What Do We Know For Sure, Really? (For therapists)

The past year has seen a mental growth spurt for this therapist. After years of feeling isolated as an evidence-based massage therapist, I found an online community of MTs and related professionals with similar interests.

New Friends, New Information

Through the wonders of the internet, I was directed towards research papers, forums, and discussions that led to new worlds. Pain research, brain research, neuroscience. I listened in as therapists more learned and experienced than I discussed how to bring this new information into manual therapy practice. The problem of chronic pain, in spite of many years of clinical research, is still a difficult one to solve. Old approaches that have focused on structure have been frustratingly inadequate. Pain research and neuroscience have been giving us new understandings of the role of the brain in chronic pain. It has been fascinating but frustrating, too. What did all this mean for me, for my clients? When all is said and done, how can I use this information in the treatment room? Would I do anything differently or is it a matter, as Barrett Dorko says, of changing my thinking rather than changing my tools? Are my tools good enough? Do I need to do something differently?

Old assumptions have been challenged and some found to be flawed, some completely wrong. It is hard to give up an idea that you have been quite convinced was right, but I decided a long time ago that I'd rather be committed to truth as revealed by evidence than any particular theoretical explanation for what is observed. This is not always an easy discipline to follow. There have been moments of frustration when I felt I couldn't say anything any more and wanted to give up. I wondered if everything I'd ever been taught was wrong, whether there was any value in what I do, whether I could do any good for anyone? Maybe I should just quit trying to be a massage therapist and bag groceries at the grocery store. At least it would be honest, straightforward work. No claims made that can't be supported, no doubts about the job to be done. Just put the milk and the bread in the bag, don't smash the eggs, have a nice day, ma'am.

The more I learn, the less sure I feel about anything. Yet, in a strange way, I also feel a quiet calm, a subtle confidence in spite of it all. I'm getting more comfortable with not knowing.

Tradition or Evidence?

Massage as a practice may be as old, even older than humans. Primates and other mammals groom one another. Massage therapy as a profession in this country is in its infancy. It grew out of folk medicine and tradition. Explanations have been formulated based on a certain kind of experience. Some explanations seemed plausible enough, some not so plausible. However, we are moving into a time when claims cannot be made without some evidence to support them. It just doesn't fly any more. And what does the evidence say? Well, some of the things we thought - in fact, some of the ideas we've held dearly - turn out not to be true. Does massage get rid of lactic acid? No, it does not. Does massage lower stress hormones? Apparently not that, either. Does massage make most people feel good? Well, yes, we can say that. It is a pretty safe thing to say, a pretty safe place to start.

Thinking About the Nervous System

Meanwhile, the more I've studied about the nervous system, the more I've returned to what my teacher Zhenya told me when I met her over fifteen years ago. You can't bully the nervous system into submission. You can't force the body to cooperate, can't force muscles to relax. You can't treat chronic pain by inflicting more pain. You have to work with the body's processes. You have to coax the body to relax. Above all, you have to respect the central nervous system because that is what controls it all.

Yet here I found myself, fifteen years later, knowing this and hearing it again and struggling. Why do some of my clients seem to want me to hurt them? And why does pressure on sore muscles sometimes feel very, very good? This has been my dilemma.
 

New (to me) Ideas Worth Considering
 

There are many people in my online community who have contributed to my education and evolution over the last year. One is Diane Jacobs, a Canadian physiotherapist and a contributor to the SomaSimple forums, who has developed an approach to manual therapy she has come to call DermoNeuroModulation (DNM). Diane speaks of the nerve endings, how they connect to the skin, and how it is, through the skin, that we access the brain. In her approach to manual therapy, she often hold the skin in a lateral stretch, the thought being that this stimulates Ruffini end organs of the nerves to relax the nervous system and turn down the volume on pain. It also may put a mechanical stretch on some nerves which are entrapped as they pass through small "tunnels" in the tissues. 

As I worked in my treatment room, I would think of this. I use a lot of heel of hand friction, a very useful Russian massage stroke, and in using this stroke I am constantly moving the skin over the tissue below, tugging and stretching, gently but firmly. It feels very good. I would think of the nerves attaching on the other side of the skin and how my movement, my input might affect them, how my interaction with these cutaneous nerves might speak to the brain and what the brain had to say in response to it.

