Ruminations on sports, training, health, and wellness

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A Massage Therapist’s Notes on an Imperfect Art

Nearly 2 years ago, when I was just starting to post on this blog, I was thrilled to attend a talk given by one of my childhood heroes, Robert Ballard, who answered my questions about how to get kids excited about science. He told me to meet their passions with matched enthusiasm, and to keep asking questions of my own.

Two years later, and I’m happily in the position of doing just that — getting young people excited about science as I continue to delve into the beginnings of what I hope will be a career as a science educator. Yesterday I took my students on a tour of active biomechanics labs at a high research activity institution, and this morning we talked about physics in the context of football pads and baseball bats. It’s been a pretty awesome week already, and it’s only Tuesday night.

temp-complications-cover-203x300The highlight of my week was outside the classroom, however — I had the great good fortune to attend another Bryan Series talk given by Dr. Atul Gawande: surgeon, MacArthur fellow, and author of four highly acclaimed books. I read Dr. Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science in 2010 while I was recovering from a cholecystectomy (which made me really glad I waited until after the surgery to read it when I got to the chapter about how often cholecystectomies go terribly wrong). The book made me examine my own approach to science and knowledge; one of my great frustrations with massage school was hearing teachers parrot outdated assertions because that was the way it’s always been done, even though advances in science give us new perspective on our practices. Dr. Gawande’s approach to medicine by asking why we do what we do, whether it’s working, and how we can do it better was the first in a series of “eureka” moments that ultimately led to my decision to go to graduate school and pursue a better rounded education in STEM topics.

I’m batting 1.000 at questions I submit to Bryan Series speakers actually getting asked in the Q&A portion of the lecture; I posed to Dr. Gawande how allied complimentary healthcare practitioners, such as massage therapists and acupuncturists, can communicate better with physicians to become a more effective part of the healthcare team. Dr. Gawande described his sister in law, a massage therapist and “holistic healer” in Asheville, NC as an “artisan” whose vocabulary and rhetoric regarding medicine failed to mesh with his own and resulted in communication breakdown even when probably talking about very similar things. But, he said he recognized that his patients seek out practitioners like her for their services, so it’s important for physicians to be aware that these people are meeting some kind of particular need. And he added that his wife much more frequently seeks advice from her sister than she does from him.

Albinius-217x300Atul Gawande’s tacit acknowledgement of complimentary alternative practitioners as a bit of a fringe entity to the medical mainstream speaks to a lot of my frustrations with massage education and science education as a whole. I had a huge epiphany when I took a continuing education class on structural myofascial therapy last winter and I caught myself tuning out as soon as the instructor mentioned “energetic connection.” My woowoo-ometer is on a pretty fine hair-trigger these days. But as I willed myself to appreciate the spirit of the instructor’s message, I realized that when he talked about the implicit energetic connection between the feet (energetic grounding) and the hip (energetic centering), he was using different words to describe the principles of biomechanics that I know and embrace — kinetic energy manifested in the form of mechanical work is dispersed from the feet (ground reaction force) to the hip (joint reaction force) by the same network of musculoskeletal and connective tissues he was describing as a “myofascial meridian.” Holy crap. Mind blown. We’re talking, gray matter spattered on the walls, here.

We massage therapists devote a lot of hand-wringing to being taken seriously as medical professionals. Indeed, we have come leaps and bounds thanks to leaders in the field who are producing some very fine scholarship and advocacy for better education and standards for licensure. We’re enjoying a very exciting time for our profession as cutting-edge evidence-based practice collides with millennia of tradition to snowball into a paradigm shift. I’ve only recently come to recognize that great groups of thinkers and doers don’t become great without extremely hard, intentional work. I want to be there — out on the front lines, surging ahead at the prow as we enter a new era in integrative medicine.

I also recognize I can’t do it alone; this has to be a group effort. The old adage goes, “dress for the job you want.” We, as a profession, need to become fluent in the language of progress. We need to make a concerted effort to learn not only the common tongue of medicine, but of professional scientific practice. Let us abandon the days of “we do it because that’s the way we always have” and open wide the floodgates of the relentless, “why.” We need to be critical consumers of information and implacable questioners of the provisional. When our best understanding of our practice evolves, we have to evolve with it.

I take my fair share of barbs for voicing my criticisms, but I assure you I hold no one to a higher standard than to which I hold myself. I make no asservations of touchy-feeliness. I am utterly fascinated at the phenomenon of how different people, presented with the exact same availability of information, can arrive at diametrically opposite conclusions on any matter (science or otherwise), and I am recognizing that my convictions I hold to be self-evident are just as true to me as their mirror images are to my peers who fall on the opposite side of the fence. What I mean is that I am becoming more aware, as a practitioner and an educator, that all truths should be subjected to equal scrutiny to separate the staunch edifices from the crumbling sand foundations. When we ask the tough questions, we have to be prepared to accept tough answers.

Keep digging, friends.

Digging

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Physical Therapy Works!

It started out as just a sore back. Nothing unusual; I had just spent the last 10 days driving a total of 3,099 miles and sleeping on an antique mattress on the floor of a classroom while working 16 hour days at the Tour de l’Abitibi. Anybody would have a sore back after that.

Except this wasn’t any old sore back. After my second massage client, I asked Dr. Rodulfo the chiropractor to adjust my lumbar spine. Snap, crackle, pop, and it did feel better. After my third client, Abbey the athletic trainer ran high-volt electrical stimulation through sticky electrodes along my sacrum with an ice pack on top. After my fourth client, my eyes welled up with tears while I lay on a rolling table and steel orbs traced circles along my spasming spinal erectors. After my fifth client, Rob the acupuncturist dry needled around my lumbar spine, sacrum, and hips — those two needles in my hips were enough to briefly consider not being friends with him anymore, but they provided some short term relief. An hour later I was home, in bed, with a hydrocodone and a very furrowed brow. I just turned 27 — the same age my dad was when he first herniated a disc and became a back surgery candidate.

