This is a case report of massage practitioners exposed to bacterial endotoxins in a work environment from a seaweed massage.
Holm M, Johannesson S, Torén K, Dahlman-Höglund A. Acute effects after occupational endotoxin exposure at a spa. Scand J Work Environ Health. 2009;35(2):153–155.
Objectives Two spa workers reported symptoms such as fever, shivering, palpitation, arthralgia, and diarrhea after performing seaweed massages on clients at a spa center. This study was carried out to determine whether the symptoms were related to exposure to endotoxin.
Methods Personal and stationary air sampling for the measurement of airborne endotoxin was carried out at the spa during the preparation of a bath and the following seaweed massage. In addition, the impact of storage time on the concentration of endotoxin in the seaweed was investigated.
Results The measurements confirmed exposure to aerosolized endotoxin at the spa (11 ng/m2[sic] and 22 ng/m3). The endotoxin concentration in the stored seaweed increased as the storage time increased, from 360 ng/g seaweed for fresh seaweed to 33 100 ng/g seaweed for seaweed stored for >20 weeks.
Conclusions Organic dust toxic syndrome was diagnosed for two workers who performed seaweed massages at a spa center at which aerosolized endotoxin was measured. In order to minimize entotoxin exposure during massages, it is important to use fresh seaweed or seaweed kept well cooled for no more than 2–3 weeks.
Pulmonary aspergillosis ("the condition of Aspergillus mold infection in the lungs") seen under a microscope--notice the black dots and the rod-looking filaments in the lung tissue
Source: http://upload.wikimedia.org/wikipedia/commons/c/cd/Pulmonary_aspergillosis.jpg accessed 2 August 2012
diagnosed with suspected inhalation fever from endotoxins
To understand what an endotoxin is, we first need to get on the same page about how the word "toxin" is used in biomedical science and practice. Wikipedia's information on the subject is a pretty good introduction to the issues involved:
Toxin: A toxin (from Ancient Greek: τοξικόν toxikon) is a poisonous substance produced within living cells or organisms; man-made substances created by artificial processes are thus excluded. The term was first used by organic chemist Ludwig Brieger (1849–1919)...Toxins can be small molecules, peptides, or proteins that are capable of causing disease on contact with or absorption by body tissues interacting with biological macromolecules such as enzymes or cellular receptors. Toxins vary greatly in their severity, ranging from usually minor and acute (as in a bee sting) to almost immediately deadly (as in botulinum toxin). (Wikipedia: "Toxin" accessed 2 August 2012)
Poisonous substance: In the context of biology, poisons are substances that cause disturbances to organisms,[1] usually by chemical reaction or other activity on the molecular scale, when a sufficient quantity is absorbed by an organism. The fields of medicine (particularly veterinary) and zoology often distinguish a poison from a toxin, and from a venom. Toxins are poisons produced by some biological function in nature, and venoms are usually defined as toxins that are injected by a bite or sting to cause their effect, while other poisons are generally defined as substances absorbed through epithelial linings such as the skin or gut. (Wikipedia: "Poison" accessed 2 August 2012)
This definition is why lactic acid and similar metabolites are not toxins, despite the fact that the term is often misused by MTs in that way. Lactic acid does not cause damage on the molecular scale, nor does its buildup cause a chemical reaction.
So a toxin is a biologically-produced substance that causes harm to body tissues on contact by a chemical reaction on a molecular scale.
Here, we are talking about endotoxins, as opposed to exotoxins.
Exotoxin: An exotoxin is a toxin secreted by a microorganism, like bacteria, fungi, algae, and protozoa. An exotoxin can cause damage to the host by destroying cells or disrupting normal cellular metabolism. (Wikipedia: "Exotoxin" accessed 2 August 2012)
Endotoxin: The term endotoxin was coined by Richard Friedrich Johannes Pfeiffer, who distinguished between exotoxin, which he classified as a toxin that is released by bacteria into the environment, and endotoxin, which he considered to be a toxin kept "within" the bacterial cell and to be released only after destruction of the bacterial cell wall. Today, the term 'endotoxin' is used synonymously with the term lipopolysaccharide, which is a major constituent of the outer cell membrane of Gram-negative bacteria. Larger amounts of endotoxins can be mobilized if Gram-negative bacteria are killed or destroyed by detergents. The term "endotoxin" came from the discovery that portions of Gram-negative bacteria themselves can cause toxicity, hence the name endotoxin. Studies of endotoxin over the next 50 years revealed that the effects of "endotoxin" are, in fact, due to lipopolysaccharide.
