Wednesday, August 2, 2017

FYE: Ratchets: No going back

Have you ever had to change a flat tire on a car? It's a chore that hasn't changed much from the very first days of driving.

"Alice Huyler Ramsey (1887-1983) in 1909. Asphalt roads were a rarity and repairs frequent during the pioneer cross-country drive of Alice Huyler Ramsey in 1909. Shown here changing a tire on her green Maxwell."
By, Public Domain,

"Good driving has nothing to do with sex. It’s all above the collar." Alice Ramsey

Alice Ramsey had to change tires 11 times in her successful 1909 attempt to become the first woman to drive almost 4000 miles from the East Coast of the United States to the West Coast.

If you have changed one, or if you've ever closely watched someone doing it, then one thing quickly becomes apparent--for safety, you don't want the car falling back down onto the ground (and onto you!). Once you begin lifting the car, then you want it to securely keep going only upwards, until the time that you decide to bring it down again, under control.

The way that you guarantee that the car will only go in one direction while being lifted is to use a tool called a jack. You can see Ramsey's jack in the center front of the photo--it doesn't look that much different from the jacks used on cars in the 1960s and 1970s.

The way that a jack ensures motion in only one direction is through the use of a ratcheting mechanism. These Wikipedia images show how a ratchet works to ensure movement in only one direction.


A jack is an example of how a physical ratchet works on real objects in the material natural world. Now we're going to use that literal ratchet in a more figurative way, in order to understand the more abstract way in which science is progressive.

Visualize the sum of all human knowledge as the gear. No one human has access to everything that that gear represents, but taken all together, we--by definition--know everything that humans know.

The pawl is validation of that knowledge. If the ratchet works correctly, then it keeps moving forward, and new and validated knowledge keeps being added, while false claims and other misinformation is prevented from being added to (and ruining) the gear.

That's why reality-based client-centered healthcare professionals don't resort to "energy medicine" or vitalism or any number of discredited alt-med ideas that MT in the US actively promotes as being associated with massage. Those ideas have been tested, repeatedly, and they failed.

No number of mulligans or do-overs is going to make them true, because they are not true. We have the choice of accepting that fact and moving forward with our clients and our prospective healthcare professional colleagues, or of losing ourselves in that denial of reality, hoping in vain that, just this once, the metaphorical ratchet will--against all nature--run backwards and finally, finally, validate those ideas.

Applying the principle of charity: a lot of people who truly believe in an idea don't know that that idea has been tested repeatedly, and has repeatedly failed the test. Others know that intellectually, but feel that the emotional and psychological consequences of deeply understanding the consequences of that fact are too high for them to pay.

Sometimes, you will see people who don't understand science misinterpret research literacy to mean that every hypothesis in every research study has a 50-50 chance of being true. Reality literally seems to them as though you could flip a coin, and it really could go either way.

I want you to have a more solid and deep understanding than that. If you understand that there is a scientific consensus about knowledge of the natural world--not a perfect, complete, frozen one, but rather a provisional, incomplete, and contingent one--then you are already in a better position to evaluate the validity of knowledge claims (and to protect your client and yourself from fraudulent ones) than most people are.

Behaviors that you are not expected to tolerate: The physicist Robert Oppenheimer said, "There must be no barriers to freedom of inquiry … There is no place for dogma in science. The scientist is free, and must be free to ask any question, to doubt any assertion, to seek for any evidence, to correct any errors. Our political life is also predicated on openness. We know that the only way to avoid error is to detect it and that the only way to detect it is to be free to inquire. And we know that as long as men are free to ask what they must, free to say what they think, free to think what they will, freedom can never be lost, and science can never regress.".

That is literally true, but scientifically-literate people also know that the ratchet effect of validation and the scientific method serve to test and discard false ideas, and to prevent them from being incorporated into the sum total of human knowledge. We don't revisit "energy medicine", reiki, or vitalism any more than we revisit the possibility that 2 + 2 = 7, and for exactly the same reasons.

