Persistant Pain, Part 3

What can you do about my pain?

This is Part 3 or 3.  Here is Part 1 and Part 2

All of the reasons massage therapy works aren't known, and that is important to admit.  If you see someone who seems to have a simple answer to explain every ache and pain, you are probably being scammed.  Many such "experts" will move all pain into their own scope of practice, regardless of whether it truly fits there.  I believe this practice is unethical, as it costs money and time for a patient that could be getting appropriate treatment elsewhere.  Sadly, I can't help everyone, and neither can anyone else.

My approach to treating pain has 3 principle lines.  I will attempt to briefly discuss each one and describe why I feel they are important to helping you get better.  The human body is an extremely complex organism, and still largely inaccessible to our probing.  Just this week, a ligament that is likely present in 97% of the population was "discovered."  This ligament was there all along, and first hypothesized in 1879, and we just now found it!

1.  Explain Pain, The more you know...

1879 that hypothesized

1879 that hypothesized

Pain, unlike ligaments, can not be seen or measured objectively.  For this reason, it is often conflated to be something that can be measured (heat, electricity, force, tension, etc.) and treated accordingly.  This thought process started by Descartes, and was carried forward until science within the last 40 years overturned it. Believing all pain was in the tissues and needed to be "fixed" has led to invasive, unnecessary, and dangerous treatments as well as discrediting any pain that has no physical origin.  To this day, if you imply that a person's pain comes from their brain (a fact that is hardly even disputable anymore) they become defensive and think you are claiming their pain isn't real.

The understanding of pain is integral to its treatment.  I can not stress this point enough, so I will let research stress it for me. "For chronic [Musculoskeletal] pain disorders, there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance."

and pain education works better than "core strengthening":
"a brief psychosocial education program that reduced fear and threat of low back pain decreased incidence of low back pain resulting in the seeking of health care."

Massage Therapists should never diagnose anything.  Often times we skirt the rules and describe pain as coming from a particular muscle or other tissue (fascia, nerve, joint) but that does not, and should not, serve as a diagnosis.  For the type of pain that I treat, a diagnosis is rarely helpful anyway.  If the patient thinks the pain in his ankle is due to tissue damage, he is much less likely to get better quickly.  I find it is very helpful to describe pain as coming from the brain's interpretation of a situation or condition.  This is why soldiers on the battlefield often feel no pain when shot, and why a phantom limb can be excruciatingly painful. Your body will report tissue damage directly to the brain, but if your brain does not find that report compelling, you will not experience pain.

More info here: http://www.bboyscience.com/pain/ 
And here:  http://www.bodyinmind.org/teaching-people-about-pain-part-1/

2.  Communication with the nervous system (Trigger Point 2.0)

If your pain is due to actual damage to the tissues of your back, neck, or ankle, massage should only be used in combination with other medical treatment.  While massage may have a role in assisting the healing of damaged tissue, that role is still largely unknown.  It can be safely used to mobilize soft tissue around a recent injury to prevent adhesion, for example.  Regardless, the main purpose of massage should be communicating with the nervous system and with the brain.  To turn down the volume knob on pain, and increase the specificity of the pain itself. 

The brain, when in pain, is overwhelmed with a barrage of signals coming from the body and bounced back from the memory and meaning parts of the brain.  Each painful stimulus is interpretted and compared against past painful experiences.  The brain is constantly searching for meaning and patterns in everything, especially with something potentially dangerous.  Humans have thrived because of our ability to find such meanings and patterns, but that talent has a side-effect of Pareidolia, Matrixing, and Simulacrum aka finding shapes in clouds and Jesus on toast.

When a pleasant, or more noticeable stimulation occurs, the brain takes notice.  When I press on Tibialis Posterior, and you take notice and say, "That's the spot."  I'm not physically altering the muscle very much.  Now, instead of a vaguely painful ankle, your brain has a better story--that muscle, right there--and the mystery and unpredictability is lessened.  This alone will make the pain more tolerable.  Repeated a few times, the soreness often fades, or goes away all together.

Travell and Simons credited this effect to resolving an energy crisis within the muscle, Mense and Shah are still testing and refining that hypothesis.  Neuromuscular or Trigger Point Therapy was built on the model that pressure and stretch into the hyper-irritable point and taut band within a muscle will relieve pain.  I still largely follow this model, although I attribute the changes in pain to the nervous system and the brain.  It seems unlikely, to me, that physiological changes could happen that instantly.

