Podcast Episode #27 Myofascial Release And CLB, What Does The Evidence Say?


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

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

James Johnston RMT 0:22
Our objective is to simplify how to be a more evidence informed practitioner. Let’s dig into this episode.

So often said that you can’t judge a book by its cover. And I think you could say the same when it comes to research. We’re going to look at a paper today called myofascial release for chronic low back pain, a systematic review and meta analysis. And funding when I looked at it, I just assumed that they would be trying to point out wonderful and effective myofascial releases. But the paper tells us otherwise.

Eric Purves 1:04
Yes, I liked that. The, the title kind of brings you in, I use that as a manual therapist, as massage therapists, you’re like, okay, my apologies, chronic low back pain, all of a sudden, my, my alarm bells were up and I was like, Oh, I’m going to tear this paper apart. It’s going to be crap. You know, my bias was coming into effect. And I was like, oh, no, you would send me you’d send this you’d found this paper and send it to me. I thought, Okay, well, let’s just let’s just see what it has to say. And I was pleasantly surprised. There’s a few things in here, which, you know, I didn’t agree with it. I’m sure you as well. But I was pleasantly surprised how they went about it. And the findings that they came up with? was not what I expected.

James Johnston RMT 1:44
No. And it turns out, I did confirm my bias as I read through it.

Eric Purves 1:47
Yeah. Yeah, yeah. I mean, it basically, you know, you know, slow, stretchy skin techniques to the low back aren’t as wonderful as some people claim. But there is some positives, and there’s some nothingness of this. What is what did it find, though, is lost or is never mentioned in these studies? And I think this is the problem with these type of studies like this, like these quantitative studies, where there’s like, assigning value or numbers to things is there’s no qualitative aspect of like, what does this mean to the personally, the person getting the most is going to put into this air quotes MFR treatment for the low back? Do they value that? Or do they value exercise? Or do they value rescue? They value medication? Do they value that type of massage technique? Or like, what is it that they want, because when we’re looking at these kind of patient centered care stuff, you know, all these buzzwords we hear all the time. And that’s really the way things should be going as person centered care. If someone comes in and you give them this, like slow, stretchy skin, technique, of varying forces, whatever feels good for you, and the person receiving it, you know, we say we call that myofascial release is the person value, that is what they want.

Jamie Johnston 3:05
Yeah, yeah. And rarely,

Eric Purves 3:07
that makes a big difference in terms of the outcomes are going to come because you can’t, you can’t force somebody if something they don’t want and expect them to get better. Yeah.

James Johnston RMT 3:15
And like to go along with that, it’s they also never mentioned anything about contextual factors of treatment, the interaction between therapist and patient, the, you know, all those other things that we know, matter so much. And granted, in this case, because it’s systematic review. You know, they’re just looking at all the papers that have been done. And so it’s not necessarily necessarily their responsibility at this level of the research to, to look at that. But at the lower levels of the of the research of the papers that they would have looked at, they it’s still not talked about, none of those things are, are taken into account. And, you know, it’s not talking about the confidence of the therapist and doing those techniques, compared to one that they don’t like, right, and so, even though it’s, you know, one of the things they looked at was myofascial release versus Sham, and I’m not sure what the sham was, but, but it still showed that, you know, it wasn’t getting better. So, so it’s, you know, I wish that they would start doing research papers to take all of those things we just talked about into account as as part of it.

Eric Purves 4:20
And that’s the thing that that I find is seems to be a problem is they keep on doing these studies, and people putting these papers when they’re looking at the same thing again, and again and again. And again, you think, why do you like and then they always a conclusion always is more research is needed. But why don’t you do the other research as needed rather than doing the same research again? I mean, this is this paper was done at universities, some china and Italy looks like this where the researchers were, and it was just done last year, and it’s just time Yeah, July 2021. So it’s relatively like it’s a newish like a very new study. But you have to keep putting these resources and times into it and you’re studying. Myofascial release for chronic low back pain. And I think this is the problem with this, when you call things like this, it tends to probably add more validity to the term myofascial release than it really deserves. Because if you’re doing myofascial release, and someone can be like, That’s what I do, I guess why I call my technique. And I think, you know, myofascial release sounds nicer than slow, stretchy skin technique, if you know, for sure, probably triple s t technique. But the problem is, is that it’s inferring that you’re making that you’re like imparting change, or you’re like creating change in the muscles and fascia. Yeah. And that is and that and in order for that to be true, that has to be validated first. And we know that from other studies, that your manual techniques don’t actually create long standing changes in that tissue. Yeah, through the mechanisms proposed, proposed, right. So we know it’s, there’s this neurophysiological things which have these more reflexive effects. But that’s, that’s, you know, when when you’re using it, you’re myofascial just, it makes a lot of assumptions, right. And it, I think it creates this idea that tissue needs to be addressed in a specific way for a specific problem in order to get results. And you know, and there’s a lot of assumptions made about how this works. I think in the paper, they talk about, like changing this visco elasticity of the fascia and increasing blood flow and, you know, increasing neural function through like opening space, creating space from I can’t remember. Yeah, the like, Okay, well, that’s a lot of assumptions. Those are assumptions. Those are not science facts. Those aren’t those are hypotheses or theories,

James Johnston RMT 6:47
which was, which is what a lot of the myofascial release research has been based on.

Eric Purves 6:54
Yeah, and even in here, and his paper when they talk about near the end when they’re there, and we’ll get to there. And when they talk about the, you know, how this is supposed to work, they’re using old research, which isn’t even, like, physic neuro, are there even physiological anatomical studies, really, they’re like, just old, like ideas by like, SCHLAPP. And our, you know, and just just going like, Okay, well, these are ideas, and they helped us get to where we are now, but those ideas are kind of not fully complete, we have

James Johnston RMT 7:25
to put those in them are completely wrong. Yeah, we have to put those away now, and, and go with, you know, start looking at the stuff that Bilasa T is doing. And that’s the more modern interpretation of what’s going on, right. So that’s the stuff that should be included in their paper like this, when we’re talking about how things work. And interesting, like, towards the end of this paper, or even talked about, like, looking through all the papers, they couldn’t define one specific technique that was used, it was all different myofascial release techniques that were used. So they can’t, It can’t even be narrowed down to say, you know, doing a hold on the area around the QL, for X amount of time in this direction, was is the way to do it. Because there were so many different styles that were used, that they couldn’t pinpoint that. And kind of funny to go with that because I just was looking at a paper recently about manual lymph drainage. And they were trying to say that manual lymph drainage works. And then when you read through the paper, all they do is say we did general Swedish massage in that area. So they weren’t doing MLD technique. They were using Swedish massage and saying manual lymph drainage works. Wow. Right. So so so that’s, that’s like one of the big issues with all of these modality based or technique based things is that there, there’s nothing concrete about it. And the more that we understand about how things work, when we put our hands on people, we can realize that none of these are all outdated ideas and theories that should really be

Eric Purves 9:03
put to bed. Totally, totally agree with these things to what you see is, you know, all these studies, like all these manual therapy studies, right, they all kind of show doesn’t really matter what you do, you name your technique. And they all show that you’ll have a short term decrease in pain and maybe a little bit of increase in physical function, depending on how those are measured short term, but doesn’t matter what these myofascial release are cranial sacral or Swedish or anything else, they all kind of show the same thing, which I know some people might who are listening maybe people who listen to this podcast before and like oh my god, these guys are who are they? They don’t know what they’re talking about. We promise has a million times the last thing on the podcast we’ve done now 2530 of them something like that. That it’s it actually should be empowering to us because it means we have more opportunities. 100% And it doesn’t have to follow the specific protocols and in the courses that we teach together or individually, you know, we always talked about that like, it’s just like, beaks, explore, be curious, find something that feels good that you like to do that the person likes to do. That’s, you know, harder, softer stretch, your faster, slower doesn’t matter as long as it feels good to the person, that’s the person centered care. You don’t have to worry with these very specific interventions. And I know that people are that, you know, are gonna argue that, but that’s okay. You can argue that all you want, like, there’s not the data sport, you may have your clinical experience to support it. And I would never argue with clinical experience. But the reasons why you’re getting those results from your clinical experience are probably very different than what you think. Yeah. And this is where we have that ethical obligation as healthcare providers to to be less wrong. Yeah. Don’t claim you’re releasing fascia.

James Johnston RMT 10:46
When we know that that’s not possible.

Eric Purves 10:50
Exactly. But you can make people feel good doing those techniques. Yeah. And that’s, I think, where the the discussion gets bogged down a little bit.

James Johnston RMT 11:01
Yeah. Funny enough, you know, the discussion that we were involved in offline this morning was something around, I think the term was used, elitism. Where, you know, people that are, you know, they’re discussing things with physios and things like that. And there seems to be this manual therapy elitism. And, and as I was watching some of the comments around that, I was like, Well, you know, people could probably point at us and say the same thing. Because we’re pushing so much for evidence based care, there’s probably a certain population of massage therapists that look at us and go, Well, these guys are, you know, they’re, they’re trying to be elitist in what they’re doing. But it’s, it’s just not the case, we’re just trying to bring the education around what we do. So this sort of a little bit of a tangent off track there. But you know, it’s a podcast. But it’s, you know, I think we just got to be, be careful when we’re, you know, when we’re interacting with other therapists and things like that. And like you said, there’s probably lots of people that listen to this, and these guys are idiots. They don’t know what they’re talking about. Because we’re looking at this stuff and trying to get rid of those old narratives. So, you know, we just probably want to get across that we’re not trying to be elitist about anything, we’re just trying to bring forward the most the most up to date information about the things we do in order to help other therapists.

