Download Instructor Biography - American Massage Therapy Association

AMTA NATIONAL CONVENTION
October 19-22, 2011
Pelvic Stabilization
“The Key to Structural Integration”
The “Cutting Edge” in Orthopedic Massage
and Pain Management Training
James Waslaski, LMT
Author and International Lecturer www.orthomassage.net
A Unique Multidisciplinary Approach to
Chronic Pain and Sports Injuries
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Instructor Biography
James Waslaski, LMT
James Waslaski worked 20 years as a paramedic, and in a trauma center, while teaching emergency medical courses, and studied pre‐med in college prior to his massage training in Florida. James served as Professional Relations Chair for Florida and received the 1998 FSMTA outstanding state service award. He also served as AMTA Sports Massage Education Council Chair from 1993‐1997 receiving the AMTA National Officer Award. He is a self published author and international lecturer who has pioneered deep pain free orthopedic massage, pain management, sports injury, and sports enhancement treatments. His unique structural and multidisciplinary bodywork approach has been taught throughout the United States, Ireland, London, Scotland, Canada, Costa Rica, Puerto Rico, Greece, Australia, and the Caribbean. His seminars are being requested now in New Zealand, South Africa, Amsterdam, Holland, Italy, Egypt, Russia, and Dubai. James was the 1999 recipient of the FSMTA International Achievement Award. James has presented at state, national and international massage conventions, as well as chiropractic conventions, osteopathic conventions, the college of sports medicine, the University of South Wales, the Olympic training center in Australia, and the osteopathic and manipulative massage therapy convention in London. His audience consists of Massage Therapists, Physical Therapists, Occupational Therapists, Athletic Trainers, Osteopaths, Chiropractors, Nurses, and Physicians. He has worked with collegiate, professional and Olympic athletes, including the 1996 Olympic Games and the New York Yankees, and has published articles, books, manuals, and a series of DVDs on sports injuries, chronic pain, and complicated orthopedic conditions. James has also produced a powerful motivational audio series, highlighting success strategies of leaders in the wellness industry, to help guide massage therapists to their true spiritual blueprint for success. James book has been released since September 30, 2011 , Clinical Massage Therapy­A structural Approach to Pain Management with hopes to bridge the gap between all health care providers throughout the world. James was inducted in 2008 into The Massage Hall of Fame. www.orthomassage.net
The Center for Pain Management PO Box 822141 North Richland Hills, Texas 76182 (800)643­5543 NCBTMB APPROVED PROVIDOR
No. 049978-00
CE Broker – 50-1075
Copyright © 1996-2011 James Waslaski. All rights reserved. No part of this handout may be reproduced, in
any manner whatsoever, without prior written permission of James Waslaski.
This handout does not offer medical advice and is not intended as a replacement for appropriate health care
and treatment. For such advice consult a licensed physician. The author shall not be liable or responsible
for any loss, injury, or damage allegedly arising from information in this manual.
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The Twelve-Step Approach
Assessment, Treatment, and Rehabilitation
It is vital that the following twelve steps are not used as a “cookbook” approach to therapy. Each step is
dependent on the client’s individual response to the preceding step. You do not progress to the next step
until each area of tension is appropriately released. It is critical to apply specific work to release specific
structures and also critical to differentiate between soft tissue problems due to myofascial restrictions,
versus trigger point tension, or strained muscle fibers since the specific release techniques for each will
vary greatly. The goal is to maintain structure, posture, movement and balance. As you put this twelvestep program into use, you will realize that soft tissue balancing is the missing link to long term pain free
musculoskeletal alignment.
*Precaution note- do not work on a client with a recent injury (acute condition).
Twelve Steps:
1. Client History
2. Assess Active Range of Motion
3. Assess Passive Range of Motion
4. Assess Resisted Range of Motion
5. Area Preparation
6. Myofascial Release
7. Trigger Point Therapy
8. Cross Fiber or Multidirectional Friction
9. Pain Free Movement
10. Eccentric Scar Tissue Alignment (Pain Free)
11. Stretching (Pain Free)
12. Strengthening (Pain Free)
Pelvic Stabilization
Pelvic stabilization techniques should be a routine part of a massage protocol, prior to dealing with
chronic pain in any other area of the body. The goal will be to assure that each client achieves a balance
between five basic muscle groups. This means each muscle group has the ability to release to the full
range of motion on both the left and the right sides. Deep pelvic contractions can cause distortions
throughout the entire body. This is why pelvic stabilization is the key to structural balance.