The key effects of endotoxins on vertebrates are mediated by their interaction with specific receptors on immune cells such as monocytes, macrophages, dendritic cells, and others. Upon challenge with endotoxin, these cells form a broad spectrum of immune mediators such as cytokines, nitric oxide, and eicosanoids. [1] (Wikipedia: "Endotoxin" accessed 2 August 2012)
Lipopolysaccharide: a molecule with a lipid (fat) component and a saccharide (sugar) component. They are a very important component of the cell wall of Gram-negative bacteria.
Gram-negative bacteria: Bacteria can be classified according to the biochemical properties of the cell wall that encloses the bacterial cell. Bacteria of one type, Gram-positive bacteria, have a cell wall structure that holds a purple stain, visible on a microscope slide, when dyed according to a particular cell-staining protocol. Gram-negative bacteria have a different cell wall structure that does not hold the stain from that dye, and so they do not appear purple. The same cell wall structure that does not hold the dye is also responsible for the endotoxins that Gram-negative bacteria release when the cell wall is broken, meaning that Gram-negative bacteria are often very strong pathogens (causes of disease).
In this photo, the small blue spheres (cocci) are a Gram-positive bacteria, so they stain purple. The long rods (bacilli) are a Gram-negative bacteria, so they do not hold the purple stain, and appear pink.
The first Gram-negative stain I ever did, Klebsiella pneumoniae, a Gram-negative rod, implicated in pneumonia and urinary tract infections. Stained 23 September 2009, Bellevue College, Bellevue, WA.
Case 2:
27-year-old woman, history of celiac disease [American spelling], otherwise healthy
Coeliac disease [British spelling]...is an autoimmune disorder of the small intestine that occurs in genetically predisposed people of all ages from middle infancy onward. Symptoms include chronic diarrhoea, failure to thrive (in children), and fatigue, but these may be absent, and symptoms in other organ systems have been described...Coeliac disease is caused by a reaction to gliadin, a prolamin (gluten protein) found in wheat, and similar proteins found in the crops of the tribe Triticeae (which includes other common grains such as barley and rye). Wikipedia: "Coeliac disease" accessed 2 August 2012
had worked about 3 months at same spa as case 1 worked when she went to doctor about these symptoms--no longer employed at spa
after seaweed massages: complained of 12-18-hour-long episodes of shivering, palpitation, fever, and diarrhea, that then went away completely
diagnosed with suspected inhalation fever from endotoxins
symptoms started about 5 hours after facial seaweed or algae massage treatment for clients
Seaweed is a loose colloquial term encompassing macroscopic, multicellular, benthic marine algae. The term includes some members of the red, brown and green algae. (Wikipedia: "Seaweed" accessed 2 August 2012)
Algae are a very large and diverse group of simple, typically autotrophic [synthesizing their own food, instead of eating other living things] organisms, ranging from unicellular to multicellular forms, such as the giant kelps that grow to 65 meters in length. Most are photosynthetic like plants, and "simple" because their tissues are not organized into the many distinct organs found in land plants. The largest and most complex marine forms are called seaweeds. (Wikipedia: "Algae" accessed 2 August 2012)
Massagenerd has YouTube videos of how to perform a seaweed treatment--Spa Seaweed Treatment 1 of 2:
and Spa Seaweed Treatment 2 of 2
She makes what is, unfortunately, a very common mistake among MTs at the 30-second time-point. Where she says, "The seaweed mixture acts as a detoxification", that is simply factually wrong, and you should not believe that. It's a very common massage myth.
She also does something very, very right at the 17-second time-point, something that I was very happy to see: before actually applying the seaweed paste, she tested the temperature on a small spot with her client to make sure that it was not too hot.
You should always do that when applying any kind of heat therapy.
The maximum safe temperature for human skin is around 110 F, while the pain threshold is at about 105 F.