Always be open to something new going forward, and if it doesn't match the consensus of human knowledge about the material physical natural world, ask yourself why that is. If it's a truly new frontier finding, then you can reasonably expect people to work hard to resolving the apparent contradictions, and to communicate that information credibly to you. But if it's just another eternal revival of an idea that's been discredited, and the person reviving it hasn't done the homework to know that it's already been discredited many times--or, if they know that, but they just don't care--you're under no obligation to spend your time on a futile argument.

You may be accused of being dogmatic or close-minded, even something as over-the-top ridiculous and inflammatory as "Left-Brained Taliban", by people who truly envision themselves as courageously calling out such things. You may even be accused of "attacking" their character, or of "bullying" them, simply because you refuse to pretend as though a fantasy is real.

You are not called upon to tolerate or listen to such accusations, nor to take them to heart. They just mean that you currently find yourself among people who are not prepared to accept and appreciate what you have to offer. But it's a big world out there, and there are many, many other people who love reality, and will be eager to welcome you as a fellow explorer and discover.

Go find your people! You won't regret it.

Tuesday, August 1, 2017

FYE: Our triple bottom line--Touch is good, natural, and universal

Our bottom line—the very most important thing that I can say to you about our work—has 3 parts:
  • touch is good (Claim 1/Assertion 1); 
  • touch is natural (Claim 2/Assertion 2); 
  • and touch is universal (Claim 3/Assertion 3).

This book begins with these simple principles. We state them explicitly, so that everyone is on the same page about the shared core assumptions that we begin operating with.
From there, we’ll go on to examine what we know about the ways in which massage is good, that everyone universally—regardless of their culture or personal experience—could potentially agree on. Perhaps even more important, we’ll also examine how we can know these things, through research and information literacy—based in the fact that massage is grounded in our material physical natural world.
This is something that we aspiring massage healthcare professionals need to do explicitly, because not every single thing that everyone represents publicly as massage is true. Some of these things may be true for some of us, or in some circumstances, but not necessarily always so; some other things are simply mistaken.
But this book is guided by an additional simple principle, as well: That massage is strong enough and good enough and important enough to be studied objectively, without being damaged as a result[1].
Letting go of wrong information about what massage is (as well as what it is not) does not require attacking people who—for whatever reason—were taught wrong information in the past.
It does require us to be strong enough and mature enough and professional enough to look at what we believe that we know—and, if necessary, if that's where the evidence leads—to grow and change and learn. I believe that the very qualities that make us able to care for others, in the ways that we do, also make us able to care for ourselves in this way, as massage weathers these professional growing pains.
It all comes back to the crucial question of how we get the best information possible about massage to our clients, as the centers of our practice.
If—as we often say—we really want to become full-fledged members of the patient/client-centered professional healthcare team, and we want massage to evolve into a true profession in more than name only, then our clients have to be at the center of it all. Their well-being has to be more important to us than is protecting misinformation—even misinformation that we may be emotionally attached to.
Change may not be easy or fun, but since that change has now become necessary, then we can take comfort in knowing that massage—and we—are up to the task. Because the bottom lines are that massage as touch is good, natural, and universal, and—as a direct result—we are providing something very valuable to our clients. That is always going to remain true, regardless of the specific details we learn about how it actually works.
In this book, we'll talk about how we figure out those details. But nothing in this book, nothing in research and information literacy, and nothing in critical thinking, will change those bottom lines.
On the contrary: when we base our claims about massage on reality and on what is factually true, we can open up more and better options for directing the development of massage as a truly client-centered profession.
Of course, that does not mean that the path will always be an easy one. Online, an MT voiced her honest and deeply-felt concern about aligning ourselves professionally with biomedical healthcare providers.
What other profession gives you a solid hour of hands on bodywork? My fear as we strive to align ourselves more closely with 'traditional' medicine [here, meaning "biomedicine"] that our standard hour will be taken away and we will be perceived as short-term cheaper physical therapy. I see the insurance companies making a push for it and it makes me sad.

