Safety of massage

Laura Allen embodies the very ideas of transparency and accountability when she says that anyone is free to quote anything she says anytime and anywhere, and I believe I'll take her up on that.

Over on her Facebook account, which you may or may not be able to see unless you're already friends with her, she writes:

It's a concern to me that three times in the past couple of days, I have seen stories on here about employers who don't want the massage therapists to change the sheets for every client. That is so unethical, not to mention a health hazard. If you are working in such a place I suggest getting out immediately and reporting the owners to the massage board AND the health board. As one person said to the owner who was mad about her changing the sheets, would you want to check into a hotel and sleep on the sheets the last person used? I don't think so. And if the guilty owner happens to be reading this, do us all a favor and get the hell out of this business.

Clear, concise, and correct. And if the guilty owner was reading the post, they didn't choose that hill to (metaphorically) die on; Laura's commenters were 100% supportive of the bright shining biomedical and ethical line in the sand that she drew.

It occurred to me that there could be correlation between the type of massage practiced and its underlying conceptual model, with the degree of sanitation and hygienic practices adhered to.

For example, if you truly believe that disease is caused by a bad wind entering the body, or by negative thinking, or by karma, then that's not really much of a motivation for paying attention to getting rid of germs on surfaces.

And an interesting followup question is, if you do believe in one of those conceptual models, and you are scrupulously diligent about observing good hygiene, then why do you go to that trouble?

I mentioned that that would be a fascinating study that I would probably never get around to carrying out, but if someone else did, I would love to read about it.

Well, ask and you shall receive, I guess.

One of Laura's commenters told a story from her own experience, that is a perfect case study of the correlation I was thinking about:

I had an MT friend who worked in a chiro's office and he reused disposable acupuncture needles. He was quite careless with them and they'd often fall on the carpet where you wouldn't notice them until you got off the table, barefoot, and get one in your foot. When the MTs in his office complained, he waved them off for being too "Western." In China, they reuse needles from person to person. At least, he bragged, he only reused them on the same person. Eventually he agreed not to do acupuncture in the massage rooms so massage clients didn't get stuck by stray needles. Sheesh.

/facepalm

There are so many issues here, that it's difficult to know where to start.

Disease transmission by infected reused needles, or Hygiene 101, is only the first one.

To get back to our topic from needles, I'm sure the POEM commenters can name several conditions that can be passed from one person to another by dirty bed linen.

Sources: Left: http://www.stanford.edu/class/humbio103/ParaSites2004/Scabies/scabies.jpg accessed 29 April 2012, Right: http://www.stanford.edu/class/humbio103/ParaSites2004/Scabies/scabies1.jpg accessed 29 April 2012

And although this may come as news to the chiropractor in the story, in resource-poor areas of the world, they don't share needles because they *want* to; they do it because they have no other options.

Every time something like that reinforces the perception of MTs as elitist, classist, ethnocentric, and generally oblivious, it just makes more work for the rest of us to dismantle that perception.

So here we go, gradually chipping away at it:

First of all, the session is about what the client wants and needs, not about forcing the client--with or without full disclosure and informed consent--to settle for what people in resource-poor environments are compelled to make do with. The chiropractor in the study is not practicing in a client-centered way; his practice is centered on something else, where infection control is not a priority.

Second, in chiding others for being "too 'Western'", he probably sees himself as all diversity-oriented, and transcending elitism and ethnocentrism.

Nothing could be further from the truth.

He is claiming, in effect, that Chinese people don't value their own lives and bodily integrity enough to care about basic biomedical best practices. Where he got the idea that he gets to speak for them is unclear, but his claim positively advocates poorer medical care based on nationality and ethnicity.

This violates Ethics 101 in a big way.

If Chinese people do reuse needles, what could be the explanation?

Unlike the chiropractor in the story above, who implies they are choosing to do so when they have better options, I think that looking at the availability of resources is a useful source for possible explanations.

According to the Wikipedia article "List of countries by GDP (nominal) per capita", the US per capita annual income ranges (depending on the reporting source) from $47,153-48,387.

The per capita annual income in China ranges (depending on the reporting source) from $4,428-5,414.

The per capita annual income in Ethiopia ranges (depending on the reporting source) from $300-360.

I'll leave as an exercise for the readers to evaluate whether Chinese people and Ethiopian people reuse acupuncture and injection needles because:

• they don't care about their own lives and health, or about each other, and consider infection control "too 'Western'", or whether
• unused needles are much harder to come by in environments where the average person earns 11% (China) or 0.007% (Ethiopia) of what the average American earns.

