This is not a New Year's Resolution post.

I recently got serious about taking off the baby weight.  

 

When my wife and I got pregnant last year, we stopped exercising almost entirely.  My priorities shifted and I completely let myself go to focus on taking care of my wife, my business, my house, my pets, anything other than my physical health.  I made sure to cook healthy meals, but I also followed those meals with huge helpings of ice cream and cookies and cakes and...  you get the idea.

When my daughter arrived, my excuses rapidly disappeared. It was time for me to look at what I could do to reverse the damage done.

"Dad, there is no easy way to tell you this: you're fat."

Starting this new year I am about 25 lbs. heavier than last year.  I still have my gym membership, because we kept paying for it, like tithing to assuage guilt.  That only leaves the matter of what to do and how to get started.  For me, that answer came from trading massage sessions for personal training sessions from a certified trainer/massage therapist friend of mine.  I'm about 3 weeks in, so wish me luck.  By this time next year, I hope to be writing a victory blog.

What does this have to do with massage?

 

The universe is full of irony, it should come as no surprise that as I'm starting to get back in the saddle (trotting toward physical fitness) that I should start to encounter a huge uptick in avid athletic types.  CrossFit competing, marathon running, workout slaying types have helped to illustrate two very key things about my journey back.

1. I have a long way to go.  Determination, discipline, and motivation will be necessary.
2.  Injuries can quickly derail even the most motivated, disciplined, and determined.

There are a million different ways of staying mentally committed to your goals, and thousands of books and websites to help you along the way.  Find one, and if it doesn't work, just move on to the next.  Contrary to all the claims, there is no perfect program, routine, or diet.  You will need something to keep you on track though.  People fail far more often than they succeed when it comes to weight and health goals.

The same may be true for injury prevention, but that is needlessly complicated.  My one piece of advice?  Listen to your body.  If you have to "work through the pain" or ignore injuries to keep up with your goals, you are hurting your goals in the long run.  Injuries are avoidable, but one probably will happen.  You have to have a plan to deal with that injury.  Chronic pain may also happen, especially if you do insist on working through the pain.  Ignore any pain that has lingered longer than 3 months at your own peril.  Pain is a messenger, but it doesn't have to be a harbinger.

Massage can help maintain, even improve your performance.

 

There is plenty of science out there showing massage to be helpful within active and athletic populations.  It is certainly more beneficial than the supplements these folks often take, especially since one-third of supplements tested contained none of the plant extracts indicated on the product label.  Even when the right product is in the bottle, is there any evidence that it works as it claims?  Probably not.  One,  Two,  Three,  Four,  Five...  You get the idea.

It is no accident that my personal trainer is also a licensed massage therapist.  If your trainer isn't, find a licensed massage therapist that works with athletes.  A large number of NBA, NHL, MLB, as well as Olympic teams, have massage therapists on staff; along with the very best in physical therapists, trainers, and orthopedic surgeons on call.  It just makes sense to have that base covered.

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?

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?