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Massage in a biopsychosocial model

Submitted by RST on Sun, 01/13/2013 - 22:30
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[reposted from Massage in a biopsychosocial model (#29/31)]

 

 

Psychosocial and cognitive approaches don't require that you become a clinical psychologist but that you have a broad concept of the influence of those factors and that you account for them in your encounters with your patients. Know the literature and be able to give management advice based on evidence. When people come to see you they want a plan. Have a plan that is defensible and that works toward their goals. Address concerns, fear avoidance, other stress, and unhelpful beliefs with compassion, understanding, empathy, and informed knowledge.

Understanding why people hurt is part of our professional responsibility and should change most everything we do on a daily basis away from traditional methods and towards methods defensible with modern science.--Jason Silvernail accessed 5 August 2011

 

Since I'm advocating massage in a biopsychosocial model, it's my job to connect the dots and explain what I mean by that.

A biopsychosocial model of health and illness is one that takes into account the role of biology (and other sciences), psychological factors, and sociocultural factors, as well as the interactions among those different factors, in seeking to understand what health and illness really are.

An example of a biological factor in health could be increased cortisol in the bloodstream in response to chronic stress. The interaction of that biological factor with the increased daily stress in modern society would be an example of interactions among biological factors and sociocultural factors.

An example of a psychological factor in health could be a man who is less likely to seek professional treatment for pain than a woman is, because of his perception that stoically enduring pain is what men do in the society he grew up and lives in. The increased structural damage that can occur as a result of ignoring symptoms and delaying treatment is an example of the interactions among psychological factors and biological factors.

An example of a social factor in health could be the relative stigmatization of mental or behavioral illness, as compared to how more clearly structural conditions are regarded. This stigmatization can drive psychological conditions underground--say, for example, if someone did not get needed psychological treatment because they didn't want it to show up in their medical record. That would be an example of interactions among sociocultural factors and psychological factors.

Biopsychosocial massage is client-centered. That means that the psychological and social factors in the client's unique experience, as well as the universal biological factors we are all subject to, is the center of where we focus our attention and caring. It doesn't mean that we accept everything in someone else's experience is literally true. It does mean that we recognize that, for them it feels true, and for that reason alone, it is important in where we meet the client in the therapeutic encounter.

Biopsychosocial massage welcomes self-expression and the art of massage. It is clear, however, that sometimes our need for self-expression can come into conflict with clients' immediate healthcare needs, and--when that happens--we recognize that, in order to act as healthcare professionals, our ethical fiduciary duty is to put the clients' needs first, ahead of ours if necessary.

Biopsychosocial massage is wholistic, integrative, and evidence-based. That means that it does not draw upon supernatural explanations of mechanisms, and it builds upon foundational knowledge in the sciences to evaluate and validate the evidence for or against particular claims of effectiveness or mechanisms.

Since our encounters with clients will always run ahead of the available high-quality evidence, we don't limit ourselves only to what has been rigorously validated by studies and nothing else. We take our professional experience into account, and we actively seek to understand and incorporate the clients' preferences, whenever possible, in treatment. But in all these cases, in developing our approach to caring for the client, we remain clear on what is evidence, what is speculation, what is science, what is art, what is literal, and what is metaphor.

Understanding the material physical universe around us, and the centuries of cumulative human knowledge about that universe, give us powerful tools to draw upon. That understanding, combined with the caring that characterizes so many people who choose to go into massage as a career, is the heart of biopsychosocial massage.

Neil deGrasse Tyson sums it up almost perfectly:

I am driven by two main philosophies, know more today about the world than I knew yesterday. And lessen the suffering of others. You'd be surprised how far that gets you.

--Neil deGrasse Tyson

 

That quotation demonstrates the core of massage in a biopsychosocial model.


Source: http://healthskills.files.wordpress.com/2008/10/biopsychosocial.jpg accessed 7 August 2012

What Seth said

Submitted by RST on Wed, 10/03/2012 - 17:04
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Seth Godin writes, on the natural human tendency to deny facts we don't like:

The problem with Orwellian talking heads, agitprop, faux news and Ballmer-like posturing is that they take away a foundation for a genuine movement to occur, because once we start denying facts, it's difficult to know when to stop.

 

Still, it's understandable--when reality seems overwhelming, the temptation to deny that reality, and avoid the pain of dealing with it, can be very strong. Barrett Dorko also has an excellent take on that phenomenon and this article, over at SomaSimple.

We've got a lot of massive problems in massage--for example, at the same time that we have the chance for a place at the healthcare professional table under Obamacare, and that we say we want to be taken seriously as professional members of the healthcare team, our major credentialing organizations grant recognition to courses that take money for teaching claims like "body cells carry emotional memory", "craniosacral therapy moves skull bones", and "all past traumas are stored in the fascia".

Anyone who had a decent education in anatomy should be able to debunk those claims after the first day of the first class.

Yet our major professional organizations visibly sanction the teaching of claims like these and grant CE credit for them, at the same time we say we want to be real healthcare professionals.

Our walk doesn't match our talk, and the problem's not going to go away just because we refuse to face it.

If we refuse to face it and discuss it in a civil and professional way in an attempt to reach solutions, history's going to make us eat the decisions that others make for us about these problems.

And if we claim we want to incorporate the latest neuroscience findings into massage as a healthcare profession, and we start that process off by being Neurophysiology 101 denialists, how, exactly, is that supposed to work?

No one's denying the fact that this shift to accepting facts and material physical reality is going to cause a great deal of disruption and moral distress. The world has entirely shifted out from under us, and the old social contract that we were comfortably used to just does not work any more.

That fact is going to cause an unforeseeable amount of pain and distress, and we need to be extra kind to each other as a result.

But denying reality is not a sustainable choice anymore, and the only real question is whether we'll make the change in time to make use of these new opportunities, or whether our process will make us too late to accept the invitation, and we'll totally miss out.

Godin provides an aspirational ideal to assist in that process:

Transformational leaders don't start by denying the world around them. Instead, they describe a future they'd like to create instead.

 

We can't change the larger universal material physical reality that confronts us. What we can change is how we react to it, and that reaction--what we commit to--will sow the seeds for the future we want to create.

Source: "13 Plus Myths of Massage Therapy", by Lee Kalpin RMT http://www.massagetherapypros.ca/wp-content/uploads/2012/03/Myths-of-Massage-Therapy.jpg accessed 3 October 2012

Sometimes evidence shows that the old ways actually are the best

Submitted by RST on Wed, 10/03/2012 - 09:17
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While cherry-picking--the act of suppressing evidence that doesn't support our own particular biases--is something to be avoided, berry-picking, on the other hand--carrying out our searches for information in a way that is not strictly linear and that incorporates cognitive questions, by allowing those searches to evolve and change in response to what we initially come across--is not only to be encouraged, but can be absolutely delightful in the unexpected directions it leads us.

This morning, berry-picking took me in a most unexpected direction. On the way to looking up something else, I came across this:

Risks of consuming fermented foods

Alaska has witnessed a steady increase of cases of botulism since 1985. It has more cases of botulism than any other state in the United States of America. This is caused by the traditional Eskimo practice of allowing animal products such as whole fish, fish heads, walrus, sea lion, and whale flippers, beaver tails, seal oil, birds, etc., to ferment for an extended period of time before being consumed. The risk is exacerbated when a plastic container is used for this purpose instead of the old-fashioned, traditional method, a grass-lined hole, as the botulinum bacteria thrive in the anaerobic conditions created by the air-tight enclosure in plastic.--Wikipedia, "Fermentation: Risks of consuming fermented foods accessed 3 October 2012

 

Slightly off-topic, but interesting (I think!), in a berry-picking way, since we care about calling people by the names they want to be called: Did you notice that the paragraph used the word "Eskimo", and did that perhaps seem a little strange to you, because you've heard that you shouldn't use the term "Eskimo" when you mean the Inuit people, since the word is derogatory or pejorative or insulting?