And if you consider it a do-or-die cost issue--if your business, in the US context, is so iffy that you need to operate it in the American context with Chinese or Ethiopian standards of practice and margins on clean linens, unused acupuncture needles, or any other compromise on infection-control best practice, then your business is not dying.

It is already dead, and you just haven't acknowledged the fact. If you cannot afford to practice infection control, it's over. Deader than the parrot in the Monty Python sketch.

I'll heartily second Laura's recommendation:

And if the guilty owner happens to be reading this, do us all a favor and get the hell out of this business.

and I'll add some of my own.

Recommendations for educators:

• The history of massage is an important thing for students to know about, but infection-control trumps it every time.
• If you don't have time in the curriculum to teach both about how people used to believe humors or bad winds caused disease, AND what we know now about how to prevent infection in a massage therapy practice, so that the students not only rotely deliver the correct answer on tests, but really show that they understand and can apply it in context, then the curriculum resources have to be devoted to infection control at the expense of pre-modern concepts of illness and disease.

Recommendations for students and practicing MTs:

• Check to see if your school is teaching (or did teach, if you've graduated) proper infection-control practices.
• Make sure that you know how to protect clients by reporting unethical and unsafe practices to the correct regulatory authorities in your area.
• If not, make sure that you get all that information somewhere else, and use it in your practice--it's just that important.

Recommendations for clients:

• The time in a session is time that you have paid for, and you should not feel hesitant to ask questions about the care or service you are receiving.
• A client-centered healthcare professional will be happy to answer any questions you may have. Hospitals in the US, UK, and elsewhere are now actively promoting campaigns (as shown in the buttons below) to ask your provider whether they've washed their hands before examining you. MTs who want to be part of an integrated healthcare team will not balk at following the same infection-control best practices as other members of that healthcare team.
• Don't hesitate to ask what infection-control procedures your MT uses.
• When you are getting on the massage table, take a moment to look at the linens you will be lying on--do they look clean and unused, or do they appear to be re-used?
• How many layers of linens are on the table? If it's more than one, the establishment may be cutting corners by stacking sheets to save time between clients. The problem with stacking sheets is that mere layering will not prevent transmissible conditions from crossing those layers. Don't accept sheet-stacking from your MT; insist on a single layer of clean and unused linens every single time. This is your time and your care; it is reasonable that you expect it to be conducted in a way that looks out for your best interests.

Sources: Left: http://www.jcrinc.com/Common/Images/custom/products/HHB-05.jpg accessed 29 April 2012; Center and Right: http://www.healthcareinspirations.com/hci_fe03_single_quantity.html?&prodid=513 accessed 29 April 2012

These are steps we can take, and encourage our clients to take, to show that we are serious about developing into a healthcare profession that will accept the responsibility of self-regulation and client protection that comes along with that status.

The best, most healing thing you can do is just listen. Don’t say “I know how you feel”, because you don’t. Don’t interject your feelings, don’t say you support the war or don’t support the war, because you don't know how we feel about it. Don’t say it’s just like "Call of Duty", because it’s not. "Om" and "kumbaya" don’t help.

The worst thing you know here is maybe a car accident or a mugging—that's not comparable. Put all your possessions and all the people you care about in one house, and then set it on fire and watch it burn while people are shooting at you from all around—then maybe you understand. And if you can go through all that without the memories tormenting you, then you’re stronger than any soldier.

Just listen, and say, "I wish I could have been there for you to help and support you".

--"Jason", veteran of tours of duty in Afghanistan and Iraq, wounded twice and now living on a disability pension

Source: http://1.bp.blogspot.com/-MX0OVAYrN1E/T0Lx4qkaGYI/AAAAAAAAAxA/0PWxeTFsPug/s1600/O+Brother+Where+Art+Thou-01.jpg accessed 10 March 2012

In the 2000 film, O Brother, Where Art Thou, filmmakers Joel and Ethan Coen borrowed the basic plotline of Homer's Greek epic story-poem the Odyssey: a small number of men, led by a charismatic main character, confront massive obstacles in a determined journey home from a traumatic experience.

Of course, in that film the journey was played for laughs. so much of the shocking violence and intense struggle of Homer's original story was watered down--even though the Odyssey's emphasis on building relationships and telling stories to one another was retained.

However, the film does resemble the original epic in one respect that's easily missed.

