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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.

Podcast Episode #22 Challenging Industry Norms and Incorporating Movement

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

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

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

Jamie Johston 0:33

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Eric Purves 21:24
Yeah, exactly.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Podcast Episode #21 Allowing Research To Challenge Our Beliefs

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James Johnston RMT 0:12
You’re listening to the Massage Therapist Development Initiative. I’m Jamie Johnston. And I am 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.

You ever have one of those moments where you get faced with a piece of research that challenges, something that you’ve been saying for a long time?

We’re going to talk about that today. Because I’ve been long saying how going for a walk is one of the best things you can do for low back pain. And while it’s can still be an effective thing, we’ve come apart come upon some research that tells us otherwise. So we’ll get into that today. But I think before we get into that one, we’ve got one paper that we’re going to look at, it’s talking about the superior and middle cluneal nerve entrapment as a cause of low back pain. So we had a quick little discussion about this before we came on. And I think some of the points that you were making right away about the anatomy and things like that are probably a good place to start.

Eric Purves 1:26
Yeah, yeah, it’s good to actually come back and do some more recordings of these because it’s been too long. A few months. Yeah. Been busy start to the 2022.

Yeah, the both of things I think will be it will be interesting to discuss, because there is, you know, and this is a debate, I think that’s never going to go away. The belief is that super detailed anatomical knowledge is necessary to be a good quality therapist. And I would argue that that is a belief, that’s an opinion. But that’s not supported by research, by biological research. Now, I think it’s it makes sense for us as clinicians is that we have to understand anatomy, we have to understand, you know, kinesiology, how things move, but I think it do, we really need to know the specific font, like fine details of the human body in order to be better therapists. And I would say that goes against research. And that goes against a lot of, you know, what we know, in practice is that you can get people getting get better. There, they can become have less pain, they can be more functional, without having to like be super, super, super-specific.

James Johnston RMT 2:36
And that applies to treatments to exercise to just about everything that we do.

Eric Purves 2:42
Yeah, yeah. And the people can hear that and feel threatened. Like it makes them think that oh, well, you know, my palpation skills, what’s the point of going to school, I’m useless. And that’s not what we’re saying at all we’re saying is that, that’s, that’s important, but it might not be as important or as necessary, as you think. And there’s other people out there. They’re teaching courses, and they’re like, You need to know these specific interventions to get the specific results. I’m thinking, well, that’s your anecdotal experience. But that is your belief. You know, and you that’s only supported by your own clinical experience. But maybe people are getting better for completely different reasons. And maybe we can treat somebody more generally, and get the exact same outcomes.

James Johnston RMT 3:19
What’s funny I had, I probably shouldn’t go off on too much of a rant about this. But I had a bit of an epiphany the other day that, like, we’ve talked so many times about why people are resistant to change. And I was reading some stuff the other day and came to the my own realization, maybe that we’re doing it because our brain just wants us to feel safe. And our brain is always going to choose the thing that makes us feel safe. And when we look back at our college education we had, I don’t know how many classes that were just manual therapy technique classes. So you look at general Swedish massage, myofascial release, spinal ortho piece, orthopedics, regional orthopedics, cranial sacral, therapy, all these things. And yet, we only had one class on therapeutic exercise. We only have one small class on research with one small class on these other things, there was so much of a focus on assessment and treatment and touching people that we were actually ingrained to believe that that is the most important thing that we can do. And there’s actually I’m looking at some research on it now about how our brain interacts with that and how it’s always going to opt to the thing that is most safe or feels most safe. So that’s what we’re going to focus on. And it takes a little bit of a change in belief system and a change in a way of looking at things in order to get our brain to start going. Okay, maybe I should start looking at more things. So that’s kind of What we’re going to talk about,

Eric Purves 5:01
yeah. And that’s and that’s actually a really good point you make because of how we’re educated. That’s how we’re primed. That’s what we’re that’s what we that’s the beliefs that we take upon us. And what I always like to think though is that if what we were taught, and if what physios and Cairo’s were taught, and osteopaths and act, like if everything that we were taught in school was as effective as they made it think that we were a fixer, we can assess, we can fit, we can fair, what’s the problem, we can palpate it accurately. And we can provide a very specific treatment for if that if it was that easy, then the burden of chronic pain, which is like 20% of the population would be non-existent,

James Johnston RMT 5:44
wouldn’t exist, there wouldn’t be an opioid crisis, yeah, there

Eric Purves 5:47
would not be a pain crisis problem. And I think we need to really understand that we have massive value in what we do. But the value is not what we’ve been led to believe.

