Massage

You may have noticed that my blog posts have been sporadically timed over the past couple of months, and I have been entirely absent for three weeks.  Like everyone else, I am disheartened over our current political situation, but that alone is not the reason for my silence.  (You all still have to show up to work … I am still supposed to write my blog!)  Rather, I have been taking a little time to integrate old and new ideas about the field of massage, as it pertains specifically to those clients who see me for pain relief.  As I continue to research, it has become clear to me that we are experiencing a fundamental paradigm shift in the way we conceive of pain.  The structural model explains imbalances in the body, but it is not always sufficient to explain pain.  This shift has been happening in other disciplines over the last couple of decades, but massage has been slow to catch on.  Leaders in massage research have recently begun discussing pain science and its effects on massage therapy principles, and over the last six months I have been digging into the reading and trying to figure out my place within the entire framework.

The most basic massage school education (mandated by the state of Texas) covers muscles, joints and fascia.  Pain is understood to be related to tight muscles, adhesions in fascia, or trigger points that need releasing.  It is a starting point, a fairly simplistic stimulus-response type of model which many have argued is outdated.  In my case, I was lucky to have a mentor who introduced me to the nervous system as an alternative mechanism for understanding pain.  The first time he mentioned that when it comes to pain, massage therapists are not working on muscles but rather working on the nervous system, my brain lit up.  Relaxed nerves then relax the muscles, not the other way around.  I have written much about the nervous system and how I work with it in my practice in this blog.

However, recent pain science has revealed that pain is a little more complicated than understanding where specific nerves lie within the body and where they might be impinged.  It’s more than just general relaxation of the nervous system (although this still really does wonders).  Pain is often multifactorial and can have as much to do with heightened sensitivity in the brain and the clients own beliefs about their pain as anything going on in the tissues themselves.  The body is a complex ecosystem.  There are many cases in which clients report pain and there is no clear correlation between past or present tissue damage and the sensations being reported.  Equally confusing is the very common opposite case in which healthy pain-free individuals present with clear tissue damage.  For example, at least 40% of healthy individuals reporting no back pain are said to have bulging disks.  In other words, I could have one and yet I have no back pain.  It makes it very difficult to then say with confidence to someone with a bulging disk and back pain that the pain is definitively caused by the disk.  The bulging disk is not insignificant, but some other factor coupled with the disk was necessary to trigger the pain.  In these cases, an explanation focusing on tissue level intervention is not enough.  The same could be said for “tight rhomboids” or any other tissue dysfunction more appropriate to a massage therapist’s scope of practice.  As a discipline, massage therapy often jumps erroneously from correlation to causation.  In reality, when two conditions exist we can not be sure that one condition caused the other or if two conditions happen to be present at the same time due to some third unexplored factor or a combination of factors.  Again, structure and function are significant but we are still not clear as to how significant a role they play in certain types of chronic pain.  It is easy to see how this might throw a massage therapist into a temporary existential crisis!

However, it is not necessary to toss out the massage “baby” with the proverbial bathwater.  The issue is not whether or not massage “works”;  I have seen its profound effects as both a giver and receiver of massage.  The trick is that the mechanisms massage therapists use to explain how it works might not be exactly accurate, or at best are only part of the story.  I read a very comforting blog post by one of my favorite massage educators and writers, Whitney Lowe, about his own wrestling with this paradigm shift.  He explained that to understand pain, bodyworkers must have a good understanding not only of biomechanics, but of neuroscience, physiology, psychology, trauma and many other areas.  The explanation is now much more complicated, but it is not necessary to dismiss all of the clinical experience that has shown us that massage therapy is impactful.  Lowe writes, “I’m excited about looking at massage therapy in a new way, but also I am not willing to jettison the aspects of our work that change people’s lives and help them relieve their discomfort on a daily basis”.  My sentiments exactly!

Neuroscience education is a big part of the paradigm shift, which is essentially helping clients understand their own pain (but this means we have to understand the basic principles first).  According to neuroscientist Adriaan Louw, pain is produced by the brain based on the perception of threat.  In other words, clients’ thoughts and beliefs contribute to their pain experience considerably.  Massage therapy can find a place within this framework.  In my practice, this is most evident in prenatal massage and labor.  Helping a woman to manage her anxiety surrounding the labor is key to coping with the pain.  The difficulty is battling the lack of confidence in her own body which is implanted from the onset by the current medical paradigm of birthing.  Once a woman truly believes that she – not the doctor – is capable of birthing the baby, everything changes.  Practicing body awareness and active relaxation techniques during prenatal massage sessions makes the pain more manageable during labor, partly because mom’s perception is different.  For my many non-pregnant clients, instilling confidence in their body’s innate ability to heal is fundamental.  On a subconscious level, it is important to understand proprioception and the body’s neuromuscular signaling in hopes of reframing the body’s perception of threat.

When discussing my thoughts with my mentor, he validated my explorations and then gave me some excellent advice:  “Keep researching. Do what you do best.  Just don’t tell stories about why it works if you are not sure they are true.”  So, while I continue to try to better understand the neurophysiology as well as the psychological mechanisms of pain, I will lean into the gifts I know I can share through massage.  All of the tenets are still there and are still valid.  I create a safe space for my clients and offer them my full presence and quality of touch.  I encourage body awareness and the development of a mind-body connection so each client can hopefully access her inner healing powers.  I treat each client as a whole person, not a pelvis or a knee.  And I fully embrace that in some ways the human body is still a mystery even while I am trying to figure it all out.

