Ruminations on sports, training, health, and wellness

Posts tagged “treatment

Relentless Curiousity

IRWBXDPPRSOFLSH.20141104162200

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!


Bretagne wrap-up

Image

Sometimes in life, I have found that intense, completely immersive experiences often need time to be processed before I can appreciate the content with a more objective, analytical attitude without the haze of emotional exhaustion. A slower Saturday morning today has given me that valuable time for reflection and organizing my thoughts.

Working a major race as elite cycling team staff is not for the faint of heart, and I am coming to understand why the turnover in the industry is comparatively low: people who aren’t up to the rigors of the work for whatever reason burn out quickly, and the few who make the cut tend to become career team staff. I’m not sure who works harder: mechanics or soigneurs — both jobs require long hours of exhausting work.

The Tour de Bretagne was a UCI 2.2 stage race, which means a limited number of national teams were invited (in this case, 2: the USA team, and the Australian national team) along with European continental teams, pro development teams, and pro tour teams. It’s a very high-level race in which stage winners and riders high in the overall finish ranks have historically continued on to successful professional careers. The race consisted of 7 stages between 145 and 200 kilometers long over challenging terrain and road surfaces in the rural northern coastal country of France. The six USA national team riders selected for the race were charged with two major tasks: to ride hard and return some good results, but perhaps even more importantly to learn the skills needed to race at that level which professional teams look for in prospective riders. To paraphrase their director, former pro rider Michael Sayers, racing at events like these presents a goal that isn’t necessarily meant to be attained, but for learning to occur in the process of striving toward that goal. Bringing away a couple good results and a wealth of experience constitutes success, and in that respect the Under-23 riders of the USA national team were very successful.

As for my part, my role was to serve as an apprentice soigneur to Robert Grabowski, another alumnus of the pro leagues who worked for Liquigas-Cannondale and BMC world tour teams. We arrived at the first host hotel in the evening 2 days before the race began, which gave me a day to prepare and learn the ropes a bit.

My first task the next morning was bottle prep. The general policy is to distrust drinking tapwater in many parts of Europe, so I had to make a grocery store run to purchase bottled water for drinking and food supplies for the next few days. Every part of the process involved some unforeseen complication; nothing was easy. I drove the van, an enormous Fiat Ducato, down winding narrow French roads (having to turn back twice because the GPS wanted to take me under bridges too short for the van’s height) only to find that the grocery store had underground parking also too low for the van, so I had to parallel park it on the street. For comparison, I drive a compact hatchback Honda Fit back home — the van is roughly 1.5 Fits wide, 2.5 Fits long, and 2 Fits tall. I’m just relieved my parents insisted on me learning to drive a stick shift as a teen; that was the one part of the whole process I felt competent doing. I managed to park the van without running into anything, popped a couple of coins in the locks to retrieve shopping carts (that part I remembered!), and ascended the escalator. An hour and a half later, I had collected 250 liters of bottled water in various sizes of containers and enough groceries for a small army. It took me a long time to identify the translations of food products in an unfamiliar store layout; my basic French vocabulary got me only so far. I negotiated the transaction in my nonexistent French and haphazardly wheeled about 300 kilos’ worth of water and food back down the escalator (a feat in and of itself), drawing copious weird glares from onlookers. With water and food loaded up, I made my way back to the hotel to wrap up race food and bottle prep and begin with rider massages.

The one part of soigneur work I feel thoroughly comfortable performing is sports massage; I’ve been doing it for 7 years and have taught seminars at the graduate level for the last 3, so I feel like I have that part down. It was honestly a relief to be able to focus my energy for a couple hours on something in which I am well-versed and experienced; it’s hard work of a different kind, but work where I don’t feel like I am constantly questioning myself and I take solace in that practice. I am told that coming from a sports medicine background is surprisingly uncommon among beginner soigneurs; many come from another aspect of sport or industry and have to learn the bodywork and recovery component as they go. Having extensive training in what is ostensibly the most difficult and most important part of the job gives me time to iron out the rest of the details, which are complicated to learn but easy enough to perform once routine is more established. It didn’t feel like it at the time, but in that respect I am very fortunate.

