Quick quiz to demonstrate techniques.
Demonstration and practice of common manipulation techniques.
Passive movement of neck.
Passive movement of arms.
Passive movements of back, waist, spine.
All of these movements are indicated for low back, waist, spine problems.
It is best to perform back flexion movements when there is excessive LORDOSIS and tightness of the lower back, and weak abdominal muscles. Back flexion should NOT be used in severe back pain, pain/tingling down leg, or bulging of discs. #4 (Straight Leg Raise) is often used for diagnostic purposes of low back pain.
Back extension movements may be used for acute back pain, pain/tinglig down leg, or bulging discs, with caution. Oftentimes these techniques are combined with focused deep-pressing on a problematic area or a significant point.
Twisting movements may also be used for acute back pain. If the practitioner is able to palpate specific rotated sections of the spine, then pressure is applied to the side that "juts out", as the passive movement is applied.
Back flexion passive movements:
1) Jerk and drag to relax the waist. (Patient supine)
a) Flex and press patient's knee toward chest (diseased side first).
b) Immediately drag down and pull.
c) Repeat on other side.
d) Can be done on both legs.
2) Deep-press bent legs to tug at the waist. (Patient supine, healthy leg straight, diseased leg bent)
a) Hold diseased knee with one hand, grasp far side of table with other hand.
b) Gradually press knee into chest as far as it will go (using weight).
c) Repeat for healthy side.
3) Forward bend into sitting position. (Patient starts off supine).
a) Stand at patient's feet. Reach for patient's wrists, and grab with both hands (patient may also grab your wrists at the same time).
b) Pull toward you until patient is sitting upright. Continue pulling until patient's upper body is facing down. If you have an assistant, s/he may push on patient's back at the same time.
4) Straight leg raise. (Patient is supine).
This is the traditional SLR technique. It should be not be done past the point of discomfort. It is often alternated with the pull-shake-rotate techniques.
Back Extension Passive Movements:
1) (Patient is prone). Lower back extension, using the leg as the lever.
a) Deep-press problem area of back, waist or spine with one hand or knee.
b) Hold ankle of one leg with other hand and lift up or pull toward back to tug at the waist. This can also be done with patient bending knees to touch the buttocks, and with practitioner lifting patient's leg at the knee.
2) (Patient is sitting). Upper back extension, using the shoulders as the lever.
a) Deep-press problem area of back with one raised knee.
b) Hold both shoulders (hands over deltoids) and pull back moderately to expand chest and stretch back.
Back Twisting Passive Movements:
*Note: Twisting movements of the back can actually look very similar to Back Extension Passive Movements. The difference is in the direction of the pull. If the pull is straight back, then the technique is more oriented towards back flexion. However, if the pull is oblique, or "on the angle," then the technique tends to be more oriented towards twisting.
1) (Patient is prone). Upper back twist, using the shoulder as the lever.
a) Deep-press problem area of back with one hand.
b) Pull opposite shoulder with other hand (over deltoid) to twist spine and stretch shoulder as far back as possible. Note that you are reaching across the table to the opposite shoulder to pull it.
*Variation: to work on rhomboids: (Patient is prone, with arm behind back in arm-bar position). Either use a knife hand to slip in under the medial scapula, or use thumbs/fingers to press on rhomboids in region of medial scapula with one hand. The other hand pulls opposite shoulder, as above.
2) (Patient is prone). Lower back twist, using the leg as the lever.
a) Deep-press problem area of back/waist/hips with hand/elbow/etc.
b) Hold the front of the thigh of the opposite leg, and pull UP AND TOWARDS YOU. Note that if you pull towards you, on the angle, this becomes more of a twist, and less of a simple back extension.
3) (Patient is side-lying). Lower back twist, using the hip as the lever.
a) With the patient in side-lying position, and you standing at the patient's back, straighten the "lower" leg (the leg directly on the table), and bend the "upper" leg to an appropriate angle. Note that the angle is important. If you bend the "upper" leg so that the angle is more perpendicular to the body, then the twisting stretch is more extreme, involves the hips more, and tends to be more localized to the lower back. If you bend the "upper" leg so that the angle is obtuse to the body, then the twisting stretch tends to be less extreme, involves the hips less, and tends to involve the entire back (and side of the body).
b) "Push" or press the hip forwards (away from you) while you "pull" the shoulder/arm back (towards you, or down towards the table surface).
*Note: a variation of this involves replacing the push forwards on the hip with a deep-press with hands/elbow on problem areas.
4) (Patient is side-lying). Upper back twist, using the shoulder as the lever.
This is the opposite of #3, and is better for the upper back.
a) With the patient in side-lying position, and you standing at the patient's back, straighten the "upper" arm so that it is reaching for the upper corner of the table. Straighten the "upper" leg so that it is hanging back behind the patient's body.
b) "Push" or press the shoulder forwards (away from you) while you "pull" the "upper" leg back. Pull the upper leg back at the thigh or at the knee.
*Note: as for #3, you may replace the push forwards on the shoulder with a deep-press with hand on problem areas.
Passive Movements of Legs and Feet
We've already gone over many of the techniques for the legs and feet when we went over rectifying, pulling, rotation and shaking.
Keep in mind that rectifying, pulling, etc. can be applied to ALL joints of the legs and feet, not just the hips. So the knees, ankles, and even each individual toe can be rectified, pulled, etc.
*****
HEAD AND FACE ROUTINE
Before we go into the actual description of the head and face routine, we need to familiarize ourselves with a few acupuncture points. You will not need to use ALL of these points for every treatment, as each has somewhat specific indications. ALTERNATIVELY, you may perform the routine by just following channel lines, without paying attention to specific points. I will go over the channel method later.
Here are some important acupuncture points:
- DU 20 (sometimes written as GV or Governor Vessel 20): This point, for our purposes, lies at the vertex. More specifically, it lies a bit behind the actual top of your head. A shortcut for finding it is to draw a line up from the most posterior (back) part of the ear, up to the top of the head.
DU 20 or Baihui (100 Meetings) is where the energy of all meridians (directly or indirectly) meet. This point is used to draw energy up, or sedate excess energy. It can be used to calm the spirit, and treat headaches due to wind or heat.
- GB 20 Fengchi (Wind Pool): This point is located just below the occiput, between the origins of the trapezius and the sternocleidomastoid. If you squeeze the back of your neck, you are, for the most part, feeling the borders of the trapezius muscle on your neck. If you follow the trapezius up to the occiput, to the deep hole below it, you are on GB 20.
