8 Random Things Everyone Should Know About Massage

I try to never miss an entire year on my blog, so here is one post for 2018: a list of concepts I think everyone should know before receiving a massage. To veterans of massage many of these points will seem obvious, but I've included some not-so-well-known ideas too. Should this be required reading before someone books a massage?

I was shooting for 10 things, but I ran out at 8. If you see a major gap that needs addressing and want me to add it, submit a comment!


1) MASSAGE IS TRUST-BASED INTERACTION INVOLVING TOUCH
Touch is the most ambiguous form of communication. During any massage, the Licensed Massage Therapist (LMT) attempts to assess your comfort with being touched. If you say nothing, we can only guess. Because LMTs touch people every day, we often do not share cultural taboos or apprehensions about touch. Verbal communication is a great way to avoid misunderstandings, so share your apprehensions outright. Laws regarding professional massage vary in cities, counties, states, provinces, and countries; but avoiding sexual touch is universal. At any time, for any reason, you can end the massage; the same goes for the LMT. Bottom line: If you are nervous or just do not want your feet, stomach, chest, or butt touched, say so. If the massage feels invasive or sexual to you, end it immediately.


2) MASSAGE ≠ ALTERNATIVE MEDICINE
Our place is in conjunction with medicine, as part of a general wellness plan. Massage does not cure diseases or take the place of any standard medical care. We don’t diagnose condition, give medical advice, or have magical powers. We also don’t flush toxins, break up adhesions, remove cellulite, or trigger pregnant women to go into labor. There is good evidence that massage helps with anxiety, depression, stress, and pain. Bottom line: There are more myths than facts about massage, despite being as old as human records it is one of the least understood practices around.


3) CLOTHING IS OPTIONAL, NOT DECENCY
Getting naked is totally optional, not a requirement to receive a massage. If you would wear an outfit to the gym or sleep in it, it will work. If you do choose to disrobe, you will find many (not all) massage techniques work better on bare skin. Unworked areas will be covered with a sheet for warmth and modesty. On the flip side: Even if you are comfortable naked, you must help the massage therapist to prevent unprofessional situations. Keep your clothes on until the therapist gets out of the room. Having nothing covering you is not an option in a professional massage. Bottom line: you can take everything off or stay clothed; either way all parties should feel safe and secure.


4) MORE PRESSURE ≠ MORE EFFECT.
You are in control of the pressure, to the extent of the LMT’s skill set. However, there is no evidence supporting “deep tissue” massage, it is an expensive and painful myth. Massage should be deep enough to feel optimally good, and no deeper. Causing pain during a massage is distracting, ineffective, counter-productive, and increases risks. My approach to massage is firm-to-deep, but always with an eye on comfort and outcome. Bottom line: If I press hard, it will be for a specific purpose. Massage should be pleasantly received, not inflicted.


5) MASSAGE IS INHERENTLY SEXIST
Gender roles are a real problem with massage, but they don’t have to be. Female LMTs are often harassed, propositioned, or objectified by their clients; male LMTs have a much harder time earning a living in this industry. Some men are completely uncomfortable being touched by other men and with their wives or girlfriends receiving massage from a man. Many women are uncomfortable or apprehensive about male LMTs touching them. Bottom line: Try to keep an open mind and treat LMTs as you would any other professional. We are just trying to earn a living.


6) MODALITIES ARE (mostly) A SCAM
Over the years, I have slowly shifted away from specific over-hyped modalities. There are dozens of expensive courses that claim to have a cure for pain. Despite millions of dollars and countless hours of effort, no one has ever demonstrated that one massage modality is clearly more effective than any other. The effects generated by a massage can be optimized with individual efforts only, not with one style or technique. Every human body is different, and only careful listening and interaction will determine the best course of action. Bottom line: To a hammer, everything looks like a nail. Great LMTs use a good baseline understanding of human anatomy and physiology rather than a modality.


7) PAIN IS COMPLEX
Treating pain requires a decent understanding of the emerging science regarding how humans experience pain. The conversation should not begin and end with “muscle knots”, “bad posture”, or, worse, lactic acid. Contextual, biological, psychological, and sociological factors interplay to create pain, and all are equally important. The model of shaming people about the shape of their spine, the posture they assume, or the “tightness” of their muscles is harmful to clients and creates dependency on the LMT. Bottom line: Pain is generated by the brain; biopsychosocial factors are all relevant. You are not a broken machine, so you don’t need a mechanic.


