Is it necessary to cross the line?

Massage therapy is a very powerful therapeutic tool. Did I say something new?

Most of us who practices soft tissue mobilization by means of massage, know that massage therapy is extremely powerful in stress management, as well as in cases of painful orthopedic disorders. Also most would agree that there is no silver bullet in our occupation. There are many different types of massage that allows a practitioner to achieve desirable results, such as less pain, improved functional activities, improved sleep qualities, fewer anxieties, normalization of blood pressure and many more positive outcomes.

In my view, we are first door treatment providers. At the time I strongly believe that we have to work with chiropractors, physical therapists, medical doctors. Each of mentioned above healthcare providers, can contribute to well-being of the patients.

In many cases integrations of methods leads to solutions in cases of most difficult diseases/disorders.

Many times I wrote about negativity of creating 1000s alternative names, to massage therapy.  Individuals obtain massage therapy license, professional liability coverage for massage therapy and are members of massage therapy trade associations. Yet instead of calling themselves massage therapist they assume titles any of other 1000 alternative names. If one performs soft tissue mobilization using hands, then one is a massage therapist, and we have no need to cross lines to different scopes of practice. This is wrong, illegal and not necessary.

A few years ago, this was a massive phenomenon… instead to calling themselves massage therapists; many called themselves manual therapist. I am in very good relationships with many physical therapists in Southern California. One of them is very powerful member of Physical Therapy Association. She saw my article Manual Therapy vs. Massage Thrapy and laughingly said: ”Boris, you’ve made my day” She explained that many members of her professional associations, lately started complaining that’s more and more massage therapists use title ”Manual therapist” crossing the scope of practice line. Manual therapy CPT code can be used only, by PTs DCs and MDs. She added that many chiropractors also complained on the same line crossings.  Finally she said: ”…if your colleagues continue crossing the lines, we’ve got to stop this legally. In her assessment massage therapists have to work under PT supervision. That would guarantee no violation of scope of practice boundary lines.”

I strongly disagreed, but couldn’t answer the question: ”Why do massage therapists have tendencies to call themselves other than massage therapist?” I agreed that such trend exists however stating that overwhelming number of massage therapists practices therapy by means of massage in the frame of our scope of practice, and are very proud to call themselves massage therapists. She commented that even if a small percentage of massage therapists continues to present themselves as manual therapists it will be enough, to make all massage therapists to work under PT supervision. Thank God, the practice of calling themselves “manual therapists” is almost gone.

But creations of “new theories” and concepts continue. For many reasons I view this practice as negative and again somehow leading to crossing the lines.

Recently I have been involved in a discussion where my opponent claimed that according to Neuromatrix theory (I copied and pasted statements below).

There are four things that every therapist should know:

* There is no such thing as a pain receptor.
* The brain does not receive pain signals.
* Pain is created by the brain as a protective response to perceived threat.
* Pain science is a sub-discipline of neuroscience that has its own peer-reviewed journal(s), its own international association and conferences, and a massive amount of ongoing research and clinical work being done.

I was really shocked reading this statement and have replied.

Of course, there is such a thing as a pain receptor. It’s a sensory nerve and it’s called a nociceptor. The brain certainly receives pain signals. In most cases we address pain that is not created by the brain. In most cases pain sensation is generated on the peripheral level and is interpreted by the central nervous system. Neurophysiology is a most complicated discipline in entire medical physiology. I’m not neuroscientists, and as much I know, you also not a neuroscientists. At the time you are trying to interpret   the data and make such claims that a real clinical neuroscientists/MDs neurologist would be hesitant to do.

Pain is a complicated matter as there are many different types of pain. In some cases pain is indeed created by the brain as a protective response to perceived threat. However, if this were a general rule, then how can we explain the following phenomenon?  The brain of people who undergo brain surgery, exposed to and stimulated by electrodes during the surgery. Yet they experience no pain, even though they are NOT under general anesthesia. They can even talk and share their sensations.

As massage therapists we should focus on our work and what we know are clinically proven facts. This “neurorevolution” is unnecessary; massage therapy is not methodology under developments, but the working methodology clinically proven for long time. Surely there is always a room for improvement, but what you’ve proposed in your post, in my views is diametrically opposite from “improvement.” I am not saying this out of spite or any other negative emotion but as the one witnessing the total destructions of Eastern European Beautiful massage therapy fields, and only because of “new revolutionary ideas.”

This destruction happened at the time when massage was recognized and proven as an extremely powerful therapeutic methodology. MDs used to stay in line to study it. “If it ain’t broke, don’t fix it.” Let’s work together and to find healthy proportion.
Best wishes.
Boris

sorry to say it didn’t work. I got reply.

