Why We Don't Tell You How Much to Undress

You sound your client out, of course. “Have you had much massage?” And you hope the answer is yes, because you really don't want to have the Talk. If they're an experienced receiver of massage, you can just rattle off the old formula. “Undress to your level of comfort, and get under the covers here,” – at this point you demonstrate, sliding a hand between the sheets: you wouldn't think people could get this part wrong, but they do – “and I'll be back in after I've washed up. I'll knock.”

But if they're new to this, or new to massage in America, or if they seem particularly hesitant or uncertain – well, you're going to have to have the Talk. You're going to have to tell them how much to undress. And the trouble is, you can't do that.

The instructors in massage school make this clear, and they're quite right. You tell your clients they should undress as much as they want. You don't specify. You don't helpfully say, “most people undress all the way, but some people keep on their shorts or undies: it's all the same to me.” That would be tendentious. It would make them feel they should undress that much. So I say, as neutrally as I possibly can, “undress as much as you like, and get under the sheets here. I'll keep you covered up: I'll just uncover the areas I'm working on.” I could go on to say, “I'll keep your breasts and genitals and gluteal cleft covered, no matter what.” But it is a bit awkward, discussing genitals and gluteal clefts with someone you've just met. I could say “I'll keep your private bits covered,” but nobody really knows in this day and age, just what bits those are. Sometimes I skip that. I go on to say, “Bra straps and some waistbands – jeans waistbands, for instance – take some working around, but I can work around anything. The important thing is that you feel comfortable.” But I don't really like saying that either: it sort of implies that people should keep some clothes on.

And I know that I'm not actually telling clients what they want to know. What they want to know is: how much am I supposed to undress? And that's just what I can't tell them.

But here on my blog, I can tell you. The answer is: nobody cares. Really. All other things being equal, I suppose I'd rather have a client buck naked: it's a bit simpler. After years of doing massage, the chances that I'll uncover anything by accident are zero. I know what I'm doing. I like to be able to glide on the skin, to “tie in” all the parts of the body, as we say. But if you have your underwear on, I just leave the sheet on and glide over it, to get – for instance – from the thighs to the lower back. The only things that really present difficulty are thick waistbands – they get in your way, right where you want to get into the lumbar paraspinals and the QL – or bra straps that run horizontally across the back: they run right over that all-important lower trapezius.

But you know what? I work with that. I enjoy the challenge. I am much happier working with that than I would be working with a naked back, and knowing that you had undressed more than you wanted to. You're not dressing for me. You're dressing for yourself, and you should dress however you damn well please.

I can tell you what my clients commonly do. About half of them undress completely, and about half leave on shorts or panties. But there's lots of exceptions. I have a regular client who always wears sweat pants, and one who never undresses at all. What does that tell me about them?

Nothing. Nothing at all. I don't think about it. I don't speculate about it. It doesn't mean a thing. We all live in a larger society that's so hyper-aware of undressing, and so intensely attuned to its meaning, that it may be difficult to believe this. But we massage therapists belong to a subculture in which undressing means nothing at all. We spent years in school, working on each other, throwing our clothes off and on at the drop of a hat. Underwear isn't an intimate frontier, to us: its a bit of cloth that alters the sort of massage strokes we're going to do.

But we know that undressing can be terribly fraught for our clients. We care about that. We want people to feel as safe as they possibly can. I've been in this business for years, and I've never heard a therapist say a negative word about how much a client undressed. People are afraid, I think, that there's some secret code: that leaving their undies on or taking them off sends some sort of signal, and they're anxious not to send the wrong one. And I just want to say, as emphatically as possible: there is no secret code. There is no signal. Your therapists don't gather in the breakroom to discuss your underwear. They don't remember whether their last clients wore their skivvies or not. The answer, realio-trulio is: nobody cares.

Postpartum Massage

Pregnancy massage gets talked up a lot. I talk it up myself: it's great stuff, and it's fun to work with pregnant bodies. Pregnant bodies are stoked, hormonally: you can practically feel them growing under your fingers. They're vibrant and responsive. They feel extraordinarily alive.

Lots of people give gift certificates for massage to pregnant women. My impression from surfing the web a bit is that pregnancy massage is a booming business. And that's grand: but I tell you, if my budget allowed for only a few massages, I'd save them up for the postpartum year. That's when women need it most, and when they get it least.

Pregnancy stresses the body, but it does it relatively gradually, and the hormones surging around, while they are not always easy to deal with, at least always remind you that you're doing something out of the ordinary. During pregnancy, and especially during a first pregnancy, things feel rather epic. Your body changes drastically, and everybody's into it, often annoyingly: strangers, without permission, will be placing their hands on your belly and exclaiming. Interest in the last couple months is intense. Everybody wants to know: when are you due?

Then, bang, the birth. Huge to-do. Lots of excitement. People cooing over the baby, pictures flying around the web.

And then two weeks later – it's all done. Nobody's interested any more. The party's over. Just when you really need the support, when the new life is really starting, you're on your own. People may still be interested in the baby, but they're no longer interested in you. Your body, which was the center of the world and a matter of absorbing interest, the temple of new life, is now a seedy all-night snack bar. It has, in the space of a few days, gone through huge changes, and it has challenges every bit as big as the challenges of pregnancy to deal with. If you've had a C-section, you've got major surgery to recover from. If you had a hard labor, you have exertions and injuries to deal with that make running a marathon look paltry. In either case, especially if you've been primed by overly chirpy birth-preparation books, you're liable to feel that you somehow failed by not have an easy, radiant birth.

Even if you had an easy, radiant birth – some people do – what your body now has to accomplish is extraordinary. The uterus has to return to its former shape. All your displaced abdominal organs have to find their way back home and re-seat themselves. Your abdominal muscles have to shrink to a third of their high-tide size and recover their tone. All the ligaments and connective tissue has to tighten back up. Your nervous system has to rewire its sense of where your body is in space. And this while, in all likelihood, you're working harder, and sleeping less, than you ever have in your life. But now – at least by comparison to the glories of pregnancy and birth – nobody really gives a damn. No strangers are rushing up to coo over your shriveling stomach; nobody wants to congratulate you on the fact that in some lights your stretch marks will hardly show at all.

What surprises me, really, is that anyone doesn't suffer from postpartum depression.

This is when you need massage. When you need someone focused on helping your body, which is working harder and changing more rapidly than ever. When you need the soothing and the comfort and the being-made-much-of. This is the time when you're most in danger of losing touch with your physical self, when you're ignoring warning twinges and discomforts and spasms because you're too damn tired and there's no time to do address them: when you're tempted to stop caring for your body because nobody is interested in it anyway. This is when you realize that your body is going to be different now forever (it is) and that it's lost all its resilience (it hasn't: it's just that the big hormone party is over.)

Why don't more women get massage postpartum? Lots of reasons. Here are some bad ones:

Sometimes bowel or bladder are untrustworthy for a couple weeks postpartum. Any experienced massage therapist should be prepared to deal with that. Bodies leak: so what? You clean up and go on. No problem.

You can't get childcare. You still have options. There are places, in large cities anyway, that offer childcare as part of the package. There are a number of massage therapists who, like me, offer in-home massage and are not fussed by having an infant on the table with Mom, nor by wide-eyed older siblings wandering into the room from time to time to ask for things. I have clients who get their massage sidelying, with the baby snuggled in and nursing from time to time.

You're too tender to get massage. You do need someone who understands what the body goes through, in childbirth and after. Do find someone who thinks that massage should not, ordinarily, hurt. There are times when trigger point or deep tissue “hurts good,” but that's a special case, and the therapist should know exactly what they're doing. You neither need nor want to be manhandled, postpartum.

Your belly is still too big, or your breasts too sore, for lying face-down to be comfortable. But there's never any need to be face down, any more than there is during pregnancy. Your therapist can arrange you on your side perfectly comfortably. It's a little mysterious to me how little massage is done sidelying. In many ways it's much better position than face down: I can move the top shoulder freely, any way I want, and the hip rotators are much easier to get at. I can't get as much leverage on the thick lumbar paraspinals, but on the other hand, the pressure I do use isn't bearing down on the still-tender abdomen. I have longtime clients who took to sidelying while pregnant, loved it, and now, years later, have no intention of ever getting back on their face.

You're too ugly. This is a surprisingly common reason. I guess it comes of all those spa ads with gorgeous perfect women luxuriating in a massage: you feel you don't look the part, so you'd better wait till you do. But this is exactly backwards. The problem is not that you're ugly: the problem is that you feel ugly. And nothing dispels the delusion of ugliness like a good massage. You always deserve a massage. You don't earn the right to it by being lovely. You earn the right to it by being a human being.

Those are some bad reasons for not getting massage. There is often, unfortunately, one good reason: it's too damn expensive. So plan ahead. Make clear that one of the baby shower gifts you'd love to receive, in lieue of yet another darling onesie that will be too small in five weeks, is a certificate for an in-home massage. Or for a package of in-home massages: the perfect thing to hit up a rich aunt and uncle for. And remind your friends who were so free with offers of babysitting before the baby's arrival, but have since become too terribly busy, that a massage certificate is an acceptable substitute.

Morning

I wake briefly at five: the full moon has broken through the clouds and its light is pouring over moving boxes, the shining covers of library books, a glittering glass on the bedstand. Then, as I watch, the moon sinks below the stand of trees to the west, and everything dims again to the ordinary city glow. I fall asleep again.

