Working With Clients Who Are Medically Fragile

About 15 percent of the current U.S. population is 65 years or older, and as the baby boomers continue to age, the size of this group will continue to grow. Combine this population with those who are chronically ill or have suffered a serious injury, and it’s easy to see how now and in the future you may have clients who are deemed medically fragile.

Although the benefits of massage therapy are likely similar for medically fragile clients, there are a wide array of things that will be different when working with these clients. Read on to learn more about what you can expect—and what’s expected of you—when working with medically fragile clients.
What Is Meant by Medically Fragile?

A medically fragile client can be loosely defined as someone with serious and complex medical conditions and a frail constitution. These clients will likely fall into one of three categories: chronic or terminal illness, suffering from severe injury or advanced age. Some other common terms that are used to describe the medically fragile are medically frail, medically complex or technology-dependent.

Because medically fragile spans such a large range of conditions and client demographics, massage therapists are going to need to be prepared to evaluate how the definition of medically fragile may vary across clients. Julie Goodwin, a massage therapist and educator, considers a wide array of variables when thinking of how a medically fragile status may apply to her clients. “To me, assignment of a medically fragile or medically frail status evolves from an interview, observation, assessments of medical treatment and medication side effects, physical and social risk, and a review of medical records or treatment transcripts,” says Goodwin. “This often represents multiple health conditions from which recovery or rehabilitation is unlikely, medical treatments and medications that create side effects that interfere with daily functioning, and impairments to mobility and cognition.”

Remember, there is really no “typical” medically fragile client, so you’re going to need to be able to adapt quickly and be flexible.
When Massage Is Beneficial

Even though the session for these clients will be different, the benefits they receive are similar to the benefits massage provides to all other clients. “All the reasons why a non-fragile person would want a massage would be applicable here, too,” says Susan Salvo, a massage therapist and author who specializes in the medically fragile. Goodwin echoes this sentiment. “In my practice, pain relief, relaxation and increased range of joint motion are typical reasons for seeking massage therapy,” she explains. “Most of my clients I have deemed medically fragile are elderly (over 65).”

While massage therapy is effective for many of the same reasons as it is with more typical clients, there are still some reasons medically fragile clients seek out massage therapy that are more common than others. The most common therapeutic reasons include pain and stress management, decreased swelling, improved range-of-motion, relief from nausea, fatigue, insomnia, and a feeling of calmness and improved mood. Massage can also be beneficial for clients who suffer from psychosocial issues such as isolation, hopelessness, depression and anxiety. “Massage can bring comfort to these clients and their caregivers,” says Salvo, “which can be especially important when spoken language is difficult or impossible.”
What You Need to Know

Space. When working with medically fragile clients, the location of the massage therapy session is going to depend in large part on the client, and can range from your practice location to the client’s home to a medical facility or nursing home. For each of these settings, massage therapy sessions will need to be adapted. For example, Salvo recommends scheduling all appointments at your practice during daylight hours.

Here, too, you need to think of how you can make the space easy for the client to negotiate, like making sure there is enough space between furniture and walls to accommodate wheelchairs and walkers. “Modifications in my location include lowering the table to ease access and assisting the client around the treatment space,” says Goodwin. “Working with the client only in a semi-reclining supine position, avoiding repositioning and working with the client clothed are other modifications I often make.” You should also consider using linens in contrasting colors for those clients who might be visually impaired.

Alternatively, if you see medically fragile clients on an outcall basis— either in their home or at a hospital or long-term care facility—different accommodations need to be made. Evening hours, for example, are sometimes better in these settings because there will likely be fewer disruptions. Space is limited in these settings, too, so don’t bring a portable table or massage chair. Instead, assume you’ll massage the client where they are, whether that’s in bed, in a wheelchair or while seated in a recliner. “If the client is in bed, the bed is often placed against a wall, limiting access to all sides of the body,” adds Ann Catlin, owner and director of the Center for Compassionate Touch.

Working with the care coordinator or nurses is a must. Ask for specific instructions, Salvo encourages, and when you go to the client’s room, obtain their permission before entering. Many times, these clients may have people in their room, too, whether medical staff or visiting family, so don’t be afraid to introduce yourself and explain why you’re there. A curtain pulled around your client often indicates a health care professional is performing care that requires privacy, says Salvo, so you should wait outside the room or in the hallway until they’re finished.

Other things Salvo suggests considering include:

Safety. Some medically fragile clients are going to be unsteady on their feet or experience dizziness, and so falling will be a big safety concern. You need to make sure you don’t allow a client to move without assistance from a member of their health care team, whether that’s from a chair or their bed. Also, if you need to step away from a client, make sure the bed rails are raised before doing so.

Accessibility. You aren’t going to want to move furniture from a client’s room, but you can try to make as clear a path as possible around the bed or chair to facilitate your work. If you need blankets or pillows or linens, however, ask someone to help you locate these items instead of looking for them yourself or bringing your own.

Emergency. Be sure you ask about the facility’s emergency protocol in advance so you can take proper measures. If an emergency occurs, Salvo recommends raising the bedrails to keep the client secure and then stepping out into the hallway to call for help instead of pushing the call button. Many times, you’ll get a quicker response this way.

Intake. Intake is always important, but especially so with medically fragile clients. The length of intake will differ based on the client, but make sure to have extra time allotted as most times you’ll need to talk with these clients longer. “Intake is extensive, and likely to comprise most of the client’s initial visit,” says Goodwin. “I prepare the client ahead of time by letting them (or the person making the appointment, who is often a family member) know what information to bring, including a list of health conditions, a list of all prescribed and over-the-counter medications, and the names of primary and specialist health care providers, to name a few.”

