RESEARCH TO CLINICAL PRACTICE

As I scan research on a regular basis I often find information that supports massage practice. Many times we don't understand the research because we are unfamiliar with the terminology being used.  In this abstract I had to convert Newtons (N) to pounds and velocity to distance in inches per second. As professional massage therapists we need to wade through research and find the relevance.  I was able to find conversion tables on the internet. Took some time for me to sort it out so I did this one for ya.

Neuroimage. 2012 Feb 15;59(4):3427-32. Epub 2011 Nov 10.

Pleasant human touch is represented in pregenual anterior cingulate cortex.

 Lindgren L, Westling G, Brulin C, Lehtipalo S, Andersson M, Nyberg L.

Department of Nursing, Umeå University, Sweden. lenita.lindgren@nurs.umu.se

http://www.ncbi.nlm.nih.gov/pubmed/22100768

Abstract

 Touch massage (TM) is a form of pleasant touch stimulation used as treatment in clinical settings and found to improve well-being and decrease anxiety, stress, and pain. Emotional responses reported during and after TM have been studied, but the underlying mechanisms are still largely unexplored. In this study, we used functional magnetic resonance (fMRI) to test the hypothesis that the combination of human touch (i.e. skin-to-skin contact) with movement is eliciting a specific response in brain areas coding for pleasant sensations. The design included four different touch conditions; human touch with or without movement and rubber glove with or without movement. Force (2.5 N) ABOUT ½ POUNDS OF PRESSURE and velocity (1.5 cm/s ABOUT ½ INCH PER SECOND  were held constant across conditions. The pleasantness of the four different touch stimulations was rated on a visual analog scale (VAS-scale) and human touch was rated as most pleasant, particularly in combination with movement. The fMRI results revealed that TM stimulation most strongly activated the pregenual anterior cingulate cortex (pgACC). These results are consistent with findings showing pgACC activation during various rewarding pleasant stimulations. This area is also known to be activated by both opioid analgesia and placebo. Together with these prior results, our finding furthers the understanding of the basis for positive TM treatment effects.

SANDY COMMENTS -THE MASSAGE APPLICATION WAS ½ LB OF PRESSURE AND WOULD DENT THE SKIN AND THE SPEED WAS ½ INCH PER SECOND AND CONSIDERED SLOW.  IN MY TEXTBOOKS I WOULD DESCRIBE THIS AS A PALLIATIVE, PLEASURE-BASED MASSAGE (NONFRAGILE CLIENT).  IT APPEARS THAT SKIN TO SKIN CONTACT WITH MOVEMENT IS NECESSARY TO ACHIEVE BEST RESULTS.   

Copyright © 2011 Elsevier Inc. All rights reserved.

Knowledge Skills and Attitudes

There has been a lot of discussion about what a massage therapist should be able to do after they graduate from massage school.  While I was responding to  some of these discussions I started thinking about what I expect from graduates at my school -Health Enrichment Center. Yes there is a stepped structure to skill acquisition during learning and this process continues forever however this is a necessary level of competence for the new graduate to be able to make enough money to support themselves.  I think of my own students at graduation.  What is it that I can realistically expect they can do?  At graduation my students have completed 700 contact hours, 350 hours of that is hands on skill development and of that 350 hours they have done about 100 full massage sessions while under school supervision. 

I expect that they are able to perform a client history and basic functional assessment including posture, gait and individual joint movement. Then using that information they should be able to develop an individualized massage application plan that targets one or a combination of the following generalized outcomes - relaxation, stress and mood management, local and general pain management, mobility and functional movement related to activities of daily living and specific activities of the client (i.e. job/sport related).

I expect that they are able to do this in an ethical, professional, safe, respectful, intelligent and compassionate manner. 

 I expect that they work toward specific outcomes of clients that can realistically be achieved through massage application by adapting massage to target neurochemical function both autonomic and somatic, fluid movement (blood lymph) various forms of connective tissues and integral  skeletal, joint and muscle function.

