Thursday, November 26, 2009

Blog the fifth: Massage and Martial Arts

New and prospective patients often ask me what style of massage I do. I find this a particularly difficult question to answer. I have training in swedish massage as is required in Ontario's massage schools. Deep tissue massage was also taught in school. Since then I've completed advanced training in craniosacral therapy with Robert Harris of the Cranial Centre (http://www.cranialtherapy.ca/) here in Toronto. Prior to ever becoming a therapist, however, I studied martial arts.

In eastern cultures, martial arts and healing arts are often taught in parallel. For example, I can remember reading on a korean hapkido web page that orginally, advanced dan rankings in Hapkido (which I currently study) require certification in both massage and acupuncture (I'm afraid I can't find the link as I write this... I'll keep looking!). As far as I can tell, the healing and martial aspects divided somewhere in the middle of the last century as eastern martial arts spread west and began the process of commercialization that's culminated in martial arts "brands" in the last couple of decades.

As part of a personal path, I felt that a massage therapy career would enhance and be enhanced by my martial arts training. Being self employed would also give me the freedom to train even more intensely (It hasn't quite worked out that way... The realities of small business keep me occupied more often that I'd expected!).

I've always thought of myself as a bit of a jack of all trades. Miyomoto Musashi in his Book of Five Rings said: "Be knowledgeable in a variety of occupations, and learn the thinking of people who work in them." (http://www.bookoffiverings.com/) Aside from having had a few career paths myself, having a massage practice is also about relationships... Getting to know people and developing an understanding of how and why they're on the table. A massage career is certainly great for a martial artist for that alone.

Martial arts at its foundation is about movement and rhythm. This is an aid to me in a number of ways. In solo practice, I learn about my own bio mechanics, my personal ability to move. In joint practice, I learn about how others move. It's particularly useful to see different body types in motion when they also come from different vocations and athletic backgrounds. After years of this kind of observation, I can often tell
what a person does for a living (within some broad categories. ie. working on the phone or computer, physical labour, driving), and what they do for fun in their spare time. It's also helped me develop an profound sense of efficient posture and bio mechanics (the move efficient someone is able to move and the more integrated the rhythm of their movement, the better their posture and bio mechanics tend to be).

Even greater tools available to me through martial arts training, are an understanding of leverage, and a functional knowledge of anatomy. Leverage is learned through grappling practice (both standing and on the ground), and helps me as a therapist to apply force efficiently when necessary while remaining sensitive to the tissue response, and safety of the patient. With so many years training with different people, with different body types I found that when we studied anatomy in massage school, I was able to put labels to structures I already had a feel for and thereby increase my palpation effectiveness in both martial arts and massage. Combining those two sets of ideas gives me an intuitive sense of how to work on a patients body that goes well beyond anything that can be learned in a textbook. It's also made my style of treatment somewhat unique. I've been told it reminds people of either shiatsu, or osteopathic styles of treatment, even without distinct training in those disciplines.

I can't imagine doing one without the other. I feel I could study bodywork style after bodywork style, and collect tremendous knowledge, but without the parallel martial arts path, I'd have difficulty integrating them into a coherent personal style of treatment.

Monday, November 23, 2009

Blog the fourth - Thoughts on pain...

I've been reading The Brain That Changes Itself by Norman Doidge (His website is http://www.normandoidge.com/). The book's central theme is research into neuroplasticity, and it's application in therapy. I'm sure I'll be bringing it up again after I've finished it, but last week I finished the chapter on pain, and I have to say, it's brought into focus a couple of ideas I've been thinking about for quite some time, and radically changed another.



Research on neuroplasticity seems to be based largely around techniques to image and map the superficial structure of the brain, neuron by neuron. What they've found is that everything we do and feel is organized into "maps" that shift dynamically with use and learning. When we learn something new, our neurons grow new branches and the map grows accordingly. Adjacent maps can overlap, merge, or shrink to accommodate growing maps.



As a massage therapist, I see a lot of people in pain of various kinds. One of the hardest questions to answer is how long it will take for them to get better. Everyone's experience of pain is a little bit different, and their response to treatment is just as variable. Pain appears to be a learned experience, and I notice that generally the longer someone's been in pain, the longer it takes to get them out of it. Neuroplasticity explains this as enlargement of their pain map. Pain appears to be one of the most plastic of maps and can change moment to moment depending on our need. In other words, pain is a learned experience.



Now in the short term, the pain map "borrows" neurons from adjacent maps. If the pain subsides, the map goes back to its "resting" state taking up very little space. If the pain becomes chronic, there's potential for the map to take up residence in the borrow neurological real estate and the pain sufferer becomes over sensitized to their pain experience. They also lose the use of the borrowed neurons as they are too active in the pain map to continue with their original function.



Chronic pain suffers will often complain of their suffering "taking over their life", and from a neuroplastic perspective, this is quite literally true. I start to consider that fibromyalgia in particular might be a neuroplastic disorder. Something I've seen fairly consistently in my patients with fibro, is there's usually an underlying, often undiagnosed musculoskeletal pathology (often osteoarthritis, or spinal stenosis), or a long forgotten minor injury (ie. a fender bender that never went to insurance, or a fall down stairs or on ice). In the past I've thought that this might invalidate the fibro diagnosis, but after reading this chapter of the book, I'm thinking that the fibro might be a result of the expanded brain map.



Earlier in the book, there's a chapter on stroke in which patients are able to recover damaged neural functions (and limb movement) through exercises that give the patient small, achievable goals to help restructure the maps for their limbs and regain coordination and mobility.