Remember, however, that when working in a hospital or other care facility, you won’t always have access to a client’s medical records. “It’s important to note that a massage therapist will only have access to the medical record if they have a formal relationship with the organization, either as an employee or a contracted service provider,” Catlin cautions.

Also, be sure the room is well lit and relatively quiet. Turn down the volume on the TV or radio, for example, or ask the nursing staff to hold calls while you’re conducting your intake. Salvo also suggests being systematic in your intake, asking how the client is feeling before moving on to more in-depth questions.
The Massage Session

Flexibility. As with most special populations, massage therapists need to be flexible when working with medically fragile clients. “Therapists are challenged to remain flexible and adaptive,” Catlin explains. “You’ll need to let go of preconceived ideas about how a session will unfold or how the client will respond.”

Positioning. Of all the differences you might notice when working with a medically fragile client, the massage therapy session itself may be where you see the biggest contrast, starting with how the client is positioned. “They’re rarely going to get disrobed,” says Salvo. “Depending on how medically fragile or how mobile they are, you’ll have to be willing to massage through clothing or just with what they have on, which might be a hospital gown or leisure clothing.” Before beginning, remind the client that they should let you know if anything hurts or causes discomfort so you can make the proper modifications.

When considering positioning, the client should be in a supine, semi-reclining, side-lying or seated position. If you’re working in a long-term care facility or hospital, many times the nursing staff will prefer to position these clients if they can’t manage on their own, so be aware of that before starting the massage. Prone positions, too, are not appropriate if there are any medical devices on the anterior surface of the chest or abdomen, like drain tubes or IV lines.

Catlin suggests thinking of ways you can work with the current location and position of the client to help with positioning. “For example, use the hospital bed controls to adjust the position, or use pillows to support the arms or raise the feet off the mattress,” she says.

Timing and Technique. Although the time you spend actually massaging these clients may be shorter than usual—typically from 15 to 45 minutes, according to Catlin—the length of the session when you include intake will still be an hour or more. Remember, too, that these clients are often going to need more time for activities such as using the restroom, drinking water or getting comfortable, and they may like to share personal stories, so you need to be patient.

“Technique modifications include shortening session duration to avoid overtiring the client, limiting or eliminating techniques that may stimulate systemic circulation, and decreasing pressure and increasing lubrication,” says Goodwin. “Also, choose a lubricant unlikely to trigger an allergic reaction, and take extra steps to preclude transmission of infectious pathogens.”

Salvo echoes this caution, advising massage therapists to use only unscented products or products that have a scent that is familiar to the client. Additionally, a different container should be used for each client whenever possible, or single-use lotion packs or the client’s own lotion could be used, with permission from the client, of course. Be sure to sanitize exterior surfaces both before and after use.

Whatever technique you use, making sure the level of pressure is appropriate is a must and requires you to continually check in with the client to ensure they are comfortable.
After the Massage Therapy Session

When the massage session is over, be sure to replace a client’s eyeglasses if you’ve removed them, as well as their socks or slippers. You might also ask the client if they need anything, Salvo suggests. After placing used linens in the hamper and sanitizing your hands, make sure to complete your session or SOAP notes. “Be sure to let the patient care coordinator know if you found unreported issues, such as swelling, redness or bruising,” Salvo adds.

Clients who are considered medically fragile often want—and need—the very real benefits offered by massage therapy, but you might have to modify your approach to accommodate the unique needs of the medically fragile client. Learning ahead of time what you’ll need to know when working with this population is a great place to start.

The M Technique for the Hand

When working with medically fragile clients, Susan Salvo recommends
a technique developed by Jane Buckle called the “M” Technique. This
technique uses a patterned sequence of three repetitions and light pressure
that remains unchanged, allowing the client’s body to become used
to the new stimuli and eventually relax. Following is the “M” Technique
sequence for the hand:

1. Alternate hand stroking to elbow
2. Lateral movements palm down
3. Joint circling
4. Scissor hold/pressure point/stroke
5. Turn hand over
6. Little finger links
7. Lateral movements, palm up
8. Handshake
9. One-hand stroking to elbow

Source

Taking a Wrist Series: It’s About the Carpals

Routine radiographic examination of the wrist is not difficult, but does require some attention to positioning.

Keep in mind that to evaluate a joint on X-ray, one must be able to visualize the joint in two planes at 90 degrees to one other. The routine series for a wrist includes PA and lateral views. For further evaluation, oblique projection may also be necessary if trauma or arthritis is evident.

The PA View

The PA radiograph of the wrist is best obtained with the arm abducted 90 degrees from the trunk and the forearm flexed 90 degrees at the elbow. The wrist should lie flat on the cassette with the hand in a relaxed position, but with the fingers slightly cupped or flexed, or curled in a relaxed fist. A wedge also can be placed underneath the fingers to keep the wrist in contact with the cassette. The thumb should be extended parallel to the other fingers. (Figure 1)

PA wrist Figure 1: PA wrist The most common problem I’ve seen is that the PA projection is performed with the hand extended flat on the cassette, which elevates the wrist slightly, causing the carpals to appear jammed together. If the clinician instructs the patient to place their hand in a gentle fist position, this will help place the carpal bones of the wrist closer to the cassette. (Figure 2)

PA wrist Figure 2: PA wrist with hand in gentle fist Technical factors that are important to keep in mind include the following: 10 x 12 inch (24 x 30 cm) crosswise for two or more images on one cassette; for a digital screen, use lead masking to get more than one image one the cassette; for a detail screen, use the tabletop technique; 50-60 kVp range, mAs 4-5; and minimum SID of 100 cm.