Odysseus and his shipmates are on their way home from the Trojan War (covered in Homer's other epic story-poem, the Iliad), an arduous experience that they surely spent time recounting during their many years' voyage back to Greece.

But in the same way that the characters in the film don't spend much time talking about their experiences in prison--it begins with them escaping from their chain gang--even the characters in the Odyssey aren't shown having those discussions about the Trojan War.

It's reasonable to assume they did have them, but Homer--with his fine eye for what ancient Greek audiences would have found sufficiently dramatic--concentrated on the high points of encounters with monsters, sirens, disasters, and politics back home.

Everyday conversations among the rank-and-file soldiers ended up on Homer's cutting-room floor. Even today, we're accustomed to the idea that such "ordinary" drama as how one is affected by the violence of war doesn't rise to the level of entertainment.

But for those of us lucky enough not to have known war, just because we're not typically shown such ordinary drama in our entertainments doesn't stop those events from being extraordinarily consuming for those who lived them.

Over the ten years of the Odyssey, the crew had a lot of time to talk, decompress, tell each other their stories, and deal with what had happened to them, and to those they cared about, during the war.

Even as recently as World War II (1941-1945 for American combat involvement), getting to and from battle took days or weeks on board troop carriers traveling to battle and then traveling home.

Source: http://upload.wikimedia.org/wikipedia/en/d/d0/USS_McCawley_landing_rehearsal.jpg accessed 10 March 2012

On the voyage home to people who had not seen what they had witnessed, the troops could talk with each other about it. They could validate each other's perceptions, express their feelings to one another, and, generally, prepare to reintegrate into a very different world from what had been their recent reality.

That process began to change during the Vietnam War, and it is now literally possible for returning veterans to be back in their home country within hours of having been on the battlefield, and back home to their friends and loved ones--few, if any, of whom have shared their experiences--within days or a couple of weeks.

Returning home from war can now be trivially easy, in the physical and logistical sense only. Someone else makes the arrangements, and soon you're on a plane heading home.

But what often goes unrecognized is that, in the relative ease and convenience of returning home compared to the case in previous wars, the opportunities for sharing stories, building and reinforcing relationships, and hearing your experiences validated by others who witnessed the same kinds of things you did--these are all lost in transit.

Like its simpler relative the dilemma (δι-/di, "two" + λημμα/lēmma, “premise, proposition”), a trilemma is a difficult decision point.

The difference is how many problematic options you have to choose among. Odysseus was confronted by a dilemma (two options) in trying to find his way home from war with his ship and his crew. As Wikipedia describes it:

Scylla and Charybdis were mythical sea monsters noted by Homer; later Greek tradition sited them on opposite sides of the Strait of Messina between Sicily and the Italian mainland. Scylla was rationalized as a rock shoal (described as a six-headed sea monster) on the Italian side of the strait and Charybdis was a whirlpool off the coast of Sicily. They were regarded as a sea hazard located close enough to each other that they posed an inescapable threat to passing sailors; avoiding Charybdis meant passing too close to Scylla and vice versa. According to Homer, Odysseus was forced to choose which monster to confront while passing through the strait; he opted to pass by Scylla and lose only a few sailors, rather than risk the loss of his entire ship in the whirlpool.

Sometimes, a trilemma (τρί-/tri, "three" + λημμα/lēmma, “premise, proposition”) is nothing more than the addition of one more monster to choose among.

But often, the special nature of a trilemma lies in the nature of the relationships among the options themselves, and what those relationships do to the decision-making process.

There's a saying in the software industry that illustrates these relationships among options to choose from:

"Fast, cheap, and good: pick any two."

What that saying means is that the combination of any two of those options automatically excludes the third.

So if you want your software to be released fast, and to be of good quality, you can't have it be cheap, because you will have to put a lot of expensive extra resources into getting good quality in a short time.

You can have your software be good and cheap, but in that case you can't have it fast--instead of investing those expensive extra resources, you will have to demand a lot of extra work in quality assurance on the part of the regular team, and that extra work will necessarily take a great deal of time.

Or you can skip that quality assurance, and have a fast release of cheap software, but in that case, you skimp on quality and sacrifice good.

That's a classic example of the nature of a trilemma--not usually so much that you have to choose one of three bad options, but that you have 3 desirable options that conflict with each other, and you have to choose which option to sacrifice in order to keep the others.