A morning trip to the orthopedic walk-in clinic yielded a promising diagnosis: my x-rays looked great and showed no evidence of spinal trauma; this was a case of a good old muscle spasm. Armed with a prescription for muscle relaxers and orders to take it easy for a few days, I embarked on getting over this small road block (which, I learned, is easier said than done with a back spasm).

Ten days later, still putting on my socks and shoes laying on my bed like a dead bug because bending over was too painful, the orthopod at my follow-up appointment wrote me a prescription for physical therapy. I’m a big believer in PT — I worked at a PT’s office for over two years while I was in graduate school, and that same PT had healed my torn rotator cuff with exercise prescription.

My insurance, which I buy privately through an exchange, covers prescription pain and muscle relaxer medication at $5 copay. While tremendously useful in acute situations, these medications have well-documented, common, potentially harmful side-effects and are not recommended for long-term use.

Physical therapy, which my doctor prescribed 2-3x/week for 2-6 weeks with an excellent prognosis for full recovery from my injury, is covered at 50% coinsurance plus $50 copay per visit. It’s virtually guaranteed to make me healthier faster, and thus less burden on the healthcare system. There are no Tier 1 or Tier 2 approved providers within 250 miles of my home.

So the average consumer is looking at $10/month for something that could eventually make them sicker, or $400-$1800 for something that will almost certainly make them better than before. The irony was not lost on me.

Armed with determination, I went to my first appointment with my good friends at Physical Therapy of the Triad. Dr. Krishinda Lee met me with a smile and a clipboard, putting me through a thorough physical exam to determine the degree of my dysfunction. Then she had me stretch — 5 stretches took 40 minutes. She contorted me in a pretzel and hung me off the table by a nylon webbing strap. It was glorious. I went to work virtually pain-free all day.

The next morning, the familiar ache was back. I popped pills, and then I went meticulously through the process Krishinda had detailed. Lo and behold, it felt better — much better. I gave swimming a shot; I focused mostly on pull-buoy exercises and avoided flip-turns, but the lengthening effect was palpable and a good bake in the sauna post-swim was positively magical.

Every day so far, I’ve been doing my stretching routine. It’s tedious, but I focus on being really present throughout each stretch, letting my body talk to me and tell me when it’s ready to go a little deeper. Today I swam and felt good enough to do real flip-turns and whip kicks, in addition to freestyle drills and endurance sets. Then I went for a massage, something I had actually been avoiding because of my tendency to over-respond to manual therapies — it seems to wake things up without bedding them back down. To my delight, the therapist thoroughly tenderized my quads, hamstrings, and hips. I felt so good, I went out and biked 20 miles when I got home — on my race bike, with a 9 cm drop between the saddle and handlebars. I could feel my back, but it was more like I had a pebble against my skin, not the deep and persistent pain I had been battling. It wasn’t until this evening I realized I forgot to take my pain meds this morning, after having been leashed to the bottle for two weeks.

I go back for my second physical therapy session on Monday, and I’m excited to report my progress. It’s not very often that therapists get reports like “I’m really happy with the speed of my recovery!” That’s with just one PT session, and rigorous adherence to doctors’ orders. PT works, folks.

My takeaways from this experience:

  • Back pain is miserable. Take care of your back, and take action as soon as you have a problem. I really feel for all my clients who have to deal with this.
  • Physical therapy is a partnership between a skilled practitioner who can diagnose internal problems from observing external cues, and prescribe specific movements to correct imbalances, and the patient, who must commit to unwavering resolve and intention in owning their recovery.
  • The medical complex in the United States is filled with phenomenal practitioners across a spectrum of specialties driven to help those in need, but the payments system is really broken. We need unprecedented reform to focus on preserving wellness as well as treating sickness.
  • An ounce of prevention is, really and truly, worth well more than a pound of cure.

Go forth, people, and thrive!

The Illiotibial Band: Nefarious Foe, or Misunderstood Friend?

Runners, cyclists, and just about anyone who moves their legs on a regular (or irregular) basis has probably encountered the Iliotibial Band: a dense, fibrous tract of tissue running from the outside of the hip along the side of the thigh to connect just below the knee. And if you have experienced sensation associated with this tissue structure, chances are high that it was not a good experience.

afp20050415p1545-f1IT Band pain symptoms and range of motion inhibition, often referred to under the umbrella term “IT Band Syndrome,” is a common condition among individuals who engage in repetitive leg flexion and extension, and while exact figures for the entire population are unknown, some studies estimate prevalence over 20% in people who run or walk long distances. Symptoms usually present with pain in the lateral hip or the attachment at the knee, although sometimes tissue adhesions in the side of the leg cause pain when the structure is stretched, as in running or cutting movements.

The IT Band is itself not a muscle — structurally, it can be thought of as a long tendon tail attaching at the bony prominence at the top of the lower leg, just below the knee (at the prominent knob of the lateral head of the Tibia bone; it probably hurts a bit if you press on it), running up the side of the thigh, and fanning out to blend into the Tensor Fascia Latae hip muscles and Gluteus Maximus, which finally attach at the Iliac Crest, the upper rim of the pelvis (hence ilio-tibial). Like all tendons, the IT Band has little blood supply and nerve innervation, and is primarily composed of collagen, elastin, and fibroblast cells. While it cannot contract on its own, the muscles at the top of the hip (primarily the Tensor Fascia Latae) put tension on the IT band to abduct (bring away from the body’s center line) the hip and leg. Think of a rope and pulley system — the rope in this case represents the passive IT Band structure, serving to distribute the force applied to it from the other side of the pulley. This is particularly important in walking and running, where the leg involved in stepping forward during the “swing” phase of gait relies on the abductors and deep lateral rotator muscles of the hip to keep the pelvis level and stable. You may have seen runners or walkers whose hips “dip” with every step — this often indicates dysfunction in the Tensor Fascia Latae and hip rotators.

