Massage Therapy Journal Summer 2025

Summer 2025

CE Building an Inclusive Massage Practice with Cultural Competence

JOURNAL

What the Research Shows Massage Therapy for Mental and Emotional Health The Future of Massage How to Curate the Perfect Client Experience

The Mind & Body Connection

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Massage Therapy Journal Vol. 64 No. 2 Contents

FEATURES

16 THE MENTAL HEALTH BENEFITS OF MASSAGE THERAPY FOR PEOPLE AFFECTED BY ILLNESS People with chronic or acute health conditions often have symptoms that go beyond the physical. Massage therapy can help make that mind/body connection. By Rebecca Sturgeon and Cal Cates

24 BEYOND THE PHYSICAL: MASSAGE THERAPY FOR EMOTIONAL HEALTH Not all pain is physical, but massage therapy can still be beneficial. By David Malone

32 BUILDING AN INCLUSIVE MASSAGE PRACTICE WITH CULTURAL COMPETENCE CE Enhance your massage therapy practice by embracing

74 THE FUTURE OF MASSAGE IS ALL ABOUT

PERSONALIZATION Clients want to feel like their massage therapists curated their experience just for them.

cultural competence to create a welcoming and inclusive environment. By Susan Salvo, EdD, BCTMB, LMT

FotoCuisinette / shutterstock.com

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JOURNAL

DEPARTMENTS

Massage Therapy Journal® | Official Publication of the American Massage Therapy Association® Summer 2025 Vol. 64 No. 2 ISSN: 0895-0814 USPS 0010-218 Cover credit: Photo courtesy of Mark Hansen Photography Michelle Vallet Senior Publications Manager AMTA BOARD OF DIRECTORS (effective March 1, 2025) Cindy E. Farrar President Rick Greely President-Elect Kimberly Kane Santos Immediate Past President

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LETTER FROM THE PRESIDENT Deeper Roots and Standing Stronger

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ADVOCACY Elevating the Profession: Why Fair Licensing is Essential for Massage Therapists in Every State Across the U.S.

Jaime Bernardo, Jr. Director Heber J. Blackner Director Matthew Fecteau Director Donald Goodale Director Robert C. Jantsch Director Jane Horton Johnson Director Deb Kilty Director Cheryl L. Siniakin, Ph.D. Director Lee Stang Director

10 INTERVIEW

In Conversation with Teri Mayo, Executive Director of the Massage Therapy Foundation

EDITORIAL REVIEW OPERATIONAL COMMITTEE Jacqueline Herbach, LMSW, LMT President, Momentum Massage, Jane Neumann, BS, LMT, NCTMB Private Practice

Fitness, & Mind New York City Steve Jurch, MA, ATC, LMT Director of Allied Health Training at the Community College of Baltimore County

AMTA Illinois Chapter Communication Chair

Jessica Libero, LMT, NCTMB Connecticut and New York Licensed Reiki Practitioner Martha Brown Menard, Ph.D., CMT

80 INTERVIEW

AMTA’s 2025 National Convention Keynote Speaker Talks “The Fire Within”

Publication Management SPARK Publications sparkpublications.com

Project Manager: Jaclyn Yepsen Creative Director: Larry Preslar

Massage Therapy Journal is published quarterly by the American Massage Therapy Association (address below). Periodicals postage paid at Evanston, Illinois, and additional mailing offices. POSTMASTER: Send address changes to Massage Therapy Journal , 500 Davis St., Suite 900, Evanston, IL 60201-4695. SUBSCRIPTIONS: All subscription matters and notice of change of address should be sent to: Massage Therapy Journal Subscriptions, AMTA, 500 Davis St., Suite 900, Evanston, IL 60201-4695 (877-905-2700). Subscription rates: U.S. and Canada, $25 for one year (four issues); $45 for two years (eight issues). Foreign, $70 for one year; $120 for two years; available on a limited basis. Contact AMTA Member Experience, 500 Davis St., Suite 900, Evanston, IL 60201-4695. Phone: 847-864-0123 info@amtamassage.org EDITORIAL COPY: Queries should be sent to Michelle Vallet via email: mtj@amtamassage.org . Visit amtamassage.org/mtj for writer guidelines. Information contained in Massage Therapy Journal does not necessarily reflect the opinions or beliefs of AMTA and/or the staff of Massage Therapy Journal . ADVE RTISING: Contact the AMTA sales team at Smithbucklin to learn more about advertising and exhibitor opportunities: (301) 215-6710 Ext.130 or hbrown@smithbucklin.com. Copyright © 2025 American Massage Therapy Association MTJ-024

