Posts

She Added Massage And That Made Migraines Unbelievably Better

February 4, 2019/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Valerie Bobb

When I was 5 I started suffering from debilitating migraines. I remember having pain from my waist to my head, wrapping around the side of my face and settling behind one of my eyes.

Usually I woke up in the middle of the night in severe pain, close to vomiting before I even realized what was going on. By the time I was 6 I had an EEG to rule out epilepsy, a CT scan to check for an aneurysm and a variety of other tests to find out the source of my pain. All the tests came back negative and I was told I would “grow out of them.”

Spoiler alert: I didn’t.

In fact I spent about 20 years having some level of pain 24 hours a day. However, my parents instilled a sense of agency in me very early on. I understood I was going to have pain, but I wasn’t in danger, and that I had a choice to make. I quickly learned how to keep living while managing the headaches and pain to be minimally impactful on my life. I completed a Master’s in Physical Therapy, held a stressful job, and lived an active life.

The fact is not all headaches are created equal.

I was eventually diagnosed with chronic daily headache (headache pain more than 15 days a month), migraine without aura and tension-type migraine headaches. There are too many types of headaches to review in this setting, and the patient should always have serious conditions such as epilepsy or aneurysm ruled out.

However, the National Headache Foundation is a good informational resource for both you and your patient www.headaches.org

Decreased Headache, Increased Sleep Quality With Massage

For most patients with severe migraines, prophylactic medication will be the first line of treatment. Anti-seizure medication such as Topomax or anti-depressant such as Amitriptyline are the most common. Some patients will have full resolution of their migraines, but most will have a decrease in frequency or intensity only.

This was the case with me. I still had close to 15 days a month with migraines, but minimal intensity and only about 4 migraines a month that required additional pain medication. For me that was a win, but still meant I was in pain a lot of my life! This led me to find massage therapy as a treatment. Massage allowed me to have some days without any pain and decreased intensity on the days I did.

An interesting thing happens when you have a chronic condition for 37 years. Medicine tends to shift regarding the “why.” Migraines used to be contributed to a rapid vasodilation followed by vasoconstriction and treatment was based on blood pressure (prophylactic propranolol) and making sure we avoided this change as much as possible. Now childhood migraines are attributed to a version of sensory overload and sensory integration issues.

I had a neurologist tell me I had a “special brain.” My brain wants to process everything around me, and get a picture of how everything relates to each other and not just what is immediately in front of me. This causes an overload in environments that are noisy, with lots of lights and smells. Some kids have behavioral issues; I had migraines. This idea of equating migraines to a “sensitive” nervous system made me start looking into massage therapy as a management technique to decrease my underlying pain and continue to try to decrease my overall headache days.

The Journal of Headache and Pain published a systematic review of manual therapy and randomized controlled trials in 2014. The most RCTs were performed on patients with tension type migraines. The systematic review found manual therapy including massage to be an effective treatment for tension migraines, reducing the headache frequency and intensity better than usual care by the general practitioner. In a 2011 study, massage therapy was found to reduce pain intensity by 71% compared to the control group. Massage therapy also improved sleep quality for migraine sufferers.

So how does massage help with migraines? Well just like with any massage, it works on the nervous system. If my migraine is being triggered by upregulation, massage is an excellent intervention to modulate my parasympathetic nervous system. The benefits of massage range from the actual touch factor, to the patient resting for those moments on the treatment table, to neuromodulation, to improved sleep hygiene, all of which translate into less pain and migraine days. It’s important for the patient to feel empowered to give feedback regarding depth, strokes and intensity of massage to continue a beneficial and collaborative environment. If a massage is painful or perceived as damaging, it could increase the patient’s pain. And please avoid nocebo language!

It’s important your patient reflect on possible triggers for their migraines and address those as well. With that being said, life involves unavoidable stimulus and stress. Massage therapy can help and is a viable and a researched treatment option for patients with chronic migraines.

References:

Chaibi and Russell: Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials. The Journal of Headache and Pain 2014 15:67

Chaibi A Tuchin P Russel M: Manual Therapies for Migraine: a systematic review. The Journal of Headache and Pain 2011: 12: 127-133

Lenssinck ML, Damen L, Verhagen AP, Berger MY, Passchier J, Koes BW (2004) The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review. Pain 112(3):381–388

Yancy J Sheridan R Koren K Chronic Daily Headache: Diagnosis and Management. American Family Physician April 2014: 642-648.

