The Thinking Practitioner Podcast:

Episode 147: Palpating Fibrosis, Easing Inflammation (with Geoffrey Bove and Holly McMillan)

Whitney Lowe  

Welcome to the Thinking Practitioner podcast, a podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today. I'm Whitney Lowe 

 

Til Luchau  

and I'm Til Luchau. 

 

Welcome to the Thinking Practitioner.

 

Til Luchau  

Hey listeners, before we jump in, just a heads up to be sure to stick around after the final goodbyes, we kept the recorder running for a few minutes off mic, and Holly shared some fascinating stories about her hands-on work with radiation-affected tissues in surgical and hospital settings. If you're curious what manual therapy could look like inside a major cancer center, you won't want to miss it. The Thinking Practitioner podcast is proudly supported by ABMP, Associated Bodywork and Massage professionals, the premier association for dedicated massage and bodywork practitioners like you. When you join ABMP, you're not just getting industry-leading liability insurance; you're gaining practical resources designed to support your career, from free top-tier continuing education and quick reference apps like Pocket Pathology and Five Minute Muscles, ABMP equips you with the tools you need to succeed and grow your practice. ABMP is committed to elevating the profession with expert voices, fresh perspectives, and invaluable insights through CE courses, their ABMP podcast, their sponsorship of this podcast, and Massage and Bodywork magazine, which features industry leaders like Whitney Lowe, my co-host, who isn't here today. He's off teaching in Seattle, and myself. Thinking Practitioner listeners like you can get exclusive savings on an ABMP membership at abmp.com/thinking.  Join the best and expect more from your professional association, and welcome to the Thinking Practitioner podcast. I am Til Luchau, and today I'm joined by a special co host, since Whitney's not here. You, Cathy Ryan, my longtime colleague and collaborator, you're a respected educator, a clinician, and coauthor of Traumatic Scar Tissue Management. You're bringing a deep interest of how hands-on work can support people living and recovering from cancer and a whole lot more. 

 

Cathy Ryan  

Hey Til, thank you so much for inviting me to join you today. I'm really excited to be here because we are speaking with two remarkable contributors to both research and practice. Dr Geoffrey Bove and Holly McMillan.

 

Til Luchau  

Dr Geoffrey Bove, you're a neurobiologist, a manual therapy researcher, and a principal investigator at Bove Consulting. You're published widely on the physiological effects of massage and manual therapy. You had a big influence on my own thinking and understanding of inflammation, especially as it relates to nerve function, and now fibrosis and we have another guest 

 

Cathy Ryan  

We do. We have Holly McMillan, who is a clinical speech language pathologist and manual therapist specializing in head and neck cancer rehabilitation. She is also a clinical research fellow at the University of Texas, MD Anderson Cancer Center, where she's been pioneering the use of palpation and manual therapy in oncology care. 

 

Til Luchau  

And together, the two of you, along with a coauthor, published a study testing whether massage therapy could help reduce radiation-induced fibrosis in rats and whether a skilled therapist, otherwise known as Holly McMillan, I believe, could actually feel the difference in irradiated tissue, even when lab tests couldn't detect it. And Cathy, you first turned me on to this study in the scar tissue class you taught for us recently, and before we bring in our guests, big build-up. But I'd love to hear what was it that caught your eye about this study? Cathy. 

 

Cathy Ryan  

Okay, so they had me at the title, because there are a number of words in the title that will get my attention immediately...Bove, Barb. I did not know of Holly yet, but now I do. She's on my radar. Massage Therapy, fibrosis, and palpation. Okay, so, yeah, I've got to jump on that

 

Til Luchau  

Nice. Well, let's, let's jump in. Okay, Geoff, to start us off, what drew you to explore radiation-induced fibrosis using manual therapy? 

 

Geoffrey Bove  

I can make it try to make it a short answer.  I was working on the effects of inflammation on nerves for a long time, and I got invited to be part of the fascia congresses. So I started seeing the link between sensory pathologies and scar tissue a little more, even though that's kind of what I was doing in the first place, I found out from Leon Chaitow or Tom Findley a long time ago, that they said, "Oh, you published the first studies of innervation of fascia." I said "I did?" So I guess I did.

 

Til Luchau  

But that was, sorry, that's where I first got exposed to you and your work, and I remember you were telling us all from the podium, "Hey everybody, it's about the interface".

 

Geoffrey Bove  

Oh, that was in Washington.  I still think that, but we don't know, of course.

 

Til Luchau  

No, I think you were. You saw that coming that even since then, more and more of the research has shown that many of the effects are about sliding interfaces and things like that, more than the qualities of the past tissue, per se. But anyway, sorry,

 

Geoffrey Bove  

Oh, Holly doesn't know this. I got up at the end of a fascia congress, and I said,"Just by the way, it's probably not all about the fascia, it's probably about the interfaces," and they didn't invite me back. I got interested in radiation fibrosis through a colleague of ours, Susan Chappelle, who was treating women who had severe breast cancer with reconstruction.  However, the radiation treatment was causing one of the number one pathologies that these women had  - brachial plexus neuropathies.  I found out they were due to irradiation causing fibrotic tissue around the nerve and within the nerves, even worse. And then when I started working with Mary Barbe about that same time, she and I had collaborated previously, and in fact, we got our first grant from the same study section of the same year, same session, actually, 25-some years ago. And we started looking at the effect of manual therapy in her repetitive motion disorder model. And then something that I always, always had wanted to do, was the post-radiation fibrotic work. That was going to be our competitive renewal for that grant with the repetitive motion disorder. So it seemed like a natural progression, and it was kind of important to me to wrap up a bunch of things. It's important to know, the way I met Holly was that I was trying to find a resource to help figure out how to irradiate the rats properly so we get an effect. And the short story there is that Holly was working and still is as a speech pathologist in this department, head and neck surgery, and she can tell you more.  I went to MD Anderson to meet with the head of that department. She's the head of the department, or the head of that group, and then she introduced me to Holly, and away we went, basically. So here we are, Holly, doing this on a regular basis. It's not like a patient here or there. She's been, probably today, working inside the oral cavity of somebody with documented post-irradiation fibrosis, where she's responsible for them getting access so they can do the surgery using manual therapy.

