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The Thinking Practitioner Episode 13: Inflammation: Hands-On

 

Whitney Lowe:

And thanks to Andrew Biel and the whole team at Books of Discovery. We certainly do appreciate their support. And do be sure to check out that great offer from them as well. All right. So good afternoon, or actually, good morning. It’s still morning time here. Good morning to you Til over there in the high country of Colorado. How are things today?

Til Luchau:

Hey, Whitney. Yeah, we’re still in the midst. We’re still here in social distancing and isolation here in Colorado until the end of the month. This is middle of April. And I think we’re slated to broadcast this on May 6th, so a few weeks before you’re hearing this probably.

Whitney Lowe:

Yep. And I imagine just based on our projections at this time, there still will be a fair amount of this stuff still going on at that time. And it’s been interesting to watch how everybody has been grappling with the challenges faced by this thing. And I think we’re all with the big question mark about what it’s going to look like on the other side coming out of this.

Til Luchau:

Yeah. Grappling and rising to the occasion, and grieving, and hoping, and dreaming, and all those things that are going on right now.

Whitney Lowe:

Yeah, absolutely. Well, in our last episode, we delved deep into the whole issue of the cytokine storm, especially in relationship to how that is relevant with understanding some of what’s really happening with the COVID-19 illness itself. And we explored and discussed in there that there’s a much bigger aspect of this whole inflammatory process to look into here.

Whitney Lowe:

So we thought it would be good to really continue on that same line of inquiry today and talk about this further. And again, this is some things that you’ve been exploring a great deal with some of your writings recently and other research stuff that you’ve been doing. So I’m going to sort of ask a bunch of questions and things to try to delve into that a little bit more with what we’re doing here today and looking at this inflammation topic.

Whitney Lowe:

So before we get into this, I’m curious, is there something that sort of started you off or kicked you down this road of looking into inflammation in this level of detail? Because I think you’ve done some great work exploring that further. So I’m curious what got you going down this road?

Til Luchau:

That’s good. It was a couple of things. One, it was a puzzle. My own clients, I would see that some of them really got better from my work with inflammatory complaints. And I can talk about what those are in a minute. But I saw that some clients really got better and some didn’t. And I wanted to know what I could do as a practitioner to work better with the clients who were having different responses.

Til Luchau:

And then I’d get a lot of questions in trainings and classes like, “What do I do for bursitis?” Or, “What do I do for carpal tunnel when it seems to be an inflamed thing more than mechanical thing?” Or, “Is it a mechanical thing or is it an inflamed thing?” And then number three was my wife went through a cancer diagnosis and treatment for cancer. She’s doing great now.

Til Luchau:

But as a part of that, she did get chemotherapy, and that’s a whole inflammatory episode in one side. That’s got to be way up there on the list of whole body inflammatory states. So living with her through that and helping her through that really gave me some home study intensity on that whole question too. So it became a passion, and now nothing piques my interest or puts a smile on my face more than talking about inflammation. So I’m glad we got a chance to do that.

Whitney Lowe:

Yeah. It is always fascinating how some of those individual experiences drive us down these unique roads of exploring some of these things in greater detail. So tell me how that shows up most frequently, for example, with clients that you’re working with. What kinds of things do you see when they come in that sort of pique your interest about like, I wonder what’s happening here with inflammatory processes.

Til Luchau:

As soon as you scratch the surface of in inflammation, you realize it’s everywhere. And so just about anytime a client says they’re sore or achy, whether that involves a soft tissue or a joint, there’s inflammation involved, certainly as a result, but maybe even as a primary driver. So anytime there is for sure bursitis, the classic local inflammation symptoms.

Til Luchau:

Bursitis in a lot of tendinopathies, carpal tunnel issues. Neuropathies too have an inflammatory component, sometimes primary like sciatic pain. Migraine headaches are thought to a lot of times to be having an inflammation driver of the trigeminal nerve. Thoracic outlets syndrome. Repetitive strain injuries is like an inflammatory reaction that’s not resolving.

Til Luchau:

A lot of chronic pain seems to have elevated inflammatory markers. And there’s some interesting, unknown relationship going on between the inflammation that’s driving the pain and vice versa. I could go down the list. It’s safe to say that just about every musculoskeletal complaint, unless it’s genetic or congenital, or unless it’s an acute injury, before the inflammation is set in, has an inflammatory component.

Whitney Lowe:

So one of the things that strikes me about this and thinking about the role of inflammation and of course, I think about this a lot in terms of educational things, too, because I’m always focusing on, how do we teach people better? That’s a big part of my interest. There seems to be at least, in a lot of our education, a good bit of emphasis on acute level inflammation and managing and preparing for and not doing things that might be detrimental during that.

