In accordance with the fair use exception to copyright for teaching purposes, I am engaging with it here to bring out points that are directly relevant educationally to stakeholders in the massage community, and to provide links to clarify specialized knowledge as needed.
Where did the idea that massage promotes metastasis, and therefore, we shouldn't offer massage to patients living with cancer, come from?
What is the current best practices recommendation for massaging someone with a history of cancer, and on what basis is that best practices recommendation formed?
Why is the idea that we shouldn't massage someone with a history of cancer, because it might promote metastasis, so persistent in the face of what we actually know?
We're going to discuss meaning a great deal in this post, so it's useful for understanding if we're all on the same page about that.
That way, when we're trying to navigate among terms, concepts, and referents in discussing this article to get at what it all means, we have the advantage of a shared vocabulary and approach to help us work together with each other.
ANNALS of SURGERY VOL. LXXV FEBRUARY, 1922 No. 2
THE RELATIONSHIP OF MASSAGE TO METASTASIS IN MALIGNANT TUMORS*
* From Columbia University, Institute of Cancer Research, F. C. Wood, M.D., Director, New York.
BY LEILA CHARLTON KNOX, M.D. OF NEW YORK, N. Y.
CLINICAL
One of the most important aspects of the practical study of tumors is the determination of the anatomical and biological conditions which facilitate or prevent metastases. These phenomena have long been studied in man without much definite information having been collected. About all we know is that, in general, carcinomata are prone to metastasize through the lymph-channels and sarcomata through the blood-vessels, and that metastases do not always follow in the direction of flow of the current, but in a certain proportion of instances the emboli travel by a retrograde course or the tumors progress by direct extension, the so-called permeation of the lymphatics.
What are the important points that Knox is making here?
Structually, what part of the research article that you would expect to see here is missing? What might be a reason that this research review article does not have the structure that you would normally expect?
It has been generally assumed, without direct experimental proof, that a number of the factors favoring the production of metastasis are purely physical, for instance, the size and connective-tissue relations of the tumor cells, the pulsating or contractile movements of the organs in which they are implanted, the number of the blood-vessels and the thickness of their walls, with consequent susceptibility to trauma by pressure or massage. On the other hand, accurate clinical study and experimental work as well have caused the occult and convenient theories of tissue predispositions and specific "immunity" of organs to assume a less creditable position than they formerly held, and quite properly, for until it is shown that simple mechanical and biological facts do not account for the peculiarities in the occurrence and distribution of metastases vague theories should not be substituted.
What exactly is she saying here about material mechanical and biological facts?
Is she arguing from a realist position or not? How do you know?
At this point, unless we have some specific knowledge of particular claims about metastasis made at this time in history, it's unclear exactly what she means by "occult and convenient theories of tissue predispositions and specific "immunity" of organs". At a very general level, however, what does she appear to be talking about? Remember this point--she'll clarify it later in her discussion.
Where does she use Occam's Razor in her argument here, and why?
The importance of vascular embolism in the spread of tumors has long held an unchallenged position in instances in which the pulmonary veins were known to be grossly involved and the arterial circulation in that way obviously open to a supply of tumor cells. A valuable contribution on this phase of the subject was made when M. B. Schmidt showed that not infrequently the tumor cells readily pass the pulmonary capillaries and are deposited elsewhere before macroscopic growth appears in the lung. In a study of forty-one cases of primary abdominal carcinomata without extensive gross metastases, the lungs of fifteen were found to contain microscopic arterial emboli of tumor cells, showing that once the cells gain entrance to the blood stream they may reach any portion of the body and are not necessarily always retained or destroyed within the lungs. This may, however, be their fate, for Schmidt found many small thrombosed vessels with degenerating tumor cells entangled in the clot. These phenomena have been duplicated experimentally by Takahashi and by Iwasaki, both of whom injected tumor cells into the blood stream of animals. Both these authors have well shown that although embolic cells are frequently treated as foreign bodies and phagocyted, many, on the contrary, survive the adverse conditions, and invade and replace the vascular endothelium or undergo mitosis even before they become implanted on the vessel wall.
What does she mean by "the pulmonary veins were known to be grossly involved and the arterial circulation in that way obviously open to a supply of tumor cells"? Describe the relationship between pulmonary veins and arterial circulation that she is referring to.
What is M.B. Schmidt's valuable contribution on the subject, and why is it so valuable?
What did Takahashi and Iwasaki show, and what does it mean?
Notice the unusual term "phagocyted"; it means the same thing as "phagocytosed", which is the term you see more often nowadays, as in this example from Wikipedia:
Phagocytosis (from Ancient Greek φαγεῖν (phagein) , meaning "to devour", κύτος, (kytos) , meaning "cell", and -osis, meaning "process") is the cellular process of engulfing solid particles by the cell membrane to form an internal phagosome by phagocytes and protists...Bacteria, dead tissue cells, and small mineral particles are all examples of objects that may be phagocytosed.
For purely physical reasons, however, we must suppose that cells of small size accomplish this more readily than do larger ones, and experience shows that the large spindle and giant cells, or those distended with mucus as many from the gastro-intestinal tumors are, do not find their way through the pulmonary capillaries except in small numbers. Whether or not the ameboid motion of the cells is a factor in facilitating this is not known. That such motion exists was shown by Carmalt in 1872 and later by Lambert and Haynes.
What are two possible physical explanations that could account for smaller cells establishing metastases beyond the lungs more successfully than larger cells do?
The localization and growth of embolic tumor cells within the dilated capillaries of the bone-marrow have been explained as due to the physiological hyperaemia which is practically constant in that situation. Slowing of the blood current and adhesion of the tumor cells to the endothelium seems to produce circumstances favorable to the growth of such emboli.
Is she saying that bone marrow is particularly susceptible to metastasis from tumors that originated elsewhere in the body? Why or why not?
Lymphatic embolism, either direct or retrograde, has also been unquestionably a frequent and important means of tumor dissemination; but the status of lymphatic permeation, although very convincingly demonstrated by Handley in certain cases, is perhaps a less constant phenomenon than he at first believed.
Notice the British spelling of "tumour", and beware the typo in "pulmonary"--this image was probably created by a non-native English speaker, but is factually correct with regard to the referent, although they misspelled the term.
Tell me what we're looking at here--what structures and processes do you see?
The process, as Handley described it, consists in the proliferation of tumor cells which, having gained access to the superficial lymphatics in the proximity of the tumor, continue to grow within them and to extend through their branches, often appearing in the skin, where they form cutaneous nodules. Secondarily, there often occurs an inflammatory fibrosis and obliteration of portions of the lymph-channel, a process analogous to the thrombosis which is common in invaded vascular channels. Handley studied especially breast carcinomata and melanomata--two of the tumors which most frequently exhibit regional cutaneous recurrences and extensions; and it is on the basis of his evidence that one may perhaps regard some of the recurrences in surgical scars as accidental occurrences due to the proliferation of tumor cells present in the lymphatics prior to the incision, though possibly accelerated in growth by the increased vascularity of the wound area. Probably, however, a majority of the local recurrences are due to a mechanical transplantation from an infected to a non-infected field.
What metastases do breast cancer and melanoma frequently exhibit?
What is the connection between metastasis and surgical scars?
What are 2 possible mechanisms for their occurrence?
Notice the use of "infected" to refer to cancer cells here.
FIG. 1.-Metastasis of breast carcinoma in pectoralis muscle following massage in man.
What different kinds of cells and other material physical things do you see there?
What indicates that you are looking at muscle cells?
What, particularly, indicates the pectoralis muscle?
In the case of the melanomata this mechanical transfer by operation is not a completely adequate explanation, for the nodules are often found far from the region of the incision, and, indeed, are frequently seen in unoperated cases, giving a striking illustration of the fact that tumor cells, especially those of moderate size, have the capacity to invade the cutaneous lymphatics for long distances and to spread against the direction of flow of the lymph. When the vessel is large, as in the abdominal trunks, permeation would not be expected to occur, and it is probable that extensive backward spread of tumor cells is due to a combination of several processes. Vogel has described two such cases, one a carcinoma of the gall-bladder, which extended into the left kidney hilus [RST: This is an old name; it means the same thing as "hilum"] and there perfectly outlined the perivascular lymphatics of that region; the other a pancreatic carcinoma which extended directly along the mesenteric and aortic trunks into these nodes.
What are two explanations that Knox provides for why surgery is not the only thing that accounts for metastasis?
Vogel described two cases where the spread was far away, and it travelled retrograde to the direction of lymphatic flow.
In what direction did the gall bladder tumor have to travel to reach the hilum of the kidney?
How far did it have to travel?
What did it have to pass through to get there?
Where have we seen a hilum of an organ before in this discussion? What do they have in common with each other?
It is well known also that oesophageal carcinomata are prone to spread longitudinally along the lymphatics of the submucosa and that small secondary nodules often appear considerably below and separated from the oldest portion of the tumor by uninvolved mucosa. It used to be the fashion to describe these as implantation growths, but this view is now generally abandoned. Zahn has even described one situated as high as the tracheal bifurcation, but associated with three small carcinomatous nodules beneath the mucosa on the gastric side of the cardia. This occurred also in an oesophageal carcinoma with tracheal fistula (St. Luke's Hospital, No. 1309), the secondary nodule being 4 cm. from the main mass of the neoplasm. The mechanism of the formation of these multiple nodules, as well as of multiple papillary gastric carcinomata, has not been shown to be necessarily a process of permeation, although theoretically this would readily explain their occurrence.
"Oesophageal" is an older, Latin/Greek-based, spelling for "esophageal".
Why does the esophagus have carcinomata?
If you're a tumor cell, how far away is 4 cm in proportion to your size?
At the time Knox wrote this, did they know the mechanism by which these secondary metatastic tumors got away from the primary tumors?
On the other hand, emboli are, no doubt, prevented from growing by the mechanical activity of muscles and muscular organs. Metastases are singularly rare in the cardiac muscle, being practically never seen except in the case of extremely vascular tumors with scanty stroma from which the loosened cells spread and overwhelm the whole arterial circulation with countless emboli. The aortic valves must also act to deflect emboli from the mouths of the coronary arteries. Benecke, studying the invasion of the walls of vessels from carcinomatous thrombi, believed that the infrequency of metastasis in the muscular coat was due to the physiological tonus of the muscle. This is a reasonable conclusion, and the principle holds good for striated muscle as well. Metastases into the latter are extremely rare, due in part to the contractility of the fibres, a condition which offers considerable resistance. The fact that lymphatics are lacking within striated muscle bundles is certainly not the reason for the rarity of metastases, for if the emboli were lymphatic, not vascular, and if the motion did not play so large a part in preventing their growth, they should be present in tendons where lymphatics are very numerous. Direct permeation of both striated and unstriated muscle is, however, frequently seen, showing that the soil is not unsuitable provided the cells once gain access to the tissue.
What protects muscles, and muscular organs like the heart, against metastasis?
Does this protection always work perfectly?