86 SOOTHE

Stay Sun-Smart: Your Guide to Healthy Summer Skin

KaryB / shutterstock.com

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6 • Massage Therapy Journal

Letter from the

President

Deeper Roots and Standing Strong

Phew, we’ve been through a lot the past five years. It’s no wonder I’ve been thinking a lot about the word resilience . Anyone who knows me knows I am a logophile, a lover of words. According to Merriam-Webster.com : In physics, resilience is the ability of an elastic material (such as rubber or animal tissue) to absorb energy (such as from a blow) and release that energy as it springs back to its original shape. The recovery that occurs in this phenomenon can be viewed as analogous to a person’s ability to bounce back after a jarring setback. We are fortunate, especially this time of year, to have an ever-present example in nature of what it looks like to be resilient. I get to witness it in my own backyard. I have the joy of sharing my office backyard with an incredible, roughly 250-year-old copper beech tree. Her branches shade the entire yard. Each day I arrive, she greets me, as if saying “look, all things are possible.”

survived the significant alterations to the terrain that surrounds her, and has withstood the extremes of the ever-changing weather and climate. Year to year she springs back even more spectacular than the previous year, with deeper roots and standing stronger, showing off her beauty to the world. Research has shown trees have elaborate communication networks through their roots, bark and leaves that also serve as support systems. Thus, making forests giant tree communities. We Are One Another’s Strength As with nature, we also are designed to bounce back from jarring blows, with internal systems to help process the changes. Sometimes, maintaining homeostasis and overall balance is the best we can do on our own, and that is okay. Other times, we may need to reach out to our communities for added support. The community we have among the massage therapy profession—and especially within AMTA— is tremendously supportive. I liken AMTA to a tree: our national board and staff are the trunk, our 51 chapters are the branches, and our 106,000 members are the leaves. Our 82-year-old roots are expansive and solidly established. We have weathered many organizational and industry changes. With a sheltering commitment to the growth and protection of “our forest,” including the massage therapy profession and all those within it, our resiliency grows stronger with each changing season. If you are ever in Tucker, GA, you are welcome to visit beneath Beauty’s canopy. “How could you not be hopeful if you’ve got a tree around?”— Ross Spears

ENGAGE WITH AMTA AMTA’S local chapters are a great place to start getting involved. Find yours at amtamassage.org/ chapters.

In fact, the last day my office was open before the pandemic shut us down in 2020, I looked over at my magnificent tree one last time. I’d named her Beauty at our 20th anniversary open house the year before. In that moment, I knew all would eventually be okay. Beauty was (and still is) the perfect representation of resiliency. Centuries old, she has lived through historical battles fought nearby,

Cindy E. Farrar AMTA President

I am because We are.

amtamassage.org/mtj

flexible

8 • Massage Therapy Journal

Advocacy Advancing the Massage Therapy Profession

Elevating the Profession: Why Fair Licensing is Essential for Massage Therapists in Every State Across the U.S.

M assage therapy plays a critical role in health and wellness, offering scientifically backed benefits ranging from pain relief to stress management. Yet, despite its growing recognition within health care, the massage profession faces inconsistent licensing standards across the United States. AMTA has long been at the forefront of advocating for fair and consistent professional licensing in all 50 states and U.S. territories. Here’s why this initiative is essential and how AMTA’s work supports both Massage therapy licensure is the official recognition that an individual has met the required standards to practice massage therapy professionally in their state. It is a way to ensure that massage therapists are qualified, trained and capable of providing safe and effective care to their clients. The process for obtaining a massage therapy license typically involves education and training, certification or exam, a background check and continuing education for renewal. the profession and the public. Why Massage Therapy Licensure Matters

Consistent Licensing Across States Provides Several Crucial Benefits: 1. Public Safety: Standardized licensure ensures

that only qualified professionals provide massage therapy, helping to maintain a consistent scope of practice.