So tap water can actually be hot enough to burn the client's skin, and you should always check with the client to make sure the temperature of your heat therapy is safe and comfortable.
Based on the symptoms, test results, and apparent exposure to endotoxins, an investigation was carried out at the spa to detect whether employees were exposed to endotoxins present in the environment there.
At the spa, 1 kg of brown seaweed (Fucus serratus) was placed in a bathtub with water heated to 38°C. Clients were normally treated in the bathtub for about 30 minutes, including 10 minutes of massage. The storage time and handling procedure for the seaweed used on this occasion were not known.
A sample was taken from the water prepared with seaweed, and it was sent to the laboratory for analysis. The sample was found to contain an endotoxin concentration of 800 ng/ml.
Later in the article, they point out that this number is 100 to 1000 times the amount acceptable to find in normal drinking water.
In another test at the same workplace,
The personal air sample contained an endotoxin concentration of 11 ng/m3, and that of the stationary sample was 22 ng/m3.
The investigators concluded that the turbid water,
caused by adding the seaweed to the bathwater, was forming an aerosol (a suspension of tiny particles in air), that was carrying the endotoxins into the workers' lungs.
Often the spa workers had several clients in succession, leading to extended exposure. However, there were no symptoms if exposure was avoided. Adding seaweed to the bath made the water somewhat turbid. It is likely that an aerosol was formed from small droplets or splashes being produced when the clients were massaged with the seaweed. It was concluded that the spa workers’ symptoms had probably been caused by the aerosolized endotoxin they were exposed to during the massage procedure.
They analyzed the seaweed to see if the amount of endotoxin increased as the seaweed was stored for longer times before being used.
Levels of endotoxin found in seaweed stored for longer times, measured in units of ng endotoxin/g seaweed
They found not only that it did increase with time, as expected, but also that gram-negative bacteria was present--that would account for the endotoxin, as we discussed previously about the lipopolysaccharides in the cell walls of Gram-negative bacteria as sources for endotoxins.
In conclusion, ODTS [organic dust toxic syndrome] was diagnosed for two staff members performing seaweed massages at a spa center at which aerosolized endotoxin was measured. Endotoxin was found in fresh seaweed, and the concentration increased markedly with an increase in the length of storage of the seaweed. In minimizing endotoxin exposure, it is important to use either fresh seaweed or seaweed kept well cooled for no more than 2–3 weeks in a refrigerator.
What do these case reports mean for your responsibilities toward your clients and your employees if you are a spa owner?
What do these case reports mean for your responsibilities toward your clients and your employer if you work as an employee or a contractor at a spa?
UPDATE, 3 August 2012, 10:34 AM PDT
Elsewhere, Robin Byler Thomas asked an excellent and profoundly client-centered question about this study:
What about the client's exposure?
A very important question.
What do we know about its answer from the article?
Were the clients exposed to endotoxins at all?
If they were exposed, were they affected by the exposure?
How did any potential client exposure compare to MT exposure?
What followup were the occupational health team able to take with the spa?
What changes in their procedures did the spa make in order to protect their clients and MTs from exposure to endotoxins?
There are at least three issues involved in deciding how long to wait between massage and scuba diving, either massage before diving, or massage after diving.
Does massage make DCS (decompression sickness, "the bends") more likely to happen, or does it make it worse if it does happen?
Does massage cause a situation that makes false positives for DCS more likely, meaning that resources are used unnecessarily to diagnose and treat suspected cases that are not really DCS?
Does massage cause a situation that makes false negatives for DCS more likely, meaning that real cases of a potentially life-threatening condition are ignored or missed?
There are theoretical scenarios for "yes" answers to all 3 of those questions that are all physiologically plausible, although there is no evidence yet to quantify what the real clinical risk from those theoretical risks are.
However, the safest way to practice is to wait 24 hours after getting a massage before scuba diving, and to wait 24 hours after scuba diving for getting a massage.
If the--admittedly very low--probability of DCS actually does turn into a case:
The MT will never be able to prove that the massage did not cause, worsen, or mask the symptoms of DCS, and
If the case turns adversarial and legal, there is information on record from Divers Alert Network DAN, the pre-eminent diving medicine research and education organization, where MDs and physiologists recommend waiting as the safest principle. A lawyer will be able to point to that recommendation, and argue that the MT violated standards of practice, such as they exist, by not waiting according to that recommendation.
