After getting this question from a reader for about the bazillionth time, I decided it was finally time to write an article about it. A little salamander sass is included at no extra charge, as usual.
Should You Drink Water After Massage? Only if you’re thirsty!
Many years ago I set out to write about the “perfect spots” for massage, and I began a series of articles. Some of those became the most visited and popular articles on this website. They are alarmingly close to becoming my “legacy.” I have probably received more positive feedback about them than anything else I have done in my life, my one-hit wonder, my “Macarena.” I routinely get fan mail about them like this:
I had crippling back pain, and massaging Spot #12 was like a miracle, OMG, so easy, where have you been all my life, thank you thank you thank you thank you thank you ….
And I can tell many of my own such stories of instant, amazing relief (and I just told one in the last post, about beating a headache).
Because — confession time! — the “perfect” spots aren’t really all that good.
Because I’ve never polished them. Because they have long lacked the artwork they need to shine. Because huge numbers of people have read them with the hope that they are much more carefully prepared than they are.
And because they are not based on much science — they’re based on a lot of fallible observations that I made while working as a massage therapist. I’m not really comfortable with this being my “legacy”! I’m a science writer. I wish there were a little more hard data in my most popular work.
(This is how I like to promote things. By trash-talking myself. Pre-emptively harsh self-reviewing. Nature of the perfectionist beast, I suppose. Sure, they are popular, but so are Britney Spears and sparkly vampires.)
I’ve been hard at work upgrading the series, trying to make it something that I can be proud of. More and better artwork, more science and footnotes, more examples and stories, and … databasification. A bunch of spot data is now enshrined in a database, and can be coughed up at will in a variety of formats, making the series more and more like a tool. Such features are now visible in each spot article, especially in the form of a lovely quick reference guide to the whole series. Pick one and have a look:
Yesterday my cat, Cali, woke me up with a particularly insistent feed-me-now yowl. Normally I would find this irritating, but yesterday she was doing me a favour, because my neck was in a crazy position and I was cooking up a violent headache. Some wee muscles behind my head were in a shortened position, and the longer I lay there, the harder it was going to be to get unstuck. A headache was already spreading across the back of my skull like a toxic spill. Sleeping is dangerous!
I can only assume it would have been even worse without my furry early warning system, but within an hour my headache was yowling much more loudly and persistently than my cat — who was by then fed and settled in the “cat sauna.” Lately she has become inordinately fond of sleeping all morning in the bathroom with the heat lamp on (which is not very energy efficient, but extremely cute), apparently because the heat is therapeutic for her cranky ol’ body. I decided to follow her example.
I warmed the back of my head up with one of my big, thick and lovely Thermophore heating pads and then settled in for a dose of urgently needed massage. Then, using a Knobble massage tool, which is just perfect for this particular location, I applied some (really intense) pressures to my suboccipital muscles. And then I followed that up with a good dose of mobilizations (simple neck circles).
The headache vanished. It’s hard to overstate the degree of success I enjoyed from this simple procedure. It was a severe headache, the kind that could easily ruin a whole day. Success was by no means guaranteed, and I feared the worst. But my self-treatment didn’t just take the edge off — the headache was terminated, quickly and completely. It was gone like it had never happened, and it did not come back.
My massage target there was “Perfect Spot No. 1” — the first in a series of thirteen.
I get stories like this one from my readers all the time. The “perfect spots” articles are the most popular on this website — but somewhat undeservedly (which I will explain next). But I’ve been working hard to upgrade them, lately, and so I wanted to re-introduce the concept with this timely story of headache treatment success.
So what are the perfect spots?
They are thirteen classic trigger points or “muscle knots,” the easiest to find and most useful and satisfying to massage, accounting for a majority of common minor pain problems, and many severe ones. What exactly makes a spot perfect?
But what’s this about the perfect spots not “deserving” their popularity? Read the very next blog post.
I interviewed creator Jeff Lutz about The Trigger Point Products Symptom Checker, a unique online reference tool to help both patients and professionals visually identify the “muscle knots” that may be causing pain, stiffness and other symptoms, and appropriate massage tools to assist in self-treatment.
Read the interview.
Visit The Trigger Point Symptom Checker.
Once again I present some new bibliographic records for your reading pleasure — no, seriously. These are not dry “abstracts” (although those are also available if you click through). The whole point of the SaveYourself.ca bibliography is to explain pain science as painlessly as possible. More and more I realize that the bibliography is turning into a database of mini-articles — and they are worth sharing!
Fredsted et al. American Journal of Physiology. 2007.
