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Podcast Episode #27 Myofascial Release And CLB, What Does The Evidence Say?

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James Johnston RMT 0:12
You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston.

Eric Purves 0:17
And I’m Eric Purvis. This is a podcast by massage therapists for massage therapists.

James Johnston RMT 0:22
Our objective is to simplify how to be a more evidence informed practitioner. Let’s dig into this episode.

So often said that you can’t judge a book by its cover. And I think you could say the same when it comes to research. We’re going to look at a paper today called myofascial release for chronic low back pain, a systematic review and meta analysis. And funding when I looked at it, I just assumed that they would be trying to point out wonderful and effective myofascial releases. But the paper tells us otherwise.

Eric Purves 1:04
Yes, I liked that. The, the title kind of brings you in, I use that as a manual therapist, as massage therapists, you’re like, okay, my apologies, chronic low back pain, all of a sudden, my, my alarm bells were up and I was like, Oh, I’m going to tear this paper apart. It’s going to be crap. You know, my bias was coming into effect. And I was like, oh, no, you would send me you’d send this you’d found this paper and send it to me. I thought, Okay, well, let’s just let’s just see what it has to say. And I was pleasantly surprised. There’s a few things in here, which, you know, I didn’t agree with it. I’m sure you as well. But I was pleasantly surprised how they went about it. And the findings that they came up with? was not what I expected.

James Johnston RMT 1:44
No. And it turns out, I did confirm my bias as I read through it.

Eric Purves 1:47
Yeah. Yeah, yeah. I mean, it basically, you know, you know, slow, stretchy skin techniques to the low back aren’t as wonderful as some people claim. But there is some positives, and there’s some nothingness of this. What is what did it find, though, is lost or is never mentioned in these studies? And I think this is the problem with these type of studies like this, like these quantitative studies, where there’s like, assigning value or numbers to things is there’s no qualitative aspect of like, what does this mean to the personally, the person getting the most is going to put into this air quotes MFR treatment for the low back? Do they value that? Or do they value exercise? Or do they value rescue? They value medication? Do they value that type of massage technique? Or like, what is it that they want, because when we’re looking at these kind of patient centered care stuff, you know, all these buzzwords we hear all the time. And that’s really the way things should be going as person centered care. If someone comes in and you give them this, like slow, stretchy skin, technique, of varying forces, whatever feels good for you, and the person receiving it, you know, we say we call that myofascial release is the person value, that is what they want.

Jamie Johnston 3:05
Yeah, yeah. And rarely,

Eric Purves 3:07
that makes a big difference in terms of the outcomes are going to come because you can’t, you can’t force somebody if something they don’t want and expect them to get better. Yeah.

James Johnston RMT 3:15
And like to go along with that, it’s they also never mentioned anything about contextual factors of treatment, the interaction between therapist and patient, the, you know, all those other things that we know, matter so much. And granted, in this case, because it’s systematic review. You know, they’re just looking at all the papers that have been done. And so it’s not necessarily necessarily their responsibility at this level of the research to, to look at that. But at the lower levels of the of the research of the papers that they would have looked at, they it’s still not talked about, none of those things are, are taken into account. And, you know, it’s not talking about the confidence of the therapist and doing those techniques, compared to one that they don’t like, right, and so, even though it’s, you know, one of the things they looked at was myofascial release versus Sham, and I’m not sure what the sham was, but, but it still showed that, you know, it wasn’t getting better. So, so it’s, you know, I wish that they would start doing research papers to take all of those things we just talked about into account as as part of it.

Eric Purves 4:20
And that’s the thing that that I find is seems to be a problem is they keep on doing these studies, and people putting these papers when they’re looking at the same thing again, and again and again. And again, you think, why do you like and then they always a conclusion always is more research is needed. But why don’t you do the other research as needed rather than doing the same research again? I mean, this is this paper was done at universities, some china and Italy looks like this where the researchers were, and it was just done last year, and it’s just time Yeah, July 2021. So it’s relatively like it’s a newish like a very new study. But you have to keep putting these resources and times into it and you’re studying. Myofascial release for chronic low back pain. And I think this is the problem with this, when you call things like this, it tends to probably add more validity to the term myofascial release than it really deserves. Because if you’re doing myofascial release, and someone can be like, That’s what I do, I guess why I call my technique. And I think, you know, myofascial release sounds nicer than slow, stretchy skin technique, if you know, for sure, probably triple s t technique. But the problem is, is that it’s inferring that you’re making that you’re like imparting change, or you’re like creating change in the muscles and fascia. Yeah. And that is and that and in order for that to be true, that has to be validated first. And we know that from other studies, that your manual techniques don’t actually create long standing changes in that tissue. Yeah, through the mechanisms proposed, proposed, right. So we know it’s, there’s this neurophysiological things which have these more reflexive effects. But that’s, that’s, you know, when when you’re using it, you’re myofascial just, it makes a lot of assumptions, right. And it, I think it creates this idea that tissue needs to be addressed in a specific way for a specific problem in order to get results. And you know, and there’s a lot of assumptions made about how this works. I think in the paper, they talk about, like changing this visco elasticity of the fascia and increasing blood flow and, you know, increasing neural function through like opening space, creating space from I can’t remember. Yeah, the like, Okay, well, that’s a lot of assumptions. Those are assumptions. Those are not science facts. Those aren’t those are hypotheses or theories,

James Johnston RMT 6:47
which was, which is what a lot of the myofascial release research has been based on.

Eric Purves 6:54
Yeah, and even in here, and his paper when they talk about near the end when they’re there, and we’ll get to there. And when they talk about the, you know, how this is supposed to work, they’re using old research, which isn’t even, like, physic neuro, are there even physiological anatomical studies, really, they’re like, just old, like ideas by like, SCHLAPP. And our, you know, and just just going like, Okay, well, these are ideas, and they helped us get to where we are now, but those ideas are kind of not fully complete, we have

James Johnston RMT 7:25
to put those in them are completely wrong. Yeah, we have to put those away now, and, and go with, you know, start looking at the stuff that Bilasa T is doing. And that’s the more modern interpretation of what’s going on, right. So that’s the stuff that should be included in their paper like this, when we’re talking about how things work. And interesting, like, towards the end of this paper, or even talked about, like, looking through all the papers, they couldn’t define one specific technique that was used, it was all different myofascial release techniques that were used. So they can’t, It can’t even be narrowed down to say, you know, doing a hold on the area around the QL, for X amount of time in this direction, was is the way to do it. Because there were so many different styles that were used, that they couldn’t pinpoint that. And kind of funny to go with that because I just was looking at a paper recently about manual lymph drainage. And they were trying to say that manual lymph drainage works. And then when you read through the paper, all they do is say we did general Swedish massage in that area. So they weren’t doing MLD technique. They were using Swedish massage and saying manual lymph drainage works. Wow. Right. So so so that’s, that’s like one of the big issues with all of these modality based or technique based things is that there, there’s nothing concrete about it. And the more that we understand about how things work, when we put our hands on people, we can realize that none of these are all outdated ideas and theories that should really be

Eric Purves 9:03
put to bed. Totally, totally agree with these things to what you see is, you know, all these studies, like all these manual therapy studies, right, they all kind of show doesn’t really matter what you do, you name your technique. And they all show that you’ll have a short term decrease in pain and maybe a little bit of increase in physical function, depending on how those are measured short term, but doesn’t matter what these myofascial release are cranial sacral or Swedish or anything else, they all kind of show the same thing, which I know some people might who are listening maybe people who listen to this podcast before and like oh my god, these guys are who are they? They don’t know what they’re talking about. We promise has a million times the last thing on the podcast we’ve done now 2530 of them something like that. That it’s it actually should be empowering to us because it means we have more opportunities. 100% And it doesn’t have to follow the specific protocols and in the courses that we teach together or individually, you know, we always talked about that like, it’s just like, beaks, explore, be curious, find something that feels good that you like to do that the person likes to do. That’s, you know, harder, softer stretch, your faster, slower doesn’t matter as long as it feels good to the person, that’s the person centered care. You don’t have to worry with these very specific interventions. And I know that people are that, you know, are gonna argue that, but that’s okay. You can argue that all you want, like, there’s not the data sport, you may have your clinical experience to support it. And I would never argue with clinical experience. But the reasons why you’re getting those results from your clinical experience are probably very different than what you think. Yeah. And this is where we have that ethical obligation as healthcare providers to to be less wrong. Yeah. Don’t claim you’re releasing fascia.

James Johnston RMT 10:46
When we know that that’s not possible.

Eric Purves 10:50
Exactly. But you can make people feel good doing those techniques. Yeah. And that’s, I think, where the the discussion gets bogged down a little bit.

James Johnston RMT 11:01
Yeah. Funny enough, you know, the discussion that we were involved in offline this morning was something around, I think the term was used, elitism. Where, you know, people that are, you know, they’re discussing things with physios and things like that. And there seems to be this manual therapy elitism. And, and as I was watching some of the comments around that, I was like, Well, you know, people could probably point at us and say the same thing. Because we’re pushing so much for evidence based care, there’s probably a certain population of massage therapists that look at us and go, Well, these guys are, you know, they’re, they’re trying to be elitist in what they’re doing. But it’s, it’s just not the case, we’re just trying to bring the education around what we do. So this sort of a little bit of a tangent off track there. But you know, it’s a podcast. But it’s, you know, I think we just got to be, be careful when we’re, you know, when we’re interacting with other therapists and things like that. And like you said, there’s probably lots of people that listen to this, and these guys are idiots. They don’t know what they’re talking about. Because we’re looking at this stuff and trying to get rid of those old narratives. So, you know, we just probably want to get across that we’re not trying to be elitist about anything, we’re just trying to bring forward the most the most up to date information about the things we do in order to help other therapists.

Eric Purves 12:26
And I think that what happens sometimes is that, you know, I know, we’ve seen people before, I’ve seen have said things like, oh, you know, I’m tired of the myth busting. And, you know, I don’t believe that when you we educate, we just spend so much time busting myths. And I agree with that to some way. But the problem is, is that having been teaching CCS for so many years now, I’ve done them over 100 plus times, when you experiment to try something different, and you don’t do the mythbusting aspect of it, things go sideways, because people don’t know what you’re talking about. Yeah. And so

James Johnston RMT 13:03
as well as, as long as the myths still exist. Yeah, we have to do something about that.

Eric Purves 13:10
Yeah. Yeah, and I would say we do way less now than we used to, I used to spend so much time on it, but I just kind of got like, well, you know, I’m just kind of tired of doing it, because been doing it for seven or eight years now. And you think, how many more times do we need to do these bust these myths like these things are, but they’re still there, and the society is still there. And the profession? So yeah, we maybe would call there’s a term myofascial release. And it’s like, Oh, my God, I’ve heard these guys say this a million times. But the thing is, is still the common narrative is still the common idea within the profession of what’s happening. And there’s this like, higher level of value assigned to certain techniques over others. And, you know, I don’t think yeah, we’re not trying to be elitist. We’re just trying to say, look, we spent it, this is what we do for a living. This is like, we read this stuff, we talk with the stuff, we teach this stuff, you know, and we’re trying to change the profession to be more evidence based, be more up to date, because we don’t make these changes, then we’re gonna be left behind. And I think that we don’t want to be left behind. We want to be seen as leaders, like we know we can do we can be leaders that MSK care. And, you know, we made that comment before and of course, we be leaders and we’ve had people be like, Well, I don’t think it’s fair to put down other people or other professions where that’s not what we’re saying. But yeah, why would we not want to strive to be the best set like hands on and movement based musculoskeletal care? Why do we not want that? We can do it is within our scope? Yeah. Yeah. And then the also to sorry, I’m gonna go on a tangent here. Now just thinking of like, previous like courses we’ve taught and other podcasts we’ve been, haven’t necessarily been ours. Where people hear us terrible things. Like I think we made some discussions and some stabs at the importance of the psoas muscle on someone else’s podcast, thinking practitioner, maybe In the last pod, yeah, we talked about that. And then we got, we got some, like, from this one listener and got some very kind of like upset emails. Yeah. Basically saying that, you know, you should be better than calling out this stuff. And, you know, it makes it sound like you’re like you’re, you think you’re above everybody. And we’re like, no, like, that’s not we think at all. We’re just talking about this stuff, because this is to what we hear all the time. Now, it was a while ago, I can’t exactly remember the context of that. Maybe you might remember, but I remember thinking people hear what they want to hear. Yeah. And, and if you say something that makes them feel uncomfortable, they oftentimes will come at you as trying to be elitist or being trying to make yourself feel superior or making trying to make others feel dumb. And there’s never that’s never my intention was the intent. And so sometimes, maybe if people feel that way, I’m like, Okay, well, maybe I could have said that better. Maybe we could have had that discussion better. I don’t know. But or maybe somebody you think, well, maybe, maybe that’s, maybe that’s you listen to the listener, which I like. Because not everybody feels

James Johnston RMT 16:06
that way. Yeah. And we’re not going to be able to make everybody happy. No, right. There’s always going to be somebody who, and everybody has the right to take things the way that they want. And that’s fine. But, you know, but I think it really comes down to like, when people get their beliefs challenged, is is typically when we get that that kickback. Right? You know, I, we could go that’s a whole other podcast we could talk about. Sure. Yeah. You know, and I’ve been, I’ve been doing some, some learning and some reading around that lately. And it’s some really interesting stuff about how the brain always switches to a safety mechanism, even when it comes to that stuff. So when those beliefs get challenged, you know, it’s an automatic automatic reaction for the person to get upset and pull back and be like, no. So, you know, could we have done a better job of trying to change the opinion of somebody? I think we’re, I think we’re doing our best and, and all you can do is do your best. So if people can be offended, that’s okay. But we’re, we know that there’s other people and there’s people in the population that we’re helping, because because those narratives are getting changed.

Eric Purves 17:20
Yes, yes. All right, you want to

Unknown Speaker 17:25
paper after that ramp?

Eric Purves 17:26
Yeah. We shouldn’t, we shouldn’t go put it like thing. Fast forward 15 minutes, and you actually hear the paper.

James Johnston RMT 17:34
So one of the things that that I looked at with it, and I’ve just got the paper in front of me, so I’m gonna have my head down reading but is when they looked at the when they were selecting the papers they were going to look at and they looked at the comparison, they looked at my alpha myofascial releases versus sham myofascial release versus exercise, myofascial release versus exercise, myofascial release, and exercise versus exercise, myofascial release and spinal spinal manipulation versus spinal manipulation alone, and myofascial release and phys ed physiotherapy program versus just a physiotherapy program. And really interesting when they looked at the outcomes, the outcomes weren’t any better. Let’s just myofascial release, so and, and that was strictly just looking at pain, and doing like the disability pain questionnaires and things like that. But it wasn’t any better. But then when it looked at things like that, what really stood out to me is like physical function and mental health. And when they looked at things like that, so what really jumped out to me was like kinesio phobia, when they’re looking at mental health that myofascial release did not help at all, when it came to things like that. And, and when we look at it, it’s like, well, especially with something like kinesio phobia, how could it possibly help? Because, you know, that’s fear of fear around movement, that it’s going to cause more pain. So how would somebody laying on the table being passively touched, have any effect on that whatsoever? And that’s one of the big reasons why we need to incorporate more movement into the treatments that we do in order to help with that aspect of goals.

Eric Purves 19:04
Oh, for sure, for sure. And I think with what I get from from this, just from the very kind of like, general aspect of it is that, you know, six, manual therapy or myofascial release, right, it works for pain, and it works for certain types of function. And depending on the studies and how they measured it, but everything else kind of works, too. So, you know, it’s I think this goes back to that initial statement we made were like, it really depends on the person wants. Yeah, and what’s gonna work for them. You know, the one thing that I find is is you see a lot in the musculoskeletal literature, which I find to be, I don’t know, almost lazy research is that they do with like a plus b, right? So you look at myofascial release and spinal manipulation versus just spinal manipulation, myofascial release plus physiotherapy program versus physiotherapy program, you’re getting two interventions to one. So maybe two interventions are getting more care and more is being done to them. So oftentimes, what you see as those studies will produce better outcomes than just one thing alone. Yeah, to make this, you know, to make myofascial release as that technique to be seen as more validated that you’d have to compare that with another similar technique.

James Johnston RMT 20:31
Yes, so say you did myofascial release versus cranial sacral? Sure, yeah. But

Eric Purves 20:38
or myofascial release versus general Swedish or, or maybe just myofascial release versus spinal manipulation? Yeah. Or myofascial release versus, you know, dry needling or you’d see like, you know, intervention, you know, comparison, what are the outcomes and see which one is better? My assumption would be based on the data I’ve seen for other things is they’re kind of the same.

James Johnston RMT 21:01
Yep. And then be interesting to if they if they did a study that way, if they were to say, taking 100 People who had low back pain, and before they got there, say, What do you prefer acupuncture or hands on technique, and they put the people into the things that they thought would work better, and then see what the outcomes are? Yeah, I think that we’ll show them the opposite one, and see what the outcomes are.

Eric Purves 21:25
Yeah, Mark Bishop and his research group in Florida, they did something like that with it with acupoints. Like, they put people into different clinicians who had a different preferred way of treating spa money for the therapy or exercise. And then they, they just randomly allocated people to the treating clinicians, I could be wrong. And this I’m probably telling someone, if someone knows the studies they’d like, yeah, you’re wrong. But general idea. And what they did is what they found is that when they ask people afterward, are they the people treating the clinicians treating, didn’t know what the person’s preference for treatment was? Okay. Right. And so the clinician got to be able to do a treatment on somebody. And then afterwards, what they did is they I believe, they looked at the data and said, Okay, these 50 people got spine, we have a therapy, these 50 people had a light touch, or an exercise intervention came out it was, what they found was, if I remember correctly, is that when those people that one of those people that were given spinal manipulative therapy, if that’s what they liked, and that’s what they preferred from, and then the provider loved that was their preference and confident with it. And those things matched the person reported better outcomes, which goes with kind of with what we’re saying here is if the person values it, and I should values it, you’re gonna probably get better outcomes than if neither party does or if one party values and the other one doesn’t. Work, which, and there’s a bunch of other studies on that. That’s just the one that comes to my mind. I think that was one the first ones I read years ago, and maybe we didn’t have a podcast about that, cuz I’m probably bastardizing. The

James Johnston RMT 23:11
Yeah, we should find that paper and look at it be cool.

Eric Purves 23:15
Yeah, I haven’t someone. One thing to just when you’re talking about the manufacturer is one thing I wanted to just mention, which I thought, this is the thing that I think is something that’s very problematic for people that are reading study. So if you’re reading the studies, have a look. And if you see these type of statements, make sure you read the references that they’re coming from, because one study or that they talked about in the introduction, it says, Previous studies have found that the psoas muscle fascia may be related to chronic low back pain, that all of a sudden for me, I thought, Really, okay. And then so I went and read the other two papers that they took that reference from and what the author’s said that the conclusions. And then the conclusion is where we see changes in connective tissues and people with low back pain, this could be either the cause or the effect. So all they’re saying is that when you have low back pain, it looks like all the tissues that we’re attaching are round to low back. We’re different than those who didn’t have low back pain. And so that’s a big leap to say the psoas muscle fashion is contributing to it. Yeah. Can you be and then the author’s go on to say, and there’s other studies that, you know, when people have chronic low back pain, they’re different motor control? You know, I think a lot of them had were heavier, they might have been, like, heavier people will be in my mind might have been bigger or less active, that kind of thing. And so, you know, maybe the changes that we’re seeing because they did it all through ultrasound, or not causative, but maybe they’re a response to being in pain for a long time. And that’s what other studies I’ve read, too. So I think when you see these kinds of statements like so as muscle fashion, maybe related, well, those those authors didn’t Let’s say that they said they see a change there. It didn’t say it’s necessarily causative. I think that’s, that’s a, that’s something that we need to be very mindful of when we’re reading these papers is that these kind of bold statements, go check the references and see what those references have to say.

James Johnston RMT 25:13
Yeah. And whenever I read something like that, when it says, the psoas muscle may be a contributor, that that to me isn’t a, that doesn’t tell me that the source is a contributor. That when whenever it says May, I’m like, okay, that that just means that there’s a possibility. It doesn’t mean if it’s not a for sure thing. So, you know, just when you’re reading it, to me, anytime that it says it may do this, isn’t it’s not a be all end all. It’s a, you’re referencing a possibility, not a not an absolute.

Eric Purves 25:44
Exactly. Exactly. And yeah, if you familiar with some of the debates about the fascia, rather than so as muscles relevance, I think

Jamie Johnston 25:54
we have a whole other podcasts that sort of motivate a whole podcast

Eric Purves 25:56
on that. And TJ did a big and I think human image Austin might have done a Facebook Live on that maybe. Anyway, yeah, it’s been that’s been beaten to death. So

Jamie Johnston 26:06
yeah, so we don’t need to be

Eric Purves 26:09
talking about that too much. But it was just something I think, people if they’re listening, make sure you check the references, the references, if something seems to be a bold claim that doesn’t resonate well with you see where they came from?

James Johnston RMT 26:19
Yeah. So it is really mean. Like I said, this paper confirmed my biases. But it goes through and talks about physical physical function, quality of life, balance, function, printing, pressure, threshold, trunk mobility, mental health, all these other things that they picked apart with the information, and it still showed that myofascial release didn’t have much of an effect on any of it.

Eric Purves 26:46
No, that’s something I would I would I would love to see is that they did talk about it. And if you looked at some of the other studies, the researcher they did they usually analysis, they looked at myofascial release, and how often people got it, and how long the treatments were. And that was quite very, they used the treatments, I think, or somewhere 40 minutes or so. Yes, as your 40 minutes once every two weeks or 40 minutes once every three weeks or eight weeks, some are 40 minutes each once every two weeks for two weeks. My family six times in total. But they don’t actually describe what the author or what the clinician did. Like what was what are you calling myofascial release? Like? How are you? What’s the is it the same for everybody? A same protocol in person centered, like what what techniques are you doing? That’s the kind of stuff that would be really important for us as massage therapists to know. Now, we don’t want to follow a cookie cutter recipe approach, because that’s boring and lame. But it would be nice to know if they’re like, Yeah, we did this technique. And maybe it was just like a slow hold, you know, for two minutes. Yeah.

James Johnston RMT 28:01
Well, that’s like what I was mentioning before, just to back up, what you’re saying is right, right, at the end of the paper somewhere, makes the statement that they couldn’t they couldn’t recreate it, because they didn’t because it was all different styles of myofascial release that were being used. It was all different techniques. So

Eric Purves 28:18
yeah, exactly.

James Johnston RMT 28:21
And it’s kind of funny, because you know, this, this probably sounds like we’re picking on myofascial release as we discuss this. But you could probably take any manual therapy technique and put it at the title of this, and it would still apply the same way.

Eric Purves 28:36
Right? Yeah, I think that what you see, what I seem to see is because myofascial release is something that, you know, it’s for some reason we’ll have for whatever reason it is it’s, it’s a term, it’s a treatment style, it’s very popular in the world, and, you know, we have fashion everywhere. And so let’s try and manipulate it. And when we do these techniques, they work and so you have clinical experience of like, hundreds of 1000s of people and clients that are respond well to it. But yeah, you there’s so many different ways of doing it. And there’s so many different ways of touching and moving and manipulating people that how could you ever say that one is right and one’s wrong? Obviously, the one way is better than the other. And that’s, I think it was one of the problems that we see with this stuff. And but because myofascial release is so popular, and it does and they do saying here somewhere that, you know usually involves holding for like 100 to 300 seconds. Right? And so, and then we’re like and they’re like and then people feel better. But then if we look at what some of the neurophysiological things that occur with the slow, sustained stretch techniques, and when you put that force into tissue, we do see that there is an anti nociceptive effect through activation of a variety of things, but one of them being I believe it’s Ruffini corpuscles.

Jamie Johnston 30:03
Yep. Pressure receptors, right?

Eric Purves 30:05
Yeah, I think it’s really so and so and so I can’t remember I should know, when I teach this stuff I should know if I’m mad, but I’m tired. I just got back from vacation. So my brains a little bit. When you do the slow stretchy skin, Teddy’s a certain receptors in the skin and upper layer of the connective tissues that do actually slow down noxious stimuli through the spinal cord. So that’s why people feel better after a massage, right? It doesn’t have to be necessarily that slow, sustained one, but from what I’ve read before and other neuro physiological studies is that when those things are held for a certain period of time, they become more activated. And that’s going to create a larger antinociceptive effect. So maybe myofascial release isn’t changing the fascia, maybe it is more likely being that you’re activating these receptors, which is changing the sensory input that your bodies that your spinal cord in the brain is receiving. That, to me is makes more sense because we can measure that.

James Johnston RMT 31:02
And that’s how, that’s how every technique works.

Eric Purves 31:05
And so every time Yeah, so that’s a, that’s something I really wish that we would embrace as a profession, rather than chasing all these these techniques.

