All Parts are Equal or are They?

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When a person has back surgery or has had a limb amputated, it is standard for them to go through a rehabilitation process, including physical therapy or massage therapy to be prescribed. However, if a woman has breast surgery, rehabilitation (massage or physical therapy) is not automatically ordered and often not even suggested.
When a woman chooses to have her breasts removed, reconstructed, increased or reduced, it’s important that she understands not only the benefits of the procedures, but the risks as well. Chronic pain and postural problems can appear years later if rehabilitation is not completed following breast surgery.

Breasts are composed of mammary glands, connective tissue, blood vessels, nerves, and lymph vessels. Breast tissue can extend from the border of the breastbone near the center of the chest all the way to the armpit, and overlies the second to sixth ribs. The breast has an axillary tail, which is a tail of tissue that extends up into the armpit region. The breast lies on top of the pectoralis major muscle.
Breast tissue is part of the fascial web of connective tissue, which runs continuously throughout the body from head to foot and superficial to deep without interruption. Any alteration, even the slightest damage to the fascial network has major ramifications.
The body’s balance and symmetry can be significantly altered after a mastectomy, augmentation or reduction. This is something many women aren’t informed of or prepared for. Scar tissue is also a very important fact which women need to be aware of and prepared for. Unpredictable development of scar tissue is quite common after any surgery and can have long-term effects on the body.
Early intervention following breast surgery by a massage or physical therapist can play a pivotal roll in helping women heal and regain full function.
After mastectomy surgery a woman may experience tightness or pulling originating from her incision, which spreads across her body. This is caused by scar tissue, which is the body’s way of healing from surgery. The result can be very dense tissue under the incision, which is painful and which can restrict the arm’s range of motion (ROM). The restricted ROM puts women at risk for a painful condition known as frozen shoulder. Scars can range in size after a breast-conserving lumpectomy or a mastectomy procedure that removes the entire breast. Either way, most breast cancer patients are left with some sort of surgical scar as a by-product of their quest to heal.
In order to rebuild the breast, tissue is taken from another area of the body. It can be taken from several different locations. One host area is the Latissimus Dorsi. In the picture below you can see how much of the body is affected by this location.
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The TUG procedure uses skin and fat from the inner portion of the upper thigh; the incision scar will be hidden near the crease of the groin. The flap is named for the transverse upper gracilis muscle to which the skin and fat are connected. Muscle may be removed as part of the TUG flap.

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Radiation treatment for Breast Cancer has its own list of complications. This type of therapy not only changes tissue characteristics by making it more susceptible to breakdown, it continues to make tissues tighter for 2 to 5 years following treatment.

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It can also lead to:
Skin tightening;
Limited arm and shoulder mobility;
Chest expansion limitations;
Restrictions in and around the area of treatment.
Breast reduction surgery is still largely considered to be a cosmetic surgical procedure. However, it is most often performed to relieve significant physical and emotional problems resulting from overly large and/or heavy breasts. Surgeries are classified as “cosmetic” if it is an elective procedure that insurance does not cover. If it is a procedure that is restoring form or function, it’s referred to as “reconstructive”. Reconstructive procedures are often covered by insurance. The same procedure may be classified as cosmetic or reconstructive depending on how it impacts an individual. Public opinion still sees it as cosmetic but 9.5 times out of ten it is being performed to reduce pain or to alter the overall structure.

 

According to the American Society of Aesthetic Plastic Surgery, 112,964 breast reductions were performed in 2011. Breast reduction surgery leaves permanent scarring.

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The operation using the anchor technique leaves three scars:
One around the nipple (areola);
One from the nipple to the crease below the breast (this is the worst scar as it takes the most tension);
One from the breast bone to the armpit along the crease below the breast.

The severity of scarring largely depends on the individual. Most women are completely unaware of how the scar tissue is affecting them.

