Ruminations on sports, training, health, and wellness

Posts tagged “research

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.


The Power of the Human Hand

IMG_4707I’d like to kick off this blog by sharing some about one of my favorite things that I get to do in my job: teaching the massage lecture and lab unit for UNCG’s Master’s of Athletic Training education program treatment modalities course.

I’ve been teaching the class for the past 3 years, 2 of which while I was a Sports Medicine master’s student myself. Most people know athletic trainers from watching sports on TV, as the windbreaker-and-khakis-clad medical staff rush onto the field from the sidelines and tend to injured players. The bulk of athletic training, however, occurs behind the scenes in high school, college, professional, and industrial settings. Athletes put their health and well-being in their trainers’ hands, and these dedicated professionals address every need: the treatment, prevention, and rehabilitation of injuries, optimized fitness training to increase athletic ability, monitoring and recommending nutrition habits, and even the athletes’ psychological mindsets.

I’m not an athletic trainer — I am a licensed sports massage therapist — but I took a variety of athletic training courses in graduate school and I came to deeply appreciate athletic trainers’ unique skills and responsibilities. I’m lucky to use this nuanced understanding to help aspiring athletic trainers think differently about the fundamentals of their treatment protocols.

I  won’t deny that it’s hard to come into a classroom full of allied healthcare professionals as a massage therapist and expect them to immediately accept what I have to say, so this year I started with a video from TED. We only watched the first 2 minutes or so, but the whole thing is very worthwhile.

Dr. Verghese’s powerful argument for the role of touch and ritual in medicine is a great jumping-off point for my case for the reemerging emphasis on manual therapies in athletic training. The research on sports massage is finally catching up to the millennia-old evidence-based practice of hands-on techniques to promote recovery and treat injuries. A seminal paper from last year by Crane, et al. demonstrated physiological changes at the cellular level in tissue that received massage following an exhaustive workout that were not present in the untouched limb — the cells showed signs of hormone activity promoting cellular repair, immune changes, decreased inflammation, and formation of new healthy mitochondrial tissue. Dozens of other studies are showing promising results that echo one main point: in many cases, massage improves recovery, but in absolutely no cases have studies found that it can cause harm. Very few treatments can boast such positive results.

Mechanical manipulation of sore or damaged tissue can help tight or circulation-impaired tissue to regain its original resting length and balance. Carefully applied neuromuscular pressure can decrease pain symptoms and ease myofascial trigger points. Massage can slow the atrophy of tissue that must be immobilized due to injury, and increase lymph and blood circulation to supply nutrition to healing tissues. The science supporting sports massage makes its potential advantages abundantly clear, and sports medicine professionals of all types are increasingly expected to be familiar with its techniques and applications.

During the three hours we spent together, I felt a shift in the athletic training students’ attitudes as their preconceived notions began to erode. As they practiced a few hands-on massage techniques and carefully observed me demonstrate my methods, it was like watching gears visibly click into place and appreciation emerge. We talked about a variety of real-life conditions they had dealt with and how they could be addressed with massage or other treatment modalities, and the students came up with great ideas and questions that I hadn’t even considered. I watched with pride and admiration as 10 aspiring trainers realized the enormous potential for treatment that they already possessed and carried with them wherever they went — their own hands!

Few things get me more excited and inspired as seeing young people engage with science, medicine, and discovery in a new and innovative way. I love teaching that class so much because the students I work with give me hope for the future of my profession, of sports, and of healthcare. Through recognizing the legacy of our medical forerunners and synthesizing their methods with emerging science and technology, we can accomplish extraordinary things; sometimes, all we need is the simple power of touch.