Back Pain And Pregnancy

/1 Comment/in , , , , /by

Many women think back pain during pregnancy is very normal.

With the literature reporting as many as 72% of women experiencing pain(1), it seems extremely common.  Women seek out relief through physical therapy, chiropractic care, massage therapy or sometimes can’t find any relief at all.

But would you know what is safe and what isn’t if a pregnant client came into your practice?

As healthcare providers, we took an oath to do no harm.

When we receive a client that is pregnant, we should be fully aware that everything we do to mom, we are doing to the baby.  A recent Clinical Practice Guideline was published that reviewed all the literature regarding pelvic girdle pain in pregnancy and has some great guidelines from diagnosis to treatment.(2)

Understand What Is Causing The Pain

According to Vleeming et al (3) “Pelvic Girdle Pain arises in relation to pregnancy, trauma, arthritis and osteoarthritis.

Pain is experienced between the posterior iliac crests and gluteal fold, particularly in the vicinity of the sacroiliac joint.  The pain may radiate in the posterior thigh.”  The sacroiliac joints are the posterior point of load transfer of the pelvic girdle.  Changes in the ability to transfer load may occur during pregnancy due to increase in laxity from hormonal influence or poor coordination and muscle control now that the abdominal muscles are stretched and no longer at their preferred length tension curve.(4)

Pain can persist into the postpartum period for 25% of people with 10% still having pain 1-2 years later.(5)  It’s important to note that patients with a history of previous low back pain or pelvic girdle pain, previous pelvic trauma, increased BMI, hip/lower extremity dysfunction and pelvic floor dysfunction are at higher risk for developing pelvic girdle pain during pregnancy.  A correlation with work dissatisfaction and lack of belief in improvement also exists.(6)

Therefore it extremely important to get an accurate and thorough past medical and social history.

Pain in the low back, buttock, possibly radiating down the leg sounds like a lot of things, doesn’t it? Sciatica, greater trochanteric bursitis, facet dysfunction, lumbar disc derangement.  It is important to do a good differential diagnosis to make sure your patient’s complaints are pelvic girdle pain.

It is important to do a good differential diagnosis to make sure your patient’s complaints are pelvic girdle pain.

Testing to rule out lumbar disc involvement, hip dysfunction (including transient osteoporosis and labral tears), and any other serious disease or psychological factors should be performed.(3)  Specific testing can also be done to diagnosis pelvic girdle pain.

Literature tends to agree that clustering tests yield the highest specificity and positive likelihood ratios, although which tests should be involved varies amongst the literature.  Combining the active straight leg raise for load transfer, posterior pelvic pain provocation test (P4)/thigh thrust, FABERs for posterior concurrent pain, lunge test and manual muscle testing of the hip appear to have the highest likelihood ratios.  Postural changes do not appear to be indicative of the development of or the intensity of pelvic girdle pain.(7,8)

Photo by: Sara Neff

Choosing Your Intervention

What does the literature say about treating pelvic girdle pain?

Well, a lot of the evidence for intervention is conflicting or weak.  Poorly controlled studies or studies where the population and interventions vary greatly makes it difficult to do a true meta-analysis of intervention.  So we need to go back to what we know and what is safe for both our patient and her baby.  Both the American College of Obstetrics and Gynecology (ACOG) and the Society of Obstetrics and Gynecologists of Canada (SOGC) recommend regular exercise during a healthy pregnancy.

I recently wrote a post about the importance of activity during pregnancy.  However, the literature is conflicting regarding therapeutic exercise for treatment of pelvic girdle pain.  Much research has looked simply at group exercise compared to ergonomic/postural education, acupuncture or no intervention.

The research investigating specific therapeutic exercise has been inconclusive.  

