Oncology Massage Archives - Tracy Walton & Associates

Build a Full MT Practice in 13 Months? Really? (An Interview, Part 1)

February 21, 2019 by Tracy Walton 1 Comment

A year ago she started her private practice from nearly nothing. Now Kate Prouty sees anywhere from 15-30 clients each week. Her practice focuses on oncology massage therapy and massage for people with medically complex conditions.

In this interview she shares some excellent marketing tips and other tools she used to build her practice, Patient Relaxation, LLC, in Lansing, Michigan.

I met Kate in 2017, when she completed our 4-Day Oncology Massage Therapy foundational course. She followed it with our 40-CE hour online Oncology Massage Therapy Advanced Mentorship course, where we focused about half of our work on marketing. She completed that in December 2017.

I was interested to hear how intensely she focused on practice-building, and what worked for her.

Kate Prouty Built Her Massage Therapy Practice, Patient Relaxation, LLC, in 13 Months.

Tracy: You’ve had a busy year! What does your practice look like now, compared to a year ago?

Kate: I work full time. I see about 18 people/week average, sometimes 25 or 30. Minimum is 15. About half have complex medical conditions. About half those are people with cancer. I am on my way to seeing about 8 people per week with cancer or cancer histories.

Thirteen months ago, in late 2017 when I finished the mentorship course, I was afraid. I was working at a spa. I wanted my own practice. I thought there was no way I can make this happen. I was starting from zero.

In September 2017 I almost felt reckless when I signed up for your online mentorship program, literally the day before it started. However, it was the right decision. I threw it onto a credit card, closed my eyes and hit “purchase.” I knew that I needed a leg up in order to gain both confidence and credibility, so that I could establish a private practice (either my own or within a hospital or cancer center). I chose carefully, actually.

Tracy: How did you grow it from 11 sometime clients to 390 people on your email list, and 15-30 sessions per week?

Kate: There were a lot of steps.

First was goal setting. I wrote down goals—stretch goals, and reasonable goals—in a little notebook. Personal goals relating to the business, like I want to be able to walk into my building and smile. I want to be able to sleep at night because I’m not panicked about money.

Then I broke it down into steps. What do I need to do to get to this goal, for real? How much money do I actually need as a bare minimum, and how much each week? By getting really concrete, I realized as long as I was making as much as I had been making at the spa per week, I would be okay. Because I’d been okay, working at the spa.

I got help from a number of places. The oncology massage mentorship course, of course! I’ll tell you about the networking in a bit. In the first month when I started, a woman came to me who was an amazing marketing specialist. She had a background marketing credit cards, and she offered a trade. 30% off sessions if we can do a marketing meeting for a half hour every week. I took it.

The marketing specialist said, “I will give you an assignment every week. We did that for about 10 months. Every week. I followed her advice: Get a notebook, and fill out one page for each month, 12 in a row. As you go through every month, jot down EVERYthing you do for marketing purposes. Every single Facebook post, every article, every presentation. Keep track of the research you did or what you worked on. Did you make phone calls? Write every little bit down, then don’t think about it. Then go to the next month. But if you notice a sudden uptick in business, look back and see if you can correlate.

Tracy: Then what?

Kate: The marketing specialist advised, “After a year, sit down on January 1st. Block off the whole day. Look over with colored markers and mark the ones that seemed to have the most impact and the ones that were a waste. Now you’ve created your framework for the next year.” She also told me not to dismiss the ones that didn’t seem to make a difference, it may take longer for those to come around.

Then she told me write them in the NEW year’s notebook and you have half of your marketing plan. I look back at it and it’s pretty darn impressive! It’s clear which ones worked.

Here is an example: in June I wrote down: Ran a senior citizen special, an ad for cancer survivors, and I taught a class on self-massage for people with cancer. I emailed an MLD specialist for some information.

Fourth, I did a Groupon. I talked to Groupon and bargained. I told them, I’m just a little person. I work with people with cancer. It turned out I made more on a Groupon massage, even with the low percentage, than I had done at the spa. I was doing better than at the spa. Because Groupon is a wide net, I saw lots of different people. I got to practice setting up a practice.

Also, I tapped into local referral groups. Angie’s List for my town. On Facebook I found “Not Your Mother’s Networking Group.” It is only in this area. It’s a curated group. You have to answer questions to get in. It’s got 17,000 women in it. They post everything. Anything from, “Does anyone know a plumber?” to “My kid has these red patches on their back. What is it?” It has been a source of lots of new clients. At least 50 people came from there.

Tracy: Tell me about your networking.

Kate: I saw that the self-massage class I taught, while it didn’t yield any direct clients from the class, did give me credibility in the eyes of a doctor. Here is how: I went early to the hospital to do the presentation in a conference room. Being who I am, I introduced myself to everyone on the floor. “By the way this is who I am, if anyone asks where this class is, it is happening down the hall. Here’s my card if you need to text me that someone is lost.”

One person I told this to was an oncologist.

Sometime later, when I returned to the hospital to ask if we could bring in OMT in that part of the hospital the oncologist recognized me. “Aren’t you that person…?” I was!

In the oncology massage advanced mentorship program, it helped that we had to CREATE the marketing materials, not just do the research. We had to actually create letters. And documents. And the website. (I have had so many compliments on my website!) Writing the emails to talk to oncology social workers. Wow, did that help. That’s how I found people! I talked to nurse navigators, but Oncology social workers were the ones who knew where things were, they knew everyone I should talk to.

Tracy: How did those meetings go?

Kate: At the end of every single contact I made, I asked, “Who else should I be talking to?” People love to be asked for advice. Ask them who else I should be talking to. Who are the leading practitioners? Who are the leading referrers? If you ask that question frequently enough the same names will pop up and you see who is making the world go around.

