Listen now:

Relevant Massage Therapy (MT) research is an important component in enhancing our professional credibility. And important and viable Massage Therapy (MT) evidential information may come from some not so obvious places; for example – The 3^rd International Fascia Research Congress (FRC3).

This may in part be due to the fact that the Massage Therapy Association of British Columbia (MTABC) is hosting this event and The Massage Therapy Foundation is a Silver Sponsor.

Although fascia is the focus of this event – much of what is being presented is applicable to any Massage Therapist – even if your practice is not ‘fascial’ focused (e.g. Structural Integration/Rolf Method, KMI, MFR, Fascial Manipulation, Bindgeweb etc.).

Fascia – the soft-tissue aspect of connective tissue – has a relationship with all of the other structures/systems commonly addressed within the context of a MT practice (e.g. muscle, tendon, ligament, bone, joint capsule, nerves etc.).

Any practitioner addressing soft-tissue related issues can benefit from the information coming out of the FRC3 as there are a number of keynote presentations, panel sessions and post conference workshops that are clinically relevant to a MT practice.

For example Jay P. Shah MD will present the Myofascial Trigger Point (MTrP) research he and co-investigators at the National Institutes of Health (NIH) are conducting.

Shah et al have determined that the palpable, discrete, hyper-irritable nodules (MTrPs) can be visualized using ultrasound and are stiffer than surrounding tissue. Furthermore, active MTrPs can be differentiated from latent MTrPs and unaffected muscle (e.g. active MTrP demonstrate unique blood flow waveform characteristics, display a larger surface area and elevated levels of inflammatory mediators, neuropeptides, catecholamines, and cytokines – substances associated with sensitization and persistent pain).

Assessing for and treating MTrPs is nothing new to most MT’s but now the commonly recognizable palpable and patient subjective evaluation indicators can be supported by an additional objective, repeatable, reliable and inter-professionally recognized diagnostic test.

Furthermore, perhaps discernable changes (for the better) following manual treatment of MTrPs may also be visualized – supporting the efficacy of manual MTrP techniques.

The MTrP research being conducted by Shah and his co-investigators is of significant importance to MT’s from a perspective of assessment evaluation, supporting the viability of MT and improving treatment outcomes. This in turn supports our commitment to Best Practices and to continually improving our quality of care.

The 2012 FRC3 has sold out, but you can still expand your knowledge and skill-set and improve your quality of care by exploring all the FRC related materials. DVD recordings of the plenary sessions and proceedings books are available for purchase at: http://www.fasciacongress.org/2012/dvd-recordings-and-proceedings-books/

The organizers and sponsors of the 2012 FRC3 have announced the official call for host applications for the Fourth International Fascia Research Congress in 2015. If you are interested in hosting the 2015 Congress, they want to hear from you.

More information on hosting and attending the 2015 FRC4 can be found at: www.fasciacongress.org

[1] Dryden, T., Baskwill, A., & Preyde, M. (2004). Massage therapy for the orthopaedic patient: a review. Orthop Nurs, 23(5), 327-332; quiz 333-324.

Ann Blair Kennedy (center) with Jaxson and Blair

How did you first hear about the Massage Therapy Foundation?

I began volunteering for AMTA-SC chapter in 2000 and I remember our then chapter President, Sandi Russ, returning from a national meeting and telling us all about the Foundation. She encouraged all of us volunteers as well as our members to donate to the MTF every year; her suggested amount was what we charged for one 1-hour massage. I started donating shortly thereafter.

The chapter then contracted with Ruth Werner (then an MTF Trustee, now the President of the MTF) to come teach a class for us. As I was education chair at the time I was able to get to know her a little bit. I loved working with her for that class and we had her back again a few years later. I have greatly enjoyed getting to know Ruth and I believe I can now call her one of my friends.

Explain how you first got involved with the Foundation and the progression to Trustee/volunteer.

At the AMTA National Convention inOrlandoin 2009, I happened to have a conversation with Ruth where she asked me to consider volunteering for the Foundation. At the time I was extremely busy with my AMTA Committee and local Chapter obligations, so I had to say no for the time being. Then, a few months later at the AMTA National Board Meeting in March 2010, Ruth again asked for me to help the Foundation. I told her I wanted to start slow, but if they had a spot for me, I would do it. Shortly afterward I was asked by Tim Herbert to join the Community Service Proposal Review Committee, and for the past two years I have enjoyed this work of helping choose who will receive Community Service Grants from the MTF. The quality of these projects and the giving of the gift of massage therapy to those who may not ever be exposed to this treatment is so rewarding. I passionately embrace this committee and the work we do – it is such a wonderful group.