About PNMT: http://www.nmtmidwest.com/about.html
Evidence review for Trigger Point Therapy

3.  Listening and then responding

I ask a lot of questions.  I ask about lifestyle, activities, work habits.  I ask about what worsens the pain, and what makes it better.  I assess and palpate muscles, I look for movement patterns, I listen.  I consider myself an Interactor, not an Operator.  We are a team, trying to beat pain together.

Because of my own poor experience with both doctors and chiropractors, I am passionate about the importance to listening to the patient.  When I worked in a warehouse, I injured my back rolling barrels full of chain. I, first, went to see my primary care doctor.  My doctor prescribed ibuprofen and sent me on my way, he did no physical examination of my back, no movement testing or palpation.  "Here is your anti-inflammatory, now be on your way."

When that didn't work, and my pain became debilitating, I went to a chiropractor with the glowing referrals from my co-workers.  I got an X-ray and some vague explanation about how the bones in my back had tiny fractures in them.  I was roped in to going twice a week, then once a week, then twice a month, and so on.  The adjustments he gave me hurt sometimes, and I felt only a little better when I had them.  The relief rarely lasted more than a day or two.  This went on for almost a year before I started doing rehabilitation exercises that I found on the internet, and started going to massage school.

I even went to a 2nd Chiropractor, on the wings of yet another gleaming review from a coworker.  This chiropractor gave me another X-ray and told me (at 25ish years old) that my entire spine was irreversibly twisted to one side and that I'd likely have pain for the rest of my life.  Thankfully, by this time in my life, I was skeptical.  My back continued to improve with massage and exercise, and now I have little-to-zero backpain.

My point is this: every pain is unique, and if anyone along the way had suggested exercises, changes in movement habits, and massage I would have saved a lot of money and felt better, faster.  If massage will not help your pain, I will refer you to someone else.  I do not make a treatment plan until I find an effective approach, which sometimes takes a few tries. 

Persistent Pain, Part 2 (Everything Else)

For Acute Trauma, Severe Injury, and Disease... Always see your M.D.

For everything else, what can you do?  In part 1, we covered how the persistent pain starts, and how most of us trouble shoot it until we have exhausted our basic knowledge.  Which can often end with an unsatisfying experience with your typical M.D.

If you've read my previous posts, you'll know I'm not the "Appeal to Nature" type.  Modern Medicine has done many amazing things, but right now it is rubbish for the most typical pains that we all live with: low back pain, neck stiffness, headaches, shoulder pain, and of course foot and ankle pain. These conditions send millions of people to their family doctors, cost billions in healthcare annually and countless people just have to live with it.  So what can be done for them?
 

What's My Alternative: Things that may be worth trying

You don't want to be defined by a cranky ankle.  You've tried everything you knew to do, and your General Practitioner didn't help much.  Now what? For most people: Internet Search. (I'm assuming you don't look for answers at Pubmed)

With a basic search, you've gone from no clue to being confronted with too many possibilities.  Assuming you don't limit yourself to solutions with documented evidence, the sky is the limit.  From the statistics, it looks like most people still want an "expert"  and some kind of "medicine" to treat them, and they don't much care if those treatments are evidence-based.

So, what about Acupuncture?   Here, you may get perfectly practical treatment.  Dry-needling for example, can be useful in changing pain states, and has some evidence to back it up.  Most of the time, however, what is being treated is based on what amounts to a mistake due to poorly-translated Chinese.  Energy and Meridians didn't exist in the original ancient texts and are a construct of early 20th century translational misunderstandings. Which hasn't seemed to stop anyone from claiming it as effective, despite regularly getting "no better than a placebo" reviews by the major medical journals or at best: About 10% better than sham treatments.  You will likely be asked to come in for multiple treatments, and you will not be likely to receive a clear and reasonable explanation for why you hurt.  If you are living with pain and nothing else works, it is worth giving a try, but make sure you go to a well trained professional.  The consequences of a small miscalculation can be life destroying.

How about Herbal Medicine? (supplements, herbs, and nutrition)  Here we have a different kind of pill to take, often expensive and rarely tested properly.  Sometimes Poisonous. It is tempting to imagine that pain could be a symptom of some nutritional problem, or that supplements like Glucosamine could help.  Evidence is mixed here, and far too complicated to address in one blanket statement.  My advise?  If you want nutritional information, go to a dietician; someone with medical training at the college level.  If you want to try herbal stuff, make sure your supplements have some evidence behind them, as most don't and can quickly cost you hundreds of dollars.

