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Education In Rehab – WTF Does It Mean…?

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Education, education, education. How often do you hear this term in relation to modern MSK practice?

Sorry, I got that wrong. Education & exercise, Education & exercise, Education & exercise : )

All the bloody time is the simple answer!

But education, just like exercise, suffers from the issue that we talk about it in very general terms but have little in the way of actual frameworks for application. Every guideline going seems to point towards these as core treatments but often without any real direction. I can see why therapists fall back on more traditional perspectives faced with uncertainty.

So education about what? When? How? To who? The usual questions come out when we unpick it a bit. Education has been hijacked by PAIN education over the last few years but in reality, its formed a backbone of MSK practice…..well forever. Education is something I talk about in class A LOT,  but I do feel people are like hurry up and get to the REAL treatment Ben, i’m getting bored over here.

Is education seen as PROPER treatment? I am not convinced yet.

People Always Have Wanted Information

 

This is nothing new!

How often have you had someone come in and say “My back pain has been going on a little bit longer than usual and I thought I had better have it checked out”.  We know back pain, as an example, can last for 2-6 weeks and it’s perfectly normal for this to happen. But if someone has only ever had the problem before for a few days it’s probably a bit worrying and they want to know what is going on to decrease the worry that can flourish in stressful situations.

People definitely come to see us to get rid of their pain, but they also want to understand their problem, the implications and know how to manage it as well.

Louis Gifford highlighted a few things that is fairly universal amongst people. What is it? How long will it last? What can we do about it? Another question I get asked regularly is “Can I still do….”. People still want to do things but not to make the problem worse but often get scared into reducing activities rather than receive knowledge to sensibly manage them.

Education Or Knowledge Transfer?

 

We use the term education, but for me, that can conjures up images of stern teachers in front of naughty school kids and does not really reflect what we often do with people.  Maybe it is really about helping someone make coherent sense of the issue, decreasing the uncertainty and danger around the problem and providing paths forward. This is more of a partnership perspective that incorporates knowledge transfer than traditional didactic models of teaching. So maybe knowledge transfer or sense-making is a better term?

What Can We ‘Educate’ About?

 

SO MANY THINGS IS THE SIMPLE ANSWER!

 

What Is It?

Probably the most important thing that people want is a diagnosis. If we know what it is we can effectively treat it, right? Er…maybe as we know in so many MSK issues that are simply not possible from a structural perspective. In the absence of this, we need a positive & coherent narrative around the problem. That could include pain ed but information about pain does not need to dominate.

“Cases of nonspecific musculoskeletal pain where, although the source of the pain is unclear, diagnostic imaging is not indicated, and the pain may not always be completely alleviated with treatment. In such cases, concrete, clear, and consistent information can help the recovery process, even in the absence of a specific diagnosis” Carroll et al 2016

How Long Will It Take?

Prognosis and the factors that influence it can be really helpful with often unclear diagnoses like back, knee or shoulder pain. Setting realistic expectations is important as well. Too high and it can lead to disappointment when they are not reached, too low and the motivation to engage in the process can limit the outcomes.

What Can I Do About It?

Health and lifestyle, exercise, activity and self-management are all areas that we can help people with. Helping people to effectively create management plans is sorely missing IMO. Again perhaps this is not seen as treatment?

What Does The Person Want To Know?

 

For a really effective transfer of knowledge maybe taking the time to find out what the person WANTS  to know is important. Just throwing out information might lead to important questions remaining unanswered. There are so many questions that people have that we may not have considered or we feel are not important. If they are important to the person they should be important to us!

“What concerns you the most about your problem?”

“Do you have any major concerns you would like to talk to me about?”

“What’s your biggest fear about this?”

“What’s the most important question I can answer for you today?”

Context

 

It needs to make “biological and biographical sense” as my friend Joletta Belton would say. This was the great failing of pain education IMO, it does not automatically integrate with the person’s story, it’s like talking to a stranger in a pub when they are telling you about their life story and you are being talked AT without the conversation ever relating to YOU. A friend that just talks about themselves is another example, you just want to get the hell out of there, or . So make sure your knowledge transfer actually fits the person and their story in a way that relates.

Failure

 

Maybe this is why some of the things we expect to be helpful don’t succeed? Without a knowledge of what to do, why they are doing it and how it is going to help, exercise, as an example, does not relate to the person and their problem?