2. Professional Recognition: A robust licensing framework elevates the profession, positioning massage therapists as key contributors to health and wellness. 3. Portability: Consistent licensing laws make it easier for therapists to practice across state lines, reducing barriers to employment and ensuring continuity of care for clients. 4. Industry Growth: Licensure fosters trust, opening doors for broader acceptance of massage therapy within health care systems and the general public. The Difference Between Licensure versus Certification and Registration There is often confusion around certification, registration and licensure. Here are the key differences: • Certification is a voluntary process where a non-governmental organization recognizes an individual for meeting predetermined

Vector Stock Pro / Shutterstock.com

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Summer 2025 • 9

qualifications. While it can require a minimum level of competency (e.g., through educational hours), it does not create a legally defined scope of practice. • Registration can be either voluntary or mandatory and is typically managed by a state agency or a non-governmental entity. To be registered, an individual may need to pay an annual or bi-annual fee and comply with regulations and ethics standards, but there is usually no active oversight or enforcement. • Licensure is a mandatory process where a specific scope of practice is defined in state law and an individual must meet those requirements established by the state to practice. An authorized state agency or licensing board oversees all practitioners and enforces the state’s requirements. In summary, certification is a voluntary process in which a non-governmental organization recognizes an individual’s qualifications. Registration, on the other hand, usually involves maintaining a list of practitioners with minimal oversight. In contrast, licensure grants legal authority to practice, defines a scope of practice, and provides stronger public protection, professional accountability, and enhanced mobility for therapists across states. Because of these advantages, licensure is considered the most reliable and regulated form of recognition for massage therapists. The Path Forward Achieving consistent licensing standards across the U.S. is not just a professional goal—it’s essential for ensuring the credibility, safety and growth of massage therapy. AMTA continues to advocate for statewide licensure in Kansas, Minnesota, California and Wyoming—the last four states to achieve licensure in the U.S. AMTA will continue to lead the way, because championing statewide licensure benefits both massage therapists and their clients. Licensing is one of the many ways AMTA is committed to elevating massage therapy to

Registration

Licensure

Certification

Can be either mandatory or voluntary

Mandatory

Voluntary

Scope of practice not required

Scope of practice required

Scope of practice not required

Possible government oversight and/or disciplinary complaint process

Government oversight through State Board, with authority to address complaints, compliance, investigations, and enforce sanctions Protects public, ensures minimum education standards, curriculum, exam passage, CEs

Generally no government oversight regarding enforcement/ compliance. Can put burden on local city authorities

Minimal public protection

Minimal public protection

Title protection not guaranteed

Title protection for Massage Therapists

Title protection not guaranteed

Stakeholder input not guaranteed

Stakeholder input-rules and regulations

Stakeholder input not guaranteed

Portability not guaranteed

Portability to other states and/or licensure by endorsement

Portability not guaranteed

meet the evolving needs of health care. Join us as we advocate for meaningful change in the profession through fair and effective licensing standards! Visit amtamassage.org/action-center to learn more.

License Portability

AMTA supports the concept of an interstate massage therapy compact as a way to improve portability for licensed massage therapists across states. However, we have concerns with many barriers and restrictions on portability that are included in the current version of the Interstate Massage Compact

(IMpact) legislation. Since the inception of work leading up to the current IMpact, AMTA has been actively involved in reviewing and discussing its provisions, aiming to improve professional mobility while ensuring accessibility for more massage therapists across the country. Visit the QR code to learn more about AMTA’s position on the IMpact legislation.

amtamassage.org/mtj

10 • Massage Therapy Journal

In Conversation with Teri Mayo Executive Director of the Massage Therapy Foundation

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T eri Mayo came to the massage therapy profession in the same way many other massage therapists do—she experienced the work for herself while recovering from knee surgery. Her plans for a career in creative or technical writing stalled after graduation

supporters, relationship building is where and how bridges manifest, and that is where I most want to engage and focus my efforts. Relationships through bridge building influences everything else. We live, work and exist as humans and professionals in very complicated times right now; the political climate will impact the massage profession for sure. But it is important to remember these challenging times will have a unique impact on the nonprofit world, as well. All massage stakeholders will have to work together to get through these tumultuous times if our field- and research focused MTF nonprofit is going to thrive. The relationships we build within and external to our field will be the key to MTF’s ultimate sustainability, success and potential growth. My cultivated skills in general business, therapeutic massage, rehabilitation and health care will help me to facilitate effective relationship bridge building efforts, and I’m excited for the challenge! Q Research is the cornerstone of health care professions. In your view, what role does research play in building and maintaining the credibility of the massage profession? A As both a solo massage practitioner and massage clinic owner, when I would meet with referring providers, research allowed me to speak a universal language. I think the ability to communicate through an evidence base is true across all disciplines.

