Episode Transcript

Summary:

1. Introduction to The Thinking Practitioner Podcast (00:00-01:30)
2. The history of recommendations about massage and cancer (01:30-07:30)
3. The benefits of massage therapy for people with cancer (07:30-12:30)
4. The possible effects of massage on tumor sites (12:30-17:49)
5. Discussing a study on massage and tumor cells migration (17:49-23:00)
6. Discussing a study on massage and osteosarcoma progression (23:00-30:00)
7. Red flags and referrals for potential cancer screening (30:00-37:00)
8. The importance of communication and partnership with clients (37:00-41:00)
9. Resources for further information on massage and cancer (41:00-45:00)
10. Closing remarks and contact information for the guests (45:00-47:30)

  Transcript Whitney Lowe: Welcome to The Thinking Practitioner Podcast. Til Luchau: A podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today. Whitney Lowe: I’m Whitney Lowe. Til Luchau: I’m Til Luchau. Whitney Lowe: Welcome to the Thinking Practitioner. Welcome to the Thinking Practitioner Podcast, where Books of Discovery have been part of the massage therapy and bodywork world for over 25 years, and nearly 3,000 schools around the globe teach with their textbooks, E-textbooks and digital resources. Books of Discovery likes to say, “Learning adventures start here,” and they find that same spirit here on the Thinking Practitioner Podcast and are proud to support our work, knowing that we share the mission to bring the massage and bodywork community thought-provoking and enlivening content that advances our profession. Til Luchau: Instructors of manual therapy education programs can request complimentary copies of Books of Discovery’s textbooks to review for use in their programs. Please reach out at booksofdiscovery.com. Listeners can explore their collection of learning resources for anatomy, pathology, kinesiology, physiology, ethics, and business mastery at booksofdiscovery.com, where thinking practitioners like you save 15% by entering thinking at checkout. I am looking forward to our conversation today. I’ll introduce our very special guests in a minute, but first I want to just give the context. So, after being diagnosed with breast cancer in 2012, my wife, Loretta, has been living with breast cancer now for 11 years. So, I keep a pretty close eye on what’s happening out in the cancer and massage world in particular, cancer massage bodywork. There were two things that came across my radar in the past couple of years that really caught my eye. In both cases, the researchers unambiguous recommendation was, “Don’t massage.” So, I’m hoping our, like I said, very esteemed guests can help us put these studies into context and figure it’s a great chance to review the history of this question as well. Whitney Lowe: We would like to welcome our first guest, Cathy Ryan, who’s a registered massage therapist practicing in Canada, and actively highly regarded continuing education teacher and conference presenter, especially in the areas of scar tissue management. You’ll remember we had Cathy on our podcast previously in episode 42, and also involved with myofascial pain and dysfunction. She’s also authored works including co-authoring, Oncology Massage, An Integrative Approach to Cancer Care for Manual Therapists. Also, from Jessica Kingsley publishers. So, welcome back to the Thinking Practitioner Podcast, Cathy. Great to have you again. Cathy Ryan: Thanks Whitney. Just a quick correction there. I didn’t co-author Integrative Oncology Massage, but I am a chapter contributor to that. I co-authored- Whitney Lowe: Okay. Great. Thanks for that. Cathy Ryan: I co-authored, Scar Tissue Management with Nancy Keeney Smith. Whitney Lowe: Okay. Cathy Ryan: Thank you. Til Luchau: Thanks for that. Erika Slocum, you’re an oncology massage working at a major East Coast cancer center, which is ranked in the top five cancer centers in the country but which we didn’t have time to get approval to actually name here. So, you’ve taught intensive oncology massage workshops with Tracy Walton, who we can name. Very honored to be able to do so. Who is a pioneer in massage therapy and cancer. You’ve taught with her all over the country since 2011. Thanks for taking the time to be with us, Erika. Erika Slocum: Sure, thank you. Til Luchau: All right. So, to start out, before we get into those studies I mentioned, I wonder if you wouldn’t mind giving us your views about how recommendations on massage and cancer have changed over the years. Because, context for myself, back in the eighties, early eighties when I was being trained, we were just told flat out, “Don’t massage people with cancer because there’s a risk of metastasis and we never know if we’re spreading it.” That blanket recommendation has definitely evolved since then. I know it’s a subject of lots of great work and discussion and deep thinking. So, what are the current attitudes would you say toward working with people with cancer? Erika, would you mind starting us off on that? Erika Slocum: Sure, yeah. I mean, as we know we’ve come a long way. I think that it’s pretty fair to say that, as you said, that the blanket recommendation of no massage didn’t really leave any room for any nuance at all in our work. Massage is a great many things, and I think it’s been really important and a wonderful practice that we’ve developed over all of these years with all these wonderful big brainy thinkers, to really pick apart, what are the arguments here? What is it about cancer, what is it about metastasis, what is it about massage therapy that really may be a risk factor, if it is? I think that where we came from, which is the blanket rule of, if someone has cancer don’t massage them, is really much, much more colorful now. Also just has so much more room for question and discussion. I think really where we came to with that is, not to oversimplify this, but in all of the stages of metastasis, which is still being uncovered all the time in medicine, a lot of what we’ve come to is, don’t massage a tumor site. Don’t disturb what we know to be an active tumor site. How do we find that out? I think that’s really where the detail comes in. What questions do we ask? How do we know what questions