5 Ways to Prevent Professional Burnout

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A reader who works with a chronic pain, military population recently asked if I had any tips to prevent burnout. Here are some of mine and also some I gathered from Social Media.

 

1) Take Different Con Ed Courses

  • Most of us gravitate toward con-ed courses we are familiar with, have a certain reputation, etc
  • A good way to prevent burnout is to expose yourself to a good seminar on a topic that is novel and challenging
  • To most I would recommend Explain Pain or Therapeutic Neuroscience Education
  • Getting new ways to interact with patients, especially a chronic pain caseload that does not respond rapidly helps
    • Changing your mindset as to how you view these patients prevents the “I feel powerless to help”

 

2) Hangout and interact with like minded professionals

  • join a group like PT: Practice, Education, and Networking on facebook started by my buddy Rick Daigle of Medical Minds in Motion
  • participate in a forum like Manual Therapists, ask questions and chime in on other people’s posts
  • try to start a local Clinician’s group where you can practice techniques, assessments and discuss cases semi regularly
  • avoid arguing on the internet or with colleagues who are stuck in a model that disagrees with your practice (to a point)

 

3) Consider taking part time cases in a different setting

  • if you’re in outpatient, try home care
  • even 2 different cases in a different setting once a week really helps prevent burnout
  • prior to all my different endeavors, I worked full time in a private clinic (as a manager), did Clinical Peer Review, and taught at 3 different PT schools, needless to say, I did not get bored!

 

4) Don’t take your work home with you

  • obsessing over a case you think you could have done better often prevents you from relaxing at home
  • if you need help, ask online in a facebook group, twitter, or a forum, but otherwise enjoy your time away from work
  • just like I tell my chronic pain patients, make sure you take time to listen to your favorite music, have a glass of wine, or watch your favorite movie

5) Strive to change and adapt regularly

  • part of stagnation or burnout is a lack of change, we all need variability
  • if you have not changed the way you assess, treat, or the framework at which you make your clinical decisions at least every 2-3 years, it is time for you to rethink things!
  • finding a mentor, whether it’s online or in person really helps with this as you watch them in their patient interactions

Articles of the Week – February 14, 2021

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We’ve got some big news this week! We’ve launched a podcast! Together with Eric Purves we’ll endeavour to put out a new podcast every two weeks. Give this one a listen as we look into some research that shows how client, community, and clinician can influence a persons pain. Subscribe on one of your favourite podcast platforms!

Client, Community, and Clinician – Jamie Johnston & Eric Purves

 

There’s lots of talk about education in this week’s articles. This one specifically shows us the importance of the conversations researchers or doctors have with patients when discussing nocebo effects.

“Important Conversations” Are Needed to Explain the Nocebo Effect – Anita Slomski

 

We are all taught to not chase pain and to avoid making assumptions purely based on palpation and tenderness. However, we have some emerging evidence that physical tenderness might be a more valid predictor for making return-to-activity decisions that we once though, once we learn how to quantify it.

Tenderness to palpation predicts return to sport following acute hamstring strain – Physio Network

 

Have you ever recommended that clients cease running in order to conserve the cartilage in their knees? Or are you on the other side, suggesting that it’s beneficial? Research is still working on a definite answer, but hopefully the current evidence can help you with an informed decision.

Why Don’t Runners’ Knees Fail More Often? – Alex Hutchinson

 

We understand there can be psychosocial factors associated with pain, however we have to be careful how we discuss this with our patients. While the title of this post lends itself to the idea that a doctor told someone their pain is all in their head, there’s much more to the pain education that is necessary and what was given.

My Doctor Told Me My Pain Was All in My Head. It Ended Up Saving Me. – Isobel Whitcomb

 

Mike Reinold provides us a good review of the literature regarding compression therapy and its effects on acute soreness and recovery following exercise.

Compression Therapy for Recovery – Mike Reinold

Rules and Recipes: Moving On From Older Models Of Manual Therapy

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As I sat at the head of my treatment table this morning, looking down at my patient, I viewed their right leg in external rotation while at rest, I flashed back to my training. This patient is seeing me for sciatica-like symptoms on the right side.

