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.

Just in time for the holidays!

Starting today and going until the end of the year, I'm offering a special discount on gift certificates. So if going to the mall and dealing with the crowds gives you a headache, or if you just want to make your loved ones feel good for the holidays, this is the perfect gift for anyone on your list.

Seriously, who doesn't like getting a free massage?

Discount details:

- One 60-minute massage gift certificate: $50

- Buy three, get the fourth for half price: 4 for $175

Want to give an even more awesome gift? How about a 90-minute massage?

- One 90-minute massage gift certificate: $70

- Buy three, get the fourth for half price: 4 for $245

Massage gift certificates are the perfect gift! Call or visit my clinic to order some today!

Clinic phone: 503-445-8114
Clinic address: Grain Integrative Health, 4246 SE Belmont St.

I used to roll my ankles all the time. Sometimes I'd underestimate distance or sometimes it was just a simple misstep, but it always resulting in my ankle twisting and buckling. I blamed this painful occurrence on figure skating (my sport of choice for 11 years), since the sturdy skates I wore supported my ankles so well that they never had to strengthen on their own. I didn't know if this was actually true, but it was a satisfying excuse.

The fact remained, however - and no amount of excuses would fix it - that I had an unfortunate habit of twisting my ankle. Ouch.

And I know I'm not alone. People twist their ankles all the time. After all, we depend on our ankles quite a bit. They support all of our weight, and on top of that they're expected to be agile and flexible. That's asking a lot from a joint.

Especially a joint that doesn't move too freely. The ankle joint is a hinge joint, which means that it's technically only built to move along one plane (backwards and forwards). The unique structure of the ankle allows for limited rotation and side-to-side movement, but again, the main function of the ankle is for flexing and pointing. Flexing, pointing, and holding you up.

These are all important actions, used for basic things like walking, running, and standing. Since ankles are expected to do so much, we need to keep them strong. And did you know that there's an easy way to do that?

Here's what you do:

• Stand up.
• Lift up one foot.
• Stand there for as long as you can.

Yep. That's it. Just stand on one foot.

--
Why does this work?

Most of the time when we stand or walk or run, our weight is being distributed between both ankles. By putting all of your weight on one foot for a significant amount of time, you're demanding that the muscles around this one ankle work extra hard to keep you stabilized. Remember - your body doesn't actually have to be doing anything active in order for your muscles to be working. That's why your muscles can ache so much just because of posture problems. Holding your bones in place is a full time job!

Naturally, you can do this little exercise all the time. Give it a try whenever you have a free moment and happen to be standing around (or at least, whenever you don't have to be sitting). Personally, it's my favorite "waiting for the bus" activity. Standing around never felt so productive!

People often tell me about their shoulder pain. They'll use words to describe the pain - sharp, dull, achey, shooting, etc - and they'll also use their hands to point out exactly where the pain is.

Shoulders are oddly complicated. There are two groups of muscles that make up your shoulders: the ones that connect at your rotator cuff, which are involved with arm movement; and the ones that connect at your scapula (the "shoulder blade"), involved more with your upper back. Muscles in both of these regions are commonly known as the shoulder muscles, even though they're in different places and perform different actions.

But let's talk about the muscles near your shoulder blade. What muscles are here? Most notably, the rhomboids (see diagram below) and your mid-trapezius. They're involved in pulling your shoulders back (imagine touching your shoulder blades together), and shrugging your shoulders (rhomboids help bring the shoulder up, trapezius helps bring it down).


The problem area. Look familiar?

Why does this area hurt? It can hurt for a variety of reasons, usually due to overuse or posture (or both!). Personally, I find that these muscles bother me after a lot of physical activity. And the best course of action for making these muscles feel better is - would you believe it? - massage.

But unless you're extra flexible, you can't really reach that area yourself. And even if you could, the muscles you'd be using when massaging are the ones that you'd simultaneously be trying to relax, so it would all be a bit counterproductive. Solution? Tennis ball!

What to do:
Lie on the floor. Put a tennis ball under your back, between your spine and shoulder blade. Roll up and down on the tennis ball and vary the amount of weight you put on it. I would hold any uncomfortable spot for at least a few minutes - sometimes I'll even take out a book and read for a bit while in this position.

Don't have a tennis ball on hand? Try standing in a door frame with the edge digging directly into the muscles. Feels better than it sounds, I promise.

And that's it! Applying ice to that region afterwards wouldn't hurt either.

Naturally, if the pain keeps creeping back, a visit to a massage therapist would be the best long-term solution. But using a tennis ball for self-massage is great to ease muscle tension in between sessions.

Just a quick update about my health care reform essay (see previous post)... I sent out a link to my essay (with an introductory email) to the Oregon Health Authority, one of the government organizations working on health care reform. Last Friday I received a reply:

Hi Natalie,

  Thank you for your e-mail. I'm sorry for the delay getting back to you. I appreciate your e-mail and input, and thank you for providing the link to your essay. Since the Oregon Health Policy Board finished the Action Plan, the Legislature passed and Governor signed House Bill 3650 to transform the delivery system for the Oregon Health Plan, incorporating in many of the aspects of the Action Plan. HB 3650 would create Coordinated Care Organizations (CCOs) which  would be responsible for all of the care for Oregon Health Plan members in their communities. The idea of CCOs is exactly what you've outlined: allowing communities the flexibility so people receive the right care at the right time and experience better health, better care, and lower costs. This includes both looking at how providers are utilized, and also the types of services that we incentivize. The idea is to provide patient-centered care and have a prevention focus, instead of just paying for more services after the fact. If you'd like, I'd be happy to forward your message along to the Oregon Health Policy Board, which will be making recommendations to the Legislature in February 2012.  

For more information, I encourage you to visit www.health.oregon.gov. We will be continually updating that page as the work progresses.  

Please let me know if you have any questions.  

Best,
Jeremy

Exciting! Also, last week I shortened my essay into an op-ed and submitted it to a local Oregon paper. I heard back in regards to my personal info (that I was a massage therapist practicing in town), but haven't heard anything beyond that yet. Naturally, I'll post about it if I do.

In America's complicated health insurance infrastructure, not everyone can receive private coverage. Some can't afford it; others aren't eligible for any one of a variety of reasons. But health care is a right and should be available to all citizens. Government programs are in place to cover many of those without access to private insurance, but as of now they don't have the capacity to insure everyone who needs it.

In 2009, the Oregon Legislature created the Oregon Health Care Policy Board in order to create a comprehensive health reform plan for the state. The overarching goal for this plan is that by 2015 the large majority of Oregonians will have health care, whether through public or private insurance. The board outlined strategies that would move the state towards that goal, systematically implementing new policies and improving old ones.

The board determined three aims for the new health care system, as discussed in Oregon's Action Plan for Health:

"Improve the lifelong health of all Oregonians; increase the quality, reliability and availability of care for all Oregonians; and lower or contain the cost of care so that is it affordable for everyone."ⁱ

One of the questions these aims raise is whether insurance should cover all licensed health care practitioners – not just those in the tradition of Western medicine, but also those thought of as "alternative" options, such as chiropractic, acupuncture and massage. Research has demonstrated the effectiveness of many of these practices for a variety of medical needs. But with an already expanded population of insured individuals, would there be enough money to cover an expanded field of medicine? It turns out that Washington state already mandates such coverage for their private insurance providers. And a 2010 study showed that this addition of CAM (complementary and alternative medicine) to basic insurance plans can actually reduce costs in health care. Widening the scope of covered treatment while still controlling the cost of medical care is exactly the solution that Oregon needs.

Improving Lifelong Health
Beyond treating for acute issues, how can insurance coverage improve the health of its clients? This has a lot to do with shifting the focus of medical treatment from cures to prevention; stopping problems before they even become problems. A big goal for this approach – known as "holistic" medicine – is helping people adopt healthy lifestyles. For example, tobacco use, poor diet, and inactivity are three modifiable factors that are otherwise some of the biggest causes of health problems. Many medical practices have realized the benefits of holistic care, and so has the Oregon Action Plan: "The future: A holistic approach that focuses on the patient, not the symptoms, and emphasizes preventive care and healthy lifestyles."ⁱⁱ

Quality, Reliability and Availability of Care
But no single doctor can wholly care for a client. The Oregon Action Plan wants to create "a community-based team of health care professionals, not just doctors, [who] will help keep people healthy and treat them when they are sick."ⁱⁱⁱ With different practitioners from a variety of backgrounds, medical teams will have a wider base of knowledge and be able to solve health problems more effectively.

