Along with seeing tons of clients for chronic pain from stress and day-to-day habits, I also work a lot with clients who have been in recent motor vehicle accidents (MVA), usually as drivers or passengers (as opposed to cyclists or pedestrians).

The most common problem in MVA clients is whiplash, which happens when the head and neck snap back (decelerate) after accelerating forward in the car. Whiplash produces immediate muscle knots - in order to protect the bones and internal organs, muscles will reflexively tighten... but later have trouble loosening up. Such a severe strain on the muscles will also create a lot of trigger points.

Symptoms will vary, depending on a number of factors. How fast was the car moving? From what direction did the car get hit? (or, what angle did the car hit something else?) Was the client facing a different direction than the impact? All of these variables determine the severity and location of the injuries.

The pain and tension pattern in my MVA clients is similar to what I see in my office worker clients, but the different causes - long term overuse and poor posture versus a single instance of physical trauma - result in the damaged muscles having completely different qualities.

To get an idea of what I mean, imagine throwing a pebble at a window. This might not have a noticeable effect, since the pebble is pretty small. But imagine doing this over and over, continually throwing a pebble at the same spot on the window. Over time, the window will start to crack and break. Think of this as the damage done to muscles through repetitive motions and poor posture.

Now imagine throwing a rock at a window. Creates an instant break, no previous damage necessary. This is like the damage done to the muscles during a car accident - a singular instance with very little connection to how healthy the muscles were before.

While the end result for both of these situations is the same (a broken window), both the means of getting there and the details of the outcome (that is, the specific features of the broken window) are dependent on the cause. And, going back to the massage side of this metaphor, these details will determine all of the variables of treatment - how much time it will take, areas of focus, level of intensity.

(The metaphor breaks down right here of course, since the only solution for both broken windows is replacing them. But never mind that.)

Turns out, injuries obtained during a car accident is one of the reasons people are required to have car insurance. It's for fixing your car, sure, but the insurance companies will also pay for the treatments necessary to get yourself healed after an accident.

Massage treatment for MVA requires a doctor's referral, so you need to go to a doctor before coming in for massage (which is probably a good idea anyway). From there, the massage therapist will just bill the insurance company directly for payment. You don't need to pay out of pocket at all.

Just like trigger point work in non-MVA clients, it may take several sessions before feeling much better. And as mentioned above, there are usually muscle knots to work out before I can even start to feel the trigger points [see here for a quick visual comparison between knots and trigger points]. But because the symptoms are so severe, and because the client isn't responsible for payment, it's not uncommon to work weekly (or even biweekly) with MVA clients. And more frequent massages lead to a more successful outcome, no question about that.

What do you know about placeboes? Definition-wise, a placebo is an inert substance that will elicit a response in its consumer. Take a sugar pill and your pain goes away. The placebo effect is essentially a null effect - the pill didn't do anything; brain is merely "tricking" the body into a reaction. Pharmaceutical companies test new drugs against placeboes all the time to see if their drug works - that is, that it does something.

But there's another way to frame this whole situation, one without such a mind/body dichotomy. The placebo isn't the sugar pill, the placebo is the act of taking the sugar pill, and this act creates the necessary internal environment for the reaction to take place. The placebo effect doesn't mean that nothing happens. It means that whatever drug is being tested has no effect beyond that which the body does for itself.

Because, as it turns out, the body can do a lot for itself.

I've often heard people invoke the placebo effect in regards to massage - usually about specific massage styles that may not have the strongest scientific basis. They say that the massage is just fooling the client into thinking that it's doing something. Ok, sure, the massage may not exactly be telling someone's heart to pump slower or breaths to be deeper, but it provides the setting for the client's mind and body to make this happen. When I work on someone's jaw with craniosacral therapy, I'm not forcibly putting the jaw back into the right place. I'm loosening the surrounding muscles and relaxing the body, and this allows the bones to shift on their own. Indeed, many of my clients report that the biggest changes they feel in their jaw come several days following the massage. I didn't move the jaw myself; all I did was create the right environment.