(A convention in this book will be that black type on a gray background will always be used for quoting other people, so that you can clearly tell where the ideas and words come from.[2])

My response to this MT was the following:
Well, we could always decide, as a group, that we stand for a solid hour of hand-on massage, and—on the basis of evidence that that in itself is good for clients—actively resist any attempts from outside to water it down.

We can serve as advocates for our clients and for what massage stands for in reality.
I think that would be a much better use for our clients and ourselves of our time, money, credibility, and political strength, than is what we often do now: using so much of those resources aligning ourselves with and defending implausible and repeatedly-debunked mistaken ideas about how the universe works.
That is a core philosophical stance that this book is based upon; as such, we will return to it again and again.[3]

Massage as touch is good because it promotes positive outcomes in people and other animals. We often feel better after we get a massage, and sometimes, just feeling better is enough for us. At other times, there are specific positive outcomes that massage promotes. We'll examine those in more detail over the course of the book.

In 2008, the psychologist Christopher Moyer proposed an evidence- and science-aligned specialization of massage, Affective Massage Therapy[4].  In making the case for his proposal, he conducted a research literature to determine the strength of evidence for specific massage outcomes.
However, the other two general effects [reduction of anxiety and reduction of depression] are well-supported by scientific data and widely agreed-upon by MT researchers. Quantitative research reviews show that a series of MT treatments consistently produces sizable reductions of depression in adult recipients. The effects of MT on anxiety are even better understood. Single sessions of MT significantly reduce state anxiety, the momentary emotional experiences of apprehension, tension, and worry in both adults[5] and in children[6], and multiple sessions of MT, performed over a period of days or weeks, significantly reduce trait anxiety, the normally stable individual tendency to experience anxiety states, to an impressive degree in adults5

According to Moyer's interpretation of the evidence—which I trust, because he has repeatedly demonstrated both a solid understanding of the actual science involved, plus the integrity to stand up for that understanding in the face of intense pressure to water down the findings–massage supports many of the beneficial goals of client-centered healthcare professional care teams. For this reason, we are confident that the claim "massage is good" stands on solid ground.
When we claim that "massage is good", we are implicitly asserting that we can actually measure massage compared to some standard, and—because of that measure—assign it to the category of "good", rather than "bad", "indifferent", "neutral", or any other possible category. How is it possible to measure the goodness of massage?

The psychologist Dinghy Kristine B. Sharma and her team were interested in a similar research question—is it possible for a university to design supportive programs for Alaskan Native college students that are consistent with values and experiences that those students regard as ‘‘what makes life good’’, in order to encourage them to stay in school and complete their education?

You can read here about how her team consulted those students to learn from them about what measures they considered to make life good. The language of this article should be reasonably easy to understand. How might you conduct a study similar to this to learn what aspects of massage are considered good and valuable, and to whom?
Massage as touch is natural simply because we find touch throughout so many organisms in nature. Many different species besides humans have been observed to use massage or massage-like techniques—specifically, soothing touch—as part of their normal behavior.

The neuroscientist Laura C. Grandi wrote a survey article about pleasant touch and the way in which that behavior promotes bonding and other types of social affiliation in various non-human primate species, as well as in humans. You can read the entire article here if you like. Don't worry about their technical terms; just getting the general idea at a very high level is fine for our purposes.
This excerpt is a sample of her survey of pleasant touch across primates.

