Articles Of The Week July 4, 2021

We frequently talk about the importance of changing basic education in our profession. However, we’re not alone. This article demonstrates that even doctors may need an overhaul of their profession as well. At least it’s good to know we’re not alone. 

How well do doctors understand probability? – Sebastian Rushworth

Super interesting article to look at how focusing or paying attention to one thing could make us miss another thing. Makes me think of using things like the “pain scale” with patients, if we’re too focused on their pain and not focusing on some other helpful things in their life, are we missing something?

Sometimes, paying attention means we see the world less clearly – Henry Taylor

Trauma can be a result of many things and of course trauma can also cause many things including a persons pain experience. So, how can we work and help people as a “trauma informed” therapist? Read on and see. 

Trauma Informed Massage Therapy – Jenn Sharman

I really like to get my bias confirmed because it makes me feel like I’m right…but am I? Sometimes yes, most times probably no, but at least there’s a name for it. Motivated Reasoning. 

Why you think you’re right — even if you’re wrong – Julia Galef

Trigger point therapy is a hotly debated topic in manual therapy. Here’s an updated discussion on what this actually is and how it can be applied in our clinical setting.

What Is Trigger Point Therapy? – Nick Ng & Tania Velásquez

Talking Templates for Common Misconceptions

I saw a post on Facebook a couple of weeks ago where a therapist was looking for advice on communicating with their patients.

This is partially because of frustration when a patient has an outdated belief around pain and their body, but you’re now trying to give them a different story.

This can be tough, especially as we learn new research and terminology and try to update ourselves.

Sometimes we want to vomit all the info we know, and people aren’t always receptive to this new information.

So, I figured I’d take a shot at how we can better communicate some of the things in question.

Here we go.

Do I Feel Tight?

This one is a classic.

I’m sure we’ve all had that person get on the table, turn and look at us, then ask, “Am I the tightest you’ve ever felt!?”

The funny thing about “tight” is that somehow as a society, we’ve bastardized this into being something associated with pain. Tight is just a sensation, and it’s a very personalized sensation.

I like feeling tight. When I go to the gym in the morning and do a good workout, I usually feel “tight” for the rest of the day. It makes me feel like I’ve accomplished something, and I’m taking care of myself. However, I don’t associate this feeling with pain (but again, this is a personal, subjective experience).

I think back to an experience I had working with some athletes a few years ago, and this is usually how the conversation goes with someone who asks about this:

Athlete: Do I feel tight?

Me: I don’t know. I’ve never treated you before, so how would I know if you feel tight or not?

Athlete: Oh, well, it’s just that my therapist at home always tells me how tight I am.

Me: Well, the more important thing is how you feel. Do you feel especially tight today?

Athlete: No, I don’t really feel tight at all?

Me: Then you’re probably good!

We then carried on the treatment, and at least for the rest of the camp, the athlete never really worried about feeling tight.

In the case where this is someone who maybe we’ve seen for a while, and they come in and ask if they feel tight, we could change the term to “protected”.

Perhaps we say something like: “well if this area is feeling tight to you, maybe for some reason the body is trying to protect the area, let’s just try to calm the area down and send some safety signals to decrease that protection”.

Whatever language we develop around something like this, let’s make sure we’re not using language that could cause someone to catastrophize what’s happening.

Don’t be the therapist telling people they’re “tight” like it’s a bad thing; let’s reassure them this is okay, normal, and they’re not damaged or broken.

My Posture Is So Bad

Unfortunately, there is so much in the media these days proclaiming that bad posture is the root of all evil.

People have heard things like “sitting is the new smoking” or that they have “text neck”.

Well, we know neither of these things is true, but it’s likely our patients don’t.

But this is where we could take a little time to educate them and even ask questions like, “well why do you think your posture is so bad”?

Depending on their answer, we could try to re-direct their thoughts by making some comparisons.

On things like text neck, we could point out that in the past, we’ve never seen anything like “encyclopedia neck,” “knitting neck,” or in reverse “ceiling painters neck”.