You're not wrong, if you remember hearing that--the word "Eskimo" probably does, historically, have connotations that are belitting and insulting, and Native American and First Nations people have spoken out explicitly and firmly against the use of the word.

At the same time, there is no good inclusive replacement term that includes the Yup'ik peoples of Alaska--if you just say "Inuit" instead of "Eskimo", that's fine if you mean only Inuit people and no one else.

But if you mean Inuit people together with Yup'ik people, then there really isn't a well-known acceptable term that means both. So often, you will see Alaskan Native American (more so) and Canadian and Greenlandic First Nations and Inuit people (less so, or maybe even not at all, per Lee Kalpin's comment following this post) compromising, and using the term in order to be inclusive, despite the connotations that go along with the word.

 

What's happening in Alaska?

Alaska has witnessed a steady increase of cases of botulism since 1985. It has more cases of botulism than any other state in the United States of America.--Wikipedia, "Fermentation: Risks of consuming fermented foods accessed 3 October 2012

 

Botulism is a condition that paralyzes people and animals who eat food contaminated with botulin toxin, or who have an open wound through which the bacteria that produce the toxin (Clostridium botulinum) can enter the body. C. botulinum is an obligate anaerobic bacterium, meaning that it is obliged to grow in an environment without air--oxygen is deadly to it.

VERY IMPORTANT WARNING

This is why you absolutely never, under any conditions at all, give honey to babies under 1 year old--they don't yet have the immunity to fight off the bacteria that produce the toxin.

After 1 year of age and older, people can fight off the actual C. botulinum bacteria themselves, so the bacteria can't gain a foothold in their systems to begin pumping out the toxin.

But if the neurotoxic poison produced by that bacteria has already contaminated the food somehow--as opposed to the bacteria themselves--then that toxin can produce botulism in anyone.

 

Facial paralysis which spreads through the body is a typical symptom of botulism; very bad cases can actually cause death by paralyzing the muscles needed to breathe.

The 14-year-old in these pictures from Wikipedia show the paralysis that's typical of severe botulism. Although he appears dead, he was actually fully conscious, yet unable to move. His eyelids were drooping and his eyes were paralyzed, and the pupils were fixed and dilated. We hope he made a full recovery--Wikipedia doesn't tell us how his story turned out--but even if he did, it would require a long, slow, difficult path to rehabilitation.

 

"A 14-year-old with botulism. Note the bilateral total ophthalmoplegia [paralyzed eyes] with ptosis [drooping eyelids] in the left image and the dilated, fixed pupils in the right image. This child was fully conscious."

Source: http://upload.wikimedia.org/wikipedia/commons/b/b4/Botulism1and2.JPG accessed 3 October 2012

 

From 1950 to 1997, 105 confirmed outbreaks of foodborne botulism involving 214 persons occurred in Alaska (there were no confirmed cases during 1947-1949)...All cases occurred in Alaska Natives. The average annual incidence among Alaska Natives increased from 3.5 cases/100,000 population during 1950-1954 to 10.7 cases/100,000 during 1995-1997 [in other words, right about 3 times as many cases as you'd expect, based on history].--State of Alaska Public Health Epidemiology Report: Botulism in Alaska--A Guide for Physicians and Health Care Providers, 1998 Update accessed 3 October 2012

 

Source: State of Alaska Public Health Epidemiology Report: Botulism in Alaska--A Guide for Physicians and Health Care Providers, 1998 Update http://www.epi.hss.state.ak.us/pubs/botulism/fig_1.gif accessed 3 October 2012

 

The Rose Urban Rural Exchange, in its own words, "aims to strengthen relationships between urban and rural Alaskans by building mutual respect and understanding, and fostering a statewide sense of community through cross-cultural immersion.".

They have a website where they promote cross-cultural understanding by presenting pictures and reports of daily life, festivals, and other events.

In a post, "The Best of the Whale", one of their writers, Bogdan, presents pictures from Ilisagvik Inupiaq Culture Camp, where elders and others share a meal of traditional foods.

Notice the blue plastic container, and the Ziploc plastic bags--we're going to get back to those in a moment.

 

Source: http://ecci-2012.s3.amazonaws.com/thumbs/20120814_ecc_grp_iic_awi_70_502ab33f88f97.JPG.poster.jpg accessed 3 October 2012

 

Bogdan describes the scene:

The most desirable food served at the blanket toss festival is fermented whale meat and blubber (mikiaq). Elders particularly like mikiaq, because it is easy to chew. To keep the audience interested and at the site, mikiaq is served last, after all the other food items have been distributed.

 

Mikiaq is

raw whale blubber that has been left to soak and ferment in the whale's blood.

 

Fermentation occurs when, under anaerobic conditions (reduced or no oxygen), you convert sugars (carbohydrates containing carbon [C], hydrogen [H], and oxygen [O] atoms as building blocks) like the kinds of glucose here:

Source: http://upload.wikimedia.org/wikipedia/commons/0/06/DL-Glucose.svg accessed 3 October 2012

 

 

 

into ethanol, the kind of alcohol in drinks such as beer, wine, and spirits, a process which rearranges those atoms into this arrangement:

Source: http://upload.wikimedia.org/wikipedia/commons/3/37/Ethanol-2D-flat.png accessed 3 October 2012

 

Greenlandic to English Dictionary

nuna iterssaliorpâ: digs a hole in the ground, p. 180 (Old orthography)

qasaerdlâq: a seal which has been put by whole and left to ferment, p. 211 (Old orthography)

 

Back in the old days, fermenting the mikiaq was accomplished by digging a hole in the ground, and leaving it there for as long as it took the process to occur naturally.

Nowadays, just like most of the rest of us reading this, circumpolar peoples have access to modern conveniences like the blue container and the Ziploc bags you saw in the photo from the festival.

Plastic bags, containers, and utensils, no matter how bad they are for the environment, have some convenient qualities that make them so widespread in food preparation. One of those properties is the ability to keep food fresh for longer periods of time.

It does this by sealing the food away from exposure to air that would cause it to decay faster. In other words, it promotes an anaerobic environment.

And that's where the connection to the increased cases of botulism lies.

This is caused by the traditional Eskimo practice of allowing animal products such as whole fish, fish heads, walrus, sea lion, and whale flippers, beaver tails, seal oil, birds, etc., to ferment for an extended period of time before being consumed. The risk is exacerbated when a plastic container is used for this purpose instead of the old-fashioned, traditional method, a grass-lined hole, as the botulinum bacteria thrive in the anaerobic conditions created by the air-tight enclosure in plastic.--Wikipedia, "Fermentation: Risks of consuming fermented foods accessed 3 October 2012

 

Fermentation in a grass-lined hole, while still an anaerobic process, is less efficient at keeping the oxygen out, since air will circulate in and out of the hole and between the blades of grass. The C. botulinum bacteria have to overcome the deadly oxygen in that air, if they are going to establish a strong enough foothold to produce enough neurotoxin to make the mikiaq dangerous to the people who eat it.

A plastic container, on the other hand, does a much better job of keeping out the oxygen. Less oxygen in the container means a more welcoming environment for C. botulinum, where they can start to churn out neurotoxin.

As plastics have come into wider and wider use in the general population, and as they have made their way to more remote areas, where the convenience appealed to people, they took the existing risk of botulism, and--by providing a better anaerobic environment--sent the cases of botulism much higher than had been the case when mikiaq used to be fermented in the traditional grass-lined hole.

 

What all this means is that--contrary to what you may have heard--evidence-based practice does not mean that you have to give up traditional practices just because they are traditional, and adopt modern practices just because they are modern.

It means that instead of a top-down simplistic rule-based approach (either "Old = Good! New = Bad!": the "Argument from antiquity" fallacy, or the other way around, "Old = Bad! New = Good!": the "Argument from modernity" fallacy), we take a bottom-up approach of examining the evidence itself, and then deriving more nuanced and accurate rules that we can turn around and apply. Which, in turn, means that everything, traditional and modern alike, gets examined to find out:

  • what works in the way it claims to,
  • what doesn't work in the way it claims to, and
  • the mechanisms for why that is the case.

