Ep 49 – Combining Manual & Movement Therapies with Dr. Joe Muscolino

00:00 Kristin Coverly: Anatomy Trains is excited to announce a new on-demand video course with Tom Myers coming soon, Deeper Ground: Restoration and Vitality for the Female Pelvis, reach your deeper ground of embodied awareness and strategic confidence with this four-hour tour of the female pelvis, including its key points and unique challenges. Course highlights include hands-on palpation certainty and technique review for the major muscle groups, assessments, and techniques for posterior and anterior pelvic floor, so as complex and diaphragm, common perinatal bio-mechanical issues explained, and much more. Sign up for the Anatomy Trains newsletter at anatomytrains.com to be notified when the course is available.

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00:57 Darren Buford: Welcome to The ABMP Podcast. My name is Darren Buford, I'm the Editor-in-Chief of Massage & Bodywork Magazine and Senior Director of Communications for ABMP. I'm joined by my co-host, Kristin Coverly, licensed massage therapist and Director of Professional Education for ABMP. Our goal is to connect with luminaries and experts in and around the massage, bodywork and wellness profession in order to talk about the topics, trends, and techniques that affect our listeners' practices. Dr. Joe Muscolino has been a manual and movement therapy educator for more than 30 years. He is the author of The Muscular System Manual, The Muscle and Bone Palpation Manual with Trigger Points, Referral Patterns, and Stretching, and Kinesiology. He teaches continuing education workshops around the world, including a certification in Clinical Orthopedic Manual Therapy, and has created LearnMuscles Continuing Education, a video streaming subscription service for manual and movement professionals, with seven new video lessons added each week. And he has created Muscle Anatomy Master Class, the most comprehensive and detailed muscle anatomy online class in the world, with each muscle taught in five distinct video lessons. Visit learnmuscles.com for more information. Hello, Joe and Kristin.

02:13 Dr. Joe Muscolino: Hey, there. Hi.

02:15 KC: Hi, so excited to have you here, I... In my position at ABMP have been very lucky to be able to work directly with you to create some continuing education courses for our members, and they love them. I can tell you Rave Reviews online, so thank you for that. Darren, I know, gets to work with you with... On the magazine, on your articles. And you have such a huge breadth of knowledge. There are so many things that we could talk to you about today. But today we're gonna focus on your most recent massage and bodywork magazine article, it's the cover issue of the November, December issue 2020. The title is Combining Manual And Movement Therapies, why it makes sense for you and your clients. So before we do the deep dive, I'd love to start just so everyone's on the same page as we have this conversation, can you let us know what you mean when you say manual therapies and movement therapies? What type of practitioners fall into each category?

03:13 DM: Okay. And first, the preface, it's my pleasure and honor to be here, and I really enjoy working with you folks. I have for a bunch of years now, so thank you. A manual therapist would be anyone that uses their hand. Manus from Latin means hand. So a massage therapist is a manual therapist. You would include really physical therapists. The rest of the English-speaking world would refer to them as physiotherapists, occupational therapists, some people are stretch therapists, any other similar field maybe that might not want to... Like for example, ABMP talks about the massage and bodywork, there are some fields that do not want to be lumped into massage, even though they work with their hands, and they manipulate soft tissues, so they might bristle a little bit of that, so you could take any and all of those types of ones, Reiki or whatever else it might be, and if it's hands-on, to me, it's a manual therapist.

04:12 DM: Or if it's elbows on or feet on, to be very fair, because I look at it more as manipulation of soft tissues by the therapist or really also a physician. A chiropractor is a manual therapist or manual physician, so then to the movement, pilates, yoga, fitness training, are the first ones that come to mind, but any... A martial arts instructor, a tennis pro, could be considered a... Golf pro. I mean anyone that's working with the movement of the client is a movement professional or a movement practitioner or to me, you could say a movement therapist because they are doing therapy, they're rehabbing the person's body.