*Note- it is imperative to place a bolster under the client’s hips or use a Body Cushion, when prone,
during pelvic stabilization. This allows the ilium to rotate posteriorly and helps lengthen the entire spinal
column to open up facet joints and help relieve vertebral compression of the spine.
*Precautions: Be gentle and non-aggressive with your work. Assume the client could have
“conditions” including bulging or herniated discs, sacroiliac (SI) joint pain or dysfunction, etc.
High velocity chiropractic manipulation to the SI joint on someone with a sprain or a tear at the SI
joint is not advised.
Client History: Ask the client when, where and how the problem began. Have them describe the area of
pain and what makes it better or worse.
Assess Active Range of Motion (ROM): As you work through the specific order for releasing the muscle
groups ask the client to perform each of the six primary single plane movements of the hip joint, with zero
discomfort. Determine if the range of motion is normal. If the ROM is less than average, identify which
muscle groups are restricted and therefore preventing normal movement.
Hip Joint Single Plane Movements:
Flexion 90° (knee extended)
Primary Muscles:
Iliacus, Psoas
Rectus Femoris
Sartorius
Tensor Fasciae Latae
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Flexion 120° (knee flexed)
Primary Muscles:
Iliacus
Psoas
Rectus Femoris
Sartorius
Tensor Fasciae Latae
Extension 35°- 45°
Primary Muscles:
Biceps Femoris (long head)
Gluteus Maximus
Semimembranosus
Semitendinosus
Medial/ Internal Rotation 30°- 45°
Lateral/ External Rotation 60°
Primary Muscles:
Adductor Brevis
Adductor Longus, Magnus
Gluteus Medius
Gluteus Minimus, Tensor Fascia Latae
Primary Muscles:
Gemellus Inferior, Superior
Gluteus Maximus
Obturator Externus, Internus
Piriformis, Quadratus Femoris, Sartorius
Adduction 30°
Abduction 45° (pelvis stationary)
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Primary Muscles:
Adductor Brevis
Adductor Longus
Adductor Magnus
Gracilis
Pectineus
Primary Muscles:
Gluteus Maximus
Gluteus Medius
Gluteus Minimus
Sartorius
Tensor Fascia Latae
Assess Passive Range of Motion (ROM): Gently test the end feel of the above movements. All
movements should be soft and leathery except for extension which will feel more ligamentous and abrupt.
Assess Resisted Range of Motion (ROM): The client attempts each of the hip joint single plane
movements while the therapist applies reverse resistance. If the client experiences pain or discomfort, ask
them to point to the specific spot. This is most likely a muscle strain. This area will be worked last.
1. Psoas Major and Iliacus (Iliopsoas)
The psoas major attach to the transverse processes of lumbar vertebrae 1-5 and the intervertebral discs
above each of these vertebrae. The iliacus attach to the iliac fossa. Both insert on the lesser trochanter of
the femur. Together they are called the iliopsoas and they are strong hip flexors and low back stabilizers.
Restricted, dense connective tissue where the iliacus and psoas major join on the inside rim of the iliac
crest can be a major cause of pain in the lower back. Tight psoas major muscles compress the lumbar
spine downward and forward onto the nerve roots causing pain and can also herniate and rupture the
lumbar discs. Tight iliacus muscles can rotate the ilium anteriorly because they are directly attached to the
ilium. Think about the psoas major for lumbar compression, bulging and herniated discs, nerve
compression and excessive lumbar lordosis. Think about iliacus for anterior pelvic tilt and sacroiliac (SI)
joint pain.
Typically, the client’s dominant side will have more anterior ilium rotation, which will also elevate the iliac
crest on that side. This causes stress between the articulation of the sacrum and the ilium, which can
cause sacroiliac (SI) joint pain to occur. The sacrum can be pulled onto the vertebrae, which are then
pulled onto the nerve roots, causing low back pain. Imbalance in these two muscle groups in the pelvis
can affect the entire body and must be corrected first before any other orthopedic massage is performed.