 

Once we better understand the answers to those questions, we can better decide which practices fit better into our client-centered model of service, and why they do so. This example was a perfect demonstration of how sometimes evidence supports the traditional practice as objectively better, as measured on the basis of outcomes (number of cases of botulism), than the modern practice.

 

Source: http://upload.wikimedia.org/wikipedia/commons/e/e2/PSM_V37_D324_Greenland_eskimo.jpg accessed 3 October 2012

What Seth said

Submitted by RST on Wed, 10/03/2012 - 07:38
Posted in

Denying reality is not a sustainable choice anymore, and the only real question is whether we'll make the change in time to make use of these new opportunities, or whether our process will make us too late to accept the invitation, and we'll totally miss out.

Godin provides an aspirational ideal to assist in that process:

Transformational leaders don't start by denying the world around them. Instead, they describe a future they'd like to create instead.

 

We can't change the larger universal material physical reality that confronts us. What we can change is how we react to it, and that reaction--what we commit to--will sow the seeds for the future we want to create.

Click here to join the discussion.

Part 1: Foundational concepts--anatomy, physiology, life, levels of organization, and regulation

Submitted by RST on Sun, 09/30/2012 - 14:03
Posted in

 

What we are going to do in this course is this: for validated scientific anatomical knowledge, we are going to create and make openly available anatomical knowledge organization templates (KOTs), based on the original Anatomical Knowledge Organization Templates developed by my teacher, Cornelius Rosse.

 

 

KOT here

 

 

 

 

 

 

 

 

 

 

 

 

http://sig.biostr.washington.edu/education/resources/KOTorgan.html

 

sections of NCETMB and NCETM that we address here

 

 

Examples:

 

anatomy: gross, histology, microscopic, comparative ==> levels of analysis

 

physiology: how do the anatomical parts actually work, how do their structure and orientation and location influence what they can do, how body systems work together, and how they influence each other ==> regulation, emergent properties, systems science

 

can we always separate those questions? mouse prostate example

 

 

but most of the things we are dealing with will be much more straightforward than that. when it's harder, we'll flag it.

 

 

 

 

 

============================================

 

How do we study anatomy and physiology?

 

Anatomy is easier to visualize with our eyes, with dissections, and instruments like microscopes: "learning to see what we're trying to understand".

 

Physiology is processes: we need to know how to approach more complicated visualizations

 

what we can see and touch on dissections: gross anatomy (and you can imagine the jokes punning off of "gross")--formalin smell

 

histology: study of tissues, built up of cells (cytology)--uses microscope in order to understand how tissues can work (physiology), we have to understand structure of cells on microscopic level (anatomy)

 

neural tissue made up of neural cells can support memory because their structure can carry electric signal. other types of tissue cannot because they cannot carry electrical signal. so if you see claims that body cells carry emotional memory, you have to choose between that and histology. What we see inside the cell, how the cells are arranged in relationship to each other, how much space is between the cells--all of these material physical anatomical aspects of cells influence what physiological functions the tissues made up of those cells are able to carry out

 

microscopic anatomy: looking at cells and tissues under a microscope/histology

 

cytology

 

we are getting into levels of analysis here

 

two resources that we will draw upon here as necessary are embryology (developmental biology) and comparative anatomy--together, they are called evo-devo

 

you won't be tested on these subjects. but the knowledge they contain will support our reasoning about the anatomy that we *are* responsible for knowing, so we'll take them into account in order to more fully understand the subject.

 

comparative anatomy: why do humans have 1 prostate and mice have 5? why do bears have anucleate cells? the answers to these questions provide valuable information about human anatomy, in a (metaphorically) similar way to how learning a foreign  language can help us better understand why our native language does things in the way it does. this is one of the bases for comparative medicine: MIN

 

model organism examples: in-depth understanding

 

levels of analysis:

 

(smaller ones we haven't talked about yet)

cellular anatomy and histology

gross anatomy

(larger ones we haven't talked about yet)

 

notice that the levels of analysis are very different from each other. MIN

this will become important when we look at how people try to talk about massage and quantum physics. when we get to that, it will be your job to decide whether what they say makes sense. To do that, you need to be aware of what it means to talk about different levels of analysis, and how structures and functions of the same thing at one level of analysis can be very different from structures and functions of that same thing at a different level of analysis

 

 

look at one level of analysis, and understand how it leads to supporting structure and function at the next level of analysis

 

"system by system and connect the dots"

 

anatomy: how do we use our "eyes, microscope, and imagination" to develop a good, solid, and in-depth understanding of anatomy and physiology that will support us in providing high-quality, client-centered care?

 

 

physiology: how do we use our "anatomy knowledge, logical thinking, and basic knowledge of chemistry and cell biology" to develop a good, solid, and in-depth understanding of anatomy and physiology that will support us in providing high-quality, client-centered care?

 

"anatomy is very visual"

 

you can't understand how body parts and systems work (physiology) if you don't understand the anatomy where physiology happens (and, later, pathology--abnormal functioning)

 

 

logical thinking: "a lot of physiology is connecting dots, step-by-step" -- how these parts work together

 

 

basic chemistry and cell biology that you need to understand to make physiology make sense: plausibility

 

 

"Complementary principles

 

Function cannot occur without structure

 

Functions are often dictated by form" MIN

 

you need physiology to stay alive. dead bodies can have anatomy.

 

"interconnected: you need both to stay alive, and you need a good knowledge of both to be successful" this is a bridge or an obstacle to integration

 

 

"What is life"

Always an interesting question to ponder

Schrödinger's paradox--order comes from disorder

Socrates--objects are a reminisce of previous objects

Hooke & Schwann cell theory (more later)"

 

 

when we say we practice massage because we want to make a difference in people's lives, what is the implicit knowledge that we are drawing upon to ground what we say

 

 

many viewpoints on this: philosophical, Socrates, "The Republic", the Cave--we're shadows of former objects

 

science: order comes from disorder==?chemical reactions, cells, movements of molecules and ions into and out of cells--"there needs to be some kind of chaos on the molecular level for us to stay alive"

 

chaos: sperm in water, hormones rather than vasculature in fish

 

 

cell theory (what is a theory), then modern cell theory==life cannot occur

without cell, cell is functional unit that drives life--this is why viruses are not considered alive to understand what it means to be alive, we need to understand levels of organization--at what level does life actually begin?

 

we have to talk about matter--matter is anything that takes up space and has mass--some kind of physical presence

 

atoms--smallest simplest forms of matter in nature, can't see, have various behaviors--examples C, H, O,N, K+, various behaviors

 

molecules/compounds--combinations of atoms; glucose, protein, lipid, hormone, chemical message, structural protein like cell membrane--is a protein or a sugar alive? they don't have a metabolism

 

organelles--look at a cell, as we will next week, see distinct parts, nucleus, ER, Golgi apparatus, ribosome: sacs with enzymes that drive biochemical reactions--can a fuel factory be alive? no, separate and not organized

 

cells--organized organelles, start to see life take place--nucleus, DNA inside can start to use all other organelles for chemical reactions--this is where life begins, at cellular level--political implications, pro-life,

pro-choice

 

tissues--put cells of different varieties into organized tissues

 

organs--organized tissues of different types

 

organ systems--11

 

organism

 

population systems--how long can you go without any human contact? how well

could you survive on your own? we need each other to survive. everyone is

different in levels of need, but we need each other

 

fractal: population system, analogies with organ systems and with cells

 

image of levels of organization

 

where does life begin? at cellular level

 

"Interrelationships of organ systems

cells rely on organ systems to maintain life

cells drive the function of organ systems

the interrelationship of these two concepts drive life"

 

MIN

 

we have to go all way down to cellular level for good understanding of

physiology

 

good part of physiology n day 2 day level is keeping cells alive: example

respiration

 

bridge to pathophysiology

 

what are the pathological changes that occur at the cellular level--what drives disease to happen? what cellular changes occur that make the tissue go awry?