And OHP is right to look beyond medical doctors to provide care. An April 12, 2010 article in the Wall Street Journal states, "Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges."^iv Utilizing a wide range of health care providers isn't just a good idea; it's a necessary one.

But how can a team of medical professionals really be effective if they aren't all covered by insurance? CAM treatments, such as acupuncture and massage, are still considered a privilege, a fancy addition for expensive insurance plans. But proper treatment shouldn't just be available for those who can afford it. If the future of medicine is to work in teams, with each practitioner able to contribute his or her expertise towards a patient's better health, every practitioner should be covered equally by insurance. If a patient's doctor refers her for massage, why should she have to pay out of pocket for this treatment? Without comprehensive coverage, she'll be less likely to get the medical care that she needs.

As mentioned in the Action Plan, an estimated 30% of care is either not necessary or ineffective^v. People are spending money on treatments that aren't actually solving any problems. But research exists that supports the effectiveness of many CAM treatments for a variety of conditions. Massage therapy, for example, is good for muscle pain^vi, depression^vii, stress^viii, anxiety from drug withdrawal^ix, pain and anxiety from cancer treatment^x, hormone imbalance^xi, and immune function^{xii xiii}, among many other physical and emotional issues. From this wide range of research, it's easy to see that massage has benefits both for acute problems and preventative care, making it a natural addition to any health care team.

Containing Costs
Holistic care is a great idea for many reasons – stopping problems before they become problems, encouraging healthy lifestyles, and even saving money: "Focusing on prevention will yield significant returns on investments by improving health."^xiv Preventing disease and staying healthy cost less than treating or managing problems once they arise.

Unfortunately though, there are plenty of people with severe problems already, and despite best efforts there will be more. Chronic pain, for example, is a condition that affects "more than 75 million Americans…over 50 million of these individuals are partially or totally disabled from pain."^xv Not only is this widespread, but it seriously impacts productivity: Chronic pain costs more than 50 million lost workdays at a cost of more than $3 billion in lost wages and more than $100 billion in lost productivity^xvi. How can we get a handle on this disease?

While painkillers and other drugs are the most common solution for chronic pain, the most effective treatment is a holistic one^xvii. Through things such as psychotherapy, nutritional evaluations, and relaxation massages, treating the patient for all symptoms – mental and emotional, not just physical – is the best solution. By focusing on the bigger picture when it comes to chronic conditions, and working not just to minimize symptoms but also to make lives better, medical costs can be cut and productivity can increase.

CAM and Cost Savings
As outlined above, improving health through holistic care is cost effective. And a huge part of this type of care is CAM treatments – naturopathic and chiropractic medicine, acupuncture and massage. Because these therapies don't depend on expensive technologies or pharmaceuticals, and instead "harness the power of vis medicatrix naturae (the body's natural ability to heal itself)"^xviii, could CAM treatments alone save money? Recent research suggests that they do^xix.

Beginning in 1996, the state of Washington mandated that private insurance companies must cover every category of health care provider given that the provider is providing treatment for a basic service that he or she is licensed for. In short, that means CAM providers in the state of Washington are covered under private insurance policies in the same way that conventional providers are covered. A visit to an acupuncturist, for example, would be available for the same copay as a visit to a medical doctor.

From the mandate:

"(1) Every health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 1996, shall:
(a) Permit every category of health care provider to provide health services or care for conditions included in the basic health plan services to the extent that:
(i) The provision of such health services or care is within the health care providers' permitted scope of practice; and
(ii) The providers agree to abide by standards related to:
(A) Provision, utilization review, and cost containment of health services;
(B) Management and administrative procedures; and
(C) Provision of cost-effective and clinically efficacious health services." ^xx

This wouldn't mean that everyone in Washington would start getting CAM treatments, but it would mean that those who did utilize CAM weren't just those who could afford to pay out-of-pocket. Recently, researchers took a look at two years worth of claims to see if patients who did and did not use CAM treatments differed in total medical expenses.

Because most CAM research relies on self-reported data (ie, whether the patient feels better after a treatment), these studies often have an inherent bias. Whether or not CAM treatments provide tangible evidence of being effective, they often lead to a general sense of well-being. While the interaction between mental and physical health cannot be denied, this was not what researchers wanted to study. Rather, this study took a "cost-minimization approach" in order to find out whether CAM users differed from nonusers in their medical costs.

In an analysis of insurance expenditures for matched groups of CAM users and CAM nonusers, it was found that CAM users had significantly lower overall expenditures. Specifically, while they did have a slightly higher expenditure for outpatient visits (including massage appointments, chiropractic adjustments, etc, which the other group – by definition – did not utilize), inpatient expenditures and other expenditures (imaging, lab work, etc) were significantly lower. It was found that CAM users were less likely to be hospitalized, less likely to get a hysterectomy within one year of diagnosis, and more likely to have some type of imaging done and done early. Although having more imaging done should seemingly be more expensive, the imaging was typically of a less expensive variety. And because the imaging was done early, it had the benefit of being a preventative measure.

Researchers predicted that, given the findings, CAM users would save an enormous amount of money:

"Given the expected $356 lower expenditures for each CAM user, we would expect an overall $9.4 million lower expenditure in a group of 26,466 CAM patients with these medical conditions compared to a similar group of CAM nonusers of equal size." (pg 415-416)

For some analyses, subjects were divided into three levels of "disease burden", which created groups based on their expected resource use. The low disease burden group were generally healthy individuals, high disease burden group were generally unhealthy individuals, and the medium disease burden group was in between these two. When divided in this way, CAM users in the low and medium groups had higher overall expenditures than CAM nonusers – they had more outpatient visits to CAM providers, and neither group had many inpatient visits or labs. But in the high disease burden group, CAM users had significantly lower expenditures than nonusers, which more than made up for the higher expenses of the healthier groups. CAM was used for preventative care by the high risk group, just like in the other groups, but it was also the less expensive way to treat acute problems.

OHP
OHP (Oregon Health Plan) is Oregon's Medicaid program for low-income adults. While it insures many, space is limited and it had been closed to new enrollment for years. In 2008, Oregon increased the number of spots available for the program. Because it couldn't accept everyone on the waiting list of 90,000 people, it utilized a lottery system for a randomized and fair selection.

A paper was released in July 2011^xxi that discussed the effects of the expanded OHP coverage after the first year. Were people actually taking advantage of their new health care coverage? This paper affirmed that the intension of the Medicaid expansion – that people who needed coverage were using it – was the reality. OHP patients had significantly higher health care utilization, less out of pocket expenses, and better reported physical and mental health than those who had not been chosen to receive OHP.

The paper also notes that those with OHP coverage are generally in poor health, with high rates of depression, asthma, diabetes and high blood pressure. Were they to have been in the Washington study, they probably would have been placed in the high disease burden category. There's no reason to expect, then, that the medical savings found in the Washington study would be any different than if OHP covered CAM treatments. After all, the strongest finding in the study came from this group – mean expenses for CAM users were predicted to be $1,421 lower than nonusers. The message is clear: Making CAM treatments available through insurance, especially insurance like OHP, will save money.

The Oregon Action Plan for Health said it best when it talked about the need for a holistic approach to health. The world is moving towards using teams of health care professionals, not just doctors, in order for patients to get the most benefit. But for this to happen most effectively, insurance would need to cover all health care providers. By covering CAM therapies, OHP would be satisfying each part of its Triple Aim. Improving lifelong health: Along with acute care, CAM providers focus on holistic and preventative treatments. Increasing quality, reliability, and availability of care: Including CAM practitioners in insurance coverage will widen the scope and availability of treatment. Covering costs: It's impossible to ignore the evidence found in the Washington CAM paper – overall, CAM users cost significantly less than their counterparts. The addition of CAM therapies to even the most basic health plans will result in medical care that is effective, affordable, and available to all.