There might be oncology social workers at one hospital who aren’t nearly as influential as the ones at another hospital. In your course, I had to collect all that contact info and run it by you.

Pretty soon I had a whole bunch of contact info that was redundant. I realized, “AHA.” This person is THE person. Then I spoke to her and asked her who else I should talk to? She said, “This other person, but let me call her first.” So then I got an introduction.

Tracy: Let’s talk about your radical fee increases. You started low, then moved your fees up quickly over the year.
How did that work?

Kate: Remember, I was starting from nothing. I needed to make what I had made at the spa. That was low.

At the beginning, my weeks were pretty empty. I would post on “Not Your Mother’s Networking Group.” I would offer $30 massage that week. I did 30 massages that week. The next week, all $40 massage. Then I did $49.

In the beginning, I told every client, “It’s a new practice. Can you please go back into the “Not Your Mother’s…” FB group and write that you liked it, so people trust me? Before the end of that week I had 20 recommendations.

Every time I would fill up the week, I’d say, “I’m full Thursday but there are six openings on Saturday. Which bumped up the post, my clients saw it, they would comment, “Kate is awesome.” That momentum would barrel me into the next week.

Sunday night, a post again, when people are looking, filled up with more. All of this in the first few weeks.

I offered $49 massage for a couple of weeks. My marketing friend said that was a distinct breaking point. She said “You can’t keep going at $49 because you train people that your work is too cheap.” One goal was more emails for my list. I had wanted 100 people on my list in 8 weeks. Well, I was there. I got it.

Tracy: How did you break the $49 barrier?

Kate: So then I bumped up a bit. I sold packages at $150 for 3. Lots of the $49 people bought 3. Then I had 200 people on my list. Then they were referring people to me. But I had to get a critical mass up.

Kate Prouty’s Massage Therapy Space in Lansing, Michigan.

My fee at end of 2018 was $80, but not everyone was paying that. I was still running a lot of specials, or leftover packages at the lower rates.

At the New Year, 2019, I moved into a more affluent area. I brought my fees up to $95. BUT, I gave all of my existing clients either 1 or 4 massages at last year’s $80 rate.

If they had one massage last year, they get one in 2019 at the old rate. If they had 4 or more last year, they can get 4 at the old rate.

I call these my “Startup Support Specials.” I make a big fuss over them. I tell them, “You were here in my first year, you helped me do this.” I sent out an email to them that said, “Look what you helped me do!”

Tracy: Your private practice sounds like a real partnership between you and your clients!

In Part 2 of this interview, to post next week, Kate will answer more questions, starting with her partnerships with hospitals, a work in progress. She will talk about her study of hospital-based massage therapy at the Mayo Clinic. She’ll share some more outreach tips. Finally, she will offer advice to other MTs and OMTs about practice-building.

See Kate’s business Facebook page, Patient Relaxation LLC, here.
Check out her website, here.

Ethics (Mine), Massage Therapy, and Cancer Spread

June 7, 2018 by Tracy Walton 32 Comments

A debate was recently revived around the possibility of massage therapy spreading cancer. I encourage all oncology massage therapists, massage therapy instructors, and interested parties to catch up on that conversation. Links are at the bottom of this post.

The conversation recently took a disagreeable turn when my judgment and professional ethics were challenged. It’s a serious accusation, deserving a serious response. This post is my serious response.

For those who have missed it, our dispute has focused on the role of a single massage study. We disagree about how to use it, and I’ve been faulted for questioning it. Here is an open letter to the two authors who cited the research, then used that research to mount a challenge to the practice of oncology massage therapy.

***

Dr. Turchaninov and Dr. Cullers, the foundation of your argument is that I am attacking a “bulletproof” study from a respected group of oncologists, and in doing so I’ve succumbed to personal opinion and bias.

And yet…

The quality of the Wang et al. (2014) study on massage in bone cancer is not, in and of itself, the foundation of my position.

(I do think it is far from “bulletproof,” and I don’t think the investigators’ credentials carry your argument for you when they have left out so much critical information, but I already stated that and I’ll just leave that there.)

My position: You have misinterpreted the study findings.

You are trying to take a study of a certain time point (massage given pre-cancer-diagnosis, nothing known about cancer) and apply it to a different time point (massage post-cancer-diagnosis, lots known about cancer). You are using this to justify your guideline, that all massage therapy should be stopped after diagnosis, then resumed after cancer treatment starts, in order to avoid spreading cancer during that window.

One medical director has already looked at Wang’s work and the poor cancer outcomes following pre-diagnosis manipulative therapy. That physician observed that it is entirely different from the work of oncology massage therapists, post-diagnosis.

The difference?

Pre-diagnosis, MTs are pressing away, with various levels of skill, trying to relieve pain that does not have a cause that they can relieve.

Post-diagnosis, oncology massage therapists (OMTs) swing into action with specific interview and hands-on skills that avoid direct pressure on tumor sites. They have the benefit of images and other test results that pinpoint location of masses, symptoms, and complications. Pre-diagnosis, no information. Post-diagnosis, rafts of information. We use that information to work with them safely.

This difference is significant, and you haven’t addressed it.

Moreover, you extrapolate from that osteosarcoma study, saying your prohibition must also apply to all other cancers. Many other primary tumors are deeper and much less accessible to our hands. It is problematic to apply this clinical scenario across the board to all cancer cases.

Your misinterpretation of the study is a serious concern, and it’s been echoed by others.

As of this writing, you have not responded to this concern.

(For those of you just tuning in, a full account of the conversation is available from the links at the end of this post. Here, I highlight a few points.)

The Wang et al. (2014) study, the center of this conversation, has two parts.

In the mouse study, they point to direct pressure at a tumor site being a harmful thing. I agree. I have never advocated for that kind of focused pressure on a tumor site.