Chiropractic?  You want to see different kind of doctor, usually get an xray, but there is no medication to take.  Not all chiropractors are the same.  The treatment you receive here can be practical  such as manual therapy and rehabilitation exercises. But much more often, the treatments are baseless or scientifically disproved; such as applied kinesiology, detoxification, or spinal subluxations. Most chiropractic treatments are focused on the spinal joints supposedly impinging nerves and affecting surrounding tissue.  You may get a back adjustment to fix your ankle (or even your allergies.)  The subluxation of the spine model has been written off by many chiropractic authorities:Here is one.    And another.  The experience, most of the time, is to be asked to come in 3 times a week at first, and keep coming (slowly tapering down to monthly) in some capacity forever.  If you choose to go to the chiropractor, go to several and really listen to what they have to say.  Find one that gives you a clear understanding of what is being treated and how the applied treatments will help. 

Exercise and Yoga?   Generally, these can be both pain creators and pain reducers.  Ignoring the spiritual and energy faith practices of Yoga, I'm an advocate of most movement and exercise regiments to reduce pain.  The evidence, however, is still quite mixed.  As an example of how mixed: exercise (unsupervised) has been shown to decrease future ankle problems, while exercise (supervised) has been shown not to help much. And of course, you'll also get a fair amount of nonsense included with your practical exercise advice.  Back pain, for example, probably has nothing to do with a "Weak Core."  You will likely hear a lot of "no pain, no gain" with some trainers going so far as to claim that the pain holding you back can be cured by toughing through it.  Pain is a warning message, and it is best not ignored completely.  Be sure to find someone you trust not to push you into injury.

I'm excluding Physical Therapy, Occupational Therapy, and other rehabilitation medical professionals here. Seeing one of them requires a referral from your M.D., which would makes this whole section not really apply to you.  I have a lot of respect for PT and OT treatments, although they too can fall short of following the best available evidence and science.  Many of my patients come to me because their insurance didn't cover the amount of PT/OT sessions they needed, or because they didn't know where else to turn after conventional and/or alternative treatment didn't work, but I'd always rather they come to me AND get conventional treatment.

In part 3, I will discuss massage and my own approach. What should you expect if you see me for your persistent ankle (or any other) pain?

Persistent Pain (Part 1)

Persistent pain is complicated 

New patients usually come to me after everything else failed to help them.  Massage therapy, neuromuscular therapy, manual therapy, basically any of the things that I do, are not chosen as the first line of defense.  This should come as a surprise to no one, human beings want a quick solution to even the most complex problem, and manual/massage therapy is far from simple.  Nothing I do is as easy as taking a pill, popping a joint, or getting poked with a needle, therefore at least one of these things will likely precede me.  So I'd like to take some time to talk about everything else; the stuff people do to address their pain other than massage therapy.

Is it dangerous? Does it mean something?

When a pain starts, let's say you wake up with a sore ankle, what is the first thing you do?  Attempt to ignore it, walk it off, maybe do some stretching, and if any of these things work, the problem ceases to get any attention.  This is important because it illustrates the usefulness of pain.  Your body says to your brain, "Hey, there is something going on in the ankle, you may want to check on it."  Your brain responds by directing conscious attention to the problem and applying basic solutions:

False Alarm? "Ignore it, if it's legitimate this won't help."
Positional or Muscle Energy Issue? "Walk it off, if it's serious or dangerous this won't help."
Tissue Tension Issue? "Stretch it out, if this doesn't help, try something else."

Something Else: You have an acetaminophen deficiency.

Now, you've exhausted your simplest solutions, and for some reason the pain hasn't gone away.  Maybe it has been a day or a week, maybe two, and you are beginning to worry about it,  so you try more complex problem solving.  Over the counter medicines, aspirin and acetaminophen, maybe ibuprofen or naproxen.  With the exception of acetaminophen, if you have an inflammation issue, these medicines will take the edge off.  By altering the chemical milieu in the body you effective turn down the volume on pain.  At this point, you are supposed to heal from whatever damage is causing the discomfort, and with the aid of the meds, that wait should be more tolerable.

