Authors Janet Penny and Rebecca Sturgeon join the podcast to discuss their new book and how it builds on the work of professional luminaries like Gayle MacDonald and Tracy Walton. We discuss mythbusting massage therapy and cancer care, working as part of an integrative team with other health-care providers, and considerations and treatment approaches. With the chances ever-increasing that all practitioners will work with someone either currently undergoing treatment or having undergone treatment in the past, it’s critical to understand considerations when working with his population and the nuances of pressure, position, duration, and site to ensure client safety.
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0:01:30.1 Darren Buford: Welcome to The ABMP podcast. My name is Darren Buford, and I'm Editor-in-Chief of Massage & Bodywork Magazine and Senior Director of Communications for ABMP.
0:01:38.9 KC: And I'm Kristen Coverly, licensed massage therapist and ABMP's Director of Professional Education.
0:01:44.0 DB: Our guests today are Janet Penny and Rebecca Sturgeon. Janet Penny is a registered massage therapist and has extensive experience working with people living with cancer in both her private practice and at an Integrative Cancer Center in Ontario, Canada. She has developed an approach that addresses the multi-faceted needs of oncology massage clients, including focus on pre and post-surgical treatments, scar tissue, radiation fibrosis and neuropathy. Rebecca sturgeon started her career as a massage therapist in 2008 and began working with oncology patients in 2010. She has worked in clinical and community environments providing massage and manual lymph drainage, she has been a massage therapy educator for the majority of her career, and currently works as the Education Director for Healwell, for more information about them and their new book, "Oncology Massage: An Integrative Approach to Cancer Care", visit handspring.com. Hello, Janet. Hello, Rebecca. Hello, Kristen.
0:02:44.7 Janet Penny: Hello.
0:02:45.7 Rebecca Sturgeon: Hi.
0:02:46.2 KC: Hello and welcome to you both we're so excited to have you here now, obviously, we're gonna talk a lot about oncology massage today, and your exciting new book, "Oncology Massage: An Integrative Approach to Cancer Care". But before we do a deep dive into that topic, let's introduce both of you to our audience, let's get to know a little bit more about you, so each of you please tell us about your background, how you got into massage therapy, and specifically oncology massage.
0:03:12.2 RS: So this is Rebecca. I started massage, it was about my fifth or sixth career, I guess, because I was working in senior care, I was doing marketing for nursing homes and continuing care communities, and realized that what I really wanted to do was to take care of the people, and massage was... Seemed like it would give me the most time with people with the least amount of paper work, [laughter] to be honest. So that's why I went to massage school and I started oncology massage kind of by accident. I had no intention of learning, but I was working at a spa, which I hated, and they had the chance to send some of their therapists to work at a cancer treatment center, and asked who would be interested, and those who would be interested would be trained in oncology massage, and I was like, "It gets me out of the spa, sign me up." And [laughter] then I realized that I love this. I was at the cancer center and I wanted to be there all the time and just learn everything.
0:04:18.5 KC: And Janet, how about you?
0:04:20.6 JP: Yeah, this is Janet. It took me, unfortunately, about seven or eight years to complete my training as a massage therapist. Typically here in Ottawa it takes two to three years, but there were many, many life events that got in the way. So by the time I completed my studies, I really had no idea if I wanted to be a massage therapist. Fortunately, I found out that I loved the work. I started a private practice of my own, and then I noticed an ad for an Integrative Cancer Center here in Ottawa looking for massage therapists. So the night before the interview, I looked up massage and cancer, thinking that I'd take about five minutes to flip through a few things that I could throw into the interview, and it was at that time that I realized that oncology massage was a thing I had never heard of it in all my years of studies and in all the advanced training I'd done after graduating. Never heard of oncology massage. So I went to work there and found that we have, we being massage therapists have an incredible amount to offer to people living with cancer and going through cancer treatments, and that was the beginning of how I got into oncology massage, and that was just seven years ago. So in those seven years, I went from not knowing that oncology massage was a thing, to now being integrated in that world a little bit and hoping that the word gets spread a little bit more in Canada.
0:05:40.4 DB: I think a little bit, maybe a bit of an understatement as we move into talking a little bit about this book that the two of you written together. Now, I know the two of you did not know one another before beginning work, so how did you connect?
