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The following was a treatment plan submitted during our clinical training at the Swedish Institute in NYC. It provides detailed, step-by-step instruction on a western style, medical massage approach for clients dealing with severe rheumatoid arthritis. While it might be more on the technical side, it should underscore the amount of consideration taken in a clinical setting where massage is administered every week, for a 6-8 week period.

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Goals for treatment should include: increasing flexibility and range of motion (ROM); relieving aches and pains related to muscle stiffness; increasing circulation – especially in clients with cardiovascular issues; reducing inflammation and joint pain during chronic flare ups/remissions; reducing contractures and adhesions; reducing anxiety and depression related to RA.

Bolstering to the knees, hip/lower back, and cervical spine may aid in relieving undue stress at these joints. Staying within a client’s pain threshold and using care to not apply overpressure when performing ROM, should also be observed. Some clients may develop osteoporosis, so caution should be taken with the amount of pressure used during a session.

Starting in supine, so as to better perform ROM and stretching techniques, we would begin at the arms. Moving the shoulder joint through coronal abduction/adduction, flexion/extension, medial/lateral rotation several times in order to warm up the joints and increase ROM. Moving down to the elbow and performing flexion/extension, supination/pronation, and finally the wrist with flexion/extension, radial/ulnar deviation, and circumduction. Taking the client through these gentle movements is invaluable in breaking up any fibrotic changes that may have taken place.

Applying myofascial release with passive stretching to the wrist flexors, biceps at the forearm, and pectoralis major at the shoulder, is a great way to promote length along these potentially hypertonic muscles. Resisted isometric tests (RIT) to the clavicular and sternal fibers of pectoralis major, followed by circular friction, will help to open up the chest and promote deeper breathing in this restricted area. Trigger point work, especially to the flexors of the wrist, may help to break up adhesions and promote blood flow to the area. Passive extension of the digits of the hand along the MP & DIP joints will promote lengthening in flexor digitorum superficialis and flexor digitorum profundus, respectively. Care should be taken with any ROM techniques at the wrist and fingers, since arthritic flare-ups and local osteoporosis are very common in these areas.

At the knees and ankles, gentle ROM would be performed. Cross fiber friction along the patellar ligament and muscle stripping of the quadriceps would promote length in these muscles. Mobilization of the patella itself, if not too painful for the client, would help to break up any fibrotic adhesions related to joint degeneration. Muscle stripping the tendons of the plantar-flexors and peroneals, would promote length and increase ROM. Cross fiber friction to the tendons would help to realign any scar tissue that may be present. Deep effleurage and petrissage to the foot will help to relax the client and increase blood flow to the extrinsic muscles of the foot.

In prone, vibration up the paraspinal muscles, followed by some myofascial release, would promote a deep state of relaxation and provide a nice warm-up of the area. Circular friction along the attachments for levator scapulae and upper trapezius would help to separate and realign its fibers. Muscle stripping and cross fiber friction to the erector spinae would help to release any adhesions related to muscle imbalance. At the hip, deep petrissage and circular friction along the fibers of quadratus lumborum would help to increase circulation and alleviate any pain resulting from contracture of this hip hiker muscle. Finally, RIT to the Hamstrings followed by myofascial release along its fibers would increase inhibition and allow for a deeper stretch of the fascia and its fibers.


joe-azevedo2Joe Azevedo is a New York State/NCBTMB Licensed Massage Therapist, ARCB Certified Reflexologist, and an Advanced Reiki Practitioner. He is a graduate of the Swedish Institute and is the owner and founder of Brooklyn Reflexology.

Rheumatoid arthritis (RA) is an autoimmune disease which causes chronic inflammation of the joints of the body. Systemic by nature, it can also affect surrounding structures such as muscles, tendons/ligaments, blood vessels, and organs. The most commonly affected sights, however, include the small joints of the hands and feet, elbows, ankles, and knees. Women are three times more likely to be affected and its onset commonly occurs between the ages of 40 and 60.

RA often impacts multiple joints in an insidious, bilateral fashion (that is, if the right wrist is affected, the left will be as well). Sufferers often experience episodic flare-ups followed by remissions, which can last weeks to years. During flare ups, symptoms can range from fever, chills, fatigue, muscle pain, loss of appetite, to joint inflammation (redness and heat) and joint stiffness – which in most cases gets progressively worse.

In extreme cases, the condition can lead to gnarled and distorted deformities of the joint, loss of range of motion (ROM), and chronic pain. Inflammation of organs such as the heart and lungs can cause serious cardiovascular disorders and invariably results in organ failure. It has also been known to cause a condition called Vasculitis (inflammation of the blood vessels), which if not treated properly, can lead to necrosis of tissue. Since RA is a degenerative joint disease, it is not uncommon for suffers to eventually develop some form of muscular atrophy and local osteoporosis surrounding the affected joints.