----------------------------------------

ⁱ Oregon Health Authority. December 2010. Oregon's Action Plan for Health, pp 5.
ⁱⁱ Oregon's Action Plan for Health, pp 22.
ⁱⁱⁱ Oregon's Action Plan for Health, pp 22.
^iv Sataline, S., Wang, S. U.S. Faces Shortage of Doctors: Medical Schools Can't Keep Up. The Wall Street Journal, April 12, 2010.
^v Kimbuende, E., Ranji, U., Lundy, J., Salganicoff, A.U.S. Health Care Costs. KaiserEDU.org. Retried August 8, 2011, from http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx.
^vi Preyde, M. (2000). Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. CMAJ, 162, 1815-1820.
^vii Field, T., Grizzle, N., Scafidi, F., & Schanberg, S. (1996). Massage and relaxation therapies' effects on depressed adolescent mothers. Adolescence, 31, 903-911.
^viii Hayes, J., Cox, C. (1999). Immediate effects of a five-minute foot massage on patients in critical care. Intensive and Critical Care Nursing, 15, 77-82.
^ix Black, S., Jacques, K., Webber, A., Spurr, K., Carey, E., Hebb, A. & Gilbert, R. (2010). Chair massage for treating anxiety in patients withdrawing from psychoactive drugs. Journal of Alternative Complementary Medicine, 126, 979-987.
^x Smith, M.C., Kemp, J., Hemphill, L., & Vojir, C.P. (2002). Outcomes of therapeutic massage for hospitalized cancer patients. Journal of Nursing Scholarship, 34, 257-262.
^xi Field T, Hernandez-Reif M, Diego M, Schanberg S, Kuhn C. (2005). Cortisol Decreases and Serotonin and Dopamine Increase Following Massage Therapy. International Journal of Neuroscience, 115(10), 1397-1413.
^xii Ironson, G., Field, T., Scafidi, F., Hashimoto, M., Kumar, M., Kumar, A., Price, A., Goncalves, A., 2, Burman, I., Tetenman, C., Patarca, R., Fletcher, M. (1996). Massage Therapy is Associated with Enhancement of the Immune System's Cytotoxic Capacity. International Journal of Neuroscience, 84(1), 205-217.
^xiii Billhulta, A., Lindholm, C., Gunnarsson, R., Stener-Victorina, E. (2009). The effect of massage on immune function and stress in women with breast cancer — A randomized controlled trial. Autonomic Neuroscience, 150(1), 111-115.
^xiv Oregon's Action Plan for Health, pp 30.
^xv Joint Commission on the Accreditation of Healthcare Organizations. Pain: Current Understanding of Assessment, Management, and Treatments. Oakbrook Terrace, IL: Joint Commission on the Accreditation of Healthcare Organizations; 2001.
^xvi Fox CD, Berger D, Fine PG et al. Pain assessment and treatment in the managed care environment. A position statement from the American Pain Society. Glenview, IL American Pain Society; 2000.
^xvii Grumbach, K., (2003). Chronic Illness, Comorbidities, and the Need for Medical Generalism. Annals of Family Medicine, 1, 4-7.
^xviii Herman, P., Craig B., Caspi O. (2005). Is Complementary and Alternative Medicine (CAM) Cost-effective? A Systematic Review. BMC Complementary and Alternative Medicine, 2, 5-11.
^xix Lind, B., Lafferty, W., Tyree, P., Diehr, P. (2010). Comparison of Health Care Expenditures Among Insured Users and Nonusers of Complementary and Alternative Medicine in Washington State: A Cost Minimization Analysis. The Journal of Alternative and Complementary Medicine, 16, 411-417.
^xx Partial text of RCW 48.43.045 from Washington State Legislature.
^xxi Finkelstein, A., Taubman, S., Wright, B., Bernstein, M., Gruber, J., Allen, H., Baicker, K., The Oregon Health Study Group. The Oregon Health Insurance Experiment: Evidence From The First Year. NBER Working Paper No. 17190, July 2011.

In one of my massage classes, we learned briefly about different "genres" of massage - Thai, craniosacral, Shiatsu, etc. We studied the general theories behind each style and received a basic overview of the techniques. We also learned about pregnancy massage. This was less of a specific type of massage than it was a specific type of client, but there were still some details that made pregnancy massage different from the norm. The biggest detail was positioning, since pregnant clients (well, those in their third trimester) were often most comfortable lying on their side. So we wouldn't be caught off-guard later, we practiced in class how to properly and effectively massage people in this position.

But we didn't actually get to massage pregnant women, so it was all pretty theoretical. It wasn't until much later, after I had already started my practice, that I realized how rewarding this type of massage could be - for both the client and the therapist.

I'm going to go out on a limb here for a moment and say that being pregnant must be hard work. Hard, constant work, with no breaks or days off. That's why spending an hour on the massage table can be such a relief for these women. It isn't a full break - that is, you don't suddenly become "unpregnant" for a while; your body and hormones are still in flux - but it's a temporary refocus of priorities. For a full 60 minutes the pregnant women herself is most important, not what's forming inside.

As I've talked about before, massage can have all sorts of effects - physical, emotional, mental. For pregnancy massage, while the physical effects (i.e, pain relief) are still very much present, the emotional effects often take precedence. My clients glow a little brighter, breathe a little deeper, smile a little wider. Like I said above, when a client is involved with something as consuming as pregnancy, there's a lot to gain from something as simple as massage. And I'm happy to be a part of it.

There has been, and will continue to be for a little while longer, a lack of new posts here. My apologies! I'm currently packing and moving into a new place, and I'm also spending a lot of time writing a letter/essay about the healthcare reform in Oregon (see here).

New content should be back by mid-September!

Got pain? Want to take care of it?

Because I do medical massage - that is, massage for the purpose of relieving pain and helping muscles get better - I'm aware that my massages are most beneficial in larger numbers. Getting more massages will have a higher payout, so to speak. But massages cost money, sometimes more money than people are able to spare.

Honestly, I don't think money should be a deciding factor on whether or not someone can do what's best for their health. That's why I volunteer regularly - I like giving massages to people who otherwise might not be able to afford them.

But I do have a business to run. And until we have a health care system that provides everyone with comprehensive care at very little cost (ah, won't that be the day), people will continue to pay out of pocket for care that they need.

To that end, I'm offering a new deal for my clients in need of pain relief: 4 massages (60-minute or 90-minute) for the price of 3. You heard me, that's one whole free massage.

Ok, but what's the catch?

The catch is that all 4 massages need to be scheduled within 2 months. Weekly, biweekly, whatever. Why? Because frequent massages give the best results. And I like it when my massages have good results (I bet you do too!).

Here's the math:
Four 60-minute massages for $195, which comes out to $48 per massage
or...
Four 90-minute massages for $270, which comes out to $67 per massage

What else is there to say? It's time to start investing in your health.

How to participate: Just call my clinic (503-445-8114) to schedule a massage. We'll work out payment and details when you come in for your first session.

Amy [not her real name] first came into my clinic for an acupuncture treatment because she had heard it might help her pain. And it might have, in the long run - acupuncture is great for pain relief - but the needles themselves hurt so badly that Amy couldn't continue beyond the first session.

Unsure of what to do (since the treatment was causing more pain than it was fixing), the acupuncturist called in one of the clinic's doctors. Together they discussed the client's condition, and somewhere in that talk the words "trigger points" came up. Well, they knew who to send Amy to next.

Amy came in for her first massage with me during the second week of December. Reason: debilitating shoulder pain.

Amy's job had her both working at a computer and working with children. This meant that, not only did she have the classic desk-work posture problems (Amy admitted to not usually sitting up straight in her chair), but bending forward to talk to children put a strain on her muscles as well. And, naturally, high stress in the workplace didn't help either.

On the body diagram I give every new client as part of their intake, Amy had circled her entire back, shoulders, neck and head, indicating pain in all of these places. Dots - to note extreme pain - were all along the right side of the neck, shoulders, and upper back.