Whitney Lowe:

But there doesn’t seem to be the same level of attention, for example, on some of the maybe more ongoing inflammatory processes that you’re talking about. So do you think that’s because of maybe lack of ability to recognize some of the lower level inflammatory things when there’s not necessarily an immediate acute injury as a part of that or maybe because it’s less visible and it’s harder to see and harder to identify? Do you think that decreases our attention to it as a pertinent factor to think about?

Til Luchau:

I bet there’s a lot of factors there, everything you named. And then the fact that it’s a different kind of process than we’re usually used to working with as hands-on practitioners. It’s not a tight tissue. It’s not tension, some muscular tension. It’s not a fascia thing per se. It’s not like undifferentiated fascia. It’s not even a pain phenomenon. It’s none of those. And it’s more of a process than any of those things are. It takes more time and involves more complexity. And it’s a progression more than it’s a thing in itself, and we’re not used to thinking that way.

Whitney Lowe:

Do you see maybe a common… Or maybe I should say, what is the most common misunderstanding people have about inflammation in terms of the soft tissue practitioners that we’re addressing here that are in the trenches doing this work on from a day-to-day basis? Do you see any real common misunderstandings or maybe knowledge gaps too of things where they don’t have as good understanding what’s really happening?

Til Luchau:

Yeah, absolutely; in myself, but then also in the trainings and classes and talking to other teachers. I actually got my famous five of things people don’t know about inflammation or these hands-on body workers don’t know about information.

Whitney Lowe:

All right. I got to hear those. I want to hear those.

Til Luchau:

Okay. First thing is-

Whitney Lowe:

Oh, wait. Do you have a cool acronym for those as well?

Til Luchau:

Oh, I don’t. I’ll get one. It’s super common. And as I said, it’s involved in just about anytime there’s achiness or soreness. It also is involved in autoimmune issues, any kind of allergy. A lot of those autoimmune issues are systemic and mysterious, but that still can be presenting in our practice. One of the things that practitioners see might be a background systemic inflammation. It’s involved in aging. It’s involved in a growing list of mental and behavioral disorders as well.

Til Luchau:

So the first thing most people don’t know about inflammation is how common it is. The second thing people don’t know is that it isn’t bad. It’s not a problem in and of itself. Inflammation is actually what allows healing to happen. It is the beginning of the healing process; we can even say it is the healing process. So anytime there is an injury or an infection, or irritation, you got to have inflammation to rectify that, to put that right. Number three, you ready for that?

Whitney Lowe:

Ready for it.

Til Luchau:

It’s a symptom; it’s not a condition.

Whitney Lowe:

Yeah, that’s big, I think.

Til Luchau:

Yeah, it’s a sign that something’s going on. And sometimes it’s a mystery. Like with the autoimmune issues, we don’t often know what it is that’s triggering those. But it’s a symptom of something else. It’s the body’s protection and repair response. So it’s not something to try to fight or stop per se, or it’s not even a problem in and of itself.

Til Luchau:

It’s a result that is a symptom of something else going on. Number four: It’s not like tension or stress or factual issues, if you think that way, or pain issues, if you think that way. We can’t rub it out. We can’t release it. We can’t relax it. It’s a whole different way of thinking and a whole different way of working.

Whitney Lowe:

So if we can explore that for just a moment, what do you think or sense is the key thing that we can do when we talk about maybe systemic inflammation or more large scale and non localized inflammation? What kinds of things can we do that are most beneficial for that?

Til Luchau:

That’s the key question, and that’s actually my number five, is that there are things we can do to help. And some of that helping depends on that question you just asked, is it systemic or is it local? And the key things for systemic work are in my acronym.

Whitney Lowe:

Well, let’s hear the acronym. Shall we jump into that next?

Til Luchau:

Maybe I want to lay a little more groundwork.

Whitney Lowe:

Okay, let’s lay-

Til Luchau:

Lay down a little bit more groundwork so the acronym makes more sense. But yeah, half of those letters in the acronym are about systemic inflammation. But yeah, just really briefly, the difference between a systemic inflammatory response and a local one is really simple. For the systemic response, it’s your whole body or it’s your whole system or it’s diffuse reactions.

Til Luchau:

You might have local inflammatory responses. You might have a sore shoulder because your systemic inflammation is acting up in a low level, making you more prone to the local flare ups. But that’s a really important distinction to think about as a practitioner: is it just a local flare up, or could it be a background systemic inflammatory process? And the question you ask is the key one, what are levers for systemic or low grade, whole body inflammation?

Til Luchau:

So we got to think about again, the background I want to lay before it to answer that question are some things like, what causes it? And what is inflammation trying to do? Basically, anytime there’s inflammation, it’s a response to an injury, an infection or an irritation. An injury is clear. You stub your toe, you get the immediate nociception or painful responses stubbing your toe.

