Getting Nick Ng, Founding Editor of Massage & Fitness Magazine, Drunk

My friend Nick Ng is visiting Denver, the city where I reside.  I had plans to have him over to my apartment to cook him dinner, but circumstances forced a change of plans and so we agreed to get together later for a drink or two.  And right away, I knew this would be fun.

That’s because Nick is always fun.  He is a very positive guy.  But it is also because Nick has a famously low tolerance for alcohol.

Now, before I go any further, I realize you might be asking ‘what does this have to do with massage research or education?’  I admit there is no direct connection.  Alcohol is a dangerous recreational drug that you should not abuse and I should probably not celebrate it in this blog.  But there is an indirect connection, in that Nick is the Founding Editor of Massage & Fitness, an online magazine that seeks to elevate the practice of massage therapy with professional and scientifically-accurate content.  Are you a member of the profession?  I urge you to subscribe.  (And to be clear, that’s coming from me – Nick doesn’t know I’m making this post, a fact that I think will become evident from the photographs that follow.)

I decided to take Nick to Stem Ciders.  I like the product and the atmosphere and thought that cider would be more agreeable to Nick than other alcohol-delivery systems.

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Stylish etched glasses at Stem Ciders, Denver CO.

 

In addition to full-pour servings, Stem also serves ‘flights’ that allow one to sample four different varieties of cider.  I handed Nick a menu and glanced over his shoulder as he perused the ‘Flights’ section.  And, somehow, I accurately predicted that he would choose the ‘Fruity’ flight over the others.  Did I mention Nick isn’t much of a drinker?

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The Fruity Flight.  OD is off-dry, is raspberry, PC is a pear cider, and HS is scented with hibiscus.  We’re not talking rocket fuel here.

 

I ordered the first of several ‘La Chene’ ciders for myself (“Red Zinfandel barrel aged.  Smoke, caramel, and vanilla on the nose, smooth velvet mouth feel and slight oak tannin astringency on the finish.”  Alcohol by volume = 6.4%.) and wondered to myself how many of the little sample tumblers it would take before there would be noticeable signs of intoxication in our subject.  Nick himself declared that the flight, rather than serving as a tool to help him make a later selection, would be all that he could drink…

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“I don’t like selfies.”  -A still sober Nick Ng.

 

Nick started in on his flight from left to right, just as you would expect of a writer and editor.  And, remarkably, before he had even finished the first small tumbler, his face started turning red and his forehead beaded with sweat.  And he began laughing.  A lot.

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Nick Ng, Founding Editor of Massage & Fitness magazine and the world’s cheapest drinking date.

 

About halfway into the flight, Nick was drunk enough to express astonishment that the establishment had a dishwasher behind the bar.  I reminded Nick that this was the 21st century, after all.  What will they think of next?

I ordered myself a second La Chene and paced myself so that I would complete it as Nick reached the end of his Fruity flight, which would likely be his limit.  (He didn’t know it yet, but I planned to push him a little bit beyond that limit.)  Eventually Nick progressed to the rightmost drink on the board, a cider scented with hibiscus.  I cannot find a flavor profile description of this one on the Stem Ciders website, so I’ll just note that it is pink, floral, and a ridiculously low 4.4% alcohol by volume.  Nick, who was now quite drunk, loved it.

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That hibiscus cider is a monster.

 

Nick completed the flight as I downed my second La Chene.  I waited a few minutes and then ordered a third, at which point I indicated to Nick that it was time to use his newfound cider knowledge to select which one he would now have as a full pour.  In my mind I made a bet as to which one it would be, and instinctively knew it was safe to bet it all on the hibiscus.  I was not wrong.

As Nick and I drank some more, we discussed the high-level challenges confronting massage therapy and his long-term plans for Massage & Fitness magazine.  (Did I mention you need a subscription?  Honestly, if you’re serious about your work in this area, do it now.)

Actually, I’m kidding.  Mostly, Nick laughed.  A lot.  If you’re ever out with Nick Ng, want to have a good time, and have eleven or twelve bucks to spare, take him drinking.  It’s an incredible value.

Eventually, after Nick had finished his hibiscus-scented cider, we made our way to the car.  Nick was WAY too drunk to drive, so it is good that I was still nearly stone sober, of course.  I teased Nick, in a good-natured way, for getting bombed on 4.4% ABV pink cider scented with flowers, and he made me promise to never mention this to Sarah Haag or Sandy Hilton of Entropy Physiotherapy.  Your secret is safe with me, buddy.

 

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No more pictures!

