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Critical Thinking And Planning Your CECs

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I’m coming up on my 15th year as a physical therapist.  It’s hard to believe, as I still feel so young and I still have so much to learn!  

Over the years, I’ve spent many weekends in courses, trying to become a better physical therapist. Earlier in my career, I would walk in, wide-eyed and hopeful that I was going to learn the ‘one thing’ that I was missing from my skill set…another tool for my toolkit.

Over the years, I’d like to think I was more helpful than harmful , but I don’t have any data to support that.  I can recall smooshing on ‘trigger points’, trying to release very specific muscles, and giving ridiculously long home programs. I followed protocols, and made a very organized binder of Muscle Energy Techniques.

I would often go home a bit tired, because I spent the day trying to figure out what I was doing wrong, trying to figure out why some people got better and some didn’t. I spent lots of time, energy, and money hoping my next class would be the one where I’d walk out with the skills that would let me help more people.

Then I started hanging out with Sandy Hilton. And reading more research. And talking about what we know vs. what we do vs. what we say we’re doing with researchers and clinicians from all over the world.

It was discussions like these that really made me reconsider how I was looking at continuing education.

How To Start Critically Thinking About Your Continuing Education.

Below is a list of four methods I like to use when picking my next CEC. While it can be tough making these choices at the start, it has been a really beneficial way to start changing my outlook and my practice for the better.

1. Look for courses that teach you principles, not protocols.

  • Recipes are wonderful when you’re baking. However, people are not all the same. Trying to make everyone fit the same box results in lots of  ‘non-responders’ or ‘non-compliance’

2. Look for instructors who don’t mind being questioned, and question them.

  • It’s often said that if you’d really like to learn about something, teach about it. I believe this is true, and it’s not just the research to teach a topic! I learn so much from people asking me questions, or asking me to further clarify something I’ve said. None of us know everything, so instructors who rely on people just following instruction are actually just looking for followers. Which takes us to the next point…

3. Question what you’re doing and why!

  • Sometimes it pays to act like a three year old: ask why, a lot. To yourself or out loud. Or a slightly more mature approach that I learned from Sandy Hilton is, “can you walk me through that?”. There should be answers as to why people do what they do. There can be discussions as to why what they are doing may work. You should be able to discuss, defend or explain what you’re doing.

4. Choose courses that challenge your beliefs.

  • Having people agree with you can feel fantastic! But if you constantly surround yourself with people who agree with you, it’s not likely you’ll come to have a deeper or broader understanding of much. Move out of that comfort zone, and at least consider alternatives to your usual way of doing things.

 

Photo by: qimono

A New Perspective

Any class or lecture I was attending was no longer a quest for an answer, but rather gathering more information to review and question my current practice.  

I embraced that I could walk out of a class and think ‘Nope, I’m not going to do that’. The most wonderful part about realizing I was allowed to critically think about why I was choosing to do (or not do) things in the clinic. I realized I was allowed to respectfully disagree and question ideas. I finally realized that there were no magic answers, and the best we can do is strive to be less wrong.

It was so freeing to say ‘I don’t know’! To embrace the unknown, to acknowledge that I would have to actively work to know more, and even then I would get it wrong.

One thing these realizations did was make me start to question the people I was learning from.

What’s interesting, is that some people embraced my questions and my challenges! And that’s when it hit me:  I didn’t need to learn any specific technique! I needed to be a better critical thinker!

A large majority of the continuing education for Physical Therapists (at least in the United States) seems to focus on specific techniques, some involving expensive trademarked tools. Some ‘techniques’ require several levels of training to become ‘competent’. Other courses seem to promise the impossible (or at lease biologically implausible).

The purpose of this post is not to discourage any technique or school of thought.  It is to encourage questioning!  And thinking!  And discussion!  And to challenge your biases. (Because we all have them!)

Now when I go  to courses, I don’t plan on learning anything to actually do. I plan on listening with an open mind, gathering information, and looking at my entire practice. I’m much more vocal asking questions when points don’t seem to be supported by science or seem to contradict what is commonly accepted. As healthcare providers,  we feel a need to do things, to help our patients or clients feel better and be healthier.  So on the quest to be better (and we can all be better), acknowledge that the next technique you learn won’t be any more magical than the last one you learned.  However, if you reflect and think critically, you may just be able to use what you already know to be better.

What Do Massage Therapy Associations Do For You?