PA wrist Figure 3: PA wrist When evaluating the PA view of the wrist (Figure 3), the joint spaces of the wrist have a width of 2 mm or less. Only the radiocarpal joint is slightly wider. The carpometacarpal joints are slightly narrower than the midcarpal joints. The capitolunate joint is considered the baseline joint width to which other joint spaces can be compared. Make sure to look at all of them: the radiocarpal, the proximal intercarpal, the midcarpal, the distal intercarpal and the carpometacarpal joint spaces.

The carpal arcs Figure 4: The carpal arcs The carpal joint spaces should be symmetrical. The cortical margins of the bones should be parallel. One excellent way of looking at the positioning of the carpals is by using three carpal arcs. (Figure 4) The first arc is a smooth curve outlining the proximal convexity of the scaphoid, lunate and triquetrum. The second arc traces the distal concave surfaces of the same bones, and the third arc follows the main proximal curvatures of the capitate and the hamate.

The carpal bones Figure 5: The carpal bones: scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate An arc is disrupted if it cannot be traced smoothly. A break in one of the arcs indicates a fracture or the disruption of a ligament leading to a subluxation or dislocation.

Here’s a common board question: What’s the most commonly fractured bone in the body? Ah, I’ll bet you thought it was the scaphoid. It’s actually the clavicle. But the most common region fractured is the wrist, with the scaphoid being the most commonly fractured wrist bone. (Trick question, matter of semantics, but what do you expect from a board exam?)

Lateral wrist positioning Figure 6: Lateral wrist positioning Can you remember the names of all the carpal bones? You’ve got the scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate. (Figure 5)

The Lateral View

Lateral view of the wrist Figure 7: Lateral view of the wrist The lateral radiograph of the wrist is obtained with the arm adducted with the ulnar side of the forearm on the cassette. The elbow is flexed to 90 degrees, adjusting the hand and wrist to make certain they are in a true lateral position. The same technical factors can be used for the lateral projection as for the PA projection. (Figure 6) If an X-ray table is not available, any sturdy table will do. This is a non-bucky technique.

pisiform Figure 8: Position of the pisiform for the true lateral wrist projection When evaluating the lateral view of the wrist (Figure 7), it is important to first determine if a true lateral view has been performed. A true lateral view is defined by the relationship between the pisiform, capitate and scaphoid bones. On a standard lateral view, the palmar cortex of the pisiform bone should overlie the central third of the interval between the palmar cortices of the distal scaphoid pole and the capitate head. (Figure 8)

Once it’s been determined that a true lateral projection has been obtained, the spatial relationships between the carpal bones can be evaluated. The most important axes are those through the scaphoid, the lunate and the capitate. The true axis of the scaphoid is difficult to appreciate since the midpoint of the proximal pole is often not visualized clearly, but a parallel line can be used to determine if the scaphoid is spatially aligned. Drawing a line along the most ventral points of the proximal and distal poles of the scaphoid will achieve the same spatial relationship. (Figure 9)

Axis of the scaphoid Figure 9: Axis of the scaphoid The axis of the lunate runs through the midpoints of the convex proximal and concave distal joint surfaces, and can best be drawn by finding the perpendicular to a line joining the distal palmar and dorsal borders of the bone. (Figure 10) The capitate axis joins the midportion of the proximal convexity of the third metacarpal and that of the proximal surface of the capitate. (Figure 11)

Axis of the lunate Figure 10: Axis of the lunate Since we are discussing the lateral view of the wrist, we can’t ignore the most commonly luxating/dislocating bone in the body, which is the lunate. Scapholunate instability can be assessed in the lateral view by measuring the scapholunate angle (30-60 degrees is normal – Figure 10) and the capitolunate angle (<30 degrees is normal – Figure 11). If the lunate is angulated dorsally, it is termed a DISI type of instability, which stands for dorsal intercalated segmental instability. Most agree that anything over 80 degrees for the scapholunate angle indicates instability. As far as VISI, volar intercalated segmental instability, or palmar flexion instability, when the lunate is tilted palmarly too much, most agree that VISI cases are most likely a normal variant, especially if the wrist is very lax.

Axis of the capitate Figure 11: Axis of the capitate The Oblique View

The other common view performed in a wrist series is the oblique view, which allows for visualization of the trapezio-trapezoidal joint. Again, this is a tabletop film. The patient is seated with the elbow flexed 90 degrees and the hand/wrist supinated. The fingers and hand should be slightly flexed to align the carpal bones. Rotate the wrist and hand internally 45 degrees toward the cassette; a 45 degree angle sponge can be used for support and stability. (Figure 12)

Oblique wrist Figure 12: Oblique wrist Other Considerations

trapezio-trapoidal joint Figure 13: Oblique wrist demonstrating the trapezio-trapoidal joint Functional views can also be performed if there is a question of ligamentous injury. Radial and ulnar deviation projections place stress on the intercarpal ligaments, which is used most often to evaluate the scaphoid bone. The clenched-fist PA wrist view can be also used to demonstrate a widening of the scapholunate distance.

Wrist injuries are common and may lead to degenerative joint disease, which can prove debilitating. A simple wrist series can be quite helpful in evaluating most acute wrist injuries.

Physical Activity Can Prevent Stroke

Silent brain infarcts (subclinical strokes) “have an increased risk of dementia and a steeper decline in cognitive function than those without such lesions” for older people. This study found that “engaging in moderate to heavy physical activities may be an important component of prevention strategies aimed at reducing subclinical brain infarcts.”

Abstract

BACKGROUND:

Silent brain infarcts are frequently seen on magnetic resonance imaging (MRI) in healthy elderly people and may be associated with dementia and cognitive decline.