:”the mislabeling of nociceptors as “pain receptors” is not my opinion. It’s what the pain scientists say. You’ll have to take it up with them.

Patrick Wall is one of the leading pain scientists in the world. Patrick Wall and Ronald Melzack were the authors of the “Gate Theory of Pain.”

Fellow massage therapist, please pay attention at denying existence of pain receptors/ Nociceptors

* There is no such thing as a pain receptor.
* The brain does not receive pain signals

The same person continues writing:

”Nociceptors are high-threshold receptors. Low levels of pressure, for example, on normal tissue will not usually cause them to respond. However, high levels of pressure can make them fire, sending impulses to the brain. The brain processes this information and if it deems the pressure threatening may generate the sensation of pain as a protective mechanism. If the brain does not deem the situation threatening, it may not.“

It didn’t end up there. My opponent continued

“Pain researcher Patrick Wall stated, “The labeling of nociceptors as pain fibers was not an admirable simplification, but an unfortunate trivialization under the guise of simplification.”

I personally never labeled nociceptors as pain fibers, I calling them pain receptors, which is a free nerve ending , afferent nerve ending,  it brings information of pain/ pain impulse from the periphery toward the brain.

Dear colleagues, I wouldn’t bring up this discussion, if not for the fact that this new “neurorevolution” became a massive trend.  In my opinion it disseminates disinformation as well as misguides many massage therapists toward crossing the line. In the discussed case, and in many other cases, a massage therapist pretending to be a scientist capable to interpret scientific data would lead to statements “There is no such thing as a pain receptor.”
* The brain does not receive pain signals.

There were a number of people who participated in this discussion.  If all stated by my opponents would spread, our entire professional community would experience ill effect of this disinformation.  In an attempt to make this discussion a real educational experience I have asked a medical doctor, double board certified in: Clinical Neurology and Clinical Neurophysiology to reply to these statements.  FYI, there aren’t too many neurologists possessing double certifications. Clinical Neurology and Clinical Neurophysiology, is a bit different then theoretical neuroscience.

The doctor kindly agreed to help us out and this is what he wrote.

Boris,

This could not be further from factual science that is highly documented. There ARE multiple pain receptors, from somatic, cutaneous, visceral receptors. OF COURSE the brain receives the pain signals! How else would we perceive pain. Pain is simply an electrical impulse (the “pain impulse”) from the receptors that is activated (by heat, mechanically/ trauma etc., cold, hyperstimulation) through the spinothalamic tract in the anterior spinal cord, iplilaterally to the thalamus. The thalamus is commonly referred to as the “pain relay station,” because it seperates out the various sensations to communicate with the cortex and limbic system. The cortex perceives the pain, and the limbic system is the emotional center to “feel the pains effect.” In addition, there are multiple modulating centers in the spinal cord, brainstem, pons, and “peri-aqueductal grey” that is collectively known GATING THEORY OF PAIN. Some evidence of brains role in pain is that a stroke in the thalamus produces a famous syndrome in Neurology known as the Dejerine-Roussey syndrome of hemibody excruciating pain, even without an actual cause of pain in the body.
Pain is not exclusively “created by the brain.” Not sure who wrote this to you Boris, but this is highly amateurish and wouldn’t take much stock in it. The human body spends a great deal of energy, brain power, and a significant portion of the spinal cord, in order to monitor pain for protection. These pain signals are DESIGNED to be produced at or near the site of pain. AGAIN, the brain CAN produce pain on its own, but the design is meant to sense pain in the body for protection. An example of this is phantom limb pain. When a limb is cut off, the brain is unsure how to handle this and pain of the stump is perceived by the brain as in the phantom limb. This is because the brain WANTS to continue to receive SIGNAL FROM THE LIMB.
E. B. MD, FABPN
Board Certified in: Clinical Neurology and Clinical Neurophysiology.

This, however, wasn’t enough for this group of people who pretended to be a neuroscientists and the following rebuttal was posted:

”Boris, if you think you can fix broken tissue with your bare hands, through a thick layer of cutis/subcutis, full of neural array, there to protect the brain’s thermoregulatory organ and everything beneath it from external deformation, without engaging the brain itself, especially since epidermis, sensory receptors, nerves and brain all come from ectoderm, then, my friend, you are well and truly self-deluded and are going about blithely deluding others.
If you admit you are treating a person’s pain with your hands, then join the club – that’s all anyone else does, either. Via the perfectly scientifically acceptable mechanism of stress reduction.
I.e., you don’t have magic hands and you are no better “healer” than anyone else on this thread. So no one should have to look at your links or have your stuff presented in the context of a discussion.
It’s also possible you are just being a deliberately obtuse salesperson.”

