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The bedrock of a robust massage therapy practice is always having a variety of treatment techniques. In particular, variety is integral to any treatment system that addresses musculoskeletal conditions. How to address each client's problem depends on the condition specifics, stage of recovery, and the client. Employing diverse treatment options that fit the condition and the client will lead to greater success with your clients. One of the core systems in my Clinical Orthopedic Massage program is what I call the ladder of engagement (LOE). I developed this system to simplify and organize the diversity of treatment options you face when working with musculoskeletal disorders. The LOE system is a progressive application of techniques to make your treatments more specific and effective. The system allows the practitioner to customize each treatment for the condition and client. And it will help you customize the treatment to the condition and client's specific healing process. The LOE system is valuable to help you move away from simple recipes and routines in your practice. It is an excellent approach to treating complex pain and injury conditions. It also applies in other settings and will expand your treatment options. In this article, we'll cover the general basics of the LOE system and look at a few examples. Please know that the following is a simplified and greatly abbreviated version of this system. PRESSURE APPLICATIONS Before going into the LOE system levels, let's look at a core consideration you will face when applying the techniques. At each level or rung of the ladder, you will choose how much or how little of your hand surface to use and how much pressure to apply. How, why, and when to use a particular amount of pressure and hand surface is a critical component in treatment. The contact surface has a significant bearing on the physiological effects of the treatment. Pressure and contact surface choices are key considerations at each level of your therapeutic plan. The amount of contact surface determines how localized or dissipated the pressure of your technique will be. A broad contact surface, like the palm of your hand, backside of your fist, or your forearm, spreads the pressure out over a larger area. As a result, the pressure and specificity of the force are more muted. Spreading the pressure out is highly beneficial in areas where pressure on the tissues produces pain, or in the early stages of an injury in which tissues are highly sensitive or should not sustain more pronounced pressure. Eff leurage (gliding) is a common broad pressure application, for example. 20 m a s s a g e & b o d y wo r k n ove m b e r/d e ce m b e r 2 0 2 2 The Ladder of Engagement TECHNIQUE By Whitney Lowe CLINICAL EXPLORATIONS 1 KEY POINTS • A great benefit of the ladder of engagement system is taking what you may already know as relatively simple techniques and multiplying the variations on those methods to create dozens of new technique options. • The ladder of engagement system is valuable to help you move away from simple recipes and routines in your practice. Technique Only Technique + Movement Technique + Movement + Contraction Technique + Movement + Contraction + Additional Resistance The ladder of engagement.

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