Grooming as an Affiliative Behavior Among Non-Human Primates
Echoing the gentle caress for humans, allogrooming is a social affiliative behavior for non-human primates [lemurs, monkeys, and apes]. Allogrooming is a widespread behavior, primarily carried out to clean others’ body parts that are inaccessible or invisible to self-grooming (Barton, 1985[7]), and for the control of lice infection (Zamma, 2002[8]). Nevertheless, the amount of time devoted to grooming exceeds that necessary for cleaning, suggesting that there is a social reason beyond the hygiene function (Kummer, 1968[9]; Boccia et al., 1989[10]; Spruijt et al., 1992[11]). Indeed, allogrooming is the most common affiliative relationship and social strategy to create and maintain relationships and reliable alliances (Maestripieri, 1993[12]; De Waal, 2008[13]; Dunbar, 2010[14]; McFarland and Majolo, 2011[15]). It has been reported that allogrooming enhances relaxation and the sense of security (Dunbar, 2010), while simultaneously reducing anxiety levels (Schino et al., 1988[16]; Boccia et al., 198910).
"Allogrooming" means grooming behavior performed on another individual of the same species as the groomer(s).
"Affiliative" means creating bonding or other sorts of positive social relationships among individuals.
Notice how the final sentence in this excerpt reports allogrooming as reducing anxiety. That is consistent with what Moyer found in analyzing other studies about massage, and—as such—is an example of consilience: independent lines of inquiry converging on similar conclusions, which are stronger for that confirmation from different independent approaches.


Figure 1-1. The power of touch in macaques. Social grooming in macaques demonstrates an example of the important role that massage and massage-like activities play throughout nature. Source:
accessed 22 December 2013

Since those species—although not totally insulated from political, social, and cultural influences—are less directly influenced by them than are humans, it's reasonable to start with the working assumption that there are clearly strong biological and natural aspects to the acts of seeking and carrying out touch and massage.
These biological and natural aspects of touch are so strong and so important that, when Sue Fairbanks, a professor of ecology and wildlife biology, needed to anesthetize a mother bear to re-collar her for radio-tracking, she called on her own mother and daughter to cuddle the bear cubs to keep them warm for the half-hour or so that they needed to be away from their mother for the procedure.

By Brocken Inaglory -, CC BY-SA 3.0, (Used as placeholder for other picture while awaiting permission for use)

Nature is the scope of what we will be examining in this book, and science is about observing and learning about what happens in the natural world. For this reason, we'll look at these natural behaviors surrounding massage in more depth, and try to gain understanding about them, throughout the course of this book.
But positive outcomes resulting from touch aren't limited only to complex animals like primates and other mammals. In this article, Gabriele B. Monshausen and Elizabeth S. Haswell describe how basic functions necessary to the lives of plants are regulated and carried out by response to touch and other forms of mechanical stimulation. If you'd like to read the entire article, you'll find it here. I'll warn you in advance that it's quite a slog to read. If you do read it, I certainly don't expect you to know off the top of your head what all the chemical and gene names mean, nor to understand all the details of every mechanism that she explores (I certainly don't!).
If you come out of reading the excerpts below, or even the entire article, understanding the following points:
  • Touch, along with other forms of mechanical stimulation, plays a role of life-or-death importance in physiological processes of plant growth, development, and normal function;
  • As we focus in more on smaller and smaller levels of analysis, such as genes and proteins, we naturally change from bigger and more sweeping observations to many more smaller but detailed ones; and
  • Chemical and other stimuli operate at the microscopic and sub-microscopic level like a key turning in a lock to open a door—no conscious thought required, just does the key fit, so it works? Or does it not work, because it doesn't fit right?
then you have done very good and solid work in this part.

