Awakening the Organic Girdle with Stability Ball Exercises for Massage Clients

Eighty five percent of the population will experience at least one episode of low back pain (LBP) in their lifetime (Damkot 1984, Walker 2000). It is estimated that up to 70% of these individuals will experience 3 or more recurrences (Waddell 1995) and up to 89% will continue to experience recurrence over a 10 year period (Frank 1993). 30-40% of all work place absences can be attributed to back pain (worksafebc.com). Primary care physicians report that 97% of all back pain is mechanical in origin (Kuritsky 1997, Deyo and Weinstein 2001).

This article addresses an issue fundamental to back pain occurrence and recurrence; re-awakening the organic girdle of myofascia that supports our spinal column!

Introduction

Developing and assisting clients to reduce the incidence of recurrent back pain episodes is of utmost importance. Encouraging our clients to engage in self-care expands their potential for well-being and supports the value of involvement in one’s own care. This speaks to one of my primary therapeutic philosophies … give a person a fish and he/she will eat for a day … TEACH a person to fish and he/she will eat for a lifetime! I am also a firm believer in practice what we teach! As back pain is a familiar occupational hazard among massage therapists, this can be a useful self-help tool for the care provider as well!

When it comes to the human body, absence of pain is not synonymous with absence of dysfunction. With regard to the low back, more recent research (Richardson et al 1999) supports this understanding quite clearly. In this article we will explore some crucial factors which place us at greater risk for recurrence following initial incidence of back pain. I will also be providing a few rehabilitative exercises that can help alleviate back pain and reduce the potential of future episodes.

The Organic Girdle

Organic is defined as: that which is derived from or arising from a living organism. Girdle is that which encircles or surrounds to bind, belt, band or support. (Webster’s Dictionary 1991).

Our Organic Girdle (OG) helps to support and stabilize the thoracolumbar and lumbopelvic region. It is formed by the Multifidi and Transversus Abdominis (TrA) muscles and their associated fascia. The OG is considered to be the workhorse of spinal segmental stabilization. The psoas major, internal oblique, the pelvic floor and diaphragm muscles also play a role in local/spinal segmental stabilization.

We will be focusing our attention to the OG along with a few other major players while relying heavily on the work of some outstanding researchers from Australia (Richardson et al 1999) This is a generalized overview of their very extensive work.

The major players of spinal stability and motion are the Local Stabilizers (or OG), Global Stabilizers and Global Mobilizers. These muscles are grouped together by the types of functions that they serve. Let’s examine how each player functions!

Let's look at each component of the organic girdle in detail.

Local Stabilizers (= the Organic Girdle) often attach directly to joint capsule. They contain a large number of proprioceptive nerve endings which provide information pertaining to joint position, range and rate of movement. These muscles provide stability between the individual spinal segments, control segmental movement and are active at all times during movement even when movement does not occur locally.

The multifidi function primarily to produce fine movement or adjustment between the vertebrae and to stabilize each individual segment. The transversus abdominus assists with stabilizing the thoracolumbar and lumbopelvic regions during movement and load lifting. The local stabilizers are tonic muscles.

Tonic muscles have the following properties:

they tend to be postural muscles
respond to overload or repeated strain by shortening and tightening
a lower threshold of stimulation than phasic muscles and are primarily recruited at low loads of less than 25% of maximum voluntary contraction
are comprised of at least 51% (red) slow twitch muscle fibres (slow twitch muscle fibres have a greater capacity for endurance activity and managing the impact of gravity)
utilize oxygen more than sugar for fuel
a higher proportion of fascia than phasic muscles
a higher density of muscle spindles (sensory endings) than phasic muscles and therefore provide a greater amount of feedback to the brain (this impacts the setting of tone!!! i.e. tone as in pre-tension)

Global Stabilizers (Oblique abdominal muscles, Spinalis, Gluteus Medius): generate force, control range of motion movement (especially inner range) and low load momentum and deceleration.

Global Mobilizers (Rectus Abdominis, Iliocostalis, Piriformis): provide the power/speed for acceleration, deceleration (via eccentric contraction), gross joint movement, heavier load lifting and propulsion. These muscles can be recruited for stability when under heavy load or at high speed (Comerford and Gibson 2001).

Global Stabilizers and Mobilizers tend to be phasic muscles.