Til Luchau:

But then within seconds, if there’s been some tissue damage or injury, you’ve had some inflammatory responses coming in, And they will cause pain themselves. The inflammation itself causes the pain of an injury. The cytokines that get released, like we talked about last episode, irritate nerve endings. So they sensitize those nerve endings and start a whole lot of pain signals being generated.

Til Luchau:

And then they do a weird thing, where the nerves themselves, once your nervous system is upset or once the nerves are upset, they can actually inflame the tissues too. So you can get a new neuro genic inflammation, an inflammation that’s caused by the nervous system.

Whitney Lowe:

So that really becomes sort of a self perpetuating cycle, then, of the system kind of spinning out of control and then we’re kind of in the realm of what we were talking about in the last episode with the cytokine storm, where things are just kind of spinning out of homeostasis or out of balance?

Til Luchau:

Around a feedback loop.

Whitney Lowe:

Yeah, exactly.

Til Luchau:

The nociception upsets your nervous system. The nervous system releases inflammatory cytokines right into the tissues, and that continued inflammation continues to generate those signals in a loop. The good news is that anywhere we can interrupt that loop, we can change the cycle. We can interrupt it on the level of the nociception through all the descending modulation, the mechanism we talked about.

Til Luchau:

Basically, all those contextual effects, all the ways that people understand what’s happening. We can interrupt it on the tissue level by actually changing the inflammatory concentrations in different ways. And then we can support it on the big system level too through immunological competence. So there’s lots of ways we can interrupt that cycle.

Whitney Lowe:

Yeah. And to me, these all indicate some extremely powerful potential benefits of the soft tissue manual therapy, regardless of the way in which that’s practiced, but then many extreme benefits of long, slow applications of hands-on manual touching therapies in engaging a lot of those kinds of processes.

Whitney Lowe:

And again, once we can kind of get a little bit outside of that sense of the mechanical effects of what we’re doing with soft tissue manipulation and look at some of those from the bigger picture. To me, this is tremendously exciting and gives us a great potential to look at for our future research studies and looking at the health benefits of what we’re doing with massage.

Whitney Lowe:

That it really does extend significantly beyond the kinds of things that are easy to study. And this gets back into that challenge of, we have some really good theoretical models of why this might be really helpful for people, and we certainly do believe anecdotally and clinically that that’s the case.

Whitney Lowe:

The difficulty comes in maybe, how do we validate that? How do we study it? How do we find some ways to really delve into some of these things from a research perspective?

Til Luchau:

There’s some really interesting research going on, both recently and as you looked back about the effects of manual therapy on inflammation. And then a lot of practitioners, too, have a body of experience where they realized that they could work with inflamed things and make them better, even though most entry-level massage people, and certainly was true in my structure integration training.

Til Luchau:

They said, “If it’s hot, recently injured, inflamed, leave it alone for a while. You’re not going to directly make it better. Work on some other part of the body or work in a different way or use light touch. Use a different modality.” Those are all really good pieces of advice, but it turns out there are ways to work more directly with inflammatory conditions and make them better too, if you know what you’re doing.

Whitney Lowe:

Yeah. And I had a question that I wanted to ask too to get into this in a similar way. In one of your articles about inflammation, that was from maybe a year or two ago, something like that, you had mentioned something in there about there was a possibility for impacting or affecting myofascial tissues in a distant region, from inflammatory reactivity, meaning an inflammatory process in one place may cause distant impacts or effects in other myofascial tissues somewhere else in a different locale of the body. Can you speak to that a little bit or maybe clarify how that occurs?

Til Luchau:

I’m not remembering the exact thing I wrote, or even the context, but I could riff off that a little bit.

Whitney Lowe:

I’ll see if I can pull it up a little bit there while we talk.

Til Luchau:

Yeah. I’m wondering if it’s talking about just the systemic effects. When you have an inflammatory load on the system, it changes your whole physiology. And there are different sorts of hormonal receptors for short term changes in fascia and there’s the fibroblast activity and things like that that can change fibrosity and inflammatory reactivity of fascia throughout the body in a systemic inflammation episode. I wonder if that’s what I was talking about.

Whitney Lowe:

Yeah, that could be. And I was going to see if I could pull it up and find it really quick here because I had this article on my desktop, but I didn’t find that.

Til Luchau:

Keep looking. I’ll just say too, while you look for it, it’s really simple. If you break it down to local inflammation, where a joint is hot or swollen or painful, and systemic inflammation, where there’s a whole body response. There’s two ways to work with that, and they correspond to the words we used to describe the inflammation. You work with local inflammation locally.

Til Luchau:

You work with systemic inflammation systemically. And there are things we can do with our hands and in our manual therapy context that have local effects and there are things we do that have systemic effects. That’s huge right there. And it’s so simple. But at point your right toward the tools you need to work with someone’s inflammatory situations.