James Johnston RMT 31:15
Well, I I was having a thought the other day. And this can this can go back to that I was writing a blog post about it. The the whole thing where we will get our beliefs challenged. And I was thinking, Well, what if, what if, when we were in college, we didn’t actually name any of the technique courses? It was just called manual therapy technique. Class one. Yes. And then we had equal amounts of classes in research and exercise. And we did two manual technique courses. So what if we had five classes on how to do a massage five classes on some exercise and five classes on some research? And all we called all the classes were massage therapy technique, manual therapy technique. Yeah. Then when we got into school, we wouldn’t run into this whole identity thing where it’s Well, I’m a myofascial release therapist, or I’m a cranial sacral therapist, or I’m a general Swedish massage therapist, or I’m this and that, it would be just a manual therapist. And then it wouldn’t be so daunting when those beliefs get challenged. Because the beliefs wouldn’t be there for the most part, right?

Eric Purves 32:33
Well, because they’re put in there by school, or any, you know, thing I’ve talked about before is that the what you learn in school forms the foundation for what you’re how you’re gonna practice. And it’s very hard to unlearn those things. And I agree, I love that idea. That if we could just stop naming these techniques is like the special thing, but teach a variety of those techniques, but teach them under like a general manual skills thing. Use those techniques to work with specific populations. So teach people some manual skills. Well, here’s some different ways this is, this is like what we would normally call Swedish massage, it’s kind of long or slower or faster. Yeah, sliding and gliding techniques. And there’s ones over the stretch here, ones and ones that are maybe a little more specific, maybe you want to use like your thumbs, your fingers, your knuckles, your elbow, whatever, you know, here’s ones that are maybe a little more pressure. And here’s what’s more, like, maybe you’re doing some trigger point type things with little more pressure in a certain spot, or whatever that looks like, you know, like get people to teach everyone the skills and how to touch because that’s really important. And that’s what I think separates us from other MSK professionals is we do as a profession have our touches is better in terms of that, because we do all day more experience with more experienced patients like betterment, and we’re more experienced with it. So but yeah, just so that we you move away from all these different name techniques and creates people to kind of pick and choose what they want to do, rather than just gravitating towards a specific way of thinking. Yeah, and you could easily do you could be here’s to all these populations that you’re going to treat. Here’s a class on geriatrics. Here’s a classroom class, no sport, here’s a class on, you know, surgical rehab, you’re the one on like, I mean, we do I do anyway, did some neurological stuff. And all this stuff was very, it was kind of very, it was quick, quick, and there wasn’t really a lot of thought process. It’s like, well, I can use these techniques and use these techniques for this person. Yeah, but you don’t really have to think about it. I mean, I know some schools probably do a better job than than others. But when we went to school, you were really taught to think you were taught just to basically copy and paste. Yeah, yeah.

James Johnston RMT 34:37
Yeah. What was it the neural stuff was like roots techniques and things like that. Yeah. And

Eric Purves 34:42
a couple other other other technique, things that you learned, but the focus was always on technique, technique, technique, and it was never enough on like critical thinking or interaction or how would I communicate with this person? How would I explain to them what’s going on? They’re gonna be like, Why do I hurt what’s going on? What are some strategies that you can use that aren’t like pathway anatomical tissue blaming. Unless there is a tissue, you’re injured, yeah, yeah, there it is inflamed here that’s going to take, you know, for six weeks to recover, like just to learn these basic things, which we do in clinic. But I find that when people come out of school, they’re not given that they’re just given a visit to basic. Yeah. And I think that can result in more. Not not the total

Jamie Johnston 35:27
results and what we have now. Let’s, it results in what we have, though.

Eric Purves 35:32
Yeah, exactly. Exactly. So yeah, that would be that’d be nice to change those techniques. And I like that you brought that up? That’s good.

James Johnston RMT 35:40
Yeah, I’ve been looking at a lot of stuff about that whole belief system thing lately, and I’m trying to make change. So yeah. Yeah, some thought reversal kind of stuff.

Eric Purves 35:54
For sure, ya know, as important stuff, right?

James Johnston RMT 35:58
Well, I think we beat a lot of that to death. But I think getting towards the end of the paper, it also pointed out, there was like five or six points that it made about, basically why the research they looked at wasn’t good. Which is important to take into account. And some of the things that they pointed out is like, a lot of the papers didn’t have long term follow up with the patients to show whether the whether the pain relief or whatever lasted for them. You know, it talked about like, it didn’t include things about disease duration, how long this has been going on for them. The risks in terms of randomization, so there was like, a whole list of things that he pointed out by there needs to be more research done on this stuff, because the research we have isn’t good.

Eric Purves 36:46
Yeah, they said that the quality of evidence to was only the best, it was moderate. And that was for pain, and physical function, which is what they that was what they said the conclusions were from the data that painted physical function is the best thing for that we can say myofascial release does, based on the current data we have, all the other stuff was low or very low. And the but there’s only moderate. So it’s not like high quality level of evidence. So it’s like, less. So okay, it’s not great. But that’s seems pretty consistent with what you see most other any type of manual and massage therapy, literature’s the outcomes can be monitored, at best for short term. And we all know clinically, right? People come to see us they leave, they often will feel better. And

James Johnston RMT 37:33
it’s, there’s so many things that go into that more than just us putting our hands on them.

Eric Purves 37:38
Exactly more than just the technique. Right? So yeah, what I did like, though, in his paper, there was they did say, you know, when they’re talking about the limitations and talking near the end, right, they’re talking about, like, they say, you know, integration of sensory information, central nervous system processing, neuromuscular activity, and they start using a lot of appropriate receptors, the overall adjustment of the nervous system, they talked with all this, they started talking about all these other things that occur. So it’s funny, it’s just funny to me that they, they started paper being like myofascial release is supposed to do these things. And then when we go to talk about the outcomes, and the things that, that you see in people with, you know, when they’re looking at their measurements, like these are all the things that we see in proprioception, sensory challenges and this kind of thing, and you’re like, now they’re talking about neuro physiological stuff, which I feel like they should have been talking about it earlier, when they kind of were building the background.

James Johnston RMT 38:36
Or when the it’s funny when they’re building that that background part, the part you’ve commented on a couple times, it was like a long couple paragraphs where they were basically saying, This is what the papers say myofascial release does. And then they went through and I, honestly, I kind of glossed over a bunch of that, because I’m like, No, it doesn’t do that. But they were referencing what the papers say and then, and then get into what manual therapy actually does with this stuff. You’re just talking about the neurophysiological input and things like that. So it’s good that they came around to almost correct that part of it.

Eric Purves 39:10
Yeah, which made me feel feel happy with the two and and they did say yeah, like, it kind of has short term impacts, but sounds great. It’s gonna be better than much else that’s out there. But they did say, you know, at the end, too, which was just great. As I said, future randomized controlled trials should strictly limit interventions and reduce the use of combination interventions, which is what we’re saying earlier, like the a plus b, right? You do this and this, versus that. So just do like, a single one to see is this type of treatment. And you can you can you put that, can you quantify that Troodon? Or can you put it into like something like, this is something that we’re going to deliver, like this is how we’re going to do it, which I know isn’t very person centered, but if you wanted to see if a technique work, it has to be standardized. Yeah. Like do you have to like this is what we’re going to do for all these people that come in, at SCORE whatever it is on this Back Pain measure? Yeah, and that we’re gonna do this very specific protocol, and we’re gonna see what happens. Right? And you probably the results probably aren’t gonna be great, but at least you, you know, they’re not gonna, it’s not gonna be like, Whoa, amazing. We’ve, you know, found the cure. But it’s, it’ll, I think that’s what the better way of doing you say. So we can say, Look, this type of technique can help or the technique type per technique, man doesn’t is. That’s what we like to do. Go ahead and do it, which I think is what I got from this. If you’d like to do it, go ahead, do it. It’s not going to be the be all end all the works for you, of course, people who come to see you, then it is part of the overall treatment plan.

James Johnston RMT 40:37
Yeah. I mean, the other thing that I take from papers like this as well is it really reinforces to me why the clinical guidelines of MSK care or education reassurance movement and some manual therapy, right? Because we know that reassurance and education plays a huge role in the mental health and the functional aspect of things. And then, of course, so does integrating the movement into things because of things like kinesio phobia, and, you know, other issues that that people have. So it really reinforces to me why manual therapy is the thing at the bottom of the list, and why those other things are more important, because it shows that the technique alone doesn’t really do a whole lot, by comparison with pain and physical function and all these other things. It’s a piece of the overall

Eric Purves 41:25
puzzle. So yeah.

James Johnston RMT 41:29
So I think to kind of wrap it up, and to go back to what you were just commenting on is, if you really liked doing myofascial release techniques, and your patients like it, continue to do them. But the problem is that we just need to change the narrative around it, we need to stop telling people that we’re releasing fascia, we have to, you know, change those things and start talking about, you know, inputs to the nervous system and how things actually work. And then of course, start if you’re not already start into integrating more movement, education and reassurance as part of your treatment plan with your people.

Eric Purves 42:05
And people feel good to catch on when it feels nice, as we always say, TPN touch people nicely, that can such a subjective thing, right? That’s totally different for everybody. So it doesn’t mean you have to be super gentle, it doesn’t mean you have to be, you know, it doesn’t mean don’t touch them, it just means fine touch that feels good. Make them feel good. Give them movement, if they value moving to find them to do something that they that’s important to them as well, because yeah, that’s the a plus b right there. If they can do something else as well, or when they’re not in a treatment with you, that’s gonna be in most of the population, that’s going to be

James Johnston RMT 42:37
good for them. Yeah. And make that make that interaction with them meaningful to them. Right, make the make the treatment, make the movement, make the homecare all meaningful to that person, and you’re probably going to have better outcomes than just doing myofascial release

Eric Purves 42:52
alone. And I think what you said beautifully in our last podcast, was he talked about engage in treatment, rather than just give or provide human engagement. So I think I like that I think it plays really well with kind of wrapping up this discussions. Yeah, engage with people and have them, have them have a say in what they want to do like to do and facilitate that for them.

James Johnston RMT 43:13
Perfect, we’ll end it there. Alright, see you next time, everybody. We hope you enjoyed this podcast. These kinds of topics are what we are all about. If you’d like to learn more, go to our websites,

Eric Purves 43:26
themtdc.com or Ericpurvs.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.

References

  1. Wu Z, Wang Y, Ye X, Chen Z, Zhou R, Ye Z, Huang J, Zhu Y, Chen G, Xu X. Myofascial release for chronic low back pain: A systematic review and meta-analysis. Frontiers in medicine. 2021 Jul 28;8:697986.

Podcast Episode #26 The Biopsychosocial 40 Years Later

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Jamie Johnston 0:12
You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston. And I’m Eric Purvis. This is a podcast by massage therapists for massage therapists. Our objective is to simplify how to be a more evidence informed practitioner. Let’s dig into this episode.

As somebody who just turned 47 years old, I can’t quite remember things that happened 40 years ago, but the biopsychosocial model of pain has been around for about 40 years now. And it’s very important for us to take a look at anything like this and understand what changes have taken place in 40 years. And how have we improved?

Eric Purves 0:57
And this is a this is actually a really kind of Hot Topic, really the the bio, psychosocial, social model and, you know, is it like, how do you apply it in practice, you know, and there’s a lot of arguments back and forth about like, you know, it’s on a predictable model, right? It’s not like a mathematical model. It’s, it’s a conceptual framework and the authors of this paper, this paper is called the biopsychosocial, social model of pain. 40 years on time for reappraisal, it’s in a relatively recent journal of pain. And, yeah, it’s good because I think it it challenges or brings into discussion, a lot of the points that you hear, especially those of us that spend time reading the debates on social media, and a lot of problems people see in the bio, psycho social. And I what I feel is that in, in my experience, my understanding is, the bio psycho social model is itself not much of a problem, because it just it seems, has been around right for over 40 years, in the pain world longer. I think it first was talked about 1947 or 1977, I think, by George angle, and then, you know, loeser or loeser, have you printed him and Waddell had it? You know, and, you know, fears after that. But the facility is still around, I think there’s there’s still a lot of value. But the biggest problem seems to be is how was it used in clinic? Or how was it researched? And then that’s what we’ll talk about today is in this, this research paper, or this discussion paper, they talk about how when people use the terms biopsychosocial oftentimes, the studies are just looking at one aspect of it. They’re not well defining other like, well define the psychosocial or what is social? Or what is conservative psychological. And, you know, in the bio, like when we’re looking at bio, what, like what’s included in that. So there seems to be lots of a gray area there. And I think that’s probably when people are critiquing the model. And I think they do have reason to critique it. It’s because more often of how the model is applied, rather than the muscle word to use the conceptual, conceptual framework of what the model is supposed to represent, which is this full person care.

Jamie Johnston 3:14
Yeah, and one of the things that really stood out, as I read through it is how much they touched on multidisciplinary care, where they had psychologists that are dealing with the psychological end of it and physios that are maybe handling the bio, and you know, and then the social factors that come into play, and the importance of communication between all parties, when they’re trying to help that person and, and interesting, I’m sure we’ll get into it when we’re looking at the the social aspects of the person returning to work, the importance of communication with the workplace, from the people who are delivering care so that it’s more of a, it’s more of a person centered approach, when you’re trying to help that person get back to their job or get back to those things that they enjoy doing.

Eric Purves 3:59
What I found funny with this, though, when you think about it, you know, you think about medicine, and you think about musculoskeletal care and MSK pain and, and whatnot. And you look at this, this model has been used for pain for 40 years, or it’s been talked about for 40 years. And the reasons that they say here was Waddell and Loeser. They observed that many of their patients with low back pain didn’t improve after corrective surgery. So the pain cannot be attributed to only biological influences. It’s funny though, cuz it makes you think what happened to all the years before that when people didn’t get better? You know, it’s funny how like, it took that long for people to actually start wondering if there’s something else going on. Yeah. And excited. Seems like, that’s like, seems to make sense, but it’s funny to think of how people must have thought about the body and pain.

Jamie Johnston 4:54
Yeah, and really interesting that those two, those two people that you mentioned was with Wadell and Loeser. You I would almost say that they were surgeons.

Because I wouldn’t have thought that that was coming from surgeon because we, I mean, we say it tongue in cheek a little bit and maybe make fun a little bit that we’re like, oh, you’ve, if you’re a scalpel, you just want to cut everything. Yeah, right. So great to see that they that it was surgeons who were looking at, hey, maybe we need to change the way that we’re doing things. And also really interesting that, you know, that happened 40 years ago. And maybe it’s just because you and I haven’t been therapists for 40 years, obviously. But we’ve only really seen it catch on and become more of more of a thing when we’re helping people in the last 10 years. Yeah, I would say model.

Eric Purves 5:43
Yeah, yeah. Oh, for sure. And even if I think you know, back to when I first started diving into the stuff and trying to understand it, and think I did my first CE course teaching in 2015. And I remember just kind of bringing these very basic ideas, because I was only still learning to two courses to try to be like, hey, there’s some interesting stuff that’s out there, maybe, you know, like, let’s, let’s talk about this. And then that was kind of the general idea of those early course stakes. Nobody, nobody knew about a psychosocial as then. Yeah. So it’s been around for 30 years. Yeah. And so nobody knew. And I was only had just been I’d heard of it before, but I didn’t really pay attention to it. Like, I didn’t really mean much to me. I was like, oh, yeah, okay, whatever. But it’s interesting to to, to see like those early days. And we know from our experiences, when we searched for spare teaching together in 2018, we started talking about things and bring up the biopsychosocial. And little bit of myth busting in there and some of the science of pain stuff, and how that stuff was completely new. To like, 99% of the people, whereas now, obviously, the last three or four years or two or three years, particularly. It’s everyone’s, yeah, it’s a common term. And people can have a general idea of Oh, biopsychosocial, yep. That’s like treating the whole person like person centered care. You know, what that exactly means? How do you do that in practice is still that’s the difficult thing. But that’s what we call our practice. Not a perfect. Right is to that’s the hard part, but at least people become more aware of it. But yeah, it’s taken 40 years. Yeah. It isn’t our profession where we are in our part of the world. Yeah.

Jamie Johnston 7:21
But then you look at, like the Louis Giffords that we’re doing this ages ago. Right. So like you said, it might be that it’s our profession or part of the world. Because I think Louie was a UK guy. He was yeah, nice, 80s and 90s. So maybe that was more prevalent there than then it was here. We don’t know.

Eric Purves 7:42
And this without going on too much of a tangent, which we might want to and we’ll see what happens here is the is when we look at the stakeholders involved in our profession, at least here in BC, right, we got the association, we’ve got the college, the cmtbc. And we’ve got all the all the schools that and there’s now 10 of them, maybe I think it was probably about 2014 2015 around there. If you tried to teach a Con Ed course, that said, and I said had bio psychosocial and you would not they would not approve it is out of scope. With the argument being that they hadn’t really the idea was they had no idea. They had no idea what it meant. Our own regulatory body had no idea what it meant. And even you know, our association in the schools and stuff still don’t adequately teach that stuff like the association. You know, they have conferences, and they put out content out there, but I don’t ever see anything on there being I think what biopsychosocial Yep. And you know, the it but it however, in Ontario, they put out some really good stuff. You had some great stuff there too. And so if we want to compare ourselves right to to another province has been around for a very long time and Ontario regulated province, is what I meant to say if I didn’t say that, there’s no province has been around for a very long time. So I’m tired back from the gym, my brain still foggy. The they had a conference in 2019, which I was fortunate enough to be at. That was I think it was called like bio psychosocial care or something for RMTS or something. So they actually had a conference those three years ago now. And they’ve had other things subsequently, which have been been kind of trying to bring us this idea to to the professional to the members. So we don’t have that here. And I really wish you know, this is a call to action thing. I wish the schools known I know some schools are great. I’ve talked to some the the people that are clinic directors and stuff of schools here and they are trying to do it but it’s just not widely accepted and just not widely accepted or maybe understood. And so I would suggest anybody that’s curious about what biopsychosocial means this is this is actually a pretty good paper to start at.

Jamie Johnston 10:04
Yeah, yeah. Well, and it’s it’s very cool that there was a lot of things in here as I read through that resonated with me because of my, because of my background. And also, because I’m somebody who works at a job in industry where people get hurt. So a lot of this really stood out to me. And it’s funny, one of the guys at work, told me he’s like, why don’t you go to the chief and see if you can come in once a week? And just do what you do with guys here who who need the help, but I think there would be a big conflict of interest. If I did that. If I, you know, if I was working on guys, and WCB was like, well, you’re one of his co workers, you can I think there would be too much of a conflict of interest for me to do that. But it would be very, yeah. Yeah.

Eric Purves 10:48
And that would be really cool, actually. Because that way, you would have the social and the bio, and the psycho all together in the workplace, in with their colleagues and their, their social network. And then yeah, you became the new exercising, which would be bio and Psycho and social would be the whole thing, right, are getting moving. And we’re going to be doing any hands on stuff. I mean, that’d be brilliant idea.

Jamie Johnston 11:12
I think so. And I’d love to just take a portable table and and be able to set up the table in the gym and be able to go through rehab with guys and do some treatment. And like I mean, guys are coming to me all the time anyway. And being like, Hey, this is sore. What should I do? So yeah, it’d be cool to just have like, you know, a day of clinic hours at the fire hall. So that somebody who needs it could come in and, and get what they need. But, but I think the problem is once WCB or something like that was involved, they’d be looking and going, No, you can’t have one of his co workers doing the work, because we’re not going to get an honest feedback about what’s going on with him. I think I think there would be too much of a conflict of interest score. Yeah. Yeah, that would be really cool. Yeah, very cool. Yeah. So just quickly skimming through, of course, we talk about psychological treatments, when we’re talking about the bio psychosocial and quite often, quite often, we’re looking at things like mood disturbance, and high levels of unhelpful thoughts like catastrophization, you know, the person kind of thinking that they’re broken, and lowered self efficacy. So when they talked about it throughout the paper, that’s a lot of the things that they talked about. And that was, were they, in my understanding it anyways, as I read through the paper, that those things were better handled by, say, a psychologist or a mental health expert, to be able to help them through that as part of that multidisciplinary care that we talked about a little bit at the beginning.

Eric Purves 12:36
Yeah, this paper, what I thought was really interesting was they broke down, like they broke it down into that, like a psycho bio social, and looked at the research. Because I think it’s just really important, you know, that the common term, you know, if you’re a hammer, you see nails, right. And if you’re a psychologist, and you’re treating people with that are hurting, of course, you’re going to be viewing them through a psychological lens, of course, your interventions are going to be more on the psychological end of things, right? Just like when we, as massage therapists, were treating people we’re going to we should be aware of the psychological and social stuff. But really, I mean, we’re working primarily on bio things. We’ve meant in touch and exercise, you know, a little bit of education, but most of our more focuses in the bio like so. It’s I liked that they they broke it down into this and talked about, like, what was included in psychological research, and what was included in bio was good in the social stuff. But what I thought was really interesting, though, was like the little quote here says that, you know, there is positive effects is positive outcome seen with the psychological interventions to focus on the things you said thought processes, beliefs, behaviors, this type of thing that says that the size of these effects have generally been found to be a small or moderate, and systematic reviews of randomized controlled trials with chronic pain samples. So with this, I mean, go shows is that, and I think if you look at all the research, they’ve probably I think they quote this all and throughout this paper, is that it doesn’t really seem to matter what you do. When you look at the literature, the outcomes are all relatively small to moderate at best. Yeah. So what that can sound to some people defeat us, to me that sounds Oh, that’s actually sounds pretty good. Because if you’re doing something done, or you’re doing something, you’re seeking care and someone is providing care to you, chances are you’re probably going to feel better than not. So doing something is like this is good. And that lets us know that there’s not like a right or wrong but they do say in here, though, is it’s not necessarily providing a specific treatment. It’s finding the treatment that works for that person. Right. So it’s not like you need this. It’s like what’s going to work for this person, this presentation here today. I like that rather than you step was the person need rather than what are we going to do to the person?

Jamie Johnston 15:04
Yeah. Interesting as we go through like, there’s a couple things that stand out to me is when they’re talking about the psycho psychological treatments, they mentioned how there hasn’t been a lot of research about involving the the person’s family, but one place that they did look at. And I would like to know if this was any of Melanie wells research with stuff that she does with kids. But it showed that the more that the parents are involved in, in helping the kids, it can actually have a positive effect on the parent and the parent experience. So when you’re when you’re teaching, how do they say they’re teaching kids and adolescents, about different strategies that they could use, whether it’s communication or how they handle things at school, and the more that the parents involved, it can actually have a positive effect on the pain experience that a parent feels? Yeah, unreal. Is that great stuff.

Eric Purves 15:58
And there’s nothing that I thought was really interesting wasn’t like, you’re talking about how, yeah, when the way kids are treated with that, with chronic pain is very different from adults are treated with chronic pain. Because in adults, it’s like the individual is being but is being treated, whereas kids, they involve the whole kind of their social narrative family, which is, I mean, just makes it makes sense. But it’s just funny how you’re like, Oh, you’re no longer a child, you’re now an adult. So therefore, we’re just screw up family. Like, we’re all gonna involve you. Right? That’s not necessarily included. But I guess it does make sense though, because the kids need to be cared for. And so the parents have to be involved in care as an adult, you’re independent, least in our most of our cultures out so we distance ourselves from our family a little bit. Yep.

Jamie Johnston 16:45
Yeah, or different circumstances. I mean, you look at me 47, single, no family in town. So the experience that I would go through if I was experiencing pain is a lot different than, say, somebody who has a family at home that they come home to, right. And if the kids were dealing with something, then the parents dealing with that is going to have more of that connection, feeling between the family and probably better care and all those things, especially if, say, the doctor or the physiotherapist is in really good, or having good communication with the family, about me, and education and all those things, then it’s it’s a more cooperative experience. Yeah, yeah. Oh, yeah.

Eric Purves 17:25
Which would be more biopsychosocial that would actually be a better application of the model, right, involving everything. Yeah.

Jamie Johnston 17:34
So they, I mean, they went into, and they talked about a lot of the biological stuff, and separating that into different categories, about how people are experiencing pain, and you know, whether it’s peripheral or central mechanisms, inflammatory pain, chronic pain, and all those kinds of things. And then talked about the treatments that they can use for those things. And what I found very interesting is that when they started talking about exercise, because exercise, obviously, I’m a big fan of that. But when they talked about the exercise, they were they were talking about usually exercises is driven towards building muscle or loading the joints and doing these other things. Whereas they found or my understanding is they found if you geared the exercise more towards just what they were doing at work, or or their chosen activity, and getting them back to doing that thing, then they had more success.

