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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.

Being Of Service, While Still Being Kind To Yourself

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Several years ago, I started this blog, and the whole reason was to be of service to my community of like-minded Massage Therapists while trying to educate and lift up the profession. 

Well, the last year has been really tough to do that, and I feel like I’ve kind of let you down as a reader of this blog. 

So, I thought I would share why. 

Like it has been for most of us, this pandemic over the past couple of years hit hard, but I truly didn’t understand how hard it hit me and ended up going through some health issues if any of you were going through something similar, I’d love to hear back from you. 

There were a few big things I dealt with and what I learned about them along the way. 

Insomnia

I was dealing with major bouts of insomnia, and several things contributed to it; and fortunately for me, I live in a part of the world where I could get referred by a doctor and get help with this as part of our medical system. So I was referred to a psychologist who helped me start sleeping again. 

I didn’t know this, but there are two types of insomnia, one where you have a hard time getting to sleep and one where you have no problem getting to sleep; staying asleep is the issue (this is what I had). 

During our sessions, the doctor had me make a sleep log, and we determined that, on average, I was getting about five and a half hours of sleep a night. I’d go to bed around 9:30 and usually try to get up between six and seven in the morning. When I made my sleep logs, there were big gaps throughout the night where I was awake. So, the strategy we used was to “condense” my sleep. 

We picked a time I would like to get up in the morning, so I chose 6:30 am. The doctor counted back 5.5 hours and said okay, then I want you to start going to bed between 12-12:30 pm. Basically, getting myself to the point that I’m so tired around midnight would make sleeping easier to stay asleep. 

We continued to fill out the sleep log, and as the sleep became more condensed, we would start adding 15 minutes to my go-to bedtime. So instead of 12 pm, I’d go at 11:45 pm, and as that sleep got better, then 11.30 pm and so on, until I was going to bed around 10 pm and sleeping much better. 

He also recommended that when getting up in the morning, I immediately expose myself to light as this helps reset the circadian rhythm, which made going to bed that night more inducive to sleep. 

Interestingly he also told me that all the things we are told in the media etc about “sleep hygiene” doesn’t really matter. If you wanna watch TV right until bed, go ahead, and many of the other things we are taught don’t really matter either…except one. 

Alcohol. I enjoy my wine, and I know over the pandemic, probably enjoyed it a bit too much. Now, I was told there’s nothing wrong with having a glass of wine at night, just don’t have any alcohol three hours before bed because while we quite often think it helps our sleep, it actually messes it up pretty good. So avoiding it three hours before bed is a good rule if you’re trying to sleep better. 

Burnout

I know I’m not alone on this one. 

But over the past year, burnout has played a big role in my life, and my mental health has taken a beating for it. I’m sure it contributed to insomnia as well. 

However, there were a few things to learn with this as well. 

Figuring out the things that are important to you and focusing on those things. 

For me, I know exercise does a lot to help my mental health. Especially if it’s sports like hockey, or golf where I get to hang out with the boys and enjoy camaraderie in conjunction with an activity. Going to the gym was helpful as well, but getting that social aspect helps a lot as well. 

It’s also really important to give yourself a break and be kind to yourself. 

If you’ve been dealing with the same and are wanting to become more productive, one thing that’s helped me is just setting small daily goals of accomplishment. Everything seems so overwhelming most of the time but it has helped to just break things up into small chunks and try to accomplish a little each day, even if it’s just a half hour to an hour of work, at least I’m getting something done.

While the outside pressure of careers etc will never go away, sometimes we just have to accept that we can’t do it all, all of the time. It’s okay to take a break, it’s okay to have downtime, and it’s okay to step away from some things if you don’t have the capacity to do it all without beating yourself up about it. 

A Break-Up and Mental Health In General

As I know probably happened to many, I also had a good relationship come to an end. 

So taking into account insomnia, burnout, and, more recently, the end of a relationship, my mental health over the past year, as I said, has taken a bit of a beating. 

BUT, I came to learn that it’s okay to ask for help. 

I think all too often in our career we don’t ask for help. We are considered the ones people come to for help, but how often are we asking for help ourselves?