The second part is the human study of cancer outcomes. They looked at people who received massage before they knew they had osteosarcoma. In this, the Wang et al. study may have implications for better basic massage therapy education, including referral skills and interviewing clients about pain before working with them. I already noted that, too.

But to withhold oncology massage therapy entirely? Based on this two-part study? That is overreach.

Here is an analogy.

It is not perfect, but it helps illustrate what is going on here:

Within days of receiving her new bunk bed, my child tumbled off the top bunk and broke her arm. It healed quickly, but of course we reinforced a rule: no standing or playing on the top bunk. We enforce the rule with all visitors playing in her room. This is a measured, appropriate guideline for a bunk bed.

An overreach would be to ban standing on or playing on all beds: single beds, trundles, with and without box springs or frames, and even mattresses on the floor.

These overbearing solutions are sometimes tempting, but they do not necessarily make a safer or livable world. No standing on the mattress on the floor. Or avoid a whole city because of a single dangerous traffic circle. These are extreme measures.

You are suggesting something just as extreme.

Using the Wang study—which is aimed at pre-diagnosis—to forbid all massage therapy for people who are between diagnosis and the beginning of treatment is an excessive guideline.

Despite what you imply about it, the Wang et al. study never reports anything about the post-diagnosis period; they do not state a guideline for post-diagnosis. They talk about direct massage of tumor sites in mice. And although it is not easy to tell from their human reporting, a quick look at previous research suggests they are talking about clumsy attempts at manipulative therapy for pain relief, right on the areas of pain, swelling, and tumor. The study subjects were human patients whose real problem was undiagnosed bone cancer, not excess muscle tension.

If there is a real link between manipulative therapy and later cancer outcomes, then it remains a massage therapy problem—how to address pain, how to ask about it, when excess muscle tension contributes to it, looking at the cause, ferreting out the possibility of bone cancer, and referring clients appropriately instead of treating them inappropriately. Massage therapy educators: Standards for handling this should be addressed in basic massage therapy education.

This is not an oncology massage therapy problem.

This point is really important. You are arguing about a problem in the field of massage therapy, not a problem in oncology massage therapy.

Moreover, your misinterpretation and misapplication of this study has been pointed out numerous times, here, here, and here.

Yet you have offered only a few leaps of logic in trying to make the Wang study fit an entirely different clinical situation than the one it describes. To the problems raised by Wang, you propose an overzealous fix. Your solution has been challenged because it affects large swaths of people, not just those in the window between diagnosis and treatment.

When pressed on your logic, you merely double down on the Wang study, claiming it as a “proof” and “scientifically a done deal.” You throw shade on the ethics of one daring to question it.

That would be me.

Wang et al. is not the focus of my challenge. Instead: your use of Wang et al. is a serious problem, and as of this writing, you have not addressed that. You continue to throw out obstructions and distortions. You continue to insist that I produce a counter-study, when you haven’t even adequately defended yours or its poor reporting. You try to shift the burden onto me to provide research to counter your misinterpretation.

Then you change the subject. You focus outrage at my ethics and professional judgment and it sounds impressive and righteous. You repost this repeatedly, where your followers can also question my judgment, my ego, and the motives of “people like me.” Perhaps I’m just trying too hard to sell courses. It clouds the judgment, right?

After all, this is social media in the year 2018. Everyone has a sound bite and a snap judgment. We don’t need anything more to form an opinion of character, nor do we have to consider each point carefully ourselves before we pile on.

But at the end of the day?

While you and I argue, lymph moves. Blood flows. Quietly, all day long, it moves in everyone, diagnosed or not. And yet you continue to harp on some pivotal role in cancer spread, as though we should slow it down somehow and order every patient to lie quietly on the couch until their cancer treatment starts. With that reasoning, we should probably disallow blood pressure readings, saunas, scary movies, body lotion applications, and position changes, as well. Wait until treatment starts. Only then will it be safe to to move, and to move fluid again.

Your inordinate focus on lymph and blood flow as the prime contributors in cancer spread returns us to the dark ages when we didn’t have a clue about how metastasis actually worked. As Gayle MacDonald has aptly and repeatedly pointed out, we didn’t understand how a complex set of circumstances including genetics, tissue affinity, and microenvironment had to line up in order for cancer to metastasize.

Those dark ages prevented people from getting massage therapy when they really could have used it.

People need MT while they’re waiting for cancer treatment

This is an enormously stressful time for patients. It is not a good time to withhold massage therapy, waiting until cancer treatment starts.

To support your point, you cite a case where Cullers did just that, turned away a very sick patient, in a story that is supposed to sound principled.

I believe your good intentions at the time, yet the growing number of oncology massage therapists worldwide have already figured out how to support that patient with thoughtful, careful massage therapy. They’ve collaborated with nurses and physicians because they agree that symptom relief is possible and that metastasis is more complex than simple fluid flow. They know that the patient’s blood and lymph are already moving, and that their own role in that is minuscule.

And although you’ve vilified it, we offer up again our “exercise argument” to your concern: If blood and lymph movement were primary factors in cancer spread, oncologists would prohibit exercise in people diagnosed with cancer. They would send people to bed, not to the gym. They would limit the actions of skeletal muscle on vessels.

This is emphatically not the case.

Exercise and movement typically are encouraged in cancer care.

In response to my line of reasoning here, you venture out onto the fringe even more. You question whether oncologists the world over should be recommending pre-treatment exercise. You take on the common, growing practice of “prehabilitation,” exercise programs to strengthen patients for treatment.

This is important. You act as though the question of whether movement and exercise will spread cancer is still an open question. You act as though you alone have information that thousands of oncologists, PTs, nurses, OTs, and exercise scientists have somehow missed.

I don’t think you intend to sound arrogant there? But it sounds that way, for sure.