 

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Kelly Bowers, a massage therapist from Washington, DC states:
“I had breast reduction surgery in 1992. By 2012 I rarely thought of it and certainly didn’t think the scars were an issue any more. They were barely visible! Then I had scar release work. I was stunned at how far I felt the effects of the work. I felt it from my shoulder to my hip! I’m delighted I had a chance to experience this work and finally take care of these scars as they deserved to be taken care of.”
The American Society for Aesthetic Plastic Surgery also reported that breast augmentation is the most popular surgical cosmetic procedure for women, with more than 316,000 procedures performed in 2011. Yes, augmentation is an elective cosmetic surgery, but it is still a surgery that alters the body. Rehabilitative therapy is necessary after any surgery.

Women who have breast augmentation frequently experience:
Limited upper extremity mobility (range of motion);
Arm weakness and swelling;
Fatigue;
Shoulder dysfunction;
Back pain;
Chest pain.

 
Scar tissue can occur at any time after the augmentation has been performed, not just within the first few months. Capsular contracture is the term used to describe scar tissue that can form around breast implants which may cause the breasts to harden, look or feel different, and may cause some discomfort from the tightening of the capsule. Capsular contracture is an unpredictable complication, but it is also the most common complication following breast augmentation.

 
Scars left by breast augmentation surgery are usually hidden in the crease beneath the breast (inframammary fold incision), around the nipple (peri-areolar incision) or in the armpit (transaxillary incision). Rehabilitation/therapy and physical activity are integral to recovery and to reduce post-breast surgery side effects such as:
Scar tissue/soft tissue immobility;
Flexibility limitations;
Limited range of motion;
Decreased strength.

 
Even if a woman does not actually develop pain or limited function directly after the procedure, at some point pain and disability will become present if scar tissue is not addressed in a timely and proper fashion.

Words can cut like a knife – leaving deep wounds and scars….

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At this past weekend’s Scar Tissue Release, class we were fortunate to have a Registered Nurse volunteer as the demonstration client. She was incredibly generous with her feedback on what she was experiencing during the treatment and answered questions for the students. Two of her scars were from 18 & 20 year old C-sections, respectively. As she told us the stories of the surgeries, the conversation turned to the trauma, both physical and emotional that the events caused.

Apparently, as the surgeons were preparing to cut her open, they were busy discussing their golf game. The surgerical nurse stopped the banter and gave them a what for. Just think how you would feel at that moment, laying on a cold operating table, about to have your abdomen sliced open in order to bring your child into the world, being denied the experience of natural birth. As she told her story, you could see that even after 18 years, she was still very emotional about it.

Since she is a cardiac recovery nurse, I took the opportunity to emphasize a few points I had made during the class lecture. Specifically how “donor” sites, areas where skin or veins are removed in order to repair another injured area of the body, are ignored once they have healed. When I asked her opinion on this matter, she agreed whole heartedly that no further thought is given to these areas; however, she referred to these areas as the “harvest” site.

Everyone in the room took a breath. I knew what they were all thinking as I looked at each of them. The Nurse looked around puzzled, and I explained to her that I refer to the area as a “donor” site. She thought about it for a minute and shook her head. “I never even thought of that, but you are totally right…how horrible.”

How we–doctors, therapists, trainers, family and friends–refer to someone, something, or situation sets the intent. This, in turn, dictates how we regard, and therefore treat or not treat. Most often when we think of harvesting an organ, we think of cadavers. So of course an area that was used for “harvest” does not need further care or concern.

The next day, one of my current clients was among the volunteers for the student practice session. He had burns over 2/3rds of his body from a car fire. He is one of the most balanced and centered people I know. He shared two very important points with the group. First, that he never even considered that there was any kind of restriction, much less a need for therapy, on the areas where they took skin for grafts and that he was blown away by the resulting treatment’s effects all of the areas, grafted and donor. Second, while still recovering in the hospital, a representative of a burn group came by to help him understand and deal with how his life was about to change. “How everyone was going to stare at him and treat him differently…” You can imagine the rest of the conversation. He could not believe this person was there to help him and fortunately he choose not to listen to her doom-and-gloom speech.