It is important to view the above graphic as a representation of the actual structure within the body; I like how the artist has indicated that the white tendinous fibers of the IT Band blend into the muscle tissue at the hip, but I think the characterization of the IT Band as a separate bundle of tissue laying on top of the surrounding muscle is a common misunderstanding, and refining our concept of the IT Band as it actually exists and functions in the body has great implications for practitioners and athletes alike.

the_muscles_of_the_leg_919014Our understanding of human anatomy comes largely from dissection of cadavers, wherein individual muscles and anatomical structures are identified by being excised with a scalpel from the surrounding tissue. This gives us a detailed sense of the three-dimensional body, but by manually separating the tissue, we also often tend to mentally isolate these structures and forget that the elegant, intricate musculoskeletal system recruits fibers from a broad range of tissues for almost every motion. Take a look at Leonardo da Vinci’s drawing of a dissected leg to the right (click to expand to full size). This intricate and amazingly accurate drawing from the early days of human anatomical study indicates the same fanning connective tissue structure in the upper hip as it blends with the hip abductor muscles, but we don’t see the same IT band structure drawn separately from the surrounding tissue — it’s more of a thickened strip of tissue that forms a groove in the side of the thigh. You may have seen athletes with highly defined, sculpted musculature who exhibit the same structure; the IT Band appears as a groove along the side of the thigh and forms a tendon bundle at the tibia attachment. Just as the connective tissue structure of the IT Band blends into muscle at the hip attachment, there is also a great deal of “feathering” into the muscles of the lateral thigh — namely, the lateral quadriceps and hamstrings.

DSC_0151Why is this distinction important? To go back to the previous rope and pulley analogy, we can refine this understanding to not just a single rope pulling on a single endpoint in a single plane of movement, but a network of pulleys pulling on a web of ropes that disperses tension across a wide area, with each structure interacting as tension is applied and released. The interactions are so intricate that even the most sophisticated biomechanics models can only provide simplified schematics of the forces at work in the living body. You may have seen similar art and architectural structures, called “tensegrity models” that exemplify this concept. Below is a video of renowned bodywork practitioner, researcher, and teacher Tom Myers showing an example of a tensegrity structure and how it relates to the body:

Watch how the model moves when Tom pulls on a piece of the elastic thread — look closely and you will be able to see other elastic threads disperse tension, with some going taut and others going slack, which changes the position of the rigid dowels. The model demonstrates how a rigid structure with limited elasticity can affect the contractile structures it attaches to. An example of this in practice might be flexion of the hip to kick a soccer ball. As the leg is brought up and the angle of the hip becomes more acute, the quadriceps fire to extend the knee and flex the hip. Since these fibers tie into the IT band, this motion exerts force along the length of the IT band, which will functionally rotate the leg inward (medially). To prevent rotation, the deep lateral rotators that run across the glutes must fire to compensate. This is a simplified explanation of the processes at work, but is meant to demonstrate the kinetic chain of events that occurs with movement and the forces at work to stabilize and compensate to promote strength, accuracy, and protect against injury.

Taking this same example a step further, suppose one of the muscles working in concert to accomplish the kicking action is weak or impaired due to injury or improper training. The Piriformis, one of the deep lateral rotators of the hip that runs beneath the glutes from the Sacrum to the Femur, is a common offender for hip instability and insufficiency. Without the Piriformis firing properly to prevent medial rotation, other muscles that may not be as well adapted for hip rotation must be recruited to preserve stability, including the Tensor Fascia Latae. The IT Band, already under tension from its connection with the Quadriceps, comes under additional tension from the Tensor Fascia Latae to pull the leg into alignment, putting even greater stress on the IT Band attachment at the knee. Can you see how this could lay the groundwork for pain, inflammation, and chronic injury?

The prescribed treatment for pain and tightness in the IT Band has long been stretching, manual therapy, and foam rolling along the length of the outside of the leg, which still assumes the concept of the IT Band as its own discrete, free-gliding bundle of tissue and discounting the connectivity to the surrounding muscle. I’m making the argument that this isn’t necessarily the most effective nor the best biomechanically sound approach to treating IT Band Syndrome symptoms. Stick with me here.

Think again back to the tensegrity model Tom Myers was playing with. If one segment of the elastic thread was under significant tension, it would produce slack on other thread segments — that’s how vector energy dispersal works. What if, instead of approaching the problem by addressing the tight thread, we look for ways to bring appropriate tension into the slack threads? This accomplishes the same goal of dispersing tension equally, without further assaulting already inflamed, sensitive tissue.

In the case of the IT Band, this translates to gentle stretching and mobilization of the Tensor Fascia Latae — remember, the IT Band itself is essentially a passive structure and translates tension from other muscle attachments instead of exerting any force itself — and rehabilitative exercise to strengthen the deep lateral rotators in the hip and glutes. I am not recommending this as a cure-all approach for every presentation of hip and lateral knee pain; always seek evaluation from a medical practitioner to properly diagnose pathology and pursue the best course of treatment. For everyday tight, tender IT Bands, here are three exercises that target the supporting musculature to promote balance and optimal movement patterns:

First, the Clamshell — the model in the video is using a resistance band, which can be omitted and introduced later as strength and mobility progress.

