Why a regular massage may help depression in my opinion …..

In recent years there has been a movement where Physiotherapy treatment has had a more “hands off” approach, where physical activity and exercise has been the main choice of therapy for rehabilitation instead of the traditional manual therapy. I have found this very difficult to swallow, now don’t get me wrong, exercise as therapy is powerful! In almost every instance a regular exercise and movement practice is a must in order to assist the body to heal. However I am wondering if as therapists we have forgotten the power of therapeutic touch.

Besides the intention of providing joints more freedom of movement and releasing myofascial restrictions, there is something deeper that happens with therapeutic touch. Field et al (2004) studied the effects of massage therapy on 84 depressed pregnant women. The researchers put the women in three groups; a massage group where the women received hands on massage twice a week for 16 weeks, a progressive muscle relaxation program and the third group received standard prenatal care alone. What the researchers found was that the women who were in the massage group had a 23% decrease of cortisol in their saliva, a 25% increase of dopamine and a 23% increase of serotonin in their urine.

Now remember cortisol is the end product of the sympathetic nervous system or the “fight or flight” response, basically cortisol is what is released in your body as a response to stress or danger. On the other hand dopamine and serotonin are activating central nervous system neurotransmitters that contribute to feelings of well being and happiness.

Field and another group of researchers did another study looking at 32 depressed adolescent mothers. They had 2 groups; one group received relaxation therapy over 5 weeks while the other group received ten 30 minute massage sessions over the same time. In this study the researchers found that only the massage group showed behavioural and stress hormone changes, in particular there was a decrease of salivary and urine cortisol by 28% at the end of the 5 weeks.

The positive biological and physiological effects of human touch is not just seen in “therapeutic touch” but also in hugging! A study completed by Light et al (2005) examined 59 premenopausal women before and after contact (hugging) with their husbands. What they found was that frequent hugs between spouses and partners are associated with lower blood pressure and higher oxytocin levels in premenopausal women. Oxytocin is a hormone this is often called “the love hormone” as it plays a role in social bonding, sexual reproduction and childbirth.

In another study where researchers took 230 cancer patients and put them into 2 groups; one group received massage therapy and “healing touch”, while the other group received standard care. What they found was that the group that received massage and “healing touch” had a decrease in blood pressure, respiratory rate and heart rate, basically they were more into their parasympathetic nervous system or “rest and digest”.

So as you can see interpersonal touch wether in the form of manual therapy or a hug plays an important role in governing our emotional and physical well-being. So if you’re on a healing journey and your addressing your physical health through diet and exercise; why not also think about receiving or seeking out regular manual therapy to improve your emotional and physical health.

Ericka offers Zen Thai Shiatsu massage therapy, with a special interest in head, neck and jaw and pre and post natal care.

Field, T., Diego, M., Hernandez-Reif, M., Schanberg, S., & Kuhn, C. (2004). Massage therapy effects on depressed pregnant women. Journal of Psychosomatic Obstetrics & Gynecology, 25(2), 115–122. doi:10.1080/01674820412331282231

Field,T., Grizzle, N., Scafidid, F., Schanberg, S. (1998) Massage and relaxation therapies’ effects on depressed adolescent mothers. Complementary Therapies in Medicine, 6(1), 57. doi:10.1016/s0965-2299(98)80070-8

MuLight, K. C., Grewen, K. M., & Amico, J. A. (2005). More frequent partner hugs and higher oxytocin levels are linked to lower blood pressure and heart rate in premenopausal women. Biological Psychology, 69(1), 5–21. doi:10.1016/j.biopsycho.2004.11.002

Post-White, J., Kinney, M. E., Savik, K., Gau, J. B., Wilcox, C., & Lerner, I. (2003). Therapeutic Massage and Healing Touch Improve Symptoms in Cancer. Integrative Cancer Therapies, 2(4), 332–344. doi:10.1177/1534735403259064

Part II Voice Physiotherapy & altered head posture in my opinion ….

In part I of voice physiotherapy I explained what MTD is and what physiotherapy for the voice involves. In this post we are going to talk about what you need for efficient voicing and things you can start thinking about for yourself .

There are a few things you need for effortless use of your voice, such as;

  • Healthy vocal cords
  • dynamic vocal cords that are able to be used in an efficient way in walking, sitting and talking
  • efficient breathing pattern and control
  • good laryngeal posture and also overall posture

In this blog my main emphasis will be overall posture. Why? Well In my experience physiotherapists loooove to harp on about “good posture” …… and well … I guess I better stick to the stereotype. But in all seriousness, it is often the one basic thing, that is contributing to peoples symptoms and often all that is needed is a little conscious awareness of habitual positions to change symptoms.