James Johnston RMT 6:00
And the thing that I like, as I’ve been looking at this stuff is, and I put a post up on Facebook a couple years ago, that kind of went viral, and it was all about creating a safe space for your patients, is as long as we continue down this path of anatomical and, you know, palpation, and all that kind of stuff is we’re creating safety. In our minds, our brain is creating safety for us, but we’re not creating safety for that person on the table. So we’re actually doing more to make ourselves feel safe, than we are to make the person on the table feel safe. And it’s not until we start to challenge those things and start to change our thought processes, that we’re actually going to start helping the person on the table.

Eric Purves 6:44
While so my friend

James Johnston RMT 6:49
went through this, this thing for the last couple of weeks and looking at some stuff and coming to some profound realizations myself that that, hey, it’s, you know, as much as I think over the last number of years, there’s been so much manual therapy where we get a lot of people feel like we’re pointing the finger at them, saying, You’re wrong for doing this. I think we also have to take a step back and go, Hey, it’s not your fault. Yeah, you were actually primed to think this way, you were primed to believe this. So we just started to have to start changing some of those belief systems.

Eric Purves 7:25
Yeah. And we all were right, we’re all guilty of I mean, we’re all we all have gone through this journey. And we’ve all kind of, you know, gone our own directions and some of his cross to another side. And some of us have stayed where we are, and some have crossed another side and people people change. The one thing I do notice, though, and the reason we wanted to talk about these things today was there has been you know, in the the wonderful social media world there there has been some people out there that I think are without saying it, I think are uncomfortable with what we’re with what we are doing. And the message we’re trying to get out there, which is I said, I mean, I think the messenger trendier is more empowering, and having people feel how give more freedom and be more explore more movement and more touch and, and to not worry about these things which aren’t helpful. Like that’s what the message I think that we’re trying to get across. But other people out there hear that message. And they think, oh, that’s, you know, like myth busting is you shouldn’t be doing that. Or they think that no, you need to be teaching specific things or no, you know, you you have to, you know, certain ways you have to assess, and you have to have these these super specific palpation skills, you know, you have to have these magic hands that can find the root cause of pain. And you have to release this specific tissue this way. And you see this stuff and you and you see these other courses out there, people are teaching them and there’s people putting that information out there and their websites and social media. And it seems like maybe we’re just more aware of it. But seems like a lot of this stuff, I think is is almost in response I just said that we’re doing but others in our kind of community or people that are trying to push our profession forward. And seems like we’re trying to push the profession forward. And there’s those people who feel threatened by that. And they like they’re trying to pull us down. Yeah. And

James Johnston RMT 9:12
that I think goes I mean, I was just talking about how, you know, part of what what happens is that the brain is trying to make us feel safe. So makes us keep doing the things that we’ve been trained to do. And in those cases, I don’t think it’s a matter of maybe it’s a little bit the brain trying to feel safe, but I think it’s also because the finances are getting involved. Yeah. And people are trying to make a living off what they teach and and when it gets challenged. They kick back a little bit harder, because they’re what’s the word their income is depending on what they’re trying to say.

Eric Purves 9:48
Yeah, exactly. Yeah. And that’s and that I think that’s because Who are you right? If you have identified yourself as a clinician that has a specific system similar process and you you teach like a shoulder, pelvis and neck, a lower extremity course and you have like this specific way you do. It’s been two days teaching people all these these things on how to treat this area how to assess that area and how to be, you know, release the tissues a very proper way. And who are you, then when you’ve built a career or a industry or business around that? Who are you when that when that’s been taken away? Like, how do you adapt? And I think that’s the thing is, is if you hold on to these ideals who strongly you don’t tend to adapt? Because yeah, there’s your beliefs are challenged, and how you can earn money.

James Johnston RMT 10:39
Yeah. And I mean, that’s part of your identity. Right? Yeah. I mean, we haven’t I don’t think we’ve talked about it a whole lot on here. But for, for me being raised in a very, very staunchly privileged family that we had a quick little chat about before I came on here. It’s sort of the same thing. It’s your that’s your identify that your identity, you’re identified by a title, you’re identified by what you do. And that’s a really hard thing to take a step away from, and then a really hard thing to change. But it can also be really valuable when you do. Yeah.

Eric Purves 11:14
So the key message here is don’t be scared. Don’t be afraid to change.

James Johnston RMT 11:18
Yeah. And it’s funny, because you used the word uncomfortable. A little while ago, and there’s been so much that I’ve read over the last couple of years that the more uncomfortable you get, the better because that means that you’re changing. And if it feels uncomfortable, it probably means you’re on the right track. Yeah. Oh, get on get uncomfortable. Yeah, be willing to change and start making changes in your practice and changes in your life and things like that. But maybe that’s a maybe a longer rant than we