Assess Active Range of Motion (ROM): The client is prone with their knee bent 90°, or less than 90° if
they have tight quadriceps. Ask them to lift their leg up off the table and explain to them this is to be
performed with zero discomfort. Tell them to only lift their leg to where it is comfortable. Normal range of
motion is 35°-45°. If they can not achieve this then the hip flexors; psoas and iliacus are contracted and
tight and need to be released.
Assess Passive Range of Motion (ROM): The client is prone with their knee bent 90°. Place one hand
under their knee. Place the other hand on their hip to stabilize it as the ilium must stay on the table.
Move one of these fingers over the SI joint, inferior of the iliac crest, to assess if the ilium is moving with
extension. The client’s lower leg can rest across your forearm. Gently lift their leg only to the restrictive
barrier, pain free, and assess the end feel of the hip joint. It should feel soft and leathery. If it feels like a
bone on bone end feel, the hip needs joint capsule work.
Assess Passive Psoas ROM
Hip Joint Capsule Work: The joint capsule work is one of James Waslaski’s unique trademark
techniques. An imbalance of the muscles around the hip joint can set up a neuromuscular response
attempting to restore balance. This also creates tension in the joint, which eventually leads to joint
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degeneration and arthritis, as the cartilage wears down. The resultant discomfort also limits range of
motion causing a formation of adhesions in the joint capsule itself. Adhesions in the hip capsule are more
predominant in the anterior capsule due to excessive or prolonged hip flexion. The articulating fascia acts
as “superglue” and limits range of motion in the hip. These deep fascial adhesions however can be
melted much like you would melt jello. The head of the femur can be used as a massage tool to melt the
fascia or “superglue” in the hip joint capsule using very gentle, pain free movements. Heat, pressure, and
gentle stretch facilitates myofascial warming and myofascial release. Perform joint capsule work if any
ROM end feel feels like bone on bone.
The client is supine with one hip flexed 90°, their knee is bent. Having the hip flexed 90° is important, as
this allows the plunging to be performed straight down toward the table, so that the lumbar spine is not
compromised. Place both hands around their thigh. Their lower leg can rest on your forearm, which
becomes a lever to facilitate the stretch. Gently move and rock their leg to make sure they are fully
relaxed. Push down on the thigh gently, so that the femur goes into the hip socket, rotate it into lateral
rotation and then pull it out. Contact, rotate, decompress. This is a “plunging” type of technique, cartilage
on cartilage, to warm and melt the joint capsule adhesions.
Tell the client to visualize the joint capsule “softening, releasing, and letting go”. Ask the client if this is
uncomfortable. It usually is not, as you are taking the pressure off the hip joint by shortening the fascial
adhesions. This must be performed pain free as even minor muscle tension prevents joint capsule work,
as muscles will splint the area in response to discomfort.
Repeat the plunging several times, warming up the fascia inside the hip. Then plunge once into the joint
capsule, make contact, rotate it laterally to the restriction, and then give a deep capsular stretch. Back off
the stretch, return to neutral, and then pull back out of the joint capsule. Watch the ilium; if it moves with
the femur, you are not stretching the joint capsule.
Joint Capsule Plunging
Joint Capsule Lateral Rotation, Stretch
Watch the client’s facial expressions and look for any changes in their breathing to indicate discomfort.
Making your plunges non-synchronized, and stretching the capsule when the client least expects it
prevents them from guarding or “helping” during this work.
Next, repeat this sequence, rotating and stretching the femur medially. On joint capsule work, lateral
rotation usually moves freely on most clients. Performing capsule work laterally first is to gain a sense of
trust with clients who have had a painful iliopsoas or manipulation experience. Medial rotation is usually
more adhesive due to prolonged shortening of lateral hip rotators and this is where your focus of therapy
should be. Plunge and rotate the femur several times, then plunge once into the joint capsule, make
contact, rotate it medially to the restriction, and then give a deep capsular stretch. Back off the stretch,
return to neutral and then pull back out. Repeat this sequence again, if needed. You must rotate the hip
both ways, as there could be multiple adhesions in different directions. Start with lateral rotation. Medial
rotation is usually more adhesive and restricted; therefore work it second.