0:05:55.5 JP: That's a fortuitous story. I was contacted by Kathy Ryan to see if I might be interested in working on an oncology massage book. She put me in touch with Mary, the publisher at Handspring Publishing, and through a long and circuitous route, Mary said that it was probably gonna be a go ahead for the book, but that there should be a co-author. So again, one thing led to another, and Rebecca popped up and we actually met on Skype, so that shows that it's going back a while 'cause who uses Skype anymore? And we met for the first time on Skype, we talked for maybe an hour and at that point, we decided that we would go ahead and work on the book together, and it wasn't until four or five months later that we actually met in person in Vancouver at a conference.
0:06:45.3 RS: Yeah, and that happens to be the only time we've met in person because our other plans were thwarted by this... This virus thing.
0:06:53.1 KC: Okay. So the two of you met. I know, Janet you said Kathy Ryan threw out a question to you about possibly writing about oncology massage, but let's really talk about the impetus for writing on this topic. In the preface of the book, and within the book, you honor the work of many people including Gayle McDonald, Tracy Walton, Mary Kathleen Rose, Don Nelson, Irene Smith, Deborah Curtis and others. I could go on and on. How does your book build and expand upon their work?
0:07:22.6 RS: It's hard to answer since the book is new, because I think that these things develop over time, and they're like, we've written this thing and we won't really know what it is until it's been out there for a while, but I think that first of all, this, we could not have done this had people not come before us, all of those people and more who I'm sure there are names we're forgetting. I think what we did, and this was like Janet's... This was born in Janet's brain. The idea for it, and the sort of structure of it, and I feel really fortunate that I got to come in and kind of ride on the Canadian coattails [chuckle] and do this. But I think what we have done is have taken what Gayle and Tracy and Deborah and all of these people have started, and what it's built into with what they started, which is a practice that is really integrated into healthcare, and we have pulled that forward and made that part of... A really central part of the book that this is, you're not necessarily... Actually, you're not ever really working in isolation because even if you never speak to them, what you do affects what the oncologist does, what the nurse does, what the social worker does. And I think that we have taken the knowledge and pulled it forward into, okay, so this is how you do this as a team. And also have even widened the lens to look at, this is how this is developing everywhere, which Janet's chapter about oncology massage around the world really spoke to that.
0:09:09.7 JP: Yeah, it's only about 30 years ago that it was believed that providing massage to people living with cancer was not a good idea because of the possibility of contributing to metastasis of the cancer. And it was the work of Gayle McDonald and Tracy Walton and others who really systematically debunked that myth. So although that's going back a long way, there are still many places in the world where that's believed. So our book has built on the work of those women and I think it's taking it or systemizing it, taking it a step further or systemizing it a little bit, so that the information that's out there that we've gathered and made as much as possible, evidence-based, is very easily accessible to the reader, and that can be someone who's just starting out in massage or who has extensive experience but doesn't know that much about working with people with cancer. Also, we really wanted to bring the work of massage therapy into integrative health care and help it find its place in that world so that it's very well established as a modality that's incredible, not only in its safety for people with cancer, but also as a possibility of contributing to their rehabilitation from the incredible range and symptom burden after completing cancer treatments.
0:10:37.0 DB: Janet and Rebecca, can you walk us through... Through the listeners through right now and potential readers through the book, of the organization of the book? How did you decide to structure it?
0:10:45.3 JP: Good question. It really evolved quite naturally, and what we have created is a book where each chapter reflects a critical component of providing massage to people with cancer or who have had cancer. So this ranges from General but important information such as, what is cancer and how does it spread to an in-depth look at biomedical cancer treatments and what considerations must be made in planning and implementing the massage treatments. We also look at the lymphatic system, the therapeutic relationship, and cancer and emotional health. We wanted the reader to be able to quickly access the information, and to this end, we created tables and charts that make this access very streamlined without sacrificing depth or quality of information.
0:11:37.4 KC: And I will echo that, as someone who loves the table and chart embraces them thoroughly, but it really is organized so well. And that actually leads us to our next question. So the content is so beautifully structured and so deep. When you wrote this book and collected all this information, did you have in mind that it was for any massage therapist of any level of experience with oncology massage or for a specific group of massage therapists within the profession, maybe that already have oncology massage training. Who was your ideal reader?
0:12:09.7 RS: There's layers to this. We feel strongly that this book belongs in the library of every massage therapist period, end of. And that being said, so we wrote it in such a way that it's accessible, or we hope that we've written it in such a way that it's accessible for the new... The person who is new to oncology massage and is just learning it, and also the person who's been practicing for however many years and wants to have a good reference in their library to enhance and support their knowledge. I also think that this book belongs in the library of PTs of anyone who works with the body of humans who are going through cancer treatment as a way of getting information, like there's general information about cancer in here and about cancer treatments that's useful for any integrated medical professional. And also as a way of understanding more of massage therapy as a modality and how this can fit in with what you do and to provide better care for humans.