Lots of my failures (professional ones : ) may have come from not aligning in terms of treatment philosophy with the person I am working with. My vision of what to do does not match theirs and in part that might stem from my inability or failure to ‘educate’ about the what, why’s and how’s.

Conclusion

 

  • Education IS treatment
  • What does it really mean?
  • People have always wanted information from therapists
  • Think person centred rather than teacher style
  • What is it? How long will it take? What can I do about it?
  • Find out what the person wants to know
  • Apply information in context

A Good Response To: “Manual Therapy Sucks”

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Not too long ago, we did a post about how manual therapy actually works (as opposed to many of the narratives offered in continuing education).

While we know manual therapy can be a very helpful component in helping people dealing with pain, we still see some opposition to this once in a while.

We see people making some bold statements like:

“manual therapy sucks” or

“exercise is the only thing that works.”

In reality, neither of these things are true but using both in treatment will likely give you better outcomes than just one as a singular intervention.

Putting The Human Back In Human Touch

For the past few years, the manual therapy field has paid a lot of attention to the biopsychosocial aspects of pain management.

However, it almost seems like manual therapy has taken a back seat to other interventions like exercise (which I’m a big fan of using in treatment).

But is this the best approach for us to take?

A great new paper¹ outlines several reasons why it is still REALLY important for us to use and incorporate manual therapy into treatments and fortunately, there are a number of things I never thought of.

Firstly, think about the aspects of your clinical encounter when a patient comes to see you, especially when it’s the first time.

Usually, we would start with some orthopedic tests and a good conversation. Part of what is happening during this time is demonstrating your clinical competence

Your hands-on movement of an injured area shows not just that you know what you’re doing, but it also demonstrates compassion and humanizes the treatment for the person receiving it.

This also helps us set up treatment boundaries where we find out what the person is comfortable with while creating a safe space. While it is very important for us to set up our clinical encounter with people to create that safe space (and to show your clinical competence) there are some other really important aspects to touch that are invaluable in helping a person with pain.

Analgesic Touch

Ever hit your shin on the side of a coffee table and then rub it incessantly like Peter Griffin in family guy (obviously after you’ve sworn at the table!)?

Well, there’s a reason we do this because touch feels really good!

There is a pain modulation that happens with touch that feels good. While there are other techniques we use that do things like distraction to take attention away from a painful area, good touch actually helps to downregulate pain signals through various fibres and pathways that are mediated at the brainstem.

Affective Touch

When touch is delivered in a therapeutic setting, it prepares the brain for touch which stimulates C-Tactile fibres which set things up for a positive therapeutic experience. This promotes positive feelings like safety and relaxation while also reducing things like avoidance behaviours and stress.

Now because this is an empathetic touch it helps remove some of the psychosocial barriers that contribute to a person’s pain experience.

Somatoperceptual Touch

We have seen over the past few years how when a person dealing with persistent pain can experience a misrepresentation of how their body actually feels and what it experiences.

Turns out a therapist’s touch can help in this regard as well.

Just by putting our hands on people, we can help to change a person’s body perception by helping to reorganize mental representations of their body. This helps a patient be able to discriminate between safe and threatening stimuli while also showing how their body isn’t damaged.

This also helps to reduce stress, anxiety, and avoidance behaviours around pain.

Does This Mean Our Touch Is Enough?

Well…it depends.

There are certainly times when someone just needs a good old delicious feeling massage and there is certainly NOTHING wrong with that.

If we have those people (say nurses or other first responders for example) who aren’t necessarily dealing with an injury and are using us as part of a wellness plan, then by all means give them that delicious massage.

However, when we have those individuals who are dealing with an injury say from a car accident, workplace, sports, or some other type of injury we need to incorporate more than just hands-on into the treatments.

We still need to follow the best guidelines for MSK care and provide education, reassurance, movement…and of course some massage. While a lot of what we do in treatment is communicating with our hands, our communication verbally is still a really important part of the therapeutic experience. This paper ¹ points out how this should also be a responsibility of educators and students alike to veer away from the biomechanical constructs of communication to include the person’s emotional experiences as well when we talk to them. While I will always be an advocate to include exercise and movement into our treatments, it doesn’t mean we need to abandon manual therapy (as some would like to promote) and strictly adhere to an exercise-only program. It’s quite the opposite. To be a better therapist and have better outcomes with our patients, let’s not throw the baby out with the bathwater as it were, let’s include education, movement, and massage. The more well-rounded we are as therapists and the more well-rounded our delivery, the better it is for the people who come to see us. As for those who say manual therapy sucks…well…this paper proves that wrong. There is still a really important place for that delicious feeling massage.

