Articles Of The Week March 18, 2018

Do you focus on a biomechanical style of treatment, or do you prefer to focus on pain science? Not sure what the difference is, or confused how to integrate both? Well, this post should help out with that. It’s only the first one in a series, but it’s a good way to get started if you’re not sure about those topics.

“Biomechanics Vs Pain Science: Bridging The Clinical Divide” – Curtis Tait

They say exercise is medicine. In clinical studies, it has been shown that regular aerobic exercise is as effective as anti-depressants for reducing symptoms of mild to moderate depression. Unfortunately in our society inactivity is the norm, so exercise isn’t used as much.

“Running From The Pain”  – Scott Douglas

More about exercise! Intense exercise can cause dramatic improvements in heart health, even at older ages.

“Hearts Get ‘Younger’, Even At Middle Age With Exercise” – Patti Neighmond

There are four critical questions we ask ourselves which make us feel like we are connected to our communities. It turns out taking one extra second to be connected with others can actually improve the quality of that presence. 

“How To Change Your Life In One Second Flat” – Katherine Schafler

There is a subheading in this article that is truly amazing. “The best workout isn’t always the most extreme one. The best on is the one you enjoy.” I’d say the same would apply to exercises you recommend to patients for homecare.

“Whatever Happened To Moderate Fitness?” – Colleen Stinchcombe

It’s Time To Start Building Your Tribe

“If you think leadership is only for other people, you’re wrong. We need YOU to lead us” – Seth Godin

We live in a time where information and innovation are at our fingertips.

Yet, within our profession, we still sit steeped in outdated information and a lack of updated education for our students coming out of college.

But there is a reason for that. It’s easier!

It’s easier to teach people to be sheep that follow along, rather than challenge the status quo. It’s easier to go decades without updating curriculum, while still teaching old information with confidence, and failing students for questioning otherwise.

What’s also easier is to just follow rather than question. And there’s nothing wrong with that, it’s human nature. Why would we question what educational institutions and regulatory bodies say?

Well, we have to in order to grow. 

This is where you come in. Your community needs you, and our profession needs you. We need you to embrace the tension between what you were taught and what new information says (it’s literally at your fingertips). 

If you don’t think you can do something like this, you’re wrong. There is a leader in all of us, sometimes we just need to learn how to bring it out.

So with that, here are some examples of therapists doing great things in their communities both locally and professionally to bring about change and make a difference.

Four Therapists Building Their Tribe

Rajam Roose

She was not a professional event organizer and had never taken on the task of organizing a conference while running her massage therapy practice. But, in January of 2014, after organizing a combination CEU course with Barrett Dorko, and Diane Jacobs, a light bulb went off. Rajam would go on to create the “San Diego Pain Summit,” which would officially start in 2015.

Rajam reached out to presenters and would organize them coming to one place to present on pain science, which would, in turn, start to influence our industry (this is where she started building her tribe). Many don’t know that she does everything for the conference herself, from managing the website, organizing speakers, hiring video, negotiating venues, and organizing volunteers (just to name a few of the necessary tasks), which has led her down a road into being more of an educator than strictly a Massage Therapist. Not only has this opportunity led into more business developments, it has also developed quality relationships with therapists from around the world, and gives her a feeling like she is serving our Massage Therapy community by helping therapists change how their patients pain is managed.

All too often many of us sit back because of “imposter syndrome” for fear that we can’t do something, or don’t know enough. So, I have to include this quote from Rajam:

I also have a bit of a rebellious personality. From prior life experiences, I’ve learned that we can do anything we set our minds to. I enjoy shaking up the status quo. For example, most people may be shocked to learn that I have very little formal education. I only have 2 years of high school and 1 year of a college education under my belt. I hope people will read this here, learn what I have and am doing, and be inspired to know they can do anything if they want.

Sarah Haag

Six years ago sitting on a train platform in Milan, Sarah was talking to her friend Sandy Hilton discussing how much better the world would be if healthcare was better, simpler, more efficient, and more scientific. They shared common goals and dreams when it came to patient care, so they started Entropy Physiotherapy.

Part of the goal was to host courses in their clinic where they and other therapists could learn from the best in the world, not just the best who happened to be closest to them when they needed a course. When picking speakers, they chose the ones that would challenge them, make them a little uncomfortable, and start discussions that would make practitioners better.

They wanted course offerings that left you energized from new ideas, collaborations, and developed new relationships. They reached out and started to find those exact kind of instructors, and also took a different approach in dealing with them. As a team, Sarah and Sandy would be very mindful of treating speakers well and not gouging them, or the course participants. While they didn’t have the intention of building a tribe, it has happened in the ensuing years. The people they’ve met at courses and conferences have become their tribe, which is something they’re only too happy to be a part of, not one they feel like they are leading (and they’re having a lot of fun doing it).

