Ep 283 – Heart Rate Variability and Biometric Devices: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

An image of a woman looking down towards her smartwatch showing her heart rate.

A client with a complex health situation wants massage to improve their heart rate variability, and they are prepared to track results with a smartwatch and a smart ring.

What does this mean?

Why does HRV matter?

Are there downsides to biometric tracking related to massage?

These questions are answered, but more are raised in this episode of I Have a Client Who . . .


Pocket Pathology: https://www.abmp.com/abmp-pocket-pathology-app

My video on HRV: Heart Rate Variability (2020). Available at: https://www.youtube.com/watch?v=c-NWz8Kbbbk (Accessed: 28 September 2022).

Heart Rate Variability (HRV): What It Is and How You Can Track It (no date) Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/symptoms/21773-heart-rate-variability-hrv (Accessed: 28 September 2022).

*Privacy Not Included review: Oura Ring (no date) Mozilla Foundation. Available at: https://foundation.mozilla.org/en/privacynotincluded/oura-ring/ (Accessed: 28 September 2022).

Singh, N. et al. (2018) ‘Heart Rate Variability: An Old Metric with New Meaning in the Era of using mHealth Technologies for Health and Exercise Training Guidance. Part One: Physiology and Methods’, Arrhythmia & Electrophysiology Review, 7(3), pp. 193–198. Available at: https://doi.org/10.15420/aer.2018.27.2.

The New York Times (2021) ‘The Oura Ring Is a $300 Sleep Tracker That Provides Tons of Data. But Is It Worth It?’, 27 July. Available at: https://www.nytimes.com/wirecutter/reviews/oura-ring-sleep-tracker/ (Accessed: 28 September 2022).

Author Images: 
Ruth Werner, author of A Massage Therapist's Guide to Pathology.
Ruth Werner's logo, blue R and W interlinked.
Author Bio: 

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP’s partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner’s books are available at www.booksofdiscovery.com. More information about her is available at www.ruthwerner.com.   



About Til Luchau and Advanced-Trainings.com:  

As a Certified Advanced Rolfer™, Til was on the faculty of the Dr. Ida Rolf Institute® for 20 years, where he served as Coordinator and Faculty Chair of the Foundations of Rolfing Structural Integration program. The author of the Advanced Myofascial Techniques textbook series (which has been translated into 6 languages), his regular Myofascial Techniques and Somatic Edge columns have been featured in Massage & Bodywork magazine since 2009, and (along with Whitney Lowe) he co-hosts the popular Thinking Practitioner Podcast. He is the Director of Advanced-Trainings.com which since 1985 has offered short, credit-approved professional trainings and certification for manual therapists of all types, in person and online.

Website: Advanced-Trainings.com

Email: info@advanced-trainings.com

Facebook:  facebook.com/Advanced.Trainings1/

Instagram: instagram.com/tilluchau

YouTube: youtube.com/user/AdvancedTrainings

Full Transcript: 

0:00:00.2 Speaker 1: Join Toluca on a floating raft house in Thailand, surrounded by a jungle eco-preserve for 10 days of myofascial bodywork, Zogo movement and restorative learning starting February 20th, 2023 or join Till for some powerful at home learning with his monthly subscription, giving you unlimited access to more than 35 curated classes including advanced myofascial techniques, movement for body workers, fell in Christ and more, it's super affordable and you can pause or cancel at any time. Sign up now at advancedtrainings.com. 


0:00:42.0 Ruth Werner: Hey, I Have a Client Who listeners, did you know I have a growing library of NCB approved one-hour online self-paced continuing education courses that you can do any time, anywhere. Well, now you know. Current classes include, What's next covid-19 updates for massage therapists and A Massage Therapists Introduction to pharmacology Part 1 and brand new, A Massage Therapist's Introduction to pharmacology Part 2, classes are $20 each and they confer one hour of continuing education credit. Wanna know more? Visit my website at ruthwerner.com and check it out. Be sure to sign up for my mailing list so you'll never miss a new class. 




0:01:36.3 RW: Hi, and welcome to, I Have a Client Who pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. 