Eric Purves 11:52
That’s all right, you people are listening. They chose to be here. So they may have turned us off by now. But yeah, those guys going off again. But yeah, let’s, let’s talk about some of this, this colonial nurse stuff there. I mean, there’s two papers that we found recently, one of them was called the anatomical study of the middle cranial nerve, Rajon the study of middle cranial nerve entrapment. And the other one was superior middle cranial nerve entrapment as a cause of low back pain. Both of these were rather interesting, I found was because the, like the superior and middle cranial nerve entrapment was basically to summarize what these without paper was, our Mo was like, this is a sore, this might be a source of common pain complaint to people. But they did like they did it through like, I think they did, like surgeries. They did like imaging to find out where the nerve was. And then they either did like surgeries to kind of release the tissue around it, or they did like injections in it, and nerve blocks and stuff. But what was interesting was, what I felt was not paper was that they were saying that this was a big cause of low back pain, but it was I think it was less than half

James Johnston RMT 13:05
of people. And there’s their sample sizes were small,

Eric Purves 13:09
the sample sizes were quite small. And the results weren’t like they weren’t overwhelming for everybody. That’s not like everybody that had a nerve entrapment that was diagnosed from their medical imaging or surgery. Not every person that had that treated, got better. And so what that always makes me think is, it’s might be a generator of noxious or nociceptive stimuli, and might be related to the pain experience. But, you know, for us as massage therapists, we can change it. But the like, so doesn’t matter.

James Johnston RMT 13:46
When you look at the area, like we’re talking about where that is right over top of the iliac crest. Right, right. There’s we’re not talking about BT tissues, we’re talking about things that are very superficial to wear, like, just simply hitting it could cause pain. You know, we’re not, we’re not talking about anything really deep that’s going on. So to label it. I mean, there’s, there’s no doubt that you can definitely have pain in the area. But because it’s so superficial, we’ve probably got a pretty good odds of when we’re delivering a massage, being able to reduce that pain by just going in and making it feel good. Yeah,

Eric Purves 14:25
exactly. So do you and that’s the thing I would want to ask is does that do you need God specific? Do you need to actually try and target that specific nerve? And if you if the nerve is, say trapped, so to speak in there for whatever might be causing it? Is there value in trying to go and being specific and try to like, release it? Because if it’s a trapped nerve, it’s probably inflamed. It’s probably very tender and sensitive. So does it make sense to try to go work in like poker right in there. I think you You’d want to work around it. And and whether it is joints, whether it’s nerve, whether it’s doesn’t matter what, what might be the, the main contributor to the person’s pain, it shouldn’t really make a difference what it is that because our treatment should still be the same would be to find touch and movement. It feels good.

James Johnston RMT 15:22
Absolutely. And then, like one of the things that I noticed reading through, I only read through one of the papers, the the low back pain. One is that, basically, they’re talking about a lot of cutaneous nerves, and then they’re comparing it a lot to trigger points. And when we look at the research background on trigger points is that it’s likely, like it’s most likely that just cutaneous nerves are having a referral pattern or for real pain. Right. So, because they talked so much about trigger points in it is, is the actual source of the pain coming from the middle clinical nerve, or is it a referral from a trigger point? Right. Right. Like they’re like, there’s so many other things going on. And because it’s so superficial, I just don’t think that we need to give it as much attention as as what it’s being given in these papers.

Eric Purves 16:19
No, no. And and I would say to that thing is always going to kind of bugs me a little bit is that when you’re reading this, this paper that the we’re talking about are things from 2018. So it’s not that old. But they’re still talking about trigger points as being being a thing that they have to accurately palpate. Yeah. And then we look at some the other the wealth of research on trigger points, they show that they’re not always that easily agreed upon when palpated from different clinicians. So yeah, it’s it’s, like interesting anatomy. But so what?

James Johnston RMT 16:54
Yeah, but it’s almost like they’re ignoring the other research on trigger points. Yeah, it’s right to prove their theory.

Eric Purves 17:03
Right. Yeah. No. And here, one thing they mentioned is they talk about how do you assess for how do you like, diagnose it? And one of them is they say, the canal signs, is that tapping over? The very specific part, which is, let’s see if I can find it here. I guess what, right where the nerve goes kind of over around the psis. Find it here. It sounds like science detected at the site of nerve penetration, but three to four centimeters from the midline. So So basically, it’s a tonnelle sign around the area, where the around the iliac crest, and if you get like a nerving a nervy type sensation, then that means that it could be potentially a nerve. But what I always like to say is like, Okay, interesting, but so what so as a massage therapist, right, someone comes in, they’re complaining of pain around the restaurant, they’re low back, it’s radiating a bit. Okay, well might be a bit of a nerve. But do we need to go on being provoked? Do we need to go and provoke it? Like, do you want to go in there and assess it and poke it and punch it? And like, see more? What’s that

James Johnston RMT 18:13
and make it more aggravated than it already is?

