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Articles of the Week November 15, 2020

November 14, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jon Cain

Here we have an article using one of our favourite terms, “resilience”. This study looks at the implications of coaches pressuring athletes to be “perfect”, which we may be able to translate right over to the effect that clinicians have on clients when doing the same.

On Perfect Technique – Derek Miles

We hear this one a lot in the exercise rehab world: “Don’t use the knee extension machine!” Like many old beliefs, however, it may be time to crunch the facts on this one.

Is the Knee Extension Machine Safe to Use? – Tommy Mandala

If you’re newly certified and fresh in the field of your practice, you may have experienced imposter syndrome at one time or another. This is a fantastic article to help you get past your barriers and be the best practitioner that you can be!

5 ways to beat imposter syndrome: These health and fitness pros tell you how they did it. – Camille DePutter

It’s never okay to fat-shame a client. But, as the holiday season approaches us, many of our clients may have concerns about their weight – especially if it may exacerbate some of their pain – and look to you for advice on how to keep it under control.

Top 3 Tips for Weight Loss During Physical Therapy – Dr. Sean M. Wells

Hamstring strains are one of the most common sports injuries that we see, especially in active populations. It’s also common for these injuries to become a recurring problem. Mike Reinold talks on his podcast about the importance of treating these chronic strains individually to best help our clients.

Chronic Versus Acute Hamstring Strains – Mike Reinold

In Defence Of The Advice To Remain Active For Back Pain

November 2, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Ben Cormack

There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!

Firstly this HERE is from the folks over at Cochrane.

“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”

It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.

Now I am going to give you a bit of my opinion as well!

Being active, IMO : ), is NOT a treatment. It’s about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.

It’s About Belief

Certainly, we don’t want to demonize the idea of resting or taking it easy if things are too painful, that is not evidence-based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.

This is highlighted in the two papers below that look at people’s opinions around what affects pain in the positive AND negative.

Darlow 2014 – Beliefs about back pain: The confluence of client, clinician and community.

Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives

We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self-reported perspective of what triggers back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare-ups

Costa 2019 – What Triggers an LBP Flare? A Content Analysis of Individuals’ Perspectives

Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.

Suri 2018 – Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

The implication might be that when we ask people to remember what triggered their back pain it is a simple ‘go-to’ blame physical activities (especially when other things are not considered), but when the flare-up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare-ups seems to decrease.

This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!

It’s About Positive Messages

Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.

I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple, and important message from my perspective.

There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.

But could our short term attitudes impact on the longer term?

Short Vs Longer Term

What we do seem to have some data on is that having low pain self-efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster – 2010, we see that low pain self-efficacy is related to worse disability outcomes at 6 months.

The question is how do our own attitudes, and other people’s attitudes as well, towards our backs influence our behaviours? Food for thought perhaps?

Key Messages From Advice To Remain Active

Hurt does not equal harm – It’s OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.

Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.

Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.

4 Ways To Improve Your Clinical Communication

October 26, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Emily York

My journey to learning effective communication started because I was pissed off and frustrated.

I have always wanted to help people, it’s why I became a massage therapist.

I define helping people as supporting and empowering them to be the best versions of themselves and the more I worked as an RMT the further I felt from that goal. Before me was this void, a place where I threw in my frustrations like, “well this isn’t my scope of practice so there is nothing I can do about it”, or the idea that “no ones going to change, the problem is too big anyways”.

I could visualize that if I empower my patients it would create self-efficacy and I saw this as the best way to help.

I could see how empowering people was the goal but I was lacking something needed to achieve this which was creating a barrier.

The tools I was given in school did not prepare me for the complexities of what it means to help people, I was given a rake and told to dig a ditch. This frustration created a gap between where I was and where I wanted to be.

The first step to closing this gap was identifying the source of my frustration, which was not my patients and the complexities they presented with, but actually myself.

I’ve also been impacted by my lived experience through trauma and healing and the frustration of feeling so overwhelmed and lost while everyone is telling you what you ‘should do’. Because of this, I knew how empowering it was to have an active involvement in my own health and healing journey, however, I also knew what worked for me wasn’t enough. This all led to the realization I was seeking, and what my patients needed was to be seen, heard, and validated and if I wanted to cross this barrier it would be through effective communication.

Why Communication Is Of Great Benefit To You And Your Patients

When I think about what brings the greatest benefit to my patients I think about emotional intelligence, the “ability to recognize and understand emotions in yourself and others, and your ability to use this awareness to manage your behaviour and relationships” (Bradberry & Greaves, 2009, p. 17).