And placeboes can be more than specific actions - they also be something less concrete, like a belief that a treatment will work. Even when it comes to drugs that have been proven to work, believing that they work plays a huge part. Recent research found that when patients were told that a specific pain reliever was going to relieve pain, the effects nearly doubled (compared to when they were not told to expect anything). In contrast, when patients were told that the pain reliever would actually increase pain, this negative expectation completely abolished the effects of the (proven, tested) drug. What you believe about something can often be more important than the thing itself.

A client came to see me with extreme pain in his right shoulder. I started to work on that area and, no surprise, I discovered some trigger points... so I spent the entire hour working on them. He returned the next week absolutely elated - his pain was gone! - but I knew that the trigger points were still there. And indeed, when I massaged that same area again, he reported tenderness. How strange that the body was still experiencing something that the brain no longer noticed.

That didn't mean that my client was wrong about his subjective experience, but it did illustrate the fact that pain relief is more than just releasing the trigger points and reducing inflammation. That first massage, coupled with his expectations of a positive outcome, had a greater-than-normal effect on his pain.

On a slightly different note, the placebo effect can take place even when people aren't being "tricked". A recent study showed that even when subjects are told explicitly that they're just taking a sugar pill, that anything they may feel is placebo, the effect still takes place.

But I think there's a line to draw here. Patients in the study were told that they'd be taking "placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes”. This is certainly different than saying, "this is a placebo pill, which won't do anything in and of itself, but it has been shown to trick the body into thinking that it will". It's all a matter of framing.

As the title of this post would imply, I generally come down in favor of the placebo effect. The mind and the body are wonderful and amazing things, capable of more than we give them credit for. And if the body can heal itself - with only a slight nudge from outside factors - should we really argue against it? Or should we encourage it?

I want to take a little time and talk about some new research that came out about the benefits of massage in the context of exercise.

Before I begin, though, listen to one of the researchers talk about the set-up of the study. He can explain things a bit better than I can, plus he has a nice accent.

Buck Institute Faculty Simon Melov, PhD, Discusses Recent Study on Molecular Benefits of Massage Therapy Following Exercise from Buck Institute on Vimeo.

As the researcher explains above, exercise actually causes minor damage to muscles, which, as a result, causes inflammation. This inflammation is what's happening when someone experiences an ache or soreness after exercising. While the typical response to this pain is to take anti-inflammatory drugs, such as ibuprofen, researchers tested to see the effects of massage on these damaged muscles.

One of the great things about this study is that they tested such effects in an objective fashion - they weren't giving participants questionnaires or anything; researchers actually took biopsies of the participants' leg muscles. Both legs, three times each - before the exercise (resting muscle), after the exercise (damaged muscle) and after the massage (tested muscle). Since only one leg got massaged after exercise, the other leg was used as a control for comparison.

What did the researchers find? They found that getting a massage immediately after strenuous exercise turned on genes to decrease muscle inflammation. This is similar to the effect of painkillers. Perhaps more importantly, though, they found that the massage turned on genes that promoted the creation of mitochondria in the muscle cells.

Why is this second finding so important? Mitochondria are essential for cells in order to produce energy (ATP). More specifically, having more mitochondria allows the cells to bring in more oxygen, which means that more sugars can be broken down for energy. And this, in turn, makes the muscles stronger.

The purpose of exercise is to make muscles stronger (which it does), but when exercise is coupled with massage, the results are even more pronounced. In short: exercise is good, but exercise plus massage is even better.

And while this study may have a fairly small reach (ie, these effects were found when massage was given immediately after intense exercise - would there be effects from a massage a few hours after? A few days? What about less strenuous exercise?), the implications are still really cool. Massage can change the cellular structure of muscles in order to make the muscles stronger. So rad!