when an economic downturn meant even getting an internship was difficult. Remembering her previous experience with massage therapy, Mayo decided to go to massage school. “It was my prior rehabilitative impression, combined with being a very kinesthetic person, that made exploring massage as a clinician an intuitive choice.” What originally was supposed to be a temporary stopgap turned into a more than 30-year career. “Once I began practicing massage therapy I loved every aspect of it,” she says. “And, I never looked back.” Massage Therapy Journal had the opportunity to talk with Mayo about the experience she brings to her role as Executive Director, the role research plays in the massage therapy profession, and what she hopes for the Massage Therapy Foundation’s (MTF) future. Q You bring a background of business, team management and professional mentoring, among other skills, to the Executive Director role. How will these skills help you bring your vision and hopes for MTF to reality? A I think that all these things will help take MTF to the next level. But the through line for me in all of this is rooted in relationship building . It’s the component I love the absolute most in all my roles. With staff, stakeholders, researchers, colleagues and

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12 • Massage Therapy Journal

Massage has a complicated and complex history with regard to communicating through this lens, which can increase barriers across health professions and ultimately to our clients. Many within health care or the health professions consider massage therapy as external to clinical work, or not necessarily part of health care. I had the personal experience of providers ignoring me until I shared research with them. Over the years, sharing peer-reviewed, large scale research studies transformed some skeptics into massage advocates—and some of my biggest referring partners. I believe that education and research give the therapeutic massage field credibility. While research isn’t the “end-all-be-all” (I believe massage is both an art and a science), being able to speak in terms of evidence base, outcomes, specific dosing, technique variation and impact is critical for massage therapy’s credibility in health care environments. Even for those who do not directly work in a health care environment, doing the research, dissemination and interpretation work is still impactful. Take, for example, working in a spa environment in which a massage clinician is talking to and treating a client with a specific condition. Speaking from an evidence informed standpoint and relating evidence back to the work regardless of environment demonstrates the discipline’s “root” and training within research. That’s a game changer. Q What is one common misunderstanding you hear about research, and how might MTF’s work help to bridge some of those gaps in understanding? A I think that many think that “every study is a good study.” Just because one reads something that begins with the phrase “A study suggests/ says …” doesn’t make it research. Having basic research literacy is critical. I also think that many people may inappropriately generalize personal experiences over research. One’s own clinical experience

is valuable within an evidence-based practice paradigm, but on its own, is not statistically or potentially even clinically a robust piece of the evidence puzzle. MTF can help bridge the study applicability gap in a few ways. For the LMT, utilizing our BRL (Basic Research Literacy) class is just one critical first step. Reading research in trusted places is also another ( IJTMB , for example). The other way that MTF makes an impact in the world of massage research is that it works diligently to support research reflective and relevant to the therapeutic massage field. Such research is also conducted systematically, utilizes rigorous methodology designed and performed by competent and skilled researchers, is objective, and produces reliable and valid results that can be replicated and appropriately generalized. Research proposals submitted to the MTF are rigorously peer reviewed following several criteria of the National Institutes of Health. Meritorious proposals to the MTF are reviewed, provided developmental feedback, and potentially get presented for funding, either to the MTF board or to the AMTA board, depending on the source of the funds. Q You’re talking with a massage therapy student nearing graduation. What do you tell them about the role research can play in their building a long and successful career in the massage profession? A In school, your instructors give you context, content, information and research … but once out of school and in practice, you must know where to go to find the most current information to both be a better practitioner and to help you know best practices. Research is key in helping massage therapists learn what works and, of equal importance, what doesn’t. And it can also help you stay safe as a practitioner. Knowing how to read research, knowing where to go to look up modalities and impacts, or to look

Research is key in helping massage therapists learn what works and, of equal importance, what doesn’t. And it can also help you stay safe as a practitioner.

DID YOU KNOW? The Massage Therapy Foundation was signed into being by the Secretary of the State of Illinois on August 3, 1990. Since then, the MTF has provided more than $1 million in research grants studying the science of therapeutic massage!