The ability to sense and respond to a wide variety of mechanical stimuli—gravity, touch, osmotic pressure, or the resistance of the cell wall—is a critical feature of every plant cell, whether or not it is specialized for mechanotransduction. Mechanoperceptive events are an essential part of plant life, required for normal growth and development at the cell, tissue, and whole-plant level and for the proper response to an array of biotic and abiotic stresses. One current challenge for plant mechanobiologists is to link these physiological responses to specific mechanoreceptors and signal transduction pathways. Here, we describe recent progress in the identification and characterization of two classes of putative mechanoreceptors, ion channels and receptor-like kinases. We also discuss how the secondary messenger Ca2+ operates at the centre of many of these mechanical signal transduction pathways.
Concluding remarks
Plant responses to mechanical perturbation occur in a variety of specialized and non-specialized tissues and span a wide range of developmental time. Linking such responses to specific perception and signal transduction events has been difficult in the absence of well-characterized molecular pathways. However, recent progress in the three main areas described here should help to elucidate commonalities and specificities in the ways plants experience and adjust to their mechanical environment. First, MS channel activities are abundant in plant membranes, as is evidence for their importance in a variety of biological roles. Furthermore, as three distinct genes or gene families have been identified that are likely to underlie some of these activities, it has become possible to match electrophysiological activities with the genes and proteins that produce them, and we anticipate that further efforts to combine the toolkits of patch-clamp electrophysiology and Arabidopsis molecular genetics will begin to shed light on the long-proposed role played by MS channels in the perception of mechanical stimuli. Secondl, potential candidates for cell-wall integrity sensing are also abundant. RLKs are ideally suited to transmitting information from the cell-wall environment to the cell interior, and future studies should provide a clear link to mechanical signal transduction pathways. Establishing whether candidate RLKs are genuine mechanoreceptors that are activated by conformational change in response to a mechanical force, or monitor cell-wall stress by binding cell-wall-derived ligands, is an important goal for future research. Finally, physiological studies have positioned the secondary messenger Ca2+ at the centre of many mechanical signal transduction pathways. Identifying the transporters shaping Ca2+ signatures and mediating other downstream ion fluxes is essential to our understanding of how Ca2+ signals are generated and interpreted and may provide tools to manipulate Ca2+-dependent mechanoresponses. In summary, the future will probably bring many exciting new discoveries regarding the molecular mechanisms of mechanotransduction.

"…" means that there is a great deal of text that I have left out, in order to focus especially on the parts that I wanted to include.

MS: abbreviation for "mechanosensitive" (meaning responsive to touch, gravity, or other kinds of mechanical stimuli)

RLK: receptor-like kinases, the name of a family of chemicals. Just think of them as "one specific family of chemicals", and don't worry about its exact name.

And Sean Maguire describes how a very simple worm— Caenorhabditis elegans, typically abbreviated to C. elegans—uses its touch response to escape a fungus that would act as a predator if it succeeded in entrapping the worm.
C. elegans is a roundworm, somewhat like the earthworms we're used to in the garden, but much smaller and simpler.
By Bob Goldstein, UNC Chapel Hill - Own work, CC BY-SA 3.0,

This next picture is of a different animal (an ant) and a different fungus (Cordyceps), but it shows the same process of predation by a fungus on an animal that this article refers to. This poor ant was unlucky enough to fall prey to this fungus.
It invaded the ant, taking control of its nervous system, and turning it into a living zombie. The ant continued to travel through the jungle, and the fungus continued to grow inside of it, until the animal couldn't go on anymore, and it died. Then the fungus erupted from inside the ant's corpse, ready to spread out and thrive in its new location that the ant had carried it to.

By Bernard DUPONT from FRANCE - Ant Killed by Fungus, CC BY-SA 2.0,

Maguire studied a similar process in C. elegans worms, and how they used their touch response to avoid falling prey to the fungus Drechslerella doedycoides.
Predator-prey interactions are vital determinants in the natural selection of behavioral traits. Gentle touch to the anterior half of the body of Caenorhabditis elegans elicits an escape response in which the animal quickly reverses and suppresses exploratory head movements [1, 2]. Here, we investigate the ecological significance of the touch response in predator-prey interactions between C. elegans and predacious fungi that catch nematodes using constricting hyphal rings. We show that the constricting rings of Drechslerella doedycoides catch early larval stages with a diameter similar to the trap opening. There is a delay between the ring entry and ring closure, which allows the animal to withdraw from the trap before being caught. Mutants that fail to suppress head movements in response to touch are caught more efficiently than the wild-type. This demonstrates that the coordination of motor programs allows C. elegans to smoothly retract from a fungal noose and evade capture. Our results suggest that selective pressures imposed by predacious fungi have shaped the evolution of C. elegans escape behavior.
hyphal: related to the threadlike elements of a fungal body

