Barefoot and pregnant…in my massage room.

As soon as I finished massage school, I kicked off my shoes and socks and have massaged in my bare (clean) feet ever since! I just feel more comfortable barefooted: grounded, comfortable and stable. I prefer to be in bare feet at home and while squatting and deadlifting too!

What I didn’t expect was I was setting myself up for some seriously achy feet late in my pregnancy!

However, my sore, tired feet were definitely the least of my pregnancy worries while working as a Massage Therapist. I finished working at 35 weeks pregnant and now at 37 weeks I am nesting, resting, enjoying working out and being outdoors before baby arrives.

Many of my amazing colleagues and friends gave me fantastic advice on how to survive pregnancy while working as a self-employed RMT. It’s hard to know how you will feel while pregnant, but I thought I would share some of this wisdom and some personal experience of my own.

It is important to note that every woman is different and every pregnancy is different. So what worked, or didn’t work for me may not be relatable to you! The number one rule of being pregnant: Listen to your body!

How to Thrive During Pregnancy

Before pregnancy – There are a few things I suggest are important to consider before becoming pregnant.

• Maternity leave – To pay into Employment Insurance (EI) or not, that is the question as a self-employed therapist! This is an extremely personal decision and I think it’s important for each person to do their own research and discuss with their partner. (Government of Canada Employment Insurance information). It is important to know that in Canada once you start paying into EI, you must continue to do so for the remainder of your self-employed career.

In my life, it was a better and simpler decision to work hard at saving money to allow myself a few months of maternity leave and have my partner, Shaun, take parental leave which he is entitled to through his work. What an amazing opportunity for him to bond and spend time with our son or daughter!

My flexible plan is to go back to work two half days a week after being off work for five months. This will obviously depend on how my family is doing and if, mentally and physically, I feel ready!

• Mental Preparation – Honestly, I have struggled being pregnant. While I’m so grateful and excited for Shaun and I to be having a baby soon, I have struggled with the lifestyle change more than I expected. Growing another human is HARD!! Much harder than I expected. I do wish I had mentally prepared myself a bit more for the fact that I might have to slow down more than some women have to, that I might feel nauseous every day, that I may not sleep well and that I needed to gain more weight than I thought I would. Again everyone is different, but I do think it is important to note that some of us will find it a big change from what life is normally like.
• Get strong – I cannot believe how good my body has felt during pregnancy! I have had almost zero complaints about aches and pains during and outside of work. Maybe I’ve been lucky, but I actually think it has a great deal to do with the fact that I was/am fit and strong. Strength training is a huge passion of mine, and the benefits have clearly served me well during pregnancy. Being able to lunge, squat and press helped me stay strong at work. Having strong posterior muscles (glutes, erectors, rhomboids, etc) have helped me to stay balanced with all the extra weight that I have gained on the front of my body. Having a strong core also makes it easier to support yourself while leaning over and onto a massage table.

Trimester 1.

Oh the hormones, nausea and exhaustion! Luckily, not every woman experiences a terrible first trimester and I hope you are one of them! Unfortunately, I was not so lucky. Here are some tips on making it through!

•  Scheduling – are you able to be flexible with your schedule? They call it morning sickness, but many women experience it in the morning, the afternoon or the evening or in my case all dang day! If you are able to schedule your clients during the times that you feel the best, I suggest doing so.
• Eating – nausea and food aversions are a challenge for anyone. But for a massage therapist with a hard, physical job, food is necessary to keep you energetic! In my case, if I didn’t eat, I threw up. My strategy became to eat a few bites of food after each client. This seemed to keep my nausea controllable and my energy high. Find things that are appealing to you and snack on them all day. Most recommended were high protein foods that would keep me feeling fuller longer and blood sugars stable.
• Planning – soon you will be telling everyone that you are pregnant! So exciting! So this is a good time to think about how long you would like to work. Your clients will want to know so they can take full advantage of you while they can!

Trimester 2

I hear most women start feeling really good during their second semester: a lot more energy and a decrease in morning sickness. Time to take advantage!

• Scheduling – If you’re feeling good and are trying to save money for maternity leave, I suggest trying to work as much as you’re comfortable, while not overdoing it. Likely, you will want to drop your hours down during your third trimester.
• Eat healthy and Eat often – My trick was to make a large healthy meal (or normal for me before pregnancy) and divide it into two or three smaller meals. I would then eat these smaller meals throughout the day to keep my energy high. This also helped with my constant nausea. I ate like this my entire pregnancy. Remember you’re nourishing not only your body but your baby as well!
• Constant advice – be ready for opinions and unwanted advice from EVERYONE! I have to say, most of what I experienced was fantastic and useful advice!  You will be flooded with people being excited for you and maybe some clients making you feel a bit guilty about going off work for a while (“can’t you just bring baby to work with you?”). Remember everything is your choice and you should do your own research into what is best for you, your body, your baby and your family.