Side Note: Tylenol may also help with mental anguish - or with watching David Lynch films.

What about Ice or Heat?  What about Ice and Heat?

The Intolerable Wait: Bargaining with an unreasonable body.

More time passes, countermeasures are becoming less effective as you become more conscious of all things ankle.  The medicine dosage has been increased to keep up with your tolerance level and the pain's persistence.  You start avoiding anything that makes the ankle hurt, including walking like a normal person.  People comment on your hobbling gait and it makes you even more conscious of the ankle.  This ankle has gone from a supporting role to a starring role in your life.  At this point, you want expert advise.

(Heads Up: Mildly explicit language warning on this video)

Standard medical doctors aren't great with mechanical pain.  They have a huge amount of competency and skill with internal medicine, but not-so-much when it comes to chronic or positional or muscular pain.  Here is a very thoughtful post about dealing with chronic pain from a doctor's perspective.  If you don't get referred out to a physical therapist or an orthopedist, you are likely to get more over-the-counter meds or in some cases, prescription pain meds and/or muscle relaxers.

At this point, the pain could become suffering if you don't find some way to cope with it.  In the next blog, I'll talk about the alternative medicine route, and its various advantages and drawbacks.

TED Talks For You, Understand Pain Better (Part 2)

For a massage therapist and massage patients, understanding pain is absolutely essential. Reading books and research papers is not for everyone, and that is what makes TED such a great concept. Here are some quick and interesting videos to help you get a better grasp on the often head-scratching reality of pain.

To understand pain, it helps to understand what is going on inside the brain.  Pain is first and foremost a brain state which can be altered by input from visual, psychological cues:



How one perceives their pain, and whether or not one feels in control of it is directly correlated to how much one suffers.  At the PNMT Colloquium, David Flueke spoke about psychosocial aspects of pain, one point he made was that pain feels threatening to quality of life, but when that pain begins to threaten ones identity it becomes suffering:


Past and present pain states are altered by memory and expectation. The amount of happiness and the intensity of pain that one experiences and remembers can change based on how we interpret and define the story around these experiences.

Anxiety, Depression, Stress, Pain, and Massage

One of the least disputed claims made about massage is that it lowers stress.  This seems so much like "common knowledge" that very few people have seriously questioned it. Most of the studies point to this effect being legitimate.  Massage is supposed to feel good, and as that pleasant feeling is the focus of the session, it not only decreases pain, it improves overall mental health

Massage decreased pain, and improved mental health in this study  but the result on mental health disappeared after week 8, which marked the end of receiving weekly massages.  In other words, massages made them feel progressively better, until they stopped receiving them, which understandably made their numbers plummet.  Interestingly, 1 hour of massage weekly out performed 2 1/2 hours of weekly meditation and yoga coupled with daily meditation audio tapes in both pain and mental health.

Another study showed that the relaxation brought on by massage may have a wide variety of health benefits, although it lacks the rigors of good science (no control group or placebo control).  Improving immune function is a very old claim, but it does seem to have some validity.  These subjects were med school students who were stressed already and worried about an upcoming exam.  Check out the results for yourself

Massage seems to get its biggest boost from studies done with various cancer patients.  Once you throw aside myths about spreading cancer via lymph or circulation changes, you can make a huge difference in the well being of individuals who most need it.  Interesting to note, this study showed the decrease in stress and anxiety, but no corresponding drop in cortisol.  It seems to me, that cortisol is a Red Herring.

Very often, when a therapist wants to be taken seriously in the massage therapy field, the first inclination is to insist that massage isn't "Fluff and Buff."  That term has been around for years, and it is meant to imply that if a massage is gentle and feels good, it isn't doing anything.  Which is not at all what the research shows.

When a massage therapist like myself gets education in Neuromuscular Therapy, Trigger Point Therapy, Myoskeletal Alignment, etc.  We use all these impressive sounding names to describe our work and distance ourselves from what we are actually doing.  When it comes to relaxation, it's just massage, no matter how much time you spend with your nose in a book (trust me, that is my hobby) it doesn't transform your work into something entirely different from a baseline massage.  You add tools, knowledge, experience, and confidence to your work, and all those are good things...  your clients do care how much you know as long as they like you and you have a good reputation.  Oddly, they don't seem to care if you have good listening skills.

The Bridge Is Smoking, But It Hasn't Yet Been Burned.