Eric Purves 18:30
Which makes sense, because it’s that your your task or your goal, your functional desire, whatever it is, it’s tailored towards that specifically. Yeah. Makes sense. Yeah. Well, I thought it was interesting that they it says exercises, you know, it’s considered they consider that bio, but I think it’s almost, I mean, obviously, there’s bio going on there, but I would say, Well, yeah, like, it can’t just be bio because you’re not, you know, there’s going to be psychological and probably social unless you’re like in your garage by yourself. Okay. There’s, there’s not like a social influence ever. There’s a psychological influence, like exercises, if something of value something you enjoy doing that it’s not just gonna be bio, so I think that was fine when they said it’s exercise is considered a bio intervention. We’re like, well, it’s I think it probably includes the whole bio psychosocial.

Jamie Johnston 19:23
Yeah, yeah. And I think that’s, I’m trying to remember who the presenter was in San Diego this year when he, he stood up and he said, Okay, who wants to go home and do some homework tonight? And then he’s like, Yeah, neither do your patients. So stop giving them homework, stop giving them exercises to do.I forgot what that yeah, that was great. Great, which was brilliant. Because they and I think that’s whereand, you know, I was on a podcast a little while ago with some some of our friends down in the US and when I was talking about therapeutic exercise, and they’re saying it’s not in our scope. I’m like, well, movement is so I think we have to Start also approaching this and being like, well, let’s stop talking, let’s stop calling an exercise. Let’s just call it movement. And let’s just talk about what meaningful movement is for this person. And how do we get them back to that meaningful movement. And that meaningful movement might be a specific task that they do at their job that they can’t do right now. So how do we, how do we change that task? Or how do we make it so they can do that task? So it becomes more meaningful, and they feel more fulfilled? At their job, or whatever the recreation thing? Is that, that they’re trying to get back to doing

Eric Purves 20:32
that’s a weird thing. Hey, still movement is allowed. But exercise, isn’t? We?

Jamie Johnston 20:38
Yeah, well, it’s funny. How do they define exercise? Well, so my understanding of it, because when I was on the podcasters, two folks from the US, and I said, but you guys can do active range of motion and passive range of motion and a treatment under like, Yeah, that’s fine. Like, so why can’t you do movement? They’re like, it’s that we can’t prescribe exercise for them to do at home. I’m like, But what about if your prescription was gonna work in the garden for half an hour? They’re like, yeah, we can do that. I’m like, so just prescribe movement. And, yeah, that’s, what about if it’s get on the ground and play with your kids? Yeah. What if it’s, you know, so let’s, let’s change, let’s change the opinion around those things. And I think a lot of times, we’re also really, really scared that we’re going outside our scope. And we might get disciplined for going outside of our scope. You know, and then as soon as it’s got the word, in this case, as soon as it has the word exercise attached to it, they people automatically say, Oh, well, that’s out of scope. But if we say it’s movement, there’s no reason that can’t be in your scope.

Eric Purves 21:46
Yeah, just move lots. That’s your that’s your prescription. And that’s exercise.

Jamie Johnston 21:51
Yeah, there’s no reason you want to do you know, somebody comes in and they’ve got a shoulder issue, there’s no reason you can’t grab their arm and passively move their shoulder and get it into different ranges, or do some adaptive movements with them, you’re not prescribing an exercise for them to take home, you’re not prescribing something, you’re, you’re just helping them get back to doing the movements that they enjoy or that are meaningful to them. So and to me, it makes more of a psychosocial. Not psychosocial sense. But it makes more sense to me to, to talk about rather than us giving a treatment or delivering a treatment. We’re engaging in treatment with our people. Yeah. Because we’re, we’re engaging and educating and conversing and finding out what’s important to people, rather than us just saying, okay, get on the table, and I’m going to do this to you.

Eric Purves 22:40
Yeah, yeah, sure. Yeah, I 100% agree, that’s such a great point to make, right? You’re engaging with with the treatments, you’re not just doing it, you’re not doing something to them. Now, some of them is great. Like, I mean, I mean, sometimes when I go, if I go for a massage, I often want something done to me, because I don’t necessarily have something wrong that is bugging me. It’s just like, I want to feel good. That’s different. Right? There’s the field, I think, is a seven point distinction to make is that, yeah, you can go and get the table and just someone just like spoil yourself. That’s fantastic. But if it’s like, if it’s something that you’re suffering with, it’s bugging you for a long time. And, you know, that passive approach isn’t working. Yeah, try and engage a bit more with with your clientele.

Jamie Johnston 23:18
Yeah. Like, well, like we’ve talked about so many times before, too, you know, we were fortunate here, because we have so many people that have unlimited benefits that, that maybe they come in once a week, but that’s just an hour break from life that they get, which is good. And there’s no reason you can’t just do a passive relaxation massage. Maybe I shouldn’t say that a relaxation, massages password, because you’re still having an influence. But you know, in those cases, there’s no reason but somebody comes in and they’re like, I’m having a hard time moving my shoulder, or moving my hip or my knee or whatever, then, you know, we want to, we want to engage more with them and figure out how we can get them back to doing the moving that shoulder or so that they can do the things important to them. Yeah, yeah.

Eric Purves 24:00
I agree. I love that term, engaging in treatment, rather than just doing something, doing a tree gauging your dramatic that’s, that’s a very important distinction to make. So hopefully, I’ll catch on. I hope you should do like a social media campaign hashtag engaging in treatment or something.

Jamie Johnston 24:15
Yeah, yeah. Well, I’m working on some stuff now, but doing some thought reversals and things about that to cool. Medicine, but but we’ll see. We’ll see if anybody wants to listen to me now.

Eric Purves 24:28
Yeah, well, some people listen, some people listen this podcast so enough to keep it keep us keep doing them. So there we go.

Yeah. What it was, it’s just kind of keep talking about this, the biotherapy about it and just kind of expanding on the bio to like expand into the bio psychosocial. And this is a there’s gonna be a bias statement here, but it’s okay. It’s our podcast. I just I just think it’s really important for us to emphasize that. Even though we are engaged, we are educated in a bio dominant biomedical We’ll thing and we are hands on therapy is mostly, mostly by Oh, there is always going to be psychosocial stuff, right? With moving exercise coming for treatment, there’s an interaction between two people that’s social, right and psychological. So it’s just that we are, regardless of what you think of the biopsychosocial. Every aspect of a human is being engaged with during a during a treatment. And this was the thing is, though I find interesting is I find it very difficult to understand how any other MSK profession other than massage therapists and physical therapists are able to actually provide a full BPS experience in their treatment. Like if you’re coming in and say it’s chiropractic, and it’s like five minutes and just getting adjusted and gone. Is that biopsychosocial? Like, can you actually apply all the kind of aspects of this? I don’t know, I would say that I think what we have as physios is we have time. Some points are short, but I would say on average, they’re, you know, 30 to 45 minutes long. Least we are.

Jamie Johnston 26:09
And I think that, in fairness, some chiropractic appointments are as well, depending on the look.

Eric Purves 26:16
Yeah, yeah, I am not saying all I’m just saying, like, if you look in general, the two professions that are set up to be able to really do this properly with the problem if we have proper education or proper understanding, I think we we should, you know, chiropractors only are listening to this podcast anyway. But massage therapists, you know, I think we really are set up to do this, because we have so much time with people, we can listen and validate. And we can educate, and we can rule out red flags. And we can reassure when, if it’s, you know, there’s nothing nasty going on, and we can revive touch, soothing, safe, comfortable environment, and educate and engage with people to do the things that are important to them. And that’s something you can’t do in 10 minutes. 15 minutes. No, I and some people I mean, I’m sure somebody’s gonna bother, you can you’re full of shit. Okay, maybe. But I would say that’s, I’m not convinced. No, no, anytime you do this. And so when you’re looking at just quick, quick, quick appointments, boom, boom, boom, those are bio nature, bio focused, you’re missing the bigger part of treating the person.

Jamie Johnston 26:40
And interesting, if you look at the psychosocial aspect of things, I don’t know, of any, or if there are any psychologists or counselors that offer a 15 minute treatment. They’re all 45 minutes or an hour. Exactly. Because they want to have a long discussion with people they want to, they want to have that chat, and they want to figure out what’s going on with them. So, you know, when we look at the other aspects, there’s very few that are that short of a treatment. Unless it’s maybe a quick check in about something. Right?

Eric Purves 27:57
Even medical doctors right like USC Medical Doctor for something like they they’re gonna rule then a like, Oh, you have psychosocial that might be that stuff happens. But they’re looking at the bio, they’re looking, what’s the disease? What’s the pathology? What can I rule out here? Right? So it’s when you read this stuff, and we can go and talk about, you know, the, you know, how this is often applied in these kind of interdisciplinary or multidisciplinary pain clinics. You know, those little requirements, we will have a long time, these are something you can’t just like, have, I don’t think you can have like a high volume, bio, psychosocial practice, and do really good work with engaging in small amount of time, a small amount of time, I think it’d be really hard. Yeah,

Jamie Johnston 28:40
I agree. So this, this is where I think we could get into it now is when we’re talking about, they’re talking about the social aspects. And they they talked a lot about the workplace, and people who are on a return to work program. And this is where it kind of hit home to me because of my past, being a first aid attendant in a, in a sawmill, and watching, you know, treating dealing with people who got injured, and then watching them deal with compensation and coming back to work. And they really focused on this about the importance of communication with the workplace, and how important that is for, you know, the person who’s trying to get back to their job, where the physiotherapist or the therapist who’s helping them should be in contact with the workplace, but then also in the workplace, that the supervisor should be trained in how to speak appropriately to the person who’s injured. And to me that just like that would be phenomenal compared to what I’ve seen in the past, because, from what I’ve seen in the past, companies would always be like, Oh, safety is our number one priority, until it cost $1 To change the safety program, and granted, you know, this is back in like 2006 Next one, I was doing this. So hopefully things have changed a lot since then. But the I just think it’s amazing that they looked at it and said, if you’re in communication with the workplace more, then you’ll have better outcomes for the person who’s trying to get back to work. Right? just phenomenal. And that’s where, like we talked a little bit before we came online. That’s where our friend Corey Blickenstaff who is a physio who works in a workplace, and helps people who are injured, like how, how that, like the outcomes that he must have, compared to somebody who was maybe off site. And I don’t know if there’s ever been a study done on it, but it must be amazing. And give the workers confidence that they’ve got somebody there, who’s there to help, should they get injured? So the social aspects of that must be phenomenal.

Eric Purves 30:50
Yeah, it makes sense to me, it just, I mean, okay. Sometimes things that make sense logically, aren’t always true. But, you know, using making an informed opinion, based on this, some this body of research, you know, if you had if, if a large enough workplace could afford it, and I’m places probably could write, you know, a large enough workplace could afford to have a physiotherapy physiotherapist, for example, on on staff or on a contract to come by? I mean, that would that would be such a benefit. And I bet you, I would be, I would love to see if that increased productivity, if that decreased, miss. Locks, work, you know, less work safe for workplace injuries, you know, I think that would be such a great thing. And there’s probably studies out there and for anybody has them, please send them our way. I just thought it would be that would be such a brilliant thing. And maybe some parts of the world they do it in. But if that’s I’ve never heard of that here in Canada. No. Having like an on site, or something that comes by once a week or whatever, or every two weeks to to treat staff.

Jamie Johnston 32:02
I’m actually starting to hear a bit more because I have a friend who is an athletic therapist. And I can’t remember the name of the company. But she had me come in to do some first aid stuff with the company. And she’s there as like, a director of like exercise and things. So they have an exercise room there for the employees where she can take them in. She has somebody who’s a massage therapist that comes in once a week. And she she organizes all of this for for everybody who works for that company. So it must be catching on a little bit. That to the point that she’s got a full time job doing this. Yeah. That’s brilliant. Yeah, great. Yeah. It’s very cool.

Eric Purves 32:37
Shouldn’t you think it’s such a hard worker, particularly in the the environment we’re in right now where it’s impossible to find workers like, like everyone, everyone’s hiring and you know, what a great perk it would be to if you’re like, hey, it comes with our workplace. We got you a massage and physiotherapy come in. It’s all included as part of your years. Part of working in package. Yeah, that’d be brilliant.

Jamie Johnston 32:59
Yeah, I’m sure it would be a draw. Yeah, huge. Bigger companies like Google in that have, like full time massage therapists to work there. And yeah, and things like that. So but I mean, that’s a multibillion dollar company. So you know, compared to smaller companies, that’s a lot tougher. But one of the things that I that I think is important to touch on that I would love to see is they didn’t, they didn’t talk in here about educating the workplace, about educating all of the other employees who aren’t injured.And I don’t mean that like when somebody’s injured, the rest of the people have to be educated about that person’s injury, it’s educating them about why Return to Work Program is important. Because like, for instance, when I worked at the mill, it was always if somebody was off injured, they’d come back to a place that’s, you know, full of bravado that guys are going, you’re just a wimp, you’re just trying to get a claim, or you’re an idiot, there’s no reason you weren’t hurt. And so when you look at that social aspect of it, that can be really detrimental for the person who’s trying to get back to work. So if they would be really interesting to see if there was a really good education program they could do in those places to be like, Hey, we know that we’re going to have better outcomes if this person isn’t made fun of if, you know, your opinions are kept to yourself, and we’re able to work through whatever the person’s injury is, and we’re here to support you as well. So that if you get hurt, we can take the same approach with you. And, you know, research has shown us we have better outcomes, and this is going to be better for your home life. It’s going to be better for when you have to pay the mortgage, and all those other things and explain to them, you know, the benefits of that? Because I think that would make a drastic improvement on those return to work programs withwith people coming in.

Eric Purves 34:51
I think that sounds like a brilliant idea. You just said. Education regardless, it seems like doesn’t matter what The topic is, you know, education often seems to be the answer. Yeah, you know, the more you understand what’s going on, the more accepting we are the better decisions we make about things, generally, right? These things all play a role. So, you know, why would that be any different in the workplace? I think it would just be a brilliant thing for it to educate the workers as well. What’s going on? And why it’s important? Yeah.

Jamie Johnston 35:24
Yeah, it would be cool. Maybe I shouldn’t approach the firewall a little bit and be like, hey, once a month, I could do like a safety education thing or something?

Eric Purves 35:31
You really should, I think you should see it just I think it’d be probably more rewarding as well as probably see, I would, I would be surprised if you didn’t see. Cause of benefits from that with your coworkers. Yeah, yeah.

Jamie Johnston 35:44
Cuz and it’s great, because we have a, like a light duty program, because we do our own dispatch. So if somebody is injured, we have it set up that they can actually just go and do dispatch, so they get to sit in the in the room, and they’re answering the phones and doing all that stuff. So they’re not out, you know, having to find a structure fire, but they still get an hour or two a day to go in the gym and do some movement. And you know, try to be healthy. So it’s, it’s a pretty good program. But there’s definitely improvements we can make.

Eric Purves 36:10
What it mean for meeting this paper here, too, it’s definitely in the workplace, engaging workplace is under utilize, you know, the one of the quotes here says, engaging with the workplace as part of the treatment seems to be rarely attempted. And I don’t have the paper in front of some notes I made. And I think it said where it was, like maybe only three papers that actually involved, you know, family or social networks in kind of Pain Rehab. So it’s almost it’s rarely done.

Jamie Johnston 36:42
Yeah, I’m just scrolling through to see if I can find it. But yeah, that’s basically what’s sad is that it’s rarely done in that way. So yeah, and I think the maybe the difficulty as well is that, you know, if we’re trying to help somebody who’s injured, the workplace isn’t necessarily going to want to talk to us. Right. So it might be a big hurdle for us to overcome, if we’re trying to engage in that way, whereas they probably be more likely to listen to a physio if they if they recall it, but hopefully, hopefully, if it’s a multidisciplinary approach, and we’re working with a physio about and with somebody, then we can have some input on that as well. But it would be, it would be great. If you know, even if you could, if you could have the person go back to work and say, hey, if your employer wants to talk to me, I’m happy to have a chat with them about, you know, what we can do to help you out, then that might be an approach where the employee is making the approach rather than us approaching the employer?

Eric Purves 37:43
Yeah, yeah. Yeah. The I think one of the barriers you do you have, though, at least in our profession here in BC, and probably throughout Canada, as well, is that nobody wants to work with the, like, WorkSafe or, like, workers compensation. Yeah. Because it’s a pain in the butt lot of paperwork for like, no pay. So even though, it’s probably would be really good to have more of this return to work, thing involved in our profession, and these opportunities to be able to go into people’s work, you know, finances are gonna are gonna win, right? Like, I could treat somebody my clinic and make this much money, you know, or I could go over here and leave my office and treat people that are returning to work and make like, totally, like, no money, almost. Right? What am I gonna do, people are gonna look after their families or unpaid bills and mortgages, food, you know, the gas, they’re going to say, in the clinic, so the idea would be not lovely to do this. But it’d be I would be so I would think that in a lot of these cases, the the money’s out there for it. Yeah.

Jamie Johnston 38:50
Absolutely. And but I mean, again, hopefully, that’s changing as well, because 10 years ago, there was absolutely no money. Yeah, to be able to do it, and now there’s a bit so hopefully, that will continue to go up and we can have more of a roll.

Eric Purves 39:05
Yeah, for sure. No, yeah, I think it definitely be beneficial. Yeah. to kind of wrap up the the the rest of this paper, they talked about the interdisciplinary bio psychosocial treatments for chronic pain, and camper did a review. And so despite their concerns about definitions of bio psychosocial interventions, camper et al found that a coordinated intervention covering several domains of the biopsychosocial model and delivered by clinicians from different backgrounds is more likely to benefit patients with chronic low back pain in the long term than his usual care or physical treatment alone. Which I thought was good because it talks about like the interdisciplinary right so involving multiple different disciplines the problem that you’re going to find me obviously in a in a like this was in a like a pain, kind of rehab or pain. in clinic, everybody’s going to all the treating clinicians are going to be working from the similar model and understanding about pain and they’re gonna stay in their lanes of what their areas of expertise and education are. What we see all the time in practice, I’ve seen other papers on this I don’t have I don’t have a reference here, unfortunately, is that there is an association between seeing too many different people. Oh, yeah, and poor longer term outcomes. But what what I understood from this and other parts of this, this paper is that you see multiple people as long as you’re working together under the same framework, to provide the best care for that person that they need. So that’s an important distinction to make. So I know oftentimes, in the courses I teach, I’m like, get the more people someone sees the less the worst, their outcomes tend to be, right clinically, as well as there’s data to support that. But doesn’t that that’s if you’re getting, I think, if you’re getting different stories different, you know, you see your physio, your car, your massage, your osteopath, your acupuncturist, your medical doctor, specialist, they’re all telling you something different. They’re all doing something different to you, and there’s no coordinated care. And that’s when you get these problems. But it seems, seems this one, if you have a singular model of care, everyone’s kind of falling as bio bio psychosocial. And they’re working together, outcomes tend to be better than doing nothing more than what they call the usual care, which is usually medications or rest.

Jamie Johnston 41:26
Yeah, and I think the, you know, I’ve seen that so many times in my career where, you know, somebody’s coming to see me on a Tuesday, they’re going to their chiropractor, Wednesday, they’re going to Doctor Thursday, they’re going to physio Friday, and they’re just appointment hopping. And the added stress that that gives them of having to go and see all these other practitioners to satisfy what the insurance company wants them to do. Is that added stress that’s taking away from a better outcome. So like you said, if it was all under one roof, and you know, it was a conjoined group of people that are trying to provide that care in a reasonable amount of time and things like that, then you’re likely to have better outcomes. But the, the current way that it’s done, or that I’ve seen is when you’re constantly hopping from practitioner practitioner appointments all week. It’s just stressing people out.

Eric Purves 42:13
Yeah. And I’ve never gonna be careful saying never and always, I very rarely have seen that benefit people by seeing multiple practitioners over time forever, years and years and years. Because we’re all just looking for that fix, right? Everything’s like, oh, my gosh, scar tissue here or this isn’t here. No, this is weak, this is tight. This is short, this is inhibited. This is out, you know, they’re constantly just being put back together is that kind of general understanding they have their body and that that rarely works. And and each practitioner is trying to make a living and rebooking people. Yeah. Money, Money Talks, right, that the financial aspect of it is is as powerful. And that’s, you know, that’s a different conversation, I guess. But that’s comes down to the ethics of it, right? We have to pay our bills. But you know, ethically, if we know better, should we still be doing that? Probably not.

Jamie Johnston 43:06
Yeah, I know. I’ve fallen on the sword a few times and told people, you’re going to hold these appointments. Don’t come and see me next week, take the day off. Yeah, take a rest. I mean, somebody else will look at it. It’s not that big of a deal. Just go take a rest. And but it always comes back to that same thing. And really what this entire paper is about is patient centered care.

Eric Purves 43:24
Yeah, yeah. Based on its care, and providing team based care seems to be the thing too, right, that involves all of the domains. And it’s what I understand is it seems very difficult for one specific professional to treat all domains because we’re not educating them. We’re not We’re not bio psychosocial therapists. It’s not like its own brand is. It would be attendance. Yeah. Well, it’s, it would be a 10 year course.

Jamie Johnston 43:50
Yeah. Oh, manual therapy, and psychotherapy and social therapy, you’d be. So not it’s not a terrible thing. But you’d be in school for a long time to be able to do all that.

Eric Purves 44:00
So yeah, I think what we should get from this is that, you know, we have to start thinking about psychosocial, thinking, there’s a lot of influences on people. We never want to just say it’s just the bio, we don’t wanna swing too far. We don’t say it’s just a psychosocial we want to kind of, you know, play in that middle. There’s a pendulum swinging too far and be aware of, you know, is this more of a bio driver? Oh, yeah, you’ve got it. Like there’s tissue injury, there’s inflammation, there’s brake, there’s whatever, there’s something you know, or is this more like, is there more psychosocial things going on that are amplifying kind of some of that nociceptive sensory stuff that’s going on? Right. These things all work together. And it’s, you know, part of the problem we see in the research as well as what we see in these online discussions is, it’s like one swing to the right of one swing to the left, it goes back and forth. Right. And, you know, the quote that the authors use here, which I thought was great, it said when they’re talking about bio psychosocial interventions, it says, working closely together with regular team meetings, face to face or online agreement on diagnosis. therapeutic aims and plans for treatment and review is important to know the emphasis on the need for the treatment team to reach agreement on diagnosis goals and treatment plans, hopefully, before the plan is implemented. And this is just basically saying like, this is what you should be doing and ultimately, multidisciplinary treatment environment. But that in reality, at least for our profession, I, we’ve lived our lives before, that’s very difficult. When you’re one on one with person in a room for 45, 60 minutes, and you’re busy and everyone else is busy. It’s very, very difficult to coordinate care appropriately, at least the way things are set up here. But ideally, in a proper pain clinic. This is how things should be done. And I think some places they’re the only I got I can’t speak from my own knowledge, but I would hope that some places they do things that way.

Jamie Johnston 45:50
Yep. Yeah, hopefully, it’s, hopefully that’s coming. But we know how long it takes to implement research. So as long as as long as as long as we’re working towards providing better care whether it’s individually or as a team. And as long as we’re going after patient centered care, then hopefully that means we’re doing whatever’s best for the person in front of us.All right, everybody. We’ll we’ll see you next time on the podcast.

We hope you enjoyed this podcast. These kinds of topics are what we’re all about. If you’d like to learn more, go to our websites, themtdc.com or ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.

References

Nicholas, Michael K.. The biopsychosocial model of pain 40 years on: time for a reappraisal?. PAIN: April 19, 2022 – Volume – Issue – 10.1097/j.pain.0000000000002654
doi: 10.1097/j.pain.0000000000002654

Podcast Episode #25 Making Sure Your Continuing Education is Evidence Based

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Jamie Johnston 0:12
You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston.

Eric Purves 0:17
And I’m Eric Purves. This is a podcast by massage therapists for massage therapists.

Jamie Johnston 0:22
Our objective is to simplify how to be a more evidence informed practitioner. Let’s dig into this episode. We’ve been talking lots lately about continuing education seems to be a bit of a theme with us. And talked recently about how the standards are changing for us here in British Columbia. And while that seems to only affect us, I think it’s going to have a wide ranging reach how that’s actually going to affect things. Because it seems like our college kind of followed suit of what Ontario did. And if that keeps going, it’s probably going to happen in other places as well. So good conversation to have. But the the bigger thing we want to talk about is when you’re deciding to take a continuing education course, we it’s almost like a buzzword. Now. There’s actually a couple of buzzwords for a long time that seem to be pain science was the buzzword for a course. And now evidence based seems to be the other buzzword. So the question remains, how do you decide whether the course you’re taking is actually based in pain science? And isn’t actually evidence based?

Eric Purves 1:31
Really not a question. Yeah,

Jamie Johnston 1:33
it can be a very tough thing to weed out when you’re looking at just say course titles or descriptions. So how do we dig in deeper to decide whether the course we’re taking is what we should be taking?

