Finding Naturalism in Massage

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Finding Naturalism in Massage

naturalism and massage

Many of us in the massage industry spend a lot of time talking to other therapists about massage therapy. What is holding it back? Is it the non-science based nature that is the issue? Is it the lack of research? Is it the people it attracts? Is it the professionalism? What about the spiritual aspects that some seem to want to connect to?

As most of you know, I am firmly in the science-based camp. My background is  pain management with rehabilitative exercise. This is what I was taught in school and I was exposed to nothing else. Prior to my RMT training, I had taken pre-med courses in college, and before that all the AP science classes offered in high school so the Canadian program fit right in with my science-based ideals. It made sense to me.

The US massage industry frustrates me to no-end. I desperately want it to change because, after working in Canada as part of a heath care continuum, I know how good a massage program can be.

I know there are a lot of us pushing for a shift to a science-based program. However, given the condition of the US system and its irregularity, changing to science-based might be asking too much transitionally.

The US massage industry faces a number of problems. With such a large number of workers currently in the industry, the change would surely need to be gradual. One of the things I constantly think about is, with the current requirement of 500-1000 hours and no competency requirement, are we barking up the wrong tree demanding science? Is science even doable? Of course I learned some science in my education, but I didn’t necessarily learn the act of science in massage school. Often times what we receive is the outline of science, the puppetry of science, the mimicry of science…not actual science, even from the best and brightest who teach and share knowledge.  I am not saying don’t teach the science aspects, I am saying expecting meta data analysis from someone still trying to figure out where the elbow is, is probably unrealistic.  The results may be as poor and dangerous as pseudoscience.  Maybe what we should be asking for is naturalism…and leave the science to the experts.

Naturalism is defined as: A philosophical viewpoint according to which everything arises from natural properties and causes, and supernatural or spiritual explanations are excluded or discounted. 

Massage therapy lends itself  very well to naturalism. At its base even the most complex thing that I have done with a patient through a rehabilitation is simply mimicking how the body would normally behave in a controlled, suggestive state in the hopes that the body realizes it can keep moving and that it does not need whatever protection or feeling it has produced.  I try to remind the body of its normal function by setting the stage with relaxing/safe elements, and then lead it through passive, active and resisted activities.   And follow up by assigning exercises that will re-enforce that. There are only so many things the body can do. We take the body through these activities in order to start a dialogue. A dialogue with words like – rest, slack, stretch,  move, stimulate, sense, resist and strengthen.  I try to build windows of time where there is an altered signal or decreased signal, so the body can get back to doing what it loves to do…homeostasis. I monitor all of it through range of motion and pain scales. It is not rocket science;) Of course it can get more complex when you start building in limitations and conditions, but at its base its fairly simple.

Science can be a complicated system of testable questions and answers. There are entire systems in place to understand how to correctly ask the questions, let alone address  the answers. Rarely is it simple. It takes years to study, explore and even begin to understand even small parts of it. Naturalism however is beautiful in it’s simplicity. With 500-1000 hours of training and little time to test the application let alone question it, perhaps some of the answers lie there.

Starting with a few simple observations, perhaps we could make a safer, simpler, more ethical massage world. Here are some of the simple statements I keep in mind when practice daily.

  • Relaxation has value and potential.
  • The body is fine the way it is. Homeostasis works. For the most part the body will correct itself naturally, unless disease is present.
  • In the end, all change comes from internal function, not external force *other than trauma
  • Setting the stage for rest and digest may help remind the body that things are ok, which may let the person move more or differently, so they can get back to their normal.
  • Form is not necessarily representative of function.

What are the statement you practice under? More and more I see statements like “the science of massage”. Yet that statement is pretty misleading, when I think about what I do, as I am not really doing anything. I am simply setting the stage for what the body does for itself…naturally. Absolutely there is room for more advanced practitioners in advanced practice settings,  but at the core we need to get comfortable with who we are.

*I want to make a small disclosure here, as to the above statements of rehab. Rehab or rehabilitative exercise falls within the scope of an RMT (Canada). In no way do I advertise the practice of that here in NY, the example is based on my past experiences where it would be very normal for me to work with stroke patients, whiplash patients, etc combining manual therapy, movement and rehab exercise on my own. Your scope will depend on where you practice, and you should follow the local law to that effect.

 

Massage Therapy and Pain (Continued)

FullSizeRender (1)Massage Therapy and Pain

Working with Clients in the Pain Zone

This is a continuation of the last pain blog which offered some history on pain science and also some really general guidelines on massage therapy and pain.

If your client has no red flags in assessment and you have decided it is safe to touch, working with clients experiencing chronic pain not associated with an injury has its own challenges. For many people, pain has the distinct effect of stopping us from moving, regardless of its cause, and so getting your client back to a place where they feel that they can move can be considered a success. To work safely as a massage therapist with an understanding of this, you are going to want to switch from the treatment model where massage is passively received by a client into one where the client has full control of the experience, both physically and mentally.