Brian Rutledge

“Necessity is the mother of invention” – Plato

After years of co-owning a successful group practice, Brian decided to go out on his own. 

He thought he had all the right skills and all the right plans, but he had no idea what was in store. While solo practice hasn’t exactly been great for his wallet, there have been other opportunities develop.

Having extra time, he has been able to learn about himself, while growing and refining his vision and purpose. This has given Brian the time to start teaching (even though advocating for up-to-date science can be an uphill battle and one that isn’t exactly rewarded), to engage with other professionals, and to pursue other interests. Some of those interests have led into building a community locally and online, as well as creating more educational content, to put on more courses locally for other practitioners.

Those interests have helped shape his practice and resulted in more enjoyment in what he does, a better relationship with patients, and the ability to refine crucial communication skills which have brought about a greater connection with people.

Two years of personal and professional development haven’t been easy, but building his tribe has been priceless.

Jenn Sharman

In October 2017 Jenn teamed up with an old classmate to open a new clinic.

They had a strong desire to create a clinic grounded in evidence-based approaches to treatment and patient care within the biopsychosocial lens while staying within their scope of practice as RMT’s. 

Knowing there was new research detailing advances in pain science for patient care, that wasn’t taught in school, they wanted to discuss these developments with other colleagues. They decided to create a monthly ‘pain science discussion group’ at their clinic. So far the response has been far more enthusiastic than expected (especially since it’s on Friday nights).

So far, three meetings in, the discussions have been on topics like “reconceptualizing pain, enhancing placebo-minimizing nocebo, and shifting from structural pathological to biopsychosocial.” 

Their group has a wide range of people from new grads to seasoned veterans who are all helping in their own way. While this represents an exciting time for manual therapy, it has brought about concerns. If students are not taught up to date information on pain it is doing a disservice to the public, which highlights how we need to come together as a profession to understand current best practices and let go of approaches or theories not supported by scientific evidence.

In creating this group, there is an attempt to share relevant research and get conversations started based on where to look for valid research and information.

This is another spot where I will include a quote:

it’s really exciting to see the level of interest amongst the community of RMTs. Once you get a group of passionate people talking in the same room, new connections and opportunities to create change will grow from there. I’m really excited to be a part of the conversations that need to happen to move our profession forward so that we can provide effective, compassionate and evidence-informed patient care.

Photo by: rawpixel

Now It’s Your Turn

I hope some of those examples will resonate with you as a therapist. 

It doesn’t take a fancy education, huge credentials, or a big financial backing to start making a difference. It just takes some motivation and the desire to create change. 

Part of what needs to be done is changing the effect some of the “modality guru’s” have within the manual therapy professions, they have made their own tribes. But those people are not where we are going to make change. Growth happens when we reach out to those who aren’t committed members of a tribe, but rather those who are at the fringes questioning modalities, old theories, or questioning those gurus. 

Looking at your local community right now, there are a few ways you can start to build your own tribe. Start by reaching out to other practitioners, whether they are Physio’s, Chiro’s, Athletic Therapists, or other Massage Therapists and be willing to start a conversation (just for the love of all that is good, please make sure it’s evidence-based). You will soon find out if they can be part of your tribe. 

Start pulling people in and discussing best practices, business, education, and whatever else will help each person in your tribe grow professionally and personally. 

Be a leader!

Once you have started locally, reach out online. Start fostering relationships with other practitioners, join in conversations, start conversations, watch debate and see what you can learn.  Join some facebook groups that will challenge your thinking, you will soon find out who you can learn from, and who is still stuck in old theories. Just make sure you join in the conversation.

As Jenn Sharman said, “it’s an exciting time to be a manual therapist,” and it’s a lot more exciting when more people are joining in. 

 

 

Articles Of The Week March 11, 2018

Is yoga effective for managing chronic pain? Maybe, but then again maybe we just need to look at safe, non-threatening movement as a way to cure or manage chronic pain.

“Yoga, Mice, Pain and Your Brain” – Sarah Haag

There are some great points in this article about doing aggressive psoas work on patients, but there’s some things I don’t like about the article. To say that only those trained in visceral work should be doing this kind of work (because there’s not much evidence to say visceral manipulation is effective), is a bit of a stretch. However, I like the overall gist, that only trained professionals should be doing the work, and to be careful, there’s no need to do “aggressive” work.