to ask? This is a lot of what we teach in our classes is the fact-finding mission of being able to really have a good conversation and uncover the details that we need to and the information that we need to in order to work safely with someone. That’s incredibly important. I don’t get the question very often any more from clients or patients of, “Geez. Will massage therapy spread my cancer?” But it does happen still. I love that question because, gosh. I don’t want someone to come on my table just blindly accepting that it’s going to be okay, you know what you’re doing, sort of thing. But really get into why we think massage therapy is safe if applied correctly, and asking the right questions. We’ve really come quite a long way in our thinking. Again, our big takeaway is we don’t massage tumors, we don’t massage areas of active cancer. Til Luchau: I know there’s probably a whole lot more to it than that, this question of how we keep it safe. Erika Slocum: Mm-hmm. Til Luchau: But that’s a pretty key point I think, that we want to unpack so we don’t massage tumors. You said, “Sometimes it happens.” You’re saying the question still comes up sometimes, just to clarify that. Erika Slocum: Sometimes the question still comes up. Yeah. Til Luchau: Yeah. Erika Slocum: I don’t get it very often I have to say, but every now and then someone will ask. Til Luchau: Please fill me in, and Cathy jump in too if you’d like, but fill me in. But my impression is there’s a substantial body of evidence that there’s benefit from massage during cancer treatment. Erika Slocum: Yes, absolutely. Yeah. There is a growing body of research that certainly suggests there are… Particularly in the areas of pain and depression still to this point. But certainly, I mean I know Cathy, I’m sure you can jump in on all of the ways in which we hear from our patients and our clients, on the way that it benefits them. Certainly side effects, symptom management, side effect management of cancer itself, but also the treatments come with a whole host of potential side effects, and really being able to help alleviate some of that is certainly part of the joy in my work. Cathy Ryan: I’ll just jump in, again just speaking to a little bit of the historical context too. Like you, I did my original training back in the eighties, and certainly that was the prevailing mindset was that we just do not touch anybody with cancer period, that blanket perspective. So, the first person that I’m aware of that really challenged that in a significant way is one of the iconic Canadian massage therapy educators, Deborah Curtis. She’s the first one that I am aware of, that really came out swinging. Really I think Deborah was, for me, one of the first individuals to really be what I would describe as an evidenced informed educator. This was what she was known for here in Canada. She wrote an article back in the 1990s, picking apart what we knew at the time about what was understood about how cancer spreads and what we understood at the time, what was essentially potentially what we are capable of with our hands and how those two things intersect. That’s really where historically my mind started to shift around that, was very much rooted in Deborah. Then of course Gail MacDonald around the same time was starting her process of oncology education. Then Tracy pretty much right on the heels of that as well. Til Luchau: Tracy Walton. Cathy Ryan: Then it really is- Til Luchau: All pioneers in that shift, that paradigm shift. Cathy Ryan: Exactly, exactly. Just to speak to the benefit of massage therapy for people who are living with cancer, people going through various types of cancer-related therapies. I think really two of the most robust areas of research for massage therapy are in pain management, and as well as just mood, anxiety, depression. Those are the areas that there’s a lot of research to support how massage therapy can be of benefit to people. The Society for Oncology Massage is one of those organizations that is good for them, a little more current research as well as, Whitney mentioned, Oncology Massage: An Integrative Approach to Cancer Care, which was co-authored by Janet Penny and Rebecca Sturgeon from Healwell. Also, a more current resource. Til Luchau: We’ve had them as guests on the show here. Cathy Ryan: Right. Til Luchau: We’ll link to those two things you just mentioned in the show notes as well. Whitney Lowe: One of the things that I know that I hear a lot from practitioners as a concern, when we say, “Don’t massage active tumor sites,” everybody’s like, “That’s a no-brainer. That certainly does make sense.” But then the question always comes in, “Well, how do I know if somebody has potential metastasis? How do I really know what might be an active site?” Thoughts on that, in terms of how we manage that? Cathy Ryan: I think Erika brought up a really important point and it really emphasizes the importance of a thorough health history the first time that we’re seeing someone, to see if we can see any kind of red flags that might lead us into a direction that needs further investigation. I think it also, for me, emphasizes something that I beat a drum a lot about here in Canada, is the need for what I would describe as advanced practice education and training in certain complex areas of care, oncology being one of them. Not to in any way devalue those educators like Tracy Walton, who is doing a phenomenal job and her associates of educating people, or Gail or Healwell, but I think we need something that is more standardized. We need some kind of valid accreditation process that doesn’t exist. So, there are individuals out there who are certifying people, but there’s no, let’s say, third party that’s ensuring that certain standards are being met. Whitney Lowe: Yeah. That’s a rampant issue I think everywhere, in terms of a lot of these areas of specialized care for people with healthcare complaints. Cathy Ryan: Even here in Canada, considered the Shangri-La of massage therapy education and training where we have really rigorous standards, I still really strongly believe that there’s a need for that. Erika Slocum: Yeah, I couldn’t agree more. I think having some foundational oncology massages is