How do we know that it's not just the lack of lymphatic vessels in skeletal muscle that protects them?
Normal peritoneum has been shown by Jones and Rous to possess a high resistance to the implantation of tumor cells, but when it was injured by a mechanical irritant, tumor growth was at once made possible. This offers an explanation for the frequently observed fact that carcinoma of the stomach often metastasizes into the ovary, producing the so-called Krukenberg tumor of the latter organ, without any intermediary deposits on the peritoneal surface. That such deposits will eventually occur in late stages of carcinomatosis is, of course, well known, but it is probable that the constant motion of the opposed serous surfaces is an important factor in destroying whatever cells may find their way to it. It has long been recognized that it is the gelatinous carcinomata of the ovary, stomach, and intestine that are most widely distributed in the abdominal cavity. This is, of course, as would be expected, for the bulk and consistency of the mucus make it in a sense a foreign body and must keep the cells in contact with the peritoneum and also irritate it, and so indirectly facilitate adhesion and ultimate vascularization, whereas a few free cells would be more likely to be destroyed.
Is peritoneal tissue normally relatively vulnerable or relatively resistant to metastasis?
What is a proposed mechanism that could account for that tendency?
What can change that tendency?
Post-operative human results have occasionally shown the remarkable persistence which cells from malignant tumors may exhibit. During the quiescent period the cells are probably most frequently inactive in the lymph-nodes, occasionally for as long as ten to twenty years. Late recurrences usually appear first in the nodes to which drainage was directed, and if the morphology of the tumor is that of the primary growth there can be no question that these are really late recurrences from previous metastatically deposited cells. For example, small groups of living cells from a gastric carcinoma have been observed by Rohdenburg in the liver and omentum ten years after the operation on the primary tumor, with a clinical cure. Such a case may be the result, like many of the very late cutaneous recurrences from breast tumors, of slow permeation along the efferents of a node or even from a small group of cells for years quiescent in the tissue spaces.
How long after a tumor is removed can a recurrence or metastasis happen?
How can it do that, since the tumor was removed?
How can they tell it was a recurrence of the old cancer, rather than the development of a brand-new different cancer?
A spindle-cell sarcoma has occasionally recurred after a very long period. A tumor of this type, originating in the cervical fascia, has been seen by the writer recurring as a mass the size of a walnut twelve years after the first operation, the patient being free from symptoms during the greater part of the period. Such a phenomenon is difficult to explain, since only rarely does this type of sarcoma metastasize into the lymphnodes, and there form a focus for new growth. As this recurrence was in the centre of a large skin graft made at the first operation, it seems more probable that it was a recurrence in situ of very slowly growing cells situated in the deep fascia below the graft.
What happened in this case?
Was it what you would usually expect?
How does Knox explain it?
Other rare and late metastases which give no hint as to the mechanism of their localization and long course are cited by Schmidt and Goldmann, who observed a cerebral metastasis four years after a rectal carcinoma with no local or lymphatic return. Schmidt believes that such tumors are derived from latent intravascular cell groups in the pulmonary vessels. Another still more remarkable observation is that of Crouzon, who described a cerebral metastasis eighteen to twenty years after operation on a bilateral breast carcinoma. Gathmann and Schmidt have each observed cases in which four years after operation on similar tumors, with apparent cure, widespread skeletal metastases appeared. In such a case a general emboli distribution of cells by the blood into the capillaries of the myeloid canals must have occurred fairly early, and the growth processes have been very slow.
What happened in these cases?
Why are they so surprising?
How does Knox explain these events?
The frequency of skeletal metastases is so much greater than can possibly be demonstrated by clinical or röntgenological means until a very advanced stage that the high percentage of such growths is not often appreciated. Although the vascularity of the marrow is great, the stroma reaction may be here as marked as elsewhere and the metastasis of a scirrhous breast carcinoma be only a sclerotic nodule of the same appearance as the primary growth. When the bones are noticeably eroded or spontaneous fractures occur the process is far advanced and statistics drawn from such cases only give misleading data as to the frequency of the process.
"Röntgenological" is an old-fashioned word for "x-ray", because in 1895 the German physicist Wilhem Röntgen was the first person to discover x-rays in nature.
Is the skeleton particularly resistant to metastasis?
What does that translate to in clinical observations?
This view of the localization of metastases has not, however, been universally accepted, and many convenient hypotheses have had to give way to the increasing weight of pathological and experimental evidence. The theory of the specific adaptation of some tissues, as the liver, for neoplastic cells, and the relative immunity of others, as the brain, has been prevalent in the literature for many years. Virchow stated that organs in which carcinoma is never primary do not serve as a site for metastases. Recent observation has shown these conclusions to be wholly incorrect, as the brain is the site of secondary metastatic carcinomatous deposits in at least 0.3 per cent. of all autopsies (Krasting). Adherents to this theory point out, however, that some types of tumors have distinctly greater capacity to metastasize into certain organs than others, since not all tumor cells readily grow within the bones, but others very commonly do so, as those of the breast, thyroid, adrenal and ovary. Von Recklinghausen even advanced the idea that breast and prostatic carcinomata were apt to form metastases in similar regions because they were in a sense analogous organs, each being a part of the genital system. Bamberger and Paltauf believed that there was some specific organ susceptibility, and offer as evidence the fact that not only the small-cell carcinomata of the prostate metastasized to the bones, but the large-cell medullary carcinomata of the gland behaved in the same way.
Remember earlier, when she mentioned "occult and convenient theories of tissue predispositions and specific "immunity" of organs"?
What are some of those theories?
Rudolph Carl Virchow is called the "father of modern pathology", because of all the discoveries and knowledge contributions he made. Was he correct about metastasis sites? Why or why not?
When it comes to the concepts and terms of a big name, versus material physical referents, which do we believe, and why?
What is the other choice of belief called? Is it a logical fallacy?
The spleen also has been called "immune" to metastases by various writers because gross tumors in it are not especially frequent and microscopic ones often escape detection; but late stages of breast carcinoma are not infrequently accompanied by palpable enlargement of that organ due to a diffuse carcinomatosis, while E. E. Goldmann demonstrated that animal tumors inoculated into the spleen grow as readily there as elsewhere. While the vascularity of the organ exposes it to numerous emboli, yet as it possesses no efferent lymphatics and is in practically constant motion, embolic cells can not proliferate within it with as much facility as in some other organs. The great vascularity of the adrenals, as well as their protected position and absence of intrinsic motion, provides a suitable location for the secondary growths so often found in them. It is possible that the wide vascular sinuses of the pituitary, which resemble those in the adrenal, facilitate the location of metastatic tumors in this organ as well.
Again, this is an example of the "occult and convenient theories of tissue predispositions and specific "immunity" of organs" she referred to earlier.
Is the spleen immune to metastases? What does the evidence say?
How about the immunity or vulnerability of the adrenal glands and the pituitary? What might explain their situations?
External mechanical influences have for some years been recognized as an important factor in dealing with any malignant tumor. Gerster, in 1885, discussed the apparent breakdown of the forces which keep a malignant tumor for a time localized, and believed them to be largely mechanical. He pointed out the need, for example, of high amputation, not alone for the purpose of obtaining an uninfected field, but in order that the neoplasm itself should be free from manipulations, and so facilitate cellular dissemination. This writer further compared the results of malignant tumor massage to that which is sometimes effected by massaging a sprained joint--a process which certainly disseminates inflammatory exudate rapidly and widely. The effect of pressure, rubbing, or active massage on the tumor has been frequently observed in human beings as the result of osteopathic or massage treatment of malignant tumors, and many examples have been seen in recent years of wide dissemination of a primary growth very effectively accomplished by this procedure.
What were the two reasons Gerster advocated amputation in the case of cancer?
What is the analogy he drew with massage?
Does the evidence back up that analogy?
Such an instance has recently occurred at St. Luke's Hospital, and furnishes one of the rare instances in which extensive gross metastatic invasion of muscle could be observed. The patient stated that massage treatment had been regularly employed for some time previous to admission. When the breast tumor was examined there was found a fairly extensive area of eczema overlying a large very hard tumor which was fixed to the pectoralis fascia. Small white tumor nodules were scattered widely throughout the muscles, even invading the individual fibres. (See Fig. 1.)
What was unusual about this patient's case?
Does the evidence back up Knox's claim that massage accomplished this metastasis?
EXPERIMENTAL
While, therefore, much interesting and important information has thus been obtained by clinical, operative, and post-mortem studies, the number of cases is too small to enable final conclusions to be drawn.
Is this consistent with everything that Knox said earlier?
The determination of the weight of a factor in producing metastases can not be judged from single experiences on man, as it is impossible to eliminate conflicting conditions. Only by the use of a homogeneous material in which the size of the cells, their histological and biological qualities, and the vascularity of the surrounding tissue, etc., are practically constant can valid conclusions be drawn, and this elimination of variables is possible to obtain only by the use of animal tumors of a long transplanted strain, so that the morphological and biological characters are well known. The possibility of obtaining by inoculation in a single day more tumors than any one surgeon observes in a lifetime of active practice also eliminates the occurrence of errors due to random sampling affecting the result--a condition never possible in human material. For example, following the discussion produced by the publication from the Crocker Fund of a paper on the results of the incision of tumors, many surgeons brought forward individual instances which they thought were of value in proving the danger of diagnostic incision, not realizing that from a statistical aspect a single instance is of no value. Even from a basis of reasoning, so remote from the complexities of mathematics as what is ordinarily termed common sense, many of those who cited these single instances were unable to deny on cross examination that pre-operative manipulation by the patient, or that dragging or pressure on the tumor during the operation might have equally well caused the evident dispersal of tumor particles, as evinced by the subsequent course of events.
What is she saying here about individual observations? About confounds?
It was not until Tyzzer, in 1913, demonstrated that gentle massage of a transplanted carcinoma in a mouse greatly increased the number of metastases observed in the lung that definite evidence was brought forward to substantiate these occasional clinical observations. The number of Tyzzer's experiments was small, and he obtained results with only one tumor, a highly malignant neoplasm of the Japanese waltzing mouse. With the Ehrlich mouse tumor No. 11 and the Jensen rat sarcoma he was unable to obtain metastases artificially by massage of the implanted tumors. Rous states that his experiments in massaging rats with adenocarcinoma resulted in the death of all the animals, but did not cause more than the ordinary number of metastases.
What did Tyzzer's and Rous' studies demonstrate? Were they definitive?
Several recent clinical experiences of the writer in which after the removal of a very small primary tumor of the breast by perfect surgical technic (no involvement of the axillary nodes being present), the patient died of generalized carcinoma in a short period thereafter, pointed to the desirability of further extension of Tyzzer's experimental results. We will say, in passing, that in one of these human tumors which had been somewhat vigorously palpated by a number of physicians, a small hemorrhagic area was found in the middle of the growth, and in the vessels surrounding the tumor numerous emboli of cancer cells were present.
What is the clinical relevance of Tyzzer's and Rous' studies?