First lets look at the physical aspects of a client having control

This can be challenging, especially considering that most massage therapy programs teach massage as a passive activity that is ‘done’ to the client. In this role the massage therapist acts more as a facilitator to touch. Consider that touch is not a one way experience and that every time you gently “rub” a muscle, you also have the ability to instead have that muscle and skin move gently under/against you. If someone is in pain, you have the option of saying “I am going to gently put my hand here on your back, why don’t you try breathing up into that feeling”, or “I will never press harder, why don’t you try pressing gently into me?”, or “I am going to hold your arm gently, why don’t you just tense the muscle a little and then relax or wiggle your fingers?”. There should be a direct relationship to the amount of pain present and the amount of control the client has. The more pain present, the more the patient should be in control of what is happening.

This does 3 things in my opinion:

1. Lowers the anxiety associated with treatment, and the anticipation of pain, and possibly dropping their pain level.
2. Facilitates change in the body by signaling normal function and behavior as the patient moves.
3.Protects you the therapist from stepping over a boundary. If the client has control, they only go as far as they want, and no further. 

I want to be clear that if you are using this kind of treatment with someone who is in pain, you never want to cause pain. Their may be pain associated with the treatment, but it should not be from a new stimulus you are providing, such as pressure or forced movement. The pain associated with treatments of this nature should be caused by a patient moving through their own pain signal. What does that mean? It means that if someone has had long standing neck pain, and they are completely cleared for treatments, with no red flags, you should never aggressively treat with traditional deep massage. Instead I should gently guide the person to the edge of their painful experience and create a safe, controlled, comfortable setting in which they can explore going further-if they choose to do so. If the feeling of pain does not abate, you should, discontinue and refer out, but often reducing the anticipation of pain and giving the client control is the first step in the pain management in Massage Therapy.



How do you do it?

It all sounds pretty simple-give the client the control and they might get past their pain, but its actually a bit more complicated than that, because you don’t want to be randomly trying techniques. I divide my techniques up into graded categories to help me organize the treatments.

  • Low pain– resisted eccentric/concentric contractions and dynamic stabilization, and holding the tissues muscle while the muscle moves beneath
  • Medium pain– gentle active resisted techniques, holding the skin while the muscle moves underneath, simple isolated muscle movements
  • Higher intensity pain– tense and relax exercises for muscles or groups of muscles, breathing exercises that activate accessory breathing muscles

You will notice the different categories of pain could also be explained as acute, sub acute, chronic, or you could use a pain scale to divide them up. The important thing is that you know where you with the person you are treating. I use LP, MP and HP for short hand charting proposes. Lets look again at that client with the neck pain so we can get a better idea of the application of these techniques for the different pain categories.



Lets look at some examples to make things clearer

Client with HP  neck –  This client is afraid to move and has pain on movement of any aspect of cervical spine or upper thoracic, with a history of whiplash. Does not go about normal activities.

Treatment– Is a gentle skin deep gliding massage. The goal is just to get used to the client getting used to touch. Once the client is relaxed we are going to begin graded breathing exercises to see if we can get them to reduce the bracing in the accessory breathing muscles. I isolate a muscle by gently touching it and say “can you make this expand and contract by moving air?” We go though each and every muscle that would be effected by breathing. Then we switch to tense relax and do the same. Isolate the muscle, or muscle group by gently touching it, ask the client to control it by tensing up and then relaxing. I finish by going back to very gentle surface treatment of gliding massage.

Client with MP neck -Client has some movement but feels very limited by their pain. Range of motion is reduced to about half, and some of the ranges are less quality than others. Goes about normal activities but has stopped participating in any sports or anything unnecessary to their day.

Treatment– General massage with light to medium pressure. Once the client is comfortable I begin holding isolated areas skin in areas of pain and asking the client to gently pull away from me. If the client experiences pain we go back to the above treatment. We reverse the technique and this time I isolate muscles and have the client push into me (essentially bowing the muscle) If the clients pain level keeps dropping we then move to full simple isolated muscle movements. I hold the muscle and they run though a full rang of motion. (Video example of type of activity)I often do this by saying “ok now try to squish my fingers with your neck”. I correct any movement where they are recruiting another unnecessary muscle to complete the movement or avoid moving through the whole range. At the end of the treatment we return to gentle massage.

Client with LP neck-This client has pretty much full range of motion, but experiences pain at the end range. In their words “I just feel I can’t get past the final stage of the injury”. They are going about their daily lives, and participating in sports with occasional flairs. (this is the client you should most often be treating and seeing unless you are an advanced practitioner)

Treatment–  A general massage with light to medium pressure. You can use any of the above mentioned techniques to warm the tissues. As the treatment progresses, I move to holding the muscles firmly while they go through a range of motion. If no pain is present I ask the client to gently resist the movement for the selected muscle. (Video example of activity)If still no pain is present, I ask the client to resist with movement and move on to eccentric concentric moments. All of these activities are still gentle (the client need only meet you with enough force to activate the muscle)We end the treatment with the same general massage. If at any point the pain or the tone of the muscle rises, we go back to a previous treatment plan.