really vital. Particularly because you can’t not see someone that has a history at least of cancer, there’s so many people that will walk into our doors, will have a history of cancer, maybe active cancer as well. Knowing what to do, even if you’re not intensely trained, I think getting some foundational education around, okay. Well, what can I do safely in this case? Then we can refer them to someone else who has more training, can work with them a little bit differently. Or we get our training ourselves and then they can come back, whatever it is. I would love to see that. I would love to see that. I think when it comes to not knowing, that’s always the concern, coming back to this question of, well, what if we don’t know? What if the person doesn’t know if they have an area of metastasis, for example? I think this is an incredibly important conversation. I think it’s really at the crux of some of this research that we’re going to be talking about, these studies that we’re going to talk about too is… The big question for me is, when do we refer, when do we bring in a medical voice if we need to or need more information before we work? I think that’s a problem across massage therapists in general, not just in this cancer realm. But when do we refer to other clinicians and practitioners? I think that we talk about pain, reports of new pain. Is it nervy pain? We ask them to describe what they’re really going through to see if we can suss out a little bit further, does this sound like the old injury from 1978 football, whatever? Or is this something different? Trying to get information. Some of this, to be honest with you, I think we all have quite a lot of experience and we’ve heard many, many things. So, some of it comes with experience, and in lieu of experience or extra training, how do we respond? What do we do? Til Luchau: You’re saying there’s a role for experience, there’s a role for training, there’s a role for careful histories, there’s a role for careful monitoring of what’s happening and the symptoms that are arising during the treatment. Let’s talk about those studies some, because in some ways this is one of the key questions in our understanding of them. First study, well, let me just say too before we get into the studies. My wife really does benefit quite a bit from hands-on work in her now 11-year process, and both from me and from lymphatic practitioners. I’m just remembering that at one point she said, “Hey, you’re working with my lymph, couldn’t you be spreading my metastasis around?” Her practitioner says, “No. No, you need the lymph to move. That’s what helps deal with the cancer.” That was the quick answer for the client-facing interaction that happened there, and it reassured my wife. She’s watching this very closely though, as we’re having this discussion of course. Okay. So, these studies that make me want to think harder about it and talk more about it. First one from Peter Friedl, at the Facial Research Congress in Montreal, 2022. It’s unpublished work. Dr. Friedl actually responded to my requests for a conversation here with him about it really quickly. He’s willing to come talk. However, the work he presented at that Congress hasn’t been published and he wants to wait until it’s published later in the year. Maybe we’ll get him to circle back around to comment on some of the things we talk about today. But his presentation at the Facial Research Congress, you were there Whitney, showed live mouse tissue with pigmented tumor cells in it. He was massaging the tissue with a probe and you could visually see the pigmented tumor cells being pushed out or migrating out into the extracellular channels around the tumor. His recommendation on the slide that came up there right after showing us that, “Don’t massage tumors.” Did I summarize that more or less fairly, Whitney? Whitney Lowe: Yeah. That’s what I got out of there too. Then I know for me there was a couple of questions that came up out of that, which there always is with research in particular. Til Luchau: Yeah. I was like, “What? Wait a minute.” Lots of questions which I want to unpack and go through. I want to also just- Til Luchau: Yeah. You said that was right before lunch and over lunch everyone was like, “Wait a minute. How dare he say this without X, Y and Z?” Now, to be fair to him, I’m sure I’m oversimplifying his research as well. We must acknowledge that. Whitney Lowe: I think there was, a question that came up for me if I remember, and this has been a couple of years now so it’s a little fuzzy in my memory. But one of the things that did come up for me as a question at that point was, it looked as if he was able to massage those tumor sites with a very, very fine instrument or probe or something like that, to get very specific pressure in that area or something like that. My question was, does that translate into the very broad-based applications of pressure that would be done during massage, and would that have the same effect on there? Til Luchau: Yeah. Well, let’s go through those questions. What questions come up in your minds, Erika and Cathy? Cathy Ryan: Well, for me, initially anytime I see a study like this, my first question always is, was there any involvement of massage therapists in the research study design? Because for me, the question that always comes up is, what kind of pressure, how much pressure, is it any pressure at all? Or does there have to be a certain amount of pressure? As Whitney brought up, does that pressure have to be very point-specific, or if there’s pressure around the area, does that also produce this same kind of results? For me, that’s always the first question that I have when I’m trying to critically evaluate research, because I think it is important for me to not go to the extremes of completely dismissing it because it doesn’t align with my understanding or my beliefs, or the other side of the coin that… All in. Absolutely, it’s part of picking that apart and critically evaluating, in what context is this important for me to know as a practitioner? That’s always the first question for me. Erika Slocum: Yeah, absolutely. I would absolutely… Right on that one. Again, it goes back to the nuance of what our work is. I work