But what if you're in a much worse situation, and rather than getting two out of the three things you want--a frequent enough situation in the course of normal life--two of the three things you want have gone away, and it's a struggle just to hold on to the last one remaining?

In a workshop in Seattle yesterday, sponsored by the Veterans Training Support Center at Edmonds Community College and led by Lori Daniels, we talked about what we civilians back here at home can do to be supportive of veterans returning from war and dealing with physical and psychological trauma.

Lori presented a view of multiple dimensions of loss experienced during trauma, such as, among others, the physical loss of friends to violent death, as well as multiple losses on an emotional level. She brought up the book Loss of the Assumptive World: A Theory of Traumatic Loss by Jeffrey Kauffman as a useful resource.

I'm paraphrasing her interpretation of a book written by someone else and that I haven't read myself, but I think this description is pretty faithful to our discussion yesterday.

Kauffman writes about the loss of self-worth that happens in trauma, describing it as a trilemma facing the person who has experienced the trauma, although I would be surprised if he actually uses the word "trilemma".

He states (again, paraphrased and filtered through 2 different people) that, as humans, we tend to share 3 foundational assumptions about the world around us:

1. The world is organized in some capacity, and events in that world happen for a reason;
2. The world is benevolent and good, and good things happen to good people and bad things happen to bad people; and
3. The self is worthy of being loved and accepted.

He proceeds to describe how trauma "annihilates" (Lori's term for his description) 2 of those assumptions:

1. Trauma is random and unpredictable; uncontrollable and unorganized; and
2. Bad things happen to good people.

It is impossible to prepare emotionally and psychological well enough for that—we're just not wired that way.

So something has to be done on a psychological level in order to bring the system back into order.

In the old days, in the company of others who knew what each other had been through, there used to be an opportunity to validate each other's perception over time in the sharing of stories. Now, when you can be home within hours of being on the battlefield, that particular opportunity is no longer there, and other opportunities have to be found or created.

Kauffman describes how, if a trauma survivor contains the experience and feelings inside without disclosing, or if that survivor gets shut down by others for disclosing, then they have to contain experience and solve the conflict among the three foundational ideas all by themselves.

Their task is to navigate the ordinary world with this trauma experience behind them. But there is now an inherent conflict in the 3 ideas, because what they've seen makes it clear that bad things do happen to good people.

That realization means facing the prospect of the horror that is a chaotic, unpredictable, uncontrolled world around us, where bad things happen to good people, and undeserved good things go to bad people, for no reason at all.

But the image of the world as a reasonable, organized place, where the correct things happen to the appropriate people can be regained--but that restoration comes at a tremendous price.

If the trauma survivor lets go of the assumption that their self is worthy, they can regain the other two assumptions in that way.

If you judge yourself as unworthy, someone who failed by making the wrong decisions, that bad things happened to good people only because you yourself blew it, then you can regain other two assumptions, recapturing the idea of a fair world, by sacrificing the idea of yourself as worthy of love and acceptance.

A large part of recovery, then, is the problem of how to bring back the worthiness of one's own self while still managing to navigate a random and crazy world around us.

Again, this is not my original interpretation. I am paraphrasing Lori's presentation of Kauffman's work, and any errors in representation here are totally my fault and not theirs, since I have not read the book for myself in order to interpret and present it. I will put it on the task list, so that my informed interpretation can serve as a resource here at POEM in the near future.

My interest in taking this series of free workshops (and I will put an enthusiastic plug in here for them as they are an excellent and fully-open resource; if you're anywhere near enough to Seattle or Lynnwood to attend, I recommend them whole-heartedly) is in learning how MTs can be of more effective service to returning veterans, and in making that knowledge freely and openly available here at POEM.

Lori is an experienced social worker; she has training and a scope of practice that is not the same as ours, so I asked her several questions about how we could translate this information into something MTs can use knowledgeably, ethically, and within our scope of practice.

The first question I asked was when she said we can provide a service by letting them tell us about their nightmares. I asked what an MT needs to know in order to make sure that we could do that without exceeding our scope of practice and bordering on practicing psychotherapy ourselves.

She responded that we are not practicing psychotherapy if we just listen supportively, without trying to structure the discussion. or to interpret it, or to try to draw out disclosure from the veteran.

If they bring it up of their own accord, during an assessment/history or during a massage, we can reasonably and ethically:

• Reflect their disclosure back in a sympathetic and non-judgmental way: "That must have been a very difficult thing to have lived through."
   