 

Til Luchau  

So, Holly, just for context, should we be thinking about your findings as they result to radiation specifically? Or do you think as we listen to the details we're going to provide, there's a there's effects that apply to other kinds of fibrosis as well.

 

Holly McMillan  

That's tough, from a basic science standpoint, really understanding the mechanism of action and what we're treating is really difficult. But the good news is we do see a nice effect with manual therapy in this population-specific. So, my bias for today is that mostly what I'm saying is related to head and neck. So all things head neck. I do have a massage therapy license, so I can work all around the body, but my specialty is in head and neck. So just as a caveat, that's where my focus is. But we don't see as much repetitive use injury in head and neck. When it comes to oncology, the radiation fibrosis just sort of takes over. So while it may be able to translate, I really think it just comes down to the mechanism of action. What are we treating I think we have still yet to see if they absolutely translate from one to the other, but I would hopeso

 

Til Luchau  

That's a clear answer and cautious. And I get excited as I read your work too. And let's see how we get expired in our imaginations, at least as we go forward.

 

Geoffrey Bove  

I'd like to add that the reason, one of the primary reasons that Mary Barbe and I didn't continue with that research is because of funding. And regarding the funding, the program officer told us that it wasn't much of a stretch to think that post-irradiation fibrosis would be any different than the fibrosis from repetitive motion disorders, and we saw her point.  But doing that comparison is not the kind of project that they're going to fund us to do, to look at the difference between, or if there is a difference.  It would be not that hard maybe, to compare them, but certainly on a time course, they were very different. The mechanisms are likely highly different. I mean, the radiation is mutating genes, so fibroblasts, I don't know if this is still mechanistically how people are thinking, but one of the reasons that was supposedly getting out of hand with people, even though there was no more stimulus, is that the fibroblasts had been mutated by the irradiation to just keep cranking out collagen without shutting down like they normally would. Is that still thought to be true, Holly? 

 

Holly McMillan  

Yeah, and it's, it's that in combination with the pathophysiology, you know, we continue in a radiation world, we just continue to change over time, and then we see late effects. We see all these other things, and I don't know if we see that with repetitive use injury as well. I don't I don't know.

 

Til Luchau  

Just for personal context, my wife went through many years of cancer treatment, including many rounds of radiation, sometimes in the same tissue, and I got a lot of hands-on experience working with her, and the things I learned, both cognitively and like I said, Dr Bove, you were influenced there, on my approach there, but also with my hands, really did translate out into my work in general, in their practice. I think it's been a big influence for me. But this, you know, your study was really unusual in that it included palpation like a hands-on subjective skill as one of your formal outcome measures. What was your rationale for including that? And how do you see it connecting to therapeutic goals in a massage therapy practice? 

 

Geoffrey Bove  

Well, I always wanted to do that. The main goal is that there kind of remains no correlation between pathology and palpation, and still, that's what I was hoping. Holly wasn't feeling something that wasn't present, and wasn't tested. We simply didn't choose the right assay to show something objective from what she could feel subjectively. So actually, to me, the strength of that paper was that it didn't show any fibrosis after the fact, because I was so biased that it was deep fibrotic tissue.  If you looked at the preliminary data file that I sent you this morning, it was clear that there was post-irradiation fibrosis down in the deep structures with that same model. So it was a big surprise that there wasn't when we got the histology. But that said, good surprises in science are the best things, because then you can kind of trust them better. I would absolutely be looking at skin and developing some other sort of assay in that model, again, if I were going to be doing it over or further.

 

Til Luchau  

So you were, Holly, you were able to correctly identify all of the irradiated limbs by touch alone. Hope that's not a spoiler on the study itself. What, what were you feeling for? 

 

Holly McMillan  

Yeah, that's a good place to start. I was trying to keep an open mind. Geoff and I had very different opinions about what I would feel, because we work on different cohorts. I work on humans. So we just had different ideas of what we were going to find. And I wasn't particularly on the hunt for fibrosis, but I was just trying to discern a difference between limbs. To start, rat forms are very, very they're very tiny. So, trying to feel that when I'm used to, you know, a bigger structure was interesting, but trying to feel for a difference, and really it's difficult to quantify this, because we are feeling something. It is difficult to articulate what we're feeling, and then to have that supported on imaging or some sort of more objective gold standard method, if you will. So we're feeling something. The word I'll use is buoyancy. I was trying to feel buoyancy in the tissue, because in my mind, I'm thinking more, this is an early stage. This is more likely to be lymphedema, really, than fibrosis. I'm still in inflammation. I'm feeling for fluid at this point, but I was just feeling for a difference in buoyancy.