METHODS:

We studied the association between silent brain infarcts and the risk of dementia and cognitive decline in 1015 participants of the prospective, population-based Rotterdam Scan Study, who were 60 to 90 years of age and free of dementia and stroke at base line. Participants underwent neuropsychological testing and cerebral MRI at base line in 1995 to 1996 and again in 1999 to 2000 and were monitored for dementia throughout the study period. We performed Cox proportional-hazards and multiple linear-regression analyses, adjusted for age, sex, and level of education and for the presence or absence of subcortical atrophy and white-matter lesions.

RESULTS:

During 3697 person-years of follow-up (mean per person, 3.6 years), dementia developed in 30 of the 1015 participants. The presence of silent brain infarcts at base line more than doubled the risk of dementia (hazard ratio, 2.26; 95 percent confidence interval, 1.09 to 4.70). The presence of silent brain infarcts on the base-line MRI was associated with worse performance on neuropsychological tests and a steeper decline in global cognitive function. Silent thalamic infarcts were associated with a decline in memory performance, and nonthalamic infarcts with a decline in psychomotor speed. When participants with silent brain infarcts at base line were subdivided into those with and those without additional infarcts at follow-up, the decline in cognitive function was restricted to those with additional silent infarcts.

CONCLUSIONS:

Elderly people with silent brain infarcts have an increased risk of dementia and a steeper decline in cognitive function than those without such lesions.

Copyright 2003 Massachusetts Medical Society

 

The Multidisciplinary Model: A Trend That Can’t Be Ignored

This past year was an eye-opening one for me, especially from an international perspective. It all started with the World Federation of Chiropractic’s biennial congress in Rio de Janeiro, Brazil, in April 2011.

More than 1,000 enthusiastic attendees participated, and what particularly impressed me was the representation from the World Congress of Chiropractic Students.

Students from all over the world traveled to the congress, led by WCCS President Dr. Stanton Hom from California. Dr. Hom is a West Point graduate and completed his chiropractic studies at the Southern California University for Health Sciences. His natural leadership skills helped bring a large body of energetic chiropractic students together, all of whom were hungry to learn about chiropractic and other health care disciplines that complement it.

Their energy was contagious. Sometimes I meet people who seem to have forgotten their passion for chiropractic, so I enjoyed meeting students from every corner of the world whose hearts are still full of love for the profession.

In October, I returned to Brazil to host a seminar in Sao Paulo at the Universidade Anhembi Morumbi, part of Laureate International Universities, a vast network of colleges with campuses in more than 70 locations around the world. The Sao Paulo location features a multidisciplinary health care facility that includes chiropractic, medicine, physical therapy, massage therapy, and other services. The facility itself has 47 treatment rooms, and all the disciplines collaborate with one another in their studies and in their delivery of care.

The common thread in my conversations with students at each of these stops was this: The multidisciplinary model of both learning and treating patients that I observed in Sao Paulo is spreading like wildfire around the world. Practitioners are accepting the model as an effective way to improve their own skills and to enhance the patient experience by creating a one-stop destination to manage all patient health concerns. International students are being exposed to this model without awareness of how things might have worked historically, which is accelerating its integration into the health care landscape.

We have been relatively slow to adopt this structure in the U.S., but we need to take note of the enthusiasm and satisfaction of students and practitioners who are following this model in their daily studies and practices. My international travels have demonstrated to me that this model is the one we should follow, and I hope that our U.S. chiropractic contingent will continue to experiment with a multidisciplinary approach to discover its true benefits.

In economies around the world, this model is working and chiropractors are thriving, which is why the student population continues to grow. Let’s learn from our colleagues in other nations and leverage those opportunities here in the U.S. to continue elevating our profession among all health care disciplines.

Conservative Care Beats Medication for Neck Pain

A study published in the Jan. 3, 2012 issue of the Annals of Internal Medicine and widely reported by mainstream media suggests conservative care consisting of either spinal manipulation or home exercise is more effective than over-the-counter and prescription medication for relieving acute and subacute neck pain.

Spinal manipulative therapy was more effective than medication in both the short and long term, as was home exercise in the form of self-mobilization of the neck and shoulder joints – a point media outlets were quick to emphasize in a classic attempt to downplay the value of the chiropractic intervention.

The study involved 272 adults ages 18-65 with nonspecific mechanical neck pain of two to 12 weeks’ duration. Participants were recruited from a university research center and a pain management clinic in Minnesota. Other inclusion criteria included pain equivalent to grade I or grade II according to the Bone and Joint Decade’s Task Force on Neck Pain and Its Associated Disorders; and neck pain score of 3 or greater on a 0-10 scale. Exclusion criteria included cervical spine instability, fracture, neck pain referred from peripheral joints or viscera, progressive neurologic deficits, diffuse idiopathic hyperostosis, inflammatory or destructive changes of the cervical spine, previous cervical spine surgery, and blood-clotting disorders, among other criteria.

neck pain Subjects were randomized at their second baseline appointment to one of three groups for 12 weeks:

  • A spinal manipulative therapy group, which received “manipulation of areas of the spine with segmental hypomobility by using diversified techniques, including low-amplitude spinal adjustments … and mobilization.” According to the study, six chiropractors, each with at least five years’ experience, provided treatment, with the specific spinal level to be treated and the number of treatments rendered left to the discretion of the individual chiropractor.
  • A home exercise advice group, “with advice provided [by six therapists] in two 1-hour sessions one to two weeks apart. Recommended mobilization exercises included “neck retraction, extension, flexion, rotation, lateral bending motions, and scapular retraction, with no resistance.” Participants received a booklet and laminated cards of prescribed exercises, and were advised to perform 5-10 repetitions of each exercise six to eight times daily.
  • A medication group monitored by a licensed medical physician, with nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or both serving as the first line of pharmacological therapy. With patients who did not respond to or could not tolerate these drugs, narcotic medications and muscle relaxants were prescribed. With each patient, the MD determined the type of medication administered and the number of patient visits.