At seven I wake again, wander out to the bathroom. Tori intercepts me on my way back: can I help wake Mom? They need to be going at 7:30.

I make affirmative noises. I can't remember what they have to do, or why Tori is here. But I can wake Martha. I begin with the shoulders, sliding a hand under each scapula in turn, to loosen it up as I work the traps and the back of the neck. Then the arms and the hands, and back again, the pecs and anterior neck, some brief face work, then down the breastbone, over the abs to work the quads and adductors – pushing one of my pajama-ed thighs under hers to serve as a bolster – and the calves, on to the feet. The metatarsal of the big toe gives a satisfying click as it shifts, and Martha gives one of those involuntary groans that tells you you've hit the sweet spot. I'm not really very awake, but I don't need to be. I pay special attention to the feet and work my way back up. Catch the lower back by reaching under – always my favorite route to the QL and the lumbar paraspinals. She's waking, slowly but surely, and finally she turns over on her side. I find myself up on my knees, with a wide stance, working the rich field between the sacrum and the greater trochanter with paired thumbs. There's that trigger point. I'm rounding up the usual suspects. I roll her over and do the other side, and I finish by coming back to the hands, twining my fingers in hers to spread the metacarpals apart and get to the little interosseous muscles that sit between them.

I check the clock. It's been fifteen minutes, and I've done a creditable full body massage. When I worked at the East-West clinic I used to hate trying to cram a full body massage into an hour. I know a bit more now than I did then, but mostly it has to do with knowing the body I'm working with so well: that and not having to fiddle with drapes or lubricants, and not having to worry about steering around breast and vulva. Makes me realize how much time and attention I have to put in, “tying in” different areas of the body by circuitous routes, when I work with clients. We pay for having taboo areas of the body: we pay in time and attention, we pay in a loss of somatic unity. I know, Esalen and the Revolution are history, and we meekly accept the boundaries of a fallen world. But like Galileo, I permit myself to mutter, “still, it does move,” as I leave the court.

Martha's awake and grateful. People scurry to and fro, collecting what they need for work and school. The moon has gone wandering far to the west, hanging now huge over pre-dawn Hawaii, I suppose, and scattering trails of glory over the ocean. Morning and the workaday world, here. And coffee calling me, like a thrush singing in the yard.

My Poetry Book

Well, this is tangential to my massage practice, but -- my book is here, and it's gorgeous! Go buy a copy to reward Jo for her rashness in publishing a completely off-the-radar poet. She's done an amazing job. Order it here.

---

Dave Bonta made this "moving poem" out of a reading of one of the poems in it. Being a massage therapist impinges, of course: there isn't that much poetry, I suppose, that speaks of scapulae and vertebrae and the sacrum :-)

The Last Brave Ship by Dale Favier from Dave Bonta on Vimeo.

(Read his post about the mole, the video, and the book.)

Hamlet and Energy Work

On Facebook I wrote:

There's a long overdue conversation starting up, I hope, about whether you have to believe in "energy" in order to take "energy work" seriously. (Hint: do you have believe in Prometheus in order to take "Prometheus Unbound" seriously?)

---

When I first read Hamlet, as a teenager, there was a lot that I didn't understand, but only one thing that really bothered me: that no one seemed to care about who Hamlet really was. Was there really a Danish prince? Did he really kill his uncle? Nobody seemed to know. Nobody seemed to care.

After a lifetime spent with literature, this seems natural and ordinary to me: I remember my young distress with some amusement. Of course no one cares about the "real" Hamlet, or the "real" Macbeth, or the "real" King Lear. What matters is what Shakespeare did with them. What matters is the poetry.

---

But actually, it's a more complicated than that. Shakespeare, I've always suspected, cared more about it than his 21st Century readers do. Did Shakespeare believe Hamlet was historical? Almost certainly. Did he know he was making things up, too? Probably. He must have known he was making up words for him to speak. Did Shakespeare believe in Hamlet? That's probably the wrong question. It's more, How did Shakespeare believe in Hamlet?

As a (very minor) poet myself, I know the way that a character from a chance-read history can invade your consciousness. For me it was the confederate general, John Bell Hood. A few details about him from Shelby Foote's history of the American Civil War took root in my mind, and would not get out. There was a poem that needed to be written, and it was crystallizing around the figure of the young, blond-bearded, impetuous, not-quite-smart-enough Hood. There was something I knew about Hood that nobody else knew. Something I understood, and that needed to be said.

I knew well enough that my Hood was not the real Hood. I knew that I'd never seen the eight-year-old John Hood lose a playground fight, and refuse to cry uncle, even when his face was pushed into the mud. But I also knew that didn't matter. I had to write about it anyway. There was a connection that I had to honor, a story that I had to tell.

---

All of this is second-nature to anyone trained, as I was, in the hot-bed of postmodernism that was the Yale English Department in the 1980s. I had the further advantage of Buddhist meditative training -- a long, if somewhat haphazard course of it -- designed to shake the conviction that the world as we perceive it is the world as it is. It's one thing to think that's true: quite a number of people pay lip-service to the idea. But it's quite another to practice seeing, hearing, tasting the "real" collapse in front of you.

If you don't have that kind of training, and few people do, your response to being told something is not real is almost certainly going to be that someone is denying your experience: and there are few things that make people angrier, especially if the experience is important to them.

If you tell an energy worker that energy is "not real," you can expect some pretty fierce responses: especially if you smugly think that the electricity in your own mind, for instance, is "real." In fact, if you watch carefully how your mind actually handles the concept of "electricity," you'll find that it uses a bunch of silly and downright false images and concepts to manipulate it. When it comes down to it, most of us picture electricity as a stream of warm light running through wires like water through a hose: some of us may have a slightly more sophisticated picture of electrons, like tiny BBs, crowding and bumping their way through a tunnel. But nobody honest is going to be able to tell you that the "electricity" in their mind really corresponds to what science can tell us about electricity, and you won't do yourself and favors by trying to banish the hose or the BBs from your mind. You need to think about it somehow.

So, what is the "energy" that a massage therapist who "does energy work" works with? To me, it's the exact equivalent of the John Bell Hood whose eight-year-old face got pushed in the mud. There was, in fact, a real John Bell Hood: but nobody can know him directly. There is also the John Bell Hood that Shelby and I have in common: a set of characteristics compounded of all kinds of people we have known: a kid I knew from the deep South who had more courage than sense, a shading in of Custer with his long blond hair, antique glimpses of military gallantry. And then there's the poem that I write later, when I reach out through, and with, this phantom "Hood" to try to communicate with other people, to move them, to make them stop and think about the suffering and beauty of a sort of person they might ordinarily hold in contempt. Just so, there's the "energy" in the practitioner's mind, largely bogus; the "energy" as a possibly shared understanding of chakras with their emotional charges and all the images and metaphors gathered around them through a couple millenia's hard use; and finally there's the massage, the interaction informed by all this, which can be as profound and important as any play of Shakespeare's.

---

So it's not adequate to say that the "energy" is unreal. Pretty much everything that our minds manipulate is unreal, in that sense. The Hamlet in Shakespeare's mind was not just something made-up. It was something he recognized as of desperate importance, something that needed to be said, something he needed to say and that other people needed to hear.

On the other hand, insisting that "energy" is real is the quickest way to destroy the massage traditions that have grown up around it, particularly if you make false medical claims on the strength of it. When you make a medical claim, you step into the arena of science, and you're subject to all of science's laws and procedures. If you say you can improve someone's immune system by balancing their chakras, you'd better be able to do it, in a reasonably consistent, measurable, verifiable fashion. But there's no need to make this sort of claim. There's a certain sort of fundamentalism that equates spiritual health with bodily health, but the two things have little to do with each other. The Dalai Lama is going to get sick and die, just as Mother Theresa did, just as Ghandi did, just as you and I are. Until we get clear on this we're going to be muddying the water on both sides.

Looking for a New Partner

I've been thinking I should bite the bullet and find a new partner, so I can do simultaneous in-home couples massage again. (Lauren has up and gotten married and gone off to Taiwan, and I haven't had the heart to look for a replacement.)

If this person is interested, they're so hired!

Three Must-Reads for Massage Therapists

I'm going to be writing in response to all three of these, when I get time. For now, I'll just pass them on:

David Lauterstein on "Energy and the Integrative Vision"

Ravensara Travillian's response at POEM

Alice Sanvito's blog post, "What is Energy Work?"

I have been hoping to see this conversation start up for a long time.

Why I Became a Massage Therapist

Too many times like passing ships, at both ends of missed
opportunities. Why can’t we touch at the center, in silence?

-- Luisa Igloria, Ghazal of Unattainable Silence

Ingraham on Cherkin

I loved this article this article about the Cherkin study on massage for low-back pain.

About the bad news for "advanced massage techniques" in this study, Paul nails it:

The results make typical so-called advanced massage really look bad, and they make the popular modality empires and structuralism as a paradigm look ridiculous. The technique gurus push and sell the idea that their methods are dramatically more effective than humble Swedish. If they were even half-right, these “advanced” therapists should have gotten results at least 50% better than their lesser-trained comrades — not just better by a statistically significant margin, but much better, impressively better, decisively better, undeniably better, argument-stopping better, better with bells on …

Instead, it’s like the New York Yankees accepted a challenge from a beer league softball team and couldn’t do better than a tie score.

