Is Massage An Art Or A Science?

Let’s cut to the chase. The answer to the question ’is massage an art or a science’ is that it is both. Massage is one of the oldest practical arts and one of the newest sciences.

Ok, that was easy enough but now we have answered that question let’s take a closer look at what we actually mean by massage being an art and a science.

Art in this context could be defined as: the application of human creativity and imagination using practical and personal skills. Science is the pursuit of knowledge and the exploration of the world based on evidence.

Put simply science teaches to ‘know’ and art teaches to ‘do’.

The Art of Massage

The art of massage involves more than the practical skill of a well developed sense of touch and may involve the following:

Thinking intuitively

Being intuitive is not an excuse for woolly mindedness or delusional thinking. It is a practical way of making sense of a complicated and immediate situation. An instinctive strategy for dealing with novelty in an urgent and complex world. This may involve carrying out tasks and making decisions partially below the threshold of conscious awareness – this is very different from performing a task mechanically or mindlessly. It is a natural and very human ability that comes with experience. If you have ever learnt a musical instrument you will remember how at first you needed to concentrate hard on every note. Eventually you can play automatically without immediate focal awareness of individual notes. It could be argued that the tune has just been memorised but that doesn’t explain how experienced musicians can jam and play skillful variations in real time. Making clinical decisions intuitively, on the fly, is akin to this creative musical process.

“Therapists must be able to think along multiple lines and often think on different levels at the same time.”
Jones & Rivett (2004)

Pattern recognition

Finding relationships between signs and symptoms, joining the dots and seeing the big picture is an essential skill for any therapist. And just as importantly, recognising when a relationship doesn’t exist and interpreting the meaning of the relationship correctly.

Seeing patterns is a natural and extremely useful function of the brain, the downside to this is that we have a tendency to find patterns in random data that aren’t there. It even has a name – Apophenia is the spontaneous perception of connections and meaning in unrelated phenomena and figures prominently in conspiracy theories, pseudoscience and the misinterpretation of statistics and scientific data.

Taking an holistic approach

Few words will have science fundamentalists frothing at the mouth more than ‘holistic’. The holistic approach is often sneered at as hippy, new age nonsense. This is because science traditionally reduces and dissects the world to study it (we will look at why this is a useful thing to do later). An holistic view means recognising that natural systems should be regarded as a whole and not just as a collection of individual parts. The workings of biological systems are dependent in large measure upon the total setting in which they occur.
Few medical conditions are simple and straightforward and most involve the interplay of very many factors including physiological, psychological and socio-economic that require multifaceted solutions. Scientists are now beginning to investigate how our emotional state can affect our immune system and modern pain management models recognise that the patient’s fears, attitudes and beliefs are just as important factors as tissue damage. Research has demonstrated that for some patients just imagining movement of a painful joint can cause inflammation in that joint!

Empathy and communication skills

The ability to understand and share the feelings of another person is an art in itself. It’s often the case that those people who think they are good at this aren’t. Empathy is different from sympathy. Feeling pity and sorrow for someone else’s pain and misfortune isn’t necessarily helpful and may be viewed as patronising behaviour. Sympathy may be a driving force in wanting to help someone but empathy enables us to understand how we may best accomplish this. This is one advantage we have as masseurs. We get to spend time with people and can empathise and treat them as individuals. Therapists need strong verbal and nonverbal communication skills. Patients begin healing the moment they feel they are being listened to and understood.

A sense of salience

Recognising what is relevant and important. A new therapist may ask every question and carry out every measurement and every test in the book. An experienced therapist will know when it is expedient to cut corners and avoid an information overload. But we have to be careful. The risk here is that we have a tendency to see what we believe. If we make an early assumption about a patient’s condition we may only carry out tests and ask questions that confirm our beliefs rather than challenge them. This is the complacency of experience.

Use creative thinking

Creative thinking involves learning to generate and apply new ideas. Seeing existing situations in a new way, identifying alternative explanations and finding novel solutions to an individual’s unique problems. Eddie Caldwell from the Northern Institute of Massage needed to get creative when one of his elderly patients needed to carry out exercises on the vastus medialis as part of her knee rehabilitation. She wasn’t a member of a gym nor did she own any weights. The solution had to involve things she would have around the home. An oven glove hung over the leg with a tin of beans in each pocket did the job perfectly.