The Tour required several hotel transfers, so the plan was for me to get the riders to the race, do the feed zone, and get to the finish to bring them back to the hotel while Robert drove the box truck to the next hotel and prepared all the details. The first stage didn’t require a hotel transfer, so I was able to shadow Robert and learn the responsibilities and layout of a race stage. I wrote this list up during the week, and it is a pretty darn accurate characterization of most of the stuff a soigneur needs to keep in his or her head at all times:

Before the race

  • Up early, shower and pack, breakfast
  • Prepare race food
    • Get baguettes from hotel
    • Make sandwiches for soigneur(s), mechanic, and director. Pack in musettes with goodies
    • Make post-race sandwiches and rice for riders. Also fill a musette with fruit. Pack condiments, tuna, oil, and utensils for the rice
    • Make 2 thermoses of coffee and one of hot water for tea. One coffee for team car, one for riders. Pack cups, sugar, creamer, and stirring things
    • Make snack sandwiches with milkbread for riders and pack in aluminum foil. Do one savory variety (ham and cheese is good) and several sweet ones (Nutella, honey, jam, etc). Make 1 per rider with some extras for musettes
    • Wrap cake or waffles in aluminum foil for riders
  • Restock race food bars and gels
  • Prepare bottles
    • At least 5-7 per rider — 2 for musettes/feeds, 2 for the bike, and 1 for every half hour of racing. More is better and topping off the coolers is recommended
    • Pack water and fresh mix in the cooler for the team car. Include some mini Cokes and Fantas, some sparkling water for director and mechanic, and any other goodies they request
    • Rotate the previous day’s mix from the car cooler to the van cooler and put it on the top row to go on the bikes and in musettes first. Put fresh mix as needed on the bottom row.
    • Dump mix after day 2; it’s no longer good
    • Pack mini soda in the gaps and include a bottle of ice if necessary
    • Make sure the van is stocked with water, empty clean bottles, chocolate milk, and plenty of mix for hydration, preload, and recovery mixes
    • Mark mix with an X and recovery with an R
    • Bring a large bag of clean empty bottles to fill during the race
  • Fill empty 1.5 L bottle with tap water and put in the freezer to use for ice
  • Pack gels and bars in the team car as per director preference. Some use a box, others just stuff them in the door pockets
  • Clean and stock the van
    • Vacuum and sweep floors, wheel wells, bike area, etc
    • Wash the exterior and Windex on mirrors and windows (this can also be done the night before)
  • Program start parking into the GPS
  • Pack the following race items in the main compartment:
    • Towels and washcloths for each rider plus spares
    • Podium bag with bottle for recovery
    • Race food — bars and gels
    • Spare clothing bag
    • Supply box with chamois cream, massage creams and oils, baby wipes, sports wash, embrocation, sunscreen
    • Medical box
    • Finish cooler bag with bottled water and Fanta for each rider
    • Spare musettes
    • Food box of snacks, coffee, race rice, tuna, bowls, utensils, condiments, etc
    • Folding chairs for each rider
    • Wind vest for the feed zone
    • 2 helmets (small and medium) in the van, 2 in the team car
  • Pack in the bike compartment:
    • Cooler
    • Trash bags
    • Spare bottles
    • Aluminum foil
    • Mixes and hydration supplies
    • Extra water
    • Extra soda and juice
    • Milk/soy milk/whatever they want for recovery that day
  • Black and white permanent markers

At the start

  • Drive riders to the race start and park so as to make a nice area for them
  • Put out folding chairs (under the awning, if necessary)
  • Put out cooler, race food, regular food box, supply box
  • Offer pre-load and put 2 bottles on each bike of whatever the riders want to start
  • Massage legs/apply embrocation as needed
  • Program feed zone location into the GPS
  • If time permits, go to start line with riders to top off bottles and take extra clothing

Feed zone

  • Drive to the feed zone
  • Stop for gas on the way if necessary and time permits
  • Find a good, visible parking place near the end of the feed zone
  • Program the finish line into the GPS
  • Prepare musettes for each rider
    • 1 bottle each of water and mix on opposite sides
    • 1 bar
    • 1 gel
    • 1 bit of cake or Nutella sandwich in aluminum foil
  • Tie a knot at the top of the strap
  • Prepare recovery, mark bottles, and place in the cooler
  • Prepare 1-2 dishes of post-race rice for riders taking the team car instead of the van
  • Fill bottles for the next day if needed
  • Pass musettes to riders on the right side of the road
    • Step into the road no more than 1 meter and face riders fully. Hold the tab straight up so it presents the bag at hand-level to the rider. Let go quickly and gently
    • Pass any extras to the team car
  • Jump in and proceed to the finish location post haste