8) TOUCH IS POWERFUL
The detrimental effects of loneliness and touch-deprivation are not controversial. Beyond that, the skin is a dense network of nerves which talks directly to the brain, and thus can change pain states. Touch (in the right context) provides comfort, reduces stress, increases happiness, reduces pain, and feels really good. Bottom line: Massage can have powerful effects based completely on the nature of touch.

Rational Prenatal Massage

Prenatal massages are among my favorite massages to give. The absolute gratitude pregnant women express after receiving relief from the increased burden on their bodies reminds me why I wanted to by a massage therapist in the first place. Pregnancy is very taxing; massage provides needed time to recuperate and feel comfortable within your own body again. Prenatal sessions also have the added benefit of treating two humans at once, since it is reasonable to expect that the relaxation felt by the mother is passed via biological signaling (hormonal, biomechanical, etc) to the growing fetus. But, along with every good idea comes a load of really bad ideas, and prenatal massage is no exception. Much to my chagrin, several bad ideas are propagated by educators in my field, the major franchises, and even by the agencies meant to regulate massage.

Massage doesn't cause miscarriage!

If you walk into a major franchise massage chain, and you happen to be in your first trimester, there is a good chance you will be asked to leave. Sure, they'll be happy to take your money when you hit the magical second trimester, but until then it is "no massage for you!" Why? Because of persistent mythology around the effects of massage, and fear of getting sued if you should have a miscarriage. It is suspected that somewhere between 1/3rd and 1/2 of pregnancies end in miscarriage (often without the woman even knowing she was pregnant in the first place), and 80% of those happen in the first trimester. So even though no study has EVER linked massage and miscarriage, and experts suggest moderate exercise and massage may in fact be protective against miscarriage, fear often beats reasoning. As for me, I'm happy to report many women, after rejection from strip-mall massage places, come find me and still get their massage. That is, if they aren't convinced that massage will somehow harm their baby.

Contrary to popular beliefs, there are no magic points on the body that work like a baby eject button. Acupuncture points are silly, inconsistent, and based on pre-scientific ideas. I know that isn't a popular opinion, and frankly, I don't care. Even attempts to directly stimulate such points in overdue (41+ weeks) women ended in disappointment. This has also been repeatedly shown to be true with blinded studies. So much so that Cochrane weighed in on it.

Massage is safe and good (even directly on ankles and feet) for pregnant women.

Evidence of the benefits of massage for pregnant women is actually pretty slim, mainly because it has a certain obviousness to it that prevents researchers from investing time in it. Tiffany Field has made quite a career out of looking at the benefits of massage; I have some ambivalence about her work (especially when it comes to her claims about cortisol) but her research is pretty much the only thing out there right now. Here is a partial list:

"Only the massage therapy group, however, reported reduced anxiety, improved mood, better sleep and less back pain by the last day of the study. In addition, urinary stress hormone levels (norepinephrine) decreased for the massage therapy group and the women had fewer complications during tabor and their infants had fewer postnatal complications (e.g., less prematurity)."
- Pregnant women benefit from massage therapy

• Massage therapy is the most common alternative therapy recommended during pregnancy.
• Massage therapy has been demonstrated to be effective during pregnancy. The women reported decreased depression, anxiety, and leg and back pain.
• Depressed pregnant women given the pregnancy massage experienced fewer prenatal complications.
• In our study on labor pain, the women receiving massage therapy experienced significantly less pain, and their labors were on average 3 h shorter with less need for medication.
• The most important finding was the lower incidence of prematurity and low birthweight in the massaged depressed women.
• Postpartum depression and cortisol levels were decreased in the massaged women. The newborns of the massaged mothers also had lower cortisol levels than the newborns of the control mothers, and performed better on the Brazelton Neonatal Behavioral Assessment habituation, orientation and motor scales. An underlying mechanism we have been exploring is that these effects are mediated by increased vagal activity.

- Pregnancy and labor massage

Don't even think about talking to pregnant women about "toxins."