Why is it so important in voice physiotherapy?

It is because head and neck position has a direct influence on how the larynx is positioned.

An “altered head position” often results in a forward head and has been found to decrease the natural curve of the neck. As a result of this angle change, there is a change in the resting length in the neck muscles, in particular, the suprahyoid group. These muscles are located above the hyoid bone (horse shoe shaped bone) and are made up of mylohyoid, digastric, stylohyoid and geniohyoid.

What tends to be the issue is that there is a relative shortening of these muscles. The flow on effect is that this results in a lift of the hyoid bone which then results in an elevated larynx due to the fact that there are muscles that attached from your hyoid bone to your thyroid cartilage.

When this happens there is a disruption to the way the cricothyroid muscles work (see below for image). The cricothyroid muscles are not attached to the vocal folds however they influence their length and thickness by causing movement at the cricothyroid joint, which indirectly causes the vocal folds to elongate and narrow, raising the pitch of the voice. When there is an elevated larynx the cricothyroid muscles are placed in a biomechanical disadvantage where they have to work harder to elongate the vocal folds.

So to put it simply, having an altered head position results in vocal range difficulties due to structures and muscles having a biomechanical disadvantage. This makes muscles work harder and inevitably making them weaker. It takes time to improve your posture, you may need some flexibility in your thoracic spine, strength and endurance in the posterior muscles of your body and you may even need to increase your body awareness. However if you are having issues with your voice whether that may be poor quality, increased effort, fatigue or pain why not see if using your voice with a nice neutral position of the head and neck and see if that changes your symptoms.

References:

  1. Honda, K., Hirai, H., Masaki, S., & Shimada, Y. (1999). Role of Vertical Larynx Movement and Cervical Lordosis in F0 Control. Language and Speech, 42(4), 401–411. doi:10.1177/00238309990420040301
  2. Jull, G. A. (2000). Deep Cervical Flexor Muscle Dysfunction in Whiplash. Journal of Musculoskeletal Pain, 8(1-2), 143–154. doi:10.1300/j094v08n01_12
  3. Rubin, J. S., Blake, E., & Mathieson, L. (2007). Musculoskeletal Patterns in Patients With Voice Disorders. Journal of Voice, 21(4), 477–484. doi:10.1016/j.jvoice.2005.02.001

Voice physiotherapy (Part I) in my opinion …..

When you think of physiotherapy, your first reaction may not necessarily be to think of the voice, rather you might think about shoulder or back pain… and to be honest voice physiotherapy is a relatively new concept in the physio arena. However over the past decade there has been an increase in evidence to show that there is efficacy for the use of manual therapy of the laryngeal and perilaryngeal (around the larynx) area for Muscle Tension Dysphonia (MTD).

So lets talk about Muscle Tension Dysphonia. What is it?? MTD is a common disorder of the voice where there is excessive muscle recruitment which results in incorrect vibratory patterns of the vocal folds and altered voice production. This can really negatively impact your life especially when you think about the fact that your voice is how you communicate with the world and if you use your voice as part of your profession and daily work then it may impact you quite heavily. I think it is important to remember that it is not only singers who use their voice in their profession… school teachers, trainers, lawyers, hairdressers, call centre employees all use their voice an extensive amount.

How does MTD start? Before we answer that lets think about normal anatomy of the voice, when there is normal voice production the expiratory airflow causes the small intrinsic muscles of the larynx to vibrate. The muscles contract and relax allowing the vocal folds to move and produce sound. The larger extrinsic muscles such as the supra hyoids and infra hyoids give the larynx stability while the voice production is being made.

Tomlinson and Archer (2015) explain that MTD starts when there is an increase in tension of the extrinsic muscles, this increase in tension can cause mal-positioning of the larynx which then has a flow on effect of increasing the tension of the intrinsic muscles and vocal folds.

What symptoms do people report with MTD?

  • Altered vocal quality
  • increased vocal effort
  • vocal fatigue
  • pain
  • elevated hyoid bone and thyroid cartilage

What does voice physiotherapy involve?

The main aim with voice physiotherapy is to restore the tissue quality, length tension relationship between muscles and improve bio-mechanical efficiency, with an overriding goal to improve the efficiency of the vocal fold vibration and voice production.