Amy assured me, however, that she didn't hurt everywhere all the time. But she hurt a lot, she hurt often, and that was a problem.

She got on the massage table and I started to work on her muscles. Sure enough, there were trigger points everywhere - and they were so sensitive that even the slightest touch had Amy flinching. She told me that it felt like I was digging my nails into her body (which, I assure you, I wasn't).

In general, trigger points are very sensitive to touch. That is, a little pressure from massage goes a long way in fixing the problem. And since Amy couldn't tolerate much, a little was all I could do for now anyway. Gradually, as the trigger points decreased in severity, we would be able to increase the pressure and fully release the points.

I outlined my treatment plan for Amy at the end of the first session. She would continue to come in for weekly massages to work on her trigger points. After three more sessions, she would feel a noticeable improvement in pain levels and muscle tension. In seven more sessions, the trigger points would be released.

At the start of the next few sessions, Amy would report that her muscles had felt better immediately following the previous treatment and had remained like that for the next few days. But then the pain would return, back to where it had been before. I assured her that this was normal, and that the pain-free days would increase until eventually the pain didn't come back at all.

At the start of her fourth session, Amy told me that she realized she hadn't been complaining about her pain at all during the week. Noticeable improvement! During the massage that day I noticed that, although pressing on the trigger points still made her flinch, I was using much more pressure than I had been before. We were definitely getting somewhere.

After eight weekly massages, the trigger points had diminished in size and strength so much that we decided to push her treatments to every other week. At the end of February, after two more sessions (making ten in total), Amy's trigger points were gone and she reported no pain.

Amy still comes in for monthly massages, mostly for general wellness and tension relief. Trigger points do pop up in her neck and shoulders occasionally, but never to the extent or severity that they did before - and I can usually release them within a session or two.

While, sure, I like maintaining some humility in my profession, it would be foolish of me to undervalue the importance of massage. Amy's case is a clear example, but it's not terribly unique. Massage in general (and trigger point therapy in particular) can relieve pain, even fix the muscles so that the pain doesn't return. Simple as that.

Complementary and Alternative Medicine: Integrating Evidence-based and Cost-effective CAM into the Health Care System [PDF]

This is a great write-up about the effectiveness and usefulness of complementary and alternative medicine (most notably, massage therapy, acupuncture, chiropractic care and naturopathic medicine). I was going to make some bullet points about its best points and statistics, but it's all really fascinating.

It's a short and concise read too, so if you're at all interested in the ways CAM can help resolve issues of healthcare cost, access and quality (and you should be interested, because it's important!), I'd definitely recommend checking this out.

Ok, here's one point they bring up. In 1996, the state of Washington mandated coverage for services provided by all of the state's licensed health care providers. That means that massage therapists and naturopathic physicians are covered in insurance policies just like medical doctors.

In a recent analysis of claim costs for Washington (seeing if and how this new law changed anything), researchers found that "among insured patients with back pain, fibromyalgia, and menopause symptoms, after minimizing selection bias by matching patients who use CAM providers to those who do not, those who use CAM will have lower insurance expenditures than those who do not use CAM." (emphasis mine). Like, $9.4 million lower (for the 26,466 CAM users in the study). Whoa.

Seriously, though, read the whole article.

7 reasons why you should get a massage even though it's summer time and why would you want to be indoors?

1. The best way to relax while still doing something worthwhile.
2. Something to brag about and make your friends jealous.
3. A way to congratulate yourself on your recent accomplishments (going on a hike, weeding the garden, cooking dinner, etc)
4. Make getting a massage your one accomplishment of the day.
5. Spend the hottest hour of the day inside with A/C.
6. You lost your sunglasses and didn't put on sunscreen, so you can't enjoy the sun properly anyway.
7. Sun? What sun?

No pain, no gain. It's words like these that have been instilled in our culture, driving home the idea that pain is always a good thing, that we aren't really trying hard enough unless we're hurting.

But that's just not true. Pain usually tells us when we've done something we shouldn't have (e.g. twisting an ankle) or when we've done too much (overstretching a muscle).

Pain tells us when something's wrong.

Some people don't understand that a lot of pain has a muscular origin. Clients come to me for massage, knowing that it will make them feel better but maybe not quite knowing why. That isn't to say they think their pain arises from somewhere else; they just haven't put much thought into it. The point is that they hurt and they want the pain to go away.

But then, not everyone minds the pain as much as they probably should. I've had too many clients tell me about their pain but then follow it up with "but it's alright, I can pretty much just ignore it now". As if ignoring the pain is just as good as doing what needs to be done to make the pain stop. Because, again, there's too much in this culture that frames pain as something just to work through, something you shouldn't let hold you back.

Some people I've talked to are hesitant about getting massages at all (despite their constant pain) because they don't want to be made aware of all their muscle problems. They just don't want to know how much they hurt.

Awareness is a funny thing. If you're aware of your pain - if you know where you hurt, why you hurt - then you'll be more likely to take care of it. But what if treatment doesn't work? I imagine that's what most people are afraid of: being stuck with acute awareness of their problems but not knowing how to solve them. So instead, they avoid thinking about the pain, continuing on with life as best they can without confronting the underlying issues. Ah, blissful ignorance.

But the pain is still there; sometimes with unresolved muscle issues (as basic as a knot or a trigger point), sometimes not. Untreated pain can lead to serious injuries (for example, in athletes) or become a chronic condition:

[From chronicpain.org]"Chronic pain disables more people than cancer or heart disease. It costs the U.S. economy more than $90 billion per year in medical costs, disability payments, and productivity."

Yikes!

People (usually friends, sometimes not) tell me all the time about their pains and muscle problems. Comes with the territory, I suppose. I always empathize, trying my best to understand their situation and feel their pain. But then I try to help - usually with a quick massage on the affected area or by teaching them a useful stretch. Sometimes they're taken aback, as if they weren't looking for a solution; they just wanted to tell me their problems. But what if the answer is really as easy as a massage?

I know I've talked about it on this blog before (primarily here) - I'm a very firm believer that insurance should, in some shape or form, cover massage treatment. Fleshing out this argument can get tricky, discussing what exactly qualifies as a medical necessity (physical need? emotional need?), or whether massage should be considered part of both preventative care and acute treatment. But the point remains that, in some sense, massage is a medical treatment, and sometimes it's the best option for a specific situation (like, for example, muscle pain).

Anyway. That's the background; that's my opinion on the whole thing. So what?

Well, it turns out that the state of Oregon is in the process of creating an affordable healthcare option for all its citizens. The Oregon Health Authority is currently fleshing out details of its plan. Lots and lots of details. How best to improve health, increase quality and availability of care, and lower costs? As you can imagine, there's a lot of planning that needs to go into it.

And this is great. Affordable, accessible, quality healthcare should be a universal right. But as for the details...

Will the healthcare plans adopted by the OHA include complementary/alternative treatments? Specifically, will it include massage coverage? There are a million reasons why it should, but the reality is that massage won't be covered unless we (that is, the massage therapists, the professional organizations and their lobbyists) communicate with the OHA and push for recognition.

I know that the Oregon acupuncturist board is pushing and lobbying the government to get acupuncture included in whatever healthcare plan gets created. I emailed my local massage chapter to see what they're doing and if I could help, but it turns out they aren't doing anything. They don't have much of a budget as it is, and they have no real plans to talk to the OHA.

Besides, wrote the woman in response to my inquiry, "there is still a substantial portion of the population who still views massage as a luxury and not a necessity".

Right... but that's just my point. People think things that aren't necessarily true - including the idea that massage has no benefits beyond the most general sense of "feeling good". And the best way to fix this misperception is by getting massage (rightfully) included in the new healthcare reform and thus considered a viable treatment option.

Since there isn't already a massage group lobbying the OHA, for now it's up to me. I'm educating myself on the OHA action plan [pdf], and eventually writing a letter to someone in charge. Sounds like fun!

In short, I'm planning on changing the world, or at least trying to make a state-wide impact. My effort might not actually amount to much, but I'll keep you updated on my progress.