In 2010 at the AMTA National Convention Cliff Korn asked me to Chair the AMTA Chapter Outreach Workgroup – I believe this work with my great committee of John Combe, Cliff, Mary White, and newly added David Otto is having a great impact. The new programs to ensure the AMTA Chapters understand and value the MTF has been very satisfying work indeed.

Being elected to the Board of Trustees was not a path I originally set out or even envisioned for myself. However, when the new road was lit for me I could not pass up on the chance. I am very much looking forward to my service to the Board of Trustees in the future; this is a new adventure that I am excited to start.

How has the Foundation impacted you as a professional?

The Foundation has had an overwhelming affect on me and my life. In 2007, while on an AMTA Governance committee call, we were discussing why AMTA members weren’t writing position statements for the association. Dan Barrow, a committee member, suggested that members should go to the MTF website and see what research was new and then maybe they could get an idea for position statements. I took that idea and ran with it and have been authoring and co-authoring position statements ever since. I found such a joy in reading, looking and compiling research about massage therapy. (I can tell you I had no idea that would happen.) And it all started with simply going to the MTF website and finding a study indicating that massage therapy could mitigate post-operative pain. Over the past few years I have noticed that the wealth of massage therapy research is not great. There are some good studies out there, but we need more. So, with this idea in mind, I thought I needed to learn more about research and maybe I could do some of that research myself one day if I learned enough. I have applied and been accepted into a program at the University of South Carolina Arnold School of Public Health -Health Promotion, Education and Behavior Department to earn my Dr.PH. I start my studies in August of 2012. And all this started with a visit to the MTF website.

I am also passionate about volunteering. “Dum Vivimus Servimus” or “While we live, we serve” was the motto of my College for my undergraduate degree and I truly want to live that motto. I grew up watching both my parents volunteer. My mother taught Sunday school and helped out with the PTA, and other such things that mothers do, while my father served his professional organization. I was taught early on to work for the betterment of my profession. I watched as my father served, at one point as its National President, and has been honored multiple times by his professional organization theAmericanCollegeof Sports Medicine (ACSM). By his service and example I knew that I wanted to one day join a professional organization and hoped to one day volunteer for the betterment of my profession. I feel that is exactly what I am doing with my service to the Foundation, working to better my chosen profession.

What would you like others to know about the MTF?

I want others to know that we need their help and support, financially and with volunteers. It would be wonderful if every massage therapist, massage client, EVERYBODY would donate to the Foundation. Even just a little, it goes such a long way and it can help so many. I also challenge each and everyone who reads this to go and learn something new about the Foundation that they did not know before. Go to the website, do some digging, see what you can find. You never know, it could change your life – it did mine.

Of the MTF’s Case Report Contest, Thomason said, “Research is a strong passion of mine, and I was so excited to see it being promoted among practitioners. That is why I conducted a case study to be a part of this contest. Research is so important, for it answers the questions that we all have about our own practices… I didn’t know if massage would help my client with Lyme disease, but I was excited to find out the answer.” Thomason’s conclusion was that massage therapy is a promising treatment for the symptoms of pain, fatigue, and impaired concentration in patients with Lyme disease, and that further research is needed to validate these efforts.

The Second Place Silver Award goes to Robin Streit of Camden, New Jersey, for her case report titled “Massage Treatment Improves NTOS Symptoms and Mobility: A Case Study on Neurogenic Thoracic Outlet Syndrome.” The Third Place Bronze Award was awarded to Glenda Keller of Ontario, Canadafor her case report titled “The Effects of Massage Therapy after Decompression and Fusion Surgery of the Lumbar Spine: A Case Study.” Full abstracts for all three winning case reports can be read here.

The Foundation has offered the Case Report Contests since 2006 as a way to encourage the writing of case reports, and to provide an opportunity for massage and bodywork practitioners and students to develop research skills, and to enhance their ability to provide evidence informed massage to the public. Information about all previous Case Report Contest winners, as well as details regarding how to enter the upcoming contests, can be found on the MTF website. The deadline for participation in the 2012 Practitioner Case Report Contest is October 1, 2012.