This point, as its name implies, is used to treat Wind (which involves all sorts of problems, from dizziness to headaches). It is also an important point to treat eye disorders.
- Yintang (Hall of Impressions): This point is basically located at the third eye. It is at the midpoint between the medial extremities of the eyebrows. It is used to calm the shen, and to treat headaches, and nasal disorders.
- Du 26 (or GV 26: Man's Middle): This point is on the FRENULUM, that little valley between the nose and the upper lip. It is about 2/3 of the way up (or 1/3 of the way down). This point is a "balanced" resuscitation point, but in a larger sense, it unites the Yin and Yang energies of the body.
- Du 27 (or GV 27): This point is on the upper lip. Used primarily for local lip issues.
- Ren 24 (CV 24 Chengjiang, Container of Fluids): This point is in the mentolabial groove, that dent between your chin and the lower lip. Used for mouth disorders, including problems with salivation.
- UB 1 Jingming (Bright Eyes): This point is located just (0.1 cun) medial and superior to the inner canthus of your eyes (the inner corner of your eyes). It is used, as the name implies, for eye disorders.
- LI 20 Yingxiang (Welcome Fragrance): This point is located at the top of the nasolabial grooves (the crevice that joins your nostrils to the edge of your lips). It is technically about halfway up the ala nasi. This point, as the name implies, is used for nasal disorders.
- St 4 Dicang (Earth Granary): located a little off the corner of the lips, at the bottom of the nasolabial groove. Used, in conjunction with the next two points, for mouth disorders (deviations of the lips, Bell's palsy, etc.).
- St 7 Xiaguan (Below the Joint): feel the cheek bones (maxilla). Now feel the hollow under the cheekbones. Follow the underside of the cheekbones back towards the ear, until you stop because you hit bone (the condyloid process of the mandible). This is St 7.
- St 6 Jiache (Jawbone): Have the patient clench their teeth. The jaw muscles (near the angle of the mandible) should bulge up. This point, St 6, is on the belly of those muscles (the masseters), about a finger's-breadth anterior to the angle of the mandible.
- Taiyang (Greater Yang): This point is located on the temple area. Find the lateral extremity of the eyebrow (SJ 23) and the outer canthus of the eye. Now take the midpoint of those two points, and slide your finger very slightly back into a depression. This is Taiyang. It is used for migraine headaches.
- SI 19 (Tinggong, Palace of Hearing): This point is level with the prominence of the tragus, which is the flap of cartilage that "lids" the ear. It is used for hearing disorders.
- SJ 17 (Yifeng, Wind Screen): This point is located in a deep depression behind the ear lobe. It too is used for ear disorders.
***
HEAD AND FACE ROUTINE
(Patient is sitting)
1) Stroke and caress the head to benefit the brain.
a) Stroke head front to back from hairline to hairline; start slow to fast, rubbing the scalp repeatedly. Rub left side first, then right side, and then middle.
b) Interlace fingers and rub both GB 20 with thenar eminences joined together.
c) Clutch and grasp large handfuls of hair (don't PULL!!! BE GENTLE!).
d) Pound Du 20 with open fists lightly.
2) Open Passes and dredge Apertures
a) Divide the forehead by rubbing outwards with both thumbs from Yintang to lateral hairlines.
b) Pinch the browline between index finger and thumb of both hands, from Yintang out to the end of the eyebrows several times.
c) Nip and knead (30 small circles) the following points: Yintang, Du 26, Du 27, Ren 24 (Generally, for activating and balancing Yin and Yang); UB 1 (for eyes); LI 20 (for nose); St 4, 7, 6 (for jaw problems; you can use your thumb, index finger, and middle finger to hit all three points at once); Taiyang (for migraine headaches); SI 19 and SJ 17 (for ear problems).
d) Lift and pull both ears from behind several times.
ALTERNATIVELY, you may treat the head and face in supine position, using the chart provided.
***
Homework: Please practice the routine for the Head and Face, so that you can demonstrate it next week.
Monday, June 24, 2013
Wednesday, June 19, 2013
Apologies
Hi everyone,
I'm not sure how many of you access this blog (as the tracker does not register many views), but it is the best way to communicate. I apologize for having to miss this past week's class. I had a family emergency; my uncle was passing away due to pancreatic cancer. I will make up the class, either by extending the class one week longer, or by extending individual classes 30 minutes longer until the time is made up.
Re: the homework, please complete it and we'll go over it next week. I do want to have you demonstrate some of the individual techniques that we have gone over as well.
The plan for next class is to go over manipulations in greater detail (as I just briefly introduced them at the end of the last class). I also want to talk about combined techniques (that is, doing one technique with one hand, and another with the other hand). We will also be starting off routined (or set) segments to address the head.
Thank you for your understanding,
Randy
I'm not sure how many of you access this blog (as the tracker does not register many views), but it is the best way to communicate. I apologize for having to miss this past week's class. I had a family emergency; my uncle was passing away due to pancreatic cancer. I will make up the class, either by extending the class one week longer, or by extending individual classes 30 minutes longer until the time is made up.
Re: the homework, please complete it and we'll go over it next week. I do want to have you demonstrate some of the individual techniques that we have gone over as well.
The plan for next class is to go over manipulations in greater detail (as I just briefly introduced them at the end of the last class). I also want to talk about combined techniques (that is, doing one technique with one hand, and another with the other hand). We will also be starting off routined (or set) segments to address the head.
Thank you for your understanding,
Randy
Class Notes 6
Class Notes 6
Tuina 1 Class Notes 6
Today we will talk about what are usually described as "manipulations," in which we attempt to improve the function of different joints of the body by traction or rotation of those joints. Manipulations are on the border between Tuina (a form of bodywork) and Zheng Gu (bonesetting). When we perform manipulations, keep in mind that we are primarily encouraging the SOFT TISSUE to lengthen to accommodate our manipulations; we are NOT forcibly trying to reset the bones. While resetting may occur as a result of our manipulations, this is not our chief aim.
REAL INJURY can result from attempting to forcibly perform any manipulation. Furthermore, manipulations designed to improve the function of a given joint CAN RESULT IN A WORSENING OF THE CONDITION if they are performed without proper sensitivity (forcibly). So keep the proper spirit when doing these techniques!!!
Usually, manipulations are performed at or near the end of a treatment. You want the tissues of the body to be as soft as possible, so that they can be more or less receptive to the manipulation. You may place manipulations at the very end, or before percussive techniques.