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“What do massage therapy associations even do?” I get this question all the time.

We’re not an insurance company, although we do offer insurance, and we’re not a union, although we do represent Massage Therapists. We’re not lobbyists, although we do promote massage therapy to government and stakeholders, and we’re not a money grab because we put every single penny back towards working for you.

We’re an association.

We’re a group of like-minded individuals with a common goal.

So why would you want to give your hard earned money to your professional association? What’s the benefit for you? What do you get for your money? In addition to the obvious benefits like preferred rates for insurance, continuing education opportunities, networking opportunities, access to research, and referral services, we provide insight and guidance, programs and services, tools and resources. But there is a much larger long-term benefit.

We Advocate For You

Advocacy, in its most basic form, means to speak in favour of something.

So, your association speaks in favour of the profession of massage therapy. We promote massage therapy as a part of primary health care to government, the insurance industry, the general public, and other stakeholders. We make people aware of what it is that massage therapists can do, how well you do it, and why it works. We make sure that massage therapy is an important part of the healthcare landscape.

We work for you.

Advocacy is often seen as “big picture work”. Sometimes it’s complicated and often takes a long time, but it also has a direct and practical impact on your career as an RMT. It impacts how you practice, how patients find you, and how you’re viewed. It’s not only your professional association that can make a difference – you can too.

There are really two ‘yous’ when it comes to advocacy. There is the ‘smaller you’ and the ‘larger you’. The ‘smaller you’ is each individual health professional (that’s you!). You demonstrate a commitment to professional practice, ongoing education and continuous improvement. You are the health professional that people point to and say “they are the reason that massage therapy is a valuable health care profession”. You are dedicated to your profession and are able to easily articulate why you have chosen massage therapy and why it works.

The day-to-day interactions with patients and the way you present yourself professionally are ways that you advocate for the profession – perhaps without even knowing you’re doing it. This is advocacy on an individual level and is incredibly important.

It is, in fact, the basis of all advocacy.

The ‘larger you’ is all Massage Therapists combined. It is a “coming together” as an association with a common purpose. It is team work, co-operation and collaboration combined, and that team work has the power to make a real difference. A large group with a common goal can do things that individuals can’t. Doors are open for associations that are not open for individuals. Together, the ‘larger you’ has a louder voice.

The “larger you”, the association, amplifies that voice and directs it towards the appropriate people and organizations. We get the right message to the people who are in a position to make change happen. There’s power in numbers, and numbers get people in a position of power to take notice.

A rising tide lifts all boats. Whatever the association achieves for Massage Therapists will affect you whether you’re a member of the association or not. I get it – it’s easier to save your money, put your head down, and do your job. But as part of the association, you get a say in the way the wind is blowing and how the boat is steered. When you’re not a part of the association, you’re along for the ride whether you like it or not.

Associations reach out to their members to get feedback. We want to know what you need, when you need it and how we can make it happen.

Most, if not all, RMTs think we should have access to extended healthcare benefits. They want to be respected as a primary health care provider. They expect and deserve to earn a suitable income.

Massage therapy associations are the groups that make sure massage therapy is a viable, respected and accessible profession. We want to make it easier for Massage Therapists to do their jobs. You already know how to get a patient back to optimal health. Our job is to make sure that you can provide your professional healthcare services and earn a living so that you can continue to do so.

Photo by: RMTBC

Increasing Credibility Of Our Profession

Massage therapy associations are run by a board of your peers, chosen by you, who identify the issues and trends that will impact the profession and what we should do about it.

The board does extensive research to ensure they are representing the profession and the issues that are current to the day. They talk with members – the people these decisions will directly affect – and determine the way to position the profession for maximum success and the steps that should be taken in order to achieve the vision for the profession.

Massage therapy associations are run by Massage Therapists, for Massage Therapists. We keep a finger on the pulse of the profession and the landscape in which it operates.

Massage therapy associations work for the profession, and massage therapy regulatory bodies are primarily concerned with the public interest. Although these two groups may seem to be opposites, they are really two sides of the same coin. We both work in the best interest of the patient by making sure they are able to access massage therapy receive proper and appropriate care from Massage Therapists.

Both the association and the college must communicate with each other to work towards our separate mandates and our common goals. We both want Massage Therapists to be able to positively contribute to the health of Canadians.