Is Pain Really A Math Equation?

January 29, 2019/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Valerie Bobb

In the January 2019, Pain Journal published an article comparing pain to the Bayes rule in math.

PAIN Symptom Perception, placebo effects, and the Bayesian brain. It suggests the brain can follow a theory of probability in math known as the Bayes rule. In statistics/math, the rule looks at the likelihood of a given hypothesis. It takes into account prior evidence, current evidence, likelihood probability of other related hypotheses and makes a prediction. The brain generates a top-down, out of our awareness, neurally encoded hypothesis about the state of us and the world. So cool!

This top-down hypothesis is met by its bottom-up sensory input. Any mismatch between the two results in a “coding error” or “prediction error” and the brain revises it’s hypotheses and prediction rules for next time. These hypotheses include those built in from evolution and the person’s personal experiences. Throughout our lifespan, they are constantly changing and updating to help predict the next set up sensory inputs. The implication of this theory is that we perceive not how the world actually is, but the brain’s best guess of it. This definitely makes sense when we think about visual perception.

In the case of chronic pain, the brain puts a high emphasis on the hypotheses generated by the brain and less precision on the sensory experience. Slight and otherwise harmless stimulus (or bottom-up experiences) cause the brain to misinterpret these as contributing to the pain and continue to modify the hypothesis to include these. Individuals without chronic pain would tend to ignore these inputs as “noise.” Conditions such as anxiety, threat, and catastrophizing have a tendency to worsen symptoms by maintaining vigilance to these predictor hypotheses.

So how does the Placebo Effect fit into this theory? The Bayesian perspective states relief of symptoms is not necessarily due to restoring bodily function but more about the lack of interference from the bottom into the hypotheses. As sensory input diminishes the hypothesis again changes. This change, however, seems to be slower if the patient does not have external cues that the change is happening. It’s almost like the brain ignores the improvement as “noise” unless there are other cues to say it’s time to revise the hypothesis. This may be why avoiding nociceptive language AND encouraging our patients that they are RESILIENT and CAN DO their important activities is so important. Your body is getting better so go ahead and revise your hypothesis! This may also be why the placebo effect works. Experiments where the patient was given analgesics in a manner that did not let them know the medications were supposed to help reported significantly less pain relief than those who were told what they were receiving.

I don’t think the article was saying anything we haven’t already approached with pain science. However, I appreciate this statistical analysis way of looking at it. Maybe it’s because I live in Seattle and there are tons of tech-driven people here, but I feel like I have one more analogy to help my patients. AND I don’t actually have to calculate any statistics!

Using “AIDET” To Successfully Communicate With Your Patients

January 14, 2019/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Valerie Bobb

In school, we are taught a list of history questions to ask patients.

But, how often do we allow patients to ask us questions? And should we?

The Journal of American Medical Association Neurology recently published an opinion commentary addressing fundamental questions every patient has but never asks. While the article is geared towards physicians, it is applicable to all healthcare providers. Keeping the patient’s concerns in mind can help solidify the relationships with our patients and improve adherence to the treatment plan.

Research repetitively shows that one of the largest predictors of successful care is the patient thinking the treatment or provider will help.

While it may seem daunting to keep these concerns in mind, many places use a simple framework called “AIDET.” It is a simple acronym that represents an easy but powerful way to communicate with people that improves connection, expectation, and compliance.

Acknowledge (use person-first language and call the patient by their preferred name. Key message “you are important”)
Introduce (who you are and what role you play in their care. Key message “you are in good hands” )
Duration (what can you expect today and in the future. Key message “I anticipate your concerns”)
Explain (who, what, why, next steps. Key message “I want you to be informed and comfortable”)
Thanks (thank the patient for taking the time to see you. Key message “I appreciate the opportunity to care for you”)

How do you think you can implement the commentary or this framework in your practice?

Link to cited article: “Five Questions Every Patient Has but Never Asks”

Pain Education – How Much Neuroscience Do We Really Need?

November 19, 2018/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Ben Cormack

Pain education has for many become an integral part of the treatment process and rightly so, being able to help people understand what is happening to them is a must. One of the most frequently used methods to help people better understand pain is based on the neuroscience and physiology of pain.

In some cases, this can be sufficient to help people understand more about pain but is neuroscience ALWAYS required? Many patients may benefit from explanations that do not include information related to these aspects.

