fbpx

Articles Of The Week July 1, 2018

 

There are always arguments to be had in our manual therapy fields, and this one ranks right toward the top. Trigger Points. We’ve all “treated” them using various methods, and the explanation behind what they are is debatable, and so are the methods of treatment. So, it’s good to see that both the trigger point and the treatment are being debated.

“Trigger Points – Myofascial Pathology, Or Fight Starter?” – Aran Bright

Throughout manual therapy professions whether massage, chiro, physio, kins, or any other one, there are antiquated explanations that are still being taught. However, in order for all of us to use best practice and evidence-based approach, things need to change. While it’s directed at physio’s, this article is applicable to all of us.

“Orthopaedic Physiotherapy Training In Canada; Reflections On Manual Therapy And The Orthopaedic Division” – Greg Lehman

As therapists we are great at taking care of our patients, but how good are we at taking care of ourselves? It’s really hard for an entrepreneur to fit in vacation time and recharge, but what if there were other ways we could help ourselves to recharge? It could be just 30 minutes a day.

“How To Take Mini Vacations At Work And Not Feel Guilty” – Daniel Olexa

All too often the general public associate’s pain with tissue damage. Hopefully, most of us medical professionals are promoting a different explanation. This article is a great explanation of how there is a medical trap with bad explanations. We can do better.

“Feeling Pain? Get Active: How To Recognise When You’re In A Modern Medical Trap”  – Jill Margo

The brain is more than amazing. This post shows how exposing a child to music education can actually make a difference in reading skills, language skills, and effective communication.

“A Childs Brain Develops Faster With Exposure To Music Education”  – Anita Nee

The Environment For Movement

I just got back from an enjoyable three-day multi-family camping trip. Like several other camping trips or vacations, it for some reason prompted me to write a short blog post. Which is good, because I should really be writing more frequent short blog posts and not just infrequent long blog posts.

What I found interesting about this trip is that for some reason my ten-year-old daughter spent a LOT of time biking. Which is unusual for her, because at home, she hardly spends ANY time biking. If you asked either one of us why, we might have said that biking is not one of her interests, or that she is just not the kind of person who likes biking. In other words, we would have explained her biking behaviour in reference to her internal psychological state.

But during the trip, for whatever reason, she was instantly transformed into the kind of person who really likes biking. She was on her bike within ten minutes of waking up, and then on and off until about ten minutes before going to bed at night.

What changed? Did she somehow become the kind of person who is into biking? Did she have a transformative biking experience that changed her mind? Was she convinced by parents or friends that biking is actually a fun thing to do?

No, because as soon as she got home she went right back to not riding her bike. The only thing that really changed was the environment. Something about this change made a radical difference in her movement behaviour.

We tend to assume that people’s movement behaviours are driven by internal states of the mind, or the fitness of the body, or personal preferences, or discipline, or intentions. All these factors certainly matter, but in some cases, the environment is the most powerful determinant.

Here at home, my daughter has access to a bike, places to ride, and friends to ride with. On the campsite, all these variables were altered a little bit in favour of more biking (perhaps most significantly in the absence of electronic devices), but these small alterations led to a huge change in her biking behaviour.

In terms of complex systems thinking, we could say that her movement behaviour underwent a nonlinear phase shift due to changes in environmental constraints.

I think we should all be more aware of how the environment affects our movement behaviour. And how small changes can sometimes make a big difference.

Articles Of The Week June 10, 2018

I had someone unsubscribe from this blog a couple weeks ago because one of the posts had a swear word in it. Fair enough, some people take offence to things like that (I’ve always used cuss words in my typical language) and to each their own. But it begs the question of whether business people should swear on social media and we found some great advice on that topic.

“Should Entrepreneurs Swear On Social Media?” – Nishi Sood

While it’s sad to see what happened to the surgeon who wrote this piece, it’s great to see that a shift is happening. Becoming more educated about pain and modern research on how we handle that has caused a major shift in one surgeon’s practice.

“Why I’m Leaving My Spine Surgery Practice” – David Hanscom

Remember two articles ago when we talked about swearing? Well, this article has some of that, so be forewarned (but it’s via Ron Burgundy videos, which speaks right to my heart)! But, what the author is talking about is changing the narrative of the osteopathic profession. But, it’s information that could be applied to all manual therapy professions.

“Sixty Percent Of The Time It Works Every Time” – Samuel Jarman

It’s important to understand whether a patient is likely to respond to treatment, and it’s hard to determine that. However, if we understand more about how our treatments work, we are likely to have greater success.

“Who Responds Well To Psychologically Based Treatments For Chronic Pain” – Helen Gilpin

Setting boundaries are important in relationships, especially in therapeutic relationships. Sometimes it can be tough when you get a friend request from a patient, or they start to cross boundaries. Here are 10 tips on building and preserving boundaries.