0:01:49.9 RW: I'm Ruth Werner, author of A Massage Therapist Guide to Pathology. And I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer, even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice, and sometimes as we have all learned, that is harder than it looks. Today's story comes from a friend of mine who loves to collect data about her clients and about her client who also loves to collect data, and together they made a surprising discovery about how massage seemed to be affecting this person's function. And you know me, I'm always scanning the environment for potential case reports, and this one seems like it could be a good one, and it goes like this. 


0:02:55.4 RW: I have a complex client who sees a wide variety of practitioners, a regular doctor, an integrative holistic medicine doc, a sleep specialist, a Craniosacral therapist, and a pelvic floor specialist, and then little old me, because they're a bit stressed. After a single session of my more problem-solving approach to massage, they decided they wanted something more fundamentally relaxing. 


0:03:21.4 RW: Although there are a variety of things going on in their overall health, the thing they wanted to improve when it comes to me is stress and sleep disruption. So I found a new album of relaxing binaural tracks, paired down the bells and whistles in my session, and I leaned into some silent relaxing flow. This has never been an area of specialty for me, in part because I've always wanted data and to be able to track progress. Luckily for me, the client came ready with a solution for this, the minutiae of data being offered by their Oura ring and a smart watch, specifically by tracking their heart rate variability, they could see that they were much more likely to get better night time scores, showing better deep sleep and productive rest in the days after receiving massage, if all other factors like doctors and treatments and so on were the same or influx. 


0:04:21.6 RW: The massage seemed most linked to HRV being more restful at night, where the baseline prior to seeing me had really been the reverse with daytime HRV being more relaxed and none of it being in a consistently healthy range prior to starting regular, weekly or bi-monthly treatments. Now the client is getting consistently more favorable HRV readings for several days post-massage and has less sleep disruption and has been able to eliminate some other interventions such as medication to get to or stay asleep. I did mention to this client that I would like to submit the topic of heart rate variability results and some things about their massage experience to you and your podcast and got enthusiastic assent to do so. 


0:05:09.5 RW: Wow, what an amazing world we live in. I'm gonna unpack this in a minute, but first, here is my initial response. This is fascinating. I did a video on HRV once. Let me see if I can find a link, and then I found it and I will put it also in our show notes for today. My question is, does knowing their HRV is increased with massage make them feel better? To me, this gets to the difference between clinical and functional goals. Increasing HRV is a clinical goal, feeling rested when they wake up in the morning is a functional goal, if your client is good with understanding that both of these can be beneficial, then why not use the data you can collect for their best outcomes, I think it's probably great if your clients like the idea. Okay, first of all, let's talk about HRV, heart rate variability. 


0:06:05.7 RW: You are aware, of course, that healthy hearts beat in a steady, reliable rhythm like this, but you may not be aware that that rhythm is not as steady as you might think, our hearts are constantly making tiny adjustments and changes in rhythm that reflect moment to moment responses to changes in our environment or emotional reactions or other stimuli, and it turns out that within limits, the more variable that rhythm is, and really we're talking about micro-micro seconds here, then the healthier, our cardiovascular and nervous system partnership is. When we're stressed the rhythm of our heartbeat gets much more rigid and unchanging the variability diminishes. When we're relaxed, the rhythm of our heartbeat becomes more flexible, more responsive, more resilient. 


0:07:02.6 RW: This observation has led to measuring heart rate variability as a validated way to quantify a physical experience of stress, and there is an association between low heart rate variability, that's that rigid, unchanging heart rhythm and an increased risk of health problems and not just issues related to heart disease, but all kinds of things. Okay, so HRV is one potential way to see how massage therapy might affect our physiology. Until recently, it's been the kind of measurement you really can only get in special clinical settings, but now with these biometric devices like smart watches and Oura rings, and I confess, I had to look this up, I had never heard of Oura rings before, we can gather all kinds of data on things like heart rate and HRV and breathing rate, and skin temperature and lots more. 


0:08:00.9 RW: So that's what they did, this massage therapist and their client, they tracked daytime and nighttime heart rate variability, the client's goal was to increase their HRV especially at night, so they could sleep better. And that appears to have worked. Remember our contributor said specifically by tracking their heart rate variability, they could see they were much more likely to get better nighttime HRV scores, showing deep sleep and productive rest in the days after receiving massage. The massage seemed most linked to HRV being more restful at night, where the baseline prior to seeing me had really been the reverse with daytime HRV being more relaxed and none of it being in a consistently healthy range before starting regular, weekly or bi-monthly massage treatments. 