Eric Purves 18:15
Yeah, I just did me it just to me seems a little bit. It seems a little bit like does it. So what I guess is why we think like, it doesn’t matter, right, you know, most low back pain regardless what it is, is going to be aggravated by certain movements, positions, or prolonged postures in one way or another or not. And maybe yeah, if there’s more numbness reported, and maybe there’s more of a nerve, than if it’s more kind of like a muscular or joint sensitivity or ligamentous strain or something. But I think your treatment would still be the same. And because when I’ve seen these things in clinic, you’re like, Okay, well, let’s just see what feels good. Let’s find movements that feel good. Let’s find exercises that feel good and just the dark. To make it easier. Yeah. So I know, it’s kind of interesting. But so I just how I feel about some of these ones, but they get a lot of they get a lot of attention. And I think because like you said, we like we started off with, is this comfortable to know the specifics? Oh, your source of pain is this, and I’m the one that can fix

James Johnston RMT 19:17
it. That’s, I think where it comes from? Well, I think we’d pick that apart.

Eric Purves 19:24
Yeah, there’s just one other one too. And this one, this one got a lot of got a lot of press to call the called anatomical study of middle cranial nerve entrapment. This was the one that was there was a the researchers had made an assumption that basically that the middle cranial nerve can get trapped under the long posterior sacroiliac ligament, right, which kind of goes like, kind of between the sacrum and the psis. There, right. And they thought, well, this is an undiagnosed cause of low back or leg pain. That’s what the that was kind of what they’re looking at. So they they actually what they did, they did a cadaver study, where they had 30 pelvises with the mean age You’re 80 years old. So these were seniors senior pelvises, that they were in cadavers, right. But the thing that was interesting was, they did find that about 13% of people in this anatomical study had middle cranial nerve and trauma and under this long posterior sacroiliac ligament, but they don’t know if any of these people have had pain. All they like so because did those 13% of people that had that injury? Did they experience pain? We don’t know. It doesn’t say in the study. So there’s a lot of assumptions here. It’s saying, this is a thing that happens the leg of the 13% of people that the nerve can kind of go through or under this, this, this ligament, and we know that all humans are different, right? And our anatomy is different. So it goes through or under there. But does that mean you’re going to get pain, maybe it increases the chance that you might get, you might experience pain. But this study doesn’t show us anything other than interesting anatomy doesn’t say there’s any relevance to pain. And then again, it doesn’t say if there’s anything you can do about it. With manual therapy. Oh, really?

James Johnston RMT 21:06
It’s all just a big maybe.

Eric Purves 21:07
It’s a big maybe. Yeah. So I just do I see, when I see people commenting on these things, I see that I saw this this paper shared and a bunch of different pages. I thought, Okay, well, maybe I met let’s let’s be skeptical. Maybe there is a thing here. It didn’t really. I it was like interesting. So what, again, great.

James Johnston RMT 21:27
It’s sort of like that. I don’t know if there’s much clinical relevance to it. But remember, in college, they told us that there are certain amount of the population that the sciatic nerve goes through piriformis. Yeah, but there was never mentioned that, you know, and I, somebody can call me out on this. I think the number was 4%, when I was in school that 4% of the population has that. And I could 100% be wrong. But there was never a discussion of those 4% experience more pain or have more disability or anything else. Right than the other. It’s just this is an anatomical difference. Yeah. So.

Eric Purves 22:02
So that’s, yeah, and that’s what I see with these things, too, is that the eye, oftentimes, it seems that people want to find a specific anatomical thing. And then they that can give them a reason or an explanation for why somebody might hurt, which it might be, but us without using a fluoroscopy or ultrasound machine or an MRI, which we don’t have access to in our clinics. If we do then you’re going money and training. But we don’t know.

James Johnston RMT 22:35
Well, they

Eric Purves 22:37
and they even say that too. They say even say here that the gold standard is a fluoroscopy. Where are they? And then they do an injection. And that’s how they find out. But that’s not something that we can do at our clinic. So what do we do if we think that somebody might have a middle middle cranial nerve or superior cranial nerve and treatment, and it’s not getting better with kind of traditional or conservative care, maybe you can refer them to a doctor and maybe they can get sent to a specialist where they can get this diagnosed, and maybe they can try something. But my I’m always concerned, because early in my career, I worked right next door to like an interventional pain management clinic where basically all I did was inject and cut people that and blocked things and ablated things. I didn’t see we didn’t. I didn’t see a lot of people get a lot better.

James Johnston RMT 23:27
Yeah. Well, I mean, even looking at the paper you were talking about, they’re like, they’re they’re doing these studies on cadavers. But there’s no report as to how much pain this person was in. So let’s just say that this person was experiencing pain in the low back, just before they passed away. Well, that the anatomical difference didn’t change a year before they passed away. It’s been like that their whole life. Yeah. Right. They their body grew that way. And they didn’t experience pain through their entire life because of this corneal nerve thing. That is an anatomical difference. Right? So again, why does it matter?