Yeah, we see posts online about “self-care” which is usually followed by suggestions for yoga or some other thing (not that there’s anything wrong with these suggestions), but how often do we really ask for help regarding our mental health?

We have people come in every day, lay on the table and vent about what’s going on in life (yet it’s suggested we don’t influence mental health at all), and quite often, we take some of that on ourselves. But how often are we talking about it? 

I’d venture to guess not nearly as much as we should be. 

So I’ve started having regular counselling appointments so that while the gym and sports for me is beneficial, especially for my physical health, it’s time to really start making mental health just as much of a priority. 

Now, I didn’t write this article to gain sympathy or anything like that, I don’t want that. 

I did it to highlight the need that we as healthcare professionals need to recognize our health is just as important as the people we are helping. To show that it’s okay to talk about it and that yes, sometimes WE need help, and it’s okay to ask for it. 

As I mentioned at the beginning, I started this blog to be of service to my community, so if you’ve been dealing with anything similar, I hope you know you’re not alone, there are probably more of us dealing with this than we care to admit. 

And if there’s some way I can help you, please email me and know there’s someone on the other end who’s going through the same but still pushing forward.

 

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.

 

Evidence Based Practice – Do You Love Or Loathe It?

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It seems there has been a real backlash against evidence-based practice (EBP) of late and part of the issue, I believe, is that there is sometimes a very real MISUNDERSTANDING about what evidence-based practice is and is not.

This backlash in part seems to revolve around the idea that EBP is too restrictive and hasn’t got all the answers and that some folk CAN place too much emphasis on ‘evidence’ in their practice, perhaps not with enough critical appraisal leading to rigid and inflexible perspectives.  We do, in my opinion, have to acknowledge that an overly empirical perspective can be as problematic as simply rejecting EBP because it does not provide all the answers or is not correct 100% of the time.

So perhaps a better understanding of EBP is needed? Something being ‘evidence based’ does not create certainty about what will and will not ‘work’. It’s not a rigid protocol that produces individually consistent results. It is a way of making informed decisions based on a scientific process rather than just someone’s opinion or experiences.

What has become clear is the binary and tribal way that such topics, in this case, EBP, are approached in the therapist space. Are you an evidence-based therapist? Are you a manual therapist? Are you an exercise therapist? Are you a pain science therapist? They seem to have become labels that are used to generalize and berate others with.

EBP & BPS

Maybe, just maybe, this discussion is not really about EBP but also more about how EBP is USED by people? It is a pretty blunt tool if it is not used, as Sackett suggested originally, in a “judicious” way. EBP is a lot like the BioPsychoSocial model in that it’s much more of a philosophy, a way of thinking, than a step-by-step method to follow.

Both EBP & BPS are far more conceptual and broader than traditional clinical methods/models which is probably both a blessing and a curse and often a criticism is that they do not provide clear clinical application. The biggest flaw I see in how both EBP & BPS approaches are used can be the choosing of one of the domains to justify clinical decision-making. The 3 areas of EBP, being research data, clinical experience and patient preference are to be used TOGETHER rather than being trichotomized to support or justify clinical decisions. Housman pointed out this in the use of statistics in his famous quote:

“Some individuals use statistics as a drunk man uses lamp-posts — for support rather than for illumination”

A great example of this bastardization of EBP is the use of patient preference to satisfy the criteria of EBP. Patient preference is not simply about which intervention someone should receive. There are many decisions beyond intervention that a person could need to be involved in. Maybe a better term would be patient perspectives as this encompasses a much wider view of the therapeutic process rather than just “they wanted acupuncture (just an example), so I gave it to them” and this satisfying an EBP requirement and therefore is a justification for it being used.

What Are Some Of The Issues?

As someone biased towards EBP it’s important to confront the problem, issues and perhaps misconceptions that exist with regard to EBP:

EBP Does Not Simply Give Clear Answers

Evidence can often be unclear and conflicting; it does not give a clear, un fallible pathway to clinical success. This needs to be accepted as part of the process of using research evidence. Unfortunately, this can also be a reason used by some to reject EBP.

