Podcast Episode #21 Allowing Research To Challenge Our Beliefs


James Johnston RMT 0:12
You’re listening to the Massage Therapist Development Initiative. I’m Jamie Johnston. And I am Eric Purves. This is a podcast by massage therapists for massage therapists. Our objective is to simplify how to be a more evidence-informed practitioner. Let’s dig into this episode.

You ever have one of those moments where you get faced with a piece of research that challenges, something that you’ve been saying for a long time?

We’re going to talk about that today. Because I’ve been long saying how going for a walk is one of the best things you can do for low back pain. And while it’s can still be an effective thing, we’ve come apart come upon some research that tells us otherwise. So we’ll get into that today. But I think before we get into that one, we’ve got one paper that we’re going to look at, it’s talking about the superior and middle cluneal nerve entrapment as a cause of low back pain. So we had a quick little discussion about this before we came on. And I think some of the points that you were making right away about the anatomy and things like that are probably a good place to start.

Eric Purves 1:26
Yeah, yeah, it’s good to actually come back and do some more recordings of these because it’s been too long. A few months. Yeah. Been busy start to the 2022.

Yeah, the both of things I think will be it will be interesting to discuss, because there is, you know, and this is a debate, I think that’s never going to go away. The belief is that super detailed anatomical knowledge is necessary to be a good quality therapist. And I would argue that that is a belief, that’s an opinion. But that’s not supported by research, by biological research. Now, I think it’s it makes sense for us as clinicians is that we have to understand anatomy, we have to understand, you know, kinesiology, how things move, but I think it do, we really need to know the specific font, like fine details of the human body in order to be better therapists. And I would say that goes against research. And that goes against a lot of, you know, what we know, in practice is that you can get people getting get better. There, they can become have less pain, they can be more functional, without having to like be super, super, super-specific.

James Johnston RMT 2:36
And that applies to treatments to exercise to just about everything that we do.

Eric Purves 2:42
Yeah, yeah. And the people can hear that and feel threatened. Like it makes them think that oh, well, you know, my palpation skills, what’s the point of going to school, I’m useless. And that’s not what we’re saying at all we’re saying is that, that’s, that’s important, but it might not be as important or as necessary, as you think. And there’s other people out there. They’re teaching courses, and they’re like, You need to know these specific interventions to get the specific results. I’m thinking, well, that’s your anecdotal experience. But that is your belief. You know, and you that’s only supported by your own clinical experience. But maybe people are getting better for completely different reasons. And maybe we can treat somebody more generally, and get the exact same outcomes.

James Johnston RMT 3:19
What’s funny I had, I probably shouldn’t go off on too much of a rant about this. But I had a bit of an epiphany the other day that, like, we’ve talked so many times about why people are resistant to change. And I was reading some stuff the other day and came to the my own realization, maybe that we’re doing it because our brain just wants us to feel safe. And our brain is always going to choose the thing that makes us feel safe. And when we look back at our college education we had, I don’t know how many classes that were just manual therapy technique classes. So you look at general Swedish massage, myofascial release, spinal ortho piece, orthopedics, regional orthopedics, cranial sacral, therapy, all these things. And yet, we only had one class on therapeutic exercise. We only have one small class on research with one small class on these other things, there was so much of a focus on assessment and treatment and touching people that we were actually ingrained to believe that that is the most important thing that we can do. And there’s actually I’m looking at some research on it now about how our brain interacts with that and how it’s always going to opt to the thing that is most safe or feels most safe. So that’s what we’re going to focus on. And it takes a little bit of a change in belief system and a change in a way of looking at things in order to get our brain to start going. Okay, maybe I should start looking at more things. So that’s kind of What we’re going to talk about,

Eric Purves 5:01
yeah. And that’s and that’s actually a really good point you make because of how we’re educated. That’s how we’re primed. That’s what we’re that’s what we that’s the beliefs that we take upon us. And what I always like to think though is that if what we were taught, and if what physios and Cairo’s were taught, and osteopaths and act, like if everything that we were taught in school was as effective as they made it think that we were a fixer, we can assess, we can fit, we can fair, what’s the problem, we can palpate it accurately. And we can provide a very specific treatment for if that if it was that easy, then the burden of chronic pain, which is like 20% of the population would be non-existent,

James Johnston RMT 5:44
wouldn’t exist, there wouldn’t be an opioid crisis, yeah, there

Eric Purves 5:47
would not be a pain crisis problem. And I think we need to really understand that we have massive value in what we do. But the value is not what we’ve been led to believe.

James Johnston RMT 6:00
And the thing that I like, as I’ve been looking at this stuff is, and I put a post up on Facebook a couple years ago, that kind of went viral, and it was all about creating a safe space for your patients, is as long as we continue down this path of anatomical and, you know, palpation, and all that kind of stuff is we’re creating safety. In our minds, our brain is creating safety for us, but we’re not creating safety for that person on the table. So we’re actually doing more to make ourselves feel safe, than we are to make the person on the table feel safe. And it’s not until we start to challenge those things and start to change our thought processes, that we’re actually going to start helping the person on the table.

Eric Purves 6:44
While so my friend

James Johnston RMT 6:49
went through this, this thing for the last couple of weeks and looking at some stuff and coming to some profound realizations myself that that, hey, it’s, you know, as much as I think over the last number of years, there’s been so much manual therapy where we get a lot of people feel like we’re pointing the finger at them, saying, You’re wrong for doing this. I think we also have to take a step back and go, Hey, it’s not your fault. Yeah, you were actually primed to think this way, you were primed to believe this. So we just started to have to start changing some of those belief systems.