One of my notable realizations is that the type of massage I do - therapeutic/medical massage, a combination of pain relief and relaxation - would have a great home in a hospital. Whatever the problem may be, working holistically (that is, not just focusing on the disease or disorder or broken bone, but taking the whole physical and mental state into consideration) has so many benefits, and massage plays a big part in this type of treatment. And where best to complement Western treatment but in a hospital? Even in school, I had the grand idea of one day giving massages in such a setting.

Many hospitals in Britain include massage services, and one article states that "more than 100 hospitals and 200 health services around Britain offer 'touch therapy' such as massage to patients alongside conventional medicine." [source]. There's even a growing number of hospitals in the US that offer massage [PDF].

And the research promotes this addition. Just pulling some titles from the abstracts located here, massage has been shown to reduce hospital stay for adults and preterm infants; increase relaxation and decrease anxiety in intensive care patients; cause women in labor to release more endorphins, which lowers the need for pain killers; decrease anxiety in pre- and post-op patients; and decrease pain and anxiety for cancer patients (as previously discussed). Another study that I recall reading in school showed the positive effects of short chair massages for nurses at a hospital. Just like giving massages to caregivers, being able to help and support those who help and support others is a true gift.

But massage employment is a tricky situation, especially in this city. When I first looked into it, the few massage posts I found for hospitals required two years of experience. Now that I have this experience, all of those job postings are gone. As a temporary solution, I decided to pursue some massage-related volunteer work at one of the hospitals nearby. I could get a taste for the hospital environment and maybe even network among departments and staff in hopes of future employment. And everyone loves volunteers, right?

Well, in theory. But I've contacted volunteer coordinators at the three largest hospitals in town and they've all turned me down (to be fair, though, only two turned me down outright; one just never responded to my email). I'm fully trained, fully licensed, fully insured, and willing to use my special skills for the benefit of others... for free! But they said no.

When I asked one of the coordinators about this refusal, she mumbled something about how being "hands-on" was a liability issue. Never mind that I have complete liability coverage through my professional organization, and never mind the fact that I'm trained and compliant in Oregon's health and safety standards. Because most volunteers don't have this education, the hospital probably has a blanket rule against hands-on work for its volunteers.

This just means that they need to have proper positions for massage therapists on the actual staff. But they don't. My dream job is at Providence Hospital's children center, where they utilize physical therapists, occupational therapists, speech-language pathologists, audiologists, and nutritionists for holistic wellness. But there are no massage therapists on staff. And if hospital directors can't see for themselves how useful massage would be because volunteers can't do hands-on work, then they won't ever create these positions.

And therein lies the problem.

I haven't given up hope, though. My next plan is to contact the hospitals' HR departments and market my chair massage as "employee wellness". And I have a few contacts who might help with my networking. Naturally, I'll keep you all posted if anything comes of it.

A prospective client called to ask about my services, specifically about trigger point massage. How long does treatment take? she asked me.

I explained that this really depended on several factors, such as the client's activity level and general stress level. Typically, I told her, within 5 treatments she'd feel a huge difference, and by 8 to 10 treatments the trigger points (and pain) would be gone.

Despite the fact that every session and every person and every treatment plan is different, I've learned to be more confident about the specific benefits of my massages. It's part marketing, part psychology, but mostly me realizing that people don't want to hear about caveats or limitations - they just want a straightforward answer.

So that's what I gave the woman on the phone, as clear of an answer as I could without knowing the specifics of why she hurt or where or for how long, and without actually palpating the muscles.

But she wasn't satisfied. After considering my response for a moment, she asked me if she would feel any better after just one session.

I knew what she was getting at. I come across this sort of mentality every once in a while in new clients. Impatience. Because if there's one thing that Western medicine has "taught" us, it's that we shouldn't have to wait for results. Pain medication works instantly, so any sort of natural healing should work just as fast. As a society, we've grown to expect quick fixes and immediate results.