Trimester 3  

As baby grows, so will you! This may leave you feeling heavy, large, hot, fatigued and starting to get uncomfortable. Lucky for me I have had a lot of energy during my third trimester and my arms are long and ape-like so I didn’t find massaging uncomfortable. I actually loved going to work and worked five days a week until 35 weeks! Sure, I decreased my hours a bit but I was still doing four to five 60 minute massages a day. Working helped keep my mind off of being nauseous and my nervousness of labour and delivery.

• Grow some thick skin – People will tell you anything and everything while you’re pregnant. I had comments on my body: “You need to get a handle on your weight gain” and “I hope you’re still exercising.”  A lot of comparison with other women: “Oh my sister was way sicker than you” or “my friend was still running until 37 weeks.” The horror stories of birth: “36 hours of labour and 4 hours of pushing and she still had to have a caesarian section.” And the tough love: “It’s not about you anymore.” My normally overly sensitive self was left feeling down and defeated after some comments. While some things can be hard to hear, at some point, you have to just let it all go and know you’re doing your best.
• Put your feet up – One of the best pieces of advice was someone telling me to book a significant break in my day to put my feet up. I found in the last month of working I needed to sit down and put my achy (and still bare!) feet up for least 20 minutes. It’s also a great time to eat and cool down (baby makes your body feel like a furnace!). Sometimes longer breaks are good for fresh air or having a quick nap if needed.
• Listen to your body – This has to be the best but also a challenging thing to do. Some women will feel amazing their entire pregnancy and will work a lot more and longer than I did!  Some women will be a lot more active than you and I are. And some will need to be on bedrest or stress leave. Everyone is different, so do what is best for YOU!

Other Things To Consider

• Stay active – If you were into some activity before pregnancy, try to continue to do some form of it during. You have a physical job and you need to keep up your strength and endurance for it! You are about also about to do the most challenging workout of your life when labour begins! I think it’s very important to be fit and strong to push out a baby, recover well after a vaginal or caesarian birth and take care of your new baby and yourself. At 37 weeks pregnant, I still strength train 2-3 days a week. I crave fresh air and so I walk most days. I swim and oh man, does it feel good! Do what you enjoy, but  again listen to your body.
• Electric table – I was so lucky to be able to work with an electric table. The further my pregnancy went along, the higher I needed to set my table. If you have access to one, use it.
• Your memory might suck! – There were times where I questioned whether I had massaged the other side of the body already, where I couldn’t remember the name of an easily identified muscle and had no clue the name of the person on my massage table. It is and was such a weird feeling! One trick I did use with new clients was to say their name several times within the first few minutes of meeting them. It seemed to help solidify their name to my memory during the massage!
• Be Proud – You are growing another human and that takes a lot of work, physically, mentally and emotionally! My favourite piece of advice came from my good friend and fellow massage therapist, “Be gentle with yourself. You and your body are doing amazing things and you should be proud!”

A little while ago we wrote a piece on circulation and whether massage is actually moving fluids around and increasing circulation.

As it turns out, we aren’t increasing circulation the way we used to think was happening (you can read that post here if you like).

One thing that came up as a result of that post, was the question of whether we need to decrease the length of our strokes when giving a massage in certain conditions?

Looking back through my textbooks and notes from college, conditions like diabetes and hypertension were given similar contraindications. In fact with diabetes CI’s it was recommended that massage strokes are modified to short, segmental strokes to prevent large volumes of venous and lymphatic fluid return to the heart. It is also recommended that repetitive, passive large limb movements should be avoided as well.

So are these CI’s really necessary?

Stroke Length

When someone has diabetes and blood glucose is high for extended periods (years), then plaques can form in blood vessels causing damage and impaired blood flow to neighbouring cells. This is called Peripheral Arterial Disease (PAD).

This poor circulation can be one of the causes of peripheral neuropathy along with excess body weight and high blood pressure. 

One study showed that using massage therapy helped increase circulation in the lower limbs of type II diabetic patients with improvements in arterial pressure and greater skin blood flow. Fortunately the study acknowledged the parasympathetic nervous systems role. Indicating decrease in heart rate and a rise in oxygen saturation. This study was done to see if there were improvements in peripheral arterial disease and fortunately it showed that massage could help slow the disease progression. 