 I also expect that they are able to adapt massage position, location, duration, method use to the unique condition of the client (i.e. medical treatment, age, size, mental state ).

 I expect that they are able to read, determine validity and translate research to massage practice using PubMed, especially targeting met analysis such as Cochrane reports which helps them determine validity.

I expect them to conduct literature research using Med Line plus to learn about individual medications and or conditions relevant to individual clients.

 I expect that they can explain and justify what they are doing during a massage and why they are doing the method.

 I expect that they can provide clients with an effective and pleasurable massage experience that target the whole body primarily,  while also specifically addressing client outcomes. 

I expect that they can perform 20-25 massage sessions of this type each week without hurting themselves.

I expect that they can adapt to multiple work environments from the spa/massage franchise to the sport field to the hospital and all points in between.

I know I expect a lot but these are the criteria necessary to pass the final exam.  I do not expect they remember every bony landmark or the individual names of all the nerves but I do expect they know how to look it up . I do not expect that they feel confident working with a client with multiple complex issues but I do expect they know how to refer and work within a team approach.  I do not expect that they know every pathological condition but I do expect that they know how to ask intelligent questions and find additional information to educate themselves.   So how does this become a description of what a massage therapist needs to be able to do?  I can state for myself that a massage that is worth paying for is provided by a massage therapist who has these skills and any massage educational program that allows for less does the student a disservice, is acting unethically, taking student's and maybe federal money under false pretenses and should not be allowed to continue to teach.  I do not expect that an educational program can do this in 500 contact hours but I do a good job in 700 hours. If I had my way I would like to have double that. As it is now I have an entry level program and an advance program. Michigan state licensing is requiring 500 hours and upon reflection I estimate this would put my students at about mid term still level. -about half baked. I considered creating an entry level program at 500 hours but not going to do it because it is wrong to send graduates out into a professional world without the necessary knowledge, skill and attitudes.  A definition of ethics is doing the right thing at the right time and so that is what I am going to do.

Yup, I expect a lot. I present all the necessary information to be able to achieve the knowledge, skills and attitudes in the two entry level textbooks- Mosby's Fundamentals of Therapeutic Massage and Mosby's Essential Sciences for Therapeutic Massage.  There is no excuse for an educational program to not have a curriculum that prepares the graduates for the real world of professional massage. 

I do have the knowledge and continue to learn, I do have the skills and continue to improve and yes today as I write this I have an attitude!

Facia Congress

Fascia Congress  

http://www.fasciacongress.org/2012/

The meeting started with a welcome and blessing from the First Nations of BC and it was a beautiful way to begin the program. Topics included:

Fascial Anatomy

Changes in Fascia Related to Repetitive Motion Disorders

Adaption of Tendinous Connective Tissues to Exercise

Mechanical Loading & Fascial Changes

Scars and Adhesion

Fluid Dynamics

Interfacial Fluid

Myofascial Trigger Points

Developing Clinical Trials for Bodywork and Massage

The presenters were excellent and included researchers such as Carla Stecco, Geoffrey Bove, Robert Schleip, Paul Standley, Maureen Simmonds Leon Chaitow, Jay P. Shah, Jean Claude Guimberteau, Karen J. Sherman, Gerald Pollock, Helen Langevin, Diane Lee, Raúl Martinez Rodriquez, Antonio Stecco, Hal Brown, Susan Chapelle, Michael Diamond, Michael Kjaer, Rolf K. Reed, Michael Kuchera , Andrjez Pilat, , Gil Hedley, Lisa M. Hodge and many more wonderful people. 

In attendance were many leaders in the massage field but more importantly where many disciplines represented- chiropractors, physical therapists, DO’s MD’s, ND’s structural integration practitioners, massage therapist and others that were interacting in a peer processes of support instead of turf battles. 