Eric Purves 12:26
And I think that what happens sometimes is that, you know, I know, we’ve seen people before, I’ve seen have said things like, oh, you know, I’m tired of the myth busting. And, you know, I don’t believe that when you we educate, we just spend so much time busting myths. And I agree with that to some way. But the problem is, is that having been teaching CCS for so many years now, I’ve done them over 100 plus times, when you experiment to try something different, and you don’t do the mythbusting aspect of it, things go sideways, because people don’t know what you’re talking about. Yeah. And so

James Johnston RMT 13:03
as well as, as long as the myths still exist. Yeah, we have to do something about that.

Eric Purves 13:10
Yeah. Yeah, and I would say we do way less now than we used to, I used to spend so much time on it, but I just kind of got like, well, you know, I’m just kind of tired of doing it, because been doing it for seven or eight years now. And you think, how many more times do we need to do these bust these myths like these things are, but they’re still there, and the society is still there. And the profession? So yeah, we maybe would call there’s a term myofascial release. And it’s like, Oh, my God, I’ve heard these guys say this a million times. But the thing is, is still the common narrative is still the common idea within the profession of what’s happening. And there’s this like, higher level of value assigned to certain techniques over others. And, you know, I don’t think yeah, we’re not trying to be elitist. We’re just trying to say, look, we spent it, this is what we do for a living. This is like, we read this stuff, we talk with the stuff, we teach this stuff, you know, and we’re trying to change the profession to be more evidence based, be more up to date, because we don’t make these changes, then we’re gonna be left behind. And I think that we don’t want to be left behind. We want to be seen as leaders, like we know we can do we can be leaders that MSK care. And, you know, we made that comment before and of course, we be leaders and we’ve had people be like, Well, I don’t think it’s fair to put down other people or other professions where that’s not what we’re saying. But yeah, why would we not want to strive to be the best set like hands on and movement based musculoskeletal care? Why do we not want that? We can do it is within our scope? Yeah. Yeah. And then the also to sorry, I’m gonna go on a tangent here. Now just thinking of like, previous like courses we’ve taught and other podcasts we’ve been, haven’t necessarily been ours. Where people hear us terrible things. Like I think we made some discussions and some stabs at the importance of the psoas muscle on someone else’s podcast, thinking practitioner, maybe In the last pod, yeah, we talked about that. And then we got, we got some, like, from this one listener and got some very kind of like upset emails. Yeah. Basically saying that, you know, you should be better than calling out this stuff. And, you know, it makes it sound like you’re like you’re, you think you’re above everybody. And we’re like, no, like, that’s not we think at all. We’re just talking about this stuff, because this is to what we hear all the time. Now, it was a while ago, I can’t exactly remember the context of that. Maybe you might remember, but I remember thinking people hear what they want to hear. Yeah. And, and if you say something that makes them feel uncomfortable, they oftentimes will come at you as trying to be elitist or being trying to make yourself feel superior or making trying to make others feel dumb. And there’s never that’s never my intention was the intent. And so sometimes, maybe if people feel that way, I’m like, Okay, well, maybe I could have said that better. Maybe we could have had that discussion better. I don’t know. But or maybe somebody you think, well, maybe, maybe that’s, maybe that’s you listen to the listener, which I like. Because not everybody feels

James Johnston RMT 16:06
that way. Yeah. And we’re not going to be able to make everybody happy. No, right. There’s always going to be somebody who, and everybody has the right to take things the way that they want. And that’s fine. But, you know, but I think it really comes down to like, when people get their beliefs challenged, is is typically when we get that that kickback. Right? You know, I, we could go that’s a whole other podcast we could talk about. Sure. Yeah. You know, and I’ve been, I’ve been doing some, some learning and some reading around that lately. And it’s some really interesting stuff about how the brain always switches to a safety mechanism, even when it comes to that stuff. So when those beliefs get challenged, you know, it’s an automatic automatic reaction for the person to get upset and pull back and be like, no. So, you know, could we have done a better job of trying to change the opinion of somebody? I think we’re, I think we’re doing our best and, and all you can do is do your best. So if people can be offended, that’s okay. But we’re, we know that there’s other people and there’s people in the population that we’re helping, because because those narratives are getting changed.

Eric Purves 17:20
Yes, yes. All right, you want to

Unknown Speaker 17:25
paper after that ramp?

Eric Purves 17:26
Yeah. We shouldn’t, we shouldn’t go put it like thing. Fast forward 15 minutes, and you actually hear the paper.

James Johnston RMT 17:34
So one of the things that that I looked at with it, and I’ve just got the paper in front of me, so I’m gonna have my head down reading but is when they looked at the when they were selecting the papers they were going to look at and they looked at the comparison, they looked at my alpha myofascial releases versus sham myofascial release versus exercise, myofascial release versus exercise, myofascial release, and exercise versus exercise, myofascial release and spinal spinal manipulation versus spinal manipulation alone, and myofascial release and phys ed physiotherapy program versus just a physiotherapy program. And really interesting when they looked at the outcomes, the outcomes weren’t any better. Let’s just myofascial release, so and, and that was strictly just looking at pain, and doing like the disability pain questionnaires and things like that. But it wasn’t any better. But then when it looked at things like that, what really stood out to me is like physical function and mental health. And when they looked at things like that, so what really jumped out to me was like kinesio phobia, when they’re looking at mental health that myofascial release did not help at all, when it came to things like that. And, and when we look at it, it’s like, well, especially with something like kinesio phobia, how could it possibly help? Because, you know, that’s fear of fear around movement, that it’s going to cause more pain. So how would somebody laying on the table being passively touched, have any effect on that whatsoever? And that’s one of the big reasons why we need to incorporate more movement into the treatments that we do in order to help with that aspect of goals.

Eric Purves 19:04
Oh, for sure, for sure. And I think with what I get from from this, just from the very kind of like, general aspect of it is that, you know, six, manual therapy or myofascial release, right, it works for pain, and it works for certain types of function. And depending on the studies and how they measured it, but everything else kind of works, too. So, you know, it’s I think this goes back to that initial statement we made were like, it really depends on the person wants. Yeah, and what’s gonna work for them. You know, the one thing that I find is is you see a lot in the musculoskeletal literature, which I find to be, I don’t know, almost lazy research is that they do with like a plus b, right? So you look at myofascial release and spinal manipulation versus just spinal manipulation, myofascial release plus physiotherapy program versus physiotherapy program, you’re getting two interventions to one. So maybe two interventions are getting more care and more is being done to them. So oftentimes, what you see as those studies will produce better outcomes than just one thing alone. Yeah, to make this, you know, to make myofascial release as that technique to be seen as more validated that you’d have to compare that with another similar technique.

James Johnston RMT 20:31
Yes, so say you did myofascial release versus cranial sacral? Sure, yeah. But

Eric Purves 20:38
or myofascial release versus general Swedish or, or maybe just myofascial release versus spinal manipulation? Yeah. Or myofascial release versus, you know, dry needling or you’d see like, you know, intervention, you know, comparison, what are the outcomes and see which one is better? My assumption would be based on the data I’ve seen for other things is they’re kind of the same.

James Johnston RMT 21:01
Yep. And then be interesting to if they if they did a study that way, if they were to say, taking 100 People who had low back pain, and before they got there, say, What do you prefer acupuncture or hands on technique, and they put the people into the things that they thought would work better, and then see what the outcomes are? Yeah, I think that we’ll show them the opposite one, and see what the outcomes are.

Eric Purves 21:25
Yeah, Mark Bishop and his research group in Florida, they did something like that with it with acupoints. Like, they put people into different clinicians who had a different preferred way of treating spa money for the therapy or exercise. And then they, they just randomly allocated people to the treating clinicians, I could be wrong. And this I’m probably telling someone, if someone knows the studies they’d like, yeah, you’re wrong. But general idea. And what they did is what they found is that when they ask people afterward, are they the people treating the clinicians treating, didn’t know what the person’s preference for treatment was? Okay. Right. And so the clinician got to be able to do a treatment on somebody. And then afterwards, what they did is they I believe, they looked at the data and said, Okay, these 50 people got spine, we have a therapy, these 50 people had a light touch, or an exercise intervention came out it was, what they found was, if I remember correctly, is that when those people that one of those people that were given spinal manipulative therapy, if that’s what they liked, and that’s what they preferred from, and then the provider loved that was their preference and confident with it. And those things matched the person reported better outcomes, which goes with kind of with what we’re saying here is if the person values it, and I should values it, you’re gonna probably get better outcomes than if neither party does or if one party values and the other one doesn’t. Work, which, and there’s a bunch of other studies on that. That’s just the one that comes to my mind. I think that was one the first ones I read years ago, and maybe we didn’t have a podcast about that, cuz I’m probably bastardizing. The

James Johnston RMT 23:11
Yeah, we should find that paper and look at it be cool.