 

cells drive live; most of our physiology is spent keeping life going at the cellular level

 

"Requirements for life

 

boundaries

movement

responsiveness

digestion

metabolism

excretion

reproduction

growth and change

 

what organ systems drive each of these functions?"

 

 

physical boundaries; borders between tissues, organs, cells, internal ve

external--skin is major outer boundary, connective tissue serve as boundaries inside

 

why do we need movement? get meal, look at animals who don't get blood clots in hibernation—musculoskeletal responsiveness to changes--changes in environment (int or ext) occur all the time--we need to be able to adapt to them, and if we can't, we will die--

nervous, endocrine--homeostasis later

 

digestion--breaking food down into simplest building blocks so that we can absorb it and make use of it--1, eat the food 2, break it down 3, absorb it 4, excrete it what don't absorb when finished--if you understand these concepts, then you can understand diseases like Crohn's disease or diarrhea

 

metabolism--what is metabolism? burning calories? digesting food? only 1/2 the equation--metabolism is about all chemical reactions that occur in body--certain systems help regulate, nervous, endocrine--life-giving chemical reactions occur within cell itself--building up and breaking down molecules in the chemical reactions that sustain life

 

excretion--where there is metabolism, there has to be excretion, because there are waste products left over--CO2, for example. respiratory system--urinary system, kidneys, waste filtering organs--without kidneys, won't live very long--skin can sweat out some waste, digestion--kidneys biggest one,

cells constantly excreting waste products (lymph)--constantly producing waste products, must be removed--remove organic waste products

 

reproduction--permits continuity of life--extremely important organ system--we are reproducing faster than we are dying off--panda bears--poaching is a problem--big mammals in general take a long time to reach sexual maturity, so vulnerable to poaching--when are we readily physically to reproduce--puberty--8-13 years after we're born. physiologically, not

psychologically. we as a species not threatened enough to get us to point where repro is big issue for us.

 

growth and evolution--growth necessary for life to take place. compare birth. grow to self-sustainable, mature organism. evolution as well--evolution is just change--adapting to environments and surviving--we need to evolve to changes in environment as well--and animal or plant that does not evolve will not survive--

 

"survival needs

 

oxygen

nutrition

water

normal temperature

pressure"

 

oxygen big part of making ATP and cellular energy--big metabolic deal

 

nutrition--calories, fuel, making energy, protein to make plasma proteins, need structure--protein deficient people look very wasted away because digesting own muscles--vitamins, minerals, proteins  fats for energy storage, structural purposes, driving metabolic reactions

 

water main transport medium, bulk of body is water--most people have ~40 liters of water in blood and tissues, helps drive chemical reactions, thrermoregulator

 

temp--is big, 98.6, but without temp, metabolism going to go nuts, ability to circ O2, metabolism, going to die if hindered --too high or too low

 

pressure--why pressure? important for breathing, transport--no one ever talks about BP in good context, always hypertension--BP necessary because without it, how would we circ blood, filter nutrients out of capillaries into tissues

 

respiration--must be enough pressure to drive oxygen out of air, into our tissues,

 

"homeostasis

 

maintenance of a stable internal environment, i.e., balance

 

dynamic equilibrium--we operate around various set points that fluctuate when exposed to various stimuli

 

if we fail to return back to our normal set points, disease and sickness ensue"

 

what constitutes life, what life is, homeostasis is a big, not well-understood concept

 

we strive for on day to day basis==

 

phys balance

 

dyn equil. -- 98.6F your temp goes up and down, all during the day

 

go outside in cold weather, your body tem goes down

 

body water levels maintained by monitoring sodium levels, if osmolarity drops below certain point, body salts get too high, we get dehydrated, and need to get fluid back into our system--

 

certain set points that we need to survive=-homeostasis maintains balance around those certain set points how do we know what those points are?

 

always fluctuate around set points, but if we fluctuate too far, and don't get back to the set point, that's some form of disease

 

98.6F--temp goes down in cold air, so physiological mechanisms protect us, and help us reverse the drop in temp

 

body water level by monitoring sodium levels, osmolarity drops, salt too high, dehydrate, have to get water back in system

 

how do we know what a "normal" body temperature is, what a normal sodium level is, set points correspond to lab values among other things

 

nutrient levels, metabolism, what organ system is responsible for constant monitoring of this?

 

the most important system in human body is nervous system. some systems self-regulate to some degree, but regulation of body systems is the nervous system's job

 

 

if we fail to return back to normal set points, sickness occur--BP goes up and down, sit, stand, walk run move around, BP up to meet increased demand on body, as we age, BP tends to rise. we have mechanism that tend to compensate, but if those mechanisms fail, that's high BP

 

if our own systems fail, that's where medical intervention comes in

 

if body can't regulate BP, pills prescribed--bring in Olney at this point--if we need help to get physiology back to normal

 

maintain balance through feedback loops

 

"maintenance of homeostasis

 

always exposed to internal and external stimuli

 

requires constant monitoring by the nervous system

 

main form of regulation is through feedback loops

 

two loops: negative and positive feedback"

 

 

some organs do kind of self-regulate, like pancreas self-regulates insulin secretion, for most part in general, nervous system regulates everything

 

when nervous system detects changes in body, it needs to "figure out" (metaphorically) how to return to normal.

 

uses feedback loops

 

"negative feedback loop

 

three components: receptor, control center, effecter organ"

 

loop: something circular

 

negative most common regulatory mechanism in human body

 

receptor, control center, effecter organ

 

neg feedback begins with receptor, specialized cell or group of cells in nervous system, whose job is to detect changes--stimuli--stimulus, singular--factors that upset or disrupt physiology, changes in environment

 

all these receptors do is constantly wait for a stimulus

 

receptor detects a change, generate impulses to control center--main

control center in body is brain--central nervous system is brain and spinal

cord. receptors pick up on changes, send info about changes to control

center. control center (CNS) "develops" "plan of attack" for bringing situation back to normal (xref with innervation)

 

communicates with effector organ. effector organ carries out right response to get us back to normal set point, receptors, control center, effectors

shut off, because continuing to correct would over compensate, and take us in the wrong direction (tacking in a sailboat)

 

example: classical example: thermostat. cold air comes into house, thermostat set at 70F. 0F air comes in for 3 minutes. cold air came in, now house temperature of kitchen lower. as a result, something picks up on this, thermostat is receptor as well. temp to 65F, thermostat detects.

thermostat sends signal to heater, turns heater on. heater starts pouring out heat, only until gets back to 70F. then shuts off so house doesn't get too hot above 70F

 

 

overheating compared to hyperthyroidism. if we don't shut off response, that could kill us, oversecrete hormone while trying to get back to normal.

 

BP: say BP goes up from 120/80, 145/86 mm Hg. we need to get it back down.

if exercising, ok, but don't want it that high at rest. there is a baroreceptor (baro means heavy or pressure). the baro receptors are in carotid arteries in neck in carotid sinuses, sensitive only to changes in BP

 

 

 

 

BP up, baroreceptors detect it, communicate with control center. control center in this case is brainstem. effector organs in this system are heart and blood vessels (arteries).

 

heart rate will respond to high BP by going down, output of blood volume pumped out will go down. are we going to increase dilate or constrict decrease diameter of arteries down HR and dilated arteries with less pressure will make BP go down dilated arteries easier blood flow, then entire response shuts off at reset to 120.80

 

what happens if gets too low? pass out, bc brain not getting enough oxygen

 

carotid sinus massage

 

 

vasovagal syncope response to high-stress situations.

 

orthostatic hypotension

 

negative feedback is most common regulatory mechanism in body why is it called negative?

 

negates or changes a stimulus--back to normal and then shut off when get back to set point.

 

 

"positive feedback loop

 

can be life-threatening"

 

this is what we call an amplifying cycle

 

positive feedback is good but can be life-threatening as well, because it just keeps getting greater and greater and greater over time--there is no automatic shutoff valve, like there is on a negative feedback system

 

like neg, has to be some kind of stimulus that triggers it to begin

 

here's the difference

 

example childbirth--once uterus stretches to certain point, it starts generating active nervous potentials to brain, and the brain is going to respond by releasing hormone called oxytocin

 

uterus got stretch, stimulus is baby in this situation that stretched uterus, oxytocin makes smooth muscle of uterus start to contract, it's a labor contraction, what happens with labor contractions over time, they get worse, more intense, they do not get more pleasant over time, intensity goes up, and the amount of time in between the contractions goes down.