Next, the Glute Bridge; I like this single-leg variation because it requires more global hip engagement than a symmetrical bridge hip raise. Adjusting the angle of the raised leg (pointing more toward the ceiling) will help to recruit more low back, hip flexors, and hamstrings to maintain balance.

Finally the Triplanar Hip Exercise (one of my clients fondly refers to this as the “fire hydrant;” if you are a dog owner, you will quickly recognize why!). The model in the video has good form but I would recommend slowing down the pace for more accurate muscle recruitment. The three elements are full extension of the leg, lateral rotation, and flexion pulling the knee into the torso.

These exercises are a great starting place to promote hip mobility and strength for runners, cyclists, swimmers, and active individuals in general. You can make them more difficult by taking away the stable base of the solid floor, for which Bosu Balls and wobble boards are excellent tools. These also make a great pre-activity warm-up or post-activity mobilization. If you have sciatica or back pain symptoms, consult a health professional before beginning these exercises, as excessive tension in the deep lateral rotator muscles can sometimes exacerbate nerve impingement symptoms. Always stop if you feel pain or pinching, and work within your abilities, progressing as your strength improves.

I hope this perspective on the IT Band sheds some light on its function and structures. This essential tissue mass in the leg is an important factor in all activity and movement, and healthy function will improve performance and prevent injury.

A Change of Scenery

Hi friends!

It’s time again to set aside lofty expectations of mind-expanding academic inquiry in blog post form, and present instead a newsy update of life and times in massage therapy and bodywork.

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In the beginning of November, I joined Dr. Damien Rodulfo’s sports chiropractic practice, Healing Hands Chiropractic. Just around the corner from my old digs, this office houses two chiropractors with advanced specialized training — Dr. Rodulfo and Dr. Herman — a physical therapy assistant, an acupuncturist specializing in dry needling and neuromuscular therapy, and me — sports massage therapist and science nerd extraordinaire. It is truly a dream team of allied practitioners and I am tremendously excited to be settling in and finding my niche in the practice.

download (1)This past week was my first week of class back at the Body Therapy Institute, where I attended massage school in 2009, this time taking the Advanced Myofascial Massage Certification course. This approach to bodywork more closely resembles Structural Integration or Rolfing while applying the principles of deep tissue massage to treat fascial restrictions. The concept is based on Tom Myers’ groundbreaking theory, presented in Anatomy Trains, wherein the connective tissue web that encapsulates every bone, muscle fiber, bundle of muscle tissue, and organ in the body is treated as a single unit — thus, a restriction in one extremity can affect movement and postural patterns in a completely different part of the body through the kinetic chain. The first week of class was an eye-opening and invigorating shift that turned my approach to massage on its ear (sometimes literally!), and it has really gotten me excited about the possibilities for applying this work in a sports and physical activity capacity.

As such, a unapologetic plug for my business: To complete the certification requirements, I must log several sessions of massage using these techniques between now and February, including a case study. This is your chance to get some awesome bodywork at a substantial discount. Myofascial structural massage is most effective if performed in a series with one session every week. If you book a 3-week massage series between now and February, you will receive 3 90-minute massages for just $50 each — a $120 savings. Payment in full is due at the time of the first appointment. These sessions are non-refundable for cancellation and non-transferable (re-scheduling accommodations within reason can be made). To book your myofascial structural massage series, you can call me at 336.253.4263 or book online at www.saraclawson.com (put “myofascial series” in the notes section to receive the discount). Myofascial massage is perfect for anyone — you will be able to remain clothed, move around, and notice immediate changes to posture and movement patterns. I really believe my existing and new clients alike will be impressed with the effectiveness of this approach!

2015 is shaping up to be a year of education for me: not only will I be completing my Advanced Myofascial Massage certification, but I am stepping over to the other side of the classroom as a science educator in several different venues.

post-greensboro-college-304I’m excited to be joining Greensboro College’s kinesiology department as an adjunct professor of biomechanics in January, offering a course and lab both spring and fall semesters. This is my first foray into higher education as a professor teaching a complete course, so I’m really nervous about doing a good job and getting my class excited about physics, math, and the elegantly intricate body in motion. Do you have any memories of great professors (or terrible ones) whose teaching methods have impacted your life? Let me know in the comments — I need all the help I can get!

I am also joining the faculty of Kneaded Energy School of Massage in January as the anatomy, physiology, and pathology teacher for the night program. We’ll be starting out with musculoskeletal anatomy until April, at which point I get to dive into physiology, chemistry, and pathology. This is a great step for me to bridge the gap between education and massage therapy, and I can’t wait to see the next generation of massage therapists in action as they enter the career at a time of wonderful growth and development. If you’ve ever been interested in pursuing massage as a career, KESM is a great place to start.

Also on the massage front, I am extremely excited to be offering a continuing education class of my own at the Body Therapy Institute in April: Sports and Performance Massage. If you are a massage therapist, physical therapist, or athletic trainer, this course is for you! We will be drawing from biomechanics, sports medicine, and evidence-based practice methods for therapeutic manual bodywork in an athletic setting. This is going to be a major on-your-feet, get-up-and-move class, and in the course of 3 days we’ll cover the body in motion, practical approaches to sports injuries, and coaching rehabilitative exercise to maximize performance (and save your hands). It’s a 21-hour course, which (combined with 3 hours of mandatory ethics training) satisfies the North Carolina requirement for massage therapy license renewal. We are going to have so much fun!