I had another client, a massage therapist, who, while filling out her intake form, said to me in regard to the question asking her to list all surgeries, “Well, I did have a C-Section, but I do not really consider that a surgery.” Unbelievably, she was not the first woman to make this statement to me either.

As health care providers we must take care of how we phrase our words, and just as or more importantly, we need pay attention to and assist in altering how our clients refer to themselves. The first step on the road to healing is understanding and awareness.

To tired… or is it too weak… to see straight?

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When was the last time you exercised your eyes?  What no idea?  hhhmm…let’s try some easier questions.  When was the last time you used your ipad or tablet? or how about your computer? How long did you spend staring into the tiny lit up phone screen?  Oh, better yet how much television did you watch this week? I bet you had no problem answering those huh?

There has been a dramatic rise in the last decade in the number of people needing glasses due to the increase of use and reliance on electronic devices. And it is only  going to get worse. Bookstores are going the way of the dinosaurs as electronic readers become more and more popular.  Textbooks are being phased out and schools are  issuing ipads. “The dog ate my homework” excuse is no longer plausible as children are now logging onto school websites to do their homework. Leaving the neck and shoulder issues aside for the moment lets literally take a look at the one thing we take for granted -our eyes.

We all assume that as we age we will need eyeglasses. A belief that is coming of age much sooner by our constant computer/TV use. The problem is not really fixed with the glasses either, as your sight will continue to worsen once you start wearing glasses.  We become dependent on the eyeglasses causing stronger and stronger prescriptions to be needed.

Another issue not being recognized is how fashion is also affecting our eyes. Back in the day we wore the Elton John style, large tinted frames (mine where blue to match my eyes) . images (9)These larger frames allowed us to use our eyes normally to see up and down right and left. images (8) The fashion of today have us wearing small Annie Hall style frames. In order to stay within the small frames we are forced to limit our eye movement and move our heads to see in all directions other than straight forward.  Limited movement means muscle, and therefore vision atrophy.

 

Our eyes like any other muscle in the body needs to be exercised.   Practiced faithfully, eye exercises may actually help delay the need for glasses or contacts in some people.

originalIf you regularly experience symptoms such as eyestrain, blurred vision, headaches, increased sensitivity to bright light, tired eyes, or difficulty sustaining attention, eye exercises could very well be the answer.

Side note-exercising eye muscles will not eliminate the most common maladies that necessitate corrective lenses — namely, nearsightedness, farsightedness, astigmatism, and presbyopia (age-related lens stiffening).

 

There are some very simple exercises that take only a few minutes to do.

1. Repeated blinking. This simple action, that we often take for granted, places a vital role in  health and vision– it replenishes the tear film that covers the surface of the eye (the cornea), lubricating it and protecting it against dryness, dust particles and other irritants. Some research shows that when we watch TV or use the computer, we tend to blink less, which dries and irritates the eyes, potentially causing headaches and other types of discomfort. Blinking every three or four seconds for about a minute is thought to help reduce eye strain by clearing the cornea and allowing the eyes to rest.

2. Palming the eyes. This is achieved by lightly pressing three fingers from each hand against the upper eyelids for a couple of seconds, then releasing. Repeating this process at least five times helps relieve tension accumulated in the ciliary muscles of the eye, while also replenishing the eyes’ tear film. Taking a few deep breaths before performing this exercise will improve relaxation.

3. Rolling your eyes, first clockwise, the counter-clockwise. While this may not sound much like an exercise, it is actually one of the most popular do-it-yourself vision therapies, believed to both tone the eye muscles, and improve local blood circulation. It is generally advised to start rolling your eyes slowly, then faster, and to do this about fifteen or twenty times in a row.

