
Normally, the ligaments and tendons surrounding the knee pull taut and stop the femur and tibia at the point where they lie directly in line with each other. The tissues at risk of being overstretched causing knee hyperextension include:

· The cruciate ligaments deep inside the knee

· The medial and lateral collateral ligaments on the inner and outer surfaces of the knee

· The popliteal ligaments, which cross the back of the knee

· The hamstring tendons coming down from the back of the thigh

· The gastrocnemius tendons coming up from the calf

According to Tressa Gorman Crehan, associate director of the University at Buffalo dance department and a professor of anatomy and kinesiology for dancers, hyperextension "can cause trauma to the knee capsule and, eventually, depending on the severity, can cause tearing or strain on the ligaments in the back of the knee." The anterior cruciate ligament, which helps prevent the tibia from moving too far forward in relation to the femur, is particularly susceptible to injury.

Repeated hyperextension of the knee places high levels of stress on the lower leg as well, and can lead to shin splints. In more extreme cases, it can result in tibial fractures. Knee hyperextension can also tilt the top of the pelvis forward, which can stress the hip joints, overarch the lower back and disturb posture all the way up to the head.

Causes and Exacerbation
Hyperextended knees can develop at an early age, lending credence to the belief that some are genetically more prone than others. However, this over-straightening of the knee is a common result of posture and movement anomalies from certain types of activities, such as from volleyball, dance, gymnastics, soccer or yoga.

Because a tight soleus can pull the tibia back, activities that tighten this muscle may encourage knee hyperextension. Women who wear high heels are particularly prone to this misalignment because of the tension the foot's angle places on the soleus. Massage therapists working with knee hyperextension can work to enhance circulation and lengthen the soleus to reduce this vulnerability.

Several ballet forms and yoga poses encourage participants to "lock" their knees, a position that strains the knee joint's extension capacity. A "locked" knee relies on shortened quadriceps muscles. Thus, bodyworkers can provide relief by kneading this large muscle group to achieve quadriceps relaxation.

Bodyworkers can help those with knee hyperextension problems by advising clients to avoid exacerbating activities and by working on the tightened muscles encouraging the misalignment. Strengthening the thigh musculature, minimizing stress on the soleus, massaging the soleus, quadriceps and other local tightened muscles as well as avoiding locking the knees, can all help prevent future pathologies arising from chronic hyperextension of the knee.

Recommended Study:
Anatomy Review for Professionals
Sports Massage
Swedish Massage for Professionals

References:

Cole, Roger, Please Your Knees, Yoga Journal, February 2009; 101-04.

http://www.dance-teacher.com/sections/health/122, Hyperextension and Bowleggedness, Michelle Velucci, Retrieved February 15, 2009, DanceTeacher, MacFadden Performing Arts Media, 2009.

http://www.yogajournal.com/practice/997, The Hyperextended Knee, Julie Gudmestad, Retrieved February 15, 2009, Yoga Journal, 2009.

by Nicole Cutler, L.Ac.

Infertility affects millions of couples around the world. Although there are a wide range of physiological reasons for infertility, medical treatment to foster conception can have many side effects and is typically very expensive. Because of its effectiveness, safety and relative low cost, Shiatsu is a favorable option for a growing number of men and women hoping to expand their family.

What Is Infertility?
Affecting 10 to 15 percent of American couples, most experts define infertility as not being able to get pregnant after at least one year of unprotected, sexual intercourse. Women who are able to get pregnant but then have repeat miscarriages are also considered infertile. Infertility may be due to a single cause in a man or woman, or a combination of factors that prevents a pregnancy from occurring or continuing.

A result of a complex sequence of events, the following four phases must occur for a woman to become pregnant:

1. Ovulation - A woman must release an egg from one of her ovaries.

2. Egg Travel - The egg must travel through a fallopian tube toward the woman's uterus.

3. Fertilization - A man's sperm must find and fertilize the egg.

4. Implantation - The fertilized egg must attach to the inside of the uterus.

Infertility can result from problems that interfere with any of these steps.