Maguire includes photographs of worms trapped by the predatory fungus' hyphal rings:
If the worms can avoid this trap, they get to survive longer. And Maguire found that some of them did just that, and that it was touch that made that survival possible.
Most of the worms that the fungus caught were larvae, rather than adult animals, and most of them were caught on the head end of the body, rather than the tail end. Maguire and his team found that light anterior touch (and, to a lesser degree, nose touch) caused the worms to stop moving their heads and to abruptly reverse, often giving them time to successfully escape the trap in that way (because the trap tended to catch them at the head end). Posterior touch often caused the worms to accelerate forward, escaping the fungus in that way. They used touch-insensitive mutant worms and tyramine-signaling deficient mutant worms as sorts of controls to confirm that the results that they were observing were really caused by touch, rather than by something else that they might have overlooked.
If you read the entire article, it will be easier than the Monshausen plant article was, but there is still plenty of technical jargon and gene- and protein-names waiting there for you. Like the Monshausen article, don't worry about understanding every detail. If you can read the article at a high level, and see what the differences were that made the fungus more or less able to trap worms, and how the tyramine and other chemicals interacted with the receptors like the locks and keys we previously discussed, then you have done a good job or reading the article for understanding.
No one owns massage. It belongs equally to all humans and all animals who practice it.
And massage, as good and natural and universal as it is, is clearly up to the task of engaging with science and evidence on a basis of integrity. Knowledge and understanding do not harm massage—they only help deepen our appreciation of its natural power in promoting therapeutic relationships and positive outcomes.
Previously, we saw how touch provided good outcomes for primates, plants, and worms. Now let's look at humans in a variety of cultural contexts, to better understand another aspect of the universality of touch and massage.
(Disclosure: I used to work with Dedra Buchwald[17] at the Refugee Clinic at Harborview Medical Center in Seattle, and so it's my job to let you know that, so that you can read what I write, and decide whether you think that I am showing any bias for that reason.)
This article is more of an ethnographic or anthropological description of cultural practices that were used by patients at a primary care clinic in Seattle. While the two articles we just looked at are very detailed and focused on mechanisms, this is more descriptive than mechanistic.
Types of Traditional Health Practices
Coining was the most commonly used traditional health practice among the Cambodians (70%), the Chinese (35%), and the Lao (10%); however, this practice was not reported by the Mien (Table 2). Similarly, massage was used by all groups except the Mien. Coining and massage were the only practices reported by the Lao. Cupping was used commonly by the Cambodians and the Mien but not the other two groups. Moxibustion and healing ceremonies were used almost exclusively by the Mien.

It raises some interesting questions—given the amount of cross-cultural interaction and trade in Southeast Asia, why are some of the medical practices so different from group to group? Why don't the Mien use massage? And why are they the only ones in this sample who report using moxibustion and healing ceremonies?
Although they are very different questions, they are also scientific ones, like the ones in the previous articles, because they use similar methods of observation, explication, verification, and evaluation as the previous studies do.
In addition to description of observed cultural massage practices, Falle[18] implicitly opens the door to some crucially important ethical and moral questions as well.
Oil massage
Baby massage with mustard oil was a universal practice (99%) among recent deliveries.

In India and in the countries within the range of Indian cultural influence, baby massage with mustard oil is a very important and widely-used—universal—cultural practice. A major principle of healthcare professional ethics is that we demonstrate respect and create a safe environment for our clients.
But what if a widely-accepted cultural practice also causes harm? What are our responsibilities as healthcare providers in that case? You probably would have no reason to have come across this knowledge earlier, but at the lock-and-key cellular level that we looked at earlier, mustard oil can clearly and repeatedly be shown to damage the fragile skin of the premature infants who most need the skin's protection against infection and hypothermia.
Later in this book, we'll talk more about that question. For right now, I will say only that the Sharma article—in another example of consilience—provides some very good tips for us, and we'll discuss how to apply those ideas in massage practice.
Let's finish with a case report of how massage is good, natural, and universal in practice.

A little girl from a family of Italian nobles, Clarice Strozzi, and her dog, in 1542 by the Italian painter Tiziano Vecelli (Titian).