Whitney Lowe:

Yeah. Okay. I found what I was looking for here. So this was from your article that was in Massage & Bodywork Magazine, March/April 2019.

Til Luchau:

Yay, massage and bodywork.

Whitney Lowe:

Yeah. So I’m going to quote this briefly. So in this paragraph you said, “Inflammation doesn’t just affect the fascia and connective tissues of the locally painful area. Over time, local pain can also inflame other myofascial structures far from the injury site.” And then also mentioned, “Neurons that connect the injured areas with the brain.” And you used to mention here, also strangely, “The ankle area of your brains body map.” Tell me about that, because that seems interesting.

Til Luchau:

Okay. When you have a chronic inflammation… And I think the ankle example later got changed to sciatic example. Maybe I sent you an early proof or something. Because the research is around sciatica, and it probably applies to the ankle, but no one that I know has studied the same thing in the ankles. So let’s stick with sciatic for a minute, where there is pretty clear research.

Til Luchau:

In sciatic pain, not only does your rear hurt and your lower back and the back of your leg, like in classic sciatic pain, but those corresponding regions in your brain’s sensory motor homunculus are inflamed. There’s measurable inflammation in those parts of your brain. There’s glial cell activities, which are the inflammatory cells of the brain.

Til Luchau:

They turn on as if they’re locally inflamed, and it seems to be because your leg and your rear and your back are hurting. And that’s probably true elsewhere in the body too, that when you have a chronic ongoing pain, it actually inflames the brain. And then to finish the thought, we know that when the nervous system’s upset, it can also upset the tissues. It goes the other way around to back too. It’s back neurogenic inflammation.

Whitney Lowe:

Yeah, right. So those feedback loops are things that we want to do our best to intervene and then find ways to intercept somehow rather. And I think it’s a fascinating aspect of looking at the more holistic pictures of what soft tissue manual therapies can do in so many of these instances here.

Til Luchau:

Well, it made a lot of sense to me. I mean, after a background in fascial and structural work, and then also a psychotherapeutic approach, and then getting into the pain science thing for the last decade and really looking at the bio-psycho social integration of those ways; the inflammation thing made so much sense to me as the neuro immune idea.

Til Luchau:

And again, it was Moseley and Butler who started… It wasn’t their idea, but they started talking about it a lot. How pain modifies our external motor behavior, it’ll cause avoidance behavior. That’s one of the biological functions of pain. And then all of the psychological constructs we get around things we’re avoiding or protecting from.

Til Luchau:

And then inflammation modifies our internal cellular immunological behavior. It actually moves cells in ways that help protect. So they’re both protective function systems, different scales and happening in different systems. And they work in conjunction and that neurogenic pain is one way they stay coordinated.

Whitney Lowe:

Yeah, right. Great. Well, I want to come back to the acronym that you had talked about or some things that you use in discussing this. So we’ll pause for just a moment. We’re going to hear briefly for a moment from our halftime sponsor. And then when we come back, we’ll take a look at what this acronym is and how that relates to our inflammation or your inflammation trainings that you’re doing.

Til Luchau:

And our halftime sponsored is Handspring Publishing. When I was looking for a publisher for the book I wanted to write a few years ago, I was lucky enough to have had two offers: one from a huge international media company and the other from Handspring, a small publisher in Scotland run by four great people.

Til Luchau:

I’m glad I chose them because not only did they help me make the books I wanted to write and share the advanced myofascial techniques book, but their catalog has emerged as one of the leading collections of professional-level books written especially for body workers, movement teachers, and as they say, all professionals who use movement or touch to help their patients achieve wellness.

Whitney Lowe:

And note that Handspring has a new instructional webinar series called Moved to Learn. It’s a regular series of 45-minute segments featuring some of their amazing authors there that they’ve gotten the catalog. So head on over to the website at handspringpublishing.com to check those out. And while you’re there, have a look at their excellent catalog of books and resources. And be sure to use the code TTP at checkout for a discount. So thank you again, Handspring.

Til Luchau:

Thanks handspring. So where were we? Were we up to the acronym yet?

Whitney Lowe:

We were. So you’ve got an acronym that you use frequently in your trainings about inflammation. So tell us about that and what that can help guide us with.

Til Luchau:

It started as just five ways that we could help inflammation. And there’s research about generally accepted ways that we, as manual therapists, can help people dealing with inflammation. The acronym is CALMS, C-A-L-M-S. The first one, C, stands for client engagement. You got to engage your client, if they have an ongoing inflammatory condition that they want to change.

Til Luchau:

It’s really tough to passively do something to a client who’s not engaged and change their inflammatory reactions. Sometimes we can. But especially for the chronic ones, the ones that are going on, especially if it’s systemic, they need to be involved in terms that means them having an interest in their health. Their being willing to explore their edges around movement.