RMTs are working with doctors, physiotherapists and chiropractors, in palliative care, and in hospitals – situations that may not have seemed possible in the early years of the profession. Massage therapy is now seen more often as a valuable healthcare option, which was made possible through years of advocacy undertaken by associations.

I suppose that provides an example of the answer to that frequently asked question ‘what do massage therapy associations even do?’ Associations determine the direction this profession should be heading, determine what we need to do to get it there, and then we actually do it.

The credibility of the profession has increased dramatically over the past few decades, thanks in part to the work of associations. Massage therapy remains the most utilized paramedical benefit in Canada behind drugs and vision care.

But we still have work to do.

Advocacy takes time. To make a significant change takes time. Developing the argument with the inescapable conclusion that massage therapy is an effective and critical piece of the healthcare puzzle is how we spend a large part of our time.

But this is time well spent.

It will ensure that massage therapy is and remains a solid and respected part of the health care landscape. It will ensure that you are appropriately rewarded for your time and effort. It will bring new patients to you because they will be aware of what massage therapy is and how it can help them, and it will ensure that you remain valued as a healthcare professional.

Canada is searching for solutions to the impending healthcare crisis. Massage Therapists are a part of that solution. It is the dedication and passion of Massage Therapists, which can be amplified by professional associations, which ensures massage therapy can remain an important part of health care. In your own community, and through your day-to-day professional life, you can advocate for the profession by the way you practice and the way you communicate that practice.As the larger you, your professional association is part of the important conversations, the important decisions, and the necessary actions now and in the future. Check out what your association is doing about the issues that affect you and your profession. It’s your profession and your association.

Taking Advancement Of The Profession Into Our Own Hands

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What do you get when you have a group of PT’s, MT’s and Trainers from the US, Canada, New Zealand and Australia drinking beer in a hot tub?

A lengthy discussion on what’s wrong with our profession.

And I use the term “our” profession even though all of us have a different scope of practice, because to my surprise, we’re all facing the same issues. At every level there is an issue with education, regulatory bodies, our peers and even some associations.

You see the problem in all of these industries is a lack of change.

The schools have too much invested within themselves to make changes that would help improve the profession. They are still stuck in research from 20-30 years ago, and well, change is difficult.

The regulatory bodies are concerned (as well they should be, as it’s their role) about protecting the public. All too often they err on the side of caution and ignore new developments in research and practice, which in turn harms the profession. And when I say harms the profession, I find it shocking just how badly it can harm the profession. This is exactly what I love to hear.  

Little did I know the extent it was happening in our industry until the above conversation.

When regulatory bodies ignore things like mental health and the biopsychosocial approach, but still promote and teach research and science that is long outdated, not only do we suffer as therapists but unfortunately so does the public, which these regulatory bodies are supposed to be protecting.  By their very definition they need to adopt new standards or they are strongly in breach of their core duty.

As the frustration grows among therapists who are trying to do right by their patients (and their profession), it is beginning to become apparent that we have no choice.

It’s time to take things into our own hands.

Creating CEC’s

Where this can be a bit of a problem, is the lack of therapists who want to get involved. Like it or not we are a fairly apathetic group. We tend to get lost in just going to work doing our treatments and shutting down at the end of the day. Then we are usually scrambling at the end of the year to fulfill our CECs.

I’m not saying there is anything wrong with that (well actually I guess I am), I used to be one of those therapists. I wouldn’t bother going to a college or an association AGM, wouldn’t bother to vote on anything, and would take whatever CEC’s came to town, just to fill the quota. But as time went on, started to realize change was needed, not only in myself but also in the profession.

Since it’s apparent that nothing is going to change when it comes to entry to practice standards, if we want change it’s going to be up to us.  The best way to change our profession and influence practice standards is to have a critical mass of therapists lobbying and demanding change.

This can be a bit tricky.

Since entry to practice won’t change, we look to continuing education to help shape our careers. Tania Velasquez wrote a great piece on Modalities vs Concepts and not getting caught up in the modality empires. Now, there’s nothing wrong with learning a new modality, in fact through most regulatory bodies it’s encouraged. However what we need to do, is be careful not to get caught up in the bias’ that usually go with some of those classes and make sure they’re backed by sound research and encourage critical thinking. Part of the problem is that there aren’t a lot of courses that encourage this.

So, what do we do in cases like this?