 

References:

  1. Geri T, Viceconti A, Minacci M, Testa M, Rossettini G. Manual therapy: exploiting the role of human touch. Musculoskeletal Science and Practice. 2019 Dec 1;44:102044.

 

Things I Wish I Knew About “Rotator Cuff Disease”

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It was the first time I’d seen this patient. 

When I asked what brought them in they showed me how they could only get their shoulder to about 90* abduction and it had been this way for two years. 

Digging a little deeper to find out what happened, they explained they had a rotator cuff surgery due to a tear. 

This was life-changing for them. 

Not only could they not move their shoulder correctly, but it also resulted in a change from a job they loved to one they hated due to the lack of mobility. 

So, was surgery the best approach in this case? 

While I’ll never know the true answer to this, I can look at the most up-to-date research and attempt to make an educated guess ( and I think I know where this is going). 

Rotator Cuff Disease

A recent paper¹ came out on this topic, and I’ll admit I was surprised to see them refer to this condition as a “disease.”

However, when we look at the dictionary definition of disease² it states: 

“disease, any harmful deviation from the normal structural or functional state of an organism, generally associated with certain signs and symptoms and differing in nature from physical injury.”

So, in this case, the limited function of the shoulder has deviated from its normal functional or structural state, so I guess it can be classified as such. But, I would never want to communicate it to a patient that way as it suggests a more damning diagnosis than it is. 

Now, in order to define this “disease” they put some classification around it which includes: 

  • Pain that is worse at night
  • Pain exacerbated by specific movements which included overhead activities
  • Loss of function and weakness

In addition to the above rotator cuff disease was basically used as an umbrella term to classify issues with the rotator cuff regardless of the cause and would include: 

  • Positive painful arc test (physiotutors gives a great example of how to perform the test HERE)
  • Positive external rotation resistance test

These tests together were the most accurate diagnosis unless it was a full-thickness tear. In this case, the use of a positive lag test was most appropriate. Here is one example of how to do the test, but this can also be done with the shoulder at 90′ rotation, called the “drop arm sign.” 

It is also worth noting that the review found an increased prevalence of this with age, especially in those people who performed repeated overhead activities. 

What Do We Do For Treatment?

So, this paper was a BIG review; there were 3620 participants in 60 different trials with a median age of 51. 52% of these were women and the average duration of symptoms was 11 months. 

What they found was that people were rarely given just one intervention. 

This makes it really difficult to say if just manual therapy, just exercise, or a single other intervention was the best approach as there was always a combination of things offered. 

The average duration of therapy offered was six weeks. When they looked at what manual therapy was offered, this included: 

  • Joint mobilizations
  • Massage
  • Spinal or neck mobilizations
  • PNF stretching
  • Dicutaneous Fibrosis (I had to google this as I’ve never heard of it, but it’s IASTM with a stainless steel hook)

Exercise interventions included: 

  • Strengthening
  • Stretching
  • Progressive resistance
  • Pendulum exercises
  • Eccentric training
  • Postural training
  • Motor control
  • Proprioceptive training
  • Self-mobilization (yay for self-care)
  • Dynamic humeral centring (movement aimed at humeral head depression) 

Interestingly, they compared the above to some other trials that included things like steroid injection, NSAIDs, surgery, naturopathic care, and a few other interventions. 

When it was all said and done, they compared what was seen as high-quality evidence to low-quality evidence. 

Under the umbrella of “high quality evidence,” their findings showed no difference between manual therapy, exercise, and placebo for overall pain, disability, and function. But there was also a risk as manual therapy and exercise were frequently associated with adverse effects like short-term pain (although very mild). 

When looking at “low quality evidence,” it was pretty consistent with the aforementioned high-quality evidence but also showed that the use of glucocorticoid steroid injections helped with global treatment success. 

Overall, this doesn’t sound like a real positive for manual therapy and exercise, but there are some things to consider. Throughout the studies, manual therapy and exercise were always incorporated with some other type of therapy. Also, much of the exercise used was very vague by description and didn’t include whether this was done supervised in the clinic, or at home. Finally, while the comparison to glucocorticoid steroid injection seems like it could be of benefit, this was based on low-quality evidence, so this doesn’t give the intervention much credence. 

Looking at what they considered placebo, they used modalities like ultrasound (which in other studies has been shown to have a high level of placebo). This review doesn’t really talk about the interaction between patient and therapist or other contextual factors of treatment. We might see a more detailed description of the exercises and modalities used as interventions if these were included. 