Just Because Its Published Does Not Make It ‘True’

The idea that because it says something in the conclusion of a paper that it magically gets propelled into concrete truth beyond reproach or critique is probably a major flaw in the way EBP is used. This can lead to therapists trading pub med abstracts on various social media platforms, sometimes (fuck it, many times) without the paper even being read. Equally though when it does not fit our biases outcomes the fine-tooth comb to find a problem : )

Answers Are Often Not As Broad As Desired

Clinicians perhaps want more from EBP than it can actually currently provide such as really big questions being answered definitively by a single paper. A popular example is “Does exercise work better than manual therapy”. That question has never, ever been asked (as much as we might want it too : ) because it is way too broad. You have to define the condition you are looking for it to “work” on, how you measure ‘working’, the population you are studying and the way in which the exercise or manual therapy is performed etc etc.

It’s Not A Binary Yes Or No

Another issue is this idea of what “works” as a concept. This may stem from the idea of accepting or rejecting a hypothesis such as in a Frequentist approach. Simply put two binary options, so something works or it does not work by accepting or rejecting a hypothesis.

P values have often been used to make these decisions, although thankfully this is being moved away from, they are not really fit for that purpose of making such decisions. P values tell us about the correctness of the statistical model rather than the correctness of a hypothesis. The stats are only as good as the methods used to generate them and why methodology is a big factor in the conclusions taken from a paper.

Not Only The Data Counts

Patient narratives are also a really important part of the evidence we should use to make decisions. Yes, this is not double-blinded and randomised but also the experiences of THIS person that needs our help. Patient narratives are also far more than just what treatment they received and how successful it was which are often used to point out the unreliability of someone’s narrative

It’s The Body Of Literature Not Just A Single Paper

The evidence base around a subject can be vast, take back pain for example. So this needs to be considered rather than just a favourite paper that supports a bias. My paper beats your paper is like a game of top trumps and not really how EBP is supposed to work.

Moving Forward

Before we start accepting or rejecting EBP, maybe we should formulate our own idea of what it is and what it tells us. What is our personal approach or philosophy in this area? Perhaps too often personal philosophies on this and other subjects are influenced by other people’s rather than taking the time to formulate our own?

What’s my view? Well, EBP does not give us a cast-iron answer for the patient in front of us. It does not predict precisely what is going to happen in 2, 6 or 12 weeks and it often does not tell us precisely why something has happened, there are so many things not being controlled for or measured. But it can help us understand probabilities and estimates around a question at a broader population level in a less biased way. It should afford me an estimate or a parameter of what is most likely to happen, provided that there has been sampling reflective of my patient and appropriate methods used.

This is exactly why statisticians appear to be moving away from fisher-style hypothesis testing to estimates of effect such as a greater emphasis on confidence intervals. It does also help us control for some of the natural biases that go into making us, humans! Things like randomization & blinding are positives, although they can be applied in a very blunt way as criticism of research methods.

Just because EBP is not perfect or provides all the answers does not mean it should simply be rejected. That is exactly the binary approach that has led us to this point and to accept or reject EBP is not the answer. Imagine if we were not in a position to test methods and interventions? It would be like the wild west of rehab with machines that go bing everywhere. It comes back to the judicious use of evidence that involves an understanding of what EBP is and the current best data on the subject being questioned out there. Evidence may often not tell us exactly what to do, but its value might also lie in telling us what NOT to do, and I think there is a HUGE value in this.

Probabilities Not Certainties

So the research base gives me a jumping-off point and a way to narrow down my decision making; by simply rejecting research it can be replaced by a heap of other shit that certainly is not optimal healthcare. It doesn’t give me all the answers, but as I understand EBP it’s not meant to.

We need to see therapy as much about informed trial and error rather than a set-in-stone process predicted by a research paper. The research is the informed part and the application and outcome are often a little more fluid and the trial and error bit.

Conclusion

It’s the middle ground where the truth probably lies in this debate, to be too accepting or reliant on research & evidence and we miss the point of what research is. But the opposite end of dismissing research because it’s not perfect or something worked that had been ‘proven’ not to is not the way forward, I suspect this will actually take us backwards. Instead, let’s come back to the judicious use of research fuelled by a better understanding of what it does and does not tell us.

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