Til Luchau:

Their being able to track their symptoms and report back to you. Did that session make it better or make it worse? That’s the kind of information you need as a practitioner. You need them engaged in the process. C sands for client engagement.

Whitney Lowe:

So let me ask about that a little bit because this is something that I think we run into a good number of times with challenges in this kind of thing with clients in a number of different situations. There is so often a perception from many people that they come to let’s say their massage therapists, their body worker, structural integrator, whoever it is, wanting to have something done to them, to fix them and make them feel better.

Whitney Lowe:

So it’s your job, practitioner, to make me feel better. I’m just going to come here and unwind and relax. So what kinds of things do you think are most helpful for trying to get that process of engagement sort of kick started with these people? Because that is such a challenge, I think sometimes, to get people on board and motivated and in an active part of that process.

Til Luchau:

There’s a toolbox of ways, but some of the simplest are questions; just asking questions during either the intake interview or during the run up to your session or even as you’re discussing and debriefing the work during and afterwards. Questions like, how do you feel about your overall health? What do you do for your sleep? How much do you feel about your movement?

Til Luchau:

It’s questions that are really going to get people interested and have them reflect. I’m not giving them prescriptions. I’m not telling them they are or aren’t a doing good job. Most people know how well they’re doing and have some ideas about how to do that. But I’m helping raise their awareness and bring attention to the fact that things like sleep movement and overall stress levels are really going to impact their inflammatory conditions, whether it’s a sore shoulder or a whole autoimmune disorder. So one way is questions and just awareness raising.

Til Luchau:

There’s a whole panoply of ideas you could offer too, including say take-home movement exercises. That’s one way to get clients engaged. Actually having them move on the table. But then I guess the other big one, the other low lying fruit that makes a lot of difference is getting your clients to report back on the table about the pressure and the direction and the specificity of what you’re doing.

Til Luchau:

You do some great stuff, I know, around say direction or a force that elicits the pain and elicits the sensation. That’s like a kind of client engagement technique that gets the client reporting on what they’re doing that hurts as you’re working on them, and that helps you target what you’re doing quite a bit.

Whitney Lowe:

Yeah. I was in another discussion with somebody the other day. I can’t remember where I was having this discussion. But we were talking about that very factor of that particular type of work of the active engagement techniques, where you’re having the client do active movement at the same time that you’re doing massage. It has real benefits in simply calling people’s attention to those areas and making them feel like I’m aware that this is being worked.

Whitney Lowe:

I’m aware that this is being engaged here and there’s significant power and benefit, I think there, in calling the brains attention to those tissues in an attention to engaging them in those processes. So yeah, I certainly think those things are a valuable part of hopefully what can continue on once they leave them the treatment room.

Whitney Lowe:

I can’t remember the math number in my head right off the top of my head, but if I’m correct, I believe it is 168 hours in a week. And if we’re lucky, we get them for one of those once a week. But probably for many people it’s not once a week. And so really that amount of time that we’re spending with people in terms of the whole big overall scale of their life is pretty small. So the more we can work with them to get those things reinforced outside of the time we are with them in the treatment room is really helpful.

Til Luchau:

Mm-hmm (affirmative). Yeah, I’m with you.

Whitney Lowe:

All right. So what’s the A?

Til Luchau:

The A in CALMS is autonomic calming. So that’s basically turning down any stuck fight or flight reactions in the body. Here’s the paradox: stress is anti inflammatory. When you have a stress reaction, when you have a fight or flight reaction, that shuts off your inflammation reactions. Adrenaline is what you use if you get a bee sting, epinephrine. EpiPen is adrenaline, because that’s a super powerful anti inflammatory. It stops all the unneeded reactions so that you can basically escape. It stimulates the motor impulse, all these kind of stuff so you can escape. In

Whitney Lowe:

So how do you think-

Til Luchau:

In the short term-

Whitney Lowe:

Just if I can interrupt for a second and pose question. For those of us that we hear all the time of how detrimental it is for us to be constantly in that fight or flight response because of the increased stress levels of our current society and our jobs and our busyness and all that kind of stuff that keeps us going. If that does suppress inflammatory activity, can we say that’s a good side to that process or is it just like

Til Luchau:

Well, epinephrine is good to turn off that inflammation. And we talked last episode in the COVID storm, you need to survive. If you’re going to survive, you got to turn that off sometimes. But if you keep doing that, if you do that over time, what you’re also turning off is all the healing processes. And you’re fatiguing, you get cortisol fatigue, you get worn out from all that stress and you don’t have what it takes to see the inflammatory reaction through. So what happens is, when you get stressed out, the inflammatory reactions lose their juice and they can’t complete. They get stuck in this acute phase, which is actually fairly destructive to the body.

Whitney Lowe:

Yeah. It’s back to balance, isn’t it?

