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Sleep Hygiene and Massage Therapy

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Sleep Hygiene and Massage Therapy

“Sleep is the golden chain that ties health and our bodies together”

-Thomas Dekker

What is sleep hygiene?

The CDC defines sleep hygiene as “the good habits that can lead to you getting a good night’s sleep” As a yoga therapist, I talk a lot about sleep hygiene and refer our clients to sleep hygiene resources in our massage therapy practice. Good sleep habits are one of the fundamental lifestyle modifications that you can do to improve your health and wellbeing. The steps are simple and there is a fairly significant payoff for small changes. Many people have never heard of sleep hygiene, and even if they are complaining of poor sleep, poor health and chronic fatigue, they do not realize they may be inadvertently contributing to those feeling with their behavior. Sleep hygiene alone may not be enough to ensure quality rest. You may require additional intervention from a medical professional, medication, or cognitive behavioral therapy. You should check with your medical provider. This is an excellent self-care place to start.

What does sleep hygiene have to do with massage therapy?

As both a yoga therapist and a massage therapist, I wanted to do this little post on sleep because over the years I have had clients and patients who are specifically using massage as a sleep intervention. Back in my early days of massage, I worked at a number of locations that were open until 10 pm. I remember thinking, “who would want a massage that late?”. Those 9-10 pm spots were always booked though. It turns out, many people are NOT good at relaxing. They do not know how to send the message to their brain that it is time to turn off. They probably did not know what sleep hygiene was, but they had reached the conclusion that they needed HELP and they were getting it.

Massage therapist demonstrating Sleep hygiene for healthy sleep habits

I have always said loosely, that since massage is a passive intervention, that what I am really doing as a massage therapist is more of a complex mediation using touch, where I am teaching people to relax. Even with the massage treatments that I do that are more complex, for example a manual therapy treatment that is more movement based, I am trying to get you to move in a relaxed way and guiding you through that.

Those late night massages that I used to do did not come cheap! Not everyone has the means to spend $150 dollars a few days a week to help communicate with their brain that it needs to shut off. The good news is, sleep hygiene is free. Read on to see some of the basics I suggest as a Yoga Therapist. (p.s if you have children and have sleep trained, these steps might seem familiar to you or you can try them to help make bed better)

1. Do not try to sleep unless sleepy

Only try to sleep when you are actually tired. If you find that around bedtime you have no desire to sleep, you may need to move your bedtime or adjust some of your other habits discussed below. If you get into bed and find you can’t shut off, get out of bed and do something relaxing, then try again in 20 minutes.

2. Stick to a schedule

One of the best ways to tell your body it is time for bed is to keep a regular schedule. Going to sleep at the same time and waking at the same time (regardless of the day of the week) can help your body and mind know how to behave depending on the time of day.

3. Avoid caffeine and alcohol

If possible, avoid taking in caffeine, alcohol, and nicotine within 6 hours of bedtime. Caffeine and nicotine are stimulants that can disrupt your natural sleep rhythms and your ability to fall asleep, alcohol is a depressant, and while it can encourage falling asleep in the short term, in the long term it disrupts the sleep cycles and your ability to get deep restful sleep.

4. Develop a pre-bed routine

Communicating with your nervous system that it is time to shut down can be hard. Doing the same thing every night as a soothing routine can help cue your body and mind that it is time for bed. Examples of quality sleep routines are: baths, meditation, self-massage, gentle stretching in a dim room, or drinking a ‘good night’ tea. Most people do well to avoid overly stimulating activities like checking the news or watching sports. Pick something that works for you and stick with it.

5. Use your bed primarily for sleeping

Help cue yourself that it is sleepy time by ONLY using your bed for bedroom activities. Refrain from eating, reading, watching TV, using your phone, or working in bed. This will help you associate your bed as a restful stress-free space away from the rest of the world.