You even misinterpret an opinion paper I offered on exercise and cancer by Koelwyn et al. In that paper, the authors’ overwhelming emphasis is on understanding the tumor-suppressing effects of exercise. Yet you picked out a couple of tiny, more circumspect sentences about the need to better understand effects of exercise on different patients. You used them to support your own position, that exercise/fluid flow could contribute to cancer spread. You cast aside the thrust of the Koelwyn article in the other direction, and amplified only a single sentence, then somehow accused me of cherry-picking information.

Listen to the data, don’t sensationalize it

People with cancer will be better served when you stop fitting evidence and ideas to your worldview. Science works the other way around, to shake our beliefs and help us formulate a more accurate worldview. Let the data speak and really listen. Mind the gaps. I have joined you in this inquiry, but you have gone in a different direction with the answers.

Your academic and clinical credentials have been pointed out by followers, but the way you have conducted yourselves so far flouts some of the basic standards of academic debate.

Instead, when your data are challenged, you become more shrill. You continue to pummel me with exclamation points and all-caps and the Wang et al. study. You continue to recycle arguments, then copy/paste them into social media group after social media group. You are trying to prevail with volume rather than substance. Now you’re questioning my character. That always gets people’s attention.

To the untrained eye, your arguments seem more scientific than they are.

You point to a research paper. You use the word, “proof.” These all appear under the umbrella of your Journal, and readers might not recognize that self-publishing your views in your own journal does not subject them to the same rigor as submitting them to another journal and a blind peer review by other scholars. Self-publishing shifts the review process from a formal pre-publication review by other experts, to informal post-publication on social media, for all of us to feed on. There, readers may or may not notice the missing pieces, or the logic leaps that don’t add up.

As a result, some readers may actually come to believe oncology massage therapy (and, by extension, exercise therapy), is endangering patients the world over, cancer center by cancer center, hospital after hospital, hundreds and hundreds of thousands of patients served.

By reviving the old massage-spreads-cancer debate, you’ve created undue alarm. Following your reasoning, massage therapists could be deterred, not only from massage during a specific window, but also from working with wider swaths of the population. As Gayle MacDonald points out, this has broad implications.

We’re not making up standards on our own

You have singled me out because of my writing, but your argument is with the entire workforce in oncology massage therapy. Oncology massage therapists have already taken care of your safety concerns. Not by dreaming them up in isolation, but by partnering with countless nurses, physicians, and legal departments at hospitals to develop protocols. We have had their supervision, standards, and input in place for more than 20 years. We have taken great care to develop tools. We have lines of interview questions, assessment skills, referral skills, and hands-on modifications.

We have done so for clients who are post-diagnosis, in treatment, post-treatment, and beyond. In partnership with hospital staff around the world, we’ve made sure the care is cautious and compassionate.

We’ve done that so that we can help more people, and not have to turn people away.

Unfortunately your analysis would turn back the clock, and turn people away.

Calling all cancer centers

You have pledged to contact cancer centers one by one to “correct” their oncology massage therapy practice. On this crusade, you will likely be dismissed more often than not. Not because we have already brainwashed hospital administrators about oncology massage therapy. (In fact, massage therapists do not have a super-successful record of brainwashing hospital administrators.)

Instead, your points will be dismissed because all your audience has to do is take a quick look at the research, and at Wang’s previous research, to see immediately how you are using a scant amount of data in error.

I know you want your alarm to help, not to hurt, but it backfires. As MacDonald points out, you cast doubt on the safety of massage therapy for many different populations. You’re compounding fear about massage therapy. There is already enough nervousness about working with clients with cancer.

Ethics and Argument

You’ve lobbed serious accusations my way, and you probably need to revisit your language there. You’ve tried to paint my opposition as a self-interest problem. An ethics problem.

More generally, your views are compromised by a bombastic approach. At times you are strident and impatient. This does a disservice to the many thoughtful teachings and writing you offer. You lose people when you depart from civil, scientific discourse.

Alarmism can be damaging.

Who does it hurt the most?

Not me.

I am confident my ethics are sturdy, so I’m not concerned about that.

I’m concerned about the patients turned away under your rigid rule.

Patients are hurt the most. Newly diagnosed patients, especially: They often feel isolated during a frightening time. They need all the symptom relief and stress relief that we can humbly offer.

They have a right to receive our care.

***

Readers:

If you have read this far, I hope you will take a look back at the various installments in this conversation. Listen and come to your own conclusions. Contribute to the conversation on blog posts and on social media.

We’ve had 20+ years of active oncology massage. Now, the fear that massage could spread cancer has re-emerged, fanned by Turchaninov and Cullers.

We need to air any concerns and put them to rest again, once and for all.

Please read, share, and participate.

Here are the articles, columns, and pivotal posts so far:

Turchaninov & Cullers initial articles, raising their concern about massage post-cancer-diagnosis and pre-treatment, and citing Wang et al. article (2014), focused on massage prior to cancer diagnosis:

Turchaninov and Cullers Part 1

Turchaninov and Cullers Part 2

My initial response, focused on the Wang et al. paper, “Does Massage Spread Cancer? An Update”
Turchaninov and Cullers’ response
My second response, “Could Massage Spread Cancer in the Newly Diagnosed?” focused on Turchaninov and Cullers’ reasoning and interpretation of the Wang et al. article
Turchaninov and Cullers’ response:
Laura Allen weighs in on her blog, with comments from Turchaninov
Gayle MacDonald’s post
Wang et al. (2014) paper. Wang, J.Y., Wu, P.K., Chen, P.C., Yen, C.C., Hung, G.Y., Chen, C.F., Hung, S.C., Tsai, S.F., Liu, C.L., Chen, T.H., Chen, W.M. Manipulation therapy prior to diagnosis induced primary osteosarcoma metastasis–from clinical to basic research. PLoS One, 2014 May 7;9(5):e96571.

