Articles Of The Week May 27, 2018

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Not all of our patients enjoy doing exercise, no matter how much it helps. But what if we could change the way it’s delivered, to get them to adhere to recommendations more? What if we could actually make it fun?

“Making Rehab Fun” – Jon Cain

There were a few questions floating around social media this week on plantar fasciitis. This is a great article outlining five things you can do to help patients with this.

“5 Tips For Better Self Management Of Plantar Fascitis For Athletes” – Ellie Somers

This is essentially a massive list Lars has put together of videos and interviews with some of the worlds leading pain researchers. There is a ton on this list, that could make your knowledge and learning about pain a lot easier.

“Pain Lectures With Pain Experts” – Lars Avemarie

No matter what part of the health industry you work in, there is always room for improvement. This article outlines many things I would never have thought of (but can certainly learn a lot from), and I’m sure it’s applicable no matter what part of healthcare you’re in.

“Making The Fitness Industry A Better Place”– Leigh Peele

We’ve all mismanaged time before and possibly messed up our schedule when booking patients in. As it turns out, one of the things that could prevent this from happening is taking better care of ourselves!

“Time Management And When It Goes Wrong” – Sinead Kelly-Barber

 

A Massage Therapy Discovery

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*This post was written by an RMT who wishes to remain anonymous because it deals with legal issues. Their lawyer has advised them that while it is fine to share the information, to help us all, it is better to stay unidentified due to the legal concerns.  

 

So this is not the deep soul searching, self-reflective, becoming a better person type of discovery that I am talking about but rather an examination for discovery of the legal variety. 

That being said this legal discovery did help me discover that I dislike discoveries. I also discovered that lawyers can be pretty darn nice and helpful…at least the ones I interacted with.

Before I get into the Discovery itself I would like to say; I wish I could give the details as to what occurred but, as recommended by my lawyer, I cannot give any details which may affect client confidentiality. Due to my strong desire not to be sued, there will be no names, specific details, or any information directly related to the treatment. 

If the information was to get out and people began to talk I would then need to hire Jamie “Knuckles” Johnston for his…ahem… “silencing skills” but he is far too busy and his fees, although a great value, can add up quickly. 

What I can say is I have been an RMT for a good number of years, I had treated this patient quite a number of times over a few years, there was a long break between treatments and then there was an MVA followed by several treatments along with some underlying pathological issues on top of the typical MVA injuries.

A Legal Discovery

I think many of us have given a treatment when someone has had difficulty getting off the table, they were sorer afterwards, they were bruised, or perhaps there was a snap, crackle, or pop that occurred. On that fateful day, I gave one of those treatments and this is a bit of the process that followed.

After the treatment when the incident occurred I did a lot of thinking, rethinking, over thinking and then I thought about it some more. After all of the thinking, I felt very confident in the treatment I gave. The patient returned a few more times over the next few weeks and then life goes on and continues.

Fast forward 22 months after the incident. I received a 3rd party notice for Civil Claim from defendants of the MVA.

A claim of negligence:

  • failing to recognize the physical & medical condition of the plaintiff
  • failing to use reasonable care & skill
  • failing to properly examine, investigate, assess, test

*The clinic where I work also named in the lawsuit

I immediately contacted a lawyer, then my insurance company, and so the paper trail began. All of my notes for the treatments from the MVA and previous to the MVA were scanned and emailed.  In the first brief phone conversation with the lawyer, we discussed some of the basics from the treatments. I was told my charting was pretty good which should make things a bit easier. That was the first bit of good news I had received which helped make me slightly less stressed.

FYI: should you ever receive such a notice it states that you must respond within 21 days if you reside in Canada, 35 days if you reside in the U.S. and 49 days if you reside elsewhere.

Approximately 6 weeks after the 3rd party notice, 28 months after the incident, I received another envelope (really starting to develop a phobia of large envelopes at this point). It was a Notice of Civil Claim from my patient. Apparently, this is a normal part of the process that would allow the plaintiff to claim against me, as well as the MVA defendant.

Our Reply was sent a couple of weeks after the 2nd notice, so it seems the time period you must respond by was not quite as much of a “MUST DO” as originally stated. My Lawyer called their Lawyer and told them of our intentions so it was all good.

And now we wait.

During this waiting period, expert witnesses are used by both parties to review my clinic notes. The expert witness used by my Lawyer was of the view that I met the standard of care in the circumstances. Not gonna lie, I was really hoping for more of a statement like “there is absolutely no chance, no way, no how that I could ever in a million years have done anything even remotely wrong,” but I will take what I can get.