 

start out 20-30 minutes apart, by the time it's time to give birth, they're about 20-30 seconds apart. so there's a stimulus that activated the response, but the response continued to enhance, it got greater and greater and greater over time.

 

 

the only thing that's going to shut off a positive feedback loop is when the stimulus--in this case, the baby--is removed from the body

 

 

removal of stimulus turns off positive feedback

 

fever another example, this can be threatening,

 

you have pathogen within you

 

big initial spike in body temp, maintain high body temp, or slowly rises,

if body temp gets too high, it can kill you

 

if body temp gets too high, requires medical intervention, or it will kill you

 

my fever story

 

blood clotting mechanisms is pos feedback mechanism--too many clots stuck in circulation can impeded blood flow to essential organism somewhere

 

my blood clotting story

 

 

problem is, if too intense of stick around too long, can threaten our life, but it is a kind of feedback loop

 

you have the stimulus (stretch receptors in uterus picking up on presence of baby_

 

communicating with control center of brain on this

 

 

the difference here is the brain is continuing to amplify an amplify and amplify, making the response greater and greater and greater until the stimulus is gone

 

neg--stimulus triggers response to get back to certain set point, then stops--you can't get rid of body temperature or body water, can['t get rid of stimulus itself

 

pos & neg fb--we use these to maintain and regulate homeostasis--physiological balance

 

this is what our everyday life revolves around--keeping ourselves balanced, keeping all our set points in check to keep ourselves alive

 

topics and concepts you need to understand

 

understand difference in levels of analysis, claims about "balance", what has been shown and what hasn't, semantics

Massage in a biopsychosocial model (#29/31)

Submitted by RST on Wed, 08/29/2012 - 12:16
Posted in

Psychosocial and cognitive approaches don't require that you become a clinical psychologist but that you have a broad concept of the influence of those factors and that you account for them in your encounters with your patients. Know the literature and be able to give management advice based on evidence. When people come to see you they want a plan. Have a plan that is defensible and that works toward their goals. Address concerns, fear avoidance, other stress, and unhelpful beliefs with compassion, understanding, empathy, and informed knowledge.

Understanding why people hurt is part of our professional responsibility and should change most everything we do on a daily basis away from traditional methods and towards methods defensible with modern science.--Jason Silvernail accessed 5 August 2011

 

Since I'm advocating massage in a biopsychosocial model, it's my job to connect the dots and explain what I mean by that.

A biopsychosocial model of health and illness is one that takes into account the role of biology (and other sciences), psychological factors, and sociocultural factors, as well as the interactions among those different factors, in seeking to understand what health and illness really are.

An example of a biological factor in health could be increased cortisol in the bloodstream in response to chronic stress. The interaction of that biological factor with the increased daily stress in modern society would be an example of interactions among biological factors and sociocultural factors.

An example of a psychological factor in health could be a man who is less likely to seek professional treatment for pain than a woman is, because of his perception that stoically enduring pain is what men do in the society he grew up and lives in. The increased structural damage that can occur as a result of ignoring symptoms and delaying treatment is an example of the interactions among psychological factors and biological factors.

An example of a social factor in health could be the relative stigmatization of mental or behavioral illness, as compared to how more clearly structural conditions are regarded. This stigmatization can drive psychological conditions underground--say, for example, if someone did not get needed psychological treatment because they didn't want it to show up in their medical record. That would be an example of interactions among sociocultural factors and psychological factors.

Biopsychosocial massage is client-centered. That means that the psychological and social factors in the client's unique experience, as well as the universal biological factors we are all subject to, is the center of where we focus our attention and caring. It doesn't mean that we accept everything in someone else's experience is literally true. It does mean that we recognize that, for them it feels true, and for that reason alone, it is important in where we meet the client in the therapeutic encounter.

Biopsychosocial massage welcomes self-expression and the art of massage. It is clear, however, that sometimes our need for self-expression can come into conflict with clients' immediate healthcare needs, and--when that happens--we recognize that, in order to act as healthcare professionals, our ethical fiduciary duty is to put the clients' needs first, ahead of ours if necessary.

Biopsychosocial massage is wholistic, integrative, and evidence-based. That means that it does not draw upon supernatural explanations of mechanisms, and it builds upon foundational knowledge in the sciences to evaluate and validate the evidence for or against particular claims of effectiveness or mechanisms.

Since our encounters with clients will always run ahead of the available high-quality evidence, we don't limit ourselves only to what has been rigorously validated by studies and nothing else. We take our professional experience into account, and we actively seek to understand and incorporate the clients' preferences, whenever possible, in treatment. But in all these cases, in developing our approach to caring for the client, we remain clear on what is evidence, what is speculation, what is science, what is art, what is literal, and what is metaphor.

Understanding the material physical universe around us, and the centuries of cumulative human knowledge about that universe, give us powerful tools to draw upon. That understanding, combined with the caring that characterizes so many people who choose to go into massage as a career, is the heart of biopsychosocial massage.

Neil deGrasse Tyson sums it up almost perfectly:

I am driven by two main philosophies, know more today about the world than I knew yesterday. And lessen the suffering of others. You'd be surprised how far that gets you.

--Neil deGrasse Tyson

 

That quotation demonstrates the core of massage in a biopsychosocial model.


Source: http://healthskills.files.wordpress.com/2008/10/biopsychosocial.jpg accessed 7 August 2012

Looking into the abyss (#26/31)

Submitted by RST on Sun, 08/26/2012 - 06:56
Posted in

It's not easy to face the realization of having been misled.

And the misleading does not have to be intentional; it could have been done with the best intentions in the world.

But those good intentions don't change the facts that, as a result, the student is launched into real-life practice operating with poor information, is bringing misinformation into the relationship with the client, and is being publicly evaluated on the basis of that misinformation by other potential partners in a unified healthcare team.

It could have happened to any of us--the field of massage is notorious for promoting teachers out of the ranks of students who have simply passed the class they're now expected to teach. Biomedical physicians have nothing on massage when it comes to "See one, do one, teach one".

No blame, no shame: one set out to create that situation; it just evolved that way, undirected. And there was an unspoken social contract that allowed it to continue, because the need for teachers was so high.

But the social contract has changed out from under us, and the current situation is no longer sustainable in light of the responsibilities expected of healthcare professionals.

Ralph Stephens names the problem as the very first one in his list of the educational "seven deadly sins":

Standardizing the number of hours or the curriculum content (ELAP) will not improve educational outcomes as long as our massage educational institutions are allowed to:

  1. Employ unqualified instructors.

...

Two things are needed to "heal" the problem, money and moral conviction. ABMP, AMTA and FSMTB must be persuaded to give substantial and ongoing financial support to COMTA and AFMTE to assist them with their respective missions. COMTA because we need a strong accrediting agency dedicated to the field of massage therapy. That is the natural place for educational standards to live. AFMTE because their Teacher Education Standards Project (TESP) is the trail that the entire education sector must follow if we are to truly "elevate" the profession from the sad state in which it currently exists.

These organizations also need to take a public stand - an unequivocal position - that the operational practices listed in the "Seven Deadly Sins" are no longer acceptable in the massage therapy field; that we expect better from our schools and programs. They may not have the force of law, but such moral courage on the part of community leaders, consistently stated, can and will instigate a change in institutional behavior.

 

Stephens is right about going forward--but what about all the students, practitioners, and teachers who are coming to grips with the fact that much of what they were taught is exaggerated, counterfactual, or simply wrong?

It takes a great deal of courage on their part to stare unflinching into that abyss, and to engage with what's needed to collect, assimilate, organize, and share good information.

The upheaval and disruption in the process is causing a great deal of moral distress and pain in people who are re-evaluating where they are, and how far away they are from where they need to be.