On Not “Charging What You’re Worth” in Oncology Massage Therapy

March 8, 2018 by Tracy Walton 11 Comments

Recently, in a group of oncology massage therapists, I started a discussion about setting fees for massage therapy.

In this particular group, we were all in private practice. They were all participants in my oncology massage therapy mentorship program, and we were talking about money and pricing.

It is a charged topic, this question of what to charge. Massage therapists in private practice are the deciders, but those decisions can be fraught with pressure and confusion.

Our conversation went in several directions and plunged through several layers. How high, how low, whether to discount, how to raise fees when it is time.

But by the time we brought the discussion to a rest, we had focused heavily on one topic:

The Tangible Value of Oncology Massage Therapy

This might not seem like a new or particularly earth-shattering topic. But it is worth revisiting with care. Here is why:

As we talked, we shifted our conversation away from the therapist and toward the therapy. Eventually we did one better and shifted it toward the therapeutic outcomes.

By focusing on outcomes rather than our service, or ourselves, we achieve an important separation. Setting fees requires that we separate ourselves from our work. Even though who we are is a part of what we bring to the session, it is liberating to see our service as separate from ourselves.

Why?

“I Should Charge What I’m Worth**” Can Be a Trap

It’s too easy to fall into the trap of “I should charge what I am worth.” I’ve even encountered MTs who ask each client to pay what the client feels the therapist is worth. Deferring to the client for the final word can be problematic, to say the least.

But equally troubling is the notion that we charge based on what we are worth.

When we do, a simple fee for a simple service becomes gnarled up in self-worth. Add in all the emotional energetics of money and self-esteem, along with the gender wage gap and other social forces, “charging what I’m worth,” is a prescription for confusion. Pile on the intimacy of massage therapy and the therapeutic relationship, and it could take decades to disentangle it all.

Here is an important nugget that can clear things up in a hurry:

The Intrinsic Value of a Human Being is not up for Sale.

It never was. Each person is perfect and sacred, beyond the language of “value.” Not a single person’s worth is affected by their choice of pricing. Not one person’s worth can ever be captured in a $50 or $80 or $150 hourly fee.

No, you’re not for sale.

Even the value of your time is not up for debate. So what are you selling?

Your solutions are for sale.

It’s useful to remember that we work in a service industry. In service industries, we solve problems. We bring expertise and energy to problems that are hard or impossible for people to solve by themselves.

I do not know how to shingle a roof or fix blown plumbing. I cannot cut hair well enough for school picture day. When I hire the roofer, the plumber, or the hair stylist, I pay them for their service. Not because they are “worth” something, but because it is worth something to me have those problems solved. Especially the night before picture day.

The Industry of Solutions

In massage therapy, we would do well to remember our membership in the service industry. It is important to focus on the problems we are known to solve, and those we have the potential to solve.

In oncology massage therapy, that list of problems is compelling. People in cancer treatment and post-treatment deal with pain, nausea, fatigue, stress, trauma, insomnia, isolation, poor body image, stigma, anxiety, and depression.

That’s the short list.

Does Research Back up These “Solved Problems?”

Research on oncology massage therapy is still in a tender place, but there is growing research on massage therapy helping the “Big 5” symptoms in cancer care: pain, nausea, fatigue, anxiety, and depression. From that body of research, the strongest support seems to be for pain relief and easing anxiety.

More generally (across multiple populations, not just oncology), there is compelling evidence that massage therapy is as helpful as psychotherapy for the problems of anxiety and depression.*** That alone is worth celebrating.

We can make clear and accurate claims about massage as follows: “Research suggests massage therapy can help people with cancer and cancer histories with the following: pain, anxiety, fatigue, depression, and nausea,” or, “There is strong research showing massage therapy is as effective as psychotherapy for anxiety and depression.”

Neither of these claims over-promises or overstates what we know. (For a list of claims to avoid because they do overstate and over-promise, download my free e-book, “5 Myths and Truths about Massage Therapy: Letting Go without Losing Heart.”)

Clients Tell Us We Solve Problems

Research aside, we have other reasons to promote our work to oncology clients. These reasons come from the clients themselves.

Over many years, my clients have told me tangible, intangible, and sometimes surprising benefits that they attribute to massage therapy: That massage helps them sleep. With massage therapy they feel less isolated and stigmatized. Massage helps them feel feel cared for and appreciated. They look forward to pleasurable sensations from massage, after months of needle sticks and scans. They tell me that when they receive regular massage therapy, they feel better able to cope.

These benefits are worth money.

Our clients’ observations count for a lot. They are telling us why massage matters to them, with or without rafts of research behind them.

We Solve Other People’s Problems, Too

In addition to the client with cancer, there are others in the circle of care who are helped by our services. Nurses tell us that that massage therapy eases the nursing workload. They notice that when MTs are working with inpatients, the nurses themselves do not have to respond to so many call buttons. This is worth money.

Other people’s burdens are also eased by oncology massage therapy: The out-of-state uncle or daughter who purchases a session for a family member. A group of co-workers who finds a meaningful gift in a package of sessions. An exhausted caregiver who gets an hour off while the MT sees their loved one in the home. The cancer rehab PT who works more effectively when a patient’s muscles are already relaxed.

These things are worth money.

Our clients, client communities, and health care providers tell us that massage is solving problems. With or without research, theirs is an honest truth.

Charge for Solving Problems

Oncology massage therapy has enough of a track record to be well-compensated. We can charge accordingly, without getting ourselves or our self-worth mixed up in it. Oncology massage therapy is well-received. It feels really good.

That sigh of contentment once we’ve bolstered and positioned a client–even that is worth something. (So often, after I’ve set up my client for the session, she’ll sigh and begin to relax deeply. When I suggest I just excuse myself for an hour while she rests on my warm table, she nods…”Whatever.”)

Relaxation is part of the solution. Sometimes it is the entire solution.