04:55 KC: Perfect. Thank you for that. I think that'll help everyone be on the same page for our conversation. So let's start our conversation where you start your article. Tell us about the balance between how guidelines and standards for massage therapy have both helped to advance the profession, but have also set parameters around it, potentially limiting its advancement, what turf battles has this created?

05:17 DM: That's an excellent question, and it's a question that could probably be chatted about in 30 seconds or a couple of hours, and I know it because I've had both of those conversations in the past. I first wanna say that I have long been... I taught for about 25 years at a massage therapy school. When they created a clinical program that was 1100 hours, I taught there, and I've always... I began with the science classes then moved on to the assessment classes and then treatment classes. And being a soft tissue-oriented chiropractic physician, I'm comfortable with that breadth of expanse from fundamental science to applied manual movement techniques. And I've always been a big proponent that people should be able to show a proficiency. However, that does create literally turf battles, both in the sense of intellectual, financial, and ego-based drawing of lines and distinctions.

06:22 DM: So I'm just gonna go back for a second and say, decades ago, I was an advocate of having two different designations in the world of massage in the United States, and regardless of what name you put on them, one is more of a practical massage therapist, the other one's more of a clinical, or you could say orthopedic, or you could say medical, or the rest of the world that's English-speaking uses the term remedial. And Canada and Australia and New Zealand, these other countries, they have different designations of massage. And whenever I would bring this up, people would say, "You're splitting the field. You want to split us up." And what I saw was not everyone... And I taught in Connecticut... Not everyone could afford $10,000 to $20,000 for an 1100-hour program or even a minimum 750... Well, our state, I think requires 500, but almost everyone goes to the government minimum to get the maximum financial aid, so almost every program is around 750, 770 hours, and that's expensive.

07:29 DM: And even though I'm firmly in the ranks of clinical orthopedic work, where you want to remedy a specific musculoskeletal, myofascial skeletal, neuromyofascial skeletal condition with which the client presents, I still feel that there is a place for people to do what might be called spa massage, relaxation massage, and I'm in no way denigrating that. What I'm saying is they don't necessarily need to understand the fine points of the attachment of the anterior cruciate ligament or tibiofemoral... Whatever the case might be.

08:09 DM: And I've always felt that by creating these minimum standards that we need to have, that it's wonderful because we get to show the world that didn't believe necessarily that massage was a bona fide therapy in the world of health, that massage has to still at times pull itself up from being associated with massage parlors of years ago and probably still today in places, and it's wonderful that we can show that, and be colleagues with other health professionals, but at the same time, it creates limitations for some people who might be fabulous massage therapists, not working clinically, orthopedically, but be financially out of the loop because they simply can't get there.

09:02 DM: So that's one aspect, and that's kind of away from linking with manual movement, which is what the article was about. First of all, there's licensure and there's certification. Massage is licensed in almost all the states, and that means it's government regulation, and that means it's state by state, and it gets hard to talk about how easily something like that can be changed. But if it's not licensed, it's certified, and certifications are much easier to work with. With all due honesty, anybody can say, "It's the Joe and Kristin and Darren certification for something," and who's certifying it? We are. So it's based on our reputation. Maybe some certifying bodies then go to larger certification bodies to then certify them, but you do end up saying, "Okay, well, this is who we are, and by nature of that, you're not us and we're not you."

10:02 DM: And it means that you will have people who will say, "Well, you're a massage therapist, but you can't do fitness training. You can't do exercise for your client." And I don't remember if Connecticut still has the statute, but I know it used to. The program in which I taught at the Connecticut Center for Massage Therapy, even though they had something like 300 to 400 hours of anatomy, physiology, kinesiology, pathology, that they were not legally allowed as a licensed massage therapist to do physical strength training exercise, yet someone could go to a weekend workshop, and come out and say, "I'm a certified fitness trainer." They might not be with the larger NASM and other organizations, but they could do that. And to me, that was crazy because the massage therapists in my program, they learned what joint actions, motion patterns, muscles do, and if you do that against any kind of resistance, whether it's body weight or added resistance, you are strength training.