Eric Purves 23:15
Yeah, I haven’t someone. One thing to just when you’re talking about the manufacturer is one thing I wanted to just mention, which I thought, this is the thing that I think is something that’s very problematic for people that are reading study. So if you’re reading the studies, have a look. And if you see these type of statements, make sure you read the references that they’re coming from, because one study or that they talked about in the introduction, it says, Previous studies have found that the psoas muscle fascia may be related to chronic low back pain, that all of a sudden for me, I thought, Really, okay. And then so I went and read the other two papers that they took that reference from and what the author’s said that the conclusions. And then the conclusion is where we see changes in connective tissues and people with low back pain, this could be either the cause or the effect. So all they’re saying is that when you have low back pain, it looks like all the tissues that we’re attaching are round to low back. We’re different than those who didn’t have low back pain. And so that’s a big leap to say the psoas muscle fashion is contributing to it. Yeah. Can you be and then the author’s go on to say, and there’s other studies that, you know, when people have chronic low back pain, they’re different motor control? You know, I think a lot of them had were heavier, they might have been, like, heavier people will be in my mind might have been bigger or less active, that kind of thing. And so, you know, maybe the changes that we’re seeing because they did it all through ultrasound, or not causative, but maybe they’re a response to being in pain for a long time. And that’s what other studies I’ve read, too. So I think when you see these kinds of statements like so as muscle fashion, maybe related, well, those those authors didn’t Let’s say that they said they see a change there. It didn’t say it’s necessarily causative. I think that’s, that’s a, that’s something that we need to be very mindful of when we’re reading these papers is that these kind of bold statements, go check the references and see what those references have to say.

James Johnston RMT 25:13
Yeah. And whenever I read something like that, when it says, the psoas muscle may be a contributor, that that to me isn’t a, that doesn’t tell me that the source is a contributor. That when whenever it says May, I’m like, okay, that that just means that there’s a possibility. It doesn’t mean if it’s not a for sure thing. So, you know, just when you’re reading it, to me, anytime that it says it may do this, isn’t it’s not a be all end all. It’s a, you’re referencing a possibility, not a not an absolute.

Eric Purves 25:44
Exactly. Exactly. And yeah, if you familiar with some of the debates about the fascia, rather than so as muscles relevance, I think

Jamie Johnston 25:54
we have a whole other podcasts that sort of motivate a whole podcast

Eric Purves 25:56
on that. And TJ did a big and I think human image Austin might have done a Facebook Live on that maybe. Anyway, yeah, it’s been that’s been beaten to death. So

Jamie Johnston 26:06
yeah, so we don’t need to be

Eric Purves 26:09
talking about that too much. But it was just something I think, people if they’re listening, make sure you check the references, the references, if something seems to be a bold claim that doesn’t resonate well with you see where they came from?

James Johnston RMT 26:19
Yeah. So it is really mean. Like I said, this paper confirmed my biases. But it goes through and talks about physical physical function, quality of life, balance, function, printing, pressure, threshold, trunk mobility, mental health, all these other things that they picked apart with the information, and it still showed that myofascial release didn’t have much of an effect on any of it.

Eric Purves 26:46
No, that’s something I would I would I would love to see is that they did talk about it. And if you looked at some of the other studies, the researcher they did they usually analysis, they looked at myofascial release, and how often people got it, and how long the treatments were. And that was quite very, they used the treatments, I think, or somewhere 40 minutes or so. Yes, as your 40 minutes once every two weeks or 40 minutes once every three weeks or eight weeks, some are 40 minutes each once every two weeks for two weeks. My family six times in total. But they don’t actually describe what the author or what the clinician did. Like what was what are you calling myofascial release? Like? How are you? What’s the is it the same for everybody? A same protocol in person centered, like what what techniques are you doing? That’s the kind of stuff that would be really important for us as massage therapists to know. Now, we don’t want to follow a cookie cutter recipe approach, because that’s boring and lame. But it would be nice to know if they’re like, Yeah, we did this technique. And maybe it was just like a slow hold, you know, for two minutes. Yeah.

James Johnston RMT 28:01
Well, that’s like what I was mentioning before, just to back up, what you’re saying is right, right, at the end of the paper somewhere, makes the statement that they couldn’t they couldn’t recreate it, because they didn’t because it was all different styles of myofascial release that were being used. It was all different techniques. So

Eric Purves 28:18
yeah, exactly.

James Johnston RMT 28:21
And it’s kind of funny, because you know, this, this probably sounds like we’re picking on myofascial release as we discuss this. But you could probably take any manual therapy technique and put it at the title of this, and it would still apply the same way.

Eric Purves 28:36
Right? Yeah, I think that what you see, what I seem to see is because myofascial release is something that, you know, it’s for some reason we’ll have for whatever reason it is it’s, it’s a term, it’s a treatment style, it’s very popular in the world, and, you know, we have fashion everywhere. And so let’s try and manipulate it. And when we do these techniques, they work and so you have clinical experience of like, hundreds of 1000s of people and clients that are respond well to it. But yeah, you there’s so many different ways of doing it. And there’s so many different ways of touching and moving and manipulating people that how could you ever say that one is right and one’s wrong? Obviously, the one way is better than the other. And that’s, I think it was one of the problems that we see with this stuff. And but because myofascial release is so popular, and it does and they do saying here somewhere that, you know usually involves holding for like 100 to 300 seconds. Right? And so, and then we’re like and they’re like and then people feel better. But then if we look at what some of the neurophysiological things that occur with the slow, sustained stretch techniques, and when you put that force into tissue, we do see that there is an anti nociceptive effect through activation of a variety of things, but one of them being I believe it’s Ruffini corpuscles.

Jamie Johnston 30:03
Yep. Pressure receptors, right?

Eric Purves 30:05
Yeah, I think it’s really so and so and so I can’t remember I should know, when I teach this stuff I should know if I’m mad, but I’m tired. I just got back from vacation. So my brains a little bit. When you do the slow stretchy skin, Teddy’s a certain receptors in the skin and upper layer of the connective tissues that do actually slow down noxious stimuli through the spinal cord. So that’s why people feel better after a massage, right? It doesn’t have to be necessarily that slow, sustained one, but from what I’ve read before and other neuro physiological studies is that when those things are held for a certain period of time, they become more activated. And that’s going to create a larger antinociceptive effect. So maybe myofascial release isn’t changing the fascia, maybe it is more likely being that you’re activating these receptors, which is changing the sensory input that your bodies that your spinal cord in the brain is receiving. That, to me is makes more sense because we can measure that.

James Johnston RMT 31:02
And that’s how, that’s how every technique works.

Eric Purves 31:05
And so every time Yeah, so that’s a, that’s something I really wish that we would embrace as a profession, rather than chasing all these these techniques.

James Johnston RMT 31:15
Well, I I was having a thought the other day. And this can this can go back to that I was writing a blog post about it. The the whole thing where we will get our beliefs challenged. And I was thinking, Well, what if, what if, when we were in college, we didn’t actually name any of the technique courses? It was just called manual therapy technique. Class one. Yes. And then we had equal amounts of classes in research and exercise. And we did two manual technique courses. So what if we had five classes on how to do a massage five classes on some exercise and five classes on some research? And all we called all the classes were massage therapy technique, manual therapy technique. Yeah. Then when we got into school, we wouldn’t run into this whole identity thing where it’s Well, I’m a myofascial release therapist, or I’m a cranial sacral therapist, or I’m a general Swedish massage therapist, or I’m this and that, it would be just a manual therapist. And then it wouldn’t be so daunting when those beliefs get challenged. Because the beliefs wouldn’t be there for the most part, right?

Eric Purves 32:33
Well, because they’re put in there by school, or any, you know, thing I’ve talked about before is that the what you learn in school forms the foundation for what you’re how you’re gonna practice. And it’s very hard to unlearn those things. And I agree, I love that idea. That if we could just stop naming these techniques is like the special thing, but teach a variety of those techniques, but teach them under like a general manual skills thing. Use those techniques to work with specific populations. So teach people some manual skills. Well, here’s some different ways this is, this is like what we would normally call Swedish massage, it’s kind of long or slower or faster. Yeah, sliding and gliding techniques. And there’s ones over the stretch here, ones and ones that are maybe a little more specific, maybe you want to use like your thumbs, your fingers, your knuckles, your elbow, whatever, you know, here’s ones that are maybe a little more pressure. And here’s what’s more, like, maybe you’re doing some trigger point type things with little more pressure in a certain spot, or whatever that looks like, you know, like get people to teach everyone the skills and how to touch because that’s really important. And that’s what I think separates us from other MSK professionals is we do as a profession have our touches is better in terms of that, because we do all day more experience with more experienced patients like betterment, and we’re more experienced with it. So but yeah, just so that we you move away from all these different name techniques and creates people to kind of pick and choose what they want to do, rather than just gravitating towards a specific way of thinking. Yeah, and you could easily do you could be here’s to all these populations that you’re going to treat. Here’s a class on geriatrics. Here’s a classroom class, no sport, here’s a class on, you know, surgical rehab, you’re the one on like, I mean, we do I do anyway, did some neurological stuff. And all this stuff was very, it was kind of very, it was quick, quick, and there wasn’t really a lot of thought process. It’s like, well, I can use these techniques and use these techniques for this person. Yeah, but you don’t really have to think about it. I mean, I know some schools probably do a better job than than others. But when we went to school, you were really taught to think you were taught just to basically copy and paste. Yeah, yeah.