“Massage Therapists: The People who Practice Massage Best.”

Zoom out. Look at the field of massage therapy, not just oncology massage therapy. Even massage therapists do not always appreciate the value of basic relaxation massage therapy. Sometimes we search for more powerful techniques, forgetting how highly effective our Swedish massage foundation is.

Years ago, I attended a workshop on breathing problems with Leon Chaitow. He presented the osteopathic view and the PT view and an intricate account of the problems to address with precise manipulations. Then he said something like, “But massage. Don’t forget massage! It’s really helpful.” Gesturing to the crowd, he continued: “And you’re the only ones who can really do it. Or, at least, you are the best at it. Remember to massage!”

It was amusing to have to be reminded of this, but I loved the simplicity of his endorsement. We’re good at massage. Unadorned, un-fancy, effective massage.

When questions of worth enter in, they can confuse matters. Yet all by itself, massage therapy is a compelling service. Our skills are badly needed.

Those Skills are Worth Something

We live in a market economy, where services are exchanged for money to solve problems. Our services should be no exception. We can exchange skilled touch for money, because skilled touch solves problems.

I have more to say about pricing, and our tendencies to over- and undercharge in some cases. There are sometimes special circumstances in force, or a client’s financial need to consider in pricing. I’ll share those thoughts soon.

Meanwhile, remember this important starting point: Pricing does not have to be so personal.

Pricing Does Not Have to be Personal

It is not so much about the problem-solver, or what you, as a therapist or a person are worth. It is more about the results.

Disentangling the self from the service can be freeing. A focus on the service can reveal a much clearer perspective, one where difficult problems demand good solutions.

With that perspective, we are uniquely equipped to provide good solutions.

We can and should be well-compensated for them.

**********

*After I wrote this post, I noticed a Facebook discussion about “charging what you’re worth.” I did not have time to incorporate that discussion here, but if you follow Irene Diamond or Sandy Fritz on Facebook, they tackled this as well. I highly recommend taking a look.

** Do not get me started on the fuzziness of the term, “deep tissue.” That’s a topic for another post.

***Moyer CA. Rounds J, Hannum JW. A meta-analysis of massage therapy research. Psychol Bull. 2004 Jan;130(1):3-18. Every MT should read it.

Cold Caps, Frozen Feet, and Massage during Chemotherapy

February 2, 2018 by Tracy Walton 11 Comments

Two clients come in with interesting stories. The first tells you she received chemotherapy two days ago while wearing an odd-looking cap with a chin strap. It was a special “cold cap” cooled her scalp during the chemotherapy infusion. It made for a chilly session, so the infusion staff took pains to keep the rest of her body warm during the infusion.

The second client tells you about wearing frozen gloves and socks throughout his infusion, also a couple of days go. He didn’t find it comfortable, either, and the staff took extra measures to keep him warm.

As uncomfortable as it seems to add these accessories to the treatment, there were good reasons to cool the scalp, hands and feet in these clients.

Meet the Latest Tool in the Cancer Care Toolbox

A new strategy—cold therapy—is being used on the scalp, hands, and feet to diminish the effects of certain chemotherapy drugs. Massage therapists have questions about how to modify massage therapy for clients using this strategy. The purpose of this post is to answer those questions.

To back up: Most chemotherapy is delivered by infusion directly into the bloodstream. From there, it is distributed throughout the body. Delivery through the bloodstream means that the drug goes to nearly every tissue, not just to the tumor. Delivery through the bloodstream also means that side effects are systemic, rather than selective. In a sense, chemotherapy drugs cannot tell the difference between friend and foe, or the difference between healthy tissue and tumor.

Systemic side effects of chemotherapy, such as hair loss, chemo-induced peripheral neuropathy (CIPN), nausea, and fatigue are caused by this wide, nonselective distribution.

Some side effects of chemotherapy are distressing and uncomfortable, but others can be devastating. Some, like hair loss, are short-term effects. Others, like neuropathy, can last for years or even indefinitely, causing pain and debilitation long after cancer treatment is over.

Freezing out the Medicine

Local cold applications are used to steer chemotherapy away from certain areas by constricting the vessels in that area, minimizing blood flow through them. It doesn’t stop flow entirely (and you wouldn’t want it to. Hypothermia! Tissue damage!), but it narrows the vascular plumbing in the protected area. The goal is to reduce the exposure of local tissues to the drug. To protect the scalp, a cold cap on the head is designed to ease hair loss. To protect the hands and feet, frozen gloves and socks are designed to reduce the amount of drug flowing through their vessels, limiting the injury to local peripheral nerves.

These local cold applications take the form of caps, gloves, and socks. Here are some examples:

“Cold caps” and scalp cooling systems are used immediately before, during, and just after some chemotherapy sessions to diminish hair loss. Cold caps such as Penguin and ElastoGel work similarly to ice packs, and are replaced as they thaw. Scalp cooling has been used in Europe for decades, but is fairly new in the US. Cooling systems made by Paxman or Dignitana offer continuous coolant circulating through the cap. DigniCaps have been approved by the FDA for use in the US since 2015. (Click here for a picture.)

Cold gloves and socks are being applied to lessen chemo-induced peripheral neuropathy. In one study by Hanai et al, reported very recently in the Journal of the National Cancer Institute, participants received cold therapy on one hand and foot, and no cold therapy on the other side. Thus, they served as their own control in the study. Investigators found significant differences in the two sides in subjective experiences of neuropathy symptoms as well as objective performance in manual dexterity tests.

For massage therapists working with clients before, during, or after chemotherapy infusion, how do these new technologies affect your approach? Should you massage the hands or feet? The head? If not now, when?

How to Adapt Massage Therapy to the Scalp?