Eric Purves 7:25
Yeah. And we all were right, we’re all guilty of I mean, we’re all we all have gone through this journey. And we’ve all kind of, you know, gone our own directions and some of his cross to another side. And some of us have stayed where we are, and some have crossed another side and people people change. The one thing I do notice, though, and the reason we wanted to talk about these things today was there has been you know, in the the wonderful social media world there there has been some people out there that I think are without saying it, I think are uncomfortable with what we’re with what we are doing. And the message we’re trying to get out there, which is I said, I mean, I think the messenger trendier is more empowering, and having people feel how give more freedom and be more explore more movement and more touch and, and to not worry about these things which aren’t helpful. Like that’s what the message I think that we’re trying to get across. But other people out there hear that message. And they think, oh, that’s, you know, like myth busting is you shouldn’t be doing that. Or they think that no, you need to be teaching specific things or no, you know, you you have to, you know, certain ways you have to assess, and you have to have these these super specific palpation skills, you know, you have to have these magic hands that can find the root cause of pain. And you have to release this specific tissue this way. And you see this stuff and you and you see these other courses out there, people are teaching them and there’s people putting that information out there and their websites and social media. And it seems like maybe we’re just more aware of it. But seems like a lot of this stuff, I think is is almost in response I just said that we’re doing but others in our kind of community or people that are trying to push our profession forward. And seems like we’re trying to push the profession forward. And there’s those people who feel threatened by that. And they like they’re trying to pull us down. Yeah. And

James Johnston RMT 9:12
that I think goes I mean, I was just talking about how, you know, part of what what happens is that the brain is trying to make us feel safe. So makes us keep doing the things that we’ve been trained to do. And in those cases, I don’t think it’s a matter of maybe it’s a little bit the brain trying to feel safe, but I think it’s also because the finances are getting involved. Yeah. And people are trying to make a living off what they teach and and when it gets challenged. They kick back a little bit harder, because they’re what’s the word their income is depending on what they’re trying to say.

Eric Purves 9:48
Yeah, exactly. Yeah. And that’s and that I think that’s because Who are you right? If you have identified yourself as a clinician that has a specific system similar process and you you teach like a shoulder, pelvis and neck, a lower extremity course and you have like this specific way you do. It’s been two days teaching people all these these things on how to treat this area how to assess that area and how to be, you know, release the tissues a very proper way. And who are you, then when you’ve built a career or a industry or business around that? Who are you when that when that’s been taken away? Like, how do you adapt? And I think that’s the thing is, is if you hold on to these ideals who strongly you don’t tend to adapt? Because yeah, there’s your beliefs are challenged, and how you can earn money.

James Johnston RMT 10:39
Yeah. And I mean, that’s part of your identity. Right? Yeah. I mean, we haven’t I don’t think we’ve talked about it a whole lot on here. But for, for me being raised in a very, very staunchly privileged family that we had a quick little chat about before I came on here. It’s sort of the same thing. It’s your that’s your identify that your identity, you’re identified by a title, you’re identified by what you do. And that’s a really hard thing to take a step away from, and then a really hard thing to change. But it can also be really valuable when you do. Yeah.

Eric Purves 11:14
So the key message here is don’t be scared. Don’t be afraid to change.

James Johnston RMT 11:18
Yeah. And it’s funny, because you used the word uncomfortable. A little while ago, and there’s been so much that I’ve read over the last couple of years that the more uncomfortable you get, the better because that means that you’re changing. And if it feels uncomfortable, it probably means you’re on the right track. Yeah. Oh, get on get uncomfortable. Yeah, be willing to change and start making changes in your practice and changes in your life and things like that. But maybe that’s a maybe a longer rant than we

Eric Purves 11:52
That’s all right, you people are listening. They chose to be here. So they may have turned us off by now. But yeah, those guys going off again. But yeah, let’s, let’s talk about some of this, this colonial nurse stuff there. I mean, there’s two papers that we found recently, one of them was called the anatomical study of the middle cranial nerve, Rajon the study of middle cranial nerve entrapment. And the other one was superior middle cranial nerve entrapment as a cause of low back pain. Both of these were rather interesting, I found was because the, like the superior and middle cranial nerve entrapment was basically to summarize what these without paper was, our Mo was like, this is a sore, this might be a source of common pain complaint to people. But they did like they did it through like, I think they did, like surgeries. They did like imaging to find out where the nerve was. And then they either did like surgeries to kind of release the tissue around it, or they did like injections in it, and nerve blocks and stuff. But what was interesting was, what I felt was not paper was that they were saying that this was a big cause of low back pain, but it was I think it was less than half

James Johnston RMT 13:05
of people. And there’s their sample sizes were small,

Eric Purves 13:09
the sample sizes were quite small. And the results weren’t like they weren’t overwhelming for everybody. That’s not like everybody that had a nerve entrapment that was diagnosed from their medical imaging or surgery. Not every person that had that treated, got better. And so what that always makes me think is, it’s might be a generator of noxious or nociceptive stimuli, and might be related to the pain experience. But, you know, for us as massage therapists, we can change it. But the like, so doesn’t matter.

James Johnston RMT 13:46
When you look at the area, like we’re talking about where that is right over top of the iliac crest. Right, right. There’s we’re not talking about BT tissues, we’re talking about things that are very superficial to wear, like, just simply hitting it could cause pain. You know, we’re not, we’re not talking about anything really deep that’s going on. So to label it. I mean, there’s, there’s no doubt that you can definitely have pain in the area. But because it’s so superficial, we’ve probably got a pretty good odds of when we’re delivering a massage, being able to reduce that pain by just going in and making it feel good. Yeah,

Eric Purves 14:25
exactly. So do you and that’s the thing I would want to ask is does that do you need God specific? Do you need to actually try and target that specific nerve? And if you if the nerve is, say trapped, so to speak in there for whatever might be causing it? Is there value in trying to go and being specific and try to like, release it? Because if it’s a trapped nerve, it’s probably inflamed. It’s probably very tender and sensitive. So does it make sense to try to go work in like poker right in there. I think you You’d want to work around it. And and whether it is joints, whether it’s nerve, whether it’s doesn’t matter what, what might be the, the main contributor to the person’s pain, it shouldn’t really make a difference what it is that because our treatment should still be the same would be to find touch and movement. It feels good.

James Johnston RMT 15:22
Absolutely. And then, like one of the things that I noticed reading through, I only read through one of the papers, the the low back pain. One is that, basically, they’re talking about a lot of cutaneous nerves, and then they’re comparing it a lot to trigger points. And when we look at the research background on trigger points is that it’s likely, like it’s most likely that just cutaneous nerves are having a referral pattern or for real pain. Right. So, because they talked so much about trigger points in it is, is the actual source of the pain coming from the middle clinical nerve, or is it a referral from a trigger point? Right. Right. Like they’re like, there’s so many other things going on. And because it’s so superficial, I just don’t think that we need to give it as much attention as as what it’s being given in these papers.

Eric Purves 16:19
No, no. And and I would say to that thing is always going to kind of bugs me a little bit is that when you’re reading this, this paper that the we’re talking about are things from 2018. So it’s not that old. But they’re still talking about trigger points as being being a thing that they have to accurately palpate. Yeah. And then we look at some the other the wealth of research on trigger points, they show that they’re not always that easily agreed upon when palpated from different clinicians. So yeah, it’s it’s, like interesting anatomy. But so what?