 I had the chance to go to dinner with many of the speakers and interact with them on in a relaxed manner and what a great bunch of people.  As many of you know I have had a long term mentor relationship with Dr. Leon Chaitow and he has opened many doors for me and given me the opportunity to interact with many of the experts in this field.  I have been following the work of the Stecco’s for years and it was really fun to meet and spend time with Carla Stecco.  She is a beautiful person inside and out with a sweet and gentle manner but has no problem standing her ground when discussing fascia anatomy and manipulation.  I got to meet Gerald Pollock who I have also followed for years.  He researches water and his findings about how water can act as a liquid crystal and well as generate electrical charge. I encourage all to learn more about the research he is performing. http://depts.washington.edu/bioe/people/core/pollack.html.   Fascia is highly water dependent and by understanding the multiple properties of water we can better understand the physiology of fascia.

Very pragmatically, I did not learn anything brand new and that is great. To me this means that I am well informed and current.  I am also pleased that when I compare the information at the meeting to what I have included in the textbooks I write that almost all the information is in there.  It continues to make me wonder how those textbooks can be used in many massage classes and yet the information does not get integrated into massage therapy professional practice. Some of the reasons include: students not reading their textbooks, students being overwhelmed with too much information in too short of a school time and a lack of motivation to develop critical thinking skills. I also know that if an instructor is not familiar with a piece of information they will gloss over it.  For those that are teaching that is really a no no.  We must follow the research and adapt as more information becomes available.

There are a couple of clear principles I gleaned from the presenters:

·         Too much of a good thing becomes a bad thing

·         Body layers and parts should slide and slip around.

·         Fascia can get thick and sticky

·         Inflammation is a big problem when it does not resolve.  Chronic inflammation contributes to fascia getting thick and sticky

·         Fascia responses to cyclic loading and goes from thick and sticky to slippery and sliding.

·         Deform the shape of the tissue and the cells respond.

·         It takes about 90 seconds of continuous loading of tissues to elicit a change- This means that during massage if we perform a gliding stroke in an area it should begin a bit before the binding tissue (thick and stuck), slowly drag through the area making sure the tissues change shape (use a lot less lubricant) and then stop a little past the bind.  This should take about 90 seconds.  The change direction and do it again.  Think- with the tissue grain and a crossed the tissue grain. If the tissue is able to respond- and not all tissue is-it should be more slippery and sliding.

·         We need to explain what we do using mechanical forces- tension, shear, torsion, compression, etc.  We need to describe how we are creating the mechanical forces with pounds of pressure, direction, drag, speed, anatomy targeted, frequency, duration and so forth.

·         Let’s support the researchers with clearly thought out questions and describe what we do in clear generic and common language.  

·         A variety of connective tissue types connect everything to everything so you need to massage the whole body. 

·         We need to stop putting strange names on methods that are basically the same and trademarking the application of mechanical force application.

·         Fascia is a tissue type and not the answer to every pathology.  Let’s not get gimmicky or overemphasis one particular process. 

·         Let’s not explode basic research finding into more than what they are and let’s not turn possibilities into facts.

·         Let’s continue to explore the possibilities.

·         Let’s continue the dialog among the various professionals that move soft tissue around purposefully and with an outcome in mind and the researchers. 

·         Let’s partner actively with researchers who have access to the facilities and equipment to do the research. 

·         Let’s support research financially- it is expensive. The best way we have as massage therapists is the Massage Therapy Foundation.  If we all gave the Foundation each year what we charge for one massage there would be resources for research.

My main question is:

What is fascia release? I heard a hundred descriptions at the meeting.

I suggest that there are ways of adapting introduction of mechanical forces into soft tissue ( you can call it what you want- I call it massage) that more influence the properties of this tissue type primarily speed-slow, work in and out of bind, and target areas with a large amount of fascia such as the lumbar dorsal fascia, the musculotendinous junctions, scalp and plantar fascia while working with the whole body.

Finally there was one small group of individuals researching how much force we apply when we apply massage and I hope they continue with their focus.  This topic speaks to body mechanics and ergonomics.