4. Focusing on a distant object. This exercise is recommended especially for individuals who suffer from computer vision syndrome, but it can also help relax the eyes after any other strenuous activity. Choose an object that is located six to ten meters away from you, and focus on it for about twenty seconds, without moving your head. Doing so provides rest to the ciliary muscles that we tend to put a lot of stress on when we focus intensely on the computer screen.

5. Zooming in on an object. This simple (and somewhat hilarious) exercise can be performed by holding a pencil in front of you at arm’s length, then slowly moving the arm closer to the nose, while focusing your eyes on the tip of the pencil. The goal is to bring the tip of pencil as close to the nose as possible, until your eyes can’t keep focus. Doing this exercise ten times in a row helps improve eye movement control and strengthens the eye muscles.

Just for irony here is a website with an easy to follow routine. http://eyepitstop.com/

And here is another simple way to exercise your eyes:

The picture in these exercises was developed by Tibetan monks.

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When performed as described below, the exercises are designed to stimulate muscles and optic nerves. Practicing these exercises twice daily, in the morning and evening, may improve vision problems over time. Build up to the 30 seconds twice a day to avoid eye strain.

Copy and  print the snowflake. You can also get the Tibetan Eye Chart as an app. It’s at www.TibetanEyeChartApp.com.

Remove glasses or contacts.

Sit with back straight and the chart centered about one inch directly in front of your face with the center dot at nose level.

Move only the eyes, not your head.

Hold each movement for 30 seconds. It is important to hold for this length of time as this is the time required to break down the protein bridges holding your muscles locked as they are presently.

Begin by relaxing the eyes, closing them gently and cupping with the hands.

Movement #1
Move both eyes clockwise around the outer circle from dot to dot, beginning with 12 o’clock.

Movement #2
Repeat this pattern, moving counterclockwise, again beginning with 12 o’clock.

Movement #3
Move eyes back and forth between dots at 2 o’clock and 8 o’clock positions.

Movement #4
Move eyes back and forth between dots at 4 o’clock and 10 o’clock positions.

End by relaxing eyes and cupping them with your hands.

No part of the body should ever be ignored. Make sure to keep your day bight and in focus and remember to exercise your eyes!

 

 

 

 

 

The children are our future…So how about we pay attention now!

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I received a call the other day from a fellow Massage Therapist. He was
referring one of his clients, a 15 year old male athlete ( lacrosse
goalie and football linebacker) with severe pain in his right knee. The boy’s coach told his mother he needed an MRI and that he most likely tore
something. My friend did not agree and wanted to see what I
thought and if Integrated Therapeutic Stretching would help. He had tryouts in two days and they were concerned about injury.

According to the client he only felt the pain when he was crouching in goalie position. I had him do it for me. He had all of his wait on the outside of his feet which were not wide enough apart to support his weight properly.

I ran him through some quick range of motion & muscle tests as he lay on the table with no resulting pain but revealed very limited ROM throughout the boy’s lower body. As we started to stretch it was quickly discovered that his left glutes were locked up. Hip rotators on both sides were in as bad a shape. IT Band and hamstrings were at 60% ROM and his quadriceps were down to 45%. This is 15 years old folks!

It is terrifying to see the physical shape of children today. Either they are overweight and under exercised or they are over worked, participating in multiple sports where proper strength and flexibility training is nonexistent.

Sports injuries are on the rise in children and teenagers. Each year more than 3.5 million sports-related injuries requiring medical treatment occur in children under age 15. Today, as more and more children and adolescents participate in the same sport year-round, many young athletes are developing overuse injuries. In fact, overuse is responsible for about half of the sports injuries that happen to middle and high school aged students.

We worked together through each stretch, showing him how his body is supposed to move utilizing body proper form and mechanics. He was very eager to learn as was his mother. I assisted and guided him through the stretches focusing especially the ones which really opened his restrictions. Both he and his mother were surprised at how tight he was in the beginning and at speed with which he loosened up.