A recent systematic review concluded that there is no conclusive evidence to support exercise as a standard treatment for low back pain or PGP after determining only 2 studies to be of “good” quality.(9)  Other individual studies have found stabilization exercises to significantly reduce generalized back pain compared to no intervention.(10)  However, there are no studies that first classified patients (based on a differential diagnosis of the region) and then specifically treated based on the clustered tests.  The clinical practice guideline recommends clinicians consider the use of exercise in the antepartum patient because it is low risk and the RCT and studies have been non-specific.(2)  There is also a call for more studies.

So what about manual manipulation/therapy/massage?

Normal movement in all directions is advocated in our moms.(2)  This can include soft tissue mobilization, myofascial release, massage, muscle energy technique or even manipulation.  Studies have shown that adverse effects from high-velocity thrusts are rare, although several are documented.(11)

Every practitioner needs to decide their level of comfort when treating pregnant women.  Personally, I do not manipulate my pregnant women.  I feel they rarely need it, and I can accomplish the same goal with less aggressive manoeuvres.  Manual therapy continues to be a hotly contested intervention in the therapy world.  There is much discussion regarding what system and how we are actually affecting our patient’s pain and the pregnant population is no different.  The evidence for long-term pelvic girdle pain relief is weak, however, clinicians may consider manual intervention.  There is little to no adverse effects reported from manual therapy and may help back specific function2.

Overall the evidence is strong for predisposing factors and differential diagnosis. Conversely, our intervention evidence remains weak and conflicting at best.  More research is needed!  However, we can definitely do more intervention than we traditionally thought.  An accurate diagnosis is important as is the patient belief system.  If you have those two things, you’ll be in good shape.

References

  1. Albert HB, Godskesen M, Westergaard JG. Incidence of four syndromes of pregnancy-related pelvic joint pain. Spine. 2002;27;2831-2834
  2. Clinton, Susan C.; LaCross, Jennifer. Pelvic Girdle Pain in the Antepartum Population. Journal of Women’s Health Physical Therapy . July 2017 41(2):100-101
  3. Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008; 17(6):794-819
  4. Vleeming A, Stoechart R, Volers ACW et al. Relationship between form and function in the sacroiliac joint: part 1: clinical anatomical aspects. Spine 1990; 15:130-132
  5. Albert HB, Godskesen M, WEstergaard JG. Prognosis in four syndromes of pregnancy-related pelvic pain. Acta Obstet Gynecol Scand 2001; 80:505-510
  6. Kanakaris NK, Roberts CS, Giannoudis PV Pregnancy-related pelvic girdle pain: an update. BMC Medicine. 2001; 9 (1):15
  7. Albert HB, Godskesen M, Westergaard JG. Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain. European Spine Journal. 2000;9:161-166
  8. Cook C, Massa L, Harm-Ernandes I et al. Inter-rater reliability and diagnostic accuracy of pelvic girdle pain classification. J Manipulative Phys Ther. 2007; 30(4):252-258
  9. Lilos S, Young J. The effects of core and lower extremity strengthening on pregnancy-related low back and pelvic girdle pain: A systematic review. J Women’s Health. 2012;36(3):116-124
  10. Kluge J, Hall D, Louw Q, Therone G et al. specific exercises to treat pregnancy-related low back pain in a South African population. Int J Gynaecol Obstet. 2011;113(3):187-191
  11. Khorsan R, Hawk C, Lisi AJ, et al. Manipulative therapy for pregnancy and related conditions: A Systematic Review. Obstet Genecol Survey. 2009;64(6):416-427

Putting Your Safety As A Massage Therapist First

/4 Comments/in , , , , , , /by

It was the strangest thing to happen in my career to that point.

Something just felt off, right from the introduction to a new patient. I couldn’t explain it, it just felt off.

The patient came in and was very demanding. Telling me over and over again, “deep pressure is the only thing that works for me, it HAS to be deep pressure.”

Fair enough, I weigh around 215lbs, I should be able to put enough pressure into this.

After they got on the table, I went to work. As I pushed in with more pressure, I would continually check in to make sure they were satisfied with the pressure.

Then about 15 minutes into the treatment the patient abruptly said: “this isn’t working for me, I want to stop!”