Intense and unfamiliar exercise damages muscle cell membranes and correlates with a flood of calcium into the cells, causing fatigue. But what causes the damage and starts the flood? Mechanical damage has never been ruled out. This experiment chemically blocked 90% of contraction strength in rats, effectively eliminating physical strain from the contraction equation. The rats’ muscles were then electrically stimulated to simulate exercise without mechanical stress. Unfortunately for the rats — actually, nearly everything about this was unfortunate for the rats — their muscle cell membranes were damaged just exactly as they would have been in a normal, intense rat workout. The implication is clear: cell membranes are damaged in exercise by metabolic stress not mechanical stress. The authors concluded that “cell membrane damage depends on Ca2+ influx and energy status and not on mechanical stress.”
width='300' height='278' alt=''>
But now we know that mechanical stress is probably not what damages cell membranes in exercise. Which is pretty interesting. Thank you for your sacrifice, rats.
Woo et al. British Medical Journal. 2010.
What’s the harm in acupunture? A small but real risk of infection — as with anything that breaks the skin. Acupuncture has not only failed to prove that it works, but this British Medical Journal editorial presents new evidence that it also involves a risk of mycobacteria infection, and even that “… outbreaks of acupuncture transmitted infections may be the tip of the iceberg. The first reports of meticillin resistant S aureus (MRSA) transmitted by acupuncture appeared in 2009. The emergence of community associated MRSA infections may aggravate the problem.”
A common objection to Woo’s article has been that it is “mongers fear” and that he cites old evidence, from the 1970s and 1980s, before sterized needles were widely used. But critics conveniently overlook that Woo also cite modern evidence of infection — about as blatant a case of biased interpretation as you could ask for. And is Woo a fear mongerer? He does not claim that the risk is great: he just reports what is known and titles his piece neutrally. It is always worthwhile to examine treatment risks, and especially when treatment benefits are also hotly disputed. It hardly constitutes “fear-mongering” to report risk data in a medical journal! If not there, then where?
Häkkinen et al. Clinical Rehabilitation. 2008.
Researchers tested the effectiveness of strength training for neck pain and disability by comparing two different exercise regimens, kicked off with ten group training sessions. A hundred patients participated: fifty did a year of strength training combined with stretching, and the other fifty did just stretching. No significant differences were found in pain or disability.
The authors also noted that patient dedication to the exercises probably left something to be desired, but that’s so inevitable in any group of average people that it can be almost be considered a natural weakness of exercise therapy. So this evidence strongly suggests that strengthening is unremarkable at best as a therapy for neck pain, either because it doesn’t work particularly well, and/or because you can’t get people to do it long enough and well enough even if it did.
Middelkoop et al. Best Practice & Research. Clinical Rheumatology. 2010.
This review of the science of exercise therapy for low back pain included only randomized controlled trials of adults with chronic nonspecific low back pain that evaluated of at least one of the most relevant outcomes (such as pain). The results were positive but unimpressive: “[exercise] effects are small” and there is “no evidence that one particular type of exercise therapy is clearly more effective than others.” This is a reality check and an ego blow for a massive industry devoted to selling patients on many specific and branded styles of exercise therapy. All these findings suggest is really just that “being active” is a little better than not being active, and the type of activity probably doesn’t matter much.
Epsom salts supposedly relieve aches and pains, especially muscle pain, but there are many problems with this idea, which I have written about in truly ridiculous detail (believe it or not). It’s not at all clear how salts can get through the skin barrier, which is pretty substantial. But a simple 2006 experiment showed that magnesium and sulfates do get into the blood somehow: their levels were higher after people bathed in dissolved Epsom salts.
But when you encounter surprising results in science, don’t just settle on the first explanation that comes to mind — it could easily be wrong. The study author, Dr. Waring, says that she “assumed that it simply diffuses across the stratum corneum,” and that certainly is possible (despite the problems with it). But what other explanation could there be for the results? How else could magnesium sulfate have gotten into the bloodstream in her experiment? Reader Adrian J. had an unusual idea (which just screamed “funny sidebar!”):
Is it possible that the salt diffuses across the epithelium in the anus and/or rectum, if the anus relaxes to some degree in the warm water?
Wow, that’s some creative lateral thinking! It’s probably a bit of a reach: I find myself (uncomfortably) wondering … just how much do I relax in a hot bath? That much? And how much salt could diffuse across that more permeable but much smaller membrane? It’s a small target! And I shudder to think of the measures required to test this hypothesis …
So it’s not a particularly plausible idea, which Adrian acknowledged on his own initiative in a follow-up email. But it’s getting air time here because it’s still a wonderful (and fun) example of an important way of thinking about evidence: the creative search for non-obvious explanations for data is very much at the heart of science.
Sometimes I criticize poor quality writing as a corollary of poor quality thinking in the world of therapy, because it’s alarmingly common. Many deluded and fraudulent purveyors of bogus treatments are often incoherent when they try to ’splain themselves.
People out there in on the interwebs often write to scold me for this — how dare I criticize writing when there’s a tipo off my own on the very same page? Why don’t I just stick to the idees?
Of course, whenever I make criticasms of sloppy writing, I do open myself up to a charge of hypocrazy, because there are certainly scattered errrs on my website, probbly even on this veru page. But it’s a matter of dagree. I only criticize someone’s communiation skills when their writeing problem are signicifant and revelant : when the errors are thick and nasty and thick and nasty, when they arre combimed with style problems like SHOUTING IN CAPS!!!, or abusing “quotion marks”; or just horrible spellung and grammer and sentense structure, and and whn they betray ignoranse of the subjet matter,, like a chiropracor who writes the “veterbra” three times in the same short email but incests “I’m a proffesional”.