Despite the fact that there is absolutely no evidence that massage releases "toxins" and 99% of the time, the person making such a claim can't even define what the word toxin means, let alone which toxins they are specifically worried about, this myth is still floating around. Carrying around a tiny growing person is stressful enough without adding imaginary toxins. So I'll just leave this here:

No, 
No,
No,
And also, no.

Sidenote: You probably don't have to lay on your side either.

Further Reading: https://view.joomag.com/massage-fitness-magazine-pilot-april-2015/0817501001417732043?page=15

INB4 2017!

I didn't miss an entire year!  2016 has been busy, crazy, exciting, tragic, and it isn't quite over yet. Between school, and Valence Massage, and social media, and having a little girl to keep me constantly moving, I have had little time to sit and write any meaningful reflections.  This is probably not going to be a meaningful reflection.  I would like to acknowledge that one of the most influential teachers in my life has been blogging here: <http://www.nmtmidwest.com/blog/> You should probably be reading that instead of this.

I'm currently reading Diane Jacobs new book, DermoNeuroModulating. It's a very good read for clinicians looking to understanding working with the skin as an agent of neurological change. As a massage therapist, working on the skin every day, it is very strange how underappreciated it really is in our field. As far as I have seen, this is the first book that focuses on treating pain primarily focusing on movement of surface structures in the skin. Why have we spent so much time focused on less innervated tissue hidden beneath?

If you are starved for content, I still regularly share interesting reads on the Valence Massage facebook page. I try to put something interesting there every few weeks.

Happy New Year everyone!

What makes a massage good? What can make it better?

Terminology in the world of massage therapy can be difficult to navigate, even for an experienced massage therapist. Where does that leave the customer? For example: if you know that you have persistent pain, and you want someone to help you get rid of it, what type of therapy will get the best results? Do you want sports massage, deep tissue, myofascial, or trigger point therapy? What are the differences, and do any of them work better than others? Believe it or not, there is no clear science on this. All the hype you see spinning around a certain modality is anecdotal, and is usually created by the people selling that style!

The truth of the matter is that the majority of these titles are legally unregulated. I have a couple of these titles myself, which I earned for completing long and complex continuing education programs. When such titles are proprietary, it is because they are trademarked in order to make money, not help patients. Anyone, even with the most basic education in massage, can brand themselves as any of these things. This is a major problem in our industry, since the customer is left guessing whether they are seeing someone with real practical skills and knowledge.  If I tell everyone to forget about these titles, I'm going to have to attempt to give the customers (and anyone else) a little guidance here.

Massage is more effective when certain conditions are met.

...and this is often contrary to the way our (American) culture looks at massage.

For one thing, you need to have good communication and rapport with your massage therapist. This means finding someone whom you trust and going to them regularly to build a strong therapeutic relationship. Massage is a type of communication between the hands of the practitioner and the nervous system of the recipient, and communication is always more difficult with strangers. With the current focus on getting cheap massages (think Internet deal sites like Groupon) we have started a race to the bottom in this regard. The same goes for spas that focus on the trendy add-on services (think foot scrubs, reflexology, or aromatherapy) rather than the building of therapeutic relationships. The idea that providing more services creates a better experience takes you directly into a quantity of quality model.

Also, massage shouldn't be painful. You have probably heard the exact opposite, and it was probably couched in the myth that massage milks lactic acid out of muscles, or physically breaks up tissue nodules (knots, adhesions, trigger points) through deep pressure. This is simply not true. It bears repeating, massage is a conversation, and painful massage is like trying to improve a conversation through shouting and intimidation. New therapists are often very soft in their approach, and after being reprimanded repeatedly, they either quit massage or learn to give deeper work. If learning to give more pressure is a good thing, when is there too much of a good thing? There is a clear line, and when you have studied several dozen modalities as I have, it begins to emerge as almost universal. Pressure should feel significant, relevant to the goal, and should not exceed that line.

Science, art, or skill?

            There are some basic necessities for any decent massage therapist. Every massage therapist should have a good working knowledge of anatomy, human physiology, and a decent grasp of basic science. Clinical reasoning is absolutely essential and often overlooked. They should have the confidence to evaluate themselves, their practices, and come to rational conclusions about different therapeutic approaches. Also, because our services involve physical touch, an understanding of ethics should not be forgotten once we get into practice. I am increasingly convinced that for best practices, a course in modern pain science should also be required!