However, when we look at other papers that discuss the clinical guidelines of MSK care the best steps are typically shown to be: 

  1. Reassurance
  2. Education
  3. Exercise
  4. Some manual therapy

If we were to apply the same to issues with the rotator cuff, we’d likely see better outcomes than if these weren’t used. Even though this review says there is no clinically important benefit to manual therapy and exercise over placebo, it doesn’t mean they aren’t of benefit. But if we used those as a combination in treatment the high-quality evidence shows this to be the best approach. So, with any shoulder issue, continue to use exercise and massage. Just remember there are other factors that contribute to a successful treatment. Things like patient preference, demeanour, education, reassuring them, and providing validation will all help contribute to better patient outcomes. Let’s just remember to incorporate as much as possible.

 

Applying The Biopsychosocial Model In Clinical Practice

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The biopsychosocial (BPS) model is one of those things you probably feel like you should be doing but maybe don’t know exactly how or you don’t have the skills? There does seem to be a fair amount of uncertainty and a bit of anxiety associated with the BPS model HERE and even the papers that discuss it rarely seem to actually define it!

This take on the Dan Ariely “big data” quote sums it up quite nicely (kudos to the author!)

Biopsychosocial management of back pain

Is like teenage sex;

Everybody talks about it;

Nobody really knows how to do it;

Everyone thinks everyone is doing it;

So everybody claims to be doing it.

But maybe we don’t need to FULLY define or understand the BPS to start to implement it in some way. The first thing we need to do is actually know MORE about it. I was told recently that the BPS model is “old and we should move on” in a Twitter discussion. A little bit further into the discussion, it turned out the other party had not read much about it, I think this happens a lot. We all seem to have our own interpretations around what BPS is and is not, so this is my attempt!

What Is It?

 

There seem to be two main perspectives that are summed up in these quite differing quotes:

“The centre of interest in biopsychosocial model is not the disease but a sick individual”  – Havelka  

 “The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to understand a person’s medical condition it is not simply the biological factors to consider, but also the psychological and social factors” Physiopedia

The first is focused more on the person we are treating and the second is more focused on the condition or problem, so no wonder we have a bunch of confusion and NEITHER really give much guidance about what to do next.

One of the perspectives that I feel gets lost in some views of the BPS model is the focus on the ‘humanisation’ of healthcare which is a feature of Engel’s writing. To understand the biopsychosocial model we also have to understand why we needed it in the first place and this was to come away from the reduction of healthcare to pathology and numbers that was the biomedical model.

Isn’t it fascinating we now quantify the success of a BPS approach simply by an outcome measure!?

Philosophy Of Care And Person Focus

 

Maybe this is the real spirit of the BPS? A ‘philosophy of care’ and a person focus.

The cool thing is it does not require extensive training to implement, instead, it simply requires us to appreciate there is another person who is more than a disc or a tendon or whatever issue they have. They also will have a history and experiences that shape their emotions, perspectives and ultimately behaviours.

This for me is summed up nicely in this quote.

“Look at the world through the patients eyes and walk through the world in the patients shoes” –   

 This quote from Joanne Bourke also sums up how we can focus more on the pain than the person who has it.

‘Pain’, rather than a person-in-pain, is given agency. A pain-event always belongs to the individual’s life; it is a part of her life story”  

When it comes to the human side of the BPS perhaps we can get stuck on the idea that everything we do has to result in a better outcome e.g. a change in pain. So this interaction is measured and judged via change in pain, empathy is measured via change in pain, you get the idea. This is exactly the positivist/empirical perspective Engel seemed to be arguing against, reducing everything to a hyperfocus on the problem and then measuring its change! We should be being aware of how we interact NOT just to get a better outcome measure but also because it’s the RIGHT THING TO DO!

Evidence-based medicine is important but not at the expense of a person. We really need to zoom out to the whole often rather than separating into smaller parts and descending DOWN Engel’s hierarchy of systems.

The aspect of the BPS model that is probably most important is our own self-reflection on how we think, act and interact but I have rarely seen this discussed. Just reflecting on how we communicate or care for the other party or conduct ourselves is enormously valuable.

The thing is that if we want the BPS to be an effective treatment tool then it probably requires the human aspect that is being discussed here. Many psychosocial factors that relate to pain require changes in behaviour. These changes also require trust and belief in what we are saying and this can be tough when it is contrary to all the other concepts and ideas around pain that people get exposed to.

