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Downplaying Pathology

One of my favorite podcasts is Dr. Oliver Thomson’s Words Matter. Through his podcast, Dr. Thomson addresses a wide range of topics relevant to my practice, both as a physical therapist as well as an educator. While an entire hour spent unpacking concepts surrounding the way a clinician approaches a patient presenting with back pain may sound rather niche-y and not of particular interest to an SLP, voice professional, or other professionals, but the episode that I just finished listening to is completely relevant for all of us. If you can broaden the context to include all aspects of diagnoses and envision how our patients enter our clinic, you’ll see the immediate relevance of the information covered in this episode.

One of the takeaways is revealed in the portion of the talk that looks at patient expectations in how we assess, and the expectation of all of the things that we will find wrong with the patient.

Much of this feeds into the traditional medical model that is ramped up in manual therapy evaluations. Our patients pay us to find out what is wrong with them and then do things to make them less wrong. In past articles I’ve covered my views on concepts of causation and pathology and how, when presented in the silo-based format of a specific manual therapy mindset, makes us seem the expert on finding problems with their fascia (or joint, or muscle, or trigger points).

They expect this from us, but by telling them what is wrong, we may be doing a disservice at many levels.

First off, our silo-based training makes every problem look like a problem based on our training. In my post life as an MFR therapist, every problem was explained in fascial-based language. But that language, and the concepts that underpinned it, are not ones accepted by the outside medical community.

So by telling my patient what was wrong with their fascia, I may have been telling mistrusts.

Second, by telling what is wrong with them I am reinforcing how broken they are. Sure, I am offering solutions (my services), but layering on pathological perceptions builds strongly on nocebic concepts (not a good thing).

In the podcast episode, Dr. Thomson and his guest, Dr. Ben Darlow, speak about how reinforcing the positive during an evaluation can step our patients back from the edge of feeling broken. While most want a diagnosis, what most really want is reassurance that they are NOT broken.

Most patients come to us having seen a few other professionals and, most likely, have been told some rather sorry explanations for why they are having problems. 

If the poor input came from someone at the top of the food chain, such as the ortho surgeon, or similar, those explanations are hard to undo. One cannot forget what they’ve already heard. But many of the bad explanations for problems come from those on a equivalent level, professional-wise. It’s not easy to undo the crappy thoughts injected into our patient’s brains by others, but we can start by telling our patients what is NOT wrong as we assess. The podcast explains this much better than I can, and there are a whole lot more gems that I believe all will benefit from.

You can listen to the entire podcast from the links at this page.

Articles Of The Week April 11, 2021

There is many a fanciful description behind many of the techniques that are taught in our profession. However, sadly, most of them aren’t true. It’s important for us to understand exactly how we are interacting with people while they’re on our table and the mechanisms behind what we do.

Mechanisms of Manual Therapy – Eric Purves

“In a major change of pain treatment policy, the National Institute for health and Care Excellence (Nice) say that in future, doctors should advise sufferers to use physical and psychological therapies rather than analgesics to manage their pain.” Good to see things are changing in the management of chronic pain.

Chronic pain sufferers should take exercise, not analgesics, says Nice – Denis Campbell

Marketing ourselves, or our practice can be time consuming and difficult, especially when it comes to social media. While this is directed at personal trainers, there’s a few tips you could use in promoting your practice as well.

How to Promote Personal Training on Instagram (Without Getting Half-Naked) – Meghan Callaway

Shin splints can be a difficult thing to help our patients manage. It’s a difficult area to try and stretch, but Rob gives some great advice on how to help with this video.

Shin Splints – Rob Haddow

I was honoured to be on The Concast podcast with Conor this week. We talk about exercise and movement within a clinical setting, make sure you subscribe to his podcast!

The Concast: Episode #63 – Conor Collins & Me!

 

Articles Of The Week April 4, 2021

Social media is an interesting thing. Sometimes people share things without thinking about it other times there’s plenty of thought put into it. When it comes to our professional associations, they have a responsibility to make sure anything they are sharing is not only accurate but also good for the profession as a whole. We need to hold them to a higher standard.

If professional associations don’t read the studies they share, then who does? – Tristen Attenborough

This could be a game-changer for the chiropractic profession (at least here in British Columbia). Their regulator is taking away their ability to do routine x-rays unless there is a history of red flags in a patient’s intake. We know that more imaging is not conducive to good outcomes, so it will be interesting to see what happens here.

Battle over chiropractors’ ability to do routine X-rays headed for B.C. court– Bethany Lindsay

Great info around the limitations of MRI in detecting what someone is actually feeling or thinking, and whether MRI can find a ‘signature’ for pain. Along with emotional learning and pain. Make sure to give this one a listen.

Podcast With Dr. Melissa Farmer on Pain and Emotional Learning – Todd Hargrove & Melissa Farmer

Sometimes it can be tough spotting what is ‘good science’ vs ‘bad science’. This is especially true in many online debates within our profession. These are five great ways to know if someone is trying to mislead you in those arguments…I mean discussions.

5 ways to spot if someone is trying to mislead you when it comes to science. – Hassan Vally

I remember one of my teachers in college saying: “you may have people come in for treatment just to be touched”. We all know how important human touch is, but what happens during times like this where touch is limited, and how can we handle it? Read on to find out.

Humans are made to be touched — so what happens when we aren’t? – Mary Halton

Play Involves Risk

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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