6. No screen time before bed

TVs, computers, and phone screens give off blue light, which makes your brain think it’s the middle of the day. Set your timers for nighttime modes without blue light and do not use electronics within at least 30-60 minutes before bed. Make sure your dings and alerts are silenced so that your sleep is not accidentally disrupted.

7. Control your sleep environment

There are some common things that set the stage for good sleep that you can do in your home to create a sleep-friendly environment. Make sure the room is cool, dark, and quiet. If the room is not quiet, use a sound machine to fill the space with white noise or a sound you find relaxing. Blocking out the outside light can also be helpful, especially if you live in an area with ambient lighting. Have a blanket on hand, and consider experimenting with a weighted blanket.

Summing up…

Sleep is an important activity. We often think of sleep as passive because we are not up and doing things, but our body is in an active state of rest and digest. Massage therapy can be important in your sleep hygiene routine. In today’s world, it is easy to put emphasis on the more conscious active parts of life. It also may NOT feel natural or easy for you to communicate with your brain and tell it to slow down and prepare for the function of sleep. Taking the above steps into consideration is a great first step. The CDC recommended The American Alliance for Healthy Sleep for more information on sleep hygiene. It is also important to remember this is not a prescription, it is an assessment and a tool. You should check in with your care provider if your sleep issues persist.

You can read more on relaxing on or blog: Don’t tell me to relax!

Pain and the Zombie Apocalypse

Whether it’s another exhausting election cycle or the impending zombie apocalypse, many of us are a bit more stressed and anxious lately than usual.  Intense times, it’s totally normal to start experiencing some physical symptoms that might feel abnormal if you don’t realize their source.  Some of your old injuries might start hurting again, your back or neck may become stiffer or achier, and if you’re already dealing with some kind of pain, that may become worse.

Stress and/or anxiety can increase or decrease normal pain thresholds directly or indirectly.  Prolonged stress will tend to decrease a person’s pain threshold so that the exact same physical stimuli might become more painful than usual, or something that didn’t used to hurt might begin hurting.  People with persistent pain are often aware of how a stressful day at work can cause a flare-up, but far fewer people realize that stress and depression are two of the biggest predictors of painful flare-ups in people with acute low back pain.

Stress can also decrease pain thresholds by influencing behavior.  Most of us know that a stressful day, week, or decade can make it harder to get to sleep or stay asleep.  Lack of sleep and non-restful sleep are significant risk factors in developing physical pain and prolonging it.  Being tired can also make it far more difficult to push yourself to get some of the physical activity our bodies need to stay happy and healthy.

In these stressful times, it’s perfectly normal to begin experiencing all sorts of symptoms that might seem as if they came out of nowhere.  That’s all the more reason to take care of yourself in all the ways you can.  Spend time engaging in meaningful activities, talk to the people you care about, make time to be mindful or to relax, practice good sleep hygiene, ask for and accept more help from others, and get in some movement where you can.  You’re not broken and you’re not falling apart—we promise.

By Matthew Danziger

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795524/?report=classic

https://journals.lww.com/spinejournal/Abstract/2018/03150/Do_Physical_Activities_Trigger_Flare_ups_During_an.14.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046588/

The Benefits of Manual Therapy- An Interview from the Knowledge Exchange

Benefits of massage therapyOur Massage Therapist, Matt Danziger sits down with the Knowledge Exchange to talk Manual Therapy or rather what manual therapy is NOT in this blog/podcast

One of the things we pride ourselves over here at Body Mechanics Orthopedic Massage is our devotion to science and giving people a real outlook on what massage can and cannot do. We are for the most part, for what its worth science based-ish with the understanding that minds do not change over night and therapists need room and time to grow. When Matt told us that this podcast blog post was coming out we immediately asked him if we could re-post it for the Knowledge Exchange.