Iliacus Release: To perform the iliacus release, the client is supine with their hip flexed 90°. Always get
the client’s permission before you treat this area. Use a visual aid, if needed, to explain where you are
going to be working. Lay their bent leg over your leg so their muscles are shortened and completely
relaxed. Palpate the ASIS (anterior superior iliac spine) and to make sure the client is completely relaxed,
perform a positional release by gently moving or rocking their leg. Have the client take a deep breath and
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on their exhale go in using your finger pads, very slowly. Do not go in too far or too fast toward the
psoas. Lead with your little finger, with your hand at a slight angle. Come back to the iliacus and pin the
fascia directly onto the inside of the ilium. Then lift, and lengthen the fascia superior toward the same
shoulder and pin it there (pin and stretch). You want to create an upward traction on the fascia.
Now, while keeping your finger pads on the iliacus, place your other hand under the client’s knee. Help
the client drop their heel down onto the table and allow them to actively drag their heel toward hip
extension. As they engage their extensors (hamstrings and glutes), they inhibit their hip flexors. This is
called reciprocal inhibition. Repeat the above procedure several times, going in a little deeper onto the
iliacus, sweeping, scooping, pinning and stretching the connective tissue upward each time. This will melt
the fascia so you can gently isolate and deactivate any tight bands and trigger points in the iliacus.
*Note- you must continually “check in” with the client, are they guarding? Watch their face, voice tonality,
and breathing. What is their comfort or discomfort level? The iliacus release must be performed pain free.
Iliacus Release Hand Placement
Close-up of Same Hand Placement
Psoas Release: Tight psoas can create compression and rotation of the lumbar spine. The client is in the
same position as the iliacus release. On their exhale, go in using your finger pads, very slowly toward the
psoas, at a 45° toward the spine. To find the psoas have the client attempt to bring their knee toward their
chest. The psoas will “pop” up under your fingers. Gently pin it down with the fingerpads, not the
fingertips, as they can be painful. Give it a gentle stretch by passively moving the client’s hip into
extension. Gently move and rock their knee on your knee toward extension. Repeat this psoas pin and
stretch several times. These are very subtle movements.
Then, go to the end of the table. Grasp the client’s ankle, lean back and give a gentle stretch and traction
to their hip, knee, and ankle for 5 seconds. Release very slowly.
*Precaution note: be cautious when pressing directly downward on the psoas, as there could be
an underlying medical condition. If you ever feel a massive pulsation in this area, consider the
possibility of an aneurysm, or you may be pressing on the wrong structure. Immediately
reposition your hand.
Iliacus and Psoas Stretch: The client is prone with their knee bent 90°. Place one hand under their knee.
Place the other hand on their hip pulling the hip inferiorly and laterally and then stabilize it. The ilium must
stay on the table. The hand on the hip can also determine if the ilium is moving with extension, indicating
a joint capsule problem.
Their lower leg can rest across your forearm. Remind them to do nothing that is uncomfortable. Then,
ask them to gently press their knee into the table with 20% force for 5-10 seconds, as you provide
resistance. They relax, take a deep breath, and on their exhale they lift their leg up, only to where they
are comfortable, while you assist the stretch for about 2 seconds. Keep the leg at this new height, put
your knee under their leg as a restrictive barrier, and repeat this contract-relax, contract-antagonist with active assisted stretching 23 times. Do not stretch past a pain free end feel.
Next, ask the client to actively lift their leg up several times, only to where they are comfortable, for neuromuscular re-education.
*Note- to isolate the psoas, have the client move their leg into 30° abduction and perform the stretch. To isolate the iliacus, have
the client keep their leg adducted (knees closer together) during the stretch.
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Iliacus and Psoas Stretch
Re-assess Active ROM: Reassess the range of motion of the psoas and iliacus. You may need to repeat
the iliacus release and stretch and joint capsule work several times to achieve optimum results.
2. Quadratus Lumborum (QL) and Erector Spinae
The QL originates on the posterior iliac crest and inserts on the 12th rib and the transverse processes
of L1- L4. Its actions are to unilaterally elevate, or “hike” the hip and laterally flex the vertebral
column. The QL are usually dominant side tight with the other side over stretched. The erector
spinae is a group of muscles that run from the sacrum to the occiput along the spine. They extend
and laterally flex the vertebral column and can create SI joint symptoms if they are not balanced.