There are a number of points that we can appreciate to implement a more person-focused version of the BPS model that is NOT directly treatment-focused but might have an effect on the process.

  • Having pain can affect our emotions as much as our emotions might affect pain. It is a BI-DIRECTIONAL model.
  • Socioeconomic status and health literacy directly affect the entire therapeutic process
  • Appreciate how beliefs are in part formed at a societal level and this can make them pretty sticky. They often don’t simply change in a session
  • Having pain is HARD and can limit motivation and belief in recovery
  • This person may have had to tell their story multiple times and this can be very frustrating
  • A constant search for the answer can be frustrating and tiring. Modern medicine can paint the picture there is one to be found
  • Uncertainty and the worry it brings makes people feel worse. Not just their pain but also their well being
  • Hope, motivation, optimism and instilling confidence are important not just for pain but also for LIFE and the person

None of these things are treatments but do help us understand the person and their levels of engagement, optimism and outlook for the future. The appreciation of these points also does not require a huge amount of training to implement.

Causes And Treatment Focus

 

A more traditional diagnostic and treatment-focused use of the BPS seems to be the most popular way it is interpreted and implemented and perhaps this can cause a bunch of issues for both clinicians and patients. To treat thing’s specifically the thought is we have to kind of know what the problem IS first and we can get hyper-focused on finding the CAUSE of the problem, but now we have way more potential problems across lots more areas to confuse us! Sticking to traditional pathologies can be hard enough and this is without having to be an expert in other fields too!

I think there is a case that we could see this as a biomedical application of the BPS as we could treat multiple BPS ‘factors’ WITHOUT actually treating the person in the spirit of the BPS and with a focus on person-centred care. A real aim would be to successfully implement a person AND pain-focused model.  Many of the factors we need to identify to implement a pain-focused model actually need the person-centred model to make them work anyway. Without a good therapeutic relationship and trust and rapport, how do we get people to tell us the information we need? How do we help implement the behaviour changes that are often required? The simple answer is we don’t.

Triggers Not Causes

 

Maybe a better way to see this all would be factors/behaviours that TRIGGER pain not always viewing it through a causation lens. Many things might trigger, exacerbate or modulate a painful state. Is this semantics? Potentially, but maybe less focus on CAUSE might take the pressure off clinicians to pinpoint a cause and does not feed people’s desire to find the one thing that they need to fix their pain. We might swap disc/nerve/alignment for stress/sleep/job and a triggers perspective may help people make sense of their pain situation rather than search for the cure or fix it in the same way that can often prove frustrating and demoralizing.

As we can see HERE 9, yes 9 psychological factors were identified as being involved with rotator cuff tendinopathy pain, function and quality of life. No wonder a BPS find and fix it model is seriously daunting for most clinicians.

A good analogy might be that of a cut that is grumbling away in the background. Sometimes I am unaware of it, others it is giving a slight twinge. But get something in it that irritates it and it’s a whole other story. This added element has interacted with the cut and triggered a response. Without the cut it might not have done so perhaps on its own we might not see it as a casual element. There is sometimes a danger we simply swap biomechanical impairments for psychosocial ones.

The interaction of BPS factors is inherently messy. Humans are a complex web of interrelating systems that display non-linear responses between things acting on the system and the responses it makes. This can mean we could have huge changes in a variable such as stress but only minor changes in how it affects a target variable such as pain. We also might target one variable, that may not change significantly, but another mediating variable change and this changes a target variable. This may be different to the sometimes linear approaches that we can see in research and clinical models that involve a primary outcome measure and intervention.

If we approach the BPS model as a simple view of linear causation and impairment fixing this kind of goes straight back to a biomedical perspective.

 

Positives Not Negatives?

 

There are positives and negatives to this messy non-linearity of the BPS with treatment. Positive in that treatments can have wide-ranging effects across many variables and the negative that they also might not! Exercise can have implications for general health, mental health and pain through a whole bunch of different mediating variables. One way to start to approach the BPS model is not in trying to fix an impairment but to improve aspects we know are beneficial and may provide an overall effect. This would fit with Antonoskys salutogenic model of focusing on wellness rather than illness.

Screen Shot 2020 06 10 At 11.04.02

 

Perhaps an issue is we now see it as “just do some exercise” and the person will be ok.