Also, does a neuroscience-based approach adequately explain the EXPERIENCE of pain and acknowledge the person EXPERIENCING it?

The neuroscience of pain could be explained in a standard way involving the various bits of neuroanatomy and the associated physiological processes to a room full of people, BUT if we were to interact individually with the PEOPLE in the room we may find that they have wildly varying EXPERIENCES associated with that pain.

Pain As An Experience

So neuroscience may explain how the sensation of pain is created, and many of the oddities that surround it, but does it fully explain the experience? Human beings, after all, are much more than the sum of their parts, and this is what makes us individuals, and does a generic universal explanation imply that pain is all the same? A neuroscience-based approach could be described as an objective view rather than a subjective one, but perhaps it is subjective that seems to most explain the impact of pain on people’s lives.

A question to ponder is that if structural anatomy, and the damage to it, does not adequately explain pain does neuroanatomy and physiology? It certainly pokes holes in the common belief in a simplistic relationship between damage and pain but does it fall short in explaining the experience and the behavioral responses that have such a profound impact on the wellbeing of the person and those around them?

We could take brain imaging or nociceptor firing thresholds or the dorsal horn sensitivity of anyone and display it on a screen, can I differentiate the different experiences that people have by doing so?

From my perspective I want people to know that pain is MORE than just a sensation to be recorded in a score, rating or questionnaire. It is in an experience that can puncture or our existence in many ways and that many parts of our existence can affect our pain experience as well.

Pain is far more than just physical, it affects our overall well-being and emotional state and this is completely NORMAL. For example, our mental health is part of our wellbeing and goes up and down in the same way that physical health does. We often place a much greater stigma on mental health though and we might need to let people know IT IS OK NOT TO BE OK with regards to this facet of their pain experience.

We can feel low, worry about the implications of the pain and have greatly reduced expectations for recovery. These aspects form our individual experience and addressing these aspects for some people could be the key to their recovery.

The common sense model is a great way to start to understand some of the aspects that make up our individual pain representations

Leventhal – HERE

Hale HERE

Bunzli HERE

Pain Has Meaning

The MEANING that someone associates with pain, the emotions, and changes in behavior, the belief structures, these are the things that make the pain experience unique to the individual. These are the things that differentiate one person’s experience from another and why some can cope whilst others are disabled by pain that might be of a similar intensity.

We could say that neuroscience is merely a process involved in that experience, but instead of putting the person at the forefront of that experience do we now place the therapist and the information they hold as the star of the show?

A very simple analogy ( and please remember that they are never perfect!) I use for helping people understand the different meanings people attribute to pain is that of a Petrol gauge.

We could conceptualize both pain and a petrol gauge as warnings. How we respond to these warnings can be very different. In the case of the petrol gauge some people may be quite comfortable to drive on even though they have the gauge on empty, perhaps they know their car and exactly what it is capable of doing. Someone else may rush to get petrol straight away; their response to the same situation is completely different. Perhaps they have run out of petrol before and remember a bad experience? If we changed the context would that have an impact? Would the comfortable people feel different in someone’s car?

Individualize It

Education should be something we do WITH people rather than something that is done TO people.

One of the key aspects in the clinical encounter is the individual journey that someone has had in relation to their pain. How do we use our increasing knowledge of pain to adequately explain THEIR therapeutic journey, story and ultimately their overall pain experience?

Qualitative research tells us that people crave an explanation for their problems, that they want a diagnosis HERE & HERE. This is often not possible and so a narrative becomes vital and this can often involve learning more about their pain and the way it behaves. There is a huge difference between helping generate an alternative positive personal narrative and just the application of information about pain, however.

Rather than an information dump, the selective use of pain-related information should relate to something that is involved in the dialogue that is occurring between two people. A large criticism of and negative responses to medical interactions appears to be HCP’s not listening to people and talking AT them rather than to them. There is a danger of this with any application of information in a generic way.

This is a fantastic paper on the use of metaphor with people in pain HERE

Education Has Many Parts

There are many ways in which we can educate people about their experience. Part of this DOES include neuroscience, especially from the perspective of a clinicians understanding of pain. How much of this needs to be part of the educational experience of the person though?

Basic information about a normal timeline for recovery might influence perception and behaviours. Understanding the lack of association between many physical factors and activities and pain might influence perception and behaviours. There is a recent example of back pain HERE

Some of the factors that are associated with worse outcomes in back pain, such as increased passive coping and low self-efficacy HERE, might actually help change behaviour. Informing people that THEY are the key to their own recovery!