(NOTE: when we learn the routine, we may place certain manipulations at different points in the routine just for logistical purposes. It is inconvenient, after all, to work on the patient in prone position, then supine position, then have the patient get back into prone position to do manipulations. GENERALLY, however, for ANY GIVEN SECTION of the body, we will do all of our other softening techniques, and then perform a manipulation appropriate for that part of the body, in that particular posture.)
When you perform manipulations, you need to be aware of the natural movements of the joint you are working on. The elbows and knees, for example, are hinge joints, and can basically only open and close. Any techniques on them should only encourage opening and closing, NOT TWISTING. If you perform a manipulation on a joint that is not proper to the movement dimensions of that joint, then you are essentially injuring that joint (arguably, you would be doing joint-LOCKING, or even joint-BREAKING).
[Let me amend this: while the elbows and knees are hinge joints, the soft tissue surrounding them may allow and be capable of more dimensions of movement. Note that, with the elbow bent, you can still pronate and supinate the hand; this illustrates a “twisting” motion across a hinge joint.]
In addition to the above, you need to be able to FEEL the borders of a patient's range of motion. A good place to practice is the shoulder. Shoulders are ball and socket joints, and they generally have a wide (spherical) range of motion. With a patient seated, cradle the wrist of the patient's arm with one hand (between your thumb and index finger- tiger's mouth) and place your other hand on the patient's shoulder. First of all, as you extend the patient's arm out, try to feel the weight of the arm. Can you tell if it is relaxed or not? Experiment. Ask the patient to tense up, and see what that feels like. Then ask the patient to relax, and feel the difference.
[This is crucial for these manipulation techniques. Nothing obstructs these techniques more than a patient “superimposing” their volitional movements over your manipulations. Manipulations, in general, are intended to be passive. Note that there are situations in which you would want the patient to actively participate and move a part of the body while you are working on it. We may go over these situations later.]
Now, attempt to take the patient's arm through circles. Start off with very small circles, and gradually, gradually get larger and larger. Eventually, you may begin to reach the borders of the range of motion. You will "feel" it as a kind of resistance, like rubber bands holding back your motion. The sooner you can feel this without "going through it," the better. You may also be able to tell that you are reaching this border by observing your patient's reactions; s/he may tense up as you reach the border. HOWEVER, this is an unreliable marker, as a lot of patients try to mask their reactions (particularly men). Learn to read, through feeling, where the borders are.
So there are three general categories of techniques that I class under Manipulations: Shaking/Trembling (DIFFERENT FROM VIBRATING!), Rectifying/Pulling (basically, it can be thought of as Tractioning), and Rotating.
SHAKING/TREMBLING: This technique is only applicable on the limbs (arms and legs). You grasp the wrist or ankle with both hands, lift the limb slightly (off the table, with the legs, or about level with the shoulder with the arms), FEEL whether or not the limb is relaxed or not, and then, with repeated up and down motions, you SHAKE/TREMBLE the limb. Start off with small and gentle shakes, and gradually build up to larger shakes. DO NOT MAKE YOUR SHAKES TOO LARGE, particularly if the patient has some kind of injury in that limb; it could exacerbate the condition!
Throughout this technique, try to develop the feeling of passing waves through a jumprope.
Different forms include: single arm (usually in seated position), single leg (prone, or side-lying), both legs.
[Note: Just as it is difficult to pass a wave through a rope that is TOO slack, so too is it difficult to pass a wave through a limb that is so slack that it is bent/folded. Gently extend the limb prior to performing shaking/trembling.]
FLEXING/EXTENDING or FOLDING/UNFOLDING joints: This category comes from Maria Mercati's book. It is used for knees and elbows, the hinge joints of our body. All this involves is flexing and extending these joints. Sometimes you can use a fist in the joint, and fold the joint around it like a "nutcracker."
[As stated previously: the elbows and knees are hinge joints, but it is possible to perform other motions with them (or rather, through them) besides opening and closing. To be precise, these motions do not directly involve the hinge joints, but involve the soft tissue either proximal to or distal to the hinge joint. Let’s take the elbow:
Say you have the patient keep their upper arm next to the body, as though it were glued to it. Have the patient bend their elbow 90 degrees. Now, while keeping the upper arm next to the body, you can use the lower arm like a lever, and “turn” the arm in or out. This can also be performed with the upper arm at other angles, like 45 degrees out from the body, or 90 degrees out from the body. This type of motion actually involves what is called “internal or external rotation of the humerus,” and is actually a test for the flexibility and integrity of the rotator cuff muscles in the shoulder (and not the elbow).
Here’s another example. Again, start from the same position as above. Lock the patient’s elbow by gently wrapping your hand around it. Then, have the patient turn their hand palm up and palm down. These motions involve the muscles of the forearm, and are called “supination and pronation.”
Similar exercises can be performed around the knee (although the foot cannot really do the “supination and pronation” motions cleanly).]
ROTATION (YAO): This category involves taking joints through circular range of motions. In the experiment above, we basically did a Rotation technique for the shoulder. It is also possible to do Rotations on the wrist joint, or the hip joint (usually this is done with the patient in supine position), or the ankle joint. Variations for the hip joints include: single straight leg, double straight leg, single leg with the leg folded in towards the chest, both legs bent and together.
Note: Rotation is not performed on the neck. It's not that the neck is incapable of such motions, but it is not necessary for you to control them.
RECTIFYING/PULLING: This is basically traction, although for some reason, depending on the direction and the part of the body you are working on, it can resemble Rotating.
On the limbs, this is relatively simple; you are always pulling OUT from the body. A simple example of pulling is "snapping the fingers."
Note: this is a gentle PULL, NOT A YANK!!! It should feel as though you are pulling a heavy boat into dock with a rope. You don't jerk on the rope, rather, you feel the rope's full length, and THEN using your own body weight, you just allow your "influence" to transfer through the rope.
A slight modification involves combining a pulling motion with a pushing motion. If you want to focus on, say, the wrist joint, then you can use one hand to "push" proximal to the wrist while the other hand "pulls" the patient's hand (distal to the wrist). This "opens" the joint. You can do the same thing for the elbow.
Pulling/Pushing need not only be longitudinal/lengthwise. For example, you can turn the head to one side, "pulling" the head to one side with one hand while the other hand "pushes" on the shoulder.