Voice physiotherapy sessions may involve:

  • soft tissue and myofascial releases
  • trigger point therapy
  • laryngeal mobilsations
  • cervical spine mobilisations
  • TMJ management
  • soft palate release
  • diaphragm release
  • shoulder girdle management

A common theory that is spoken about in voice physiotherapy is the idea that a “maladaptive voice cycle” occurs with MTD. When you are in the cycle compensatory neuromuscular recruitment keeps you in the loop. It is also important to note that there are many other factors feeding into this loop such environmental, psychological and vocal load.

Because MTD is multifactorial in nature it is really important to have a team to support you on your healing journey because once you start to get a better length tension relationship with your voice muscles it is important to use this window to then reeducate the muscles in this area to produce a more efficient voice production. So as well as physiotherapy it is crucial to have one or more people on board; voice coach, speech pathologist, ear nose and throat specialist, GP.

If any of this resonates with you, please feel free to contact me to book an appointment.

References:

Tomlinson, C. A., & Archer, K. R. (2014). Manual Therapy and Exercise to Improve Outcomes in Patients With Muscle Tension Dysphonia: A Case Series. Physical Therapy, 95(1), 117–128. doi:10.2522/ptj.20130547

Rubin, J. S., Blake, E., & Mathieson, L. (2007). Musculoskeletal Patterns in Patients With Voice Disorders. Journal of Voice, 21(4), 477–484. doi:10.1016/j.jvoice.2005.02.001

Van Lierde, K. M., Bodt, M. D., Dhaeseleer, E., Wuyts, F., & Claeys, S. (2010). The Treatment of Muscle Tension Dysphonia: A Comparison of Two Treatment Techniques by Means of an Objective Multiparameter Approach. Journal of Voice, 24(3), 294–301. doi:10.1016/j.jvoice.2008.09.003

In my opinion…..Why we may find it hard to do things that are good for us.

Over the years working as a physiotherapist I have given countless exercise programs, advice for injury prevention and have provided things for people to do to promote an environment conducive to healing. During my initial years of practising as a physio I became confused and frustrated with the amount of times that people didn’t follow through with what I had asked of them. I wondered why they didn’t do the very things that would help them out of the situation they were in. Along the way on my own healing journey, I realised that in different scenarios I too was much the same. I found it difficult to maintain a regular meditation practice and strengthening program in the mornings, the very things that I knew would really benefit my health.

It has only been recently that I’ve started to ponder why we as humans find it hard to do things that are good for us. Then I heard about the “I am not enough” epidemic. Have you heard of this?

Therapist and behaviour expert Marisa Peer talks about an “I am not enough” epidemic that starts at a very young age. From infancy to age 3 we can do absolutely anything and still feel unconditional love from our caretakers. We can break expensive pieces of furniture, throw our entire plate of dinner on the ground, spill milk and we still will always receive unconditional love. However beyond the age of three we start a process where we need to ‘do things’ to get positive reinforcement and praise, which sets up a thought process where we feel that we need to do something external to be loved. We need to put toys back in the toy box and then we get love, we need to get a sticker on our homework then we will be loved, we need to excel at school and get good grades then, we will be loved. Peer talks about how these messages can be translated into core beliefs about ourselves and as adults we may feel that we are not enough until others say we are enough.

When you really think about it, feeling that you are enough is a feeling of self love and acceptance. If we don’t have this basic self acceptance and self love it would be difficult to conjour the motivation and energy to do the very things that we know are good for us. If you don’t feel that strong sense of self love there may be a lot of resistance to doing nice things for yourself.

I have realised that there is no use in feeling frustrated or lecturing people about what they need to do… but rather, to simply help support them and encourage a space where they can cultivate this self love and acceptance themselves. Inevitably they will become the the loving parent, the encouraging teacher, and their own greatest fan. When we live from a place of such high self worth, doing even just a little self care in the morning becomes easy. Once we are at the top of our own priority list, those things we need to do for ourselves become easier to get done.

So in honour of loving ourselves I share this poem written by Charlie Chaplin, written the day he turned 70! It is said he discovered that self-love puts everything in a different perspective and makes life light and more beautiful.

As I began to love myself I found that anguish and emotional suffering are only warning signs that I was living against my own truth. Today, I know, this is “AUTHENTICITY”.

As I began to love myself I understood how much it can offend somebody if I try to force my desires on this person, even though I knew the time was not right and the person was not ready for it, and even though this person was me. Today I call it “RESPECT”.

As I began to love myself I stopped craving for a different life, and I could see that everything that surrounded me was inviting me to grow. Today I call it “MATURITY”.

As I began to love myself I understood that at any circumstance, I am in the right place at the right time, and everything happens exactly at the right moment. So I could be calm. Today I call it “SELF-CONFIDENCE”.