42 months after the incident I learned that bad news does not have to come in a large envelope as I received an email that did not make me happy. I received a notice that I have been requested for Discovery in two and a half weeks. There were many emails back & forth to my Lawyer over these next couple weeks as I had many questions while my anxiety grew. Although I am sure panic, stress, irrational thoughts, endless questions and emails are probably fairly normal with this type of procedure I can only imagine what my poor Lawyer must have been thinking about me.

Here are some of the tips that I received from my lawyer:

  • The Supreme Court Civil Rules allow each party an opportunity to question the other parties for up to 7 hours, I anticipate that counsel will likely only take half a day to ask you questions about your knowledge of the treatment that was provided to the plaintiff.
  • Answer the question being asked and not to offer any information. The general rule is that you answer with as little information as possible to address the specific question asked, so it is very important that you understand the question.
  • This is not your opportunity to “make your case” or to convince the other side that you did nothing wrong. An examination for discovery is a hurt not help situation. I cannot use anything that you say at the examination for discovery as evidence, however, the other side can. If we went to trial then we would make sure that you provided a full explanation of your background, training, and involvement with the plaintiff.
  • You cannot be asked about your opinion regarding the plaintiff’s condition or anything else at issue in the litigation. I will be present to ensure that the questions are not objectionable. Some examples of objectionable questions are those that are ambiguous, those that seek your opinion, or those that seek information which is covered by privilege. We can also object on the grounds of relevance, although the scope of what is relevant to discovery is quite broad.
  • If I do object, then I will instruct you not to answer the question and it is very important that you follow my instructions, even if you think the answer to the question might be helpful to our case.
  • The most important advice I can give you is that you listen very closely to the question you are asked and that you answer honestly and accurately (to the best of your ability).

Requests made by Defence Counsel, I needed to provide the following information/documents:

  • Advise as to what continuing education course you last took prior to the incident
  • Provide a copy of any contract that was in place between you and the clinic you work at as of the date of the incident.

Important Advice For Every Massage Therapist

D -Day Arrives – (42 1/2 months )

I met with my Lawyer one hour before Discovery to further discuss, answer questions, and calm my frazzled nerves. I am feeling pretty good, although still quite nervous.

And so it begins.

In the conference room we all gather:  court recorder for transcript & audio recorder, ICBC lawyer for the MVA defendants, Lawyer for another healthcare practitioner, Lawyer for the Plaintiff, and last but not least my Lawyer, and of course myself. I am a little disappointed that not one of them is wearing the white wig you see on Canadian TV shows.

I was questioned only by the one Lawyer.

We went over and briefly discussed EACH and EVERY treatment. There were more specific questions if/when the treatments or any other details changed, and even more discussion/questions for the day of the “incident”. I can say that I did not feel pressured, harassed or intimidated. A couple of the questions did catch me off guard and made me think a bit, but nothing that wasn’t fair. The questioning lasted approximately two hours. At the end of the Discovery, I shook hands with the opposing Lawyers and exchange pleasantries that actually felt pretty genuine. The questioning Lawyer said something along the lines of; “would have been nice to meet under different circumstances.” We left the room but the other 3 Lawyers stayed behind to discuss their next step….that hopefully did not involve me being stepped on.

Thankfully I was able to have a bit of a post-discovery debriefing with my Lawyer. I was told I represented myself and my case well. There were a couple of points that I guess I didn’t pick up on but overall I felt good and I could begin to breathe again. Sadly I had to go back to work at this time even though I would have really liked to go to a pub to celebrate.

49 months after this all began I received an email that made me quite happy, it was the lawyer stating I am to be let out of legal action.  Thankfully the information gathered at my Discovery combined with my patient stating during her Discovery that during the treatment I did not do anything different than previous when “the incident” occurred allowed them to come to the conclusion I was not at fault.

What have I learned from all of this?

  1. Charting is important!!! VERY, VERY important! I was able to easily understand everything in my charts years after the treatments and the Lawyers could also understand them. Very little clarification needed.
  2. Listen to your gut. There were a couple of comments made by my patient in the treatments that immediately followed the incident that I wished I would have charted. I recall thinking that was an odd statement but then failed to put it in my notes. Chart that stuff too!!!!
  3. ALWAYS work within our scope of practice. I cannot even begin to imagine how this could have ended if I had done anything even remotely questionable.
  4. Insurance is a good thing. I know we all complain, at least sometimes, at that time of year when our fees are due. I will never complain again (at least not out loud).
  5. Lawyers are not like they are portrayed on TV….at least not all of them, BUT they are VERY expensive, so please go back and re-read point number four!
  6. Oh yes and one more thing large envelopes are very bad!!!