What did the physical evidence show in one case?
What does this table tell us?
A considerable variety of transplantable carcinomata or sarcomata of the mouse and rat were used for the experiment. Some of these tumors under normal conditions, especially the spindle-cell sarcomata, do not produce spontaneous metastases in the animals in any number. Others, especially the carcinomata, are apt to metastasize early.
What were they comparing in this experiment? What is the internal validity likely to be?
The following tumor strains were employed: Crocker Fund mouse carcinomata, Nos. 5, 11, and 48, the Borrel mouse carcinoma, the Ehrlich mouse carcinoma and the Flexner rat carcinoma; Crocker Fund mouse sarcomata Nos. 7 and 180, and the Ehrlich mouse sarcoma.
The method employed was as follows, with the exception of the two series described separately below: The animals were inoculated subcutaneously in the inguinal or axillary region with a tumor particle weighing about 0.003 gm. When the tumor reached a diameter of approximately 5 mm. it was gently massaged for half a minute every other day for about two weeks. The tumor was then removed by operation to prevent further metastasis, in order to obviate the difficulty of having to decide whether embolic masses in the vessels of the lung were really growing tumor particles, or only recently deposited emboli which might ultimately die without giving rise to a tumor nodule. In the final results only those masses are considered as true metastases in which the vessel wall was invaded, a separate column giving the number of instances in which emboli were found in the lumen of the pulmonary vessels.
What were they studying in this experiment? What did the method provide?
In one series, mouse carcinoma No. 11, the experiment was repeated, and the technic was varied as follows: The tumor was massaged vigorously for one minute on each of two consecutive days. After the second massage treatment all tumors, both controls and those which had been manipulated, were excised and the animals all killed twenty-seven days later. (No. 11, Series II.)
In order to check the results a third series of mice were inoculated two years after the first lot with the Crocker Fund mouse sarcoma No. 180. The mice were all of the same breed, and the conditions were kept as nearly as possible the same as in the preceding experiments. This time the mice were inoculated in the right axillary region, and as soon as the tumors were easily palpable the massage was begun on one-half of the mice, the others being reserved for controls. As before, the massage was carried out for thirty seconds on alternate days for about two weeks. The tumors were then very large, and many of the mice died at this time. In those surviving the tumors involved the thoracic wall too extensively to make removal feasible, so the aninmals were, therefore, allowed to die and then were autopsied. The results of this experiment are recorded as No. 180, Series II.
What does the variation in the method mean for the validity of the study?
In all the series the lungs were carefully removed, distended through the trachea with 4 per cent. formaldehyde, and hardened, and six sections from each animal were examined. Much difficulty was experienced in determining microscopically whether a mass of cells in a vessel should be considered as a true metastasis or merely an embolus. When emboli cease to be capable of forming a tumor we do not know. Careful morphological studies have been made by Takihashi and others to determine the early degenerative and proliferative changes which occur in emboli of tumor cells, but the two processes are frequently coincident, and, as many groups showed no evidence of either process even after being in the vessels many days, we cannot be too cautious in deciding whether a death point has been reached. Such emboli were found, for example, in specimens 9515, 6363, 6359, thirty-two, twenty-seven, and twenty-six days after removal of the primary tumor and no local recurrence at the site of inoculation had taken place from which such emboli could have been derived. Presumably such cells are dead; hence these groups have been called emboli, not metastases. In one sense, however, they are just as important as a growing lung tumor in showing that emboli of cancer cells can be set free in the blood stream by massaging a tumor, and any embolus in its early stage carries the potentiality of metastasis formation.
What is the meaning of the different kinds of things they found in the animal's lungs?
What do they tell us about massaging a tumor?
How meaningful is that for the kind of massage that we would do for someone living with cancer?
Only six sections of the lungs were studied, for it was found after a few complete sets of serial sections had been examined that the gain in number of emboli or small tumors discovered was unimportant.
This means that the distribution of emboli and small tumors was relatively uniform throughout the lungs they studied, and they were able to work with a smaller data set than they had originally thought they would need.
The tabulated records of the experiments are self-explanatory and need no further elucidation.
No, I disagree. Remember, a lot of the statistical tests that we presently use to interpret studies were being developed at about the same time as Knox wrote this article.
While I don't fault her for not using something that she didn't have access to in her time, it remains true that without those tools to interpret her results with, we necessarily have to consider them weaker than we would similar results that had stood up to robust statistical testing.
The point of these tests is to make sure that we are, in reality, seeing what we think we see. Without the assurance provided by those tests, such as tests of statistical significance, confidence level, and the like, we just cannot consider these results as explanatory and self-evident as she considers them.
DISCUSSION
Examination of the chart (Fig. 2) shows that, in general, with nine tumor strains, there was a more or less distinct increase after massage in the number of embolic particles in the lungs, the increase varying from 1 to 37 per cent.
FIG. 2.-Chart showing percentage of emboli (hatched areas) and of metastases (solid areas), and their relative numbers in controls and massaged animals. In each case the column at the right represents the massaged animals, that at the left, the controls.
Tell me, what does this bar mean?
What does this one mean?
What does this one mean?
What does this one mean?
What does this one mean?
Can you find any cases where the control animals had more emboli or metastases than the study animals did? How does Knox explain these unexpected results?
The actual percentages can be considered of little importance, and it is even surprising to find that the tendency is so general. With the carcinomata the results are in many cases unequivocal; for example, the Ehrlich carcinoma, at the time showing no regression and 75 per cent. of takes, in other words, in its positive phase, formed more than twice as many metastases after massage as without it. A similar condition obtained with the Borrel carcinoma, at that time spontaneously regressing in 50 per cent. of inoculations, but still showing numerous metastases after massage. The ratio is probably artificially high as the number of control animals which survived was very small.
"The actual percentages can be considered of little importance"? Well, no; they are vitally important to the question we are trying to answer.
You can see here a cultural shift in how science used to be interpreted from how it now is.
The emboli are found in both lymph-and blood-vessels, frequently in both locations in the same lung. The perivascular space can frequently be seen filled with cells from which the parenchyma is invaded, but the primary process is evidently in the vessels, as it is seen in all stages within them. The lymphatic system of the mouse being developed to a much less extent than in man, it may also be expected to show relatively less tumor involvement. One reason for this may very probably be, as is pointed out by Murray, that the lymphatics are so delicate and quickly obscured by an inflammatory reaction that metastatic particles apparently freely growing in the tissues may have originated from an embolus either in a lymph-vessel or the nodal capsule. In these studies, however, there is seldom room for doubt that the emboli are vascular in the great majority of cases. Multiple emboli nearly filling both large and small vessels of a lobe are occasionally found, in the controls as well as in the massaged animals, but cell groups are much more frequent in the treated ones.
The illustration (Fig. 3) is from a massaged animal which died twenty-four days after inoculation. Both proliferation and degeneration are seen, and most of the stages described by Takahashi may be found in some area.
FIG. 3.-Multiple emboli of tumor cells in pulmonary vessels of a massaged mouse tumor.
Which things in this slide are the vessels? Which are the emboli?
How can you tell the difference?
Fig. 4 (No. 18363) and Fig. 5. (No. 18319) each show a small embolus which is certainly undergoing dissolution, as the surrounding lung is well preserved, but the tumor cells stain poorly. The outlines of cell walls and the nuclear membrane are indistinct, and the cytoplasm granular.
FIG. 4.-Degenerative changes in cells of a tumor embolus in pulmonary vessels.
Can you see the embolus clearly?
What is different about the pulmonary vessel the tumor embolus is in, compared to the other blood vessels in this slide?
FIG. 5.-Embolus of tumor cells in pulmonary vessel. Embolic cells are undergoing early degenerative changes. The lung tissue is well preserved.
What is the meaning of her explanation here?
On the other hand, occasionally even small emboli may be seen in which the actively invasive tendency of the tumor cells is plainly demonstrated.
Fig. 6 (No. 18322) shows a small embolus which has apparently lifted up the endothelium from the vessel wall and so given itself a fibrous surface upon which to obtain a footing.
FIG. 6.--Endothelium of vessel containing embolic tumor cells stripped from wall. Early stage of attempt to localize.
Tell me, what do you see here?
What do you see here?
What looks to you like an "attempt to localize"?
Another phase of apparently successful implantation is shown in Fig. 7 (No. 18343), where a number of well preserved tumor cells are growing in direct continuity with the endothelium.
FIG. 7.--Later stage in implantation of embolic tumor cells. A few have replaced the endothelium.
What do you see here? Where do you think the emboli have replaced the endothelium?
Figs. 8 and 9 show two small pulmonary emboli from a case of carcinoma of the stomach in a human being. In Fig. 8 there is no adhesion of the embolus to the endothelium, although nearly a third of the mass is made up of mucus produced by the epithelial cells;
FIG. 8.--Small embolus from case of carcinoma of stomach in man, showing invasion of pulmonary vessels. Nuclei surround a central mass of mucus.
Where do you see the vessel here? The nuclei? The mucus?
in Fig. 9 one cell only appears to have invaded the endothelium.
FIG. 9.--Beginning adhesion of tumor cells to endothelium in pulmonary capillary from case of carcinoma of stomach in man.
What structures and processes do you see here?
Another lung furnishes a picture of a more advanced stage of invasion, Fig. 10 (No. 18384). The endothelium can no longer be distinguished, as practically the whole circumference of the muscularis is lined with the tumor cells, and the lumen is almost filled with a carcinomatous embolus in which early degenerative or thrombotic changes have occurred [sic]. Similiar parietal thrombi were examined by Schiedat throughout their length and were found to extend for some distance along the surface of the wall and eventually to break through it.
FIG. 10.-Embolic tumor cells replacing endothelium of pulmonary vessel.
What do you see happening here?
The same process is illustrated in Fig. 11(a) where a large vascular sinus is shown containing many embolic cells from a bone sarcoma in man. The nuclei already show pycnosis, swelling, agglutination by fibrin, and are being surrounded by polymorphonuclear and lymphocytic cells. In (b) is another large blood-vessel from the same tumor with a giant cell among the red blood-cells. This, although of the "endothelial" type and not itself likely to invade other tissues, is of interest in showing that all types of cells may gain access to the blood stream.
FIG. 11.--(a) Embolus from bone sarcoma in man. Cells are of several types and illustrate early degenerative changes and phagocytosis. (b) Giant cell in blood-vessel in bone sarcoma.
That most of the small vascular emboli are derived from larger ones in the main vessel, and not from primary lymphatic involvement, is seen from such an extensive embolus as appears in Fig. 12 (No. 18343), a fairly frequent picture. A very large mass is found in one of the main pulmonary veins and many of its cells are degenerating, the nuclei are pycnotic, and some of the cells have been phagocyted.
FIG. 12--Larger tumor embolus in pulmonary artery.
Figure 13 shows a smaller group of cells surrounded by a thrombotic mass containing many polymorphonuclears, as would be expected in such a situation.