Assess Passive ROM: The client is prone. Make sure they are straight on the table. Perform a visual
posture assessment of the client. Do they have a low shoulder or the appearance of a shorter leg while
lying on the table? Palpate the QL and erectors with your thumbs coming off the iliac crest superiorly.
Assess which iliac crest is elevated. This will indicate which side is contracted and short. This is the side
you will release; regardless of what side the client reports the pain. Remember, pain is an unreliable sign
of where the problem is. For those therapists with advanced palpation skills, palpate the PSIS (posterior,
superior, iliac spine) and assess which side is elevated. Equally balancing the QL and erectors insures
that the lumbar spine is not unilaterally out of balance and compressed on one side.
Palpate Iliac Crests
Myofascial Release: With the client prone and your hands on their back, start with gentle rocking motions
to relax them. Next, perform myofascial spreading of the QL and the erector spinae, at a 45° angle up
and out, moving toward the upper back. Repeat this several times.
Have the client move into a side lying position. Provide support under their neck and upper bent leg so
they are comfortable. This allows their muscles to be as relaxed as possible before you begin. Have
them place their arm over their head and keep their spine in alignment; not rolled forward or backward.
Perform myofascial release with your forearm, up the erectors, to lift and lengthen them. With your other
hand, stabilize the client’s hip and pull downward toward the foot of the table.
Forearm Myofascial Release
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Tendinosis of the Elbow; Muscle-Tendon Strain without Inflammation.
Clinical Features and Findings of Histological, Immunohistochemical,
and Electron Microscopy Studies.
• Investigation performed at Nirschl Orthopedic Sports Medicine Clinic, Arlington; Arlington
Hospital, Arlington and Georgetown University Medical Center, Washington, DC
• Barry S. Krashaar, MD and Robert P. Nirschl MD, MS
Tendinosis vs. Tendinitis
• Tendinitis- Acute tendon injuries such as laceration of the flexor tendons of the fingers are
traumatic in nature and have associated inflammation.
• Tendinosis- Chronic overuse injuries are the result of multiple microtraumatic events that
cause disruption of the internal structure of the tendon and degeneration of the cells and
matrix, which fail to mature into normal tendon; at times such injuries result in tendinosis.
There is an absence of acute inflammatory cells in tendinosis.
Tendinosis-Tendon Strain without Inflammation
• Examinations of specimens from patients who have tennis elbow serve as a model for
investigation of other areas where tendinosis has been reported. Other areas include the
rotator cuff, Achilles tendon, patellar ligament, the adductors of the hip, the triceps, the flexors
and extensors of the elbow, and the plantar fascia.
Tendinosis or Tendinitis?
• While the terms epicondylitis and tendinitis commonly are used to describe tennis elbow,
histopathological studies have demonstrated that tennis elbow is not an inflammatory
condition. It is a fibroblastic and vascular response called angiofibroblastic degeneration, now
more commonly called tendinosis. Thus, proper treatment depends on a correct
understanding of the nature of the injury and goals of therapeutic intervention.
• Tendinosis is incompletely understood. Although the term tendinitis is used frequently and
indiscriminately, histopathological studies have shown that specimens of tendon obtained
from areas of chronic overuse do not contain large numbers of macrophages, lymphocytes, or
neutrophils. Rather tendinosis appears to be characterized by the presence of dense
populations of fibroblasts, vascular hyperplasia, & disorganized collagen.
• It is not sure why tendinosis is painful, given the absence of acute inflammatory cells, nor is it
known why the collagen fails to mature.
Tendinosis Treatment Hypothesis
By Author and International Lecturer, James Waslaski
Based on this research study it is not known why dysfunctional collagen fibers fail to heal. It is
my firm belief, based on many years of tendon pain treatments, that functional collagen or
fibroblast formation is only possible when the underlying cause of tendinosis conditions are
addressed prior to addressing the resultant microtraumatic symptoms.We must restore normal
muscle resting length to antagonistic muscle groups prior to treating the resulting tendon pain
and we must be less aggressive and more specific in our approach to the working on the
resultant strained fibers.
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