There are many ways in which we can educate people that don’t involve the neuroscience of pain.

Creating A Positive Experience

Regardless of what type of information provided, the most important thing is to create a positive experience for the person and to try to describe pain as a positive part of the human experience. After all, you would not want to live without it!

Another very simple analogy I use, and of course is context dependent, is to compare pain to red wine. A glass of red wine for many is a good experience but have a bottle instead of a glass and that can be too much of a good thing, especially the next day. We would like pain at the appropriate times and the appropriate levels.

With the biopsychosocial model we are opening up many new therapeutic influences and targets for treatments but amongst all these problems we can also work on things that are positive within peoples lives and in negative times, such as during pain, this may be a great way to alter someone’s current experience. This is a fantastic paper on focusing on resilience and sustainability HERE.

As a recap, these are some key patient messages (IMHO of course)

Pain is an experience, not just a sensation
It is more than just physical it affects our well-being and emotional state and that is NORMAL.
It may become more about these affective factors as it persists.
The way that we think and feel directly effects recovery
Human beings are very complex and much more than anatomy that becomes damaged or even sensitized.
Focus on positives factors, not just negatives ones.

Predictive Coding: Why Expectation Matters For Movement And Pain

October 22, 2018/1 Comment/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Todd Hargrove

Predictive coding is a hip new model for perception that I have been studying lately. In some ways, it is very common sense and intuitive, and in others, it is very challenging and mind-expanding. Here’s a post describing what I’ve learned that I find interesting and practical. Before getting into that, let’s review why any of this should be interesting to anyone concerned with movement and pain.

First, good movement requires good perception. The skill of moving your body with coordination is inseparable from the skill of perceiving where your body is in space and how it is moving. We perceive to move and move to perceive, and that is why we often say that great movers have amazing “body sense” or “proprioception.”

Second, pain is in the nature of a perception. It depends on the brain’s interpretation of whether the body is in danger and what needs to be done to protect it. If your foot hurts, that means your brain perceives, rightly or wrongly, that it is damaged. Perceptions about the body (like anything else) can be mistaken, which is why we can have pain in areas that aren’t damaged, and damage in areas that aren’t painful. By learning more about the science of perception, we necessarily learn more about pain and how to treat it.

The Conventional Model For Perception: Bottoms Up

The conventional model of perception works roughly as follows. We collect sensory information through nerve endings in the eyes, ears, skin, muscles, etc. This information is relayed to the brain, which processes the information, interprets its meaning, and then creates a perception about the cause.

For example, when I see my wife’s face in front of me, this is because light bounced off her face, the pattern of the light was registered by my eyes and sent to my brain, which recognized the pattern as coming from my wife’s face, so it created the perception of her being there (so I would know who to take orders from.)

Or, if someone feels pain in their knee when they take a step, this is because the mechanical force of the step triggered nociception (nerve signals about potential damage), the signals reached the brain, the brain concluded the knee was under threat, and it created pain to encourage protection (maybe by limping). This model is therefore very “bottom-up” or “outside-in.”

It emphasizes the flow of information from the outside world to the periphery of the body, and then from the periphery to the brain. What’s missing from this story? What the model fails to explain very well is the role of past experience in determining how the brain interprets the meaning of the incoming sensory information.

This is where the predictive coding model adds value – it explains how “top-down” factors modify incoming sensory input.

Predictive Coding: Expectation Matters

According to the predictive coding model, the brain is always building and refining its representations or models of the outside world (and our bodies). Our perceptions depend in large part on these models, not just incoming sensory data.

For example, I have an internal model of my house that includes only one four-legged creature – my dog Levi. So if I walked through the living room in low lighting and glanced at a wolf, I would probably literally see my dog, Levi. In other words, my perception would be determined by more by my expectations than by actual sensory data from my eyes.

Check out the pictures below for some other examples of how expectation can determine perception.

In the first two images, you perceived something very different from what your eyes told you, based on your prior assumptions about how words are usually ordered or spelled. In the third picture, you saw two normal looking faces, based on your prior experiences with face parts being arranged in certain ways. (Turn the picture upside down to see a very different arrangement.)