I am often criticized for taking too clinical an approach to massage. I am interested in getting a clearly trackable goal for each session and keeping records to see progress. I am quick to read and report what the science shows can and can't be done by massage. I am candid about what I know, what I don’t know, and I am also very dismissive of the many myths and tropes on which other massage therapists continue to cling. Massage is often sold as an intuitive, natural healing art. Healing because it channels some ancient pre-language energy that holistically guides the receiver to better health. I think there is a nugget of truth to that idea. I also think it opens the door to ignoring reality and therefore must be avoided. 

Every good massage will have "non-specific effects" which can cause the practitioner and the recipient to believe it is magical. Research, however, shows that these effects are often fleeting, unreliable, and temporary. One has to have something else behind their approach, or failure and client-shaming are soon to follow. I've heard it said by many other massage therapists. Calling their clients "energy vampires." Saying "that client is so negative, he/she really drains me." Or worse, telling the client that it is their negativity, their inability to let go that prevents their symptoms from improving. This takes me back to the conversation analogy, lousy conversations are not improved by telling the other person that the lousy conversation is their fault. It is up to us, the massage therapists, to guide that conversation back on track, to change the subject when it is obviously causing strife, or to end it when there is nothing to be gained.

The business of massage and other things I don't really know.

I have seen some recent musing about whether we, as massage therapists, have "patients," "clients," or "customers." After 8 years in practice, I honestly don't know. I use them interchangeably for that reason. Every person comes to me with a unique story and a unique set of needs, and I do my best to provide the right service to meet those needs. Some people have chronic pain, some have acute pain, some have anxiety and/or depression, and some just want some time to feel good. None of these are bad reasons to get a massage, and none of these have any greater need for my services than any of the others. Our field has an identity crisis, is it supposed to be a luxury service or a medical practice? I think it is both and neither. Therapeutic touch is too essential to be called a luxury, and too vague and unregulated to called medicine.

Another stumbling block is pricing and frequency. We, as a field, really do not know how much to charge or how often you should get a massage. For certain physical conditions, you have clear limits, but for most people, the sky is the limit. Monthly, weekly, perhaps daily? My answer for this is often, at least as often as you have the desire and the means. Let your body be your guide. What then should it cost: $40, $60, $80 an hour, or more? I value my work, and charge $75 an hour. But then I offer all kinds of price-breaks and discounts and deals to first-time and regular customers. I have often toyed with the idea of making my business a Pay-what-you-will model. I would do it too, if I thought it wouldn't be alienating to those who have been kind enough to see me regularly at full price.

Accepting, rejecting, or ignoring ideas. (Part 2)

Part 2, How do we know what we know?

In a recent video making the rounds on social media, we see a "non-conventional" view of how the solar system and the universe work.  Despite the many errors in word choice (vortex rather than helix, universe rather than solar system) the quality of the animation looks very professional.  In this video, the planets are seen being dragged behind the sun as it races, corkscrews, and bobs around the universe.  This video is now approaching 2 million views, and climbing.  Nevermind that the information presented is false, it is very compelling.The second video by the same author doubles down and builds upon these misconceptions.  This is a great example of all the concepts I want to talk about in this blog.

It's Wrong?  Says you!

 

If you've read previous entries, it should go without saying that I'm not going to ask you to take my word for it when I say this video is inaccurate.  If I did that, I would be presenting even weaker evidence than the video in question.  At least he has a very pretty 3d animated demonstration. 

But wait, the model he is trying to dispute has gorgeous 3d models too!  It also has a long history of accurate predictions.  It also has consistently observable effects, like the positions of space probes, placement of stars outside the milky way, and events like planetary transits across the sun.  To convey this, let us consult an expert.  What would an astronomer say about this video?

It’s wrong. And not just superficially; it’s deeply wrong, based on a very wrong premise. While there are some useful visualizations in it, I caution people to take it with a galaxy-sized grain of salt.

 What was that saying about extraordinary claims again?

 

How much evidence would be required to unseat the sun as the center of our solar syst...err... group of planets?  At the very least, you would need a model that functionally explains all the observations we can make with the naked-eye.  This one fails that very first test.