Eric Purves 1:47
Yes, and to be in full, open, honest and clarity. I mean, we teach a course called clinical applications of pain science. And we first launched that course in 2018. That was a bit of a buzzword, because it was a good way to market a course. Yeah. And it was

Jamie Johnston 2:05
designed for that. Now, that’s not the title we’d use. No, and I’ve

Eric Purves 2:09
taken pain science out of a lot of the stuff that I use, because I feel that it has become a bit trendy. And also it makes it that makes you people think that pain science is a thing. Yeah, it’s just science is just research evidence. It’s and we’re just focusing on understanding pain. And so when we look at like the the pain science courses that we teach, it’s a little bit more but like, it’s kind of the some of the sensory mechanisms involved in kind of the science, the science, and then they just kind of the nature of the complexity of the pain experience. It’s not this kind of linear, find that dysfunction, find that problem thing, and that’s kind of what we focus on. So I think the way pain science is often perceived or explained is, is is I think people are using it as a buzzword. But then when you go and take a course, people will use pain science as a way to justify a more specific modality. Yes, I think that’s a strong word, use bastardization of the term, it’s an improper use of the term AI, in my opinion, because you can’t, if you actually understand the science of pain, it does not validate your specific modality or modality. Pain is not a singular thing. It’s a complex thing. So therefore, you can’t apply your modality to pain science doesn’t work that way.

Jamie Johnston 3:35
Yeah. You can’t come in and say, My not not that I want to pick on one thing. So I’m just going to use this as an example is when I’m doing a myofascial release technique, I’m altering pain with this modality. Yeah, like, it’s, there’s so much more behind it. So to do incorporate that into I mean, important that we incorporate the science into any modality or technique course. But to say that a technique is the application that pain science is probably not overly accurate. Yes, for and

Eric Purves 4:10
you see that in all in all the courses now to start seeing, and people started using terms like nervous system and using evidence based using pain science, and these kind of buzzwords, and I know that we use them as well. But I like to think that when you look at how we apply or teach or communicate those things, it’s more about it’s not about a fix. It’s more about like, this is just what this body of knowledge informs us in the material that we’re talking about. It’s not like we’re teaching you or teaching you pain science. We’re teaching you evidence based practice, right teaching we’re using the evidence or the science raise areas, the framework to provide content like so like therapeutic movement, you’re using movement and stuff and you’re using that within a framework of of understanding how, in a less wrong way how that these things might have an impact on someone’s experience of pain. Yeah. Or on their level of function doesn’t have their pain maybe helps their function like so I think there’s, I mean, I’m very critical. I’m critical of the stuff that I put out on purpose stuff that we talk about all the time. And I look at some of the things I even did a year or two ago. I think I yeah, that’s, I don’t, I don’t like how that sounds.

Jamie Johnston 5:27
Yeah. I like what, what TJ put up yesterday when he said the nervous system, nervous system is the new trigger point. Yes. Because it’s almost be like, it’s the nervous system is becoming this new thing that we’re blaming for pain and dysfunction and, and these other things, right? So we want to be very careful that we’re, we’re not just finding another tissue to blame. But we’re looking at the overall concept of how the nervous system influences things and how we’re influencing the nervous system when we’re communicating and touching and moving people in and working with

Eric Purves 5:58
them. Yeah, and that’s, you know, and you sometimes you see those things, and you think, Oh, I wouldn’t be surprised if part of that nervous system dominant narrative was probably some of the stuff that myself and yourself have probably contributed to that because you try to focus from moving people away from like, connective tissue. And so I think more about like nociceptors and sensory mechanisms and more the nervous system and the neuro immune system, and how all this stuff plays a role in transmitting information. And and, and so you try to you, you take the focus away from like the fascia and muscles and stuff and try to think more about what’s the what’s the tissue that is responsible for making change, for creating or implementing change making change? Right, that’s, that’s the nervous tissue. So you try to you but then I think what happens is people will then swing too far towards the nervous is, oh, what’s the nervous system? Everything I’m doing is just impacting the nervous system really? Well. You’re impacting all the systems. Yeah. Right. So we can’t just pick one. I think that’s, that’s, that’s one of the things that I am trying to be more mindful of, too. We communicate, teachers vote, yes, I use the nervous system a lot. But it’s, the goal of it was to move people’s focus away from the structural anatomical stuff. But it wasn’t meant to replace it with a completely different narrative that blames the nerves or the dresses.

Jamie Johnston 7:20
And it’s kind of funny, I was having a conversation with somebody in the UK this week. We talked about how they’re trying to get more recognized as, as medical professionals so that they could possibly bill insurance or do things like that. And I was talking about how when we teach, we we come across these people that have been therapists for 20 and 30 years who are like, all the stuff you’re saying is the stuff we were saying 20 years ago until we tried to medicalize everything? Yeah, so it’s almost like the the pendulum swung so far towards the description of a technique or modality and how that’s going to work back to the nervous system. And now we need to come somewhere down in the middle. Yeah. And talk about because there’s, you know, I mean, there’s so many, so many more ways to make change in somebody’s pain or their experience than just hands on. I mean, communication movement, all those things are, are such pivotal areas. So let’s, let’s try to get that pendulum to come back down. Yeah, to the middle, so that we, we have a better understanding of everything.

Eric Purves 8:18
Yeah. And this is what happens right over time to um, we’ll see these days, we’ll see somebody new come up or something, further development in something, and that’ll become more important. And I think it’s just a matter of by being evidence based, it’s kind of a topic of this, it really allows us to kind of check our biases and into into incorporate with the current evidence suggests, right, so it avoids us from swinging too far one way, and kind of keeps keeps things in check based on what the body of evidence says

Jamie Johnston 8:44
that it should make change a lot easier for us. Yeah,

Eric Purves 8:49
if you follow a large body of evidence to inform your practice, the practice and the profession and everything and the courses that are taught, then you know that it’s your you’re basing it on a body of knowledge that is defensible, less wrong, rather than belief based off and so what we see lots of times we see courses being called evidence based, but there’s still the body of evidence that they’re drawing for these courses is, is based on a very small or very specific area. Yeah. And a lot of this goes, I strongly believe into is a bias mine into how are introduced will inter jurisdictional competency documents, guidelines for foundational knowledge, the practice competencies and practice indicators that basically create the guide or the framework for how the profession is educated and how people learn what they learn in school, then how the regulatory body does their licensing exams and yeah, Create scope of practice and all that stuff is based on a very narrow bit of evidence and lot of time does not even have this love. It’s just faith or historical stuff. And when I think we’ll come back to the beginning of like, these courses are evidence based, but I think in order to do that, we should probably pick apart some of the reasons why there’s a problem with the so called Evidence based courses, and where that information is coming from.

Jamie Johnston 10:25
Yeah. And I think, like, I know, you’re gonna go into the inter jurisdictional company report, but I think we touched on it on the last podcast a little bit. But if we look at our education, just from our college education, like, everything is so modality based, we take so many courses that are based on modality so that when people come out, there’s a belief that that’s the best way to help people in pain. So then when somebody’s putting a course together, and I’m gonna say that they’re putting a course together with the absolute best of intentions in mind, you know, they’re not doing it to cause harm or to not be evidence based. They’re looking at it and going, well, of course, it’s evidence based, because it’s blame, but it’s not blame. It’s based on all of these techniques that we learned in school. And we were taught that this was the evidence in school. So that makes it makes it difficult for the person who’s putting the course together. But then also difficult for the person who’s deciding what course to take, because there’s a true belief system behind it that these things are evidence based, because they’re based on the things that we’ve learned in college that are already out of date. Right?

Eric Purves 11:36
Yeah. And this, and this is, yeah, this is where it becomes I want to be careful where we’re mindful. We’re not blaming any individual. No, I would say that what I if I can put blame, I blame on the stakeholders for not taking more of a leadership role, not just the college, not just cmtbc, or any other massage colleges, but also all the associations across across the country, as well as educational institutes, which are the ones that create are the ones that are the ones teaching the material. And if you think if you’re teaching a course you’re like, oh, evidence based techniques for the jaw and neck, for example. But what’s that mean? Jason? Yeah. So yeah, so what’s, what isn’t evidence based course was evidence based techniques, you know, and usually, when you look at those things, I’m just put, I haven’t, I don’t know if there’s a course that a name of a course that I didn’t, wasn’t aware of. So if somebody teaches that course, I’m sorry, this is not a direct picking on you not picking on you at all. But I’m just saying that that’s the kind of a name of a course that you might see. But that’s going to probably be a modality courts, this is the modalities that you use that I have learned in my practice, work that work, and UK. Okay, so when we’ve talked about the definition of evidence based practice, I’ll give that a second here. That’s part of evidence is your clinical expertise. Yeah, it’s an important part. However, what’s really important, I think, with evidence based practice for like our teas, is that you have to have that kind of foundational knowledge based, and that foundational knowledge needs to be based on the current research evidence. So let’s look at what’s the current research evidence suggests about pain or about certain populations? Or about certain conditions or presentations, or the role of manual therapy? What does manual therapy do? What does movement do? What does exercise do? How does communication and self management, right, how are these things? What’s the research suggesting all that for a specific presentation, right? So if we look at like, okay, so if you’re looking at, say, TMJ course, for example, and it’s like, evidence based TMJ course, in order to teach that course, and make it evidence based, you would have to have the foundational knowledge based on all those things. Yep. And then you say, okay, look, I understand, you know, this is what we know about the TMJ, this will be understandable pain, is this some some risk factors, this is how it might present. Maybe this is a way that we can assess what might be contributing to it. I don’t know, I don’t have a breadth of TMJ knowledge. So I’m just throwing stuff out there. But then you’re like, and in my practice, I have found that these techniques work well for this population. Fine, that’s great. That’s that could be an evidence based course. However, it’s not evidence based. If your foundational knowledge is not up to date. If you’re like, Oh, well, the reason why people have TMJ pain is because they’ve got, I don’t know, protracted shoulders, they have a rounded posture and bad posture with a scapular. dyskinesias. Maybe they’ve got a little bit of, you know, maybe they maybe they I don’t know, there’s the mild feathers, myofascial adhesions that need to be released. And there’s like all this always mechanical stuff. But the thing is, as massage therapists as any I would say, I’m gonna say every MSK profession is is that we are educated to think within that narrow lens, totally. We are educated to think about, okay, jaw, joints, connective tissues, mechanics, such as posture, these things are really important. So if I can correct or fix those things, then the pain is going to go away. Yeah. And it might be. And we know that everything can work. People wouldn’t. Yeah, there’s certain groups, people that’s going to work. But it’s not evidence based if you’re teaching that

Jamie Johnston 15:30
stuff. No, no. And then that really goes back to what I was talking about before. Because like, we had 10 modality courses in college and one course on research, that wasn’t a very good course. And I was I don’t know who I was talking to. But somebody recently said that the research course now in school is even worse than the one that we had. It’s sort of like, just enough to show you how to look up some stuff to do your case study. Yeah. Right. So unfortunately, we’re geared for this right from school. So to focus on the certain things and, and not really be evidence based.

Eric Purves 16:07
And this goes back to a lot of the research too, that I did in my in my graduate studies. What we learned in school forms the foundation of the rest of our careers. And I know Dr. Gallin danielda. We had her on Facebook live back in pandemic lockdown a

Jamie Johnston 16:26
couple years ago, couple years ago, and her her

Eric Purves 16:30
Master’s study looked at the use of evidence based practice for massage therapists in Saskatchewan. And what she found, if I remember correctly, is about 60% of people. And this is consistent and this was because of the research I did as well in my studies was that across all all allied health professions, but 60% of people will not change their practice behaviors or their beliefs, if what they learn contradicts what they learned in school, so they learned it outside of school. For 60%, people won’t change if it contradicts what they learned in school. Yeah. What’s that called? As part of that might be what’s called the sunk cost fallacy. Is that part of it, like you’ve invested his time and energy into school, maybe even money into it? I think that might be the right term, if not something I’m sure will tell

Jamie Johnston 17:14
me. Well, probably also that, you know, I mean, I’ve talked about my background before, but I was watching a Netflix documentary last night, but it was about some of the Adventists down in Utah. And so it’s almost the same thing, they were confronted with things that that was the exact opposite of what they believed in, some of the people decided to leave, but some stayed and were faithful to the exact opposite information of what they were led to believe someone, I think, all too often with many of these modalities, that becomes a and some of the history of massage becomes a bit more of a belief system that is really easy to, to hang on to. And when you’re confronted with things that are against it, it’s it’s hard to recognize that that’s the way you should

Eric Purves 18:06
Oh, yeah. Oh, for sure. For sure. Yeah. So probably, before we move on, we should just like the definition of evidence based practice we’re talking about so what is evidence based practice, and simply, it’s just an integration of the best evidence with your clinical expertise, and a patient’s unique values and circumstances and requires healthcare professional to take into account the characteristics of the practice content in which they work. And so the process of integrating all this information is your clinical reasoning. So we said before, your best research evidence should inform the population or the base of knowledge, and then use your clinical expertise to kind of help navigate that with what the patient wants. That’s what evidence based means. evidence base doesn’t mean I have a paper that shows me that it’s important to people got results when I changed when they changed. You know, the way the scapula moved? Yep. Well, that’s one paper that doesn’t sound abroad. That’s not the best research evidence because a lot of stuff that contradicts that so there’s not the Sonic, scapula dyskinesias I’m just picking random things on top of the air, or I’ll top my head is not an evidence based thing that we talked about shoulder pain. Yeah. So anyway, but I think what what goes what you say to beliefs and this was this is actually plays right into what we’re want to talk about when we’re looking at the competency documents was in the competency documents, there’s a thing called entry level proficiency. And I’m not gonna read the whole thing, but says, the entry level massage therapist applies relevant competencies in a manner consistent with generally accepted standards in the profession. I see that generally accepted standards in the profession as very problematic.

Jamie Johnston 19:49
Yes, because we accept that these modalities are the the way to treat and the way to do things. Yeah,

Eric Purves 19:56
yeah. And the and this means that I read this and says, Well, it that’s it so okay to do what we’ve done historically, and that is okay. And say, well, it doesn’t necessarily change your touch. But it might change how or why you do something. But maybe if we understand the science of pain a little bit better, we understand or say, we understand that, you know, aggressive techniques on an area that’s already sensitive and sore, might actually make it more sensitive and sore, because we understand, kind of somehow the nociceptive system works, and that might not be good, or understand how inflammation works. Now, like that kind of information. That film goes into the evidence base that goes into the clinical reasoning. And in all the years of doing this stuff, and we’ve been teaching this stuff, I’ve been teaching stuff since 2015. And always learning and adapting, you start to realize that when you talk with stuff with students that are still graduating now, students, Dr. Seuss, Mr. RMTS are still graduating now, or people that are still in school. They’re still being taught these kind of historical accepted standards and belief systems that are not based on evidence. Yeah, based on beliefs,

Jamie Johnston 21:08
and like, the things that you’ve just talked about are pretty crucial things for us to understand and know, you know, similar to, like doing cross fiber friction is on a tendon. Right? Those are the things that we were taught in school were like, and all of the research now is like, Don’t massage a tendon at some point. Yeah, right. And yet, we were told to go in and aggressively work on these things. And I don’t know if that’s still being taught in school. But if that’s one of those things that hasn’t been updated, that’s a pretty crucial thing to know, if you’re trying to help somebody with a tendinopathy in any way.

Eric Purves 21:42
Because when I’ve asked people before, and courses either on my own or we’ve done together, I like to I out will often ask about, you know, what do you do with tendons? And it’s usually stretch and friction. Yeah. Not anything about low progressive load, you know, which seems to be the predominant, best available research evidence. Yeah. One thing that another thing too, which is, which is interesting is that when they the in the doc documents, it goes on to the a little definition about the practice competencies and performance indicators. And it says at the entry level RMT, must practice in a manner that’s safe, effective, and ethical. All three doesn’t mean safe or effective or ethical. It’s like safe, effective and ethical. There’s all three. Yeah, and we’ve discussed that previously. And it’s important for us to understand that the narrative or belief system is not based on evidence, then it can cause harm and harm doesn’t have to be physical harm, harm, do we anything that kind of takes away the person’s ability to look after themselves or to feel comfortable in their body. And if that’s the case, then that’s unlikely to be safe. Right. And also, the most important thing that you’ve taught it was before you might want to go on this, again, is that it’s not ethical either. If the information we’re providing the treatments we’re providing, the language we’re using, is is a Mipro is a misrepresentation of reality, or of our current less wrong understanding of manual therapy, Pain Rehab, disability. So people come to see us, and we don’t have this evidence base to support that knowledge. And we’re like, oh, yeah, I seem to correct this dysfunction are going to, well, I can feel this here yet feels like your, your liver isn’t rotating properly, or Oh, you’re your sacrum is stuck up here. And these things, which we know don’t have evidence to support them. And there’s different explanations, which are more based on evidence, so we could use to explain why you might see or feel something that area. That’s not ethical, because we are actually giving a misrepresentation to the person about what is actually happening in their body.

Jamie Johnston 23:50
Absolutely. And, and funny like, just to add to the ethical thing, when I when we look at the statements on the entry level proficiency, when it talks about if it gets to, you know, a massage therapist recognizes that something’s unusual, difficult to resolve, or it’s a complex situation, which might be on their ability, then they take the appropriate and ethical steps to address those situations by seeking consultation supervision or mentorship or reviewing research literature or making a referral. So it’s, and this I don’t think, should just be an entry level proficiency. This should be if you’ve been a person who’s been at in for 10 years, and you get something in front of you that you’re not sure about, you should still be referring to the latest research, maybe talking to some colleagues who have a bit more knowledge on something that you are taking an appropriate course. That is an evidence based course that is going to help you deal with said population that you’re confused about.

Eric Purves 24:46
Yes, you know, and guarantee there’s people gonna be listening to this. And they’re going to suddenly be like, Why do that? You know what, you guys are full of crap. Yeah, and I think I saw like I have every right to say that. I think less Cleany posts Did something recently, and one of the one of the groups about how in Ontario, they’re like, they don’t have a list of the modalities anymore, because we’re putting that onto the massage therapists to decide what should be used or what shouldn’t be used. And I think it’s great that yeah, the college didn’t tell us what to do. But But you probably provide a framework and the thing is, I think with the comment he made, he listens to our podcast so maybe he’ll maybe he’ll copy and

Jamie Johnston 25:33
he’s a beauty I love him. Maybe

Eric Purves 25:34
he’ll he’ll put he’ll he’ll he’ll have a point to say about this. But we do live in an echo chamber of those of us that are more than like to be where we are, there were like, we describe ourselves as evidence base, or describe ourselves as trying to be advocates for the profession by, you know, reading and trying to like, you know, apply evidence of the course we teach having this podcast where we’re kind of putting our thoughts out there. So hopefully, people will listen. And they’ll think, hey, you know what, like, this is, you know, these guys have something worth worth listening to. Yeah, and are worth doing to change. And so so he said that we’re in a bit of an echo chamber. And so I think that we talked about the stuff that makes sense to us. Other people might read this, or might listen to this and be like, Yeah, of course I do that. But we can guarantee from our experience, so anecdotal experience, okay, not evidence based. But there is a lot of stuff we’re talking about, we see every friggin day. Yep. At this non evidence based way is still the predominant way of thinking doing and teaching see courses?

Jamie Johnston 26:41
Well, and the thing is, there’s probably just as many echo chambers out there that are modality based echo chambers, or belief based echo chambers, where those people are probably looking and going, those two guys are idiots in the wrong. Yeah. Because they don’t understand how this technique works, or this modality works. And there’s probably a large group of people that are all, you know, based their practice around a certain modality that they have their own private Facebook groups, and they talk about that, right. So I’m sure that you know, every, every little thing within our profession probably has its own echo chamber with people that are that are deeply involved into those things just as much as we are into the evidence base. Right.

Jamie Johnston 27:24
Yeah. And you know, by slurred again, is, I would say that our echo chamber, though, changes based on the evidence that stops and thing and I think we are like to think of ourselves a little more malleable. Whereas there is a group out there who people are going to know when I say this, that is very popular in BC now, you made a comment about what they are heart centered framework that is used. That group there would not respond well to research, or probably anything we’re saying, or anything that we’re saying. And because they are their own echo chamber, and that’s what they do. And I don’t want to quote them, I don’t want to out them because I don’t want to be that person. But they that that there is groups out there for sure.

Jamie Johnston 28:19
Yeah. Where are they, you know, they have the Edit kit. And it could be very small silos of, of people who, who have that echo chamber and, and rely on each other, which, as a concept is a wonderful thing. You know, that if you’re focusing on a certain population or mean, hopefully, you’re not focused on a certain modality. But if you’re focused on a certain population or a pathology, that you’ve got people that you can bounce ideas off of and work together, but we would just hope that you’re using the most recent research on it. But I’m not sure that’s happening.

Eric Purves 28:56
Who knows? Right? I mean, I think it’s great that there is you do, we are seeing more of this, where people are there is more kind of courses and and communities are more population focused rather than technique, focus. So that is that is a shift, there still is the modality techniques up there, the acronyms stuff is still out there. But there is more population based things, which is great. The hope would be that those populations would those courses and groups that are focusing on populations would not just take their personal experience. So they’d say, hey, look, people with this in this population, these are things that we need to be aware of this is this is what we know is best practice behavior, you know, and how can we incorporate this with our within our clinical experience? How can we use our clinical experience within this evidence?

Jamie Johnston 29:42
We use that evidence to shape our experience

Eric Purves 29:45
or Yeah, attempt to to make it even better. And I would say that that is something that I would love to see. It might be happening in subtle levels. In some ways. It’s slow. But I would say based on what I see in my perusing and listening and teaching experiences that That’s still not out. They’re not there yet. There’s a lot of this comes down to, though right to the, to the things like the foundational knowledge that we learned in school. Is this one statement here and the document says, massage therapy relies heavily on application of principles of the physical, biological, health, social and behavioral sciences, does it? It’s a great statement. But if the principles of biological, social and behavioral sciences contradict the Moral Majority of the content instructed in the curriculum, examined on the exams, and taught in the CEE network, then that’s an untrue statement.

Jamie Johnston 30:36
Well, that and how many times over the years? Did you or I or us together apply to get a course approved? And when it’s a biopsychosocial? It got denied? Yeah. Yeah. Because it said biopsychosocial, even though right there, it says, Yes, we’re taking all these things into account.

Eric Purves 30:57
I know. That’s funny. That’s such a great point. And I didn’t see that when I read through this. But that makes that makes perfect sense. It says massage therapy relies heavily on the application of principles of bio psychosocial.

Jamie Johnston 31:07
Yeah. Yes. If that’s in your course, we will deny it for credits. Yeah. And in all fairness, I don’t think they’re doing that anymore. That was no years ago that that was happening, but quite

Eric Purves 31:17
a few years ago. Wow. Yeah. Not long enough ago. Yeah. Yeah. But yeah, that’s, that’s right. That’s funny. But still, right. And you look at all this stuff, and the foundational knowledge, and it says, you know, says here RMTS have a specialized foundational knowledge base related to the structure function and interrelationships of the body systems, and their response to manipulation. That sounds great to have, these are great statements, but how they are applied in curriculum, emphasize and see, not all see a lot, many C E courses. I’d say again, that’s not really that accurate, because if this were true, then the cricket and then the curriculum is emphasizing things like patho anatomical and structural ideas. If two students are still being taught all these different modalities, and each modality has a different story, changing fashion, I’m increasing circulation, I’m changing, writing joint alignment, whatever it is, this information actually, that’s that’s being taught that directly contradicts the current research evidence can’t be evidence based. No. But then when you look and you go through, we don’t have to go through the entire document. But there is a thing in there that says, massage therapists must employ critical thinking. And they must utilize research and professional literature and utilize self reflection to identify personal strengths and areas for improvement. This is within the documents. This means that the call the schools are supposed to have like performance or competencies and indicators, practice competencies, performance indicators. But I would say, I would be very surprised if this stuff was taught well, well, because if you how are you supposed to utilize research and professional literature when they’ve actually gotten rid of that quote that course in a few colleges? I know that and you said that they’ve changed it and some people you’ve talked to, to maybe even make it even less? How are you supposed to? If you don’t learn that information in school? You don’t you’re not sure of like, how do you ask researchable questions? Do you know how to search for it? What are good questions to ask? How do you critique it? Is a study good is a bad isn’t relevant? Right? Is is the type of research you’re looking at appropriate to answer the type of question you want answers to. Yeah, like this is big stuff like this is this is stuff that you can’t just learn in like a weekend workshop, this isn’t stuff that you can learn. Even it’s a late master, it’s a lifetime, but you should learn this stuff kind of threw out like every core every term of school, there should be some that and about how to use that information to employ critical thinking, look at your biases to do self reflection to understand where’s your knowledge come from? Why do I think this way? If something contradicts my my knowledge? What process do I do to reflect on that and understand, to go through, and it’s a very complex thing. Very, very important. This stuff is supposed to be taught, but it’s not. And you see this then is reflected in the evidence based courses that are out there are suppose evidences of courses out there, because this stuff isn’t routinely understood or used our profession. We could talk about it’s not like we’re experts on this either. And I’m like, I’m an expert on this. But I’ve done a lot of work on this stuff. So I know that I’m can be less wrong. Well and more comfortable in uncertainty than I used to.

