Podcast Episode #22 Challenging Industry Norms and Incorporating Movement


Jamie Johnston 0:12
You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston.

Eric Purves 0:17
And I’m Eric Purves. This is a podcast by massage therapists for massage therapists.

Jamie Johnston 0:22
Our objective is to simplify how to be a more evidence-informed practitioner, let’s dig into this episode.

Jamie Johston 0:33

It’s often been said that, you know, you’re doing something right when you’re making other people mad. And I don’t mean that in a in an aggressive way that you’re going out and attempting to make people mad. But when you’re putting out content consistently, and it’s starting to disrupt the norm, within an industry, which is what both of us are trying to do, it’s obviously starting to have that effect. Because we’ve noticed after our last podcast, that we’ve been blocked by somebody who was a colleague and a friend for many years. So we just find it interesting that, that maybe we’re actually having some success, because now people are starting to get upset by something that we’re saying.

Eric Purves 1:19
Yeah, it’s interesting. I mean, I’m sure there’s, there’s probably, there’s probably a handful of people that don’t like what we have to say, or, or want to want to block. So it’s funny, though, that, you know, because people have said certain things to me before, they’re like, Well, why do you teach? What Why do you? Why do you have a podcast? Why do you do your courses? Why do you blog and all that stuff, because a lot of times, it comes across as being like calling, calling stuff out, right? Calling out the crap. And as can be, and there’s there can be a negative undertone sometimes. But the goal always is, is to elevate our profession to inspire people to think more in line with the science and, and I would say that the vast majority things that we talk about are not always our own opinions. I mean, I think will state its own opinions or own beliefs or our own thoughts or experiences when when we need to, when that’s relevant, but a lot of time, we’re just, we’re just the messengers, right? We just were reading research or attending conferences or having conversations with with, with smart people. And we learn and we try to bring that information to our listeners and to our students. And sometimes people don’t like that message. But I would say that if you don’t like the message, then maybe listen to what we’re saying. And don’t take it personal. Because it’s never a personal attack on somebody. It’s more about, well, these are things that we’ve said, and these are things that, that maybe other people believe, but what’s the evidence suggest? And what is the what is a biologically plausible explanation for these things? We talk about that quite a bit. Just question don’t attack the messenger, so to speak, just accept that, you know, what, maybe what you think is not 100% supportable. And let’s just let’s just, and let’s look at what is supportable, and, and this is happens all the time, right? I mean, you read stuff, or you see conversations or hear conversations with people that people have. And they’re like, Oh, well, you know, what’s wrong with saying that you’re releasing fascia? Well, it’s wrong. For one thing, you’re not doing that you’re not doing that. But maybe the experience of the person is they feel like there’s something lengthening or softening. But okay, we have there’s a different explanation for that. So let’s not just keep perpetuating these these unhealthy these narratives, which can be unhelpful, maybe they’re not, but at the very least, are not correct. And this goes to something I think you’ve talked about before, I don’t know if you want to touch on this about the idea of informed consent.

Jamie Johnston 3:53
Yeah. And I mean, really, I think what it comes down to is like not only informed consent, but it also comes down to being an ethical practitioner. Because if you’re, if you’re still preaching those old narratives, you’re not getting informed consent from your patient. So when you’re when you’re doing work on them, and I’ve really been thinking about this a lot, I could go off on a rant, but I feel like we need to stop saying that we’re working on people or we’re treating people and I think we need to start talking more about engaging with our patients, and having them engaged in the, in the therapeutic treatment. Because it it should never be that we’re doing something to them. It should be that we’re collaborating with them and engaging with them. So I want to start changing. I wanna start changing my language around that, but I’m gonna start changing all of the language around that too. Let’s engage in treatment with people anyways.

Eric Purves 4:49
That’s brilliant. I really liked that. Because because we are often do I think the way we’re taught and the kind of common expectation is that people come in and we fix them. We do Do something to them to fix them. Yeah. But that’s,

Jamie Johnston 5:03
that goes back to that old narrative thing. That’s a belief. Yeah.

Eric Purves 5:07
But the reality is that we we aren’t actually fixing people, but we’re facilitating or collaborating or engaging gauging was offered to us, right? Yeah. Like we’re engaging with another human to try and find out a way to make them feel better. Maybe that is them just lying on the table for an hour and getting a beautiful massage. Yeah. Or maybe it’s involving Exercise and Movement and lifestyle changes, right, whatever else is in our scope of practice, wherever you where you live.