“10 Ways To Build And Preserve Better Boundaries” – Margarita Tartakovsky

5 Variations On Cervical Retraction

 

The cervical retraction exercise is a classic and works very well for cervical pain, cervicogenic headaches, and general upper quarter complaints. Yes, posture does not directly predict or relate to pain any more than knee flexion causes knee pain. However, common prolonged or repeated activities often cause predictable triggers that should be avoided and novel movements in the opposite direction often desensitize the area and reset the symptoms.

Here are 5 variations on the cervical retraction to make it as comfortable and effective as possible. Remember, it’s the dosage of the home program that really promotes recovery between patient visits, not what you treat the patient within the clinic.

Articles Of The Week June 3, 2018

There is much debate about which treatments work best. Some even demand that some types of treatment don’t work at all, while others are the gold standard. But, in reality, who are we to say which is best, and in turn taking the choice away from the patient? This is a great article debating just that and is WELL worth the read.

“Using The Socratic Method Debate On The Debate About Passive Treatment” – Carl Davies

Hearing stories from those who deal with chronic pain can be a crucial component of being a therapist. This story is a good one. After being fearful of movement, a great therapist gradually exposed the patient to movements with a good explanation, which had a profound effect. Listening to the patients story, and some good education can go a long way in helping patients in pain.

“Why Goldilocks Is My Rehab Heroine” – Cheryl Lee

I don’t think any of us learn enough about business coming out of school, and going into business for yourself is a scary thing! However, all of us are small business owners, even if we don’t own the clinic. So, here’s some great advice from a successful entrepreneur in our industry on how to get started as a massage business owner.

“How To Start A Massage Business” – Rajam Roose

We all know there are lots of ‘myths’ within our industry. Here are seven myths related to health that you may be asked about in your practice. While the author doesn’t go into too much depth in their explanations, they are definitely myths we can forget about.

“7 Health Myths We Need To Forget About”  – Steven Baldwin

There are many aspects that can make us a good therapist. However, probably one of the most important, is how well we can coach our patients when it comes to homecare, or any kind of exercise prescription. If we are all focused on patient centred care, coaching and communication are crucial to beneficial outcomes for our patients.

“How Good Are We At Patient Education?” – Roma Forbes

Are Painful Flare Ups To Exercise, Just Like A Sunburn (and why we might need analogy anyway)

Whilst Exercise CAN be a wonderful tool to use during the rehab process we must remember it is not a stick on, we can’t just fire and forget or plug and play and for every success, there are also failures. There just is not such a thing as a magic bullet in rehab.

Sorry about dat!

Before we get to the analogy stuff we might want to first ask WHY we might want to help people understand what is happening to their bodies and how ANALOGY can help with that?

In some cases, it can be much more about HOW we do things rather than WHAT we actually do.

Why? 

For all the studies we have extolling the virtues of exercise, although make sure you consider the effects sizes, an important question to ask is how generalisable are they to the real world? If I was being all sciencey and shit we could term this the external validity of a study.

Why might these studies lack external validity? In the tightly controlled world of the scientific study participants probably tend to adhere a little bit more to the protocol laid out than they do on their own, otherwise, studies would never get finished. Researchers can also employ things like the “intention to treat” analysis (ITT) that are designed to scientifically smooth out things like dropouts and missing data.

Out in the real world when we throw in the complications of life, exercises, however evidence-based, in some cases can tend to fall by the wayside. This is a problem with human beings they don’t always just fit neatly into EBM boxes. In fact, they can render all the science a touch redundant through things like their beliefs, preferences and lifestyles.

Differences in the definition of adherence used, measurement and estimative of how many patients do not comply with their prescribed exercises vary, but evidence converge on a figure of 50% or higher”  *HERE*

We can all agree that that is a pretty high percentage of shit that is not getting done! What we CAN say is exercise is likely to infer some benefits IF IT GETS DONE! SO how do we go about doing that? And that, of course, is the $1 million question!

Barriers

This is an awesome piece of research that looks at barriers to people adhering to therapeutic exercise programs *HERE* One of the major reasons that people don’t adhere, or a much better term to use, commit, to exercises or exercise programs when they have pain is the fear of INCREASING that pain.

Here is a slide from my recent presentation at the San Diego pain summit.

 

Now, this is completely understandable. Our fears drive our behaviours, so if I am scared of making the problem worse that may drive me to, well, simply not do it. It may then be key to help people make sense of what they feel and how they can manage that.

For a lot of people, the science of both pain and exercise are pretty alien subjects. What’s the difference between exercise-induced discomfort and actual pain? For someone who has never experienced the former then perhaps not a lot! I have been pretty sore from training before and found some activities really quite painful.