What is a case report, anyway? It’s simple: a case report is a story from your clinical practice, translated into a common format (Intro/Methods/Results/Discussion), and then shared with your colleagues out in the world. The reasons to write a case report are many, but the biggest reason is this: it’s what you should do when you have something to share. It’s part of our responsibility as clinicians to occasionally open a window into our practice, so that others may benefit.

When I say clinician, I’m talking about you. The person reading these words. Someone who gets paid to help people feel better, function more fully, and awaken more fully into themselves. What happens in your practice? What do you wish could be seen by physicians or researchers? What is common but undocumented? What is vexing or mysterious? I want to know.

I can tell you one mystery that has thoroughly disappeared: “How does one even get started with a case report?” If you’ve done the work of becoming licensed in massage therapy, you have the necessary skills to begin. Getting done is a bigger challenge, but we’ve got your back there, too:

Want to know how case reports are put together? Check out the Massage Therapy Foundation’s case report contests for step-by-step guidelines, outside resources, and examples from past contest winners. Do you feel rusty with finding or understanding research articles? Enroll in our excellent new online course – Basics of Research Literacy. Are you looking for inspiration or indignation? Just type the words “massage therapy case report” into Pubmed.gov and click on the first thing that looks interesting.

The most important thing is begin the story. Everything else is grounded in that act.  Your first draft doesn’t need to be fancy — just write as if you were speaking to a colleague.

Here, I’ll start:

Case Report. A 30 year-old male patient hands me a self-typed letter that carefully conveys his medical history: a rare form of leukemia that took him down fast but somehow decided not to kill him.

He was eighteen when the cancer announced itself and confined him for years to a hospital bed. It was surreal for him to be suddenly so infirm, but by that time he had already accrued a lifetime of random calamity: A freak car accident at age two. A wicked bike fall at twelve. Broken bones and open wounds. Avascular necroses in his hips and knees. Thyroid and pancreatic swings. His eyes meet me briefly and then return to some distant horizon. He speaks quietly, as if sharing a secret, not entirely believing his own presence in the room.

His reason for visiting me is symptoms relating to the most recent diagnosis: Graft-versus host disease (GVHD). It’s an auto-immune reaction instigated by some donated bone marrow. His immune system, stimulated by an intermittent sense of invasion, had proliferated its inflammations and fibroses in a variety of ways. GVHD is a trickster disease, able to mimic a number of other autoimmune disorders and then morph into new modes. In recent years, the condition had manifested like a patchy, regional scleroderma. The skin on his left ribcage, left shoulder, left neck and left arm contains a number of quarter-sized skin adhesions, where the superficial fascia had spontaneously scarred and grabbed hold of the overlying epidermis. Each adhesion is colored a little pale, depleted of its melanin, and his normally mobile skin is like stiff leather under my fingertips.

He says his left shoulder felt glued down, stuck, tight and sore. The drape of his t-shirt and the taut meat below conveys a sense that his left upper trapezius has been suffering under heavy downward opposition. His knees and shoulder sockets ache “occaisionally” but he said they feel “OK” today. His low back ached more or less all the time, and he described his neck as “stiff but not usually painful”. I asked about headaches, and he said “Not usually. Not for long, anyway.”

He says that he wants freedom in the left shoulder, some reduction in back pain, and maybe some better sleep. I have him remove the t-shirt, and I notice that several of his adhesions lie along the path of cutaneous nerve roots (C6 through T4 dorsal rami on the left side) and the radial and axillary nerves of the arm. The overall effect is one of strapping the scapula close to the upper ribs, and the trapezius, serratus anterior, levator scapulae, and rhomboid muscles all seem to struggle mightily during scapulo-humeral abduction. The arm feels to me like it wears a tight stocking, and every motion seems oppressed by this constrictive garmet. He works as a carpenter-contractor, is two years married, and had recently recovered enough to finish his GED.

I figure that some careful fascial release might be able to improve his shoulder mobility, and to the degree that cutaneous nerves were entrapped, it would be worth trying to free them. However, I’m concerned about inflaming the tissue, especially with a mysterious autoimmune process going on. I will have to cover ground slowly, and ask for communication as we do the work. And what about his pain perception, given the gnarly history of accidents and hospital care?