If you have never heard of the Knowledge Exchange, they are a professional education group that runs courses and mentor ships on the BPS model of pain (that’s Biopsychosocial if your not up on your acronym’s).  They have some wonderful online resources and blogs you can check out and they specifically define what they do as:

“We don’t see our selves as educators but rather facilitators of ideas, discussion and critical appraisal. We do this because we aren’t satisfied with the status quo of health care and believe we can all do far better for our patients.”

I do not want to give too much away in what this podcast covers but it gives some great insight into how Matt sees the role of massage in terms of fitting into the BPS framework. Frequently, a massage therapist who uses this model is viewed as anti-manual therapy and that is not the case.

You are also going to get a great look into Matt’s personal journey as a massage therapist as well as his journey with pain.

Want to check it out? Go ahead and read their post by following this link to listen to the podcast.

You can check out this blog with Adam Meakins  by the Knowledge Exchange if you want to go further into the manual therapy rabbit hole.

If you want to book with Matt and his talented mind, you can read more about Matt’s Massage therapy her or book here.

To connect to Matt’s blog follow this. 

Body Mechanics NYC

1 W 34th St
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Phone: 212-600-4808
Email: info@bodymechanicsnyc.com

Don’t Tell Me to Relax

Relax….

You book the massage appointment. You take the risk. It is a financial stretch but you have to do something because you have not been able to manage on your own. You lay down on the table. The massage therapist says “Take a deep breath…Relax…”

In the last few years I have become very conscious of what I say to people. As I have gotten older I have given less ‘%#@’s’ about some things and more about others. One of the things I have given more about is how I might accidentally harm someone whom I am caring for. That fills two categories; people I treat, and the people I teach to treat.

I primarily work with massage patients in  pain. Frequently those people have the kind of pain that has been untreated, underestimated, and has fallen through the medical cracks. They are sometimes angry, vulnerable, difficult to deal with, as well as they are often generous beyond belief, humble, and full of hope. They come in all forms and shapes and sizes…but what they have in common frequently is they cannot relax. This may pertain to their whole body, or a single part…but if they could simply relax and gain control of whatever they are seeing me for, they would have done it long ago.

And so, it really bothers me when people say ‘relax‘. It has become somewhat of a trigger word because, what I hear is the response: “Don’t you think I would if I could? I booked an appointment specifically because I need HELP relaxing, and here you are telling me to relax, when I have admitted, I can’t”. In fact, in my case being told to relax, specifically makes me more anxious. I am pretty sure every dentist I have ever known has said “take a deep breath and relax” right before he has done something awful.

I think in terms of massage therapy, the word relax is old, is loaded and full of harm. It is like a brand that has ceased to have meaning to us, and yet has become the only word we use. For people looking for a spa day, it may have no connotation, but for many it could be one of the worst things I say to them all day.

While it is hard to watch your words all the time, I have tried to omit relax completely from my massage practice. I had to think for a bit on what exactly should take its place. Frequently I am communicating a lot with people on how an area feels to them, and I will ask whether or not they felt a tone drop in an area or if that is my perception- ie ‘should I move on? Do you feel more comfortable now? And then, of course, the old stand by word “release” pops up. I am not a big lover of the “release” description either. What has been released? Certainly I am releasing nothing…something might be relaxing…but then there is that word again!

Neither word is the correct thing I want to say to anyone, but those two words are flung about, both of them holding too much meaning, and way too little at the same time. What I want is to give someone an actionable word or words, that they have control of, something that removes my hands from the picture, other than to bring awareness. The words I want to use need to suggest that they have self efficacy in a process that I am creating a space for. And so for the moment, I have settled on “Let go” or “Be heavy”.  As in, “I am going to be gently moving you around for a moment, and so there is no resistance, I would like you to try to let go of that area/practice being heavy, but if you cannot, that is okay…we can just move together for a little while and it will be just as good.”

 

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:

Screen Shot 2015-03-29 at 12.47.01 PM

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

Body Mechanics NYC, 1 W 34th St, #204, , New York 10001, United States (US) - Phone: 212-600-4808