Til Luchau:

Yeah, back to balance. You need a certain amount of parasympathetic experience and time in that zone to help the inflammatory reactions actually resolve. And it’s a resolution we want, not just stopping the reactions.

Whitney Lowe:

Great. Okay. How about the L?

Til Luchau:

L is liquids. Inflammation, you could say on this most simplest level, is a liquid phenomenon. It’s about fluids, liquids leaking out of cells and leaking out of vessels into the tissues and that’s what causes the swelling. That’s what causes the coughing and pneumonia. So on the simplest and most immediate level, inflammation is the movement of liquids. And to resolve, liquids need to be moved too, because otherwise they sit there with all of their breakdown by-products and signaling molecules and cause more problems.

Til Luchau:

If the liquids don’t move, you end up with this stuck state of inflammation or chronic inflammation that’s just from the status. So moving liquids around, and there’s a lot of different tools for doing that. Certainly, the whole lymphatic traditions, several of those: Chikly, Vodder, Sandra, have their ways of working with moving lymph fluid.

Til Luchau:

It turns out in the fascial point of view, there’s a whole lot of fluid movement within the superficial fascias, within the outer layers of fascia in the body. There’s quite a bit of interstitium or interstitial fluids moving around and they connect to the lymph eventually. But they seem to have a really strong immunological function in the body of keeping these inflammatory fluids in check, keeping the right dilution and the right mobilization to places where they’re needed. And that’s happening anywhere there’s loose fascial tissues in the body, including in the gut, including right under your skin.

Whitney Lowe:

Yeah. I know a lot of these things are still difficult for us to quantify specifically through some of the research processes that we’ve done, but especially with the work has been done with lymphatics and things like that. I think there’s a pretty good understanding that a lot happens with the potential for tissue fluid movement in many instances from wide varieties and methods of hands on soft tissue manipulation in a lot of different areas there.

Whitney Lowe:

Some of this has gotten… This, again, kind of gets back into some of the difficulties of interpreting certain research. But for so long there was a lot of research or a lot of sort of common knowledge that was passed on through our training about massage does wonderful things to increase circulation because everybody was saying that was a big benefit of massage.

Whitney Lowe:

And then some of these studies came out and said, “Well, in terms of measuring blood volume changes in large arterial structures, no. Actually, it really doesn’t do that much.” And then that sort of squashed that idea a lot. Again, you got to be careful in terms of what that actually is saying.

Whitney Lowe:

Because while there may not be significant changes in the blood volume traveling through large arterial structures, that doesn’t necessarily say we’re not moving tissues through small capillaries and, like you said, in between tissue layers and things like that. That they could absolutely be impacted there. And those things are just much, much more difficult to study. So we don’t have good evidence about that kind of stuff, yet.

Til Luchau:

That’s true. The evidence base isn’t as strong there. It’s sidestepping the circulatory question, because the arguments there being exercise and movement and activity moves fluids maybe more effectively than local manual therapy. That’s a really good argument.

Til Luchau:

There are times though, that when people aren’t able to exercise for sure, and let’s say recovery from a surgery or recovery from an ongoing lymphedema and things like that, where approaches that facilitate the movement of that fluid can be super helpful, certainly experientially. There’s a lot of case studies that show amazing results, and I’ve seen them myself.

Til Luchau:

You can visibly reduce the swelling pretty predictably on acute injuries too through some of those interstitial techniques. Even within the lymphatic field, there’s a debate between, are we moving the fluid, like pushing fluids around, or are we facilitating the body’s ability to move its own fluids? And there’s people taking both approaches. And there’s probably some usefulness in both those ways of thinking.

Whitney Lowe:

I would agree. Yeah. And I think that we see certainly the benefits of the actual muscle contraction back and forth from contraction to relaxation, just the natural pumping effect of those very small capillary structures and just the movement that occurs from mechanical pumping through the lymphatic system because of movement and changes and those things throughout the body. There’s I think a lot of potential benefits that we’re seeing there. Again, difficult to measure in some instances, but we see that stuff all the time in terms of the outcomes.

Til Luchau:

Well, that feeds right into the M. Should I jump into that one?

Whitney Lowe:

Let’s hear it.

Til Luchau:

So the M is movement, movement safety particularly. Making it okay for people to move. And that is going to have liquid effects. It’s going to have effects on their brain maps. It’s going to have effects on their autonomics. It’s going to effect on their engagement. But basically, M for movement safety means whatever we do that helps it be safer for people to move is beneficial. Touch has a great potential to do that.

Til Luchau:

When you have someone touch you and produce novel sensation, like you were saying, and you’re engaged with, especially if you’re moving as well, your brain gets a new color in its coloring book and it goes, “Oh, I guess I maybe don’t need to protect that quite so much through immobilization, let’s say, or withdrawal or contraction.” And as we begin to elicit or invite or schmooze in the willingness to move in small ways, but also in big ways, then that has a lot of impact on inflammatory resolution.