One of the most critical areas to apply Pushing/Pulling is the back. The back moves in a variety of ways. It can, of course, flex and extend (bend forwards and backwards). Flexion can be "assisted" with the patient in supine position, reaching for his/her toes, while the practitioner (sometimes) works on the back. There are Thai versions of this, but they require the practitioner to "stand on the table." Overall, flexion can best be practiced on the patient in supine or standing positions (there are also side-lying options).
Extension, on the other hand, involves bending backwards (or, alternatively, "opening up the front"). Such exercises involve pulling up or back on corners of the back. The four corners of the back are the shoulders and the hips. If you decide to use the shoulder levers via the arms (particularly the wrists), then you need to be sure that the shoulders are flexible enough to accommodate your pulls (it is often the case that patients cannot extend their arms behind them). If they cannot accommodate your pulls at the wrist, then you may have to directly use the shoulders, which can involve a lot more work on your part. Again, there are a variety of Thai stretches that can provide assistance in this regard, notably the Cobra stretch variations, but they do require a bit of "balancing". There are also variations that can be done in the sitting position.
The back can also side-bend. The side can be worked on in the side-lying position, and it is possible to do some manipulations that open up the side (mostly via a cross pushing motion on the two levers, the rib cage and the pelvis). More extension side-bending can be accomplished in the sitting position, as the table isn't in the way: an elegant (if somewhat ambitious) Thai version is available for this.
The back can twist/rotate. This is by far the most complicated movement of the back. There are versions of twisting the back that can be approximated in both the prone and supine positions. If you think of the back as a rectangle, you are trying to "twist" the rectangle by either "folding back" individual corners, or having opposite corners move in opposite directions. For example, if the patient is prone, you can accomplish some degree of rotation and twist by "lifting" one shoulder (preferably as you "push" into the rhomboids). Or, if the patient is in side-lying position, you can have the top shoulder go "forwards," and the bottom leg go "backwards", and vice versa.
It is also, of course, possible to accomplish a twisting motion in a sitting position. There are varieties of this that can be accomplished in both Thai and Tuina formats.
DEMONSTRATED TECHNIQUES:
NECK: Seated Position, Prayer Hands, Flexion, Extension, Sidebending, Rotation
Supine Position, Cradle/Bridge Hands, Lifting with Slight Traction
Supine Position, Cradle/Bridge Hands under Occiput, Circles
Supine Position, Cross Hands Under Neck, Flexion
Supine Position, One Hand Cradles Occiput, Other Hand placed on Opposite Shoulder, Turning Stretch
SHOULDER TO WRIST:
Seated, Stand to one side and behind patient, Place one hand on top of shoulder (holding points like LI 15), Other hand grasps wrist. Pull at wrist, “Push” (anchor) at shoulder. Accomplish this mainly by turning your whole body slightly rather than by actually using your arms to “pull” or “push.”
In same position, try Shaking, first with very little waves, and then gradually larger and larger, and then Rotating, first with very little circles, and then gradually larger and larger. PAY ATTENTION TO PATIENT’S END RANGE OF MOTION.
*More advanced: Stand to one side of the patient. Step one leg up onto the working surface, such that your knee, if possible, goes into patient’s armpit. One hand goes on patient’s shoulder. The patient’s arm goes BEHIND your back, and you grasp the wrist with your hand. To accomplish traction, you slightly “push” up with your knee, and “pull” primarily by turning your body away from the patient (not by actually “pulling” with your hand).
*Other variations: Opening the Armpit, Finding Wings (using one hand to open front of shoulder while the other Presses in the space under shoulder blade), Water Pump.
Swimming/Brushing Back Hair: Seated, Stand to one side of patient, Support Patient’s Right forearm with your Left forearm (patient’s wrist at your tiger’s mouth), take Patient’s arm through swimming motion or brushing back hair motion to test internal/external rotation at humerus.
Supine. Stand at head of patient, Pull one arm up, Shake (either vertical or horizontal), Rotate. Alternatively, you can try both arms simultaneously.
Supine. Stand at side of patient, Pull one arm, Shake (either vertical or horizontal), Rotate.
ELBOW and WRIST: Pulling/Traction at the elbow and wrist can be accomplished by PULLING below the joint and PUSHING (or rather anchoring) above the joint.
The Elbow can be opened and closed via the Nutcracker technique.
The Wrist can also be flexed and extended, and go through rotation. There is also a technique called Water Faucet which helps with supination and pronation.
Tuina 1 Class Notes 6
Today we will talk about what are usually described as "manipulations," in which we attempt to improve the function of different joints of the body by traction or rotation of those joints. Manipulations are on the border between Tuina (a form of bodywork) and Zheng Gu (bonesetting). When we perform manipulations, keep in mind that we are primarily encouraging the SOFT TISSUE to lengthen to accommodate our manipulations; we are NOT forcibly trying to reset the bones. While resetting may occur as a result of our manipulations, this is not our chief aim.
REAL INJURY can result from attempting to forcibly perform any manipulation. Furthermore, manipulations designed to improve the function of a given joint CAN RESULT IN A WORSENING OF THE CONDITION if they are performed without proper sensitivity (forcibly). So keep the proper spirit when doing these techniques!!!
Usually, manipulations are performed at or near the end of a treatment. You want the tissues of the body to be as soft as possible, so that they can be more or less receptive to the manipulation. You may place manipulations at the very end, or before percussive techniques.
(NOTE: when we learn the routine, we may place certain manipulations at different points in the routine just for logistical purposes. It is inconvenient, after all, to work on the patient in prone position, then supine position, then have the patient get back into prone position to do manipulations. GENERALLY, however, for ANY GIVEN SECTION of the body, we will do all of our other softening techniques, and then perform a manipulation appropriate for that part of the body, in that particular posture.)
When you perform manipulations, you need to be aware of the natural movements of the joint you are working on. The elbows and knees, for example, are hinge joints, and can basically only open and close. Any techniques on them should only encourage opening and closing, NOT TWISTING. If you perform a manipulation on a joint that is not proper to the movement dimensions of that joint, then you are essentially injuring that joint (arguably, you would be doing joint-LOCKING, or even joint-BREAKING).
[Let me amend this: while the elbows and knees are hinge joints, the soft tissue surrounding them may allow and be capable of more dimensions of movement. Note that, with the elbow bent, you can still pronate and supinate the hand; this illustrates a “twisting” motion across a hinge joint.]