Phasic muscles have the following properties:

they tend to be the prime movers of the body
respond to overload or repeated strain by lengthening and weakening
are comprised of at least 51% (white) fast twitch muscle fibres (fast twitch fibres have a greater capacity for explosive, powerful movement and are recruited at higher loads of more than 40% maximum voluntary contraction)
utilize sugar more than oxygen for fuel

When healthy (no previous history of back injury or back pain) the brain separately controls each of the three units:
· local stabilizers/OG
· global stabilizers
· global mobilizers

In an uninjured back, with low/lighter loads, the brain will normally activate the OG first to stabilize and protect the spine. The global units are designed to kick in when moderate to higher loads are present.

Global Stabilizers (Oblique abdominal muscles, Spinalis, Gluteus Medius): generate force, control range of motion movement (especially inner range) and low load momentum and deceleration.Global Mobilizers (Rectus Abdominis, Iliocostalis, Piriformis): provide the power/speed for acceleration, deceleration (via eccentric contraction), gross joint movement, heavier load lifting and propulsion. These muscles can be recruited for stability when under heavy load or at high speed (Comerford and Gibson 2001).Global Stabilizers and Mobilizers tend to be phasic muscles. Phasic muscles have the following properties: · they tend to be the prime movers of the body · respond to overload or repeated strain by lengthening and weakening · are comprised of at least 51% (white) fast twitch muscle fibres (fast twitch fibres have a greater capacity for explosive, powerful movement and are recruited at higher loads of more than 40% maximum voluntary contraction) · utilize sugar more than oxygen for fuel When healthy (no previous history of back injury or back pain) the brain separately controls each of the three units: · local stabilizers/OG · global stabilizers · global mobilizers In an uninjured back, with low/lighter loads, the brain will normally activate the OG first to stabilize and protect the spine. The global units are designed to kick in when moderate to higher loads are present.

The Relationship between these Control Systems and Low Back Pain

Any event that results in tonic muscle distress (shortening and tightening), will usually result in lengthening and weakening of opposing (antagonistic) phasic muscle(s). This is thought to be the basis for the common patterns of muscle imbalance that are frequently seen in the body (Janda 1985).

It has been hypothesized that low back pain, in great part, is due to mechanical derangement of the spine. This is termed “clinical instability” (Nachemson 1985). This stability system relies on the effective (healthy) functioning of three subsystems: neurological, spinal stabilizer muscles and spinal column (Nachemson 1985, Punjabi 1992). When any, or all, of these subsystems are not functioning properly things can go awry.

For example: any event that results in undue compression or deformity/deviation of spinal alignment (including inability to remain fixed in neutral/safe position during movement and load bearing), neurological dysfunction (including improper recruitment sequencing of the local stabilizers/OG, global stabilizers or global movers) or deformity of any pain sensitive structure (i.e. ligaments, muscle, neural stretch etc.) significant enough to cause pain inhibition will ultimately interfere with the proper functioning of the stability system.

Following back injury - or significant degenerative changes and subsequent pain - the brain no longer initiates separate control but instead a more simplified control system predominates.

The following changes often occur:

The local stabilizers/OG exhibit recruitment deficiency (timing and amplitude), inefficient low threshold recruitment, pain inhibition, reduced stabilization capacity, poor segmental control and loss of control of joint neutral position. This appears to be a result of mutifidi atrophy (at the ipsilateral spinal segment associated with the pain). To complicate matters more, the TrA tends to spasm like its associated global units (Rectus Abdominis, Obliques) and converts to a phasic rather than a tonic nature (Mottram and Commerford 1998).

The global stabilizers/mobilizers become over active in a compensatory attempt to stabilize and protect the spine. In particular, the global stabilizers exhibit poor low threshold/tonic recruitment, poor eccentric control and rotation dissociation, loss of inner range joint movement, and muscle spasm/shortening (fixed long or in a state of eccentric hypertonicity). The global mobilizers exhibit over active low threshold/low load recruitment, myofascial shortening and spasm (fixed short or in a state of concentric contraction) and reduced ROM (Mottram and Commerford 1998).

Back Pain Destabilization.JPG

Once the components of the OG become pain inhibited the larger global muscles take on the role of trying to stabilize during low load situations. These larger/phasic muscles are not well suited for this job and thus the chorus of cacophonic dysfunction ensues! When the components of the OG are in a state of pain-inhibition and because they are designed to respond to low load … working through the pain and “work hardening” approaches to rehabilitation will generally prove ineffective.