Why I Use Massage Oil (not Lotion, Cream, or Gel)

Massage lubricants fall into two basic categories: oils and waxes. Sweet almond oil is maybe the commonest oil, and jojoba “oil” the commonest wax. Both are entirely natural. Neither of them is water soluble. You can play with adding esters (oil derivatives), which are water-soluble, at a severe cost in shelf-life. (Basically, the reason oils and waxes have such a good shelf-life is precisely that they aren't water-soluble.) Oils are called “oil.” Waxes, with or without esters, are called “lotion,” “gel,” or “cream,” often with a great deal of hype, and without much precision. It's very difficult to know exactly what the sellers mean by these different words, even though the basic chemistry of all of the lubricants is quite similar.

In massage school, five years ago, we always had both lotions and oils in the supply closet. I preferred oil, both to work with and for its feel. Most students preferred lotion. The story was that lotion a) didn't stain linens or clothes, b) absorbed faster into the skin. As a practical matter, if you work with it every day, and you care about your clothes, you tended to use lotion. And reportedly you felt less “greasy” after being massaged with lotion.

The truth seems a bit more complicated than that. Oil stains darker, for some reason, but the waxes most definitely stain as well. I suspect that the waxes seep more, especially when they're warm, so that you don't end of up with defined edges to your stains.

Everyone agrees that you have to keep adding lotion, as you do massage, to keep the skin slippery. There are two theories about why. One is that the lotion absorbs into the skin better than oil. This may be so, though I can't think of any reason why it should. I'd love to see experiments (the cosmetic industry has probably done these. I wonder what they've found?) The other theory is that lotion “dries.”

Now, if it's not water-soluble, it can't “dry.” It can only harden. If it's not going into the skin, and it's not evaporating, I can't think of any other reason why it would get less slippery. If you come back to an area, a couple times, and repeatedly add more wax (lotion, cream, gel) most likely what you're doing is building up a crust of wax. Since waxes are very near (often below) their melting point at room temperature, it doesn't feel particularly like you have anything on your skin when you're no longer in warm room being rubbed. But when you go to take a shower, that evening, it takes a long time to get all the damn wax off.

My preference for oil is probably clear by now. For me, there's a couple reasons, specific to my personal practice, that tip the scale. One is that I do, by preference, long massages, 90 minutes plus, on average. I come back to areas again and again. Lotion gets tacky if you do that. Oil just stays there: you don't have to replenish it often, and if even if you do, it doesn't build up. So I don't have to be continually reaching for the pump bottle, which is that much more attention to the massage itself.

The other reason is that I do mostly out-call, in unpredictable environments. I can't control the air temperature where I work. I use a table-warmer, which usually keeps the client feeling warm. But the ambient temperature varies. Melting point, for the waxes, is often in between the air temperature and the temperature of the warmer. That means that, on the skin exposed to the air, the waxes harden almost immediately; and also, if they have a water-soluble component, they'll feel way too cool. Some temperature contrast is welcome in massage: all of us play with that for various effects, I'm sure. But too cold is just too cold. Oil feels warmer.

And the last reason is just that I'm a stodgy dinosaur, and I like old things. People have been using oils for massage for thousands of years. They didn't start using waxes on the skin very much until the 19th Century, really, when spermaceti became all the rage. Now that sperm whales are rare, and many people are less eager to be using stuff scooped out of whale skulls on their skin, jojoba and occasionally beeswax has replaced it, but it's still (by my reckoning – remember, I'm a medievalist by training) a newfangled, suspect innovation.

So what about the big complaint, that oils leave people feeling greasy? Well, I do two things about that. One is simply doing the long massage. I take enough time to really work the oil in: I don't leave a slick, because I'm not working fast. And the other is that I wipe the client down as I leave the area for the last time. I use nice thick flannel sheets that take up the oil very nicely, and the sensation for the client is a pleasing one, a sort of brisk upbeat finish. My sheets take the hit, of course. They have a hard life, and they don't last long. But that's what they're there for.

I do have lotion on hand, for people who ask for it specifically. The client is always right. But I suspect that most people who ask for it would be just as happy – or happier – with oil, the way I use it. To me, there's a voluptuous richness to the oils that waxes just can't match: the oils are darker, sweeter, and nearer the heart.

Training and Boundaries

Over on my personal / poetry blog, writing about writing on this blog (I really don't know if this two blogs thing is going to work!) – I wrote this:

. . . I really think that a fifteen-year-old who gives her grandma back rubs probably does as much good for her as would the most highly trained specialist in Myofascial Some-Guy's-Name Technique or a level 6 master of some supposedly ancient Asian (conveniently untranslated; if pressed, untranslatable) lore. I don't think rubbing people and making them feel loved and soothed and comforted is really that abstruse or that difficult: the only reason it's a viable “profession” is that our culture is so isolating, so high-pressure, and so hypersexualized, that the only way most people can get the humane, attentive, non-demanding touch they crave is by paying for it. (Whole post here.)

Zhoen (surgical nurse and herself a qualified massage therapist) made a couple great points in the comments to that post:

Dunno. That's only about 50% of what I see a therapist for. The rest is the knowledge, knowing where to look, feel for the pain, the stress. I know when you are going to start and stop, know that you will listen when I ask for more or less pressure. A friend, a relative, may not have bothered to learn this, may not listen to me, may make it an emotional debt. When I pay a massage therapist, I have discharged my debt fairly and completely.

So, yes, in a way, you are right. But you are also half wrong. And it's not that everyone can't do it for everyone else (which is debatable) but that the in-kind cost is too high most of the time. You guys are a bargain.

In saying that knowledge was useless, I overstated the case for the sake of emphasis, something I may possibly have been observed doing before. Because I do depend on my knowledge, and it does serve me. But it's difficult to assess how much it serves me, because I can't really think my way back to how I would have done massage before I knew muscular anatomy. How many things would I have figured out anyway, or learned from the work of other therapists? I didn't know the subscapularis even existed before I studied anatomy. (It's the large muscle nestled, like the flesh of a limpet, in the underside of the shoulder blade). My first thought is, how would I know to work it, if I didn't know it was there? But actually I would have learned what you can do with it from getting massage. The practical lore is out there. I would have learned that, on some people, you can “wing” the shoulder and reach right under the medial edge of the scapula; and you can take the arm up over the head to get under the lateral edge. (If I was designing the curriculum for massage therapists, by the way, the “professional exchange” would figure largely in it: it would be monthly, if not weekly, event. If you want to learn to do massage, the biggest bang for your buck is not a class or a workshop – it's getting a massage from a good, experienced therapist.)

And of course, I use my book-learning about trigger points all the time, modified by my experience. But the book-learning is dangerous as well as useful. What if, as suggested in this excellent blog-post, trigger points (as muscular phenomena) are imaginary? What if all my laboriously acquired knowledge of muscular anatomy is mostly beside the point? The fact that some things work according to the theory may easily disguise from me the fact that other things don't. The more compelling the theoretical story, the more easily it overrides both common sense and my “intuitive” sense of what's wrong and what needs to be done. (“Intuitive” in quotation marks because it's shorthand for “probably tactile and visual sense processing of information gathered by mirror neurons.” But that's another post.) And the more I spend on acquiring a theory, in time, money, and brain-sweat, the more committed I become to believing it was worth it.

The other point Zhoen raises is the value of boundaries. The emotional, social, or sexual debts incurred by amateur massage may more than we can afford. We don't have social conventions defining and bounding amateur massage – or rather we have them, but they're mixed up with the conventions we have for sex. In Nepal (I'm told by someone who married into the society), a woman who marries, and moves into her father-in-law's house, is expected to do massage for her father-in-law, as a matter of course. But here such physical contact, without the boundary of a commercial transaction around it, implies that one is a lover. One of the tiresome tasks that's part and parcel of working as a massage therapist is reinforcing that boundary: making clear to clients that they have not, by getting a massage, become your lover. It takes some of the thick, amiable skin of the bartender or barmaid: “thanks, but no thanks, love. Drink up, and on your way now.” How distressing you find doing this is one good indicator of how long you'll last in massage: but again, its not a task you get trained in or tested on in school. Or not much. There's some high-minded and perfectly true talk of boundaries and how things oughta be, but not much that's helpful about what you actually do, unless you're fortunate enough to have an instructor who wanders off the syllabus. And even then, I'm not sure how much of this can be usefully taught in a classroom. It has more to do with confidence and having your feet on the ground -- with being neither particularly offended nor particularly pleased by people responding to you that way. You have to understand viscerally that it isn't, for better or worse, a response to you; it's a response to being touched. But -- this, too, is another post.

Not Quite Enough Air

An impulse, instantly regretted, to say to Skepchick et al: if you take up with people who make a regular habit of contemptuously dismissing other people's perceptions and experiences, what do you expect?

---

I can't quite get enough air, in the discussions about massage. I always feel that I'm misrepresenting myself. I really do value massage very highly. I just don't think it's medicine or spiritual instruction. To me it's a conversation, conducted by touch. Sure, conversations can be terribly important, even life-changing. There's a chance that you'll say exactly what someone needs to hear exactly when they need to hear it: and the chances of that go up, the more closely you listen, the more deeply you care, & the better you are at dismissing your own agenda. But you never know, and it's hit or miss at the best of times. And it doesn't make you a doctor or a psychiatrist or a priest. You're just one human being touching another.