FIG. 13.-Polymorphonuclear cells surrounding a few embolic tumor cells; probably an early stage of thrombus formation.
It may only occasionally be seen that the cells break into the lymphatics and there grow freely, but it is shown in Fig. 14(No. 18307).
FIG. 14--Large embolus of tumor cells in perivascular lymph space; probably an extension from a vascular thrombus.
Not infrequently, as in tissues from human beings with tumors, multiple emboli are found in the vessels which may be densely crowded with cells, most of them small, and though hyperchromatic only with difficulty to be distinguished from lymphocytes--in fact, to make a differential diagnosis is very hazardous in spite of the absence of inflammation elsewhere in the section (Fig. 15).
FIG. 15.--Multiple emboli of small cells in pulmonary vessels, possibly tumor cells, but resembling lymphocytes.
Inspection of Table III shows that among the controls metastases and emboli were coincident only four times in twenty-one animals, or in 19 per cent., while among the massaged this occurred nine times in twenty-five animals, or in 36 per cent. of the cases. The average duration of life was the same in each case. There seems little doubt but that the massage has effected a wider distribution of the tumor even though it is impossible to decide in all the cases just what the ultimate fate of the scattered cells may be, whether they will die or succeed in establishing themselves in the vessel wall.
TABLE III
Crocker Fund No. 180
Total number metastases in controls = 23
Total number emboli in controls = 24
Total number metastases in massaged = 41
Total number emboli in massaged = 38
On the whole, the polyhedral-cell sarcomata (Crocker Fund No. 180 and Ehrlich mouse sarcoma) seemed just as apt to produce metastases as the carcinomata. In the spindle-cell tumors, metastases are apt to be scanty. This may be explained upon mechanical grounds, from the fact that the cells of most fibro-or spindle-cell sarcomata are more definitely intermingled with and attached to the surrounding connective tissue than in the case of the free-lying cells of the carcinomata. This sustains the view that anatomical relationships of the cells are important in determining metastases.
It would be incorrect, however, to assume that the mechanical factor is of so great importance in determining the ultimate production of a growing tumor as distinct from an embolus as the biological characteristics of the tumor itself. Examination of the chart shows that the correlation between the percentages of total metastases in controls and massaged animals is negative, that is, that those tumors which metastasize spontaneously in a high percentage do not show as great an increase after massage as do those in which spontaneous metastasis is low. For example, the Crocker Fund carcinoma No. 5 shows a smaller increase in its percentage of metastases than does the Flexner rat carcinoma. The same is true of the Ehrlich sarcoma, a strain in which Haaland also found a high percentage of spontaneous metastases; in fact, this writer reports approximately the same percentage of metastases in the twenty-three mice which he observed (60 per cent.) as were seen in the twenty-six animals used in this experiment (58 per cent.).
What is she claiming in her discussion here?
In these freely metastasizing highly vascular tumors the organism is evidently flooded with emboli before manipulation, and hence many tumor cells may be found in the pulmonary capillaries at all times. Less difference, therefore, can be detected following the massage.
What is the effect of massage in these cases, and why?
There can be no question under these circumstances that concomitant immunity has any influence on the prevention of appearance or growth of the metastases.
Is it clear what she means here?
CONCLUSIONS
1. Study of human material in many ways suggests, but does not finally prove, the importance of massage as a means of inducing metastasis of tumor cells. In animals, on the contrary, very gentle massage for a total period of from two to five minutes, distributed over a number of days, has been shown to set free numerous particles of tumor which form emboli in the lungs.
Is this the correct approach to take in studying the question?
Does the study show what she states that it shows?
2. Such emboli produce metastatic tumors in a variable proportion of instances, depending upon the growth activities of the tumor. Tumors which take in low percentages when implanted in the subcutaneous connective tissues give much fewer metastases than those of high virulence.
Is this consistent with what you would expect to see?
3. Carcinomata and also sarcomata of the loose polyhedral-cell type are easily generalized, but sarcomata of the compact spindle-cell variety are not influenced.
How do we know this from the information in her article?
4. The importance of avoiding diagnostic or operative manipulation of a tumor in man is obvious.
I agree it's a good idea in general. Does the evidence show that it's as obvious as Knox says it is?
No, it cannot. Massage of a solid tumor site should be avoided, but there is more to a person than a tumor site.
An old myth warned that massage could, by raising general circulation, promote metastasis since tumor cells travel through blood and lymph channels. We now recognize that movement and exercise raise circulation much more than a brief massage can, and that routine increases in circulation occur many times daily in response to metabolic demands of our tissues. In fact, physical activity usually is encouraged in people with cancer; there is no reason to discourage massage or some form of skilled touch. Massage is practiced widely at the Dana-Farber Cancer Institute, Memorial Sloan-Kettering, and growing numbers of hospitals around the country. Metastasis is not a concern; instead, patients and researchers report countless benefits.
BIBLIOGRAPHY
Bamberger and Paltauf: Wein klin. Wchnschr., 1899, vol. xii, p. 1100.
Benecke: Beitr. z. path. Anat. u. z. allg Path., 1890, vol. vii, p. 95.
Carmalt: Virchow's Arch. f. path. Anat., 1872, vol. lv, p. 481.
Crouzon: Bull. et mém. Soc. méd. d. hôp. de Par., 1920, vol. xlvi, p. 500.
Ernst: Beitr. z. Path. Anat., 1905, Supp., vol. vii, p. 29.
Ewing: Neoplastic Diseases, Philadelphia, 1920.
Gathmann: Ein Fall von allgeimeinen Karzinome des Knochensystems, Leipzig, 1902.
Gerster: New York M. J., 1885, vol. xli, p. 233.
Goldmann: Bruns Beitr. z. klin. Chir, 1897, vol. xviii, p 595.
Goldmann: Bruns Beitr. z. klin. Chir., 1911, vol. cxxii, p. 1.
Haaland: Berl. klin. Wchnschr., 1906, vol. xxxiv, p. 1126.
Handley: Arch. Radiol. and Electroth., 1919, vol. xxiv, p. 137.
Handley: Cancer of the Breast and Its Operative Treatment. London, 1906.
Handley: Lancet, 1907, vol. i, p. 927.
Iwasaki: J. Path. and Bacteriol., 1915-16, vol. xx, p. 85.
Jones and Rous: J. Exper. M., 1914, vol xx, p. 404.
Krasting: Ztschr. f. Krebsforsch., 1906, vol. iv, p. 315.
Lambert and Haynes: J. A. M. A., 1911, vol. vi, p. 791.
Murray: Seventh Scientific Report, Imperial Cancer Research Fund, London, 1921, p. 63.
Poirier et Charpy: Traite D'Anatomie Humaine, Paris, 1909, Tome II.
Rohdenburg: Proc. New York Path. Soc., 1920, n. s., vol. xx, p. 141.
Rous: J. A. M. A., 1913, vol. lx, p. 2021.
Sabin: The Harvey Lectures, 1915-16, Series xi, p. 124.
Schiedat: Ueber den Untergang maligner Geschwulstmetastasen in der Lung, Leber, und Lymphdrusen, Inaug.-Diss., Königsberg, 1908.
Schmidt: Die Verbreitungswege der Karzinome und die Beziehung generalisirter Sarkome zu den leukämischen Neubildungen, Jena, 1903.
Takahashi: J. Path. and Bacteriol., 1915-16, vol. xx, p. 1.
Tyzzer: J. M. Res., 1913, vol. xxiii, p. 309.
Van Raamsdonk: Nederlandsch Tijdschrift v. Geneeskunde, 1921, vol. i, p. 3355.
Virchow: Die Krankhaften Geschwulste, Band 2. Berlin, 1864-5.
Vogel: Virchow's Arch. f. path. Anat., 1891, vol. cxxv, p. 495.
Von Recklinghausen: Virchow's Arch. f. path. Anat., 1885, vol. c, p. 503.
Wood: J. A. M. A., 1919, vol. lxxiii, p. 764.
Zahn: Virchow's Arch. f. path. Anat., 1899, vol. cxvii, p. 30.
What have we learned from this discussion?
At the beginning of this post, I asked you the following questions:
Where did the idea that massage promotes metastasis, and therefore, we shouldn't offer massage to patients living with cancer, come from?
What is the current best practices recommendation for massaging someone with a history of cancer, and on what basis is that best practices recommendation formed?
Why is the idea that we shouldn't massage someone with a history of cancer, because it might promote metastasis, so persistent in the face of what we actually know?
Have your answers to them changed over the course of this discussion? If they have changed, then in what way have they done so?
What else did you learn during this discussion? Can you explain it to someone else now?
How relevant is this discussion to what we practice as MTs?
From Latin embolus (“piston”), from Ancient Greek ἔμβολος (embolos, “peg, stopper”).
embolus (plural emboli)
(pathology) An obstruction causing an embolism: a blood clot, air bubble or other matter carried by the blood stream and causing a blockage or occlusion of a blood vessel.
endothelium
Wiktionary "endothelium", accessed 27 December 2012
endothelium (plural endothelia)
(anatomy) A thin layer of flat epithelial cells that lines the heart, serous cavities, lymph vessels, and blood vessels.
In medicine, a fistula (/ˈfɪstjʊlə/;[1][2] pl. fistulas (/ˈfɪstjʊləz/), or fistulae (/ˈfɪstjʊli/ or /ˈfɪstjʊlaɪ/)) is an abnormal[3] connection or passageway between two epithelium-lined organs or vessels that normally do not connect.
A highly malignant epithelial tumour with a fulminant [quick, intense, and severe] clinical course, bizarre histologic appearance and poor prognosis [predicted outcome]; it is most common in the lung and thyroid, but is well-described in the endometrium, breast and elsewhere.
From Ancient Greek ὑπέρ (huper, “over”) + αἷμα (haima, “blood”).
hyperemia
excess of blood in a body part.
lymphocyte
Wiktionary "lymphocyte", accessed 29 December 2012
A lymphocyte is a type of white blood cell in the vertebrate immune system.
Under the microscope, lymphocytes can be divided into large lymphocytes and small lymphocytes. Large granular lymphocytes include natural killer cells (NK cells). Small lymphocytes consist of T cells and B cells.
A Krukenberg tumor refers to a malignancy in the ovary that metastasized from a primary site, classically the gastrointestinal tract, although it can arise in other tissues such as the breast. Gastric adenocarcinoma, especially at the pylorus, is the most common source. Krukenberg tumors are often (over 80%) found in both ovaries, consistent with its metastatic nature...
Pathogenesis
There has been debate over the exact mechanism of metastasis of the tumor cells from the stomach, appendix or colon to the ovaries. Classically it was thought that direct seeding across the abdominal cavity accounted for the spread of this tumor, but spread by way of the lymphatic is considered more likely.