It's easy to picture how massage can help with physical stress. Physical activity uses the muscles; the muscles become overworked or tired; they develop adhesions and trigger points. Simple. Depending on the cause of the physical ailment (low back pain from working every day in a kitchen versus suddenly tripping and twisting an ankle), massage might fix the problem in one session or take several months to put things back in order. Likewise, it also depends on how much the client is invested in recovery. If a client injures his shoulder doing an activity but continues doing this same activity during treatment, the shoulder may take longer to heal than if he made some adjustments to limit recurring strain. Healing works best when the client is an active participant in the process.

How massage can help with emotional stress, though, is harder to gauge. Massage increases relaxation and decreases the production of stress hormones, but what else can it do? It depends, really, because everyone handles stress differently. Some people don't hold stress in their bodies at all - they're the rare and lucky ones. But most people hold stress somewhere, most commonly in the neck and shoulders.

Alright, so emotional stress can cause muscle tension. And what's the best way to alleviate muscle tension? Yet again, massage is a huge help.

But particularly intense situations - such as the end of a relationship or the death of a loved one - can be draining on the whole self. A whole build-up of emotions can be manifested physically, and without any direct cause the entire body just winds up aching. Can massage help in these cases also?

I had a client who was coming to see me every week for debilitating shoulder and back pain. After a few months of progress, emotional stress came back into her life to an alarming degree. She'd come to the sessions completely frazzled; maybe she'd relax a little during the massage, but as soon as she left my office everything was back to where it was before. No amount of massage was going to fix her physical ailments until she could get everything else under control. We both decided it was best for her to seek treatment from a mental health therapist before coming back to see me.

Just like with a physical injury, in which the client needs to make changes in his posture or activities so as not to further aggravate his muscles, a client with emotional stress needs to take care of underlying factors in order to see progress with the physical symptoms. Sometimes this is just a matter of time - time to relax and unwind, which massage can provide - but occasionally it may require some extra support.

But is the line between the emotional and the physical really so clear? I recently had a young client referred to me who had been hospitalized earlier in the year for anxiety. Not only was she anxious, she was also in pain... which made the anxiety worse, which made the pain worse. The cycle was so entrenched that it would have been useless to take care of one symptom while ignoring the other.

There's a huge overlap between physical and emotional states, much more than Western medicine would have us believe. Sure, the messy emotions are internal sensations, but you can't hide them completely - not from other people, and especially not from yourself. If you're upset or stressed or angry, you can't just keep it inside: your body knows how you feel and will react accordingly. It turned out that the pain my client was experiencing was from a plethora of trigger points in her neck, shoulders and low back, activated by her anxiety but now very much a physical symptom.

In the end, I suppose I just want to emphasize (again!) the usefulness of massage. It has benefits for the physical, the emotional, and the physical/emotional blend that you couldn't pull apart if you tried. Massage can't solve everything, but it can do a lot - both by itself and in conjunction with other practices.

I used to work so much with kids - as a figure skating instructor, babysitter, and all-around friend/big sister - that people (parents, onlookers) always assumed I would be a teacher when I grew up. I guess it's the natural progression when working with the younger generation, going from after-school jobs and volunteering to an actual profession in the same general field.

But teaching isn't really much like babysitting, and I never saw myself ending up in a classroom. Coming up with lesson plans or enforcing discipline was not what I dreamed of. I loved working with kids, but a room full of them wasn't where I saw my future.

As anyone can tell you, though, teaching doesn't just take place in a designated classroom. You don't just learn English in a room with the cursive alphabet lining the walls; you won't only learn science in a room with a microscope. Teaching happens wherever there's knowledge to be passed on and discussed.

It just so happens that, as a massage therapist, I know a lot about a subject that many people don't know about. The body - their bodies. Their muscles. And this is something that people definitely want to learn.

A client comes in and fretfully tells me about her pain, how she doesn't understand it, doesn't know what's going on. Whether it's muscular or nervous or psychosomatic she couldn't say, she just knows she hurts and maybe I can help.

As it turns out, I usually can. I can help by massaging (relieving the pain) and I can also help by teaching (understanding the pain). I love explaining to my clients how muscle pain arises (going into specifics about trigger points and knots, stress and bad posture), and how they can take care of themselves so that the pain doesn't return.

One of the best things about this sort of teaching is that it extends to all ages. Anyone, it doesn't matter how old, can benefit from knowing more about their body. Indeed, the self-awareness that comes from getting older may even make these muscle lessons more effective - people can apply what I teach them to their own experiences. They can start to see the connections between high stress or an unsupportive pillow to the neck pain they feel at the end of the day, and then do what it takes to help themselves.

Flying is a pain, really. Too many lines, too much running through terminals and waiting around. Removing shoes and jackets and belts and putting it all back on while people push you out of the way. But it's the quickest way to get from Point A to Point B, especially when Point B is across the country (like my family). It's a pain, sure, but it's a necessary one.

And then there are the airplane seats. For the vast majority of us who travel in economy class, these one-size-fits-all seats don't actually fit anyone. Why must they be so uncomfortable?

Office chairs can be uncomfortable, but they can be adjusted. Indeed, there are people who make a living by adjusting chairs and desks in order to minimize workplace injury. But it's not the same with airplane seats. Different people of different sizes sit on these seats for every flight, but instead of making them adjust to everyone's size and needs, these seats just don't adjust at all.

Ah, the things that airlines can get away with.

Well, what's wrong with the seats? The easiest problem to identify is the lack of lumbar (low back) support. We hear about lumbar support all the time because it's the essential thing for office chairs. When you're sitting at a desk, the curve in your lower spine needs the most support. Airplane seats don't have this, although it's easy to improvise with a jacket or pillow.

The biggest problem, I would say, is neck support. Unlike office chairs, which typically only rise to the upper or mid back, airplane seats cradle the entire posterior side of the body. And since a good portion of fliers fall asleep or at least rest their head during their trips, they're going to utilize the upper portion of their seat.

I've already written about how important neck support is when you sleep. Your neck has an inward curve that needs to be stabilized with a pillow. Unfortunately, what the airplanes pass for neck support is worse than nothing. There's a pillow-ish thing attached to the seat around neck level, sure, but here's the kicker: You can't adjust it. So unless you're the perfect height (and you don't slouch or move at all during the flight), the neck support won't actually be at your neck.

Whether you're flying across country or just sitting at a desk, being in a sustained position for hours at a time is troublesome. Your muscles need to take this time to relax, but sometimes that's not possible. On an airplane, the comfort of your body - your arms, legs, gluts, etc - really depends on how you sit and who you sit next to.

Are you able to use your arm rests? (and, given that, are the armrests at a proper height?) If your arms are stuck too tightly by your side (in the case of a larger neighbor encroaching on your space), your shoulders (and pecs!) can cramp up. The same is true for your legs. Perhaps you can fix the problem by sitting differently, but this might put uncomfortable pressure on your tailbone and hips. Really, sitting in an airplane seat will always bother at least a few muscle groups.

So air travel is terrible for your muscles. Big surprise there. But what's the solution?

Some easy things to do: Use pillows! Last time I traveled I brought my neck pillow from home, but those travel pillows will do the trick as well. Adjust yourself throughout the flight. If you spend an hour curled up at the window, spend the next 30 minutes sitting up. Recline your seat: it's not much, but even that slight tilt is better than nothing. Get up and walk around. Don't worry about bothering your neighbors - they should get up and move too, so really you're doing them a favor.

And don't forget to do some neck stretches after you land! If you can, try to schedule a massage soon after traveling, or at least demand a back rub from whoever you're visiting. Traveling can be a pain in many ways, but at least you can do a few things to minimize its negative effects on your muscles.

A shy client asked me after a short chair massage: "Was that supposed to be... painful?"

Well, it depends on what your definition of pain is.

Well, it depends on a lot of things, actually.

There's a well-known maxim describing the direct relationship between discomfort and success that can easily illustrate the connection between pain during a massage and the subsequent release of muscle tension. But is it true? Is there no gain, no long lasting benefit of massage, without first causing pain?

Not necessarily. But again, it depends.