Traditional Chinese Medicine
Traditional Chinese medicine (TCM) considers infertility to be a reflection of an energetic blockage or imbalance. With the goal of unblocking and rebalancing the affected individual's energy flow, TCM treatments have demonstrated effectiveness in improving male and female reproductive function.

In the traditional literature of TCM, fertility is closely related to the health of the following channels: Kidney, Liver, Spleen, Governing Vessel and Conception Vessel. More specifically, the following TCM patterns are known to interfere with conception:

· A deficiency in the Kidney and Liver energetic organs disrupts the endocrine system, resulting in a hormonal imbalance that can prevent ovulation or implantation.

· Stagnant energy and/or blood in any of the five channels (but especially in the Governing and Conception Vessels) can easily prohibit ovulation, egg travel, fertilization or implantation.

· Besides hampering sperm and egg production, damp heat in the Liver or Conception Vessel channels causes inflammation that can irritate the delicate tissues needed for reproduction - thus impeding their function.

According to experts, stimulating key points encourages the energy within these channels to flow in a smooth, healthy fashion - thus improving chances for conception.

Shiatsu
Based on TCM theory, Shiatsu is an ideal, non-invasive application to improve circulation in the Kidney, Liver, Spleen, Governing Vessel and Conception Vessel channels. After Shiatsu practitioners evaluate their clients and conclude which TCM pattern is most likely responsible for infertility, they can focus on stimulating the following points:

· Kidney and liver deficiency - Kidney 3, Conception Vessel 4 and Spleen 6

· Stagnant energy or blood - Liver 3, Spleen 8, Spleen 10, Spleen 6

· Damp heat inflammation - Spleen 6, Spleen 9, Stomach 40, Gallbladder 34

While carefully directed Shiatsu treatments can help resolve an imbalance that is prohibiting conception, practitioners must remember which points to steer clear of on women who might be pregnant. On pregnant (or potentially pregnant) women, avoid:

· Points on the sacrum and lower abdomen
· Spleen 6
· Large Intestine 4

Of particular interest is Spleen 6 - which is advised in all stages of fertility treatment, yet contraindicated during pregnancy. Thus, whenever working with clients trying to conceive (whether they are having trouble or not), Shiatsu therapists must know if there is any chance of a pregnancy.

When a couple's attempts to procreate have been unsuccessful, they are likely to explore their options within allopathic and alternative medical practices. Massage therapists with an understanding of reproductive health, TCM pattern differentiation and Shiatsu can help balance their clients' energetic channels to overcome their fertility challenges.

Recommended Study:
Advanced Anatomy and Physiology
Prenatal Massage Fundamentals
Shiatsu Anma Therapy

References:

http://www.acufinder.com/Acupuncture+Information/Detail/Acupuncture+Points+to+Avoid+During+Pregnancy, Acupuncture Points to Avoid During Pregnancy, Diane Joswick, L.Ac., MTOM, Retrieved April 12, 2009, Acufinder.com, 2009.

http://www.altmd.com/Articles/TCM-for-Infertility, Traditional Chinese Medicine (TCM) for Infertility, Retrieved April 11, 2009, altMD LLC, 2009.

http://www.associatedcontent.com/article/150987/acupuncture_acupressure_and_massage_pg2.html?cat=68, Acupuncture, Acupressure, and Massage All Help Infertility, Lea Barton, Retrieved April 11, 2009, Associated Content, Inc., 2009.

http://www.mayoclinic.com/health/infertility/ds00310, Infertility, Retrieved April, 11, 2009, Mayo Foundation for Medical Education and Research, 2009.

http://www.womenshealth.gov/faq/infertility.cfm#a, Infertility, Retrieved April 11, 2009, US Department of Health and Human Services, 2009.

Jin, Yu, MD, Handbook of Obstetrics & Gynecology in Chinese Medicine - An Integrated Approach, Eastland Press, Seattle, WA, 1998; 69-85.

Maciocia, Giovanni, The Foundations of Chinese Medicine, Churchill Livingstone, New York, NY, 1989; 223.