Eric Purves 24:06
Yeah, yeah, that’s fine. Why does it matter? I don’t know if they’ve gone

James Johnston RMT 24:09
their whole life without getting in. These weren’t people that they dissected when when Oh, they’ve been dealing with persistent low back pain for the past 30 years. Let’s look and see what the difference is. This is just oh, that we’ve just noticed anatomical difference,

Eric Purves 24:22
right? And that there may be other studies out there and hopefully someone that’s listening or something, maybe they maybe they do exist, haven’t seen them, but doesn’t mean they don’t, they don’t exist, that maybe they do maybe can have, you know, do cadaver studies on people that had suffered from low back pain, severe pain, and then look to see what you find. You’d always would have to compare that versus somebody that didn’t have low back pain that was around the same age and could do a comparison to see and

James Johnston RMT 24:48
then lifestyle and saying,

Eric Purves 24:50
Yeah, based on other like anatomical studies, it shows that you can have those things and have pain or you can have those things are not happening. So the relevance right doesn’t really matter. I think a lot of times we can get jump into these these these thought rabbit holes where we think all this stuff is, is going to be the reason why we can fix people, which is I don’t think it’s helpful. Okay, next one.

James Johnston RMT 25:24
Yeah. Okay, so the next one is walking, cycling, swimming for nonspecific low back pain, a systematic review. I really liked this, because I will constantly be an advocate that as massage therapists, we need to incorporate more movement and more exercise into our treatments. And I’m starting to lean much more to the side of let’s stop calling it exercise because people don’t necessarily want to do exercise. But typically, people want to do movement, so let’s just call it movement. So this is where my bias has got really challenged, because I’ve long been an advocate of telling people that they can, that going for a walk is one of the best things they can do for back pain. But that may not be the case.

Eric Purves 26:12
Yeah, and this, this was interesting, for sure that the, you know, a lot of the things that you’d want to believe to be true. You’re like, I want this to support my bias. And that’s why I’m set for a walk with my patients. Yeah. And this, this one says, basically, summarize it says, walking is better than doing nothing. Yeah. But it’s not better than doing other more specific low back exercises, more specific meaning, I think they did, like they did some trunk conditioning, they did some of McGill exercise protocols. And then they were they called Pilates was on here as well as, but they called usual physical therapy, whatever that means, which probably means some type of manual therapy and stretching, strengthening kind of stuff.

James Johnston RMT 27:02
pullback stabilization exercises, were one of the things that stood out to me as okay. Yeah. So really interesting, because they, they went through and looked at it. And of course, when they did the study, they ruled out red flags. And they looked at this and said, Okay, we’re, we’re just going to look at the people who are being treated for nonspecific low back pain. So which I’d say is, I mean, I can’t make up the I’ll make the stat up on the spot, but it’s not accurate. I’ll say that 99% of the people that we see that with low back. That’s definitely not an accurate number. But but most of the people that we see, I would say, are dealing with nonspecific low back pain. So and which meant that they had pain or discomfort localized in the posterior aspect of the body from the 12th rib, down to the gluteal. folds. And with or without referred pain into the legs. And if, if we could see everybody who’s listening, put your hand up if you treat somebody like that everybody everyday. Yeah. Yeah, it’s so common. So caught it, probably five people a day who come in, and that’s what they’re dealing with. So they basically looked and said, they compared like swimming, walking, running. And there’s there wasn’t a ton of studies that had been done on swimming, however, or sorry, swimming and cycling. But for walking and running, there was a lot that hadn’t been done. And it basically came down to not one of them is more superior than the other. And I think you can also look at it and go, which one does the person like the most? Yeah, go do that thing.

Eric Purves 28:40
Yeah, and that’s a that’s a great point. And that because that was the question I had to was how meaningful reads intervention is to the person, the right person? Do they value or they enjoy walking, cycling, running, swimming? You know, that would be a question I think worth asking is, if you gave people a certain amount of options, say, these are the things that might help you, which one of these is the one you would like to do, which is, which is the one that you think you could commit to do on a certain schedule that you would set up with a person? Yep. And if they show and they go, they’re probably gonna have the best results and they get to choose the one that they like to do most,