• Reassure them that they are safe in disclosing to you--not only will you not betray their confidences and secrets, nor will you reject them for what they went through, but also that they don't have to worry about protecting or shielding you.
  
  Only tell them this if it is actually true, however.
  
  If you really need to believe in a benevolent world to the degree that you are going to meet their self-disclosure with a response like "everything happens for a reason", then it is better to work with different populations.
  
  This is, after all, a population where many of its members need to find their way back to self-acceptance after already sacrificing their own self-worthiness to the ideal of a benevolent world.
  
  If they disclose to you, and then experience that you can't handle it, or that you are judging them, then you can actually contribute to a setback on their part.
   
• Refer calmly and matter-of-factly to our own limitations in scope of practice for being able to help them: "What you're telling me is very moving, and I can see that it's having a profound effect on you. I want to help and be supportive of you, but what we're talking about is outside of what I have been trained to help you with. Have you ever thought about talking to someone who is in a position to help with issues like these?"
  
  Of course, you'll find your own words, but the point is that you are not shying away from either what they tell you (you are not rejecting them), or from your own professional limitations (scope of practice).
  
  What you need to have prepared in advance is a list of resources in your area they can draw upon.
  
  Sometimes, people are skeptical of professional therapists for various reasons, so it is a good idea to include informal peer-support groups, as well as professionals, on your resource list.
  
  You can also have brochures in your office, so that if someone doesn't yet (or ever) feel safe disclosing to you, they can discreetly take one for possible use later on.
   
• Never let anyone just "dump and run", because that reinforces isolation and feelings of unworthiness.
  
  Don't solicit disclosure (because that would be practicing psychotherapy without a license), but if someone does disclose, then acknowledge it, communicate that you appreciate their trust in you, that you do not judge them, and that you want to be supportive (including referring to someone else with a different scope of practice, if that's appropriate).
  
  Don't just let them disclose, and then hurry past it in an awkward way, or laugh it off and change the subject, because what you have communicated then is that you don't want to hear it--and that reinforces their previous injury to their self-worth.
  
  The big secret of trauma survivors is the feelings of unworthiness that accompany the event.
  
  By letting them tell you their nightmares, or other disclosures, if they bring it up and want to talk about it, you can help them to start chipping away at that secret, by letting them know they don't have to keep it anymore.
  
  If it's more than you can help them deal with while staying in your scope of practice, don't be afraid to say so.
  
  It is perfectly ethical to say I care, I want to help, I can do this but not that because I am not trained for it, but if you like, I can help you to look for help from people who are in a position to help you in ways that I can't.

We have the privilege of (literally) reaching people, many of whom--veterans or not--will be trauma survivors.

By learning how we can use our touch skillfully and ethically, we have the potential to be of great service to an increasing number of people living with the aftereffects of trauma.

I hope more of us step up to that challenge, and I hope we share our stories with each other about how we are doing so.

Source: Still picture from the film "now, after (a PTSD/VA autobiography)" by Kyle Hausmann-Stokes, available at http://www.youtube.com/watch?v=NkWwZ9ZtPEI accessed 11 March 2012

(I recommend this film most highly, but before you watch it, you should know that it contains very violent scenes of death and dismemberment where the person's face is visible. You should consider, before you watch it, whether a film with such vivid potential triggers is right for you or not. There is no shame at all in deciding that such a film is too violent for you personally, and deciding not to watch it for that reason.)

Summary

There are at least three issues involved in deciding how long to wait between massage and scuba diving, either massage before diving, or massage after diving.

1. Does massage make DCS (decompression sickness, "the bends") more likely to happen, or does it make it worse if it does happen?
2. Does massage cause a situation that makes false positives for DCS more likely, meaning that resources are used unnecessarily to diagnose and treat suspected cases that are not really DCS?
3. Does massage cause a situation that makes false negatives for DCS more likely, meaning that real cases of a potentially life-threatening condition are ignored or missed?

There are theoretical scenarios for "yes" answers to all 3 of those questions that are all physiologically plausible, although there is no evidence yet to quantify what the real clinical risk from those theoretical risks are.

However, the safest way to practice is to wait 24 hours after getting a massage before scuba diving, and to wait 24 hours after scuba diving for getting a massage.

If the--admittedly very low--probability of DCS actually does turn into a case:

1. The MT will never be able to prove that the massage did not cause, worsen, or mask the symptoms of DCS, and
2. If the case turns adversarial and legal, there is information on record from Divers Alert Network DAN, the pre-eminent diving medicine research and education organization, where MDs and physiologists recommend waiting as the safest principle. A lawyer will be able to point to that recommendation, and argue that the MT violated standards of practice, such as they exist, by not waiting according to that recommendation.