Self-reported outcomes, including pain, were measured six times during the 12-week treatment period in all three groups: at both baseline appointments; two, four, eight and 12 weeks after randomization; and on two occasions post-treatment (weeks 26 and 52). Objective measures of cervical spine motion were measured at four and 12 weeks by seven trained examiners blinded to treatment assignment.

Of the 272 participants, essentially equally assigned to the three treatment groups (91 SMT, 91 home exercise and 90 medication), “improvement in participant-rated pain significantly differed with SMT compared with medication at 12 weeks … and in longitudinal analyses that incorporated pain ratings every two weeks from baseline to 12 weeks. At 12 weeks, a significantly higher proportion of the SMT group experienced reductions of pain of at least 50% [compared to the medication group]. Differences in participant-related pain improvement between the SMT and [home exercise] groups were smaller and not statistically significant.”

Specifically, at week 12, more than 82 percent of the SMT group reported a 50 percent or greater reduction in pain; 57 percent reported at least a 75 percent reduction and 32 percent reported a 100 percent reduction. By comparison, the home exercise group reported pain reductions of 77 percent, 48 percent and 30 percent, respectively, while the medication group reported reductions of only 69 percent, 33 percent and 13 percent.

In terms of long-term improvement, 75 percent of the SMT group reported at least a 50 percent reduction in pain after 26 weeks, while nearly 81 percent reported at least a 50 percent reduction at 52 weeks. At 26 and 52 weeks, 71 percent and 69 percent of the home exercise group, respectively, reported at least a 50 percent reduction in pain. In long-term follow-up, the medication group’s improvement fluctuated from 59 percent reporting pain reduction of 50 percent or more at 26 weeks to 69 percent reporting the same reduction at 52 weeks.

“Spinal manipulation therapy and [home exercise advice] led to similar short- and long-term outcomes,” stated the authors, “but participants who received medication seemed to fare worse, with a consistently higher use of pain medications for neck pain throughout the trial’s observational period.”

Meditation Promotes Mindfulness

The Default Mode Network (DMN) involves regions of the brain associated with mind-wandering – namely, the medial prefrontal cortex and the posterior cingulate corticies, that may cause lapses in attention and anxiety.   To assess whether mindfulness-based meditation can reduce activity along this brain axis, Judson Brewer, from Yale University School of Medicine (Connecticut, USA), and colleagues analyzed 12 experienced mindfulness meditation practitioners, and a group of 13 control subjects who never practiced the technique.

The researchers used functional MRI to assess brain activation during both a resting state and a meditation period in each subject.  Compared with novice meditators, experienced study participants had significant deactivation in parts of the brain associated with the DMN.  As well, the team found that practiced meditators reported less mind-wandering during meditation than did their less experienced counterparts.

The study authors conclude that: “Our findings demonstrate differences in the default-mode network that are consistent with decreased mind-wandering. As such, these provide a unique understanding of possible neural mechanisms of meditation.”

Aside from attention lapses and anxiety, the “default mode network,” or DMN, has also been associated with certain conditions, including ADHD and Alzheimer’s disease. Conversely, mindfulness training has been shown to benefit certain conditions, such as pain, substance use disorders, anxiety, and depression.

Action Points


  • Explain that this study found that meditation diminishes activity in areas of the brain associated with mind-wandering, the so-called default mode network in the medial prefrontal cortex and the posterior cingulate corticies.
  • Note that the study used functional MRI to assess brain activation during both a resting state and a meditation period in experienced mindfulness meditation practitioners and controls.

So to assess whether mindfulness-based meditation can reduce activity along this brain axis, the researchers analyzed both experienced meditators and controls who’d never practiced the technique. The researchers used functional MRI to assess brain activation during both a resting state and a meditation period in 12 experienced mindfulness meditation practitioners and 13 controls.

Groups attempted three different types of meditation: concentration, loving-kindness, and choiceless awareness. Concentration is intended to prevent practitioners from engaging with their preoccupations; loving-kindness focuses on fostering acceptance; and choiceless awareness allows for focusing on whatever arises in the conscious field of awareness at any moment.

Brewer and colleagues found that experienced meditators reported less mind-wandering during meditation than did controls, which was true across groups.

At the same time, they generally saw less activation in the main nodes of the DMN — the medial prefrontal cortex and the posterior cingulate corticies — in experienced meditators than in controls.

While there was significantly less activation in the posterior cingulate cortex/precuneus and in the superior, middle, and medial temporal gyri and uncus, the trend toward diminished activation in the medial prefrontal cortex was not significant, they noted.

With regard to the specific types of meditation, the researchers found less activation in experienced meditators than in controls in the following regions:

  • Concentration: posterior cingulate cortex, left angular gyrus
  • Loving-kindness: posterior cingulate cortex, inferior parietal lobule, and inferior temporal gyrus extending into hippocampal formations, amygdala, and uncus
  • Choiceless awareness: superior and medial temporal gyrus

When using the posterior cingulate cortex as a seed region, the researchers saw significant differences in connectivity patterns with several other brain regions, notably the dorsal anterior cingulate cortex, for experienced meditators compared with controls. And when using the medial prefrontal cortex as the seed region, they found increased connectivity with the fusiform gyrus, the inferior temporal and parahippocampal gyri, and the left posterior insula.

These patterns held during the resting-state baseline period as well, the researchers said, suggesting that meditation practice “may transform the resting-state experience into one that resembles a meditative state, and, as such, is a more present-centered default mode.”