11:09 DM: It ends up creating this argument where you can't be a Feldenkrais practitioner unless you go into the Feldenkrais Guild. And maybe you can do pilates, but are you going to the PMA Pilates Method Alliance or to a traditional authentic pilates training program? Are you... It's suddenly everybody has their corners and everybody's trying to protect their turf, which I guess might be reasonable because we all need to make sure that we keep some purity in our field, but it ends up becoming at a certain point, like money-oriented unions that's quite against everybody else. One other quick example, then I'll stop, is that I would receive as a chiropractic physician letters from the Chiropractors Association saying, "The physical therapists are trying to do this and trying to do that, and they're not trained to make diagnoses, and this is going to be dangerous," and I never would sign those because I knew physical therapists that were so competent.

12:13 DM: Now since then, they've gone to a DPT training and it's different, but then when I entered the world of massage therapy, I knew teachers at our school who would say, "No, no, don't say that because the physical therapists are breathing down our back if we say we're doing treatment," and it's like everybody is trying to push everybody else aside instead of coming together and saying, "Wow, we have a commonality of the musculoskeletal," and I'll keep saying it that way, but I did say it once, neuromyofascial skeletal system. When I say musculoskeletal, I'm not ignoring the importance of fascia and I'm not ignoring the importance of the nervous system to be the master coordinator controller. It just takes too long to say all that. So we have that commonality and yet we are separating out and fighting against each other.

13:06 DB: Let's take a short break to hear a word from our sponsors.

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13:41 DB: Now, let's get back to the podcast. Joe, I think this plays perfectly into the article where you mentioned that when you were working in Singapore that you noticed something really interesting regarding the people who were taking your class and their training. Can you tell us a little bit about that experience?

14:00 DM: Yeah, and I'll... Yeah, it really was almost like a flash of light or a lightning bolt, like a smack to the side of my head, because I was so unprepared to see what I saw. So let me first step back for a second and say, I've always been very proud in the United States of being in the world of massage, where the field of massage has been organizing itself in getting more and more states to get licensure and minimum requirements, and whether it's the national cert exam or MBLEx or things that really... That show who we are. Therefore, when I've been teaching in the United States, I almost only had manual therapists, mostly massage therapists. And when I started teaching overseas, the audience that was in my work... That would be in my workshop, was largely the audience of the organizer, and some organizers were prevalent in the world of physiotherapy, physical therapy, some were prevalent in yoga or pilates, some in fitness training.

14:58 DM: So I was brought out to Singapore and it was almost 10 years ago, and the workshop organizer was in the world of fitness athletic training, and we were even holding the workshop in a separate room of a gym. And as I was walking through the main gym to get to the separated glassed off wall, where roomed, where we were working, I saw massage tables lined up on the periphery of the gym. And I was like, "Huh, now that's kinda funny, I've never seen that in a gym." And then we went in, and I always ask people in the introductions to just let me know their name, where they're from, what their field is, how long they've been there, and about, I don't know, maybe two-thirds of the people were fitness trainers. There were a few pilates, few massage, few yoga, and a couple of instructors. And as I found out very quickly, because much of Asia is not as organized as the United States, it's more of a Wild West, that there aren't really rules and regulations about who can do what.

16:10 DM: And at first I thought, "Oh, well, they're going to have to mature their fields," but then what I realized was there was a beauty to this, because turf lines had not been drawn out, fitness trainers would learn massage. And they were doing it with... I believe I'm an instructor of integrity, and they would talk about other workshops they would go to, and people who are coming out now to Asia who are well known, and they really wanted to learn how to do massage well, and they were mixing it into the movement strength and stretch training that they were doing. And I quickly fell in love with it, realizing that there was a tremendous advantage to having an area of the world or a country that had not yet solidified, built their walls around their professions.

17:05 KC: Joe, can you tell us a little bit about what the goals are for manual therapies, what the goals are for movement therapies, and then how stretching is the intersection between the two?