Emotional intelligence (EQ) can further be broken down into personal and social competencies which is the “ability to stay aware of your emotions and manage your behaviour and tendencies” while also understanding “other people’s moods, behaviour, and motives in order to improve the quality of your relationships” (Bradberry & Greaves, 2009, p.23-24).

The more I became focused on developing my self-awareness, (which is one of the EQ skills), the greater my ability to acknowledge that the way I communicate with people is influenced by every past experience. This means I have to take into account my privileges, biases, and assumptions when I am communicating with my colleagues and patients.

This is a great benefit to patients because “you can only choose how to respond to an emotion actively when you’re aware of it” (p. 98) and when I am aware of how my past experiences influence my communication I can start with the intent to listen and understand before anything else.

Secondly, humbleness is needed because I’ve gotten it wrong more than I’ve gotten it right. I’m quick to jump ahead of myself and shove new information and science down my patients’ throats. I want to give them the best treatment and sometimes I get lost in making it about myself and how effective I can be instead of centering my care around their needs and concerns.

Being humble as a therapist is a continuous reminder that patient-centered care cannot be about me, I don’t know everything, and I must consistently choose to listen first and be ok with getting it wrong. Effective communication is not about you, but it is about your actions because it creates an environment of safety by validating whatever our patients bring to the table.

Four Tips To Help Improve Your Communication

Letting a patient be seen, heard, and validated means recognizing it is not about us and our identities as healers and therapists but about our patients and how we can use the resources we have to support and empower people to be the best version of themselves.

When it comes to communicating more effectively, think about an iceberg, most of what you will learn is internal growth and used to inform your perspective.

Some helpful tips to put effective communication into practice are:

Check-in with yourself and ask questions about your intentions, “what perspective and bias am I coming into this conversation with?” The narrative behind your intentions matters and in order to work on your communication I challenge you to ask yourself if the story you created matches the facts of the situation. For example, I can tell myself a story thinking a patient is lazy and doesn’t want to get better instead of looking at how I don’t know everything that is impacting my patient and what may be a barrier in their healing journey.
Focus on inquiry over advocacy. This could look like asking your patient “tell me what you’re experiencing, where is (insert patient’s concern) having the biggest impact in your life? If your patient’s concern is, for example, persistent low back pain, by inquiring first you can get a better understanding of what the biggest driver behind their pain is and have a better idea as to what intervention would be most effective. I can recall many times where I have focused purely on advocacy, where I was driven to make my patient understand that in order to eliminate low back pain they needed to know why core bracing and hip hinging were so important. In some cases, these interventions are incredibly helpful because they create safety for the patient, but in my drive to advocate for what was best for my patient I did not ask what they needed.
Learn to be ok with what’s uncomfortable, you won’t always get it right, and changing how you communicate can feel awkward. When in doubt less is more, I frequently repeat back to the patient what they have shared with me, and confirm the treatment goals so the patient knows their concerns have been heard and will be addressed.
Stay humble and make a commitment to always ask ‘why?’. “Why am I irritated by new information that challenges my belief system as a therapist?” “Why am I apprehensive about treating a certain patient population?” “Why do I make always or never statements, and is that narrative actually true?

Reference

Bradberry, T., & Greaves, J. (2009). Emotional intelligence 2.0. San Diego: TalentSmart.

To Predict Chronic Pain, Look to the Brain

October 19, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Mental Health, Pain/by Todd Hargrove

Low back pain is extremely common. In fact, if you don’t have at least some back pain every year or so, you’re kind of abnormal. (Not that you’re really missing out on anything.)

Fortunately, if you do get back pain, your chances of getting rid of it in fairly short order are excellent. More than 90% of acute back pain resolves on its own in just a few weeks or months without any specific intervention. But for some people, pain becomes chronic, lasting for years. Why does the course of back pain differ so much between different people?

The answer probably cannot be found by looking solely at the back itself. Experts have tried for years to explain back pain outcomes in reference to the results of physical examinations. But collecting evidence about posture, core strength, or the condition of vertebrae and discs does very little to help you make good predictions. Posture and MRI results correlate poorly with pain, and a single structural/physical cause for back pain is rarely found.

More recently, there has been more emphasis on subjective factors – pain intensity, negative mood, catastrophizing, depression, or job satisfaction. Accounting for these factors will help you predict back pain outcomes quite a bit better than just looking at the physical condition of the back. But a good deal of mystery would remain.

Some recent research from the lab of Vania Apkarian has led some very smart people to wonder whether he has discovered the “Holy Grail” of explaining pain – the precise factors that cause some people to develop chronic pain and others to recover.