I quickly asked if I had done something wrong?

“No, I just want this to stop now, it’s not working for me.”

I ended the treatment and said I would meet them outside when they were ready. As the patient exited the room, their hand reached out with a credit card in it. I said there would be no charge as it was only a 15-minute treatment (they were booked in for 45) and were also dissatisfied with it. But they refused and paid for the treatment.

I sat there even more confused (although happy I would have the next 1/2 hour to figure out what just happened).

As they walked out the door, the patient turned back and said: “thanks a lot for making me feel safe.”

Now, I was even more confused (and convinced the person had been sent in as a test or something), but even in the confusion, there was something that I was concerned with even more.

What about MY safety?

Right Of Refusal

This is where things can get a bit tricky.

When I look at our provincial bylaws (I’m just going to assume most other places are about the same) under the code of ethics there is a wide range of topic and wording that apply to us in practice. And that wording can be read a couple of different ways, depending on your interpretation.

To highlight a few that are applicable to the point of this post:

  • Massage therapists must set and maintain appropriate professional boundaries with a patient.
  • Despite section 23(iii), a massage therapist may immediately terminate the therapeutic relationship with any patient that:
    • sexualizes or attempts to sexualize the treatment or environment, or
    • threatens the massage therapist or otherwise endangers the massage therapist.
  • Massage therapists must protect and maintain personal and professional integrity.
  • Massage therapists must maintain a safe and healthy treatment environment.

Now granted, the colleges responsibility is to protect the public and most of these are probably in place with that thought in mind, as opposed to protection of a therapist.

The reason I bring all of this up is because of the story I mentioned in the beginning but also because, most of the time when I hear of someone who has been falsely accused of something (these are just things I’ve heard in passing, not from anyone directly who has been accused), I also hear, they regret not ending the treatment themselves because something just felt “off.”

Since we are to maintain appropriate professional boundaries with a patient, the responsibility lies with us. If the patient is going beyond a boundary it is up to us to end and or alter the treatment.

As laid out, we can terminate a therapeutic relationship if a patient threatens or otherwise endangers us as a therapist. In this case, I’m sure the intent was if a patient was actually threatening or physically endangering us. But what about when they are doing something that could possibly endanger your career, your mental health, or your overall well being? If something during the treatment happens and our gut tells us something isn’t right, we should have the full right to end that treatment. It won’t be easy to do, but in the long run, it could save not only a career but also mental anguish. This is also a way we can protect and maintain our personal integrity.

Since we are also expected to maintain a safe and healthy work environment, have we taken the time to think how that affects us as opposed to our patients?

In my past career before becoming an RMT, I worked in an industrial setting dealing with health and safety. The one thing that always came up was our right as employees to have a safe work environment. Part of those rights was the ability to deny unsafe work. If you were told to do a job but considered it to be unsafe, you had the right to deny doing it.

While you had to give sound reasons for why you considered it unsafe, the company could not force you to do it until the safety concerns were rectified.

In this case, if a patient is doing something that is setting off some red flags for you, it is your right to demand a safe workplace environment and in turn should be able to deny treatment to a patient if you think your safety is at risk.

Photo by: JESHOOTS

Working Alone

This is another one of those areas that is often overlooked because we are either self-employed or work as contractors.

There was an article being circulated a month or so ago, which highlighted a massage therapist getting killed on the job as she was doing mobile, home care work (I think it later came out that she was working under less scrupulous employment) with no one else around.

If someone was working as a mobile therapist by themselves, or even working alone in a clinic, there are certain safety guidelines set out through WorkSafe or department of labour that stipulate conditions that are to be met to protect someone in this case.

Some of the guidelines that are set out in order to protect someone working alone or in isolation are as follows:

  • Develop and implement a written procedure for checking the well-being of a worker assigned to work alone or in isolation.
  • Procedure for checking a worker’s well-being must include the time interval between checks and the procedure to follow in case the worker cannot be contacted, including provisions for emergency rescue.
  • A person must be designated to establish contact with the worker at predetermined intervals and the results must be recorded by the person.
  • Time intervals for checking a worker’s well-being must be developed in consultation with the worker assigned to work alone or in isolation.