Oola, pictured here, is a Great Dane, although she is not the puppy treated in the case report. This picture of her, taken at 6 months of age, shows approximately what we might expect the 5-month-old puppy in the case report to look like. Photographer: Jon Hurd from Boulder, Colorado, USA.  Title:  "Oola - 6 months"

Journal of the American Animal Hospital Association. 2010 Nov-Dec;46(6):433-8.
Successful treatment of necrotizing fasciitis in the hind limb of a great dane.
Csiszer AB (1), Towle HA, Daly CM.
Author information: (1) Oregon Veterinary Referral Associates, 444 B Street, Springfield, Oregon 97477, USA.[19]
Metadata (information) about the article, journal, and authors. At the time this article was written and published (2010), the first author (AB Csiszer) worked with Oregon Veterinary Referral Associates, in Springfield, Oregon, USA.

A 5-month-old, intact female Great Dane was presented for an acute onset of rapidly progressive lameness, severe pain, and diffuse swelling of the right hind limb. Ultrasound evaluation revealed echogenic fluid pockets extending along fascial planes of the right hind limb, from the proximal femur to the hock. Necrotic soft tissues were debrided, and closed-suction drains were placed. No foreign material was identified at surgery. Fluid culture identified a beta-hemolytic Streptococcus sp., and affected fascial histopathology was consistent with necrotizing fasciitis. Postoperatively, the puppy was managed with intravenous broad-spectrum antibiotics, local infusions of amikacin, and daily physical rehabilitation. Oral pentoxifylline was administered to treat bronchopneumonia and streptococcal toxic shock syndrome that developed secondary to necrotizing fasciitis. To our knowledge, this is the first report of a successfully managed case of beta-hemolytic, streptococcal, necrotizing fasciitis successfully managed after a single surgical debridement in combination with systemic broad-spectrum antibiotics, local amikacin infusion, active closed-suction drainage, daily cytology, massage, and passive range-of-motion exercises to maintain limb function.
There is a great deal of technical jargon in this paragraph. I've added links to definitions to help with unfamiliar words and ideas, but don't worry about understanding every single last detail.
If you can read this, and generally describe in words that a non-medical audience would understand, why the dog's owners brought her to the veterinarian, what the veterinarian did to treat the dog's condition, what happened after that, and how the treatment team responded, then you have done good work, and you have gotten what you need to from the paragraph.