For these reasons, POEM recommends spacing massage and scuba diving at least 24 hours apart in each direction as the safest course to follow.
Years ago I recall reading somewhere that massage is contraindicated within 24 hours after scuba diving. In searching now, I'm finding contradictory information. Anyone have a reliable source re this? Thanks!
Divers Alert Network (DAN), the go-to site for medical information about diving, doesn't answer the question directly, but sketches out some of the issues involved.
Decompression sickness (DCS; also known as divers' disease, the bends or caisson disease) describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurisation. DCS most commonly refers to a specific type of underwater diving hazard but may be experienced in other depressurisation events such as caisson working, flying in unpressurised aircraft, and extra-vehicular activity from spacecraft.
Since bubbles can form in or migrate to any part of the body, DCS can produce many symptoms, and its effects may vary from joint pain and rashes to paralysis and death. Individual susceptibility can vary from day to day, and different individuals under the same conditions may be affected differently or not at all.
Some have cautioned against massage before diving. The clearest justification is to avoid muscle pain that might be attributed to DCS.
So he's not saying that massage makes a diver more likely to actually get the bends; he's saying that the massage may cause slight soreness afterward that can confuse the diver and the healthcare team into thinking it's a case of the bends: a false positive for DCS.
The other possibility, which the DAN physician doesn't address here, is that the diver could actually get the bends, but ignore the symptoms and fail to seek medical attention for a serious condition, thinking that the soreness comes just from the massage: a false negative for DCS. We'll discuss this more later on in this post.
The nature and action of micronuclei has not been confirmed, but it is believed that they are the seeds from which bubbles form. There is a theoretical concern that tissue massage may induce [bring about] micronuclei formation and thus precipitate [promote] bubble formation. Tissue stimulation could also increase blood flow which may either positively enhance tissue gas elimination or precipitate problematic bubble formation.
See how things are interconnected? The claim that massage increases blood flow is problematic, but whatever the evidence that emerges for or against that claim, it can play a role one way or another in whether or not massage increases the risk of DCS.
As you can see, there is no clear sense of what massage might do and this effect would likely vary depending on dive profiles and intensity of the massage. We should note that massage has not been confidently associated with any of the cases of DCS that have come to us, and we are not aware of any study done to address this question. The clearest piece of advice is that deep tissue massage should probably be avoided, so that the potential of post-dive pain and diagnostic confusion are minimized.
Decompression safety, as with many things, is a matter of balancing strings of decisions so the net outcome is in your favor. My approach is to stack as many factors as feasible in my favor to compensate for the Murphy effect or chance that we see frequently in decompression sickness.
Neal W. Pollock, Ph.D.
What are some of the factors involved in decompression sickness?
In general, being at a healthy weight works in your favor, while being overweight is thought to slightly increase your risk of DCS. Exercise, especially forms that put strain on the joints, is discouraged right after diving, as it's considered a slight risk factor.
Dehydration is thought to raise the risk of DCS as well. so the tradition of encouraging people to drink plenty of water after a massage cannot hurt, and may provide a tiny bit of protection.
The prohibition against flying or mountain climbing within 24 hours after diving is a result of the way the gas laws work in physics.
The ideal gas law (the description of the way gases work) is:
PV = nRT
The (P)ressure times the (V)olume of the gas equals the (n)umber of molecules [amount] of the gas times a constant R times the (T)emperature.
(V)olume [the size of the nitrogen bubbles that migrate to the joints and cause the bends] is what we care about, so let's isolate that variable on one side of the equation.
So the behavior we care about is described by:
V = (nRT)/P
The (V)olume
1. goes up as the amount of gas (n) goes up;
2. goes up as the (T)emperature goes up;
3. goes down as the (P)ressure goes up, and vice versa.
Since massage cannot add to the amount of nitrogen in the body, and in fact during the massage, the body will continue to shed excess nitrogen, I hypothesize that (1.) is not an issue.
