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Title: Manual therapies


1
Manual therapies
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Alexander technique
4
Alexander technique
  • Every man, woman and child holds the possibility
    of physical perfection it rests with each of us
    to attain it by personal understanding and
    effort.
  • FM Alexander

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Definition
  • The Alexander technique is an educational and
    therapeutic method of encouraging an individual
    to expend a minimum of effort to achieve the
    maximum efficient use of muscles and movement
    with the aim of relieving pain and improving
    posture and overall health.
  • Put more simply, it is a practical method for
    finding out what habits of body use a person has
    and how best he or she can promote the most
    beneficial actions and prevent the most harmful
    actions.

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Theory
  • 1. End gaining and the means whereby Alexander
    used the term end gaining to describe the
    tendency to follow some course of action almost
    automatically without first thinking through
    ones intended actions carefully. He called the
    opposite process of waiting, thinking and
    assessing the most appropriate activity the
    means whereby.

10
Theory
  • 2. Faculty sensory appreciation with this term
    Alexander acknowledged the presence of habits of
    proprioception or feeling underlying habitual
    actions. This can result in a feeling of
    uneasiness during the correction of a
    long-standing incorrect posture because it
    represents a change from what has been regarded
    as normal behaviour in the past.

11
Theory
  • 3. Inhibition the third idea is linked to the
    second. It represents a natural self-control of
    unwanted and inappropriate reactions without any
    sense of suppressing spontaneity. When Alexander
    discovered a way of integrating these concepts he
    found the solution to his problems. By
    recognising the strength of his old habits and
    the inappropriateness of end gaining, he was
    forced to consider the means whereby he could
    secure the necessary improvements in posture. To
    do this he had to overcome the faulty sensory
    perception of how his body should be. This he did
    by inhibiting his end-gaining behaviour.

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Practice
  • The technique involves a process of
    psychophysical re-education that engages both
    mind and body.
  • This learning process is best achieved through a
    series of one-to-one lessons with a qualified
    teacher who, using very gentle non-manipulative
    touch, gives the pupil the necessary new
    experiences.
  • Modern practitioners recommend up to an hour to
    enable changes to be made.

13
Practice
  • In group classes the emphasis is more on
    experiment and observation.
  • Pupils are also encouraged to observe the thought
    processes and tensions associated with their
    activities in daily life.
  • As the principles are assimilated, the pupil
    begins to develop the tools necessary to make his
    or her own discoveries and can continue to learn
    independently.
  • Alexander technique may not be effective for
    everyone. Most teachers consider that 2040
    lessons are required.

14
Feldenkreis method
15
Feldenkreis method
  • A technique similar to the Alexander technique
    has been developed by Moshe Feldenkrais
    (19041984) in Israel over a 40-year period.
  • The Feldenkreis method (FM) is viewed as an
    educational system for the development of
    self-awareness, which relies on the body as the
    learning instrument.

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Feldenkreis method
  • It deals with the question of how to enable the
    individual to reorganise and recall forgotten
    movement patterns.
  • Unlike other complementary and alternative manual
    and touch modalities, FM is not aimed at curing
    or healing a client but rather at bringing about
    a change in his or her awareness, self-image and
    attitude towards the self, and taking
    responsibility for his or her wellbeing.

17
Bowen technique
18
Bowen technique
  • The Bowen technique involves a gentle, rolling
    motion, with very light touches. The practitioner
    stimulates sets of points, often with pauses
    between sets.
  • Bowen therapy was pioneered by Tom Bowen of
    Victoria, Australia (191682) in the 1950s. It
    has been suggested that the Bowen technique may
    introduce specific harmonic frequencies to the
    body systems.

19
Bowen technique
  • The Bowen technique is not a form of massage,
    although it does claim to release areas of
    built-up stress in the muscles, and clients
    usually experience profound relaxation after a
    session.
  • A typical session takes place over 3045
    minutes, with occasional 2- to 5-minute breaks
    during the session to allow the body to respond
    to the treatment.
  • The Bowen technique has been used to treat back
    pain, neck pain, frozen shoulder, tennis elbow,
    repetitive strain injury and other
    musculoskeletal disorders.

20
Chiropractic
21
Chiropractic
  • Chiropractic is gaining in popularity and in the
    USA its practitioners are third in number to
    physicians and dentists.
  • The discipline is the most popular example of
    complementary and alternative medicine (CAM) in
    the country, with as many as one in three
    patients with lower back pain being treated in
    this way.