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up pathologies being impacted by particular techniques or dosing schedules, is essential. Along with continuing education, research is the thing that will help you continue to be a deeply knowledgeable practitioner and continue to grow as a massage therapist. Research also helps you build rapport with your clients and increase referrals. Being able to speak to your clients about your evidence-informed practice is vital. Being able to answer questions such as “can massage help with _____?” builds trust and deepens the clinical relationship. Lastly, it can help you build relationships with other integrative health providers. Q As Executive Director, can you briefly give us an idea of some of your top priorities and how you see meeting some of the goals you and others have for the Foundation? A The MTF is going through some big but exciting transitions regarding staff support and Board make-up. Such multiple transitions are a lot at once, so one of the first things I want to do is stabilize things, get everyone oriented and looking in the same direction, and then, together, look ahead. I am approaching this as a new beginning for MTF and all our stakeholders, while also incorporating a growth mindset. I am also working to be smart and intentional with this moment and all its related contexts. Q From your perspective, what is the future of the massage profession? What role do research and organizations like MTF play in this future? A I think that the future of the massage profession will increasingly become focused on research and evidence-based practices.

This is a good thing: as the massage therapy toolbox is filled with more effective treatments, consumer uptake will grow and our credibility as a field will increase. We’re already becoming a viable treatment alternative for pain management, for example. I think that there are many, management and, as the research in our field continues to reveal the impacts of what we do and the injuries, pathologies, diseases and rehabilitative impacts we can have, our influence will only grow. MTF will be a critical participant in this as we drive funds toward the best research opportunities and continue to be a respected voice in the realm of legitimate research for our field. Q We’re talking one year from now. What do you hope to be able to say about MTF? What is one goal you have that you hope is either achieved or well on its way in the coming year? A From the operational side, I hope that the MTF is stabilized from a resources standpoint, with an effective staffing composite, board structure and volunteer cadre so we are poised for growth. And I hope that we’ve begun to deepen relationships with new stakeholders and perhaps reconnect with some old ones. From a vision standpoint, I hope that MTF will have begun to forge some new paths and that we’ll feel “stretched” in some new ways. The year-out plans and ideas are just starting to be formed, but I think that we will continue to refine and more robustly define key goals and benchmarks for the good of the field and the MTF’s research support endeavors. If multiple new paths are forged, and MTF has maintained and perhaps expanded others, I’ll feel like it was a great year. many ways we can continue to be a wonderful part of our client’s health

LEARN MORE ABOUT TERI MAYO Teri Mayo, new Executive Director of the Massage Therapy Foundation, also has experience in health care administration. Visit us online to learn more about her career in health care and massage therapy, as well as the integral role she envisions community building and collaboration will play in maximizing the MTF’s potential. Read more now at amtamassage.org/mtj .

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16 • Massage Therapy Journal

The Mental Health Benefits of Massage Therapy for People Affected by Illness People with chronic or acute health conditions often have symptoms that go beyond the physical. Massage therapy can help make that mind/body connection.

By Rebecca Sturgeon and Cal Cates

NStafeeva / Shutterstock.com

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18 • Massage Therapy Journal

M assage therapy and physical pain are kind of besties—well, more like frenemies, maybe. We often think of them together and we get excited about massage therapy’s potential to address and lessen pain, but we forget that pain is just one of many experiences.

Destigmatizing “relaxation.” How many times have you heard the phrase, “Just relaxation massage” as though the “brand” of massage that delivers relaxation is less valuable or legitimate than other types of massage? As a profession, we have downplayed, undersold and essentially ignored the deeply important therapeutic significance of relaxation. There is a worthwhile body of research 2,3,4 that explores the experience of both patients and caregivers beyond the quantitative measures of pain and anxiety. Relaxation is key to those experiences. Well-being is another word that has essentially lost its meaning in modern language, but the authors of this article feel confident that massage therapists have the potential to profoundly impact well-being in the lives of people affected by serious illness. When we talk about quality of life, we’re talking about well-being. When we talk about having less pain, that’s also about well-being. When anxiety and depression feel less pressing, less heavy, less suffocating—these are all aspects of well-being, and they are not individual. They are all pieces of what make up any one human’s (and every human’s) experience. And they can all be facilitated by massage therapists with the right tools. Byron* believed entirely in his own agency and ability to control his fate—until he received a cancer diagnosis. In that moment, he felt as if his entire identity collapsed into one unwanted label: Cancer Patient. A lifelong entrepreneur, Byron suddenly felt that all his future projects became impossible in the face of this diagnosis. In his mind, his world shrank to the size of the errant cells Cancer: Massage + Cancer related Distress

