Articles Of The Week July 18, 2021

We have written posts on this topic before but this is a good refresher on some issues our patients could be having with their sleep. Some of the results of sleep paralysis include muscle soreness and headaches. So while someone may not know they have sleep paralysis it could be something we recommend they have checked out by another professional.

Sleep Paralysis – Krista O’Connell

Quite often people with joint pain (especially stemming from arthritis) are prescribed steroid injections to help with the pain. As it turns out, new studies are showing this may be doing more harm than good.

A Warning From a Doctor Who Has Done Thousands of Steroid Injections for Arthritis – James Hamblin

No matter what our profession is within the manual therapy community, we all have a defined scope of practice from our regulatory bodies. It’s important we stick to these as giving advice that is out of scope can have some serious ramifications.

Chiropractors aren’t qualified to give COVID-19 vaccine advice, health experts warn – Scott Fralick & Denise Wong

Ahhh yes, anecdotal experience. This is often used in discussions online as a way to say someone doesn’t need to read or apply research in their practice. There are a lot more reasons something works in practice and a technique itself is probably not the reason.

The trouble with “it worked for me” and “athletes use it” – Paul Ingraham

We’ve written articles before on how many of us deal with “imposter syndrome”. But what about the opposite outlook “the dunning-kreuger effect”? Well, this might be the reason for some anti-vax attitudes that we are seeing right now.

How the Dunning-Kruger effect explains anti-vaccine attitudes – Paul Ratner

My Response To The EIP vs EBP Debate

Sometimes we write posts around here that ruffle some feathers. 

This happened a few weeks ago when we talked about being evidence-based or evidence-informed. 

The post was basically making some arguments for being evidence-informed and looked at some of the limitations or downfalls around being evidence-based. 

A number of articles were thrown my way to look at the contrary, so let’s dig into those and see what they have to say and perhaps I’ll have to change my stance. 

Successful vs. Unsuccessful

It’s probably important to state right from the start there are limitations to both evidence-based (EBP) and evidence-informed practice (EIP). 

As I read through some of the research cited on EBP a few things stand out to me. 

First off, the literature (¹) fairly consistently talks about EBP in a multidisciplinary setting, typically in a hospital setting. 

This is not the same as working in a multidisciplinary musculoskeletal care clinic as most of us work in. In our case, you can’t interview your patient, then leave and chat with a few other colleagues for an extended period, then go back in and conduct your treatment. 

This is a situation that is probably very valuable for our Physiotherapist friends who are working in a hospital setting; however, there aren’t a lot of Massage Therapists who work in this environment (I know there are a few, but it’s not the norm). 

Part of how to successfully apply EBP is by giving staff opportunities for discussion. So, when we look at a hospital setting, you typically have union, hourly paid positions which enable this to happen. They are encouraged and given paid time as part of their employment to engage in this kind of activity. 

However, in our case, if we aren’t working, we aren’t making money, so implementing this is a lot more difficult. I know some clinics try to have monthly meetings and discussions (which is a noble effort), but I think most of us want to go home at the end of the day. 

Another caveat is that people are placed into (again paid hourly positions) leadership roles to accomplish the efforts mentioned above in these hospital settings; their sole job is implementation. 

When they compared hospitals who were trying to implement EBP, they were referred to as “high performing sites”, and “low performing sites”. 

The high performing sites had a consistent and strong emphasis on EBP throughout the organization along with: 

  • guideline development and implementation
  • evidence-based teams
  • leadership that provided an environment of support
  • they strove to build relationships with patients by placing them at the centre of the organization
  • structural mechanisms in place to support patient-centred care with contributions from all staff

When they looked at the low performing sites, they saw things like: 

  • it was up to individual providers to stay up to date
  • staff felt it was everyone’s responsibility to keep up with new developments
  • low numbers of implementation and support
  • more variation in leadership support 
  • more transactional interactions with patients
  • staff delivering patient-centred care instead of it being done as an organization
  • a passive or punitive culture

This is important to take into account because while we may be working in a multidisciplinary clinic, the values of each practitioner working there can be drastically different. 

We are most likely involved in what this paper would have called the low-performing site.

Even if we as Massage Therapists strive to be evidence-based, it doesn’t mean everyone else in the clinic is. We could be working with other practitioners pushing old narratives, so we don’t get the team environment that would make the clinic more successful as EBP and us. 

The Sicily Statement

There is a quote in this paper(2) that I love: 

“Knowing is not enough, we must apply. Willing is not enough, we must do.”

A few other things stand out in this paper. First off, it points out there are increasingly growing specialist databases for the professions working on EBP. However, there is very little research specifically on massage therapy. So we regularly have to depend on research being done in the Physio or manual therapy realm and using that to apply in our practice. 

So, there is no “specialist database” for us to rely on (hopefully, this changes at some point). 

Another part of implementing EBP is reading research, applying it in practice, all so you can build your knowledge and wisdom (which is something I hope we’re all doing), but this can take years of work to be proficient at. 

They propose we go from EBM to EBP to benefit entire health care teams and organizations adopting this approach. But, unfortunately, even in a multidisciplinary clinic, we don’t work in teams. So until our associations start setting firm boundaries and creating policies to put EBP in place, this won’t happen (and I doubt it will in my career). 

