July 31, 2011

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.

July 15, 2011

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.

July 6, 2011

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.

July 5, 2011

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.