0:13:16.7 JP: I think one thing that was behind my thinking at all times in writing the book was the rates of cancer that most countries now have. So every country is a little bit different. Is it one in two, one in three, one in four people, whatever the statistic is, the number of people getting cancer is growing, and the number of people surviving cancer is growing. Therefore we as massage therapists can expect to work with people who have cancer almost without question. So even for people who are not interested in oncology massage per se, they do need to know some of the basics of safety in working with people who have cancer or who have been through cancer treatment. And an example of this is someone who has been through radiation treatment, which has a really broad and deep effect on the soft tissues, which is what we work with all the time as massage therapists. Someone could come in years after treatment, and I mean, years, it could be three years, it could be 10 years, it could be 20 years. And for example, someone who has had radiation to the chest wall for lung cancer or for breast cancer. They can end up with all kinds of signs and symptoms that are related to the cancer treatment.
0:14:31.8 JP: When the client comes in, they might actually forget that they've been through cancer treatment, that might have an impact on what is being asked by the massage therapist. A client might present with range of motion problems or neuropathy or lymphedema, all kinds of different things, it could be directly caused by the cancer treatment. So every massage therapist needs to know, if not how to treat this, at least how to ask the questions to get to the bottom of what's behind the signs and symptoms, and if they're not comfortable working with it, to be able to refer it to someone who is.
0:15:07.1 KC: Absolutely, and then on the other end of that spectrum too, so you were talking about a client who had cancer previously and then came years later, but also our existing clientele, just by the nature of how human life unfolds, the chances of us having a client who develops cancer or has that diagnosis are high. I think every one of us has had that experience. So also, even if your intent isn't to practice oncology massage, just like you were saying, Janet, to have the information, to recognize the questions you need to ask and the referrals that you may need to make.
0:15:40.7 DB: Let's take a short break to hear a word from our sponsors.
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0:16:21.0 KC: Okay, let's talk a little bit about training. So if we've got someone listening to the podcast, they've read your book, they're now very interested in an oncology massage, what type of training is required to work with this population and to work in a hospital setting, if they're really interested in working in that setting?
0:16:38.8 RS: I have so many opinions about this, as you know, Kristen, being also an education person. You need in-person training, I feel very strongly that you need in-person training, if only for practicing the pressure modulation, the understanding of the Walton pressure scale and what that actually looks and feels like is something that I strongly feel is best done with coaching, in-person training or coaching. While this book gives you extensive information and extensive information that you would get in an in-person class, I think everyone would benefit from some kind of in-person class, and the standard kind of in the US is at least 24-hour class that includes lecture stuff and hands-on time, and part of the hands-on time is a clinic where you work with a cancer patient or with the scenario of a cancer patient to practice the hands-on skills. So those modifications, I think with many things in massage therapy, the modifications that we read about can make a lot of sense in our head, but I don't think we have them until we've kind of been coached through them with our hands.
0:17:56.4 JP: And I think, Rebecca, that really takes an incredible amount of awareness of the therapeutic relationship, which you covered really well in the book, and that's a topic that should never get old because there's simply no way that any of us can ever be perfect at it. It's always a working process.
0:18:15.7 DB: So I wanted to jump ahead a little bit and ask you a question about the intake process. And the reason I'm asking that is because if you haven't been trained in this and a client presents with this during the intake, should you not perform the massage, refer out, get more education before agreeing to the massage for the client? What happens at that point if you're not specifically trained with hands-on work and a client presents during the intake?
0:18:46.0 JP: That is such an important thing. I know the intake form that I'm required to use has a checkbox for cancer, so if people check that... I can't even tell you how many years I worked where I would have taken note of that and not asked a single question about it, not having a clue that there was anything that I needed to know. So, the intake is essential, and it really depends on the client's goals. So if a client comes in and they want a more rehabilitative massage to deal with some of their signs and symptoms from the cancer treatment, that really belongs in the hands of someone who's got formal training and experience, and preferably some mentorship as well, in order to continue learning how to best work with those presentations. I think if a client is looking for a relaxation massage, providing the massage therapist knows enough to offer safe massage to moderate the pressure, to be careful of the site and the duration of the treatment, then most massage therapists should not have a problem working with someone with cancer, again, providing they have that very baseline safety knowledge.