differently than Cathy, than Til, then Whitney. I mean, we all work differently. So, what is it about the massage that is contraindicated or needs to be adjusted in some way? Not just all of massage, what is it specifically about massage? As Cathy said, it’s sight, it’s pressure, it’s how much pressure, that kind of thing. The reaction I typically get from one of these, something that comes out too is always, my first reaction is always like, “Oh, man. We’re going back again.” Then with this in particular, I was like, I read through this other study a couple of times, I looked at this video and in a way it’s actually validating for what we’re already doing. When it says, “Don’t massage a tumor,” we’re not massaging tumors. To your point earlier, we probably didn’t have to have extra training to know that we don’t massage tumors. But that’s essentially what I took… One of the big takeaways here was, we don’t massage tumors and that remains. I’m not sure necessarily if some of these things change what we’re going to be doing in oncology massage therapy as a practice, because that is tenant number one in oncology massage therapy. Til Luchau: Okay. Of course my mind got busy after seeing this presentation on looking for the chinks I could get in with my biases and beliefs, and I’ll just narrate some of them to you. For sure we don’t knowingly massage tumors, and even unknowingly we don’t know the directionality of what we’re doing in relationship to the tumor. If the tumor is unknown, we don’t know if we’re massaging toward the tumor or away from the tumor. What does research show? Very careful, specific scraping away from the tumor did passively migrate some of the pigmented cells out of the matrix. What’s to say that going toward the tumor doesn’t slow the progression of cancer as well? So, you just say rationally or mathematically the odds could be even, that we’re accelerating or slowing down cancer, who knows? Unless that’s actually been studied, we don’t know that it doesn’t slow down cancer, there’s not a benefit toward massaging toward tumors. Anyway, again, that’s my rational mind looking for arguments to have with him. Hopefully I’ll get to have that discussion with him at some point too. Erika Slocum: If I can just make a quick point too. I think that there’s this question of rate of metastasis or speeding up the process. There’s a question of encouraging metastasis, and I think they’re actually very different. When it comes to urging metastasis, that is tumor, me, pressure directly applied. That’s what that feels with. I feel like too, by the way, I also want to add not just my mechanical pressure with my hands, but joint movement as well can also affect or potentially dislodge or encourage cell movement or whatever from this tumor. So, there’s that piece. But then it’s the movement of those cells. So, we know that cells are constantly shedding off of the primary tumor site, whether we press there or we don’t, it’s happening all the time. Many, many of those cells, millions of those cells, they’re getting killed off by the body’s own immune system as it passes through our blood and our lymph. So, I think that’s really important to note, that first of all, those two distinctions. Then I think the question back when Deborah Curtis was writing that article was, “Can we actually speed that process up? If we’re massaging someone, does that mean we’re A, increasing blood and lymph flow?” Which I think jury really is still out on that. I don’t think we have a lot of data about systemic increases in blood and lymph flow. Til Luchau: We know that compared to exercise, no. Example. Erika Slocum: Exactly. Right. Thank you for making that point, because yes. Can we as massage therapists speed up the rate and also does that matter? So, even if we’re speeding up the rate of which those cells are moving around the body, does that mean that it’s going to plant somewhere quicker? I don’t think so. I’m not sure. But then also to your point, patients are often, almost always told, “Please move as much as you’re able to.” Some people are still running 12 miles, some people are on the couch, so what does that variation look like? But they’re increasing their blood and lymph flow by moving their bodies, and they’re encouraged by their medical teams to move their bodies. Til Luchau: So, if we take this to the logical extreme, does that mean we shouldn’t do mammograms because they also involve pressure? Does that mean that we shouldn’t be sitting on places that might have a tumor? Does that mean we shouldn’t be lying on them? Because basically, again I’m probably being unfair to his conclusions, but his recommendation was, pressure can passively move tumor cells, that’s his basic takeaway. So, does that mean we should just leave people on a couch or on bed forever and not move? We don’t want to- Erika Slocum: And we’re also putting pressure from that chair or that bed or that couch. Til Luchau: There you go. Okay. Erika Slocum: So, I mean, I have a patient that I work with almost weekly. She has bone metastasis all over. I give her an exceedingly gentle massage, I’m not disturbing anything, the tissue is not moving. She gets a wonderful relaxing massage. Sometimes I have this thought of, I am putting less pressure on her body than the back of a chair would. People hug each other without thinking about it. Are you giving someone a hug and then… I feel like we focus in so much on massage pressure and touch, but there is so many other things that we do in our lives that include more firm touch than a massage sometimes. Til Luchau: Let’s talk about the second study too, if you’re ready. This was- Whitney Lowe: Before- Til Luchau: Go ahead, Whitney. Sure. Whitney Lowe: Just one more quick question before we get to that. I wanted to go back to this effects thing for just a second, because Til, as you mentioned, there’s been studies that have indicated that the blanket statement that many of us were taught back in the eighties of, massage increases blood flow, has not really been borne out in terms of systemic blood flow increase. But there is certainly suggestion that soft tissue manipulation may encourage superficial increases in say capillary perfusion or something