That’s all for now — gosh, I’m tired already just from proofreading this list, and it’s not even January! I hope the coming weeks and months hold winter wonderment for you and your family, and a special thank-you goes out to all the friends, family, clients, and mentors who have supported me on what has been a wild and amazing journey in sports medicine this year. Here’s wishing holiday cheer to all you happy runners, determined triathletes, crazy cyclists, and everyone else this year and 2015!

Relentless Curiousity

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It’s autumn in North Carolina, which can only mean three things: spectacular sunlit leaf color, a distinct uptick in latte consumption, and NCAA college sports in full swing.

I get the privilege of working with several Division I college sports programs, most notably my graduate school alma mater: the University of North Carolina at Greensboro. I’ve been feeling the Spartan love this week with lots of outcall sports massages in the athletic training room, and working with these talented young people never fails to keep me on my toes.

The Internet Age has given athletic people vast resources to learn more about sports, nutrition, physiology, training, and therapies. On the whole, I am impressed that the availability of knowledge seems to help my massage clients to be well-informed and discriminating consumers of information. People who participate in sports at a high level view their bodies as tools — their vehicles for recreation and competition. This insight frequently leads them to constantly seek and evaluate information that will improve their performance, health, and experience. It also means they ask practitioners a lot of questions.

It’s easy to view “why?” as a challenge: a threat to authority and credibility. But forcing myself to dig deep into the body of knowledge through the incredibly effective (and sometimes incredibly annoying) Socratic method makes me a better practitioner and helps me build a reputation among my clients that I am a trustworthy source of information. The college students I work with ask questions that often catch me off guard, and the exercise of thinking analytically and critically to construct a thoughtful answer is often a missing ingredient in massage education.

Let’s apply it to a common instruction massage therapists give to clients following a bodywork session: “Be sure to drink plenty of water after your massage.”

But why?

The pat answer many of us learn in massage school is “to help flush out metabolic waste.” But what does that mean, and most importantly, is it a rigorous and factual response to the physiologic processes at work?

To be thorough and deductive in crafting an answer, consider all the pertinent facts. Massage therapy has a demonstrable effect on blood and lymphatic circulation, because the mechanical manipulation of soft tissues introduces heat and pressure, which creates a mild inflammatory response. The body’s response to topical heat is rapid dispersal by dilating capillaries in the tissue, which decreases blood pressure because of decreased vascular resistance. To maintain homeostasis, the body responds to the drop in blood pressure by adjusting fluid uptake in the blood stream and changing heart rate to stabilize blood pressure. One important role the circulatory system performs is transportation of the surplus substances of metabolism and energy production and expenditure to the kidneys to be excreted from the body. An example is the process of converting protein into energy: the leftover substances include ammonia, urea, and uric acid, which are toxic if they remain in the body. Massage is not directly shown to release metabolic waste from soft tissues under study conditions, but in consideration of the peripheral responses to massage, appropriate hydration supports homeostatic processes to promote optimal muscle function and recovery. Most importantly: with the exception of a few conditions such as hyponatremia (abnormally low electrolyte dilution), drinking water is an appropriate recommendation for overall health an wellness; the risks are vanishingly small, and the potential benefits are great.

For many clients, this explanation goes in to way too much physiology detail. However, I think as a therapist, it is important to understand the complete picture and to be able to articulate it accessibly and intelligently. It establishes credibility and develops the ability to think critically and scientifically about the therapeutic intention of our work. It also helps me to be better able to talk about the effects and benefits of massage to other medical providers, which has made a huge impact on building my client base and becoming regarded as a skilled practitioner, able to get into a variety of unique opportunities as a massage therapist. For me, it’s simply not enough to regurgitate pat answers; I am voraciously curious and keeping current on research helps me to continuously refine my methods and understanding.

If you are a consumer of massage therapy, I encourage you to ask your therapist questions about what he or she is doing and effects on the body. I think most therapists are like me — we get really excited when clients show an interest in our specialty and we want to share with you information that can positively impact your health, wellness, and understanding of your body. Learning about physiology and anatomy in school was like getting an owner’s manual to my body and I love sharing that feeling of empowerment through knowledge with my clients. I don’t think it’s appropriate to try to test therapists’ knowledge with “trap” questions, but to approach your therapist as a resource to broaden your understanding of health, wellness, and activity. Additionally, most massage therapists maintain an extensive referral network of other allied healthcare professionals, so even if we can’t directly answer your questions, we can almost certainly direct you to another expert who can.

Do you have a burning question about massage therapy, or are you a practitioner who has encountered great questions from your clients? Shout out below!

I’m a rookie soigneur — ask me anything!

How can you possibly top a crew like this?

A while ago, a user on the Bicycling forum of Reddit posted a request for an “Ask Me Anything” (AMA) interview with someone working in elite or pro cycling. I thought it would be a fun opportunity to get a little more involved in the Reddit community, and to talk some about my experiences as a rookie soigneur this year with USA Cycling. If you aren’t familiar with Reddit, it is a vast website where users post links, pictures, questions, and information, which other users can then comment and up-vote or down-vote to determine its page rank and impact. It’s actually a fairly useful way of getting a pulse of the Internet and current affairs. It’s also a great vehicle for the dissemination of cat pictures, so there you go.

The following is a slightly edited transcript (only for syntax, not for content) of the questions and comments I received in my AMA. It was a really low-key, fun experience and I was pleased with the reception. Most of the questions were more about training and recovery, and how regular recreational cyclists can benefit from the concepts used in elite cycling. I was impressed with the questions (plus, this saves me actually having to write an original blog entry). Without further delay, my AMA:

 

User JurreNawijn asks:
Which races did you visit in my beautiful country, the Netherlands?

SwannySara:
USA Cycling is based out of Sittard, in Limburg. I really fell in love with the area and all of the Netherlands. My favorite race we did was the Koga Ronde van Zuid-Oost Friesland in May with the juniors team, where three of our riders went off the front of the breakaway for a spectacular 1-2-3 podium sweep finish.