Being open minded

“Your assumptions are your windows on the world. Scrub them off every once in a while, or the light won’t come in.” Isaac Asimov

Open-mindedness engenders a willingness to question current thinking and practice, to be receptive to emerging possibilities, to share ideas and to consider differing perspectives. Therapists need to be willing to revise firmly held views on the basis of evidence.

The Science of Massage

The science of massage involves a logical and analytical approach that could involve the following:

Quantifying and measuring

Much of science involves taking measurements. Massage therapists can record Range of Movement (ROM) using an instrument called a goniometer. Comparing these measurements to normal ranges has to be done with caution as what is normal for one person may not be for another. Measuring ROM is useful to monitor changes over time, to demonstrate improvement to a patient and also as evidence if conducting research and compiling case studies. To some degree pain can be quantified using numerical scales. Again this is useful to compare changes over time but has limited value when making comparisons between different patients as pain is subjective.

Care has to be taken when quantifying and recording data that the emphasis doesn’t shift from looking, thinking and understanding to depending on tables of measurements. We are health workers not accountants.

Taking a reductionist approach

Reductionism is the belief that the world can be explained by breaking it down into smaller component parts. It does not mean we are simplifying things: on the contrary the closer we look at something the more detail we see. Most special tests we use in the clinic aim to isolate specific body tissues in order to assess them, and whenever we study the physiology of the human body in close detail we are taking a reductionist approach. Reductionism gives us high definition whereas an holistic approach may allow us to see the interconnectedness between things but we will lose the detail. Being able to switch between the two ways of examining the world is a useful ability.

Using critical thinking skills

If being open minded is part of the art of massage then doubting and questioning everything we know and learn is part of the science of massage.

Doubt is the origin of wisdom

…or as G.P. Ann Robinson suggests “keep your skepticism wrapped around you like a cloak”. Critical thinking involves interpreting, analysing, evaluating, reasoning. This includes appraising, questioning and testing rather than just accepting new ideas. Being skeptical is not the same as being cynical! We may have our reservations about some techniques we come across but should be willing to give them a go. In this case we apply the “do no harm” rule. Some techniques may be dropped after a trial period if they prove to be ineffective, others may be excluded if we believe the risks outweigh the benefits such as spinal manipulation and ‘neck cracking’.

Being familiar with latest research

There is an increasing amount of research being carried out on the musculoskeletal system and on the various methods of treatment for the associated injuries and conditions. However care has to be taken. The scientific method is robust but it is still a human being who implements and interprets the research. All research will be flawed or limited to some degree (see a brief discussion of this in the notes below). It is a good idea to pool the evidence from lots of different trials and case studies. Luckily for us the Cochrane network carries out systematic reviews of health care research and is recognised as the highest standard in evidence-based health care resources.

Monitoring effectiveness

This can be as simple as getting feedback from patients or using measurements as described above.
One way to monitor the success (or non-success) of a technique is to compile case studies. It is important to record the failures as well as the successes.

Using evidence based practice

EBP is an approach to making quality decisions and providing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic.

Keep training up-to-date

This involves not only learning new skills but also revisiting and revising old ones. Acquiring knowledge and being able to use and act on that knowledge as part of lifelong learning is important for any therapist.
Continuing Professional Development (CPD) refers to the process of tracking and documenting the skills, knowledge and experience that are gained both formally and informally as we work, beyond any initial training.

In conclusion, analytical thought and creativity are two sides of the same coin. It is unnecessary to place these disciplines into separate silos.

Most geniuses, from Da Vinci to Einstein seem to have been highly creative as well as logical and analytical. Research on Einstein’s brain (preserved in two jars apparently) has shown he had a very high degree of interconnectedness between areas of the brain associated with logic and creativity. Few of us fall into this category but it does suggest that massage therapists and other healthcare workers should develop this crossover thinking and find the balance between logic and intuition, science and art, in order to provide the best treatment for their patients.

Notes, References and Further Reading

Main Image: HEALTH, 2009, Get Color. Album cover detail.