If Apkarian is right, the grail is in the brain. (An important reminder and caveat: even when the brain is a major player in pain, this does not imply that pain is “in your head”, that pain is your fault, that you can just think pain away, or that the body doesn’t matter.)

Following is a collection of quotes from several papers from Apkarian’s lab. (See the bottom of the post for cites. Full text for each is available free online.) These help summarize the results and interpretations of his very interesting research, which mostly involves scanning the brains of people with and without back pain, and at various stages of recovery or chronicity.

The Relationship Between Nociception, Acute Pain, Movement, and Emotion

Pain is a conscious subjective experience that is most commonly driven by nociceptive activity. Baliki 2015.

Conscious acute pain perception is highly malleable … pain perception can reflect moment-to-moment shifts in value judgments. Baliki 2015.

The emotional limbic brain plays a critical role in bridging nociception and pain perception. Baliki 2015.

[N]ociceptors can be active in the absence of pain perception . . .The primary reason I fidget in my chair while writing this article is because nociceptors innervating my skin, muscle, and bone command that my posture needs adjustment. Baliki 2015.

The nociceptive control of behavior routinely occurs in the absence of consciously perceived pain, rendering it “subconscious.” Baliki 2015.

Daily motor movements could easily produce injury and tissue damage if one exceeds their natural range of motion . . . which supports the conclusion that motor behaviors are collectively inhibited by nociceptors. Baliki 2015.

We argue that nociception continuously occurs in the absence of pain perception and it is a fundamental physiological process . . . we presume that behaviors modulated by nociception, in the absence of pain, are contingent on already established habitual repertoires. In contrast, when pain is evoked it gives rise to new peripheral and spinal cord nociceptive learning/ sensitization, as well as emotional learning that is potentiated by the salience and perceived value of the aversive event. Baliki 2015.

The Transition From Acute To Chronic Pain

[O]nly a fraction of subjects who experience an acute painful injury develop chronic pain. Hashmi 2013.

The majority (>90%) of individuals with acute low back pain recover full function in days or weeks with little or no lingering pain. Apkarian 2009.

The 2 critical questions that the field has yet to address regarding chronic pain are 1) Who is vulnerable to developing it? and 2) What underlies this vulnerability? Hashmi 2013.

Earlier clinical studies have identified a long list of risks for chronic pain, such as demographics, affective states, lifestyle, comorbidities, and others, yet collectively such parameters account for a relatively small amount of variance for chronic pain (10% to 20%). In contrast, the brain’s anatomic and functional properties predict development of chronic pain at 80% to 100% accuracy. Hashmi 2013.

Ample evidence now shows that the anatomy and physiology of the brain in chronic pain is distinct from that of healthy subjects experiencing acute pain. Vachon-Presseau 2016.

An accumulating body of animal and human literature has identified the cortico-limbic system, which is central to reward and motivated behavior, as a modulator for acute pain and as a mediator for chronic pain. Vachon-Presseau 2016.

In a longitudinal brain-imaging study, individuals who developed an intense back pain episode were followed over a 1-year period, during which pain and brain parameters were collected repeatedly. At the time of entry into the study, strength of synchrony between the medial prefrontal cortex and nucleus accumbens (i.e. functional connectivity) was predictive (>80% accuracy) of individuals who subsequently transition to chronicity 1 year later. Apkarian 2016.

Persistently enhanced functional connectivity between the mPFC and NAc may be interpreted as an increased emotional salience signal. Vachon-Presseau 2016.

There is now good evidence that all components of the corticolimbic system are either affected by or control or amplify persistent pain states. Vachon-Presseau 2016.

Redefining Chronic Pain

The definition of chronic pain remains tautological, as it simply asserts that it is a long-lasting pain, or a pain persisting past the normal healing period. Baliki 2015.

We propose a novel definition of chronic pain. Rather than defining pain by its sensations, we propose a definition that emphasizes the neurobiological mechanisms that control behavioral adaptations, and we hypothesize that persistence of pain is likely mediated through the reorganization of the cortex by corticolimbic learning mechanisms. (Baliki 2015)

Long-term shifts in the threshold mechanisms that gate the conversion from nociception to pain also underlie the transition to chronic pain. We further propose that the threshold shift is dependent on limbic circuitry invoking synaptic learning-based reorganization. Taken together, these ideas can be simplified as a lowered mesolimbic threshold for the conscious perception of pain, which functionally renders the brain addicted to pain. (Baliki 2015)

The Connection Between Chronic Pain and Negative Mood

Just as nociception and pain protect against bodily injury by limiting behavior, negative moods minimize exposure to danger and promote survival by inhibiting behavior as well. (Baliki 2015)

Just as chronic pain conditions are associated with decreased hippocampal volume, a rich parallel literature indicates that depression is associated with hippocampal volume decrease. (Baliki 2015)

It is therefore not surprising that these conditions are often comorbid, and indeed, there is now a small but emerging literature regarding the interaction between negative moods and acute and chronic pain. (Baliki 2015).