Now as we were working I observed a deep scar about 1inch in length on his left knee which he claimed was “no big deal” and said it was over a year old. His mother chimed in “the bad one was on his foot”. Three years prior he flayed his right foot open on a fence. There was a huge c shaped scar on the sole of his foot which upon palpation showed to have spread and attached into the arch.

I asked if he wanted to see something cool and then I proceeded to release the scar on his knee. When I asked him to bend his knee his eyes opened wide and said “That’s Sick!”. His knee flexion had increased by 20% . Next with his mother’s permission I went to work on his foot. When I was done I had him stand up. He laughed out loud and said “No Way! Thats Totally Sick! I can feel the bottom of my foot”. His mother , shocked at his reaction said ” I didn’t know you couldn’t feel your foot?!” “Neither did I” was his reply.

We followed this up with gait re-education and proper mechanics required for his respective sports positions (i.e. crouching and squatting). While he still had some minor pain he could see how adjusting his stance took the pressure off his knee. After having him go through the stretches once more I recommend to the mother that if the pain comes back or increases then she should indeed seek their doctor’s advice.

The mother was shocked at how much the scars were affecting her son. I explained to her that scars and adhesions are generally overlooked by health professionals because the extent of physiological affects they can have on the body have never really been acknowledged. The slightest restriction from falling off his bike at 4 could alter how he grows and have major repercussions from one end of his body to the other.

Four days later the duo returned, the tryouts went great and when asked about his knee he said “it still hurts every now and then but whenever I felt it start I shifted around until I felt right and the pain stopped.” I asked if had been stretching and he say before and after the games. (In the four days since I had seen him he had two lacrosse matches and two days of football tryouts). He was also very excited for more scar therapy “It was so weird but I could feel my foot moving better as I played!” His mother than asked if I had any extra time to look at her two scars that have been driving her crazy for years.

During the course of my career I’ve treated many patients whose problems could be traced back to a scar they had forgotten they even had. While not every scar presents a problem, very often they do. Doctors, along with basically everyone else, tend to ignore scar tissue from surgery and accidents especially in children.

Today children are playing more and more sports driven by the need of scholarships and future fame. It is time we start to pay attention to the adverse affects of training and playing so hard so young. We need to make sure that the fall off the bike or the cut from climbing over the fence does not lead to issues later on.

Wide Band Narrow View

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A_HAD_1p_P36Should we stretch? Does it help or does it cause harm? This is a very popular debate. One that usually ends in “Well… there is no evidence that proves it is good… but everyone does feels better afterwards.” or “It is a waste of time that can only lead to loss of strength.”

When we think about stretching we tend to think only about the muscles and static holds. These narrow views are what gives stretching a bad reputation and where all of the misunderstandings occur. We should be stretching the whole body, which is primarily made of fascia, in line with the way it was designed to move, dynamically.

For example let’s look at the knee. Usually when there is an knee issue most look to stretching the Quadriceps or Hamstrings muscles. body_worlds_knee When the IT Band comes to the knee joint it binds into a large network of connective tissue or Fascia. This fascial network comes across the front of the knee depending on the direction of force and it connects down into the shins. The IT Band fascially connects into the Peronals & Tibialis Anterior. The knee cap is embedded in fascia. When we have Knee injuries such as patella tracking, meniscus tears, ACL we often focus our view on the Hamstrings and Quadriceps addressing only half the possibilities of causation. Perhaps the fasica is inflamed. A common complaints of knee pain is a sweeping type of pain across the knee and under the knee cap. For it to be sweeping across it must be the fibrous attachments across the knee. This is not the type of pain a Quadricep or Hamstring would be causing.

So by opening up our point of view to encompass all of tissues involved, while recognizing the patterns in which it is connected and functions leads to a productive pain reducing, fascial lengthening, muscle educating and recovering stretching session.