I’ve also had the pleasure of working Three Days of Axel in Zeeland, the Bavaria Ronde van Lieshout, Math Salden and Heerlen Klimcriteriums with the juniors teams, and Ronde van Gelderland with the elite women. I was lucky to take in (as a spectator and cycling fan only) the Ridder Ronde post-tour criterium in Maastricht, and the final stage and finish of the Eneco Tour in Sittard.

User velohead2012 asks:
What are some things that athletes could do on their own to better help with recovery in regards to stretching and body work?

Anything you see people neglect that should also be addressed?

What are good resources and tools that every cyclist should have or know to get the most out of their recovery?

SwannySara:
I find the contrast between the elite riders I work with as a soigneur and the athletes I see in my private practice back home to be very telling in terms of attention to recovery. Cycling at the elite level is a sport of marginal gains, where the best riders emphasize everything they do from the very moment they wake up to make them faster on the bike.

The biggest aspects of recovery that the USAC program emphasizes are nutrition and hydration, muscle tissue recovery, and periodized training. The moment a rider finishes a race, their soigneur will typically hand them a tiny can of Fanta (the tasty little shot of sugar seems to improve glycogen deprivation and aid rehydration), a fresh bottle of cool water, and a bottle of recovery shake. My guys love OSMO Nutrition recovery mix with chocolate almond milk. The first 30 minutes following intense riding are critical for replenishing glycogen and protein. One of the the directors is fond of saying “race for today, recover for tomorrow.”

The muscle tissue recovery component includes massages, Podium Legs pneumatic boots, compression clothing, stretching/foam rolling, and appropriate rest. Riders get a massage every day during stage races, and usually every other day during training. When athletes get massage that often, I find that they acclimate to the bodywork really quickly and 30-45 minutes is generally ample time to accomplish my goals. The pneumatic boots are big favorites in the rider’s lounge while they are hanging out; these are medical-grade compression boots that strap up the entire leg and use air pockets to gently massage the tissue. Compression clothing is not used during training but socks and leggings are useful at rest and especially while traveling to promote circulation. Stretching is huge, and a lot of the young riders who come over to the program are not familiar with it. Prior to riding, shorter ballistic stretches that prime the muscle tissue for warming up are commonly overlooked but a great tool to speed up the warm-up process and prepare for activity. After riding, riders spend a long time doing deep static stretches and yoga poses with therabands and foam rollers. They often integrate some core exercises in with this. For regular recreational riders, a big stretching routine isn’t always practical or possible, so in my private practice I like to tell people to think like a cat: every time they get up, sit down, jump, run around, they are constantly stopping to stretch for a few seconds. If you make stretching a habit throughout the day instead of a huge production, it’s more likely to get done and also helps to combat the physical stresses incurred with everyday things like driving and sitting at a desk.

The last component is integrating recovery into the training schedule. Total rest days with no riding are very rare, and a recovery ride usually consists of an hour to 90 minutes of high-cadence, low-power output spinning. Recovery days sometimes include a few very small jumps or efforts with the goal of activating sore tissue and promoting circulation. Mostly, it’s important to keep everything moving with active recovery. It’s a misnomer that the day before a big ride or race has to be a recovery day; it really depends on the type of riding and the entire mesocycle of training period. Each coach approaches it a little differently, but the goal is the same: to integrate high-demand days with low-demand days to keep riders fit and fresh when it counts.

User kytap22011 asks:
are there any massage techniques you can do yourself after or before a ride?

SwannySara:
Before riding, a lot of elite riders like to use a light leg oil or embrocation (even on relatively warm days) to work into the muscle and wake up their legs a bit. It has more of a sensory effect than anything, but it feels nice and makes your legs really shiny!

After riding, I am a big advocate of foam rollers. These large, dense cylinders come in a variety of shapes and sizes but the basic inexpensive ones work great. They are particularly effective for lateral hip, glutes, quads, and hamstrings and you can find lots of Youtube tutorials that give good techniques for use. There are a number of commercially available products like TheraCanes and trigger point balls that work very effectively, but I’m a fan of inexpensive or free alternatives like tennis balls (great for getting hard-to-reach knots) and frozen water bottles. Probably one of the best things you can do is to lay with your legs straight up a wall so your back is on the floor and your legs are straight up (putting a pillow under your hips can ease back tension). This is a great method to help restore circulation, ease local inflammation, and bring tissues to a healthy resting length.

User sjg91 asks:
In your opinion, do foam rollers make any difference?

SwannySara:
I worked on a study when I was in grad school on self myofascial release using foam rolling. There is a paucity of research on the subject, so most of it is inferred from normal sports massage and deep tissue research study methods. The study was small-scale but one thing we noticed was that people seemed to have more appreciable lasting results when foam rolling was performed a bit longer — about 10 minutes per leg was the sweet spot. I think that’s the biggest mistake people make; they lay on the foam roller, it does its searing agony work, and they let up too quickly. It’s more effective to ease into it gradually over a long period of time.

Another mistake I think people make is when rolling the IT band. The illiotibial band itself doesn’t have a lot of vascularization or contractility on its own; it is simply the long tendon tail of the tensor fascia latae muscle located on the side of the hip. Rolling the IT band doesn’t really do much to relieve IT band tightness or attachment point pain, but gentle, progressive rolling on the TFL muscle is quite effective.

AlvaSt-SnowGiant comments:
Thanks for the insight. I’m going to try rolling the TFL: I have hip pain on the right side during my rides – the kind that makes me stand up and pound my fist on my hip while cycling. Maybe this will help.