In addition to the above, you need to be able to FEEL the borders of a patient's range of motion. A good place to practice is the shoulder. Shoulders are ball and socket joints, and they generally have a wide (spherical) range of motion. With a patient seated, cradle the wrist of the patient's arm with one hand (between your thumb and index finger- tiger's mouth) and place your other hand on the patient's shoulder. First of all, as you extend the patient's arm out, try to feel the weight of the arm. Can you tell if it is relaxed or not? Experiment. Ask the patient to tense up, and see what that feels like. Then ask the patient to relax, and feel the difference.
[This is crucial for these manipulation techniques. Nothing obstructs these techniques more than a patient “superimposing” their volitional movements over your manipulations. Manipulations, in general, are intended to be passive. Note that there are situations in which you would want the patient to actively participate and move a part of the body while you are working on it. We may go over these situations later.]
Now, attempt to take the patient's arm through circles. Start off with very small circles, and gradually, gradually get larger and larger. Eventually, you may begin to reach the borders of the range of motion. You will "feel" it as a kind of resistance, like rubber bands holding back your motion. The sooner you can feel this without "going through it," the better. You may also be able to tell that you are reaching this border by observing your patient's reactions; s/he may tense up as you reach the border. HOWEVER, this is an unreliable marker, as a lot of patients try to mask their reactions (particularly men). Learn to read, through feeling, where the borders are.
So there are three general categories of techniques that I class under Manipulations: Shaking/Trembling (DIFFERENT FROM VIBRATING!), Rectifying/Pulling (basically, it can be thought of as Tractioning), and Rotating.
SHAKING/TREMBLING: This technique is only applicable on the limbs (arms and legs). You grasp the wrist or ankle with both hands, lift the limb slightly (off the table, with the legs, or about level with the shoulder with the arms), FEEL whether or not the limb is relaxed or not, and then, with repeated up and down motions, you SHAKE/TREMBLE the limb. Start off with small and gentle shakes, and gradually build up to larger shakes. DO NOT MAKE YOUR SHAKES TOO LARGE, particularly if the patient has some kind of injury in that limb; it could exacerbate the condition!
Throughout this technique, try to develop the feeling of passing waves through a jumprope.
Different forms include: single arm (usually in seated position), single leg (prone, or side-lying), both legs.
[Note: Just as it is difficult to pass a wave through a rope that is TOO slack, so too is it difficult to pass a wave through a limb that is so slack that it is bent/folded. Gently extend the limb prior to performing shaking/trembling.]
FLEXING/EXTENDING or FOLDING/UNFOLDING joints: This category comes from Maria Mercati's book. It is used for knees and elbows, the hinge joints of our body. All this involves is flexing and extending these joints. Sometimes you can use a fist in the joint, and fold the joint around it like a "nutcracker."
[As stated previously: the elbows and knees are hinge joints, but it is possible to perform other motions with them (or rather, through them) besides opening and closing. To be precise, these motions do not directly involve the hinge joints, but involve the soft tissue either proximal to or distal to the hinge joint. Let’s take the elbow:
Say you have the patient keep their upper arm next to the body, as though it were glued to it. Have the patient bend their elbow 90 degrees. Now, while keeping the upper arm next to the body, you can use the lower arm like a lever, and “turn” the arm in or out. This can also be performed with the upper arm at other angles, like 45 degrees out from the body, or 90 degrees out from the body. This type of motion actually involves what is called “internal or external rotation of the humerus,” and is actually a test for the flexibility and integrity of the rotator cuff muscles in the shoulder (and not the elbow).
Here’s another example. Again, start from the same position as above. Lock the patient’s elbow by gently wrapping your hand around it. Then, have the patient turn their hand palm up and palm down. These motions involve the muscles of the forearm, and are called “supination and pronation.”
Similar exercises can be performed around the knee (although the foot cannot really do the “supination and pronation” motions cleanly).]
ROTATION (YAO): This category involves taking joints through circular range of motions. In the experiment above, we basically did a Rotation technique for the shoulder. It is also possible to do Rotations on the wrist joint, or the hip joint (usually this is done with the patient in supine position), or the ankle joint. Variations for the hip joints include: single straight leg, double straight leg, single leg with the leg folded in towards the chest, both legs bent and together.
Note: Rotation is not performed on the neck. It's not that the neck is incapable of such motions, but it is not necessary for you to control them.
RECTIFYING/PULLING: This is basically traction, although for some reason, depending on the direction and the part of the body you are working on, it can resemble Rotating.
On the limbs, this is relatively simple; you are always pulling OUT from the body. A simple example of pulling is "snapping the fingers."
Note: this is a gentle PULL, NOT A YANK!!! It should feel as though you are pulling a heavy boat into dock with a rope. You don't jerk on the rope, rather, you feel the rope's full length, and THEN using your own body weight, you just allow your "influence" to transfer through the rope.
A slight modification involves combining a pulling motion with a pushing motion. If you want to focus on, say, the wrist joint, then you can use one hand to "push" proximal to the wrist while the other hand "pulls" the patient's hand (distal to the wrist). This "opens" the joint. You can do the same thing for the elbow.
Pulling/Pushing need not only be longitudinal/lengthwise. For example, you can turn the head to one side, "pulling" the head to one side with one hand while the other hand "pushes" on the shoulder.
One of the most critical areas to apply Pushing/Pulling is the back. The back moves in a variety of ways. It can, of course, flex and extend (bend forwards and backwards). Flexion can be "assisted" with the patient in supine position, reaching for his/her toes, while the practitioner (sometimes) works on the back. There are Thai versions of this, but they require the practitioner to "stand on the table." Overall, flexion can best be practiced on the patient in supine or standing positions (there are also side-lying options).
Extension, on the other hand, involves bending backwards (or, alternatively, "opening up the front"). Such exercises involve pulling up or back on corners of the back. The four corners of the back are the shoulders and the hips. If you decide to use the shoulder levers via the arms (particularly the wrists), then you need to be sure that the shoulders are flexible enough to accommodate your pulls (it is often the case that patients cannot extend their arms behind them). If they cannot accommodate your pulls at the wrist, then you may have to directly use the shoulders, which can involve a lot more work on your part. Again, there are a variety of Thai stretches that can provide assistance in this regard, notably the Cobra stretch variations, but they do require a bit of "balancing". There are also variations that can be done in the sitting position.
The back can also side-bend. The side can be worked on in the side-lying position, and it is possible to do some manipulations that open up the side (mostly via a cross pushing motion on the two levers, the rib cage and the pelvis). More extension side-bending can be accomplished in the sitting position, as the table isn't in the way: an elegant (if somewhat ambitious) Thai version is available for this.