First of all I never consider myself to be a healer, but a massage therapist. Secondly, to me all this post was a bunch of words, without meaning.  I requested to explain me the meaning of “broken tissue” and never got the answer.
Also this person repeatedly stated that there was no such thing as “pain receptors” at the same time mentioning “sensory receptors.” Again this is an example of confusion and misunderstanding of scientific terminology.

By the way, there is no shame in trying to become a good salesperson. In my case, however, I have miles to learn.  Otherwise why would I offer so many free educational materials?

”If you admit you are treating a person’s pain with your hands, then join the club – that’s all anyone else does, either.”

My answer was:

”When it comes to treating a person’s pain with my hands, applying massage techniques I can reduce size of lymphedema, stimulate muscles to normal resting tone, release tension within fascia, apply techniques of trigger point therapy/ischemic compression. Of course in case of successful massage therapy application, I have mentioned above, my client will experience less pain. I clearly communicated the definition of Physiological effect that massage has on the human body. That explanation included the main power/ “engaging the brain itself.”  However, not only brain, spinal cords are part of CNS. You are welcome to read it again if you miss it. Meantime don’t forget to explain what you meant by saying: ”Boris, if you think you can fix broken tissue with your bare hands…”
Two factors define the physiological effect of massage on humans:

  1. The local or mechanical factor is expressed by mechanical acceleration of venous blood drainage, some degree of lymph drainage acceleration, passive exercise for soft tissues, breaking down deposits of calcium in soft tissue and stimulation of its removal from the body.
  2. The main power of massage therapy is in reflexive therapy. By mobilizing skin, connective and muscular tissue, we deform the mechano receptors, which in turn release action potentials/impulses. Through neurological pathways these electrical impulses stimulate motor and vasomotor centers. As a reflex, or involuntary reaction of organs and systems to original stimuli, the body responds by expressing positive changes such as: muscular relaxation, vasadilation, reduction of blood pressure, reduction of stress hormones production, etc.

My fellow colleagues, I have decided to extend my blog and to exhaust this subject.

And knowing that not everyone likes reading long blogs, I apologize.

I will try to explain my views why all this  NEW, NEW often happening with in our community .I mean wrong interpretation of data. For example ,findings of constricting fibers within fascia, almost led to “Revolution” of massage therapy approach. When I asked is fascia containing nerves/fascia junctions, like muscles containing? It was a silence. Even when Dr. Schleip , was just talking on front of the camera, shared his excitement about ongoing research, immediately “pretending to be scientist” Lady interpretated this interview, as an scientific data presentation, and came  to conclusion, that fascia is not stretchable. I would ignore some statements and data interpretation like this, if she wouldn’t have  a lot of followers, to repeat this nonsense.BTW. Using the opportunity, and in case if some of you believes that fascia is not stretchable, then you’ll have to claim that fascia is not composed by collagen and reticular fibers.  I mean if fascia is not composed by collagen and reticular fibers, then fascia is not stretchable, as well as ligaments not stretchable, in case  if ligaments wouldn’t composed by collagen and reticular fibers.

Dear friends,

Biomedical field contains specialists of three equally important types: intellectuals, intellectuals/clinicians, and just clinicians. The “intellectuals” are mainly academicians who teach theoretical concepts of a particular science. Some of them possess great skills and academic backgrounds, in doing meta-analysis, and or performing medical statistics. They contribute to design  of research protocols ,research coordination, collecting medical statistics, and contributing to writing research papers, etc.

Intellectuals/clinicians are mainly people in clinical practice, scholars of science, professors of medicine, mainly principal investigators in clinical trials, as well as professionals practicing different medicine and or different methods of treatments.

These people serve as a bridge between intellectuals and clinicians.
Intellectuals and Intellectuals/clinicians practically work for clinicians. This two departments develop protocols/methods of treatment while clinicians learn techniques and theoretical concept well, and then applying on patients.

Intellectuals and clinicians live in different realities. When they communicate and discuss issues almost always many misunderstandings arise. In most cases there is no understanding. At the time intellectuals/ clinicians perfectly communicate with clinicians as well as with intellectuals.

In general intellectuals/ clinicians represent a very small percentage in the entire biomedical fields. Mainly these are scientist intellectuals, and clinicians. These structures are applicable to fields of medicine, physical therapy fields, and chiropractors, as well as to massage therapy fields. Lately many from our community have tendency to pretend to be scientists intellectuals, with no academic backgrounds, skills and capability to do interpretation of scientific data.

Most of us, including myself, are simple, hard-working massage therapists, who use massage therapy techniques in order to achieve results. Some of us possess skills in orthopedic massage, some in full body stress management massage. In principle, massage therapy is very simple but a very powerful methodology of treatment. For us it is crucial to understand physiological effect of massage as well as not to confuse deep tissue massage, with vigorous pressure.

