Ruminations on sports, training, health, and wellness

Posts tagged “evidence based practice

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my own approach to science and knowledge; one of my great frustrations with massage school was hearing teachers parrot outdated assertions because that was the way it’s always been done, even though advances in science give us new perspective on our practices.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


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!


Why We All Need Evidenced-Based Practice

evidenceYou may have heard the term “evidence-based practice” bandied about in relation to a broad range of disciplines, from medical practice to education to social psychology. Although the term was coined in 1992, the idea has been around for much longer, emphasizing a synthesis of rigorous peer-reviewed research, clinical observation and expertise, and interpretation of anecdotal and intuitive information through the scientific method. Evidenced-based practice has quickly gained traction among the medical community and has helped to improve patient care and practitioner credibility through establishing standards of practice and reliable sources of information.

Evidence-based practice (EBP) was a new concept to me when I started graduate school, which in retrospect is actually a little alarming. I immediately saw the potential to apply EBP to my massage therapy, and found it a little hard to believe that this wasn’t being already routinely taught and reinforced in massage schools. The school I attended has an excellent reputation and I believe that I got a high-quality foundation in massage therapy. However, the two days of class (out of an entire year) that we spent on reading and evaluating peer-reviewed journal articles were sorely inadequate (and the information on how to evaluate the impact of studies was cursory at best). I don’t think everyone needs to have taken graduate-level research methods and statistical analysis to be a great massage practitioner and consumer of information, but the disconnect I see between empiricism and practice in my profession troubles me.

I feel like massage therapy, as a discipline, is at the same crossroads that chiropractic medicine was 15 or 20 years ago. Chiropractors faced a conflict between highly educated, skilled practitioners whose methods were informed by keeping up with current research and their own expertise built upon observation over years of practice, and practitioners with dubious credentials who peddled quackery and “cures” on par with the snake oil salesmen of yesteryear. Chiropractors managed to change and improve standards of practice and the educational gateways to certification and licensure, bringing the profession as a whole into a more credible light in the medical community.The key to this paradigm shift was attention to the existing body of empirical evidence and constantly questioning tradition, asking “is there a more effective way to do this” than simply accepting that the current methodology is best because it’s the way it has always been done.

I routinely hear massage therapists insist that massage helps to flush lactic acid from the body to reduce the onset of muscle soreness. While this was an accepted explanation of mechanism 30 years ago, advances in muscle physiology now suggest that lactic acid uptake occurs rapidly following intense efforts and physiologists agree that lactate buildup is not responsible for delayed onset muscle soreness (although the exact mechanism remains unclear). The research has progressed to offer new answers and better understanding because we continue to question why and how. Keeping up with current empirical evidence and developments is an essential part of EBP – otherwise, our practices stagnate and we end up reinventing the wheel with each iteration from teacher to student. (On a side note, a slightly devious confession: I actually like using the lactic acid uptake question as a litmus test for massage therapists to see if they are keeping up with the literature or just parroting what they learned in school. It’s surprisingly revealing.)

Perhaps EBP’s greatest strength is the emphasis on blending old with new, looking to history and tradition as well as the latest empirical research and clinical evidence to offer the best possible clinical reasoning. I often einsteinhear things like “massage wouldn’t have been around for thousands of years if it didn’t work,” and I think there is merit to this argument. At the same time, it is essential to use all the modern tools at our disposal to question tradition; otherwise, people might still be saying the same thing about antiquated practices like bloodletting that have been discontinued, having been disproved by scientific inquiry. By testing traditional wisdom through carefully designed experimentation, we can confirm methods that promote beneficial effect and eliminate those that may be ineffectual or even harmful.

What I hope for you to take away is an appreciation for the rigorous questioning of information. Assess the reliability of your sources and note where they agree or diverge. Seek a multitude of resources and opinions, and ask meaningful questions about why we do what we do. Be confident in your convictions but always ready to entertain questions and defend them honestly and with awareness of all factors, even when they are in conflict. Don’t settle for “this is the way we do things,” but challenge the norms – at the very worst, you will confirm the veracity of your claims, and at best you will be armed with new knowledge to improve upon your methods and reach toward excellence. This is the very basis for growth in everything we do, and it is an absolute win-win. My charge to you is to challenge something small every day, and keep digging tenaciously until your curiosity is satisfied.