22
Definition
  • Chiropractic (chieri, meaning hand, and
    praktikos, meaning performed) is a complementary
    discipline that focuses on the spine as being
    integrally involved in maintaining health,
    providing primacy to the nervous system as the
    primary coordination for function and thus health
    in the body.

23
Definition
  • Maintenance of optimal neurophysical balance in
    the body is accomplished by correcting structural
    or biomechanical abnormalities or
    disrelationships through the use of manipulation
    and adjustment.
  • Chiropractors specialise in the diagnosis,
    treatment and prevention of biomechanical
    disorders of the musculoskeletal system,
    particularly those involving the spine and their
    effects on the nervous system.

24
History
  • Although manipulation dates back to ancient
    times, its popularity in modern times is
    attributed to Daniel David Palmer (18451913), a
    selfeducated scientist from Iowa.
  • He founded that the nervous system was the
    ultimate control mechanism of the body and that
    even minor misalignments of the spine, which he
    termed subluxations, could significantly impact
    on a persons health.

25
History
  • In the closing years of the 19th century, Palmer
    produced his theory of musculoskeletal effects on
    the central nervous system and developed the
    first manipulative techniques to relieve them.
  • Palmer is reputed to have opened his own school
    in the 1890s some texts quote 1895 and others 3
    years later.
  • The profession celebrated its centenary in 1995
    so the earlier date would seem to be the more
    appropriate!
  • Daniels son, Bartlett Joshua (18821961),
    promoted chiropractic enthusiastically, helped by
    a number of his fathers contemporaries and his
    own students.

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Theory. There are four aspects of chiropractic
philosophy
  • 1. The importance of the nervous system 31
    different pairs of spinal nerves travel through
    openings in the vertebrae to and from the brain.
    If one of the vertebrae is partly displaced from
    its correct position, it can cause an impingement
    and pressure, or irritate the surrounding nerves.
    As a result, essential nerve messages are
    distorted, causing damage to the surrounding
    tissues.

30
Theory. There are four aspects of chiropractic
philosophy
  • 2. The bodys inherent ability to heal itself
    this is embodied in the phrase vis medicatrix
    naturae.
  • 3. The effect of subluxation or joint
    dysfunction such abnormalities are believed to
    interfere with the ability of the neuromuscular
    system to act in an optimal fashion, in turn
    contributing to the presence of disease.
  • 4. The identification and treatment of
    subluxations.

31
Practice Examination
  • As spinal manipulation is of such importance to
    the chiropractor, examination of this area of the
    body is of particular interest, following an
    initial history-taking.

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The acronym PARTS (steps of examination)
  • Pain pain and tenderness are identified using
    observation, palpation and percussion.
  • Asymmetry this may be identified by palpation,
    radiograph analysis or observation of gait.
  • Range of motion this includes assessment of
    different types of motion, including stability of
    joints using palpation and radiographs.
  • Tissue characteristics these include tone,
    texture and temperature abnormalities a range of
    diagnostic techniques may be employed.
  • Special procedures EMG, ultrasonography and
    kinesiology may be considered to augment
    information obtained from previous tests.

33
Treatment
  • Procedures used during chiropractic treatment may
    include gentle massage, ultrasonic treatment and
    adjustment.

34
Treatment
  • The chiropractic adjustment (often also called
    manipulation) to joints in the spine or
    extraspinal regions entails placement of the
    practitioners hands on appropriate contact
    points.
  • This is followed by positioning of the joint,
    during which the patient may feel tension of the
    muscles and ligaments a popping sound may occur.

35
Treatment
  • A short sharp thrust may then be delivered.
    Chiropractors use different parts of the hand to
    direct the thrust, depending on the joint being
    adjusted, e.g. the middle or base of the index
    finger may be used to adjust the neck whereas an
    area of the wrist bone may be used to adjust the
    lumbar spine. In cases of injury an indirect
    thrust may be used.

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Treatment
  • The joint to be manipulated may be gently
    stretched over a pad or wedge-shaped block until
    realignment is accomplished.
  • A typical course of treatment for uncomplicated
    cases may involve six sessions over a 2- to
    3-week period.