Exercise ‘works’ is a common perspective but this really does not tell the story of the data. It is not so much if it ‘works’ at a population level but how much effect does it have for this person in front of me. For all this potential to have wide-ranging effects we still don’t see dramatic benefits in the research and often clinically too on the outcome measure of pain. Maybe this is because we expect exercise to automatically transfer to whatever the issues are? Effects on strength, sleep, mental health and ultimately pain are all potential effects/mediators that we see in the research base but we are not GUARANTEED these effects. This paper found HERE found that strength and power scores did not make people feel automatically ready to return to play. Although physical conditioning MIGHT make people FEEL mentally stronger it is not an automatic and linear relationship.

Summing Up

 

We probably need a bit of both perspectives to make things work effectively.

If we put this into context, firstly we need to consider the effects we might want from exercise based on finding out more about the person we are working with. Do we want to improve health? Wellbeing? Function? Exposure? We might have to set up exercise in some different ways to achieve these different aims. Secondly, our deeper knowledge of this person and their journey might help us frame, explain and implement the exercise in some different ways that could have a better potential to have the desired effect.

If a BPS approach just ends up in do some exercise because it CAN have wide-ranging effects I think we have lost sight of what the BPS just might be!

 

Talking Templates for Common Misconceptions

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I saw a post on Facebook a couple of weeks ago where a therapist was looking for advice on communicating with their patients.

This is partially because of frustration when a patient has an outdated belief around pain and their body, but you’re now trying to give them a different story.

This can be tough, especially as we learn new research and terminology and try to update ourselves.

Sometimes we want to vomit all the info we know, and people aren’t always receptive to this new information.

So, I figured I’d take a shot at how we can better communicate some of the things in question.

Here we go.

Do I Feel Tight?

This one is a classic.

I’m sure we’ve all had that person get on the table, turn and look at us, then ask, “Am I the tightest you’ve ever felt!?”

The funny thing about “tight” is that somehow as a society, we’ve bastardized this into being something associated with pain. Tight is just a sensation, and it’s a very personalized sensation.

I like feeling tight. When I go to the gym in the morning and do a good workout, I usually feel “tight” for the rest of the day. It makes me feel like I’ve accomplished something, and I’m taking care of myself. However, I don’t associate this feeling with pain (but again, this is a personal, subjective experience).

I think back to an experience I had working with some athletes a few years ago, and this is usually how the conversation goes with someone who asks about this:

Athlete: Do I feel tight?

Me: I don’t know. I’ve never treated you before, so how would I know if you feel tight or not?

Athlete: Oh, well, it’s just that my therapist at home always tells me how tight I am.

Me: Well, the more important thing is how you feel. Do you feel especially tight today?

Athlete: No, I don’t really feel tight at all?

Me: Then you’re probably good!

We then carried on the treatment, and at least for the rest of the camp, the athlete never really worried about feeling tight.

In the case where this is someone who maybe we’ve seen for a while, and they come in and ask if they feel tight, we could change the term to “protected”.

Perhaps we say something like: “well if this area is feeling tight to you, maybe for some reason the body is trying to protect the area, let’s just try to calm the area down and send some safety signals to decrease that protection”.

Whatever language we develop around something like this, let’s make sure we’re not using language that could cause someone to catastrophize what’s happening.

Don’t be the therapist telling people they’re “tight” like it’s a bad thing; let’s reassure them this is okay, normal, and they’re not damaged or broken.

My Posture Is So Bad

Unfortunately, there is so much in the media these days proclaiming that bad posture is the root of all evil.

People have heard things like “sitting is the new smoking” or that they have “text neck”.

Well, we know neither of these things is true, but it’s likely our patients don’t.

But this is where we could take a little time to educate them and even ask questions like, “well why do you think your posture is so bad”?

Depending on their answer, we could try to re-direct their thoughts by making some comparisons.

On things like text neck, we could point out that in the past, we’ve never seen anything like “encyclopedia neck,” “knitting neck,” or in reverse “ceiling painters neck”.

When it comes to sitting, we could point out how any posture held for an extended period will likely get irritating. I can’t imagine how those guards outside Buckingham Palace who have to stand in that “perfect” position all day aren’t going home and just wanting to sit for extended periods after work.

The reality is our best posture is our next posture (I don’t remember where I first heard that to reference it, but I think it was Greg Lehman).

Just showing them that any posture is safe and frequently moving to change your posture is a good idea might be enough to get rid of those old beliefs.

If not, we could cite several research articles that show posture doesn’t correlate to pain, but I’m not sure how many non-therapists want to dig deeply into that info.