This happens with many other kinds of sensations. If you think satanic messages are hidden in rock lyrics, you can hear them if you play Stairway to Heaven backwards. If you come up from behind someone and say “hot!” at the same time you put ice on their arm, they will feel heat. The painkilling effect of a placebo is based purely on the expectation that it will reduce pain. And nocebos work the opposite way – expecting pain can cause pain. To some extent, we perceive what we predict.

Comparing Top-Down to Bottom-Up

The predictive coding model has a great explanation for exactly how expectation affects perception.

The nervous system is arranged in a hierarchical fashion with the brain cortexes at the top and nerve endings at the bottom. Higher levels of the nervous system are constantly predicting the incoming flow of sensory data from lower levels. These predictions create a neural activity that flows downward (top-down) to meet incoming sensory data (bottom-up).

When the meeting occurs, a comparison is made between what has been predicted and what has been sensed and this generates a prediction error. Put another way, top-down “shakes hands” with bottom-up, and disagreements are discussed and compromises are struck. If the error (or disagreement) is relatively small, it is disregarded as being random noise or “close enough.”

Higher levels of the nervous system are not informed of their prediction errors, and the world is perceived exactly as expected. If the error is large, higher levels are notified of their mistake so they can update their model of the world. This creates a subjective feeling that something surprising or important has happened, and attention is automatically shifted to the incoming sensory data so that perception and action can be adjusted accordingly.

The strength or confidence of the prediction has a big effect on how prediction errors are treated.

If the prediction about incoming sensory data is highly confident, (perhaps based on tons of past experience) even significant errors will get ignored. But if the prediction is not confident (perhaps because the context is novel and errors are anticipated), then bottom-up sensory information has a better chance of ascending to higher levels of the nervous system and causing changes in perception.

Attention also matters for how prediction errors get processed.

If I pay attention to a certain stream of sensory information, it increases the chance that prediction errors will be noticed and not dismissed. The system can, therefore, bias perception in favor of top-down or bottom-up factors based on relative levels of confidence or attention to either one. For example, according to my model of the world, the only black SUV in my garage is my car. If you switched it for another one, I would probably get in without even noticing. My perception would be controlled by expectation, not the information from my eyes. But I wouldn’t suffer the same illusion in a crowded parking lot where my perceptions would be controlled far more by bottom-up sensation than top-down prediction.

Now that we have a basic understanding of how this model works, let’s look at how it explains some common and not so common phenomena related to perception.

Pain

The predictive coding framework helps explain why pain is affected by past experiences, thoughts, expectations, and emotions, and not just tissue damage.

For example, if you have a good deal of experience where flexing your low back causes pain, you will start to build an internal model of your back that predicts it will hurt with flexion. This will strongly bias you to feel pain each time you bend, even if the back isn’t actually producing that much nociception.

You can reduce the contribution of top-down factors to your pain by updating the model of your back. To do this, you need to cause a prediction error by violating your expectation that bending will hurt.

A good strategy would be to perform low back flexion in some novel way, perhaps in quadruped or supine, while paying attention to how it feels while bending so that any predictions errors are not disregarded. That sounds like a high percentage of movement therapy in a nutshell.

A more aggressive and risky strategy would be to perform some movement where the back muscles have to work very hard to prevent flexion, say a heavy deadlift. Perhaps you do the deadlifts with good form to prevent flexion. It hurts a little, but nowhere near as much as you expected. In fact, you have a visceral feeling of surprise at how strong you feel. This is evidence that you have violated an expectation that your back was too weak and fragile to handle any significant force, and that your map for the back is being updated to account for the prediction error. Good sign!

The bottom line is this – a great deal of what can help with pain in the short term is violating an expectation that something will hurt. There’s probably a lot of ways to do that – massage, deadlifts, cat-cows, stretching, isometric resistance exercise, active or assisted joint mobility exercises. What they all have in common (if they help with pain) is that they don’t hurt as much as you would expect.

Moving Better – Prediction And Action

According to the predictive coding model, there is a profound connection between perception and movement, because each can help correct a prediction error, and minimizing error is really all the system cares about.

When the system is confronted with a prediction error, it can do one of two things – update models to reflect the new information (change perception) or alter action in a way that gathers sensory information consistent with the prediction (change movement).

For example, let’s say I am squatting to a box with my a barbell on my back. When I squat to a certain depth I expect sensory feedback from my butt indicating touchdown. But there is a prediction error – my butt is silent. I can do one of two things – I can change my perception about the location of the box (oops I forgot to put it in place!) Or I could change my action – move my butt a bit lower or further back until I get the predicted feedback.