 

Til Luchau  

And you could feel something. You could. Feel a difference. Thank you for trying to describe that. I think what you just said could be the tagline of the episode, that we're feeling something and it's hard to articulate. And then in clinical practice, it's somehow bridging what we feel into things that actually help our clients. 

 

Cathy Ryan  

And I think for me, this was one of the really exciting pieces of this paper was the fact that, you know, someone with trained hands can feel a difference. Maybe we don't fully understand yet exactly internally what that difference is, but the acuity and the accuracy with which Holly was able to determine radiated versus non radiated limb, was really exciting for me as a manual therapist, because, you know it, it's such a subjective piece, and often is excluded in research because of that. You know, for anyone like myself, until like you, practicing for you know me, 35 years, I know I'm feeling something. I know that this over here feels different than that over there. So for me, that was just such an exciting and important piece about this. And really important too. I think, Holly, that you talk about the fluid environment, and the difference, because I know in the world of lymphedema, they talk about fibrosis in a different context than what we do here, where we're referencing it to, the changes in collagen. So in the lymphedema world, they used the word fibrosis to describe a difference in the fluid environment. And I've heard it described as that feel of a stale marshmallow. If we want to relate it to something. So, yeah, you know, it goes back to both. 

 

Geoffrey Bove  

It's a very, very slippery slope to go from palpation to mechanism and pathology. And that's why I wanted to do this in the first place a long, long time ago.  At all the fascia congresses I'd ask therapists, "I've got things that are messed up on myself," and say "if you can feel adhesion or a restriction or something you're going to release, here's an arm.  Show me how to feel it." And no one really could. And so I was frustrated clinically, always frustrated, because it's very easy to trick oneself into feeling something someone else told you you can feel. Sensory illusions are well documented. I won't throw any particular person like myself under the bus right now. Maybe I will later, but I mean, we're all subject to sensory to palpation illusions and having people describe very, very different things, like you two just described, kind of very different things, which that tells me either there's illusions or there's multiple mechanisms, and there's probably both. So far, we have no correlation still between a pathology and a palpation finding. Holly kind of is developing the palpation-pathology link, ongoing, or kind of has already.  Can I ask that question Holly, if you could explain how you're going to correlate palpation findings with pathology and what you're doing now?

 

Holly McMillan  

Yeah, so there's actually a nice paper out by Shitong Mao. He's first author on it, and it was published earlier this year, looking at MRI biomarkers and the correlation between lymphedema and fibrosis. So I sort of want to highlight two different papers. The other paper that I love and I refer to all the time is actually out of the Vanderbilt group, Jia dang and Barb Murphy. Jia dang is a PhD nurse and Barb Murphy is a medical oncologist, and they're really pioneers in this field as well. But they published a nice paper. I believe it's in 2016 but I love how they describe it. It's sort of a trajectory from lymphedema into fibrosis, not really separating the two, but looking at them as a continuum. And I really love that, because anecdotally, we can feel that in clinic. That is what we're feeling. Things are very soft, and again, not to bring everything back to food, but we have this really soft edema, and it feels squishy, kind of like, well, a water balloon, but then it's pitting, it turns into like raw pizza dough, and then it gets hard, like cooked pizza dough, and then it's beef jerky. So we sort of go along this continuum, but they do a really nice job in that paper of describing that continuum. And then back to Dr Mao's paper that we put out earlier this year. We looked at findings of patients and their biomarker biomarkers on MRI. And what was interesting is we're looking at different amounts of signal intensity, so how much fluid is in these tissues. And one of the most interesting. Findings was the fibrosis group had less fluid than the normal tissue the healthy tissue, and that's directly correlated from what we palpated and then tied into a biomarker on imaging. So we're starting to see the proof. I almost want to say of yes, these muscles are dehydrated. They're not holding onto as much water. They're smaller in volume than normal tissue, and that's what we palpated. So anyway, there's a beautiful correlation. So I encourage listeners to go ahead and look at that paper by Dr Shitong Mao,

 

Til Luchau  

Okay, I'm going to link to those two papers in the show notes. I'm also going to link, if it's okay with you, Dr Bove to your supplement to this paper that we're talking about today, so that people can see these really cool images of what you were working with. But the question we were untangling there was, how does what we feel relate to, say, fibrosis or lymphedema, and then especially, how does that correlate to patient experience or client experience?

 

Holly McMillan  

Yeah, so again, shouting out to the Vanderbilt group. They do a lot of great work in the prevalence data, we're seeing about 90% of folks from a head and neck standpoint. So head and neck cancer ending up with lymphedema, thinking about internal, external and then about 75% at 18 months for fibrosis. So these are high prevalence rates, and they can be exceptionally symptomatic. It's hard to differentiate, you know, just because of ethics and because of the type of studies that we do, the causation of something, but we do see strong associations, and we see them in clusters. So, lymphedema not typically painful, but functionally problematic. It causes difficulty with swallowing, range of motion, saliva, things like that. And then it things just change over time. So if we see fibrosis, there can be pain in that world, especially with, you know, Geoff can speak to this, but nerve damage and issues, weakness, that kind of thing. But we do see clustering for the patients, they're very symptomatic when we see both lymphedema and fibrosis.