0:19:51.0 RS: Yeah, and that safety knowledge is really... For me, the first thing I think of is the lymphatic system, being also a lymphatic drainage therapist, that if you don't have an understanding of how cancer affects the lymphatic system and what that means for modifying your massage, then you need to refer out, in my opinion. Because the possibility that good intentions with poor application could trigger lymphedema is not just an oopsie, it's a lifelong chronic illness. So that is enough, I think, for me to be really wary of saying that, "Oh yeah, if you sort of know about cancer, you can probably be okay." I would really like people to be trained.
0:20:40.2 DB: Has research in an integrative approach changed massage therapy's acceptance in the oncology field?
0:20:47.7 JP: That is very location-specific, I believe. From what I know of this topic in the States, it's much more advanced than certainly in Canada. And here it's a work in progress, and it is in progress. I often hear from clients that their oncology team suggests that they get a massage, but I also think that the oncology team don't really know exactly how much we can bring to the clients who come for a massage. So the research is important, it's not yet broad enough or deep enough, and the integrative approach is also important. Again, that's a work in progress.
0:21:25.7 RS: I wanna echo that the research is important, and even more important than the research is the person who is presenting the research to the professional that they want to work with. So I think absolutely, we need to be doing more broader research, we need to build that into our profession as to something that we do and something that we understand, but also something that we are able to talk about with other healthcare professionals as a healthcare professional. The places where I have seen massage therapy is really truly integrated into care in a meaningful way, there is... Without exception, there has been a person or people who are really good at communicating and also at communicating in a way that starts with the assumption that I am a massage therapist, I am a healthcare professional, I belong here. So, it is research and the person who is presenting and communicating the research. So it's equally important for us as therapists to step into the shoes of the therapists that we want to be and learn that language and have that confidence and be really clear about, "No, this is how I can benefit your patients who will soon be our patients."
0:22:57.2 JP: That's the collaborative approach. Yeah, very important.
0:23:01.3 KC: You chose to use the term "complementary and integrative modalities" or CIM instead of CAM, "complementary and alternative medicine". Can you tell us more about that?
0:23:12.1 JP: This is a very clear and conscious decision that Rebecca and I discussed, and as I remember it, we're very sure that we wanted to use "complementary and integrative modalities". We wanted to stay away from the suggestion that the work we do and that other integrative practitioners do is alternative. Very few people in this realm that I know of actually provide their services as alternative to biomedical care, and our goal is to work in conjunction with the biomedical practitioners who are offering medical help that eradicates or helps to manage the cancer. And we wanna work integratively with them, with all of these strengths that we bring to that field.
0:23:56.5 KC: Let's talk about massage therapy treatment and techniques. So in the book, you wrote five separate chapters for massage therapy treatments and techniques based on different types of biomedical cancer intervention. So surgery or chemotherapy, etcetera. So, are there any universal considerations for working with this population, or does it vary based on the treatment the client's receiving?
0:24:18.5 RS: Oh yeah, I think there's a lot of universals for working with this population, one of which is just pressure, the idea of if someone is in active cancer treatment that modulate pressure to one or two on the Walton pressure scale is a universal no matter what kind of biomedical treatment they're receiving. Also just an understanding of that treatments have effects on the body that can be short-term, long-term or late, so that your intake needs to consider all of this and you have to be prepared to modify for the rest of this client's time with you or their time receiving massage. I think the through line through all of these, like, we wrote these separate chapters, because the treatments are complicated and what they do to the body is very complicated, these could have been... I remember reading drafts of Janet's chapter on surgery, which I'm looking at right now, and that could have been a whole book, right, Janet?
0:25:23.9 JP: Yes, I hit delete a lot in that last one.
0:25:27.3 RS: There was a lot of kill your darlings in that chapter. [chuckle] So there are separate chapters on the treatments which are each complicated in their own right, but what I'm hoping that people take away is that holistically cancer treatment affects more than the cancer, it affects the entire body, all of the body systems, and that that is a consideration for any type of treatment.
0:25:53.8 JP: Absolutely. You mentioned, Rebecca, the Walton pressure scale, which is easy to find online, and what Tracy has done is actually put images with each of the five different depths of pressure, so that anyone wanting to learn what a pressure one is or a pressure three is, can actually see what a hand looks like on a person's body with that amount of pressure. It's a really practical way of being able to do that. And the four things that we consider mostly are the position, the duration, the site, and as Rebecca mentioned, the pressure. So these four qualities are like a framework that a massage therapist can use when they're working with a client. And it simplifies the approach that we have with the client, and it is simple, massage is simple, biomedical cancer treatments are not simple, but what we offer is very basic. I'm not saying that it doesn't have a huge impact, but it's basic in its application. So for instance, if a client comes in who has had abdominal surgery, we wanna go through the position, the duration, the site, and the pressure that can be used so that they're safe. Well, with a recent incision on their abdomen, obviously they're not gonna be lying prone, they're gonna be lying supine or side lying or even seated.