Discussion: Limitations in research

• The observer effect in science recognises that any observation will affect the system being observed. Think of measuring the pressure of a car tyre, impossible to do without letting out some air. In physics the observer effect can be minimised to make it almost insignificant but in biology and particularly medicine it is difficult to isolate the subject from the observation technique.
• We like to think of science as being objective but the way we decide if the result of our research is significant is by using an arbitrary statistical figure! As a general rule, the significance level is arbitrarily set to 0.05 (5%)
• There is a difference between recognising the limitations of research and flawed or fabricated data. If researchers or their sponsors have a vested interest in the results then this is almost certainly going to introduce bias. Researchers should always declare potential conflict of interest that might introduce bias. For most researchers a positive, significant or interesting result is normally going to be the preferred outcome and this could potentially introduce a subconscious bias; researchers are human after all. In surveys asking about the falsification of data, admission rates were 14.12% for falsification, and up to 72% for other questionable research practices. Sadly this is a conservative estimate of the true prevalence of scientific misconduct. Believing in research can be an act of faith and we are more likely to trust the research if it supports our own world view.
• Different research is often contradictory, this is only to be expected and is a normal part of the scientific process. This is why we have to pool the results from many different trials. But until an adequate consensus is reached we are left trusting our instincts and making educated guesses.
• In some cases, even when the evidence from research is overwhelming and when a rational consensus has been reached it may be dangerously ignored by policy makers. This is hardly the fault of science but it places a huge collective responsibility on all researchers to get it right as poor research that is uncovered, and it always is eventually, will very quickly be held up as counter evidence and other valid researchers will be guilty by association.
• Sometimes the basic premise of the research is flawed. For example, a good deal of research on back pain and the efficacy of different treatments and techniques is flawed even before the research begins. Back pain is not a medical condition or disease it is a symptom. In the same way as a cough is a sign that can be caused by a many medical conditions from colds and allergies to cancer. A technique that helps with back pain caused by a prolapsed disc may not help with back pain caused by a tight psoas or tight quadratus lumborum or any of the multitude of other causes of back pain. Lumping together all these conditions makes the results from the research at best worthless and at worst misleading.
• The reductionism of science works well for the physical sciences but in medicine it often takes the research so far out of context that it becomes meaningless.
• Research can be limited by sample size and selection, duration and location amongst other factors.
• After the research is complete the statistical analysis and interpretation of the results is often flawed and research can be overblown both by researchers and the press.

Despite all these limitations and flaws, science is still a very powerful tool and the best we have but perhaps its pedestal should be a little shorter.

References

1. Definition of science
   http://sciencecouncil.org/about-us/our-definition-of-science/
2. Moseley G.L (2004), Imagined movements cause pain and swelling in a patient with complex regional pain syndrome. Neurology 62. 1644
3. Price D.D (2000) Psychological Mechanisms of Pain and Analgesia Vol. 15. Seattle, IASP Press 223
4. The corpus callosum of Albert Einstein‘s brain: another clue to his high intelligence https://academic.oup.com/brain/article-lookup/doi/10.1093/brain/awt252
5. Explain Pain, Lorimer, Moseley, David, Butler. Noigroup Publications ISBN 978-0-9873426-6-9
6. Association between socioeconomic status and pain, function and pain catastrophizing at presentation for total knee arthroplasty http://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-015-0475-8
7. Dangers of neck manipulations. https://youtu.be/ezKnjah7nwI
8. How Many Scientists Fabricate and Falsify Research? A Systematic Review and Meta-Analysis of Survey Data http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0005738
9. Open mindedness in health care http://www.transformnursing.eu/working-definitions/open-mindedness.aspx
10. Ann Robinson https://www.theguardian.com/profile/annrobinson
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18. Pattern recognition Eysenck, Michael W.; Keane, Mark T. (2003). Cognitive Psychology: A Student’s Handbook (4th ed.). Hove; Philadelphia; New York: Taylor & Francis. ISBN 9780863775512
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21. History of massage http://www.naturalhealers.com/massage-therapy/history/ 
22. Stepping out of silos – art and science http://www.artsprofessional.co.uk/magazine/268/article/stepping-out-silos