I can give the same massage - focused work on uncomfortable trigger points - to two different people, and only one of them will consider the massage painful. It doesn't necessarily mean that one client's muscle tension is worse than the other's, just that they each perceive it differently. Some will feel the massage (or at least parts of it) as painful, full stop. Others will feel the massage as bothersome, maybe painful... but for a purpose. A means to an end. Productive pain.

At the start of an intensive trigger point treatment (that continued weekly for 2 months), one of my clients likened my massages to medical procedures. She grimaced and flinched through each one, and while she certainly felt better afterwards, the massages themselves weren't something she looked forward to. But when I shared this metaphor with another client of mine (who was seeing me for the same reasons), she merely shrugged. The massages weren't painful - they were useful.

As a massage therapist, I'm not looking to cause my clients pain. But I am looking to relieve my clients' muscle tension, and sometimes pain is the conscious response.

When a client tells me that my pressure is causing pain, sometimes I'll back off and use a lighter touch. Other times, though, I'll just instruct them to take deep breaths and distract themselves from the discomfort. I'm not just trying to make my clients occasionally suffer, I promise. Rather, there's a tangible difference in the muscles in each circumstance.

Pain can be a good thing. Sometimes pain is the signal sent from the muscles to the brain that says ouch, that really hurts, stop doing it. That pain is how you save yourself from injury. Other times, though, pain is just the response from an oversensitive muscle that shouldn't be reacting the way it is. This pain is a sign that something in the muscle is not right. In a broad sense, that's the distinction I can feel during the massage.

So with all this discussion, what am I trying to say? When is comes to massage, sometimes it's hard to distinguish productive pain from injurious pain. There's a thin line between "hurts so good" and "hurts so much I want to punch you in the face". While some amount of pain may be necessary (depending on how much muscle tension you have), don't assume that all pain is good pain. Don't be afraid to communicate with your therapist so that you can have the most relaxing and productive massage possible.

Now that you know why your pec muscles are so important, I want to teach you how to take care of them. Namely, by stretching the muscles when they're tight or achey or overused (from a long day sitting at a desk or from doing too many push-ups, for example).

Really, you can stretch them all the time and your body will just be that much happier.

Pec Stretch:

1. Find a doorframe (or pillar, lamppost, etc).
2. Stand next to the doorframe and slightly behind it.
3. Raise your arm to shoulder height.
4. Bend your elbow and rest your forearm against doorframe (so your forearm is behind the doorframe, leaning forward).
5. While keeping forearm/elbow anchored, rotate your chest and torso away from door.
6. You should feel a stretch in your upper pec area (in red on picture below).



7. Raise your arm higher and repeat the process.
8. You should feel a stretch in your lower pec area.

And that's it! A really easy stretch that you can do pretty much anywhere.

Note: If your muscles get even more achey after stretching, don't continue! You might already have trigger points there that you're irritating further. See a massage therapist first.

Pec muscles are perhaps some of the most overlooked muscles in the body, and not just when it comes to massage.



This is your pectoralis major. It's big. It's your chest muscle. It helps with arm movement - moving your arm up, down, over and in. Any movement that brings your arm or shoulder closer to the midline of your body - that's probably the pec major.

There's another related muscle - the pec minor - underneath this muscle that's, well, smaller. It has a slightly different structure (it connects from your ribcage to the scapula instead of the arm), but it functions in the same general way: it pulls your shoulders forward.

Now then, back to my original statement. Why are pec muscles so routinely ignored?

Quick show of hands: Who here works at a desk? Who here experiences shoulder pain? And if this isn't you, I bet you can easily think of someone who complains regularly about shoulder and back pain.

Shoulder pain, back pain, sure. But how many of these people also complain about tightness in their chest, in their pec muscles? Not many. But in fact, most of the problems are stemming from this area. Take a look at my overly simplistic diagram:



This is a person sitting (at an imaginary desk) with good posture. Back up straight, no hunching over. The back muscles and the pec muscles are in good shape. Moving on to the second diagram:



Now this person is hunched over his or her imaginary desk. Take a look at what the muscle are doing. The back muscles have elongated in order to compensate for this posture. But the pec muscles - the pec muscles have shortened.

Some quick facts: Short muscles are more problematic than long muscles. When a muscle is shorter than normal, it means that the muscle is being constantly overworked (as opposed to just getting stretched out), which makes it ripe for trigger points and knots and all of that.

More to the point, a massage therapist needs to correct the shortened muscles before he or she can make any progress with the lengthened muscles.

Pec muscles usually have a lot of tension and adhesions, making them prime candidates for massage. And as for self-care, pec muscles are great - and really easy! - to stretch out. But that's for next week.

"I feel like I'm a lump of clay, and you're the artist."

A client said that to me last month, and it's a nice image to have in mind when I work.

When massage is used in a research, it adheres to a strict routine. Two stroke up the arm, two strokes down the arm; 1/2 tsp of lotion rubbed onto the shoulder; 10 seconds of compression on the hamstrings (for example). Massage is stripped down like this because it needs to be controllable, uniform across every single massage performed in the study. Without this specificity, researchers wouldn't be able to draw any general conclusions.

It's great, for the sake of research, that massage can be so scientific and precise, but massage outside of the laboratory isn't like this at all. Even if a massage therapist has the same goal, the same amount of time - the same client! - for two different treatments, the end result (the massage that gets created) will always be different.

You can turn every lump of clay into a bowl, but no matter what, every bowl will be unique.

Research is wonderful, practical, and I'm glad it's there. It gives the profession credibility in the healthcare world. But at the same time, you don't have to read the research in order to know how effective massage can be.

Massage is an art because it's impossible to define completely. You can look at it from a million different angles and always discover something new. That's why I come up with metaphors in order to describe massage, or at least pin down parts of it at a time. Massage is like dance; massage is a conversation; massage is its own language. Sometimes the essence of an art can only be captured through comparisons.

Massage is an art because when I talk about the essence of massage, whatever lies beneath the basic, tactile motions, people don't immediately look at me like I'm crazy. There is something there, some mixture of muscle interaction and social interaction, emotional and physical, internal and external. Massage makes people feel good only the way an art can.

The SOAP chart is what doctors and medical professionals use to document and organize information about their clients. Each letter stands for a different note section:

Subjective - what the client tells you (health history, current problems);
Objective - what you observe/find;
Assessment - what you do during the session (type of massage, areas worked on, etc) (this section is used differently in other healthcare professions);
Plan - what happens after the session.

I use the Plan section to note my recommendations - if the client should apply ice to a particular area, for example, or if I taught the client any stretches. I also note goals for the treatment, that is, what I'm working with my client to achieve. I can be pretty specific here, determining how many sessions it'll take for the trigger points to be released or the muscle adhesions to break down.

I couldn't make these kind of goals if I wasn't acutely aware of the effects that massage has on the body. Increased circulation (through vasodilation, improved cardiovascular function), reduced lactic acid in active muscles. Massage can affect the nervous system - stimulating it (as with a sports massage) or calming it (thereby activating the parasympathetic functions). Massage at a particular muscle or around a joint will lessen inflammation and swelling, which can alleviate pain and improve range of motion. A relaxing massage can decrease cortisol (stress hormone), and increase serotonin and dopamine (happy hormones). All of these effects have been scientifically proven.

And beyond the research, on a more practical level, muscle tension and pain are easily measurable. Muscles feel different, respond differently to touch, when they're causing problems. As I massage, the tension decreases; as the tension decreases, the problems decrease. Funny how that works.

But you've heard all of this before; you know there are biochemical and physiological effects of massage (and if you didn't know, you should!). The point I'm trying to make is simply that there are these measurable, provable effects. The science of massage.

A client has been coming to me for the past month to treat whiplash symptoms after a car accident, and recently her muscles have begun to show improvement. Last week I was able to spell out my goal for her: by the end of next month, her muscles would be back to where they were before the accident (that is, minimal tension and no pain). There was a moment of disbelief, but then she smiled. And then she beamed; she glowed with excitement at the mere prospect of being pain free. My reassurance was enough for her to trust the progress she was making.