 

-CM

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MT Journal Club ep 2.1 – Delayed-Onset Muscle Soreness

After testing the idea out with two pilot episodes (ep 1 and ep 2), I am streamlining the format of the Massage Therapy Journal Club and introducing new episodes.  The most notable change will be to have one or occasionally two guests per episode instead of four or five.  I think this change will improve the program itself while also simplifying planning behind the scenes.

The first of the ‘Season 2’ episodes will air live on December 12th at 1 p.m. EST / 10 a.m. PST and will also be available for subsequent viewing (use this link for either).  Mark Retzlaff will join me to discuss the recent meta-analysis of the effect of massage therapy on delayed-onset muscle soreness.  Whether or not you can find the time to scan the article first (recommended, but not required), I hope you’ll join us.

To try and make this and related projects sustainable, I have created a Patreon page.  Please consider making a contribution if you find the Massage Therapy Journal Club valuable and are in a position to do so.  Thank you.

-CM

Massage Therapy Journal Club ep 2: Moraska & Chandler (2008)

Join us today at 4:30 Mountain Standard Time for the latest episode of the Massage Therapy Journal Club.  I will be joined by Jennifer Barrett, Lauren Davis, Til Luchau, Alice Sanvito, and Ravensara Travillian to discuss a study published by Moraska & Chandler entitled “Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study.”

You can use this link to watch live or the recording after the episode has aired.

Here is an outline of the article that we may use to facilitate the discussion:

 

Moraska, A., & Chandler, C. (2008). Changes in clinical parameters in patients with tension-type headache following massage therapy: a pilot study. The Journal of Manual & Manipulative Therapy, 16, 106-112.

Introduction

Focus is on tension-type headache (TTH)

Most prevalent type

Lack of effective medical options may drive popularity of non-pharmaceutical options

Forty percent of patients visiting a headache clinic reported using one or more CAM modalities

Some (est. 25%) TTH sufferers engage in self-massage for pain relief

Previous studies

Puustjarvi et al. (1990) found that massage reduced TTH frequency in women, including at 6mo follow-up

Quinn et al. (2002) conducted a case series using highly trained massage therapists and found as little as two 30min massage sessions reduced headache frequency 50%

Nature of TTH

Muscular involvement

Physiological and physical abnormalities

Increased tenderness

Greater incidence of myofascial trigger points

Forward head posture

Reduced cervical muscle strength and endurance

Study objective was to “evaluate a specific massage therapy treatment dirercted at cervical and cranial musculature on primary and secondary measurers of headache as well as a measurer of disability associated with headache” (p. 107)

Methods

Study design

3-wk baseline period

6-wk treatment period

Biweekly 45min massage treatments

Massage directed to soft tissues of cervical and cranial regions

3-wk follow-up period

Daily headache diary

Headache Disability Index administered at 3-wk intervals

Subjects

Conformed to international Headache Society guidelines for episodic or chronic TTH

Regular headache pain prior 6+ mos

Headaches lasting 4+ hrs

21-65 yrs of age

<1 migraine headache per month

Subject recruitment via newspaper and flyers at local physician offices

18 subjects enrolled, 2 dropouts/removals = 16 subjects for data analysis

Twelve of sixteen were women

Mean age = 43.8 yrs, range was 28 to 56

In prior six months four reported having received no massage, twelve reported having received at least one massage from a professional massage therapist

Massage therapists

Six therapists

Mean = six years professional experience

All received 6 hrs specific training in treatment protocol for this study

Subjects received all treatment from same therapist for duration of study

“To isolate the effect of the massage procedure from therapist-subject camaraderie, therapists and subjects were directed to minimize conversation…” (p. 107)

Therapists were not informed about subject progress during the study

Massage protocol

Two 45m sessions per week across six-week treatment period

Each session separated by at least 48 hrs

Specifics

First 15min = palmar strokes to “warm-up” tissues of back, shoulders, chest, and neck

Middle 15min = up to six myofascial trigger points palpated and treated; muscles addressed included upper trapezius, sternocleidomastoid, suboccipital, and splenius capitis

Final 15min

5min post-isometric relaxation directed to lateral cervical flexion

5min circular or cross fiber friction on masseter, temporalis, and occipital-frontalis muscles

5min gentle effleurage and petrissage on neck and shoulders

Assessments

Headache diary

Completed daily before bedtime

Indicate if TTH occurred

Duration

Peak intensity on 0-100 scale

Headache disability index

25-item standardized measure of TTH impact on daily living

Separate emotional and functional subscales

Was administered 5x at 3wk intervals

Was never administered on same day as massage was administered

Data analysis

Headache measures averaged for each 3wk phase

Repeated measures ANOVA (i.e., this is a within-group study with no separate control group)