At the finish

  • Park the van near the finish line in a good location for getting out after the race
  • Prepare an area for the riders
    • Folding chairs out for each rider
    • Bottle of recovery, towel, and washcloth on each chair
    • If in a safe location, put out food box and supply box
    • Riders bags out if someone is there to watch it, otherwise locked in the van
  • Program hotel address into the GPS
  • If there are multiple circuits, take a musette with bottles to feed
  • If no circuits (or time doesn’t permit), also take the finish bag and podium bag with a bottle of recovery inside
  • Set up at a visible location well past the finish line and flag down riders. Give water and Fanta, give directions to the van, and give the first rider the key
  • Check anti-doping at the finish line, and take a picture of it if possible
  • Head back to the van, do first aid if needed, and pack everything up
  • Give post-race recovery food to the director for riders going in the team car
  • Put dirty bottles in a bag or another cooler. Throw away bottles used for recovery; they will always have a weird funky sour milk smell
  • Pack everything up and head out

At the hotel

  • Unload and tidy up the van while riders are getting showered
  • Put perishables in the refrigerator
  • Start a load of riders’ laundry
  • Set up massage table and supplies, overturning furniture or using a hallway if necessary. Try to get linens and towels from the hotel, if not use stock and wash daily
  • Massages for all riders, ~30 minutes each
  • Put riders’ laundry in the dryer or on drying racks
  • Go eat dinner
  • Leave dry clothes in the hall with bottled water for the riders
  • Wash van and team car if weather/time permits
  • Wash dirty bottles if needed
  • Go for a run or straight to bed. Or beer, this is a good time for beer too.

So that’s it, in a nutshell. In addition, hotel transfers require all kinds of tedious minutiae, like getting room keys and wifi passwords, so those responsibilities are added in with a bare-bones staff.

Murphy’s Law hung like a shadowy specter nearby all week — if something could go wrong, it invariably did. One rider crashed in the last few kilometers of the first stage, a face-first header that left him bloodied and concussed, forcing him to withdraw from the competition. Another rider succumbed to a nasty illness during stage 4 and abandoned the race. On stage 5 I had a fender-bender with the team van when another car tried to pass and cut me off in a one-lane roundabout, and the French police refused to help with the paperwork so I did the best I could with the chasm of language barrier. I fumbled musette feeds and completely forgot to check anti-doping on one stage, delaying the whole team’s departure from the finish site. The sky poured rain and blew gale force winds and baked the slimy, muddy roads and cobbles with searing sunlight. I chastised entitled French sports fans trying to steal bottles right out of my musette for circuit feeds (seriously, guys?). I forced back tears on more than one occasion and struggled with the language barrier and shame over my beginner’s pitfalls with Robert, and his frustration with having to take the time to train a novice when time itself is at a premium. It had its tense and terrible moments, and I found myself wondering what I had gotten myself into frequently.

But it also had its moments of beauty and levity; I made it through the week, and I came back to Sittard visibly changed: more confidence in my abilities, more relaxed around the riders and other staff, with better strategies to ask the right questions and keep track of the answers, and a wealth of notable information in my brain and in detailed notes on my iPad. Serving as an apprentice soigneur helped me understand the structure of an elite cycling race and with the basics established, I can focus more of my attention on helping the riders and the other team staff to have a great race.

Bretagne feels like a distant memory now that I’m packing up and preparing to head to the Czech Republic for the Course de la Paix (“Peace Race”) the day after tomorrow. I’ve graduated from second-string soigneur to having my very own program in my charge: the USA national juniors team, a group of six outstanding 17-18 year old racers, some of whom are on their very first trip to Europe. I’m starting to get beyond my new-job anxiety and excited about what I can teach them and learn from them. Putting oneself wholly in the service of others is a humbling and enriching experience. As tough a job as this is, it really is an honor to be a part of the journey for riders on their way to achieving great things.

Tomorrow we make all the necessary preparations to depart, and adventure again awaits. More dispatches from the East to follow!

 


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.