This is a case report of a 5-month-old puppy who recovered successfully from an attack of flesh-eating bacteria. Massage was part of her rehabilitation treatment after surgery. The veterinarians attribute maintenance and recovery of her limb function to massage and passive range-of-motion exercises.
If you're at an institution that has free access to this article, it's actually kind of interesting to read how they first approached treatment, how they changed things when that didn't work, and why they made the treatment choices they did. I found this article a good read. However, if you have to purchase it from behind a paywall, I would have to recommend that there is just not enough massage-specific information to make it worth doing so for the massage information alone.
Necrotizing fasciitis (NF) is a life-threatening emergency. The puppy in this case report came very close to dying, before the story turned around to yield a happy ending. Fortunately, cases such as this one are rare--but when they do happen, it is an extreme medical emergency and requires immediate intervention and hospitalization.
The main reason that NF is so dangerous is indicated by its name:
necro: from Greek νέκρωσις (, pronounced "nekrosis"),  meaning "death"
-(t)izing: "causing"
fasci-: fascia, from Latin "fascia", meaning "a band, a bandage"
-itis: inflammation
or, "a death-causing inflammation of the fascia" (sparing skin and muscle).
The authors of this case study report that:
In humans, reported survival rates are 70% if surgery is performed within 24 hours of diagnosis of NF infection and only 35% if surgery is ≥24 hours after diagnosis. QUOTE
To put that in natural frequency terms, for every 100 people operated in within 24 hours of receiving a diagnosis of NF, 30 of them die from the infection, and 70 of them survive. If surgery is at or later than 24 hours after diagnosis, then 65 out of every 100 people in that situation die, and only 35 of them survive.
I've put links to these next two pictures, rather than embedding them, because you may find them quite disturbing, and may wish not to click on them. The image" shows a bad case of NF in a Caucasian male, and the image shows the surgery to remove the necrotic (dead) tissue from the same patient.
It's also commonly called "flesh-eating" bacteria. In reality, though, cellular and tissue necrosis (which happens here), and eating (which does not happen here) are two very different things. LINK TO TOXINS, LYING TO CHILDREN
Let's get into the story, and we'll discuss those points as they tie into it.
The owner of a Great Dane puppy brought her to the veterinarian because she was showing signs of food bloat and non-weight-bearing limping with her right hindlimb. There had been no apparent trauma to the limb.
The veterinarian conducted an orthopedic examination, and took x-rays of the limb, as well as a CBC and serum biochemical profile. Nothing remarkable or abnormal showed up on any of the examinations.
Based on those results, the vet referred her to an emergency hospital for follow-up. At the emergency hospital, the orthopedic exam revealed some swelling and pain. Further x-rays confirmed the swelling, but did not reveal any more information. The emergency vet suspected a right partial cranial cruciate ligament rupture, and released the dog from the hospital that evening with medication (tramadol) for pain relief and activity restrictions to prevent worsening the suspected injury.
Over the next three days, the puppy's condition continued to worsen, and the owner brought her back to the emergency hospital at that point. She was not responding to medication, the leg was stiff, swollen, and painful with pitted edema, and she had stopped eating. They were able to withdraw a fluid that was consistent with pus and infection, and they sent that off to be cultured. Ultrasound examination revealed a great deal of fluid in the affected leg. Based on the findings, the vets suspected a massive soft-tissue infection, and recommended immediate surgery, not waiting for the cultures to grow, be identified, and reported on. As a result of these findings, the puppy was in surgery within 6 hours. Surgeons removed a great deal of fluid and necrotic tissue, and were able to close the incision cleanly.
Her post-operative care consisted of cold compresses for 10 minutes every 4 hours, followed by massage and PROM exercises. IS THIS A BASIS FOR BEST PRACTICES?
The massage is not well-described, and it is difficult to know how to replicate it from the minimal description provided. They do not mention who provided the massage; I suspect from context, but do not know for sure, that it was performed by veterinary technicians.
The PROM description, on the other hand, is sufficiently clear that it can be replicated. After 48 hours, the cold compresses were changed to warm ones. WHAT IS THE LOGIC HERE? WHAT WERE YOU TAUGHT?
The puppy continued to recover well, and was discharged from the emergency hospital after a 9-day stay. She was examined 40 days later, and was eating normally (had gained weight) and otherwise doing well at home. Her leg was normal size, and the joints worked almost normally. Her leg was not 100% weight-bearing 100% of the time, so she was left with a little bit of lameness, although most of the function had returned.
1.     What happened here biologically?
2.     Based on the facts the vets presented, what role could massage play in the rehabilitation of NF in humans?
3.     How can massage be integrated with veterinary medicine?
4.     What do veterinarians and vet techs know about massage?
·      How often are they called upon to do it in practice?
·      How can we build bridges to them by meeting their information needs about massage?
5.     How did they handle problems that occurred while they were treating the puppy, and what can we learn from their experience?

In this part, we have explained why we consider massage, as touch, to be good, natural, and universal. In the next part, we will explore why those aspects of massage are not always obvious, and what we can do to change the situation for the better.

[1] Principle 1: Massage is strong enough and good enough and important enough to be studied objectively, without being damaged as a result.
[2] Convention 1: A convention in this book will be that black type on a gray background will always be used for quoting other people, so that you can clearly tell where the ideas and words come from.
[3] Core philosophical stance 1: We can serve as advocates for our clients and for what massage stands for in reality. I think that would be a much better use for our clients and ourselves of our time, money, credibility, and political strength, than is what we often do now: using so much of those resources aligning ourselves with and defending implausible and repeatedly-debunked mistaken ideas about how the universe works. That is a core philosophical stance that this book is based upon; as such, we will return to it again and again.
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