 

Cathy Ryan  

So, can I backtrack for a second here, Til? I totally I just want to go back to your previous point about the correlation, or, you know, lymphedema essentially, maybe being a precursor to fibrosis and that correlation. And I'm just wondering if you find in your practice, as I do in mind that those typical timelines that we attribute to in the inflammatory stage, into proliferation, into remodeling, I see a difference in, say, a patient who's had, you know, knee reconstruction, you know, like new knee or a new hip, and those timelines, and say, someone who's had cancer related surgeries where we see more of a prolongation, you know, so when we might expect collagen remodeling to start with, say, an orthopedic type of surgery, I see it pushed out further, Sometimes in those patients. So fibrosis maybe starts further out than say, do you see that in your practice? Just curious.

 

Holly McMillan  

Yeah, I would say we see that differently. We see the radiation fibrosis further down, further down the chain. So we anecdotally, anecdotally, do see surgery is interesting. So when they're surgery only can we see fibrosis? Yes, absolutely, but those prevalence rates are significantly less than the radiation group. So yeah, we are more eager to get in there and get mobilizing that tissue and really move moving on those surgical groups, the radiation group, are usually dealing with the upfront, upfront fluid issue, then later down the road, trying to get that more diffuse global instead of that nice scar, like the definitive scar line, where we can just really get in there, versus that diffuse global radiation scar tissue damage. But yeah, I would agree with you. We ours is just further down for the radiation here. 

 

Cathy Ryan  

Great. Thank you. Yeah.

 

Til Luchau  

So in your study, you could feel changes, differences in the land or difference in the tissue that didn't show up in the histology or electrophysiology. How do you interpret the gap between what your hands could feel and what the test could detect?

 

Geoffrey Bove  

They didn't show up in the tests I did. That's very different than saying they didn't show up in the test, because I didn't do comprehensive enough tests. I had to trim out quite a number of the assays I was going to use because of the budget compared to what we had planned in the first place, and so I went by the preliminary data, which showed deep fibrosis, and that's the only gap that there really is here. I didn't look in the right place. Kinda like using a thermometer to measure humidity. Well, you kind of can do that indirectly, but you know, right tool, right place.

 

Til Luchau  

Thank you. For that, because I one possible takeaway was like, wow, our hands can detect so much that science can't even find. But maybe another possible takeaway is we need funding to be able to find things that our hands can feel.

 

Geoffrey Bove  

I don't know if it's called a platitude, but that's something I've heard my whole career - "you can't measure it, what we feel." We can measure everything. To measure every force that if a scientist can't measure it, it probably doesn't exist, or at least doesn't exist in this physical world. You know, scientists tend to go with a description. I've always gone with myself or with somebody, the description of how that person is feeling it. Like if Holly and I had this. By the way, having her contribute in the way she did was an add-on. It wasn't planned in the beginning. I mean, I wanted to do it, but it wasn't planned because it's a little bit it's quite pitfall-y. But if she and I had spoken in depth about this, specifically the word "buoyancy," I would have developed a different I would have used a different test, a different set of tests. I wouldn't have dehydrated all the tissues to do the histology, looking for fibrosis, for instance. So this communication between the description, and the having scientists listen to the descriptions to develop the appropriate assay, that's the gap that I've tried to close my whole career. It's hard to find scientists who do that, that's coming along, I think, but it's been very difficult.

 

Til Luchau  

Well, I keep going back to your previous work and how creative you've been about what to look for and how to measure it along the way it's and you're really, you've really helped me close the gap in my thinking between mechanisms and effects and what I do with my hands. And you're right. It's a slippery slope. When we start talking about mechanisms, that's there's a lot of possible places that could go. And then there's the question of, how does that impact us clinically anyway? Right? So how about movement, though? Because one thing that kind of jumped out at me in the discussion was about how their housing, you said, and their increased movement might have helped mitigate fibrosis, too. So what about that effect of movement on fibrosis?

 

Geoffrey Bove  

We all have our sayings. I say "movement, good; stasis, bad," Holly said, What did you say today? 

 

Holly McMillan  

We have "movement is medicine".

 

Geoffrey Bove  

"Motion is lotion". Yeah, so that's that's been a long time coming too, By the way, I have a niece and a good friend who both are in their mid-40s and went through breast cancer with radiation, and both of them were extremely active. One doing CrossFit, like pretty soon after the surgeries, and the other doing high-intensity interval training.  Neither of them developed anything. My niece had some lymphatic cording transiently, and it kind of broke up and went away because she was really pushing herself. And, you know, anecdotes are anecdotes, but,

 

Til Luchau  

My wife, another anecdote, my wife used movement a lot to help recover or mitigate the effects of her radiation, and everything from pretty focused yoga to more gentle restorative things, and then Qigong as well, just taking large movements of her limbs with focused attention. And then, like I said, I learned a lot with my hands about how to help with things like cording as well.

 

Geoffrey Bove  

Holly, what do you do with patients that come in with advanced post-radiation, like, let's say for me, advanced would be someone five or six months or a year after they've had irradiation. I know that's not so beef jerky-ish to you.

 

Holly McMillan  

Yeah, our advanced group are usually, you know, five years or more out when they come in really feeling like that. We do see a difference clinically. We will do the manual therapy. We'll do the hands-on, but then we have to, we encourage them to keep we'll do specific stretching, strengthening exercises that they maintain at home. And we can see a difference. We'll use a goniometer, we'll take objective range of motion measurements, and we see improvement with stretching and strengthening alone. Yoga is just so showing some fantastic promise in the literature right now. There's some great studies going on with yoga and even Qigong as well. So it's just so exciting that movement medicines are also starting to have a voice. They're very effective. 