For these reasons, POEM recommends spacing massage and scuba diving at least 24 hours apart in each direction as the safest course to follow.

Over at Massage Practice Builder's Wall on Facebook, an MT asks:

Years ago I recall reading somewhere that massage is contraindicated within 24 hours after scuba diving. In searching now, I'm finding contradictory information. Anyone have a reliable source re this? Thanks!

Divers Alert Network (DAN), the go-to site for medical information about diving, doesn't answer the question directly, but sketches out some of the issues involved.

A DAN physician recommends against deep-tissue massage before diving, but says nothing about it afterwards:

Massage & Diving

I've been told not get a deep tissue massage the same day as diving because it can cause DCS. Is this true?

You raise an interesting question about the possible association between massage and DCS risk.

* DCS = decompression sickness, colloquially called "the bends".

Wikipedia's article on DCS provides a very good summary:

Decompression sickness (DCS; also known as divers' disease, the bends or caisson disease) describes a condition arising from dissolved gases coming out of solution into bubbles inside the body on depressurisation. DCS most commonly refers to a specific type of underwater diving hazard but may be experienced in other depressurisation events such as caisson working, flying in unpressurised aircraft, and extra-vehicular activity from spacecraft.

Since bubbles can form in or migrate to any part of the body, DCS can produce many symptoms, and its effects may vary from joint pain and rashes to paralysis and death. Individual susceptibility can vary from day to day, and different individuals under the same conditions may be affected differently or not at all.

Source: Inside the underwater caisson--building the Brooklyn Bridge, http://xroads.virginia.edu/~ma03/pricola/bridge/images/caisson2.jpg accessed 4 February 2012

DAN's article continues:

Some have cautioned against massage before diving. The clearest justification is to avoid muscle pain that might be attributed to DCS.

So he's not saying that massage makes a diver more likely to actually get the bends; he's saying that the massage may cause slight soreness afterward that can confuse the diver and the healthcare team into thinking it's a case of the bends: a false positive for DCS.

The other possibility, which the DAN physician doesn't address here, is that the diver could actually get the bends, but ignore the symptoms and fail to seek medical attention for a serious condition, thinking that the soreness comes just from the massage: a false negative for DCS. We'll discuss this more later on in this post.

A more speculative [theoretical, not yet backed up by evidence] concern is to minimize the development of micronuclei [micro-bubbles filled with gas, less than 10 µm in diameter: less than 1/8 the width of a human hair].

Source, first picture: http://www.d.umn.edu/news/2008/August/Human_hair.jpg, accessed 4 February 2012

Source, second picture: http://www.seas.ucla.edu/~pilon/Photos/1.jpg, accessed 4 February 2012

The nature and action of micronuclei has not been confirmed, but it is believed that they are the seeds from which bubbles form. There is a theoretical concern that tissue massage may induce [bring about] micronuclei formation and thus precipitate [promote] bubble formation. Tissue stimulation could also increase blood flow which may either positively enhance tissue gas elimination or precipitate problematic bubble formation.

See how things are interconnected? The claim that massage increases blood flow is problematic, but whatever the evidence that emerges for or against that claim, it can play a role one way or another in whether or not massage increases the risk of DCS.

As you can see, there is no clear sense of what massage might do and this effect would likely vary depending on dive profiles and intensity of the massage. We should note that massage has not been confidently associated with any of the cases of DCS that have come to us, and we are not aware of any study done to address this question. The clearest piece of advice is that deep tissue massage should probably be avoided, so that the potential of post-dive pain and diagnostic confusion are minimized.

Dr. Nick Bird MD.

A physiologist at the DAN site reiterates the precautionary principle:

Decompression safety, as with many things, is a matter of balancing strings of decisions so the net outcome is in your favor. My approach is to stack as many factors as feasible in my favor to compensate for the Murphy effect or chance that we see frequently in decompression sickness.

Neal W. Pollock, Ph.D.

What are some of the factors involved in decompression sickness?

In general, being at a healthy weight works in your favor, while being overweight is thought to slightly increase your risk of DCS. Exercise, especially forms that put strain on the joints, is discouraged right after diving, as it's considered a slight risk factor.