“I… don’t have a normal relationship to pain”, he says.
“In what way?”
“If a pain is really bad, I feel it for a second, and then I kind of turn it off.”

His leukemia treatment ten years prior had involved a thick stream of pain medications, but he didn’t like the mental haze or the digestive side effects. “I hated the painkillers, so I started not taking them. I just learned how to change what I’m feeling.” The doctors were dumbstruck, he says.

I could respond in any number of ways, but our intake time is already lengthy. “Can you feel this pressure?” I ask, pressing my thumb with medium force into his forearm.

“Ow, yes” he replies.
“That’s what I don’t want to exceed in our work. So let me know, ok?”
“OK.”

Fast forward three months. So far we’ve had 8 hour-long sessions. Our results have been mixed: In terms of shoulder mobility, we’ve had some good success. The first 3 sessions, especially, saw him go from severe limitation to only mild restriction (e.g. He went from a labored 70 degrees scapulo-humeral abduction to a comfortable 120.) “I’ve never gotten that kind of relief with massage” he reports with a sigh. The cutaneous adhesions have also reduced in size and number, although the skin remains discolored in the previously adhered spots.

His back pain has been fluctuant, but overall I don’t think it’s improved. There is still generalized ROM limitation, point tendernes, and muscular hypertonicity throughout his thoracic and lumbar spine. It has admittedly been a secondary focus. It’s also possible that a reduction in exercise is to blame: He’s been sitting in college classrooms recently, and running less.

His sleep disturbance had some early improvement, but then did not seem correlated with receiving massage. He tells me halfway through that his thyroid medication is “messed up” again, and that he’s waiting to adjust it with the doc. Two sessions later he says the sleep has normalized since reducing his thyroid medication.

Our current plan is to re-focus on the back pain, and leave the shoulder complex as a secondary focus. He seems quite grateful for the work, and seems less focused on his symptoms and more on the day-to-day frustrations of a carpenter and a 30-year-old college student. I take this as a good sign: perhaps he his comfortable enough most of the time to indulge in more pedestrian complaints.

I have to admit that as the sessions progressed, I became less focused on the tissue-level pathology, and more aware that his definition of “health” was expanding along with his range of motion. As I gained familiarity with his body, my clinical intent shifted to include not just fascial release, but kindness and embodiment.

My early tendencies as a massage therapist were to become so enthralled with dramatic conditions that they made opaque the person suffering in front of me. My role, I thought, was to understand, and in the absence of understanding, I could not really treat. My tools were few, but my curiosity was relentless, and this mostly worked well. The trigger points were found and muscles made loose. Scars were frictioned and ranges of motion increased. Except that this constant striving made me unable to arrive. Their healing would be a victory in my mind, their stasis a defeat, and I would sacrifice their sense of independence for my sense of accomplishment.

I wonder now if my early patients left feeling well-examined but never truly heard. It’s a constant balancing act when you’re asked to deploy a compassionate art within the constraints of a complex medical condition. The best sessions — from my perspective — seem to be those where love for the work and love for the patient seem to be one and the same.

I’m curious how other massage therapists have dealt with similar situations, and I’m looking forward to the day when we have better evidence around the efficacy and contraindications of massage for autoimmune conditions like GVHD.

The Massage Therapy Foundation offers two Case Report Contests each year: one contest is for Practitioners (submission deadline is October 1 annually), and another contest for Students (submission deadline is March 1 annually). Learn more by visiting the Case Report Contest section of our website.

Mike Hamm teaches anatomy, technique, and research literacy at Cortiva Institute Seattle, and maintains a full time bodywork practice focused on orthopedic injury and trauma recovery. He was the winner of the Massage Therapy Foundation’s 2005 Student Case Report Contest, and presently serves as a reviewer for the Foundation’s Professional Case Report Contest. He has published articles in various research journals and trade magazines on subjects including nerve entrapment and research literacy education. When not teaching or doing bodywork, Mike plays music in a Seattle band.

The 2013 IMTRC will:

• Present research findings that help explain how massage therapy works through physiological, psychological, and neurological mechanisms;
• Emphasize the potential for community outreach programs to provide research data through evaluation, and discuss program implementation strategies;
• Explore the current status of massage research in preparation for updating and advancing the Massage Therapy Research Agenda.