It’s easy to modify massage for a client receiving scalp cooling therapy. A person attempting to preserve their hair through cryotherapy is not going to want their hair pulled or dragged in any way. They are instructed to brush gently to hang on to as much hair as possible. Massage should honor this goal, throughout treatment, as long as it is vulnerable.

If a client wants touch on the head, we keep it to stationary holding rather than any friction that would pull on the hair. This avoids pulling, and avoids any strokes thought to be circulatory. While we’re at it, avoid getting lotion or oil on the head, if the client prefers.

How to Adapt Massage Therapy to the Hands and Feet?

The key here is also to align with the goals of the health care team. The purpose of cold therapy is to reduce blood circulation to an area. Classical massage strokes—notably effleurage, petrissage, friction, repeated compressions—are thought to increase blood circulation in superficial tissues in the areas worked. As massage therapists whose work is circulatory in intent, we need to work with the purpose of the cryotherapy in mind.

Here is where crystal clear guidelines get fuzzy. How do we avoid raising circulation to the hands and feet?*

You can avoid raising redness, but unfortunately visible hyperemia is only visible after you’ve already raised superficial circulation. So redness is only a reliable indicator of failure to stay within the lines, not of success.
We can avoid the strokes listed above, but then we get into an argument about which pressures make those strokes circulatory. Is it pressure level 3 on this scale? Pressure level 2?

The safest approach would be to avoid contact with the hands and feet altogether. Maybe light holding of each, but only brief. You don’t want to warm the hands or feet if they are supposed to be staying cool.

This guideline is in place just before, during, and just after the infusion. It continues until the drug has been fully eliminated from the body.

How Long is That?

Recall that your client has come to you a two days after the infusion. The cold therapy was applied during the chemotherapy infusion, and for 15-60 minutes beforehand and afterward.

For patients using cold therapy on hands and feet, we avoid circulatory work on the hands and feet as long as the drug is thought to be present in circulation.

Turns out, this length of time can be difficult to determine. The time it takes to completely eliminate a drug from the body is dependent upon the drug, dose, size of the patient, health of the patient’s kidneys and liver, and other factors. The best source of information about a given situation is the hospital pharmacist, but most MTs do not work down the hall from the pharmacist to ask this question.

The Dana-Farber Cancer Institute blog gives a general idea, though. They say that most chemotherapy drugs remain in the body for a matter of hours or a few days. So avoiding circulatory intent at the hands and feet is a good guideline for several days following the infusion.

Massage in the Infusion Room, during Chemotherapy?

Common sense can answer this question: Not on the areas that are cooling. The cap/gloves/socks are in the way! They present a physical obstacle to massage, and a mental reminder of the areas to be careful with afterward.

How about Other Patients at Risk of Neuropathy?

So let’s extend this discussion. Suppose your client has just had chemotherapy with a risk of CIPN, but did not receive cold therapy? What does this mean for the client? Should the client receive hand and foot massage just before, during, or in the hours/days after infusion?

This is a larger question, and one that the oncology massage therapy field should discuss. In the safest approach, we would follow the same guidelines and avoid raising circulation for these clients, as well. We would take care during the hours and perhaps several days after an infusion.

Yet many massage therapists suggest that foot or hand massage can ease neuropathy, and there is at least one published case report of this finding. Given the considerations above, the timing of that hand/foot intervention seems important. I would not do it until several days have elapsed after chemotherapy.

These newer treatments require new discussions: Many MTs are providing hand and foot massage in infusion units. Together, we need to arrive at meaningful standards of practice for the timing of hand and foot massage for people at risk of CIPN.

What Else Do I Need to Know?

This post is devoted to just two issues: hair loss and CIPN. But there are other side effects of chemotherapy, and other guidelines in place for them. During chemotherapy, hands and feet may be at risk of skin breakdown from certain drugs. Nausea and fatigue require a careful approach. Low blood counts require thoughtful interview questions and massage modifications. Even a surgery history can require a complicated array of massage modifications, and massage must be adapted to signs and symptoms of cancer itself.

So it’s important to have training, or at least read the literature on oncology massage therapy before working with a client during chemotherapy. It turns out, there is a lot of literature, and one should be required of all therapists: the 3^rd edition of Gayle MacDonald’s Medicine Hands: Massage Therapy for People with Cancer.

I did not start my career knowing what to do with this question. Cold treatment wasn’t a thing back then. But using a few principles, including aligning my goals with those of the health care team, and looking up some information, asking knowledgeable people, using the best sources in the field, we can adapt to new developments in cancer care.

With thought and care, we can work safely with people during treatment, even as treatments evolve.

*Note

Although a rise in blood flow is assumed to be an effect of Swedish massage techniques, the accuracy and significance of “circulatory massage” is a live question. For the purpose of this post, we’ll assume massage could raise circulation in superficial tissues of the hands and feet, at the site of massage. For more on this topic, see my free downloadable e-book, 5 Myths and Truths about Massage Therapy, below.

Resources

Hanai A, Ishiguro H, Sozu T, Tsuda M, Yano I, Nakagawa T, Imai S, Hamabe Y, Toi M, Arai H, Tsuboyama T; Effects of Cryotherapy on Objective and Subjective Symptoms of Paclitaxel-Induced Neuropathy: Prospective Self-Controlled Trial, JNCI: Journal of the National Cancer Institute, Volume 110, Issue 2, 1 February 2018, djx178.

MacDonald G. Medicine hands: massage therapy for people with cancer (3e). Forres, Scotland: Findhorn Press 2014.

Neighmond P. Cooling Cap May Limit Chemo Hair Loss In Women With Breast Cancer. National Public Radio, February 14, 2017.

Peachman RR. Scalp-Cooling Caps Help Prevent Hair Loss in Chemo. The New York Times, February 14, 2017.

Walton TW. 5 Myths and truths about massage therapy: Letting go without losing heart. Massage Therapy Foundation, 2015.