Latin, from Ancient Greek μέλας (melas, “black, dark”) and -oma (“disease, morbidity”).
melanoma (plural melanomas or melanomata)
(oncology, pathology) A dark-pigmented, usually malignant tumor arising from a melanocyte and occurring most commonly in the skin.
metastasis
Wiktionary "metastasis", accessed 27 December 2012
From Late Latin, from Ancient Greek μετάστασις (metastasis, “removal, change”), from μεθίστημι (methistemi, “to remove, to change”)
Pronunciation
metastasis (plural metastases)
(medicine) The transference of a bodily function or disease to another part of the body, specifically the development of a secondary area of disease remote from the original site, as with some cancers.
obliteration
Wiktionary "obliteration", accessed 27 December 2012
Latin permeātus, participle of permeāre, meaning to pass through.
permeate (third-person singular simple present permeates, present participle permeating, simple past and past participle permeated)
To pass through the pores or interstices of; to penetrate and pass through without causing rupture or displacement; -- applied especially to fluids which pass through substances of loose texture; as, water permeates sand.
To enter and spread through; to pervade.
phagocytosis
Wikipedia "phagocytosis", accessed 29 December 2012
Phagocytosis (from Ancient Greek φαγεῖν (phagein) , meaning "to devour", κύτος, (kytos) , meaning "cell", and -osis, meaning "process") is the cellular process of engulfing solid particles by the cell membrane to form an internal phagosome by phagocytes and protists...Bacteria, dead tissue cells, and small mineral particles are all examples of objects that may be phagocytosed.
Wiktionary "phagocytosis", accessed 27 December 2012
From the German Phagocytosis; equivalent to phagocyte + -osis; compare the French phagocytose.
phagocytosis (countable and uncountable; plural phagocytoses)
(immunology, cytology) The process where a cell incorporates a particle by extending pseudopodia and drawing the particle into a vacuole of its cytoplasm.
Pyknosis (from Greek pyknono meaning "to thicken up, to close or to condense"), or karyopyknosis, is the irreversible condensation of chromatin in the nucleus of a cell undergoing necrosis[1] or apoptosis.[2] It is followed by karyorrhexis, or fragmentation of the nucleus.
polymorphonuclear cells
Wikipedia "Granulocyte", accessed 29 December 2012
Granulocytes are a category of white blood cells characterized by the presence of granules in their cytoplasm. They are also called polymorphonuclear leukocytes (PMN or PML) because of the varying shapes of the nucleus, which is usually lobed into three segments. In common parlance, the term polymorphonuclear leukocyte often refers specifically to neutrophil granulocytes, the most abundant of the granulocytes. Granulocytes or PMN are released from the bone marrow by the regulatory complement proteins.
Wiktionary "retrograde", accessed 27 December 2012
From Middle English < Latin retrogradus.
retrograde (comparative more retrograde, superlative most retrograde)
Directed backwards, retreating; reverting especially inferior state, declining; inverse, reverse; movement opposite to normal or intended motion, often circular motion.
serous (comparative more serous, superlative most serous)
(medicine) Containing, secreting, or resembling serum; watery; a fluid or discharge that is pale yellow and transparent, usually representing something of a benign nature. (This contrasts with the term sanguine, which means blood-tinged and usually harmful.)
Spindle cell sarcoma is a type of connective tissue cancer in which the cells are spindle-shaped when examined under a microscope. The tumors generally begin in layers of connective tissue such as that under the skin, between muscles, and surrounding organs, and will generally start as a small lump with inflammation that grows...Spindle cell sarcoma can develop for a variety of reasons, including genetic predisposition but it also may be caused by a combination of other factors including injury and inflammation in patients that are already thought to be predisposed to such tumors. Spindle cells are a naturally occurring part of the body's response to injury. In response to an injury, infection, or other immune response the connective tissues will begin dividing to heal the affected area, and if the tissue is predisposed to spindle cell cancer the high cellular turnover may result in a few becoming cancerous and forming a tumor.
(anatomy) Of, pertaining to, or containing vessels that conduct or circulate fluids, such as blood, lymph, or sap, through the body of an animal or plant.
Minimum scientific knowledge needed for this discussion
What anatomical system (or systems, depending on how you count them) do we and other complex animals (like dogs, cats, bears, elephants, and tigers) use for movement?
Easy question straight out of Anatomy 101, right? But did you ever think about how organisms or organism parts that don't have muscles and bones are still able to solve the challenge of moving from one place to another?
The Free Dictionary "ameboid movement", accessed 27 December 2012
movement like that of an ameba, accomplished by protrusion of cytoplasm of the cell.
Amoeboid movement is a crawling-like type of movement accomplished by protrusion of cytoplasm of the cell involving the formation of pseudopodia. The cytoplasm slides and forms a pseudopodium in front to move the cell forward. This type of movement has been linked to changes in action potential; the exact mechanism is still unknown. This type of movement is observed in amoeboids, slime molds and some protozoans, as well as some cells in humans such as leukocytes. Sarcomas, or cancers arising from connective tissue cells, are particularly adept at amoeboid movement, thus leading to their high rate of metastasis.
While several hypotheses have been proposed to explain the mechanism of amoeboid movement, the exact mechanism is still unknown.
What it comes down to, then, is that sarcomas and other cells use a method of movement very similar to the amoeba (or ameba: a one-celled animal-like microscopic organism) you see in this video:
As the definitions mentioned, in the video, you saw the cytoplasm slide to stick out (protrude) in the direction the amoeba moved.
Like the amoebas, individual cells in multi-cellular organisms (like us) can also move in a very similar way. Watch how nimbly responsive the human neutrophils (white blood cells) in this video are to the presence of a chemical attractant (this response is called chemotaxis):
As the Wikipedia definition mentioned, the ability of sarcomas to move in this way--although not yet fully explained--is thought to be a factor in their ability to metastasize aggressively.
The esophagus (oesophagus, commonly known as the gullet) is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach. The word esophagus is derived from the Latin œsophagus, which derives from the Greek word oisophagos, lit. "entrance for eating."...
Histology
The layers of the oesophagus are as follows:
mucosa
nonkeratinized stratified squamous epithelium: is rapidly turned over, and serves a protective effect due to the high volume transit of food, saliva and mucus.
lamina propria: sparse.
muscularis mucosae: smooth muscle
submucosa: Contains the mucous secreting glands (esophageal glands), and connective structures termed papillae.
muscularis externa (or "muscularis propria"): composition varies in different parts of the esophagus, to correspond with the conscious control over swallowing in the upper portions and the autonomic control in the lower portions:
From German Mitosis, from Ancient Greek μίτος (mitos, “thread”) + -osis, probably in reference to the thread-like chromatin seen during mitosis.
mitosis (plural mitoses)
(cytology) The division of a cell nucleus in which the genome is copied and separated into two identical halves. It is normally followed by cell division.
Occam's razor
Wikipedia "Occam's razor", accessed 29 December 2012
Occam's razor (also written as Ockham's razor, Latin lex parsimoniae) is the law of parsimony, economy, or succinctness. It is a principle stating that among competing hypotheses, the one that makes the fewest assumptions should be selected.
In animal tissue, stroma (from Greek στρῶμα, meaning “layer, bed, bed covering”) refers to the connective, supportive framework of a biological cell, tissue, or organ.
The stroma in animal tissue is contrasted with the parenchyma...Stromal cells are the non-tumor cells in tumors.
Parenchyma is the bulk of a substance. In animals, a parenchyma comprises the functional parts of an organ and in plants parenchyma is the ground tissue of nonwoody structures.
The term parenchyma is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour".[1]
The parenchyma are the functional parts of an organ in the body. This is in contrast to the stroma, which refers to the structural tissue of organs, namely, the connective tissues.
In cancer, the parenchyma refers to the actual mutant cells of the single lineage, whereas the stroma is the surrounding connective tissue and associated cells that support it.
Early in development the mammalian embryo has three distinct layers: ectoderm (external layer), endoderm (internal layer) and in between those two layers the middle layer or mesoderm. The parenchyma of most organs is of ectodermal (brain, skin) or endodermal origin (lungs, gastrointestinal tract, liver, pancreas). The parenchyma of a few organs (spleen, kidneys, heart) is of mesodermal origin. The stroma of all organs is of mesodermal origin.
The peritoneum (pron.: /ˌpɛrɨtənˈiəm/) is the serous membrane that forms the lining of the abdominal cavity or the coelom—it covers most of the intra-abdominal (or coelomic) organs—in amniotes and some invertebrates (annelids, for instance). It is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum both supports the abdominal organs and serves as a conduit for their blood and lymph vessels and nerves.
The abdominal cavity (the space bounded by the vertebrae, abdominal muscles, diaphragm and pelvic floor) should not be confused with the intraperitoneal space (located within the abdominal cavity, but wrapped in peritoneum). The structures within the intraperitoneal space are called "intraperitoneal" (e.g. the stomach), the structures in the abdominal cavity that are located behind the intraperitoneal space are called "retroperitoneal" (e.g. the kidneys), and those structures below the intraperitoneal space are called "subperitoneal" or "infraperitoneal" (e.g. the bladder).
Diane Jacobs, talking about dermoneuromodulation (DNM)--a practice that she has developed, and that we'll talk more about here later--answered that intellectual property question first, and better than I could have come up with off the top of my head.
When asked:
What's a good name for working top down and bottom up?
she answered:
Dermoneuromodulation.
It covers the manual territory from skin cell to self of self and leaves out the mesoderm entirely. It is not a copyright term.
Anyone can use it, to describe what they do, manually, if they want. This made-up word is not copyright. I give it away. Please take it. Use it to get away from words like "fascia" and "muscles" and "joints" and "bones" and "ligaments" and "tendons".
In the same way as Diane practices with regard to her development of DNM, I don't claim any restrictions on anyone's access to use of the term through copyright or ownership over the term "biopsychsocial massage (BPSM)".
I give it away to the community to use freely, in the same spirit of open access and Creative Commons licensing that POEM is founded on.
There is only one condition of usage--you cannot apply the term to something it is not, any more than someone can make a dog into a cat, just by calling it one.
In a similar way, you can't make non-BPSM practices into BPSM simply by slapping that label on them.
Diane explains that, although she gives the term away freely, that
It should contain only nervous system considerations though, because really, when push comes to shove, only the nervous system can respond (short term, OR, and ESPECIALLY, long term) to what we "do" to another person, manually. Of that I'm convinced.
Similarly, if you're not practicing biopsychosocial massage, the term does not apply to what you actually are doing.
You have every right under principles of freedom of conscience to reject classical Newtonian physics, for example, and to say that it does not apply to the work that you are doing. But that claim is inconsistent with the principles of BPSM, and so that inconsistency means, beyond the shadow of a doubt, that your practice is not a biopsychosocial massage practice. Which is fine in itself; you are entitled to practice any way you want to, subject to professional ethics and to regulations in your jurisdiction. All it really means is that you don't get to label it something that it is not--no more, no less.
There is a Cambodian saying that men are like diamonds and women are like silk--if you drop them in the mud, you can wash the diamond and it's as clean as it ever was, but the silk is stained forever.