0:08:52.8 RW: Now, the client is getting consistently more favorable HRV readings for several days post-massage and has less sleep disruption and has been able to eliminate some other interventions such as medication to get to, or stay asleep. Cool, right. I have a couple of reactions to this, one, really enthusiastic one, less so, part of me says, Yeah, man, the client has less sleep disruptions and has been able to take less medication to get to or stay asleep, and that sounds like a great big win. Write up that case report, baby. Because this is good data. And part of me says, let's not lose sight of the fact that the measurements here are just measurements, they aren't the client. I get a little frustrated when I see any kind of healthcare provider seeming to be more interested in treating test results than in treating the person. Am I interested to see this client's HRV improve? Sure, but I'm way more interested in seeing if the client feels like they're getting better sleep. Part of my reticence about encouraging all of our clients to get smart watches and Oura rings is this, what if other things come up and their HRV doesn't move in the direction they want?  


0:10:14.6 RW: Will they give up and ignore any functional gains 'cause their numbers weren't right as I did with that stupid step counter watch thing? Well, okay, actually, I put my smart watch through the laundry, so maybe that's not a great analogy, but still... And this also brings up some interesting questions about giving clients health-related advice. This contributor also offered this, they said, "I wanted your thoughts or remarks about the use of smart watches or bio-tracking devices to help track client outcomes." It's not something I would have come to without this client suggestion and avalanche of data, frankly, but since then, I have made suggestions to other clients that they utilize these devices that they already own to try to parse out whether those feelings of tightness in the chest might be heartburn or anxiety or A-fib, for example, and it has made me better able to refer out when appropriate. I have a few things I wanna address here. I like that this massage therapist isn't suggesting a client go out and buy a new piece of equipment that they use what they already own. As for parsing out the tightness in their chest, or shortness of breath or whatever other kinds of experiences they have. 


0:11:29.6 RW: Yeah, that makes me a little nervous, but conceivably, getting information from your biometric device could help identify something urgent like A-fib or atrial fibrillation, and this make sense for someone who's dealing with long-term low-grade symptoms, not something new or extreme, of course. And if we can use data from their device to make good recommendations for referring out or for recommending that client's consult their primary care providers, that seems like a good outcome. There are a couple of other things to consider though, before jumping on the biometric device band wagon. One, is accuracy. The client in our story was using an Oura ring and a smart watch. To me, this seems like a decent calibration strategy, but if we aren't sure the device is reliable, then we can't make decisions based on whatever information it provides, so we wanna know that this device has been calibrated correctly, and anyway, should we be making massage decisions based on the readings from a smart watch? This brings me back to the treat the person, not the test result point of view. And secondly, for me, there is an important question about data privacy, smartwatch and data collection, ring manufacturers have all kinds of public statements about not sharing any individual's information, but if you and your client are concerned about such things, this decision has to fit within your own comfort level, of course. 


0:13:00.4 RW: So my take away from this contributor story is this, fantastic, you set some goals, you gathered some baseline information, you did your sessions and tracked what happened, and you saw some measurable changes in HRV, but also in your client's experience of getting to and staying asleep, and that's a case report right there. And frankly, the research on massage and sleep is not as rich as you think it would be, so information like this could provoke more interest in this important topic. That said, the biometric tracking band-wagon is not for everyone, and I urge this contributor and all massage therapists to stay focused on the client, not on the numbers, the numbers are a tool, not an outcome. I hope that makes some sense, and I am interested to hear what you think about using devices to track real-time changes with massage. I think it has a lot of potential to be helpful, but also to be unhelpful. Can we create a situation that maximizes benefits and minimizes risks? Good question. That is up to you. 


0:14:10.1 RW: Hey everybody, thanks for listening to, I Have a Client Who, Pathology conversations with Ruth Werner. Remember, you can send me your, I Have a Client Who stories to, Ihaveaclientwho@abmp.com. That's, Ihaveaclientwho, all one word, all lowercase, @abmp.com. I can't wait to see what you send me and I'll see you next time.


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