like that at the surface level. I know some of the concerns about metastasis or spreading it has been not so much about pressure but about increased blood flow. I’m just curious to hear your thoughts about something when we think along the lines like, well, maybe that’s not going to impact a deeper tumor so much, but maybe what about something like skin cancer where there would be an increase in superficial perfusion of blood through the skin? Does that come up in any concerns or discussions about some of these possibilities? Cathy Ryan: Well, I think we need to talk about the whole concept of flow. I mean, oftentimes we’re thinking about lymphatics and blood vascular. Stuff is going to flow through our body just by virtue of breathing. If stuff doesn’t flow through our body, we cease to exist, so it is going to flow. I think this goes back to the root of some of Deborah Purdy’s early arguments about, “Should people with cancer not exercise, go up a flight of stairs, do anything that would increase flow, have an orgasm?” All these things that we do as human beings, should we stop living essentially? So, there’s that point I think to be made. My understanding of metastasis is, there is the movement or shedding of cell and then there is the state of the environment of where that cell goes to. In order for a tumor to start to form or take hold, there has to be a certain thing going on in that distant environment in order to support the development of that. I think these are some of the really important questions that are still unanswered in cancer research about, all of those things that have to happen in concert, in order for something to move and then establish itself. Certainly we saw at the Fascia Congress in Berlin, Dr. Neil Theise is talking about the interstitium, the new system or tissue, and talking about they had discovered cracks in the interstitium. At first they thought they were artifact, but after these cracks allow for the movement of fluid to move from one space to another space, and that the flow channels and the interstitium, essentially that is your pre-lymph. At some point, that flow channel aligns with the lymphatic vessel and that’s how eventually flow goes into the vessel. There is that potential for stuff to move throughout the body by a variety of means. Mechanical pressure being one of them, movement being another, breathing being another, muscle contraction being another. As well, the other physiologically driven things that are low. But on the other end, there has to be something that allows for that tumor to be able to establish itself. Whitney Lowe: Good. Thanks. Til Luchau: Thank you, Cathy. All right. Our second study, Karda et al, a team out of Indonesia, doing a very interesting design study, Massage, Manipulation and Progression of Osteosarcoma. Does it Really Correlate? Again, to be fair to them, they put that question right in the title of their study. They studied, again I’m going to grossly oversimplify the study, so I’ll put it in the show notes so you can go read it yourself. They studied patients at a large hospital in Jakarta, who over time were dealing with osteosarcoma. They did self-reported, did you get massage or not as part of your medical record or not? Divided their cohort into two groups, those that got massage while they had treatment for osteosarcoma and those that didn’t. Then they did some careful comparison of the two groups, those getting massage, those who didn’t, to see, was there benefit or was there a risk involved? Their findings were that those who received the massage therapy that was available to them there had an increased in earlier metastasis risk and a lower five-year survival rate. How did I do summarizing that, Whit? What do you think? Whitney Lowe: Yeah. Yeah, that sounds accurate there. Til Luchau: All right. So, how do you think we should contextualize this one? Cathy, you want to start us off? Cathy Ryan: Yeah. I think at some of the same points that we’ve already talked about is, again, for me, when I see research about massage I want to know, was there any involvement of massage therapists in the research design? First and foremost. Because I think it’s important that the context of what we do and how we do it be considered in the design. Secondly would be, is when we see that overriding M word, massage, those of us who practice within the field of manual therapy knows that that can mean many things. For me, one of my go-to’s is Sandy Fritz’s book, The Fundamentals of Massage. She has a chapter in there that she did with Leon Chaitow, where they talk about, and I know it’s not exactly called this, but the concept of it is therapeutic loading. Where they talk about the different ways that we can engage tissue, we can stretch it or tension it, we can compress it, we can shear it. That apparently the different way that we engage tissue produces different outcomes. My classic example in the scar tissue work that I do is, Langevin’s work seems to imply that fibroblasts have an affinity for stretching or tensioning types of engagement. Whereas based on Carlos Deko’s work, fascicides have an affinity for shearing types of methods or engagement. Those produce different types of results. So, I think when we’re going forward, for me, studies like this I think really is an encouragement to get more detailed in the research. When we’re doing research about massage, I think it’s important to identify, what is the mechanism or what is the way that we’re engaging the tissue, and what are the potential implications of that? Til Luchau: Yeah. That’s a great point. Erika, before I check in with you just to say, the type of massage was unspecified in this study. It was, interestingly, and it was basically happening in the wild or in people’s daily lives, and they made the point that many people there in their cohort would, because of socioeconomic or availability questions, delay conventional treatment and address it first with traditional methods, which Indonesian massage wasn’t specified or described what was available to them there. If I do a quick Google search of Indonesian massage, I get several things. But the common element seems to be pressure with the thumbs and a circular motion