 

Cathy Ryan  

So there's another piece in that environment component that for me stood out, and that was the communal environment. So like particularly in in your lab, Geoff, the rats were not on their own, they were there with others. Which I think is another, you know, kind of piece that speaks to me as a massage therapist, because I think a really important part of my practice, too, is a therapeutic alliance piece, you know. And we certainly heard that spoken to at the M track at the International Massage Therapy Research Conference, where I just saw you long ago, and, you know, and your work was one of the reasons why I wanted to go there so I couldn't hear you talk about that, but I think that's something too to think about as well. As you know, when we're doing research in massage therapy that sometimes that piece gets missed too, and the value of that communal therapeutic alliance kind of component. So I'm wondering too, how would that affect the rats? Because, you know, they're not necessarily solitary animals. They're used to being around other rats, and perhaps that was a component in their their healing process as well. 

 

Geoffrey Bove  

Rats are exceptionally communal, and they get depressed, and they overeat and gain a lot of weight when they're alone, even if there are other rats in the vicinity without the direct contact and the grooming, they think they're more sociable than humans. But how did this happen? If you looked at the preliminary, the slides from the preliminary studies that I sent earlier, I mean, it was drastic fibrosis with less of a dose. And so I had to blame myself first, like, maybe I didn't push the button right to start the radiation, but I did it, right? I mean, I did it. I did it all myself too. It's like I couldn't blame it on anybody. So I had to say, well, maybe the machine wasn't working, but I checked the machine. I mean, I took a dosimeter, I checked it right before I used it. And so there has to be some reason, and that was one of the only things that was different, and my, the rats here are not only housed communally, but they also had a place to run around. I had the cages connected in the back like little condominiums. And so they got a lot more activity. There are also no studies on activity and weight, and mood in rats.  That's not a study that exist either. So I just had to make it up as I went along in the paper and the discussion.

 

Holly McMillan  

Cathy, can I add on to that? I sort of love that you brought up the communal, I can't tell you how often any chance I get to introduce touch therapy between spouses, mothers and children, anyone that comes in that room with our patients. I don't need the technique to be perfect, but introducing touch therapy and integrating that back into a healing process makes a world of difference.  I prefer patients to come in with someone so that we can introduce touch and then when we, you know, we have the conversation, obviously, like, let's avoid the carotid and some, you know, important structures that we don't want to cause more damage. But introducing touch therapy, and then we also have the conversation if it needs to go the other way too, right? So if you're getting massage, then you massage your partner. It just introducing that sort of whole circle. Touch therapy is exceptionally therapeutic in ways that I'm not sure we totally understand yet, but it makes a difference when you introduce that back into a relationship that's in your room.

 

Geoffrey Bove  

Something I don't know. Like, I said at that last presentation I gave, I always said that my vision would be, and i"m not in a place to do this,  that you should get a manual therapy treatment the day before the day of and the day after each irradiation session. And that seemed like a low hanging fruit for prevention fora longitudinal study.

 

Holly McMillan  

Yeah, we're looking, there are several trials happening right now, and I'm so grateful to the teams here. I'm included in that as a speech pathologist, but for my manual therapy, that's why they have me on there. So it's so exciting. We are now looking prospectively at some different things and watching fibrosis over time. So it's very exciting. But what's challenging about that is, as patients go through again, head and neck but as they go through head and neck radiotherapy, usually about week two and a half week three, they don't want touched anymore to that specific area, so we just transition, we move into the trunk or somewhere else that's, you know, safe space to work. But it would be interesting. I bet we would see a change on quality of life metrics. You know, when they fill out patient-reported outcomes, things like that, but it'd be challenging to study the acute change. Maybe we'd see some change after I don't know.

 

Til Luchau  

Yes, there are acute changes. There's your question, Geoff, about the other.

 

Geoffrey Bove  

At the same time, prevention is nine-tenths of the cure. Like I'm having it, doing the therapy to keep everything moving in the first place seems like I said. That's how I always thought as a clinician, anyway, but like, get the person in as soon as they injure themselves, and at least indirectly stimulate the area that was, you know, by stretching or other movement that was affected. That proved true with the repetitive motion rats. When we went in and tried to treat established fibrotic changes, we didn't have any luck. Rest was pretty much just as good. That's the most relevant model I've ever seen for repetitive motion disorders. I kind of extend that into this realm, and that's where, honestly, having papers like the one we just published, I can see Holly while you were saying, that's a critical reference to go by, because it introduces this to the people who are making the decisions as to the protocols for future research like as supports it, right? 

 

Til Luchau  

I think that's really important. What you just said that you didn't see the results once the repetitive strain was in a more fibrotic state, but the prevention was the lever you had, and that that's exactly opposite of what I was taught, say as a Rolfer, that we need to wait til it gets we didn't say fibrotic, but til we wait til it's some tissue healing had happened before we could actually have a beneficial effect. And yet, in my 40 years of practice, I think I'm more inclined to go with what you're saying, that we can have so much more effect the earlier we're there. And it depends on maybe how we're thinking about it, how we're touching I mean, so far, we've been talking about like community or movement, as if they're just one thing, or touch, as if it's a single thing, you know, undifferentiated intervention. What? How do you think, based on your guesses or research, we should be thinking about our touch? What kind of touch is helpful?

 

Geoffrey Bove  

A number of years ago, I developed a timeline for healing and when manual therapy for tendons, ligaments, muscles, and when manual therapy is contraindicated, like, where does it turn the switch, just based on data of where it becomes it's not therapeutic yet. One of the books that came out of the Handspring Publishing Group, in which Susan wrote a chapter using this data. But there is a time when you have to let it sit. Not months. Until data shows me otherwise, established fibrosis is going to take a lot to get rid of. Over to Holly.