Implications and New Questions

How does this research add to what we already know? We have known for a while that chronic pain involves central sensitization and brain changes. But it was still possible that those changes were driven by persistent peripheral input. Apkarian’s research seems to suggest that peripheral nociception is not the central driver of chronic pain.

It should be noted that some of Apkarian’s research needs to be replicated and that others may interpret his findings differently.

Apkarian was a featured speaker at the 2018 San Diego Pain Summit, I spoke there a few years ago and wrote about my experience attending here.

I was sure to ask Apkarian some questions which are basically unanswered in his various papers: if chronic pain is mostly about the brain’s emotional systems, what can we do, as a practical matter, to help treat or prevent it? And for people who do recover from chronic pain (like me and many others), how did their brains change? Did they revert or evolve?

I suspected there are no simple answers that apply to everyone, and that success for any particular person involves somehow changing the way their brain subconsciously connects movement, threat perception, and a sense of value or meaning.

Resources/Citations

Apkarian, A Vania, Marwan N Baliki, and Melissa A Farmer. 2016. “Predicting Transition to Chronic Pain” 26 (4): 360–67. doi:10.1097/WCO.0b013e32836336ad

Hashmi, Javeria A., Marwan N. Baliki, Lejian Huang, Alex T. Baria, Souraya Torbey, Kristina M. Hermann, Thomas J. Schnitzer, and A. Vania Apkarian. 2013. “Shape Shifting Pain: Chronification of Back Pain Shifts Brain Representation from Nociceptive to Emotional Circuits.” Brain 136 (9): 2751–68. doi:10.1093/brain/awt211.

Vachon-Presseau, E, M V Centeno, W Ren, S E Berger, P Tétreault, M Ghantous, A Baria, et al. 2016. “The Emotional Brain as a Predictor and Amplifier of Chronic Pain.” Journal of Dental Research 95 (6). International Association for Dental Research: 605–12. doi:10.1177/0022034516638027.

Baliki, Marwan N, and A Vania Apkarian. 2016. “Nociception, Pain, Negative Moods and Behavior Selection” 87 (3): 474–91. doi:10.1016/j.neuron.2015.06.005.Nociception.

Apkarian, A.V., Balik, M.N., Geha, P.Y. 2009. “Towards a Theory of Chronic Pain.” Progress in Neurobiology 87 (2): 81–97. doi:10.1016/j.pneurobio.2008.09.018.Towards.

Articles of the Week October 18, 2020

October 17, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jon Cain

There are a lot of really great “go-to’s” in the exercise world. However, some of them become so staple that proper execution becomes a problem. This article consults with multiple experts on how to correct them.

4 Exercises Most People Butcher (And How To Fix Them) – Shane Mclean

We coach our clients in injury prevention every day. Likely, none of these points will really be new, but this article summarizes ten great key takeaways for when we want to prevent pain when training. This is great for problem-solving with your clients or to provide them the entire article altogether!

10 Commandments of Injury Prevention – Dr. John Rusin

If you’re here, you love reading research and expanding your toolkit. However, there are some research biases that we need to be aware of in ourselves in order to make sure that we’re not unfairly filtering the wrong information in or out. (Enjoy this two-for-one!)

Top 5 Fridays! 5 Types of Fallacies Part 1 and Part 2 – Cameron Faller

Back in June, Greg Lehman wrote about his experiences with pain science regarding his own health. We know these concepts already, but it’s extremely handy to see new examples of them at work.

Pain lessons from my terrifying persistent stomach distress – Greg Lehman

Finally, one more older study on a topic that isn’t discussed very often. Researchers, a few years ago, looked into the sensation of “throbbing” pain that is typically related by professionals to circulatory flow. However, it’s shown that this link may not actually exist and that more research into the central nervous system is the key, instead.

Is There a Relationship between Throbbing Pain and Arterial Pulsations? – Mirza et al.

Motor Learning Pitfalls and Autonomic Resilience

October 13, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Jon Cain

Sometimes, I’ve found that teaching a movement cue to a client can backfire.