along energy pathways. But there’s probably, again, many different things people were getting. But that seems to be at least what’s made it to the internet about Indonesian massage. So, we’re guessing, but we don’t really know. What do you think, Erika, what would you have to say about this study? What do you think about this? Erika Slocum: Yeah. Again, I think the methods being not research methods, but the method of massage therapy and how it was applied is definitely, I mean it’s just not described, so it’s almost hard to have a further conversation if we don’t really have the background of what was done. It’s difficult to say. Additionally, the way that I read it, and please jump in if I read this, but it seems like all of these people did get massage before having, like you said, traditional medicine or health visits. So, it was an unknown… It was basically someone had this report of pain, they went to their massage therapist, “I have this pain here,” and the massage therapist directed massage therapy. They called it massage manipulation so I’ll use that term, to the site of where the pain was, which then was discovered was osteosarcoma. Cathy Ryan: Yeah. I think… Oh, sorry Erika. Erika Slocum: No, go ahead. Cathy Ryan: I think Til, you brought up an important point where they talked about that people who gravitated towards the complementary forms of care versus traditional medicine, maybe there was a delay- Til Luchau: When we say… Sorry, just on terms. By traditional you’re meaning Western? Because in the study they using traditional as traditional Indonesian. Cathy Ryan: Yeah. So, more allopathic mainstream medical approaches. I think we all know that staging is an important component in potential for metastasis as well. Was that looked at in this study? At what point were these individuals who had previously had massage, what was their staging and was that different than say the ones who more quickly went in for mainstream medical diagnosis or evaluation? Erika Slocum: I think the other tricky part that I found in this too were, how many massage… They called it massage frequency, but actually I think it was, how many massages? I think that’s what they meant to say is how many massages did these people get? It was something like, I think, less than three. So, one or two. Til Luchau: You could qualify for the study with one or two massages, that’s right. Erika Slocum: One or two massages, yeah. Then there was the three and over. So, it could be 25 massages, it could be four massages, we don’t know and we don’t know the frequency or the timeline of this. There are definitely things that made it a little murkier and a little harder to follow in that sense of, okay. Also I think too, I think what the researchers did with the osteosarcomas that they studied, these folks had… They were high grade osteosarcomas, that they had a higher rate of metastasis. I think they did that just to keep some of the confusion of it. You don’t want some that are high risk, some that are low risk, they were all high risk. Til Luchau: Standardized for that factor. Yeah. Erika Slocum: In my mind it is like, “Oh, that’s an interesting point.” They had a high risk metastasis anyway. Yes, it does appear that this group of people that did receive massage therapy did have metastasis earlier than these other folks. But I think in effort to make it less confusing, there was a muddling of what happens there. So, then again, it’s like, okay. Well, what really was the process that happened? What was the thing that… Til Luchau: We’re guessing. We’re guessing a lot of things here. I did actually reach out through my source, which was Indonesian, to see if I could get in touch with the researchers and wasn’t able to there. Because I would be very interested to hear more about it, because these unknowns mean we can’t really get too nitty-gritty about it. But there’s a concern there, for me personally. There’s a concern that says the people that sought unspecified massage therapy for their pain before they perhaps knew it was cancer, had worse outcomes. So, maybe that says to me, we shouldn’t be just poking on things because it’s painful, if there’s a chance that it’s malignant. Is that a fair concern, fair takeaway? Erika Slocum: Yeah, I think it is, and I think it’s a really hard question. But something again that I think the profession as a whole needs to consider perhaps. I think if I have pain and it feels to me maybe like a musculoskeletal pain, I will probably see my massage therapist for that pain. My first line might not be to go to my primary care physician. I think we have a lot of those people that come through our doors. I think too, to me, there’s a little bit of the dichotomy of, there’s the people that have a history of cancer that come in with new reports of pain. That to me is a little bit more of a red flag. Then there’s people that don’t have a history who come in and have reports of new pain. I think some of the questions that we talk about in our course, for example, are again, get granular. “Tell me what that kind of pain was? Is it explainable by anything? Is it getting worse, not better? Do you have nerve symptoms with this or even motor function symptoms with this?” The more- Til Luchau: Which would be red flags for you to refer for an evaluation? Is that what those are? Erika Slocum: Yeah. Absolutely. Especially if there’s, again, because I work almost solely with cancer population, so my view is like, if someone has a history of cancer and they’re reporting these things, all the flags go up and you say, “I really think you need to talk to your doctor before we go ahead. You need to get this checked out.” Til Luchau: What can you tell us about things our listeners should be aware of in working with a random population? What are things that might cause them to refer for potential screening in that sense? Erika Slocum: Yeah. I think that’s harder in some ways. I think some of the same questions apply. The not getting better, not improving thing. Pain tends to have some kind of arc. Especially if they are receiving massage therapy or other interventions, there usually is some kind of improvement that you see. If there’s not getting better, that’s a red