James Johnston RMT 16:54
Yeah, but it’s almost like they’re ignoring the other research on trigger points. Yeah, it’s right to prove their theory.

Eric Purves 17:03
Right. Yeah. No. And here, one thing they mentioned is they talk about how do you assess for how do you like, diagnose it? And one of them is they say, the canal signs, is that tapping over? The very specific part, which is, let’s see if I can find it here. I guess what, right where the nerve goes kind of over around the psis. Find it here. It sounds like science detected at the site of nerve penetration, but three to four centimeters from the midline. So So basically, it’s a tonnelle sign around the area, where the around the iliac crest, and if you get like a nerving a nervy type sensation, then that means that it could be potentially a nerve. But what I always like to say is like, Okay, interesting, but so what so as a massage therapist, right, someone comes in, they’re complaining of pain around the restaurant, they’re low back, it’s radiating a bit. Okay, well might be a bit of a nerve. But do we need to go on being provoked? Do we need to go and provoke it? Like, do you want to go in there and assess it and poke it and punch it? And like, see more? What’s that

James Johnston RMT 18:13
and make it more aggravated than it already is?

Eric Purves 18:15
Yeah, I just did me it just to me seems a little bit. It seems a little bit like does it. So what I guess is why we think like, it doesn’t matter, right, you know, most low back pain regardless what it is, is going to be aggravated by certain movements, positions, or prolonged postures in one way or another or not. And maybe yeah, if there’s more numbness reported, and maybe there’s more of a nerve, than if it’s more kind of like a muscular or joint sensitivity or ligamentous strain or something. But I think your treatment would still be the same. And because when I’ve seen these things in clinic, you’re like, Okay, well, let’s just see what feels good. Let’s find movements that feel good. Let’s find exercises that feel good and just the dark. To make it easier. Yeah. So I know, it’s kind of interesting. But so I just how I feel about some of these ones, but they get a lot of they get a lot of attention. And I think because like you said, we like we started off with, is this comfortable to know the specifics? Oh, your source of pain is this, and I’m the one that can fix

James Johnston RMT 19:17
it. That’s, I think where it comes from? Well, I think we’d pick that apart.

Eric Purves 19:24
Yeah, there’s just one other one too. And this one, this one got a lot of got a lot of press to call the called anatomical study of middle cranial nerve entrapment. This was the one that was there was a the researchers had made an assumption that basically that the middle cranial nerve can get trapped under the long posterior sacroiliac ligament, right, which kind of goes like, kind of between the sacrum and the psis. There, right. And they thought, well, this is an undiagnosed cause of low back or leg pain. That’s what the that was kind of what they’re looking at. So they they actually what they did, they did a cadaver study, where they had 30 pelvises with the mean age You’re 80 years old. So these were seniors senior pelvises, that they were in cadavers, right. But the thing that was interesting was, they did find that about 13% of people in this anatomical study had middle cranial nerve and trauma and under this long posterior sacroiliac ligament, but they don’t know if any of these people have had pain. All they like so because did those 13% of people that had that injury? Did they experience pain? We don’t know. It doesn’t say in the study. So there’s a lot of assumptions here. It’s saying, this is a thing that happens the leg of the 13% of people that the nerve can kind of go through or under this, this, this ligament, and we know that all humans are different, right? And our anatomy is different. So it goes through or under there. But does that mean you’re going to get pain, maybe it increases the chance that you might get, you might experience pain. But this study doesn’t show us anything other than interesting anatomy doesn’t say there’s any relevance to pain. And then again, it doesn’t say if there’s anything you can do about it. With manual therapy. Oh, really?

James Johnston RMT 21:06
It’s all just a big maybe.

Eric Purves 21:07
It’s a big maybe. Yeah. So I just do I see, when I see people commenting on these things, I see that I saw this this paper shared and a bunch of different pages. I thought, Okay, well, maybe I met let’s let’s be skeptical. Maybe there is a thing here. It didn’t really. I it was like interesting. So what, again, great.

James Johnston RMT 21:27
It’s sort of like that. I don’t know if there’s much clinical relevance to it. But remember, in college, they told us that there are certain amount of the population that the sciatic nerve goes through piriformis. Yeah, but there was never mentioned that, you know, and I, somebody can call me out on this. I think the number was 4%, when I was in school that 4% of the population has that. And I could 100% be wrong. But there was never a discussion of those 4% experience more pain or have more disability or anything else. Right than the other. It’s just this is an anatomical difference. Yeah. So.

Eric Purves 22:02
So that’s, yeah, and that’s what I see with these things, too, is that the eye, oftentimes, it seems that people want to find a specific anatomical thing. And then they that can give them a reason or an explanation for why somebody might hurt, which it might be, but us without using a fluoroscopy or ultrasound machine or an MRI, which we don’t have access to in our clinics. If we do then you’re going money and training. But we don’t know.

James Johnston RMT 22:35
Well, they

Eric Purves 22:37
and they even say that too. They say even say here that the gold standard is a fluoroscopy. Where are they? And then they do an injection. And that’s how they find out. But that’s not something that we can do at our clinic. So what do we do if we think that somebody might have a middle middle cranial nerve or superior cranial nerve and treatment, and it’s not getting better with kind of traditional or conservative care, maybe you can refer them to a doctor and maybe they can get sent to a specialist where they can get this diagnosed, and maybe they can try something. But my I’m always concerned, because early in my career, I worked right next door to like an interventional pain management clinic where basically all I did was inject and cut people that and blocked things and ablated things. I didn’t see we didn’t. I didn’t see a lot of people get a lot better.

James Johnston RMT 23:27
Yeah. Well, I mean, even looking at the paper you were talking about, they’re like, they’re they’re doing these studies on cadavers. But there’s no report as to how much pain this person was in. So let’s just say that this person was experiencing pain in the low back, just before they passed away. Well, that the anatomical difference didn’t change a year before they passed away. It’s been like that their whole life. Yeah. Right. They their body grew that way. And they didn’t experience pain through their entire life because of this corneal nerve thing. That is an anatomical difference. Right? So again, why does it matter?