The back can twist/rotate. This is by far the most complicated movement of the back. There are versions of twisting the back that can be approximated in both the prone and supine positions. If you think of the back as a rectangle, you are trying to "twist" the rectangle by either "folding back" individual corners, or having opposite corners move in opposite directions. For example, if the patient is prone, you can accomplish some degree of rotation and twist by "lifting" one shoulder (preferably as you "push" into the rhomboids). Or, if the patient is in side-lying position, you can have the top shoulder go "forwards," and the bottom leg go "backwards", and vice versa.
It is also, of course, possible to accomplish a twisting motion in a sitting position. There are varieties of this that can be accomplished in both Thai and Tuina formats.
DEMONSTRATED TECHNIQUES:
NECK: Seated Position, Prayer Hands, Flexion, Extension, Sidebending, Rotation
Supine Position, Cradle/Bridge Hands, Lifting with Slight Traction
Supine Position, Cradle/Bridge Hands under Occiput, Circles
Supine Position, Cross Hands Under Neck, Flexion
Supine Position, One Hand Cradles Occiput, Other Hand placed on Opposite Shoulder, Turning Stretch
SHOULDER TO WRIST:
Seated, Stand to one side and behind patient, Place one hand on top of shoulder (holding points like LI 15), Other hand grasps wrist. Pull at wrist, “Push” (anchor) at shoulder. Accomplish this mainly by turning your whole body slightly rather than by actually using your arms to “pull” or “push.”
In same position, try Shaking, first with very little waves, and then gradually larger and larger, and then Rotating, first with very little circles, and then gradually larger and larger. PAY ATTENTION TO PATIENT’S END RANGE OF MOTION.
*More advanced: Stand to one side of the patient. Step one leg up onto the working surface, such that your knee, if possible, goes into patient’s armpit. One hand goes on patient’s shoulder. The patient’s arm goes BEHIND your back, and you grasp the wrist with your hand. To accomplish traction, you slightly “push” up with your knee, and “pull” primarily by turning your body away from the patient (not by actually “pulling” with your hand).
*Other variations: Opening the Armpit, Finding Wings (using one hand to open front of shoulder while the other Presses in the space under shoulder blade), Water Pump.
Swimming/Brushing Back Hair: Seated, Stand to one side of patient, Support Patient’s Right forearm with your Left forearm (patient’s wrist at your tiger’s mouth), take Patient’s arm through swimming motion or brushing back hair motion to test internal/external rotation at humerus.
Supine. Stand at head of patient, Pull one arm up, Shake (either vertical or horizontal), Rotate. Alternatively, you can try both arms simultaneously.
Supine. Stand at side of patient, Pull one arm, Shake (either vertical or horizontal), Rotate.
ELBOW and WRIST: Pulling/Traction at the elbow and wrist can be accomplished by PULLING below the joint and PUSHING (or rather anchoring) above the joint.
The Elbow can be opened and closed via the Nutcracker technique.
The Wrist can also be flexed and extended, and go through rotation. There is also a technique called Water Faucet which helps with supination and pronation.
Class Notes 5
TUINA
Class Notes 5
Pile Standing Practice 4 minutes
Silk Reeling, Taiji Symbol, Teacup exercise
Stretching out Wrists and Forearms
Rooting Practice, Hand on shoulder
Review of Techniques:
Rubbing, Pressing, Pushing
Vibrating, Rolling, Swinging, Kneading
Grasping, Grabbing, Pinching, Nipping, Plucking, Lifting
We've worked on many of the fundamental techniques in Tuina. As is implied by the name "Tuina," the "core techniques" of this form of bodywork are Tui (or Pushing) and Na (or Grasping). Keep in mind that Tuina (as opposed to Anmo) emphasizes more the musculoskeletal aspect of the body, and the techniques of Tui and Na are really best at releasing tension in the muscles.
Today, we are going to be working on what I class as percussive techniques, techniques which involve "striking" the body repeatedly. What's the point of percussive techniques? To answer this, we should consider whether percussive techniques are Yin or Yang. As they remain on the surface (really, we're not trying to "break boards" here!) and as they are generally somewhat rapid (a percussive technique that simply pounds once is like the slap of one wet fish), we can definitely consider such techniques to be Yang. Yang techniques invigorate, and promote general circulation and relaxation.
In practice, I think it is best to apply percussive techniques towards the end of your treatment. Why? Percussive techniques tend to be a bit too jarring and invasive at the beginning of the treatment. They can in fact cause the patient to "tighten up" more, as it is somewhat uncomfortable to have someone strike tissue that is already tight. Percussive techniques are also inappropriate in the middle of the treatment; generally, the middle of the treatment is when you would like to be doing your deep, focused work, and is when you would like the patient to be as relaxed as possible. At the end of the treatment, when you want the patient to sort of revive and wake up, I think it's fine to perform your percussive techniques, particularly if you end with the patient in sitting position. By then, their tissues have been relaxed and prepared somewhat by everything preceding, AND the patient has grown accustomed to your touch; at that point, it's ideal to perform percussive techniques, to spread and invigorate the relaxing, warming sensations you've initiated.
Aside from invigorating/relaxing, etc. percussive techniques are also great for chest congestion and lung problems. It is a way to "jar" blockages in the chest loose.
There are MANY FORMS of percussive techniques. I will introduce the main classes from the Sun-Chengnan text, and introduce a few that I learned from my Shiatsu days.
Keep in mind a few principles:
1) you are not trying to "penetrate" so much as you are trying to lightly bounce off the tissue. If you have ever drummed, you know that "sticking" to the skin after impact deadens the sound; the best sound is produced when you are able to lightly glance off the surface, so the vibration of the impact can travel.
2) stay relaxed and loose. This actually follows from the previous point. You are trying to impart energy (whether you think of this as qi or as vibratory energy doesn't matter). If you are very tight when you do a percussive technique, then that energy stays locked up in YOU, not in your patient.
3) following upon #2, but perhaps deserving of a separate point: keep your hands LOOSE! This is true whether you use a fist or a chopping hand. While you want your hands to adopt a certain shape for any given technique, you do NOT want to hold that shape stiffly! This will again deaden the impact, and keep the vibration/qi locked up in YOU.
4) start off with a slow rhythm, just to get in a groove. I like to start off in a kind of syncopated rhythm, sort of like a limping horse. For some reason, starting off with a square, even rhythm feels really "clunky," and I have a harder time accelerating. Of course, this is just personal preference.