James Johnston RMT 29:16
then but that probably going to be the more effective one. And one of the things that that looking through it. Of course, they did. I don’t know if you notice, but I didn’t notice a whole lot of focus on like, the psychosocial aspects of things. It was more just on the, the bio and the exercise side of it. But in the included trials, they talked about people who use a treadmill, they were supplied Nordic walking poles, or they were doing things in a community setting. And I looked at those and I was like, you look at the site, psychosocial factors involved in both of those. That’s that’s going to have a huge make a huge difference in what the person’s going through. Because if you think about somebody who on a treadmill, they have the support of the treadmill around them that should they trip, they can grab it, you know, if they all of a sudden have low back pain, as opposed to say, being out in the middle of the street where they don’t have a support around them, should they start to experience back pain. Because I know I’d like I have intermittent back pain once in a while, where something happens. And it’s like, oh, it kind of takes your breath away. And, you know, having the psychological side of, Oh, I’ve got the support of the side of the treadmill that I can catch myself on, I’m probably more likely to do that, then going out for a walk by myself. And then I looked at, like, if you’re using Nordic walking poles, then you’ve got a whole lot more upper body involvement in this exercise. And then in a community setting, yeah, if you’re going out for a walk with a group of people, then you’ve got that social support when you’re going out and doing it. So there wasn’t any mention of those factors. But they mentioned that those are things that are effective in helping these people. So I’d love to see some more research or some more looks at how much those social settings make a different sort of psychological social settings make a difference when when people are using walking as a as an exercise for low back pain?

Eric Purves 31:10
For sure. Yeah, that actually would be really interesting, what kind of follow up study because this one was there, basically, it’s looking at outcomes. Right? So for mechanisms not looking for rationale. So I think you make a good point there that, you know, these things are, I mean, all I would say anything, any intervention has a psychosocial aspect it has to. And some might be more so than others. I mean, even coming and getting a massage is has psychosocial, because you’re with somebody in your room, and you’re hanging out with them, and you’re, you know, interacting with them. You can’t. There’s a human there, and there’s two humans interacting, right. And I think that’s a good point with this tool is that people that I was the people that valued the activity, and they they valued doing something with other people or being out in the community, you know, is probably better than sitting at home doing nothing.

James Johnston RMT 32:01
said, Yeah, especially if that was part of your social system before. That there’s people that you went for a walk with everyday, or you went for a run with everyday, and now that’s taken away from you. The quicker you can get back to doing that, I think the bigger difference it’s going to have.

Eric Purves 32:16
Yeah, it was interesting, though, that the there was no I think there’s only been one study each that looked at the effects of cycling. Another one another site that looked at the effects of swimming on low back pain, I thought that was surprising that they these read these, when they did this review, they only found one study of for each of those. I thought there have been more,

James Johnston RMT 32:37
especially to me, like because we there’s so much about aquatic exercise with rehab, you would think there would be 1000s of studies in swimming as part of aquatic exercise. Yeah, but yeah, there wasn’t, wasn’t much at all. Yeah. But I know, like we said before, if there’s one of those things that you enjoy more, it’s probably going to have a more profound effect. Because if I’m having a little back pain, and you told me to go swimming, I’m going to tell you where to go because I sink like a stone and I’m worried about drowning in the pool.

Eric Purves 33:07
I’m a terrible swimmer too. I, I if I if I go and like lie in the water and put my body out and take a deep breath. And like people like you’re supposed to fit this in like no, I will go straight to the bottom of the pool. I’ve always been like, ever since I was a kid hasn’t changed. Even as you get older and heavier. You’re like, I don’t float. Yeah, I still don’t float. I’m like an anchor.

James Johnston RMT 33:30
Yeah, I think we both have the lower body density or something that just makes us sing. But

Eric Purves 33:35
yeah, my legs just go straight down. Yeah. Yeah. So that would work for me. No, I, I can swim. But I’m not a good swimmer. And I don’t

James Johnston RMT 33:46
care for water. Yeah, maybe we’re going to depend on next weekend and the girlfriend wants to go surfing and I’m like, That’s great. You go ahead, I’ll be at the VRBO oven.

Eric Purves 33:59
here and drink coffee or beer or whatever. And yeah. This this study, though, is I think we’ll include this in the show notes. What I did like with this so and you don’t they don’t see this enough in studies, I find it but they actually have at the end there live thing is that key messages for clinicians. For those people and in our industry and those people that are actually working clinicians that want to be mindful of the research and be able to like apply to the practice, I think you need like the synopses that so clinicians can kind of flip through it and they don’t want to have to go through all the results and analyze all the data they want to like what’s like what’s the actionable items and what can I do with this? And I do like that they had this here and I’m just gonna read it because it’s I think it’s it’s important, says under key messages for clinicians, walking, running, cycling and swimming, appear to be slightly less effective than alternative interventions for Treating low back pain. So kind of traditional care, or physical therapy care as well as some, you know, specific low or anxious, I should say specific exercises designed for low back, whatever those might be, are more tended to be more effective. Right? Is walking impossibly swimming provides small benefits when compared to minimal or no intervention for treating chronic or recurrent, nonspecific low back pain. So like we started this off with doing something is better than nothing. But not much better.

James Johnston RMT 35:33
Yeah. What do we look at? Like, let’s talk about the the other interventions, the things I noticed that they mentioned were stabilization exercises, tai chi, general exercise or physical therapy. So all of those are just different forms of movement. Yeah, that we’re using, right? So those forms of movement are just a bit better than what going for a walk or going cycling are. And if you have a patient who hates going for a walk, hates going on a bike and hates going swimming, then use all those other things. Yeah, if you can use some of those other things, but they love one of those other things, then incorporate that into it as well.