Maybe it's unusual, being so confident about something I don't have complete control over. But I know - through scientific research and through practice - that massage gets results.

Why would insurance cover massage at all?

Well, why do people get massages? Relaxation, sure, but also for tangible reasons such as regaining range of motion after a joint injury or alleviating extreme muscle pain. Things that need to be taken care of by a healthcare professional - which is why insurance has a part in it.

I work with a variety of insurance companies. Not all massage therapists do this; usually just those working closely with a doctor or chiropractor. I've found, however, that not only does taking insurance benefit my practice, but I actually do enjoy it.

That isn't to say that I like being on hold for 30 minutes every time I call the insurance company with a question, but the set-up has its advantages. The main benefit for me is that I don't need to market directly to potential clients. When members want to find a provider, they search on their insurance's website. My name and contact information come up; they call the clinic and schedule an appointment. Plenty of clients with minimal effort.

In return, I fill out extra paperwork (for billing and for establishing a "medical need" for continued care), and I have to abide by their (sometimes overbearing) rules. As a concrete example, one insurance company will only pay $45 maximum per massage (30% less than my normal cost), and I'm not allowed to bill the clients for the remainder. But this insurance company sends me, by far, the most amount of clients. Less pay per client, but more clients overall. It's a trade-off worth taking.

And because clients are only responsible for a small amount of the cost (copay or coninsurance), they're more willing - indeed, more able - to come in frequently. For my clients with acute pain or injuries (I have a lot of them), this is the difference between getting rid of the problem in two months and letting the problem linger for years.

Generally speaking, acute problems are the types of things one goes to the doctor for. That is, we have health insurance to protect ourselves against agonizing injuries or pain that restricts our daily life. But what happens when these problems are muscle related, when massage is the best answer? Should health insurance always cover these circumstances as well?

A client came to see me last month because of debilitating shoulder pain. I quickly determined that the cause was trigger points, and she needed to come to see me every week for treatment to be most effective. After a few sessions we were making progress, definitely heading in the right direction. But since her insurance didn't cover massage, she was paying out of pocket for every treatment. The cost adds up; there's no denying that.

Her insurance covered physical therapy, however. She found a PT who could do trigger point treatment, cancelled her massage and went there instead. I wasn't angry with her, or even upset at losing a client. We both wanted her to get better, but at what (monetary) cost? Her coming to see me was better for my bottom line, sure, but that's not why I'm a healthcare provider.

I'm not trying to argue that all massages are medical necessities. But if the physical therapist is doing the same thing that I'm doing, why should he be covered through insurance when I'm not? I know that massage therapy has decades of baggage and still struggles for legitimacy in the modern world, but the point is this: Licensed massage therapists are healthcare professionals. They should be under the same insurance umbrella as other healthcare professionals.

(The client in question returned to me a week later, after an unproductive "trigger point" session with the physical therapist. But I digress...)

Should all insurance cover massage?

Well, no. At least, not in our current multi-payer, private company layout. There are still plenty of insurance tiers, everything from the most basic, bare-bones coverage to the all inclusive, medical/dental/vision/anything you've ever dreamed of coverage. It would be silly of me to say that massage should be covered even when most services are not.

But if someone's coverage includes rehabilitative/complementary care such as physical therapy or chiropractic, shouldn't massage be included as well? I would say yes. But then I would immediately challenge my answer.

If all LMTs are healthcare professionals, can all massages be considered medical needs? What about massage in a spa setting? (And if these count, would spas need to start billing insurance?) What's considered a medical need? Physical pain, sure, but what about stress? Non-clinical anxiety and depression?

There are so many types of massage; would insurance cover every single modality (e.g. Thai massage, deep tissue, polarities, etc)? Or would insurance companies decide which styles they considered "medically relevant"? Who would make that decision - some CEO who thinks he knows best? A group specially trained in examining massage research?

So many questions!

I know that this post is mostly rhetorical, bringing up a lot of points without solving any problems. But there are no easy answers. I think that it's time for a serious discussion about the role of massage in healthcare, and I hope this post can shed some light on a few murky topics.

This NYT article talks about a recent study on cancer treatment. Specifically, the research found that, for a significant portion of women with breast cancer, having surgery to remove cancerous lymph nodes is not necessary.

Let me back up and explain for just a second. When it comes to cancer, there are three main types of treatment: radiation, chemotherapy and surgery. Radiation is radiation, chemotherapy is drugs, and surgery can include both removing the tumor (such as through a lumpectomy or a mastectomy) and removing the cancerous lymph nodes.

But let's back up even more. The lymph system is often thought of as the body's sewage system - it filters out cellular debris, foreign particles and other waste. Most of the action happens at lymph nodes, which are spread throughout the body but are also found in clusters at the neck, axillary (armpit), and inguinal area. In cases such as breast cancer or head and neck cancer, where the cancer cells are close to one of these clusters, the lymph nodes themselves sometimes become cancerous.

Cancerous tumors, cancerous lymph nodes. Logic would say that the best thing to do is to surgically remove this infected tissue - that's the surefire way to get rid of as much of the cancer as possible. And indeed, that's the widely accepted treatment. But this new study says that for a significant portion of early breast cancer patients, removing cancerous lymph nodes (along with the typical radiation and chemotherapy treatment) is no more effective than just undergoing radiation and chemo. Why? Because these procedures wipe out the cancer in the lymph nodes all on their own. No surgery needed.

Well, that's great, but what on earth does it have to do with massage?

Lymph nodes are important. They filter out waste, clean our bodies. One risk of having lymph nodes removed is that the lymph system will get backed up, with too much fluid to filter and not enough nodes to do the filtering. The limb (for breast cancer patients, this would be the arm on the affected side) will swell up with lymph fluid. Proteins molecules in the lymph might cause nearby tissue to harden, and the stagnant fluid will increase the risk of infection. This is called lymphedema, and it's a chronic, sometimes debilitating, condition that requires lifelong management.

Damaged lymph nodes will put you at risk for lymphedema, but what actually causes it? That depends. First of all, there's no real logic behind who gets lymphedema or when. There's no window of risk that closes after a certain time post-surgery; someone with damaged or removed lymph nodes will always have an increased risk. Any sort of high stress - especially the physical kind - that causes inflammation in the muscle tissues could potentially upset the lymph balance and overload the system.

And here's where we come to massage: Most massage styles cause inflammation or hyperemia, which is an increase of blood to a certain area. You know how your skin turns red after applying pressure? That's what I mean. Because of this, massaging limbs at risk for lymphedema requires extra care.

This doesn't mean that a massage therapist isn't allowed to work on these parts of the body at all; it just means they have to be smart about it. First of all, when working with the cancer population it's extra important to get a client's complete and accurate history, so that the therapist will know who is at risk. And when working on these affected limbs, massage techniques should be limited to light strokes and gentle holds.

With the results of this study, though, the medical field will be able to limit the number of lymph node surgeries performed (a procedure that has been ingrained in cancer treatment for decades). Less surgery means less people at risk for lymphedema, which is great news for everyone.

Well, it's been a year - one year working as a self-employed healthcare professional. From the new-business perspective, it was the most difficult year. But not only has my business survived (in this economy, no less), it's also grown quite a lot. I started off with maybe two clients per week, usually friends fulfilling a promise to help me out. But now things are different. Every so often I'll overhear the clinic secretary say on the phone, "I'm sorry, but Natalie's all booked for the rest of the day" and I still can't believe it.

Perhaps more importantly though, I've grown. I've learned about myself and what I'm capable of more this year than any other. And since anniversaries are a standard time for reflection, here are a few things I've learned:

Learning: Yes, yes; I learned about learning. How original. But this year I found out how much learning is a continual process, especially when it comes to massage. I finished school with the very minimum requirements, no specialized training. That part was up to me. So I figured out what I wanted to learn, and took classes or read books on the topic. One of the things I love most about massage is that I can never be overqualified for the position; I can never know too much about massage. The more I learn, the more I can shape and refine my practice.