THE TECHNIQUES ACCORDING TO SUN-CHENGNAN
So the Sun-Chengnan text has three general categories for percussive techniques, and they are mainly differentiated from each other by the shape of the hand and the striking surface.
TAPPING (DOTTING): Dotting is performed with the tip of the middle finger as the striking surface. The middle finger is braced by the index finger "on top" and the thumb "below," such that it looks like a goose head (similar to "holding the single whip" in taijiquan). It is the only percussive technique that uses a single finger as the striking surface. It is primarily intended to be a form of stimulation for specific points. It can also be used over a larger area in cases of numbness, where the objective would be to restore sensation.
In the Sun-Chengnan text, for example, the indications list "Hemiplegia, numbness, flaccid paralysis, muscle wasting and atrophy" first.
KNOCKING: Knocking is performed with the fingertips (all of them, not just one), or with the large thenar mound, the small thenar mound and the heel of the hand. Actually, four techniques are specified: knocking with the finger tips apart (with your hands forming loose "claws"), knocking with the finger tips together (such that they form a single "point"), knocking with a cupped palm, and knocking with the back of the hand (which, oddly enough, should be considered a fist).
CHOPPING: Envision the karate chop, and you get an idea for this technique. You can chop with a single hand (using the ulnar edge), chop with both hands in alternation (perhaps the most common version of this technique), or chop with both hands together (this is called, in Japanese, "gassho," in that it resembles placing your hands together as if in prayer).
POUNDING: Pounding is performed with the fist. There are several striking surfaces of the fist, though the most common is the "ulnar edge" (in which the fist is used like a hammer). You can also use a "prone fist" (in which the palmar side strikes) or a "supine fist" (in which the back side of the fist strikes). You may also pad the fist by using your other hand as a cushion.
While you should ALWAYS keep your fist relatively loose, if you are striking certain areas (like the scalp), you should keep it particularly loose and open.
OTHER TECHNIQUES: Okay, so some of these are not technically percussive techniques. Some of them are actually Rubbing Techniques or Pinching/Plucking Techniques. I introduce them here because they are usually performed with percussive techniques at the end of a shiatsu treatment.
FISHTAILING: This is used on the crest of the trapezius (although it could very well be used in several other places). Place the ulnar edge of your hand on the patient's GB 21 area. Imagine that your hand is like a fish's tail. Allow it to "flap" back and forth rapidly, while rubbing the ulnar edge into the patient's skin.
CENTIPEDE AND CRAB: Use both hands to pluck the crest of the trapezius. Then, using your thumbs, walk straight up and down in the space between the scapula and the spine. This is the Centipede. After doing this for a few repetitions, you can walk laterally across the scapula. This is the Crab.
BALL OF AIR POUNDING: This is hard to describe and can be hard to perform. Cup both hands together to form a loose ball. Then, strike with the ball, using the back of one hand as the striking surface. Ideally, it should feel as though the ball "bounces" off the back, and as it strikes, all the air rushes out of the ball. You can actually "hear" this.
BUTTERFLY HANDS: No, this is not a reference to that cheerleading movie... Make your hands into a butterfly shape, with the thumbs of either hand on the paraspinals, and the fingers extended out and upwards. Then, let the butterfly "flutter" by rapidly rubbing your hands in and out, and up and down over the upper back.
WHERE should percussive techniques be performed? Most percussive techniques can be performed just about anywhere on the body. The central caveat is that you do not strike over bone. This is uncomfortable for both your patient, and for you (and can damage your hands). You also typically do not do percussive techniques over vulnerable areas of the body (like the abdomen or the groin or the front of the neck).
"Flatter" percussive techniques are best when you wish to stimulate the exterior. Think of the Hakka (the warrior dance used by the UH Warriors, aka the Mosquito Extermination Dance), which involves a great deal of slapping. Pre-game, or pre-battle, you would want energy/qi/blood to rise to the surface, and slapping accomplishes just this. You can use flatter techniques on just about any part of the body, but they probably are more "effective" on flat areas of the body (the back, the chest of men, etc.)
As your hands develop more specialized "shapes" (for example, a chop), your techniques tend to go deeper, and thus, tend to be more ideal for "shaped" areas of the body, like the limbs. Think about how you orient your "shaped" percussive tools on the body, as this can translate into very different effects. If you chop across tissue, then you tend to get a deeper (and sometimes more uncomfortable) effect, versus if you chop with the tissue.
PRACTICE ASSEMBLING A ROUTINE for the back and shoulders:
Think about what you have learned so far, regarding the fundamental techniques. Now, try to put what you’ve learned together to try to work on someone’s back and/or shoulders. Experiment with the order of techniques, the strength of techniques, etc., focusing on keeping a smooth flow to everything.
Class Notes 5
Pile Standing Practice 4 minutes
Silk Reeling, Taiji Symbol, Teacup exercise
Stretching out Wrists and Forearms
Rooting Practice, Hand on shoulder
Review of Techniques:
Rubbing, Pressing, Pushing
Vibrating, Rolling, Swinging, Kneading
Grasping, Grabbing, Pinching, Nipping, Plucking, Lifting
We've worked on many of the fundamental techniques in Tuina. As is implied by the name "Tuina," the "core techniques" of this form of bodywork are Tui (or Pushing) and Na (or Grasping). Keep in mind that Tuina (as opposed to Anmo) emphasizes more the musculoskeletal aspect of the body, and the techniques of Tui and Na are really best at releasing tension in the muscles.
Today, we are going to be working on what I class as percussive techniques, techniques which involve "striking" the body repeatedly. What's the point of percussive techniques? To answer this, we should consider whether percussive techniques are Yin or Yang. As they remain on the surface (really, we're not trying to "break boards" here!) and as they are generally somewhat rapid (a percussive technique that simply pounds once is like the slap of one wet fish), we can definitely consider such techniques to be Yang. Yang techniques invigorate, and promote general circulation and relaxation.
In practice, I think it is best to apply percussive techniques towards the end of your treatment. Why? Percussive techniques tend to be a bit too jarring and invasive at the beginning of the treatment. They can in fact cause the patient to "tighten up" more, as it is somewhat uncomfortable to have someone strike tissue that is already tight. Percussive techniques are also inappropriate in the middle of the treatment; generally, the middle of the treatment is when you would like to be doing your deep, focused work, and is when you would like the patient to be as relaxed as possible. At the end of the treatment, when you want the patient to sort of revive and wake up, I think it's fine to perform your percussive techniques, particularly if you end with the patient in sitting position. By then, their tissues have been relaxed and prepared somewhat by everything preceding, AND the patient has grown accustomed to your touch; at that point, it's ideal to perform percussive techniques, to spread and invigorate the relaxing, warming sensations you've initiated.