The OG does not automatically return to normal functioning following the cessation of pain and return to pre-injury activity. The question here is why doesn’t it automatically return to normal? Why does our proprioceptive system somehow lose the ability to detect subtlety (low load) and initiate the anticipatory pre-tension that stabilizes the spine? The answer may lie in the research abstract presented by Dr. Paul J. Moga D.O. PhD. at the First International Fascia Research Congress. Dr. Moga’s research shows that chronic LBP patients over estimated a weighted object twice it’s actual weight. He also noted that in addition to altered proprioception and nociception, fascial tone may also play a role (Moga 2007). So perhaps it is our perception of the load and interference within our fascial system that diminishes our capacity to return to normality following a back pain episode. I won’t even begin to go down the path of fascial-dom in this article but I will stress that this piece not be ignored!!!

The images below illustrate multifidus atrophy and fatty change that frequently occur. Click on the image to access the journal article it came from!

One can see why after the interrelated changes that occur as a result of their dysfunction, and which often tend to lock this dysfunction in place, normal segmental support is lacking and as a result the risk of re-injury is amplified.

Research has determined that only 10% of those with a history of low back pain could activate the TrA, compared with 82% of non-low-back-pain subjects. Over a 10 week period, patients performing exercises that specifically targeted the TrA experienced a significant decrease in pain and an increase in functional ability. An important part of rehabilitation is to re-establish the appropriate sequence of firing of the muscles: local stabilizers/OG first, global muscles after (Richardson et. al 1999).

Another interesting note about TrA: in non-injured individuals TrA will display anticipation activation or setting of spinal stabilizer pre-tension prior to movement of the arms. In those with a history of LBP, TrA activation has been shown to be significantly delayed (Hodges and Richardson 1996, 1997).

In the next section we explore how to re-awaken the OG, resolve back pain that arises from core dysfunction and prevent its recurrence!

Spinal or Lumbopelvic Stabilization … the Road to Restoration of Function

In 1992 Panjabi proposed that muscle involvement and neurological control play key roles in joint stability. When it comes to spinal segmental stabilization … timing is everything! The local stabilizers/OG fix the spine in a neutral position allowing for the larger global units to work in a safe and efficient manner. Without the ability to set pre-tension and secure the spine in neutral we are at much greater risk for re-injury or escalating the problem.

The predominant issue with the multifidi following an episode of back pain is that of inefficient recruitment. Because the multifidi are not being adequately stimulated they atrophy. As well, putting higher load demands or working to exhaustion will only encourage TrA to remain in a state of un-natural phasic dysfunction. To further complicate the problem the over development of the Global units interferes with local stabilizer/OG action. As already noted working through the pain and work hardening approaches have proven to be ineffective with regard to the re-awakening the Organic Girdle.

Reawakening the OG requires the emphasis to be placed upon re-establishing correct timing of engagement, low load stimulation and repetition. I use the term “engagement” rather than contraction in reference to the OG to more clearly define the difference between; subtle stimulation vs. a power generating force.

The stability ball is a powerful means by which to re-awaken the OG. The unstable and dynamic nature of the ball’s shape stimulates the neuromuscular system and engages the OG in a way that many other forms of exercise do not. Once stabilization has been re-established one can progress toward more demanding exercise. When the exercises are performed correctly, working to keep your balance on the ball will engage your OG while you perform more challenging movements or resistance exercises that target the global stabilizers and mobilizers. Remember however that, with stability ball exercise, the emphasis is placed upon precision and control rather than power and load.

Prior to work on the stability ball it is recommended that one first learns to engage the Organic Girdle (in neutral spine) prior to initiating movement or resistance exercise.

GENERAL BENEFITS OF WORKING ON THE BALL

Other benefits of working on the ball include improved: balance, proprioception, coordination, strength, range of motion, flexibility, cardio-respiratory health and postural re-education.

Working on the stability ball can either offer support and assistance, or challenge and resistance. When working on the stability ball you can either neutralize gravity or use it to make the exercise more challenging. Cardiovascular conditioning can be achieved by creating a sequential program of increasing intensity and progressive energetic rhythm while incorporating upper and lower body movements.