It’s time to start developing our own. If we truly care about the advancement of our profession, it’s high time we start breaking the mold of what is being offered and rely on each other to develop continuing education. Over the past couple of years (and I’ve wrote about it on here) I’ve started attending more conferences for my CECs instead of just hands on manual courses. For each conference I’ve been to, it has been amazing to meet like minded therapists from, not only different countries, but also different backgrounds and certification levels who all want to improve their profession.

And the beauty of it all…they’re all willing to work together.

We all have different strengths that would lend itself to quality CEC courses. In the last two weeks alone I’ve had discussions with other therapists on possibilities for courses on motivational interviewing, pain science introduction, DNM, assessment and of course first aid. The more we can collaborate and work together to develop the education happening after college, the bigger change we can make in bettering ourselves and the profession.

 

Photo by: Unsplash

Mentorship

There are a few ways we can make this happen.

Typically when we think of a mentor, we think of a one on one coaching type dynamic. While this is a great option and should be highly sought after, it can also be difficult to find an agreement that works for both parties.

Our local association encourages a mentorship program in which a more experienced therapist takes a less experienced practitioner and gives them tips and advice when starting out. This is a great way for a new grad to learn the ropes and build confidence. However if this is something you’re thinking of, there should be compensation (I don’t know if our association encourages that or not) given to the mentor. Years of experience and of course their time should only be given away if they choose to allow that, but it would be a wise investment on the part of a new grad.

Online there are several ways to gain mentorship. Joining several of the Facebook groups out there, you can learn a ton just by watching the comments and interaction among other therapists. But just like anything else, you have to choose wisely. Just like when choosing your CEC course, make sure the group(s) you decide to follow are quality and backed by research and science, or at least promote those two topics.

You can also create meet-ups in your area, to see if other therapists would like to get together and just talk shop. I’ve learned more from going out for a couple pints with other practitioners to pick their brain about what they’re good at (and probably forgot a lot of it) than I can ever pay back to them. You’d be amazed if you just put a request out how many therapists would be willing to do this. But don’t keep it to just Massage Therapists, meet up with ATs, Chiros, Physios and Personal Trainers, they all have knowledge you can learn from.

Blogs. Start following some good quality blogs, there are a ton out there! However the same caution I talked about earlier should be applied when deciding which ones to follow. Find the ones who cite quality research, give advice and focus on patient centred care. I’ve been fortunate enough to meet some of the bloggers that I follow and every time have been amazed at their humility. While some of them charge for products on their sites, they are usually quite willing to give away lots of free content. If you can use some of their paid content as CECs all the better (and easier) for you to learn from.

As therapists, there is no end to the amount of things we can learn. But we do have a choice in what we learn. Shaping your career and profession is all of our responsibility, not to be left up to the regulatory bodies. When you go take new courses that give you quality information, there is also a responsibility on your part to share that information in your community with other practitioners. There are some therapists out there doing some pretty amazing things, but we can make greater change as a group than we can flying solo.

Free Massage!

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Do you ever feel like you have a sign on your forehead that says “Free Massage?”

Every day on my social networks, I see massage therapists talking about being asked to do free massage. “Come and do free chair massage at our event and it will get your name out there….” never mind that you’ve been practicing for 15 years and your name is already out there.

I recently saw on FB post where a chiropractor wanted someone to come to his office and do a week’s worth of free massage so he could get the client feedback and decide whether or not he would hire the person…I guess he thought she just wouldn’t need any rent money or groceries that week. If he’s located near a massage school that’s turning out graduates or an area that’s saturated with massage therapists, he could feasibly keep the “audition week” going for a long time–and quite probably billing insurance for the massage that he’s not even paying the therapist to perform.

At the massage school I attended, back in the day, we were required to perform 25 hours of community service…free massage on a deserving population. 15 years later, I still don’t mind performing free massage on a deserving population. I occasionally volunteer time to what I think is a worthy cause.

I once gave weekly massage to someone for almost a year because he had spent nearly a year in the hospital, his medical bills were in the millions of dollars, and he just plain needed the work and couldn’t pay. One of my staff members has given a lot of massage at an abused women’s shelter. Another did deeply discounted work on someone who was seriously injured and didn’t have any insurance, and many of us have done that kind of thing at one time or another, for nothing other than the warm fuzzy feeling of having helped someone.