Eric Purves 24:06
Yeah, yeah, that’s fine. Why does it matter? I don’t know if they’ve gone

James Johnston RMT 24:09
their whole life without getting in. These weren’t people that they dissected when when Oh, they’ve been dealing with persistent low back pain for the past 30 years. Let’s look and see what the difference is. This is just oh, that we’ve just noticed anatomical difference,

Eric Purves 24:22
right? And that there may be other studies out there and hopefully someone that’s listening or something, maybe they maybe they do exist, haven’t seen them, but doesn’t mean they don’t, they don’t exist, that maybe they do maybe can have, you know, do cadaver studies on people that had suffered from low back pain, severe pain, and then look to see what you find. You’d always would have to compare that versus somebody that didn’t have low back pain that was around the same age and could do a comparison to see and

James Johnston RMT 24:48
then lifestyle and saying,

Eric Purves 24:50
Yeah, based on other like anatomical studies, it shows that you can have those things and have pain or you can have those things are not happening. So the relevance right doesn’t really matter. I think a lot of times we can get jump into these these these thought rabbit holes where we think all this stuff is, is going to be the reason why we can fix people, which is I don’t think it’s helpful. Okay, next one.

James Johnston RMT 25:24
Yeah. Okay, so the next one is walking, cycling, swimming for nonspecific low back pain, a systematic review. I really liked this, because I will constantly be an advocate that as massage therapists, we need to incorporate more movement and more exercise into our treatments. And I’m starting to lean much more to the side of let’s stop calling it exercise because people don’t necessarily want to do exercise. But typically, people want to do movement, so let’s just call it movement. So this is where my bias has got really challenged, because I’ve long been an advocate of telling people that they can, that going for a walk is one of the best things they can do for back pain. But that may not be the case.

Eric Purves 26:12
Yeah, and this, this was interesting, for sure that the, you know, a lot of the things that you’d want to believe to be true. You’re like, I want this to support my bias. And that’s why I’m set for a walk with my patients. Yeah. And this, this one says, basically, summarize it says, walking is better than doing nothing. Yeah. But it’s not better than doing other more specific low back exercises, more specific meaning, I think they did, like they did some trunk conditioning, they did some of McGill exercise protocols. And then they were they called Pilates was on here as well as, but they called usual physical therapy, whatever that means, which probably means some type of manual therapy and stretching, strengthening kind of stuff.

James Johnston RMT 27:02
pullback stabilization exercises, were one of the things that stood out to me as okay. Yeah. So really interesting, because they, they went through and looked at it. And of course, when they did the study, they ruled out red flags. And they looked at this and said, Okay, we’re, we’re just going to look at the people who are being treated for nonspecific low back pain. So which I’d say is, I mean, I can’t make up the I’ll make the stat up on the spot, but it’s not accurate. I’ll say that 99% of the people that we see that with low back. That’s definitely not an accurate number. But but most of the people that we see, I would say, are dealing with nonspecific low back pain. So and which meant that they had pain or discomfort localized in the posterior aspect of the body from the 12th rib, down to the gluteal. folds. And with or without referred pain into the legs. And if, if we could see everybody who’s listening, put your hand up if you treat somebody like that everybody everyday. Yeah. Yeah, it’s so common. So caught it, probably five people a day who come in, and that’s what they’re dealing with. So they basically looked and said, they compared like swimming, walking, running. And there’s there wasn’t a ton of studies that had been done on swimming, however, or sorry, swimming and cycling. But for walking and running, there was a lot that hadn’t been done. And it basically came down to not one of them is more superior than the other. And I think you can also look at it and go, which one does the person like the most? Yeah, go do that thing.

Eric Purves 28:40
Yeah, and that’s a that’s a great point. And that because that was the question I had to was how meaningful reads intervention is to the person, the right person? Do they value or they enjoy walking, cycling, running, swimming? You know, that would be a question I think worth asking is, if you gave people a certain amount of options, say, these are the things that might help you, which one of these is the one you would like to do, which is, which is the one that you think you could commit to do on a certain schedule that you would set up with a person? Yep. And if they show and they go, they’re probably gonna have the best results and they get to choose the one that they like to do most,

James Johnston RMT 29:16
then but that probably going to be the more effective one. And one of the things that that looking through it. Of course, they did. I don’t know if you notice, but I didn’t notice a whole lot of focus on like, the psychosocial aspects of things. It was more just on the, the bio and the exercise side of it. But in the included trials, they talked about people who use a treadmill, they were supplied Nordic walking poles, or they were doing things in a community setting. And I looked at those and I was like, you look at the site, psychosocial factors involved in both of those. That’s that’s going to have a huge make a huge difference in what the person’s going through. Because if you think about somebody who on a treadmill, they have the support of the treadmill around them that should they trip, they can grab it, you know, if they all of a sudden have low back pain, as opposed to say, being out in the middle of the street where they don’t have a support around them, should they start to experience back pain. Because I know I’d like I have intermittent back pain once in a while, where something happens. And it’s like, oh, it kind of takes your breath away. And, you know, having the psychological side of, Oh, I’ve got the support of the side of the treadmill that I can catch myself on, I’m probably more likely to do that, then going out for a walk by myself. And then I looked at, like, if you’re using Nordic walking poles, then you’ve got a whole lot more upper body involvement in this exercise. And then in a community setting, yeah, if you’re going out for a walk with a group of people, then you’ve got that social support when you’re going out and doing it. So there wasn’t any mention of those factors. But they mentioned that those are things that are effective in helping these people. So I’d love to see some more research or some more looks at how much those social settings make a different sort of psychological social settings make a difference when when people are using walking as a as an exercise for low back pain?

Eric Purves 31:10
For sure. Yeah, that actually would be really interesting, what kind of follow up study because this one was there, basically, it’s looking at outcomes. Right? So for mechanisms not looking for rationale. So I think you make a good point there that, you know, these things are, I mean, all I would say anything, any intervention has a psychosocial aspect it has to. And some might be more so than others. I mean, even coming and getting a massage is has psychosocial, because you’re with somebody in your room, and you’re hanging out with them, and you’re, you know, interacting with them. You can’t. There’s a human there, and there’s two humans interacting, right. And I think that’s a good point with this tool is that people that I was the people that valued the activity, and they they valued doing something with other people or being out in the community, you know, is probably better than sitting at home doing nothing.

James Johnston RMT 32:01
said, Yeah, especially if that was part of your social system before. That there’s people that you went for a walk with everyday, or you went for a run with everyday, and now that’s taken away from you. The quicker you can get back to doing that, I think the bigger difference it’s going to have.