So one way or the other, the essential goal is always to reduce prediction error, and it doesn’t really matter whether that is done by changing perception or action. The important thing is that I don’t crash to the ground with a barbell on my back. Either way, good internal models and good predictions are the basis for generating functional perceptions and actions.

Getting better at movement is therefore very much about improving your internal models for movement and your predictions for what kind of sensory feedback you will get during the movement. This means you need a lot of experience, you need to make mistakes, and you need to pay attention to the right streams of sensory information to identify and correct those mistakes through better perceptions and actions.

Of course, we know most of these things anyway, but I think it’s cool to see that application of the predictive coding framework gets us to the right answers. Here’s some cool stuff that we might learn from predictive coding that we don’t already know and is not easily explained by other models.

Schizophrenia, Autism And Babies

Check out this picture of Albert Einstein – is his nose closer to you or further away?

We expect noses to be closer to us, so most people will see this mask as being convex when it is in fact concave.

Interestingly, schizophrenics (and people stoned on marijuana) are actually less likely to make this mistake. This might be because their perceptions are controlled more by bottom-up sensation than top-down models of the world. And maybe this is why they can both tend towards paranoia. Schizophrenia involves delusions where everyday events are regarded as incredibly salient and important.

Imagine sitting in a crowded coffee shop and hearing your name in a nearby conversation. This might get your attention, but it would not probably register in your consciousness as being profoundly surprising.

But if you had a problem whereby the relevance of unpredicted incoming sensory information was massively magnified, then the mention of your name might feel profoundly important, and perhaps contribute to delusions of reference or paranoia. So perhaps paranoid delusions involve assigning too much importance to minor errors in prediction.

Autism can be also be understood as a condition where bottom-up sensation dominates top-down predictions. Even the smallest prediction errors are considered important.

Thus, all incoming sensory information is regarded as “newsworthy” and people with autism are “slaves to sensation”, constantly distracted or irritated by minor inputs like labels on their clothes, or random noises. Interestingly, people with autism often self-soothe by engaging in repetitive rhythmic movements. These create a stream of sensory information that is highly predictable. Better prediction allows the suppression of sensory information that would otherwise be overwhelming.

Maybe this is why babies like rhythmic movements, or to be carried around all the time, or to be swaddled. Because they don’t have much experience in the world, they have no strong internal models to create confident predictions about their incoming sense data, and they just get blown away by all of the information they are getting about the unpredictable movements of their arms and legs, the variations in the way their back is touching the car seat, and the random noises created by the TV, traffic, etc.

Adults are exposed to all of this information too, but we can easily predict it and therefore ignore it. But for babies without good internal models of the world, everything is a blooming, buzzing confusion. Perhaps they are soothed by getting a nice stream of predictable rhythmic sensory information. Aren’t we all? Lots of interesting food for thought here. Here are some further resources if you want to learn more.

Good Articles On Predictive Coding

An Aberrant Precision Account of Autism

Prediction error minimization: Implications for Embodied Cognition and the Extended Mind Hypothesis

Active Interoceptive Inference and the Emotional Brain

The Hard Problem of Consciousness is a Distraction From the Real One

It’s Bayes All the Way Up

(Thanks to Derek Griffin and Mick Thacker for linking many of these.)

Home Care Plans: Instructions Vs. Adherence

October 14, 2018/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Jon Cain

I remember going to physiotherapy when I was in high school and having my exercises prescribed to me for my knee pain. I was instructed to do them every day, which I think I may have managed to do for about a week. Past that, they tapered down to as little as once per week only, followed by lies to my physio about doing them regularly.

Was I just a bad client? Maybe. Let’s fast-forward a decade or so, though.

When I began my career as an Athletic Therapist, I would instruct my patients along the same lines. Do the exercises every single day in order to get better. It’s the standard I wanted and, if nothing else, it would make the clients exercise to some extent.

But my method didn’t work.

Adherence to my instructions was poor and my clients had a difficult time getting better. Truth, maybe there are “bad clients” out there, but at some point, you have to look at the coach rather than the players. Which brings us to the key error so common to many of our practices:

“I tell my clients to do their exercises every single day knowing that they won’t, but at least, then, they’ll do them every other day.”

Does this sound familiar?

As health practitioners, we’re used to working with patients who are only partially or completely non-compliant when it comes to their exercise rehab. As a result, we become accustomed to “tricks” in order to get them to exercise and be able to recover.