Jamie Johnston 5:31
Yep. But to go back to the ethics thing. I would think that most of us would, when we think about being an ethical practitioner, we’re, we’re probably looking more at the things like, Well, I wouldn’t build their insurance company, when I didn’t provide a treatment, I wouldn’t overcharge them here, I wouldn’t do this. So I want my practice to be ethical. But when it comes to treatment, and I’m not saying that anybody is intentionally not providing an ethical treatment, but if we’re not staying up to date and getting rid of those old narratives, then we’re not providing an ethical treatment, because we’re giving people misinformation, no different than if we’re giving an insurance company misinformation about what we did for treatment. So if we’re going to remain as ethical practitioners, we have to stay up to date with the new information that’s coming out. And I realized that can be difficult. But it’s, it’s part of what we have to do. So in order to get informed consent on all those other things, we have to treat ethically, and that means staying up to date on things. So there’s, there’s been plenty of times where other people and actually just recently, there was a thread where people were knocking the NOI group and stuff like that. And I was kind of getting pissed off reading it, because obviously, I liked those guys and like what they do. But when you start to get that pissed off feeling, maybe it’s time to take a step back and go, Well, maybe it’s just because I’m getting challenged, and I don’t like it. So maybe I should just take a deep breath, look at what they have to say, and see if there’s any validity to it. And sometimes it can be somebody that you just don’t like that saying it. And then in that case, fair enough, if you want to just ignore it and move on, that’s fine. But if you’re starting to get challenged, maybe that’s just a sign that you need to take a step back and go, Okay, maybe I need to look a little closer at this, rather than getting upset. Yeah. Or maybe reach out to that person. If you’re friends with them and be like taken, we have chat about this. Like, where are you coming from? What does the research say and have a legitimate professional colleague chat with each other, and see what you can do to help each other?

Eric Purves 7:28
It my experience, in all the years doing this is that when people block you or they don’t want to, they don’t want to hear what you have to say it’s because they are usually they’re challenged by or they don’t like what you have to say, because it doesn’t fit with what, how they think. And I mean, I’ve never, I don’t think I’ve ever blocked anybody or I’ve ever. I don’t think I’ve ever attacked anybody. Personally, I’ll attack ideas all day. But I don’t think I would ever attack a person. Because, you know, I know from my own experience that I I use the word thought wrong. My thinking was incomplete for a lot of years until you start to be able to learn more and put pieces together, you start to realize, okay, how I practice and how I thought and how I communicated was incorrect. But I knew that I was often helping people, but the reasons why I was helping them were very different from what I thought. And when people didn’t get better. Oh, rather than, you know, now thinking, knowing what you know, now you realize, oh, there’s an explanation for that. Because, you know, this person didn’t need to be fixed. They needed some support. They needed some, some management, they need to be engaged with not to be fixed. And, and that that, that I think we need to have that humility and say, Yeah, I was wrong. I made mistakes. Every day I make every day. And that’s okay. Because that’s part of it. That’s why they call it a practice. Yeah, we, yeah, we try and do the thing that’s less wrong. So no, it’s it’s tough, tough business to be in. We’re always putting ourselves out there.

Jamie Johnston 8:58
Yeah. And you got to, you got to, I think you have to expect some reaction. But you also have to accept that, you know, just sometimes you’re just gonna say things that people don’t like, unfortunately, in this case, the person had an issue with it. And it’s too bad that there couldn’t be more professional discourse on on whatever we said to upset the person if that’s what happened. And maybe down the road one day that will be hopefully exemplary. So they say, Yeah, so we’ve got a couple. Now that we’ve got that ramps out of the way. Yeah, no, it’s

Eric Purves 9:31
good. Just as good to adding some memes just to talk about that.

Jamie Johnston 9:34
Yeah. So a couple papers that we’re going to look at. I’m just bringing it up here on my iPad. The first one is called comparison comparison of an exercise program within without manual therapy for patients with chronic neck pain, neck pain and Upper Cervical rotation restriction, and randomized controlled trial. So there’s a bunch of stuff I liked about this paper and some stuff they didn’t like. And one of the things I thing that I really liked about it is they, and it’s just confirming my bias, again, is that they talked more about preventing disability in this paper than they didn’t talk about just treating a person’s pain. Because they talked more about, you know, getting that person back to for full cervical rotation, and then flexion and extension and things like that. So there was less of a focus on pain, even though there was some mention on that. But it was more about getting people back to doing the things that are important to them, which I think is the most important reason people come to see us. So that it totally confirmed my bias in that. So that’s one of the things that I really liked about it. And we’ll get deeper into it. But the other thing that I really liked about it, is that so like all of the movements, and all of the exercises they provided, were really simple things that you can do on your treatment table. It didn’t require a gym, it didn’t require, you know, going and having to do all these fancy things, it was literally just simple things you can do right on your table. And, and I think all too often, as I try to push with the course we teach together and in my own courses is that we need to stop being scared about doing exercise and movement with people, we need to do more of that. And this was a great example of how you can just do it in your treatment of