Eric Purves 32:16
Yeah, it was interesting, though, that the there was no I think there’s only been one study each that looked at the effects of cycling. Another one another site that looked at the effects of swimming on low back pain, I thought that was surprising that they these read these, when they did this review, they only found one study of for each of those. I thought there have been more,

James Johnston RMT 32:37
especially to me, like because we there’s so much about aquatic exercise with rehab, you would think there would be 1000s of studies in swimming as part of aquatic exercise. Yeah, but yeah, there wasn’t, wasn’t much at all. Yeah. But I know, like we said before, if there’s one of those things that you enjoy more, it’s probably going to have a more profound effect. Because if I’m having a little back pain, and you told me to go swimming, I’m going to tell you where to go because I sink like a stone and I’m worried about drowning in the pool.

Eric Purves 33:07
I’m a terrible swimmer too. I, I if I if I go and like lie in the water and put my body out and take a deep breath. And like people like you’re supposed to fit this in like no, I will go straight to the bottom of the pool. I’ve always been like, ever since I was a kid hasn’t changed. Even as you get older and heavier. You’re like, I don’t float. Yeah, I still don’t float. I’m like an anchor.

James Johnston RMT 33:30
Yeah, I think we both have the lower body density or something that just makes us sing. But

Eric Purves 33:35
yeah, my legs just go straight down. Yeah. Yeah. So that would work for me. No, I, I can swim. But I’m not a good swimmer. And I don’t

James Johnston RMT 33:46
care for water. Yeah, maybe we’re going to depend on next weekend and the girlfriend wants to go surfing and I’m like, That’s great. You go ahead, I’ll be at the VRBO oven.

Eric Purves 33:59
here and drink coffee or beer or whatever. And yeah. This this study, though, is I think we’ll include this in the show notes. What I did like with this so and you don’t they don’t see this enough in studies, I find it but they actually have at the end there live thing is that key messages for clinicians. For those people and in our industry and those people that are actually working clinicians that want to be mindful of the research and be able to like apply to the practice, I think you need like the synopses that so clinicians can kind of flip through it and they don’t want to have to go through all the results and analyze all the data they want to like what’s like what’s the actionable items and what can I do with this? And I do like that they had this here and I’m just gonna read it because it’s I think it’s it’s important, says under key messages for clinicians, walking, running, cycling and swimming, appear to be slightly less effective than alternative interventions for Treating low back pain. So kind of traditional care, or physical therapy care as well as some, you know, specific low or anxious, I should say specific exercises designed for low back, whatever those might be, are more tended to be more effective. Right? Is walking impossibly swimming provides small benefits when compared to minimal or no intervention for treating chronic or recurrent, nonspecific low back pain. So like we started this off with doing something is better than nothing. But not much better.

James Johnston RMT 35:33
Yeah. What do we look at? Like, let’s talk about the the other interventions, the things I noticed that they mentioned were stabilization exercises, tai chi, general exercise or physical therapy. So all of those are just different forms of movement. Yeah, that we’re using, right? So those forms of movement are just a bit better than what going for a walk or going cycling are. And if you have a patient who hates going for a walk, hates going on a bike and hates going swimming, then use all those other things. Yeah, if you can use some of those other things, but they love one of those other things, then incorporate that into it as well.

Eric Purves 36:15
I would love to see a study that looked at, say, walking compared to getting a massage.

James Johnston RMT 36:25
Yeah, because and that’s one of the things that they talked about in this is they did not compare those things. Yeah.

Eric Purves 36:29
Yeah. Because it’ll be interesting to see, you know, someone values coming from I love massage helps with my low back, someone comes in to get a massage. And another group goes and just goes as low back pain, they just go for whatever 20 minute walks or whatever, 10 minute walks, whatever they decide, you’ll be interesting to see to see how the what the outcomes were for people, if there were if anyone was better or worse than the other? And I would say a lot of it would probably come down to patient preference. Yep, I’d be my guess.

James Johnston RMT 36:57
Yeah. Yeah. But with that, I will constantly advocate that we shouldn’t be constantly doing passive treatment, we should be doing some sort of active treatment as well. Yeah, that could be going for a walk with your patients. And, and I know, you’re like when we look at the industry, you’re you’re commonly thought of as the pain guy. Because you, you know, that’s the stuff that you teach about more. And I think for me, I’m looking more as the Preventing disability guide, because I’m more on the movement side of things. And wanting to encourage encourage more massage therapists to be involved in movement. And, and we looked at the when they looked at the differences, they said compared to no Underbase to no intervention, using these exercises, is better for reducing both pain and disability. Yep. Right. So for for both of the things that we love talking about. Yeah, his exercises work well for him.

Eric Purves 37:52
Yeah, exactly. And I totally agree with you is the being able to incorporate more movement, or movement advice or movement, exploration and treatments is really, I think we really powerful for people. Because I think we all have in our industry, we all have certain types of people in society, and that come to see us. So people just want to get on the table and have massage feels good. Right? Great. You’re not going to force those people to do something, you’re not going to force them to go through a barrage of orthopedic tests and all this movement stuff, if that’s their like, I just want to get I just want to chill out I just want to. But then you have those other people that come in, they’re like, I don’t care. I’ve seen everybody nothing’s working. Just make helped me feel better. Those ones I think those ones there, you probably agree those are the ones that you really want to encourage more than just the passive care, use the massage in conjunction with the movement, and then the exercise or movement. Plan movement program. We don’t want to go and exercise I think is is super valuable. And yeah, I think that’s that’s totally your your niche that you can have a lot to offer to how to incorporate that stuff.

James Johnston RMT 39:03
Yeah. Because Because those people that are coming in, they’re like, I just want to massage. In those cases, we’re typically not dealing with pain or disability. We’re just helping somebody that just wants to feel better. Maybe they need to chill out for an hour. Maybe they just need a break from the family. They need a break from work and they didn’t have it on the table just to have time to themselves. So like you said, in those cases, we’re not going through a whole barrage of different things in order to help them they just need to chill out for a little while. But for those other people that’s that’s where we need to do more for them. For sure. Easy I think that’s a great way to wrap up. Yeah,

Eric Purves 39:40
I think there’s the the two key points in this was low back pain might have something to do with cranky nerves. Yep. And she nerves, but we don’t really know. And it shouldn’t really matter because your treatment interventions would should still be the same and movement Doing something is better than doing nothing. But for pain, but I think overall health moving is better.