37
Massage
38
Massage
  • Although remedial massage has its own methods and
    procedures, at its simplest it may be considered
    as being the age-old response to a painful
    stimulus, i.e. rubbing the bit that hurts!
  • It is used in physical therapy, sports medicine,
    nursing, and as an adjunct to chiropractic,
    osteopathy and naturopathy.

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The aims of massage are to
  • relieve pain and reduce swelling
  • relax the muscles
  • encourage the healing process after strain and
    sprain injuries.
  • Contrary to popular opinion, it cannot prevent
    loss of muscle strength or reduce fat deposits.

40
Definition
  • Massage is the systematic manipulation of body
    tissues, performed primarily (but not
    exclusively) with the hands for therapeutic
    effect on the nervous and muscular systems, and
    on systemic circulation.
  • The primary characteristics of massage are touch
    and movement.
  • It may be performed in association with another
    therapy or alone.

41
History
  • Massage is reputed to have been used more than
    3000 years ago by the Chinese.
  • Later, the Greek physician Hippocrates used
    friction in the treatment of sprains and
    dislocations, and kneading to treat constipation.

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History
  • Early in the nineteenth century, Per Henrik Ling
    (17761839) of Stockholm devised a system of
    massage to treat ailments involving joints and
    muscles. Ling believed that vigorous massage
    could bring about healing by improving the
    circulation of the blood and lymph. In the past
    2030 years complementary therapists have adapted
    Swedish massage so as to place greater emphasis
    on the psychological and spiritual aspects of the
    treatment.
  • The benefits of massage are now described more in
    terms such as calmness or wholeness than of
    loosening stiff joints or improving blood flow.

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History
  • In contrast to the vigorous and standardised
    treatment recommended by Ling, current massage
    techniques are more gentle, calming, flowing and
    intuitive. Lings Swedish system was popular at
    European spa towns in the nineteenth century,
    when it was used in conjunction with
    hydrotherapy. It was taken to the USA in 1854 by
    Dr George Taylor and his brother Dr Charles
    Taylor.
  • Others later extended the treatment to relieve
    deformities of arthritis and to re-educate
    muscles after paralysis.

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Theory
  • Massage involves two main components touch and
    pressure.
  • Attaining a balance between the two is an
    important skill.

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Practice
  • The most commonly used therapeutic massage is
    known as Swedish massage, although many other
    variants exist, including deep-tissue massage
    (used to release chronic patterns of muscular
    tension), sports massage (similar to both Swedish
    and deep-tissue massage) and acupressure.

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Practice
  • Craniosacral massage is designed to deal with
    cranial and spinal imbalance. Treatment often
    involves several different procedures and may
    last between 15 and 90 min. It starts with the
    case history, although this is usually relatively
    short compared with other complementary
    therapies. The patient is ideally treated
    unclothed on a specially designed massage couch.
    This normally incorporates soft but firm padding
    and a hole for the face.

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A variety of strokes are used
  • Effleurage is a deep stroking movement in the
    direction of the venous flow that relaxes
    muscles, improves circulation to the small
    surface blood vessels and is thought to increase
    the flow of blood towards the heart.
  • Pétrissage is a compression procedure that
    includes kneading, squeezing and friction it is
    useful in stretching scar tissue, muscles and
    tendons so that movement is easier.

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A variety of strokes are used
  • Friction or rubbing is carried out with a slow
    elliptical or circular movement to increase blood
    flow and muscle movement.
  • Tapotement or percussion uses the sides of the
    hands to strike the surface of the skin in rapid
    succession to improve circulation.
  • Vibration or shaking is used on the extremities
    and is said to lower muscle tone.

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A variety of strokes are used
  • Massage practitioners who treat sports injuries
    and musculoskeletal disorders may incorporate
    techniques derived from physiotherapy, osteopathy
    and chiropractic. These include deep massage,
    passive and active stretching, and muscle energy
    techniques (in which the patient moves against
    resistance from the practitioner).

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Massage of the joints
  • Stiff and swollen joints can be cured by massage
    combined with mechanical movements.
  • Massage is, however, not recommended in serious
    inflammatory cases of the joints and in
    tubercular joints.
  • Sprains and bruises can be cured by massage.
  • In these cases, affected parts should first be
    bathed with hot water for 1530 min.
  • Next the massage should be done for a few
    minutes.
  • Gentle stroking and kneading are recommended on
    and around the injured tissues.
  • Fractures can also be treated through massage.