Ethics in Oncology Massage and Hospice Care

August 4, 2016 by Tracy Walton 12 Comments

My client complained about her doctor, the nurses, and the general care she was receiving during cancer treatment. She went on for some time.

Now and then, she took a breath, then looked at me as though to ask “Do you agree?”

I held her gaze.

It seemed like a challenge to choose sides.

Agree, that she was getting poor care? Disagree? Question her account of her treatment?

I breathed. I wavered. I considered the options.

In the end, I chose reflective listening: “It sounds really hard, what you’re going through.” And a few more questions: “What happened next? Who have you talked to about this? What kind of support are you getting, or do you need?”

I drew her out a bit, and eased the conversation over to the plan for her massage session. Next session I did the same, while encouraging her to vocalize her concerns to her care team.

What would you have said?

This exchange could happen anywhere, with any client, but it is somewhat unique to a massage practice focused on cancer care, hospice care, or people with medically complex conditions.

Why?

In massage therapy, the relationship dynamics are delicate. Clients are typically unclothed and hurting in some way, and are hoping for some sort of help.

Our clients are uniquely vulnerable.

A health crisis compounds that vulnerability. The uncertainty of diagnosis, the transition at end of life, the challenges of treatment–these heighten a client’s needs and sensitivities. Massage therapists navigate trickier waters.

In such situations, my words have as much weight as my touch.

There are countless examples specific to this kind of work: How to manage family dynamics and funerals. How to turn down requests for more pressure when the tissues are frail. How to answer hard questions when the stakes are high.

How to manage professional relationships with physicians, nurses, and PTs I might never meet, but who are lifelines for my client.

In the example above, I knew my client needed moral support, but that I needed to not undermine her care team. Whether or not I agreed with her, I knew the most professional response was to stay supportive, encouraging, and neutral. To let her vent a bit, without joining her on the bandwagon. To support her finding her own, best solution.

These circumstances call on our ethics.

Then I thought of Dianne Polseno

A dear colleague of mine, the late Dianne Polseno, wrote a regular column, “Ethically Speaking” for the Massage Therapy Journal. It was one of a great body of work and service that she left behind.

Over our long, collegial history, I found myself agreeing with Dianne about 50% to 75% of the time. The disagreements did nothing to diminish my admiration for her. Instead, they spawned a rich dialogue.

Recently I dug up an old column of hers and found a great statement.

“Ethics is a verb.”

She explained that it makes itself known through behavior more than belief or commitment.

I loved that, of course. Her writing was always clean and to the point.

Yet reading this, five years after Dianne’s death, I found myself once again agreeing with some parts, but not with everything.

For me, ethics is also profoundly inner process

Yes, it’s a measure of behavior, but the struggles are set in my internal landscape. Reflection and searching are in order. Ethics comes from my relationship with me.

Why? Because tricky situations make me uncomfortable. Uncertainty makes me rush to solutions. Strong feeling gives me…strong feelings.

It’s super easy, when I’m uncomfortable, to act on impulse.

My impulse was to join in my client’s righteous anger.

This needs to stop, to change! She needs to tell them X or Y! Someone should write a letter! Maybe I should write a letter!

Yet I knew that in that particular relationship, my outrage would not serve my client. I needed to control that particular impulse.

Instead, I sensed that the best stance was supportive, but neutral. I knew that doctor-bashing, an all-too-popular sport in my field, would serve no one.

In the pause between stimulus and response, ethics entered in.

Ethics needs a clear invitation, and a little time.

In the moment, I needed to breathe. I needed to notice my body. To acknowledge my strong feelings, and let them know I would get back to them later, but I hit the pause on my righteousness.

Instead, in breathing, I found my compassion for my struggling client, for all of us who struggle to be heard, seen, and understood.

When I finally spoke, I spoke from that compassion.

Charged circumstances, high-stakes conversations, pain and suffering. All can give rise to tender ethical dilemmas for massage therapists.

For decades, I’ve heard and tended these dilemmas in my oncology massage classrooms.

So I made a new course.

Two courses, actually.

A new one, “Ethics in Oncology Massage and Hospice Care.” Launching in September in Boston, it’s 4 CE hours.

Paired with a 3 CE hour course, “Cancer and Massage Therapy: What Does the Research Say?”

I want to address the ongoing needs of massage therapists in cancer care and hospice. I want to support them in the challenges that come up.

Aside from the spectacular convenience of knocking out two common CE requirements in one day, why these two in tandem?

Because of overlap.

The common theme is truth.

Ethical dilemmas present competing truths, and call us to deal with the hard truths. Some truths are liberating, such as the one, “I don’t have to solve this client’s problem, I only have to give them the best massage I can” dangling at the end of the process.

Research is about the search for truth.

There are competing truths about the effects of massage, and competing research results. Some of the massage truths we’ve relied on (Endorphin bursts! Toxin releases!), aren’t really true when lifted up to scrutiny. Yet there are others, underappreciated, that have been waiting in the wings: The potential for massage to help with the worst of anxiety and depression, or ease a distressing symptom or side effect.

In our search for truth, we raise more questions.

What do I do? How do I respond? How does massage help my client with cancer? How do we know? How do I market the effects of massage when we’re not quite sure?

What do I say to my client who complains?

And feelings.

What happens when I feel helpless?

How do I manage my own strong feelings? What if I listen to my pain and it actually speaks? What if it drags me down?

How do I cope, seeing and touching the hardest of human experience, day in and day out?

Do I have a right to complain? Compared to my clients’ struggles, mine are trivial.

And so on, yada.

What about you?

I’m curious about the kinds of challenges MTs face on the front lines of illness. I’m curious how you are handling yours.

I can’t respond to comments here for a couple of weeks, it being August and heading off the grid and all, but I’m grateful for anything you contribute, and I look forward to reading it when I return.