So, if you are a clinic owner, think of how this applies to some of the people working in your clinics. Are there times in the day when they are at the clinic alone? Is anyone calling in to check on them? Are there emergency procedures in place if something were to happen to one of them?

How about for those of you who do mobile massage on your own? Do you have a check in system before and after your treatments? Does someone know your schedule for the day and the addresses you’ll be working at? Do you have a contact in case of emergencies?

This doesn’t have to be an expensive complicated endeavour, even if it is regular contact throughout the day to a loved one or co-worker, who can regularly check in with you, as long as there is constant contact with someone.

However, there are companies out there who offer this kind of check in service. When I used to work alone I would have to call in to a company every two hours. If they didn’t hear from me, they would try to make contact. If contact failed they would dispatch emergency help to come and check on me (fortunately this never happened). There are now even some phone apps available like this one to handle these types of scenarios. The whole point of this post was not intended to scare anyone, but as self-employed people, we rarely take the time to think about possible safety issues within our work. We are trained to constantly think about what is safe and appropriate for our patients, when in reality isn’t our safety just as, if not more important?

Therapeutic Exercise And Inversion Ankle Sprains

/in , , , , , , /by

When she came in, you could see the pain on her face.

Wincing with each step toward the treatment room, her limp was noticeable as she was protecting the ankle.

As I helped her sit down, of course, my first aid protocols popped into my head first, so I ran through the typical questions:

“What happened?”

“Did you hit your head at all?”

“Did you hear a pop in your ankle?”

“How are your pain levels?”

Fortunately, she didn’t hit her head and there was no “pop.”

She had just rolled her ankle and had a pretty typical inversion sprain, the swelling was already noticeable. What made it worse for her was the stress and worry of whether she could run as it was her favourite thing to do.

She wanted to get that ankle back to her normal activities ASAP.

Helping Protect The Injury

As I mentioned, the first thing I thought of was the first aid protocols when it comes to an injury.

This particular incident was obviously in the acute stage, so all the RICE protocols are the first thing I thought of. While there has been lots of debate online about using ice and rest, I still believe that in the acute stage it’s the best way to go.

Where I have changed my opinion is how long to use RICE.

In the past, we would use ice and rest for way longer (at least I did) than was probably appropriate. During the inflammation phase, (which is the first 48 hours) it is important to rest and support the tissues involved in the injury but still, keep up with some movement and continue to load the tissue within pain tolerances.

Since most of you probably already know how to rest, ice, and elevate I thought we would go over the compression portion and demonstrate how to properly wrap and inversion sprain, to give it some support and help control swelling over that first 48 hours.

Properly wrapping an ankle like this can give it that little bit of extra support (and confidence) in order to help the patient continue to move and also help with pain management.

Loading The Tissue

More and more over the past few years, we have been hearing and seeing more research on the importance of loading tissues post injury.

I’m sure we’ve all heard the stories about how they get patients up and moving almost immediately after surgeries.

Research is showing that loading the tissue or causing mechanical tension (muscular force) is actually a way to help influence wound healing. As the injury enters into the repair phase we can start to load the tissue even more.

This, of course, depends on pain and weight bearing abilities. If the patient can do full weight bearing pain-free you should be able to load the tissue more than if they can’t do full weight bearing. If they can’t bear full weight, giving the patient something to hold for balance will help decrease the amount of weight we are loading into the tissue and help with a decrease in pain, but still have the ability to move and load the tissue.

Here is an example of how you can begin some weight bearing exercises and load for an inversion sprain.