“Serious Warning – If You Do Any Releases To Your Psoas or Abs, You Must Read This” – Antony Lo

Load management in athletes is an important factor in making athletes available for, and being in the best shape possible for competition. This post reviews three factors related to load management to help your athletes.

“Load Management Is Not About Decreasing Minutes” – Tim Gabbett

I love sleep, so I hate this part of the year where I lose an hour of it putting the clocks forward (why are we still doing this!?). A lack of sleep can lead to a host of health conditions and can affect brain health. Fortunately, massage therapy helps with sleep, so this could be a good article to share with your patients as another reason to get a massage!

“Why Are We So Sleep Deprived And Why Does It Matter?” – The Conversation

I’ve been asked many times if I would ever open up a practice at home and while it’s not for me, I know plenty of therapists who do. This post lays out several things to consider if you are wanting to open a home-based practice.

“Opening A Home Based Massage Business” – Allissa Haines

The Adolescent Female And The Athlete Triad

 

Many RMTs, Athletic Therapists and Physios start their career wanting to work with athletes, I know I did.

I had dreams of spending my days in the locker room and on the field, being part of a team and sharing in the glory of winning (having never been talented enough to compete myself!).

For many years, I did just that.

I worked in a sports clinic with my physical therapy “hat” on treating sports injuries and my evenings and weekends covering athletic events wearing my athletic trainer “hat.”  During my time at an all-girls high school, I became involved in female athlete triad research and bone stress injuries.

It opened my eyes to how athletics can affect females differently than males.

Since then, how we view the triad and how we treat it has changed.

Can you recognize and screen for the signs of the triad?  Do you know who is at risk?

What Is The Triad, And How Do We Recognize It?

Adolescent girls should participate in sports.  I want that to be clear.

Girls participating in sports have better communication with their parents, are less likely to get pregnant, have more positive body image and are 20% less likely to get breast cancer later in life.

But they are at risk for injury,  48% of female athletes will have injury severe enough for them to miss playing time.

Bone stress injuries are common in adolescent females, occurring in up to 21% of competitive females.  Injuries can range from a stress reaction to a stress fracture and occurs from a disturbance in osteoblastic bone formation and osteoclastic resorption.  The most common places are the foot, lower leg and pars in the spine.  Risk factors include endurance sports, sudden changes in training (duration, intensity, equipment) and inadequate recovery time.

90% of peak bone mass is gained by 18 years of age and research shows athletes have approximately 10% more bone density than non-athletes.  So any non-traumatic bone injury is cause for concern.  

It is imperative that the underlying cause is investigated and treatment includes resolving more than just the fracture.

Any time there is a bone stress injury, the other components of the Female Athlete Triad should be considered.

The Female Athlete Triad was first described in 1992 as disordered eating, amenorrhea (specifically missing more than 3 periods in a row) and osteoporosis.  The triad has now been expanded to include a spectrum of each pathology.  Screening should include having less than 6 periods a year (not necessarily consecutive missed cycles), dietary counselling and a DEXA bone density scan that compares the Z-scores, which matches the athlete to others her age. A  -2.0 standard deviation or greater is concerning.

The crux of the triad seems to be low energy availability due to disordered eating.

The athlete doesn’t necessarily try to restrict their calories, although some do in body-conscious sports, or if they are concerned about their weight.  Many are just unaware of the amount of food it takes to fuel their daily activity.  Sometimes they are just eating poorly: fast food, processed food, you know….they are teenagers!  This low energy availability leads to hypoestrogenism and disrupts menstrual cycles.

Estrogen normally inhibits bone turnover and maintains a balance between resorption and formation.  When there is a nutritional deficit and a lack of estrogen, this balance is disrupted.

Back when we started the research, we thought the best thing to do was replace the estrogen. Makes sense right?  Studies now show that using oral birth control does not change the bone density, even with prolonged use.  The first treatment should be nutritional counselling and improving caloric intake.  There are great resources online at www.femaleathletetriad.org that includes a nutritional calculator to get you started.

Also, find a nutritional counsellor in your area used to working with athletes.

Photo by: KeithJJ

What Can We Do?

So what do you do as a healthcare professional?

Know the signs….an athlete presenting with even one component has a 3x greater risk to develop one of the other components.  The Female Athlete Triad Coalition has a great screening tool that is non-confrontational and can easily be done as part of pre-participation screens.

Have information available.  Adolescent females need 1300mg of calcium a day and the best source is spread out throughout the day with food.  Raw green leafy vegetables, broccoli, almonds, canned sardines with bones, low-fat milk products are the best sources.  Certain medications can also impact bone health and may predispose your athlete to bone injuries.

Antiseizure medications (also used for migraine control), prednisone, SSRIs, thyroid medications are common medications for adolescents to be taking for a variety of disorders.