Jamie Johnston 34:31
And part of the problem is it’s not only influencing the kitchen, the education courses that are provided, it’s influencing the people who are deciding what course to take. Yes. Right. So it’s, it’s it’s like a multifaceted tiered level of things going down and like to look back at the college education that like the, the piece that stood out to me when he read that stuff was the critical thinking aspect because like, I don’t know about you, but what I was going through I mean, I was in my early 30s, when I went through and I hadn’t been in school for 15 years or something like that. It was like I was drinking from the firehose, and I’m just trying to memorize as much stuff as I can to get through that two years. At no point, did I critically think about anything? As I went through, because I was just trying to memorize an origin assertion action, what do I do with this? What you know, all those things? And it’s always funny when I tell that story about, you know, the myofascial release class and the cranial sacral class that are teaching me the same thing. At no point did I critically think and go? Well, that doesn’t make sense. It wasn’t until like, 10 years later that I could critically think about that. So if that was, if that was a fundamental part of the education, that you could critically think it, then when you’re citing what forced to take, you’d have a better a better understanding of how to critically think whether that’s an appropriate course to take or not.

Eric Purves 35:55
It’s that’s actually that’s a really that’s a really great a great point. Because yeah, the critical thinking we were never taught really critical thinking it was, you always learned a pathology, yep. Right, or a presentation of some kind. And then you would learn a technique. So in that technique course, the myofascial release in that technique course you would then apply myofascial technique to correct or alleviate that methodology or presentation and then remember we did when when you know kind of near the end of the program, you could kind of pick and choose the modality you want it will help that Yeah, to to help to help that presentation. And the thing the problem is is that we we learned recipes, yeah, even if a teacher even if teachers said oh, you know you’re you’re not learning recipe. You learned a recipe you had Rattray that said you do diaphragmatic breathing you do do a hat do a number of big sweep superficial, superficial deep you know, do the Palmer and eating knuckle Nene finger kneading, be more specific? Bow back out? It was a very, like it was it taught you how to give a massage of felt really good. Yeah. Which is, which is a great thing, which is amazing. But it didn’t tell you how to critically think about why am I doing this? Yeah. And do I have to do it this way in order for in order to get the result? Or can I do something else like it

Jamie Johnston 37:24
didn’t we never were taught or inspired to think it was just do do to remember it like, because it was so hammered into you that I was working like it was in one of the tests where you had to do a treatment in front of a supervisor. And I was working on somebody’s back and I was starting at the hip and I was working up towards the shoulder. And then I kind of turned around and I went the other they told me they’re like, try going the other direction. I’m like, That’s okay. And I was like, shocked that I couldn’t go the opposite direction because it was always proximal to distal or distal to proximal, whatever, whatever it was, but I just remember being like, but no, you’ve told me and that that’s the other thing that drove me crazy when we got into the ML D class because all these teacher teachers have been saying for like two terms. You know, don’t don’t stick to a recipe do you do how you like it? And then I get into that class they’re like, No, this is a very specific recipe where you have to touch this way touch this weight. And I’m like, you’ve been telling me for two terms not to do that

Eric Purves 38:27
it’s it’s kind of it Yeah, it’s it’s bit funny to think of how things are and there is some there is some schools I know from people I’ve talked to it’s different institutions that are doing good work, but it’s still it’s I think we’ve we’ve probably talked about before that you have a couple individuals you know trying to make change but you still have a whole faculty that is still like no I’m gonna teach people how to do what I like to do that and they have they just like pass the board exams, pass your tests and that’s the way it is critical thinking and the use of the research isn’t there? Yeah. If you did do that though, and this is this something I’ve heard before from people and I this is a statement I don’t agree with but I’ve heard this from a school I won’t say which one is they were like well if we if we teach if we take out all this stuff, what do we replace it with?

Jamie Johnston 39:21
You can still do this with a better narrative.

Eric Purves 39:24
And my response was actually you know what if you took all this stuff you could you could create a massive program Yeah, like a huge program. They can be as big as you want it to be or you can can you know if you want to do the five semesters which is way too little in my opinion you could you could you could you could still you could fill it with way more beneficial stuff and you’re gonna have therapists are gonna come out they’re gonna be better to be more knowledgeable even more skeptical. They’re probably be a little more frustrated in school, but I can guarantee you that once those of want to be good therapists are gonna get out and they’re gonna, and they’re gonna be they’re gonna be the ones that are gonna be a leaders number. Question. Yeah. Which is what we need more of? Yeah, we definitely need more of that. Because there’s more people talking about this stuff now than it was. But so,

Jamie Johnston 40:08
oh, compared to five or six years ago, when we started teaching this stuff, it’s it’s late years now. But one thing I think is important to bring up because we touched on it at the beginning is how do you decide when you’re taking a course? So some of the things that I’ve seen online that I’m going to say, as a red flag, is, if you see a course provider online, that when they get challenged, lashes out at everything that’s being sent to them. That’s probably a good indicator that that course isn’t overly evidence based. Yeah. You know, if because, I mean, I mean, we say it all the time, whenever we teach a course. And I’ll say it to anybody who follows my page or blog or anything like that, if you want to challenge me Go right ahead. Because I 100% can be wrong. And I may not, I may not know the answer to the question that you have, I can try to find it. But I certainly don’t know everything. I actually, I only know a tiny little bit. And that’s the old saying to have like, the more I learned, the less I know. But if you’ve got somebody where they get challenged, and they are lashing out, and for lack of a better term spewing kind of hatred, and, and that kind of talk, then it’s, it might be a course that you want to shy away from. That’s true.

Eric Purves 41:34
Lashing Out is a big red flag. I’d say another one too, is research dumping. Yeah, we know, we’ve seen that lots where people will question a course. And they’ll just throw a whole bunch of research at you hoping that it’s like overwhelms you with like, your berries,

Jamie Johnston 41:50
you Oh, it must be true. Because these.

Eric Purves 41:53
And then that’s a big red flag too. And other one, too, is and I’ve seen this recently. We’ve seen a lot, but I did see it recently, which brings it to my mind is that somebody was asking about research for a course. And the person was like, Well, when you take my course I’ll give you all my research. Oh, and that, to me is a bit of a red flag to it’s like, well, I have the secret information. Yeah, that if you only have access to, once you pay me and take the course. And you know, I think we can both be honest is that, like we if someone wanted research before the course I’d give it to them. No one’s ever asked though. I don’t think there’s a rush. But after a course. So we always give like I always send people a big document with all the references, with references. And if anybody ever was like, hey, I need a specific I get these occasions of these questions occasionally. You meant in your course you mentioned whatever. Can you do you have any specific papers to back that up? Yeah. And that’s a Yeah, I do or actually, no, I don’t. But this is where I got that information from. So I’m glad you challenge me on that. You know, maybe I’ll be more mindful of how I say that next time. Yeah. So rather like I don’t know, I just the only time I think that we you and I when we’ve talked I’ve ever had negative interactions with people talking about research is I think when they themselves have been challenged. Yeah. And they are like, Well, I’ve been I’m, you know, I’ve been teaching for 25 years, or I’ve been doing this for forever. And, you know, what you’re saying completely contradicts my experience. Okay, great. That’s what research is for your, your, your what your assertions are? Well, no, but this is my I know, okay. Well, I’m saying that. That’s your opinion. Yeah. And this is why it’s important for us to employ things like to understand critical thinking, to understand our biases, to understand the evidence, because if we just rely on our personal anecdotes, or personal opinions, those are subject to so many flaws, so many errors of thinking and fallacies. That that’s why we have the evidence to say look, I think I used to think because I did when I did all my content stuff, when I first practically got out of practices, is my favorite stuff was fashion. I loved it. I did all the fashion stuff and took a bunch of courses on it went to the fascial research Congress in 2011. Which actually, was the starting point for the thing that got me challenging what I thought I knew, because it was some people were like, Oh, that was some of you are probably listening. Think that was great. I love that. I’m gonna say no, that actually there was nothing in there and that core in that conference that really validated anything about what we do about fascia. That information actually contradicted what we had what we knew about fascia. Yep. As manual therapists. Yeah. Anyway, I learned I did all that stuff. And so I you To think that when I was seeing changes in people when I was doing stuff, and they felt better, they’re getting areas getting softer, it’s getting warmer to get more movement. That was because I was changing their fashion. Because my evidence base said, that’s what you were doing was so narrow, and I looked through at everything through that fascia lens. It wasn’t until I was able to, to zoom out and look at the bigger picture that realized, oh, maybe that’s happening for a different reason. Yeah. Right. And but because like you said, before we learn this stuff in school, or in our lives, our lens is so narrow, that we’re looking for courses based on one school. Well, I want to learn more about this thing.

Jamie Johnston  45:40
Yeah. Yeah. And with that, you know, that like, like you were saying, with the research and stuff that you’ve got, but I’ve had people reach out over the years. And they’re like, do you have anything on low back pain, and I’ve got a Google Drive that has like, research things for all those things. And I can just send somebody a link to a Google Drive and be like, yeah, there’s like 10 papers in there, and low back pain, which I’m based what we use for the poor. So you know, that sort of thing. But I think it’s also important to mention too, is that if you’re going to challenge somebody, whether it’s online or in a courses, just to be respectful in the way that you do it. Right, if you’re if somebody, if somebody has gone through the effort of putting the course together, and they’re promoting their course, and maybe you don’t agree with them going on, and maybe calling them an idiot, or something like that is not the way to do it. But, you know, respectfully challenging them. And I, you know, I’d look at some of the things that you and I have done over the years, where, like, I can think of one example, that was great to where somebody who has now become a mutual friend of ours took our course. And there was a discussion around the link between depression and low back pain in the course, and the person came up and pulled us both aside, didn’t do it in front of the class and said, hey, you know, you might want to change the way that you talk about that, or the way that you word that and spoke from personal experience and said, you know, as somebody who deals with this, you know, the way you said it was maybe not the best than that. And then that gives the instructor time to kind of step back and go, Okay, so the next time I teach, maybe this is the way to verbalize that, to make it to make it better, right. So just making sure that if you’re, if you are challenging somebody do it in a respectful way. And not not to try to grandstand in front of a whole bunch of people, whether online or in person, you know, just

Eric Purves 47:22
just be respectful. And if I remember that situation, and that you recall there correctly, I think I believe that I think it was at break. And then after break, we actually went back and we’re like, just wanted to clarify what we’re saying here. Because this is this is how it might have been heard by by someone. And that was great. And personally, when I’ve taken courses and the the instructor has a little bit of humility, like you want to be confident, because you want them to know their stuff. Like that’s why I want to learn this course me because you know your stuff. Yeah. I don’t want you to be cocky about it. Yeah. And I think I mean, I don’t know, cockiness is a thing. And confidence is often a perceptual thing, too. Yep. Right. You know, you’re like, Yeah, we teach courses and there’s, there’s information, you’re confident that you’re gonna be competent about it. But you know, if if it comes across or you’re like, Oh, my God, these guys, they think they know everything. I say, Okay, well, that’s, that’s a you problem. Yeah. Because because I think that both of us are like, this is the best available research. This is just our interpretation of it. This is how we are applying it to what we’re teaching. And also not not is this this is not a right or wrong thing. These are ideas based on this research that we’ve put together.

Jamie Johnston 48:29
Yeah, and this is, this is the best available research that I could find. Yeah, right. If you found some better research than by all means, throw up my way. I’m happy to take a look at it. And if it changes what I’m teaching that all the better. Yeah. Right. But But again, just making sure that whether online or in person, you’re doing it in a respectful way, to the person who’s put the effort into to build a course and is is trying to better the profession through what they’re teaching.

Eric Purves 48:56
And actually might be a good topic for another another podcasts in the future. We the amount of effort it takes it for to do courses like to put them together and I think it’s something that not a lot of people understand. And I never understood from when I’d be fine till I started teaching courses. I never realized the hours what it took to do it and you know, I’ve seen things before not necessarily in BC but another in other provinces, other parts of the world. Why are courses so expensive? And you know, I can’t afford that and you think okay, I understand finances are was a thing, and it’s a thing. But I also think this is going to probably well, I guess this goes into the the evidence based course thing. That if you have a course that is thoroughly researched, and it’s like you can defend with good quality research what it is, you really as the learner really need to I think it’s important to understand how much time they put into that. Yeah. And developing it like how Drudes of hours. Yeah. So maybe you’re paying 500 or 600 hours for that course. But that person is probably put in hundreds of hours to get to that, and plus the constant updating it, plus the marketing and the admin side of it. And, you know, the expenses, especially so as much now if you’re teaching it online, but still, when you’re traveling, Detroit is 1000s of dollars. So there’s a lot of things there that people might not be aware of.

Jamie Johnston 50:27
Yeah, that’s one thing I was gonna say is the, if the instructor is worth their salt, they’re they’re continually updating. Right, the hopefully, whatever course you take right now is not going to be the same course from that person two years from now. Because as new research comes out, they shouldn’t be updating it. Yeah, and making it better for you and whoever else is taking it, for sure. So I think that’s a good way to wrap up. That’s probably a long winded way to talk about how to choose an evidence based course. But we hope that it, it’s an effective way to look at things. For those of you who are looking to spend your hard earned money on a course and we’re not saying that it has to be one of our courses that you take. But when you are looking to spend that hard earned money into progress your career, just make sure that you’re making wise decisions when you choose your course. Love it. All right. That’s it. We’ll see everybody next time. We hope you enjoyed this podcast. These kinds of topics are what we are all about. If you’d like to learn more, go to our websites,

Eric Purves 51:32
themtdc.com or ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe

 

Podcast Episode #24 Maintaining Professionalism When Given The Benefit Of The Doubt

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Jamie Johnston 0:12
You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston. And I’m Eric Purves. This is a podcast by massage therapists for massage therapists. Our objective is to simplify how to be a more evidence-informed practitioner. Let’s dig into this episode.

Sometimes things in our profession change, sometimes for the better sometimes for the worse. And sometimes we’re not sure if it’s for the better or the worse.

This is one of those instances where I know that this is instituted with other colleges, but for our college in British Columbia, they have come out with a new standards of practice for us, where we don’t necessarily have to take a continuing education course for credit, but they have sort of laid the onus on us, and they’ve come up with career spanned competencies that we look at, for us to decide which direction we would like to take our own practice. That’s right.

Eric Purves 1:21
I think yeah, I think that’s that’s very, right. It’s, I have mixed feelings about this. And there’s a lot of goodness, but there’s also a lot of stuff that makes me concerned. And I think we should probably start off by saying our bias is that as people that earn a living, teaching Con Ed and providing educational opportunities to massage therapists, you know, we do get a lot of people that take courses just because they need the credits. Yeah. And they don’t necessarily really care what the course is, they may be aren’t that engaged with the material. I would say this is a minority of people. But this does, this does happen. And you always see and, you know, I’ve been doing this since 2015. And you always say no, then to cycle, you get a massive rush of people that are desperate for credits. And they just ended oftentimes, when you ask them, they’re just like, Well, this was available. And it was the closest one to me, is the closest one to me before we added online stuff. So people would, would do that. And so from a financial perspective, and from a business perspective, the old system was was good. But it also, I think you’d probably agree that it was not always you wouldn’t always get a full room of desire of people that really wanted to be there, that were really engaged. You’d have some people there’s like, I think the credits.

Jamie Johnston 2:40
Yeah. And that’s, I mean, even if I’m teaching a first aid course, it’s the same thing. It’s, you know, some, I mean, you try to make the class fun and make it so that people walk away going okay, that was fun class, but they’re the biggest reason they’re there is because the college just said, you have to take it. Yes. Right. So

Eric Purves 2:56
I mean, and it’s important for us to to have these, these, what they call this career span competencies, or what do they call it, they call it the professional practice Development Program, or the calling of the PDP, the practice development program, which looks very similar to Ontario strive program, where it’s basically more of a self reflective self directed learning plan, which you create yourself. And you basically have to follow these kind of 15 where they call them career span competencies, and we’ll talk about those I think individually here in a minute, the abyss, you have to follow those, and you have to basically create a learning plan that meets those competencies that are relevant to you, which I really like because I think if you as a clinician, and so as someone who still needs to take CS, even we teach them, we also have to take them ourselves, it can be very difficult to find stuff that is interesting or relevant to you, or that you want to take or that you want to take. So I think this actually is good. So good. The negative is from a business perspective, like it’s easy to sell courses when there’s minimum. CCS. Yeah. This is good, though, in the fact that it gives it gives our mentees the ability to choose and pick the kind of the direction they want to go based on their interests and based on where they are in their career. And based on the the populations they treat, or the environments they work in. That is good. And I’m not going to do that. I think that’s good. I’m very curious about how this is gonna be adopted by the profession.

Jamie Johnston 4:26
Yeah, it’s more like more in this case of a practitioner benefit, which is great. Right? Because this way, you get to decide where you want your career to go, which is we should we should all have that autonomy within our career to be able to to say, you know that I don’t want all that to say that we specialize in something but this is the things I want to focus on in my career. These are the directions that I want to go and they’re giving you the leeway to say good then go do that. Which is great. But the I think it’s important that are hopefully are going to talk a little later now, but it’ll bring it up. Now, it’s important for us to take into account that they’re giving you that leeway, and giving you the benefit of the doubt that you’re actually going to do it. So, we’ve seen, we’ve seen some debates, for lack of a better term in some of the Facebook groups where people are like, great, I don’t have to take CTCs. Now, that’s not what they’re saying. They’re, and by saying that, you’re actually almost like, kicking dirt in their face, because with them doing it this way, they’ve taken a step back. And when we’re giving you the benefit of the doubt, we’re giving you some some leeway for you to decide which direction you want to go. It doesn’t mean you don’t have to not take courses. You’re so they’re putting their faith in you that you’re going to be a professional and say, Okay, I’m going to keep up with this. And I’m going to make sure that I’m as highly educated as I can be in my career, in order to be of best benefit to my patients, which is the college’s job is to protect those patients. So they’re now giving you the benefit of the doubt that you’re going to do everything you can for the benefit of those people. Yes, yeah, and

Eric Purves 6:07
I think the only difference with this is, is you don’t have a minimum number of credits to take, you don’t have to go through the approval process, which I must admit like, right, it’s kind of annoying as the you have to submit all this paperwork and fill it all the stuff every time for a course. It’s it’s kind of a pain in the butt. So now people can pick and choose when they want, they don’t have to worry about going through that process. My worry. The worry, though I do have this as is the college was going towards a their evidence informed practice thing, which was good, which was moving in the right direction, even though stuff that wasn’t in this might be another podcast, if there wasn’t evidence based or evidence informed, was still getting pushed and being called Evidence Informed. And being approved. So I would say the approval process for that was probably not as stringent as it should have been. But they were moving in the right direction. Now they’re doing this and they’re saying we’re gonna we trust you to come up with stuff yourself. But without an approval process. How do you How is this ensuring that people are going to learn stuff that’s relevant? Yeah. Or learn stuff that is science based or evidence based or stuff that is defensible with current research? And that is where I get a little bit kind of concerns those being like, well, how is this going to be implemented? Or how are people going to adopt this into the practice? And I don’t know enough about Ontario’s program. It’s been around for longer.

Jamie Johnston 7:35
I think a few years, it hasn’t been around like a super long time, I don’t know, but

Eric Purves 7:39
maybe three or four years longer than like previously. And they used to have a minimum like a CDC requirement as well. And now they have more freedom. The freedom is good, because allows us to choose. But it does. I think the problem that results in is I think it can potentially allow more of the pseudoscience, more of the on defensible or non-evidence based stuff to flourish, because now that stuff doesn’t have to be approved. Yeah. So I’m kind of stuck in this this, I’m not really sure how to feel about it yet. Until I see it in action. Yeah. Yeah,

Jamie Johnston 8:17
I agree. And especially like, you know, when we look at the list of things, sorry, I’m just going to bring it up again, here. Of course, I mean, the the topics that they give, that we have to meet up to are great, you know, maintaining a safe work environment, maintaining comprehensive records, manage time and resources effectively treat others respectfully use evidence informed approach and your work interact effectively with other professionals like all great things that we should be focused on, within our continuing education, but not a lot of those are instances where there’s courses offered on them, which is probably why they’ve developed some of those courses that we have to take, which is fine. But when we look at some of the other ones, like functioning in a patient-centered manner, we should all be for patient-centered care. But to go back to the point that you were talking about, we see a lot of other comments and a lot of other terminology that’s used that isn’t patient-centered, that is still being pushed as a narrative that we should use with patients. So So there, there comes back to that concern about whether those things are going to be approved for people to take to take courses that aren’t patient-centred has absolutely

Eric Purves 9:36
yeah, yeah. And I agree that there’s, you know, you look at this, the 15 CSE isn’t, you know, I don’t know if we can do one read them all. We don’t read them all. And we’ll read the ones that are the ones out that are probably most relevant. You said the first one here was function a patient-centered matter. Right, and that’s a good one. So working in the best interest of the patients and so their brief descriptor here is I won’t read the whole thing it says you ensure that patient one wellbeing is at the center of the decisions you make, and are aware of your obligations to safeguard young persons and vulnerable adults. Okay, that makes That’s seems very, that makes sense, right? That’s, that should be. That should be just a given right? You give each patient your complete attention and allow sufficient time to fully address their needs. You respect patient uniqueness, and take into account their views, preferences and concerns, which is great, right? So when people come in, they tell us what their issues and concerns are. And then we do our best to help them within our scope of practice. You actively involve patients in decision making and ensure that they’re fully informed about and consent to the services you provide. Which is great, because so people come in, we allow we give them information, we allow them to make decisions, based on on our own. But the problem isn’t, I think you and I’ve talked about this before, if we haven’t talked about the podcast, we definitely talked about almost every time when we teach is patients are fully informed about and consent to the services you provide. Yeah. And if you want to expand on that, because I know you, you have a great little spiel about this is that, but if we’re giving them information that’s not evidence based, that’s based on beliefs or historical ideas, but not based on current science, is that informed consent? Are we giving them proper information to allow them to make decisions about their health care?

Jamie Johnston 11:27
It’s not. Right. So as long as as long as we’re stuck to those, many of those old narratives that we’ve learned in schools that have since been proven wrong, if we’re still relying on that, I think a perfect example was, and I don’t know who the person was. So I’m not, you know, trying to put them out of them in any way. But when we went to the, the RMTBC conference couple years ago, that was based around cancer. And the person stood up and said that they had been a therapist for 25 years, and they were shocked that we were allowed to treat people with cancer. So in 25 years, this person had taken, I don’t know what for continuing education, but had not gotten past the fact that cancer wasn’t a contraindication anymore, at least, parts of cancer weren’t a contraindication anymore, I was baffled that it was okay to give somebody with cancer massage, when we know now that’s like one of the best things we can do to help. So for for whatever course, courses that person had taken in 25 years, had obviously not been given enough updated information to understand that. So I would make maybe a bad assumption that they’re probably still using techniques and narratives that were based 25 years before. And so if you’re doing that, you’re not getting informed consent from your patients, because you’re still telling them that you’re unwinding their fascia or your you know, altering their craniosacral rhythm or, or any of these other things that we learned that we know are true,

Eric Purves 13:09
increasing circulation, and therefore spreading cancer, putting too much load on the heart, that kind of stuff, which we know has no science behind it,

Jamie Johnston 13:20
that you’re increasing the risk of a diabetic reaction with a massage, right? Like there’s so many of those, right. So if you’re still using those outdated narratives, then you’re not getting informed consent from the patient, because none of those things are real. So that, again, it’s, you know, depending on what the course is people are going to be taking are, and the more that we talk about patient centered care, we see in many of these forms, people use a number of other I don’t want to say it’s a description, many other terminology, terminologies to try to represent the same thing. And one of the ones that I see that I that I never really understood was heart-centered care. And then I Googled it. And if you look at the definition of heart centered care, so I literally Googled heart centered definition. It says being heart-centered means that you are aware of what you desire in life, you know, your values, you know, how to take responsibility for yourself and your emotions. You make choices that honor your needs, values and beliefs. No point does that say anything about a patient and collaborating on what you’re doing with them? It’s every everything in there is you you’re you, you, you. So if you’re going in and saying that you’re providing heart centered care, it has nothing to do with the patient.

Eric Purves 14:42
It’s clinician centered. Yeah, yeah.

Jamie Johnston 14:45
Which is the exact opposite of what the college is requiring us.