Aside from invigorating/relaxing, etc. percussive techniques are also great for chest congestion and lung problems. It is a way to "jar" blockages in the chest loose.
There are MANY FORMS of percussive techniques. I will introduce the main classes from the Sun-Chengnan text, and introduce a few that I learned from my Shiatsu days.
Keep in mind a few principles:
1) you are not trying to "penetrate" so much as you are trying to lightly bounce off the tissue. If you have ever drummed, you know that "sticking" to the skin after impact deadens the sound; the best sound is produced when you are able to lightly glance off the surface, so the vibration of the impact can travel.
2) stay relaxed and loose. This actually follows from the previous point. You are trying to impart energy (whether you think of this as qi or as vibratory energy doesn't matter). If you are very tight when you do a percussive technique, then that energy stays locked up in YOU, not in your patient.
3) following upon #2, but perhaps deserving of a separate point: keep your hands LOOSE! This is true whether you use a fist or a chopping hand. While you want your hands to adopt a certain shape for any given technique, you do NOT want to hold that shape stiffly! This will again deaden the impact, and keep the vibration/qi locked up in YOU.
4) start off with a slow rhythm, just to get in a groove. I like to start off in a kind of syncopated rhythm, sort of like a limping horse. For some reason, starting off with a square, even rhythm feels really "clunky," and I have a harder time accelerating. Of course, this is just personal preference.
THE TECHNIQUES ACCORDING TO SUN-CHENGNAN
So the Sun-Chengnan text has three general categories for percussive techniques, and they are mainly differentiated from each other by the shape of the hand and the striking surface.
TAPPING (DOTTING): Dotting is performed with the tip of the middle finger as the striking surface. The middle finger is braced by the index finger "on top" and the thumb "below," such that it looks like a goose head (similar to "holding the single whip" in taijiquan). It is the only percussive technique that uses a single finger as the striking surface. It is primarily intended to be a form of stimulation for specific points. It can also be used over a larger area in cases of numbness, where the objective would be to restore sensation.
In the Sun-Chengnan text, for example, the indications list "Hemiplegia, numbness, flaccid paralysis, muscle wasting and atrophy" first.
KNOCKING: Knocking is performed with the fingertips (all of them, not just one), or with the large thenar mound, the small thenar mound and the heel of the hand. Actually, four techniques are specified: knocking with the finger tips apart (with your hands forming loose "claws"), knocking with the finger tips together (such that they form a single "point"), knocking with a cupped palm, and knocking with the back of the hand (which, oddly enough, should be considered a fist).
CHOPPING: Envision the karate chop, and you get an idea for this technique. You can chop with a single hand (using the ulnar edge), chop with both hands in alternation (perhaps the most common version of this technique), or chop with both hands together (this is called, in Japanese, "gassho," in that it resembles placing your hands together as if in prayer).
POUNDING: Pounding is performed with the fist. There are several striking surfaces of the fist, though the most common is the "ulnar edge" (in which the fist is used like a hammer). You can also use a "prone fist" (in which the palmar side strikes) or a "supine fist" (in which the back side of the fist strikes). You may also pad the fist by using your other hand as a cushion.
While you should ALWAYS keep your fist relatively loose, if you are striking certain areas (like the scalp), you should keep it particularly loose and open.
OTHER TECHNIQUES: Okay, so some of these are not technically percussive techniques. Some of them are actually Rubbing Techniques or Pinching/Plucking Techniques. I introduce them here because they are usually performed with percussive techniques at the end of a shiatsu treatment.
FISHTAILING: This is used on the crest of the trapezius (although it could very well be used in several other places). Place the ulnar edge of your hand on the patient's GB 21 area. Imagine that your hand is like a fish's tail. Allow it to "flap" back and forth rapidly, while rubbing the ulnar edge into the patient's skin.
CENTIPEDE AND CRAB: Use both hands to pluck the crest of the trapezius. Then, using your thumbs, walk straight up and down in the space between the scapula and the spine. This is the Centipede. After doing this for a few repetitions, you can walk laterally across the scapula. This is the Crab.
BALL OF AIR POUNDING: This is hard to describe and can be hard to perform. Cup both hands together to form a loose ball. Then, strike with the ball, using the back of one hand as the striking surface. Ideally, it should feel as though the ball "bounces" off the back, and as it strikes, all the air rushes out of the ball. You can actually "hear" this.
BUTTERFLY HANDS: No, this is not a reference to that cheerleading movie... Make your hands into a butterfly shape, with the thumbs of either hand on the paraspinals, and the fingers extended out and upwards. Then, let the butterfly "flutter" by rapidly rubbing your hands in and out, and up and down over the upper back.
WHERE should percussive techniques be performed? Most percussive techniques can be performed just about anywhere on the body. The central caveat is that you do not strike over bone. This is uncomfortable for both your patient, and for you (and can damage your hands). You also typically do not do percussive techniques over vulnerable areas of the body (like the abdomen or the groin or the front of the neck).
"Flatter" percussive techniques are best when you wish to stimulate the exterior. Think of the Hakka (the warrior dance used by the UH Warriors, aka the Mosquito Extermination Dance), which involves a great deal of slapping. Pre-game, or pre-battle, you would want energy/qi/blood to rise to the surface, and slapping accomplishes just this. You can use flatter techniques on just about any part of the body, but they probably are more "effective" on flat areas of the body (the back, the chest of men, etc.)
As your hands develop more specialized "shapes" (for example, a chop), your techniques tend to go deeper, and thus, tend to be more ideal for "shaped" areas of the body, like the limbs. Think about how you orient your "shaped" percussive tools on the body, as this can translate into very different effects. If you chop across tissue, then you tend to get a deeper (and sometimes more uncomfortable) effect, versus if you chop with the tissue.
PRACTICE ASSEMBLING A ROUTINE for the back and shoulders:
Think about what you have learned so far, regarding the fundamental techniques. Now, try to put what you’ve learned together to try to work on someone’s back and/or shoulders. Experiment with the order of techniques, the strength of techniques, etc., focusing on keeping a smooth flow to everything.
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