«បុរសជាមាសទឹកដប់ ទោះធ្លាក់ចូលភក់ ហើយលើកមកវិញ ក៏នៅតែជាមាសទឹកដប់ដដែល តែនារីវិញ ប្រៀបបាននឹងកំណាត់សំពត់ស បើកាលណាធ្លាក់ចូលភក់ជ្រាំហើយ ទោះខំប្រឹងបោកគក់លាងសម្អាតយ៉ាងណា ក៏មិនដូចដើមដែរ» (courtesy of Frank Smith)
Let's put aside for the moment the blatant sexism in that proverb ("dropping them in the mud" is a metaphor for their being sexually active, and this is the classic embodiment of the double standard against women in so many traditional societies), and see if there is any useful imagery there for us to communicate a distinction in a totally different domain, without being insulting to more than half of the population.
The term "biopsychosocial massage" refers to massage practiced in an evidence-based, science-based, client-centered way, that understands health, wellness, and disease in terms of natural (not supernatural) processes in the material physical universe among biological, psychological, and sociocultural aspects of life, as well as their interactions and the emergent effects that arise from them.
Anyone who practices massage in this way is practicing BPSM.
If that term is consistently applied to only those practices, then it is a clean and brilliant diamond that clients and other massage stakeholders can use as a baseline to understand exactly what BPSM has to offer.
If the term is (figuratively) dropped in the mud by applying it to anything and everything, no matter whether or not it is consistent with the principles of BPSM, then--like the silk--it is stained forever, and it becomes useless for clients and other massage stakeholders to use as a guide to understand what BPSM has to offer.
So I give the terms "biopsychosocial massage" and "BPSM" to the community to use freely, on the one condition that they not be diluted by applying them as mere buzzwords to massage or other practices that are not massage practiced in an evidence-based, science-based, client-centered way, that understands health, wellness, and disease in terms of natural (not supernatural) processes in the material physical universe among biological, psychological, and sociocultural aspects of life, as well as their interactions and the emergent effects that arise from them.
(Not yet clear on what that means in actual practice? That's ok; there's a great deal of rich material there to explore in depth. We're going to spend some quality time connecting the dots, and translating them into what they mean for actual practice. I just want to get that general principle out there; now that it is, we can do some real work on establishing what it means in practice.)
So the answer to the question in the post title, "Who owns BPSM?" is: It is entrusted to the responsible and sustainable stewardship of the massage community.
cheers, to Diane Jacobs!
UPDATE, 18 November 2012, 10:57 AM PT:
Gayla Coughlin points out that some of my statements above, as written, are unclear in what they mean for actual practice, and might result in outcomes that I don't want.
I thank her for giving me the opportunity to correct my inaccuracies, and to get closer to my intended outcome.
I am thus taking out a Creative Commons license on biopsychosocial massage (BPSM), and here are the conditions attached to that license.
The particular form of the Creative Commons license that most suits my intent for this work is Attribution-ShareAlike CC BY-SA.
Their blurb explains:
This license lets others remix, tweak, and build upon your work even for commercial purposes, as long as they credit you and license their new creations under the identical terms. This license is often compared to “copyleft” free and open source software licenses. All new works based on yours will carry the same license, so any derivatives will also allow commercial use. This is the license used by Wikipedia, and is recommended for materials that would benefit from incorporating content from Wikipedia and similarly licensed projects.
What this means is that you can build on, develop, and grow biopsychosocial massage, but only on the condition that you share your work with the community in the same way ("license their new creations under the identical terms")--you cannot take the work that I and others have done on biopsychosocial massage, and trademark or copyright it for yourself. This license thus protects biopsychosocial massage for use by the entire community, rather than having someone seize it away from us in a proprietary way.
to Share — to copy, distribute and transmit the work
to Remix — to adapt the work
to make commercial use of the work
This means it is approved for Free Cultural Works
Under the following conditions:
Attribution — You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work).
Share Alike — If you alter, transform, or build upon this work, you may distribute the resulting work only under the same or similar license to this one.
With the understanding that:
Waiver — Any of the above conditions can be waived if you get permission from the copyright holder.
Public Domain — Where the work or any of its elements is in the public domain under applicable law, that status is in no way affected by the license.
Other Rights — In no way are any of the following rights affected by the license:
Your fair dealing or fair use rights, or other applicable copyright exceptions and limitations;
Rights other persons may have either in the work itself or in how the work is used, such as publicity or privacy rights.
Notice — For any reuse or distribution, you must make clear to others the license terms of this work. The best way to do this is with a link to this web page.
If my statements above sounded like I objected to commercial use on anyone's part, then that was due to my inaccuracy--I have no objection to anyone earning a living by teaching classes, writing books, or anything like that, as long as you honor the moral rights that attach to my Creative Commons licensing of biopsychosocial massage. And by "mere buzzwords", I was not objecting to using the term to market your works based on biopsychosocial massage. I specifically meant slapping the label on practices where it does not apply, in order to market something that is incompatible at its core with biopsychosocial massage.
By "moral rights", I specifically mean that I do not want anyone to use the label "biopsychosocial massage" to endorse practices that are anti-scientific or pseudoscientific, or that are not client-centered. Those violate the spirit of biopsychosocial massage, and are an infringement of my moral right to delineate a set of massage practices and theory that are consistent and compatible with modern science and with evidence in the material physical world.
If you respect that moral right, then you are free to build on and develop biopsychosocial massage for non-commercial or commercial uses, but you cannot take it away from the community by trademarking or copyrighting it for yourself.
So I believe that the conditions of this license protect my intent to release it to the responsible and sustainable stewardship of the community, at the same time that it protects the content from being distorted by misuse of the label to apply to something that contradicts the heart of biopsychosocial massage.
There is grandeur in this view of life, with its several powers, having been originally breathed into a few forms or into one; and that, whilst this planet has gone cycling on according to the fixed law of gravity, from so simple a beginning endless forms most beautiful and most wonderful have been, and are being, evolved.
Their many letters to each other over the years (preserved online in the Darwin Correspondence Project) stand as a testament to how much they thought, cared, and worried about each other.
The state of mind that I wish to preserve with respect to you, is to feel that while you are acting conscientiously & sincerely wishing, & trying to learn the truth, you cannot be wrong; but there are some reasons that force themselves upon me & prevent my being always able to give myself this comfort.
--Darwin Correspondence Project, Darwin, Emma to Darwin, Charles [c. Feb 1839] accessed 17 November 2012
She wants to feel secure that, if she (or he, or anyone) is really trying diligently and sincerely to learn what is true, that that effort guarantees that she cannot possibly be mistaken about what she is learning. The reason she is so concerned about this is that she was devoutly religious, and she knew that Charles had doubts about religion.
To be impossible to be wrong, through sheer effort and sincerity, is a lovely wish--and yet, in the same sentence, she admits to her beloved husband that even she herself cannot always keep up that belief.
She was right to be concerned about that issue--the history of science at that time in England contains many examples of geologists, paleontologists, biologists, and other scientists who set out on a journey to find evidence in the materialphysicalnatural world that proved the stories in the Bible to be literally true.
For example, if the story of Noah's Ark and the Flood were literally true, you would find evidence of it in the layers of rock in that part of the world. The scientists who set out to find it discovered that that evidence is not there, but other evidence, showing that other things happened, is indeed there.
The scientists who set out to demonstrate that the earth is literally only a bit more than 6000 years old demonstrated instead that they would have to reject all the other multiple sources of repeatable, verifiable evidence that showed the earth to be much older than that.
Darwin himself demonstrated that--rather than the Genesis creation story that species were created one time in their present and unchanging form--species actually change over time to better adapt to the environments they find themselves in.
When the evidence these scientists found contradicted what they wanted it to say about the literal truth of the Bible, they faced a test of their own moral character in deciding what to do next about that fact:
Some of the most solid scientific knowledge that we rely on every day came from people who had the courage to face the implications for their beliefs that the evidence presented them, and the integrity to not turn away from or deny the contradictions, but rather to engage with them.
To take a more contemporary example of that same spirit, this quotation from Julie Onofrio is, for me, the essence of the courageous engagement that we so urgently need to participate in if we really want to become a profession:
Having an open forum and getting some help in analyzing research is really needed in our profession. Yes, I have to say it disturbs me when the researchers say things like traditional modalities don't work--it's like a slap in the face to all who are doing energy work, or reiki, or Rolfing, and having results and success. It's very hard not to take it personally, but also to set emotions aside and remain in communication. But that is why I support it. I want to learn more and to support the profession in understanding research.
This willingness to remain engaged, even when it's difficult because it contradicts what we've been taught, is nothing short of admirable. Julie is showing the courage of facing difficult dilemmas that evidence presents us about how massage actually works, and she is actively engaging with that process, and in that, she is going the extra mile.
Like Emma and Charles Darwin, most MTs are good, decent, caring, and loving people, who want to understand the truth.
If just wanting it sincerely, and working hard at it, were enough by themselves to avoid error, most of us would be there already.
Sadly, in this material physical universe, those good intentions are not sufficient to help us to be correct.
The Board has undertaken a major revamp of policies and procedures, one which is causing a great deal of disruption among nationally certified MTs and continuing education providers.
Its CEO, Mike Williams, states that the purpose and effects of this change are
streamlined online processes, enhanced communications, and improved programs that elevate the profession and better serve the public.
Some of those changes may well have that effect--I am not personally nationally certified, and I have not yet examined the changes in depth as other MTs and bloggers such as Laura Allen have.
Q: Will NCBTMB continue to accept alternative courses like energy work, aromatherapy, animal massage, etc?
A: Yes. Massage therapy is part of the holistic profession as are several other modalities and techniques. NCB will continue to accept modalities and techniques that can be legally practiced by a massage therapist without another healthcare provider, (i.e., DC, MD, PT) present. As long as the technique or modality can be shown to be embedded in the lineage of massage, it will be accepted. This means that if the core information of the technique or modality can be referenced as a derivative of another technique or modality that is within the massage therapy scope of practice it will be accepted.
The argument over the relationship between massage and "energy work" is nothing new.
In the early 1990s, when I was in massage school, the NCBTMB was developing the first national certification exam--the National Certification Examination for Therapeutic Massage and Bodywork (NCETMB). Eventually, as a result of consumer pressure, they were forced to offer an energy-free alternative, the National Certification Examination for Therapeutic Massage and Bodywork (NCETM), for those MTs who did not want to be coerced into an anti-evidential belief system as the price of their professional training and licensure.
Although the argument is nothing new, there was a fresh opportunity to do something innovative here among the other disruptive changes--but NCBTMB did not take that opportunity.
Instead, they opted to permit teaching any information (which includes misinformationand malinformation) as approved continuing education, as long that that can be shown to be "embedded in the lineage of massage". Considering the long history of "massage myths", documented by Laura Allen (here and here), Lee Kalpin, Paul Ingraham, and many others, it is clear that just because an idea has been embedded in massage, even for a very long time, that does not mean the idea is correct.