When it comes to sitting, we could point out how any posture held for an extended period will likely get irritating. I can’t imagine how those guards outside Buckingham Palace who have to stand in that “perfect” position all day aren’t going home and just wanting to sit for extended periods after work.

The reality is our best posture is our next posture (I don’t remember where I first heard that to reference it, but I think it was Greg Lehman).

Just showing them that any posture is safe and frequently moving to change your posture is a good idea might be enough to get rid of those old beliefs.

If not, we could cite several research articles that show posture doesn’t correlate to pain, but I’m not sure how many non-therapists want to dig deeply into that info.

Did You Feel That Release?

Well, we know that we can’t actually “release” anything with our hands.

However, many people have been told by other very well-meaning practitioners that they’ve released their fascia, a muscle, or a trigger point.

So what would be a simple way to communicate how we aren’t “releasing” anything but rather are having an influence on the nervous system?

As we mentioned earlier, it could be a matter of changing the language to a chat about protection mode and sending a safety signal to reduce that protection.

Another way is to say:

“Well all the new research has shown us that we’re actually having more of an influence on the nervous system. So, this area is probably a little sensitized right now, we’re not actually releasing something, we’re just calming down that sensitized area. So what you felt is more likely just the nervous system calming down.”

We will all have our way of communicating these things, and I’m sure you can come up with something better than what I’ve jotted down (and honestly, I’d love to hear your take on it).

Let’s make sure that we’re changing the narratives on many of these things along with the techniques we use, and we’re not giving our patients any reason to catastrophize an individualized sensation. We can do better than that.

Articles Of The Week June 27, 2021

I had a great conversation with a fellow skeptical Massage Therapist about a continuing education course they had taken and were debating taking “the next level”. This is an issue in our profession and I love how this post pokes a bit of fun at it but also teaches a valuable lesson.

The ABT Dilemma: Testing The Limits Of Evidence -Based Practice, Or Undermining It? – Tristen Attenborough

Any of you suffer from imposter syndrome the same way I do (honestly I hope you don’t). This is a great breakdown of how to overcome some self-doubt, but also a great rundown of how to look at information and gaining new knowledge.

The 5-step method that turns “I don’t know what I’m doing!” into a coaching superpower. – Alisa Bowman

The therapeutic relationship we have with our patients is a crucial part of any therapeutic intervention. But what happens if our empathy for people actually worked against us and how would we recognize that?

Three Ways Empathy Can Work Against You and How to Avoid Them – John Woolf

There are many, many things that can influence a person’s pain experience. One that is being brought to my attention with this article is the stigma of being a woman, and yes, some research is being done to show this.

The Stigma Of Being A Woman In Pain – Bronnie Lennox Thompson

With any hope we are helping the people who come to see us with establishing some achievable goals that will reduce disability and increase what they are able to do on a day-to-day basis. But something important to take into account is how we are communicating with our patients about this, so they are engaged in the importance and increasing their buy in.

Language Matters: Why No One Cares About Your Functional Goals – Heidi Jannenga

Putting Patient Preferences and Values Back In EBP

Evidence-based practice (EBP) has been the accepted norm in medicine and rehabilitation for nearly 30 years, though exploration began of its concepts in the early 1970s (Zimerman, 2013).

EBP consists of three elements: the best available evidence, the clinician’s knowledge, and skills, and the patient’s wants and needs (APTA, 2020).

This latter component is also stated as patient perspectives and values (ASHA). All descriptions of the EBP model point to an equal weighting among the three tenets, though most provide little detailed instructions on how to assure the weighting is carried out in that fashion. Many professional bodies established clinical guidelines and pathways to determine how to rank evidence, with case studies and clinician experience at the bottom of the ranking and systematic reviews and RCTs at the top. Clinicians are expected to use their clinical reasoning, expertise, and judgment to apply the evidence appropriately. However, how to go about assuring patient preferences and values are met is a bit unclear.