Massage does raise skin temperature, so if you want to take a 100%-risk-avoidant path, you could say that the slight theoretical risk of that gain in temperature means that it's absolutely contraindicated. However, my experience in anatomy and physiology leads me to think that the distribution of the nitrogen bubbles throughout the entire circulatory system is not likely to be affected enough by local changes in skin temperature for that to be a significant risk. I hypothesize that the theoretical risk of (2.) is not going to make a real clinical difference.
(3.), in my opinion, is, of all the risk factors, the most likely to have an effect. I honestly don't know whether BP-lowering effects of massage could make the bubbles large enough to create a real increased risk. That would however, make an excellent study.
That was as far as I was able to take it with my basic physics; since I was rapidly getting in over my head (ha!), I put out the bat signal for someone with specialized knowledge on both sides of the question: physicist/MT Keith Eric Grant.
He was able to clarify the question more:
Like you, I can see the basis for diving and flying, but not for massage. Massage may change skin temperature, but I think that's mostly by dilating superficial capillaries; i.e. not an actual change in blood temperature. Nor would I expect that massage would create anymore of a change in pressure than moving around or sitting down.
The real issue here is solubility. Gas solubility does decrease with temperature, but your body is simply not going to let that change.
The pressure dependence of solubility isn't the ideal gas law per se but Henry's law.
That law states that the concentration of the dissolved gas will be proportional to the pressure. As I recall, commercial airlines pressurize to about 7000 ft.
I would think that the greater danger would be not from the massage but from not recognizing symptoms of the bends and doing a massage in their presence rather than referring to medical care. http://en.wikipedia.org/wiki/Decompression_sickness#Signs_and_symptoms
I remember Donald Schiff talking some years back about a pilot coming in for a massage and referring him to emergency care.
I agree with his point about the risk of not recognizing decompression sickness.
Case 8 – A diver with back trouble developed pain and motor weakness in his back and legs after 11 dives over three days complicated by altitude exposure. He had partial resolution during a long series of recompressions.
A 63-year-old male divemaster had made 50 dives during the past year and more than 200 lifetime dives. He had a history of degenerative lumbar disc disease and hypothyroidism for which he took synthetic thyroid hormone. He was on a liveaboard vacation and had made 11 dives over a 3 day period with a maximum depth of 128 fsw [feet of salt water] (39 msw [meters of salt water]) and a last dive depth of 100 fsw (30 msw). All dives were uneventful and used 32% nitrox [nitrogen-oxygen combination] with dive times according to an air computer.
He performed five dives the first day, four the second, and two morning dives on the third day. He stated he was well hydrated, well rested and had not consumed any alcohol. While returning to the boat after the second morning dive, he developed pain in his lower back consistent with his pre-existing disc condition, but he was able to climb onto the boat without assistance. He did not make another dive but opted to rest, have a back massage, and eat lunch. Feeling better, he participated in a walking tour of a local island which took him to an altitude of about 2,000 ft (610 m). During the tour, the back pain returned, and he had difficulty walking due to numbness in his legs but was able to return to the vessel where a physician also on vacation was concerned that might have neurological DCS. They informed the boat captain who placed the diver on first aid oxygen while they traveled to a nearby island with a hyperbaric chamber [where the air pressure can be increased or decreased in a controlled way].
Upon evaluation, the hyperbaric [high-pressure] physician found the diver had abnormal skin sensations bilaterally from his navel down to his toes, exhibited profound difficulty walking, and unsteadiness while standing. The diver was recompressed on Table 6 ["tables" here are hyperbaric medicine compression/decompression protocols] with extensions but had minimal improvement of his symptoms. Another Table 6 administered the following morning provided only slightly greater relief. Given the history of disc problems, the hyperbaric physician arranged for transfer to a hospital with greater diagnostic capability than on the island. As weather delayed air evacuation until the third day, the diver was treated again on a Table 5.
He was taken by air ambulance pressurized to one atmosphere to a larger hospital, but further diagnostic tests were inconclusive, and it was decided to continue hyperbaric therapy. The day after arrival, the diver received two treatments at 33 fsw (10 msw) for two hours with no improvement and later that day, a Table 6. Over the next seven days, he received 1-2 wound-care hyperbaric treatments (33 ft/10 msw) for 2 hours during which he reached a clinical plateau with no further improvement. His symptoms decreased over the next few months but intermittent symptoms continued, perhaps because of the existing disc problem.