Once the patient feels more comfortable and pain has decreased, you can then progress them to this kind of exercise in order to load the tissue more:


As the patient continues to progress, here is a 3rd progression you can use to load into the injury more:


It is important to work within your patients pain tolerance when doing any kind of exercise, but one study showed that doing isometric contractions actually helped to decrease pain in patients with a tendinopathy. While an inversion sprain isn’t a tendinopathy, we can use it as a reminder that it is okay to load the tissue early in the healing process. So, in addition to doing some massage therapy, actually loading the tissue will not only help strengthen the area but also assist in decreasing pain for the patient. However you decide to set up your treatment plan, these are movements that can be taught in the clinic and incorporated into your treatment but also given as homecare exercises to help the patient progress. For those of you who don’t have “exercise” in your scope of practice, let’s just call it “therapeutic movement!”

What Is Really CI’d With Hypertension?

/4 Comments/in , , , , , /by

 

Was it 140/90 or was it less than that?

Wait, 160/95 is what’s too high?

I always had a hard time remembering what was CI’d and what wasn’t. Positioning, heat, which blood pressure numbers were too high?

Many of these CI’s were based on massage increasing circulation, making it too hard on the heart when blood pressure was already too high.

But what about now that we know that massage doesn’t increase circulation and move fluids around like we once thought?

Are these things still a contraindication?

And do we really need to take every patients blood pressure before treatment?

Do We Really Need To Take Blood Pressure?

Part of the problem with hypertension is that it quite often goes unrecognized.

It has been called the “silent killer” because of the damage it can cause to the blood vessels, heart, brain and kidneys before any other noticed symptoms occur.

Where we need to pay attention is the degree of hypertension the person is experiencing.

  • Normal blood pressure: 120/80
  • Prehypertension: between 120-139 systolic over 80-89 diastolic.
  • Stage 1 high blood pressure; 140-159 systolic over 90-99 diastolic.
  • Stage 2 high blood pressure; 160 or higher systolic over 100 or higher diastolic.
  • Hypertensive crisis, a medical emergency; 180/110 or higher.

Looking back over my notes from college, we were told that 160/95 was contraindicated for a massage. This is probably true in the case of someone who doesn’t know they have hypertension and should see a doctor. If they are under the care of their doctor, they’re probably coming to see you for help with this very thing.

Which leads us to why we should be taking a patients blood pressure in the first place.

One paper examined the role of manual therapists taking blood pressure prior to treatments as an aid to their clinical reasoning, risk assessment, and vascular profiling. The paper presents three case studies where patients were having either neurological or musculoskeletal pain in the neck and/or thoracic chest area.

In each case blood pressure was taken, two of the cases were abnormally high, and one was low. Once the patients were referred out to appropriate care and the issues causing the rise or drop in BP was corrected, the issues they were experiencing decreased and manual therapy could continue.  The only way these issues would have ever been recognized was by the manual therapist taking blood pressure readings as part of their treatment protocols.

Also important is another study which showed a difference in blood pressure measurement depending on the position the patient was in. Systolic blood pressure decreased in semi-fowlers and sitting positions compared to being taken when the patient was supine. This stressed the importance of making sure measurements were being taken with the patient in the same position before and after treatment to get a true reading on whether therapy was effective.

If you took the initial measurement when the patient was sitting before the treatment started, then took a second measurement at the end of the treatment while they were laying on your table, your comparison before and after treatment wouldn’t be accurate.

So even if you think the patient you’re treating doesn’t fit the profile of someone who would be dealing with high blood pressure, it should still be part of your routine, especially if it’s the first time you’re seeing someone.

Photo by: Gadini

Shortening Strokes And Positioning

As we have discussed on this blog before about massage and circulation, many of the contraindications we learned in school probably aren’t as applicable anymore.

We were taught to shorten our strokes when it comes to hypertensive patients, but as research has shown, we aren’t increasing total body circulation, there is just a bit of circulation increase locally to the tissue we are working on. So, we probably don’t need to worry about specifically shortening our strokes with a hypertensive patient.