James Johnston RMT 34:37
Yeah. What was it the neural stuff was like roots techniques and things like that. Yeah. And

Eric Purves 34:42
a couple other other other technique, things that you learned, but the focus was always on technique, technique, technique, and it was never enough on like critical thinking or interaction or how would I communicate with this person? How would I explain to them what’s going on? They’re gonna be like, Why do I hurt what’s going on? What are some strategies that you can use that aren’t like pathway anatomical tissue blaming. Unless there is a tissue, you’re injured, yeah, yeah, there it is inflamed here that’s going to take, you know, for six weeks to recover, like just to learn these basic things, which we do in clinic. But I find that when people come out of school, they’re not given that they’re just given a visit to basic. Yeah. And I think that can result in more. Not not the total

Jamie Johnston 35:27
results and what we have now. Let’s, it results in what we have, though.

Eric Purves 35:32
Yeah, exactly. Exactly. So yeah, that would be that’d be nice to change those techniques. And I like that you brought that up? That’s good.

James Johnston RMT 35:40
Yeah, I’ve been looking at a lot of stuff about that whole belief system thing lately, and I’m trying to make change. So yeah. Yeah, some thought reversal kind of stuff.

Eric Purves 35:54
For sure, ya know, as important stuff, right?

James Johnston RMT 35:58
Well, I think we beat a lot of that to death. But I think getting towards the end of the paper, it also pointed out, there was like five or six points that it made about, basically why the research they looked at wasn’t good. Which is important to take into account. And some of the things that they pointed out is like, a lot of the papers didn’t have long term follow up with the patients to show whether the whether the pain relief or whatever lasted for them. You know, it talked about like, it didn’t include things about disease duration, how long this has been going on for them. The risks in terms of randomization, so there was like, a whole list of things that he pointed out by there needs to be more research done on this stuff, because the research we have isn’t good.

Eric Purves 36:46
Yeah, they said that the quality of evidence to was only the best, it was moderate. And that was for pain, and physical function, which is what they that was what they said the conclusions were from the data that painted physical function is the best thing for that we can say myofascial release does, based on the current data we have, all the other stuff was low or very low. And the but there’s only moderate. So it’s not like high quality level of evidence. So it’s like, less. So okay, it’s not great. But that’s seems pretty consistent with what you see most other any type of manual and massage therapy, literature’s the outcomes can be monitored, at best for short term. And we all know clinically, right? People come to see us they leave, they often will feel better. And

James Johnston RMT 37:33
it’s, there’s so many things that go into that more than just us putting our hands on them.

Eric Purves 37:38
Exactly more than just the technique. Right? So yeah, what I did like, though, in his paper, there was they did say, you know, when they’re talking about the limitations and talking near the end, right, they’re talking about, like, they say, you know, integration of sensory information, central nervous system processing, neuromuscular activity, and they start using a lot of appropriate receptors, the overall adjustment of the nervous system, they talked with all this, they started talking about all these other things that occur. So it’s funny, it’s just funny to me that they, they started paper being like myofascial release is supposed to do these things. And then when we go to talk about the outcomes, and the things that, that you see in people with, you know, when they’re looking at their measurements, like these are all the things that we see in proprioception, sensory challenges and this kind of thing, and you’re like, now they’re talking about neuro physiological stuff, which I feel like they should have been talking about it earlier, when they kind of were building the background.

James Johnston RMT 38:36
Or when the it’s funny when they’re building that that background part, the part you’ve commented on a couple times, it was like a long couple paragraphs where they were basically saying, This is what the papers say myofascial release does. And then they went through and I, honestly, I kind of glossed over a bunch of that, because I’m like, No, it doesn’t do that. But they were referencing what the papers say and then, and then get into what manual therapy actually does with this stuff. You’re just talking about the neurophysiological input and things like that. So it’s good that they came around to almost correct that part of it.

Eric Purves 39:10
Yeah, which made me feel feel happy with the two and and they did say yeah, like, it kind of has short term impacts, but sounds great. It’s gonna be better than much else that’s out there. But they did say, you know, at the end, too, which was just great. As I said, future randomized controlled trials should strictly limit interventions and reduce the use of combination interventions, which is what we’re saying earlier, like the a plus b, right? You do this and this, versus that. So just do like, a single one to see is this type of treatment. And you can you can you put that, can you quantify that Troodon? Or can you put it into like something like, this is something that we’re going to deliver, like this is how we’re going to do it, which I know isn’t very person centered, but if you wanted to see if a technique work, it has to be standardized. Yeah. Like do you have to like this is what we’re going to do for all these people that come in, at SCORE whatever it is on this Back Pain measure? Yeah, and that we’re gonna do this very specific protocol, and we’re gonna see what happens. Right? And you probably the results probably aren’t gonna be great, but at least you, you know, they’re not gonna, it’s not gonna be like, Whoa, amazing. We’ve, you know, found the cure. But it’s, it’ll, I think that’s what the better way of doing you say. So we can say, Look, this type of technique can help or the technique type per technique, man doesn’t is. That’s what we like to do. Go ahead and do it, which I think is what I got from this. If you’d like to do it, go ahead, do it. It’s not going to be the be all end all the works for you, of course, people who come to see you, then it is part of the overall treatment plan.

James Johnston RMT 40:37
Yeah. I mean, the other thing that I take from papers like this as well is it really reinforces to me why the clinical guidelines of MSK care or education reassurance movement and some manual therapy, right? Because we know that reassurance and education plays a huge role in the mental health and the functional aspect of things. And then, of course, so does integrating the movement into things because of things like kinesio phobia, and, you know, other issues that that people have. So it really reinforces to me why manual therapy is the thing at the bottom of the list, and why those other things are more important, because it shows that the technique alone doesn’t really do a whole lot, by comparison with pain and physical function and all these other things. It’s a piece of the overall

Eric Purves 41:25
puzzle. So yeah.

James Johnston RMT 41:29
So I think to kind of wrap it up, and to go back to what you were just commenting on is, if you really liked doing myofascial release techniques, and your patients like it, continue to do them. But the problem is that we just need to change the narrative around it, we need to stop telling people that we’re releasing fascia, we have to, you know, change those things and start talking about, you know, inputs to the nervous system and how things actually work. And then of course, start if you’re not already start into integrating more movement, education and reassurance as part of your treatment plan with your people.

Eric Purves 42:05
And people feel good to catch on when it feels nice, as we always say, TPN touch people nicely, that can such a subjective thing, right? That’s totally different for everybody. So it doesn’t mean you have to be super gentle, it doesn’t mean you have to be, you know, it doesn’t mean don’t touch them, it just means fine touch that feels good. Make them feel good. Give them movement, if they value moving to find them to do something that they that’s important to them as well, because yeah, that’s the a plus b right there. If they can do something else as well, or when they’re not in a treatment with you, that’s gonna be in most of the population, that’s going to be

James Johnston RMT 42:37
good for them. Yeah. And make that make that interaction with them meaningful to them. Right, make the make the treatment, make the movement, make the homecare all meaningful to that person, and you’re probably going to have better outcomes than just doing myofascial release

Eric Purves 42:52
alone. And I think what you said beautifully in our last podcast, was he talked about engage in treatment, rather than just give or provide human engagement. So I think I like that I think it plays really well with kind of wrapping up this discussions. Yeah, engage with people and have them, have them have a say in what they want to do like to do and facilitate that for them.

James Johnston RMT 43:13
Perfect, we’ll end it there. Alright, see you next time, everybody. We hope you enjoyed this podcast. These kinds of topics are what we are all about. If you’d like to learn more, go to our websites,

Eric Purves 43:26
themtdc.com or Ericpurvs.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.


  1. Wu Z, Wang Y, Ye X, Chen Z, Zhou R, Ye Z, Huang J, Zhu Y, Chen G, Xu X. Myofascial release for chronic low back pain: A systematic review and meta-analysis. Frontiers in medicine. 2021 Jul 28;8:697986.

Being Of Service, While Still Being Kind To Yourself

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

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

So, I thought I would share why. 

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

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


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

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

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

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

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

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

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

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


I know I’m not alone on this one. 

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

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

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

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

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

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

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

A Break-Up and Mental Health In General

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

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

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

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

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

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

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

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

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

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

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

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


Podcast Episode #26 The Biopsychosocial 40 Years Later


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

As somebody who just turned 47 years old, I can’t quite remember things that happened 40 years ago, but the biopsychosocial model of pain has been around for about 40 years now. And it’s very important for us to take a look at anything like this and understand what changes have taken place in 40 years. And how have we improved?