Results

Headache frequency

Decreased significantly across time

Means

Baseline period = 4.7

Tx period 1 = ? (estimated 4.6 from graphic)

Tx period 2 = 3.7

Follow-up period = 3.2

Headache intensity

Decreased significantly across time

Means

Baseline period = 46.9

Tx period 1 = ? (estimated 38 from graphic)

Tx period 2 = ? (estimated 33 from graphic)

Follow-up period = 32.8

Headache duration

Decreased significantly across time (but not as uniformly as other effects)

Means

Baseline period = 4.0

Tx period 1 = ? (estimated 4.2 from graphic)

Tx period 2 = 3.4

Follow-up period = 2.8

Headache Disability Index

Total and subscale scores decreased across time

Means for total score

Baseline period = 44.2

Tx period 1 = ? (estimated 37 from graphic)

Tx period 2 = ? (estimated 24 from graphic)

Follow-up period = 25.1

Similar trajectories for Functional and Emotional subscales

Discussion

Summary of results is restated

Observation that improvements generally persisted or continued in follow-up phase

Detailed discussion of trigger point theory

Consideration of whether longer (60min) treatments might be superior

Consideration of whether early phase of treatment is a period of becoming accustomed to treatment

Noted that observed 19.1 point improvement on Headache Disability Index does not meet 29 point improvement that some have said is indicative of “clinical significance”

“The comparison to a baseline standard and not a placebo control group limits the ability to assess causality of the treatment” (p.111)

Conclusion

“The observed improvement in clinical headache parameters provides an intriguing look into the therapeutic effect of massage and is encouraging for placebo-controlled research in complementary and alternative treatments for TTH” (p. 111)

 

Discussion points and questions

What specific challenges might arise when studying treatment of headache?

Symptoms were generally reduced to a statistically significant degree – what the possible explanations for this finding?  How is the study limited by not having a control group?

The Discussion section of the paper includes much discussion of trigger point theory.  How important is that theory in relation to this study?  Is this study a test of trigger point theory?

Massage Therapy Journal Club ‘postgame’ summary

In launching the new Massage Therapy Journal Club, I’ve made the decision to learn some things as I go and to refine and improve things as the project progresses.  A couple days after we completed the first episode, it occurred to me that it would be worthwhile to make a blog post that summarizes some of the key discussion points and which includes helpful links for folks who might want to learn more.

We talked about a lot of different things as we considered Field’s 1998 article entitled “Massage Therapy Effects” and I would like to try and summarize and expand on three of those here. They are (1) publication bias; (2) the possibility that reduction of cortisol is the mechanism by which massage therapy works; and (3) models and methods that massage therapy research could borrow and adapt from other research areas.

Publication bias. In her article Field mentioned the likelihood that the body of massage therapy research might make massage therapy appear to be more uniformly effective than it actually is in reality due to publication bias. This can happen in many areas of science and research. Briefly, it is much more likely that a study will be published if it reports upon a positive finding, and especially if that finding is strong, unexpected, or very positive. Studies with null findings or an absence of findings may never be written up or submitted for publication by the persons who conduct them, and when they are submitted for publication they are more likely to be rejected because they may be judged to be uninteresting and/or a poor use of a scientific journal’s limited space for presenting studies. This is an important concept to be aware of when evaluating clinical research. Fortunately, there are quite a few good ways to account for it in quantitative reviews of research. For more detail on what publication bias is, and also how we can avoid being misled by it, have a look at the Wikipedia entry on publication bias.

Cortisol. Cortisol is a stress hormone produced by the adrenal glands. In her 1998 review article Field argues that massage therapy may work by reducing the recipient’s cortisol level; notably, she continues to strongly assert that this is how massage therapy works in many of her subsequent publications. My own research counters this. When my colleagues and I have carefully analyzed the data examining the effect of massage on cortisol, we consistently find that massage therapy does not significantly reduce cortisol. (Here is a detailed scientific paper on this, and here is Part 1 and Part 2 of a YouTube presentation that gives a slightly less technical summary of that research.) Some of the participants noted, also, that even though cortisol is a “stress hormone” it was probably not accurate to conceptualize it as having anything like a 1:1 relationship to stress. They are exactly right to be thinking this way – the relationship between stress and cortisol is complicated and is only one part of a complicated system for responding to a range of stressors.