If there is an event going on that I think we need to have a presence at, I will pay staff members to do chair massage; I don’t expect people to work for free. We just can’t and/or won’t go everywhere we are asked to go. If the event is more than ten miles away from my office, I’m not really inclined to go there. There are plenty of massage therapists in our county, and if there’s a health fair that’s all the way at the other end of the county and plenty of practicing therapists between here and there, I’d rather let one of them have it.

I have recently been receiving invites to an event in Shelby, NC. That’s 25 miles away from here and I know at least half a dozen therapists that practice there, so I’m not going to go encroach on their territory. The last time the organizer called, I told him he was wasting time by continuing to call me about it and suggested he contact therapists from that area. I also turned one down that was relatively close, but on a holiday. When the woman called me, I said, “thank you, but our staff members want to spend the holiday with their own families that day.” Not only do they want us to do free massage, they also want us to pay them for a booth to do it in.

Sometimes MTs are distressed or hesitant about saying “no,” because “it’s at my mother-in-law’s church,” or “one of my clients asked me to do it, but it’s 30 miles away,” and that kind of thing. If you’re a new therapist, or an old one who’s feeling torn on this issue, then here’s the answer: “Thank you for thinking of me, but I already have clients booked for that day.” Or you can say “Thanks, but I don’t give my services away,” with no excuse. You don’t need an excuse.

If you have the time, and so much money you don’t have to worry about paying your bills, then feel free to give away all the massage you want to. Say yes to everyone who asks. You’ll probably get some business out of it, but keep these thoughts in mind: Some people will do anything just because it’s free, that they would never think of actually spending money on. Some people who are already consumers of massage and already have their own therapist of choice will sit down and get the massage, again, just because it’s free. And many times, people don’t place much value on something they get for free.

If you need an actual return on investment for your time, then you need to pick and choose what you’re going to participate in. Realistically, you stand a much better chance of getting business from an event that’s 5 miles away from your office than one that’s 25 miles away from your office. Some events, like an annual festival, attract a lot of people from out of town that are never going to become clients, but you’ll have to massage them along with any locals who might potentially become clients.

Your dentist isn’t going to do your root canal for free. Your doctor isn’t going to do your appendectomy or deliver your baby for free. The plumber, the electrician, the washing machine repairman isn’t coming to your home for free. You can’t walk into Walmart and load up on free goods, but for some reason, many people seem to expect that massage therapists are always available to give it away.

Here’s the reality check: most of us have overhead directly related to our work. It also costs money to get educated, to get licensed, and to keep up with continuing education requirements. It costs money to run our homes and our lives–just the same as it does for the people who are soliciting us to come and do free massage. We have mortgages, car payments, student loans, and debts to pay. We need food and utilities and medicine and school tuition and child care just like everyone else.

Doing free massage is sometimes a good marketing opportunity. It’s always providing a public service, and you should do it only when you genuinely want to. Don’t allow yourself to be talked into doing it when you don’t want to, and don’t allow yourself to feel guilty for turning anyone down.

Motivational Interviewing In Your Clinic

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A great deal of our work as therapists involves helping people to make changes in order to get better outcomes, be it for general health and well-being, reductions in pain, or increases in mobility.

Our training and education means that we know a lot about what people need to do to achieve these outcomes. We are smart and we know it! We assume the patients coming in to see us, know that too. So it should be simple right, we tell them all the things that they need to know, and they go away and do it. But here lies the problem, no one really wants to be told what to do.

Take for example the person who has recently had a heart attack but is also a smoker. They are very likely to be informed of the fact that continuing to smoke is going to contribute to poor health outcomes including increasing the risk of another heart attack. With such a frightening near death experience, one might assume that being given sufficient information, combined with the fear of the experience would be enough to make someone stop smoking.

However the studies tend to tell us that only about half the people in this situation will actually quit smoking! (1) Mind blowing isn’t it? What this and many other studies in similar fields of healthcare continue to show us is that information and fear are not enough to change behaviour, no matter how dire the consequences. (2)

Changing Our Approach For Better Outcomes

Self management forms a big part of the picture in managing all chronic diseases. As we start to view pain with a more modern and science based understanding, our approach to treating it should start to shift away from trying to “fix” the patient and towards an empowering model of care that encourages the patient to take their health into their own hands.

Sounds easy doesn’t it?,  but many of us have been experiencing as practitioners what an uphill battle this is. Particularly in our western culture where there is an understanding around medicine being able to “fix” everything, so that the mere presence of pain is viewed as being “wrong”, and the understanding that as a consumer based system,  you just have to pay for the “thing” (manual therapy/ acupuncture/ surgery/ injections etc) and it will be done to you and will be effective.