Eric Purves 11:16
it, there’s a few things I mean, with this paper that were good, and there’s there’s some as bad and I’m very critical when I read these things. So I’m gonna, I’m gonna start off with kind of some myths if I didn’t like. And the first one was the journal that it was in, never heard this journal before. So it is an open access journal, which means you can access the papers for free, there’s no paywall. You don’t have to go to Sai hub and, you know, go back door on it. Yeah, do the back door. But when I did find it, it was like its impact factor and its ranking was quite low in this field. So I was like, you know, that’s, that’s usually a concern, which means these papers might not have the best peer review process, or they may not go through a very rigorous process before they publish it with the editors. So that was a little bit of a, I was always a little bit skeptical. I read those things. A couple of things. Which Who is it these tests, these type of studies? There’s lots of them out there probably 1000s. It’s like a one plus one study. So this is exercise plus manual therapy compared to just exercise.

Jamie Johnston 12:23
Which is that? Actually, I don’t want to take you off your neck. No, no. But that’s one of the things that I liked about it is, is usually it’s the other way. It’s okay, could we add exercise to manual therapy? To get an outcome, whereas this was going the other way? It’s like, Well, we already do exercise. So is adding manual therapy to the exercise gonna help. So I actually liked that, that they’re, they’re going that direction rather than it’s always manual therapy and then adding exercise.

Eric Purves 12:52
Yeah, and that and it’s it is I mean, there’s nothing wrong with that, per se, because the lot of these days we’ll say we’ll show and there’s, there’s 1000s that are out there, where you add one thing to a treatment. It’s usually better. Yeah. Then then note, like if there’s like another paper we’ll talk about maybe later, it’s like talks about doing exercise. Well, doing exercise is better than not doing exercise.

Jamie Johnston 13:13
Yeah, doing something is better than nothing. Yeah, so it’s doing something better, I

Eric Purves 13:16
think so this was kind of like, doing something is better than nothing. But doing something plus something is better than just the one thing. So that is, you know, it’s good to know, but the studies are also are pretty common that you do one thing, it’s better than you’re gonna have better outcome. Yeah, better. The other. The other thing, one of the things that, you know, when the that was a little bit when they’re looking at their measurements, one of the things they’re, they’re looking at range of motion. And so range of motion also is and the way they assessed it was subjective, it was the examiner doing it, and when they felt an end feel, or the person reported pain, you know, and then they would measure that that’s very, that’s not very reliable. So it’s, you know, that there is like, a measurement, not so sure. And the other one they did is they looked at what they called hypermobility through manual assessment where they actually just, you know, we’re testing the movement of the of the joints through manual techniques, and we know that those things well aren’t very reliable. But there was a couple things in here which think you know, I did all those are kind of big red flags for me. But I didn’t put I would normally read those things and throw the paper away. But because we were going to talk about this one, we’re like, okay, let’s just dig a little bit further.

Jamie Johnston 14:32
Yeah, I know like there was a number of were there like the measurement of upper trapezius the measurement of lips gap and you can’t really do a measurement just on those things when you’re looking at rotation because it’s a group of muscles that are doing the action not one singular muscle so

Eric Purves 14:47
yeah, yeah, yeah, cuz they also this way looked at so their their primary outcome measure which was the NDI which is an architect’s disability index, which is good because that’s a that’s a very common reliable disability measure. which, which was good, I liked it. That was the primary one, which goes with what he talked about about function, which just should be the primary goal, reduce secondary measures, lower pressure, print pressure, pain, threshold, pain, intensity and range of motion. Those are also kind of very subjective things. So there, those are not always the best. But well, when we looked at the how they did manual therapy, in this, it was basically it was spinal manipulation. We were I didn’t really like it. Yeah. Okay, well, it’s not massage. Yeah, we things. We don’t see a lot of papers like massage therapy papers looking at this. And so you know, they were they were doing chiropractic manipulations, or hivelocity, although I think it was physios physiotherapy, but they did hivelocity manipulations. And they also did low velocity manipulations on different areas to see. So anyway, it was there’s a few things there. But I think the if we were like, Okay, let’s try and be positive with this. It wasn’t complete garbage. There were some things they could have done better. But they did look at function. And they did find, you know, that doing a combination of these manual techniques with exercise helped. In the short and longer