17:17 DM: That's excellent. So, you know, there was almost something I put in the article, and actually I had it in the first draft and I took it out just because I'm always running against word counts and all, and I didn't want it to seem opportunistic, but I'll mention it here. My wife has been a pilates instructor for 25 years, she has been a massage therapist for 21 years, she's been a Feldenkrais practitioner for something like 12 years, and she was a ballet dancer professional way back when. I started actually the article with the very next paragraph being that my wife does mostly pilates and massage, and if a pilates, a client comes in one day and they feel a little bit tight and restricted and they feel a little under the weather and not able to quite do a physical workout and exert themselves, she might say, "Well, would you like to have a massage instead or would you like to do a half-hour workout and a half-hour massage?"

18:16 DM: And when she'd have massage people come in and they'd see the pilates people walking out, all standing up straight and looking so healthy and strong and glowing, they'd be like, "What's that person doing?" "Well, they're doing pilates." And she would... She mixes and matches it comfortably because she has a room for the massage and she has the pilates studio. And I wanted to talk about that as being an intersection of it. Now, she went through the cost of a 600-hour pilates training. She went through the cost of a 1000-hour massage training. She went through a four-year Feldenkrais, but you know, she had loans to pay for years, and as I said before, it's not easy for everyone to do. If I have a client that's lying on the table, and instead I'm working their cervical thoracic region, the neck area, top of shoulder area, and after I've done the massage, which I... When I treat patients, I spend an hour with a patient. I do mostly massage, so that to me is my primary modality, even though I'm a chiropractic physician. If I were forced to choose one modality, I would choose soft tissue manipulation massage. Of course, no one has to choose one, and the very purpose of this podcast is talking about expanding.

19:34 DM: But going back now, my wife introduced me to a concept in the world of pilates that said that the three major keys to musculoskeletal good health, and I know there are other keys like sleep and spiritual balance and all that, but let's... The three primary major keys are strength of musculature, flexibility of soft tissue, and neural control, motor control. So if you go to the average fitness trainer as an extreme on one end, perhaps, most of the time, if they're spending 50 minutes with a client, an hour, 50-minute session usually, they will spend probably 45 minutes doing strength resistance training, and maybe five minutes as a nod to stretching. Not always. And I forgive myself for generalizing people out there who are more balanced about that, but that's mostly what they do, and their goal is to make the client's body stronger. And that's great because most people do need to be stronger. But I'll get some clients who come to me from a fitness training regimen, and I'll say, "So what are you doing in your regimen?" They'll say, "Oh, 45 minutes strength, five-minute stretch." And I'm like, "But you're so tight and you're strong already, your big muscles, you need to tell your fitness trainer to switch it around and change the balance."

20:53 DM: If we were to make a stereotype about massage therapy, massage therapy is primarily geared toward the flexibility of soft tissue in those three elements, and it's almost... Really is the vast preoccupation of most massage people to loosen taut, tight tissue. And I had an illustration drawn because I was so in love with that idea of the three major keys. And I think I put it in the article, I believe, and I had to try and talk about three sides of something. I thought a coin is perfect because there's two sides of a coin and the edge is a third side. So I had my artist draw a coin on a shelf with a mirror behind it, so we could see one side and we could see the other side in the mirror, and we could see the edge of the coin, and one side says strength of musculature, the other says flexibility of soft tissue, and on the edge is neural control. And I think that to a great degree, it's like two sides of a coin. Most movement people, and I really... There's a spectrum here, and I know that I'm going to hurt people's feelings if I make it too broad. Like yoga is very much more towards stretching, and pilates, is more strengthening, but they both do both, but if you go to the ends of the spectrum, fitness training is making you stronger, massage is making you looser.

22:21 DM: Pilates and yoga fit somewhere in between. And now to exactly hit the nail on the head about your question. If I ask my client to do a stretch themselves, my hands are not on them. Technically, it's not manual therapy. If I say, "Go home and you're going to do a self-care stretch where you're going to do this, or you're going to do that," that's not... And if they were in the office and I say, "Do this or do that," it's not a manual therapy technique, my body's not contacting their body, my hands are not on them. A fitness trainer very often tells the client to do stretches without their hands on, but the fitness trainer can also put their hands on as a yoga and pilates person can, and then it becomes an augmented stretch with manual therapy.