However, if you’ve used the above trick in the past, I’m sorry to say that you’re terribly misguided. (As I was.)

Let’s consider that by saying this, we’re raising the expectations for a patient to what is, for all intents and purposes, an unrealistic level. (If it was realistic, then we wouldn’t be assuming failure on the client’s part.) Now ask yourself, have unrealistic expectations ever proven to be a formula for success?

We know this to not work with raising children or dieting, so why in the world do we assume this to be effective when it comes to rehab?

Poor exercise adherence has been shown to be, in large part, due to anxiety regarding the process and an expectation of failure. Think about it; if we’re told that we absolutely need to do 100% to recover, but we know we won’t achieve that 100%, are we going to be motivated to do 50% in hopes that it will be enough? Not likely!

More likely, the guilt of not adhering completely will derail the behaviour change altogether.

So, I’m sorry, there is no easy and effective “trick” such as simply telling a patient to perform a mile while expecting an inch. Instead, actual investment in coaching patients through their exercise barriers is required.

Such coaching techniques include:

Helping them understand the starting process and develop a feeling of control
Understanding their hesitations regarding exercise
Finding exercise and time routines that work with their lifestyles
Making small changes at a time
Developing relapse expectation and management

So, let’s look into how we can take those points and put them into action with our patients.

Education

As clinical professionals trying to induce behavioural changes, we need to ensure our patients have a thorough understanding of the recovery process and the importance of exercise. With this understanding, clients will develop a feeling of control over their recovery and become motivated by being able to see the direct benefit of their actions.

Exploring Barriers

If a patient has barriers to physical activity, you’re allowed to dig a little bit to understand them for yourself.

Perhaps it’s that anxiety about the process, which education will address. Maybe it’s a time constraint or limited equipment-availability, which signals the need to carefully strategize with their plan. The patient could simply hate the idea of exercising, and so you might have to come up with something that does not necessarily feel like formal exercise.

Discussing these obstacles with your patient will let them know you’re investing time and energy in creating the right plan for them and create trust between the two of you.

Which brings us to…

Individualizing Their Routine

If you have a go-to-patient that is hyped and happy to set aside 30 minutes per day and run through all of their rehab homework daily, then great. For the rest, we need to explore different methods.

For some patients, requesting their rehab exercises to be done every 2-3 days might be the realistic and attainable option. You can also consider programming them as a warm-up before working out, sports, or even just going out to walk, which is great for those with perceived time-restrictions.

Split-routines are an effective method as well, especially when it comes to combatting boredom or monotony. If you have six exercises you want your patient to do, try splitting them into three on one day and three on the other.

Finally, for those who are averse to traditional exercise, in general, you might have to be a bit more creative and find movements that are fun or don’t resemble the “work” of a workout. What I find beneficial is simply reintroducing the activities that patients want to do upon recovery as graded-exposure therapy.

Throughout all this, though, let’s remember to make small changes to lifestyle at a time. As we know, gradual modifications are much more successful in the long-term than massive overhauls.

Develop A Relapse Plan

Finally, it’s crucial we create somewhat of a risk-management plan with our clients.

A lot of things can potentially derail an individual’s adherence to change. Missing a day or two of exercise might demotivate someone from continuing further. A relapse of pain might be the clincher that causes a patient to give up and think they failed. Even simple life events might throw a wedge into the ability for someone to focus on their health.

In these cases, I drive home the point that relapses and derails are likely to happen. By predicting the possibility, we can create methods of coping and moving on. Let a patient know that it’s ok if they miss a day or even a week of exercise and that they’ll continue to reap the benefits as soon as they get back on the horse.

Pain relapses should be normalized as an expected event, and if the patient can use it as a learning opportunity rather than as a sign of a failed recovery. Like with anything we do in life, recovery will involve ups, downs, and plateaus to work around.

In truth, this ability to work with a client to create longer-term habits and adherence is something that many fitness professionals commonly excel at over medical ones. Personal trainers know that it’s an easy way to lose their client by telling them to do cardio six times per week or that they need to work out for three hours per day. Bringing those expectations back down to a realistic level and adjusting their plans as the client changes are the sure-fire way to success. Cookie-cutting a method for motivating that person to exercise is as bad as cookie-cutting the program itself. We have a duty to individualize our patients routine which includes the frequency basis on which it’s performed. And don’t expect failure; aim for success.