Shared Decision-Making: Putting the Patient Back in the Driver's Seat – With Walt Fritz

 


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As our profession pushes toward patient-centered care, one thing is becoming clear — the old clinician-as-the-expert model isn’t serving our patients the way we think it is.

In this episode, Jamie sits down with Walt Fritz — a physical therapist with nearly 40 years of experience and someone who famously walked away from a prominent role in the myofascial release world to publicly question the narratives he’d built his career on.

They talk about shared decision-making, informed consent, power sharing in the therapeutic relationship, and why the “soft skills” might actually be the most important skills we have.

In this episode:

  • Why the clinician-as-the-expert model is failing our patients
  • How the language we use (like “releasing fascia”) affects informed consent
  • What shared decision-making actually looks like in a treatment room
  • The concept of *metatherapy* — and why how you apply a technique matters more than the technique itself
  • How to give patients a range of treatment choices including home care, frequency, and movement
  • Why the “micromanaging patient” is actually your greatest asset
  • Carl Rogers’ 1957 paper and what psychotherapy figured out 70 years ago that manual therapy is still catching up to
  • Why Walt calls these “human skills,” not soft skills

Whether you’re deep into manual therapy or just starting to question some of the narratives you were taught — this conversation is going to make you think differently about the person on your table.

Safety video Walt Referenced can be found by clicking HERE

References: 

Helou, L. (2017). Crafting the dialogue: Meta-therapy in transgender voice and communication training. Perspectives of the ASHA Special Interest Groups, 2(10), 83-91.

Cerritelli, F., Chiacchiaretta, P., Gambi, F., & Ferretti, A. (2017). Effect of continuous touch on brain functional connectivity is modified by the operator’s tactile attention. Frontiers in Human Neuroscience, 11, 368.

Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of consulting psychology, 21(2), 95.

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12 People: One Family’s Story and Why Massage Therapists Need to Start Talking About Suicide

 


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We’ve been told a lot of things by our regulatory bodies about what we should and shouldn’t do in our treatment rooms. But there’s one area where I think we’ve been steered in the wrong direction — and that’s mental health conversations.

Of all the musculoskeletal professions out there, our patients open up to us the most. They’re on our tables for an hour, relaxed, vulnerable, and trusting. And yet we’ve been consistently told to shut those conversations down and hand them a referral card.

This episode is about why that needs to change.

⚠️ *Content warning: this episode discusses self-harm and suicide. Please honour where you’re at before listening.*

In this episode:

  • Why massage therapists are uniquely positioned to hold space for mental health conversations
  • Jamie’s personal story of losing 12 people to suicide — and what every one of them had in common
  • Why suicide isn’t what most people think it is — and why that reframe matters
  • Why it’s better to say something than nothing — every time
  • The ALGEE framework from Mental Health First Aid and how it applies directly to your treatment room
  • What the research actually says about asking someone directly if they’re thinking about self-harm
  • Two real-life stories about asking the hard question — and what happened next

This is the conversation our profession has been avoiding. It’s time we stopped.

🎓 Want to feel genuinely equipped for these conversations?
Jamie teaches both Psychological First Aid and Mental Health First Aid. Sign up on the waitlist: https://go.themtdc.com/mhfa-waitlist

🆘 In crisis or know someone who is?
Call or text 988 (Canada & US) — someone will answer.
Here is a link to find a helpline anywhere in the world https://findahelpline.com/

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Articles Of The Week October 10, 2021

We are big proponents of implementing research into your practice, but sometimes it can be hard to tell what is good and bad research. A systematic review is generally considered one of the better kinds of research papers to look at, but there can still be flaws with them too. This article helps us understand this a little better.

What is the difference between a systematic review and a meta-analysis? – Jennifer Hanratty

Learning is different for everyone. If you’re teaching in a massage college, or a continuing education course you’ve probably seen how students learn in a variety of ways. Perhaps the exams that go with courses should be changed to a ‘learning opportunity’ to focus on actual learning instead of memorizing?

Why I Went from Proctored Exams to Open-book – Debbie Fetter

Relationships are an important part of being a Massage Therapist. As we know therapeutic relationships are a crucial part of the interaction we have with our patients, but how much attention do we pay to our business relationships?