BALANCE

The unstable and dynamic nature of the ball engages the spinal stabilizers and joint proprioceptors during all exercises performed while on the ball. The ball generates a great deal of intrinsic feedback challenging our bodies, in an unconscious manner, to make rapid postural adjustments reinforcing the coordinative linkage between postural muscles. Regular repetition of various exercises performed on the stability ball can significantly improve balance. Maintenance of good stability and balance will ensure the preservation of a higher level of functional ability.

Aging and issues with balance present the potential risk of falling, fracture, post-surgical recovery complications and the impact on quality of life. It has been estimated that the mortality rate following hip fracture surgery is 30% at twelve months (Moran et al 2005). Stability Ball exercise is one of the best ways to improve balance, coordination and stability. The ball quickly brings attention to issues with balance and various muscular imbalances.

PROPRIOCEPTION, MOTOR CONTROL and SENSORY PERCEPTION

Improved awareness of our bodies positioning in space is a key component of balance, coordination and joint health. The ability to adapt easily to changes in positioning decreases the incidence of injury and assists in the protection of our joints. Bouncing and transitional movements on the ball stimulate joint receptors and muscle spindles. The stimulation of proprioceptors during stability ball exercise results in strengthening and greater stability of joint associated soft-tissues.

Greater motor control is achieved through the integration of all interacting systems: cognitive/limbic, cardiopulmonary, musculoskeletal, neuromuscular, sensoriperceptual, gravity and the individual’s morphology. Stimulation of vestibular nuclei and the reticular formation mediates increased general arousal and alertness. The dynamic nature of the ball stimulates visual and vestibular somatosensory systems integrating multi-modal sensory information. The widespread excitatory and inhibitory physiological effects, via vestibular stimulation, results in increased tone of the postural extensors and excitation of coordination and equilibrium responses.

COORDINATION

By being mind-full and aware during movement we can develop greater control of our movements. Stability ball exercise places a greater emphasis on precision, alignment and technique rather than number of repetitions, sets and level of exertion. In addition to improvement in balance, coordinated and precise movements are more energy and alignment efficient resulting in less strain and fatigue.

SOME GENERAL INFORMATION TO CONSIDER WHEN PURCHASING A BALL

QUALITY

A variety of brands are now available. Along with the vast variety of brands, colours, names (Stability Ball, Swiss, Exercise, Physio or Thera-ball) there are also variances in quality. Physiotherapy supply and reputable fitness equipment stores tend to carry the more professional quality products.

choose a ball that feels relatively heavy when un-inflated (better quality stability balls are often made with thicker material)
some of the cheaper stability balls have a very strong vinyl/plastic odour
better quality stability balls are burst resistant, they do not explode when punctured but deflate gradually (this will usually be stated on the packaging)
look for one that is weight tested up to 1000lbs.
cost: anywhere from $10.00 to $100.00 (many come with a pump, instructional DVD, video or booklet)
if you will be using your ball as a weight training “bench” and/or for cardio exercises it is recommended that you spend a bit more and purchase a better quality ball

SIZE

Using a variety of sizes can change the nature and effect of various exercises. The following guidelines are applicable for general use. Selecting the correct size stability ball is typically determined by your height.

up to 4'11" : 45cm (18")
4'11" to 5'5": 55cm (22")
5'5" to 6'0": 65cm (26")
6'0" or taller: 75cm (30")

SEATED TEST FOR PROPER INFLATION

sit with your feet flat on the floor and slightly wider than your hips
knees at 90 degrees or heels slightly ahead of your knees
thighs parallel to the floor or knees slightly HIGHER than your hips

SAFETY and PRECAUTIONS

perform all exercises slowly enough so that you can maintain control of the movement at all times
make sure your exercise area is safe: free of sharp objects or anything that you could fall on or into and potentially injure yourself (the exception would be to sit near a wall in the beginning or use a chair to provide assistance with some balancing exercises)
make sure you have enough space to roll around without bumping into something
exercise on a slip resistant surface (a yoga mat works well)
wear slip resistant footwear or go bare feet

CAUTION

Loose clothing or long hair can get caught under the ball as you roll into/out of certain positions, take the necessary measures to ensure that this does not happen.