Whitney Lowe:

Yeah. I was talking with somebody the other day about massage effects. I can’t remember how we got onto this, but I said… For those that will kind of be of our same age group and can remember this, there’s a lot of instances in which a massage session can sometimes feel like an Etch A Sketch. Do you remember that toy back from the ’60s or so?

Whitney Lowe:

And you could erase this thing. And it feels like what we can often do with a lot of these sessions is kind of, maybe not completely erase, but we can, to a large extent, erase a lot of the dysfunctional proprioceptive activity and just clean the slate a little bit for them to get off the table and say, “Hey, I can move like this. It can be better,” that sort of thing.

Til Luchau:

The pathways have been scratched into the… That’s why we should just take her clients upside down and shake them.

Whitney Lowe:

It might work.

Til Luchau:

Reset the whole thing.

Whitney Lowe:

Put a couple of dials on your massage table, then turn this back and forth, like have these things go down and create some new patterns in there.

Til Luchau:

So the movement safety thing, examples of ways you’re already using that: anytime you’re talking to your clients and reminding them to relax or giving them images or inviting them to move, you’re working with their movements safety. This also includes all the nerve glide work, because essentially you’re probably having fluid effects within the nerve.

Til Luchau:

You’re having inflammatory effects too. But you’re showing the brain it’s okay to do these movements, even though there’s a little bit of sensation, let’s say in a sciatic. That if I can find the edge of that and move around it, the protective impulses reduce, and that helps reduce that neurogenic inflammatory loop.

Whitney Lowe:

Yeah. Great. Tell me about the S.

Til Luchau:

S is the one that we reserve for special cases. It doesn’t sound for special, it stands for stimulate. So it’s stimulating an inflammatory response through usually direct pressure or direct work, and that includes things like Gua sha or coining, or direct deep tissue work. All of the kind of no no’s that beginners are taught. Don’t do this inflammation because it does make it worse. It does make the reaction worse.

Til Luchau:

In the right situations with the right clients, who are not medically fragile and who we have rapport with, and when you have the training, those kind of approaches can really help resolve inflammation that doesn’t respond any other way. They’re tricky because they do actually worsen, and in the case of Gua sha coining, they cause visible bruising. And then for some practitioners, that is the point.

Til Luchau:

And I don’t use instruments in my work. The instruments work were bruising the tissue. That’s not the model I have or think about. But there is an inflammatory rationale for essentially rebooting the inflammatory cycle. Starting it over again so that hopefully we complete and complete the second time instead of getting stuck.

Whitney Lowe:

And I guess the intention behind that too, is that when you do that, that you can sort of reboot it in a therapeutically beneficial way and not get it sort of rebooted out of control or out of whack a little bit. Because I’ve seen some results or adverse effects from some of those things, where I think people went too far and were a little bit too aggressive and too vigorous with what they were attempting to do in there.

Til Luchau:

It takes a lot of skill, and a lot of skill is around dosing. All these things come down to dosing. Like, how much do we irritate it to make it better? It’s not just the irritation, it’s the skillful irritation. That in certain cases, with certain clients, and certainly wouldn’t be anybody with the systemic. By the way, that’s not something I would use with the systemic inflammation.

Til Luchau:

I wouldn’t work them hard to try to get them to reboot. That’s more for a local thing where they’re otherwise healthy and we have a good report. They’re already moving their lives, things like that. It just seems to be stalled out. And that kind of approach would be what I consider if I have training in it. Again, it’s something that I’m trained in and know the considerations around.

Whitney Lowe:

Yeah. So what would you say are some of the biggest key takeaway points for us in terms of working with inflammatory things? What are the most important key things for everyone to take away from a practice perspective?

Til Luchau:

You got to expand your toolset. Resist the thinking about it like a tight muscle or fascia release or even pain to bio-psycho socially shift around. All those things can help. But inflammation is its own thing and you need a diverse toolset that can help you work with it as an ongoing process. That’s the first one of those five summary points.

Til Luchau:

But the second one is finding the right dose. You really got to… Not even just that last S, but any of these techniques, including the autonomic one, including especially movement safety, it’s all about dosing. And it’s the haircut principle, you start slow and you can always do a little more later next session, but you can’t do less. So you start and you have people report back to you how the work is progressing.

Whitney Lowe:

Yeah, that’s an important one because I think so many times people look for protocols or recipes or guidelines like, how many of these do I do, or how much of this do I do? And we don’t teach stuff really in that kind of way, so the dosing question. And I think this comes up in all different types of bodywork and addressing so many different types of challenges that we find with our clients.