But let me stress this, and I don't think I could say it enough: Pain medication only takes care of the symptoms. It does not take care of the underlying problems. If the problem is muscular (and indeed, lots and lots and lots of everyday pain is muscular), then the muscles need to go through the processes of loosening, relaxing, stretching, healing. That takes time.

I knew what the woman on the phone wanted to hear, but I had to be honest with her. I told her that immediately following the first appointment, she'd feel great. In all likelihood, she'd be nearly pain-free for a number of days. But then the pain would return, and it would return for a very simple reason: The problem wasn't yet solved. That, as I had said before, would probably take 8 to 10 sessions.

She thanked me for my answer, told me she'd think about coming to see me, and hung up. I knew immediately that I had lost a potential client. But her expectations were out of sync with what the reality of the treatment would be, and it didn't sound like there was anything I could do about that.

Thinking through this situation, I wondered what this reluctance meant for the woman (and for the various clients who stop coming to see me because their muscles haven't been "fixed" fast enough). Would she just continue to live with the pain? Maybe she would take medication to help, and over time the pain would become just another ignorable factor of life. On the flip side, working with me for two months would force her to focus on the pain. It would also make her more aware of the difference between being pain free and living in pain, which might be more than she could handle.

It takes the right mindset to heal, I suppose. You can't just be a passive player when it comes to non-Western medicine, but some people would rather have a quick, temporary fix than gradual, although much more permanent, relief. It's an unfortunate thing when someone considers physical wellness not worth the effort, but there are enough people who do realize the benefits of massage to make my job more than worthwhile.

I've heard a little bit about fibromyalgia, especially in recent years. Occasionally I'll have a client come in with the disorder, and although we never learned specific techniques for fibromyalgia in massage school, I've been able to work effectively with these clients. It is, after all, a pain condition, and managing these conditions happens to be my specialty.

But you might not know anything about the disorder, besides the name. So let's start from the beginning. What is fibromyalgia?

Fibromyalgia is a widespread, chronic pain disorder. It has an unknown cause, and there are no objective tests to diagnose it. Rather, a patient is diagnosed with fibromyalgia if they have pain in 11 out of the 18 predetermined sites (see diagram below). These areas need to be in all 4 quadrants - left and right side, above and below the waist.



Oh dear, that's a lot of pain.

But take a look at the diagram again. Don't those areas look... familiar? No? Well they do to me, anyway. I regularly find trigger points at all of those sites.

The painful areas in fibromyalgia patients are known as "tender points". How similar are these to trigger points? According to one study, there's a huge overlap in the two points' pain patterns, and the researchers conclude that "most of the tender point sites in FMS (fibromyalgia syndrome) are trigger points."

That's certainly good news, in my opinion. This conclusion points to the theory that it isn't the pain itself that's unique to fibromyalgia. Indeed, plenty of people have trigger points without having fibromyalgia. Rather, it's how the brain translates and experiences this pain that defines the disorder. This hypothesis is known as "central sensitization", which refers to a hypersensitivity to pain, light, temperature, and other stimuli in the central nervous system (brain and spinal cord).

Fibromyalgia isn't the only disorder with its roots in central sensitization - researchers and doctors believe that migraines, chronic fatigue syndrome, and irritable bowel syndrome (among other disorders) may stem from this as well. And conveniently enough, fibromyalgia has a high comorbidity rate with these disorders. Depression and anxiety are also common in FMS patients.

But back to the tender points. If these really are trigger points, then there's an easy fix for them, right? Well, ideally. But as I've written about before, trigger point massages are not always the most pleasant to endure. And if the patient is already hypersensitive to pain and pressure, a trigger point massage certainly won't be like an afternoon at the spa.

But the answer, as usual, is communication. The massage therapist needs to work very closely with her fibromyalgia clients in order to stay within an acceptable range of pressure. Communication will also help to keep the client focused on the goals of treatment and the positive, though gradual, progress. Overtime, the frequent massages will release the trigger points, thereby making the tender points disappear.