---

“You can't feel someone's pain directly,” said Diane, but actually you can't feel your own pain directly, either: we know that now. It's always mediated. In fact we are social animals with a considerable nervous apparatus devoted to precisely that: detecting and emulating each other's sensations.

The Cherkin Study on Massage and Low Back Pain

The NPR piece on this summarizes it nicely:

Researchers headed by epidemiologist Daniel Cherkin, a senior investigator at Group Health Research Institute in Seattle, enrolled 401 people with chronic low back pain and no identifiable reason for the pain.

Study participants were randomly assigned to one of three treatments. One group received full-body relaxation massage. A second received targeted deep tissue massage. The third group got the usual care — medication and physical therapy. . . .

After 10 weeks, the results were dramatic: Nearly two-thirds of the patients who received either type of weekly massage said their back pain was significantly improved or gone altogether. Only about one-third of patients receiving the usual care experienced similar relief.

This is a large, well conducted, and convincing study. It's a resounding win for massage: two thirds of people who got massage felt they had gotten a lot better at the end of the ten weeks, compared to one third of the people who got standard treatment. What's more, the added benefit of massage was still impressive at six months (after the patients were no longer receiving massage.) At a year, it had mostly fallen away, which probably means that massage is mostly treating symptoms, not curing anything. (Nothing wrong with treating symptoms, but it's as well to be clear. Neither the traditional treatment nor the massage was “fixing people's backs.” Mostly, low back pain just gets better.)

The big loser here is “deep tissue” massage, and advanced massage training generally. The authors of the study were actually worried that they might be stacking the deck in favor of the deep tissue therapists:

We believed that the study therapists might have provided treatment in a way that favored structural massage because that form of therapy requires more specialized training, but the apparent absence of a difference between massage types makes this possibility unlikely.

In other words, they conclude they didn't stack the deck because the deep tissue therapists didn't win. Another possibility is that the deck was stacked, and by coming out even, the deep tissue therapists showed that training actually makes you worse. Either way, it doesn't make me eager to sign up for a pricey CE course in deep tissue. The benefit of massage for low back pain could be due to a huge number of things, but one thing it's not likely to be due to is your skill in finding adhesions and grinding them away.

Of course, we don't really know exactly what the “relaxation” massage therapists were doing. I'm aware of that. People talk as if “relaxation massage” were some particular thing, but really it's just what we call massage that doesn't make any very specific or extravagant claims, and that usually backs off if something hurts. But whatever they did, it seems to have been just as effective as what the people with specific training did. And that should really make us question whether higher educational standards and more advanced training for massage therapists will do anything other than a) drive therapists who have difficulty absorbing this kind of training out of the business, and b) drive up the cost of massage, so that fewer people who need it can afford it.

Lord of the Trigger Points

A discussion on Facebook reminded me of this mnemonic I made up a couple years ago. With apologies to Tolkien fans!

Two Points in the upper traps, where temple pain is made,
Two in the levator scap causing stiffness of the neck,
Two in the SCM whence frontal headaches trade,
One in the lower traps, starting all the wreck,
In between the low thoracics and the shoulder blade.
One Point to start them all, one Point to goad them;
One Point to aggravate and stir them up and hold them,
In between the low thoracics and the shoulder blade.

Why Massage?

A Facebook post tells me that I should hit the streets and sell the benefits of massage to everyone I meet: that my business (as opposed to my work) is all about selling. I bridle at that. I'm useless as a salesman, in the first place: nobody in their right mind would set me to selling anything. The first thing I do with a pitch is queer it. I don't like tooting my own horn, and I don't like tooting horns in the received wisdom parade. I don't like tooting horns at all.

I'm skeptical about a lot the claims made for the general health benefits of massage. For the same outlay of time, spent on exercise, naps, and hot baths, I've argued – not to mention a lot less money – you can get the same or better results in lowering your blood pressure, reducing your stress, and improving your circulation. Massage does these things, it just doesn't do a very important amount of them. And its benefits are transient.

Then there's the various extravagant “healing” claims. In general I take an even dimmer view of them. A shaman is someone who comes from a vigorous tradition, has traveled in other worlds, taken genuine psychic and physical risks, usually blown a fuse or two with hallucinogens. He's not some middle-class suburban kid who's read a Ravenstar book, chewed a little peyote, taken a weekend workshop in Polarity, and changed his name to Wolf.

There's a whole slew of manipulative therapies – more than you can shake a stick at – for resolving specific problems. I practice some of them, trigger point and some MET (muscular energy technique). Sometimes it works, sometimes it doesn't. It shades off into the sort of work that physical therapists and osteopaths and chiropractors do. I don't take most of their claims all that seriously either, and mostly I've regretted it, the few times I've let those people get their hands on me. I know enough now to just look their treatments up and try them on myself, if I think they might work. Occasionally they do. But that's not what my massage practice is about. If I think something will help my client, I'll teach them how to do it. It's unusual for any of these practices, done in the standard “dosage” of therapy – once per week – to be very effective. Daily, or several times a day, is more like it. Mostly, people just get better because they heal up, and the therapy has nothing to do with it.

You see? Salesmanship is not my strong suit.

On the other hand, I get more massage than most of the massage therapists I know do. I walk the talk, even if I don't talk it. I believe in massage: it's an important part of my life.

Why? Well, it's not about health, in the narrow sense of the word. I'm not trying to lower my blood pressure or cushion my cortisol spikes or drain my lymph. It has to do with tenderness and respect, with protected spaces, with wordless friendship. It's about touch.

In a sense, it's all about the boundaries, inside and out. Outside, I measure people's suitability as friends or lovers by all sorts of criteria, most of them ridiculous. If I shake hands with them or hug them it has all kinds of meanings and subtexts. It's all tangled up with prestige, whether I'm good enough, whether they're good enough. I become more and more aware of it, as the years go by, and I hate it, but it's more than a lifetime's practice to shake free of it.

Within a bounded space, though – the physical space of the massage table, the temporal space of the session – we can play the Vajrayana game. Just pretend: for an hour and a half I don't have an ego. I don't care what anyone thinks of me. No one knows that we are in this relationship, so social prestige has nothing to do with it. The clients eyes are closed, so all my trappings – clothes, jewelry, whatever – are out of the reckoning; they're naked, so all their trappings are absent too. It's down to touch, to two human beings, an ordinary pair of hands and an ordinary body. It feels sacred to me, in the same way that wilderness feels sacred to me. There's nothing here that's been put here to mark anyone's power or subservience. Nobody owns anything here. Nothing we do has any social meaning or importance. All the nonsense has been cleared away. This is touch, touch as simple as stone, water, or tree. It doesn't need anything else.

And of course – like all Vajrayana practice – it fails. I do care what my clients think of me. They care what I think of them. We veer into distraction and ideation. There's what the boundary-pros call transference and counter-transference: we make each other into parent or child or lover figures, superimpose old relationships onto this one. But of course that's what we do all the time, with all our relationships. What's different about this, is that there's space and time enough to see it clear, in all its absurdity; to set it aside, with more or less success; and to return to the love, to the hands and the skin. It's not perfect. But it plays, there, with the perfection that we know is possible. It keeps alive our yearning for a connection that is simple and real. And that's gift enough. That's what brought me to massage, and what keeps me here.

How to get a Bad Massage

There's a lot more to getting a bad massage than just finding the wrong therapist! For those who don't want to enjoy the experience, I've assembled a few hints on how to have a lousy time on a massage table. It's easy if you know how.

1) Arrive late. This is a simple but effective technique. Make your therapist rush, or worry about whether he'll be able to finish in time for his next appointment! This is especially effective for first appointments, when you have to squeeze in the paperwork anyway. (Though some therapists may spoil this by budgeting extra time for it.)

2) Start off uncomfortable. Arrive chilled, if possible. Be sure not to go to the bathroom before your appointment.

3) Undress to your level of discomfort. It's actually harder than you might think, to make the undressing uncomfortable. Your therapist is going to tell you to undress as much as you want and get under the covers, and then he'll leave the room, and give you all the time in the world. But you can still make it uncomfortable, by imagining that that you're supposed to take off all your clothes, if you'd rather not, or by imagining that you're not supposed to, if you rather would. The sad truth of the matter is that your therapist doesn't give a damn, and he'll keep you modestly covered up with the sheets whatever you do. Five minutes after the massage he won't remember whether you had your undies on or not. So it's up to you to be sure and do what's uncomfortable for you.

4) If you forgot to arrive uncomfortable, it's not too late. You can still get uncomfortable. After 20 minutes, you might find your bladder full, and then rather than saying so, and hopping off the table wrapped in the blankets to nip out for a quick pee, you can just tough it out. Or maybe your nose will fill with mucus, with your face down in that face-cradle. Then all you have to do is not ask for a kleenex, and try to sniff it up, or surreptitiously wipe your nose on the sheets. You'd be amazed how much discomfort and distraction you can leverage out of a simple thing like that! Of course, if you ask your therapist for a kleenex to blow your nose he'll be happy to hand you one, and take the kleenex afterwards and toss it away – he does it a dozen times a day – and you'll get barely any discomfort out of it all. So don't speak up! -- Or you might get too cold, or too hot, or the face cradle might be scratchy: the opportunities are endless. The secret to maximizing your discomfort is not letting your therapist know about it.

5) If you've got an injury, or some part of your body that you don't want your therapist to touch -- for any reason -- don't tell him! Just tense up every time he approaches it. (He's not going to uncover or touch your breasts or genitals anyway: but that doesn't mean you can't worry about that, too.)