One thing that they do not have to worry about here is being blamed for having been taught wrong.

The policy here is, "no blame, no shame": it is not someone's fault that they did not get the education they deserve, and if they are trying to fix that situation, they deserve--and will have--our support in that journey.

The Buddhist concept of samma-vaca--"right speech"--is a useful guide to discourse here at POEM.

It's often summarized as, "Is it true? Is it kind? Is it necessary?".

We'll examine those questions in a slightly different order than they're usually posed.

"Is it true?": The standard at POEM is that we will not pass along misinformation here.

Massage stakeholders can depend on POEM for accurate information about massage.

If someone is making a factual error, it's ok to correct that error civilly and professionally. That means focusing on the facts, not on the person--no personal attacks, just connecting the dots on what the facts are.

Not everything is a matter of fact, of course--there is no scientific answer to the question "Is chocolate or vanilla better?"--and interpretations, creativity, and imagination are welcome topics for discussion, as long as active misinformation doesn't ride along.

"Is it necessary?": There is a wide consensus that something is rotten in the state of massage education, so yes, having a portal to the shared body of biomedical knowledge that members of a unified and client-centered healthcare professional team all draw upon to varying degrees is an absolutely necessary--and as-yet unmet--niche that POEM is being developed to fill.

"Is it kind?": Absolutely: everyone who participates here can expect to be treated kindly. Kindness does not mean letting misinformation go uncorrected; it means that misinformation will be corrected in a civil, professional, and kind manner, without attacking the person.

When someone does not have access to good and high-quality information, because of gaps in their education, the kind and considerate thing to do is to offer them a bridge to obtain that information.

Giving them an opportunity to correct themselves is far kinder than leaving them--and their clients--to the consequences of misinformation.

We're in really deep waters here, as a result of a number of historical, social, political, and cultural factors all coming together and synergizing.

But if POEM has any say at all in the matter, then we will get through these difficulties, because we'll support each other in learning and growing along the way.

 

Source: http://www.education.noaa.gov/images/article_ocean_floor_2.jpg accessed 26 August 2012

What is biopsychosocial massage?

Submitted by RST on Tue, 08/07/2012 - 08:53
Posted in

Several other people have contributed greatly to my thoughts on the topic of biopsychosocial massage, and a really profound discussion along those lines is currently going on in a social media group that I'm a part of.

I'm not going to quote those other people directly here, because they were speaking in a private group, and I respect their privacy. This lack of quotations, however, should not be interpreted to mean that I fail to recognize the influence that others have had, and continue to have, on these ideas that I'm developing here. I'll be very happy to acknowledge and cite those discussions that are not explicitly private.

I am very grateful for everyone who has mentored me and contributed to my professional development, and who continue to do so to this day.

I promise you that I will pay it forward.

 

 

Biopsychosocial massage is the practice of massage in a way that builds bridges to working on a unified team with biomedical healthcare providers by participating in the shared knowledge base of biological, psychological, and sociocultural factors that influence health and illness.

That means that practitioners of biopsychosocial massage practice massage in a way that is compatible with the current state of the evidence. We don't create obstacles to being part of a unified team by making counterfactual and unsupportable claims about how massage works.

It facilitates our professional development as healthcare providers by putting the client at the center of knowledge and information. One of the most stressful situations in life is illness--by committing to a shared knowledge base and sending a unified message to the client as the rest of the team does, we do not add to the client's cognitive burden and stress load at a particularly difficult time by forcing them to do the additional work to try to sort out conflicting alternative and contradictory messages.

It means that we are honest about what we know, and what we don't know. That includes a responsibility to develop basic scientific literacy and critical thinking, in order to ground our perceptions and experiences in the larger context of what we know about the material physical universe around us. The "bio" aspect of "biopsychosocial" actually draws on many other natural sciences than just biology, and understanding the cohesive integration of the knowledge generated by all of those disciplines is crucial to an honest evaluation of what we really know about the world around us.

It means that we always need to be aware, at a very general level, of the fact that psychosocial factors can influence the state of a person's health, for better or for worse.

It means that we need to understand the difference between being a supportive layperson versus practicing psychotherapy, which--among other things--means listening supportively without giving advice or interpreting meaning.

It means we should know what the signs are that indicate someone is in greater psychological distress than we ourselves are equipped to help them with, and to have a plan for how to reach out to the larger psychotherapeutic community, either to assist them in getting help, or in our need for supervision or mentoring in processing what our clients bring to us.

It means that--no matter how we regard those particular sociocultural factors, for better or for worse--we recognize the profound effects those factors can have on the health status of our clients, and, to the best of our ability, we take those factors into account when we try to understand our clients' experiences.

It means that we recognize that the available research evidence will always lag behind immediate needs for information in the clinic, and so evidence-based practice will always remain an ideal or a goal as a result of that fact. Working practically in real life in the meantime, it means that we practice in a way that is based on the evidence, if available, and if evidence is not available then we at least practice in a way that is consistent with the larger body of knowledge about how the physical universe works.

It means that we put our responsibility to our clients above our attachment to particular ideas and claims--if claims about massage or other related topics repeatedly fail validation tests, we accept that fact, make our peace with it, and move on to what we do actually know that can be of benefit to our clients.

It does not mean at all that the subjective experience of meaning-making, or joy, or humor, or spontaneous feeling are off-limits--it simply means that we remain clear, to ourselves and to everyone else, on the differences between objective and subjective, mind-independent and mind-dependent, universal and unique, literal and metaphorical/allegorical, and fact and interpretation.

It does not mean at all that we are not open to new ideas--it simply means that, for the sake of our clients, we expect the advocates of those ideas to do the work of connecting the dots and showing how those ideas truly lead to positive outcomes for our clients, before we go on to regard those ideas and claims to actually have the status of validated knowledge.


Source: http://healthskills.files.wordpress.com/2008/10/biopsychosocial.jpg accessed 7 August 2012

 

 

 

The Ethical Implications of Research and Education in the Massage Therapy Profession (Chunco 2010)

Submitted by RST on Fri, 06/29/2012 - 18:10
Posted in

I want to thank the International Journal of Therapeutic Massage and Bodywork for their open access policy permitting free use with proper attribution in noncommercial settings, which--along with the fair use principle--permits us to engage with the text of this article in depth.

Entries in the IJTMB are governed stylistically and ethically by the publication guidelines of the International Committee of Medical Journal Editors' (ICMJE), Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Published articles are licensed under the Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 license. Accordingly, copyright retention by authors, first publication rights for the journal, free use with proper attribution in noncommercial settings, and prohibition of derivative works are all ensured.

--Glenn M. Hymel, From the Executive Editor's Perspective ... IJTMB, Vol 1, No 1 (2008)

 

Full disclosure: Rosemary Chunco has been a supporter of the ideas behind POEM since the day I first mentioned the idea to her, and she has donated countless volunteer hours of technical and massage content expertise to bring it to fruition, as well as providing emotional support when I needed it along the way.

You should always read critically, and think about whether what you read makes sense, and that is especially true in this article, because I have a personal connection to the author.

It is my job to connect the dots and build my case to evaluate whether or not what she writes is correct, totally separate from the high esteem I personally hold her in.

Then, it is your job to read what I have written, and decide whether I was really successful in separating my evaluation of her work from what I think of her personally, or whether I am permitting my very high positive regard for her to bias what I write here about her work.

I hope you let me know in the comments whether or not I have succeeded at that task.

 

"The Ethical Implications of Research and Education in the Massage Therapy Profession", by Rosemary Chunco, LMT, BA, MSc, Owner (Private Practice), Shamrock Therapeutics LLC, Plano, TX, USA, International Journal of Therapeutic Massage and Bodywork, 2008:3(3).