SwannySara:
One thing that I think cyclists are really notorious for neglecting is deep lateral rotator strength and balance. I did my master’s practicum on motion-capture bike fitting as a diagnostic tool for unexplained lower extremity pain, and we found that the vast majority of it can be traced back to insufficiency of the piriformis, gluteus medius, and deep six to stabilize hip balance and knee tracking. This frequently precipitates IT band pathologies because failure of the piriformis to support hip stability throughout the pedal stroke recruits the TFL and lateral hip to compensate. In addition to foam rolling, you may want to try incorporating clam shell exercises, glute bridges, and tri-planar hip mobility in the quadruped position (good explanations of all these exercises are a Google search away). Good luck!

User AlvaSt-Snow comments:
That may explain it: I’ve had problems with weak piriformis … I thought I had nailed that issue; I will look up those exercises (I know clam shell already…)

User 1138311 asks:
How does one become a professional soigneur? My girlfriend is an LMT who would love to start working with/building her business with local teams in our area but so far while people express interest she’s been having trouble helping people follow through on their interest – any advice?

SwannySara:
I found my way into it partly by chance, and partly by doggedly pursuing every avenue I could. I really wish there were more training available, but it’s still very much a “who you know” kind of ordeal. My best advice would be to try to get into a volunteer opportunity, which was what I did my first year of working the Tour de l’Abitibi. It’s the most work you’ll ever do for free, but it’s an excellent way to make connections and start to learn the expectations and nuances of the job. Another suggestion is to look for races in your area with elite/continental pro teams competing, and see if their soigneur will allow you to shadow him or her.
I actually lucked into my involvement with USA Cycling; I had applied to a soigneur training program offered by the Union Cycliste Internationale that was unfortunately cancelled due to lack of applicants. I had already taken the time off work and started sending emails to anyone I could think of pleading my case. My resume eventually got in front of the VP of Athletics at USA Cycling, who forwarded it on to their European operations manager.

The bulk of soigneurs are basically freelancers who find the work when they can, which is kind of where I am in my career right now. It has the advantage that I can keep my home base here in the states and my private practice, but I am interested in moving more toward a steady gig with an elite, continental pro, or world tour team (every soigneur’s dream). I’ll keep you posted!

I think the main thing that I didn’t know going into the job was that massage is pretty much the easiest part of it, and not necessarily the biggest or always the most important aspect. Big teams expect soigneurs to have a lot of experience with food prep, knowledge of sports nutrition, navigating race courses, driving team vehicles (including large vans), and to work in Europe it is almost compulsory that you speak at least one other language apart from English (I’m working hard on improving my French and German). I really didn’t know what I was getting into and there were a lot of parts that came as a bit of a shock! I’ve found other soigneurs to be wonderful and open about explaining their methods and expertise though, so I would really encourage her to get a taste of it.

User deaconwillis asks:
How do the elite cyclists you work with treat the off season differently than the race calendar? Any running, swimming, etc. to mix things up?

SwannySara:
Several of the U-23 and juniors riders also participate in cyclocross during the off-season, which has the benefits of high-intensity anaerobic demand and improving handling skills in tough conditions. One of the U-23 riders, who was a junior last year, won the cobblestone jersey at Three Days of Axel and credited his success to his cyclocross racing. It was a huge deal to post the fasted times on the gnarly pave amid a field of the finest Dutch and Belgian riders!

Most will incorporate more strength training during the off-season and I know several who ski (both Nordic and Alpine) for fun and fitness. Some of the Southern California guys love to surf, which I think contributes to their core strength and fantastic laid-back racing attitudes. Not a whole lot of swimming (unless a coach prescribes deep-water running for fitness or injury rehab, which is awesome exercise that everyone hates), but a few have said they like to run because it’s such an efficient way to keep off weight, and many came from cross country running backgrounds before they became cyclists. Everyone rides through the winter, but they back the intensity way off for several weeks before starting to add in the top-end fitness fine-tuning just prior to the start of the season. I think with the juniors, it’s more important to have other activities in the off-season just to keep them mentally fresh and motivated. With the U-23 riders, they have gotten to the point of cycling being their vocation, not their avocation, and they become much more serious about only pursuing other forms of activity that directly benefit their riding.

User AlvaSt-Snow asks:
Any advice for sore feet? The balls of my feet start to ache during my rides. I’ve swapped out the cheap foam liners in my shoes and put in stiffer ‘superfeet’ insoles (the green ones) and it helped a bit… but can foot strengthening exercises help? Some kind of foot massage?

SwannySara:
Several of the elite riders I’ve worked with have trouble with foot pain. Massage seems to help stretch the plantar fascia — the connective tissue and ligamentous tissue bundles that run lengthwise along the sole. I’ve had issues with foot pain while riding off an on through my own cycling career and stretching the sole surface out by rolling on tennis balls and frozen water bottles does seem to help.

Shoes and pedals make a big difference, and using Superfeet insoles was a great idea. Very stiff soles help, but make sure that the shoe actually fits your foot and doesn’t cause pressure points itself. I’ve cut up foam makeup wedges to help with shoe fit in the past; it’s tedious but actually works pretty well. Be sure your shoes are the right size — cycling shoes should not allow much movement of the foot within the shoe and your toes should be pretty close to the end of the toe box. A deep heel cup will help with foot stability.
One of the U-23 riders this spring was having a lot of issues with pain right on the ball of his foot; his trade team rode Speedplay pedals and he had just switched over from using larger platform Look pedals. The smaller pedal platform and “free float” skating action of the cleat/pedal interface didn’t distribute the pressure across his footbed as well, resulting in hot spots. He vowed to write his own choice of pedals into his contract for next season. Making sure that your cleat is positioned in line with your foot, not with the line markings printed on the bottom of the shoe (these are usually bogus and arbitrary), and moving your cleat back so the center is right below the widest part of the ball of your foot will help.