Why MTs Succeed: Massage Business Relationships – Mark Liskey

Some of the good research that has been done on massage is how it helps improve sleep and mood. So we know there is a potential to help those dealing with depression but we also have to ask is the lack of sleep potentially causing depression or vice-versa? This article can help us understand this a little better and has some great things we could share with our patients.

Does Depression Make You Tired And How? – Meredith Flanagan

I think many of us suffer from burnout from time to time (I know I certainly have!). While this article is directed at trainers, many of the same things still apply to us Massage Therapists. Here are 5 signs you might be experiencing burnout and if you are, please talk to someone about it because YOUR mental health is crucially important.

5 Signs You’re a Trainer Approaching Burnout – Chris Cooper

Play Involves Risk

[The following is an adapted excerpt from my new book Playing With Movement.]

Play often involves risk. When kids play, they learn how fast they can run without falling, how hard they can fight without getting hurt, and how much they can bother Mom before she gets mad. They learn where the lines are by crossing them repeatedly. There’s risk in stepping too far, but also risk in not stepping far enough, and failing to discover the limits of potential. As we age, we start with games that are very safe, and then progress to games with more risk. Many people graduate to doing things that are truly stupid. If they survive, they learn some very valuable lessons (hopefully).

But in the beginning, playful exploration presents little risk. When babies are learning to roll over and crawl, there is no way to get hurt if something goes wrong. Without fear of injury, it’s easy to engage in many trials and many errors, and to learn a ton about how to get coordinated. But they are learning nothing about how to protect themselves. As soon as babies stand up and start walking, their education in the potential risks of movement begins. 

Toddlers taking their first steps will fall many times a day. This is unlikely to cause injury because they are close to the ground and have a nice layer of protective fat over their butts. But falling creates nociception, which is the sensory signaling that can result in pain. This puts the nervous system to work in reading evidence about physical threat and deciding whether pain is necessary for protection. Has the butt been injured? Is this a dangerous situation?

There are other important questions raised by falling. Is backward better than forward? Is it a good idea to cry to get Mom’s attention? Should we give up on walking for now and return to crawling? Confronting these questions is a form of training in weighing the risks and rewards of various kinds of movement. 

As kids get older, they start playing with movements that can cause minor injuries. Jumping off couches or benches, running on sidewalks, or going down slides will frequently bruise knees and scrape hands. Each fall is a learning opportunity — did I get injured, how long will it hurt, will I need a band-aid? If I cry enough, will I get ice cream?

Kids who fall after running often don’t know exactly what to think or feel. They were running along without a care in the world, and now they are face down in the dirt. They usually look around for the face of a parent. If Mom is looking panicked and sprinting over, the kid will probably start crying. And if Mom plays it cool, gives a bit of a shrug and smile, the kid usually gets back up and continues to play. Pain always has a social dimension, and kids start learning about it through play.

After getting some significant experience with scraped knees and bruised elbows, kids will start to refine their movement strategies related to self-protection. Some will become cautious, avoiding climbing, contact sports and roughhousing. Better safe than sorry. Other kids take the opposite path: no guts, no glory. They make several trips to the ER before their 6th birthday, but are rewarded by superior skills in skateboarding. 

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I recently did some soccer coaching for eight-year-old girls, most of them novices. I watched something interesting happen on at least three occasions. A girl got hit with the ball unexpectedly in the thigh, or trunk, or arm. She would look startled, confused, and then start crying about 10 seconds later. She would leave the game, settle down, and then return to the game feeling fine. I think what happened was that she experienced a completely novel and surprising feeling and didn’t know what it meant. Eventually she learned that it was not really a problem — the body is pretty tolerant to getting smacked with a soccer ball, and this isn’t something that should cause pain.

As kids (especially boys) approach the teenage years, they may start playing with some seriously risky stuff, like fighting, extreme skiing, and football. Some of these “games” may be more in the nature of contests intended to establish dominance hierarchies. Either way, there are important lessons for the players. First, there are many occasions to differentiate between minor and more serious injuries, and this can increase body awareness and refine a sense of threat perception. Scrapes and bruises are very different from sprains and breaks. The former should be pretty much ignored, and the latter requires a trip to the doc. With this sense of perspective in place, minor injuries become more tolerable, and may not even be noticed. Another lesson from risky activities relates to fear management. For example, proper skiing technique (much like asking someone for a date) requires that you lean forward with confidence. You may fall flat on your face, but you need to forget about that for the time being. In many situations, worrying about a bad outcome will make it more likely. Fear is the enemy, and playing with risk is a way to learn to master it. Further, handling a risky situation builds confidence, and a sense of self-efficacy. These qualities are protective against chronic pain and disability.