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Massaging the nerves
  • Massage benefits many nerve problems. In cases of
    acute inflammation of the nerves, massage should
    be done carefully.
  • Light and gentle stroking is recommended.
  • Deep pressure should not be used on swollen
    nerves because it will increase the inflammation.
  • All that is needed is a gentle tapotement or
    beating of the nerve.

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Abdominal massage
  • This form of massage is beneficial in
    constipation.
  • It stimulates peristalsis of the small
    intestines, tones up the muscles of the abdomen
    walls, and mechanically eliminates the contents
    of both the large and the small intestines.

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Chest massage
  • Chest massage is helpful in many ways.
  • It strengthens the chest muscles, increases
    circulation and tones up the nervous system of
    the chest, heart and lungs.
  • It is especially recommended in weakness of the
    lungs, palpitation and organic heart disorders.
  • Bust and mammary glands can be developed by
    proper massage.

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Massage of the back
  • The purpose of massage of the back is to
    stimulate the nerves and circulation for treating
    backache and rheumatic afflictions of the back
    muscles, and for soothing the nervous system.
  • The patient is made to lie down with the arms at
    the sides.

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Massage of the throat
  • This helps to overcome headache, sore throat and
    catarrh of the throat.

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Anxiety
  • There is some good evidence from RCTs that
    massage can reduce anxiety in the short term in
    psychiatric patients who are children or
    adolescents, 83 and in palliative care.
  • In one study of cancer patients suffering from
    pain, 60 of the respondents reported a reduction
    in pain after a 30-minute massage.

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Anxiety
  • Massage has been beneficial in intensive care
    after cardiac surgery, although some concerns
    about its effect on critically ill patients have
    been expressed.
  • Long-term elderly hospital patients are reported
    to have responded to massage with a reduction in
    anxiety, tension and heart rate.

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Premenstrual syndrome
  • Massage therapy may be an effective long-term aid
    for pain reduction and water retention, and a
    short-term aid for decreasing anxiety and
    improving mood for women with premenstrual
    dysphoric disorder.

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Low back pain
  • An RCT with four parts sought to compare the
    effectiveness of massage therapy with other
    interventions for the treatment of low back pain.
  • The massage provided a benefit to patients in
    excess of the other interventions.
  • AIDS There is some evidence that massage may
    improve the immune function and quality of life
    of AIDS patients.

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Massage for children
  • A critical review of the use of massage therapy
    in children concluded that there was insufficient
    evidence to support its use without
    qualification.
  • None the less it is used in both neonates and
    older children with a variety of medical
    conditions.

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Massage for children
  • Benefits include improved mood (less crying and
    salivation), increased sleep and reduced pain in
    children with juvenile rheumatoid arthritis.
  • Supporters believe that massage has a positive
    effect on behaviour, concentration and childrens
    respect for each other.

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Osteopathy (osteopathic manipulative medicine)
  • The name osteopathy stems from the Latin words
    osteon and pathos, which translates to suffering
    of the bone.
  • This name has caused con-fusion in the sense that
    it makes people believe that an osteopath treats
    only conditions of the bones.

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Osteopathy (osteopathic manipulative medicine)
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Osteopathy (osteopathic manipulative medicine)
  • However, the name was chosen because its founder,
    Dr Andrew Still, recognised that a well-balanced,
    properly functioning body relies on both the
    muscular and the skeletal systems of an
    individual being healthy and well.
  • The World Health Organization recognises the
    osteopathic concept of somatic dysfunction as
    being scientifically proven.

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Definition
  • Osteopathy is a medical discipline that is based
    primarily on the manual diagnosis and treatment
    of impaired function resulting from loss of
    movement.
  • Its philosophy has an emphasis on internal
    relationships of structure and function, with an
    appreciation of the bodys ability to heal
    itself.
  • It uses a wide range of techniques to treat
    musculoskeletal problems and other functional
    disorders of the body.

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History
  • Osteopathy was developed in the USA in the 1870s
    by an American frontier doctor, Andrew Taylor
    Still (18281917).
  • Still used his extensive knowledge of anatomy and
    physiology to develop a method to diagnose and
    treat the body through palpation and
    manipulation.
  • He founded the American School of Osteopathy at
    Kirksville, Missouri in 1892.