Massage doesn't appear to have made the DCS worse--but can you think of any other role it could have played in this case?
If you work with scuba divers, it's useful to know the symptoms of decompression sickness. If a diver client mentions any of these symptoms, referring them to seek medical attention is the appropriate thing to do.
Signs and symptoms of decompression sickness
DCS type
Bubble location
Signs & symptoms (clinical manifestations)
Musculoskeletal
Mostly large joints
(elbows, shoulders, hip, wrists, knees, ankles)
Localized deep pain, ranging from mild to excruciating. Sometimes a dull ache, but rarely a sharp pain.
Active and passive motion of the joint aggravates the pain.
The pain may be reduced by bending the joint to find a more comfortable position.
If caused by altitude, pain can occur immediately or up to many hours later.
Cutaneous
Skin
Itching, usually around the ears, face, neck, arms, and upper torso
Sensation of tiny insects crawling over the skin (formication)
Mottled or marbled skin usually around the shoulders, upper chest and abdomen, with itching
Swelling of the skin, accompanied by tiny scar-like skin depressions (pitting edema)
I'll let Neal Pollock of Divers Alert Network have the last word, as I can't possibly improve on the way he said it.
I end with the discussion of the capriciousness of decompression sickness to remind you of the power of the old adage of an ounce of prevention being better than a pound of cure. You are ahead of the game by asking the question. You should now think about all the little things that can all work together to keep your risk at a comfortably low level.
Important note: Before you try to put any of these techniques into clinical use, make sure that you are in compliance with any laws or regulations in your area that govern the use of intra-oral techniques.
For example, Washington state requires:
Sixteen hours of direct supervised training [that] must include: Hands-on intraoral massage techniques, cranial anatomy, physiology, and kinesiology; hygienic practices, safety and sanitation; and pathology and contraindications. [1]
Other states or localities have different regulations.
Make sure that you are aware of and follow the appropriate law in your area regarding intra-oral techniques.
UPDATE, 30 October 2012, 12:29 PM ET:
VERY IMPORTANT NOTE:
For your own personal safety, make sure you only perform this technique on clients/patients who are lucid, with whom you can communicate clearly about what you are doing, and whom you can trust absolutely not to bite you.
There are populations with members who, no doubt, could benefit from this technique, but it is unsafe to put your fingers in their mouths, because there is a very real risk that they might bite your fingers, very hard. These populations include patients with dementia, children with developmental disorders, and others.
Only perform these intra-oral techniques if you are absolutely sure that your client/patient can be trusted not to bite you. If you have any doubt at all about the risk, then it's a good idea to discuss this with the case manager and other healthcare professionals on the client's care team to decide whether or not to offer this treatment.
In the section titled "How Does Massage Work?" they repeat the claim that massage can lower cortisol levels:
While some studies show that massage can reduce pain and anxiety for people with arthritis, how exactly does massage make these results happen? Research has shown that massage can lower the body’s production of the stress hormone cortisol, and boost production of serotonin, which, in turn, can improve mood. Additionally, massage can lower production of the neurotransmitter substance P, often linked to pain, and improve sleep as a result.
They follow up with another study where the reduction in cortisol levels was not significant:
In 2010, researchers at the University of California, Los Angeles, School of Medicine and the nearby Cedars-Sinai Medical Center studied 53 healthy adults receiving just one Swedish massage therapy session and found that the participants’ levels of key hormones and white blood cells were positively affected. For example, the hormone arginine-vasopressin, which may lower blood pressure, was decreased, along with some inflammatory cytokines like IL-4 and IL-10. Cortisol levels were reduced by massage in this study as well, although not significantly.
and then they proceed to the research we're discussing in Journal Club.
Commenters Christopher Moyer (first author on the Journal Club research article) and rchunco (who is facilitating this month's Journal Club are quoted in the article. It's definitely worth a read.