Jamie Johnston 16:19
term. Yeah. Which was great. Yeah, like I said, that was one of the things I didn’t really like is that they were doing spinal manipulation or thrusts. Although looking at a couple of the explanations, they were talking about doing a glide, which is basically a joint modal, which is something that we learned in school. So obviously something that massage therapists can use. But a version one sentence specifically that I highlighted, that said, Another possible explanation for the gain of motion of the lower cervical spine, since this region has not been directly addressed could be through neurophysiological mechanisms. There you go, I would like to take away the could be and say it was from neurological neurophysiological mechanisms. So but we know like when we look at Bilasa T stuff that, you know, everything. Every manual therapy technique that we use, has a neuro physiological mechanism. So even though in this case, they’re using, you know, manipulation, and thrusts and things like that, that doesn’t mean that that specific technique is better than doing a massage, or doing a joint modal or doing other stuff. Because all manual therapy works the same. So we shouldn’t take this as the only way that this is going to be a benefit as if we’re doing spinal manipulations plus exercise. Yes, we can just put that as long as we’re doing manual therapy and exercise, we should have a better outcome.

Eric Purves 17:41
And I would say that’s a fair. That’s a fair statement. Yeah, based on on how we know manual therapy works with all you know, there’s a million different stories about how it works. We’ve talked about this a million times in the podcast, you know, do the technique you like, Yeah, do it well, and do the technique that the person is expecting. And that works for them. Yeah, right. If someone comes in to see you, and they’re expecting a massage, and you just give them joint moebs, you’re probably not going to have a good Oh, you’re not going to be as and especially if you’re not confident with joint ropes, maybe, yeah, right. Or the other way around, they come to see a chiropractor, a physio, where they’re expecting like a, like a crack thrust of some kind, and they don’t get that they’re probably going to be the outcomes probably aren’t going to be as beneficial. So I think that patient or person, their expectations, in a study like this are that they are going to be receiving some type of spinal manipulation. So therefore, there’s there’s already set up to have that expectation. And probably that’s what they want as well. So that’s going to also I would say that’s going to bias the results towards favor, but that’s okay. Because, you know, people come to see us for massage, and we don’t give them a massage or outcomes are probably not gonna be very good. Very good.

Jamie Johnston 19:00
Yeah. Which doesn’t mean that every single treatment they come, every single person who comes in, you should just strictly do massage. There’s a whole gamut of things that are included in manual therapy that we shouldn’t be including as well. So. So yeah, but it’s it’s funny the points that were making there. I had a lot of the same opinions of the next paper that we’re going to talk about as well. Okay. Yeah. Yeah. Did we beat that one to death? And we should get into the next one?

Eric Purves 19:29
Yeah, that was pretty good. I think the it did show that there was decreased self reported pain over time, there was increased range of motion over time. The neck disability. They didn’t really talk about that as much. They they gave us a chart, but they usually in the results section, they’ll go and they’ll explain in more detail, but the next is really they showed a chart and said Oh, things got better, but without explaining the data. Yeah. That that’s a huge chart. And it’s a huge chart. So I thought that was a bit. I don’t know if there were a word count. issue, but I thought that would have been, that would have been the one that they should have I felt they should have gone into more. Yeah, because reading those charts on those numbers sometimes can be very time consuming and difficult. It’s nice when they kind of paraphrase what the results were in like a couple of sentences. So that that was a bit of a concern. But it basically showed that yeah, if you incorporate exercises, with these are simple exercises, like you said, with some type of manual therapy, people are probably going to feel better. So don’t be afraid to put exercise in your treatments,

Jamie Johnston 20:33
definitely get people moving. Yep, reduce reduce that disability. And it would be good to like with these papers, if they, like you said got in more detail with the neck disability index, but also how they incorporated it, how you can incorporate it more into treatment and natural your outcomes and things like that. Rather than it just being oh, here’s what we used. Go ahead and see if you can figure it out. Yeah. So it would be good if that sort of stuff was included as well. But that’s a probably a conversation for another day. Okay, so the other paper that we’re going to talk about is from Journal of physiotherapy title is some types of exercise are more effective than others, and people with chronic low back pain and network meta analysis. So it’s funny, the more of these papers that I’m reading, the more I’m just going well, Pilates for the wind.

Eric Purves 21:24
Yeah, exactly.