Permanent link to this comic: http://xkcd.com/882/

 (If you aren't smiling, hold your mouse over the image for an explanation)

Being a Massage Therapist and a science enthusiast is a very difficult position.  It isn't inherently contradictory, as there is nothing intrinsic to massage that flies in the face of science; rather it is tradition and history that drives a wedge between the two fields.  And if this discussion on LinkedIn is any indicator, that wedge is large, heavy, and very hard to shift.  For those who can't see this discussion, here is what it looks like:

The end result of the discussion, thus far, is some feel you can say nothing at all about massage scientifically, some feel that science is just another religion, some feel that they have quantum-healing-energy-superpowers, and some feel that we should, in fact, look at the research before we tell a patient what massage can and cannot do.

In other words, there is no real consensus.  This answer would be obvious in any other field; LMTs are unsure whether evidence is important in evaluating what is and isn't fiction.

My position on this is in two parts.

1.  The first part of me knows that there is no valid reason to avoid looking at the science.  You can say it is difficult, or you can say it is biased, or you can claim that your own personal evidence is better than anything that science can offer.  All of these explanations, when talked out to their logical conclusion fall flat.  
• I am too busy, it is too hard: If you are offering massage, you have an obligation to understand how it works. Do you have any business ethics?  I would never offer my patients something if I couldn't explain why it is worth spending their hard earned money on.  This is just laziness and apathy.  If you can't understand something, ask someone in the field to explain it.
• The Big Pharma Conspiracy: You think all scientists and doctors are conspiring to hide the truth and invalidate what would actually heal people?  Okay, then you have to back that assertion up with evidence.  A conspiracy of this magnitude would require complicity of nearly every major university, hospital, medical journal, and researcher.  If that is your perspective on the world, you seem to be living in The Truman Show. For that matter, how do you know the conspiracy theorists learned from weren't a part of a conspiracy to keep you ignorant?  As Christopher Hitchens said, "That which can be asserted without evidence, can be dismissed without evidence."
• I make my own evidence: If you believe your personal anecdotes are better than all the scientific research, ask yourself if it is:
• reviewed by peer-experts?
• checked for human error, effect size, chance of coincidence?
• evaluated for significance against placebo?
• replicated by other experts?
• checked against similar reports?
• controlled and measured carefully? 
2. The second part of me knows that a huge amount of this is faith-based. Some people speak about quantum physics, fascia, or consciousness in hushed tones. To them, there will never be enough evidence to overturn their desire to live in a particular version of the universe. One where their thoughts become things, their intentions produce results, and stuffy guys in lab coats are flummoxed by their deeper understanding of the world.
• Quantum Physics is mysterious, and hard to understand:  For this reason gurus have grabbed on to it, and used it to assert fiction.  A simple look at Wikipedia can offer the explanation for most of these misinterpretations
• The Observer Effect: ever check your tire pressure with a pressure gauge, and in doing so let out some air?  That drop in air pressure, the one caused by poking the pin inside the valve stem, that is the "mysterious" observer effect.
• Particles don't follow Newtonian Physics: True, because particles are too small to be effected by those laws, but thoughts, intentions, emotions, and the like are not that small, and neither is anything you will ever experience with your senses.
• Everything is energy:  Not really, everything is MADE of energetic particles.  For perspective on the difference, ask yourself this: can I breathe under water?  Water is made of Hydrogen and Oxygen, you can breathe hydrogen and oxygen, but you can't breathe water.  This is called the Fallacy of Composition.
• Fascia is everywhere in the body: It is the container that holds organs, muscles, nerves, and vascular tissues.  This is often misconstrued to mean that fascia does all things.
• I rather like this post by Diane Jacobs
• This is called the Fallacy of Division.
• Consciousness is an extremely slippery subject:  How would we measure something from the inside out?  But that doesn't mean that you can say anything you want about it and be right.  Also, we don't have to know everything about something to know something about it.
• Deepak Chopra said so: This is called the Appeal to Authority.  He is a very intelligent man, but he isn't infallible.  He is only human.  His opinions are often anti-science, and he is always selling something to improve your quantum-spiritual-well-being. 
• The Law of Attraction:  It's a LAW right?  It sounds sciencey!  Too bad this isn't actual science, but a construct of New Age Philosophy. One which lacks the values of any physical science law, it can not be verified nor falsified. It also ignores a simpler and thus more plausible explanation. 