Eric Purves 0:57
And this is a this is actually a really kind of Hot Topic, really the the bio, psychosocial, social model and, you know, is it like, how do you apply it in practice, you know, and there’s a lot of arguments back and forth about like, you know, it’s on a predictable model, right? It’s not like a mathematical model. It’s, it’s a conceptual framework and the authors of this paper, this paper is called the biopsychosocial, social model of pain. 40 years on time for reappraisal, it’s in a relatively recent journal of pain. And, yeah, it’s good because I think it it challenges or brings into discussion, a lot of the points that you hear, especially those of us that spend time reading the debates on social media, and a lot of problems people see in the bio, psycho social. And I what I feel is that in, in my experience, my understanding is, the bio psycho social model is itself not much of a problem, because it just it seems, has been around right for over 40 years, in the pain world longer. I think it first was talked about 1947 or 1977, I think, by George angle, and then, you know, loeser or loeser, have you printed him and Waddell had it? You know, and, you know, fears after that. But the facility is still around, I think there’s there’s still a lot of value. But the biggest problem seems to be is how was it used in clinic? Or how was it researched? And then that’s what we’ll talk about today is in this, this research paper, or this discussion paper, they talk about how when people use the terms biopsychosocial oftentimes, the studies are just looking at one aspect of it. They’re not well defining other like, well define the psychosocial or what is social? Or what is conservative psychological. And, you know, in the bio, like when we’re looking at bio, what, like what’s included in that. So there seems to be lots of a gray area there. And I think that’s probably when people are critiquing the model. And I think they do have reason to critique it. It’s because more often of how the model is applied, rather than the muscle word to use the conceptual, conceptual framework of what the model is supposed to represent, which is this full person care.

Jamie Johnston 3:14
Yeah, and one of the things that really stood out, as I read through it is how much they touched on multidisciplinary care, where they had psychologists that are dealing with the psychological end of it and physios that are maybe handling the bio, and you know, and then the social factors that come into play, and the importance of communication between all parties, when they’re trying to help that person and, and interesting, I’m sure we’ll get into it when we’re looking at the the social aspects of the person returning to work, the importance of communication with the workplace, from the people who are delivering care so that it’s more of a, it’s more of a person centered approach, when you’re trying to help that person get back to their job or get back to those things that they enjoy doing.

Eric Purves 3:59
What I found funny with this, though, when you think about it, you know, you think about medicine, and you think about musculoskeletal care and MSK pain and, and whatnot. And you look at this, this model has been used for pain for 40 years, or it’s been talked about for 40 years. And the reasons that they say here was Waddell and Loeser. They observed that many of their patients with low back pain didn’t improve after corrective surgery. So the pain cannot be attributed to only biological influences. It’s funny though, cuz it makes you think what happened to all the years before that when people didn’t get better? You know, it’s funny how like, it took that long for people to actually start wondering if there’s something else going on. Yeah. And excited. Seems like, that’s like, seems to make sense, but it’s funny to think of how people must have thought about the body and pain.

Jamie Johnston 4:54
Yeah, and really interesting that those two, those two people that you mentioned was with Wadell and Loeser. You I would almost say that they were surgeons.

Because I wouldn’t have thought that that was coming from surgeon because we, I mean, we say it tongue in cheek a little bit and maybe make fun a little bit that we’re like, oh, you’ve, if you’re a scalpel, you just want to cut everything. Yeah, right. So great to see that they that it was surgeons who were looking at, hey, maybe we need to change the way that we’re doing things. And also really interesting that, you know, that happened 40 years ago. And maybe it’s just because you and I haven’t been therapists for 40 years, obviously. But we’ve only really seen it catch on and become more of more of a thing when we’re helping people in the last 10 years. Yeah, I would say model.

Eric Purves 5:43
Yeah, yeah. Oh, for sure. And even if I think you know, back to when I first started diving into the stuff and trying to understand it, and think I did my first CE course teaching in 2015. And I remember just kind of bringing these very basic ideas, because I was only still learning to two courses to try to be like, hey, there’s some interesting stuff that’s out there, maybe, you know, like, let’s, let’s talk about this. And then that was kind of the general idea of those early course stakes. Nobody, nobody knew about a psychosocial as then. Yeah. So it’s been around for 30 years. Yeah. And so nobody knew. And I was only had just been I’d heard of it before, but I didn’t really pay attention to it. Like, I didn’t really mean much to me. I was like, oh, yeah, okay, whatever. But it’s interesting to to, to see like those early days. And we know from our experiences, when we searched for spare teaching together in 2018, we started talking about things and bring up the biopsychosocial. And little bit of myth busting in there and some of the science of pain stuff, and how that stuff was completely new. To like, 99% of the people, whereas now, obviously, the last three or four years or two or three years, particularly. It’s everyone’s, yeah, it’s a common term. And people can have a general idea of Oh, biopsychosocial, yep. That’s like treating the whole person like person centered care. You know, what that exactly means? How do you do that in practice is still that’s the difficult thing. But that’s what we call our practice. Not a perfect. Right is to that’s the hard part, but at least people become more aware of it. But yeah, it’s taken 40 years. Yeah. It isn’t our profession where we are in our part of the world. Yeah.

Jamie Johnston 7:21
But then you look at, like the Louis Giffords that we’re doing this ages ago. Right. So like you said, it might be that it’s our profession or part of the world. Because I think Louie was a UK guy. He was yeah, nice, 80s and 90s. So maybe that was more prevalent there than then it was here. We don’t know.

Eric Purves 7:42
And this without going on too much of a tangent, which we might want to and we’ll see what happens here is the is when we look at the stakeholders involved in our profession, at least here in BC, right, we got the association, we’ve got the college, the cmtbc. And we’ve got all the all the schools that and there’s now 10 of them, maybe I think it was probably about 2014 2015 around there. If you tried to teach a Con Ed course, that said, and I said had bio psychosocial and you would not they would not approve it is out of scope. With the argument being that they hadn’t really the idea was they had no idea. They had no idea what it meant. Our own regulatory body had no idea what it meant. And even you know, our association in the schools and stuff still don’t adequately teach that stuff like the association. You know, they have conferences, and they put out content out there, but I don’t ever see anything on there being I think what biopsychosocial Yep. And you know, the it but it however, in Ontario, they put out some really good stuff. You had some great stuff there too. And so if we want to compare ourselves right to to another province has been around for a very long time and Ontario regulated province, is what I meant to say if I didn’t say that, there’s no province has been around for a very long time. So I’m tired back from the gym, my brain still foggy. The they had a conference in 2019, which I was fortunate enough to be at. That was I think it was called like bio psychosocial care or something for RMTS or something. So they actually had a conference those three years ago now. And they’ve had other things subsequently, which have been been kind of trying to bring us this idea to to the professional to the members. So we don’t have that here. And I really wish you know, this is a call to action thing. I wish the schools known I know some schools are great. I’ve talked to some the the people that are clinic directors and stuff of schools here and they are trying to do it but it’s just not widely accepted and just not widely accepted or maybe understood. And so I would suggest anybody that’s curious about what biopsychosocial means this is this is actually a pretty good paper to start at.

Jamie Johnston 10:04
Yeah, yeah. Well, and it’s it’s very cool that there was a lot of things in here as I read through that resonated with me because of my, because of my background. And also, because I’m somebody who works at a job in industry where people get hurt. So a lot of this really stood out to me. And it’s funny, one of the guys at work, told me he’s like, why don’t you go to the chief and see if you can come in once a week? And just do what you do with guys here who who need the help, but I think there would be a big conflict of interest. If I did that. If I, you know, if I was working on guys, and WCB was like, well, you’re one of his co workers, you can I think there would be too much of a conflict of interest for me to do that. But it would be very, yeah. Yeah.

Eric Purves 10:48
And that would be really cool, actually. Because that way, you would have the social and the bio, and the psycho all together in the workplace, in with their colleagues and their, their social network. And then yeah, you became the new exercising, which would be bio and Psycho and social would be the whole thing, right, are getting moving. And we’re going to be doing any hands on stuff. I mean, that’d be brilliant idea.

Jamie Johnston 11:12
I think so. And I’d love to just take a portable table and and be able to set up the table in the gym and be able to go through rehab with guys and do some treatment. And like I mean, guys are coming to me all the time anyway. And being like, Hey, this is sore. What should I do? So yeah, it’d be cool to just have like, you know, a day of clinic hours at the fire hall. So that somebody who needs it could come in and, and get what they need. But, but I think the problem is once WCB or something like that was involved, they’d be looking and going, No, you can’t have one of his co workers doing the work, because we’re not going to get an honest feedback about what’s going on with him. I think I think there would be too much of a conflict of interest score. Yeah. Yeah, that would be really cool. Yeah, very cool. Yeah. So just quickly skimming through, of course, we talk about psychological treatments, when we’re talking about the bio psychosocial and quite often, quite often, we’re looking at things like mood disturbance, and high levels of unhelpful thoughts like catastrophization, you know, the person kind of thinking that they’re broken, and lowered self efficacy. So when they talked about it throughout the paper, that’s a lot of the things that they talked about. And that was, were they, in my understanding it anyways, as I read through the paper, that those things were better handled by, say, a psychologist or a mental health expert, to be able to help them through that as part of that multidisciplinary care that we talked about a little bit at the beginning.