Eric Purves 36:15
I would love to see a study that looked at, say, walking compared to getting a massage.

James Johnston RMT 36:25
Yeah, because and that’s one of the things that they talked about in this is they did not compare those things. Yeah.

Eric Purves 36:29
Yeah. Because it’ll be interesting to see, you know, someone values coming from I love massage helps with my low back, someone comes in to get a massage. And another group goes and just goes as low back pain, they just go for whatever 20 minute walks or whatever, 10 minute walks, whatever they decide, you’ll be interesting to see to see how the what the outcomes were for people, if there were if anyone was better or worse than the other? And I would say a lot of it would probably come down to patient preference. Yep, I’d be my guess.

James Johnston RMT 36:57
Yeah. Yeah. But with that, I will constantly advocate that we shouldn’t be constantly doing passive treatment, we should be doing some sort of active treatment as well. Yeah, that could be going for a walk with your patients. And, and I know, you’re like when we look at the industry, you’re you’re commonly thought of as the pain guy. Because you, you know, that’s the stuff that you teach about more. And I think for me, I’m looking more as the Preventing disability guide, because I’m more on the movement side of things. And wanting to encourage encourage more massage therapists to be involved in movement. And, and we looked at the when they looked at the differences, they said compared to no Underbase to no intervention, using these exercises, is better for reducing both pain and disability. Yep. Right. So for for both of the things that we love talking about. Yeah, his exercises work well for him.

Eric Purves 37:52
Yeah, exactly. And I totally agree with you is the being able to incorporate more movement, or movement advice or movement, exploration and treatments is really, I think we really powerful for people. Because I think we all have in our industry, we all have certain types of people in society, and that come to see us. So people just want to get on the table and have massage feels good. Right? Great. You’re not going to force those people to do something, you’re not going to force them to go through a barrage of orthopedic tests and all this movement stuff, if that’s their like, I just want to get I just want to chill out I just want to. But then you have those other people that come in, they’re like, I don’t care. I’ve seen everybody nothing’s working. Just make helped me feel better. Those ones I think those ones there, you probably agree those are the ones that you really want to encourage more than just the passive care, use the massage in conjunction with the movement, and then the exercise or movement. Plan movement program. We don’t want to go and exercise I think is is super valuable. And yeah, I think that’s that’s totally your your niche that you can have a lot to offer to how to incorporate that stuff.

James Johnston RMT 39:03
Yeah. Because Because those people that are coming in, they’re like, I just want to massage. In those cases, we’re typically not dealing with pain or disability. We’re just helping somebody that just wants to feel better. Maybe they need to chill out for an hour. Maybe they just need a break from the family. They need a break from work and they didn’t have it on the table just to have time to themselves. So like you said, in those cases, we’re not going through a whole barrage of different things in order to help them they just need to chill out for a little while. But for those other people that’s that’s where we need to do more for them. For sure. Easy I think that’s a great way to wrap up. Yeah,

Eric Purves 39:40
I think there’s the the two key points in this was low back pain might have something to do with cranky nerves. Yep. And she nerves, but we don’t really know. And it shouldn’t really matter because your treatment interventions would should still be the same and movement Doing something is better than doing nothing. But for pain, but I think overall health moving is better.

James Johnston RMT 40:06
And you’re probably going to have better outcomes if you can incorporate the two. Yeah, you don’t add some movement and help those people who come and see you. Too easy. Beautiful, right. Until next time, everybody. 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

Eric Purves 40:31
websites, themtdc.com or ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.

 

Weekend Courses vs Ongoing Training – Which Is More Effective?

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Many Massage Therapists look at continuing education and training as something that should be scheduled around their busy work schedule. Unfortunately, this can lead to missed opportunities, and the quality of education often isn’t what it should be.

Massage therapists have two options when it comes to training, in person, or online. 

Is one method of training more effective than the other?

We live in an era of never-ending information overload.

In our field, it’s especially true.

There are hundreds of books on how to be a successful Massage Therapist and hundreds of continuing education programs that Massage Therapists can attend at their convenience. The challenge is most of these courses aren’t very well organized, making it difficult to know what to do next. If you want to stay up-to-date in our field, you’re going to need to find the most effective way to keep learning new skills and concepts.

Some Of My Best Learning Experiences

Two of the best courses I have taken throughout my career were one delivered by Greg Lehman, and the other is the San Diego Pain Summit. 

Here’s why those were great. 

With Greg’s course, while he is a great presenter, he did something I had never seen in a continuing education course before. After the course, he sent out an email with a link to his google drive. 