Call for Abstracts
The MTF is now requesting abstracts for all oral and poster presentations that focus on the above themes. Submissions are welcome of original research, reviews, basic and applied research, translational, participatory and community-based research, case reports and quantitative, qualitative and mixed methodologies. Accepted abstracts will be published in our open-access research journal, the International Journal of Therapeutic Massage and Bodywork (IJTMB). The abstract submission deadline is September 15, 2012.

Download the full call for abstracts with submission guidelines [PDF].

Download the Abstract Submission Template [Doc].

This is the third research conference hosted by the Massage Therapy Foundation, bringing together massage and manual therapy practitioners, educators, CIM researchers, allied health professionals, and others interested in massage research. Registration for the conference will open in October 2012. Learn more about the 2013 IMTRC.

The new MTF site was designed by Good Studio, a long time design partner of the MTF. Good Studio has been the designer of the MTF’s Annual Reports since 2007, including the MTF’s first digital annual report in 2010.

Features of the new site include:

• an integrated blog (which you can add to your RSS feed, or get email updates when a new post goes live);
• a rotating homepage banner featuring important deadlines or announcements;
• an event calendar featuring CE workshops that benefit the foundation, upcoming conferences of interest, and research literacy workshops.

We hope you enjoy the new site! Please spend some time browsing around, and let me know if you have any questions: mklawitter@massagetherapyfoundation.org or 847-905-1511.

Much of Massage/Manual Therapy tends to focus on the soft-tissues and under the soft-tissue ‘umbrella’ is FASCIA. Therefore is seems clear that fascia must be considered in all aspects of soft-tissue assessment, treatment and pre/rehabilitation. But, how can we develop a sound understanding of fascia when it has been largely research-ignored and therefore not comprehensively included in commonly used health science educational materials?

The International Fascia Research Congress, a continuing series of conferences dedicated to the emerging field of fascia studies, is making great strides to amend this oversight.

As a Silver Sponsor of the upcoming 3rd International Fascia Research Congress (FRC 2012), the Massage Therapy Foundation again steps up to honour its commitment to advancing the knowledge and practice of massage therapy by supporting scientific research and education.

Considering fascia in the mix calls us to reconsider much of what was and, for the most part, is still being taught within the realm of soft-tissue related health sciences.

In an article featured in Massage Today, Whitney Lowe LMT poses the question: Does Fascial Research Alter Assessment?

Lowe explores this question citing the following example: certain orthopaedic assessment procedures operate from the premise that contractile soft-tissues (e.g. muscle/tendon) can be isolated from non-contractile soft-tissues (e.g. ligament), thereby providing a clear indication of the involved/injured tissue which in turn dictates the selection and delivery of treatment and rehabilitation measures.

Now, consider the work of Jaap van der Wal (featured at the 2nd FRC – 2009), which challenges the classical understanding that most ligaments are only (passively) lengthened or shortened during movement of associated joints and substantiates the presence of direct fascial connections that link ligaments and muscles together in series. An in-series/fascial link demonstrates that ligaments will have tensile loads applied to them when muscles contract – with or without joint movement. Therefore, isolation of contractile/non-contractile tissue via currently taught assessment procedures no longer seems plausible.

Van der Wal’s work is only one (albeit fantastic) example of the need for an extreme make over: soft-tissue edition – one that includes the dynamic nature of fascia.

Current fascia research not only insists on the alteration of assessment procedures, which in turn impacts the selection of treatment measures, but also calls us to reconsider much of soft-tissue anatomy and physiology as we knew it!

It is essential for any one engaged in a soft-tissue modality to more fully understand fascia’s neurobiology, response to stimuli, trauma, demand, contractile capabilities, significant anatomy features (e.g. normal/abnormal presentations) and functions.

The Massage Therapists’ Association of British Columbia (the hosting sponsor) invites you to advance your fascial knowledge by attending the 3rd FRC.

Don’t let all this great fascially-significant information sit idle collecting dust.

“Knows” cultivates knows how, which shifts into does, which then results in more effective outcomes – benefitting all stakeholders!

For more information go to www.fasciacongress.org.