So what does that leave us with?  Can we leap over this divide and find a space where those of us who want to help others can do so without trying to sell them our philisophical or religious values? Can someone who is deeply entrenched in ancient tradition still reach out to science for explanations without judgement?

The Dalai Lama thinks so. "If science proves some belief of Buddhism wrong, then Buddhism will have to change. In my view, science and Buddhism share a search for the truth and for understanding reality."

Who am I to disagree?

Can we talk about Cognitive Dissonance?

Other links regarding bias and dissonance:
The limits of reason
Treacherous Trio: confirmation bias, cognitive dissonance, and motivated reasoning


In a perfect world, one which we all wish to inhabit, humans are rational creatures. To make decisions, we rely on the best evidence from the most accurate sources, and choose the most prudent course of action. When confronted with the fact that something we previously believed was untrue, we throw our hands up and say, "I don't mind being wrong; that is how you learn stuff."


I don't think I have to tell you that we don't live in that world. I posted this image on facebook:

I can never know how many people looked at it, found it challenging, and then quickly found something else to look at.  I do know that it made at least one friend disgusted, uncomfortable, and even angry.  Driving him to question my education, accuse me of evangelizing science, and to ultimately abandon discussing the topic in favor of personal attacks and insults. 

When a little while later the same image appeared on The Scientist and IFLS... The reactions were very similar to what I experienced.  Most people expressed anger and outrage that whatever thing within the diagram they personally believed in was 100% real and anyone questioning it was stupid to do so.

So what is it about an image like this that causes such a visceral reaction? Why is it when people like Paul Ingraham, Alice Sanvito, and Ravensara Travillian bring research and accurate information to the public about massage they are met with personal attacks, insults, and outright derision?

Saveyourself.ca's own Venn Diagram

The answer is cognitive dissonance. Research has shown that "the primary causal agent for misperception is not the presence or absence of correct information but a respondent’s willingness to believe particular kinds of information" and that we are "...responding to information defensively, accepting and seeking out confirming information, while ignoring, discrediting the source of, or arguing against the substance of contrary information (DiMaggio 1997; Kunda 1990; Lodge and Tabor 2000)."

There is no way to turn off this bias, and it is a very strong motivator.  In evolutionary terms, it benefits our survival to feel secure in an orderly universe, and not experience doubt of our beliefs.  Like pain, the uneasy feeling we get when confronted with contradictory evidence is the brain's alarm and defense system.  One part of your brain is telling another part, "You better not go there, it will shake things up too much!"  Also, like pain, you need slow and graded exposure over time to change an existing state.  Old, deeply rooted, or cherished beliefs will not go out without a fight.


To tie this into massage, because this is a massage blog, when you hear any of the following:

Massage removes toxins -- Nope
Your pain is caused by Lactic Acid, massage removes it -- Nope and more Nope
Massage increases blood flow to the muscles -- Nope... No, but it does increase skin circulation
You need to heal your energy -- All kinds of Nope  Two  Three  Four
I'm going to stretch your fascia -- Not likely
Always massage toward the heart -- see Laura Allen link
Don't massage pregnant women in the first trimester -- see Laura Allen link
Don't touch the ankles of pregnant women -- see Laura Allen link
Don't massage cancer patients -- Wrong

More Massage Myths By Laura Allen
3 massage myths you should stop repeating by Sarah Cafiero

Remember that these things are beliefs, not facts.  You may do well to mention, delicately, that the best evidence we have shows exactly the opposite.  Do not, however, expect to be greeted warmly or to change minds.  You can lead a horse to water, but you can't make it drink.  Likewise, you can lead a human to knowledge, but you can't make it think.

One last myth worth mentioning, because it has some tragic consequences.

Vaccines cause autism  -- No -  Nope -  Still No -  And we lied in the first place.

TED Talks For You, Understand Pain Better (Part 1)

For a massage therapist and massage patients, understanding pain is absolutely essential. Reading books and research papers is not for everyone, and that is what makes TED such a great concept. Here are some quick and interesting videos to help you get a better grasp on the often head-scratching reality of pain.