0:27:10.9 JP: So that's an easy one. We also have to look at the site and where we can work on their body. Again, as an incision is in the early healing stages, we don't wanna be applying any pressure directly to the incision or even in the periphery of the incision, because pulling on the tissues can pull on the incision and perhaps interrupt the healing. So again, it's a very easy decision to make when you think about what's going on in that person's body.
0:27:37.4 DB: Two chapters at the end of the book really popped out to me. We already spoke a little bit before about oncology massage around the world, but another one was the impact of massage on massage therapists. Can you tell us a little bit more about that chapter?
0:27:52.6 RS: So I wrote that chapter. Janet, was kind enough to let me write that chapter. [laughter] And I was so pleased to be writing this chapter and then it was terribly hard to write. From my perspective, this was important, and I think that this was in your original outline, Janet, as well that this was... It's terribly important to include this because this is not work that you... For most of us, it's not work that you just kinda shake it off and go home and it's gone. Any time you are a person whose heart is open and you're in contact with human suffering, that requires some work, some inner work to be able to hold that, and to hold that effectively and work effectively. So the writing of that chapter was really... I was trying to balance two things, I was trying to balance an understanding of the therapeutic relationship that was somewhat academic, not really, but somewhat academic, and also understanding that this is not a book about the therapeutic relationship, there's great books about that. One of which Pam pitches, which I referenced a lot in this book.
0:29:07.0 RS: But also, a more softer, I would guess, understanding of yourself as a human being doing work with other human beings who are suffering and how that affects you as an emotional being. I see and mentor some massage therapists and talk to people and talk to people in this field who are... Get into this rut of, "I'm the strong one, and I'm doing this and I'm helping people and I am fine." And they're not fine. [chuckle] This is where we cause harm, this is where we have the potential to cause harm. Like, if we are not taking the time to look inward and understand our own inner landscape and how that relates to what we're doing, then that is where we become distracted, where we're tired and we make mistakes. Or we skip something that's really important, and that was why I included my story in this chapter, because it really was... It was like after a day, I had a full day of clients and I was sitting at the desk... At my desk at the end of the day, and I had no idea what had happened.
0:30:27.7 RS: It was almost like I had blacked out. So who knows what I did. [chuckle] They all came back, so hopefully it was okay. And I want... I think it's important, especially doing this kind of work, especially when you are face-to-face with the kind of suffering that really can get really intense and frightening, frankly, that it is really important before you get to that point of having a day where you don't know what happened all day, that you have a practice of considering yourself as a human being and how this work is impacting you as a human being.
0:31:05.5 JP: Very well put, Rebecca. If I can add just a little bit, there can also be the narcissism of caring where our self-importance gets bigger and broader and brighter because of what we can bring to our clients, and that's often fed back in their adoration, because we provide so much to them. And we have to be really, really careful to separate that within ourselves and from our clients, so that we know that the work we're doing is our work, and not to get self-aggrandized with it. It is a really important consideration in all caring professions, but particularly in working with people living with cancer, because their highs and their lows are so high and so very low, it would be very easy to get caught up in that with them, and we need to maintain our own integrity so that we can go home at the end of the day and live our lives.
0:32:03.2 KC: Janet and Rebecca, you've both shared such great information with us and our listeners today. What final thought would you like to share with people listening to our podcast today?
0:32:15.3 JP: Not to be afraid to work with people who have cancer, and not to be afraid to say, you don't wanna work with people who have cancer. It's not for everybody. For those who want to, it's an incredible part of our field, and for those who don't, they just need a good resource base out there that they can refer to.
0:32:33.0 RS: Yes, and I would say that you can have all the knowledge and all the training in the world, but the thing that I really want people to understand, that we say it in our trainings a lot, is that the most damage you can ever do to someone is with your mouth. It's not with your hands. So, to really... If this is the work that you wanna do, make sure that you also have your own kind of self-care and contemplative practices in place to support yourself.
0:33:02.9 DB: I wanna thank our guests today, Janet Penny and Rebecca Sturgeon. For more information about them and their new book, "Oncology Massage: An Integrative Approach to Cancer Care", visit handspring.com. Thank you so much for joining us today. This was a really beautiful podcast.
0:33:17.7 JP: Pleasure.
0:33:19.7 RS: Thank you.
0:33:21.0 KC: Thank you both for writing the book and for sharing your time and experience and education with us today.
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