Chunco sets the stage for the ethical and knowledge claims she will make in this article by grounding it in her practical experience of running her own massage practice for a number of years:

As a therapist operating my own practice, I am constantly reminded of the ethical aspects of my work in dealing with situations involving clients and the everyday running of my business. Professional boundaries and ethical practices are recognized within our profession as an important aspect of our work, as evidenced by mandatory classes on ethics in most U.S. states and also by the clearly stated ethical codes and practices set out by our professional organizations. The reasoning behind these measures is clear. Ethical declarations and a thorough understanding of them and their application are needed. They set standards of integrity. They help to define massage therapy as a profession and have significant repercussions on how massage therapists are perceived by the public.

 

From this foundation, she sets out to explore the connections between research, education, and ethics, and the meaning of those connections in everyday MT practice.

By drawing on specific points in the ethical code of each of MT's 2 major professional organizations in the US, as well as that of the NCBTMB certification board, she avoids partisanship, and focuses on what all of us--at least, those who subscribe to the ethical code of either professional organization--have in common with each other.

Whether it's ABMP's

I shall actively participate in educating the public regarding the actual benefits of massage, bodywork, somatic therapies and skin care.

and

I shall not make false claims regarding the potential benefits of the techniques rendered.

 

or AMTA's

[practitioners shall] be truthful in advertising and marketing, and refrain from misrepresenting his or her services, charges for services, credentials, training, experience, ability or results.

 

Chunco correctly emphasizes what they have in common with each other and with other professions' codes of ethics: actual benefits, not making false claims, being truthful and refraining from misrepresentations.

As she observes, this ethical value of veracity--truthfulness, accurately representing the facts--is core to the mission of a healthcare profession such as MT aspires to be.

But how do we gain that veracity about massage? She proposes:

Considering the increasing quantity—and importance—of research in our profession, and applying our understanding of professional ethics, it is apparent that keeping up to date with research findings could be viewed as an ethical responsibility. New research findings may uncover therapeutic benefits that we never learned in school. Conversely, some things we were taught in massage school have been overturned by the latest research. For example, many of us may have been taught that massage helps to release lactic acid from muscle tissue after exercise; research refutes that claim.

 

In this way, she grounds knowledge in empirical research findings, as well as describing the problem of outdated and ungrounded information that is taught in massage schools as fact.

She is touching on a huge problem here. You don't need to assume any bad intentions at all on the part of massage schools and educators in this situation--it makes perfect sense that the situation has developed because reality changed out from under us faster than we were prepared to keep up.

There was a time in the past when those explanations were the best we had for trying to figure out what was going on in the world around us.

But knowledge has moved on since then, and we were not prepared for that. So now, schools and their owners face tremendous sunk costs--costs already spent, that will never be recovered--as well as tremendous need for investment to bring the new knowledge on board, at exactly the time when the economy does not support such investment.

It is a huge problem, and you can really feel for the plight that educators find themselves in.

And yet, as difficult as the situation is, Chunco is correct: practicing MTs must, every day, confront the fact that what they were taught in school was insufficient, or even wrong, and to pass along that misinformation is to directly contradict the ethical codes of both of our major professional organizations, and of the board that certifies and attests to the integrity of our education.

Integrity means doing the right thing, not when it's easy and anyone can do it, but precisely when--although it would be easier to take the path of lesser integrity instead--you do the right thing anyway, even at greater cost. Chunco is correct in identifying that right thing as "a restructuring of existing knowledge, and that knowledge will continually evolve".

This integration of research findings into our profession’s training programs should be considered an ethical necessity.

 

"Ethical necessity" is a very strong term--and yet, entirely accurate and appropriate here. We must address the situation; to deny or ignore it is an ethical failure.

She ties that ethical necessity into what is required to actually carry it out. Our responsibilities to understand and integrate research findings run far deeper than just finding a source that says what we like, and slapping a citation onto our claims. Chunco refers to the established biomedical research literature, where others before us have encountered this challenge, to identify weaknesses in our relationship to massage research:

causism, a “tendency to imply a causal relationship where none has been established” (that is, the data are insufficient to support the claim), and data dropping...These, along with misrepresentation of findings, instances of poor research design, and an assortment of weaknesses in methodology can result in low-quality research. It follows that an uncritical acceptance of research by the massage community, and most of all by massage therapists, is a mistake, and that awareness of the ethical and methodologic issues common to any subfield of research is imperative.

 

But it's not all one-sided responsibility and burden, as she points out--there are professional benefits from being part of the biomedical healthcare team that shares a common body of translational client/patient-centered healthcare knowledge.

By sharing and communicating better with other members of the team, and by communicating a unified message to the client/patient (as she mentions with educating the public about massage), research literacy benefits us as well as putting higher expectations on us.

She deals compassionately and with integrity to common objections raised to changing practice in response to research findings:

When adherents of a specific modality are confronted with research findings showing that that modality has no therapeutic effect, I have often heard or read these three objections:

  • “More research is needed.”

  • “If the public wants it, and they believe it works, then we should supply it.”

  • “If I see results in my practice, then that’s all I need. All I want to do is help my clients.”

 

Although we frequently deal with these concerns here at POEM, she has said it in her article better and more concisely than I could do myself--I recommend you follow the link to her article and read her responses to these objections for yourself.

Chunco is clear on what needs to be done, yet she is compassionate and empathetic to the practitioners, teachers, and students who find themselves confronted with this new reality:

Having invested time, energy, and money to be trained in a modality and then being confronted with new information showing that that modality may have no therapeutic effect is undoubtedly an unpleasant and uncomfortable situation. The attachment to the modality could even go so far as to be an emotional one. Of course, the power of choice will always lie with the therapist. It is my hope that the ethical core of the therapist will make the right choice and that our profession will accept what good science is showing us; for in doing so, we are using science to raise our own levels of integrity and the universal integrity of the profession. Each of us has a role to play, and we should not view ourselves as detached. The decision that each therapist makes will affect the profession as a whole.

To conclude, it is reasonable to deduce that the link between research, education, and professional ethics is strong. Examination of our ethical codes indicates that it is our responsibility to keep up to date with research findings and to apply them in our work. The decisions that we make as a profession—from every angle and by every participant, whether it be researchers, policymakers, educators, or therapists in practice—will have a significant influence on the true ethical barometer of our field.

 

Chunco has written a very good and convincing review of the issues and a call for ethical action in integrating the volume of massage research going on into our educational system and our daily practices. As she points out, we're all in this together, and history will record the outcomes for the practice of massage from how individual therapists choose to face our common challenge.

 

 

 

Metaphysical boundary collapse

Submitted by RST on Wed, 06/27/2012 - 14:01
Posted in

One of massage's biggest culture wars at present arises out of the dispute between monistic and dualistic philosophies. It has implications for how we practice with clients, and how we teach our students in our schools.

Although we're experiencing this culture war every day in our own field, this argument is centuries-old and is not limited to massage. Throughout human history, great minds have tried--and failed--to resolve it. I don't expect us to resolve it anytime soon, but we do need to resolve whether those of us on opposite sides of the philosophical divide can work together, or whether it divides us irreconcilably.

The argument goes back much further in history, but in the early 1800s, advances in the relatively new science of chemistry caused a seismic shift in the evolving field of medicine. As Siddhartha Mukherjee describes the experiment that shattered previous thought on dualism in health and medicine:

Early interactions between synthetic chemistry and medicine had largely been disappointing. Gideon Harvey, a seventeenth-century physician, had once called chemists the "most impudent, ignorant, flatulent, fleshy, and vainly boasting sort of mankind." The mutual scorn and animosity between the two disciplines had persisted. In 1849, August Hofmann, William Perkin's teacher at the Royal College, gloomily acknowledged the chasm between medicine and chemistry: "None of these compounds have, as yet, found their way into any of the appliances of life. We have not been able to use them...for curing disease."

But even Hofmann knew that the boundary between the synthetic world and the natural world was inevitably collapsing. In 1828, a Berlin scientist named Friedrich Wöhler had sparked a metaphysical storm in science by building ammonium cyanate, a plain, inorganic salt, and creating urea, a chemical typically produced by the kidneys.

--Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer, Scribner 2010, p. 83.