But, because the internet levels the credibility playing field to a certain extent, it is important to look at new information from a critical thinking standpoint too.  I'm not an astrophysicist and you probably aren't either.  Assuming that you didn't know anything about the universe or gravity, you could still debunk the video by simple questioning. 

1. Who backs the new point of view? (A small group with religious fervor about spirals, shamans, and energy that is actively looking to recruit new followers)
2. Who has the opposing point of view? (NASA, Astrophysicists, Astronomers, Academic types: people who use knowledge of the subject to make predictions. and gain nothing from you believing them or not.)
3. Which side presents a more complete case? (Hundreds of years of increasingly accurate predictions starting with Galileo. Everyone from Newton and continuing through Einstein all the way to the modern era of space telescopes and manned space stations vs. two videos based on a theoretical model posited by an herbalist/botanist)
4. Which side has reliable experiments behind them?  (This is getting pretty obvious, isn't it?)

Sidenote: I will continue to add thoughts as time allows.  I've taken on a full-time load of classes, so I've let this blog go to the backburner.

Accepting, rejecting, or ignoring ideas. (Part 1)

Ever heard of Reflexology? Of course you have, you press on areas of the feet, hands, or ears and somehow, "reflexively," areas of the body are stimulated or healed. You've probably even seen these little pictures:

This represents a homunculus (or little person) on your hands and feet. If you squint your eyes, and use imagination, you might be able to see how they look person shaped. 

Many LMTs are remarkably bad at basic discernment. We seem, as a culture, to be willing to embrace anything "alternative" unquestioningly. That is why so many of us end up allied with the pseudosciences, health fads, mysticism, and thus kept at arm's length from the medical field. But we are only a single rung on the ladder of poor judgment. This is an epidemic.

I'm not going to tell you that Reflexology is all nonsense... I certainly could, but not today.  I'm instead going to tell you about a different homunculus

This One

"Recently, as a result of my developmental studies on human embryos, I have discovered a new version of reflexology, which identifies a homunculus represented in the human body, over the area of the buttocks. The homunculus is inverted, such that the head is represented in the inferior position, the left buttock corresponds to the right hand side of the body, and the lateral aspect is represented medially. As with reflexology, the “map” responds to needling, as in acupuncture, and to gentle suction, such as cupping. In my studies, responses are stronger and of more therapeutic value than those of auricular or conventional reflexology. In some cases, the map can be used for diagnostic purposes.

When John McLachlan, professor of medical education at Durham University in the U.K., submitted this hoax to the Jerusalem International Conference on Integrative Medicine, instead of being rejected or asked to produce evidence, he was accepted and asked to give a lecture at the conference.

These weren't LMTs, they were doctors.  Most of the names on the list end with PhD.  And they wanted to hear about this new miracle reflexology map located "over the area of the buttocks" that responds to "gentle suction."  They were basically being told to kiss their patient's asses.

More about that here. 

Much of this blog is about what is and isn't reasonable or perhaps, what works and what doesn't work. Sorting that out via discernment and judgment is increasingly difficult even though knowledge is more and more accessible. This problem has always interested me. How is it that bad ideas flourish and really good ones never take hold?

The whole of human knowledge is accessible to you right now. Want to know the main export from the Democratic Republic of Congo? Just look it up on one of many available platforms right in front of you. Turns out it is minerals, cobalt and copper and such. When I was hand-writing reports in elementary school, that would have required a trip to the library. Information has certainly become plentiful, but is all that information helpful?

What happens when misleading information, intentionally incorrect information, or naive wishful thinking present themselves as knowledge? Every conspiracy, every hoax, every email forward chain, and especially everything Dr. Oz says, will be passed around endlessly on the web. Believe that Autism is caused by gluten? There is a community for you, complete with false promises and product lines despite evidence to the contrary. Believe that 9/11 was a conspiracy? There is a community for you. Believe that reptile-like aliens are taking over positions of power in the government? Yep, that exists too.

How does one separate the good ideas from misinformation?

Part 2, coming soon.