Eric Purves 14:49
And that’s, that’s a term two that you know, I’ve seen floating around a bit and people grasp onto it because it sounds very holistic and very great, but I’m sure there are attempt is the intent is probably in the right place. But I agree with you that the if we are wanting to be a science based, mainstream musculoskeletal profession, that and we’ve said this before, we’ve said many times that we definitely have the capabilities of being leaders in the treatment of management of any musculoskeletal thing. For the most part, when we’re making up terms, or developing new terms about stuff, and trying to like, come up with their own acronyms or own explanations that have no scientific basis, that’s not serving our profession, or the public’s best interest. And we see that all the time, we have

Jamie Johnston 15:44
to keep in mind that the college’s responsibility is to protect the public’s best interest. Yes. And there goes back to their putting their faith in you that you’re going to do the right thing by them developing things this way. So, but then it also goes back to like, how closely is it going to be monitored as to what your what course you’re taking or what you’re doing? Well, we’ll see how that develops as this goes on. And hopefully, they do a good job of making it so that that therapists are taken to task for what they’re taking, what courses they’re taking.

Eric Purves 16:18
Yeah, and that’s the one thing that worries me too, is they say all these words, but they’re very vague. Nothing is really very specific. And so how is the college gonna? Like, what are the metrics for that? How’s the college going to get to know if someone is fulfilling out or not? When you don’t have? Like, here’s like, the person who is going to work in that patient centered manner. What’s that mean? Yeah, without the college, really providing specific definitions or without the schools teaching that specifically, it makes me think that’s, that’s up to so much interpretation, which is good that it shouldn’t necessarily be these hard and fast rules. But it also I think, can allow for a lot of a lot of like, really pushing boundaries of what that means, like you said, like heart centered. Yeah. You know, that’s, that’s not even a thing. Yeah.

Jamie Johnston 17:07
Yeah. At least provide a guideline of some sort. Yeah. Just a, this is what we expect. Yeah. And this isn’t going to be implemented until January. So those things could still come out. In the meantime.

Eric Purves 17:21
Yeah, the college did say that they are going to put out more kind of FAQs and more information about it. But this is this what we have to work off. So we’re just making judgments based on our initial reactions. Yeah, one of the other ones, too, which I think was worth talking about, because a lot of good stuff in here, right, maintain a safe work environment, maintain comprehensive records, personal wellness, you know, treat others respectfully, like, yeah, this just makes sense. So it’s like that shouldn’t even be on here almost, because that should just be

Jamie Johnston 17:51
given. That’s common sense. Common, it should

Eric Purves 17:53
be common sense, that should be like, and we all do that anyway. But some of this one here, which I thought was interesting. And it says, practice in a manner consistent with current developments in the profession. You take regular active steps to keep your knowledge and skills up to date. This includes reading professional literature, attending conferences, participating in courses and workshops, and consulting with colleagues. This one to me is one of the ones I like the most. Yeah. However, how this is interpreted and how this is applied in a practice or into someone’s Learning Plan. Could be the problem if someone is has embedded to a technique, or they might work in is embraces a technique, where they view themselves through a specific like acronym or through a specific just as the population of people I treat? And you maybe you have somebody, you’ve taken all of their levels of their courses. Is that Is that consistent with the current development in the profession? Not if they’re still teaching outdated things? Yeah. And so that’s where that’s where I think, okay, so what is current developments? And how do you know, or how’s the college going to decide what is the current development? I would I would read that and be like, what’s the current science say? So use the cancer example? Yeah, we can massage people that have cancer, whether they are currently undergoing cancer treatments, or whether they are palliative, or whether they fully recovered and they’ve got, you know, back whoring and surgery or neuropathy is after we can treat those people and we’re not going to increase the risk of harm, harming physical harm. However, using the cancer example, what if we start pathologizing? And so you’ve taken some, I don’t know, some courses on cancer now and oncology and those courses are taught with a non science in foreign non science based framework. Yep. And you’re treating people based on that framework. And that might not be in the person’s best interest. But that might be what you learned in the course you maybe thought an instructor was great, maybe thought the course was great. Maybe you had some great colleagues in there. But maybe the information wasn’t based on current science. But you were led to believe it was, but you were led to believe it was is that’s not that’s inconsistent with current developments in the profession.

Jamie Johnston 20:20
Yeah. Yeah. It’s it’s almost too bad that there isn’t something in there that talks about critical thinking.

Eric Purves 20:29
That’s like, that’s untrue. I just, I was thinking that too. I read this, like, there’s nothing in here about engaging in logical fallacies or critical thinking or any

Jamie Johnston 20:36
of that stuff, you know, reading, like, yeah, being able to let’s just go back to the cancer example. That if you look at like the new clinical guidelines on, say, cancer care, and M escaping, yeah, there’s a paper out there on it. I’m sure I haven’t somewhere because I’m putting a horse together on that. And then being able to go, Okay, well, that’s the the creme de la creme. That’s that. Those are the papers I should look at. And then he will take a course that has a whole bunch of case studies that have been refuted by the clinical practice guidelines. Yes. But the person teaching the course presents all these papers and says no weapons based on research, because there’s there, we need to develop something to be able to, for therapists to critically look at that and go, Okay, this isn’t based on the best research. So maybe I should go home and look at some of that now and see if that refutes, what would what I just learned in this course.

Eric Purves 21:34
Yeah, and you do get a lot of that in our profession, not just pick our profession, but not just ask, but you do get a lot of that, where there’s these anecdotal stories that are that are being sold as hard science. And we look at the evidence based framework of like your, your clinical experience, your personal experience is part of that. And you don’t want to refute that. Because there, you know, you treat somebody and they get better. And you do that numerous times. And you see, because this one results, and that’s part of your evidence. Yeah. But the problem is, is the reasons for why they might get better might be very different from what you think. Absolutely. And maybe what you’re doing, and the stories that you’re putting on some of these people and these beliefs that you’re putting onto them might be harmful, because might take away their autonomy or their self efficacy. That is, I think we’re the why it’s important for us to be mindful of the difference between using anecdotal stories to validate why it is you’re doing what you’re doing versus the science because the science is there to inform those anecdotes. Exactly. I think I don’t know if that’s the right. If I said that. Right. That’s how I see it. Saying that, again, I think you’ve got out and why

Jamie Johnston 22:57
that anecdote worked. Yeah. And that comes in, that all comes back to the second point, and their thing is communicating effectively. Yes, right. So being able to take the current science and communicate that effectively to a patient so that these things aren’t happening. So that we aren’t just using this anecdotal evidence and saying, yes, it’s it’s because of XYZ when it’s actually because of ABC.

Eric Purves 23:23
Yeah. And that’s not pain. splaining? No, are not science playing. I think that’s sometimes when we think about effective communication, we were like, well, how do I explain pain to people? Or how do I explain this dysfunction? Or how do I explain this disease people? And we just kind of like vomit information, people. That’s not what it’s saying. So I think that’s part of effective communication is communicating a level that people want, as well as our own knowledge, like how well can we communicate? And how much and what how much information do they need? And how is it received? And I think they do say thing in here, too. You communicate clear and concise as possible and take steps to ensure that you are understood. That’s a really important piece. And surely you understood it, which comes down to asking them if they’ve understood or ask them to repeat it back to you. Yeah,

Jamie Johnston 24:09
there’s that old thing of like, Tell me Tell it back to me like you’re explaining it to a 10 year old. Yeah, exactly. So that they you get whether they absolutely understand what you were saying. Because if they, if they repeat it back, and it’s not at all what your intent was, then you need to change that communication and correct it before moving on with your treatment and all that and that’s all part of that consent thing as well. Yeah. Right. And I like like what they put in there is like even reading nonverbal cues, reading body language, things like that. So that you know, if you’re saying something to somebody, because I know there’s been plenty of times in my career where I’ve stuck my foot in my mouth and you see the person kind of looking at you and being able to read that patient and go, Okay, I need to take a step back here. Because I either said something wrong or said something they misunderstood and are not taking the way I intended. So there’s a little bit more behind that. But communicating effectively is obviously going to be an important part of what

Eric Purves 25:03
we do. Yeah. I think a lot of the stuff comes comes back to that effective communication.

Jamie Johnston 25:09
Yeah, yeah. Well, especially when we look at the, the clinical guidelines, and like the best approach for MSK care is always that reassurance, education. Right? Those two first things are all about communication. Yeah. And there’s a reason that the, the importance of those things are number one, and two, and then movement and actual manual therapy, or three and four, yeah, those, those things are more important. So one of the other ones that I like, that they put in is that you work within the limits of professional knowledge and skills, because that we go back to that story I told about the person at the conference and the cancer thing, but also, when we look at the brand new student that’s coming out. So let’s just say, a student, I graduated in December, we got out of school. So let’s just say that I graduated in December of 2022. And then all of a sudden, in 2023, I look at that, and I go, Oh, I don’t have to take CCS anymore,

then you should be very

limited as to what you can do with your patients. Yeah. Right. Like, if you’re making if you’re staying within that professional knowledge and skills. When I look back at what I know now compared to what I got out of school, it’s light years difference. And I’m not trying to say that I’m some smart person, it’s just that I’ve learned a lot in the last 10 years. And the way that I treat is different now the way I communicate is different now. So I think that’s a really important one because hopefully those students that are coming out brand new aren’t going, Oh, perfect. They’ve just told me I don’t know how to fix the season.

Eric Purves 26:45
you’d hope that students like you’re frustrated and so to school would want to to learn and I mean, I’ve been the I think we’re a little bit of a bias or a little bit of an echo chamber, or at least for me it’s been for myself is that a lot of the people that take my courses or sign up for my memberships or to take some of mine are new grads are relatively new grads that want to learn more, that have been exposed to stuff. I would say that you don’t get nearly as many of the 20 plus year veterans taking stuff. So I mean, I could just just be me, but that’s just my my anecdotal experiences. A lot of the younger and younger, they’re always young, but new to new therapists. Younger field. Yeah, usually younger than me. But, but new newer therapists are those people are younger than you and me. So yeah, it’s true. That’s true. Now, didn’t used to be that way, you know, are people that want to learn and a lot of them will take stuff, even though there’s no season rolls? Yeah. Because like, I want to learn this information. This is important to me. This is important to people I want to help. I want to I want to learn all the things. Yeah. So I hope that that becomes a kind of common thing. And I hope that when people are finishing school, like the educators or the schools now are kind of planting that seed to basically be like, you’re a lifelong learner. You don’t need to see seeds, but you still need to learn like it’s really important. Find a population or find an area of interest or find people you want to learn from and take their stuff, because that’s going to be valuable. Yeah. I like what you said a few minutes ago is that the If I think back to how I used to think and how I used to practice now, I used to treat people and how is communicate compared to you know, the last, you know, seven or eight years, like it’s embarrassing.

Jamie Johnston 28:33
I’ve often said I should go back and apologize to most of those people.

Eric Purves 28:36
Yeah. And I am so surprised sometimes that people still came back. When, when when you but I guess it’s just a matter of people had this these expectations. And you provided that to them, and you thought you’re helping them. But I think a lot of times I was I wouldn’t say you’re always making them worse, but you weren’t always helping them. Yeah. Right. And I think that the it is hard to think that way. And you think even to when you’re starting to adapt and trying to be more what you call science based or evidence based. And you go through that process. I think you screw up even more because you’re trying to change that narrative. You’re trying to change how people think. And you’re you’re doing stuff and saying things which really unhelpful and probably quite harmful. Yeah. So I think there’s a learning process which we all have to go through. And I think anybody that feels that they know it all, or feels they don’t need to learn any more, I think is that’s a dangerous thing.

Jamie Johnston 29:30
You should probably leave the professionist Yeah, I

Eric Purves 29:33
mean, I always want to learn more because I never feel like I know enough. Yet. That’s that’s me. And I would hope that the majority of us that way, like Yeah, you know what, I would really like to learn more about ABC, whatever that whatever this field is, or this area is I want to learn more about, I don’t know, sensory neurophysiology or I want to learn more about you know, helping geriatric population of seniors I want to help more with athletics or I want to help more With chronic pain or whatever it is you choose you like, I think that people should just like, first. And then, and hopefully, hopefully, my hope would be with with this new stuff here with these new, like you for another cold career spanned competencies nothing in here talks about techniques. No. Right. It’s not about learning new techniques. It’s not about expanding your techniques. It’s not about the only assays they take technical knowledge and skills.

Jamie Johnston 30:35
Yeah, but at the bottom, but there’s nowhere in there that talks about technique.

Eric Purves 30:39
Yeah. Which is to me is sorry, that about the above.

Jamie Johnston 30:43
It says you apply your knowledge and technical skills, procedures, equipments, devices, techniques. But you’re you’re gathering skills, to gather information, assess, plan, land or deliver services. So even with that, they’re not saying that you go out and learn a whole bunch of new techniques, it’s that you gather everything that you know, and apply it.

Eric Purves 31:01
Yeah. Yeah, that’s right. Yeah, I read that again. And you either does say technique, but doesn’t talk about gaining new techniques. And so much of what we learned in our professional we’ve talked about this before is that people are looking to always get new techniques all the time, right, and collecting these these tools. And there’s, there’s a certain point where like, yeah, you want different ways of touching people. But I would say that, you know, majority of what we learn in terms of how to touch people, is we learned in school.

Jamie Johnston 31:29
Yeah, I probably learned everything I need to know about how to test people in the first three terms of school.

Eric Purves 31:33
Yeah. And it’s just a matter of refining that and kind of developing your own kind of.

Jamie Johnston 31:38
Yeah, the way you like to do it the way your patients like you to do it.

Eric Purves 31:42
Yeah, exactly. Exactly. One other one here, I thought was really good. Kind of next point was. And this is really what it comes down to now, we’ve talked with this before about evidence based versus evidence informed. I’m not as I initially liked the evidence informed approach or that evidence informed definition. But I’ve now kind of gone back to I think I prefer evidence based, just because that’s but same idea anyway, use an evidence blank approach in your work, right, as they say you make workplace decisions by integrating the best available evidence relating to the situation at hand, including research and credible published information, your own professional knowledge, including that of trusted colleagues, the patient perspective and the practice context. So if we’re using evidence to like, we really should be using evidence to inform our practice and combining what’s the research say, right, so usually, when we talk with the stuff, we teach the stuff, right, we usually talk about clinical practice guidelines, which are pretty special, specifically vague to be able to apply this information to people. But the thing that’s interesting with me that with this, though, is that if you said to most, I should say most if you said to many people was evidence based practice means you’re what’s evidence informed practice mean to you? You’re gonna not get it, you’re gonna get a lot of different answers. And I think the problem is, is that that terminology, or that phrase of evidence based or evidence informed, is not really well understood.

Jamie Johnston 33:21
Even within leaders in the profession, it’s not really well understood.

Eric Purves 33:25
Yeah, and I think I feel I mean, I don’t know, I feel like some of you, we say these things are pretty bold statements are kind of throwing people under the bus. But not anybody specifically. But you do see that all the time is like, so if something is evidence based, I mean, just based on the best available evidence for that. So let’s use cancer, because that seems to be the the one. So if you’re if you’re say your course, is evidence based, oncology, evidence based massage therapy for the oncology patient, there’s a core same for you. And how are you deciding what’s what? What information? Are you finding? It’s the evidence for that course. And you know, how to critique that evidence. Do you know how do you or do you know how to apply that? Is that evidence good or bad? Right? Is that are those case studies? Are these clinical practice guidelines? Are these just a single randomized controlled trial? is a systematic review with meta analyses? And then is there is there maybe some qualitative stuff there, but like, how do people feel that are being treated with cancer? How is how meaningful or important are these massage requirements for them? Like there’s a lot of different types of evidence that we could use?

Jamie Johnston 34:33
And are we applying it individually to each person who comes in because that’s going to change with each person?

Eric Purves 34:39
Exactly. So that always you know, this kind of this kind of stuff. I love it. I think it’s great. But my skeptical nature of where I’m, you know, I kind of don’t really believe in anything. Now, let’s Nilus nihilist nihilist nihilist doing bit of a nihilist sometimes is I think okay, this is great, but Is this information going to be? Is this going to be applied in it to courses or to workshops or to conferences? I don’t know.

Jamie Johnston 35:11
Or even it, even if it’s not a course workshop or conference, let’s just say it’s a therapist who has that interest and has maybe taken some and now is going, Okay, well, now I’m going to look at a bunch of the research on my own. Yeah. Are they going to apply it the same way? Right. Right. Maybe it’s not even from the course. Because Because part of this is, hey, you should be able to sit down and read a research paper and put in that, yes, I’ve done this. Are they going to? Is that individual going to look and go? Okay, how do I apply this to Bob, that comes in compared to Mary that comes in who are both dealing with cancer? Right? Right. different cancers, different expectations, different things all around that, right? So it can come down to that individual basis as well, just not the court, not just the cost basis. And that

Eric Purves 35:59
goes back to function, a patient centered manner, which was like the, one of the earlier earlier points, right. And that’s, and this is this thing is it’s interesting. So we talked about evidence informed evidence based stuff, and they say here, they say they say, including research and credible publishing information. Now, this is the problem. Right, as a profession. I was told recently that a lot that some of the schools have actually got rid of the research section of the court. Oh, I got the program. Like there’s no more research and statistics section. Wow. Because it’s time instructors. You can you don’t need to learn that stuff to pass your board exams.

Jamie Johnston 36:39
Well, then, how do you write your, your your, what did they call it? Not a case study

Eric Purves 36:45
here? You basically do a case study presentation. Yeah.

Jamie Johnston 36:49
How do you rate your case study if you don’t know how to look at research?

Eric Purves 36:52
And this is just totally anecdotal. This is what I heard was they just teach basics of that, in that when they doing that portion of the program? Yeah. I know. But But I think it’s the so if you’re not teaching, and this goes back to to, I mean, it goes back to what I did in my, in my graduate studies, was that when you’re not teaching people the basics of of science literacy, of research, interpretation and applications. Yeah, you’re not. And you don’t teach people about the Knowledge Translation From Research to Practice. Like when those basic fundamentals aren’t taught, they are never learned. Yeah. So there are colleges saying we need to be evidence informed. And our approach, we need to include research and credible publishing information. But when that information isn’t presented to people are taught to people in schools, they come up, how are they supposed to learn it? Are they gonna go take a course that teaches them how to read and interpret and understand the scientific paper? Not many. So when it feels to me when I read that, when I hear this, and I read this, I think, yes, this is great, we should be using an evidence for approach in our work. But what how do we know what’s evidence for evidence based, if we’re not taught, you don’t know what you don’t know, you don’t know what you don’t know. And you can obviously you can version A lot of us to learn it on our own. But that’s, that’s a self self regulating, self regulated thing. So I would almost like to see a 16th point was, which was like, learn how to do or how to understand research.

Jamie Johnston 38:24
But see that therein lies the problem, because like, just to expand on what you’re talking about, not only will people likely not come out and want to take the course, they won’t know that they should take the course, because they’ve never been taught it. And it goes back to I don’t know if we were talking about it on a podcast or where I was talking about it recently. But we’re, we’re primed from college, to believe that we should constantly take technique horses, because we’ve learned more technique courses in school than we do about therapeutic exercise or research or any of those things. So now, if the research component isn’t even there, but you’ve been taught five technique courses, you’re going to come out thinking the best thing I can do to help people is take more technique courses, right? Because that’s what’s been ingrained in you in school. So not only will people come out and possibly not want to, but they won’t think that they need to, because there’s never been any seed of importance placed on that. Yeah, that’s sad. Yeah, yeah. Because I remember when I did my case study, I got ripped apart. Because the research I used was terrible. Yeah. Which is good, because that showed me, Hey, you did a shit job on the research end of this, so you need to improve on that. Yeah. But now, how, how could they grade somebody on that if they’re not even teaching a research course?

Eric Purves 39:53
There’s big holes in all of this. Yeah, but the idea is good. So hopefully there will be a little more. Maybe we can do it. Hopefully there’ll be some more updates on information. Maybe we can do like a follow up podcast on it. Yeah, maybe they explain a bit more detail. Right? Yeah. Because it also so so if the next point, which I thought was, which was great, which is really relevant to all of this, which is practicing the self reflective manner, you regularly take time to consciously think about your practice, and to analyze your decisions and their impact, you obtain feedback from others, and you draw an external on external information to continuously improve your professional capacity and performance. This is very closely related to evidence informed evidence based practice, which is great to analyze your decisions and their impact. And it’s funny, like self reflection is something that they do not teach routinely in massage schools, at least far the conversations I’ve had with educators and schools and new grads, but it’s something that you see in all higher level university education. Okay, graduate studies, you know, masters, PhD studies, is that self reflective, so basically, how do you know what you know? And, and why do you do what you do? And why do you think the way you think, and why did you make that decision? Why did you say this thing? And really, it allows you to focus, you just stop and think about, and like your decision making? And, and when you stop and think about it sometimes. Like why I did this thing? I said this thing? Because I read it somewhere, and I thought it sounded relevant for this person. Maybe that’s why, or maybe it’s because you read a paper on it. Or maybe it’s because you’re like, I have no idea. This just felt like the right thing. But I think it’s really important for us to, to develop our Alexander professional capacity and performance by stopping and thinking and reflecting on our knowledge and why it is we make the decisions we do. Cool. I really liked that. Like that. One for me is one of my favorites from this and something that I would love it. This is me throwing this out there to the universe. I would love it if there was if that was something that they started teaching self reflection in massage school, I think it would drive students crazy, because they probably have no idea what you’re talking about how important it is. But I think it would be really, really important. I know I did it when we did in my graduate studies, like almost everything we did was we had to do these like self reflective journaling and stuff, which was super annoying at the time. But then once you kind of get into it, you’re you realize how important it is? Because you’re like, oh, that’s why I think that’s why I said this thing,

Jamie Johnston 42:38
but just started journaling this week.

Eric Purves 42:39
Oh, it’s really important. I feel it’s really important. And I know I’m not the only one because it seems to be a common theme. And

Jamie Johnston 42:50
but I think and this might be a really good way to wrap this podcast up. But if we look at the unless there was other points you wanted to make? No, this is this. This is this has been a good one. I think I think if we look at the end of that practice, in a self reflecting matter, what it says is you draw on external information to continually improve your professional capacity and performance. So that in itself, is shows us that it’s your responsibility to continually improve, not to look at this and go, Oh, we don’t have to take CSCs anymore. This is the onus is on you to continually improve and be a professional. Because when we look at the other healthcare professionals, especially if we look at doctors, nurses, OTs, physios, Cairo’s, like all these other ones, all of them, they may have the same idea where it’s a self paced thing. But they are required to take continuing education and our college is putting the responsibility on us to be a professional and to perform in a professional capacity by continuing to upgrade our knowledge and information that we use in our practice.

Eric Purves 44:02
Yeah, it’s very, it’s very, it’s very important. And I think if we want to maintain our credibility if we want to realize our true potential, and we follow these career span competencies, and individual arm T’s take it upon themselves to really take charge of what they learn and how they progresses as a profession. I think this is a very is a positive direction forward. And I think we said we start off the podcast with is from a business perspective, having the minimum C C’s was great. But as a profession, we do know that that doesn’t really help people. Yeah. Because people will just take stuff just for the sake of taking stuff. Whereas this is something that’s a little more probably be more time consuming. If you do it properly, because you have to create a plan and you have to engage and you have to reflect and you have to do all right All these things, too. And then you have to show how you have met these goals that you’ve chosen for yourself. And maybe that’s courses made it’s workshops, and it’s conferences, maybe that’s whatever, whatever. Yeah, I think it could be better. And I’m going to maintain a healthy level of optimism. But there’s going to be a definitely have a little a little bit of skepticism in there as well.

Jamie Johnston 45:23
Absolutely. And really, we should have skepticism with with everything that we do. So there’s nothing wrong with having that healthy level of skepticism. So I think until next time, thanks for listening, and we’ll see you on the next podcast. Thank you. We hope you enjoyed this podcast. These kinds of topics are what we are all about. If you’d like to learn more, go to our websites, themtdc.com or Ericpurvrs.com. If you know of any other therapists that could benefit from this, please tell them to subscribe

 

Podcast Episode #23 Challenge Your Bias, But Still Remain Patient Centred

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Jamie Johnston 0:12

You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston. And I’m Eric Purves. This is a podcast by massage therapists for massage therapists. Our objective is to simplify how to be a more evidence informed practitioner, let’s dig into this episode.

Jamie Johnston 0:33

There are times when your beliefs get challenged. And there are times that you have to change the way that you do things.

I’ve been seeing, we’ve been seeing lots online lately, with people that are going back and forth between what the Noy group is saying and what other research papers are saying. And so we decided we would dig into some of this because as science should, we should always challenge our bias.

Eric Purves 1:37
Yes, and I agree that this, you know, I’ve been reading some of these guys, papers, and I’ve been reading some of their blogs for a while now, just because it provides a different thing than the normal echo chambers that we get stuck in. But it seems to me that

Jamie Johnston 1:00
So with that, we will look into a couple of papers that are both from Quintner and Wiseman. One called pain medicine and its models hindering or helping. And then the other one sort of just bringing the title up is pain is not a thing and how that error affects language and logic and pain medicine. So jumping into it, sorry, I’m going back and forth between notes here. I think the the biggest thing that I take from this is words matter, which we believe in anyway.