Back to the Neuromatrix theory.

This is not a new theory, and it is the one that never really had clinical use in massage therapy. When asking my opponents on how Neuromatrix theory changed the way they practice massage therapy, I didn’t receive a clear answer but was referred to Neuro orthopedic Institute page, and other similar forums. In order to understand clinical applications based on Neuromatrix theory I also was recommended, to read the book “The neurodynamic techniques” by David Butler.

First of all, Neuro orthopedic Institute and other similar organizations are dedicated to educate about understanding pain and treating pain not massage therapists but physiotherapists and physical therapists. From what I could understand, there is no real emphasis on different variations of pain, and I really cannot understand meaning of the term “The neurodynamic techniques.”

Having said that, I carefully reviewed the book, just to see how it can be incorporated within massage therapy procedure without crossing lines of our scope of practice. The book is 96 pages long and is well illustrated.  From the page number 1 to 4, 10 to 13, 18 to 19, 22 to 24, 30 to 31, 35 to 43, 51 to 54, 61 to 65 and 71 to 86 the book presented techniques that, in my view, massage therapist legally cannot be perform. On the rest pages author proposing self stretching, and kind of exercise. Most likely it wouldn’t be legal to teach our clients this type of home programs, especially using the proposed concept.

There techniques reminded of osteopathic manipulations allowed performing to physical therapists and chiropractors. I couldn’t understand what does, mentioned in book, “nerves palpation” mean? By no means, I assert that the book is not good; it just discusses techniques that we, as massage therapists, cannot perform.

Which brings me back to the question stated in the title of this blog: ”Is it necessary to cross the lines?”

For the last 41 years I practice massage therapy with the great deal of success. I’m positive that many of my colleagues reach great results, by applying appropriate massage techniques. Lately, more and more, members of medical organizations such as doctors from Mayo Clinic, praise massage therapy outcomes. We practicing as a first door practitioners, as well as part of integrative medicine approach. Why crossing the lines? Just focus on perfecting massage performances. It is powerful enough.

Dear friends,

It is possible that Neuromatrix theory is important for clinical psychologists/ neuroscientists, psychiatrists, who deal with psychosomatic pains and other similar types of pains. But it isn’t really useful for massage therapy fields.

I am not a neuroscientist and wouldn’t take on myself the burden of presenting my own interpretation of the Neuromatrix theory.

I share with you my understanding of this theory.

1.Prof.Melzack  never proposed any clinical approach for pain management based on Neuromatrix theory.

  1. Reading his works, it was my understanding that he proposed a variety of theoretical aspects. Yet never concluded Neuromatrix theory.
  2. Neuromatrix is some kind of network connecting: ”spinothalamic tract in the anterior spinal cord and iplilaterally to the thalamus. The thalamus is commonly referred to as the “pain relay station,” because it seperates out the various sensations to communicate with the cortex and limbic system. The cortex perceives the pain, and the limbic system is the emotional center to “feel the pains effect.” In addition, there are multiple modulating centers in the spinal cord, brainstem, pons, and “peri-aqueductal grey” that is collectively known GATING THEORY OF PAIN.Dr.E.B” As you can see it is a very complicated network.

If you follow my presentation on physiological effect of massage on human body, massive release of action potentials/electrical impulses causes multiple positive changes in functions of organs and systems. All this positive changes in functions of organs and system, is a reaction of CNS to the original stimuli by massage, including stimulation of neuromatrix network. This is why in many cases of no tissue injury pains, we also achieving results. But if pain is a result of lymphedema, higher resting muscular tone, decreased blood supply to the tissues, etc. than until therapists address the mentioned above causes for pain – causes that activating neuromatrix network – client will continue to experience pain. During my career I knew about Neuromatrix  theory but never had necessity to study it deeply. Possessing the knowledge of physiological effect of massage and massage technical approaches that I was trained to perform, was quite enough to deliver results such as less pain, greater range of motion, improved functional activities,  experiencing less anxieties, control of blood pressure etc.

Perhaps the day will come when scientists will know more on neuromatrix theory, and will develop side effects free treatments, to deal with unknown origins of pain. Yet massage therapy is already known, clinically proven great methodology allowing treating people suffering from painful orthopedic disorders, muscular aches and pains related to stress and clinical depressions, etc. Let’s scientists, intellectuals and intellectuals/ clinicians, to develop methods, but meantime we shell talk less, not to pretend to be scientists. We shall continue practicing clinically proven, beloved massage therapy. Our methods of treatment work. Let’s continue helping people to get read of pain and, in general, to feel better.

The last few weeks I spent a great deal of time learning details of neuromatrix theory. It didn’t change the way I practice massage, simply because this theory has nothing to do with what I am doing.

Best wishes.

Boris

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