My training taught that pelvic asymmetries might manifest as one leg presenting as internally rotated and the other side as externally rotated. I learned diagnostic measures in standing and supine to check for those pelvic asymmetries and treat them accordingly, both at the pelvis (wedges, pelvic balancing techniques, etc.) and the legs themselves. Often, when I applied the work based on the theories presented, my patient’s symptoms improved. Many times, their pelvic torsions and leg rotations also seemed to balance out. These changes, both in reported pain and noted postural changes, worked to validate the theories taught to me.

But today, I had a thought.

While my deconstruction of much of what I was taught in my MFR (and other) training is well known, I continue to reflect on my past’s good and bad. How do I know that my patient’s leg rotation deviations are new? How can I be confident they contribute to their pain and not just a manifestation of a life of living? Bunnell (1993) points to the “normalcy” of spinal asymmetry, with 98.4% of us having a rotational spinal curve (scoliosis/sub-scoliosis), and such spinal curves will, by association, create skeletal and postural changes up and down the body. If 98.4% of us have such changes, are 98.4% of us doomed to pain and other problems resulting from that spinal curvature?

Modality training teaches us recipes. They all do. Recipes are not causational-fact-based. MFR taught me to assess pelvic symmetry as if the pelvis is not balanced, then nothing we do will last. But other training lines teach different rules that often conflict with the rules I follow and with which I found success. My MFR training also taught that unless my patient realizes the emotion holding patterns that led to the pain/problem, they will never truly heal.

I used strategies taught to me in my MFR training to get my patient to become more aware of those past emotional holding patterns and how to help them free themselves, often “pre-training” them by posting such information on my website. I was taught that emotions are stored in restricted fascia and passed that belief onto my patients, speaking with a sense of knowing and authority. I applied these principles, and my patients felt better. The adherence to the recipe, to me at least, validated the explanatory information as it was taught to me.

Do you recognize yourself in all of the above? I’m not just speaking to MFR, as such recipes exist in nearly every manual intervention model we can use/learn. I’ve heard from clinicians that if one doesn’t spend an equal amount of time working both limbs, then the patient will somehow leave the session out of balance. I’ve heard that if the feet are not balanced/levelled, then nothing we do elsewhere will be retained. I hear from upper cervical proponents that if C1 is not put in the proper alignment with the skull, work elsewhere is useless or that if we get C1 back into place, this alone will cause the body to restore its balance. Craniosacral therapy (CST) teaches that we must restore normal movement to the spinal dural tube, change is not attainable. The recipes are nearly endless. When we use a recipe, it often works, which often causes us to believe that the recipe was the correct one and, in some cases, the best one.

Is there a “best” modality? Is one recipe superior to others? Some believe that there is. I was taught so, but what sort of external measurement is done to validate these claims? I’ve seen internal validation by many (including myself in the past). “I’ve been a therapist for 30 years, and ABC MFR is the most effective modality in the history of healthcare.” In today’s pollical climate, fact-checking has become both envied and vilified. How does one go about fact-checking a claim about the superiority of one intervention over another? That is the place of rigorous research studies. To my knowledge, there has not been a reputable study that shows one branded or unbranded manual therapy intervention superior to another.

In a recent “The Thinking Practitioner” podcast, Til Luchau and Whitney Lowe interview Mark Bishop, PT, who talks about the science behind the factors at play that make our work useful. While we like to think our outcomes are due to our mastery of finding and impacting the tissues-at-fault, much more goes into the therapeutic interaction besides any tissue-based singular selection and impacts. The full transcript from the interview is available through the above link. Such conversations are becoming more common. Though many feel that their skills and education are being diminished, what is happening is there is a better understanding of how and why we, as manual therapists, influence our patient’s problems. There is dissonance from tissue-based believers, as it seems like these newer models detract from the positive outcomes they’ve seen using the recipe of their modality. If presented in a demeaning manner, few listen. But if presented constructively, one that does not put down the hands-on work we’ve done, growth can occur.