This is also hoping that EB practitioners are speaking the same language. So even in a multidisciplinary clinic, this won’t happen as many still believe they’re further up the healthcare hierarchy than us. Look at the fact it was only something like 53% of chiro’s here in Canada recently voted in favour of not using x-ray with every patient. This means that basically, 50% of the profession was choosing to remain doing something in practice that is not evidence-based. Think of how this would affect a team environment working in a clinic where this non-evidence-based approach is part of the culture. 

How in this setting could we expect to work as a team of EB practitioners, taking what an RMT says into account? It probably happens a little bit, but we have light years to go before this is standard. 

The resounding message I got from this paper is that it is necessary to work as a team for anyone to be successful as an EBP. While I think we should be working towards this, this isn’t something that happens in private practice in the manner recommended. 

The second big takeaway is that changes in education are necessary. 

Until students are taught about research, critical thinking, and how to have a critical attitude to your practice, we won’t be able to implement this as a profession properly. 

Part of the problem with this lack of education at the college level is that when students graduate and start looking for their first continuing education course they get blindsided by some of the (for lack of a better term) “guru’s” out there teaching non-evidence-based courses.

As the article points out: “Attitudes are caught not taught,” and unfortunately, a lot of this happens with these continuing education courses. 

Are We Even EIM?

So, the terms EIP and EBP often get used interchangeably, and I have no issue with this but it’s been brought to my attention this could be confusing to some, I just think when we really look at it, we’re closer to EIP than EBP. 

Fair enough. 

So, the difference I see is that EIP takes into account more types of research. As Massage Therapists, we need to consider this since there isn’t much specific massage research out there, and we have to be able to look at the research and apply it to the person in front of us. 

I like this image that was cited(4) in another article which shows the short-term and long-term goals of both EIP & EBP: 

I know it’s a bit tough to see in this image, but what stood out to me was the difference in the long-term goal comparison between EBP & EIP. While there are some similarities there are a couple of interesting differences:

EBP long term goals:

  • Improved patient assessment and treatment
  • Increased staff retention

EIP long term goals:

  • Improved patient outcomes (patient safety, reduced morbidity and mortality, and less healthcare costs to patients and patient relatives
  • An evidence-based practitioner who is a critical thinker and doer
  • Job satisfaction among practitioners

I don’t know about you, but I like the long-term goals of EIP a lot more, however it has it’s own set of challenges as well.

One of the more difficult challenges in EIP also has to do with education. One of the main factors to be evidence-informed is the ability to critically think, and be critical of research (3)

This again comes down to what is being taught at the college level; critical thinking skills are not part of the curriculum. 

When we look at the five steps recommended in EBP this is how it looks (2)

  1. The professions and their colleges should incorporate the necessary knowledge, skills and attitudes of EBP into their training and registration requirements
  2. Curricula to deliver these competencies should be grounded in the 5 step model 
  3. Further research into the most effective and efficient methods for teaching each step should be fostered and linked with ongoing systematic reviews on each step
  4. core assessment tools for each of the steps should be developed, validated, and made freely available internationally
  5. courses that claim to teach EBP should have effective methods for teaching and evaluating all components. 

Looking at those five steps it is clear to me (and also in the research papers) that changes in education are necessary!

EBP cannot happen successfully until our education changes. One of the major themes throughout the papers is leadership. 

For us, this means our associations, regulatory bodies, and schools need to step up and make a change. These organizations must create and implement policies that push the profession toward EBP. 

This isn’t limited to just our entry to practice education, it should include continuing education courses. When we look at the courses that our associations are willing to promote (and get CEC approval from the regulatory bodies), 1% of them are EB (yes, I’m making up 1%, but I’d be willing to bet it’s not much better than that).

When it comes down to it, I don’t care what we call it anymore, EIP or EBP. All that matters is we are reading the best available research and trying our best to implement evidence into practice while also putting the people in front of us first. My buddy Rey Allen left a comment on a thread that said something to the effect of “Let’s just call it science based practice”. I’m good with that too (in fact, maybe that’s better overall). But, until the leadership in our profession changes and starts to implement policies to make things like this mandatory, I’m not sure we can apply any of these titles appropriately. However,  this doesn’t mean we shouldn’t be putting every effort forth to make this happen, it’s quite the opposite. We HAVE to make these changes so the profession as a whole is applying evidence in practice. So, let’s start pushing leadership to make a change to make us better and do better for the people seeking out our help and truly deliver care that is being influenced by the best available evidence. 

References: 

  1. Engle RL, Mohr DC, Holmes SK, Seibert MN, Afable M, Leyson J, Meterko M. Evidence-based practice and patient-centered care: Doing both well. Health care management review. 2021 Jul;46(3):174.
  2. Dawes M, Summerskill W, Glasziou P, Cartabellotta A, Martin J, Hopayian K, Porzsolt F, Burls A, Osborne J. Sicily statement on evidence-based practice. BMC medical education. 2005 Dec;5(1):1-7.
  3. Finch PM. The evidence funnel: highlighting the importance of research literacy in the delivery of evidence informed complementary health care. Journal of Bodywork and Movement Therapies. 2007 Jan 1;11(1):78-81.
  4. Kumah EA, McSherry R, Bettany-Saltikov J, Hamilton S, Hogg J, Whittaker V, Van Schaik P. Evidence‐informed practice versus evidence‐based practice educational interventions for improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice: A comprehensive systematic review of undergraduate students. Campbell Systematic Reviews. 2019 Jul 23.

 

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.