When it comes to people with serious health conditions and the people who love them, pain might be a feature of their experience, but the benefits of massage therapy go far beyond addressing this single symptom. Let’s start by ensuring we’re using the same definition of massage therapy. We know this is a topic of significant debate, but for the purposes of this article, we will use the following definition: Massage therapy consists of the application of massage and non-hands-on components, including health promotion and education messages, for self-care and health maintenance; therapy, as well as outcomes, can be influenced by: therapeutic relationships and communication; the therapist’s education, skill level and experience; and the therapeutic setting. 1 Fully grasping the potential value of massage therapy , as defined above, for people affected by illness requires that we understand the deep truth that massage therapists are so much more than hands. Our words, our body language, our ability to notice and limit the impact of bias on our client interactions, and more make up this thing we call “therapeutic relationship,” which lies at the root of our ability to decrease anxiety, increase a sense of peace and facilitate an experience of transcendence. In this article, we’d like to invite you to consider the impact of those harder-to-express benefits that so many people enjoy from massage therapy but which get very little public appreciation and even less focus in research. Aspects like emotional well-being, decreased isolation and improved coping can be game changers for people living with serious health conditions.

Massage therapy consists of the application of massage and non-hands-on components, including health promotion and education messages, for self-care and health maintenance; therapy, as well as outcomes, can be influenced by: therapeutic relationships and communication; the therapist’s education, skill level, and experience; and the therapeutic setting.

venimo / Shutterstock.com

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Summer 2025 • 19

in his body, and all his resources (physical, emotional and financial) could only flow into his cancer treatment. In addition, as a person of color in the U.S., Byron already had many experiences of being ignored, mistreated and dismissed by medical professionals. As a result, he found it difficult to trust the system to care for him. What followed for Byron was a period of significant depression as he struggled in the face of his diagnosis. For Byron, a cancer diagnosis included cancer-related distress. Cancer-related distress affects almost every person diagnosed with cancer at some level, with about 40% of patients reporting “notable distress,” 5 which is defined by the National Comprehensive Cancer Network as “a multifactorial unpleasant experience of a psychological (i.e., cognitive, behavioral, emotional), social, spiritual and/or physical nature that may interfere with one’s ability to cope effectively with cancer, its physical symptoms, and its treatment .” 5 Anxiety and depression are the most prevalent mental health challenges that accompany distress. Patients report the most frequent sources of cancer-related distress as worry (55%), fatigue (54%), fears (45%), sadness (44%), pain (41%) and sleep disturbance (40%). 6 Distress can appear in anyone faced with a cancer diagnosis, and it is important to note that social factors can serve to increase or mitigate the experience of cancer-related distress. For example, distress is often associated with lower income or lack of access to health insurance. Working with people who are in or have been through cancer treatment requires training beyond our foundational education. Oncology Massage training of at least 24 hours is the minimum standard. In Oncology Massage training, we learn to understand more about the disease of cancer itself, as well as develop and practice the clinical reasoning skills we need to adapt a massage for the effects of cancer and cancer treatment. Without this training, we run the risk of causing both immediate and lasting harm and, as important, we miss the opportunity to be of specific and valuable service to the people we touch.

Beyond the hands-on adaptations and technical knowledge, we also need deep self-reflection and emotional regulation skills when working with people affected by serious illness. As humans, we may have personal experience with cancer or with caring for a loved one during their treatment. That does not qualify us to provide safe, accurate massage therapy for someone affected by that illness. We all have our own fears and assumptions about illness. We must remain aware of the history that we carry into the treatment room. Our challenge becomes remaining curious and open in the face of whatever shows up in our space, even if it “looks like” something we think we know. With the proper education, there is much we can do to improve the day-to-day quality of life for people faced with a cancer diagnosis. The ways in which massage therapy may help cancer patients experiencing distress include: • Reduce anxiety and depression: reductions of anxiety and depression are massage therapy’s most commonly reported effects, with a course of treatment providing benefits similar in magnitude to those of psychotherapy. 6 • Improve the reciprocal relationship between body and mind: massage therapy can link changes in the tissue to changes in the recipient’s cognitive self-awareness. 6 As a nervous system-based intervention, massage can help recipients reconnect their body into a whole. • Address pain and other symptoms: Massage therapy can be an effective treatment for pain, 6 but can also reduce fatigue, stress, anxiety and nausea. 6 Autoimmune Conditions: The Invisible Cost Roughly 1 in 15 people in the U.S. has an autoimmune disease. It’s no surprise that, with more than 100 identified autoimmune diseases, these diagnoses cover the spectrum