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Theory
  • The philosophy of osteopathic medicine is based
    on the idea that the human body constitutes an
    ecologically and biologically unified whole.
  • Body systems are united through the
    neuroendocrine and circulatory systems.

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Theory
  • In the study of health and disease, therefore, no
    single part of the body can be considered
    autonomous.
  • Osteopaths believe that the problems of health
    and the treatment of disease can be rationally
    considered only through the study of the whole
    person in relation to both internal and external
    environments.

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The following key principles are involved
  • The body comprises interrelated organs and
    systems, and functions as a whole unit disease
    results from an imbalance in overall health.
  • The body has an ability to heal itself and may be
    assisted in this function by the practitioner
    disease represents a breakdown in this
    capability.

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The following key principles are involved
  • The body is much more than the sum of its
    individual parts nothing exists in isolation and
    the totality must be considered, e.g. dysfunction
    in the musculoskeletal system frequently
    contributes to pain, poor circulation and changes
    in function leading to constipation, headache,
    fatigue.
  • Treatment is based on the three basic principles
    of body unity, selfregulation and the
    interrelationship of structure and function, as
    stated above.

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Practice
  • Osteopathic treatment is purely and solely based
    on manual techniques, which are used to adjust
    and correct mechanical problems in the whole
    body.
  • The osteopath does not prescribe any medicines,
    nor does he or she use any invasive techniques
    (injections, surgery, etc.), although in the USA
    the scope of treatment may be wider than this.
  • Diagnostic techniques are as for chiropractic and
    may include radiology.
  • The aim is not to treat the illness itself but to
    stimulate the patients natural healing
    processes.

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There are four phases to treatment
  • 1. Detection of changes in muscles and tissues
    (by palpation)
  • 2. Observation of any body asymmetry (e.g. leg
    length), posture and respiratory function
  • 3. Testing of mobility and sensitivity
  • 4. Application of treatment.
  • Usually, a patient will be asked to be passive
    during this phase. However, at times there are
    some techniques for which the patient must
    actively participate in the movements.

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Examples of the direct and indirect techniques
employed by osteopaths
  • Counterstrain techniques achieve release of
    restriction by placing the affected joint or
    muscle in a position of comfort, while applying a
    counter-stretch to the antagonists of the tight
    muscles.
  • Functional techniques involve gentle mobilisation
    of joints so that barriers to normal movement are
    identified until a way is found through the
    restriction.
  • Osteopathic manipulations are carried out using
    minimum force levels in order to maximise safety
    and minimise patient discomfort manipulation is
    not the mainstay of most osteopathic treatments.
  • A treatment session lasts approximately half an
    hour.

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Craniosacral techniques
  • are very gentle release techniques particularly
    suited to young children and physically frail
    individuals
  • this therapy was evolved by the Swiss
    practitioner William Garner Sutherland
    (18731954) and depends on the suggestion that
    cranial sutures have the ability to move slightly
    and their manipulation is thought to improve the
    circulation of cerebrospinal fluid, which in turn
    may relieve certain local symptoms.

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Visceral techniques
  • are used in the management of conditions
    affecting internal organs and involve gentle and
    rhythmical stretching of the visceral areas.
  • Apart from low back pain, other conditions
    treated by osteopathy are similar to those
    addressed by chiropractors and include neck and
    shoulder pain, sports injuries, repetitive strain
    disorders and headache.

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Visceral techniques
  • In addition, practitioners also treat arthritis
    although they cannot affect disease pathology or
    progression, they claim to be able to treat
    secondary symptoms such as pain from associated
    muscle spasm.
  • Cranial osteopathy has a particular reputation
    for treating children with conditions such as
    infantile colic, constant crying and behavioural
    problems.

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Reflexology
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Reflexology
  • The word reflexology comprises reflex, in
    this case meaning one part reflecting another
    part, and ology, meaning study of.
  • Put together, we get the study of how one part
    reflects another.
  • However, the discipline involves much more than
    simply a study of parts.
  • Reflexology is the most popular complementary
    discipline in Denmark.

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Definition
  • Reflexology may be defined as the scientific
    theory that maps out the reflexes on the feet and
    hands to all the organs and the rest of the
    body.
  • It involves the application of pressure to reflex
    areas of the hands or feet to produce specific
    effects in other parts of the body.