23:07 DM: So the stretch being done by my client in a manual therapy setting is a movement therapy because they're moving. If my hands are not on them, it's only movement, but if my hands are on them, it's manual and movement. A fitness trainer tells someone, "I want you to move this way." Their hands not on them, it's only movement. They put their hand on them, it's manual and movement. It is the intersection of, to me, the worlds. And I think that it's maybe a nice meeting ground diplomatically for two sides to come together. And I should add neural control, nothing works if you don't change the nervous system's coordination pattern, what people will call muscle memory. Muscle memory is not in the muscle, it's muscle tissue, it's in the nervous system, but yeah that is a third factor that's critically important. It's not the quantity of what you do, it's the quality of your movement patterns.

24:03 DB: So Joe, how do we get to the one cohesive world that you mentioned in the article, where you mentioned that manual and movement are the yin and yang to one another?

24:14 DM: Another... Boy, some great questions are great questions, 'cause I like that, I can answer that, and other ones are great questions 'cause I like it, I can't answer it. So let's start with what I would give people in Connecticut like a little bit of a work around. I would say, "Listen, you're a massage therapist already, you've already had anywhere from a 750 to 1100 hour program, you know anatomy, physique, and aetiology, you know muscle actions, you know what makes a muscle have to consensually contract, eccentrically, isometrically contract, you can do that, you just need to apply it to a direct strength resistance kind of program." And you can't do it legally as a massage therapist, but if you were to go take a two-day, a five days, a seven day, a six-hour, 600-hour program, if you went and did any program that legally, ethically gives you the scope of practice to do strength training, and then while you're working with your client, you say, "Okay, we've now done all of this. I'm also a fitness trainer." Make it very clear, you never... You always want to have absolute verbal clarity and consent with the client to say, "I know you came to me, I'm a massage therapist, but I'm also a fitness trainer, I'm also a Pilates instructor, I'm also a yoga instructor, I'm also a Feldenkrais practitioner."

25:40 DM: I think it would behoove you because you have these tight muscles, let's say your pecs are tight. So you're getting rounded shoulders, part of what's called Upper-crossed syndrome named by Vladimir Janda. So we're loosening and working on your pecs to loosen you, I'm massaging it, I'm putting more stead on it, I'm stretching it. The problem is that if you don't make your retractors of the scapula rhomboids trapezius, especially middle trapezius stronger, then you're going to collapse into protracted rounded shoulder girdle posture, forward posture this way, simply because you don't have the strength to hold the body parts against gravity, collapsing down. So it's like a... To me yin and yang, it's like a chicken and egg, right? If you have taut myofascial tissues and you make them looser, if you don't make the muscles that you need to be strong, stronger, then you're going to collapse with gravity, and you're going to, therefore, be in bad posture again.

26:48 DM: If a fitness trainer keeps strengthening your retractors, strengthening your retractors, but never helps you loosen protractor pec tissue, then your retractors are fighting against these overly facilitated hypertonic tight, whatever adjective we wanna put on this, that's the new buzz word way to say it. Muscles that are fighting it, you need to... You can't kill the chicken and let the egg hatch into chicken and you can't smash the egg and let the chicken lay a new egg. You have to take care of both, and if it's not going to be literally in the same treatment session, then it's going to have to be literally during the same treatment regimen time, where if you don't do this other side of the coin, then they need to do it, whether they do it at home or you refer them to professionals to do it.

27:43 KC: And I'm so, so glad that you brought up the Upper-crossed syndrome example. I was gonna ask you about it next if you hadn't mentioned it. Because when I was reading the article as a massage therapist, that's when I said, "Oh, that makes absolute sense. I totally get everything he's talking about". And I think that example you just gave will have the same effect for our listeners too. Because we can really wrap our heads around it. That's a practical example that we see in our practices all the time, every day.