NCBTMB had an opportunity to stand up for the principle that, in the therapeutic encounter, a professional should provide only validated warranted (justified or justifiable) high-quality information to the client.
They did not take the opportunity to stand up for that principle, and as a result of that decision, I cannot participate in their new process. I will not go on to apply for national certification as a practitioner, nor will I become an approved continuing education provider under those standards.
I regret those facts, as I consider them massive missed opportunities. But I cannot do it, because our first principles on these matters are so far apart as to be irreconcilable.
Don't misunderstand me here--I am positive that the NCBTMB members are well-intentioned, and that they wanted to do the right thing. I genuinely believe that they were attempting to have the best of both worlds for the benefit of all massage stakeholders, and to not hurt anyone's feelings.
I respect them as the kind, caring, motivated, passionate people that they clearly are.
If that, by itself, were enough to be right, as Emma Darwin wished, we would not have to have this very serious and difficult discussion.
But evidence doesn't work like that--you can't pick and choose which evidence you accept, and which you reject. Either you accept all the evidence, and you go courageously wherever those implications take you, or you just don't accept the evidence.
If they are going to accept massage's traditional explanation of "energy work"--no matter how many times that explanation has been shown by the evidence to be mythical--as validated approved continuing education with their official imprimatur, then they are not preparing MTs who are taught that explanation for modern translational science. Holding on to old ideas even after they have been disproven is an active obstacle to understanding these new developments.
The environment of massage is exhibiting selection pressures toward a type of massage that is integrated with validated high-quality information, and that prepares MTs for understanding advances in neuroscience, cognitive science, endocrinology, and pain science, and translating that understanding into clinical practices that are client-centered and effective.
As a direct response of those pressures, biopsychosocial massage is breaking off from the main lineage of massage to provide a new massage lineage that is fully consistent with those principles.
You can consider this the official birth announcement of a new lineage of massage.
Biopsychosocial massage (BPSM) is massage understood and practiced in a biopsychosocial model. It understands massage, health, wellness, and illness, and the knowledge bases underpinning those concepts in an evidence-based, natural (meaning, not supernatural), organic way that draws on what we know about biology and other natural sciences, psychology, sociocultural aspects of being human, and the emergent effects that arise from interactions among these various factors.
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
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.
That means that we understand and practice it in a holistic, complementary, and integrative way, integrated with other domains of human knowledge and with the natural universe we find ourselves in, rather than silo'ed off in an alternative universe that denies material physical reality, and isolates us away from members of the client-centered biomedical healthcare team.
If a proposed explanation for an effect requires us, for example, to reject physics, as the explanation of "energy work" embedded in massage tradition does, then we face that contradiction head on, and we work to resolve it. If that means updating old beliefs in the light of new evidence, then that is the consequence of practicing biopsychosocial massage.
Michael Hamm is another contemporary example of courageous engagement, facing the evidence head-on and seeking to better understand. I'm paraphrasing his quote here, and I trust that he'll correct me if I've gotten it wrong. If I can find the original quote, I'll replace the paraphrase, but it was something to this effect:
I understand and accept that the traditional anatomical explanation behind craniosacral therapy doesn't hold up in light of the evidence. At the same time, I can't deny that I feel something when I am doing that work, something that I can't explain. I want to better understand what is going on when I do that work.
In the absence of clear evidence of what is exactly going on, this suspension of previous belief that has been disproven (and not yet replaced) is totally in line with the principles of BPSM. We don't have to always know everything; we just have to know what we do know, what we don't know, and how strong the evidence is behind our knowledge.
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.
Over time, here at POEM, we will be following that evidence where it leads, and courageously engaging with the meanings that it shows for the practice of massage therapy. I expect intense, passionate, and fruitful discussions here over the next few years.
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.
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.
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."
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
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.
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.
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:
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.
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.
Rock climbing is a good metaphor for clinical reasoning and decision-making.
If you go climbing, you can plan a route from the bottom to the top in advance, but when you are actually in the process of ascending the rock face, you have to deal with the actual material physical reality you find in front of you. If that turns out to be different from your previous plan, then the plan gets adjusted to accommodate what you are really dealing with in the moment. If you try to privilege the theoretical plan over the actual facts, things can end very badly very fast.
To get from one place on the rock to the next place without falling, you make sure that you are in a stable position where you currently are, and you look for a way to get safely to the next place you want to be. You repeat this process over and over, and at the end--if all goes well--all those decisions in the moment about how to get from one place to the next lead you to reach the summit you were aiming for all along.
The reason that this is metaphorically like clinical decision-making and reasoning is that need to ensure that you are first in a stable place before you extend yourself to get to the next place.
Like climbing, reasoning is a process--the culmination of many smaller decisions along the way. If you take too many unwarranted risks along the way, you can lose control of the process.
Unlike in individual climbing, however, the one most harmed by a bad outcome in clinical decision-making is someone else: the client.
That's why we have an extra responsibility to do the best job in getting it right that we possibly can--our clients trust us as the experts.
As we've seen in the previous post, deductive reasoning helps you to get from one point to the next--from the general to the specific--in a safe and valid way, but the kinds of questions it can support are rather limited in comparison to the situations we often encounter in clinical situations. It's a safe and easy line from one point to the next, and the valid results may be exactly what you need in particular situations.
Inductive reasoning is somewhat more powerful, as it can take you from the specific to making generalizations about how things work in the material physical universe--but, by the nature of taking on that task, it's possible to do every thing right--to begin with a valid starting point, to reason in a flawlessly valid way--and to still end up with invalid conclusions, such as "All swans are white". It's riskier than deduction, but--if it succeeds--it opens the door to more possibilities than deductive reasoning alone can provide.
Among other things, it's this recognition that you can do everything right and still end up with invalid conclusions that makes all of scientific knowledge provisional (it holds unless and until it is replaced with better evidence) and contingent (hanging together as part of an integrated whole with other knowledge).
You will, of course, hear statements made with absolute certainty, but that certainty comes from some place other than science.
The fact that scientific knowledge is contingent and provisional does not, however, mean that it is totally random--that anything goes, and therefore, you can just make up anything you want and it will be every bit as valid as anything scientists have spent centuries testing.
The idea that nothing has any meaning at all, so it doesn't really matter what you claim, is a kind of nihilism, and we're not going to indulge in nihilism here.
Scientific knowlege always has a confidence level of how much we are sure it is true attached to it. That confidence level is never 100%--we are never totally certain without any doubt at all--but in many cases, it does get pretty close. We have tested that knowledge, and reliably repeated it so much that, for all practical purposes, we can proceed to build on it as though it were actually 100% certain.
We can trust it as a safe enough platform in our climb to use it as a base for the next bit of knowledge, reasoning, or clinical decision-making.
This is why the more extravagant claims of energy healers don't hold up--they contradict what we have spent centuries rigorously testing about how energy actually does work in the material physical universe. Principles and laws such as the inverse-square law and the laws of thermodynamics have held up so well under independent repeated testing by independent observers that we are as close to certain about them as we ever reasonably can get about anything.
If energy really did work the way energy healers claim they operate, then the inverse-square law and the laws of thermodynamics would fail so spectacularly that the world around us would look very different from how it actually does. The fact that we can rely so reliably on these laws means that what the energy healers claim cannot be true--it is a clear decision point, where you have to make the decision whether you accept or deny material physical reality.
Here's a couple of examples of how the universe around us would be very different if energy healing claims were true. Many energy healers claim that it does not matter how far away they are from the person they have intent to heal--that it's the same whether they're in the same room, or half a world away.
A fire, among other things, is heat energy and light energy.
Did you get close, so that it felt very, very hot? Did you get further away from the fire, far enough so that you could feel the cold night air? You didn't have to get very far away for that experience, did you? The heat and light energy from the fire drops off very quickly as you get further away.
Would the effect of the fire be the same, whether it was in the same room, or half a world away?
What kind of reasoning are we practicing here?
Heat energy quickly gets less effective as we get further away from the source; light energy quickly gets less effective as we get further away from the source, therefore, if energy healing is really based on energy, we expect it to quickly get less effective as we get further away from the source.
We are going from different examples of energy to derive a universal principle applying to all energy, so what kind of reasoning is that?
Now that we have derived that universal principle, we apply it in the following way:
The effect of physical energy falls off quickly with increasing distance from the source of the energy.
Energy healers claim that what they practice is not affected by distance from them as the source.
Therefore, what energy healers practice is not physical energy.
In applying the general principle about energy to a particular example, what kind of reasoning are we practicing there?
So--since they can't both be true at the same time--which one is right?
Are the energy healers right, and every bit of physics knowledge multiple independent researchers have built up over centuries wrong?
Or is the physics knowledge right, and the energy healers' explanations wrong in some way?
Since you have to choose only one of them, which possibility is more plausible: more likely, more reliable, and more believable?
Understanding these ideas--that not everything can simultaneously be true, that you really do have to choose between what is true and what is false, that scientific knowledge is never 100% certain but can at times get very close to that ideal--lays the groundwork for understanding the next form of logical reasoning we'll discuss.
Abductive reasoning is sometimes called "reasoning to the best explanation", and we'll look at how that works.
Abductive reasoning is difficult to describe concisely, or to teach, because it depends so much on what went before it. To use abductive reasoning, you have to have a solid multidisciplinary knowledge base.
If you don't have that, then, from the outside, it looks like you're making things up, or changing the rules arbitrarily or unfairly.
That's not really what's happening, but you can feel compassion for people who think that, because they don't see the entire process going on. It's like watching a far-away rock climber--you see them going in progression from hold to hold, but you don't see all the information they have up close that they are basing their decisions on in the moment.
And you can't just teach it easily, because it's not like a vending machine, where you always put the exact information in, and you get exactly the same answer in return.
These aspects of abductive reasoning can make it challenging, both to observers outside the process, as well as to learners trying to come to grips with carrying it out. We can certainly sympathize with frustrations at that challenge, yet all we can do is to try to connect the dots, and be as transparent as possible about the process, to assist those who come along afterwards in understanding why decisions are made in the way they are.
If you don't care where you're going, it doesn't matter which way you set out.
If, on the other hand, you care about going to the "best" explanation, then you have to know what that means in order to plan your journey to get there.
It's a complex question, not one that we can just answer by rote. Let's work through it by examples, and try to get larger principles out of those examples for the next situation that comes along.
Just like we had the classic "Socrates is a mortal" and "All swans are white" examples for deductive and inductive reasoning, there is a classic example of abductive reasoning that we can share with generations of people who studied these questions before us.
"The lawn is wet, so it must have rained last night" is an example frequently used to show abductive reasoning.
We have an observable, empirical, tangible fact: the lawn is wet.
We don't know why the lawn is wet, so we try to draw a hypothesis to account for our observation. There are many possibilities that could become hypotheses:
It could have rained last night.
Someone could have poured water on the lawn, accidentally or on purpose.
A passing water truck could have sprung a leak.
There are lots of other possibilities as well, limited only by our imaginations.