I have a specific podcast that I am particularly fond of, as the presenter speaks on topics dear to my values (and clicks my bias button continually). On a recent podcast, there was a conversation about applying principles of EBP while assuring the uniqueness of the individual patient was met, something not always addressed in EBP. As the best available evidence requires rigorous trials involving randomized groups, single incidents are often seen as less-than-relevant, though there is a trend toward allowing such individual cases greater weight (Anjum, 2020). While discussing how to apply EBP within such emerging models and how to allow weight to patient perspectives and values, a comment was made to the effect, “well, it is not like we can have our patients choose the intervention.” Really? Why not?

Patients lack the depth of knowledge and experience to build their treatment plan, and if they did, why would they need us? However, can’t they contribute?

In my 35-plus years as a physical therapist, I’ve overheard many different ways that clinicians try to assure that patient expectations and values are met. However, most fall short of the 33% contribution mandate of EBP standards. In a manual therapy setting, asking, “how’s the pressure?” seems to suffice for many, while in the exercise-based setting, so much power is given over to the clinician that few questions are asked. Patients often assume that we know the cause of a problem and also know the best way to intervene. Power is given. However, are there better ways to go further in allowing patient input to be equivalent to clinician input?

I once studied with a brilliant clinician who had a deep level of knowledge about how past psychological aspects often led to certain functional problems and applied his manual therapy skillset to remediate those problems.

However, I saw as problematic that though psychosocial factors leading to those problems were acknowledged, little if any attention was given to those factors during the intervention. The clinician simply applied what they knew to be necessary for the problem that they palpated. Did the clinician have an impact? Indeed, and their work was published and well-regarded. However, could they have improved their allowance of patient perspectives and values in the therapeutic interaction? Yes, indeed.

How can we elevate that 3rd leg of the EBP model to assure an equal weight is allowed to patient perspectives and values?

Many ways, but to start, we can include them more in the decision-making process. In my work, which is to improve function and reduce pain using a manual therapy-based and movement-based blended model, I make it a requirement that my patient fully participates in treatment decisions. This mandate is not always straightforward for the patient to accept, as they often feel ill-informed in treatment decisions. It takes some time to establish both the need for their input and the skillset for them to put this plan into action.

Below is an excerpt from one of my seminar manuals, in which I describe the basics of such a patient-centred model.

Once you have collected their history and complaints and spoken on their functional needs, ask them where they feel their issue. The issue/location could be where they feel the pain, the part of their body where they feel their movement difficulty, where their voice has challenges, where swallowing is impaired, where the tongue gets tight, or whatever brought them to you. Ask them where they feel the problem lies. Some may have no idea, while most will be able to localize the problem area.
• Let them know that the point of this evaluation process is for you to be able to touch, press, stretch, or do something with your hand(s) that connects them to their complaint. You may increase the feeling to a point where you bring it to the edge of the patient’s awareness or even calm the issue to a point where it is barely apparent, but either way, you need to do something with them that they feel relevant. You are looking to replicate a familiar feeling.
• If they are confused by this, or ask, “why do you want to make me feel it?” I suggest that you tell them that it is not your goal to make them worse or to make the problem worse. However, this work’s nature is such that to know that we can help requires us to connect them with their issues. If we cannot replicate the symptom or link them to their problem, both from the periphery (the tissues) and their perception (sensation), then we stand a lessened chance of helping.
• If at rest, they feel nothing, none of their issues, let them know that you may be seeking to allow them to begin to feel it through the therapy process. The concept of bringing their concern to their awareness may be difficult for them, as, for instance, they only notice the problem after doing something. Someone with a vocal strain that only occurs after a performance may wonder how you will be able to replicate the feeling when they have not sung. Someone suffering from back pain that comes on only after standing for a certain length of time may wonder how you will be able to get them to feel something familiar when they have been sitting and have no pain. Let them know that this is your mandate; to connect them with their issue, whether it is present at that moment or not.
• Ask permission to touch them and then place a hand or hands on the identified area. Initially, do nothing; allow your hand to rest on their skin lightly. I will typically then ask them if they feel any of their issues. That gives me an idea if I need to mildly replicate the feeling of the problem or try to reduce it with my stretch.