The Lost Art of Listening

(I wrote this piece for a local medical journal, I thought I'd share it here too)

The teacher who sticks rigidly to a text book and rarely entertains deviation from the lesson plan isn’t the one that inspires students.  The stalwart disciplinarian who refuses to hear questions rarely gains the favor of subordinates.  We want to inspire others to take responsibility for themselves, and that inspiration comes mostly from understanding and intuition.  Paula Denton wrote a piece for the Virginia Journal of Education called The Power of Listening.  It was written for teachers, but its lessons are easy to apply to my clinic: 

“To be known and understood is a basic human need. When we fulfill that need for students (or patients), they feel a sense of belonging and significance… “

Which brings me to my practice of massage therapy.  Patients love feeling physically better and having their needs anticipated, but above everything else, they want to be listened to. That is often what brought them to me in the first place. 

In his insightful TED talk, Abraham Verghese MD., Professor of Medicine and Senior Associate Chair for the Theory and Practice of Medicine at Stanford University, talks about the most frequent complaint he hears about doctors, 

“it is amazing how often you hear, "(S)he never touched me!" or, ". . . never laid a hand on me!" or "never looked at me" or "never listened" or "was too busy looking at the computer screen.""

His main point is that when doctors spend time trying to create a virtual model of the patient, they forget to see the actual person sitting in the room.  Although that doesn’t happen in my field, the opposite problem occurs regularly.  Patients are brought into a room without a proper interview and given a generic massage routine which addresses none of their specific complaints.

As with many complementary and alternative therapies, massage therapists spend the majority of their time with a patient one-on-one.  We are in a wonderful position to help people, and have the time necessary to listen carefully.  People often seek alternative health practices simply because they want to be treated this way.  When I see a patient for the first time, the interview and intake procedure can take 20 minutes or longer, because I listen to everything they have to say about their pain and ask all the necessary questions to understand their goals.  Time to express their complaints with my undivided attention gets nearly as many positive comments as the massage gets.

Listening isn’t easy.  

There is a misconception that if you sit quietly while someone speaks, you have met all the requirements for listening.  

Being present, with open ears, is just the beginning.  

When someone speaks to us they are trying to tell us many things.  Besides the basic message in the words themselves, there is subtext in why they chose the words they use, the expressions both in the face and the tone of voice, and body posture.  Most of these messages are lost on the active listener.  Really listening to someone for more than a few minutes is much more challenging than it sounds.  Most of the time, in conversation our brain is busy anticipating the next chance to speak.  When with a patient, we want simple clear answers to tick boxes either on a chart or in our minds.  Our own thoughts, agenda, point of view, and expectations can seep in and drown out hearing the whole message.  

In a busy environment--with computer whirring, charts with empty spaces, missed calls and texts, anticipation of several more appointments today--focusing on the task of eye-contact and evaluation of words as they are being actively spoken can seem next to impossible.  To combat this there is no computer in my treatment room, there is also no phone, and virtually no other distractions from the patient.  I don’t even write down much of what is said until after the interview is over, just quick notes to keep track.  Even with all these modifications, I still have to actively quiet my mind to avoid categorizing problems prematurely.  My scope is fairly small, and even so, a missed detail can be the difference between an effective intervention, and a null result.

More importantly, I don’t want to be another example in a long line of, “I saw so-and-so and he didn’t even listen to me.”  Most of my patients have these stories in common.  It is not unusual for a primary care physician to send a patient home having never touched them and barely talked to them, usually recommending large doses of ibuprofen or naproxen, if anything is recommended at all.  If they come back, they are sent to a physical therapist who doesn’t touch them or listen to them before sending them off to do painful exercises with an assistant who urges them to ignore the pain and stick with it.  When results from this are less than stellar, should anyone be surprised?

Anti-inflammatory medicine may have been the right call, the exercises may have been exactly the right ones, but the patient didn’t feel satisfied with encounter with his/her clinician, so compliance is minimal.  It is human nature to take the advice of someone we like or respect.  A 2010 Harvard Medical School study showed that about 20 percent of first-time prescriptions are never filled.  That number drops even lower when we look at advice given without a written script.  OTC medicines aren’t taken seriously and take home exercises, in my experience, are very rarely done properly. 

It is admittedly easier to get patients to stick to a massage regiment. Despite the expense, massage is pleasant, feels significant and specific when done properly, and gets quick short-term results. During that time, if I can convince them to dust off the PT’s orders, or follow the regiment their doctor recommended, the results only improve.