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Articles Of The Week February 24, 2019

As we all work to progress towards an evidence-based practice it usually requires a change in what we do and how we think. Well, it turns out even the way we look at evidence-based practice may need to change as well.

“Flush Your Stool Down The Funnel” – Erik Meira

Should massage therapy be considered part of healthcare? Some therapists would argue it shouldn’t be, however the only way we progress as a profession is to embrace being part of healthcare. As healthcare practitioners, there is a certain level of accountability we are held to, but should mainly be holding ourselves to and this is actually a GOOD thing.

“The Way Forward Is Together – Part One” – Lauren Cates

A new study shows three different kinds of meditation can have different beneficial results. Increased focus, enhanced compassion, and empathy, also enhanced understanding of the perspectives of others. All of this from just different types of meditation.

“Different Types Of Meditation, Change Different Areas Of The Mind, Study Finds” – Alice Walton

Over the years there have been many arguments/discussions around open chain vs. closed chain exercises for rehab. What if neither of those really matter, but the importance is how force enters and moves through the patients injury?

“The False Dichotomy Of Open Vs. Closed Chain” – Peter Malliaris

It’s no secret that exercise is one of the main tools to use in helping people overcome pain. When we deliver these messages to patients we can also deliver messages that can hinder them from actually doing the exercise. However, if we make it fun, it’s more likely the patient will not only take part but want to do the exercise.

“The Power Tool In Your Belt” – Nathan Hers

 

Learn How Movement Will Change Low Back Pain

Last week we posted an article discussing some of the research around the clinical guidelines of low back pain.

There are several modalities commonly used that aren’t recommended like Tens, laser therapy, imaging, and corticosteroids,  but when we look at what is recommended we have an opportunity to make a real difference for those suffering from back pain.

One of the big things recommended is a biopsychosocial approach along with education. In order to start this kind of approach, patient reassurance is critical in order to help the patient feel safe (as we talked about last week).

In addition to reassurance, supervised exercise is also a crucial part of helping patients deal with their back pain. However, these two go hand in hand as it will quite often take a considerable amount of reassurance to convince a patient that it is okay to move.

One way to help is by looking at what the research says for exercise and low back pain, which you can use as a tool to convince (and reassure) patients this is the best course of action.

Exercise For Low Back Pain

Remember the old days when bed rest was the main prescription for low back pain?

Well, now bed rest is actually discouraged unless the pain is too severe, then only two days of bed rest are chosen. In contrast to this, we now understand that staying active has far better outcomes than the way we used to manage this.

And I know many of you might be saying “exercise is out of my scope of practice” and while this may be true, active and passive range of motion probably is within your scope, so there is no reason you can’t incorporate some of this into your treatments. 

I know there is probably some concern over being able to recommend “specific” exercises (or movements) but don’t worry it doesn’t have to be all that complicated…in fact, it shouldn’t be! Supervised movement without the use of expensive equipment is one of the specific recommendations, so you can do this right in your treatment room.

This is especially true in the acute stage, where strengthening, extension, and specific exercises are not recommended. Rather, in this case, we want to use graded exposure to physical activity. Graded exposure is essentially getting a patient to move (gradually) into a feared or painful movement (we’ve had articles about this before which you can read HERE for a more detailed description).

For example, when it comes to acute low back pain, if your patient is scared, or experiencing pain with a certain movement like standing forward flexion, have them change the plane of movement and try flexion again. Try having them sit comfortably in a chair, then lean forward. This is still spinal flexion, it’s just in a more supportive position. When they can move in this position comfortably, point out how capable they are of the movement and reassure them that flexion is safe. You can then gradually work up to standing flexion until this feels safe again.

There are many ways to do this, it just takes a little experimentation on your part.

When it comes to chronic low back pain there is no evidence that one exercise is superior to another.

