Constantly Reproduced Clinical Evidence vs. Acceptable Language in Research Papers

From the Author

This article was inspired by a recent comment from a physician who had read my article and watched my video.

He said:

His comment made me stop and think.

I understand why physicians and researchers often use the word “may.” It reflects caution and acknowledges that scientific conclusions must be supported by sufficient evidence.

This is the issue I want to address in this article.

As I explained in my article five years ago, as an experienced clinician, I faced a professional crisis for the first time in my life. If you have not read it, you are welcome to click this link.

Massage Therapy Demand vs. Client Retention

As I began to understand what was happening and successfully address conditions associated with chronic stress-related disorders, I learned more and more details.

Little by little, as an educator, I began writing about this so-called “unknown condition.” While working with a multidisciplinary medical group, I asked physicians to read my first articles before publication—simply to receive their advice, constructive criticism, and professional perspective.

At the time I am describing, very few people really understood the phenomenon of massive, multisymptom disorders, including symptoms involving brain dysfunction.

In one of my first articles on this subject, I wrote:

By reducing excessive muscular tension, we help restore these physiological processes and support nervous system regulation.

The Physiological Pattern

Increased Muscular and Fascial Tone — Neck / Upper Back

Mechanism

• Chronic activation of the sympathetic nervous system increases baseline motor-neuron excitability, with secondary activation of the HPA axis, supporting and fueling increased resting muscle tone.
• Stress preferentially increases muscular tone in the cervical and upper thoracic musculature.
• Stress increases tonic muscle activity and reduces the capacity for relaxation. Therefore, today we are observing a continuing increase in chronic stress-related disorders.

Sustained Cervical / Fascial Tension — Impaired Venous, Lymphatic, and CSF Drainage

Mechanism

• Cervical muscles, fascia, the thoracic outlet, and the diaphragm mechanically influence:
  • Internal jugular veins
  • Vertebral venous plexus
  • Cervical lymphatic vessels
• Elevated muscular tone can reduce the compliance of these pathways.
• CSF and glymphatic flow depend on pressure gradients and venous outflow.

Key Evidence

• Venous outflow obstruction alter intracranial pressure and CSF dynamics.
• Neck posture and muscle tension can affect jugular venous flow.
• Lymphatic drainage of the brain exits through cervical pathways.

Impaired Drainage, Reduced Cerebral Perfusion, and Metabolic Waste Accumulation

Mechanism

• Cerebral blood flow depends on venous outflow and pressure balance.
• Impaired venous/CSF clearance:
  • Reduce perfusion efficiency
  • Increase interstitial and inflammatory metabolite accumulation
• Glymphatic clearance is sensitive to autonomic tone and sleep quality.

Key Evidence

• Reduced clearance increase neuroinflammatory signaling.
• Impaired glymphatic function has been associated with cognitive symptoms.

Brain Dysfunction — Secondary Autonomic Dysregulation

Mechanism

• Brainstem, limbic, and cortical regions regulate autonomic balance.
• Neuroinflammation and hypoperfusion alter autonomic output.
• This result in:
  • Sympathetic dominance
  • Reduced vagal tone
  • Poor stress recovery

Key Evidence

• Brain inflammation disrupt autonomic signaling.
• Reduced HRV has been linked to cognitive and inflammatory states.

Reducing Muscular/Fascial Tension — Improved Drainage, Perfusion, and Autonomic Balance

Mechanism

• Massage-related reduction of excessive muscular tone:
  • Improve venous compliance
  • Enhance lymphatic and CSF movement
  • Support cerebral perfusion
• Parasympathetic activation can follow sensory and mechanical input.

Key Evidence

• Massage increase parasympathetic activity.
• Massage therapy has been shown to improve regional circulation and autonomic markers.

The Question of “May”

A few physicians were kind enough to read my articles and provide advice and constructive criticism.

Their advice was essentially this:

For example, regarding my statement:

The physicians advised me to write:

They explained that “may” would sound safer and more scientific.

Honestly, at the time, I did not know how to digest this advice. Nevertheless, in some of my following articles, sometimes to my regret, I used the word “may.”

Clinical Practice vs. Research Language

Let’s remember that the practice of medical massage is based on specific clinically oriented science for the clinical application of medical massage.

Anatomy is a very old and well-established discipline in biomedical science. The first widely recognized modern anatomical textbook, De Humani Corporis Fabrica by Andreas Vesalius, was published in 1543.

The textbook of medical physiology by Professor Arthur C. Guyton, Textbook of Medical Physiology, was first published in 1956 and has subsequently been revised extensively over many editions.

Having said that, consider what happened, for example, in the field of neurology.

For much of the 20th century, Alzheimer’s disease was primarily understood as a progressive, largely irreversible neurodegenerative disorder. When Alzheimer’s occurred repeatedly within families, the familial pattern encouraged the idea that heredity was a major determinant.

The medication story also illustrates how scientific understanding can change.

For decades, medications such as donepezil, rivastigmine, galantamine, and memantine primarily treated symptoms or temporarily supported cognitive function; they did not fundamentally alter the underlying disease process.

More recently, the field moved toward disease-modifying treatments, particularly treatments targeting amyloid pathology.

• Lecanemab (Leqembi) received traditional FDA approval in 2023 after confirmation of clinical benefit.
• Donanemab (Kisunla) was approved in 2024 for patients with early Alzheimer’s disease.

In the field of massage therapy, scientists have developed more than 60 medical massage protocols specifically for clinical use in the treatment of different disorders.

Because the physiological effects of massage are well understood, and because each patient undergoes a soft-tissue examination before treatment, these protocols are designed for specific clinical applications.

In my experience, I do not remember a time when an established protocol had to be completely changed or even significantly adjusted because the underlying physiological effects of massage had suddenly changed.

Conclusion

I can understand that misperceptions, mistakes in interpreting research conclusions, and even mistakes involving effective medication prescriptions can occur. Most likely, in biomedical research, this phenomenon is unavoidable.

Generally speaking, medical science continues to improve our understanding of diseases and how that knowledge can be applied to treatment.

But the situation with chronic stress-related disorders is, in my opinion, more than alarming.

And yes, I understand that in scientific writing, “may” is often necessary. But there is a difference between making a theoretical or preliminary claim and describing an outcome that I have repeatedly observed and reproduced in clinical practice.

For example, if I say that a particular intervention may produce an outcome, I am describing a possibility that has not yet been sufficiently established.

The same distinction applies to the mechanisms I have described throughout my articles.

I am not presenting these observations as a replacement for biomedical research. I am describing what I have repeatedly observed as a clinician and educator over many years.

And this is exactly why I believe the discussion of chronic stress-related disorders deserves much greater attention.

I strongly recommend reading the following article carefully. My goal is not simply to describe symptoms, but to help people understand what they can and should do for themselves.

The Hidden Healthcare Crisis: Why the General Population Must Learn Self-Treatment Strategies — Part I

The symptoms may be unpleasant and disabling. But permanent brain dysfunction would be a tragedy.

Massage therapy, when appropriately performed and when contraindications are respected, is generally considered a low-risk approach.

I cannot guarantee an outcome for every individual. But after decades of clinical practice, I believe that appropriately instructed self-care and professional massage can have an important place as integrative strategies for people dealing with chronic stress-related symptoms.

What I am uncomfortable with is looking back at some of my own articles and seeing that I changed statements describing repeatedly observed clinical outcomes into statements using “may” simply because I was advised that this was the safer language for scientific writing.