Unfortunately, we know it doesn’t work like that.

Single modality approaches for treating any pain condition, but particularly chronic pain, are largely unhelpful in the long term and science tells us that adopting an active approach is far more likely to lead us to better outcomes. (3)

In treating pain and getting people to adopt behavioral change, some of the information we provide to help, might be of a therapeutic neuroscience education (TNE), explaining pain, pain education approach. Along the lines of what we see in situations like smoking cessation, weight loss and exercise programs, providing the information doesn’t always translate through to the outcomes we might hope.

That is not to say that we don’t use it.

The research tells us it has value (4-7) , we just understand that it is one part of the process, the information and context a person might use when deciding on taking a multidisciplinary and active approach to treating their pain.

Motivational Interviewing

Motivational interviewing is a cognitive behavioral technique that helps patients to identify behaviors that may be preventing them from achieving optimal management of a chronic condition. It has been used in many healthcare settings which require behavioral change for better outcomes such as addiction medicine, oral-health self care, smoking cessation, weight loss, medication compliance and diabetes self management. It identifies a cycle that people tend to go through (and often go back around and around) in processing a change in behaviour.(2)

 

The process of motivational interviewing is one that provides structure around helping a person to find their own motivation, the idea being that if a person has made the choice for themselves they are far more likely to follow through with change, compared to when it is something that has been forced upon them.

It is a process that requires first establishing a level of rapport with the person and then helping them to identify what behaviors they would like to change. Within the approach there are some specific techniques that can help the practitioner to elicit in the patient a better understanding of what his or her thought processes are in relation to the problem. Then through a process of reflective listening and open ended style questioning, helping the person to identify how important the change is to them and how confident they are in being able to make those changes. From there a structured, but collaborative approach can address the barriers to change, identify measures of support and create a plan to move forward that fits with the patient’s own motivation.

The best thing about motivational interviewing is its accessibility. It is a process that has been used in industries other than just psychology, (sales and human resources to name a few). This means that it is easy to learn about it and that applying it in the clinic is not an “all or nothing principle”.

You can start to learn about some of the elements and apply them straight away – the easiest way is to refine your listening and reflecting skills and resist the urge to jump in straight away and tell people what they “should” be doing. There are lots of resources available in the form of short courses, blog post summaries, books and journal articles. So if you are feeling motivated, get your google on and work out what your next best step is to start delving into some motivation interviewing skills! (2)

 

References:

1. van Berkel TF, van der Vlugt MJ, Boersma H. Characteristics of smokers and long-term changes in smoking behavior in consecutive patients with myocardial infarction. Prev Med 2000, Dec;31(6):732-41.
2. Bundy C. Changing behaviour: Using motivational interviewing techniques. J R Soc Med 2004;97 Suppl 44:43-7.
3. O’Keeffe M, Purtill H, Kennedy N, Conneely M, Hurley J, O’Sullivan P, et al. Comparative effectiveness of conservative interventions for nonspecific chronic spinal pain: Physical, behavioral/psychologically informed, or combined? A systematic review and meta-analysis. J Pain 2016, Jul;17(7):755-74.
4. Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil 2011, Dec;92(12):2041-56.
5. George SZ, Childs JD, Teyhen DS, Wu SS, Wright AC, Dugan JL, Robinson ME. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: Results from the prevention of low back pain in the military (POLM) cluster randomized trial. BMC Med 2011;9:128.
6. Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, Nijs J. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: A double-blind randomized controlled trial. Clin J Pain 2013, Oct;29(10):873-82.
7. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain 2004, Feb;8(1):39-45.

Is Massage Moving Fluids And Causing Dehydration?

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I recently listened to a presentation which talked about online arguments and how to handle things appropriately.

One of the points brought up by the presenter is to make sure you actually give credit to a person for putting themselves out there and being vulnerable. Whether the person makes a comment, writes an article or is just sharing information, it is important to recognize their effort.

A week or two ago an article was being circulated arguing that said getting a massage if you’re hungover is probably a bad idea and will make you feel worse because of the massage contributing to dehydration. While the writer made a great effort to inform people, the information isn’t exactly accurate and sadly is something still being taught in our massage education system.

Like so many of the other myths out there, we have to change our understanding and more importantly our patients understanding of what massage does and doesn’t do.