People: Going instantly from sitting in a cubicle and staring at a computer to working and interacting with people every day was something of a shock. And unlike the paper I pushed or the data I entered, which were all pretty uniform, I've learned that every person is different. Even if one client has the same aches and pains as another, it doesn't meant that my massage will be the same or that they'll respond in a similar way. That last part is key: Everybody, every body, responds to massage differently, so it's not practical or feasible to have grand expectations about solving everyone's muscle problems. Every person, every interaction, every massage is different. While this certainly makes my job more challenging, it also makes it that much more rewarding.

Marketing: If you were to go back 10 years and tell me that one day I'd have to spend my time talking to people and telling them about how great I am - and that I'd enjoy doing this - I'd have thought you were crazy. But a giant part of running a business is marketing, letting people know who you are and why you're important. I don't know where the surge of confidence came from, but suddenly I can spend all day telling you why I'm good at massage and why I love what I do (and why you should love what I do too). When I talk about massage, I literally start glowing; I get really happy and excited and there's no doubt in anyone's mind that I'm exactly where I belong.

One year down, and many more ahead!

Other people's moods and attitudes affect us. It's an obvious statement, but still worth pointing out. We're social creatures by nature, empathic. It helps us communicate when we can share the same emotions. Your friend is telling you about her great day, bubbling over with excitement; it doesn't take long before you're smiling too, happy both for her and with her.

Of course, it also cuts the other way. Bad moods can be unfortunately contagious. Your partner has had a rough day at work, and when you see him it shows. No eye contact, defensive body language. Every question you ask is met with a short, irritable response. You're trying to cheer him up but pretty soon you feel like you were the one who had a terrible day.

Imagine that sort of interaction with a client, right before giving a massage. If I let the client's bad mood rub off on me, it'll affect the quality of the massage. I might be distracted or worried, or I just won't be feeling my best. And I certainly don't want that to happen. I want to care about my clients' emotional well-being (which is very much connected to their physical well-being), but I also need to maintain enough distance to keep my head clear. How do I find the right balance?

Up through college, most of my jobs involved working with kids. Learning to handle mood swings and foul tempers in the younger population prepared me well for working with people my own age. On the one hand, clients would never be outright cruel to me (telling me, for example, "I don't like you! You're not my friend!", as I remember one three year old doing). On the other hand, when working with peers instead of children (and so, less of an age/maturity difference), it's much easier to let their words and moods bother you.

The best advice I've ever received came from the aforementioned three year old's mother: Don't take it personally. The girl didn't actually hate me; she just hated that when I was around, it meant her mother was not. Likewise, a client's bad mood has nothing to do with me, so I can't let it bother me or affect the massage.

While that's certainly easier said than done, massage therapists do learn tricks to deal with such situations: Grounding and Centering. These mean stepping away from the client's emotions (and your own emotions) while taking a step forward towards the massage session. Little things such as taking a few deep breaths, visualizing a calm setting, or doing a quick stretch can help to shut out the distractions and properly focus on the massage.

There's no way to "solve" the issue of abrasive clients. If we didn't allow people to get massages when they were in a bad mood, we'd be out of a job pretty quickly. And anyway, why wouldn't I want to make someone feel better with a massage? I love seeing my clients leave with a spaced-out grin and a cheerful demeanor, especially when they arrived at the clinic in a less-than-perfect mood. The solution, rather, is internal – the therapist needs to know when and how to step back from an aggressive situation, while still remaining close enough to heal effectively.

I'm massaging my client's neck. I find an area on the muscle that needs work. Within that area I find a spot - just a tiny spot - that feels... different. It's a trigger point. I gently hold pressure down with my finger.

This client flinches. Wow, what's going on there? What is that?

This, I say without taking my attention off the muscle, is why you hurt.

I've been having this interaction pretty frequently as of late, mostly thanks to the influx of new clients to my clinic (thanks, Groupon!). People schedule massages with me because they know they want a massage, but beyond that they don't always know what to expect.

For example: I specified with one client that she wanted a full body massage, not just work on her problem areas. She said, "Yea, of course, full body. That's what I paid for, right?" Well, no, not necessarily. People are so used to one type of massage - the feel-good massage - that they don't always realize massage can do even more.

Clients tell me that the massages they usually get feel amazing at the time, but within a few days all of the problems return. My massages, on the other hand, may not be the most pleasant (as all of the flinching and twitching will illustrate), but they'll get to the root of the problem. I don't just relieve the symptoms; I figure out why you have those symptoms at all.

I want my clients to come back for more massages, but I don't want them to keep coming back for the same reasons.

When outlining the process and goals with my clients, I always remind them that the trigger point treatment won't solve everything immediately. But after a few massages there should be a noticeable improvement. And after a few months of massage and directed self-care, the client should be pain free. For some, the very idea of living without pain is almost unimaginable. And yet the solution might be as easy as frequent, focused massages.

Massage chairs are strange. With so many hinges and levers, they take some getting used to - as a therapist, learning to make the all proper adjustments at every possible spot, and, as a client, trusting that this alien contraption will support you and even help you relax.

You've probably seen a massage chair before - maybe at an outdoor event or an office appreciation day. Sure, there might be massage tables around at events also, but the entire purpose of a massage chair is for short, less intimate sessions.

I love chair massage! Here's why:

• Length: Chair massages can be as short as 5 minutes or as long as 30, depending on the structure of the event and what I'm getting paid for (or if I'm getting paid). While I do enjoy my 60-minute massages, these short sessions allow me both to work with more clients and do the most amount of good for an individual in the shortest amount of time. Likewise, people are more willing to take 10 minutes out of their day than find the time for a longer session, so I wind up massaging clients whom I wouldn't otherwise see.


• Portability: I don't have a car at my regular disposal, so moving around a massage table is next to impossible. But my chair folds up neatly and is stored in a wheeled case. Easy to take anywhere.


• Style: I tend towards deeper massage when I work on seated clients. The way the client is angled on the chair allows for most of my pressure to come from leaning at my waist instead of pushing with my arms, and that takes a lot of strain off my shoulders. Since the client is clothed and there's no lotion involved, it's not an ideal setting for a soft, relaxation massage, but most of the people who come by know this. Rather, they expect focused work on their problem areas.


• Area of Focus: You can't get to all of the parts of the body like you can on a table. The best areas to work on are the neck, shoulders and upper back. Conveniently enough, these are also the areas that most people have problems with. Having a smaller area to work on, along with a shorter amount of time, forces the practitioner to pay attention to what's really important.


• Setting: While I don't like thinking of massages as luxuries (more on that at a later date), I like it when my presence - and my chair's presence - is seen as something special, something out of the ordinary. People don't show up to work because they're going to get a massage, but the fact that I'm there makes their day that much better. On the other side of things, events - for sports, good causes, or just community gatherings - have their own energy and excitement that I'm always glad to be a part of.

What is touch?

Not a hard question: touch is one of those five senses we've all learned about. But it's different than the others: unlike the remaining four, this one is more than just a sense - it's also an interaction. When humans touch, it's never a passive thing. You can see someone without being seen; hear someone without personally being heard. But you can't touch without also being felt.

But let's put aside semantics for now. On a larger scale, this means that every touch involves two active players. Touch - and more to the point, massage - is made up of one initial action and an infinite series of reactions. I touch the muscle; the muscle reacts; my hands respond to that reaction. And so on.

Let's say I'm massaging a client's back. I touch the muscles parallel to the spine; they're tight, taut like a rope. I press a little harder with my fingertips, but the muscles resist. That conversation is going nowhere. So I start a new one: I move my hands gently over the back, warming up the skin and gliding, slowly sinking into the muscles. This time, they don't push back so much. So I keep the conversation going, gauging the muscle's response before I respond in turn. If I apply too much pressure, the muscles tighten again and the conversation stops. If I apply too little, I might as well not be listening at all.

The conversation is touch-based, sure, but there's also an audible component - the client's conscious reaction. One of the biggest tells is breathing. Sudden slow, deep breaths usually mean I've found a troublesome muscle. Other reactions, such as flinching or even saying something (such as "ooh, that's the spot" or "what the heck is that?") are even more direct. These reactions help let me know that I'm on the right track, and that I'm having a useful conversation with a muscle in need.