 

Til Luchau  

That's the timeline question. Sorry, I gotta, I can't. I want Holly's answers. But if it's not months, what is it? How long do we need to think about letting things sit hours, days?

 

Geoffrey Bove  

Post-operative adhesion, hours. Then they're then they're going to get established. 

 

Til Luchau  

Do you remember the name of the book? Or any clues?

 

Geoffrey Bove  

Oh no, no, that was on my papers on rats.  Yeah, on people too.  People are very established and chronic. 

 

Til Luchau  

Yeah, optimal timeline, or touch modalities, anything, anywhere you want to go with that.

 

Holly McMillan  

It's so I think we're asking several different questions at one time. I think not clumping everything together as manual therapy. There's a significant difference, in my opinion, between touch therapy and movement. I think movement sooner than touch. And I think a lot of the radiation oncologists and the surgeons here, again, from a cancer perspective, are going to agree with that. Surgery alone, we're going to intervene. I'm just saying, from sort of our standard of care and what we do surgery alone, we intervene sooner, and it's really dictated by the surgeon. For manual therapy, again, movement post op, Day one, two, if the surgeons clear it, we're moving, you know, exercises, different things, as long as those suture lines are healing and we're not at risk for dehiscence or popping those open. No one likes to go back to the OR early. So surgery, we're a little more aggressive in terms of manipulating the soft tissue weeks, usually four to six weeks before the surgeons are really comfortable. Again, from a cancer surgery perspective, we go slow and steady. Again, we're likely going to see inflammation, lymphedema, before that fibrosis, so we don't need to cause more inflammation by really grinding in there. So we go gently and then for radiation. The timeline, this is a little more tricky. A. Especially considering an oncology background. So depending on the previous disease, if they had extra capsular extension, if it was into their lymphatic system, depending on the disease, I'm a little more cautious of when I start. If this was a large tumor, metastatic, it had busted out of the lymph nodes, there's they're spread until we get confirmation that we're not moving a whole lot of things around that don't need to be moved. Some of those radiation oncologists actually have us wait until their three-month scans post-treatment. They'll have us hold that long, which we respect. You know, they're the oncologist. But if, if the team's feeling good, everything's in the capsules, you know, it's perhaps smaller disease. Patients won't want you really working in that area for about eight weeks after radiation, it takes the long time for the dermis to heal. And again, this is also all dependent on number of radiation, fractions, the dose, all sorts of different things. But usually patients are a little more comfortable us going in about eight weeks after radiotherapy.

 

Til Luchau  

With direct work with the air affected areas. 

 

Holly McMillan  

Gently. And we always start bearing none of this aggressive manual therapy right off the bat. We usually save that for more of the established down the road fibrosis, if we need it,

 

Til Luchau  

Gently being the keyword.

 

Cathy Ryan  

Yeah, because it's really being the key word

 

Holly McMillan  

I get a lot of patients that come in andpretty quick after their treatments, having had some manual therapy, it's aggressive, and they're wondering why there's more inflammation and why the lymphedema is worsening. But again, we as a field just have to consider, what are we treating, and why are we treating it so that we're using the right force, the right placement, those sorts of things.

 

Cathy Ryan  

And Holly, Til knows this about me, but you have just touched on probably one of my rants as a manual therapist about, you know, really understanding what the situation is because my work is post surgical and scar tissue, so what I'm doing post surgically in those early stages, and I'm talking more specifically about nononcology surgery, just in general surgery, what I'm doing in those early stages is very different than what I'm doing three months out, you know, because and I still hear from surgeons sending me someone who they perceive needs their scar tissue broken up and Til knows, I lose my mind when I hear that phrase, you know, a month out from surgery, because they're not meeting the range of motion markers, and I'm like, there's no scar tissue that has formed yet because we haven't started into the remodeling stage. So really, your range of motion deficit. They're probably due to a high volume of fluid and it contains space. So when we talk about manual therapy and post-surgical work, I think we really have to be specific about what we're actually doing with our hands. So for me, you know, post-surgically I'm I often work with people a day out, two days out, but really the focus is on the lymphatic system and how I can use my hands to help calm or sedate the autonomic nervous system. That's what my work is. For the first two to three weeks, there's no real mobilization of tissue happening to any great degree until we get further out. So thank you for speaking to that, because that's my drum that I like to get.

 

Holly McMillan  

I couldn't agree more. The other, the other somewhat frustrating referral, is when they do say, you know, we've got excess fluid, but it's, you know, post op day one, post op day two. Edema plays a role. And right? The question is, when does edema become lymphedema? Great question. There's no consensus in the literature, right? So if we remove all of the protective edema, then we also run into trouble. So moving that fluid, but so gently, and I don't need to move all of it at one time. So it's, I couldn't agree with you more. It's, it's the right treatment at the right time.

 

Til Luchau  

You're describing such an important concept to me, which is how I think about what I'm touching, and I'm going to work on somebody really differently if I think they're beef jerky as I actually, I love that. I love that analogy, because if I if it is, if I'm thinking about it as beef jerky, I'm going to want to tenderize it perhaps, or something, or so do something that may or may not be helpful, even later in the stages, even later in the process.