Eric Purves 1:57
like, it took me a while to really understand what the heck they were talking about. Because it just seemed that they were just kind of basically critiquing everything that was quite common language are quite common beliefs or ideas or ways of practicing in pain care. And so I was like, Well, what do you got? What do you guys saying? And I think it really a lot of it comes down to is the words that yeah, the words that are being used and how things are being described, as well as it seems to be that the things that they that this group in these researchers are arguing against, is I think they’re arguing against how often, like kind of biopsychosocial models are used in practice. But not I don’t see it necessarily as a problem in the I don’t know, they use I prefer framework, they don’t really they’re not really as it’s I don’t think it’s a problem with the framework itself, as much as it is how it’s often communicated to people in pain in practice. That’s so that’s where I see the splitting hairs kind of thing.

Jamie Johnston 3:04
Wandering through, because I looked at as I was reading through it, I was kind of there was some of the challenges that they were making, which is great, because we should challenge things. But I was reading it and going well who’s saying that? Because some of the things didn’t. I’m like, those aren’t the things that I would say to a patient or those that’s not the way that I look at it. So that part of me was wondering like Who exactly are you challenging? Because there’s, there’s some of the things for sure that that are, for lack of a better term splitting hairs. But I, but I’m not sure who it is that’s communicating to patients in the way that they mentioned in some of these things,

Eric Purves 3:48
right. And the thing that I the takeaways I got from reading not just these papers, but some of the other stuff from them, a colleague Monica sent me probably a couple of dozen papers that they had sent her and then she forward them to me and I’ve read not all of them, but I’ve read through most majority of them. And I mean no I grew up and kind of mostly in that group who uses a specific language to communicate the complexity of pain, like they talked about pain being this protective response and pain can be a learned. thing, you know, and and I see the argument from this, this group hear about how that can be problematic. But what I do see from what noi has done, and mostly in their research is they seem to have taken this really complex neurophysiology and this human experience of pain, and they’ve tried to make it something more simplistic for clinicians to think or reason or use in practice. And so it’s shifted that movement away from this pathway, anatomical tissues structural problem explanation more towards a, your system, systemic sensitivity. You know, when there’s like brain and peripheral and spinal cord stuff happening, that’s like the one thing, right? And then they try and put it in a way that’s teachable and use can be used in practice. And I think there is probably some oversimplifications of the words that they use. And I, but I like what you say like I agree with what you say their jammies, I think the, it seems that your average clinician out there, if they are saying those words to people, that can be a problem. Oh, you’ve just learned your pain, oh, you’re just stressed out, you start blaming the psychosocial things, and just trying to discount completely the bio. So I know these guys are talking about the nociceptive apparatus and the nociceptive system, you know, and there’s always going to be an activation of that and every pain experience. And I don’t think that anybody is necessarily really arguing too hard against that. It’s pretty much like they’re saying like, yeah, there’s some type of activation in your system. That’s, and then and then you have a conscious awareness of that. And there’s other psychosocial stress, other things going on around you, which can influence that. Okay, I get that. But when we talked, when, when you’re talking to patients, clients, whatever, like, are you? Like, are you trying to explain away their pain? Because I don’t think that is what people are really doing anymore? And if they are, then I think it’s a misinterpretation of like, analyze teachings. Yeah.

Jamie Johnston 6:37
And I think like, just when you touched on it there, like, that’s one thing that I switched. The way that I explained it years ago, is that, you know, the psychosocial things can influence your pain, it’s not a causative thing. And I know in the one paper they talked about, like the mind body connection, and, and that they’re like, well, that, that my understanding of how I read it anyways, is that it’s it’s not what, what we should be saying to patients, but yeah, they’re also saying the biomedical model doesn’t work either. Yeah. So I get that. I mean, in the, in the one paper, they, you know, you go through and they make some good points, like, you know, they go well, I, when I look at what they’re saying, for words matter, like one of the statements was, when core concepts employed within a field are open, there’s potential for inaccurate or misleading uses of terms, which then can be amplified with the patient. And that talks about like pain, and it saying a stimulus in and of itself is not painful. By contrast, it’s the experience labeled pain that is painful. Yeah. Right. So it’s what the person’s going through is painful. Yeah, it’s not necessarily the stimulus. And then they break it down further with different objections and saying, you know, that it’s a noxious stimuli that causes the pain, that it’s a stimulus that as damaging, or threatens to damage normal tissues, which is the definition of a noxious stimuli that is capable act of activating merseysiders. Yeah, I don’t, I don’t think anyone that Noi group or or others are saying that that’s not true.

Eric Purves 8:15
Yeah, and this is where this is where it gets confusing, right? So what’s, what’s the argument? Their argument is, I think more about the well, they talk about the reification of pain. So pain being a thing. That’s that’s this, you know, this one papers called pain is not a thing, how that error affects language and logic and pain medicine. Well, pain isn’t a thing. I mean, pain is an experience of pain isn’t a tangible thing you can grab your hands on. But I failed to understand and maybe I just need to think about this, reflect on this a bit more, maybe I did just spend more time with this. But we use the term pain, because that’s an experience that people are aware, like, we all know, what pain is a pain for each of us is different. Yeah. And is anyone saying that? It’s not like, you know, and, and there is, there is lots of studies that show that, you know, there’s certain areas of the brain that are activated when someone’s experiencing pain. And then there’s lots of studies that I’ve seen that looked at like the transition from these kind of sensory nociceptive, dominant areas of the brain, and acute and then as things transition to a more persistent, there’s changes, those sensory areas go away, and there’s now activation in the limbic system and other areas of the brain, you know, and these i, and then, what I get from this group here is that they’re saying, Well, you know, you’re, you’re saying that people are thinking differently about their plant or pain or the pain is an output of the brain, you know, and that and they’re saying that that’s not true. And you think, Well, it’s, I get that argument, okay. It’s might not be true, but we do know that there is. If pain is a lived experience of somebody, then there’s going to be something happening in the brain and in the mind of that person. That could be sensitizing the overall system. Whether that’s a peripheral nociceptive or a central or cortical All thing that’s stimulating nociceptive activity? Does it? I don’t know, does it change? How we think does change how we communicate? Is it changing anything that is it something new. And I don’t think that it really is changing anything too much. Because a lot of the stuff that the kind of the last decade of pain information, there might be a little bit too much brain focus. But no one is saying that pain is not a lived experience of the person. I’ve never heard anybody be like, I’ve never I’ve never encountered anything like, Oh, you’re you’re just thinking your pain, you’re making your pain up, or your pain is an output of your brain. Yeah,

Jamie Johnston 10:38
and I know that. We’ve talked about it before where, you know, I’ve been communicating with a with a person, and probably use the long the wrong language where they went. So you’re saying it’s all in my head? And had to backpedal and go? No, no, no, no, no. So you know, if they’re making some very valid points, that the way we communicate with patients is very important. Because we don’t want people believing that it’s all in their head, but the brain is still going to be involved in whatever that pain experience is that the person is going through. And, you know, going through just looking at some of the stuff, they make the argument of the use of the suffix susceptive. They’re saying that that’s the property of a receptor, but it’s often tied to a stimulus. And this leads to an argument that the nociceptive stimulus is one that activates those receptors. But that’s what a noxious stimuli does. But that’s not a language that I would ever use with a patient. No. So I mean, important for us to have that knowledge. And I think one of the big things that they’re saying is, when we’re looking at research papers, this is the language that should be used. Yes. And I can’t disagree with him in that regard. But again, it’s not it’s not ever a way that I would communicate with a patient.

Eric Purves 11:55
Yeah. Well, and this is goes to a lot of the stuff that we have in research and in our, in our world of pain, and rehab, and movement and all that stuff, is that there’s really cool information. Yeah, but how much of it is really clinically relevant? You know, so based on, you know, like, this is some of the some of the stuff we talk about in our courses, and we teach and, you know, we communicate with others about it. But in terms of like, how relevant is that to us clinically? Is this providing new? Not really, I mean, I would say maybe I’m, I am maybe a little bit more aware of being less brain centric, but still, you’re still like neuro immune centric with this information, because that information coming from the nociceptive activity is being received within the system. And then that is that awareness of that. And meaning of that is, comes from the person and their experience. So I, it’s good, I think it’s good to get out of the echo chamber and think it’s good to challenge stuff, but it’s just I still don’t see it hasn’t changed, how I would do a lot. But I want it to like, I would love to read this and be like, I’m open book, what do I do differently? What do I do better? What do I get throw away? What do I adapt? Very slight, very slight.

Jamie Johnston 13:13
And, you know, as we look through like, does it just because I made a whole bunch of notes on this, when they’re talking about like pain sensitivity, insensitivity hypersensitivity and pain threshold, things like that, because you know, we we’ve all had those, those people on the table, that I’ve got a high pain threshold, you can dig your elbow into me, and I like that. So one of the points that they they made is, is the threshold, the quality of the stimulus or the quality of the response. So if the person has a low threshold, which means the person’s which actually means a person’s ability to tolerate the experience, they’re saying we should use descriptions like pain inducing stimulus and intensity, with more specific terms that refer to the type of stimulus which would be like mechanical, thermal, thermal or chemical. But again, that’s that probably has less to do with us digging our elbow into them more to do with how they’re experiencing pain in the outside world. And what what things are inducing pain for them or creating pain for them? Yeah, yeah.

Eric Purves 14:12
And this goes, this goes back to what we talked about all the time, is in is, there’s not a right or wrong, like a person has a high or low or insensitive to touch. What’s the right touch for that person as us as massage or manual therapists? Well, the one and the person likes the one that they can tolerate. So it doesn’t matter what their level of sensitivity is, or is it maybe just it like it just as a clinician, if you understand that there’s these different sensitivities and everyone’s going to respond differently and there’s a world around this person, there’s a person who’s experienced that might be sensitizing their system. Then all we need to really understand from this is that you always are adapting your your touch or your treatments or your you know, interventions and strategies to what fits best for that person. That day, just to help the person have a better lived experience.

Jamie Johnston 15:04
And then always, yeah, like you said, that comes back to their experience. So whether the painful experience that they’re having when they’re not with you, that’s their experience and the experience they’re having while they’re on the table with you, is their experience. So that’s where that communication aspect comes in. Of does this feel good to you? Is this a good experience for you? Those kinds of things when we’re doing manual therapy with somebody always comes back to that patient centered care. Yeah, what experience is important for them? What is it valued? experience to them was a meaningful experience for that person on the table? Yeah. Easy. It’s interesting, though, because some of the things that we’ve talked about so many times like pain catastrophizing, they they make the point that is catastrophizing, a part of the pain experience or a reflection upon the experience. And is this purpose to serve the experiencer or the observer? So if we’re talking if we think as the observer that somebody is catastrophizing? Is that more important to us? Or is it more important to the person? Person? Yeah, yeah. But it’s something that we should try to take into account. But it doesn’t also doesn’t necessarily mean we’re going to look at them and be like you’re catastrophizing right now. No, right. Yeah.

Eric Purves 16:27
And that’s a really, I mean, yeah, that’s a really important distinction, because we like that kind of moves. Like we want to move away from that operator. perspective, or we’re putting our judgment or beliefs onto the person, which would be so if we said, oh, you’re catastrophizing, that’s us putting judgment onto onto the person. It can provide us insight into thinking well, yeah. So say you’re doing the pain catastrophizing scale, and it says they have a high score on that. What it’s how is that going to that is actually can be useful information for us, because it lets us know, as a clinician, this person is suffering from their pain, and how they how they feel about how they’re experiencing their pain. But it doesn’t tell us what their level of pain is. It just tells us how it’s impacting them. So I don’t again, I don’t see how that really, you know, unless you told somebody you’re catastrophizing. Yeah. Which you wouldn’t that which

Jamie Johnston 17:39
could have a massive impact on somebody? Yeah.

Eric Purves 17:41
Then it’s just we have to be mindful of using our words, for sure. Yeah.

Jamie Johnston 17:45
Yeah. Yeah. Which leads us into also, the comments that they make on kinesio phobia or fear avoidance, they make the kind of make the same point that is that a judgement of the observer or judgment of the person who’s experiencing it. Just reading here for it says it doesn’t deny the importance in challenging challenge of interpreting the behavior of a person experiencing pain. So they suggest that we explore the person’s cognitive appraisal of their own predicament in their words. So listen to them, and whatever they tell you is what they’re going through. Yes, so comes back to that patient center character.

Eric Purves 18:25
Yeah. And that’s what we’ve I mean, that we’ve learned that before from you know, having interviews with people like like Keith Meldrum, who it’s, you know, talking about the, you know, the lived experience, the dog was every year at San Diego Pain Center, they always have the pet or the almost not always, but many years, they have that panel of people their lived experience. And that’s always emphasized as being the most important thing, like you can know all your stuff about pain, you can know all your treatments and all the things to say and do and not do. But what what matters most is really trying to be in that safe space for that person for their lived experience, and not taking that away from them or not trying to replace that with your own views.

Jamie Johnston 19:09
Yeah. And so I like how they put some of those things in there that you know, is it the role of the observer, or the role of the person who’s going through it? And there’s definitely going to be some instances where it’s our responsibility as the observer to recognize that something might be going on. But it also doesn’t mean that we have to communicate that specifically to the person in front of us.

Eric Purves 19:33
Not unless we get their permission now, unless they want to know, which is person centered again. Yeah.

Jamie Johnston 19:40
So it’s, I know this very interesting because I’ve seen this big, these big debates and arguments online. And the Yeah, I mean, the the people make some great points in these papers, but I think in the long run, we’re all saying the same thing.

Eric Purves 19:58
Yeah, and It is, you know, I know in this this this pain medicine and it’s models paper, which is a bit old now I think it’s 2010 or eight or something, it’s a while ago, it’s really an argument against the linear process of bio cycle socialism. Right and that is true that you know, in the bio psychosocial when you first encountered as a clinician, you’re often looking to be like, is this bio is a psycho is a social and you’re looking to explain pain via one of those domains. And it becomes and so they’re like, oh, no, the bio psychosocial is more inclusive, whereas traditional biomedical if the Descartes Cartesian model was very linear, so that whole was explained. And Biomedicine is very linear. But biopsychosocial is just as linear. You’re just looking to find something new to caught to blame. And I’m thinking, well, maybe it may be that some people are applying it. But that’s not how I don’t think how it’s supposed to be implied. I’ve never understood it to be applied that way. It’s more like holistic, like whole with a W like looking at the overall person, their experience, and how is the world and the person how is everything around this person is shaping their experience? That’s how I see biopsychosocial. I don’t see it as this linear process, but maybe how it’s taught or maybe how the people understand it is different. And maybe, you know, if I think back to my early days, maybe I thought it was different, too. But I know you can. It’s hard to remember we used to think not yesterday. Yeah, where am I?

Jamie Johnston 21:28
Yeah. However, and we can, I think we can go off on a little bit of a discussion about this, as well as at the end of one of the papers I there’s a statement that they made that I absolutely loved. Because I think it’s applicable to so many more things in our profession than just this one topic. They said one of the more powerful therapeutic tools available to the clinical pain practitioner, irrespective of their background discipline, is to present a clear and honest explanation that is as close to accurate as possible in the current state of knowledge. Yeah, I think that is beautiful. And I think that we, we have to take that and almost apply it for lack of a better term globally to what we do. And for those that are that are out there saying, I don’t need to look at research because I know what I do works. Ones that are still using old narratives of how their technique works. This right there, it if that doesn’t tell you that you need to change. I don’t know what else could because we have a responsibility as healthcare practitioners, to give as honest an explanation of what’s going on with the person in front of us as we can with the most updated current state of knowledge.

Eric Purves 22:47
100% And we have an ethical obligation to do that as healthcare providers, right, we should have, you know, as you learn new information, even if you look at our, like our competency documents and stuff that they have here in BC, the you’re supposed to use research and incorporate into your practice regularly. And as as you learn, you’re supposed to be able to adapt your knowledge based on your current on, on adapt your practice based on your current knowledge. And the and as we learn more if we learn stuff that contradicts or challenges what we used to know or what we used to do, then we have to, we have to change, you have an ethical obligation to change and people come to seek our care deserve that.

Jamie Johnston 23:30
And which is the exact reason why we wanted to discuss these two papers. Yeah, is in the hopes that it will either challenge or make us change. And it probably has to a degree but probably not to the degree that I thought it was going to.

Eric Purves 23:46
Yeah, and I think so too. I agree with that as well. I was trying to really my reading through these things before really trying to really trying to challenge my bias. And but as I read through this, I’m thinking No, that’s kind of what I already that’s kind of what we already say and what we already do. And and it’s good to question the stuff obviously, like we said before, it’s good to not just sit in an echo chamber but the one issue I have with these guys writings is that they don’t really they don’t really give you any further information about like here’s things moving forward. You’re fine you can fix that. Yeah, it’s very philosophical and very like well this other way is not right. But I would like to see them come up with like an idea or like a like a Knowledge Translation plan or something moving forward that says this is how this information could change your practice or could could be applied to your practice. I would love to see that because when you when it’s just challenging and saying like, this is this is wrong bla bla bla but without a que What do you replace it with? Then then it becomes harder to to incorporate into your to your practice. I think the message is gonna get lost. I think that’s why In like the, you know, RC world that we live in, is that when you’re teaching stuff, you have to find something else to replace it with. And I know, early in my career trying to just give people information hoping they would change. They don’t change, you just try and give them some information and be like, and this is how we try and use this in practice. This is how it shapes what we say and what we do and how we think. But with the absence of like, what do we do with this information? I think he gets lost in a lot of people. I think that’s probably part of the problem, at least from my anecdotal observations of this, how this stuff works in social media, when people are arguing about it. It’s like, Yes, so what do you tell me then?

Jamie Johnston 25:41
Yeah, yeah, I agree. But I would say one thing, looking at it is my impression was that they were saying this is how, like, these are the terms that should be used in research, these are the team terms that should be used in papers. So perhaps, if, if that’s the approach is if they’re saying, well, from now on, when a research paper is done, this is the term that should be used, then gradually that would start to change, perhaps how we’re communicating with a with a patient or with the person in front of us. Yeah. But that was that was just my impression of what they were trying to say.

Eric Purves 26:15
Yeah, and that’s, and that’s, I think that’s a really valid point. Because we, I think one of our first podcast we did was about like, words, the power of beliefs and stuff. So yeah, if there’s better ways of kind of communicating the similar ideas or similar or same things, then, of course, let’s change it now become the new normal.

Jamie Johnston 26:32
Yeah. Yeah. But I, but I still don’t think it would change how I communicate with the person in front of me, because I would never look at a person and use words like noxious stimuli. And, and those kinds of things. No, unless, like you said before, unless they asked and wanted to get really educated on this stuff. You know, but I see the value of using it properly and research.

Eric Purves 26:57
Yeah. Yeah. And maybe that’s maybe that’s where this stuff will be beneficial. Moving forward, is maybe there will be some changes in how the researchers are doing the things. Yeah. Rather than clinicians and I mean, we look at all this stuff through a clinicians lens, not through a researcher lens. Yeah, I mean, these guys are, you know, Quiner and Cohen are retired. And Assaf is I think he works at a university in Israel. So yeah, yeah. Israel, I

Jamie Johnston 27:26
think witness Australia.

Eric Purves 27:28
Yes. I think Cohen is too. But anyway, yeah. So there’s, but it’s interesting, because I would like we get so caught up in the details about things like these like minutiae of the neurophysiology and the language and stuff. But I would, I can be very bold. I’m gonna say if you took this information to a psychologist who treats people in pain, terms like, yeah, who cares? It’s always with the lived experience. It doesn’t matter what this other stuff.

Jamie Johnston 27:58
Yeah, if you were talking to like a millennial, well, yeah, you would probably look at this and like, okay,

Eric Purves 28:04
yeah, they’re like you, they’re gonna say, Well, why are people arguing with this? Like, doesn’t matter, like, what matters most is the person is experienced? And how can we help shape that experience? And through their, obviously through the psychological interventions or ways? You know, this? So I think this, this stuff here is very, very, there’s a lot of people out there that treat people that help people hurt. Yep. This information, I would say would be specific to maybe more physiotherapy or medicine. But I would say, I would say a lot of these guys criticism, a lot of it comes towards the physiotherapy professions, because that is going to allow us directed towards NY and mostly is stuff and Butler stuff. So psychologists and other people are, who cares?

Jamie Johnston 28:51
What we do, because then that’s why we looked at the papers. Yeah, exactly.

Eric Purves 28:54
I think I mean, I think it’s interesting. It’s,

Jamie Johnston 28:57
yeah, so I think the I think we can look at the overall message of this specific podcast is that we can come to agreement that it’s the person’s experience, that’s going to be the most important thing for us to take into account. And just communicate well with your patients. And there are certain times where we need to be the observer and just listen to what it is they’re saying to us. Yeah. Which is

Eric Purves 29:22
good quality. person-centred Care. Yeah. And we don’t need to impart our beliefs on to people without their permission or without their wanting to.

Jamie Johnston 29:33
Unless, unless they ask, unless they ask. Yeah, and, you know, and, of course, the other thing is to always be open to challenging your bias and looking at new things and, and seeing how you can improve as therapists. Brilliant, perfect. That one actually went a lot quicker than I thought it was going to. Because it took me a long time to go through those papers. But yeah, I think that’s a that’s a good way to wrap it up and thanks for listening, everybody. We’ll see you next time. We hope you enjoyed this podcast. These kinds of topics are what we’re all about. If you’d like to learn more, go to our websites,

Eric Purves 30:12
themtdc.com or Ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.

 

Podcast Episode #22 Challenging Industry Norms and Incorporating Movement

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Jamie Johnston 0:12
You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston.

Eric Purves 0:17
And I’m Eric Purves. This is a podcast by massage therapists for massage therapists.

Jamie Johnston 0:22
Our objective is to simplify how to be a more evidence-informed practitioner, let’s dig into this episode.

Jamie Johston 0:33

It’s often been said that, you know, you’re doing something right when you’re making other people mad. And I don’t mean that in a in an aggressive way that you’re going out and attempting to make people mad. But when you’re putting out content consistently, and it’s starting to disrupt the norm, within an industry, which is what both of us are trying to do, it’s obviously starting to have that effect. Because we’ve noticed after our last podcast, that we’ve been blocked by somebody who was a colleague and a friend for many years. So we just find it interesting that, that maybe we’re actually having some success, because now people are starting to get upset by something that we’re saying.

Eric Purves 1:19
Yeah, it’s interesting. I mean, I’m sure there’s, there’s probably, there’s probably a handful of people that don’t like what we have to say, or, or want to want to block. So it’s funny, though, that, you know, because people have said certain things to me before, they’re like, Well, why do you teach? What Why do you? Why do you have a podcast? Why do you do your courses? Why do you blog and all that stuff, because a lot of times, it comes across as being like calling, calling stuff out, right? Calling out the crap. And as can be, and there’s there can be a negative undertone sometimes. But the goal always is, is to elevate our profession to inspire people to think more in line with the science and, and I would say that the vast majority things that we talk about are not always our own opinions. I mean, I think will state its own opinions or own beliefs or our own thoughts or experiences when when we need to, when that’s relevant, but a lot of time, we’re just, we’re just the messengers, right? We just were reading research or attending conferences or having conversations with with, with smart people. And we learn and we try to bring that information to our listeners and to our students. And sometimes people don’t like that message. But I would say that if you don’t like the message, then maybe listen to what we’re saying. And don’t take it personal. Because it’s never a personal attack on somebody. It’s more about, well, these are things that we’ve said, and these are things that, that maybe other people believe, but what’s the evidence suggest? And what is the what is a biologically plausible explanation for these things? We talk about that quite a bit. Just question don’t attack the messenger, so to speak, just accept that, you know, what, maybe what you think is not 100% supportable. And let’s just let’s just, and let’s look at what is supportable, and, and this is happens all the time, right? I mean, you read stuff, or you see conversations or hear conversations with people that people have. And they’re like, Oh, well, you know, what’s wrong with saying that you’re releasing fascia? Well, it’s wrong. For one thing, you’re not doing that you’re not doing that. But maybe the experience of the person is they feel like there’s something lengthening or softening. But okay, we have there’s a different explanation for that. So let’s not just keep perpetuating these these unhealthy these narratives, which can be unhelpful, maybe they’re not, but at the very least, are not correct. And this goes to something I think you’ve talked about before, I don’t know if you want to touch on this about the idea of informed consent.

Jamie Johnston 3:53
Yeah. And I mean, really, I think what it comes down to is like not only informed consent, but it also comes down to being an ethical practitioner. Because if you’re, if you’re still preaching those old narratives, you’re not getting informed consent from your patient. So when you’re when you’re doing work on them, and I’ve really been thinking about this a lot, I could go off on a rant, but I feel like we need to stop saying that we’re working on people or we’re treating people and I think we need to start talking more about engaging with our patients, and having them engaged in the, in the therapeutic treatment. Because it it should never be that we’re doing something to them. It should be that we’re collaborating with them and engaging with them. So I want to start changing. I wanna start changing my language around that, but I’m gonna start changing all of the language around that too. Let’s engage in treatment with people anyways.