As I began to love myself I quit stealing my own time, and I stopped designing huge projects for the future. Today, I only do what brings me joy and happiness, things I love to do and that make my heart cheer, and I do them in my own way and in my own rhythm. Today I call it “SIMPLICITY”.

As I began to love myself I freed myself of anything that is no good for my health – food, people, things, situations, and everything that drew me down and away from myself. At first I called this attitude a healthy egoism. Today I know it is “LOVE OF ONESELF”.

As I began to love myself I quit trying to always be right, and ever since I was wrong less of the time. Today I discovered that is “MODESTY”.

As I began to love myself I refused to go on living in the past and worrying about the future. Now, I only live for the moment, where everything is happening. Today I live each day, day by day, and I call it “FULFILLMENT”.

As I began to love myself I recognized that my mind can disturb me and it can make me sick. But as I connected it to my heart, my mind became a valuable ally. Today I call this connection “WISDOM OF THE HEART”.

We no longer need to fear arguments, confrontations or any kind of problems with ourselves or others. Even stars collide, and out of their crashing new worlds are born. Today I know “THAT IS LIFE”!”

― Charlie Chaplin

Did you know that playing the Didgeridoo could help you decrease snoring?

One thing that sets physiotherapists apart from other forms of manual therapy is that we love giving out exercises to help the underlying issue. As a physio working in the head, neck and jaw area my exercises don’t always look like what a general musculoskeletal physio would give. So when I saw the literature regarding the use of didgeridoo to strengthen the muscles of the upper airways, I was very intrigued.

A question I ask every person who comes in with head, neck and jaw issues is “how do you sleep?”. There is 2 reasons for this; the first is poor sleep almost always affects your symptoms (read more about that here) and secondly some people report snoring which then tells me a little bit about the integrity of their upper airways.

The sound of snoring occurs when there is vibration of the lips, tongue, muscles of the throat and diaphragm. The vibration occurs due to these muscles having less tension and tone, when this occurs the tongue falls back and the throat narrows. The more relaxed these muscles get, the more vibration and the more vibration the louder the sound. If there is enough relaxation then the throat closes up and you are unable to get oxygen in which then would be classed as obstructive sleep apnoea (OSA).

When someone tells me they snore I have suspicions that they may not be getting a restful sleep each night (and neither would their partner!) and that they may need some training and strenghthening of their upper airways.

A recent randomised control study looked at 25 patients with a apnoea-hypopnea index (an index used to show the severity of sleep apnea) of 15-30 (classified as moderate sleep apnoea). They gave these individuals 4 months training of playing the Aboriginal instrument, the didgeridoo.

What the training involved was:

  • Teaching the participants the lip technique to produce and hold a note for 20-30 seconds
  • Circular breathing, which involves inhaling through the nose while maintaining airflow through the didgeridoo using the cheeks
  • Mastering the complex of the lip and vocal tract allowing the vibrations to move from the upper airway to the lower airways
  • Practising at home for 20 minutes 5 days a week

What the researchers found was that there were improvements with day time sleepiness and that the apnoea-hypopnoe index improved. So why did this happen?

Playing the diderigoo trains the muscles of the upper airways, it is these muscles that maintain airway dilation improving the stiffness of the walls. This is mainly done through the circular breathing process which uses the tip and mid portion of the tongue, cheek muscles and diaphragm. Do these muscles sound familiar? They are in fact the muscles that relax and vibrate with snoring!

Now don’t get me wrong, there are many ways to skin a cat, I mean through my speciality of treating the head, neck and jaw I focus a lot on training the muscles of the lips, tongue and cheeks using different techniques in order to strengthen the tongue and inevitably stabilise the jaw. However I love the sound of the didgeridoo and I am sure there may be many other people out there who feel the same. There is something very soothing and meditative about the drone sound it creates and I feel we need to remember that there are different strokes for different fokes and for some individuals the exercises I would normally provide to strengthen the orofacial muscles may be very boring and unmotivating and there may be some people out there who feel that playing the didgeridoo would mean practising an instrument they have always been fond of and at the same time they would be getting the upper airway strengthening they may need.

This study showed didgeridoo playing improved daytime sleepiness in people with moderate snoring and obstructive sleep apnoea but of course this doesn’t mean that if you snore that you need to go out and purchase a didgeridoo from your local music store! Like many studies, more extensive research needs to be produced, but if you already own a didgeridoo or have always wanted to learn how to play and you know you snore why not play a little more or give it a go and see what happens with your snoring.

References:

Wuhan et al. (2005) Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial BMJ; 332