6) Likewise, if the pressure he's using is too light or too heavy, be sure to keep mum about it.

7) If not speaking up is too difficult, there's always the opposite approach. Micromanage the massage! Indulge in your anxiety that he might not hit the right spots, before he's even gotten to that area of your body, and direct him to them with vague but plentiful instructions. This will throw off his rhythm, at the same time ensuring that you don't sink into any unwanted state of relaxation. If you keep busy peppering him with directions, your risk of really enjoying anything is small. (Be careful not to confuse this with asking him to do more, if he's leaving an area and it feels unfinished – that's the sort of thing that puts you at risk for a good massage.)

8) Be sure to make a mental inventory of everything you dislike about your body, and imagine that he's revolted by it all. It's unfortunately true that most massage therapists really like bodies, of all shapes and sizes, and they have spent years seeing what people really look like under their clothes. He probably thinks you're gorgeous. But what's to keep you from imagining he doesn't? Be creative!

9) Rush to get off the table. It's important to imagine that your therapist needs you to get out pronto, and to scramble hastily to get dressed. (If you followed instruction #1, and arrived late, this will be a bit easier, but it's certainly not necessary.) Whatever you do, don't spend five minutes looking dreamily at the ceiling and feeling content! Something like that can leave you feeling relaxed and happy for days.

Divagation on "Energy"

Wikipedia quotes Feynman:

There is a fact, or if you wish, a law, governing all natural phenomena that are known to date. There is no known exception to this law—it is exact so far as we know. The law is called the conservation of energy. It states that there is a certain quantity, which we call energy, that does not change in manifold changes which nature undergoes. That is a most abstract idea, because it is a mathematical principle; it says that there is a numerical quantity which does not change when something happens. It is not a description of a mechanism, or anything concrete; it is just a strange fact that we can calculate some number and when we finish watching nature go through her tricks and calculate the number again, it is the same.

—The Feynman Lectures on Physics

“Energy,” you might say, is the most boring of all things, in physics at least: it is the name of a quantity, and what's more, the name of a quantity that doesn't even change. There is nothing qualitative or concrete about it: it is, as Feynman says, inexorably mathematical and abstract.

It's a made-up word of pseudo-Greek origin, and I should admit that I have a prejudice against such words. There was a respectable reason for importing Latin scientific terminology into English. Latin was, for many centuries, the common learned language of the Western world. If you were going to learn just one foreign language, Latin was what you learned, and if you were going to write about something of international significance, you wrote in Latin and used Latin terms. The Polish Copernicus, The Italian Galileo, and the English Newton all wrote their books in Latin – and could all have read each other's writing with ease. The loss of this common language is one of the great intellectual disasters of our time. But that's all by the way. My point is, there was a good reason to use Latin terms: everybody who was interested in science knew what they meant, and they meant the same thing from Cracow to Pisa to Cambridge. But there's only ever been one reason to import Greek terms in the post-classical West, and that's to show off. You use Latin if you want to be understood: you use Greek if you want to impress. And often to people who actually know Greek, it's not very impressive: the Greek words get hauled into ludicrously wrong contexts, get fitted up with Latin plurals, and generally look, to someone with linguistic sensitivities, like wizards trying to dress as muggles.

One of them was a very old wizard who was wearing a long flowery nightgown. The other was clearly a Ministry wizard; he was holding out a pair of pinstriped trousers and almost crying with exasperation.

"Just put them on, Archie, there's a good chap. You can't walk around like that, the Muggle at the gate's already getting suspicious-"

"I bought this in a Muggle shop," said the old wizard stubbornly. "Muggles wear them."

"Muggle women wear them, Archie, not the men, they wear these," said the Ministry wizard, and he brandished the pinstriped trousers.

"I'm not putting them on," said old Archie in indignation. "I like a healthy breeze 'round my privates, thanks."

-- J.K. Rowling, Harry Potter and the Goblet of Fire

Well, somebody around the beginning of the 19th Century dug ἐνέργεια out of a Greek dictionary, much as Archie dug his nightgown out of a muggle shop, and we all need to pretend that it's a real word now: not because anyone is very sure what it means, but precisely because they're not. It's all very highfalutin and authoritative, but as Feynman, with his gift for isolating essentials, pointed out – it's a name for the strange fact that you can run certain calculations over at the conclusion of a change and get the same answer you got before it. It's not a description of change, or of the operations of cause and effect, or of force: in fact it's very nearly the opposite, and its co-option into English to mean things such as “vigor” or “transfer of force” is particularly inept.

Of course, that's just the way language goes: there's no use in objecting to the process, and I wouldn't even if there was. I'm just explaining my visceral response to the word: it strikes me, before we even get to bodywork, as bogus and posturing.

Don't get me wrong. It is a real word, thought not a common one, in classical Greek: it means something like "action" or "operation." But in the New Testament, where our English borrower no doubt found it, it is, as Strong says, "used only of superhuman power, whether of God or of the Devil." In other words, the English word "energy" has been trying to have it both ways ever since it was born: parading as a technical term, but deriving its energy (so to speak) from being associated with superhuman powers.

Energy in Bodywork

On Facebook recently, there was a discussion of the notion that one ought to sleep oriented north-south, to align oneself with the Earth's magnetic fields. Someone asked if there was any evidence for this, or if it was just woo, and a lively discussion ensued. I always know when I'm overstressed because I get drawn into arguments about this sort of thing, as if it mattered. I don't care if people sleep north-south – what skin is it off my nose?

Of course it's silly. How does one “align” a non-magnetized thing like a human body with the earth's magnetic fields in the first place? Who says the magnetic poles of the human body are in the head and the feet, and how do they propose to prove it? Has anyone ever noticed that these planetary magnetic fields curve? And can anyone come up with a plausible – let alone verifiable – way in which the incredibly weak influence of the Earth's electromagnetic fields would have any influence on my well-being? Of all the forces acting on me daily, I can think of few less likely candidates than those fields. My laptop, not to mention my next door neighbor's refrigerator-magnets, are blasting those fields all to hell anyway, as far as local influence goes.

But of course it's not really about the facts: it hardly ever is. The emotional investment is actually in much different things. For me it's the question of: do you believe things because they're tidy and convenient and comfy, or because they're true? I wrote in that thread: “this has 'woo' written all over it.” Not just because it strung together a whole series of absurdities and indefensible assumptions, but, much more tellingly, because it arrived at an improbably tidy conclusion: one should sleep oriented, out of all conceivable choices – “right side up.” North is up, and your head is up, so your head should go to the north. It's the childlike insistence on neatness, on the world obediently lining up with our ideas about it, that irks me. It makes me want to insist on these people moving the foot of their beds six inches away from the adjoining north-south wall, if in Maine, or three inches away in the other direction, if in Texas, to account for the magnetic declination. If you invite science to your party, you're going to have to let it play with your toys.

And on the other side, the emotional investment is in not letting schoolbook-learning quash the questing spirit, not letting your native language – which is one of correspondences, microcosms and macrocosms, the language of poetry, in short – be taken away. The people who are doing polarity therapy may be exploring something terribly important, something that has far more to do with people's well-being than correcting for magnetic declination will ever be. And there is a horrible real-world component here which most scientific people I know poo-poo or just refuse to entertain at all. The question is whether people who can't do math or memorize tables or learn Latin nomenclature get to participate. The people who are all gung-ho on a more rigorous science-based training for massage therapists often seem not to get this. There are people who can't do that stuff, and some of them are marvelously gifted bodyworkers. If you raise the academic bar on these people you really are going to cut them off from work they love, and are good at. Possibly even their vocation, the only work they would ever be really good at.

In any case, and more fundamentally, every one has to take their own journey, and will, whether we like it or not. It's one thing for us to tell people: you're not qualified to make medical recommendations based on your own outlandish misunderstanding of electromagnetics. It's another to tell them, your spiritual explorations and emotional discoveries are invalid. We must say the first, and we must not say the second. The fact that we know that Reiki practitioners are talking nonsense when they talk about “working with someone's energy,” as if they were electricians doing a bit of rewiring, doesn't mean we know anything about what happens in a Reiki session that is a decisive turning point in someone's emotional life.

What will make this easier, all round, is if people who don't really understand science stop trying to pretend they do, and stop mixing up their own terminology with scientific terminology. Don't call the damn stuff “energy.” Call it “chi.” Or make up a new word for it. Don't drag in magnetism and electricity. These are things with precise definitions. They can be measured accurately. They behave predictably. You're only going to make yourself look silly, and aid in your own disempowerment, if you try to make them fit with your meridians or sen lines or polarities.

And if you are going to work with the dream world, bear in mind what any genuine shaman will tell you: the crossing is arduous, and the translation is difficult. It's easy to think you know what things in the dream world will mean in this one, but more often than not you don't. Does it intersect with things that scientists talk about? Of course it does, but you don't know how.

To me, the bottom line – and what scientists and shamans are, ideally, in complete agreement about – is don't pretend to understand things, if you don't. Things are confusing enough already.

On the Medical Uselessness of Massage

About a year ago I posted this essay on my personal blog. I reproduce it here on request, together with the semi-retraction I wrote a couple days later, with a further observation or two at the end.