James Johnston RMT 40:06
And you’re probably going to have better outcomes if you can incorporate the two. Yeah, you don’t add some movement and help those people who come and see you. Too easy. Beautiful, right. Until next time, everybody. Thank you. We hope you enjoyed this podcast. These kinds of topics are what we are all about. If you’d like to learn more, go to our

Eric Purves 40:31
websites, themtdc.com or ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.


An Attempt At Simplifying Central Sensitization


Have you ever had one of those appointments where you’re not sure of the outcome or the patient interaction?

I remember having a patient back in college who would come in for treatment of back pain. The person was in their early 20’s and told me they were dealing with chronic pain in the area. 

During the first treatment, as soon as I put my hands on them and pressed down, they quickly informed me that was too much pressure! So, of course, I backed off and used a much gentler touch. 

I felt like I was barely touching them. 

So, I treated the person a few times; then, they booked in with one of my classmates. 

However, during their treatment, the patient said “your treatment was okay, but you don’t use as much pressure as Jamie”!

We were both perplexed as my classmate said they were using very light touch (I think I had put something in the treatment notes about pressure). 

Neither of us could figure out what was the correct approach. There is a chance this was just therapist preference, but there’s also the possibility of something called Central Sensitization. 

Understanding Pain

It’s probably important to start by talking about Nociception. 

Nociception itself is not pain; it is the detection of noxious stimuli, which is a protective response that generates a reflex withdrawal to get us to stop doing whatever thing we are doing that could cause tissue damage. (1) Another result of this is it helps us avoid doing those things again (think the first time you put your hand on a hot stove, and will likely never do that again). 

When sensitization of this nociceptive system is repeated or more intense than usual, then the amount of stimulus needed to create pain decreases and becomes amplified. (1)

So, for Central Sensitization to occur, an intense stimulus has to happen repeatedly over an extended period. (1) Think of something like jabbing your forearm with a sharp pen for a couple of minutes (don’t actually do it, I’m just giving examples!). Doing the same thing with the pen for 5 seconds won’t have the same result. 

When this happens, it leads to Nociception no longer being a protection, and pain can arise out of nowhere. 

This can result in allodynia and hyperalgesia, and it is necessary to recognize the difference between the two. 

Hyperalgesia is where an increased response at a normal threshold or increased threshold creates an enhanced pain sensitivity. This is common for things like neuropathy. 

Allodynia is pain from something that shouldn’t be painful. Like the touch of a feather, as you can see in the image below.(2) 


Image from: Tsagareli, Merab. (2013). Pain and memory: Do they share similar mechanisms?. World Journal of Neuroscience. 3. 39-48. 10.4236/wjns.2013.31005.  


As well, pain can be exaggerated and prolonged because of its response to noxious stimuli and can spread to other parts of the body, which is called secondary hyperalgesia

The research papers cited show a whole host of molecular changes and activities in the spinal cord that lead to CS, but I’m not sure we have to know those specifics. It is important to know that these changes are happening in the dorsal horn of the spinal cord which is sending signals to the brain. 

Another essential takeaway is how there is no single defining mechanism; it’s a general phenomenon that changes how a stimulus is interpreted. 

So, how often have you had a patient come in where maybe their pain experience didn’t make sense? Perhaps their arm hit the door as they walked in, and it was excruciating? Maybe their description of what they are going through didn’t make sense? 

Well, this may be in part because of some CS occurring with them. Because tissue injury is not necessary, and pain can be maintained even though there isn’t any injury that has happened (recently), these may be signs that something more is going on. 

However, we aren’t able to diagnose this, but it may be vital for us to recognize it. So, let’s look at some conditions where this is common for people to experience this. 

What About Clinically? 

So, part of the issue with CS is that the CNS can change, distort, and amplify pain all without an actual noxious input. When we look at the lack of an injury, it may seem as though the pain isn’t real, but it most definitely is.(3)

So, imagine what this is like for the patient sitting in front of you. Especially when there could be things like work-related compensation etc. involved. (3) 

Another aspect regarding this condition is that it is complicated to diagnose because we cannot measure sensory input. So, pain hypersensitivity alone isn’t enough to say someone has CS. Some of the things they look at to determine if it is CS are (and remember how I said ‘a whole host of molecular changes and activities in the spinal cord that lead to CS, but I’m not sure we have to know those specifics’): (3)

  • pain mediated by low threshold fibres (but they have to use nerve blockers and electrical stimulation to figure that out)
  • spread of pain sensitivity to other areas without any injury
  • aftersensations (prolonged sensation after stimuli has been removed)
  • something called ‘temporal summation’ (basically things happening at the action potentials of nerve conduction)
  • pain continuing on from a small stimulus that usually wouldn’t cause pain

So, clearly, for us as Massage Therapists we wouldn’t be able to develop an accurate diagnosis for one of our patients, as much of this would have to be seen under MRI. 

However, we can look at some conditions where we are more likely to see this as CS can influence the following:(3)

Rheumatoid Arthritis

  • during flare ups more pain in the joints and remote areas could set up a state of CS


  • degree of pain does not always correlate to extent of joint damage or active inflammation

Temporomandibular Issues

  •  associated with increase in generalized pain sensitivity after isometrics of orofacial muscles
  •  widespread bilateral mechanical and thermal pain sensitivity in women
  •  greater referred pain from trigger points
  •  mechanical allodynia with inflamed teeth, don’t become a dentist


  •  several studies showed increased sensitivity to pressure, thermal stimuli, and electrical stimulation of muscle and skin support CS
  •  they use medications in this case to treat the CNS

Musculoskeletal conditions

  •  Whiplash
  •  shoulder impingement syndrome
  •  tennis elbow (widespread bilateral mechanical pain)
  •  deep tissue hyperalgesia in chronic radiating low back pain, with intervertebral disc herniation
  •  characterized by spread of pain and sensitivity to deep uninjured tissue


  •  spontaneous body pain and allodynia preceeding migraine attacks
  •  chronic tension headaches referring to hyperalgesia of neck muscles
  •  CS may contribute to to chronification of tension headaches

Neuropathic Pain

  •  studies have looked at things like carpal tunnel that had enhanced bilateral sensitivity and spread of symptoms with nerve entrapment which supports CS

Complex Regional Pain Syndrome

  •  presents with increase in tactile and pressure invoked pain, presence of contralateral hypersensitivity in the absence of any inflammatory process

Post Surgical Pain

  •  depends on anasthesia and very important during recovery

Visceral pain

  •  IBS/referred pain – use local rectal anasthesia to help
  •  Non-cardiac chest pain have esophogeal  hypersensitivity   
  •  chronic pancreatitis – generalized deep pressure hyperalgesia
  •  urological tract hypersensitivity associated with: 
  •  interstitial cystitis
  •  chronic prostatitis
  •  endometriosis
  •  vulvodynia


  •  fibromyalgia, tension headache, tmj, IBS
  •  no inflammation or cause which suggest CS
  •  good chance of genetic factors
  •  can contribute to depression, fatigue, joint pain

Okay I get it, that’s a LONG list. This post was intended to be a way to simplify what CS is, but there really are no ‘simple’ answers, especially for what we do to help patients. So there may not be a lot we can do treatment-wise, but what’s really important is to recognize what the person is going through. They may not get a CS diagnosis; they may not get any kind of diagnosis at all. 