MFR, and all other modalities and styles of intervention, are helpful. On that, we can agree. But is the efficacy due to the reasons stated in those individual seminars or lines of training? Possibly. But there are aspects that are seldom discussed in those training as they are more generic and do not seem to contribute to an individual educator’s superiority claims. All of this disagreement can get ugly, I know. Continuing education is big business, and brand-building is an essential part of a big-budget model of training. If we all started speaking the same language, and acknowledging that there are marked similarities in our shared styles, the demand for any one model may diminish.

I learned some pretty hands-on skills in my MFR training and others, and I am thankful for that. What I now find less helpful is the rationales presented in those trainings, rationales that elude external validations. I learned recipes, not science. Recipes should not be discarded, but can you take that recipe and add a layer of credible understanding and utilization of neuroscience and behavioral science to form a more cohesive, universally accepted model? OI hope so.

So, as I sight down my patient’s body, I see that that externally rotated leg may be a part of her that may never change, nor may not need to. I cannot look back in time to see if it always existed in that fashion, and I no longer see the need to “correct” that deviation. I still use the hands-on intervention style taught to me in my MFR training; I just no longer force the recipe taught there. Should we, as physical therapists, massage therapists, etc., be telling our patients that their emotional holding patterns are the reason they cannot shed their pain? I believe that it is not my place, from a professional scope of practice perspective, nor do I think that this is even a credible interpretation of existing scientific understanding. Stay in your lane, folks.

Suggestions? Give a listen to The Thinking Practitioner podcast at the link above. That could be your gateway to a deeper and more thorough understanding of how manual therapy works. Don’t let detractors sway you; we mean well. Some of us, including myself, at times, get a bit pushy, but remember, we’ve all been where you are right now. I began crossing the chasm from tissue-based beliefs to a broader human-being-based understanding of pain and impacts 15 years ago, and I am still learning and evolving. If you’d like someone to walk across the bridge with you, please feel free to let me know.

Learn How Massage Therapy Could Help Congestive Heart Failure

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Over the past number of years, we’ve looked at many different medical emergencies you may have to deal with in your massage therapy practice. 

We’ve covered strokes, heart attacks, anaphylaxis, diabetic reactions, and so much more, even to the point of looking at how massage can help hypertension. 

However, after a discussion on Facebook this week around hypertension and circulation, Congestive Heart Failure came up. 

I don’t treat anyone who deals with this, but as you know, I’ve been a first responder for many years and have responded to many heart-related issues, so I figured this might be a good topic to tackle. 

As always, we’ll look into the physiology and the emergency side of things, but we’ll also dig into what we can do as Massage Therapists to help this population out. 

What Is Congestive Heart Failure?

While CHF (congestive heart failure) is a heart issue, it’s not the same as a heart attack. 

It’s a gradual failure or weakness of one side of the heart, or sometimes both sides.(1)

As you’ll recall from college (yes, I realize it was a long time ago), the left side of the heart pumps oxygenated blood to the body, while the right side receives deoxygenated blood from venous return and pumps it to the lungs.

There can be a few risk factors leading up to someone suffering from CHF, which include: 

  • Myocardial Infarction
  • Valvular Disease
  • Ischemic Heart Disease
  • Or a disease that affects the myocardium of the heart. (1)

As mentioned earlier, we’ve written blogs on hypertension before (and how we can help), but hypertension is also one of those risk factors which could lead to CHF. One paper demonstrated this to be one of the most common risk factors associated with CHF and contributed to a large volume of heart failures.(2)

This is one reason why it may be essential for you to check a patient’s blood pressure on at least a semi-regular basis.