 

Geoffrey Bove  

I'd also like to point out that none of you could go to school to learn what you're doing. There's no program, is there? I mean, it's not a massage therapy program, it's not a Rolfing program, it's not a pathologist program. It's up to the practitioners to develop programs, but it's a big mixed bag out there.

 

Holly McMillan  

Yeah, I sort of fight that quite a bit. People are asking, What continuing ed can I go to? And that's just one of the worst questions. This is not a two-day course. You turn around and you're an expert. And I struggle with that even here in my institution, it's an apprenticeship. You know, everyone's got a beautiful foundation, and you can just build on. Look, we have a completely mixed bag of foundations on this call. And I love that. I love that we all took a different route to get exactly where we are right now. I think that's a beautiful thing in the massage therapy world. I love that. But when we hone in and go in on something so deeply, I really think it sort of turns into an apprenticeship, and we sort of rely on each other, and that's why it's so important to get data out there, but not overgeneralizing that data. And it's it's difficult to sell that also in a in the healthcare model that we have to people who don't understand those sort of manual therapy needs that are unique, there's no standard operating procedure on how to do this.

 

Til Luchau  

Well, thanks for being part of my personal program in this inquiry. That's what this is for me. This is my rant through these questions and trying to puzzle them out for myself, partly so that I can use them for myself, but then share them with others, perhaps. Cathy, what else do we want to ask before we let these amazing people go,

 

Cathy Ryan  

Oh, I mean, there's just, you know, I just want to acknowledge, you know, I think that's a really important point that you made, Geoff, and certainly you have been one of those key individuals for me and the work that you've done, you know, collaborative, collaboratively with others, that has been part of my apprenticeship and and internship and developing thinking about what I'm actually doing. So I just wanted to first of all say thank you both for such a rich piece of work, you know. And there's so many pieces to this that just kind of my brain is like, Oh, now we can look, you know, we need somebody to look at this, and we need to look at that. So I really I just wanted to thank you for what you've done and what you've contributed.

 

Geoffrey Bove  

Appreciate being appreciated. 

 

Holly McMillan  

I was so excited when I saw the invite. I was like, Oh, I love, we love talking about this. This is awesome.

 

Til Luchau  

It's great. Well, what do you each want to leave us with a key thought. I hate, by the way, I hate the one important thing idea, but still, what's the closing or what you want ringing in our ears as we end our conversation,

 

Geoffrey Bove  

I always say the same thing. Keep doing what you're doing and leave the mechanisms to the scientists, which means don't make stuff up.

 

Holly McMillan  

Oh, I would actually have to say, keep seeking the apprenticeships. They're out there. People, in especially in the massage therapy worlds, love collaboration. Stop making things up, because the information is there. We just have to find it. And sometimes we have to borrow from other disciplines, which, you know, I'm guilty of, and I sort of love that. I love borrowing from what I'm doing now and pulling it into the manual therapy world. We are doing some amazing things. I think we just need to keep researching and figuring out what we're doing.

 

Geoffrey Bove  

So Holly, should listeners feel free to call you for an apprenticeship?

 

Holly McMillan  

I love apprenticeships, and I to be honest, if I had my optimal timeline, it's I'm going to quote you, Geoff, nine months to never. I think touch is a skill, and it doesn't happen overnight, and it takes a long time, but the gratitude for it, I just it's just one of my favorite things.

 

Geoffrey Bove  

Holly and I were talking about this, about developing like, oh, just show me how to show someone else how to do that. She asked me how long I thought it would take, and I said, nine months to never.

 

Cathy Ryan  

Holly. I'm not getting any younger. So can you hurry up with the apprenticeship please?

 

Holly McMillan  

Oh, I did. I just put a link in the chat. I did. I'm saying, like, no protocols, none of that. But we did publish. So we did. We did a trial here for manual therapy for fibrosis, for head and neck, and we've just published through the results this year. They're fantastic. So take a good read, and then we published the protocol ahead of time that I was going to use. I made it. I developed a protocol to share with everyone, and I made it. I defined enough things, but still allowed people don't fit in boxes. It allows practitioners to implement how they need to. So we published the protocol in 2021, and then the results just came out last year too. So there are, there are more resources out there.

 

Til Luchau  

We'll summarize those in the show notes too. Thank you. For these links, and we'll and we'll put whatever contact information you two want to share in there as well, or where you want to point us. We'll get make sure that's all in the show notes. And I just, again, I want to thank you both for inspiring me, but also for helping me trust what I do, and for helping emphasize that. And you've helped me be a lot more comfortable with what I don't know, and that's helpful as well. Cathy Ryan, thanks for being my cohost today. That was so fun.

 

Cathy Ryan  

Hey. Thank you so much. It's such a pleasure to be here with all of you. I appreciate it.

 

Til Luchau  

Holly, thanks for joining us and taking time from your busy day to come share your wisdom with us. Dr Bove, thank you so much for making the time. 

 

Geoffrey Bove  

My pleasure.  And now, can I tell you something else? Sure, it's just she's being like, overtly humble. She works in it, like in open surgical fields.  No one else does that!