Pain is an output from the preconscious brain, not an input from the tissues:

The amount of pain is not always related to the amount of damage:

Pain is subjective, personal, and complicated. (and massage works to decrease it):


... and for bonus, here is Radiolab's interesting podcast on understanding pain:

Is your massage a placebo? (Part 2)

Some note worthy links:
Seven alternatives to evidence-based medicine (this is satire, folks)
I highly recommend the "Why Science?" series here.


In the first part of this blog, I explained the origin of, and the need to understand, the placebo in medicine.  I left off with this question: how does one know if massage is a placebo or a valid physical treatment?

Before the inclusion of the Scientific Method, it is safe to assume that tradition was the foundation of clinical reasoning.  The handing down of wisdom from master to student was the best paradigm we had. Much of that wisdom was based in faulty models of how disease, health, and the human body function.  This tradition leads to very poor critical thinking, it even has its own recognized logical fallacy: The Appeal to Tradition.

Finding this appeal doesn't require much work when discussing any form of massage or manual therapy.  Modalities almost universally originate from one charismatic master, and are then carried onward by his/her followers with little room for questioning.  This origin story usually has a sequel when the best students of that master become "apologists" for their respective school and begin to make subtle changes to keep the method alive.  Here is one example of many: Chiropractic Medicine

Massage is deeply rooted in this old paradigm, it is a part of nearly every cultural tradition.  In arguing with other massage therapists (something I often find myself doing) one of the first statements they will make is, "Massage has been around for thousands of years."  This is meant as a blanket defense against all criticism; a tactic used to defend many forms of alternative medicine.  It is meant to demand respect without giving an answer to any of the difficult questions.

That line of thought is helpful in one very substantial way, if other CAM therapies use that same appeal they could be used in designing tests for massage.  In fact, acupuncture is often tested right along-side massage. The results are fascinating for these studies, mostly because they often conflict and show a wide variety of results.  The highest level of evidence you can find on acupuncture indicates that is sometimes works better than a "sham" treatment, and even that is contended for good reasons.  Poking people with needles (sometimes with heat or vibration or electricity added) is a very large sensation, which will effect how the brain reports pain. 

It's important to note here that not all placebos are created equally.  As Dr. Harriet Hall put it:

We not only know placebos “work,” we know there is a hierarchy of effectiveness:

• Placebo surgery works better than placebo injections
• Placebo injections work better than placebo pills
• Sham acupuncture treatment works better than a placebo pill
• Capsules work better than tablets
• Big pills work better than small
• The more doses a day, the better
• The more expensive, the better
• The color of the pill makes a difference
• Telling the patient, “This will relieve your pain” works better than saying “This might help.”

Here is the rest of that very enlightening article. 

You'll notice that spending time engaging one on one with a person while physically applying pressure isn't on that list.  Again, how does one fake interpersonal contact?  It has also been shown that patient expectations influence the results.

Massage research is very poorly executed, and very poorly standardized.  Researchers have to define what they mean by "massage" before engaging in a study.  The method of precise measurement of time, amount of pressure, style, direction of force, purposed model, and practitioner expertise must be worked out before the trial even begins.  That is why so many reviews are inconclusive:

"No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain."

"It is concluded that too few trials of massage therapy exist for a reliable evaluation of its efficacy."

To further complicate matters this systematic review, recommends "acupuncture massage."

Is your massage a placebo? (Part 1)

http://www.beatricebiologist.com/2013/03/evolution-of-placebo-effect.html
Since day one of being a massage therapist, the single most interesting and wide-spread concept I've run into is the Placebo Effect. When it comes to treating any kind of condition, the idea that my hard work could be irrelevant to the results can be both frustrating and intimidating. Everyone I work with knows of the placebo effect, but few understand it thoroughly, or how it applies to massage.

Lifted from Wikipedia "The word placebo itself originated from the Latin for I shall please.[1] It is in Latin text in the Bible (Psalm 116:9, Vulgate version by Jerome, “Placebo Domino in regione vivorum”, “I shall please the Lord in the land of the living”). Jerome translated as "I will please" (placebo), the Hebrew word "ethalech", "I will walk with" as in "I will be in step with". This word gave its name, placebo, to the Office of the Dead church service. From that, a singer of placebo became associated with someone who falsely claimed a connection to the deceased to get a share of the funeral meal, and hence a flatterer, and so a deceptive act to please.[2]"

Voltaire famously said "The art of medicine consists in amusing the patient while nature cures the disease." and in Voltaire's time (1694-1778), this was very true. Medicine was still mired deeply in Vitalism, The Four Humors, and Folk Medicine. During Voltaire's century people were often killed by their physician with "medicines" that proved poisonous, botched/unnecessary surgeries, and the practice of bloodletting. It is fair to say that science and medicine have evolved since then; but how has it evolved and by what method?