Eric Purves 4:49
That’s brilliant. I really liked that. Because because we are often do I think the way we’re taught and the kind of common expectation is that people come in and we fix them. We do Do something to them to fix them. Yeah. But that’s,

Jamie Johnston 5:03
that goes back to that old narrative thing. That’s a belief. Yeah.

Eric Purves 5:07
But the reality is that we we aren’t actually fixing people, but we’re facilitating or collaborating or engaging gauging was offered to us, right? Yeah. Like we’re engaging with another human to try and find out a way to make them feel better. Maybe that is them just lying on the table for an hour and getting a beautiful massage. Yeah. Or maybe it’s involving Exercise and Movement and lifestyle changes, right, whatever else is in our scope of practice, wherever you where you live.

Jamie Johnston 5:31
Yep. But to go back to the ethics thing. I would think that most of us would, when we think about being an ethical practitioner, we’re, we’re probably looking more at the things like, Well, I wouldn’t build their insurance company, when I didn’t provide a treatment, I wouldn’t overcharge them here, I wouldn’t do this. So I want my practice to be ethical. But when it comes to treatment, and I’m not saying that anybody is intentionally not providing an ethical treatment, but if we’re not staying up to date and getting rid of those old narratives, then we’re not providing an ethical treatment, because we’re giving people misinformation, no different than if we’re giving an insurance company misinformation about what we did for treatment. So if we’re going to remain as ethical practitioners, we have to stay up to date with the new information that’s coming out. And I realized that can be difficult. But it’s, it’s part of what we have to do. So in order to get informed consent on all those other things, we have to treat ethically, and that means staying up to date on things. So there’s, there’s been plenty of times where other people and actually just recently, there was a thread where people were knocking the NOI group and stuff like that. And I was kind of getting pissed off reading it, because obviously, I liked those guys and like what they do. But when you start to get that pissed off feeling, maybe it’s time to take a step back and go, Well, maybe it’s just because I’m getting challenged, and I don’t like it. So maybe I should just take a deep breath, look at what they have to say, and see if there’s any validity to it. And sometimes it can be somebody that you just don’t like that saying it. And then in that case, fair enough, if you want to just ignore it and move on, that’s fine. But if you’re starting to get challenged, maybe that’s just a sign that you need to take a step back and go, Okay, maybe I need to look a little closer at this, rather than getting upset. Yeah. Or maybe reach out to that person. If you’re friends with them and be like taken, we have chat about this. Like, where are you coming from? What does the research say and have a legitimate professional colleague chat with each other, and see what you can do to help each other?

Eric Purves 7:28
It my experience, in all the years doing this is that when people block you or they don’t want to, they don’t want to hear what you have to say it’s because they are usually they’re challenged by or they don’t like what you have to say, because it doesn’t fit with what, how they think. And I mean, I’ve never, I don’t think I’ve ever blocked anybody or I’ve ever. I don’t think I’ve ever attacked anybody. Personally, I’ll attack ideas all day. But I don’t think I would ever attack a person. Because, you know, I know from my own experience that I I use the word thought wrong. My thinking was incomplete for a lot of years until you start to be able to learn more and put pieces together, you start to realize, okay, how I practice and how I thought and how I communicated was incorrect. But I knew that I was often helping people, but the reasons why I was helping them were very different from what I thought. And when people didn’t get better. Oh, rather than, you know, now thinking, knowing what you know, now you realize, oh, there’s an explanation for that. Because, you know, this person didn’t need to be fixed. They needed some support. They needed some, some management, they need to be engaged with not to be fixed. And, and that that, that I think we need to have that humility and say, Yeah, I was wrong. I made mistakes. Every day I make every day. And that’s okay. Because that’s part of it. That’s why they call it a practice. Yeah, we, yeah, we try and do the thing that’s less wrong. So no, it’s it’s tough, tough business to be in. We’re always putting ourselves out there.

Jamie Johnston 8:58
Yeah. And you got to, you got to, I think you have to expect some reaction. But you also have to accept that, you know, just sometimes you’re just gonna say things that people don’t like, unfortunately, in this case, the person had an issue with it. And it’s too bad that there couldn’t be more professional discourse on on whatever we said to upset the person if that’s what happened. And maybe down the road one day that will be hopefully exemplary. So they say, Yeah, so we’ve got a couple. Now that we’ve got that ramps out of the way. Yeah, no, it’s

Eric Purves 9:31
good. Just as good to adding some memes just to talk about that.

Jamie Johnston 9:34
Yeah. So a couple papers that we’re going to look at. I’m just bringing it up here on my iPad. The first one is called comparison comparison of an exercise program within without manual therapy for patients with chronic neck pain, neck pain and Upper Cervical rotation restriction, and randomized controlled trial. So there’s a bunch of stuff I liked about this paper and some stuff they didn’t like. And one of the things I thing that I really liked about it is they, and it’s just confirming my bias, again, is that they talked more about preventing disability in this paper than they didn’t talk about just treating a person’s pain. Because they talked more about, you know, getting that person back to for full cervical rotation, and then flexion and extension and things like that. So there was less of a focus on pain, even though there was some mention on that. But it was more about getting people back to doing the things that are important to them, which I think is the most important reason people come to see us. So that it totally confirmed my bias in that. So that’s one of the things that I really liked about it. And we’ll get deeper into it. But the other thing that I really liked about it, is that so like all of the movements, and all of the exercises they provided, were really simple things that you can do on your treatment table. It didn’t require a gym, it didn’t require, you know, going and having to do all these fancy things, it was literally just simple things you can do right on your table. And, and I think all too often, as I try to push with the course we teach together and in my own courses is that we need to stop being scared about doing exercise and movement with people, we need to do more of that. And this was a great example of how you can just do it in your treatment of

Eric Purves 11:16
it, there’s a few things I mean, with this paper that were good, and there’s there’s some as bad and I’m very critical when I read these things. So I’m gonna, I’m gonna start off with kind of some myths if I didn’t like. And the first one was the journal that it was in, never heard this journal before. So it is an open access journal, which means you can access the papers for free, there’s no paywall. You don’t have to go to Sai hub and, you know, go back door on it. Yeah, do the back door. But when I did find it, it was like its impact factor and its ranking was quite low in this field. So I was like, you know, that’s, that’s usually a concern, which means these papers might not have the best peer review process, or they may not go through a very rigorous process before they publish it with the editors. So that was a little bit of a, I was always a little bit skeptical. I read those things. A couple of things. Which Who is it these tests, these type of studies? There’s lots of them out there probably 1000s. It’s like a one plus one study. So this is exercise plus manual therapy compared to just exercise.

Jamie Johnston 12:23
Which is that? Actually, I don’t want to take you off your neck. No, no. But that’s one of the things that I liked about it is, is usually it’s the other way. It’s okay, could we add exercise to manual therapy? To get an outcome, whereas this was going the other way? It’s like, Well, we already do exercise. So is adding manual therapy to the exercise gonna help. So I actually liked that, that they’re, they’re going that direction rather than it’s always manual therapy and then adding exercise.

Eric Purves 12:52
Yeah, and that and it’s it is I mean, there’s nothing wrong with that, per se, because the lot of these days we’ll say we’ll show and there’s, there’s 1000s that are out there, where you add one thing to a treatment. It’s usually better. Yeah. Then then note, like if there’s like another paper we’ll talk about maybe later, it’s like talks about doing exercise. Well, doing exercise is better than not doing exercise.

Jamie Johnston 13:13
Yeah, doing something is better than nothing. Yeah, so it’s doing something better, I

Eric Purves 13:16
think so this was kind of like, doing something is better than nothing. But doing something plus something is better than just the one thing. So that is, you know, it’s good to know, but the studies are also are pretty common that you do one thing, it’s better than you’re gonna have better outcome. Yeah, better. The other. The other thing, one of the things that, you know, when the that was a little bit when they’re looking at their measurements, one of the things they’re, they’re looking at range of motion. And so range of motion also is and the way they assessed it was subjective, it was the examiner doing it, and when they felt an end feel, or the person reported pain, you know, and then they would measure that that’s very, that’s not very reliable. So it’s, you know, that there is like, a measurement, not so sure. And the other one they did is they looked at what they called hypermobility through manual assessment where they actually just, you know, we’re testing the movement of the of the joints through manual techniques, and we know that those things well aren’t very reliable. But there was a couple things in here which think you know, I did all those are kind of big red flags for me. But I didn’t put I would normally read those things and throw the paper away. But because we were going to talk about this one, we’re like, okay, let’s just dig a little bit further.

Jamie Johnston 14:32
Yeah, I know like there was a number of were there like the measurement of upper trapezius the measurement of lips gap and you can’t really do a measurement just on those things when you’re looking at rotation because it’s a group of muscles that are doing the action not one singular muscle so

Eric Purves 14:47
yeah, yeah, yeah, cuz they also this way looked at so their their primary outcome measure which was the NDI which is an architect’s disability index, which is good because that’s a that’s a very common reliable disability measure. which, which was good, I liked it. That was the primary one, which goes with what he talked about about function, which just should be the primary goal, reduce secondary measures, lower pressure, print pressure, pain, threshold, pain, intensity and range of motion. Those are also kind of very subjective things. So there, those are not always the best. But well, when we looked at the how they did manual therapy, in this, it was basically it was spinal manipulation. We were I didn’t really like it. Yeah. Okay, well, it’s not massage. Yeah, we things. We don’t see a lot of papers like massage therapy papers looking at this. And so you know, they were they were doing chiropractic manipulations, or hivelocity, although I think it was physios physiotherapy, but they did hivelocity manipulations. And they also did low velocity manipulations on different areas to see. So anyway, it was there’s a few things there. But I think the if we were like, Okay, let’s try and be positive with this. It wasn’t complete garbage. There were some things they could have done better. But they did look at function. And they did find, you know, that doing a combination of these manual techniques with exercise helped. In the short and longer

Jamie Johnston 16:19
term. Yeah. Which was great. Yeah, like I said, that was one of the things I didn’t really like is that they were doing spinal manipulation or thrusts. Although looking at a couple of the explanations, they were talking about doing a glide, which is basically a joint modal, which is something that we learned in school. So obviously something that massage therapists can use. But a version one sentence specifically that I highlighted, that said, Another possible explanation for the gain of motion of the lower cervical spine, since this region has not been directly addressed could be through neurophysiological mechanisms. There you go, I would like to take away the could be and say it was from neurological neurophysiological mechanisms. So but we know like when we look at Bilasa T stuff that, you know, everything. Every manual therapy technique that we use, has a neuro physiological mechanism. So even though in this case, they’re using, you know, manipulation, and thrusts and things like that, that doesn’t mean that that specific technique is better than doing a massage, or doing a joint modal or doing other stuff. Because all manual therapy works the same. So we shouldn’t take this as the only way that this is going to be a benefit as if we’re doing spinal manipulations plus exercise. Yes, we can just put that as long as we’re doing manual therapy and exercise, we should have a better outcome.

Eric Purves 17:41
And I would say that’s a fair. That’s a fair statement. Yeah, based on on how we know manual therapy works with all you know, there’s a million different stories about how it works. We’ve talked about this a million times in the podcast, you know, do the technique you like, Yeah, do it well, and do the technique that the person is expecting. And that works for them. Yeah, right. If someone comes in to see you, and they’re expecting a massage, and you just give them joint moebs, you’re probably not going to have a good Oh, you’re not going to be as and especially if you’re not confident with joint ropes, maybe, yeah, right. Or the other way around, they come to see a chiropractor, a physio, where they’re expecting like a, like a crack thrust of some kind, and they don’t get that they’re probably going to be the outcomes probably aren’t going to be as beneficial. So I think that patient or person, their expectations, in a study like this are that they are going to be receiving some type of spinal manipulation. So therefore, there’s there’s already set up to have that expectation. And probably that’s what they want as well. So that’s going to also I would say that’s going to bias the results towards favor, but that’s okay. Because, you know, people come to see us for massage, and we don’t give them a massage or outcomes are probably not gonna be very good. Very good.

Jamie Johnston 19:00
Yeah. Which doesn’t mean that every single treatment they come, every single person who comes in, you should just strictly do massage. There’s a whole gamut of things that are included in manual therapy that we shouldn’t be including as well. So. So yeah, but it’s it’s funny the points that were making there. I had a lot of the same opinions of the next paper that we’re going to talk about as well. Okay. Yeah. Yeah. Did we beat that one to death? And we should get into the next one?

Eric Purves 19:29
Yeah, that was pretty good. I think the it did show that there was decreased self reported pain over time, there was increased range of motion over time. The neck disability. They didn’t really talk about that as much. They they gave us a chart, but they usually in the results section, they’ll go and they’ll explain in more detail, but the next is really they showed a chart and said Oh, things got better, but without explaining the data. Yeah. That that’s a huge chart. And it’s a huge chart. So I thought that was a bit. I don’t know if there were a word count. issue, but I thought that would have been, that would have been the one that they should have I felt they should have gone into more. Yeah, because reading those charts on those numbers sometimes can be very time consuming and difficult. It’s nice when they kind of paraphrase what the results were in like a couple of sentences. So that that was a bit of a concern. But it basically showed that yeah, if you incorporate exercises, with these are simple exercises, like you said, with some type of manual therapy, people are probably going to feel better. So don’t be afraid to put exercise in your treatments,

Jamie Johnston 20:33
definitely get people moving. Yep, reduce reduce that disability. And it would be good to like with these papers, if they, like you said got in more detail with the neck disability index, but also how they incorporated it, how you can incorporate it more into treatment and natural your outcomes and things like that. Rather than it just being oh, here’s what we used. Go ahead and see if you can figure it out. Yeah. So it would be good if that sort of stuff was included as well. But that’s a probably a conversation for another day. Okay, so the other paper that we’re going to talk about is from Journal of physiotherapy title is some types of exercise are more effective than others, and people with chronic low back pain and network meta analysis. So it’s funny, the more of these papers that I’m reading, the more I’m just going well, Pilates for the wind.

Eric Purves 21:24
Yeah, exactly.

Jamie Johnston 21:28
I don’t know how to do Pilates, and I’ve never done it before. But consistently, it seems like it’s coming up more and more and more that Pilates is a really effective management tool for different muscular musculoskeletal conditions, but low back pain, especially.

Eric Purves 21:42
Yeah, yeah, this was interesting paper. I really liked this one, I did a I did a brief review for this in my membership community. And just one thing that like I said before, the last, the last we were talking about was this journal, actually, from the Australian physiotherapy Association, this has a journal ranking of 11 out of about 240, physiotherapy specific journals. So it’s definitely it’s definitely up there. And in the journal rankings, it’s got a good impact factor, which means that the papers that they publish are referenced and used by other research. And so this was good. And I quite liked it. Because, you know, they’re looking at what type of exercise is more effective. So usually, when we we’ve talked this all the time about, you know, clinical practice guidelines or talk about, you know, education reassurance exercise, yeah, are kind of the three things. But what does exercise and what exercise do you do for low back pain? Because exercise is just a vague term.

Jamie Johnston 22:43
Yeah. And I’m at the point now that I’m also, like, when it comes to courses and things like that, I’m gonna, I want to get away from using the word exercise and just have it be movement. Because most people don’t want to go home and do exercise. But they do want to go home and do the movements and do the things that are important to them. So how about we reclassified as therapeutic movement?

Eric Purves 23:07
Yeah, yeah. Yeah, make some it’s, it’s, I think there’s less of a negative connotation with some people.

Jamie Johnston 23:14
Yeah. And it’s, I mean, obviously, it’s not everybody, you can have some people that are like, Oh, they want to get in, do their exercise and do everything else. But you know, some people, it’s, they want to just go home and pick up their kids. Yeah. And if we can adapt that movement, not the exercise, so that they can pick up their skins. And maybe repeatedly picking up their kids is a great movement that they can do to strengthen their back. And by doing a thing that’s meaningful to them, so I’m putting that there’s two things I’m saying we should engage in movement, we could start and stop calling it exercise, coming up into things.

Eric Purves 23:47
When that goes, that goes back to the last, the last podcast we did, where it was basically when we were looking at walking for low back pain versus swimming and cycling and running. I was the last the last podcast we did, which might have upset some people. The end and basically, the findings of that paper we’re doing something is better than nothing. But whatever physical exercise that you do, which one you like, which one you’re going to do, if you don’t like running, but you like swimming, or whatever combination might be then why don’t you do the one that you like, and that was kind of the findings of the of that paper as well. And what I liked with this one, though, is they it was just a huge meta analysis. So I think there was something about 17,000 Participants included in all the studies that they use and the analysis for this, so it was quite significant. And I liked how they they actually categorized all the interventions. And so they included core strengthening or motor control, mixed exercise types, which I don’t really know what that means. It could be Yeah, they didn’t get specific about

Jamie Johnston 24:53
specific exercises were but yeah, but it wasn’t that one I was looking at it and it was more like a global full body type. Yeah,

Eric Purves 25:00
I think so exercise. Yeah. Yeah. Which I think goes in goes kind of along with that. The other section they looked at which was our papers on general strengthening, there was aerobic exercises, once again, very general, pilates, stretching, yoga, functional restoration, which is a term that was an intervention I’m not familiar with, though. We might talk about that again a little bit later because I wouldn’t seem to be one of the top three.

Jamie Johnston 25:25
Between that McKenzie method and Pilates I think it is. Yeah. So McKenzie

Eric Purves 25:29
therapy, flexibility to other exercises. So they looked at, you know, all these different exercises and looked, they use good outcome measures. They looked at, you know, not just pain but also a disability measures. So the Roland Morris disability questionnaire, the Oswestry so for those of us in BC, that treat motor vehicle stuff, the Oswestry is a common one that you’re supposed to use when you’re reporting motor vehicle stuff for low back pain. So yeah, there’s lots of there’s lots of good good stuff in here. But like you said, I think the thing that came down to was really was Pilates for the when Pilates seemed to be the one that had the most Pilates McKenzie therapy and functional restoration. Were the were the three that seemed to be the best exercise as compared to stretching, which I think stretching after read through this again, it was like just passive stretching had kind of like was the the bottom like that was the one that didn’t? Comparatively didn’t wasn’t very good. Yeah. Yeah.

Jamie Johnston 26:25
But it’s really funny because I, I look at that. And I go, what are those three things haven’t What do Pilates Mackenzie, and I’m assuming this functional restoration have in common is that both of them, or all three of them? Whoever’s teaching it to you to be really confident in what they’re teaching. My my understanding of Pilates is they they have those machines that they do Pilates on, and then you know, we looked at it and some of it is doing like yoga type movement with Dan’s different things like that. But I think from what I understand of it, is it’s quite often with somebody and you’re being coached on how to do it, which I know is the same for the McKenzie method, because they look that up. And it’s like providing an assessment working with the person giving exercise plus homecare. So I’m wondering, things that they didn’t address in this paper is the contextual factors of being, you know, people having this extra training, that they’ve done neither McKenzie method or Pilates or whatever, and that you’re more engaged with the person. And you’re being Yeah, and the person is being coached by you, as opposed to like, go home and stretch. Yes. Right. So how much of an effect and awesome that it’s in a positive manner. But how much of an effect is because of the contextual factors as opposed to the other exercises that they were looking at?

Eric Purves 27:42
Yeah. And there’s, yeah, we look at these things, too. And one thing I thought that was really interesting with this paper, which you don’t see is they talked about Pilates, McKenzie and functional restoration as being the most expensive.

Jamie Johnston 27:58
And yeah, how much does that play into it? Yeah. And

Eric Purves 28:00
then he talked about how socio economic status might play a role those things when they’re looking at the the studies. The people that could afford to do those things, were more likely to are probably in a higher socio economic status. And there’s loads of research. And of course, I can’t remember top my head, but we know is a lot of research out there, that suggests that the lower your Setia socio economic status is, the lower your outcomes are wellness is on pretty much all measures of health related things. So, you know, the postal code that you live in a country you live in is, is gonna have a big influence. So that is something that should be I think, is important. This isn’t this has to take with this as well as that, from the study, it says Pilates is the best. But not everybody is gonna be able to afford to go to a Pilates class, or hire someone to teach them how to do it. But if you can, then it’s this is a good option for you.

Jamie Johnston 29:00
Yeah, yeah. And I mean, even, you know, you looked at I Know, Like, we’re so lucky in BC, because people have, you know, so much continuing, or extended health that pays for treatment, you know, and if you’re living in a place that doesn’t have any of that, what a profound impact that can make as well. Right? That goes back to that socioeconomic if you if you can afford to pay for 10 treatments, and go in and have them then likely to have a better outcome as opposed to maybe somebody who can afford to pay for one and then it’s gone. I can’t afford to keep coming back. But I still need to deal with this pain and which could lead to more disability. So yeah, there’s just so many other factors, but I just found it interesting that, you know, we look at the things that they found had the best outcomes were also the things that required more training and more personalized, individualized care, with the person who’s coming

Eric Purves 29:49
in. I think a really important thing to acknowledge with this, though, is that just because those ones had the best outcomes, everything else it was That was in the study had a benefit. Yeah, it just wasn’t as great. So even if it’s stretching seemed to be the one that was like kind of the one they talked about how wasn’t very effective, but it’s still more effective than doing nothing. Yeah. So if the only if you liked and this and they also mentioned this too, which, which is great to see is doing something is better than doing nothing. Right? And if you’re going to do something, they talked about this in the paper, as well as you need to do it at a higher intensity or higher load. Yeah, yeah, the lower that wasn’t as effective. Yeah. So the more and they didn’t really go into too much detail now. But my interpretation of that would be either more into that point of fatigue, right. So you’re doing to the point of where it’s, you’re, you can’t do any more either, like, it’s starting to get uncomfortable, and you’re gonna back off, because you don’t want to flare it up too much. Or you do it to the point of is, I can’t do any more, because I’m shattered. Yeah. Which is going

Jamie Johnston 31:02
to be different for everybody. Yeah. So that’s where you have to have that clinical decision making in place to go, okay, you know, my first person of the day is going to be completely different from my second, third, fourth, and fifth. So, you know, load them differently, do it to their capabilities. And that really comes back to that whole patient centered approach, right?

Eric Purves 31:21
Yeah. Yeah. Yeah. And this is, this is this last sentence they had here to the section of paper called implications for clinical practice. And this just summarizes what you just talked about. The author’s say, if the observed pain and function outcomes align with the patient’s goals, it may be appropriate to recommend these types of exercise programs, if they are available and financially feasible for the patient.

Jamie Johnston 31:45
Back to everything we’ve been talking about.

Eric Purves 31:47
Yeah, exactly. And then if we, if we look at the, you know, that kind of evidence based framework, right, you’ve got like relevant research, you’ve got your clinical expertise, your clinical experience, and you’ve got kind of patient values. And then you also have kind of that fourth part, which you don’t read too much about, it seems to be the ignored part is basically the contexts and the availability of exercise for interventions for people. Now, I would say that that will be where the financial feasibility of it is, you know, what can you do? Yeah, no. And so if we’re looking at, we’ve got evidence to suggest that research, or the research suggests that, you know, these type of exercises are good, any kind of exercise for low back pain seems better than none. And your clinical experience, what works for you, what do you like to do? What do you feel comfortable, and instructing people on if you don’t know, McKenzie therapy, and you don’t know, pilates, and you don’t know, functional restoration? Well, what other type of things can you recommend that you feel comfortable with? And what’s the person want? There we go. Yeah.

Jamie Johnston 32:58
I mean, the other side of that, too, is I could also be, you know, maybe another good thing is to make some professional referral relationships with people who do these specific things. Because I, I mean, looking around here, I don’t I only know of maybe a few Pilates Studios, where we live. Yeah, like for where I live, I think there’s one call one and it’s the only, you know, which is a couple minute drive from here, but it’s the only one I can think of, but there’s, you know, there’s a manual therapy clinic on every corner and like Starbucks around here. But, you know, that specific thing, there’s not that many. So, you know, maybe if we’ve had a patient that we’re doing some movement and exercise with, and maybe they aren’t progressing along to the point that we would like them to, or they would like them to then maybe having that professional referral relationship with, with somebody where you can get them these things. If, if the patient is able to do it, or if the person is able to do it, then then that’s a good thing for us to do as well. Yeah.

Eric Purves 33:54
I guess brilliant. Yeah, exercise is good. manual therapy is good. Combine them is better,

Jamie Johnston 33:59
even better. Yeah. So I think the big messages, for me anyway, is don’t be afraid to incorporate more movement into your treatments. The more that we can do that, I think the more disability we prevent, which is really our main goal with with anybody who comes to see us so make sure you’re incorporating movements in your treatments. Perfect. Alright, see you next time, everybody.

We hope you enjoyed this podcast. These kinds of topics are what we are all about. If you’d like to learn more, go to our websites,

Eric Purves 34:35
themtdc.com or ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.

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