The researchers concluded that the overall results “support the hypothesis that alterations in the DMN are related to reduction in mind-wandering.”

Though the study was limited by a small sample size, the researchers concluded that the findings may have a host of clinical implications, including treatment of conditions linked with dysfunction of these areas, such as ADHD or Alzheimer’s disease.

Is Soup Toxic to Your Health?

Bisphenol A (BPA) is a plasticizer that is regarded as an endocrine disruptor that may be linked to  cardiovascular disease, diabetes, and liver abnormalities.  Commonly used in food can linings, Karin B. Michels, from Harvard School of Public Health (Massachusetts, USA), and colleagues assessed the urinary bisphenol A (BPA) levels of 75 healthy men and women, ages 18 years and older, who consumed homemade soup for five consecutive days, and then ate canned soup for another five days in a row.

Urinary levels of BPA averaged 1.1 mcg/L during the homemade soup segment, but reached 20.8 mcg/L during the canned soup segment.   Observing that: “The effect of such intermittent elevations in urinary BPA concentrations is unknown,” the team urges that: “Even if not sustained, [it] may be important, especially in light of available or proposed alternatives to [BPA-containing] epoxy resin linings for most canned goods.”

Recent data from the National Health and Nutrition Examination Survey, for example, indicated that the 95th percentile for urinary BPA was 13.0 mcg/L, Michels and colleagues noted.

BPA is used in a wide range of consumer and medical products to soften plastics. Studies have shown that BPA can mimic the action of female reproductive hormones and may be linked to cardiovascular disease, diabetes, and liver abnormalities. Infants’ exposure is a particular concern because they may be more sensitive to these effects than adults.

Last month, researchers found that children whose mothers had high urine levels of BPA during pregnancy were more prone to behavioral problems.

The U.S. government, after initially dismissing concerns about BPA in baby bottles and other consumer products, reversed course in 2010 and promised a major research effort to pin down the health risks.

Because BPA is also used in food can linings, Michels and colleagues sought to examine whether canned soups would be a vehicle to increase human intake of the chemical.

They used five varieties of vegetarian Progresso soups, including tomato and minestrone, and five similar homemade soups. Participants were randomly assigned to start with the commercial or homemade soups, eating a serving of each variety at lunchtime daily for five days. After a two-day washout period, participants who first ate the canned products then had a week of the homemade soups, and vice versa.

Participants could otherwise eat what they pleased during the study.

Urine samples were collected in the late afternoon on the fourth and fifth days of each period. To minimize intraindividual variations, each person’s samples from consecutive days were mixed prior to analysis.

BPA levels in urine were adjusted for dilution, using a formula that included the samples’ specific gravity.

All the participants had detectable BPA in their urine after eating the canned soup, whereas 23% of samples in the homemade-soup phase were BPA-free.

The mean individual difference between mean adjusted urinary BPA levels following canned versus homemade soups, 22.5 mcg/L, was highly significant, with a 95% confidence interval of 19.6 to 25.5 mcg/L, Michels and colleagues reported.

Results were nearly identical for participants who started the trial with canned soup compared with those initially assigned to the homemade soups.

The researchers did list several limitations to the analysis. The study involved one institution (all participants were students or employees of the Harvard School of Public Health) and the canned soup came from a single manufacturer.

More important, Michels and colleagues indicated that “the increase in urinary BPA concentrations following canned soup consumption is likely a transient peak of yet uncertain duration. The effect of such intermittent elevations in urinary BPA concentrations is unknown.”

But they argued that the magnitude of the peaks seen in their study is great enough to cause concern.

“Even if not sustained, [it] may be important, especially in light of available or proposed alternatives to [BPA-containing] epoxy resin linings for most canned goods.”

Good for the Heart, Guard Against Cancer

As an American Heart Association Strategic 2020 Goal, “ideal” cardiovascular health is one of elements that aim to improve Americans’ heart health by 20% and reduce deaths from heart disease and stroke by 20%.  Laura J Rasmussen-Torvik, from Northwestern University (Illinois, USA), and colleagues followed more than 13,000 healthy individuals for 13 years, measuring seven “metrics” of heart health at the start and tracking any cancer that developed.

Those seven factors are: not smoking, normal BMI (a calculation based on weight and height), physical activity, healthy diet, and safe cholesterol, blood pressure and fasting blood glucose levels.  Between 1987 and 2006, the participants developed more than 1,800 new cancers, namely prostate, breast, lung and colon. But, the more “ideal” factors people had, the less likely they were to develop cancer. Compared to people who had none of the seven factors, having just one reduced the risk of cancer by 20%. Three factors lowered the risk of cancer by 22%, and five to seven pushed the risk down 38%.

The study authors conclude that: “Ideal cardiovascular health metrics are also collectively associated with lower cancer incidence.”

Individuals who don’t smoke and who maintain a healthy body-mass index (BMI), normal blood pressure and two to four other “ideal” measures of heart health have a 38% lower risk of developing cancer, according to research scheduled for presentation Wednesday at the annual meeting of the American Heart Association in Orlando, Fla.

The study authors hope the score they’ve developed will help doctors drive home the message that prevention is key to both cancer and heart disease.

“Physicians need motivation to really push the issue of prevention with patients,” said lead author Laura J. Rasmussen-Torvik, an assistant professor of preventive medicine at Northwestern University Feinberg School of Medicine in Chicago.

Other experts agreed.

“If we give patients a double whammy [message], in the ideal world, we might be preventing two of these biggest killers. It might be a stronger message,” said Dr. Tara Narula, a cardiologist with Lenox Hill Hospital in New York City.