There were tons of research papers in that drive all divided into different categories, which the course was based on. He continually updates the research, and you always have access to it. I was so impressed by this that it’s something we do in our live courses now. 

Greg went out of his way to provide extra support after the course was over, and that support continues as long as he updates those research papers. Support in our continuing education is crucial because if you’re anything like me, you take a course and then think “how can I implement this Monday morning?”. Then by the end of the week, you’ve forgotten most of it, and you’re back to the same things you were doing before. 

Now for my favourite conference (I’m sure you’ve seen me mention it on here before). 

Yes, the content is always great at the conference, but the community makes it really special. Every year I go, it feels like a family reunion. 

No one ever cares what kind of therapist you are, and you’re rarely ever asked. But when you get there, EVERYONE is excited to see each other again. 

There is even a private Facebook group where all the attendees can communicate, ask questions, and leave comments. Since I started going to this conference, there have been times where I’ve reached out to other attendees for help on certain things, and every time I’ve asked, the answer has always been a resounding yes!

That community truly makes a massive difference in the ongoing learning experience. 

So what I take from both of these experiences is: 

More Support + community = Better learning outcomes. 

Comparison of Ongoing Training and Weekend Courses

Going to a weekend course to get our continuing education is not always convenient. It is usually tough to take off work to attend such a course.

However, Ongoing Training is a great way to learn new information and to stay up to date with the latest research.

When Covid hit, it made a massive shift in continuing education. We were super stressed about how we were going to service all the great therapists who had signed up for our courses, so we decided to take them online. 

I’ll be honest the first iteration of this was not as good as our last and we are continually improving. 

The reality is, I think most education is starting to trend this way, even HUGE companies are doing it, and they’re doing it for a reason. 

I have been a first aid instructor for 11 years now and I’ve watched a huge company like the Red Cross change their approach… they’re going online!

When you look at a company like this one, they certify thousands of people a year in first aid courses. But they took a step back and realized they were usually (if not always) helping working professionals. So they transitioned to make it easier to get access to courses. In addition, other companies who had to send their employees wanted change because they were paying employees to go spend entire weekends in courses. 

Why were they complaining? The cost. 

Time is money and these companies didn’t want to have to put out the added cost of paying overtime, days off, plus the addition of the course costs. So, Red Cross transitioned. 

It’s the same thing for us. Time is money! 

If we aren’t in the clinic working, we aren’t making money. And since we don’t have employers paying us to take our continuing education, we are even more in a position where TIME IS MONEY. 

However, there was another result of a big company like this making a shift in addition to all of this. Better support and better outcomes. 

You see, there is a reason you have to re-cert your first aid every three years. This is because new research comes out and things change…much like our massage therapy practices. 

So what happened was the students were given an online program where they still had access to the information after the course, and the information was continually updated. So if they had questions, they could go back and review it, giving them more confidence if they had to face a medical emergency. 

Another benefit is the students and companies were saving money. 

What I take from all of this is: 

Community + Support + Consistent Updates + Cost Effective = Better outcomes for us professionally and for our patients. 

This is why we created theMTDC Community. 

We wanted other Massage Therapists to have a supportive community, access to consistently updated information, and make this cost-effective so you can spend more time helping your patients, less time worrying about what your next CEC course was going to be. We will do this with consistent monthly presentations that you will always have access to (so you can come back and watch them when you need a refresher), research reviews, and of course, that supportive community that we all need.

Click on the image below to join us and learn why online, ongoing training is the way to go for Massage Therapists today.

 

Articles Of The Week February 13, 2022

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We all have patients that use them, and I’m sure we’ve all recommended them. However, what does the science say about their use? Well…the evidence is mixed.

Is foam rolling effective for muscle pain and flexibility? The science isn’t so sure – Ken Nosaka

It is really important for us to understand how a treatment affects the people we are helping. Equally important is taking into account contextual factors of treatment and the language we use, or the things we say are just as important to understand.

Nocebo Effect Vs. Placebo Effect: Language Can Affect Outcomes – Joe Camoratto

We know how much the brain influences pain and the perception of pain. Turns out some mindfulness work can influence your thoughts to modulate perceptions of pain which utilizes a completely separate brain pathway than the pathway used to send the physical pain signal to your brain.

Neuroscientists Identify How Mindset Alters Pain Perceptions – Christopher Bergland

Change is difficult, REALLY difficult. However, our profession needs change but we are not alone, every manual therapy profession needs change. The best way to cause change in the profession is to look within and be the change we wish to see, this will cause a ripple effect.

Our Toxic Massage Community Can Change When We Work Together – Stephanie Rodriguez

Science is REALLY cool. While it’s still early and only one person so far, it looks like scientists have found a cure for Type I Diabetes that hopefully will change the lives of so many.

First person cured of Type I Diabetes thanks to stem cells – David Zarley

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