Peter Gray argues that young mammals have an instinct to “dose” themselves with risky situations as a way to inoculate themselves against the disease of anxiety:

In their motor play and rough-and-tumble play, juvenile mammals appear to put themselves deliberately into awkward, moderately frightening situations. . . . When they leap, for example, they twist and turn in ways that make it difficult to land. They seem to be dosing themselves with moderate degrees of fear, as if deliberately learning how to deal with both the physical and emotional challenges of the moderately dangerous conditions they generate.

Kids have less chance to do this in the modern world. Gone are the days when parents let kids play unsupervised for hours at a time near trees, fields, streets, or large groups of multi-age kids. These activities are now considered dangerous unless parents are constantly supervising, monitoring, encouraging, discouraging, coaching, hydrating, child-proofing and doing almost everything short of bubble-wrapping their kids. If the parents weren’t there, heaven forbid that a child might fall down, get hurt, be exposed to germs, or suffer a temporary drop in self-esteem. Many experts believe this approach actually makes kids less safe, and more fragile, sensitive and anxious. Helicopter parenting pushes kids toward safe spaces like couches, and away from uncontrolled spaces where they might actually engage in some playful activities like climbing a tree, riding a bike or even playing a game of tag. This prevents them for learning that they can control risk, and some argue this is a cause for rising rates of teen anxiety. It is certainly not a good idea to be reckless and irresponsible, but it can be just as destructive to fear and avoid movement that makes you healthy and robust.

All the above points have implications for adults. Perception of threat is at the root of many undesirable conditions in the body. Pain, fatigue, inflammation, anxiety, stiffness, and weakness are all caused, at least in part, by the unconscious perception that the body is weak, under attack, incapable, broken, fragile, damaged, vulnerable to threats. Playing with risky movement is one way to build a self-image that is far more robust, strong and capable. So is disregarding the well-intended but counterproductive advice of many helicoptering personal trainers and physical therapists, who would seek to prevent us from sitting, standing, running, or drawing even a single breath without the “correct” form. 

To learn more about the value of play for movement skill and health, check out my book Playing With Movement. 

 

Articles Of The Week September 20, 2020

Much of the United States, Canada, and even areas overseas are currently blanketed in forest fire smoke. Could this affect people’s pain? Here’s a study that looks at the effects of tobacco smoke on pain and rest.

Effects of smoking on patients with chronic pain: a propensity-weighted analysis on the Collaborative Health Outcomes Information Registry – James Khan et al.

 

Another mention to the constant fatigue that many of us are likely experiencing in these days and times. This article continues to go into depth about the varying causes of lower energy and provides more tips on how to combat it.

Why You Suffer from Constant Fatigue and How to Deal with It – Mark Pettit

 

We all know that pain benefits from exercise in the long term, but only some of us might be aware of the short-term analgesic effect from movement as well. An easy assumption is that this is all an endorphin effect, but are there other mechanisms at play?

Exercise Induced Analgesia –Todd Hargrove

 

If you’re looking through these articles, great! You’re a research-conscious practitioner. As such, it’s good to point out the occasional limitations of the research that you’re reading in order to fine-tune your perspective. This article, for instance, looks at the need to adjust our experimental groups for low back pain-clients in order to create better date.

A need of subgroups with the large group of people with (chronic) low back pain – Hester de Bandt

 

Research into the causes of autism are a hot topic that many of us may not want to touch, but it’s ok to look at the scientific research objectively. In particular, we stumbled upon this new relationship while researching into hypomobility syndromes.

Researchers have identified a relationship between Ehlers-Danlos Syndrome and autism – Emily L. Casanova

 

Complex Conditions Does Not Mean Complex Treatment

 

As a student, I had the opportunity to complete a case study with a client who was living with Multiple Sclerosis.