 

Holly McMillan  

One of the things that I do here at MD Anderson is I'm a co-director of the Christmas clinic, which sounds like Christmas, but it is not a gift. I mean, can't open your mouth, and that's why you have to come see us. So it's a very about 40% of folks end up with that after head and neck cancer, and it's talk about a game changer. And it's usually, usually,not always, but due to radiation fibrosis, and it just locks up everything. And there are very traditional ways of treating it, but we are sort of breaking down those barriers. Because again, my colleague and my partner in crime is an oral oncologist, so we look at everything very differently, and we love to work together. So we do have refractory cases. I do manual therapy every day for these folks. for the really refractory cases, we're having to go to the operating room, so we're doing manual therapy under anesthesia. So sometimes I do it before the surgeons start cutting. Sometimes we can avoid cutting altogether, which is so exciting as a manual therapist to there's just so much gratitude that we, as a profession, you know, are constantly working hard to, I don't say, prove ourselves, but that we can make a real difference for these patients. So if we can avoid cutting altogether, we have avoided free flaps. We've avoided feeding tubes by doing this. So anyway, we can go down. We'll do manipulation. If we can get them open, great. That's where we stop. Sometimes those refractory scar bands in the mouth will have to do like a paper cut. And then I go in and dilate with my hands while they're under anesthesia and out. And then sometimes the surgeons, yes, have to remove part of the face. Everything is open and exposed. And then I'm releasing more tissues manually, just to decrease what we're having to do in the operating room. And then the other is, sometimes they can't even access the tumor, so they ask us to come down, sort of in an urgent case, to either get a biopsy or to resect a tumor. And with manual therapy, we're able to open them enough so that the surgeons can do what they need to do from an oncology standpoint. So it's just, I love it, and it's, it's so exciting as a manual therapist to play such a critical role in oncology care.

 

Cathy Ryan  

Okay, now we have to do another one Til, because I need to pick Holly's brain about, you know, because we talk about the releasing thing, right? And the term, you know, the, you know, beef jerky came up. I know you and I have talked about this, and I said my concept is, you know, my thing is, we're not breaking scar tissue, but potentially it's byproduct collagen, changeable, right? You know? And from my perspective, it's more of a reconstituting the sun-dried tomato.

 

Holly McMillan  

Yeah, it's, it's changing morphology. There's nothing when I say it's just to understand terminology in our community. There's no release. It's changing morphology and cell structure in real time. That's what's actually happening.

 

Til Luchau  

Morphology is, is shape and, okay, sending them for morphology.

 

Holly McMillan  

Yeah, so shape, but it's more of like, tensegrity, like pliability of the tissue. Can we change the shape? and then turn that into motion so they can do their own motion with it? 

 

Cathy Ryan  

I love you, Holly.

 

Geoffrey Bove  

This is the point. All these cases,  like she just said, this, this, and this, and British Medical Journal case studies, the description of what she's called on to do, this is unique, I think. So putting that out there, where other head and neck places know, which a couple might, like she's worked with the people at Vanderbilt, and then developing that into actually seeing what variety of changes are made.  Scar tissue and fibrosis. You know, "what's what there", right? Where's the subset? Where's the Venn diagram on scar tissue adhesion and fibrosis, and which one of those? But seriously, if they're inflamed and there's a nerve around, they're going to get innervated by branches of nociceptors. This was the path that I didn't get to do in my career, that I wanted to do more of. I've shown that ectopic endometrial lesions attract sprouts. Scar tissue can, or sometimes won't. Post-operative abdominal lesions get innervated, and whether they're functionally innervated, or whether there's a stimulus to cause, and I'm saying innervated by nociceptors, All these things are getting innervated, but whether there's an adequate stimulus to evoke it.  This is to me; that was my big question. I almost put another grant application in with the massage therapy foundation for this year and then I just didn't want to at the end. It's just frustrating. It's like with NIH, they're not going to fund this. They didn't want to fund the radiation fibrosis part because they said there's no cancer in it. This is a big frustration for me, because people in Holly's world, people care about being able to eat and swallow without dying. But in most manual therapists' world, it's all about pain. It's rarely or less commonly about function. If I have to go like that, versus that, I can still reach up and get something off the shelf by using my torso or any other way to get it up there, as long as it doesn't hurt. If it hurts, you gotta fix it. And that's where, anyway, it frustrates me that Holly doesn't have, like, an open channel, like Holly's diary.

 

Holly McMillan  

Nobody wants to read my diary.

 

Til Luchau  

I'm so glad to hear about the details of the work you're actually doing in conjunction with surgeons, that's really exciting and unique and promising. All right, I'll read I'm going to thank our sponsors. Books of Discovery has been a part of the massage therapy and bodywork world for over 25 years. Nearly 3000 schools around the globe teach with their textbooks, e-textbooks, and digital resources. Books of Discovery likes to say, "learning adventures start here". You'll find that same spirit here on the Thinking Practitioner podcast, and they're proud to support our work, knowing we share the mission to bring the massage and bodywork community thought-provoking and enlivening content that advances our profession. If you're an instructor in a massage therapy education program, you can request a complimentary copy of their textbooks, and listeners can explore their collection of resources for anatomy, pathology, kinesiology, physics, ethics, and business mastery at booksofdiscovery.com where everybody can save 15% by entering "thinking" at checkout. Stop by our sites for the video, show notes, approved transcripts, and  Whitney's site is academyofclinicalmassage.com. My site advanced-trainings.com. Email us your ideas, your feedback, your thoughts, your complaints, your criticisms, whatever you want to send us info at the thinkingpractitioner.com or look for us on social media under our names. We'd love it if you'd rate us at Apple Podcasts or Spotify, or wherever you listen. So please spread the word. Tell a friend.

 

Geoffrey Bove  

Thanks everybody. 

 

Til Luchau  

Bye, everyone.

 

Cathy Ryan  

Thank you, everyone. Thank you Til. 

 

Holly McMillan  

Thanks.