flag for me at least to just say, “Gee. We’ve been working with this thing and it seems like you’re still struggling with it. I wonder if this is the time you need to talk to your doctor about that.” It is hard. I think that one gift we can certainly give to our clients and patients is a referral of some kind, either back to their medical professional or whatever. I was always taught to have a wide, I use the word Rolodex still, have a wide Rolodex of referral options- Til Luchau: Referral base. Erika Slocum: … Rolodex anymore, but having referral sources. So, not to zoom out too much, but it’s part of the same question. I think there’s a little bit of regular clinical information that we have and then there’s a little bit of a gut check of, “This is starting to sound maybe not right, something else is going on here.” Til Luchau: This is what we say to ourselves. Just to rewind a little bit, your wording to the client was really helpful. “You’ve been struggling with this for a while. I wonder if it’s not time to have it checked out by a doctor.” Something along those lines can be really helpful. At least you can have the script of the words to say. Cathy, anything to add here? Cathy Ryan: No. I think it would be almost impossible in an initial interaction with a patient or a client to discern if their pain has some more complex component to it. But I think Erika brought up a good point about that importance of looking at the big picture, taking a thorough health history, whether or not they have some history of cancer, just the context, the quality or the characteristics of their pain. Was there any kind of event that happened that they can link to how this issue started, or related to their occupation, some kind of repetitive or positional kind of issue? All of those questions, I think, are really informative for us in helping to try to figure out, is it safe for me to proceed, or in what manner should I perceive that couldn’t be safe for this individual? Perhaps on a first session, we don’t go in with the elbow right into a painful spot. Perhaps we start with something a little bit more conservative to see how the person’s body responds to that, and as we continue, to gather more information. Whitney Lowe: Yeah. I was just going to ask, in terms of trying to make some of those initial decisions. I’m curious from both of your experiences and working with a lot of people having cancer, because this is not my area of specialty by any means. If the person does not have a characteristic pattern of something that would tend to indicate a musculoskeletal problem, the standard kinds of thing that most massage therapists would run across, the kinds of things like when you do a particular active motion test or a passive motion test that would likely make a musculoskeletal complaint get more aggravated, or not get aggravated. If you don’t see those patterns and the pain that they’re having is outside those patterns, but maybe persistent or something like that, does that then increase your likelihood of thinking along the lines of, “Now I’ve got to think more about systemic kinds of issues,” or something like that that might at that point really increase my awareness and perception about the possibility of something like that being there? Does that make sense? Cathy Ryan: Absolutely. Erika Slocum: Yeah. I think that’s a good point too. A good addition is that it doesn’t follow patterns that you typically see with muscular dysfunction or tension related. Cathy Ryan: We see other examples of this in practice too. I can relate it to experience in my practice where I had a client come in who when they called me, said, “I believe I have an interfacial thing going on or a tendonitis thing. My doctor wants me to come and see you.” The person comes in and I’m looking at both of their legs and I can see in the leg that the person is having the difficulty with edema from the knee down, which very much to me was like, blood clot. Because it had all the indicators, it just didn’t follow the typical pattern of what I know a tendinopathy or a plantar fascial issue to be. That’s the moment when I say to the person, “You know what? It’s not really fitting the profile of what I think is indicated is going on here. My suggestion to you is to go to emerge, and tell them that my massage therapist thinks maybe there’s a possibility of a blood clot,” because there were other things, that persons age and other things on their health history that kind of fit. I think we see a lot of examples of this in practice that we have to be mindful, is this fitting the typical profile of what we would normally expect in the context of a musculoskeletal myofascial kind of thing? Whitney Lowe: Yeah. Great. Thanks. Til Luchau: Good point. I was going to say, I know with my wife, when she has… Years of working on her, my in of one and my own personal study here, I know that I’m more reluctant to do deep focused work on the places that hurt, knowing that she has active metastasis as part of her cancer journey at this point. That feels appropriate, it feels right to both of us. Yet the touch and the work she gets both from me and from other caregivers is such an important part of her ongoing process that I can’t imagine leaving that out completely. It’s more like incumbent on me to learn how to work with her, within the realms of what feels safe. So, that’s part of this conversation today with you all as well. Erika Slocum: I actually love… I feel like what you just talked about was a partnership with your, I’ll call her your client, I know she’s your wife. But with your client or patient, which again, we talk a lot about partnership in the clinic where I work. Yes, we have a certain expertise and we know when not to do things or when things are indicated or things like that. But it’s a conversation. It’s always a conversation, because it’s even possible if they’re going through chemotherapy and they had a massage, that the massage you gave may have been a little bit too much for them that day. It’s like, “Okay. Well, let’s timestamp this. All right, this was two days after your chemo. Okay. So, next time…” It’s this constant feedback loop and it’s so nice that you have continuity of care with your