Eric Purves 12:36
Yeah, this paper, what I thought was really interesting was they broke down, like they broke it down into that, like a psycho bio social, and looked at the research. Because I think it’s just really important, you know, that the common term, you know, if you’re a hammer, you see nails, right. And if you’re a psychologist, and you’re treating people with that are hurting, of course, you’re going to be viewing them through a psychological lens, of course, your interventions are going to be more on the psychological end of things, right? Just like when we, as massage therapists, were treating people we’re going to we should be aware of the psychological and social stuff. But really, I mean, we’re working primarily on bio things. We’ve meant in touch and exercise, you know, a little bit of education, but most of our more focuses in the bio like so. It’s I liked that they they broke it down into this and talked about, like, what was included in psychological research, and what was included in bio was good in the social stuff. But what I thought was really interesting, though, was like the little quote here says that, you know, there is positive effects is positive outcome seen with the psychological interventions to focus on the things you said thought processes, beliefs, behaviors, this type of thing that says that the size of these effects have generally been found to be a small or moderate, and systematic reviews of randomized controlled trials with chronic pain samples. So with this, I mean, go shows is that, and I think if you look at all the research, they’ve probably I think they quote this all and throughout this paper, is that it doesn’t really seem to matter what you do. When you look at the literature, the outcomes are all relatively small to moderate at best. Yeah. So what that can sound to some people defeat us, to me that sounds Oh, that’s actually sounds pretty good. Because if you’re doing something done, or you’re doing something, you’re seeking care and someone is providing care to you, chances are you’re probably going to feel better than not. So doing something is like this is good. And that lets us know that there’s not like a right or wrong but they do say in here, though, is it’s not necessarily providing a specific treatment. It’s finding the treatment that works for that person. Right. So it’s not like you need this. It’s like what’s going to work for this person, this presentation here today. I like that rather than you step was the person need rather than what are we going to do to the person?

Jamie Johnston 15:04
Yeah. Interesting as we go through like, there’s a couple things that stand out to me is when they’re talking about the psycho psychological treatments, they mentioned how there hasn’t been a lot of research about involving the the person’s family, but one place that they did look at. And I would like to know if this was any of Melanie wells research with stuff that she does with kids. But it showed that the more that the parents are involved in, in helping the kids, it can actually have a positive effect on the parent and the parent experience. So when you’re when you’re teaching, how do they say they’re teaching kids and adolescents, about different strategies that they could use, whether it’s communication or how they handle things at school, and the more that the parents involved, it can actually have a positive effect on the pain experience that a parent feels? Yeah, unreal. Is that great stuff.

Eric Purves 15:58
And there’s nothing that I thought was really interesting wasn’t like, you’re talking about how, yeah, when the way kids are treated with that, with chronic pain is very different from adults are treated with chronic pain. Because in adults, it’s like the individual is being but is being treated, whereas kids, they involve the whole kind of their social narrative family, which is, I mean, just makes it makes sense. But it’s just funny how you’re like, Oh, you’re no longer a child, you’re now an adult. So therefore, we’re just screw up family. Like, we’re all gonna involve you. Right? That’s not necessarily included. But I guess it does make sense though, because the kids need to be cared for. And so the parents have to be involved in care as an adult, you’re independent, least in our most of our cultures out so we distance ourselves from our family a little bit. Yep.

Jamie Johnston 16:45
Yeah, or different circumstances. I mean, you look at me 47, single, no family in town. So the experience that I would go through if I was experiencing pain is a lot different than, say, somebody who has a family at home that they come home to, right. And if the kids were dealing with something, then the parents dealing with that is going to have more of that connection, feeling between the family and probably better care and all those things, especially if, say, the doctor or the physiotherapist is in really good, or having good communication with the family, about me, and education and all those things, then it’s it’s a more cooperative experience. Yeah, yeah. Oh, yeah.

Eric Purves 17:25
Which would be more biopsychosocial that would actually be a better application of the model, right, involving everything. Yeah.

Jamie Johnston 17:34
So they, I mean, they went into, and they talked about a lot of the biological stuff, and separating that into different categories, about how people are experiencing pain, and you know, whether it’s peripheral or central mechanisms, inflammatory pain, chronic pain, and all those kinds of things. And then talked about the treatments that they can use for those things. And what I found very interesting is that when they started talking about exercise, because exercise, obviously, I’m a big fan of that. But when they talked about the exercise, they were they were talking about usually exercises is driven towards building muscle or loading the joints and doing these other things. Whereas they found or my understanding is they found if you geared the exercise more towards just what they were doing at work, or or their chosen activity, and getting them back to doing that thing, then they had more success.

Eric Purves 18:30
Which makes sense, because it’s that your your task or your goal, your functional desire, whatever it is, it’s tailored towards that specifically. Yeah. Makes sense. Yeah. Well, I thought it was interesting that they it says exercises, you know, it’s considered they consider that bio, but I think it’s almost, I mean, obviously, there’s bio going on there, but I would say, Well, yeah, like, it can’t just be bio because you’re not, you know, there’s going to be psychological and probably social unless you’re like in your garage by yourself. Okay. There’s, there’s not like a social influence ever. There’s a psychological influence, like exercises, if something of value something you enjoy doing that it’s not just gonna be bio, so I think that was fine when they said it’s exercise is considered a bio intervention. We’re like, well, it’s I think it probably includes the whole bio psychosocial.

Jamie Johnston 19:23
Yeah, yeah. And I think that’s, I’m trying to remember who the presenter was in San Diego this year when he, he stood up and he said, Okay, who wants to go home and do some homework tonight? And then he’s like, Yeah, neither do your patients. So stop giving them homework, stop giving them exercises to do.I forgot what that yeah, that was great. Great, which was brilliant. Because they and I think that’s whereand, you know, I was on a podcast a little while ago with some some of our friends down in the US and when I was talking about therapeutic exercise, and they’re saying it’s not in our scope. I’m like, well, movement is so I think we have to Start also approaching this and being like, well, let’s stop talking, let’s stop calling an exercise. Let’s just call it movement. And let’s just talk about what meaningful movement is for this person. And how do we get them back to that meaningful movement. And that meaningful movement might be a specific task that they do at their job that they can’t do right now. So how do we, how do we change that task? Or how do we make it so they can do that task? So it becomes more meaningful, and they feel more fulfilled? At their job, or whatever the recreation thing? Is that, that they’re trying to get back to doing

Eric Purves 20:32
that’s a weird thing. Hey, still movement is allowed. But exercise, isn’t? We?

Jamie Johnston 20:38
Yeah, well, it’s funny. How do they define exercise? Well, so my understanding of it, because when I was on the podcasters, two folks from the US, and I said, but you guys can do active range of motion and passive range of motion and a treatment under like, Yeah, that’s fine. Like, so why can’t you do movement? They’re like, it’s that we can’t prescribe exercise for them to do at home. I’m like, But what about if your prescription was gonna work in the garden for half an hour? They’re like, yeah, we can do that. I’m like, so just prescribe movement. And, yeah, that’s, what about if it’s get on the ground and play with your kids? Yeah. What if it’s, you know, so let’s, let’s change, let’s change the opinion around those things. And I think a lot of times, we’re also really, really scared that we’re going outside our scope. And we might get disciplined for going outside of our scope. You know, and then as soon as it’s got the word, in this case, as soon as it has the word exercise attached to it, they people automatically say, Oh, well, that’s out of scope. But if we say it’s movement, there’s no reason that can’t be in your scope.

Eric Purves 21:46
Yeah, just move lots. That’s your that’s your prescription. And that’s exercise.

Jamie Johnston 21:51
Yeah, there’s no reason you want to do you know, somebody comes in and they’ve got a shoulder issue, there’s no reason you can’t grab their arm and passively move their shoulder and get it into different ranges, or do some adaptive movements with them, you’re not prescribing an exercise for them to take home, you’re not prescribing something, you’re, you’re just helping them get back to doing the movements that they enjoy or that are meaningful to them. So and to me, it makes more of a psychosocial. Not psychosocial sense. But it makes more sense to me to, to talk about rather than us giving a treatment or delivering a treatment. We’re engaging in treatment with our people. Yeah. Because we’re, we’re engaging and educating and conversing and finding out what’s important to people, rather than us just saying, okay, get on the table, and I’m going to do this to you.

Eric Purves 22:40
Yeah, yeah, sure. Yeah, I 100% agree, that’s such a great point to make, right? You’re engaging with with the treatments, you’re not just doing it, you’re not doing something to them. Now, some of them is great. Like, I mean, I mean, sometimes when I go, if I go for a massage, I often want something done to me, because I don’t necessarily have something wrong that is bugging me. It’s just like, I want to feel good. That’s different. Right? There’s the field, I think, is a seven point distinction to make is that, yeah, you can go and get the table and just someone just like spoil yourself. That’s fantastic. But if it’s like, if it’s something that you’re suffering with, it’s bugging you for a long time. And, you know, that passive approach isn’t working. Yeah, try and engage a bit more with with your clientele.

Jamie Johnston 23:18
Yeah. Like, well, like we’ve talked about so many times before, too, you know, we were fortunate here, because we have so many people that have unlimited benefits that, that maybe they come in once a week, but that’s just an hour break from life that they get, which is good. And there’s no reason you can’t just do a passive relaxation massage. Maybe I shouldn’t say that a relaxation, massages password, because you’re still having an influence. But you know, in those cases, there’s no reason but somebody comes in and they’re like, I’m having a hard time moving my shoulder, or moving my hip or my knee or whatever, then, you know, we want to, we want to engage more with them and figure out how we can get them back to doing the moving that shoulder or so that they can do the things important to them. Yeah, yeah.

Eric Purves 24:00
I agree. I love that term, engaging in treatment, rather than just doing something, doing a tree gauging your dramatic that’s, that’s a very important distinction to make. So hopefully, I’ll catch on. I hope you should do like a social media campaign hashtag engaging in treatment or something.