GENERAL EXERCISE TIPS

as during any exercise make sure you are adequately hydrated
begin slowly, ease into any new exercise program (working on a stability ball can be very challenging)
a slightly under inflated ball provides a more stable base and is recommended in the beginning (provides greater contact surface area)
another tip for beginners or those with compromised balance is to use a ball stabilizer (this stops the ball from rolling but still allows for some dynamic movement when seated, lying or kneeling on the ball)
the mind guides the body, so be mindful of:where is your centre?
* what needs to remain still or stable?
* what needs to move and where?
* good posture, alignment and technique reduce the potential of injury and enhance the effectiveness of the exercises, perform movements slowly with precision and control

PREPARATION FOR STABILITY BALL EXERCISES

Video of Cathy Initiating Recruitment of the Transversus Abdominus and Multifidi

1) FINDING NEUTRAL SPINE

lying on your back with your knees bent and feet flat on the floor (place a pillow under your headed if needed)
move your pelvis into anterior tilt and then posterior tilt
find the neutral/middle place between these movements (we will designate half way between anterior and posterior pelvic tilt as NEUTRAL SPINE)

2) ENGAGING TRANSVERSUS ABDOMINIS (TrA)

lying on your back with your knees bent (place a pillow under your headed if needed)
find and maintain neutral spine
place your fingers on your ASIS (bilaterally)
move your fingers approximately 1" toward the mid-line of your body and 1"down (this will enable you to feel the TvA contract)
while maintaining normal breathing, draw the lowest portion of your abdomen up and in toward your spine (drawing your belly button toward the spine) without producing any pelvic tilt movement or flattening the spine toward the floor (i.e. maintain neutral spine)
breathe normally while holding this position for 5-10 seconds
repeat 5-10x’s
REMEMBER: this is intended to be a subtle engagement not forceful contraction

3) ENGAGING MULTIFIDUS

lying on your stomach, turn your head to one side and place a pillow under your head
place your arms (elbows bent) on the floor palms down (hands up near your head)
find and maintain neutral spine
while maintaining normal breathing, contract the small muscles along your spine by pushing pressure out, like you are trying to swell the abdomen and lower back (not as vigorous as a Valsalva maneuver!)
breathe normally while holding this position for 5-10 seconds
repeat 5-10xs (turn your head to the opposite direction for half of the repetitions)
REMEMBER: this is intended to be a subtle engagement not forceful contraction

Video of Doug Alexander Recruiting a Client's Multifidi Muscles...

CATHY'S FAVOURITE 4 FOR THE CORE

1) SEATED WALK OUT TO TABLE-TOP/ARCH

Video of Cathy Walking out to Table-Top

START POSITION:

begin seated on the ball with your feet flat on the floor
knees at 90°, and parallel with or slightly higher than your hips
place your head in a gentle chin tuck position (maintain this position until your head is resting on the ball)

WALK FORWARD:

slowly begin to walk your feet away from the ball allowing the ball to roll up your back
use your hands on the ball to steady yourself if needed
maintain good control, try to keep the ball from rolling too much to the left or right
walk forward until the ball is supporting your upper back, neck and head

ARCH/TABLE TOP POSITION:

with your feet flat on the floor and at least hip distance apart
elongate your spine, open your chest, keep a straight line from your head to your tail bone
on an inhale lift your pelvis up from the floor
ensure that your pelvis is level (left to right), and that your thighs, pelvis and torso are parallel with the floor
your knees should be at 90° with your ankles aligned directly below your knees (or heels slightly ahead of your knees)
hold the TABLE-TOP or ARCH position for 5-10 seconds (breathe normally while holding the position)

WALK BACK:

place your head back in the chin tuck position
slowly begin to walk your feet backwards towards the ball allowing the ball to roll down your back
maintain good control, try to keep the ball from rolling too much to the left or right
return to the start position
repeat several times until you feel quite stable throughout the movement

2) THE BRIDGE

Video of Cathy Performing the Bridge

START POSITION:

lie on the floor on your back with your calves and heels up on the ball and your legs/feet together
ensure that your knees and toes point toward the ceiling
place your arms (palms down) on the floor beside you
ensure that your upper back and shoulders remain in contact with the floor
elongate your spine, open your chest, keep a straight line from your head to your tail bone

FOR GREATER STABILITY: place your arms 45° or so away from your body (palms down)

TO INCREASE DIFFICULTY: keep your arms in tight to your body (elbows bent at 90° and palms facing each other)