Female Athlete Triad is primarily hormonal and dietary driven.  It’s important to have a multidisciplinary approach to diagnosis and treatment.  It’s also important to be a nonjudgmental place for your athlete.  Athletes are a lot of fun to work with and you are part of a much larger team, especially when dealing with the triad.

 

References:

  • Goolsby M, Boniquit N. Bone Health in Athletes: The Role of Exercise, Nutrition, and Hormones. Sports Health[serial online]. November 7, 2016
  • Gibbs JC, Williams NI, De Souza MJ. Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc. 2013;45:985-996
  • De Souza MJ, West SL, Jamal SA, Hawker GA, Gundberg CM, Williams NI. The presence of both an energy deficiency and estrogen deficiency exacerbate alterations of bone metabolism in exercising women. Bone. 2008;43:140-14
  • Liu SL, Lebrun CM. Effect of oral contraceptives and hormone replacement therapy on bone mineral density in premenopausal and perimenopausal women: a systematic review. Br J Sports Med. 2006;40:11-24
  • Nazem TG, Ackerman KE. The female athlete triad. Sports Health. 2012;4:302-311
  • O’Connor D, Blake J, Bell R, Bowen A et al. Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause and Beyond. J Obstet Gynaecol Can 2016;38(6):508-554
  • femaleathletetriad.org

Articles Of The Week March 4, 2018

This one is really interesting as it is several small interviews with different pain experts on different aspects of pain.

“Trust Me, I’m An Expert” – The Conversation

Next isn’t so much an article, it’s a video. But, it’s a great video you could use to help explain pain to patients (or anyone else for that matter). In less than five minutes you could give a simple explanation to patients about what’s going on with them.

“Understanding Pain In Less Than 5 Minutes” – Get PT 1st

Scientists have found “anxiety cells” in the hippocampus which regulate anxious behaviour. They have even found ways to silence them!

“Scientists Just Identified The Physical Source Of Anxiety In The Brain” – Peter Dockrill

It turns out the gut-brain connection is starting to show that certain foods influence the bacteria in our gut, which in turn can influence the mental health. The brain and serotonin are also directly influenced by the gut and dietary improvements may be a strategy for managing mental health.

“Is Your Diet Fighting Depression – Or Intensifying It?” – Natalie Shoemaker

Wow, it seems there’s lots on pain this week, but this is pretty cool! New fitness machines called Jymmin combine a mixture of working out and free musical improvisation, and they make us less sensitive to pain.

“Jymmin, How A Combination Of Exercise And Music Helps Us Feel Less Pain” – Neuroscience News

Massage Therapy, Communication, And Helping Trauma Survivors

 

I’m one of those people that nod and smile to the person next to me on the bus and 15 minutes later I have heard most of their life story. You might be nodding and thinking “mmmhmm” right about now. In fact, I think if there was a group of massage therapists gathered and a similar question was asked, many would raise their hand at being “that person”.

Massage therapists have an intimate connection with their clients. Many of us work on clients who are only one sheet away from being naked in front of us. That means we need to be exemplary in our treatment of someone on the table. It’s not only a body, but a mind with varying experiences we are working with everytime we touch a client.

Let’s go back to questioning a group of MTs. If the question asked was “How many of you are survivors of trauma” there would no doubt be hands in the air.  A lot of MTs came to the profession because of their experience with massage during a traumatic recovery, or, seeing how it positively affected a loved one. 

But for the hands that remained down, does this mean they have not experienced trauma? 

Absolutely not. 

Many people prefer not to share their stories, which is understandable and acceptable. Do not expect that your client will share their personal past or trauma with you. Do treat everyone with the knowledge they may well be in the middle of a traumatic event, or have past event(s) that continue to have an impact on their lives.

When we speak of treating a client with a past trauma we usually think of a physical injury or PTSDPTSD often brings to mind those who served in the military, but in fact many situations may cause PTSD, as well as C-PTSD, Growing up in poverty, being adopted, survivor guilt, sexual abuse/rape, confinement of any sort (prison, residential treatment centersrepeated injury such as childhood physical and sexual abuse

The person currently in the middle of a divorce or custody situation. The one who just found out they cannot birth their own children. The client who spent part of their life living with abuse-whether verbal, physical or both. The one who has been body shamed by loved ones. A person who may have spent time in confinement. A former or current member of the military or someone who has seen the effects of war firsthand.

The stories are different, sometimes similar, but affect every human in a very personal manner, consistent with their other life experiences.

Nurturing, Ethical Standards, And Trauma

A few years ago, a client of mine I thought I knew well opened up after a year of sessions. 