Dehydration is thought to raise the risk of DCS as well. so the tradition of encouraging people to drink plenty of water after a massage cannot hurt, and may provide a tiny bit of protection.

Like you, I can see the basis for diving and flying, but not for massage. Massage may change skin temperature, but I think that's mostly by dilating superficial capillaries; i.e. not an actual change in blood temperature. Nor would I expect that massage would create anymore of a change in pressure than moving around or sitting down.

 

The real issue here is solubility. Gas solubility does decrease with temperature, but your body is simply not going to let that change.

 

The pressure dependence of solubility isn't the ideal gas law per se but Henry's law.

 

That law states that the concentration of the dissolved gas will be proportional to the pressure. As I recall, commercial airlines pressurize to about 7000 ft.

 

I would think that the greater danger would be not from the massage but from not recognizing symptoms of the bends and doing a massage in their presence rather than referring to medical care. http://en.wikipedia.org/wiki/Decompression_sickness#Signs_and_symptoms

 

I remember Donald Schiff talking some years back about a pilot coming in for a massage and referring him to emergency care.

Dive Injury Case Report

Case 8 – A diver with back trouble developed pain and motor weakness in his back and legs after 11 dives over three days complicated by altitude exposure. He had partial resolution during a long series of recompressions.

A 63-year-old male divemaster had made 50 dives during the past year and more than 200 lifetime dives. He had a history of degenerative lumbar disc disease and hypothyroidism for which he took synthetic thyroid hormone. He was on a liveaboard vacation and had made 11 dives over a 3 day period with a maximum depth of 128 fsw [feet of salt water] (39 msw [meters of salt water]) and a last dive depth of 100 fsw (30 msw). All dives were uneventful and used 32% nitrox [nitrogen-oxygen combination] with dive times according to an air computer.

He performed five dives the first day, four the second, and two morning dives on the third day. He stated he was well hydrated, well rested and had not consumed any alcohol. While returning to the boat after the second morning dive, he developed pain in his lower back consistent with his pre-existing disc condition, but he was able to climb onto the boat without assistance. He did not make another dive but opted to rest, have a back massage, and eat lunch. Feeling better, he participated in a walking tour of a local island which took him to an altitude of about 2,000 ft (610 m). During the tour, the back pain returned, and he had difficulty walking due to numbness in his legs but was able to return to the vessel where a physician also on vacation was concerned that might have neurological DCS. They informed the boat captain who placed the diver on first aid oxygen while they traveled to a nearby island with a hyperbaric chamber [where the air pressure can be increased or decreased in a controlled way].

Upon evaluation, the hyperbaric [high-pressure] physician found the diver had abnormal skin sensations bilaterally from his navel down to his toes, exhibited profound difficulty walking, and unsteadiness while standing. The diver was recompressed on Table 6 ["tables" here are hyperbaric medicine compression/decompression protocols] with extensions but had minimal improvement of his symptoms. Another Table 6 administered the following morning provided only slightly greater relief. Given the history of disc problems, the hyperbaric physician arranged for transfer to a hospital with greater diagnostic capability than on the island. As weather delayed air evacuation until the third day, the diver was treated again on a Table 5.

He was taken by air ambulance pressurized to one atmosphere to a larger hospital, but further diagnostic tests were inconclusive, and it was decided to continue hyperbaric therapy. The day after arrival, the diver received two treatments at 33 fsw (10 msw) for two hours with no improvement and later that day, a Table 6. Over the next seven days, he received 1-2 wound-care hyperbaric treatments (33 ft/10 msw) for 2 hours during which he reached a clinical plateau with no further improvement. His symptoms decreased over the next few months but intermittent symptoms continued, perhaps because of the existing disc problem.

Massage doesn't appear to have made the DCS worse--but can you think of any other role it could have played in this case?