However, recommendations show that remaining as physically active as possible along with an early return to work is well supported by evidence (probably why some workplaces have a gradual return to work program). While there are no specific exercises highlighted as more effective than others, the exercises that work are simply the ones your patient will do. Find out what’s important to them and encourage them to do it. Whether it is strength training, going for a walk, playing with their kids, or playing hockey, the intent is to build confidence in their bodies as opposed to fixing a problem.

Inevitably the question of dosage comes up and the research shows that too much, or too little exercise with some patients can run the risk of developing persistent pain. This is where it’s important to experiment a little to see what works best for the patient, we don’t want them to overdo it, but also want to avoid not doing enough (one of the reasons bed rest has been eliminated).

Overall since we know a biopsychosocial approach is most effective, encourage things like movement in general, getting back to work, staying connected with the things and the people they enjoy. Just make sure these things are done gradually. If we can address peoples fear of movement by using graded exposure early on, we have a better chance of avoiding prolonged pain and disability. So, don’t stress about ‘specific’ exercises, the overall goal is to get our patients moving and keep them moving. Movement along with some education and reassurance can go a long way in not only improving low back pain but also the patients quality of life.

 

Articles Of The Week February 17, 2019

 

As a group of people who work on people’s backs every day, this is of interest to you. New research is showing that the spinal cord can process more complex functions and some of these functions open up new areas to investigate.

“Spinal Cord Is Smarter Than Previously Thought” – University Of Western Ontario

In this business one of the best things you can do for your practice is build RELATIONSHIPS. So, can you really do this with a business card? It’s probably not as effective as you getting their contact information.

“To Business Card, Or Not To Business Card” – Marty Morales

Most of the time when people come to us it’s because they are dealing with pain of some sort. But what do we do when the pain persists? How do we tell the patient that maybe we can’t help them? Can they live with the idea that their pain may never cease? There may be some things we can say which can still help the person experience a life that is fulfilling.

“Why Do Clinicians Fear Telling People Their Pain May Persist” – Bronnie Lennox Thompson

No matter the modality, someone has said: “but I’ve seen it work”. This usually results in hesitation to update our thinking or model of care in helping patients. If we update our understanding, we increase the quality of care we are giving our patients and isn’t that something we should all want?

“The Biggest Error In Pain Management (You Might Be Doing)” – Lars Avemarie

There is a direct correlation between sleep and pain management. In fact, as this article points out, one study showed a 15% reduction in pain threshold! Another trial showed that poor sleep quality resulted in higher ratings an a pain scale. So go encourage your patients to get a good nights sleep.

“Why It Hurts To Lose Sleep” – Benedict Carey

Next Time You Treat Low Back Pain, Be Sure To Provide Reassurance

 

When the patient came into the treatment room, I sat down and welcomed them to do the same.

They refused, preferring to stand, as sitting hurt their lower back too much. When asked how long this pain had been going on, it was an astonishing two years.

Unfortunately, they had been run through the medical system for the previous two years, had seen every kind of practitioner and been given competing advice from all of these medical professionals. When asked what has worked well in the past, getting massage seemed to be the most beneficial. While this sounded great, there was still a lot of work to be done, which had nothing to do with what technique I could use to help ease the pain.

There was now an education and confidence building process that had to take place.

This person was so scared of their pain, they were afraid to sit (even though they had just comfortably driven their vehicle to the clinic).

How could I help this person? What kind of education would help? Would I be able to help?

Clinical Guidelines For Low Back Pain

Looking at the studies on the clinical guidelines for low back pain,  they revolve around primary care settings, which can be described as the “first point of contact regarding patient care”, so generally thought of as doctors in medical clinics or hospitals.

Fortunately, there is a lot of good advice about managing both acute and chronic low back pain.

Unfortunately, when we look at the European guidelines it says “they cannot recommend massage therapy” for the management of low back pain. But when we dig a little deeper when it refers to treatments they cannot recommend “it is owing to lack of/conflicting evidence of effectiveness” and while many of these treatments may be effective, they require the use of more studies to prove their effect (which is a big reason we need more research on massage therapy to be done, we know it’s effective).