This study used very specific treatment patterns using both long and short strokes to the back and the lower limb of the patients. But notice they used both long and short strokes. 

As we learned in the post we did a little while ago, during a massage we aren’t increasing overall circulation anymore than the circulation increased by the person walking into your clinic. So how then would altering the length of your stroke make any difference?

I’d venture to say it doesn’t.

As far as passive large limb movements being CI’d, again there is no way it is altering circulation more than the effort it took to walk into the clinic. If professional athletes like Bobby Clarke and Max Domi can play hockey at the professional level while managing their diabetes, a passive limb movement during a massage isn’t going to cause much of an issue.

Ketoacidosis And Diaphragmatic Breathing

Ketoacidosis occurs in diabetics when their cells don’t get the glucose they need (due to a lack of insulin, or too much insulin resulting in low blood glucose), the body starts to burn fat as a replacement.

As this process develops, ketones can build up in the blood (ketones are an acid developed from burning fat) which then changes the pH balance in blood making the balance too low, where it becomes more acidic. This in turn sends a person into diabetic shock, which is a life threatening emergency. A person with diabetes can have this happen for three reasons:

1. Missing a meal.
2. Stress or sickness.
3. Insulin reaction (low levels of insulin in the bloodstream).

We were told in college that diaphragmatic breathing was a contraindication for our diabetic patients as it could cause ketoacidosis. From the textbook we were taught “To compensate for a tendency towards acidosis, the person may need to breathe more rapidly. Diaphragmatic breathing may actually change insulin levels”.

Now, don’t get me wrong, I give full props to the authors of that text as there was lots of good instruction in it, but research has been updated since then.

According to diabetes.co.uk rapid breathing is a symptom of ketoacidosis, so this is typically occurring if the person hasn’t taken enough insulin. So yes, if the person is at the point of breathing rapidly we should not be giving them a massage as this is now becoming a medical emergency.

One study ⁽¹⁾ actually showed that diaphragmatic breathing is an effective therapy for decreasing oxidative stress, improving blood sugar levels after eating, and improving glycemic parameters overall for those with type II diabetes.  

Another study ⁽²⁾ (done on people without diabetes) showed that diaphragmatic breathing decreased glycemia and increased insulin production after a meal (likely through activation of the PNS). The study suggests that even though it was done on athletes, it is worth looking at for the diabetic population because of the outcomes.

Now I know what you’re thinking, those two studies showed that diaphragmatic breathing altered insulin and blood sugar levels…isn’t that exactly what the text was talking about?

Well it is, but we were taught it was a contraindication. Studies are now recommending that the diabetic population should be using diaphragmatic breathing.

Our actual concern should be timing of food intake before someone with diabetes comes in for a treatment. If someone hasn’t eaten for three or four hours and comes in, their breathing patterns are not what is going to cause them to have a diabetic reaction, it’s the fact their blood sugar is already too low. There is nothing about the massage that is going to accelerate that anymore than if they were walking down the street or sitting on the couch at home. This is an important discussion to have with your patients who are dealing with diabetes and definitely one you should have. Once a proper management schedule is established, go ahead and move them passively, use diaphragmatic breathing and whatever length of stroke you like, they are all things that can help improve their condition.

I’d love to hear your thoughts on this in the comments below, especially if you know of any current research that says we shouldn’t do any of the things discussed in this post, cause maybe I just found the wrong research?

 

References:

1. Hegde S, Adhikari P, Subbalakshmi N, Nandini M, Rao G, D’Souza V. Diaphragmatic breathing exercise as a therapeutic intervention for control of oxidative stress in type 2 diabetes mellitus. Complementary Therapies In Clinical Practice [serial on the Internet]. (2012, Aug), [cited May 1, 2017]; 18(3): 151-153. Available from: CINAHL Complete.
2. Martarelli D, Cocchioni M, Scuri S, Pompei P. Diaphragmatic Breathing Reduces Postprandial Oxidative Stress. Journal Of Alternative & Complementary Medicine [serial on the Internet]. (2011, July), [cited May 1, 2017]; 17(7): 623-628. Available from: CINAHL Complete

 

Most of us have had the experience that somehow we “knew” something that we did not have specific prior knowledge of. It’s tempting to start indulging in magical thinking but the science-minded therapist knows that’s not how it works. So how does it happen? One obvious answer is pure coincidence. Another less obvious answer is unconscious learning.

Todd Hargrove wrote one of my favorite articles on the subject, “Why Massage is Like Chicken Sexing.” In it he describes how unconscious learning can lead us to believe in magical thinking. I’d never really thought about it but he had a good point.