Coaching a neutral pelvic position or a braced core to do exercise, for instance, are great techniques to perfect a squat and deadlift and train a person to lift a heavy load. However, if a client experiences pain or discomfort out of a regimented exercise setting, are these necessarily the best strategies to focus on?

Very often, I’ve seen individuals become extremely hyperaware of their body mechanics, whether it was due to cues from a clinician or because the assumption is that patterns from high-load fitness routines need to be maintained outside the gym.

My experience is that this can result in a couple of problems.

Pain Science

One is a concept that you’re likely familiar with by now; that being catastrophization. If we, as clinicians, don’t mind our language during our movement coaching, often enough, a person can develop a belief that anything outside of these trained movement cues will result in injury.

As you can guess, believing that “losing form” will equate to pain can lead to that belief becoming a reality. This is classic fear-avoidance coping and is why someone can perform a 300lb deadlift and then throw their back out when they finally bend their spine to tie their shoes.

For this reason, it’s important to educate clients about the resilience of the body to perform non-deliberate movement as well as to mix these types of movements into their exercise programming. While it’s important for me to teach many of my clients how to do a proper hip hinge, it’s equally important to recondition them on how to round their spines to pick up a sub max load.

At the same time, it’s also crucial to teach clients that these cues are not meant to be minded for every movement in day-to-day activity. Again, this would enforce these fear patterns and lead to what we discussed above. However, it also enforces a reliance on deliberate thought to perform these movements, which takes us to our second point.

Autonomic Neuroplasticity

Once we remember to add in these additional “natural movement” cues to accompany exercise instruction, there might still be a disconnect between the clinic and real-world conditioning.

What we need to consider is that the conscious focus on movement in the clinic or fitness setting (whether it be a traditional exercise or a natural back bend) doesn’t necessarily translate to the nervous system being able to replicate those cues in a safe manner, subconsciously.

This boils down to neuroplastic deficits within the central nervous system itself following an injury, with altered motor patterns becoming the new norm (Grooms, 2016). We can describe this by thinking about the thought processes that lead up to movement. In an “exercise” environment, the signals that precede movement are directly to do with that specific motor pattern; sending the signal to the muscle and joint on what to do and how strongly and fast to do it. Outside of this environment, these thought processes are much more complicated and the movement will need to follow more complicated reactionary signals. For instance, often we will need to simply extend our arm, reactionarily, in order to catch an object rather than having that moment of anticipation to ready the nervous system and compute the necessary speed and force that will be required beforehand.

What this implies is that being able to do a back bend in the clinic when all of your focus is on it only gets us part of the way toward being able to do the same thing at home when relying on autonomic function instead of deliberate action. This is why athletes who have undergone ACL reconstruction and rehab can be, clinically, cleared to return to play yet still be 40 times as likely to reinjure their knee compared to their peers (Wiggins et al., 2016).

Clinical settings commonly revolve around focusing on internal cues when learning movement patterns, such as relaxing one muscle, stiffening another, or bending deeper at this joint. However, external cues, such as “reach for the floor”, “aim for the target”, or “focus on the field” have been observed as being incredibly important in sports settings. These cues help to bring the attention away from the body and to the environment instead, creating a more practical situation by decreasing conscious body control.

With ACL reconstruction, again, being the studied example (Gokeler et al., 2019), it is found that relying solely on internal cues does not provide the best outcomes for when external factors are finally challenged again. Even when rehab conditioning is extremely sport or activity-specific, an ability to do a maximal sprint in a controlled environment might fail someone when they attempt to do the same thing with real-world distractions added. For this reason, a lot of rehabilitation research is actually starting to involve the use of virtual reality (Grooms, 2015) to retrain autonomic capabilities.

Obviously, we don’t expect every clinic to equip itself with a VR headset. So that brings us back to the importance of mixing in external cues with the internal ones as we educate our clients in new motor patterns. The clinical setting can take a lot of great lessons on how to do this from the performance world, with a mixture of the two types of cues, periodization of a program, and an understanding of individual variance being hugely important factors.

Takeaways

So from all of this, we can understand that mechanical cues and deliberate exercise patterns are still a step in the rehab process. Throughout, however, we need to reinforce that a client’s well-being is not dependent on these patterns being maintained around the clock or that conscious control does not need to be exerted over their maintenance.

Finally, we also need to remember that the quiet, clinical environment is usually not one that our clients spend the majority of their days in, so we also need to prepare them for the real-life hazards, distractions, and mental states that their normal workplace, sport, and home settings will challenge them with.

A client’s life is individual, and so is the preparation for it that we provide.