• Begin to apply a light stretch in the 1-2/10 range on your scale.
• Work in slow-motion; do not move quickly or apply heavy or aggressive pressure. Your pressure might be a lateral
stretch in any direction to the skin or deeper layers, used with a combination of pressure or gentle inward probing. The type and orientation of stretch necessary to connect with the patient’s condition are unique, varying from person to person. Think of this process as one of talking to a person who speaks another language. Each of you has little ability to speak each other’s language, and communication will be slow. It takes each of you a while to find the correct word to communicate an idea correctly, so you work your way through the process until each of you made your point. This process of evaluation is similar. You are trying to find a direction and pressure of stretch in and around the soft and hard tissues, one that your patient begins to feel that you have touched their problem.
• Once you have found a connection, you will need to work out if what you are doing should be continued as treatment. Ask the patient:
• Does this feel familiar?
• Are you feeling a replication or lessening of the issue?
• Does this stretch feel like it might be helpful?
• Is there anything about what you feel that feels like it could be harmful?
• Would you like me to add more pressure? If yes, slowly add pressure until the patient says that now better feel
connected to their issue.
• Finally, once you have adjusted the pressures and direction, ask them if they want you to continue with the stretch.
• When you start to use this work, hold a stretch for 2-4 minutes. During the stretch, you are asking the
patient if they still feel like the stretch is helpful. After 2-4 minutes, slowly release your pressures and retest. Do they
feel different? Have you been able to help them modify the sensation of the issue?

• Depending on your comfort with the techniques, you may now wish to treat more in the same spot or try a slightly
different area. If the patient has felt a change, you might move into the other intervention strategies you use.
• Treating for 2-4 minutes is a suggestion. I spend much longer with this work, often allowing a series of stretches
interventions to a single area take up nearly the entire session.
• No matter if you are using just this manual therapy work or combining it with other interventions, always teach the patient self-treatment. Many forms of manual therapy are too passive; they do not build self-efficacy. I always encourage my patients to follow through with self-stretching, if it feels helpful to them, and increase their movement through exercise, strengthening, or simply moving more. Passivity happens when we do not include the patient in treatment decisions, whether it is through manual therapy or exercise-based models of care.

The original intentions of EBP have been lost, though many feel they honor it. I think we can do better.

  • Anjum, R.L., Copeland, S. and Rocca, E. (Eds) (2020) Rethinking Causality, Complexity and Evidence for the Unique Patient. A CauseHealth Resource for Health Professionals and the Clinical Encounter, Springer (open access book).
  • Components of Evidence-Based Practice, 2020.
  • Evidence-Based Practice (EBP),
  • Zimerman, AL. 2013. Evidence-Based Medicine: A Short History of a Modern Medical Movement, AMA J of Ethics, 15(1):71-76.

Articles Of The Week June 20, 2021

Unfortunately in our population chronic pain can cause some prejudice towards those who are dealing with it. We can have a hand in changing this with the way we help and interact with people, so it’s time we rethink chronic pain.

Rethinking chronic pain – The Lancet

As we recognize more about mental health, it requires more of us as therapists to be trauma-informed. This article outlines four steps to becoming more trauma-informed.

Trauma-Informed Practice in Massage Therapy Settings – Jen Sharman

It’s not just our profession that is full of many myth’s, the food and diet industry is full of probably more. With the advent of “detox” diets many people are lead astray thinking they can detox their bodies with some new fad, however, we know that’s not the case.

You can’t detox your body. It’s a myth. So how do you get healthy? – Dara Mohammadi

Pain and exercise is always a bit of a hot button topic. But this is a great article that breaks down the value of exercise and pain.

Is It Safe To Do Activities That Are Painful: Exploring The Expose Versus Protect Debate – Greg Lehman

Here is a great list of must read articles to help you become a more evidence-based practitioner.

Evidence in Practice: A New Series for Clinicians – Lars Avemarie