Multiple Sclerosis (MS) is a chronic, inflammatory disease in which the immune system causes demyelination of nerves within the central nervous system. According to the World Health Organization and Statistics Canada, Canada has one of the highest rates of MS in the world: 2.9% of the population is affected. Fatigue, pain, weakness, spasticity, and paresthesia are common symptoms associated with MS.

I was excited to work on this case study, it was very difficult, in our student clinic or outreach settings, to have continuity of care with a client. To work with an individual every week, over three months, and observe the effect I was having, seemed like a great opportunity.

It also made me nervous.

I was only a student, not only that, I hadn’t received any advanced training at the time – no advanced techniques, remedial exercise, or homecare planning.  I asked my instructors to teach me some advanced techniques that would allow me to address the specific nature of the client’s diagnosis but was encouraged to proceed with what I considered to be a limited skill set. I lacked the confidence that I could make a difference.

I was not convinced but thought it was a good learning opportunity and, so, proceeded.

Help The Person, Improve A Condition

The client I worked with was in her 40’s, a mother of four. She had been diagnosed with MS 20 years prior but it had little effect on her life until the previous few years when she began to experience symptoms of drop foot. She started catching her toes on the stair lip and, by the time I saw her, she was using a walker. She had begun to make decisions that kept her from participating in her normal activities of daily living: driving, walking in winter, and trips with her kids.

At the outset, I had some challenges. I had only fundamental skills as a Massage Therapist and limited experience. The nature of a case study means it is limited in time and scope. Yet the condition itself is quite complex and can present many different symptoms. I took a very straightforward approach to tackle these challenges: listen, focus, and keep it simple.

I interviewed the client prior to starting the case study – partly to establish a baseline but mostly to understand what she wanted to address. Listening to her whole story provided context and direction for the treatment. It helped me understand what aspects of the condition were most affecting her life. Together, we identified what to ‘tackle’. 

It was important that was something measurable – not just because I was doing a case study but because the client wanted to understand the cause and effect of her efforts. Because of my limitations, keeping the protocol simple was necessary but it also turned out to be effective. The protocol used basic techniques like petrissage, tapotement, and stroking but it was applied consistently and regularly.

In retrospect, there were other aspects may have influenced the results. In choosing to participate, the client likely already felt hopeful and empowered, the regular break for self-care alone would be a change from her regular routine. Further, it provided an opportunity to get out of the house at a time when that was not easy for her. All of these aspects lie outside our treatment yet can have a significant impact on the outcomes.

Over the course of treatment, the results varied. The intervention used was a standardized massage therapy treatment approximately once a week for 12 treatments. The patient was assessed using the Multiple Sclerosis Quality of Life Inventory (MSQLI) (for the quality of life issues such as fatigue and pain) and measurement of dorsiflexion (as an indication of the degree of severity of drop foot).

The MSQLI is a comprehensive questionnaire that has been developed specifically for patients with MS and subdivided to include: health status, fatigue, pain, sexual satisfaction, bladder control, bowel control, visual impairment, perceived deficits, mental health, and social support. This self-administered survey takes approximately 45 minutes to complete. The raw scores of each section of the survey are scored, according to MSQLI instructions to determine the final representation of data. This case study, based on the patient interview, paid particular attention to Health Status, Modified Fatigue Impact Scale, and Perceived Deficits.

Most of the client’s symptoms improved steadily with a significant improvement in Perceived Deficits, meaning, the client felt she was developing the skills to cope with her symptoms. However, on three occasions, the ability to dorsiflex declined. 

Alarmingly, there were some new symptoms presenting at some points. Just past the halfway point of the treatment the client experienced the ‘worst spasticity of her life’. This was an extremely challenging point in the treatment.

Should I stop? Should I alter the protocol? Because of the random nature of Multiple Sclerosis, it was very difficult to determine how to proceed. On direction from the client, and with input from advisors, we continued. The overall result was positive, the client started with dorsiflexion of 2mm and, after 12 weeks, could dorsiflex 47mm. For her, it meant the difference between tripping and not tripping during her normal daily activities. Although she was not ready to return to driving, she had the confidence to attend a school trip to a museum with her children and successfully navigate the day with the use of a cane.

The important lesson for me was that a complex condition does not require a complex solution. Instead of employing advanced modalities or techniques, I listened, focused, and kept things simple by sticking to the basic principles of massage.

You can download the case study HERE if you’d like to learn more.