Whitney Lowe:

How much is too much, or what’s the right amount? And I get these questions from people a lot. Where do I learn this? Where do I learn how much of this to do? And I think as you’re noting, in many instances, there’s not strict rules around a lot of this kind of stuff. And the general practice guideline, I think, is to err on the side of ease before you try to do too much in there.

Til Luchau:

Especially if you suspect inflammation, do less. And usually I get this question a lot, too. How many of these should I do? How many seconds should I hold it? My general answer is three. Three is usually the right number. And that’s a joke. Pick a number if you want, but there are so many variables there: the amount of pressure, the amount of duration, the frequency, all those things. And the way you figure out the dose is to experiment. It is trial and error. You got to start somewhere. And then get a report back. It’s not always in the moment. It’s going to be two days from now. It’s going to be next week-

Whitney Lowe:

And I think a real-

Til Luchau:

-Get your clients to report back to you too.

Whitney Lowe:

– A real important part of that is understanding that one person’s three of these is another person’s six of them. And that dosing issue is highly individual and independent with people. So that’s the other thing about getting away from these protocols and recipes and routines, is that people are individuals and we can’t apply those kinds of things that rigidly to everybody the same.

Til Luchau:

Absolutely.

Whitney Lowe:

Yeah. What else we got there?

Til Luchau:

Third of five summary points, use movement. Get your client moving on your table. Get them to move. That’s going to be huge. Number four, don’t forget the power of the therapeutic interaction. Just you being there, you listening to them, you paying attention, you touching, them having taken the time out of their schedule to come to you, all those things are already going to have therapeutic effects, especially when we’re talking about the systemic inflammation.

Til Luchau:

And I should just circle back around and say, we work with systemic inflammation systemically, and that’s a lot through the interaction as opposed to like, which spot do I push and how hard? It’s more like, how do we orchestrate an experience for the person that leaves them feeling overall better? That’s a huge inflammatory help right there.

Whitney Lowe:

Yeah. Great. And what’s our last one there?

Til Luchau:

And the last one, basic health and self care. Don’t forget that people have medical issues. They need to be addressing those really for you to be able to be effective with their inflammatory symptoms, too. And they need to be getting sleep. They need to be happy in their life. They need to have a decent diet and they need to be moving. All those things we know that affect basic health are going to be the groundwork for what you do on your table as well.

Whitney Lowe:

Yeah. So these are really valuable guidelines, I think not only just in inflammatory activities, but for lots of different types of approaches and things that we’re going to be doing. And I know certainly by reading a lot of the things that are on social media right now, there’s a lot of practitioners very eager to get back to activity here and get back to working with people again.

Whitney Lowe:

So some really good tools and guidelines that you’ve provided for thinking about some of these things, and especially for dealing with more compromised health conditions and keeping in mind that so many of these things that we work with may have inflammatory components, even though they’re not directly apparent for us.

Til Luchau:

And pneumonia itself, which is what some people who have a COVID reaction end up with, that’s an inflammatory situation and it takes a while to recover from. So you may be seeing in your practice more people recovering from that, so it can be a long term recovery. And these are some tools and approaches that hopefully will help set the tone for them.

Whitney Lowe:

Great. Well, I’ve enjoyed that conversation thoroughly. I would like to say a big thank you to our sponsors of the show, and also a major thank you to all the listeners and people who take time out of their lives to listen to us. You can stop by our site for show notes, transcripts and other extras and information there at thethinkingpractitioner.com. And Til, where can people find out about you and things that you’ve got going on with your trainings?

Til Luchau:

Yep. Our inflammation trainings or fascia trainings, etc, are at advanced-trainings.com. Thanks for all the great questions, Whitney, and helping me lay it all out. Where can people find out more about what you offer?

Whitney Lowe:

Yeah, also, we’ve got information over on the academyofclinicalmassage.com for things that we’ve got going on over there. We’re doing lots of stuff with our online program now during the stay-at-home time for everybody. We had a few people send us some notes. We appreciate your input that you’ve sent us by email to [email protected] Please feel free to send us any notes over there. And you can reach us also through social media. Til, where can people find you out there on social?

Til Luchau:

Just my name, T-I-L L-U-C-H-A-U on all different social platforms.

Whitney Lowe:

How about you, Whitney?

Til Luchau:

Same thing. And you can find me through my name, Whitney Lowe, out on Facebook, Twitter, etc, out there. So we would ask you to, if you can, rate us on Apple Podcasts, Spotify or wherever else you’re listening. And tell a friend, share the word around there so we can help the other people and help everybody else out there. So thank you, Til, for that wonderful deep dive into the inflammatory process. And we will look into some new interesting stuff on our next go-around here again, very shortly in two weeks.

Whitney Lowe:

Yeah, I can’t wait Whitney. Thanks. I look forward to that.

Til Luchau:

Okay. That sounds good. We’ll see you all, then, in two weeks. Take care.

 

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