28:14 DB: I think there are so many things that we've touched on here, from scope of practice to the turf wars to... I think what really drew me to the article was where we're at right now. Meaning, I worry that practitioners aren't able to practice because of the current pandemic or arts, maybe they're new to the profession and they don't know the numbers of people who can wear themselves out physically fairly quickly, if they were just doing massage therapy. I always get really interested in the publication when I see things that they can balance their current careers with things that are just a side step away, things that are absolutely integrated. I think about it like a Venn diagram, right? And I think about the bubbles, and I think about the way the things interact. And we're so used to, in our association, seeing massage therapists also be aesthetician. That's one side of the coin. But the other side of the coin is we see many massage therapists being yoga instructors or moving into pilates.

29:24 DB: And any time I see that, I think about the longevity of their careers, protecting their bodies, getting more education, getting more continuing education and continuing to be life-long learners. When I think... When I watch those things all mashed together, that gets me really excited. Because, as you mentioned in the article, they're four-fifths of the way there. There's just... It's either because of a regulation or it's because of a technicality, whatever, there's something that's keeping them from doing the extra thing. And obviously, we have to print a scope of practice things about signing homework to clients and things like that, but I just... It's so interesting, and I thought you really hit the nail on the head by identifying something that was so close to the two worlds and their alignment that I really felt it was in some ways a no-brainer.

30:21 DM: I would... Yeah, I would have to say that I even forgot about this. For about five years, I taught at a university, I taught anatomy, phys-ed and the bio department of the State University of New York Purchase College. And at the time, my wife was teaching in the Pilates, in the phys-ed and the dance department, and I realized that there was such a closeness in these fields, and I took a look at a typical 120 credit hour bachelor's program. And I thought about some kids, that come out of high school and they don't wanna be a white collar intellectual book reader kind of person. But boy, it's good to have a college degree just to say, "I have a Bachelor's, I have a college degree", and then I was thinking that... Well, I'm gonna just cut to the short... Cut to the end of this. I created a program that fit in the 120 hours, that when the person would be done, they would have a Bachelor's in manual and movement therapy, and they would come out and they would be able to be a certified Pilates Instructor, yoga instructor, fitness trainer and be eligible to sit for a massage exam.

31:40 DM: And we got it three levels up in the university, but universities tend to be very vertically hierarchical. And usually the higher up you go, you get to someone who's older from the old world who says, "No, we've been doing it the way we've been doing it forever, we don't need to make any change", and it got mixed at a certain point, and it was a pity because we had the support of a number of levels, and I thought to myself, "Wow, you have an 18-year-old kid graduating high school, and they can come out in four years, have a college degree and be Pilates, Yoga, fitness, and then be able to segue into the massage." All the same fundamental anatomy, physiology, pathology, all of that, the same.

32:30 DM: And it wasn't my job. I didn't view my life as being a lobbyist for this, so when it didn't happen, I let it go. This, I believe, will be on the horizon at some point as universities and colleges start to look to find other ways to bring people in, if not for altruism and philosophy, because they are also money-making organizations that need to get in tuition dollars. And I need to say one other thing that I didn't think about until you brought up this COVID corona time is, I used to always think that being a chiropractic physician, being a massage therapist, being a physical therapist, you were guaranteed a job for life because they could never ship your job overseas, like manufacturing can be, like call centers can be, accounting, architecture, all that stuff can be.

33:32 DM: And this year, in February to March, when we shut down, it blew me away, because I realized that being a manual therapist requires proximity of touch and in a pandemic, that's the last thing you're allowed to do. My wife was able to go to Zoom for Pilates, but couldn't do massage for March, April, something like three months. So you might even look at this as being a plan B, alternate money when it's a salary-saving way to stay alive, and I do like your idea of Venn diagram and concentric circles that get bigger because that's what I've done my whole life. I became a chiropractor, then I taught at a massage school, then I started writing textbooks, then I wrote the DVDs, then I did online continue education, and I never did something that was on margin.