 

This drawing shows a molecule of ammonium cyanate, a compound that doesn't come from living things. It's made up of:

  • 2 nitrogen atoms, shown in blue;
  • 4 hydrogen atoms, shown in gray (since this is a 2-D drawing of a 3-D molecule, one of the hydrogens is hidden behind a nitrogen, but it really is there, even though we can't see it in this arrangement);
  • 1 carbon atom, shown in black; and
  • 1 oxygen atom, shown in red.

Source: modified from http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

Urea, a kind of waste product produced by the kidneys in many different species of living things, forms molecules that are made up of:

  • 2 nitrogen atoms, shown in blue;
  • 4 hydrogen atoms, shown in gray;
  • 1 carbon atom, shown in black; and
  • 1 oxygen atom, shown in red.

Source: modified from http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

These two very different substances, one found in living organisms and one not found in them at all, have exactly the same atoms in exactly the same amounts. The only difference is the arrangement of those atoms in 3D space.

 

 

Source: http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

 

The Wöhler experiment--seemingly trivial--had enormous implications. Urea was a "natural" chemical, while its precursor was an inorganic salt. That a chemical produced by natural organisms could be derived so easily in a flask threatened to overturn the entire conception of living organisms: for centuries, the chemistry of living organisms was thought to be imbued with some mystical property, a vital essence that could not be duplicated in a laboratory--a theory called vitalism. Wöhler's experiment demolished vitalism. Organic and inorganic chemicals, he proved, were interchangeable. Biology was chemistry: perhaps even a human body was no different from a bag of busily reacting chemicals--a beaker with arms, legs, eyes, brain, and soul.

With vitalism dead, the extension of this logic to medicine was inevitable. If the chemicals of life could be synthesized in a laboratory, could they work on living systems? If biology and chemistry were so interchangeable, could a molecule concocted in a flask affect the inner workings of a biological organism?

--Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer, Scribner 2010, p. 83.

 

In one way, Mukherjee is right--this experiment showed that the vitalistic claim that a distinction based on vital essence existed between living organisms and non-living things had no basis in material physical reality. By "dead", he means that its foundation was shown to be false, and that there was therefore no basis to continue to use it as a basis for explanations in medicine or science. His usage refers to the "referent" part of the Semantic Triangle--no referent means no vitalism.

But in another sense, he's prematurely pronouncing it dead. There are still many people who believe in vitalism and dualism, not only in their own personal belief systems, but also by bringing dualistic concepts such as "spirit" and "energy healing" into the therapeutic encounter. The fact that there is no material physical referent in support of the idea does not prevent them from operating in the "concept" and "terms" part of the Semantic Triangle.

Whoever wrote the Wikipedia article on vitalism correctly observed that vitalism didn't disappear just because of that one experiment:

The concept of vitalism in chemistry can be traced back to Jöns Jakob Berzelius who suggested that in the division of organic and inorganic that a mysterious vital force exists in organic compounds.

Vitalism played a pivotal role in the history of chemistry since it gave rise to the basic distinction between organic and inorganic substances, following Aristotle's distinction between the mineral kingdom and the animal and vegetative kingdoms. The basic premise was that organic materials differed from inorganic materials fundamentally; accordingly, vitalist chemists predicted that organic materials could not be synthesized from inorganic components. However, as chemical techniques advanced, Friedrich Wöhler synthesised urea from inorganic components in 1828.

Further discoveries continued to marginalise need for a "vital force" explanation as more and more life processes came to be described in chemical or physical terms. However, contemporary accounts do not support the common belief that vitalism died when Wöhler made urea. This Wöhler Myth, as historian of science Peter J. Ramberg called it, originated from a popular history of chemistry published in 1931, which, "ignoring all pretense of historical accuracy, turned Wöhler into a crusader who made attempt after attempt to synthesize a natural product that would refute vitalism and lift the veil of ignorance, until 'one afternoon the miracle happened'". However, in 1845, Adolph Kolbe succeeded in making acetic acid from inorganic compounds, and in the 1850s, Marcellin Berthelot repeated this feat for numerous organic compounds. In retrospect, Wöhler's work was the beginning of the end of Berzelius's vitalist hypothesis, but only in retrospect, as Ramberg had shown.

In fact, some of the greatest scientific minds of the time continued to investigate the possibility of vital properties. Louis Pasteur, shortly after his famous rebuttal of spontaneous generation, performed several experiments that he felt supported the vital concepts of life. According to Bechtel, Pasteur "fitted fermentation into a more general programme describing special reactions that only occur in living organisms. These are irreducibly vital phenomena." In 1858, Pasteur showed that fermentation only occurs when living cells are present and, that fermentation only occurs in the absence of oxygen; he was thus led to describe fermentation as 'life without air'. Rejecting the claims of Berzelius, Liebig, Traube and others that fermentation resulted from chemical agents or catalysts within cells, he concluded that fermentation was a "vital action".

 

but he/she ends the chemistry section rather abruptly with Pasteur, rather than following through continuously to the present. This, too, is premature--vitalistic thought persists to this day. The developments in chemistry and other sciences that--among people who are familiar with the subject--convinced them that vitalism is no longer a compelling alternative explanation.

I think this overlooks a great number of people who aspire to be healthcare professionals, but who have not had access to an in-depth scientific and biomedical ethics education.

The issue of vitalism/dualism in MT is a huge issue for us. To continue to insist on vitalistic mechanisms as explanations is an obstacle to integration with other members of the healthcare team in fields that have long ago accepted the scientific consensus that--as a source of explanation in the lab and in the clinic--vitalism is dead.

And it directly contradicts established consensus of what belongs in an MT body of knowledge. As we've seen, vitalism contradicts chemistry and pharmacology.

Yet MTs are expected to know basic principles of pharmacology in order to practice.

The Massage Therapy Body of Knowledge (MTBoK) calls for the following required knowledge:

Pharmacology

  • General classification and types of drugs, herbs, supplements, their effects and their side effects.
  • Massage therapy considerations and potential responses to general classes of drugs, herbs and supplements.
  • Use of authoritative, medically accepted drug reference to look up drugs, their effects and their side effects.

--MTBoK, p. 18

 

while the Massage and Bodywork Licensing Examination (MBLEX) states the following expectations:

PATHOLOGY, CONTRAINDICATIONS, AREAS OF CAUTION, SPECIAL POPULATIONS (13%)
...

E. Classes of medications

--Massage and Bodywork Licensing Examination Candidate Handbook, Content Outline, p. 15

 

and the National Certification Exam in Therapeutic Massage and Bodywork/National Certification Exam in Therapeutic Massage lists the following topics:

III. Pathology (13%)

...

L. Drug interactions with massage/bodywork
1. medications (e.g., prescription; over-thecounter)
2. recreational drugs (e.g., tobacco; alcohol)
3. herbs
4. natural supplements

--NCETMB/NCETM Candidate Handbook, pp. 21, 23

 

and yet, at the same time, they require vitalistic concepts on the very same test--concepts that directly contradict the science on which these learning expectations are based.

This puts our students in an impossible position for learning, when one set of expectations directly contradicts another, as well as putting the teachers and schools in the position of being required to teach mutually contradictory information, and to assess students on how well they perform the impossible task of integrating that knowledge.

We need to figure out what this means to us as a community and as a developing profession. As Mukherjee observes, the metaphysical boundary collapsed a century and a half ago, but not all of us have quite gotten word of the collapse yet.

We need to address, at the very least (there may be even more issues that I have overlooked here):

  • how do we balance ethical standards and best practices in the client's interests in the therapeutic encounter with the practitioner's freedom of conscience?
  • how do we--schools, teachers, mentors--provide an education to our MT students that prepares them to build bridges to integration with other members of the biomedical healthcare team?
  • what do we do about the sunk costs in the previous unsustainable path, and the tremendous investment that it will require for us to practice as an integrated healthcare profession?

 

Source: The 7 November 1940 collapse of the Tacoma Narrows suspension bridge, http://upload.wikimedia.org/wikipedia/en/5/5c/TacomaNarrowsBridgeCollapse_in_color.jpg accessed 27 June 2012

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