The client told me they were glad that I worked through the sheets when doing gluteal work, as they had always felt uncomfortable having this type of work done, but enjoyed the benefits post massage. 

They told me about being aggressively assaulted by a group of people earlier in their life. This news was of course stunning. All I could do was stutter “I am so sorry” and continue with the session.  At the end of the session, the client thanked me for listening and not offering any advice, and again for providing the additional draping. This incident opened my eyes to the knowledge that as massage therapists we rarely know more than the basic details of a client’s history.

After working so closely with the public, I realized that most people have many hidden faces underneath. 

I changed my outlook to try and recognize that when someone comes in and says they are ‘not doing great’, there is no need for me to ask why. I am here to provide bodywork. If the client decides to share information with me, it stays in the room. I will not bring it up in another session (unless it is health related to their treatment) and will acknowledge that sometimes people need an ear, but that isn’t a request for feedback.

What we do is nurturing, but we are not “healers”. We must hold high ethical standards that go well beyond not dating clients. All clients must be treated equally, and strict adherence to scope of practice is mandatory. With this in mind and the knowledge that we cannot know if someone currently is experiencing, or has been affected in the past by trauma, all clients should be treated as though trauma has affected their life in some way.

When clients do indicate “PTSD” on their health history, do not inquire about specifics. 

Usually, boxes for anxiety, depression and insomnia are also checked as PTSD comes with a host of comorbidities.  Some, such as depression and anxiety, have been shown to be alleviated by massage therapy to some degree. Other symptoms like sleep disturbances may also benefit from the use of massage. 

A common side effect of PTSD are panic attacks. Some of us have already experienced a friend, family member or coworker have a panic attack. It is a scary and debilitating experience both for the person having the attack and the others present. I have personally witnessed several clients experience a panic attack during a session. I have found it is best to stop the bodywork, redrape the client and allow them the opportunity to end the session at that time. Every experience is different. Some clients need a few minutes, a sip of water, some need to have the therapist leave the room so they can regroup, or get dressed and end the session for that day.

Be sure to ask them if they are aware if this is a panic attack. If not, symptoms can be similar to cardiac events, so familiarize yourself with the symptoms of each, or call for emergency assistance if necessary. 

While studies suggest that massage therapy may be beneficial for symptom management of PTSD, it is a priority to ask all clients about their comfort of level of undress, areas of the body to be worked or not touched- and informed consent. Remind each client this is their session, and as a therapist, you are willing to work within their boundaries.

As discussed, we cannot identify trauma in a client and many clients may not feel comfortable enough to discuss trauma, especially during early sessions, so we must do our best to avoid triggers which may result in panic attacks or other symptoms of distress. As your therapeutic relationship develops, it may be more appropriate to discuss things as the patient opens up to you, but when starting out, try to avoid those triggers. 

Some suggestions are below.

Do’s And Dont’s 

Do: Create and maintain boundaries in your practice

Don’t: Deviate from boundaries

 

Do: Allow time for a thorough intake

Don’t: Rush your client

 

Do: Ask for emergency contact

Don’t: Ask marital status

 

Do: Have a box to check for pregnancy

Don’t: Ask about children

 

Do: Ask for preferred name & pronoun

Don’t: Assume nicknames or gender

 

Do: Request current health information

Don’t: Ask about heritage, accents

 

Do: Ask for surgical/accident history

Don’t: Set time limits (ie: 10 yrs)

 

Do: Add a box for PTSD

Don’t: Expect full disclosure

 

Do: Discuss levels of undress

Don’t: Ever adjust bras/underwear

 

Do: Ask clients about working gluteal areas

Don’t: Ask when client on table

 

Do: Discuss Informed Consent

Don’t: Make assumptions

 

Do: Avoid negative words & phrases

Don’t: Talk down to clients

 

Do: Greet every client with a smile & nod

Don’t: Force a handshake

 

Do: Respect personal space

Don’t: Initiate a hug

 

Do: Give advance warning of animals in practice

Don’t: Assume a client likes animals

 

Do: Ask client about music preference or none

Don’t: Play what you want to hear

 

Do: Appreciate client’s religious preference

Don’t: Display religious emblems

 

Do: Treat a body with respect

Don’t: Ask about scars or tattoos

 

Do: Provide appropriate draping

Don’t: Discuss client weight/height

 

Do: Acknowledge each client is an individual

Don’t: Council/compare clients

 

Do: Work in scope of practice

Don’t: Offer nutrition advice or sell other services you provide

Remember, we do not need to walk on eggshells, just work within our scope of practice, treat each client as an individual and understand there are many context layers in each person’s life experience.