If all of those possibilities are equally good as explanations, then we are stuck--we remain unable to develop a causal explanation that we can then test to see whether or not that explanation is correct.
But not all possibilities are equally good as explanations--some are ruled out by patterns in our observation.
Others are ruled out, as we saw with the energy-healing claim, by centuries of shared human knowledge about the way the physical universe works--for those explanations to be true, our universe would have to look and act totally different than it does now. So we can rule out explanations like that as well, never with 100% certainty, but with enough certainty to operate on for now.
Starting out as a brand-new student in first grade at the age of 6, I was absolutely, madly, deeply in love with my teacher, Miss Kirby. I would have done anything at all to get her to think highly of me.
So I told her about my brand-new baby brother that my parents brought home from the hospital. She was very interested to hear that I was now the big girl in the family, and told me that I must be very proud.
I assured her that I was really a very good big sister.
I told her about how my baby brother escaped from his crib after my parents brought him home, and how he climbed a tree and got stuck up there, and how I had to go rescue him.
I told her I saved my little brother all by myself, and Miss Kirby reassured me that I was, indeed, a very good big sister.
Not long after that, my parents and I were at the grocery store, where we ran into her doing her own shopping. She asked my parents about the new addition to the family, and that's when the facts came out: there was no new little brother. I had just made the entire story up to impress her, and make her think I was strong and brave.
Which explanation more plausibly accounts for the facts of the matter?
Unlike any other newborn in the history of the human race, my infant baby brother really had the cognitive skills to formulate an escape plan, and the motor skills to climb out of the crib, let himself out the door, and then climb a tree, or
A little girl who doesn't know much about infant development tells a lie that makes herself look like a hero, in order to impress an adult whom she loves, and who she wants to think she is a very good girl.
(Just to complete the story, I'll mention that no punishment ensued from this either at school or at home. All of the grownups understood why I had told that lie, and dealt with it in constructive ways that supported me in not needing to tell lies anymore just to impress beloved adults.)
To figure out how plausible something is--not either a "true" or "false" answer, but values along a spectrum from "more plausible" to "less plausible"--you can't just look at it in isolation. You have to evaluate how well it fits into the integrated whole of everything else we know about.
Abductive reasoning, getting at the best explanations for facts, draws on that plausibility as one of the pillars that supports it.
To be able to evaluate that plausibility, we need to have a large, solid, and interdisciplinary knowledge base, and to know how the parts of that knowledge base integrate seamlessly with one another.
This is not an easy task, and it can't just be reduced to vending-machine science. That's why it can look to people who are not in on the process as if scientists are making arbitrary choices about what they accept and what they reject. The scientists are making choices among possibilities, but unless you are close up to the process, you can't see the details of how they're doing it.
The choices aren't arbitrary, but neither can they be easily summed up in a single concise one-size-fits-all formula, either.
You may have been introduced to logic and reasoning in your previous education--different schools vary on whether they include it, and at what grade level they include it, if they do.
If so, then some of this will look familiar to you--you've probably already encounted deduction and induction in school.
If you haven't seen this material before, don't worry--we'll go over it in more depth, to make sure that these foundational concepts get the coverage they merit.
And even if you have seen some of this before, I'm willing to venture that part of it is new to you as well. So we're all on a learning journey through this material together.
Logic is the study of how we reason about things in the world around us. We use principles of logic to try to ensure that our methods of reasoning lead us to correct answers, rather than falling into traps that give us wrong answers.
Deduction is a logical technique that takes us from general statements to specific ones, ensuring the correctness of our specific conclusion. The classic example of deductive reasoning taught in school is:
All men are mortal.
Socrates is a man.
Therefore, Socrates is mortal.
For an example of deduction that is more relevant to massage, we could create the following:
People who suffer from pain often benefit from massagea.
Robertb has an upcoming surgical operation planned, and one of the side effects of the surgery will be post-operative pain.
Therefore, Robert may benefit from massage after surgeryc.
a We know this generally from the cumulative body of massage research evidence.
b A specific client.
c A valid recommendation for a specific client, based on what we know generally.
So deductive reasoning is one way that we can take general principles from research evidence, and apply those principles for the benefit of specific clients.
One of the strengths of deductive reasoning is that--if the assumptions you start with are true--then you will definitely reach a correct, or valid, conclusion.
But deductive reasoning, as solid as it is, will only take us so far. It's a good start, but it's not going to be enough for real-life clinical decision-making.
We're going to need additional tools to help our processes get beyond the very first level.
Inductive reasoning, in a way, is the mirror image of deductive reasoning: it starts with specific knowledge, and aims to draw conclusions about general principles from that specific knowledge.
Induction is the process of observing many specific instances, and abstracting--making a generalization about what those instances have in common with each other.
For example, the sun has come up every day in the past since humans have begun observing it, so on that basis we reason, inductively, that it will rise tomorrow as well.
An famous example of inductive reasoning in clinical observation and decision-making in recent history took place in the early 1980s, when primary healthcare providers began noticing a dramatic increase in young gay male patients presenting in clinic with an unusual kind of tumor--Kaposi's sarcoma (KS), a relatively uncommon condition usually found in older men of Mediterranean heritage.
At first, it seemed like it might be a coincidence, but at some point the number of cases reached critical mass for a real phenomenon, rather than just chance. Clinicians wrote up their observations in medical journal articles like the following, for other clinicians to compare their own observations against, and to share their own observations and knowledge.
Kaposi's sarcoma, a multicentric malignant neoplasm, occurs in certain geographic areas in the world. It is most common in Equatorial Africa and Eastern Europe. The annual incidence of Kaposi's sarcoma in the United States is between 0.021 and 0.061 per 100,000 persons. The appearance of an outbreak of Kaposi's sarcoma in young homosexual men in New York and California is a new and unique phenomenon. Certain differences are already recognized between the disease in these young men and the ordinary Kaposi's sarcoma. Herein we report our observations of the first 10 cases of Kaposi's sarcoma in young homosexual men. In these patients, the disease follows an aggressive clinical course characterized by widespread skin lesions with early involvement of the lymph nodes. In some of these patients, the result was death in a short period of time after initial diagnosis. In addition, cytomegalovirus infections were seen in these patients, which suggests at least a possible association between this viral and the disease.
An outbreak of KS has been observed in young homosexual men. These patients are different from those with classical KS for the following reasons: 1. geographic distribution (clustering in New York and California); 2. age (younger, mean--39 years); 3. higher incidence; 4. sexual preference (homosexual); 5. distribution of skin lesions (face, upper extremities, trunk); 6. lymph node involvement; 7. visceral lesions; 8. associated opportunistic infections (Pneumocystis carinii, toxoplasmosis); 9. history of sexually-transmitted diseases (hepatitis, syphilis, gonorrhea); and 10. aggressive course of the disease. Awareness of these features of the new KS will enable the practitioner to better recognize this important, emerging disease.
The clinical findings in eight young homosexual men in New York with Kaposi's sarcoma showed some unusual features. Unlike the form usually seen in North America and Europe, it affected younger men (4th decade rather than 7th decade); the skin lesions were generalised rather than being predominantly in the lower limbs, and the disease was more aggressive (survival of less than 20 months rather 8-13 years). All eight had had a variety of sexually transmitted diseases. All those tested for cytomegalovirus antibodies and hepatitis B surface antigen of anti-hepatitis B antibody gave positive results. This unusual occurrence of Kaposi's sarcoma in a population much exposed to sexually transmissible diseases suggests that such exposure may play a role in its pathogenesis.
Those observations pointed to what we later recognized as the beginning of the AIDS epidemic in the developed world. Inductive reasoning based on observations that young gay men were presenting with these unusual symptoms in clinic helped alert clinicians that other young gay men (and, later, other population groups at well) might be at particular risk from whatever was causing this new disease.
It is quite possible, with the efforts at case report repository-building going on here at POEM and elsewhere (like the Massage Therapy Foundation), that someday MTs will be able to put together observations made by multiple therapists in multiple distributed clinical locations, and--through a similar process of inductive reasoning--will be able to derive more general knowledge from those specific individual instances.
But unlike deductive reasoning, which--if the beginning assumptions are true--will lead to correct conclusions, there is a degree of uncertainty about the validity of conclusions arrived at through inductive reasoning.
Using inductive reasoning, it is possible to begin with true observations, follow the procedure correctly, and yet arrive at false conclusions anyway. This is just a risk we take when abstracting from specific instances to general principles.
The black-swan problem illustrates how this can happen.
"All swans are white" is a well-known example of a positive claim.
The claim that "All swans are white" is definitively disproved by the existence of one black swan.
That's easy enough. But what does it take to prove the claim that all swans are white?
One white swan is a good start.
Another white swan is also good.
Three white swans--so far, so good.
Have we proved that all swans are white? Three is not very many, after all.
How many white swans in a row do we need to find in order to prove that all swans are white?
.....?
The problem is that no number of white swans will ever be enough for us to be 100% certain that the next swan won't be black. And it only takes one black swan to disprove the entire claim.
Let's use the white swan as a metaphor for something you might observe in clinic.
Let's say you provide pregnancy massage, and among your clients, you have noticed what seems to you to be a trend--the older the mother is in her first pregnancy, the worse her self-reported nausea and vomiting appears to be. In the same way, the younger the mother is, the less nausea and vomiting she reports.
Does that mean that you can accurately tell how much nausea and vomiting the next new pregnancy massage client you see will report having, based on her age?
Maybe you can, and maybe you can't--you could have yet another white swan in a row. Alternatively, this new client might be your first black swan, breaking the trend you had observed up until she arrived.
That's a problem for induction, as compared to deduction, which provides us much more certainty when reasoning from the general to specific instances. After all, induction, abstraction, and generalization led clinicians to reach out to other gay males at potential risk for the disease, but fallacies based on those generalizations also led to discrimination and blame against them for the disease, as well.
Deductive and inductive reasoning certainly have important purposes they can serve in clinical decision-making, yet, by themselves, they are not enough to provide us with all the validated information and support we need.
There is another form of reasoning that we can call on as well, one that goes some way toward meeting that need. But this post is already quite long, and this is a good place to end it for now.
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.
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.
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?
This site is free and open-access. As long as its business model remains viable, and the community supports it, POEM always will be free and open-access, and will belong to the massage community as a whole.
POEM depends on your donations to keep it going, and the Milestone amount indicates how much support is needed by what date in order to keep its business model viable, and to keep it accessible freely to the community of massage stakeholders.
Some inspiring quotes added by our users.
Add a quotation
(You must be logged in to add a quote.)
More...
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
William Osler
Mind your boundaries and be tolerant of the uncertainty that is clinical practice.
Jason Silvernail
Absolutely you need to think carefully about the ideas you pass along to your patients. Are they accurate scientifically? Do they serve the patient's best interest given your responsibility to them?
Jason Silvernail
Being a teacher is a little bit like being a psychotherapist. It turns out that you get much more than you give. I am eternally grateful for what I have been given.