Let's be honest. I am in no doubt as to the therapeutic value of massage, but most of it is more spiritual or psychological than medical. The medical benefits solemnly listed by massage therapists are real enough, but they're mostly trivial. Yes, an hour of massage relieves stress and lowers blood pressure -- but not more than a ten-minute nap. It improves the circulation of blood and lymph -- but not more than a stroll around the block. It triggers an endorphin release – but not more than eating a bar of chocolate. It relieves muscle tension -- but not more than a hot bath. All these effects are real and measurable; they're just not very important, medically speaking, and they are not – quite obviously to me – why people really get massage. People get massage because they ache for the touch, for the physical communication, for the sensation of being physically cared for, physically attended to, physically heard. We dress it up as a medical intervention because that makes it respectable. It's justifiable to spend money on it, if it's medical. But it's no more medical really than a momma cat licking her kittens' tummies. Perhaps that does aid the kitten's digestion, but you and I and every cat knows that's not really the point.

The point is that we must love and be loved; we must touch and be touched. It's fundamental to our well-being. My favorite massage myth is that it “releases toxins.” This has been studied, and there's not a shred of evidence for it, but the myth marches on regardless, because it feels right. It feels like you're getting rid of something poisonous when you get a good massage, when you give your body over to someone and they treat it with interest and love and respect. But the poison isn't metabolic waste: the poison is the anxiety of loneliness, the ache for acceptance, the doubt whether we really belong to the tribe. Those are the toxins massage flushes from the system.

(Okay. An exception, here, is trigger point, which has serious therapeutic value for relieving chronic myofascial pain – what's commonly perceived as joint pain. But the most common “dosages” of massage – one hour once a month, or one hour once a week – are all but useless for trigger point, which typically needs ten minutes three or four times a day to be effective. I do trigger point on myself all the time, and so should you: but save your money. See a good trigger point therapist once or twice, get them to teach you how to work the points causing your pain, and do it yourself till the points resolve. That would be my advice, for all but the gnarliest and most entrenched trigger point systems.)

The thing about the psychological benefit of massage is that it falls roughly under the rubric of placebo treatment, and from what we know about placebo, the more ritual and mystery surrounding it, and the more sense of its preciousness, the better it works. If I could talk a good line about releasing toxins or balancing energy, my massage would be more therapeutic. And if I charged more for it, it would be more effective. There's a serious case to be made for the therapeutic value of driveling, especially if you believe in the nonsense yourself. But I can't do it.

I can say this, in recompense: the love I feel for my clients is intense, and quite as real as any other kind of love. I'll stumble upon pockets of grief, I'll open up veins of lifelong loneliness, that will stagger me. Doing massage is no more soothing, ordinarily, than participating in a meditation retreat is relaxing. On the contrary, like a meditation retreat, it's most often, for me, a wild roller-coaster ride of emotions, waves of joy and sadness in quick succession, glimpses of rare colors and strange countries. The connection can be downright unnerving. You need either a thick skin or a certain amount of contemplative stability to ride it out. The end result may be – usually is – a profound sense of gratitude and well being: but it doesn't come cheap.

I suspect that if you studied people with a life history of getting regular massage, you'd find longevity benefits similar to – and as difficult to analyze as – those of marriage. But a study definitively establishing cause would be, under present funding conditions, prohibitively expensive. After all, people who get regular massage tend to be prosperous, tend to look after themselves, tend to be willing to expend resources on their own well-being, tend to be comfortable with touch and hence likely to be in healthy love relationships: you'd need to randomize your clientele, and track them over years, to avoid all that skew and get real results. A study like that is not going to happen while Big Pharma rules the medical roost.

The trouble is that if we keep making claims for short term medical effectiveness that we can't actually back up, sooner or later we're going to be discredited. Massage could go into another eclipse like that of the middle 20th Century, when it almost disappeared in America as a respectable profession. I'd hate to see that happen, because I do think we help people, profoundly and lastingly, and I do think we are the keepers of a traditional lore – of several traditional lores – that ought to be preserved. But I don't think we can compete with Big Pharma on its own ground of quick fixes and magical pain relief, and I don't think we should try.


And here's the semi-retraction:

Okay, Not Useless

I promise you, if I ever undertake seriously to argue that massage has no medical value, my paper will have footnotes and close argumentation and takedowns of several studies, and it will be longer than 500 words. I promise also that I will try to refrain from tweaking people with inflammatory and outrageous titles, although that will be a harder promise to keep. It's been part of my rhetorical strategy so long that it persists even when the ideology which formed it (essentially, that dull people are improved by being poked) has long since withered away. Habits die hard. I was given Strunk & White at a tender age, and encouraged to think that forcefulness was the prime virtue -- what all writing should aspire to all the time. I now have a middle-aged respect for accuracy and caveat, even when dull; but I still find myself fluttering the cape sometimes.

And anyway, I would never want to make that argument: it's untrue. When my essay was linked to for a group of people who work hard to do medical massage (and justify its use), they were understandably miffed. It was a nice lesson for me in how contexts can shift, on the internets. I can ordinarily assume that my audience here knows that I'm passionate about massage, that my much of my practice is what is called “relaxation massage,” rather than treatment-oriented massage (though I'm doing much more treatment nowadays.) So the “medical benefits of massage” that I was poking fun at are the ones that routinely show up on the web pages of practitioners like me -- not the pain relief, lymph drainage, and trigger point, and all the techniques that shade into physical therapy, but rather the stock list that you learn in Massage I – relieves stress, promotes circulation, lowers blood pressure -- all true, all verifiable, all temporary, and all trivial.

If massage were as effective as many of its practitioners claim, it would blow other therapies out of the water in comparative studies. In fact it comes out lackluster, most of the time. If some therapists have the extraordinary success rates they claim, that only makes the general picture worse: for every therapist two sigmas out on the right, there have to be a dozen or two whose work is completely worthless, to get the kind of distributions we see. Massage came out tops in treating low back pain, in a study a while back, but that was more because the other therapies were so ineffective, than because massage worked so well.

I started reading studies of massage back before I was in massage school, but I gave up pretty soon. What I saw then was mostly very small studies with inadequate controls documenting that massage could have a significant effect on this, that or the next thing. Which, if you're not a science person, might sound impressive. But “significant” doesn't mean “important,” in statistics: it just means “very unlikely to be a random result.” Aspirin significantly reduces low back pain, but we can be excused for not jumping up and down with delight about that fact, especially if we can't get out of bed. These studies were a start, and I'm not mocking the people who did them, who had next to no resources. They established that there's something to study, that the idea of treating various conditions with massage is not absurd. But they didn't take us much further than that.

I know. I have anecdotal evidence too. I have clients who swear that I fixed their necks, backs, hips, knees. I am confident that I've reduced a lot of pain. I even have people I think I really rehabilitated, got back on their feet again. Someone who couldn't go up and downstairs, who now runs up and down like a goat. Another who couldn't hold a pencil, whom I enabled to write again. Someone who thought it was only my work that allowed her still to stand upright, at the end of her pregnancy. That feels good, and I like believing in it, but I can hardly be classed as an unbiased observer. A scientific person has to ask: how many people were just going to get better anyway? Eighty percent of my appointments are with clients who think I'm terrific, but how much of that is because the people who didn't get any relief just didn't come back? How much of it is just because of the rapport and affection that any loving touch conveys? I like to think – be real, I do think – I'm a good therapist. I study and I think and I pay attention. If something doesn't seem to be working, I try something else. But I don't think the comparative studies are lying, and I don't think the majority of massage therapists are incompetent.

Having said that much – and possibly gotten myself in trouble again – I will also say: we don't know a damn thing. The study of massage is in its infancy. Chronic myofascial pain is very mysterious, and much of what we thought we knew about it is being daily disproven.

God, think what we could find out if we had the kind of money that gets spent researching drugs! Everything remains to be discovered. There may come a time when we can confidently tell someone with chronic back pain, “I'll have you on your feet again in a week, and after that you'll never need to come see me again.”

We are not there now, and claiming that we are only makes us look ridiculous. We want solutions that a workaday, non-brilliant, not particularly gifted therapist can execute and get reliable outcomes. The traditional lores are not going to get us there, not on their own, although they are full of hints. We need science. We need to understand how it really works. We need results that are verifiable and repeatable.

In the meantime, I'll do my best to help with the pain presented to me. But I don't have the confidence in the value of that part of my practice that I have in the supposedly vaguer, touchy-feely, cloth-mom-for-the-rhesus part of it. People need to be touched with love and understanding, and I know how to do it. The bottom is not going to drop out of that market if Methylene Blue turns out to fix discogenic back pain, or if someone builds a cool nerve-feedback acupuncture machine that fixes pseudosciatica every time. All that will do is take away one of the pretexts people have been depending on to get the touch they need. They'll find another.

So, a year later, I find this is still pretty much where I come down. I have more experience of helping people recover from auto accidents, now, and those benefits seem to me pretty clear: trauma of that sort doesn't just cause new injuries, it re-activates old, latent trigger points, and after a few days it's often old injuries are causing more pain and distress than the new ones. Massage can do a lot to put them right. It's a prime instance of medically useful massage, and the results are impressive enough to convince even me.

There are things I wouldn't say now. I've come to dislike the phrase "Big Pharma," with its hints of conspiracy and collusion: I wouldn't use it now. But I have become even more skeptical of many therapies, over the past year, than I was when I wrote this: I still think that many massage therapists routinely make claims they can't back up. In this we aren't, maybe, all that different from other health care providers. But we have other traditions and other ground to stand on: we don't have to present ourselves as an alternative to opiates, disc surgery, or chelation. We could say we're doing some else, something worth doing for its own sake.