There are still some unanswered questions for me about this ordeal but it is not very likely that I will ever find the answers. I just have to be happy with the outcome and move on.

58 months later and I just got the official paperwork to say I am in the clear.

Articles Of The Week May 20, 2018

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We’ve highlighted many times how important research is to our profession, and how we need more of it. Well, here are eight medical professionals who specialize in massage research and what they’re focusing on.

“8 Medical Experts Who Specialize In Massage Therapy Research” – Joe Neely

There have been lots of discussions this week on social media about massage therapy and pregnancy (it’s totally fine to use massage therapy during pregnancy). I’ve also heard in the past that some women use acupuncture to not only induce birth but also assist with becoming pregnant. Well, this study shows otherwise.

“Acupuncture Will Not Increase Your Chances Of Pregnancy on IVF, Study Shows” – Caroline Smith & Robert Norman

Many feel threatened by some of the new information coming out in regards to pain science and deem it as a ‘shiny new tool’ and a threat to practice. But this article shows how we need to put our clinical ego aside and embrace this new information.

“Pain Science, An Optional Tool?” – Mark Kargela

Is an interdisciplinary approach necessary for helping patients with chronic pain? Well, there are various factors that can both increase and decrease the success of this approach, and the ultimate goal should be patient improvements.

“Teamwork: Gaps Or Overlaps?” – Bronnie Thompson

Love that this article is coming from an Orthopedic Surgeon. Just because your patients MRI findings showed tears or wear, it doesn’t mean there is actually anything wrong with it, this could be completely normal.

“Shoulder MRI Findings In People With No Shoulder Pain: Are Some Tears ‘Normal'” – Howard J. Lukus

Tissue Loading During Remodelling Phase Of Healing

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Over the past few weeks, we have been going over how to safely load tissues during the acute and sub-acute phases of an injury.

Along with instructions on loading, we have been reviewing what happens during the inflammatory and proliferative phases of healing.

This is all important because it’s crucial a therapist recognize what stage of healing the tissue is at in order to load the tissue safely, recognize when the tissue is taking too long to heal, and refer back to their doctor.

We are going to continue with the topic and look at the remodelling phase of healing, which is a longer, and increased changes occur. It also means we can be more aggressive in the movements we recommend and help our patients take part in. However, there is still a risk of re-injury that we must be mindful of as we progress through the rehab process.

As we have outlined in our past couple of posts on the topic, your clinical judgement and decision making is crucial for success, so we will look at how to implement and understand what’s happening during the remodelling phase with this post. 

Repair And Remodelling 

There are two phases to the remodelling phase; the consolidation, and the maturation stage.

During this consolidation phase, the tissue becomes more fibrous and stronger due to type III collagen becoming type I (due to macrophages breaking the type III collagen tissue down). The body starts to convert the wound into scar tissue and there is a carryover of functions that occurred in the remodelling phase that continues to take place (wound contraction). This lasts for 21-60 days, and scar tissue should stop increasing in size because of the wound contraction.

During the maturation phase takes place from days 60-360.  Collagen structure, arrangement, and turnover continues to occur and is the primary function at this point until (after about four months) the tissue becomes tendon-like, and this can continue for 12-18 months.

But remodelling time has some outside influences that can either hinder or encourage the process. The amount of time immobilized, stress on the area, vascularity, and location of injury can change the amount of time remodelling takes. During the proliferative phase, the fibres were laid down in a random direction, but the injury becomes stronger if the fibres are organized in a parallel direction. This happens due to external forces being applied to the injury site, and there is a window to assist with this remodelling for 10 weeks.

Now, when we talk about external forces, it is quite often promoted that doing massage on the area is an appropriate outside force in order to realign these fibers. However, one study shows that while physical force can alter connective tissue, there is almost no data that shows manual therapy techniques have any real ability to realign fibers. 

But, guess what does? Exercise!

Tissue Loading During Remodelling 

As we mentioned earlier, this is where we can get a bit more aggressive as far as load and movement, but we want to make sure not to overdo it.

But, we do want to start placing force along the lines of stress in order to help with the collagen tissue.

At this point there should be no signs of inflammation and movement should be getting easier. You’ve progressed your patient through some mobility, PROM, and AROM exercises along with some eccentric movements. Now you can start to ramp things up a bit. 