Due to hypertension, the left ventricle is continually trying to pump against restricted peripheral arteries. The left side is also the side that takes the brunt of damage due to myocardial infarction. So, both injuries result in the heart not being able to pump blood effectively, so the blood coming in from the lungs backs up, causing pulmonary edema. (1) 

The signs and symptoms we might see with this are(1):

  • Breathing issues:
    • shortness of breath
    • faster respirations
    • shortness of breath when lying down, which gets better when standing
    • wheezing
    • coughing up blood-tinged sputum
  • Circulatory issues: 
    • increased heart rate
    • cyanosis (bluing of the lips) 
    • pale, cool, clammy skin (signs of shock)
    • normal to high blood pressure
    • confusion and disorientation (also signs of shock)

When right-sided failure occurs, it’s usually due to issues on the left side when pressure is transferred back to the lungs because of the backed-up congestion.

However, it can also be due to: 

  • pulmonary embolism
  • COPD
  • myocardial infarction

We would see that right-sided failure looks a little different because blood is getting backed up in the person’s veins. Those signs and symptoms look more like: 

  • shortness of breath
  • fainting
  • weakness along with fatigue
  • swelling of lower limbs and lower back (how many people per week do you treat with low back pain?).
  • jugular venous distension (JVD, is easiest to see in semi-fowlers or supine)
  • tachycardia or a cardiac arrhythmia 

One of the big reasons it’s essential to know all of this is that there may be things we can do to help the patient and because their safety should be our number one priority. 

When anyone is coming in for treatment, we must be cognisant of underlying issues that could lead to a medical emergency. Of course, you know I have to bring this up…these issues could lead to us having to perform CPR. If you haven’t taken a course in a while, you owe it to your patients and your loved ones to keep up to date, as it could save a life one day. 

Now that we know the signs and symptoms and the importance of checking blood pressures on a regular basis; let’s look at what effect we can have in helping this population.

What Can Massage Therapy Do?

A little tough to find a lot of research on how massage can help this (well, honestly, there’s not a lot of good research on massage out there); however, I found a few that had similar findings. 

In both studies,(3)(4) the patients were going through admission to the hospital’s cardiac ward. They began massage three days after, so it did not interfere with any medical intakes or procedures; the patients were asked to sit up and position themselves at a bedside table with a pillow. 

In each study, they showed how respiratory rate and blood pressure both decreased, and blood oxygen saturation improved. 

Interestingly one of the studies(4) demonstrated that massage helped decrease patients’ anxiety with a significant difference between men and women, with men having the more significant outcome in this regard. 

One thing I had a hard time with is both studies said: “Back massage can also improve pulmonary function and promote circulation when the amount of blood in the pulmonary artery increases. The increased amount of blood has more opportunity to exchange gases, enabling more oxygen supply throughout the body and raising the oxygen saturation level.”

While it’s true if more blood could get to the lungs, more gas exchange would happen, how is this possible with decreased respiration, HR, and decreased BP? Both studies were conducted without a control group to compare, so I have to question some of the outcomes.

I have no doubt the decrease in respiration, heart rate, and anxiety occurred because we know massage has positive effects at decreasing the SNS firing and has positive benefits for mood and depression. 

However, I have to question the “promoted circulation part.” The only explanation that would make sense to me is if decreasing respiration, heart rate, and BP makes it easier for the heart to pump; I supposed this could make for “promoting” circulation, but not sure we could say “increased.” 

Another study (5) looked at how massage could help with sleep patterns, and the results showed that patients both got to sleep faster and slept longer on average. This is another valid point as we have seen many other studies showing the benefit of massage for sleep. Sleep apnea (6) is also quite common in those with CHF, so if we can help with sleep in any way (they would need a CPAP machine to make a difference with the apnea), that’s a positive too. 

What I had a hard time finding was anything regarding patient positioning on the table. However, there was mention that standing was better than sitting, and the ability to use gravity to help in different ways would be beneficial. So, if you have patients with right-sided failure, and in turn swelling in the lower limbs having them on the table with legs elevated would presumably help with the swelling. But I also think you’d want to limit the time spent in that position, so you aren’t overloading the heart with increased venous return (I’d love to see some actual stats on this to see if duration mattered). Due to the possible breathing issues, the semi-fowlers position is probably more advantageous than lying prone, but if there aren’t breathing issues, then prone is perhaps okay for a bit. 