Reading

I pull down the blanket, then the sheet, and tuck it around the hips. It's love, pure and simple; the same love you feel when you zip up your child's jacket against the cold of winter.

Here, in the complicated space between the scapulae and spine, are rage and disappointment. I lay my thumbs in the precise center of the lower triangles of the scapulae; and there is the agony of pride. I move my fingers to the striations of the deltoids. This is a gentler woe, the long soft lamentation of vanity.

I read, with my fingers, how tightly the skin adheres. That tells me at once: how afraid is this person? An anxious skin clutches tight to what's underneath.

And then here, in the bunched muscles that rise from shoulder to neck, is the love of God: I hold there, and I can feel it coursing, weak or strong, under my fingertips.

A perfect body is not a perfect person. We live in a time too prone to conflate health and goodness. As a therapist I may want those muscles to let go. But don't mistake a lolling head for virtue.

Gently the head relaxes into my hands. Here, in two thimble spaces under the skull, is the whole story of grief. This is where the shadow of everything lost lingers on, like snow in the northward hollow at the foot of a tree. Listen, there, with one finger in each space, and they will tell you about lovers lost, children quarreled with, a favorite watch gone missing after a harrowing weekend. It's all there.

Follow the narrative, written in a turning scrawl between the ribs. The coda of the diaphragm. Cover the back, visit the glutes, and move on.

There are hidden clauses, reservations, and footnotes in the flesh of the inner thigh, just above the knees: the residue of old, poisonous stories, never believed but never forgotten.

And so to the feet, where it is all recapitulated, written small. At last the thumbs go of their own accord to the space under the balls of the feet, and there it is again, the grief met in the hollows under the skull. Just hold. It needn't always be stroking and kneading and pushing. In my end is my beginning.

Never mind: they won't see it if my eyes fill with tears. Cover the feet. Like tucking a child into bed.

"Thank you," I murmur. And then, "take your time." And I leave the room, careful not to look back as I close the door.

Trigger Point

Last week, after doing some strenuous work on my son's shoulders, I felt a sharp pain. The pain every massage therapist dreads: a deep twinge in the saddle joint of the thumb. The joint that, by some accounts, makes us distinctively human, that makes our thumbs truly opposable; the joint that's the first to go if you wear out your hands doing massage.

With visions of arthritis and bony deformation dancing in my head, and gloomily recalling how long injured tendons and ligaments take to heal, I put it through the standard active range of motion tests. Adduction and abduction, extension and flexion, fine. I could spread my thumb and fingers, and clench my fist, with no pain. How about opposition?

Ow. Put my thumb in just the right position, and push its tip against the base of the ring-finger, and the pain was exquisite. Okay. How about passive range of motion? Now that was interesting. That, in fact, was fantastic. I was flooded with relief. If I relaxed my thumb and put it through the same motion with my other hand, there was no pain at all. Not a joint problem. Contractile tissue. There was a good chance that it was purely muscular.

The opponens pollicis is a little muscle. We didn't have to study it in school, but I learned it anyway, and now I could see it in my mind's eye, a short, triangular muscle, running from the transcarpal ligament of the wrist up to the base of the thumb. Not where the pain was -- further wristwards than that.

I probed it, working methodically along its two inch length. Sure enough. The band of of taut muscle, distinctly palpable. And in the middle of it --

Ow, again. Yes. The trigger point. Hurt like blazes. And it made the saddle joint hurt too, to press on it.

But press on it I did, deliberately, seven or eight squeezing rolls. And again, at intervals, half a dozen times during the day. Next morning it was fading. I kept working it that day. And now it's gone, completely gone, and so is the saddle-joint pain, like magic.

Trigger points often -- usually -- "refer" their pain elsewhere, generally to a joint moved by the muscle, but sometimes further afield: points in the hands and forearms can result, famously, in headaches. A good proportion of the pain that's diagnosed as various joint problems, arthritis and carpal tunnel syndrome and so forth, are nothing of the sort. Sure, if you x-ray the painful joint, you'll see bony deformations. But most joints, including painless ones that work fine, show bony deformations over time.

Arthritis and carpal tunnel syndrome are real -- don't get me wrong. But you shouldn't accept them as an explanation of joint pain unless ordinary, very treatable trigger points have been ruled out.

I don't really like doing trigger-point massage, as a modality -- as a massage specialty. It's a great party-trick to push on a trigger point till it resolves, and pain elsewhere magically goes away, but more often than not trigger points won't resolve that way. Entrenched ones almost never do. They need to be worked over and and over. And you need to discover how you're abusing the muscle, and stop it, or they'll come right back. As I watched carefully what I was doing with my thumb, I realized that massage had little or nothing to do with my pain: it was the way I kept my mouse-tap thumb tensed as I typed on my laptop keyboard. That's much more the sort of muscle use that results in trigger-points -- long-term motionless or fine-work tension. Human muscles aren't designed for that. They're designed to contract and release, to shorten and lengthen, not to sit still at low tension for hours at a time. That's what people do with their neck muscles as they sit at a desk all day, and that's why practically every desk-worker who comes under my hands has a rich array of trigger-points in the neck and upper back.

We need to learn to stop periodically and stretch and move around. We also need to learn to locate and work our own trigger points. It's much easier to find and work your own than to find and work someone else's. Some people are gifted at finding other people's trigger points; I'm not, particularly. But anyone can find their own.

Travell and Simons, in their two-volume bible of research on myofascial pain, estimate that seventy-five percent of pain presented to physicians is due to trigger-points. Very little of it is diagnosed and treated as such.

There are plenty of other causes of pain. Trigger point therapy is not a cure-all. But it should be in the standard owner's manual for anyone who has a body. You might need to consult with someone who has a good working knowledge of muscular anatomy to locate them at first. Some bodyworkers have this knowledge and some don't; most physical therapists do, though many of them know nothing of trigger points. Few physicians have that sort of practical working knowledge of which muscles govern which movements, so most of them will have no idea where to look when confronted with myofascial pain.

Clair Davies' Trigger Point Workbook is an excellent handbook to start with. It's a book I think everyone should have. But no book is of any use unless you take the time to explore your own body, experiment with it, and work with it.

QL

The Quadratus Lumborum -- universally pronounced Kyoo-Ell -- runs from the back hip-bone to the bottom rib, on both sides, with connecting service to the sideways prongs of the lumbar vertebrae. Anglo-Saxons injure it a lot, because we generally hold our hips stiffly in line with our chests, and never give the poor QL a chance to completely contract or to really stretch. Belly-dancing would be impossible without the QL, as would climbing a ladder: any activity that hitches up one side of the pelvis up closer to the ribs requires that this muscle contract on the hitching side, and stretch on the other side.

Back when I used to "throw my back out" periodically -- before I learned the back exercises (really unattributed yoga, I learned later) that made those incredibly painful, disabling bouts a thing of the past -- it was the QL that I injured. So when I learned about it in massage school I was anxious to work with it.

But it was disappointing, at first. It was hard even to find it, especially on someone fleshy (like me). It's a back muscle, but it's mostly on the other side of the muscles, which at this point are pretty thick and powerful, right alongside the spine. If you try to get into it by pushing hard on the paraspinals, not much happens, because the paraspinals (being a cluster of mostly short-stranded muscles) hit their stretch limit before the QL's even started; and you can't squeeze it against anything, because there's nothing on the other side but intestines.

Well, that's one trouble with learning out of picture books: if you think of the muscle as a back muscle, then you only try to work it while someone's prone. You're stuck in two dimensions. There are a couple good ways to work the QL, but neither are from the back. Sidelying, you can bring the bottom thigh up (headwards) and nearly-straighten the top leg out to get a bit of a sideways stretch (you may need to tuck a towel or cushion under the side to make this work). then you can reach to the forward edge of the paraspinals and press nearly straight down: you've got the QL pinned against the spine, and you can really work it. Or -- this is my favorite -- with someone supine, you can reach underneath on both sides, and make fists of your hands, and simply roll their body back and forth over your fists. You can catch the edge of the QL with your thumb-knuckles and really stretch it. Their body weight does all the work. The intestines are free to get out of the way: they have all the room in the world. Most people are really grateful to get this kind of stretch -- similar to a toe-touching stretch, as far as the back muscles go, but a safe one. (I wince when I see people doing toe-touches, with a hundred pounds of torso or so pushing down on a three-foot lever; I'm always relieved when I see them come back up uninjured.) When you've done a number on the QL, you can finish off with a nice stretch -- with the person you're working with still prone -- by picking up both feet and pulling the whole lower half of the body, legs, pelvis, and all, to one side and then the other.

As Pamela Sundin-Hart, one of my favorite teachers at East-West, always insisted, "any muscle that attaches to the ribs is a breathing muscle." The QL has a crucial role in keeping the ribs stable so that when the diaphragm pulls, the rib cage doesn't simply fold in and follow it. When the QL is knotted up we favor it by breathing shallowly. Shallow breathing means less oxygen, and less oxygen means less energy: a jacked up QL will make you tired, and not just because you're in pain.

Fat and Massage

“What do you do with a client who's really fat? I mean, like 300 pounds? How can you do them any good?”

It was a fellow student in massage school asking the question, a few years ago. I looked at him in surprise. He was a big guy, heavier than me, probably only 60 pounds shy of the 300 mark himself. The question struck me as bizarre. He went on, “How do you even get to the muscle?”