A first step was the introduction of techniques to control against the many confounding factors that obscure results. Every "expert" is a flawed observer; placebo effect, confirmation bias, regression to the mean, belief bias, attentional bias, and a whole host of logical fallacies distort perception. Regardless of education or experience, humans will make observational errors that undermine their search for effective treatments. The more time and money one has spent on a particular area of study, the more likely one is to fall victim to ignoring information which disputes that area. Which is why the opinions of experts are at the bottom of the Evidence Pyramid:


In the book Trick or Treatment: The Undeniable Facts about Alternative Medicine by Edzard Ernst and Simon Singh, we start with the story of Dr. James Lind (1716-1794) who first identified oranges and lemons as a treatment for scurvy, a disease that effected the outcome of many wars by wasting away and killing millions of sailors. Lind designed the first recorded group study to compare six contemporary treatments (Cider, Sulphuric Acid, Vinegar, Sea Water, Medicinal Paste, *consisting of garlic, mustard, radish root, and gun myrrh and citrus fruit) on sailors with scurvy. It's important to note that the fruit was considered "alternative medicine" at the time and was only included by chance. The medical experts of the day would have likely prescribed bloodletting two or three times over before entertaining nutrition as a mode of treatment.

As my readers may well know, scurvy is a deficiency of vitamin C, those given cider got a little better and those given lemons and oranges got significantly better. A key point here is the five other treatments had previously shown promise when tested by themselves. The proponents of these treatments, and of bloodletting, weren't dishonest intentionally; they had fallen victim to the Placebo Effect. Placebos will look dramatic in isolation, but once you line them up in a trial against an effective treatment, their effect seems irrelevant.

This method of taking what experts think, then applying a simple test to weed out bad ideas, is the basis of the scientific method. To further illustrate the point about expert opinion, Dr. Lind didn't even understand what he had done, and waited years to report his findings. He even tried to create and sell a lemon juice concentrate (processed in a way that destroyed its vitamin C content) damaging his own credibility with its ineffectiveness.

So how does all this apply to the type of massage I do? It's not like I am curing diseases. Most trained massage therapists know better than to diagnose or claim to treat any physical condition. We should be "complementary" and not "alternative" when we do our jobs correctly. I work within the spectrum of science-based medicine, not in contrast to it. It is very important to make that distinction. I have, and will always refer patients to physicians when I see something outside of my scope of practice.

That said, when I see any patient, I must address their expectations. One who seeks massage therapy for a specific ailment (e.g. headache, neck or back pain, anxiety, depression) usually desire a specific result. How do I get that result? How do I support the claim that I can have any result at all? I know what they want, I know many different ways to approach that goal, but how do I know which to choose? In any decent massage school, we are taught muscle names, origins, and insertions. We are taught (though many forget) the finer details of anatomy and even a decent amount of pathology and kineseology. *We also get a substantial dose of non-sense... but more on that later.* We can't necessarily take this hard science of what is in the body and gain insight into what ought to work. The classic Hume Is-Ought Problem comes to mind.

To further complicate matters, hundred of "experts" over hundreds of years have claimed to have the magic bullet for pain, and have produced an equal number of modalities to capitalize on their personal panacea. Regardless of the fact that a placebo effect could explain most of their results, very little has been done to substantiate the claims of the many gurus in the field of massage and manual therapy. There are books, videos, articles, trade magazines, web pages, seminars, and even entire physical schools dedicated to teaching the "One True Cure" with thousands of methods. Some are unique, most borrow heavily from each other, and many differ in name only.

Massage has no recognized peer-review system. Often times, massage studies are done with no control group at all. If there is a control group (one receiving no treatment) how do we know the massage technique isn't a placebo? There is no established fake treatment that one can give as a placebo to measure massage against. It is almost guaranteed that anything that one person does with the intention to affect another person is a school of massage. For example, touching isn't required, neither is being in the same room. Some are actually quite specific. Other tell us that we all can heal ourselves.



So what could I do to prove any particular method is more effective than a "sham" treatment?

Is your massage a placebo? (Part 2)