But, massage isn’t alone in these studies as the modalities that “aren’t recommended”, there is quite a long list of things they would not recommend which we see used quite regularly:

  • Radiographic imaging for chronic non-specific low back pain.
  • MRI, CT, or facet blocks for diagnosis of facet joint pain, or discographies for discogenic pain.
  • EMG as a diagnostic procedure.
  • Wearing lumbar support.
  • Ultrasound.
  • Laser Therapy.
  • Traction.
  • TENS machines.
  • Acupuncture.
  • Nerve blockers, or corticosteroids.
  • Injections

However, it does recommend:

  • Looking at: work-related factors, psychosocial distress, and patient expectations.
  • Supervised exercise therapy.
  • Exercise programs that do not require expensive training machines.
  • Group exercise.
  • A short course of spinal manipulation for chronic low back pain.
  • Brief educational interventions.
  • Mulitdisiplinary biopsychosocial rehabilitation.

What the article doesn’t really mention is the interaction between the massage therapist and the patient.

While the above information is from the European guidelines when we look at the updated overview of international clinical guidelines they are consistent in recommending a focus on the identification of red flags (which we have written about HERE) and ruling out specific diseases. The only time medical imaging is recommended is when a serious pathology is suspected.

However, consistently across all of the recommendations is that patients should be reassured they don’t have a serious issue, and they should remain active.

Beliefs Regarding Pain

Sometimes it can be difficult to convince a patient they need to remain active, as they become fearful of moving because they associate it with pain.

In fact, there is a hypothesis where those experiencing low back pain fall into two different classifications: confrontation or avoidance, and this is determined by a persons fear of pain.

Those who confront their pain view it as a nuisance and are quite motivated to get back to normal activities. Whereas those who fall into an avoidance response tend to reduce physical and social activities, have a more prolonged disability and have adverse physical and psychological consequences. There is actually a correlation between avoiding activities because of the expectation of pain rather than actual experience or feeling of pain during activities.

There is even speculation that fear avoidance during an acute episode of low back pain can be a prognostic tool in identifying those who are more prone to developing chronic pain and may be the most important factor in determining the transition from acute to chronic low back pain. 

These fear-avoidance beliefs are even consistent for patients with work-related low back pain and the time it takes for them to get back on the job. Most return within one to two months after injury, but those who take longer are less likely to return to work.

Before I became an RMT, I was an industrial first aid attendant in a sawmill and I can remember having discussions with WCB (workman’s compensation) rep about employees returning to work. He told me their studies had shown if someone went 18 months without returning to work post-injury, they were likely never to return to work (I’m citing this from memory, I have no data to back it up other than remembering a conversation). So, looking back, this conversation makes a lot more sense to me now as many people returning to work were worried they would get reinjured on the job again.

Part of what contributes to fear avoidance beliefs is well…us.

All too often it is the messages patients get from health care providers who still rely strictly on explanations around pain being the result of tissue damage along with structural, anatomical, or biomechanical problems (yes these still play a role but there are other factors to consider as well). This is further reinforced by practitioners who confidently express their methods and services are the only way to relieve pain. 

So, we then have to consider how we can better help our patients with this increasingly common issue. The first step is; reassurance.

Providing Reassurance

As we have been discussing, peoples perception of pain has a massive effect on how they deal with pain.

One study shows that reduced feelings like helplessness, catastrophizing, pain being harmful and disabling, along with increased belief in control over pain can predict positive treatment outcomes.

Unfortunately, a lot of these feelings are due to things people have been told in the past (often by practitioners) that their back is ‘weak from a past injury’ or their pain is a result of genetics, lifestyle, or some other physical trait. These beliefs also bring about concerns they will reinjure or damage their back even more with activity.