I don't remember what the teacher answered. She seemed as perplexed as I was. How do you get to it? You go around the adipose tissue or through it, just like with anyone else. If there's a lot, going through it can be poky, so you use a blunter “point” – the heel of the hand instead of fingertips or thumbs, say. But we all already did that. Even a skinny person, anyone who's not downright emaciated, has patches of adipose tissue. We'd been working with it for a year. What was the big deal?

But this student was plainly distressed, and I could see that we had left the realm of the rational. He was a good guy, not a jerk. But some people are a little nuts about obesity. We had left the realm of facts and were floating in the anxiety zone.

I find it slightly easier to work on fat people than to work on skinny people. Skinny people are easy to hurt: the muscle tissue lies smack against the bone without any padding and working it without pinching it takes some delicacy. Fat people often have a few places where I change techniques so as not to poke – upper arms and inner thighs, for example. Trigger point can be a little trickier. But actually the way the body lays in fat leaves almost all of the sweet spots completely accessible. It's just not a problem. And if you work glutes and abdominals at all, you already know how to work through fat.

Every body – every body, no exceptions – presents challenges and requires some improvisations and adaptations. There's no such thing as a normal body. They all have injuries and unexpectedly tender places; joints with limited range or hyperextensible ones. If you can't modify your routine to fit the body at hand, you simply can't do massage. The clients I find most challenging are heavily muscled men, weight lifters, for instance, who are simply damned heavy to move around, and present a lot of dense muscle acreage to get through. But I don't mind that. It's my job, working with different bodies. That's what I do. I got into this profession partly because I like bodies. I'm curious about all the shapes they can take. I don't want them all to be the same.

Over and over people – especially women – apologize to me for their fat, as if they were offending me. I'll be working on what seem to me like perfectly lovely calves, and suddenly my client will be explaining to me how she has always had thick ankles and the weight just seems to settle in there, and she's been trying to diet and . . .

There's always a moment of disorientation, while I try to figure out what on earth they're talking about. But when I do, it makes me unhappy. I want to say, “Look, there's nothing wrong with your ankles, or anything else about you! Your body's lovely! I'm enjoying it! If I wanted to do massage only on bony fourteen year old models, I would have mentioned it in my ads!” But that would not quite be professional either. I don't really know what I do. Murmur something reassuring and neutral, I suppose. It's all the odder because the people who do this are often leaner than I am. If apologies are in order, shouldn't I be apologizing to them?

I have worked on some very obese people, and their obesity has never been the main thing I have been coping with, during the massage. It's the regular challenges – what's the root of this tension? How do I work with this injured shoulder? What's the best positioning for this leg? – that occupy my attention. It simply doesn't make that much difference.

A couple years ago I had an email inquiry about massage, in which the writer said something to the effect of, “I'm very big, so please tell me up front if you have issues about fat.” I was glad she felt she could ask, but I was mortified, on behalf of my profession, that she felt she had to. No one should have to ask that. We're therapists, for God's sake. We have no business “having issues about fat,” any more than we should be having issues about shin splints or headaches.

I understand that many people – erroneously, I believe, but that's a different subject – think that obesity is a self-inflicted condition. But so what? We're surrounded by injuries and conditions that are more or less self-inflicted. I see lots of people who have run on concrete until their knees or ankles are a mess. I see long-time smokers who have an eerie, system-wide dessication of tissue. I see desk workers who have so abused their neck muscles, by staring motionless at a screen for twenty hours a day, that they can no longer turn their heads. Do I suddenly get on my moral high horse and refuse to treat them? Turn them away in disgust? I do not.

Nor do I tell people they should lose weight. If they haven't been living in a particularly remote section of the Carlsbad Caverns for the last fifty years, they already know that, and they've already tried to do it – repeatedly, and at a grievous expense of spirit. The last thing they need is for their massage therapist, the person they go to for comfort, to start harping on the same theme.

Why I Don't Stretch

"What have you been doing to make it feel better?' I usually ask.

"I've been stretching it, every day," the client says. "But it doesn't seem to be getting better."

I don't know how stretching came to be, in the popular mind, the panacea for muscle and joint pain. But I have this conversation over and over. Athletes sometimes will surprise and please me by saying they're alternating heat and ice, which really is helpful, for a new injury. But mostly people say they're stretching it. If they admit to babying it and giving it rest, it's only with a certain shame. They know that what they really ought to be doing is exercising and stretching it.

Maybe it comes of a misunderstanding of yoga. To Westerners first meeting yoga practitioners, the striking thing about them was that they were extraordinarily flexible. Which they are. But they're not pain-free because they're flexible: they're flexible because they're pain-free. And they're pain-free because they move mindfully throughout their range of motion and relax thoroughly, not because they stretch.

Or possibly it comes of the mechanistic model of the body. We learned lots of wonderful stuff by thinking of the body as a machine. How the circulatory system works, for instance. It wasn't until someone thought mechanistically about it that anyone really understood what the heart does and how the blood flows.

But the body is not a machine, and you don't repair it like a machine. It's probably true, as your physical therapist will tell you, that you can't turn your head to one side because a neck muscle, maybe the levator scapula, is shortened. But we're not talking about a fan belt here. You don't fix it by stretching it out. A muscle is "shortened" because it's contracted, and it's contracted for a reason. If you try to stretch it you will simply tear it, and make matters worse.

A muscle is not a fan belt in another way, an even more important way: it's replacing itself, all the time. Muscle cells in particular have a short life span. And that means that the neck trouble you've had for years is not the original injury. It's a replicated injury. The muscle is pretty much brand-new: the pain you have now is one that's been recreated in new tissue. Fixing it is not like fixing an object. It's intervening in a system. A long-standing muscle injury is more like a bug in a computer program, causing an infinite loop of contraction, than it is like a fan belt that's too tight. Or like a snag in a current, distorting everything that flows past it. This is why surgery is so seldom effective for chronic pain. When everything heals up, the movement patterns that created the original injury will all still be in place, and they'll simply reproduce themselves. My guess is that much of the relief people get from surgery is the result, not of any changes the surgeon makes, but of the splinting and enforced rest the muscles get after the surgery. It's no simple matter to improve on the mechanical design of the body, and it's usually better not to try.

The four strategies I think are best, for dealing with chronic musculo-skeletal pain, are

1) judicious rest
2) trigger point massage
2) skillful physical therapy
3) skillfully taught yoga

First of all -- get some rest. Let the damn thing get better. I don't mean immobilize yourself. But move lightly and loosely, and stop doing whatever screwed you up, for a while.

I hesitate to recommend physical therapy and yoga, because they're such a crap shoot. It's hard to know how good the physical therapist or yoga teacher will be. Many of them are young people with perfect bodies who don't have the slightest idea what it's like to inhabit a sixty-year-old body, and they'll urge you to do all kinds of appallingly unwise things. There are terrific ones. If you find them, hang on to them! But there's a lot of bad ones too. Be careful.

Trigger point massage is also a crap shoot. You should expect to have to try a couple therapists before you find the right one. But the nice thing is, the bad ones don't usually hurt you. You can afford to try a couple. It's a much lower-stakes game.

A final note about stretching: damaging stretches can become almost addictive. It feels so good, sometimes -- like scratching a maddening itch. But it can be like scratching a rash: no matter how much relief you get in the moment, you're really just going to make it itch more. There's can be a temporary relief, and even a kind of pleasure, in tearing a muscle. But stretching should never hurt. Never. If a stretch starts to hurt, or you start to tremble with it, stop at once. Back off. You're doing too much.

If you must stretch, read Bob Anderson's book and learn to do it right. I don't even like the word "stretching," I do something in the morning that probably most people would call "stretching." But I'm not trying to make my muscles longer. They're a perfectly good length. My body looks after sizing my muscles, and I'm happy with the job it does. I'm exploring my range of motion. The idea is not to extend my range of motion, though that happens, sometimes. The idea is just not to lose it. If you never lift your arm over your head, you will, sooner or later, lose the ability to lift your arm over your head: that's why I move. Or, as some people might call it -- but I don't -- "stretch."

Under Construction

I've tried not to leave too much lumber in the yard, and to keep a clear path to the front door, but I've been remodeling practically everything about this site, so let me apologize in advance if there's dangling links or things that don't quite match up. I will always answer email promptly, if you have any questions about my practice, or about the site!

I plan to add a page of massage resources, with a global section and a section local to Portland. And also to start reviewing massage books here on the blog, at least one per quarter. Any suggestions for any of these things gratefully entertained. I won't post a link to anything I haven't looked into myself,though, so don't expect me to slap up a link or a reference right away on your say-so. Raw information is more a curse than a blessing, in the age of the internets, and anyway, that's what Google and Bing are for.

Why More for Two or More Massages?

Sometimes people want to split the $90 two hour massage between two (or even more) people, which is a perfectly reasonable thing to want. As you can see from the rates, I don't do that. Massage isn't a by-the-hour thing for me. Doing two one hour massages takes a lot more out of me than doing one two-hour massage. If I do two back-to-back massages usually I've pretty well shot my bolt for that day. Plus I don't really like doing massages that short. So that's why the pricing for multiple massages stands where it does. I'm still figuring this one out, so it may change.

I also get people asking about three or even more. Jury's still out on this, and I don't really know what to charge. It turns into something less like individual massage and more like a party, which is fun, if tiring. Just a different thing altogether. I don't know. Make me an offer.