And we know that patients (and insurance companies) really want to get a diagnosis to understand what is going on. So, our role may be to simply VALIDATE, VALIDATE, VALIDATE, the person sitting in front of us. You may be the first person who believes this person is in pain. Take the time to listen to them, let them talk, and support them! While you will likely have to adjust the pressure you use during treatment, those treatments may become supported self-management, and you may become their biggest ally for their journey. I don’t know to this day if that person I saw while I was a student had CS, I just hope I did a good enough job of minimizing their pain and feeling good, even for just an hour at a time. 

If you’d like to get more in-depth with the topic of Central Sensitization, Dr. Melissa Farmer has a great four-part series on the topic which you can read HERE


  1. Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. The journal of pain. 2009 Sep 1;10(9):895-926.
  2. Tsagareli, Merab. (2013). Pain and memory: Do they share similar mechanisms?. World Journal of Neuroscience. 3. 39-48. 10.4236/wjns.2013.31005.  
  3. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011 Mar 1;152(3):S2-15


People Don’t Follow Guidelines For Back Pain Because There Is No Path To Follow

I get the opportunity to chat about back pain now and again around the world and one of the things I often talk about is the current guidelines around back pain. I will admit to often feeling a little apprehensive around this subject as the current guidelines run contrary to the way many HCP treat this common problem.

There is always a little gasp when manual therapy, acupuncture and ultrasound get relegated to adjunctive treatments. “Don’t shoot the messenger” is often my get out of jail card.

We know that clinical guidelines around most things within healthcare are not well followed. The big question is why?

We Are Humans!

Healthcare professionals are humans just like the people we are trying to help and suffer from exactly the same issues. For me there are parallels between getting clinicians to follow guidelines and getting people to be compliant, adherent, committed or whatever you want to call it to exercise programs or health improvement or even taking medications.

We all know that getting fitter is good for us as is reducing smoking, drinking and eating crappy foods. But that does not mean we always implement this knowledge. People still smoke and drink too much and don’t get the recommended dosages of exercise. Big societal messages are needed, but so is how to put them into practice at an individual level.

The big problem I see is how gigantically broad the guidelines are around treatment. Let’s take my favourite subjects’ activity & exercise, the guidelines are clear, movement is good, but the evidence base is not really clear when it comes to putting these recommendations into practice!

We might ask ourselves which exercise? How much? How should they do it? What should it feel like? Might it make the problem worse? How to get people to actually do it? If I look back at my clinical education in back pain treatment mostly it was based around Maitland mobilisations with little about exercise treatment and implementation.

So a simple guideline turns into a much greater clinical problem.

Providing A Path

Fundamentally we cannot expect people to implement something without giving them a way to implement it. We need to provide a pathway in much the same way we need to provide a pathway for the patients we work with around exercise.

How can you guide someone in something of you have no idea how to do it yourself?

Imagine getting a bit of flat pack furniture that did not come with any instructions. The pile of pieces that lay in front of you daring you to put them together. Some hardy souls, and probably those with a heap of previous experience, might attempt to put them together. Most normal folk, myself included, would simply put them back in the box and push them to the corner of the room. This conundrum is simply too much to handle.

You have all the pieces of the puzzle, but the problem is putting them together!

Education is another prime example. Education about what? Back pain? Pain? Treatment? Prognosis? All of the above? How to do it? Again there are many questions to unpack within the broad recommendation of education. I received no education in education at undergrad or post grad as I suspect neither have many of you reading this. Again this provides a barrier to implementation at the most basic level.

In the face of uncertainty and low confidence we return to our old habits that are ingrained within us and for many that is not based on current guidelines. Uncertainty provides huge inertia to change.


Support is another factor that is often overlooked. How many people feel they cannot treat how they want to treat because of the working environment they are in and the people around them? This is something I often hear. Support again is a huge part of behaviour change and maintenance of that behaviour. A major part of self efficacy is built around social support and I doubt that it would be different in the work place.

The healthcare system that people work in can be a huge influencer of the way we practice in the same way our social systems affect our overall health and behaviours.



• Behaviour change is no different for HCPs than it is for patients

• If we want change we have to provide a path to change and support along the way

Beliefs, Communication, And How This Impacts Our Patients

I’m sure I’m not alone when I say I’ve seen some horrific things in my practice.

Now, when I say this, it’s not in the sense of major catastrophic injuries, or gory blood scenes, or something like that.

What I’m referring to is what I’ve seen and heard from patients as a result of what another well-meaning practitioner said to them. 

A patient comes in, sits down, and starts crying because another therapist told them they will never get better.

Another person who has been dealing with chronic pain for several years comes in and equates the pain they’re feeling in their back to a “rib being out”, or “their S.I. Joint is out again”.

And in the more extreme ranges someone giving up a career they love, in exchange for a job they hate because two people told them they would never be able to do their job again because of the surgery they just went through. In fact, told them if they continued doing the job they loved (and were very successful at), the surgery they just had would pale in comparison to the one they would need.

While I know none of these practitioners would intentionally have someone change their job, believe they won’t get better, or would constantly relate pain many years later to a simple biomechanical diagnosis, the reality is, their words changed people’s lives. 

And not for the better!

So, why then does this happen? Why are these enduring effects of words having such a dramatic impact on patients? And, more importantly, how do we stop this?

When Well-Meaning Beliefs Go Wrong

When we say “well-meaning” practitioners I do believe it’s just that. I doubt there are many out there legitimately trying to say harmful things to their patients (although I do believe there are some who use less than scrupulous language as part of the rebooking process).