wife, like you said, this study of one. But I am sure you’ve seen a lot of change over time with her, and I think it’s important to have the communication piece there with our clients. Cathy Ryan: Well, I think for me this fits with what is critical thinking. For me it is that intersectionality of the three pillars of evidence-informed practice, which is science and research, clinician experience and patient values and input. I think, Til, I think you just beautifully framed that. Til Luchau: Thanks for the conversation today. What thoughts would you like to leave us with? Erika? Erika Slocum: So many. But, no. I’m very appreciative of this conversation because it is true. We do sometimes have to go back to maybe some things that we thought we were done with, or we’ve moved on from. But as I said before, I think that looking at any new piece of information that comes out, is almost the same as a patient tomorrow asking me, “Are you going to spread my cancer by doing a massage?” So, I feel like I want to… As an oncology massage therapist, we don’t take risks with our patients. We’re actually quite a careful bunch, usually. I think it’s really important to, in some ways continue to have this conversation, because it validates where we came from, but where we are now and how the conversation has shifted. I think going back to what we know is true. I think it’s important to continue to have these conversations every now and then, as we do in our work. I mean, you get in the weeds a little bit. It’s good to zoom out and see what the rest of the world thinks about what we’re doing. Til Luchau: Well, thank you for joining us today. Cathy, what would you like to leave us with? Cathy Ryan: Well, always my gratitude to the both of you for your willingness to engage in these thoughtful, informed conversations, because I think that really helps all of us to grow as practitioners. I just think you’re doing such a great service to the profession by doing this. So, first and foremost, thank you for that. Again, I just think that research helps us to ask better questions. I think that these two pieces of research really prompt us to ask better questions, and to look at the design of research and get more detailed questions so that we can be both safe and effective in the care that we are providing for our patients. Til Luchau: Cathy. Whitney Lowe: Wonderful. Til Luchau: So, we’ve mentioned a couple of resources along the way. Any that you want to highlight for listeners who want to go learn more about this topic, or in particular about what you’re doing? What resources do you want to name here on our way out? Erika Slocum: Well, I think Cathy mentioned the Society for Oncology Massage, which is S, the number four, O-M.org. That’s a good resource both for patients and massage therapists and educators. Tracy actually has Tracywalton.com. You can go to her website. She actually still has this incredibly huge bibliography of some really interesting research and clinical papers. I think that would be a good thing for people to check out. Til Luchau: Cathy? Cathy Ryan: I’ll just add to that. Healwell, which is an organization that I have a relationship with in the US. They are one of the oncology and hospital-based massage therapy educators. Lots of information available through Healwell. Til Luchau: Full disclosure, they’ve been a sponsor of our podcast as well. We believe in their work as well. Cathy Ryan: Yeah. I have a colleague here in Canada, Erin Price, who has a fabulous website called The Mastectomy Guide, where she provides information for both patients and practitioners. You will find me if you’re interested in any of the courses that I teach, Healwell brings me into various parts of the US to teach our tissue course, which is mindful of the oncology component. It’s not oncology specific. Then as well, I do a collaboration machine course with Erin called, The Science of Scar Tissue, which again has a mesectomy and gender affirming top surgery emphasis on it. Til Luchau: Fantastic. How would people get in touch you Erika, if they wanted to reach out to you personally? Erika Slocum: Yeah. It would probably actually just be my good old email address, which I’m happy to leave for you, and you can put it in the notes. Til Luchau: We’ll do that. We’ll do that. Erika Slocum: Yeah, thank you. Til Luchau: Cathy, we’ll put some direct contact info for you in there as well. Cathy Ryan: Yep. Til Luchau: Thank you again, Whitney. Thanks for hanging out with me on this. I’ll do our ending sponsor. The Thinking Practitioner Podcast is supported by ABMP, Associated Bodywork and Massage Professionals. ABMP membership gives professional practitioners like you a package, including individual liability insurance, continuing education and quick reference apps, online scheduling and payments with PocketSuite and much more. Whitney Lowe: ABMP courses, podcasts, and Massage and Bodywork Magazine always feature expert voices and new perspectives in the profession, including from Til and myself. Thinking Practitioner listeners can save on joining ABMP at abmp.com/thinking. So, thanks again to all of our listeners, to all of you all and our sponsors. If you would like to stop by our sites for show notes and videos, you can get transcripts and all kinds of extras there. You can find that over on my site at academyofclinicalmassage.com, and Til, where can they find that for you? Til Luchau: Advanced-Trainings.com. If you have comments for our guests or for us or things you’d like to hear us talk about on the show, just record a short voice memo on your phone and email it to us at [email protected]. Regular emails are accepted as well. Or look for us on social media. I am at Til Luchau, my name. Whitney, what’s your name? Whitney Lowe: Today, my name’s Whitney Lowe. You can find me on social that way as well. If you would like, or actually if we would like, we would like for you to rate us on Apple Podcasts as it helps other people find the show. You can hear us on Spotify, Stitcher, Podbean or wherever else you happen to listen. So, please do share the word, tell a friend. Thank you again, Cathy and Erika for joining us today. It was wonderful to have this conversation with you both.