I also find the claim about substance P interesting, and worth a follow-up. The Arthritis Today article doesn't mention the provenance (source) of the claim, stating only that:
massage can lower production of the neurotransmitter substance P, often linked to pain, and improve sleep as a result
To follow up, I did a PubMed search on
massage AND "substance P"
and got 5 results, the following 2 of which bear relevance to the claim:
Abstract: Many animal species invest a large amount of time in grooming behavior without deriving any apparent benefit. In order for this behavior to have survived, however, it must confer some survival advantage. In seven of eight humans tested, an elevation in the skin's temperature was documented after massaging of the cheeks of the face. The elevation of the skin's temperature reached a plateau after about 40 min of massaging and was correlated to visible erythema. This effect could be inhibited by repeated pretreatment of the skin with topical capsaicin, a chemical that results in the release of substance P from peripheral nerve endings. Thus, it appears that the temperature elevation induced by stroking of human skin is controlled, at least in part, by release of the neurotransmitter, substance P. In conclusion, it appears that the release of neurotransmitter(s) may be the survival advantage that grooming confers to animals.
Abstract: Massage therapy has been observed to be helpful in some patients with fibromyalgia. This study was designed to examine the effects of massage therapy versus relaxation therapy on sleep, substance P, and pain in fibromyalgia patients. Twenty-four adult fibromyalgia patients were assigned randomly to a massage therapy or relaxation therapy group. They received 30-minute treatments twice weekly for 5 weeks. Both groups showed a decrease in anxiety and depressed mood immediately after the first and last therapy sessions. However, across the course of the study, only the massage therapy group reported an increase in the number of sleep hours and a decrease in their sleep movements. In addition, substance P levels decreased, and the patients' physicians assigned lower disease and pain ratings and rated fewer tender points in the massage therapy group.
Reading the abstracts instead of the articles is never safe; there are just too many errors in published articles and too much lack of detail to rely on the abstract to fairly represent the article enough to base an analysis on.
But I can read an abstract and decide on that basis whether it makes sense for me to go to the effort and expense of obtaining the entire article or not.
The first one may be interesting, based on the abstract. I think they make quite a huge leap from the results of their study to the conclusion that grooming necessarily confers a survival advantage in animals, and that that survival advantage may lie in the release of neurotransmitters. However, the abstract itself is necessarily quite telegraphic, for reasons of space, and the article itself may do a better job of connecting those dots.
But the evolutionary biology claims aren't what we're interested in here. We're looking for the source of the claim that massage lowers levels of substance P, and there is enough information in the abstract of the article to determine the answer to that question.
Morhenn is claiming the following:
40 minutes of firm massaging of the cheeks leads to
Therefore, the temperature elevation caused by massage involves--at least as part of the process if not the entire cause--release of the neurotransmitter substance P.
If, at this point, you're wondering whether you missed a step, no, it's not you. Morhenn is using one piece of knowledge implicitly--she is assuming that all her readers already have all the pieces--rather than stating it explicitly.
That piece of knowledge is that since capsaicin causes peripheral nerve endings to release the neurotransmitter substance P, and there is a lag time before they "recharge" with more substance P to release, that when the massage is taking place, there is temporarily no more substance P left for anything else to cause to release.
So her implicit (not fully spelled out) argument is that since massage causes increased temperature, etc. and that since this effect no longer occurs when capsaicin has caused the peripheral nerve endings to discharge their substance P, that the reason massage effects are blocked must be that massage produces its effects (at least, in part) through that very release of substance P. Since it's no longer there, due to the capsaicin, massage cannot produce the effects it normally would.
I can't tell from the abstract whether she's connected the dots thoroughly enough for a convincing interpretation--I'll have to look up the article later--but what I can tell is that this is not the source of the claim that massage reduces substance P.
In fact, Morhenn is claiming the opposite--that massage causes substance P to be released in this situation--so while I'll have a look later to see whether she connected the dots, both on this claim and on the larger evolutionary biology argument--I'll put it aside as a source for the claim in the Arthritis Today article.
That leaves only the Field article as the source of the claim, and indeed it is stated in the abstract. Since--as we're examining in Journal Club--her team used a weaker, non-standard methodology for the claims that massage lowered cortisol, I suspect the same may be true in their analysis of substance P levels.
I won't have a chance to get out to the medical library until this weekend, but when I do, I'll check it out, and report back on my findings.
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