Two things would appear to be necessary to treat chronic pain. First the patient needs to have their experience of pain reduced. This could be done with manual therapies (massage, chiropractic, physiotherapy, acupuncture for example) or through pain medication. The next think we need to know is what's been lost. I've been thinking it might be things like balance, fine motor control, reading, problem solving. If the patient exercises these kinds of functions while their pain experience is reduced, the reduced neural maps can reclaim their space. Over the course of treatment, pain experience returns to normal and the patient can get back to making the most of their life.



The biggest change in my perception of pain treatment is the role of pain killers.



In the past I've said (as most body workers that I've met do), that pain killers don't fix anything and shouldn't be used to replace manual therapies. I've recommended only using them when there's intense need. If neuroplasticity is correct, then it's essential that people spend as little time in pain as possible, to keep that expanded brain map from becoming fixed (in the case of acute injury) or to allow the surrounding brain maps to reclaim space (in the case of chronic pain). And lets face it, few people can get a massage daily. So it make sense to use over the counter pain medication in between.



I still think that engaging in lifestyle exercise (meditation, yoga, tai chi are all good examples of what I mean) is a better long term strategy. But short term use of pain management medication combined with manual therapies to help any underlying muscle and joint dysfunction could very well be the best course of treatment.



Hopefully I've done this topic some justice. For more information, pick up the book!

Tuesday, November 17, 2009

Blog the third - Evidence Based Therapy

Finally a massage themed post!

Much of massage literature uses the term "evidence based" and I find it a bit frustrating. We use the term to validate ourselves and to counter criticism that massage is untested and unscientific, but it's too soon. There just isn't that much evidence yet!

Strides are being made, research is beginning to happen. We will eventually have data that will allow us to weed through the myths and truths of the various massage therapy traditions.

It's important that we acknowledge that in it's current state, clinical massage therapy is still based primarily on experience and observation of individual cases. The phrase I like to use to describe my practice is "results driven" massage therapy. I encourage my patients to ask the question: "How much has my treatment helped you?". I had a cranial sacral instructor who recommended a target of 50% change per treatment as a reasonable goal. With most orthopaedic problems I have to agree. Chronic problems sometimes seem to require less optimistic goals. This applies to both the objective measure of joint function (ROM), and the subjective measure of their discomfort. Observable change is the best measure of our efficacy as therapists.

There are studies that do show massage is an effective therapy for chronic pain, stress reduction, and improvement of qualify of life. This give us a legitimate basis to say that we can help manage pain and reduce stress. It does not allow us to say much about most pathologies and cases. There's certainly very little we can say for certain about the techniques we use. How well do they work? Are some techniques better than others for particular conditions? What physiological processes are we engaging?

We need more data!

In schools and in courses we take post graduation we're often taught answers to those questions as we just naturally consider them to be proven and effective. And certainly they often are... But what they aren't is scientifically evaluated.

Probably the best example in recent months is the often made claim that massage is good for athletes post-workout because it reduces lactic acid buildup and increases blood flow. I can remember reading this back in school as part of our "evidence based" education. Yet, a recent study seems to disprove this claim. (http://tinyurl.com/yayhw5a)

Ok, ok... This study hasn't been replicated and wasn't done by massage therapists so I have to be a little bit suspect of it's accuracy. But it does make a point: A lot of what we claim as fact is largely untested and more study is necessary to find out what we actually do when we treat someone.

It's food for thought.

Monday, November 16, 2009

Blog the second - Thoughts on H1N1

I've been asked this question a lot lately, so I think I'll share publicly what I've been telling people:

The question: What do you think of the H1N1 vaccination?

The first thing I have to say about this question is that I'm not a doctor. My opinions about the vaccine are personal. I'm not qualified to give a professional opinion.

I think there are risks both from the flu, and from the vaccine being given to prevent it. I don't know and have been unable to find actual numbers quantifying those risks. The best I can do is to think of things in terms of relative risk: Which seems more risky? Complications from flu, or from the vaccine?

For myself, I have a fairly overactive immune system and the regular flu shot tends to make me feel somewhat ill for a week or two. I think it's fair to think that I'd likely feel much worse from the H1N1 vaccination. I'm a massage therapist working in a naturopathic clinic. I'm not coming into contact with large numbers of people in a day and we keep things clean both at home and at work. So I've decided not to get the shot.

I've had friends and patients get the shot for a number of very valid reasons: Asthma, immune suppression, young children at home and worry about flu complications seem to be the most common that I hear. The reasons I hear for not getting it largely come from a worry about side effects of the vaccination itself.

I do think it's important for people to make up their own minds. There's risk in both and since no one seems to know (and certainly no one seems to agree!) which risk is actually higher, it's the individual's situation that seems to be the most important consideration.

Blog the first... A disclaimer...

Beginnings are the hardest things to write!



I decided to start writing this after many conversations with friends and patients. My intention as I start out is to give audience to the thoughts and opinions that have built up in my mind in the past few years. With a bit of luck, more people will interact and help shape those ideas. I'd like it to be an editorial on massage therapy, health care, fitness, and anything else I feel connects to my professional life.

Everything that follows should be taken with a certain grain of salt. I'd imagine I'll refer to actual sources from time to time, but mostly these posts will be personal observations and beliefs. This isn't intended as a textbook or a journal and I'm very sure that some of what I say won't be correct. Hopefully you who read this will help point me in the right direction when necessary.

Let me know how I'm doing!