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The techniques at this ladder rung are most effective during the later levels of rehabilitation or with highly active individuals. Because you are putting a load on the muscle and simultaneously applying pressure, these techniques can be the most intense of the different levels. As a result, you don't want to do this too early in the rehabilitative stage when certain treatment techniques may be painful or increase adverse neural activity. Here are some examples of techniques at the fourth rung of the ladder. • Resistance stretching: This technique is a variation of facilitated stretching and usually starts with an isometric contraction of the target muscle. As the client slowly releases the contraction, the practitioner stretches the client's target muscle. This technique can be very effective in retraining muscles not to have neurological resistance to stretching (thereby increasing range of motion). • Stripping with additional resistance: The active engagement stripping technique described under the third rung can also be applied with additional resistance. In the previous biceps brachii example, a stripping technique was performed on the muscle while the client extended their elbow with an eccentric contraction (performing elbow extension). However, at this level, the practitioner offers additional resistance with their hand. They may start with the elbow flexed to about 90 degrees and have the client hold the position. The client then slowly lets go of that position, and the practitioner pushes their forearm into extension. At the same time, the practitioner performs a stripping technique on the elbow flexor muscles, which are working eccentrically (Image 5). • Compression with active movement with additional resistance: A similar process is used in which a static compression technique is applied to a myofascial trigger point or tender spot within the muscle. Pressure is then applied to the tender spot while the client lifts and slowly drops a handheld weight. The increased load on the muscle magnifies the effect of the pressure applied. CONCLUSION Practitioners should understand that these technique variations are not random alternatives to different techniques. There are specific reasons that should direct which rung of the ladder you choose. In the Clinical Orthopedic Massage system, I use another of my systems, called the rehabilitation protocol, as a guideline to determine a condition's severity level. The protocol also then guides the decision about what type of treatment strategies will be most effective. In general, you will usually move up the ladder from level one to level four. However, there are cases in which you might jump up the ladder to other levels more quickly. I always recommend starting with level one to ease the nervous system and relax the client. But for some situations, such as with professional sports clients, jumping to level four after level one can be beneficial. A great benefit of the ladder of engagement system is taking what you may already know as relatively simple methods and multiplying the variations on those methods to create dozens, if not hundreds, of new technique options. It is a simple but effective system that can become a hallmark of your therapeutic practice. Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His text and programs have been used by professionals and schools for almost 30 years. Learn more at academyofclinicalmassage.com. L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 25 TECHNIQUE 5 Stripping with active engagement with additional resistance.