The movements can start to go from isolated, into more multidirectional patterns and movements. We have used the example of an ankle sprain in the past couple of articles, start to think about movements like side lunges to load into the injury site, or some active movements going from side to side cutting in different directions. Use concentric (the muscle shortens) and eccentric (muscle lengthens) movements along with weight-bearing exercises. Some you can even do on your table during the massage, just to get things going. For instance, you could manually resist at the ankle (with the patient prone) while they bend the knee as a hamstring contraction, then resist again as they lower the ankle to the table (if you were rehabbing a hamstring injury).

Hopefully, along the way, you’ve had some good communication with your patient as far as what goals they had in getting back to activities. This is where you can start to build some more active exercises. Have them start to do modifications of those activities.

If the patients activity is as simple as getting a jar out of the cupboard, have them start to practice with and an empty jar for a few repetitions until they have no problem doing it with a heavy full jar.

If your patient is an athlete, get them into modified versions of their activity. Recommend slower speed with a lighter load, until more of each can be tolerated. Once it can be tolerated start including plyometric movements (explosive movement ie: jumping) for example, standing on one leg, crouching down and jumping straight up on that previously injured ankle.

In any case, as more tolerance is attained, increase the repetitions and speed of each movement. But make sure you take the time to educate your patient. Show them how a little pain is okay, but not excessive so they can avoid any possibility of re-injuring the area. Also, whatever exercises you choose, make sure they are important to the person. Choose movements you know they will do, there’s no point in recommending a nice light walk to a crossfitter, or sprints to someone whose goal is to pick up their child pain-free. Make it applicable to each individual and their individual goals. Helping a patient rehab an injury doesn’t have to be complicated, it just takes your clinical knowledge and progressing movement properly, all of which you can do in your treatment room. If exercise prescription isn’t in your scope, AROM and PROM probably are, so there’s no reason you can’t implement various movements into your treatment whether on the table or off of it.

 

 

Articles Of The Week May 13, 2018

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How many times have we heard about the importance of communication with our patients? This post highlights that same importance, but why it’s important during the initial intake to make a great first impression with your patient.

“Reading Your Audience: Determining Your Treatment Approach For Each Individual” – Ryan Darling

With summer coming, so are Ironman competitions. Here’s some great info you can use in practice, or pass on to your patients who are in training for their first, or their tenth Ironman.

“How To Prevent Injury During Ironman Training” – Mike James

More and more it is being recognized that rehab and exercise is a much better choice over surgeries and injections for back pain. This article goes through many of the dangers associated with steroid injections for back pain. Great to share with patients if they are considering having injections done.

“FDA Warns About Dangers Of Epidural Steroid Injections For Back Pain” – USA Health Times

This one is actually a video, but a great watch. Three leading pain researchers answer common questions about pain.

“Pain Scientists Answer Common Questions About Pain” – Lorimer Moseley, David Butler, Tasha Stanton

Sometimes ego can get in our way. We start to think that we are ‘fixing’ people or ‘healing’ people. There can be some serious issues with this line of thinking. This great article points out how this thinking can be harmful to us as a therapist, and how it can be harmful to the patient.

“Magical Thinking” – Rebecca Sturgeon

Where Does The Social Fit In Biopsychosocial?

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BIAS ALERT: I LOVE the biopsychosocial model.

I must tell you my bachelor’s degree is in psychology.  When I started my master’s in physical therapy and we focused on biomedicine, I constantly was screaming “but what about the rest of the patient?!?”

I had been exposed to enough injury through my athletic training degree and personally with my father’s chronic disease to know it wasn’t just about a biologic derangement.  Pain, recovery,  and function are much more complicated than that.

The reality is, this model has been around since 1977 when Dr George Engel published his paper critiquing biomedicine.  The paper considered the patient-clinician relationship, the patient’s perspective of the symptoms, the fact that pain can exist without a biological derangement and how patients are profoundly influenced by the way they are studied.

The last couple decade’s technology has allowed neuroscience to study the brain and give us a new understanding why.  Luckily people treating pain got involved and clinically applied the neuroscience to patient care.  I was thrilled when Adrian Louw, Lorimer Moseley and David Butler started a big push in the physical therapy world to incorporate pain science (therapeutic neuroscience education) to our regular PT interventions.

Traditionally our coursework focus on the bio portion of this model: What tissue issue does the patient have?  More recently many published articles focus on the psychological portion of the model.  How do the patient belief systems, stresses, mental health, and expectations affect their pain?