In 2010, Heidi Pannke, a massage therapist and Alternative Medicine Coordinator at Outside In in Portland, Oregon, was awarded an MTF Community Service grant for $5,000. Through the MTF grant, 200 homeless and severely mentally disabled Portland residents were provided with massage over the course of the year. The grant provided funding in the first year of this program, and allowed the program to continue to grow in subsequent years. We asked Heidi to discuss what led her to apply for an MTF Community Service grant and how receiving the grant impacted Outside I. Below is her story.

It had always been my dream to have more massage at the Outside In Clinic. We’d had acupuncture students coming in, as well as a volunteer chiropractor, but there was hardly ever any massage therapy. I thought, “if only we could have massage therapy here more often, great things could happen.”

Heidi Pannke administering a massage to a client at Outside In

The Outside In Clinic primarily serves homeless youth, (although other marginalized people are included as well) addressing their various needs, through case management, housing, education, employment, and medical services. Many of the youth that Outside In serves had never had a massage before I worked on them. I would always wonder if any of them had ever received any positive healing touch at all in their lives.

In early 2009, the clinic staff was at a retreat and we did an exercise where we all wrote down what our dreams were – I wrote down that my dream would be to someday offer massage at Outside In. I began working at Outside In before I got into massage school. I was hired because of my Spanish speaking abilities, and worked in the medical clinic as an interpreter. It was from working with these clients that I began to feel that I would like to do something more to help out, and after receiving a lot of massage myself one summer, I felt called to enroll in massage school.

I started my massage classes, all the while still working part time interpreting at the clinic. Once I graduated and became a licensed massage therapist, I worked part time at a chiropractor’s office, but this wasn’t fulfilling to me. I wanted to do something more with my massage license; I wanted to be able to offer massage to our clients at Outside In.

John Duke, the director of the clinic, came to me after that retreat, and let me know if I could find a massage grant, he would help write it. I did find a grant, the Community Service Grant from the Massage Therapy Foundation. The grant was written, and a few months later, we were informed that we got it.

It was a bit of a slow start as we were figuring out how best to incorporate massage therapy into our clinic services, but once we got going, it became one of the most popular services for our clients. Some of the feedback I got from our clients was amazing. One young man who had been in and out of mental institutions his whole life, told me if he could get a massage every week, he wouldn’t need to take so many of his medications, and that for once in his life, he felt good and didn’t feel so depressed anymore. Another young lady who was struggling to get off heroin told me that the massage helped her body feel relaxed during the detoxification process. I consistently heard so much gratitude from our clients, with them telling me it was the highlight of their day, their week, their month, their year.

The grant ended in August of 2011, and since then, we have consistently had massage at the clinic four times a week. We are going to be renovating the CAM space soon, and there will be a spot for four massage tables. We are in talks with a local massage therapy training program about the possibility of bringing their students to our clinic for their clinical rotations. None of this would have been possible without the MTF grant.For about 6 months of the grant, I would take my massage table out every week to one of the clinic’s outreach sites, a social service agency that helped older homeless folks find housing. Some of these clients had not seen any sort of medical providers for sometimes upward of 20 years. But once they heard a massage therapist was there, they were eager to sign up. Sometimes clients would reveal very serious things about their medical history, and I would encourage them to follow up with one of our doctor’s. Several of my clients did, and are now receiving primary care through our clinic. One client told me he didn’t think anybody cared about him before the massage, and he was so appreciative that I came out to do this.

Heidi Pannke
Massage Therapist / Alternative Medicine Coordinator / Records Fairy
Outside In – www.outsidein.org

About Outside In

The mission of Outside In is to assist homeless youth and other low-income and marginalized people move toward improved health and self-sufficiency. Outside In, established in 1968, has continually revised services to respond to changing client needs. Current programs include a Clinic and Homeless Youth Department. The clinic is a cutting-edge blend of western and alternative medicine. It is a teaching site for Oregon Health Sciences University, and the National College of Naturopathic Medicine, providing western medicine, naturopathic, acupuncture, Chinese herbal, chiropractic, massage and dental care. The clinic provides over 17,000 visits annually for homeless youth and homeless and low income adults. In addition to the on-site clinic, our mobile medical outreach program uses a 38-foot medical van with 3 exam rooms, a lab and electronic medical records to take medical care to isolated populations who lack access to care. You can learn more about Outside In by visiting their website at www.outsidein.org.

To read about all of the Community Service grants that were awarded by the MTF in 2010, read our annual report: massagetherapyfoundation.org/2010annualreport/