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20 • Massage Therapy Journal

with just about any tissue or organ in the body potentially being affected. 7 The common nature of these conditions leads to a sense of normalization that is unhelpful. We all likely know at least one person with rheumatoid arthritis, lupus, psoriatic arthritis, Crohn’s disease, type 1 diabetes or multiple sclerosis. Unless we know this person well, however, we likely almost always see them “at their best,” when they feel well enough to be out in the world interacting. That doesn’t give us a very real view into what it’s like to live with these conditions. Mental health challenges are common among people who live with autoimmune diseases. A 2013 study in Denmark 8 found that participants (who all had autoimmune conditions) were 45% more likely to develop anxiety or depression, and the Cleveland Clinic reports that as many as 50% of people with MS have clinical depression. 9 People living with type 1 diabetes often develop cognitive deficits across their lifespan that affect attention, information processing speed and executive functions, as well as depression, anxiety and decreased quality of life. 10 In their 2018 paper, “Depressive Syndromes in Autoimmune Disorders of the Nervous System,” Drs. Liu and Tang discuss “pleasure loss” and “sleep disturbance” as common aspects of depressive presentation in people with autoimmune conditions. 11 Living with or caring for someone who lives with an autoimmune condition means your life is significantly disrupted. There is worry and fear about changes in disease progression or severity, flare-ups, as well as endless and sometimes seemingly pointless medical appointments. Many people feel stigmatized and isolated by their illness, and many of these conditions come with chemical and hormonal changes

that can be unpredictable and hard to manage. Changing health status and changing energy levels can lead to one’s life feeling smaller. Many autoimmune conditions are also considered “invisible,” which presents the unique challenge of feeling like a person is constantly working to “prove” how sick they are or how badly they feel. The icing on this difficult cake is that the medications that treat these conditions can even cause depression, anxiety, loss of after appetite, and other exhausting and deeply disheartening side effects. 12 We mentioned earlier that pain isn’t all there is to consider, but we can’t ignore it either. People who live with persistent pain of the kind that can be common in autoimmune conditions are four times more likely than those without pain to suffer from depression or anxiety, and more than twice as likely to have difficulty working. 13 Despite the significant body of knowledge and growing awareness about the impact of autoimmune diseases on mental health, most traditional treatment regimens do not prioritize mental health interventions. When a client is living in a world like the one described above, therapeutic alliance can be an essential piece of what we offer. It’s our job as massage therapy practitioners to understand what these symptoms really mean to the people who live with them. We have to imagine and wonder and even ask about our clients’ experiences so we can address their needs more skillfully. We can demonstrate that we truly see our client by listening fully and believing what they tell us. We can normalize and acknowledge their grief at feeling unwell, at losing autonomy, at simply having to think and work harder to live a so-called “normal” life. As practitioners, we can read books written by people who live with these conditions. We can watch documentaries and read articles and papers. We can learn about the diseases and how they impact the people who live with them so we can bring pleasure and connection and compassion through the incredible gifts of relaxation and nervous system co-regulation. 14

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Chronic Pain: Beyond the Physical The Centers for Disease Control and Prevention estimates that 20.9% of U.S. adults (51.6 million people) live with chronic pain, and 6.9% (17.1 million people) experience what’s called high-impact chronic pain (i.e., chronic pain that results in substantial restriction to daily activities). 15 Chronic pain is defined as “persistent discomfort lasting beyond 3 to 6 months.” 16 This includes headaches, migraines, back pain, neuropathy, rheumatoid arthritis, chronic fatigue syndrome, fibromyalgia and many other common conditions. The idea that massage therapy can relieve pain is well-known, but if you’re anything like us, you didn’t learn much in massage school about how pain actually happens— its causes, its patterns and its relationship to non-physical factors. The nuanced and multifactorial experience called pain 17 tends to be understood in our profession as an amorphous experience of unpleasantness that provides us with our most primary mandate: Stop the pain. Unfortunately, not all pain is created equal. For instance, a simple online search about the cause of headaches will take you down an infinite rabbit hole that could lead you to believe that you should just stay in bed if you want to avoid a headache. Similarly, the cause of fibromyalgia is unknown, and treatments are not only varied, but an approach that works for one person may have the opposite effect on another. 18,19 Back pain has been the subject of massage therapy research for decades, but it, too, has many causes and the successful massage therapy dosage and therapeutic approach are specifically related to the cause of the pain. All of this boils down to an imperative for critical thinking and a more than tangential understanding of pain science. A healthy dose of advanced communication skills wouldn’t hurt either. 20 Pain can be neuropathic, nociceptive, musculoskeletal, inflammatory, psychogenic,