34:38 DM: I always just moved a step and I just grew my circle, and now I'm very glad I did because I have a number of interests, so I never get bored, and I also have a few different revenue streams. So even though I as a chiropractor in Connecticut was allowed to stay in practice legally, ethically, I still didn't have very many patients that came in because they were scared. So I was able to focus more on my video online streaming services. So altruistically, money-wise, life-saving, whatever you look at it, there's so many reasons, but ideologically, to me, manual and movement therapy should go together in someone's health scheme, therapist or client.

35:28 KC: So if I as a massage therapist, until I have certification or I'm able to legally practice one of the movement therapies, I may refer out to someone as maybe we partner together and we work together with our clients. Ultimately though, say I do pursue one of the movement therapy certifications, and I'm able to legally do both, and I have a client come in, what do you think comes first? Again, you mentioned chicken or the egg earlier. Which comes first, chicken or the egg? Is that a client by client basis? Or what do you recommend? If I'm able to do both and I have a client come in who maybe has Upper Crossed syndrome or something similar, which do you think is the best way to start a session like that?

36:12 DM: I do think first, it always depends. I'll give a shout out to Whitney Lowe. Whitney Lowe once said something, "The best answer to every question is, it depends." So of course, I told my students that when I taught at the massage school, and what I got when I asked every question to the class after was, "It depends." And I'd say, "Okay, fine. It depends on what?" That's the next question that you have to look at. So I think as a general rule, movement is facilitated when tissues are first warmed up. For that reason, I think that some manual therapy works better before movement. Having said that, massage is going to be more successful if they're first warmed up also. Both are more successful if they're first warmed up.

37:00 DM: But when it comes down to the two, I would not recommend that you put someone on the table, give them an hour massage, get them totally relaxed, the lights are low, the music is soft, you have essential oils and everything, and you're regressing them through a few past lives, and suddenly you say, "Get up and exercise." That's the worst thing you could do. You have just inhibited their nervous system. So I could see how you could even, if you wanted, do a little bit of massage, then a little bit of workout, and then finish with a little bit of massage. And I'm not trying to make people shake their heads and go, "Oh, he's making it too complicated."

37:39 DM: You first have to address logistics. Because I teach in Asia lot. What I found in Asia is they do a tremendous amount of massage without oil, through the towels. And it's amazing how much deep friction you can get, and you're not rubbing and abrading skin when you put a towel on and then you rub the towel. So you can do a little bit of work on someone when they're in their fitness clothing. Not spandex. Spandex is really hard to try and do any type of manual soft tissue manipulation on, but any other type of material. Really what the best thing is is that they get on an exercise bike or an arcstrider or an elliptical, or they walk in hot weather for 10 to 20 minutes and then come in and then do either one you want. If you're going to do the massage first, just make sure that it wakes up their nervous system before you get them off the table.

38:34 DB: Hey, Joe, finally, you mentioned in addition to... We've spent a lot of time today talking about manual and movement therapies, but can we talk about that third side of the coin while I'm finished on that topic? Can you tell us about the neuro component?

38:46 DM: Even though I gave this gross generalization of, "Fitness just makes you big and strong, and massage just makes you loose and goosey," whatever it is, that they both can do the other. But they do meet in the middle with stretching. They also can meet in the middle with neural motor control, and I love this saying in the world of Pilates. Joe Pilates would say, and maybe someone before him said it, I'm not sure, but I heard it first via him, that, "It's not how many, it's how." It's not the quantity of your repetitions, it's the quality of your movement pattern or your posture pattern. And certainly if you can get rid of tight adhesions and trigger points and things, you allow me to be more free and hold myself in a better pattern.

39:37 DM: But there are a lot of people... I'll give an example. I would have a patient on the table and I work their neck, and when I'm done working their neck with soft tissue manipulation, etcetera, I have theoretically helped to loosen certain muscles, and in my belief, the way it's done is you're resetting the Gamma motor system, control of the muscle spindles, which control muscle tone, muscle memory, muscle tone, but if they're used to not moving their neck because their neck is tight, what you can have happen is they can get up off the table and they're starting to walk out and you say something to them, and instead of turning their neck to talk to you, they turn their whole body around with their neck stiff because they simply haven't learned, "I can use my neck now."