RESOURCES

Confronting the Challenges of a Major Paradigm Shift, Whitney Lowe

Therapeutic Neuroscience Education, Adriaan Louw

Five Myths and Truths about Massage Therapy, Tracy Walton

Reconciling Biomechanics with Pain Science, Greg Lehman

Touch is not a luxury; touch is necessary for good health.  (Being a massage therapist, I am partial to massage, but touch could be self-massage, giving and receiving genuine hugs, or snuggling with your kitty – it all counts!)  Some form of non-sexual touch should be a part of every woman’s maintenance regimen for general well-being.  However, beyond maintenance, touch is also a powerful tool to bring about deep healing when we are not in optimal health.

When we talk about health or feeling “healthy”, often we are referring to having a good balance in both body and mind.  Not too much or too little of something, but maintaining a nice equilibrium.  Dr. Drew Leder, a brilliant philosopher and doctor, has written extensively on bodily experience in health and illness.  For him, whether we consciously acknowledge it or not, a big part of this balance is feeling a sense of wholeness:  connected to our bodies, connected to others and connected to the world which we inhabit.  In fact, the etymology of the word “health” is actually the old English word for “whole”.  When we fall ill, often this sense of wholeness is disrupted.  Our bodies can feel foreign to us, we become isolated from others and the world becomes a threatening rather than inviting place. When I suffered a stress fracture in my foot, I felt as if my body were betraying me. As I was healing, I felt disconnected from my body, unfamiliar with this new hobbling walking pattern and painfully deliberate pace.  When I began to run again, I was slow and had to take frequent walk breaks.  My body was incomprehensible, uncontrollable, totally alien.  I was inwardly yelling at myself: “this is NOT ME!”.  I would look at race photos of myself and think “THIS is me.”  There was a break in continuity in my sense of self.  I also felt disconnected from others.  I couldn’t train with my running group, and I chose to perceive this as a loss of community, a lack of unity with others in the world.  This is common when we are ailing:  to feel that others do not understand what we are going through, making us feel even more lonely and defeated.  During the time of my injury, the world itself became menacing.

The sight of my car inspired dread, knowing that I would have to wrestle with my boot to remove it and then struggle with the gas and brake pedals.  Out of safety, driving was kept to a minimum which meant my life was only about going to work and coming home (which is no fun!).  Stairs loomed like Olympic hurdles.  I maintained a positive attitude about it, applauding myself for small victories and creating new outfits around my boot.  However, navigating the outside world was still a “me against the world” type of experience.  Needless to say, I did not feel a sense of wholeness with myself or my surroundings.

Once the feeling of wholeness is lost, healing then becomes the recovery of an integrated relationship between self, body, others and the world around us.  Skilled touch can be a critical part of this process.  Dr. Leder finds that touch has the unique ability to immediately establish connection at a pre-linguistic level.  Through touch we can reestablish the connection between self and body.  My goal for the receiver of my touch is to feel grounded in her body, by bringing gentle awareness to it.  I also become her partner in figuring out which movement patterns might not be serving her, so we can come up with a plan for her to be in control of her own healing and learn to inhabit her own body in new ways.  This serves the dual purpose of integrating self and world, by shedding light on new possibilities for perceiving and acting in the world.  Touch with attention, care and compassion brings about an embodied connection with others, as well, and you don’t have to be a massage therapist to give this type of touch!  As I was healing from my injury, a friend gave me gentle leg and foot rubs, which helped me welcome the banished limb back into my life.

The key is that the touch relationship between giver and receiver is a reciprocal one:  the receiver is not completely passive.  On some level, the receiver is engaged:  body, mind and spirit have to be open to the healing.  Dr. Leder calls this “engaged surrender”.  I see it as learning to develop our “soft gaze” as receivers, allowing ourselves to focus energetically on what is happening on the physical level without allowing the conscious mind to take too much control.  As receivers of touch, there is an intuitive knowing when we allow our inner healer to come forward.  Generally, my clients do not talk to me during their sessions.  Subconsciously I think they understand that I am fully present to facilitate their healing, but the session is not about engaging with me.  Once the nervous system is calm, it is the perfect time to allow the doctor within to start acknowledging parts of the body and spirit that have been waiting patiently for attention.  When we allow ourselves to receive touch, we begin to feel our own sensations and responses, developing greater proprioceptive awareness.  We realize that we influence our own energy flow and can access dynamic healing within ourselves.

Touch is a profound way to reestablish multi-dimensional integration after our sense of being whole has been lost.  Of course, professional massage is an excellent medium for this.  However, do-it-yourself healing is powerful for in between massages or when professional massage is simply not accessible.  We can all benefit from giving and receiving healing touch to ourselves, our partners, our friends or our animal companions.   Illness and pain rob us of agency.  Touch can give it back.

RESOURCES:

“The Touch That Heals:  The Uses and Meanings of Touch in the Clinical Encounter”, Drew Leder, MD, PhD, Mitchell W, Krucoff, MD, The Journal of Alternative and Complementary Medicine, Volume 14, Number 3, 2008