Signs and symptoms of decompression sickness

DCS type	Bubble location	Signs & symptoms (clinical manifestations)
Musculoskeletal	Mostly large joints (elbows, shoulders, hip, wrists, knees, ankles)	Localized deep pain, ranging from mild to excruciating. Sometimes a dull ache, but rarely a sharp pain. Active and passive motion of the joint aggravates the pain. The pain may be reduced by bending the joint to find a more comfortable position. If caused by altitude, pain can occur immediately or up to many hours later.
Cutaneous	Skin	Itching, usually around the ears, face, neck, arms, and upper torso Sensation of tiny insects crawling over the skin (formication) Mottled or marbled skin usually around the shoulders, upper chest and abdomen, with itching Swelling of the skin, accompanied by tiny scar-like skin depressions (pitting edema)
Neurologic	Brain	Altered sensation, tingling or numbness paresthesia, increased sensitivity hyperesthesia Confusion or memory loss (amnesia) Visual abnormalities Unexplained mood or behaviour changes Seizures, unconsciousness
Neurologic	Spinal cord	Ascending weakness or paralysis in the legs Girdling abdominal or chest pain Urinary incontinence and fecal incontinence
Constitutional	Whole body	Headache Unexplained fatigue Generalised malaise, poorly localised aches
Audiovestibular	Inner ear [10][note 1]	Loss of balance Dizziness, vertigo, nausea, vomiting Hearing loss
Pulmonary	Lungs	Dry persistent cough Burning chest pain under the sternum, aggravated by breathing Shortness of breath

I'll let Neal Pollock of Divers Alert Network have the last word, as I can't possibly improve on the way he said it.

I end with the discussion of the capriciousness of decompression sickness to remind you of the power of the old adage of an ounce of prevention being better than a pound of cure. You are ahead of the game by asking the question. You should now think about all the little things that can all work together to keep your risk at a comfortably low level.

Neal W. Pollock, Ph.D., Divers Alert Network

Can we take the knowledge from last month's Journal Club and put it together with different research in a different specialty with a different population of clients/patients to produce a new and testable hypothesis about how massage oil (with or without massage, as appropriate) can provide benefit to those clients/patients?

Information that will be relevant to us is summed up in these comments from Journal Club:

• One thing about tables; and 
• The rest of the data in Table 1.

Let's combine what we know from Journal Club with the following information:

Heal and her team tested a single application of a strong antibiotic, chloramphenicol, in the prevention of infection in minor dermatological surgery.

Heal CF, Buettner PG, Cruickshank R, Graham D, Browning S, Pendergast J, Drobetz H, Gluer R, Lisec C. Does single application of topical chloramphenicol to high risk sutured wounds reduce incidence of wound infection after minor surgery? Prospective randomised placebo controlled double blind trial. BMJ. 2009 Jan 15;338:a2812. doi: 10.1136/bmj.a2812.

 

Abstract: OBJECTIVE: To determine the effectiveness of a single application of topical chloramphenicol ointment in preventing wound infection after minor dermatological surgery. DESIGN: Prospective randomised placebo controlled double blind multicentre trial. SETTING: Primary care in a regional centre in Queensland, Australia. PARTICIPANTS: 972 minor surgery patients. INTERVENTIONS: A single topical dose of chloramphenicol (n=488) or paraffin ointment (n=484; placebo). MAIN OUTCOME MEASURE: Incidence of infection. RESULTS: The incidence of infection in the chloramphenicol group (6.6%; 95% confidence interval 4.9 to 8.8) was significantly lower than that in the control group (11.0%; 7.9 to 15.1) (P=0.010). The absolute reduction in infection rate was 4.4%, the relative reduction was 40%, and the relative risk of wound infection in the control group was 1.7 (95% confidence interval 1.1 to 2.5) times higher than in the intervention group. The number needed to treat was 22.8. CONCLUSION: Application of a single dose of topical chloramphenicol to high risk sutured wounds after minor surgery produces a moderate absolute reduction in infection rate that is statistically but not clinically significant. Trial registration Current Controlled Trials ISRCTN73223053. [1]

In clean minor surgery meticulous preoperative preparation and aseptic technique by appropriately trained practitioners with access to appropriate facilities will prevent most surgical site infections without antibiotic prophylaxis [preventive treatment]. [2]

Heal and collegaues report a reduced risk of wound infection with topical antibiotics after minor skin surgery. However, the control group had a high risk of infection and the influence of pre-existing carriage of skin pathogens, as shown by the appearance of the lesion's surface, was not considered.

 

Our prospective study shows that patients whose lesion preoperatively had a crusted or ulcerated skin surface were significantly more likely to develop clinical wound infections than patients whose lesion had a normal or scaly surface.

 

...

 

The risk of infection was significantly increased (P<0.05) for crusted and ulcerated skin surfaces compared with intact skin surfaces, and for ulcerated surfaces compared with scaly surfaces. It was not affected by perioperative topical antibiotics, site of the lesion, closure technique, or surgeon experience. Staphylococcus aureus was the causative organism in 18 out of 20 infections. Patient age was a significant risk factor, and older patients were more likely to have lesions with a broken surface. [3]