In fact, I came to realize that probably most of our learning is unconscious. We learn to talk by being immersed in language and, little by little, learning to decipher what is being said by those around us without applying conscious effort. While our parents may try to help us learn to walk, the fine points of balance and running and adapting to varying terrain are learned by experience rather than specific attention to them.

The placement of buildings and trees in our environment is something we may not purposely attend to but our brain is still taking in this information. If something in our environment changes it catches our eye, even though we may not have paid much attention before.

Intuition Vs. Experiential Knowledge

About five or six years into my professional life I reached an uncomfortable plateau.

Until then, it seemed I was constantly learning new things, always progressing, but I started to feel as if I were stagnating, even going backwards. One day, while giving a massage to a more experienced massage therapist I voiced this. She said to me, “You must be learning something because you keep stopping in all the right places.” I had no idea I was doing this.

It occurred to me that my brain, through my hands, must have been picking up subtle cues that my conscious mind did not notice.

Years later there were other experiences, one with a competitive skier. About ten minutes into a massage he commented that he could tell I was very experienced. I asked him exactly what made him say that since I was just warming up and not yet doing anything specific. He he told me, “I can feel you adjusting and changing your pressure in the places that are tight and sore.” Again, I did not realize I was doing this.

The occasion that particularly stood out was with a dancer. He was the oldest member of his dance troupe and had been with them the longest. He was taciturn and clearly tired. I asked him how he felt. “Tired. Sore. Too much jumping,” he said in his Slavic accent. He pointed to a few places and lay down on the table. As I was massaging the back of his upper leg, I felt something that got my attention and the thought popped into my mind, “Old injury.” I’m cautious about what I say to athletes and performing artists prior to their performance, I don’t want to undermine their confidence in any way. Although I would never say it anyway, one should never say, “Wow! You’re really tight!” shortly before a performer is going onstage. I asked him, rather casually and neutrally, “How does this feel?” “Hurts,” he said, then added that he’d pulled a hamstring jumping. “When was that?” I asked. “Two years ago.” Wow, I thought, did I nail that or what?

Of course, it doesn’t always work like that but it was a cool moment. Later, when I told another massage therapist about it, they asked, “How did you know that?” I started thinking, exactly how did I know? Intuition? But what is intuition? Is it some sort of magic or is there a plausible explanation for it?

Then an answer came to me: my hands have been on thousands of bodies for tens of thousands of hours in varying states of injury and pain and no pain. Without my conscious awareness, my brain is paying attention at every moment. There is a large body of experiential knowledge. Probably something felt similar to other old hamstring injuries I’d felt many, many times before.

Or maybe it was pure coincidence.

Unconscious Learning And Accumulated Massage Experience

Unconscious learning probably plays a much larger role in our lives than we realize.

Is this any less awesome than thinking some sort of magic is at play? I don’t think so. It’s incredible that our brain can do that and very useful, too. If we had to put conscious effort into every single thing we learned, we wouldn’t learn very much at all.

All of these intuitive moments came about as a result of years of accumulated experience. In the beginning, sometimes someone more experienced would palpate something and point it out to me. “Here, feel this?” I would have no idea what I was supposed to feel. I had no body of experience (or enough experience of bodies) that allowed me to interpret what I was palpating. It’s important for beginning massage therapists to understand this and not become frustrated if they feel lost. It’s also important that one should not be overeager to jump to conclusions prematurely.

Too often, massage therapists are quite certain they feel things that are simply a product of their imagination, what has been called “palpatory pareidolia.” (Pareidolia is seeing patterns where none exist, such as seeing a face in a rock or a horse in a cloud.) Palpatory pareidolia can lead a therapist to pathologize normal tissues, causing unnecessary worry to the client or making themselves look ill-informed.

We want to avoid making assumptions so they don’t get in the way of seeing what is, rather than what we imagine. We want to be fully open to the client as they are, not as what we project onto them. However, as we gain many hours of experience with many, many clients, we can develop a kind of knowledge which we think of as intuitive that is probably a result of many years of unconscious learning.

In practice, when an idea comes from that intuitive place, I always check with the client, asking in a neutral manner so as not to alarm them or lead them to an answer. After all, I could easily be wrong.

The next time you have a moment where you seem to sense something without knowing why, take a few minutes to think about what past experiences or cues may have led to that. It may not be immediately apparent, but if you contemplate it for awhile you may get some clues. It will help you appreciate the role unconscious learning plays in your life. Pretty amazing, isn’t it?