The likelihood of getting some DOMS from prescribed exercises for someone with no real history of exercise and a low ‘zone of homeostasis’ could be pretty high, so it is vital we can put these sensations into perspective, allay fears and help people to SELF-manage their rehab.

A useful phrase I picked up a long time ago is “go to the P in Pain not the Y in Agony” which is a really nice way to say go into some discomfort, which of course is normal, but try to avoid rip-roaring pain. We still don’t know if painful exercise is actually bad for outcomes but certainly, it may dissuade someone from carrying on with it.

Things can and will go wrong and setbacks are normal. These setbacks can be influenced by a whole bunch of factors including stress and lifestyle that can negatively affect recovery, and no rehab plan will ever follow a linear upwards trajectory, especially if we are attempting to push the envelope and ‘vaccinate’ against future reoccurrences.

*HERE* we see psychological stress actually impairs recovery from exercise so we must be mindful of this. It may not be the intensity of the sensation that some struggle with but how LONG it goes on for. Desired adaptations such as strength might also be affected by stress too. *HERE*

Pain is often accompanied by worry and stress and could be both a cause and an effect of the current state of the individual. This is why we must be aware that our rehab programs carry the possibility that they could cause an adverse reaction in times of stress.

Analogy

Equipping people with the knowledge to both understand AND address these factors is vital for self-efficacy, another key player in the COMMITMENT to a rehab program.

An analogy is a fantastic way of helping people understand subjects that they have very little background in and for many folks, both pain and exercise fall neatly into this bracket. One of my favourite analogies for exercise discomfort AND pain is SUNBURN. The reason for this is it (hopefully) places the pain or discomfort into perspective and allows it to be seen as a temporary thing and one that can be easily modified.

Rather than viewing an exercise as simply being WRONG, a comparison to sunburn allows it to be viewed more as an issue with the dosage applied and the bodies response. We generally don’t see the sun as a BAD thing, of course, some do but we could put that on the spectrum of fear avoidance! Most people will get sunburn at some point in their lives and just see it is a little bit too much of a GOOD thing!

So what do we do if we overdose on the sun? Generally just ALTER the dosage, simply get less sun the next day by sitting under the umbrella or covering up my burnt bits with a towel, we may have just tried to rush the natural adaptation.

The negative physical reaction is only temporary, often just like the pain triggered from overdosing on exercise, the angry red skin and spiky feeling when in the shower will, of course, go away if I just alter the dose and let nature run its course. What we do see if dosed correctly is a slow natural adaptation that leaves us positively glowing.

What do you usually do next after burning? Well just be more careful when re-exposing yourself. Spend less time in the sun or apply a higher factor. We don’t freak out, in fact often we berate ourselves for being stupid! We know this happens after all. We can do the same with our exercises, just take a little time off or reduce the amount we do before building up again.

Why might we overdose? Perhaps we have been previously been underdosed. Just like coming out of a long sunless winter, not having exercised for a while probably reduces the amount I can tolerate and hence potential adverse reactions. This may explain why just a few sets could leave me pretty sore.

If we have previously been good at a sport we tend to be able to play at a much higher intensity than perhaps we can CURRENTLY handle. In fact being good at something could actually be a risk factor for some! Our skill level may far outweigh our tolerance for the level of intensity we can play at. The same is true of tanning, we tend to remember the lazy long days at the END of a holiday applying Hawaiian tropic rather than the blotchy days in the beginning, piling on factor 30.

Some people can exercise till the cows come home and never feel a thing, a bit like those really annoying people who go an amazing shade of brown by just looking at the sun! We may be predisposed genetically to being LESS tolerant of physical activity. We see discussion of the role of genetics in sensitivity *HERE*

People with fair skin and red hair are often less tolerant of the sun by nature of their Celtic heritage and those of Mediterranean or African origin far better genetically equipped to handle a greater dosage of the sun.

Now, no analogy is free from a negative misinterpretation. Whilst the sun could be seen as having dangerous consequences such as skin cancer from extreme overdosing we also see problems with underdosing such as depression from reduced serotonin. Like all things, it has an OPTIMAL dosage, after all too much or little water or oxygen can also kill you too!

How can we alter the dosage?

  • Frequency – How often. More is not always better.
  • Intensity – How heavy or how fast.
  • Volume – How much. Sets, reps and rest.

Read more here about dosage *HERE*

Take Homes

  • People don’t just fit neatly into science
  • Increasing pain is a real worry with rehab exercises
  • Arm people with information about what to expect and what they are feeling
  • Be smart in the first place – Less can be more.
  • Self-management. Give them the tools to manage the dosage.
  • Give support. If it does go wrong to help people get back on track