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Reflexology map each of the shaded areas
represents different areas of the body or organs.
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History
  • A pictograph in the tomb of Ankhmahar, a
    physician of particularly high esteem, discovered
    at Saqqara in 1979, revealed that the ancient
    Egyptians were aware of the benefits of foot and
    hand reflexology.
  • The pictograph, dating back to around 2500 BC,
    shows a therapist working on a patients foot and
    a second therapist working on another patients
    hand.

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History
  • Reflexology is also said to have been practised
    in Chinese and North American Indian cultures.
  • Willam Fitzgerald (18721942), observed that
    applying pressure to specific areas of hands and
    feet caused an anaesthetising effect on other
    areas of the body and was useful in the
    treat-ment of pain.
  • He divided the body into five longitudinal zones
    on each side of the body.

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History
  • These terminated in the toes and fingers.
    Fitzgerald suggested that a direct link existed
    between the areas and organs within each of the
    zones.
  • This idea was developed by Eunice Ingham
    (18791974), who charted reflex areas in the foot
    that appeared to correspond to areas of the
    entire body. refinements.

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Theory
  • It is suggested that, when the reflexes are
    stimulated, the bodys natural electric energy
    works along the nervous system and meridian lines
    to clear any blockages on those lines and in the
    corresponding zones.
  • A treatment seems to break up deposits (felt as
    gritty areas under the skin) that may interfere
    with the natural flow of the bodys energy.

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Practice
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Practice
  • Reflexologists do not seek to diagnose medical
    conditions, nor do they prescribe medicines,
    although the topical use of oils or herbal
    preparations is often recommended.
  • Dietary advice may also be given. Most
    reflexologists work on the feet, although the
    hands may also be involved.
  • A treatment session lasts around 40 min.
    Practitioners usually advise their patients that
    the effects of a treatment may last up to a week.

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Practice
  • The need for further treatment will vary
    according to the severity of the condition and
    the patient. The following benefits are possible
  • Improved urination
  • Improved digestion
  • Heightened sense of energy
  • Reduction in pain.

90
Rolfing
  • When the body gets working appropriately the
    force of gravity can flow through then,
    spontaneously, the body heals itself.
  • Dr Ida P Rolf

91
Rolfing
92
Definition
  • Rolfing is a comprehensive system of hands-on,
    connective tissue manipulation and movement
    education that releases stress patterns in the
    human organism.
  • As with other similar techniques (e.g.
    Feldenkrais), rolfing seeks to organise and
    integrate the body in relation to gravity by
    manipulating the soft tissues or by correcting
    inappropriate patterns of movement.
  • The final goal is that the client can move and
    function with greater freedom, and effortlessly
    maintain a more upright posture.

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History
  • Rolfing is the creation of Dr Ida Rolf, a
    biochemist and physiologist who established the
    Rolf Institute for Structural Integration in
    1970.
  • She believed that, for optimum health, the body
    must be in alignment with gravity any deviation
    from the norm requires extra energy for movement
    and imposes unnecessary strain on the muscles.
  • She contended that, as the muscles work to
    compensate for failing efficiency over the
    passing years, the fascia surrounding them tend
    to bunch up and harden, creating even more
    strain.
  • Ultimately, she said, the cumulative stress can
    interfere with normal breathing and impair
    circulation, digestion and the nervous system.

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Theory
  • The deep massage techniques employed in rolfing
    seek to loosen and relax the fascia the
    membranes that surround the muscles.
  • Rolfers believe that the fascia toughen and
    thicken over time, subtly contorting the body and
    throwing it out of healthy alignment.

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Practice
  • To break up knots in the fascia and reset the
    muscles, rolfers apply slow, sliding pressure
    with their knuckles, thumbs, fingers, elbows and
    knees.
  • The treatments are not mild and relaxing
    indeed, they can cause a degree of pain.
  • However, practitioners view this temporary
    discomfort as a sign that the treatment is
    achieving the changes necessary to bring the body
    back into proper alignment.

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Practice
  • During each session, the rolfer will concentrate
    on a different set of muscles, starting with
    those nearest the surface and moving on to those
    deep within the body.
  • To maximise the benefits of treatment, the
    therapist may also teach selfhelp exercises known
    as movement integration.
  • Sessions usually last 6090 min.
  • The basic sequence of rolfing consists of 10
    sessions through which a new structural order and
    a more efficient movement pattern are developed.

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