Is Massage Moving Fluid?

We’ve heard so much over the years about how massage increases circulation.

When I first started working in hockey, there was a player on the team who had a major health scare. He had blood clots in his lungs as a result of a Deep Vein Thrombosis and was put on blood thinners as a result. Once the clots were remedied, he went back to playing hockey but had to remain on the blood thinners. According to what we had been taught in school, this would have been a contra-indication to getting a massage. Being a worried student, I asked one of my teachers if a massage would increase his circulation enough to be a concern? His answer was profoundly simple – “no more than playing hockey would.”

That simple answer changed everything for me.

When we look into the research available concerning massage and blood flow, the results are again staggeringly simple. What do most people come in to get massage for? To relax!

Study(1) after study shows that getting a massage actually decreases blood pressure and heart rate. Other studies have shown that massage post exercise actually impairs blood flow and removal of lactic acid (another one of those wonderful myths), not increase it. While focused on the effects of sport massage, another study showed that massage did not increase femoral artery blood flow, but did increase skin temperature and skin blood flow to the area being treated (in this case the anterior quads). This showed a possibility of muscle blood flow being diverted to the skin, but also shows limited possibility of any metabolic change. Or the increase in skin temperature, could just be conduction of heat from the therapists hands?

One review on the subject points out that while some studies support the idea of massage increasing local blood flow it would also depend on the type of stroke used. The squeezing effect of some massage strokes could help to promote venous return (due to effect on skeletal muscle pump), but also points out the same strokes could temporarily occlude arteries causing a temporary reduction of blood flow, which would in turn cause an increase in blood flow when the pressure is released.

Overall there is not much evidence to support the idea of massage increasing circulation, or moving fluids around and certainly doesn’t increase it more than the effort it took for the patient walking into your clinic.

Photo by: RMTBC

Dehydration

There are a few ways to become dehydrated: 

  1. Sweating too much (exercise, hot temperature).
  2. Diarrhea or vomiting. 
  3. Urinating too much (i.e.: breaking the seal when you’re out drinking). 
  4. Fever. 
  5. And of course, just not drinking enough fluid.

Now, if someone is coming in after a night out on the town and are a bit (or a lot) hungover, they are probably already a bit dehydrated because alcohol is a diuretic, which in turn causes you to pee a lot. Then water loss is greater than water gain, and if body mass is reduced by 2% because of fluid loss, this causes mild dehydration. When blood volume decreases because of the fluid loss, blood pressure decreases, the kidneys and various nerve impulses trigger the thirst centre in the hypothalamus, telling us to drink fluids.

The other things that stimulate thirst:

  1. Your mouth is dry from decreased amount of saliva.
  2. Baroreceptors in the heart and blood vessels detect lower blood pressure.

I know what you’re thinking: “you just wrote a paragraph on how massage lowers blood pressure and now you’re telling me lower blood pressure causes dehydration!”

Not so fast.

The baroreceptors are sensing lower blood pressure and increasing thirst not dehydration. If your patient had been out drinking the night before, they’re already behind the eight ball as far experiencing some level of dehydration, so their blood pressure is probably already down to some degree because of the decrease in blood osmolarity. When we look at the mechanisms that actually cause dehydration, there is nothing happening in a massage that is causing sweat, diarrhea, urinating or fever. Nor is it possible for a massage to decrease body mass by 2% (otherwise we’d all be a lot busier!). Plus if a treatment could drop blood pressure that much, every person we treat would need to drink after their treatment.

While your patient probably wasn’t feeling great when they came in, a massage isn’t necessarily going to make them feel all that much better because their body is basically telling them they’re an idiot from the night before (my body has said this to me several times). The massage isn’t going to make them any more dehydrated than if I was at my buddies place and his kids were climbing on my back while I laid on his couch. But neither one is going to make me feel all that pleasant. So while it is nice to give your patients that bottle or glass of water after their treatment, can we do it just cause it’s nice, feels good and is good for them? And can we please stop telling them it’s because they’re dehydrated or the massage has released toxins that need flushing out?

References:

  1. Alan David Kaye, Aaron J. Kaye, Jan Swinford, Amir Baluch, Brad A. Bawcom, Thomas J. Lambert, and Jason M. Hoover. The Journal of Alternative and Complementary Medicine. March 2008, 14(2): 125-128. doi:10.1089/acm.2007.0665.

 

 

 

 

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