mechanical, or even an overlapping and cyclical combination of these. While these terms may make an incredible song for Mary Poppins II , they can befuddle a practitioner who is unaware of their complexity. Understanding pain, its characteristics and causes is key to successful and supportive care. It’s also important to understand that pain is a symptom, not a diagnosis. This truth should invite curiosity. “Of what issue or issues is this person’s pain a symptom?” “What can I learn about that issue that will help me better understand how to use the skills and techniques of the discipline of massage therapy to support this person?” As with most serious health conditions, chronic pain often results in symptoms that are challenging to mental health, including anxiety, depression 21 and sleep disruption, 22 which lead to other issues like difficulty with activities of daily living and substance use disorder. 23 People who live with chronic pain experience a shrinking of their world and ability to function in it that is similar to the experience of people with other health conditions explored in this article. When research about massage and pain is conducted, it’s rare that patient experience is captured with qualitative interviews or other tools designed to elicit the nuanced changes that may result from massage therapy. Even so, research suggests that massage therapists have the potential to reduce pain perception, 24,25 improve overall mood 26 and mental well being 27,28,29 in people with chronic pain. Improved sleep quality, 30,31 positive, nurturing touch, and reduced feelings of isolation 2,3 are also important benefits. Certainly, the hands-on part of massage therapy is important in our work with people impacted by the illnesses explored in this article, and we hope you’ll continue to challenge and expand your own concept of the value you can bring to the lives of these people and their caregivers. When researchers do invite patients to share their experiences of massage, they

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Deepen Your Knowledge,

Deepen Your Practice

Center to Advance Palliative Care (CAPC) capc.org

Here are a few resources to get you started with the necessary education and support to provide the best care for yourself and your clients.

CAPC is an interdisciplinary organization that provides training for clinicians who work with people living with serious and chronic illness. Cleveland Clinic Health Library my.clevelandclinic.org/health Cleveland Clinic Health Library is a vast resource of research-backed answers to a wide variety of health questions. Global Autoimmune Institute autoimmuneinstitute.org The Global Autoimmune Institute advances the understanding, research and treatment of autoimmune conditions. Their website compiles the latest research updates and information for people living with autoimmune conditions. Reading reputable information is important, but reading alone is not enough. We recommend that you pursue specialized training from qualified, experienced instructors in Trauma-Informed Care and Oncology Massage and Palliative Care. Do the work to build your own skills of emotional and nervous system self-regulation, to cultivate deep listening and effective communication, and always remember that pain, anxiety, depression and other common symptoms are an invitation to learn more about what they mean to the person who is experiencing them.

Archangels archangels.org

Archangels is an organization “reframing how caregivers are seen, honored and supported using a combination of data and stories, through public and private partnerships.” You can take the free Caregiver Intensity Index on their website, as well as find information about family caregivers in the United States.

Cancer Support Community cancersupportcommunity.org

Cancer Support Community provides support for people living with cancer, advocates for research and health care policy, and has a library of cancer-related information for both patients and family members.

MEET THE AUTHORS

Vital Talk vitaltalk.org

Rebecca Sturgeon is a massage therapist and the Curriculum Specialist and Lead Instructor for Healwell, a Washington, DC-based organization that offers advanced training for massage therapists, partners in research and works with people affected by serious illness. Cal Cates is a writer, speaker and researcher, and founder and Executive

They offer a variety of free resources including a helpful app, in addition to paid courses.

talk about feeling like their dignity has been restored, 32,33 they have renewed access to coping mechanisms, 34 they rest better 3 and feel a transcendent sense of spaciousness. 2,35 Our hands are the gateway, but our presence, our curiosity and our commitment to learning about and from these clients is what leaves them feeling seen and heard in a way that is truly therapeutic.

Director of Healwell. To learn more, visit healwell.org.

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