Did You Feel That Release?

Well, we know that we can’t actually “release” anything with our hands.

However, many people have been told by other very well-meaning practitioners that they’ve released their fascia, a muscle, or a trigger point.

So what would be a simple way to communicate how we aren’t “releasing” anything but rather are having an influence on the nervous system?

As we mentioned earlier, it could be a matter of changing the language to a chat about protection mode and sending a safety signal to reduce that protection.

Another way is to say:

“Well all the new research has shown us that we’re actually having more of an influence on the nervous system. So, this area is probably a little sensitized right now, we’re not actually releasing something, we’re just calming down that sensitized area. So what you felt is more likely just the nervous system calming down.”

We will all have our way of communicating these things, and I’m sure you can come up with something better than what I’ve jotted down (and honestly, I’d love to hear your take on it).

Let’s make sure that we’re changing the narratives on many of these things along with the techniques we use, and we’re not giving our patients any reason to catastrophize an individualized sensation. We can do better than that.

Putting Patient Preferences and Values Back In EBP

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Evidence-based practice (EBP) has been the accepted norm in medicine and rehabilitation for nearly 30 years, though exploration began of its concepts in the early 1970s (Zimerman, 2013).

EBP consists of three elements: the best available evidence, the clinician’s knowledge, and skills, and the patient’s wants and needs (APTA, 2020).

This latter component is also stated as patient perspectives and values (ASHA). All descriptions of the EBP model point to an equal weighting among the three tenets, though most provide little detailed instructions on how to assure the weighting is carried out in that fashion. Many professional bodies established clinical guidelines and pathways to determine how to rank evidence, with case studies and clinician experience at the bottom of the ranking and systematic reviews and RCTs at the top. Clinicians are expected to use their clinical reasoning, expertise, and judgment to apply the evidence appropriately. However, how to go about assuring patient preferences and values are met is a bit unclear.

I have a specific podcast that I am particularly fond of, as the presenter speaks on topics dear to my values (and clicks my bias button continually). On a recent podcast, there was a conversation about applying principles of EBP while assuring the uniqueness of the individual patient was met, something not always addressed in EBP. As the best available evidence requires rigorous trials involving randomized groups, single incidents are often seen as less-than-relevant, though there is a trend toward allowing such individual cases greater weight (Anjum, 2020). While discussing how to apply EBP within such emerging models and how to allow weight to patient perspectives and values, a comment was made to the effect, “well, it is not like we can have our patients choose the intervention.” Really? Why not?

Patients lack the depth of knowledge and experience to build their treatment plan, and if they did, why would they need us? However, can’t they contribute?

In my 35-plus years as a physical therapist, I’ve overheard many different ways that clinicians try to assure that patient expectations and values are met. However, most fall short of the 33% contribution mandate of EBP standards. In a manual therapy setting, asking, “how’s the pressure?” seems to suffice for many, while in the exercise-based setting, so much power is given over to the clinician that few questions are asked. Patients often assume that we know the cause of a problem and also know the best way to intervene. Power is given. However, are there better ways to go further in allowing patient input to be equivalent to clinician input?

I once studied with a brilliant clinician who had a deep level of knowledge about how past psychological aspects often led to certain functional problems and applied his manual therapy skillset to remediate those problems.

However, I saw as problematic that though psychosocial factors leading to those problems were acknowledged, little if any attention was given to those factors during the intervention. The clinician simply applied what they knew to be necessary for the problem that they palpated. Did the clinician have an impact? Indeed, and their work was published and well-regarded. However, could they have improved their allowance of patient perspectives and values in the therapeutic interaction? Yes, indeed.

How can we elevate that 3rd leg of the EBP model to assure an equal weight is allowed to patient perspectives and values?

Many ways, but to start, we can include them more in the decision-making process. In my work, which is to improve function and reduce pain using a manual therapy-based and movement-based blended model, I make it a requirement that my patient fully participates in treatment decisions. This mandate is not always straightforward for the patient to accept, as they often feel ill-informed in treatment decisions. It takes some time to establish both the need for their input and the skillset for them to put this plan into action.

Below is an excerpt from one of my seminar manuals, in which I describe the basics of such a patient-centred model.