When we look at the clinical guidelines(7) on heart failure treatment, the recommendations are for exercise. This makes complete sense to me as there is also a correlation between diabetes (8) and CHF. As well when we looked at the studies on massage and CHF, part of the improvements was on improved anxiety, and we know exercise can help both anxiety and diabetes. Exercise would also play a large role in the improvement in circulation, venous return, and respiration. So, while someone may be coming in hoping we can help them (which we can), the better approach would be to use massage in conjunction with a good exercise plan. If you’re not comfortable designing an exercise plan, why not include a fifteen-minute walk with your patient, then some treatment, or vice-versa? Or reach out to someone you trust with exercise prescription and work together with them on a treatment plan? Either way ensure that no matter what, the patient’s safety comes first, which also means being prepared for a medical emergency if their condition worsens while they’re in your care. 

References

1. The Canadian red cross society. EMERGENCY CARE for Professional Responders. ; 2018.

2. Braunwald E, Bristow MR. Congestive heart failure: fifty years of progress. Circulation. 2000 Nov 14;102(suppl_4):Iv-14.

3. Jamali S, Ramezanli S, Jahromi MK, Zare A, Poorgholami F. Effect of massage therapy on physiologic responses in patients with congestive heart failure. Biosciences Biotechnology Research Asia. 2016 Mar 31;13(1):383-8.

4. Chen WL, Liu GJ, Yeh SH, Chiang MC, Fu MY, Hsieh YK. Effect of back massage intervention on anxiety, comfort, and physiologic responses in patients with congestive heart failure. The Journal of Alternative and Complementary Medicine. 2013 May 1;19(5):464-70.

5. Sable A, Sivabalan T, Shetti AN. Effectiveness of back massage on sleep pattern among patients with congestive cardiac failure. Iranian journal of nursing and midwifery research. 2017 Sep;22(5):359.

6. Sharma B, Owens R, Malhotra A. Sleep in congestive heart failure. Medical Clinics. 2010 May 1;94(3):447-64.

7. Shoemaker MJ, Dias KJ, Lefebvre KM, Heick JD, Collins SM. Physical therapist clinical practice guideline for the management of individuals with heart failure. Physical therapy. 2020 Jan 23;100(1):14-43.

8. Kannel WB, Hjortland M, Castelli WP. Role of diabetes in congestive heart failure: the Framingham study. The American journal of cardiology. 1974 Jul 1;34(1):29-34.

Articles of the Week – January 31, 2021

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We’re not here to fear-monger. However, as manual therapist who spend some of the most time with patients among all of their healthcare practitioners, we need to be very aware of red flags with back pain and what they could mean. A good reminder of some of those basic questions that we learn in school and might be forgetting to ask.

When to Worry About Low Back Pain – Paul Ingraham

 

We’ve been hearing a lot of dialogue against the use of static stretching these days, but why? This article gives us a great explanation of the research method errors made in years past while reminding us of some of the evidence that does still support static stretching in certain circumstances.

To stretch or not to stretch before exercise: What you need to know about warm-ups – David George Behm

 

It’s been a tough year and I’m sure there are people coming in for treatment simply to experience human touch. Touch has a huge impact on our physical and mental well being, so this is an interesting read at how this pandemic has affected some.

Lost touch: how a year without hugs affects our mental health – Elanor Morgan

 

Talking DOMS again! A lengthy study to read, but one that suggests that post-exercise muscle soreness may have much less to do with muscle fiber microtrauma and more with neural microdamage. Hopefully, this new direction of research will begin to suggest different strategies for mitigating the pain.

Delayed Onset Muscle Soreness – Have We Looked in the Wrong Direction for More Than 100 Years?  – Sonkodi et al.

 

You have likely heard of exercise-induced analgesia, in which exercise creates a pain-dampening effect in the body. A very interesting study was done, however, that looked at the ability of suggestion to create a nocebo effect that directly counteracted this benefit.

Exercise Blocks Pain, But Only For Believers – Alex Hutchison

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