(I’m not making that last bit up. I actually got that message.)
Not everyone’s a writer, but writing that bad is much worse than just lacking a knack — and it exposes a lack of mental rigour and maturity. There is such a thing as a minimum literacy required for one’s ideas to be taken srsly.
Thought of the day, from my article on structuralism:
Patients with great anxiety, pain and frustration are especially vulnerable to persuasion, or “therapy by charisma.” This is why I really make an effort in my work to be reassuring without offering miracles, to be knowledgeable without claiming to “know” what the problem is. All too often, patients in pain will cling to whatever ideas you throw at them… so you have to be careful what you throw at them! Structuralists rarely seem to show such restraint, and consequently many patients emerge from therapy feeling much too sure of their diagnosis. There is no zealot like a convert! In this context, clinicians can be more like clergy than health care professionals.
Once again I will be travelling to Las Vegas this summer to participate in “TAM” — The Amazing Meeting, a critical thinking and (who are we kidding) geek convention. I went to my first TAM last year, and wrote a bizarrely long and cheeky account of the experience that was strangely popular. This year I am particularly looking forward to, roughly in order of importance:
But the main professional attraction is the science-based medicine workshops, presented by the the team of doctors that created the Science-Based Medicine blog, especially Dr. Steven Novella, Dr. David Gorski, and Dr. Harriet Hall. I have had a working relationship with SBM since I met them all last summer, and I volunteer my time doing some copyediting for SBM. If I were to rename my website, I would probably call it Science-Based something or other.
“Science-based” medicine is a conceptual upgrade to “evidence-based medicine” (EBM) that emphasizes that ideas in health care must make a reasonable amount of sense and clearly pass fair scientific tests before we take them seriously. For more information, see Why Science-Based Instead of Evidence-Based?
I am excited about SBM as a movement because I see a dire need for its sensibilities in health care and health information. I predicted that SBM — the idea and the blog — would become a big deal, and I was right. It’s really taking off, and I’m really proud to be involved. It will really be a treat to meet with the SBM writers at TAM8!
Oh, the Pain! 3 new studies from the Journal of Pain
The latest Journal of Pain was a potpourri of pain science pleasers. Today I present moist summaries of three dry scientific papers about:
Clay et al. Journal of Pain. Volume 11, Number 5, p420-30. May 2010.
How often does injury lead to chronic pain? Why do some injured people develop chronic pain and others do not? Researchers kept tabs on 168 patients who suffered non-life-threatening orthopaedic injuries.
54% reported persistent pain six months after the injury and 87% reported that this pain interfered with their normal work activities.
Long-term pain was more likely to the extent that pain was acute at the beginning (independently of injury severity), if patients felt responsible for the injury, and if they were pessimistic or emotionally traumatized. “Psychosocial factors strongly predicted persistent pain, pain-related work disability, and pain severity,” the researchers concluded, and noted that “many of these factors are potentially modifiable and should alert the clinician about the need for interventions in order to prevent the development of pain chronicity.”
Kennedy et al. Journal of Pain. Volume 11, Number 6, p579-587. Jun 2010.
Ever wish you could get rid of some nerve endings? It turns out that you can — just apply chili peppers! This experiment showed that nerve endings shrivel away from an application of capsaicin, the active ingredient in peppers. The effect was quite dramatic.
Healthy volunteers took one for the team: a single application of highly concentrated capsaicin on their thighs, for just one hour. The density of nerve endings and sensitivity to various stimuli was recorded before and after, and then checked again after 1 and 12 and 24 weeks. The results were amazing: nerve ending density was down 80% after a week, and pain sensitivity was also reduced (though much less). Touch sensitivity reduced slightly, and heat and cold sensation remained normal.
Over the next several weeks, the nerves regenerated and sensation returned to normal. Given this surprisingly potent effect on nerve endings, capsaicin may be an effective and safe way to treat some pain problems.
Ruiz-Aranda et al. Journal of Pain. Volume 11, Number 6, p564-569. Jun 2010.
This experiment presents clear evidence that “pain is an opinion”: an experience modified by mental and emotional factors.
I don’t think anyone will be surprised to learn that being a drama queen actually hurts. (“Drama queens,” of course, is exaggeration for comedic effect — please don’t actually call anyone in pain a drama queen unless you want to get smacked around.)
Two groups of women were tested for pain tolerance with the traditional, unpleasant method: immersion of the hands in ice water. One group was rated with better emotional coping skills, and (predictably) they were more tolerant of pain than women with poorer coping skills.
Although the results seem unsurprising, the authors say that “currently there are no experimental investigations of the relation between emotional regulation and pain.” Based on this study, it can be assumed that emotional state and skills are relevant to pain management.