The focus has not been on the social piece of the model.  Arguably the social piece impacts the psychological.  Patient’s interpersonal relationships can be stressors or helpers in their pain story.  The cultural norms can also affect the patient’s mental health.

Should we use the social part of this model to tap into strengths and facilitate our patient’s recovery?  Is there research behind this? 

Prescribing The Social

I started reflecting on these questions recently.

I currently treat a patient referred for chronic pelvic pain and urgency/frequency with urination.  She is an insulin dependent diabetic, has RA and has had multiple pelvic and abdominal surgeries.  She is married to a professional who travels a lot for work. Travelling with her partner used to be an option, however, with a recent trip coming, was very upset she couldn’t go.

Although there has been an improvement with treatment, and I felt like she could travel with a few modifications for her pelvic/coccyx pain.  After a long discussion I essentially “assigned” her to go on the trip. 

We discussed all sorts of strategies to manage her pain, her urgency, and allow her to enjoy her trip.  She came back a completely different person.  What also amazes me is the exceptional progress she’s made in the last 3 weeks and has even gone on another trip.

This made me think about another patient I had last year.

Their history is way too long but the short version: hysterectomy that led to pelvic pain that led to the doctor telling her “don’t do it if it hurts” which led to self-imposed bed rest for an entire year.  She was so deconditioned by the time I saw her she was wheelchair and housebound.  About 6 months into her treatment, I gave her the HEP (home exercise program)  to have lunch with her friends.  This was an activity she had done at least once a week prior to her surgery 2 years earlier.  Since the surgery, she hadn’t even allowed people to visit her in her home.  We discussed the importance of seeing her friends and how much they cared for her.  It started with her friends bringing her lunch.  Within 2 weeks she was going out to a close restaurant for lunch.

Again, this seemed to be a catalyst for recovery.

So, What Does The Research Say?

First,  the research suggests chronic pain in adults and adolescents negatively affects social relationships.

People with persistent pain have fewer friends, worse peer relationships, hindered ability to take part in social activities and tend to withdraw from social peers.  Adolescents in pain are perceived by their peers to be less likeable and less fun to spend time with.

But does increasing social interaction decrease pain?

Studies suggest that dynamic interaction and social interaction and empathy of others may reduce pain and have a positive effect on coping.  One study published in February 2018 looked at physical social interaction and pain.  Two people held hands while one was administered a painful stimulus.  Both subjects were connected to EMG.  When the two subjects were holding hands, the pain subject reported less pain and their EMG was less active in the correlative centres.

The control was the administration of the stimulus while they were not touching.  This suggests that physical touch and social interaction may change a patient’s pain experience.  It’s important to note, the subject not receiving the pain stimulus had an INCREASE of brain EMG activity and reported empathy for the pain subject.

So what does this mean?

Because the social piece closely ties with the psychological piece, we should look for opportunities to utilize this as a patient strength to facilitate recovery.  However, not all social interactions are good interactions.  We must find out what matters to the patient.  Who do they want to see? What outings matter the most to them? 

Dosing social interactions may be very similar to dosing exercise.

My patient wasn’t ready to ride in a car and go out to a restaurant after almost 2 years of being housebound.  The first graded exposure involved people coming to her and sitting a shorter time.  After that, she was ready to leave the house.

However, some people may need to repeat something like this several times before venturing out of the house.  We may need to brainstorm scenarios and coping strategies to set our patients up for success.  You can’t do this without pain education.  The patient needs to understand soreness doesn’t equal damage.  And just like exercise, we need to follow-up with them to assess tolerance and give them advancement to their program.

Next time you have a patient whose pain is causing isolation, I challenge you to look for opportunities to make social activity part of their home program.  Getting our patients to return to supportive social environments could be an important part of their care.

 

References:

Engel G. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129-136

Engel G. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535-544

Borrell-Carrio F et al.  The Biopsychosocial Model 25 Years Later: Principles, Practice and Scientific Inquiry. An Fam Med. 2004: December 576-582.

Markris U et al. Physical, Emotional and Social Impacts of Restricting Back Pain in Older Adults: A Qualitative Study. Pain Medicine. 2017; 18:1225-1235.

Block P et al. Social Interaction and Pain. Social Science and Medicine. Jan 2018: (196) 47-55

Goldstein P et al. Brain-to-Brain Coupling during Handholding is Associated with Pain Reduction. PNAS March 13, 2018. 115 (11) E2528-E2537

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