Wait!!!

But we have gotten ahead of ourselves…before you can do any of this cool stuff, you have to talk to your client about exactly what you will be doing with them and why you think it is the best choice!!!! And that’s exactly what we will go over next time.

Massage Therapy and Pain

Massage Therapy and Pain- What does it all mean?

Massage therapists live in a world of touch. So it is no surprise that the new science that relates to how touch, sensation and pain is processed and experienced would be relevant to massage therapists. This is particularly true since many clients seek out massage therapy for complaints specifically relating to pain.

Pain science in one form or another has been around for years. One of our first understandings of it was provided by Descartes [1], who theorized that pain and physical illness were limited to a nervous system experience, i.e. you hurt your hand and so you feel it. It essentially separated the mind and body experiences.

As our understanding of pain sensation grew, we realized that feeling things was a far more complex process, and that our bodies are filled with different kinds of receptors that relay information, not just one way to process. Melzack and Wall changed [2] our perception further by bringing in the “gait control” theory to our clinical understanding. In this view, when the system is stimulated, it is sent through a ‘gait’ in the dorsal horn of the spinal cord. That gait however can be modulated by some psychological components resulting in a difference in the perception of the stimulus.

Our most current and newest understanding of pain is that of the biosocial understanding of pain. [3] In this model, we have a stimulus of some kind that is relayed to be processed, but at that point many factors such as environmental, social or emotional, might come into play to determine if pain is generated and at what intensity. And from that we see pain as an output of the brain, rather than something that is the result of poor biomechanics or even, in some cases, injury. In other words, pain can stand on its own without us having to find causation in the body.

What does this mean for Massage Therapy?

For a lot of massage therapists, this has left them a little confused as to their role in treatment. If pain is not generated exclusively in the body, what are we treating? If I am not ‘fixing’ a structure or posture, what am I doing? If pain is an output, then why seek physical treatment at all? It could be easy to start feeling a little redundant in the mix of it all, but now more than ever, massage is a viable option to those experiencing pain.

From a massage therapy perspective, the biosocial model of pain is far more inclusive than exclusive. If pain is influenced by thoughts, feelings and emotions, then doing things that feel good have the potential to benefit the client, even from a general treatment perspective. Asking your client “how do you feel?” during treatments, and “was that good for you?” afterwards becomes a relevant way to guide success for generalized treatment. It’s a step towards the clinical world seeing ‘feeling good’ as a part of heath care, rather than a luxury associated with indulgence.  If the body is spending much of its time protecting us by sensing threats around us, we can also help send the message back to the body, that everything is “a ok” (within reason).

Don’t throw the baby out with the bathwater

It would be easy to read the new information coming out about pain and assume that from here going forward massage has only general feel good treatments to offer in the context. Should massage therapists stop treating for specific conditions? The answer is both yes and no. Moving forward with quality treatments is going to have to do with how humble and honest a massage therapist can be with him or her self. And that is no easy task in an industry trying to prove itself as medical professionals. Massage therapists have to accept two truths about their treatments and understanding of them. 1. that they have a limited understanding and education about what they know about the person on their table.  2. That they may never know the answer to why the body has decided to protect itself.

This model does not mean that structural problems don’t exist. The normal rules of physics involving force, friction, leverage and space are still in effect. Bones still break, posture still degrades to bone to bone contact, and fitness plans still ramp up too fast, but a therapist has to be willing to open the door to other possibilities when the evidence does not add up, question it, even when it does, and treat the structural issue as a symptom rather than a cause in some cases.

Pitfalls in Treating Pain with Massage

You may find yourself getting caught in a few traps if your a massage therapist treating people with pain. Operating safely in the biosocial model of pain does have its challenges. If pain is not always associated with injury, then assessing “pain” as a contraindication for treatment may not be the best guide. Without fail, a massage therapist must be able to  assess the signs and symptoms of pain associated with acute injury pain-vs-the signs and symptoms of pain itself. The signs may not always be so clear.  If you are inexperienced, it is always best to refer out so that you can remain safely in the boundaries of “Do No Harm”.  A biosocial pain assessment for a massage therapist looks like this:

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The sooner therapists get comfortable with treating pain, the sooner they can help get their clients comfortable. Next time we will go over the guidelines for talking to your clients about pain to provide some answers about when and how talking to people about their pain is appropriate in the contexts of Massage therapy as health care.

 

 

 

[1][2]R.Melzack, P.Wall. Science, New series, Vol. 150, NO. 3699.Nov, 19 1956 Pain Mechanisms: A new theory Retrieved from https://isle.hanover.edu/Ch14Touch/Ch14GateControlTheory.html

[3] R.J. Gatchel, Psychological Bulletin, Vol. 133, NO 4, 581-624 2007. The Biopsychocial approach to chronic pain: Scientific advances and future directions. Retrieved from http://enniscentre.com/Presentations/Gatchel-Biopsychosocial%20Approach%20to%20Chronic%20Pain.pdf

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