40:29 DM: So very often when I have a patient on the table and I've worked on them, I like to finish with stretching. I like to do stretching after massage. I feel like it resets the muscle spindles, but even beyond just doing the stretching, I'll then as I'm stretching, let's say to make it simple into left rotation and right rotation, the client is supine. I'll say, "Do you see how much movement we have here?" And I make them verbally acknowledge it. And I'll say, "Do you remember we were only here at 60 degrees and now we're around 70?" 70, 80 to 90 is considered full healthy, but let's say you pick up 10 and they go, "Yes," and then I'll take my hands off them and say, "Please show me that." And I ask them to actively do it, so they train their nervous system that they can know how to do it.

41:20 DM: So I wanna say that that neural control is something that we can pattern in by not just making them loose and saying, "Go out," and then they do all the wrong things again, but talk to them about what we've empowered their body to be able to do. And the other thing too. And I sometimes say that it's like I'm an artist working on a canvas and you're my work of art, you're my patient, you're my work of art. And they come in with a high right shoulder and I work on them and I work on them, I loosen their levator scapulae, upper trap, blah, blah, blah, blah, all that. And they get up and they get dressed, and then they say goodbye to me and they put their purse with a strap over the right shoulder and they promptly elevate their shoulder girdle. Well, now they're training, they're facilitating their nervous system to make their right side upper trap levator scapulae hypertonic and tight again.

42:16 DM: So it's not just enough to make them, let's say looser, if we generalize that way. We have to show them the change and show them how to incorporate it in their life. I'm biased because my wife is a Pilates instructor, so I've been very exposed to it and I do Pilates every day, and I fought it for a lot of years. She would tell you that. I really did. But I have to say that one thing I love about Pilates is the... And it's very true in yoga too. But Pilates people can be so exacting about the symmetry of your movement. They really wanna see that you are moving in a symmetrical way, they really wanna see that you engage that core before you move something distally, they really wanna see you stabilize your spine, they really want to see that, not... Some Pilates people go too far and they get too stiff.

43:12 DM: That's not to me a healthy read of it, but they really wanna see that. And I think some styles of yoga tend to be leaning more toward looseness than strength, but some styles of yoga are very balanced that way also. I really feel like it's almost like if you want to make that generalization, massage is one end of the spectrum, fitness training is the other, and yoga and pilates sit right between them. And I really do think yoga generally sits a little closer to massage in ethos, in ideology, in style, and spiritual way of looking at things. But that could be an argument that if you wanna move one concentric circle out, do yoga next. Or it might be an argument that, "No, I know that circle. Let me reach out two or three layers and let me go right to Pilates or go to the opposite end, the fitness." But either way, it's the quality of your postures and movements that's so important, and that's nervous system.

44:20 DB: I wanna thank our guest today, Dr. Joe Muscolino, for joining us. Joe, where can listeners find out more information about you and all of the great offerings that you have?

44:30 DM: The easiest place is to go to my website, which is www.learnmuscles.com, one word, L-E-A-R-N-M-U-S-C-L-E-S learnmuscles.com and everything that I have to offer is there, but I certainly will say check out my video streaming online continue education programs, which is one of learnmuscles continue education. At this point, we are in what? November. November of 2020. There's over 2250 video lessons there and nothing ever goes away, and I add 10 new video lessons every week, and the muscle anatomy masterclass is about 1000 lessons, but it's very organized. Five distinct video lessons for each muscle. About 178 muscles are covered from drawn anatomy to cadaver, to a person exhibiting the joint actions and movement motion patterns, to how to palpate, specifically palpate that muscle, and how to specifically stretch that muscle, and I distinguish between each for example, the 12 hip flexors. It's not the same hip one stretch for each one. We add in components to the other planes to be very preferential toward that specific muscle. So I'm very proud of those two new babies of mine.

45:51 DB: Excellent, thank you so much, Joe. Thanks, Kristin.

45:53 KC: Thank you, Joe, you've given us so much to think about. Really appreciate you being here with us.

45:58 DM: Thank you, Kristin. Thank you, Darren.

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