We were also told that positioning of the patient on the table could be a concern as well, we were instructed to not leave the person in the prone position for extended periods. Looking back through the textbooks and notes as I wrote this article, there was some good advice from one of the texts, the gist was that if the person could sleep in this position (eight hours sleeping compared to an hour on your table), they’re probably fine. Keeping communication open with that patient would be important, to see if they start feeling dizzy, or lightheaded during the treatment, but otherwise, you’re probably safe.

One study showed that just lying prone can actually help decrease blood pressure just as much as lying prone with a massage (however this study was done on healthy people and those with hypertension were excluded from the study).

Another systematic review(1) showed that massage therapy combined with antihypertensive drugs was more effective than just using the drugs alone. While researching for this, I found several articles and studies that show massage therapy to be an effective complimentary treatment for hypertension.

So with all this evidence, it’s safe to say there is a lot we can do to help patients with hypertension. Keeping in mind a few different things, like when pressure is high enough to dictate an emergency, communication with your patient and knowing that a regular length stroke is okay, there shouldn’t be too many issues with your treatment. As we continue to try and gain respect as healthcare professionals, this is one easy step we can use to add to our clinical reasoning and risk assessments when dealing with our patients. If one of your patients is coming in for this specifically, take their blood pressure before and after the treatment (with them in the same position), so you can prove what you are doing is helping them, and communicate that information with their family doctor as well. I guess I’ll have to go buy one of those digital blood pressure cuffs now, they’re probably more accurate and less of a chance I’ll screw it up when using it.

References

  1. Xiong X, Li S, Zhang Y. Massage therapy for essential hypertension: a systematic review. Journal Of Human Hypertension [serial on the Internet]. (2015, Mar), [cited July 10, 2017]; 29(3): 143-151. Available from: MEDLINE with Full Text.

Recognizing And Treating Angina Attacks With Your Patients

/in , , , , , /by

It used to freak me out all the time.

He’d come into my first aid room, complaining of chest pain, explaining that he just overdid it a little, then immediately the hair on the back of my neck would stand up.

Was this going to be the time? Should I start calling for more help? Should I just call 911 to be safe?

Inevitably I would ask the same questions every time, do the same thing, and it would usually work out just fine.

Sit him down, he’d take his meds and within twenty minutes or so, he’d be back on the job and carry on like it was any other day.

But I always worried about when one of his angina attacks was going to turn into a full on heart attack and be a major emergency.

Angina Types And Recognition

Angina Pectoralis is a coronary artery disease where people experience chest pain that comes and goes but the pain isn’t caused by a heart attack. One of the big differences is that a heart attack actually causes damage to the heart muscle, whereas angina does not.

If someone is having an angina attack it’s a sign that the heart isn’t getting enough oxygen-rich blood and usually happens during physical activities or during emotional stress.  Typically this will only last for three to five minutes, but usually for under 10 minutes. When this happens, the symptoms can look a lot like someone having a heart attack; constricting chest pain, jaw pain, neck pain, pain in the arms (mostly on the left), and sometimes difficulty breathing.

There are four different types of angina:

  • Stable Angina
    • pain is the same each time
    • brought on by physical exercise, extreme weather, heavy meals
    • relieved with rest/nitroglycerin
  • Unstable Angina
    • pain is worse than usual and lasts longer
    • brought on even when resting
    • no relief
  • Variant (Prizmental) Angina
    • caused by spasm of coronary arteries
    • brought on by medicine, cold weather, smoking, cocaine use
    • extreme pain
    • usually, happens during early morning hours
  • Microvascular Angina
    • affects the heart’s smallest coronary arteries and causes them to spasm
    • may be part of a coronary microvascular disease
    • severe unpredictable pain that lasts for an extended period
    • medication may not relieve the pain

Angina is one of those things that you may or may not have seen on one of your patient intake forms.

There are those patients who would recognize it as something you should know about and others figure that because they’re on prescribed medication and it’s being managed successfully it’s not that important to tell you. However, as healthcare professionals,  it’s important for us to know and understand all these types of angina in case a patient ever comes in complaining of chest pain.