Jamie Johnston 24:15
Yeah, yeah. Well, I’m working on some stuff now, but doing some thought reversals and things about that to cool. Medicine, but but we’ll see. We’ll see if anybody wants to listen to me now.

Eric Purves 24:28
Yeah, well, some people listen, some people listen this podcast so enough to keep it keep us keep doing them. So there we go.

Yeah. What it was, it’s just kind of keep talking about this, the biotherapy about it and just kind of expanding on the bio to like expand into the bio psychosocial. And this is a there’s gonna be a bias statement here, but it’s okay. It’s our podcast. I just I just think it’s really important for us to emphasize that. Even though we are engaged, we are educated in a bio dominant biomedical We’ll thing and we are hands on therapy is mostly, mostly by Oh, there is always going to be psychosocial stuff, right? With moving exercise coming for treatment, there’s an interaction between two people that’s social, right and psychological. So it’s just that we are, regardless of what you think of the biopsychosocial. Every aspect of a human is being engaged with during a during a treatment. And this was the thing is, though I find interesting is I find it very difficult to understand how any other MSK profession other than massage therapists and physical therapists are able to actually provide a full BPS experience in their treatment. Like if you’re coming in and say it’s chiropractic, and it’s like five minutes and just getting adjusted and gone. Is that biopsychosocial? Like, can you actually apply all the kind of aspects of this? I don’t know, I would say that I think what we have as physios is we have time. Some points are short, but I would say on average, they’re, you know, 30 to 45 minutes long. Least we are.

Jamie Johnston 26:09
And I think that, in fairness, some chiropractic appointments are as well, depending on the look.

Eric Purves 26:16
Yeah, yeah, I am not saying all I’m just saying, like, if you look in general, the two professions that are set up to be able to really do this properly with the problem if we have proper education or proper understanding, I think we we should, you know, chiropractors only are listening to this podcast anyway. But massage therapists, you know, I think we really are set up to do this, because we have so much time with people, we can listen and validate. And we can educate, and we can rule out red flags. And we can reassure when, if it’s, you know, there’s nothing nasty going on, and we can revive touch, soothing, safe, comfortable environment, and educate and engage with people to do the things that are important to them. And that’s something you can’t do in 10 minutes. 15 minutes. No, I and some people I mean, I’m sure somebody’s gonna bother, you can you’re full of shit. Okay, maybe. But I would say that’s, I’m not convinced. No, no, anytime you do this. And so when you’re looking at just quick, quick, quick appointments, boom, boom, boom, those are bio nature, bio focused, you’re missing the bigger part of treating the person.

Jamie Johnston 26:40
And interesting, if you look at the psychosocial aspect of things, I don’t know, of any, or if there are any psychologists or counselors that offer a 15 minute treatment. They’re all 45 minutes or an hour. Exactly. Because they want to have a long discussion with people they want to, they want to have that chat, and they want to figure out what’s going on with them. So, you know, when we look at the other aspects, there’s very few that are that short of a treatment. Unless it’s maybe a quick check in about something. Right?

Eric Purves 27:57
Even medical doctors right like USC Medical Doctor for something like they they’re gonna rule then a like, Oh, you have psychosocial that might be that stuff happens. But they’re looking at the bio, they’re looking, what’s the disease? What’s the pathology? What can I rule out here? Right? So it’s when you read this stuff, and we can go and talk about, you know, the, you know, how this is often applied in these kind of interdisciplinary or multidisciplinary pain clinics. You know, those little requirements, we will have a long time, these are something you can’t just like, have, I don’t think you can have like a high volume, bio, psychosocial practice, and do really good work with engaging in small amount of time, a small amount of time, I think it’d be really hard. Yeah,

Jamie Johnston 28:40
I agree. So this, this is where I think we could get into it now is when we’re talking about, they’re talking about the social aspects. And they they talked a lot about the workplace, and people who are on a return to work program. And this is where it kind of hit home to me because of my past, being a first aid attendant in a, in a sawmill, and watching, you know, treating dealing with people who got injured, and then watching them deal with compensation and coming back to work. And they really focused on this about the importance of communication with the workplace, and how important that is for, you know, the person who’s trying to get back to their job, where the physiotherapist or the therapist who’s helping them should be in contact with the workplace, but then also in the workplace, that the supervisor should be trained in how to speak appropriately to the person who’s injured. And to me that just like that would be phenomenal compared to what I’ve seen in the past, because, from what I’ve seen in the past, companies would always be like, Oh, safety is our number one priority, until it cost $1 To change the safety program, and granted, you know, this is back in like 2006 Next one, I was doing this. So hopefully things have changed a lot since then. But the I just think it’s amazing that they looked at it and said, if you’re in communication with the workplace more, then you’ll have better outcomes for the person who’s trying to get back to work. Right? just phenomenal. And that’s where, like we talked a little bit before we came online. That’s where our friend Corey Blickenstaff who is a physio who works in a workplace, and helps people who are injured, like how, how that, like the outcomes that he must have, compared to somebody who was maybe off site. And I don’t know if there’s ever been a study done on it, but it must be amazing. And give the workers confidence that they’ve got somebody there, who’s there to help, should they get injured? So the social aspects of that must be phenomenal.

Eric Purves 30:50
Yeah, it makes sense to me, it just, I mean, okay. Sometimes things that make sense logically, aren’t always true. But, you know, using making an informed opinion, based on this, some this body of research, you know, if you had if, if a large enough workplace could afford it, and I’m places probably could write, you know, a large enough workplace could afford to have a physiotherapy physiotherapist, for example, on on staff or on a contract to come by? I mean, that would that would be such a benefit. And I bet you, I would be, I would love to see if that increased productivity, if that decreased, miss. Locks, work, you know, less work safe for workplace injuries, you know, I think that would be such a great thing. And there’s probably studies out there and for anybody has them, please send them our way. I just thought it would be that would be such a brilliant thing. And maybe some parts of the world they do it in. But if that’s I’ve never heard of that here in Canada. No. Having like an on site, or something that comes by once a week or whatever, or every two weeks to to treat staff.

Jamie Johnston 32:02
I’m actually starting to hear a bit more because I have a friend who is an athletic therapist. And I can’t remember the name of the company. But she had me come in to do some first aid stuff with the company. And she’s there as like, a director of like exercise and things. So they have an exercise room there for the employees where she can take them in. She has somebody who’s a massage therapist that comes in once a week. And she she organizes all of this for for everybody who works for that company. So it must be catching on a little bit. That to the point that she’s got a full time job doing this. Yeah. That’s brilliant. Yeah, great. Yeah. It’s very cool.

Eric Purves 32:37
Shouldn’t you think it’s such a hard worker, particularly in the the environment we’re in right now where it’s impossible to find workers like, like everyone, everyone’s hiring and you know, what a great perk it would be to if you’re like, hey, it comes with our workplace. We got you a massage and physiotherapy come in. It’s all included as part of your years. Part of working in package. Yeah, that’d be brilliant.

Jamie Johnston 32:59
Yeah, I’m sure it would be a draw. Yeah, huge. Bigger companies like Google in that have, like full time massage therapists to work there. And yeah, and things like that. So but I mean, that’s a multibillion dollar company. So you know, compared to smaller companies, that’s a lot tougher. But one of the things that I that I think is important to touch on that I would love to see is they didn’t, they didn’t talk in here about educating the workplace, about educating all of the other employees who aren’t injured.And I don’t mean that like when somebody’s injured, the rest of the people have to be educated about that person’s injury, it’s educating them about why Return to Work Program is important. Because like, for instance, when I worked at the mill, it was always if somebody was off injured, they’d come back to a place that’s, you know, full of bravado that guys are going, you’re just a wimp, you’re just trying to get a claim, or you’re an idiot, there’s no reason you weren’t hurt. And so when you look at that social aspect of it, that can be really detrimental for the person who’s trying to get back to work. So if they would be really interesting to see if there was a really good education program they could do in those places to be like, Hey, we know that we’re going to have better outcomes if this person isn’t made fun of if, you know, your opinions are kept to yourself, and we’re able to work through whatever the person’s injury is, and we’re here to support you as well. So that if you get hurt, we can take the same approach with you. And, you know, research has shown us we have better outcomes, and this is going to be better for your home life. It’s going to be better for when you have to pay the mortgage, and all those other things and explain to them, you know, the benefits of that? Because I think that would make a drastic improvement on those return to work programs withwith people coming in.

Eric Purves 34:51
I think that sounds like a brilliant idea. You just said. Education regardless, it seems like doesn’t matter what The topic is, you know, education often seems to be the answer. Yeah, you know, the more you understand what’s going on, the more accepting we are the better decisions we make about things, generally, right? These things all play a role. So, you know, why would that be any different in the workplace? I think it would just be a brilliant thing for it to educate the workers as well. What’s going on? And why it’s important? Yeah.

Jamie Johnston 35:24
Yeah, it would be cool. Maybe I shouldn’t approach the firewall a little bit and be like, hey, once a month, I could do like a safety education thing or something?

Eric Purves 35:31
You really should, I think you should see it just I think it’d be probably more rewarding as well as probably see, I would, I would be surprised if you didn’t see. Cause of benefits from that with your coworkers. Yeah, yeah.