Once you have collected their history and complaints and spoken on their functional needs, ask them where they feel their issue. The issue/location could be where they feel the pain, the part of their body where they feel their movement difficulty, where their voice has challenges, where swallowing is impaired, where the tongue gets tight, or whatever brought them to you. Ask them where they feel the problem lies. Some may have no idea, while most will be able to localize the problem area.
• Let them know that the point of this evaluation process is for you to be able to touch, press, stretch, or do something with your hand(s) that connects them to their complaint. You may increase the feeling to a point where you bring it to the edge of the patient’s awareness or even calm the issue to a point where it is barely apparent, but either way, you need to do something with them that they feel relevant. You are looking to replicate a familiar feeling.
• If they are confused by this, or ask, “why do you want to make me feel it?” I suggest that you tell them that it is not your goal to make them worse or to make the problem worse. However, this work’s nature is such that to know that we can help requires us to connect them with their issues. If we cannot replicate the symptom or link them to their problem, both from the periphery (the tissues) and their perception (sensation), then we stand a lessened chance of helping.
• If at rest, they feel nothing, none of their issues, let them know that you may be seeking to allow them to begin to feel it through the therapy process. The concept of bringing their concern to their awareness may be difficult for them, as, for instance, they only notice the problem after doing something. Someone with a vocal strain that only occurs after a performance may wonder how you will be able to replicate the feeling when they have not sung. Someone suffering from back pain that comes on only after standing for a certain length of time may wonder how you will be able to get them to feel something familiar when they have been sitting and have no pain. Let them know that this is your mandate; to connect them with their issue, whether it is present at that moment or not.
• Ask permission to touch them and then place a hand or hands on the identified area. Initially, do nothing; allow your hand to rest on their skin lightly. I will typically then ask them if they feel any of their issues. That gives me an idea if I need to mildly replicate the feeling of the problem or try to reduce it with my stretch.
• Begin to apply a light stretch in the 1-2/10 range on your scale.
• Work in slow-motion; do not move quickly or apply heavy or aggressive pressure. Your pressure might be a lateral
stretch in any direction to the skin or deeper layers, used with a combination of pressure or gentle inward probing. The type and orientation of stretch necessary to connect with the patient’s condition are unique, varying from person to person. Think of this process as one of talking to a person who speaks another language. Each of you has little ability to speak each other’s language, and communication will be slow. It takes each of you a while to find the correct word to communicate an idea correctly, so you work your way through the process until each of you made your point. This process of evaluation is similar. You are trying to find a direction and pressure of stretch in and around the soft and hard tissues, one that your patient begins to feel that you have touched their problem.
• Once you have found a connection, you will need to work out if what you are doing should be continued as treatment. Ask the patient:
• Does this feel familiar?
• Are you feeling a replication or lessening of the issue?
• Does this stretch feel like it might be helpful?
• Is there anything about what you feel that feels like it could be harmful?
• Would you like me to add more pressure? If yes, slowly add pressure until the patient says that now better feel
connected to their issue.
• Finally, once you have adjusted the pressures and direction, ask them if they want you to continue with the stretch.
• When you start to use this work, hold a stretch for 2-4 minutes. During the stretch, you are asking the
patient if they still feel like the stretch is helpful. After 2-4 minutes, slowly release your pressures and retest. Do they
feel different? Have you been able to help them modify the sensation of the issue?
• Depending on your comfort with the techniques, you may now wish to treat more in the same spot or try a slightly
different area. If the patient has felt a change, you might move into the other intervention strategies you use.
• Treating for 2-4 minutes is a suggestion. I spend much longer with this work, often allowing a series of stretches
interventions to a single area take up nearly the entire session.
• No matter if you are using just this manual therapy work or combining it with other interventions, always teach the patient self-treatment. Many forms of manual therapy are too passive; they do not build self-efficacy. I always encourage my patients to follow through with self-stretching, if it feels helpful to them, and increase their movement through exercise, strengthening, or simply moving more. Passivity happens when we do not include the patient in treatment decisions, whether it is through manual therapy or exercise-based models of care.

The original intentions of EBP have been lost, though many feel they honor it. I think we can do better.

  • Anjum, R.L., Copeland, S. and Rocca, E. (Eds) (2020) Rethinking Causality, Complexity and Evidence for the Unique Patient. A CauseHealth Resource for Health Professionals and the Clinical Encounter, Springer (open access book).
  • Components of Evidence-Based Practice, 2020. APTA.org.
  • Evidence-Based Practice (EBP), ASHA.org.
  • Zimerman, AL. 2013. Evidence-Based Medicine: A Short History of a Modern Medical Movement, AMA J of Ethics, 15(1):71-76.

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