Even more important is knowing how treating an angina attack is different from treating a heart attack, even though the risk factors, pain, and symptoms are quite similar.

By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

Emergency Care For Angina Attack

The difference between angina attack and a heart attack can be a little confusing. 

Both can look the same because of the visible signs and symptoms the patient presents with. 

One big difference is that someone with angina, typically knows they have it and have been through this before, so making sure to ask the person if they’ve ever experienced this kind of pain before is critically important. If they haven’t, assume it’s a heart attack and call 911. 

If there is no record on their intake form, and you’re not sure what’s going on, asking the SAMPLE questions can help you get to the bottom of the situation. 

S – Signs and symptoms?

A- Any allergies?

M- Medications? Are they taking any?

P- Past medical history?

L- Last meal?

E- Events leading up to this emergency. 

The critical ones, in this case, are signs and symptoms, past medical history, and medications. All of those should give you a clue if this is an angina attack (if the patient is being honest with you). 

We reviewed the signs and symptoms (chest pain, jaw pain etc), and hopefully, they would tell you angina when asking about past medical history. But it is also important to know the medication prescribed in this case, Nitroglycerin. Nitroglycerin is a vasodilator that relaxes the smooth muscle and blood vessels, increasing blood return to the heart and making it work less hard. It comes in a few different forms; a sublingual tablet, a spray, patch, aerosol solution, ointment, and an extended release caplet. The most common I’ve seen is the sublingual tablet. In this case, the patient puts it under their tongue and lets it dissolve. 

If you’re assisting a patient with their medication (remember assisting means getting it for them, not administering it), make sure it’s their medication and it’s the right dose. 

HOWEVER, before they can take the nitroglycerin you have to ask them if they have taken any erectile dysfunction drugs (probably the only time it’s appropriate for you to ask a patient this), and yes even for women as some women take it as well. If they have taken any, they CANNOT take the prescribed medication as the combination of the two can lower their blood pressure to a fatal level. If they have taken Viagra or Levitra in the past 24 hours or Cialis in the last 48, they cannot take nitroglycerin. 

Sit them down and have them rest in a comfortable position (sitting leaning forward usually makes it easier to breathe) and then they can take their medication. If after five minutes the chest pain doesn’t go away, give another dose. This can be done to a maximum of three doses, always five minutes apart. If after that 3rd dose, the pain hasn’t gone away it’s time to call 911 as this could be turning into a heart attack. 

If they don’t have nitroglycerin but there is Aspirin (ASA) available (make sure it’s Aspirin, not Ibuprofen or Tylenol), they can chew two 80mg or one 325mg dose but only one dose of either, do not repeat it. If after taking the proper medication, the pain subsides and everything goes back to normal, this isn’t necessarily a 911 call. This is a condition the patient deals with on a regular basis and their medication is doing what it was intended for. 

The biggest thing we can do to help is remain calm and recognize what is happening with our patient. It can be pretty scary having to deal with any kind of emergency that happens in our clinic, or anywhere else for that matter. The differences between an angina attack and heart attack can be hard to decipher, but with a good medical history and asking the right questions you can be successful in figuring it out. More importantly, as healthcare professionals, it’s important that we know what to do in these cases in order to give our patients the best care possible. 

 

 

 

Hacking Your Way Through The Jungle Of Research Claims

/2 Comments/in , , , , , /by

“When we place our hands on a patient and act/move in certain ways our patients improve.”

Social media receives a good deal of criticism from folks who feel it is the ultimate waste of time…though those same folks are usually posting these opinions on social media. Research “findings” are frequently posted on mass media sites, but end up being fluffy opinion pieces rather than accurate and objective articles. Even published papers can be misleading or poorly conducted, creating an impression of conclusive proof when none exists.

As an active member of a number of manual therapy groups on Facebook and LinkedIn, I read many posts that speak to the “proof” of specific manual therapy modalities and their effectiveness based on published findings, but occasionally am I able to watch as a paper is deconstructed.