So, when we have these well-meaning professionals saying things to patients, part of why they are saying the things they are is because they truly believe it (even if modern research refutes it). Part of the issue is when these belief systems are passed on to our patients it can have a lasting effect in a negative way. 

Unfortunately, many of these belief systems can come from continuing education courses that haven’t been updated in years and are still preaching these outdated belief systems.

A great systematic review (1) looked at several medical and paramedical professions to look at how their belief systems, (including biomedical and biopsychosocial treatment, fear-avoidance beliefs, and attitudes) affected patient behaviours.

There were several things that stood out to me reading through this(1):

  1. High levels of fear-avoidance in practitioners are related to the same fear-avoidance in patients.
  2. Practitioner beliefs are associated with the education they give patients.
  3. Practitioners with a more biomechanical base are more likely to advise acute pain patients to limit work and physical activity.
  4. Those with high fear-avoidance beliefs are more likely to recommend bed rest (which we know is not good for low back pain) and are also more likely to recommend this if seen in a media campaign.

Now I realize it probably sounds like we’re bashing anything related to biomechanical explanations here but honestly we’re not.

As we have said so many times over the years, biomechanics are still important, it’s just one piece of the puzzle. What I’m taking from this review is that if we’re strictly relying on biomechanical explanations we’re more likely to also cling to fear-avoidance beliefs as well, which isn’t doing our patients any good.

Part of the problem here is that if a practitioner has these beliefs, they get passed on to the patients we see. One of the major issues with this (as pointed out in the review)(1) is these beliefs result in persistent disability but not necessarily a change in pain.

So, if these beliefs are held, the patient’s pain won’t always change, but there is an increase in disability. Imagine your patients coming in for care and strictly because of a belief system, not only does their pain not get any better, but they become more limited in the things they can do. 

In light of all this information, I look back and think about early in my career and how I was saying very similar things to my patients. There comes a time when we have to sit back and ask ourselves whether the information we are conveying is correct, but also, is it in their best interest?

This review showed that even though some health care professionals believed in the biopsychosocial framework (it was originally introduced over 40 years ago), they were still operating from a biomedical orientation. In the case of doctors, they understood how important psychosocial factors can be yet, they lack the time to properly integrate this into practice.

So, while I look back on my career and cringe at some of the things I used to say, I look at this information and see how beneficial this is for us as Massage Therapists. If we embrace new research and change our beliefs, we not only have the time to spend with our patients, we have the opportunity to create lasting change for what they are going through. 

Words Matter!

So, now that we understand the influence of both the patient and therapist beliefs, the question remains, where did these beliefs come from?

Quite often these beliefs are because of lived experience, observing others in pain, or things that have been told to them throughout their life. A big influence was just not having a framework or a reference of what they should do when experiencing pain.(2)

All too often we see patients going to Dr. Google for advice, however, while this is usually looked at cautiously, people do place higher importance on the advice of friends and family.(2) While people would often seek out care from a health care professional, they would sometimes reject the advice given as they questioned their competence, and would even keep their own beliefs if it conflicted with the advice of a professional.

Now, this isn’t necessarily a bad thing because there’s nothing wrong with a patient using their own intuition to choose what course of action is best for them. It’s important for patients to feel confident in the information being presented to them, in fact, it’s even possible for their symptoms to be influenced by their interpretation of the education they are given.(2)

However, even if we believe we are giving them a very simple explanation of what is happening, there can be an enduring impact. I can now hear my mother’s voice resonating from my childhood and what she would say every time my brother and I would fight: “it’s not what you say, it’s how you say it!”

This paper has several examples of the lasting effect of what we say, which I think are important to highlight.

When a doctor gave a simple diagnosis of a sprain in an attempt to decrease the seriousness of the injury, the patient understood this to mean they had moved in such a way they had strained the muscle and they would make it worse by continuing to move the same way.

In the case of a person getting help from an orthopedic specialist, the result was well…horrific:

[The orthopedic specialist] looked at my back MRIs for a little while and turned around with a grin on his face and said, “You’re a builder, aren’t you?” and I said, “Yes,” and he said, “You’re [expletive], ha ha ha,” and went back to his computer again…. So, you know, I think that was his rather odd specialist way of breaking the news to me that I wouldn’t be working as a builder for very long…. Every time I felt a little bit wrong [after that], I started to sort of add it up in my head. And then my usual way of thinking, “Oh, that’s fine, that’s nothing, that’ll go away, that’s not major enough to stop me working, I’ll carry on [changed]”…him saying that was definitely the point, because I probably would have just carried on(2)

This person actually ended up changing careers as a result of what was said to them! Sadly as I mentioned, I’ve seen the same result in practice as well.

Another example that stood out to me in the same paper was equally as life-altering:

Basically all I’ve kind of been told to do by physios is to work on my core…I’ve been tested by various different physios, and Pilates, and I’m apparently ridiculously weak…. I had an abortion because I didn’t think I could have a baby. I didn’t think I could handle it…carrying it, and having extra weight on my stomach(2)

Can you imagine what this woman went through dealing with this?

Again, I’m sure these were well-meaning practitioners but when our communication is focused more on the things we can’t do as opposed to the things we should do can have compounding long-term effects. If we shift this line of thinking and encourage movement, provide reassurance, and show people how they are safe to remain active it can (and most likely will) have the reverse effect of the quoted stories we shared.

While many practitioners have a belief in the biopsychosocial model, many are still using biomechanical explanations of tissue damage, etc in an attempt to help their patients. As we have seen this can be detrimental to the patients well being. So it’s important to have a discussion around how to change these beliefs in practitioners. Many of us went through college and learned these things (I know I learned many of these explanations in school) and unfortunately, there are many continuing education courses still offering these kinds of explanations. This becomes our responsibility as a profession to change this, and really it starts with each one of us. It doesn’t even mean you have to spend thousands on new courses, it can mean just reading blogs like this, or a new research paper a week (it doesn’t take that long I promise), because we must change our beliefs in order to have a better impact on the people we are seeing in practice. When our beliefs (and our messaging) start to change we can slowly change our patient’s beliefs for better outcomes. Then, hopefully…hopefully, patients feel safe to return to their careers or have babies, or just return to an activity they love.



  1. Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. European Journal of Pain. 2012 Jan;16(1):3-1
  2. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. The Annals of Family Medicine. 2013 Nov 1;11(6):527-3