“People generally know that healthy behaviors prevent heart disease and cancer, but to [relate risk factors such as cholesterol] to cancer is novel,” added Dr. Harmony Reynolds, associate director of the Cardiovascular Clinical Research Center at New York University Langone Medical Center in New York City. “It’s very nice to have that crossover in practice. Sometimes I talk to patients about lowering their cholesterol and exercising, and they get very fatalistic saying that, in my family, cancer is the problem. It’s very convenient to be able to say these things.”

“Ideal” cardiovascular health is one of the American Heart Association’s Strategic 2020 Goals, which aim to improve Americans’ heart health by 20% and reduce deaths from heart disease and stroke by 20%.

For this study, researchers followed more than 13,000 healthy individuals for 13 years, measuring seven “metrics” of heart health at the start and tracking any cancer that developed. Those seven factors are: not smoking, normal BMI (a calculation based on weight and height), physical activity, healthy diet, and safe cholesterol, blood pressure and fasting blood glucose levels.

Between 1987 and 2006, the participants developed more than 1,800 new cancers, namely prostate, breast, lung and colon. But, the more “ideal” factors people had, the less likely they were to develop cancer.

Compared to people who had none of the seven factors, having just one reduced the risk of cancer by 20%. Three factors lowered the risk of cancer by 22%, and five to seven pushed the risk down 38%.

“If you lower yourself by one point [risk factor], that’s a significant decrease in cancer risk and a lower risk of heart disease,” said Dr. Christopher Cove, assistant director of the cardiac catheterization lab at the University of Rochester Medical Center in New York. “That’s exciting.”

When the researchers looked at the same participants but removed smoking from the measure, the association was no longer significant but the trend was still in the right direction.

“This says that, yes, smoking is really important but we still see the trend when smoking is taken out, so adhering to a healthy diet and having a low BMI are still important for cancer risk,” said Rasmussen-Torvik.

The association might have been even clearer had the study had more participants and more cases of cancer, said Reynolds.

It’s not clear why these associations exist, but Narula hypothesized they could relate to overall inflammation, which drives both heart disease and cancer.

The study authors said they hope to see more collaboration between the American Heart Association and cancer advocacy groups.

“I think the American public is very confused about conflicting health messages,” said Rasmussen-Torvik. “If organizations like the American Heart Association, the American Cancer Society and the American Diabetes Association could work together to emphasize some core prevention goals, that could be beneficial to all groups.”

Research presented at meetings should be considered preliminary until published in a peer-reviewed medical journal.

Active Lifestyle Reduces Risk of Depression

Previous studies have reported an inverse association between physical activity and depression. Michel Lucas, from Harvard School of Public Health (Massachusetts, USA), and colleagues studied data co0llected on 49,821 US women enrolled in the Nurses’ Health Study, all of whom did not experience symptoms of depression in 1996.

Surveying for physical activity a total of five times during the study period, and following subjects for 10 years to assess for clinical depression, the team found that women who reported exercising the most in recent years were about 20% less likely to get depression, as compared to those who rarely exercised.

As well, the more hours the subjects spent watching TV each week, the more their risk of depression rose.  The researchers warn that:  “Analyses simultaneously considering [physical activity] and television watching suggested that both contributed independently to depression risk.”

According to findings published in the American Journal of Epidemiology, researchers found that women who reported exercising the most in recent years were about 20 percent less likely to get depression than those who rarely exercised.

On the other hand, the more hours they spent watching TV each week, the more their risk of depression crept up.

“Higher levels of physical activity were associated with lower depression risk,” wrote study author Michel Lucas, from the Harvard School of Public Health in Boston.

More time spent being active might boost self-esteem and women’s sense of control, as well as the endorphins in their blood, although the study could not prove directly that watching too much television and avoiding exercise caused depression, she added.

The report included close to 50,000 women who filled out surveys every couple of years as part of the U.S. Nurses’ Health Study, and covered the years 1992 to 2006.

Participants recorded the amount of time they spent watching TV each week in 1992, and also answered questions about how often they walked, biked, ran and swam between 1992 and 2000.

On the same questionnaires, women reported any new diagnosis of clinical depression or medication taken to treat depression.

The analysis only included women who did not have depression in 1996. Over the next decade, there were 6,500 new cases of depression.

After the researchers accounted for aspects of health and lifestyle linked to depression, including weight, smoking and a range of diseases, exercising the most — 90 minutes or more each day — meant women were 20 percent less likely to be diagnosed with depression than those who exercised 10 minutes or less a day.

Women who watched three hours or more of television a day were 13 percent more likely to be diagnosed with depression than those who hardly ever tuned in, but Lucas said at least part of that link might be due to women replacing time they could be exercising with TV watching.

One alternative explanation the researchers brought up is that women might have been experiencing some symptoms of depression before they were diagnosed, leading them to exercise less. A formal diagnosis could have come later.

“Previous studies have suggested that physical activity is associated with a lower risk of depressive symptoms,” said Gillian Mead, who studies geriatric medicine at Edinburgh’s Royal Infirmary but was not involved in the study.

A Golfer’s Worst Nightmare Rehabilitated Through Massage

For many golfers, the only meaningful way to spend a sunny day is out on the links. With 18 holes to look forward to — the sun’s rays caressing the greens, blue skies inviting deep breathes, and the warm leather grip of a favored club in hand — nothing much can break their joy of being alive.

Until, that is, pain strikes. Pain in the physical sense such as a muscle tear or unstable joint, or the pain they feel from a continually declining game performance. For a die-hard golfer, the two pains are equally worrisome. And, left unresolved, grow to become their worst nightmare: the end of their golfing and no more need for sunny days.