The Skeptical Massage Therapist Facebook is a rather small group devoted to those who identify themselves as scientific skeptics, of which I include myself. (While their name would imply that I, as a physical therapist, would be excluded, they are liberal in allowing a wide range of manual therapists into their group) There was a recent post on the Group made by Nick Ng, a journalist for the TellUs News Digest, formerly of Guardian Liberty Voice and massage therapist, in response to an article he had written for the TellUs News Digest on CranioSacral Therapy. He posted to the Facebook Group, asking for feedback on a specific article titled “A randomized controlled trial investigating the effects of craniosacral therapy on pain and heart rate variability in fibromyalgia patients”(link)

Bryan Quesnelle provided some excellent observations and he graciously allowed me to share those observations here. Bryan runs the Clinic Wise Clinic Management Database and online CEU courses). I am not research literate, in comparison to many of my peers and when I read a paper published in a science journal I often make assumptions that there are stringent rules to assure the writers pass certain standards before the paper is published. While I am not casting any negative light on the writers of this study or the subject matter, Bryan had some very good observations:

“The “sham” group wasn’t receiving sham cranio treatments, they were attached to a disconnected magneto therapy machine… Basically, this was comparing CST to laying down without intervention. This doesn’t help at all to validate the premise of CST, just shows that attentive human touch can impact perceived pain levels. The controls necessary to isolate CST mechanisms from other non-specific therapeutic benefits were basically nonexistent here.“

“That also presents an issue for blinding, since the “sham” vs. real interventions were obvious, leading to a lot of bias and placebo influence.“

“The p values are all over the place for each measured tender spot over time, most going from 0.6 to 0.03 between measurement periods. Some variation is normal, but they’re pretty extreme jumps. That’s a lot of discrepancy in reliability of results of the same painful areas over time.“

I realize that my own modality, myofascial release, has similar problems, as do many of the hands-on approaches used by physical therapists, massage therapists, and chiropractors.

On the  Research Page of the Foundations Seminar website,  there are dozens of published papers showing myofascial release to be a successful modality in the treatment of various disorders.

But all of those papers, while stating the oft-used and outdated explanatory model, do nothing to prove how MFR affects the body. They show the hands-on aspect to be helpful, but do not prove how it works. This is an important distinction that many therapists miss. When therapists place their hands on patients and interact in a manner that they were taught in their myofascial release (and craniosacral) training, the outcome is often positive. If we could just keep our language more general and avoid explaining the outcome based on outdated or false models,  there would be less discourse when it comes to the claims of various modalities.

This does not diminish the effectiveness of MFR/CST, it simply should make you question the claims you were taught. If we spoke in more simple terms such as these, it would place most of the claims of many of the manual therapy modalities in question…which is not a bad thing!

As I increase my science and research awareness, I have allowed my language to be more accurate as well. Some might feel the opposite to be true, as I no longer sound so sure of myself and I no longer repeat inaccurate/outdated explanatory models using fascia as the primary source of pain, dysfunction, and “cure”.

MFR is effective, but I now know that the nervous system plays a much larger role than originally thought. The extent and manner in which the nervous system impacts my work has not been fully sorted, so I use a more broad explanatory model to explain my work to my patients and my students/therapists. I include past models of hypothetical fascial change as a frame of reference as well as a few different models of how the nervous system oversees all happenings. As some point, however, I will add:

When we place our hands on a patient and act/move in certain ways our patients improve.

If manual therapists and their teachers could be humble enough to speak in these terms I believe all of us would benefit. But this sentence is too simplistic for many. It doesn’t make the speaker sound informed. But it is bluntly honest and this is my goal.

So, challenge yourself to improve your research literacy. Question what you were taught and currently believe. I am doing the same. Accepting another person’s word at face value is rare, so why accept their explanatory model without questioning?

Join and stay up-to-date!

Email Marketing by AWeber

Have a solution to a problem within our industry? We want to hear about it!

Learn More

© 2020 – 2026  James Johnston RMT • All Rights Reserved