I think the biggest thing to look at with any pain on the bike is your fit. Foot pain often comes from exerting uneven force laterally across the foot, and poor knee tracking caused by improper saddle height or fore/aft can impact the angle of contact. Sometimes people with musculoskeletal abnormalities (such as internal tibial rotation) have a lot of trouble with foot rotation, and in this case shims beneath the cleat can be useful. You can do some exercises with light ankle weights and flexing the foot to either side (pronation/supination), which will help activate the peroneals to support your lower leg stability. Good luck!

That wraps up the AMA. Do you have a question to ask? Post it below and I’ll continue to add!

In Praise of Cheap Bicycles

IMG_2940

Sara with her first, much-loved, really nice bike.

I went mountain biking with my boyfriend today. We deeply enjoy riding trails together — our first date was a mountain bike ride and it’s something we’ve built vacations, recreation, and exercise around throughout the time we’ve been together.

I pulled a switcheroo on him; instead of his trusty steel Tourney-equipped battle steed, I traded it out for a demo bike we had in the shop: a glossy white carbon hardtail Felt Nine 3. It’s a sweet bike, in his size, and I was thinking about getting it for him for Christmas if he liked it.

As soon as he met me at the shop to go riding, a curtain of suspicion fell across his face. “Where’s my bike?” he hazarded. “It’s here, I just thought you might like to give this one a shot. It has your pedals and I matched all the sizing to yours. You’ll like it.” He conceded and we were off to the trail.

“How does this thing shift? I don’t like it, it’s a dumb design,” he proclaimed, puzzling with the X9 thumb lever shifters in place of his familiar motorcycle throttle-style Gripshift. “I don’t feel like I can get any power.”

We hit the trail despite his grumblings, him taking the lead while I followed. His lines flowed smoothly, he was carrying more speed into turns and keeping his weight centered while digging into the berms. His technique was effortless, and better than I had ever seen him ride.

“How was it?” I asked expectantly. “It was ok. Different than my bike. I like mine better, we just have a lot of history.”

I felt an instant pang of guilt. By thinking I was doing something nice that I would appreciate if someone did it for me, I implied that my boyfriend’s bike wasn’t good enough to be enjoyable and that he should value and want the same things that I do. My nice gesture turned out to be a pretty hurtful, offensive action — and I was completely oblivious.

We bike people get really excited about nice bikes — owning them, riding them, reading about them in glossy magazines, drooling over them and coveting them. We enjoy our sport a little bit more when we have really nice stuff. It’s normal and it’s not a negative thing; we appreciate the subtle differences of a stiffer frame, supple suspension, responsive drivetrain components, and fast rolling wheels.

But when we impose these values on other people assuming they want the same things we do, we stumble into dangerous territory. It’s like a wine snob going up to another table at a restaurant to inform the couple that the wine they are deeply enjoying is a poor vintage. By criticizing something that others enjoy, we are extending our judgment of their values to a judgment of their character. It’s one of the reasons we get a bad reputation for snobbery and ultimately drive people away from a sport they otherwise enjoy.

The fact that my boyfriend gets just as much enjoyment, if not more, out of a $200 steel mountain bike with bald tires is an act of pure enthusiasm for the sport that many of us have forgotten. We spend thousands of dollars and hours of training to coax performance out of our bikes and bodies, and to what end? We ride faster with our wallets lighter, evaluating our self worth by the thickness of the stack of race numbers in our desk drawers. The simplicity of rolling through the woods with a focus on perceiving, not judging, is something many of us forget in our quest to possess the newest and finest.

There is a place for ultra-light spaceship bikes. The gossamer precision machines piloted by the pros allow engineers and manufacturers to push the boundaries of cycling technology, which will trickle down to inform bicycle construction at every level of performance for years to come. The bike my boyfriend rides is nicer than anything Gary Fisher charged down the hills of California at the birth of the mountain biking era. It’s hard to remind ourselves of that fact when $4,000 mountain bikes have become the norm, not the exception.

It’s easy to judge a cheap bike (and, by extension, its rider) as being less serious or committed to the sport. To be fair, it is true that the bike is probably not up to the same rigors as abuse as a purpose-built trail bike. But we need to remember how we got into the sport ourselves; we probably had a bike just like that, and we got a lighter, more expensive bike because we were convinced we needed it to progress and prove our commitment. Part of that is legitimate; once one reaches a high level of skill and performance, equipment holding us back does become a concern. But having the best just for its own sake doesn’t elevate us above those riders on much-loved cheap bikes; in fact, it probably indicates that we are less committed, and less willing to stick it out despite a little bit of discomfort or higher difficulty because of the bike.

I’m not in a position to tell anyone they should change their bike, with the exception of bicycles whose fit or safety presents a risk of physical harm to the rider. I am the owner of a super-bike that I will never reach a level of skill to truly earn its superiority. I am not trying to make anyone feel bad or guilty about appreciating wonderful, expensive things, just as I recognize that telling someone their bike isn’t good enough is an unwarranted personal affront. In wanting the best for others, it is vital to remember to take into account whether we are really acting in their best interest, or imposing our own values and desires.

Take time to appreciate your bike today. Whether it is a five-figure feat of aerospace engineering or a trusty rusty steed, bicycles are imbued with the experiences shared with their rider; they are a little closer to a living thing than most inanimate objects. Love your bike for what it is, not what it isn’t. Treat your bike with love, and it will love you back in the only way it knows how: with miles of happiness and smiles.

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