LIFTING INTO BRIDGE POSITION:

find your centre
simultaneously press down evenly into the ball through your calves and heels (heels only in advanced)
on an inhale lift your pelvis off the floor until your body is in a straight line
your body weight should be supported through your calves/heels and across the top of your shoulders (there should be no pressure or strain on your head/neck
maintain good control, try to keep the ball from rolling too much to the left or right
hold for 5-10 seconds (breathe normally while holding the position)
return to the start position

THE PLACEMENT OF THE BALL IN THE START POSITION DETERMINES THE LEVEL OF DIFFICULTY

BEGINNER: place the ball in tight to your body, up against your buttock and thighs

INTERMEDIATE: place the ball under your calves and heels

ADVANCED: place the ball under your heels only

3) THE SWIM

Video of Cathy Performing the Swim

START POSITION:

lie prone over the ball with your palms and knees on the floor (on all-fours)
keep your neck relaxed and in a neutral position
look toward the floor
elongate your spine, open your chest, keep a straight line from your head to your tail bone throughout the exercise

ARMS:

find your centre
on an inhale slowly raise your right arm straight out in front of you (parallel with the floor and in a straight line with your body)
hold for 5-10 seconds (breathe normally while holding the position)
return to the start position
repeat with the other side

LEGS:

find your centre
on an inhale slowly raise your right leg straight out behind you (parallel with the floor and in a straight line with your body)
hold for 5-10 seconds (breathe normally while holding the position)
return to the start position
repeat with the other side

ALTERNATE ARMS/LEGS:

find your centre
on an inhale SIMULTANEOUSLY raise your right arm straight out in front of you and your left leg straight out behind you
hold for 5-10 seconds (breathe normally while holding the position)
return to the start position
repeat with the other side

4) THE PLANK

Video of Cathy Performing the Plank

START POSITION:

start in the swim start position

MOVING INTO THE PLANK POSITION:

slowly push off with your toes
slide/walk your hands along the floor and roll up onto the ball until the ball is supporting your PELVIS and THIGHS (Beginner Position)
straighten your legs so that they are parallel with the floor
ensure that your shoulders, hips, knees and ankles are in good alignment
ensure that your hands are shoulder width apart with your wrists directly under your shoulders, finger tips facing forward
find your centre
maintain good control throughout, keep the ball and your body as still as possible
hold the position for 5-10 seconds (breathe normally while holding the position)
return to the start position by pushing off with your hands

THE PLACEMENT OF THE BALL DETERMINES THE LEVEL OF DIFFICULTY

BEGINNER: as noted above, the pelvis and upper thighs are supported on the ball

INTERMEDIATE: slowly push off with your toes, slide/walk your hands along the floor and roll up onto the ball until the ball is supporting your SHINS and FEET

ADVANCED: slowly push off with your toes, slide/walk your hands along the floor and roll up onto the ball until the ball is supporting the TOPS/DORSUM of your FEET (or to increase the difficulty come up on to POINTED TOES)

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Biography Cathy teaching.JPG

Cathy has more than twenty years experience in the Health and Fitness industry and has maintained a treatment oriented massage therapy practice since 1990. Her postgraduate training includes: Fascial Mobilization (workshops with Rolf Method practitioners, Myofascial Release approach and Euro Connective Tissue Massage), Sports Therapy, Rehabilitative Exercise (various modalities), Holistic Nutrition and Iyengar Yoga (currently level 3/student)

Throughout her career Cathy has worked with a variety of elite level athletes. In 2006 Cathy served as a Medical Team Leader and the Massage Therapy Clinical Coordinator at the LPGA CN Canadian Open.

Cathy has an extensive background as a health and fitness educator. She taught at an Ontario accredited school of Massage Therapy for 5 years and currently offers CEU sanctioned postgraduate courses (Manual Myofascial Therapy and Stability Ball Exercise).

Cathy was involved with the College of Massage Therapists of Ontario’s (CMTO) provincial licensing examinations from 1997-2007, is a long-standing member of the Ontario Massage Therapy Association (OMTA) and conducts 3rd party Insurer Evaluations (IE’s) and Independent Massage Therapy Evaluations (IME’s). Recently relocated to beautiful British Columbia, Cathy is now a registered member with both the CMTO and College of Massage Therapists of British Columbia (CMTBC).

Cathy continues to maintain a private practice while fulfilling her love of writing and teaching. Cathy welcomes your questions and comments. She can be reached at: cryanrmt@telus.net

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