There is strong evidence that these views are directly related to interactions with clinicians who also have high levels of fear-avoidance beliefs. Part of the difficulty with this is when patients go see multiple practitioners and are getting a different story from each one, this results in more frustration and an increase in those negative beliefs.

However, if we start to use language and descriptions that reassure and empower the patient, we can start to positively influence their pain beliefs. 

Once red flags are ruled out we can reassure the patient how things should get better over the next few weeks because the symptoms are benign in nature and this issue quite often resolves itself. More importantly, reassure that they do not have a serious disease! Along with this, we should endeavor to offer some level of education to the patient about their pain and how to self manage, otherwise, a dependence on the therapist could develop, where the patient always needs to be taken care of.

We need to start changing the narrative patients are given. 

When someone comes in who has had an x-ray or MRI and is stressed about the results I like to say something to the effect of:

“Don’t let that freak you out too much, if they took an x-ray of me right now it would probably look similar, yet I’m not experiencing any pain, your back is just sensitized right now and we just need to calm it down”.

Or when someone with chronic pain comes in I’ll say something like:

“Since we know pain is a safety and protection mechanism, your tissues have been protected for a long time now, which puts them in a safe place, your chances of re-injury is minimal”.

Now, this isn’t always going to be easy because they could be getting different messages from different practitioners. So, it may take a while to get your message across. But, for that patient who is afraid to sit down because they fear re-injuring their back, this is a good start.

While these are just a couple of examples I have used with people, they are just examples and won’t necessarily work for everyone. We need to tailor our message for each individual according to their beliefs and relationship with pain. We also need to build up our therapeutic relationship with them and provide appropriate homecare to decrease their dependence on us while reinforcing self-efficacy. These patients are wanting to be heard, have a better rapport with their practitioner, be given reassurance and education, so they know they are going to be okay. These are things rarely given by ‘primary care’ practitioners because they are given such a small amount of time with them, so this creates a valuable opportunity for those of us fortunate enough who get to spend on average an hour with each patient. Even though the clinical guidelines on low back pain could not recommend massage therapy, when we look at what they do recommend, Massage Therapist should be at the top of the list.

Leave a comment below with the language you use, or things you say to reassure your patients, we’d love to hear from you.

Articles Of The Week February 10, 2019

Whether it’s working too long of hours, compassion fatigue, debt, or any other aspect of life, experiencing burnout is all too common within manual therapy professions. If you’re experiencing this, you’re not alone but there are things you can do to help.

“Beating Burnout” – Eric Ries

We’ve all had them…the challenging patient. But is this the patient, or the culture of care? This is a great post from the patient perspective and it shows us how the words we use can make a difference for both the positive and the negative.

“The Challenging Patient…” – Joletta Belton

We all know how important sleep is but is more sleep something you should recommend to your patients? It might be really difficult for someone to get more sleep with our busy lives, but there may be ways for you to recommend they get better sleep.

“The Sleep Tip You Should Never Give A Client (And Others 5 You Should)” – Mike T. Nelson

All too often when people experience back pain they think it’s necessary to visit the emergency room and many research articles on back pain are directed at ‘primary care’ practitioners and how to deal with it. But, wouldn’t it be better if the public was educated on when visiting the emergency room is really necessary? Well, here’s an article you can share to help educate your patients.

“Severe Back Pain? Only 3 Reasons To Visit The Emergency Room” – Keith Roper

Here is a great resource of books that explore the relationship between the mind and the body. Anyone of them could help us understand various different aspects of the body, which I’m sure we would all be happy to learn more about.

“Ten Books To Help People Understand The Human Body And Its Complexity” – Richard Lebert

She Added Massage And That Made Migraines Unbelievably Better

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

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

Spoiler alert: I didn’t.

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

The fact is not all headaches are created equal. 

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

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

Decreased Headache, Increased Sleep Quality With Massage

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

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

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

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

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

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

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

References:

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

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

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

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