Notably, this exact subject was raised at the end of Robert Sapolsky’s keynote address at last year’s San Diego Pain Summit. After Sapolsky – one of the world’s experts on stress and health – finished his talk, my friend Ruth Werner asked him about the nature of the stress-cortisol relationship including how it might relate to the discrepant conclusions in massage therapy research. You can view the exchange in the first seven minutes of this video taken during the Q&A portion of his talk. (And if you’ve never seen it, consider watching the National Geographic documentary “Stress: Portrait of a Killer” which features Dr. Sapolsky’s work; here is a link to it on YouTube.

Models for massage therapy research. This is a complicated topic so I am only going to touch on it here. Briefly, our discussion touched on the fact that people interested in massage therapy research sometimes believe that this area of research presents unique problems, such as how can massage therapy ever be understood by science if science demands that it be studied under controlled and standardized conditions? And, if the success of massage depends on there being a good therapeutic relationship between the provider and the recipient, doesn’t that mean we can never really measure what it most important in treatment?

These are very important things to consider, and they can make it difficult to do good research. However, they are not insurmountable. More importantly, they are not problems that are unique to massage therapy research. There are other areas of clinical research and of intervention research that also confront these and related problems and which have developed clever and effective methods for addressing them. I have argued that the well-developed are of psychotherapy research can be an excellent model for massage therapy research. The fields of medicine, education, and occupational therapy are some other areas that have dealt with these and similar challenges and are ones that the field of massage therapy research can look to, and borrow from, to hasten its own progress. Massage therapy research does have some challenging elements due to the fact that it is based on interpersonal contact and may work best when it is not performed according to a standardized protocol; however, massage therapy researchers do not need to ‘reinvent the wheel’ to address these issues. They can and should look to these other areas of clinical and intervention research for partial or even complete solutions to these challenges.

-CM

P.S. I am conducting a promotion to help ensure the success of the Massage Therapy Journal Club. Have a look at this short video to learn how you can be entered to win a free copy of my book, Massage Therapy: Integrating Research and Practice, and please share the link if you can.

Win my book

Would you like to win a copy of my book, Massage Therapy; Integrating Research and Practice, while also staying informed about the new Massage Therapy Journal Club? Great! This short video contains all the details on how to join the list of people who receive occasional email updates about the Massage Therapy Journal Club while also entering yourself for a chance to win a brand new copy of the book. If the response is good (500+ people made a part of the list), I have plans to give away two copies. Good luck!

-CM

Massage and Fitness Magazine Winter 2017 issue

Hey Folks, if you do not already know about this you should. Nick Ng is doing some great stuff with his Massage and Fitness online magazine.  It is an antidote to some of the other industry publications that fill their pages with pseudoscience.

Have a look at the new Winter 2017 issue that was just published and consider subscribing to get well-reasoned, scientifically-grounded  information about massage therapy and related topics.

MT Research Journal Club ep 1: Done

Earlier today I, along with some top-flight participants, completed the first episode of the online Massage Therapy Research Journal Club. This was our first ‘real’ episode but it was also a test of the idea, format, and technology. It felt like a success.  There were a couple of small technical issues to overcome, and other than that I think it went very well.

You can view it here.

I want to thank Marla Cohen, Meg Donnelly, Deetria Egeli, Beth Ivy, Mark Olson, Kim Stumpf, and Julie Wolff for volunteering, taking a chance, and helping me pilot this project with their terrific involvement. Thank  you so much.

I also want to thank Allissa Haines, Alice Sanvito, and Ravensara Travillian for helping me refine the idea and test the format. You are great friends.

I think the project is off to a good start, and it seems to have generated some real interest from folks who are interested in the science of massage therapy.  I look forward to refining and improving the format.

-CM

P.S. Deetria Egeli mentioned a couple of papers from the field of occupational therapy that informed her perspective on the psychological dimensions of the therapist-recipient dynamic. She made the references available to us in some email correspondence just after the episode was completed. Here they are:

Fearing, V. (c2000). Environments that enable therapist and client occupation. In V. Fearing, & J. Clark (Eds.), Individuals in context: A practical guide to client-centered practice (pp. 15-24). Thorofare, NJ: Slack.
 
Frank, A. W. (1998). Just listening: Narrative and deep illness. Families, Systems & Health, 16(3), 197-212. doi:10.1037/h0089849 This is available via google scholar Direct link: https://www.researchgate.net/profile/Arthur_Frank3/publication/232469291_Just_Listening_Narrative_and_Deep_Illness/links/54ef402f0cf2432ba656357b.pdf