Diane Jacobs has challenged the notion that we can affect the muscles directly with our hands. She points out that the only thing we can touch directly is the skin, that the muscles lay below not just a layer of skin, which can be quite thick, but also the hypodermis, which is composed of adipose tissue, which can be quite significant on a large percentage of the population and still significant on even the most slender of individuals, and loose connective tissue, laced with a network of nerves and blood vessels . I have to admit that that she has a very significant point. I think that we need to rethink how deeply we can directly affect muscles with our touch. Even if we could, what creates the change? Always, it comes back to the nervous system, because that is what controls the muscles, the dilation of the blood vessels, the entire physiological response. And so, maybe it isn't the depth of our touch that creates the change. Maybe it is the effect of our touch on those nerve endings closer to the surface that, through the brain, in turn change the tissue deep below. Maybe. 

But still, I wonder, why do we so often crave firmness of touch? Why is it that when we have a sensation in a muscle that we call pain, and we put pressure on it, that it creates a sensation similar to what we call pain but it feels good? What's that all about? Why does our opinion of the experience change from pain to pleasure?

One Evening, an Experience of Beginner's Mind

Having all these things swimming in my mind, I walked into the treatment room one evening. The client has had some pain in the neck, shoulder, and arm for a couple of years. Like many people, his job keeps him sitting at a computer and he assumes, as do I, that this has played a role in the development and continuation of his pain. We have worked together for a few sessions. We have learned a few things together. His pain has decreased and has gone from being continuous to intermittent. We agree this looks like progress. He describes his current state and gets on the table. I think about where to begin.

He is someone who, like many clients, seems to want and respond to a lot of pressure, but I am becoming more and more reluctant. There are so many good arguments against it. Yet, that is often what I've known to be effective. So I begin, as usual, not with direct pressure, but with Russian massage - effleurage to begin and then friction. Even if I am going to use direct pressure, I usually warm the tissue with Russian massage first.

As I am wondering how to proceed, I begin to question everything I have ever been told. I question pressure. I question structure. I question whether our explanations for how changes occur are accurate. I question whether anyone really knows what they are talking about. I know what this feels like. I know what the effects feel like. But what, exactly, happens and how? What do we really know for sure?

At that moment, it all fell away. Everything. All concepts, all theories, all explanations, all notions about how to proceed. I felt like a baby, knowing nothing for a moment, beyond language. What do I really know for sure?

Well, I know what it feels like to have my hands on this client's skin at this moment. I know that at this moment I am moving skin, that the skin is moving over tissue below it. I know that as I move skin that the cutaneous nerves that attach below the surface move with the skin, as does superficial fascia and a thin (on this client) layer of adipose tissue.

I know what the tissue beneath looks like. I've seen it and can visualize it. I know what it feels like to be rubbed in this manner and I know that it feels very, very good. I know that changes occur, I can see them and feel them. Skin turns pink and warm, the muscle below softens. Beyond that, I'm not sure what else I can say. I don't know exactly how those changes occur. I don't know exactly what they mean.

Am I being an operator again? Am I acting upon my client as if he were a thing that I do something to? Or am I, perhaps, learning a different way to be an interactor, perhaps learning to speak with the body in a new way? Maybe being an interactor doesn't have to look a certain way. Maybe it doesn't have a particular way of looking at all.

A Little Different Approach, Some Words of Wisdom From a Client

I refrained from putting concentrated pressure directly into sore tissue, but instead, used a broad, moderate pressure and a firm, extended, somewhat lateral stretch. This seemed to work pretty well. It seemed to give the satisfaction that sometimes comes with pressure without pressing into tender tissue or nerve, without direct assault. This seemed good.

At a point, I shared a bit of my thoughts with my client. I confessed I once thought I knew what I was doing but the more I learn, the less sure I am of anything. This client is an exceptional client and had some words of wisdom. In fact, he was actually one step ahead of me.

The client had already learned quite some time ago that pain is in the brain. In his quest to figure out what to do with that information, he had found his way to me. Through our sessions together, he'd learned some things that helped him to help himself between sessions. We speculated, together, about exactly how the massage was helping to alleviate his pain. Did pressure on trigger points do something to decrease the pain? Why? How? Did having a pleasurable sensation in an area that was usually in pain reprogram the brain to think differently about that area? There were many possibilities. We didn't know. The client, though, felt better in his body and he was satisfied with that. We were both figuring it out as we went along.

What do we know for sure, really? I don't know, but I'm getting more comfortable with not knowing.

[A follow-up, in response to a question from a colleague, can be found here.]