Massage therapists are all well aware that, as the human body ages: muscles atrophy, tissues lose elasticity and overall flexibility declines. What many therapists have yet to fully understand, however, is that static stretching of muscles is rarely enough to correct these affects (Siff and Verkhosansky 1993, Siff 1994, and 1998). And even dynamic stretching is an incomplete course of treatment for many of our clients — especially those who golf.

Kinematic Sequencing and Therapeutic Improvements

To effectively assess and treat the unique needs of a golf client requires that the therapist first acquire an advanced knowledge of body dynamics, namely, the kinematic sequencing of the golfer’s body.

Kinematic sequencing refers to the specific order that the body engages its muscles, bones, joints and balance to perform a movement. In our golfing clients, the movement is striking the ball.

For an efficient golf swing to take place, the process of kinematic sequencing looks like this:

  • First, the pelvis is engaged and rotates towards the ball.
  • Second, the trunk engages and follows the pelvis.
  • Third, the arms engage and follow the trunk.
  • Fourth, the hands and club follow the arms until the ball is struck.

Once the ball is struck, the body again engages in a kinematic sequence, this time of deceleration, with the pelvis engaging first, followed by the trunk, followed by the arms, followed by the hands and club. That is good sequencing.

As massage therapists, the better we understand kinematic sequencing — especially in our rotational athletes who play golf, tennis, baseball, bowling and soccer — the the better we become at assessing our clients’ pains, restrictions, limitations and frustrations.

And the first step to better assessing our clients is to perform better evaluations. Specifically, how they present when they take a static posture and when they take a dynamic posture as they describe their pains, restrictions and issues.

Static posture is, of course, the position of the body at rest, sitting, standing or lying down. This is typically what we see most often as massage therapists. Our clients sitting or standing before us or perhaps already laying on the table as they describe their pains and wait for us to treat them.

Dynamic posture, on the other hand, has the patient: move, twist, lift, pull, push and balance in order to reveal the likely causes of the client’s pain or imbalance. The difference in evaluating your client’s condition using dynamic posture as well as a static posture is often the critical and missing step in properly assessing and treating our patients (Doctor Vladimir Janda “Upper and Lower Cross Syndrome” 1979, cited in Lewitt 1999).

To only evaluate your client in a static posture would be missing the holistic nature of human dynamic motion and posture. Sure, you can look at a left hip internal rotation when your client is on the table and find a deficiency of say 15-20 degrees, but that won’t give you an accurate picture of what’s really affecting the golf swing until you ask your client to stand up and perform the very movement that causes the trouble. So to replicate the golf swing, you must ask your client to do an internal rotation so as to move the trunk over the hip.

Frankenstein on the Golf Course

Here’s an example from my own clinic. I recently had the opportunity to work with a golfer who had bilateral hip replacements, a right knee replacement, and a left shoulder injury that was never repaired. I hate to say it, but he walked like Frankenstein and, as you can predict, his traumas lead to a continuing decline in his game performance.

When golfers ready themselves to strike the ball they bend their knees into a semi-squat formation. So to properly assess my client’s condition, I asked him to squat, slowly, all the way into a chair. And as he did so, I observed his ankles, knees, hips, trunk and motor control. I then asked him to stand on one leg. His ability to maintain a one-legged posture lasted less than three seconds. I also noted that he could not even begin to touch his toes; and he had limited trunk control, pelvic and spinal rotation. He had a forward head posture, kyphosis, and evaluation of his left shoulder joint presented the arm well in front of his ear instead of the proper placement which is beside or behind the ear. As you might infer, he clearly needed better flexibility. But, because of his hip prosthetics, it would be inadvisable to stretch his hips into internal rotation.

For this client, I began by making a basic golf movement better. Namely, the squat. Simply by teaching him to use his hips better, it allowed him to stay in a golf posture longer which helped with his swing path, tempo and striking distance — and his enjoyment of the game. We always combined our sessions with manual therapy, focusing around the hip rotators, to help him improve his hip hinge.

If you are ever presented with a client suffering with similar impairments, begin by writing down your assessment of how each muscle is affecting the joints in the lower extremities. Look at the flexibility of the feet as they relate to overall stability during weight shifts. Create more ankle mobility by addressing the dorsiflexors and removing myofascial restrictions. Check the client for the ability to do inversion and eversion of the ankles. Attempt to lengthen the quads, hamstrings, adductors, IT band, gluteals and psoas. Your goal is to increase the length of the flexor chain and increase strength to the extensor chain.

Once you’ve completed all of the above, recheck the client’s movement by asking your client to perform another squat or the movement pattern that is causing the concern. If your client has yet to improve, it may indicate that just stretching the lower extremity is not enough. Adding mobility without adding stability may not change the movement pattern. You may need to become a teacher of the squat. Put a chair behind the client, have them do an isometric press into their hands to activate the core, and teach them to hip-hinge back into the chair. Then repeat your manual therapy and re-check your client’s range-of-motion. Continue to do this as many times as necessary throughout the session to reveal how much your client’s motor control is improving. You will often see minor improvements during the first session and noticeably bigger improvements during subsequent appointments.

This is the protocol I implemented with my own client and he improved dramatically. In just three months, I had him transform his gate from that of a B-movie monster to that of a young man walking with a kick in his step. He also lowered his golf handicap, feels younger, stands taller and more importantly . . . he is now free of his worst fear — that of believing that he’d never again enjoy playing 18 rounds of the great game of golf.

References

  1. Supertraining: Yuri Verkhoshansky and Mel Siff.
  2. Manipulative Therapy in the Rehabilitation of the Locomotor System: Karel Lewit, Third Edition 1999.
  3. Superstretch : Mel Siff 1994.
  4. Facts and Fallacies of Fitness : Mel Siff 1998.