Jamie Johnston 35:44
Cuz and it’s great, because we have a, like a light duty program, because we do our own dispatch. So if somebody is injured, we have it set up that they can actually just go and do dispatch, so they get to sit in the in the room, and they’re answering the phones and doing all that stuff. So they’re not out, you know, having to find a structure fire, but they still get an hour or two a day to go in the gym and do some movement. And you know, try to be healthy. So it’s, it’s a pretty good program. But there’s definitely improvements we can make.

Eric Purves 36:10
What it mean for meeting this paper here, too, it’s definitely in the workplace, engaging workplace is under utilize, you know, the one of the quotes here says, engaging with the workplace as part of the treatment seems to be rarely attempted. And I don’t have the paper in front of some notes I made. And I think it said where it was, like maybe only three papers that actually involved, you know, family or social networks in kind of Pain Rehab. So it’s almost it’s rarely done.

Jamie Johnston 36:42
Yeah, I’m just scrolling through to see if I can find it. But yeah, that’s basically what’s sad is that it’s rarely done in that way. So yeah, and I think the maybe the difficulty as well is that, you know, if we’re trying to help somebody who’s injured, the workplace isn’t necessarily going to want to talk to us. Right. So it might be a big hurdle for us to overcome, if we’re trying to engage in that way, whereas they probably be more likely to listen to a physio if they if they recall it, but hopefully, hopefully, if it’s a multidisciplinary approach, and we’re working with a physio about and with somebody, then we can have some input on that as well. But it would be, it would be great. If you know, even if you could, if you could have the person go back to work and say, hey, if your employer wants to talk to me, I’m happy to have a chat with them about, you know, what we can do to help you out, then that might be an approach where the employee is making the approach rather than us approaching the employer?

Eric Purves 37:43
Yeah, yeah. Yeah. The I think one of the barriers you do you have, though, at least in our profession here in BC, and probably throughout Canada, as well, is that nobody wants to work with the, like, WorkSafe or, like, workers compensation. Yeah. Because it’s a pain in the butt lot of paperwork for like, no pay. So even though, it’s probably would be really good to have more of this return to work, thing involved in our profession, and these opportunities to be able to go into people’s work, you know, finances are gonna are gonna win, right? Like, I could treat somebody my clinic and make this much money, you know, or I could go over here and leave my office and treat people that are returning to work and make like, totally, like, no money, almost. Right? What am I gonna do, people are gonna look after their families or unpaid bills and mortgages, food, you know, the gas, they’re going to say, in the clinic, so the idea would be not lovely to do this. But it’d be I would be so I would think that in a lot of these cases, the the money’s out there for it. Yeah.

Jamie Johnston 38:50
Absolutely. And but I mean, again, hopefully, that’s changing as well, because 10 years ago, there was absolutely no money. Yeah, to be able to do it, and now there’s a bit so hopefully, that will continue to go up and we can have more of a roll.

Eric Purves 39:05
Yeah, for sure. No, yeah, I think it definitely be beneficial. Yeah. to kind of wrap up the the the rest of this paper, they talked about the interdisciplinary bio psychosocial treatments for chronic pain, and camper did a review. And so despite their concerns about definitions of bio psychosocial interventions, camper et al found that a coordinated intervention covering several domains of the biopsychosocial model and delivered by clinicians from different backgrounds is more likely to benefit patients with chronic low back pain in the long term than his usual care or physical treatment alone. Which I thought was good because it talks about like the interdisciplinary right so involving multiple different disciplines the problem that you’re going to find me obviously in a in a like this was in a like a pain, kind of rehab or pain. in clinic, everybody’s going to all the treating clinicians are going to be working from the similar model and understanding about pain and they’re gonna stay in their lanes of what their areas of expertise and education are. What we see all the time in practice, I’ve seen other papers on this I don’t have I don’t have a reference here, unfortunately, is that there is an association between seeing too many different people. Oh, yeah, and poor longer term outcomes. But what what I understood from this and other parts of this, this paper is that you see multiple people as long as you’re working together under the same framework, to provide the best care for that person that they need. So that’s an important distinction to make. So I know oftentimes, in the courses I teach, I’m like, get the more people someone sees the less the worst, their outcomes tend to be, right clinically, as well as there’s data to support that. But doesn’t that that’s if you’re getting, I think, if you’re getting different stories different, you know, you see your physio, your car, your massage, your osteopath, your acupuncturist, your medical doctor, specialist, they’re all telling you something different. They’re all doing something different to you, and there’s no coordinated care. And that’s when you get these problems. But it seems, seems this one, if you have a singular model of care, everyone’s kind of falling as bio bio psychosocial. And they’re working together, outcomes tend to be better than doing nothing more than what they call the usual care, which is usually medications or rest.

Jamie Johnston 41:26
Yeah, and I think the, you know, I’ve seen that so many times in my career where, you know, somebody’s coming to see me on a Tuesday, they’re going to their chiropractor, Wednesday, they’re going to Doctor Thursday, they’re going to physio Friday, and they’re just appointment hopping. And the added stress that that gives them of having to go and see all these other practitioners to satisfy what the insurance company wants them to do. Is that added stress that’s taking away from a better outcome. So like you said, if it was all under one roof, and you know, it was a conjoined group of people that are trying to provide that care in a reasonable amount of time and things like that, then you’re likely to have better outcomes. But the, the current way that it’s done, or that I’ve seen is when you’re constantly hopping from practitioner practitioner appointments all week. It’s just stressing people out.

Eric Purves 42:13
Yeah. And I’ve never gonna be careful saying never and always, I very rarely have seen that benefit people by seeing multiple practitioners over time forever, years and years and years. Because we’re all just looking for that fix, right? Everything’s like, oh, my gosh, scar tissue here or this isn’t here. No, this is weak, this is tight. This is short, this is inhibited. This is out, you know, they’re constantly just being put back together is that kind of general understanding they have their body and that that rarely works. And and each practitioner is trying to make a living and rebooking people. Yeah. Money, Money Talks, right, that the financial aspect of it is is as powerful. And that’s, you know, that’s a different conversation, I guess. But that’s comes down to the ethics of it, right? We have to pay our bills. But you know, ethically, if we know better, should we still be doing that? Probably not.

Jamie Johnston 43:06
Yeah, I know. I’ve fallen on the sword a few times and told people, you’re going to hold these appointments. Don’t come and see me next week, take the day off. Yeah, take a rest. I mean, somebody else will look at it. It’s not that big of a deal. Just go take a rest. And but it always comes back to that same thing. And really what this entire paper is about is patient centered care.

Eric Purves 43:24
Yeah, yeah. Based on its care, and providing team based care seems to be the thing too, right, that involves all of the domains. And it’s what I understand is it seems very difficult for one specific professional to treat all domains because we’re not educating them. We’re not We’re not bio psychosocial therapists. It’s not like its own brand is. It would be attendance. Yeah. Well, it’s, it would be a 10 year course.

Jamie Johnston 43:50
Yeah. Oh, manual therapy, and psychotherapy and social therapy, you’d be. So not it’s not a terrible thing. But you’d be in school for a long time to be able to do all that.

Eric Purves 44:00
So yeah, I think what we should get from this is that, you know, we have to start thinking about psychosocial, thinking, there’s a lot of influences on people. We never want to just say it’s just the bio, we don’t wanna swing too far. We don’t say it’s just a psychosocial we want to kind of, you know, play in that middle. There’s a pendulum swinging too far and be aware of, you know, is this more of a bio driver? Oh, yeah, you’ve got it. Like there’s tissue injury, there’s inflammation, there’s brake, there’s whatever, there’s something you know, or is this more like, is there more psychosocial things going on that are amplifying kind of some of that nociceptive sensory stuff that’s going on? Right. These things all work together. And it’s, you know, part of the problem we see in the research as well as what we see in these online discussions is, it’s like one swing to the right of one swing to the left, it goes back and forth. Right. And, you know, the quote that the authors use here, which I thought was great, it said when they’re talking about bio psychosocial interventions, it says, working closely together with regular team meetings, face to face or online agreement on diagnosis. therapeutic aims and plans for treatment and review is important to know the emphasis on the need for the treatment team to reach agreement on diagnosis goals and treatment plans, hopefully, before the plan is implemented. And this is just basically saying like, this is what you should be doing and ultimately, multidisciplinary treatment environment. But that in reality, at least for our profession, I, we’ve lived our lives before, that’s very difficult. When you’re one on one with person in a room for 45, 60 minutes, and you’re busy and everyone else is busy. It’s very, very difficult to coordinate care appropriately, at least the way things are set up here. But ideally, in a proper pain clinic. This is how things should be done. And I think some places they’re the only I got I can’t speak from my own knowledge, but I would hope that some places they do things that way.

Jamie Johnston 45:50
Yep. Yeah, hopefully, it’s, hopefully that’s coming. But we know how long it takes to implement research. So as long as as long as as long as we’re working towards providing better care whether it’s individually or as a team. And as long as we’re going after patient centered care, then hopefully that means we’re doing whatever’s best for the person in front of us.All right, everybody. We’ll we’ll see you next time on the podcast.

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Nicholas, Michael K.. The biopsychosocial model of pain 40 years on: time for a reappraisal?. PAIN: April 19, 2022 – Volume – Issue – 10.1097/j.pain.0000000000002654
doi: 10.1097/j.pain.0000000000002654