The causes of RA are unknown, although it is thought to be a genetically inherited condition. Triggers such as streptococcus infections, viral and other bacterial infections, as well as smoking in some cases, are all believed to play a part. For some unknown reason, the body’s immune system attacks the synovial membranes of the body. Antibodies (RA factor) and inflammatory mediators produced by lymphocytes and white blood cells are produced and proliferated throughout the joint spaces and synovial linings. An inflammation response ensues, causing the synovial lining to thicken and swell. A substance called “Pannus”, which is produced by the cells of the lining, slowly erodes away the joint capsule, the articular cartilage, and eventually the bone. As a result, scar tissue develops and forms an ankylosis. Whether it be a fibrotic ankylosis restricting the ROM of a joint, or a bony ankylosis which fuses the bones together, the results can be debilitating.

The emotional and psychological implications of the condition are commonly fraught with chronic pain and daily limitations. During flare-ups, sufferers often experience pain in the morning and after prolonged periods of inactivity. This fact makes getting up in the morning and facing the day a particularly daunting task. As a result, sufferers tend to group their errands and tasks into as few activities as possible – so planning and forethought is of major importance. Socially, people with RA tend to curtail their interactions and engagements with others out of sheer necessity. Dancing, playing sports, or even going for a stroll, take on a whole new meaning. Emotionally speaking, this decrease in contact with others can take its toll on some.

Common treatments for RA can include taking aspirin and cortisone to reduce inflammation to anti-biotics and physical therapy for long-term sufferers. Immunosuppressants such as methotrexate have become popular in preventing further joint degeneration. NSAIDS, gold salt injections, and various other anti-inflammatory drugs have been used to alleviate pain. And as we will see, a treatment plan during periods of remission to help increase circulation, ROM, and decrease stiffness and pain at the affected joints.


joe-azevedo2Joe Azevedo is a New York State/NCBTMB Licensed Massage Therapist, ARCB Certified Reflexologist, and an Advanced Reiki Practitioner. He is a graduate of the Swedish Institute and is the owner and founder of Brooklyn Reflexology.

Nowadays the amount of stimuli and stressors we have to contend with in our day to day lives can be overwhelming. When you consider the fact that over 80% of all disease and illness is stress related, it becomes clear how crucial lowering stress levels can be.

It’s important first of all to make a distinction between ‘good’ stressors, which can be useful and productive, and ‘bad’ stressors, which can be harmful and destructive. A certain amount of tension in the body is necessary to prepare us for life’s challenges. Exercise is an example of a ‘good’ stressor. As long as we can manage the stressor, then it can have a positive effect on our lives. When the stressor becomes chronic or overwhelming however, then it can have the opposite effect.

Hans Selye first made popular the idea of a ‘General Adaptation Syndrome’ or ‘G.A.S.’ in his book, “The Stress of Life.” In it he describes the three stages we go through during a stress response. The first stage is the ‘alarm stage.’  It is here that the body’s ‘flight or flight’ response kicks in via the sympathetic nervous system. Under stress, the body prepares itself to take action by contracting muscles, dilating pupils, elevating glucose and oxygen levels, increasing circulation, and diverting energy stores away from low priority areas, such as the digestive and urinary systems. During the alarm stage, the hypothalamus releases two important neurotransmitters that make these changes possible: epinephrine and norepinephrine.

The second stage is known as the ‘resistance stage’ or adaptation response. During this phase, the body continues to fight off the stressor long after the alarm stage has passed. With the help of the hypothalamus, the pituitary and adrenal glands release cortisol and other corticosteroids into your system. These hormones help to increase blood pressure, cardiac output and gastric secretions by elevating the body’s blood sugar levels. Cortisol has an anti-inflammatory effect but it can also suppress the immune system in varying degrees.

The third and final stage is known as the ‘exhaustion stage.’ Exposure to long-term stress can have damaging effects on the body. If the stress response does not abate, cortisol levels can accumulate in the body and eventually start to weaken the heart, kidneys, adrenals, and blood vessels. The prolonged presence of cortisol can also inhibit the formation of new bone and lead to muscle wasting. It is during this time that the body becomes vulnerable to stress related disorders. Here are a few common stress related disorders:

– Asthma

– Irritable Bowel Syndrome

– Constipation

– Insomnia

– Rheumatoid arthritis

– Gastritis or Ulcers

– Hypertension

– Autoimmune disease

– Ulcerative Colitis

– Eczema

– Depression

– Coronary disease

– Crohn’s disease

– Psoriasis

– Headaches

– Stroke

So how does one maintain a normal and healthy stress response and prevent these conditions from taking hold? The key lies in a preventative care approach to health. Preventative care can take many forms, such as:

– Regular exercise

– A well balanced diet

– Meditation

– Rest & relaxation

– Adequate sleep

– Psychotherapy

– Massage

– Yoga

All these are positive ways in which we can cope with the stresses of our everyday lives. A preventative care approach to health helps create an awareness of our mental and physical well being. It brings balance into our otherwise busy lives.  When we’re in touch with how our bodies feel, we’re better able to detect when something is off or doesn’t feel quite right. This awareness is key. The quicker you can catch something, the quicker you can prevent it from taking hold.


joe-azevedo2Joe Azevedo is a New York State/NCBTMB Licensed Massage Therapist, ARCB Certified Reflexologist, and an Advanced Reiki Practitioner. He is a graduate of the Swedish Institute and is the owner and founder of Brooklyn Reflexology.

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July 2020
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