Jamie Johnston 21:28
I don’t know how to do Pilates, and I’ve never done it before. But consistently, it seems like it’s coming up more and more and more that Pilates is a really effective management tool for different muscular musculoskeletal conditions, but low back pain, especially.

Eric Purves 21:42
Yeah, yeah, this was interesting paper. I really liked this one, I did a I did a brief review for this in my membership community. And just one thing that like I said before, the last, the last we were talking about was this journal, actually, from the Australian physiotherapy Association, this has a journal ranking of 11 out of about 240, physiotherapy specific journals. So it’s definitely it’s definitely up there. And in the journal rankings, it’s got a good impact factor, which means that the papers that they publish are referenced and used by other research. And so this was good. And I quite liked it. Because, you know, they’re looking at what type of exercise is more effective. So usually, when we we’ve talked this all the time about, you know, clinical practice guidelines or talk about, you know, education reassurance exercise, yeah, are kind of the three things. But what does exercise and what exercise do you do for low back pain? Because exercise is just a vague term.

Jamie Johnston 22:43
Yeah. And I’m at the point now that I’m also, like, when it comes to courses and things like that, I’m gonna, I want to get away from using the word exercise and just have it be movement. Because most people don’t want to go home and do exercise. But they do want to go home and do the movements and do the things that are important to them. So how about we reclassified as therapeutic movement?

Eric Purves 23:07
Yeah, yeah. Yeah, make some it’s, it’s, I think there’s less of a negative connotation with some people.

Jamie Johnston 23:14
Yeah. And it’s, I mean, obviously, it’s not everybody, you can have some people that are like, Oh, they want to get in, do their exercise and do everything else. But you know, some people, it’s, they want to just go home and pick up their kids. Yeah. And if we can adapt that movement, not the exercise, so that they can pick up their skins. And maybe repeatedly picking up their kids is a great movement that they can do to strengthen their back. And by doing a thing that’s meaningful to them, so I’m putting that there’s two things I’m saying we should engage in movement, we could start and stop calling it exercise, coming up into things.

Eric Purves 23:47
When that goes, that goes back to the last, the last podcast we did, where it was basically when we were looking at walking for low back pain versus swimming and cycling and running. I was the last the last podcast we did, which might have upset some people. The end and basically, the findings of that paper we’re doing something is better than nothing. But whatever physical exercise that you do, which one you like, which one you’re going to do, if you don’t like running, but you like swimming, or whatever combination might be then why don’t you do the one that you like, and that was kind of the findings of the of that paper as well. And what I liked with this one, though, is they it was just a huge meta analysis. So I think there was something about 17,000 Participants included in all the studies that they use and the analysis for this, so it was quite significant. And I liked how they they actually categorized all the interventions. And so they included core strengthening or motor control, mixed exercise types, which I don’t really know what that means. It could be Yeah, they didn’t get specific about

Jamie Johnston 24:53
specific exercises were but yeah, but it wasn’t that one I was looking at it and it was more like a global full body type. Yeah,

Eric Purves 25:00
I think so exercise. Yeah. Yeah. Which I think goes in goes kind of along with that. The other section they looked at which was our papers on general strengthening, there was aerobic exercises, once again, very general, pilates, stretching, yoga, functional restoration, which is a term that was an intervention I’m not familiar with, though. We might talk about that again a little bit later because I wouldn’t seem to be one of the top three.

Jamie Johnston 25:25
Between that McKenzie method and Pilates I think it is. Yeah. So McKenzie

Eric Purves 25:29
therapy, flexibility to other exercises. So they looked at, you know, all these different exercises and looked, they use good outcome measures. They looked at, you know, not just pain but also a disability measures. So the Roland Morris disability questionnaire, the Oswestry so for those of us in BC, that treat motor vehicle stuff, the Oswestry is a common one that you’re supposed to use when you’re reporting motor vehicle stuff for low back pain. So yeah, there’s lots of there’s lots of good good stuff in here. But like you said, I think the thing that came down to was really was Pilates for the when Pilates seemed to be the one that had the most Pilates McKenzie therapy and functional restoration. Were the were the three that seemed to be the best exercise as compared to stretching, which I think stretching after read through this again, it was like just passive stretching had kind of like was the the bottom like that was the one that didn’t? Comparatively didn’t wasn’t very good. Yeah. Yeah.

Jamie Johnston 26:25
But it’s really funny because I, I look at that. And I go, what are those three things haven’t What do Pilates Mackenzie, and I’m assuming this functional restoration have in common is that both of them, or all three of them? Whoever’s teaching it to you to be really confident in what they’re teaching. My my understanding of Pilates is they they have those machines that they do Pilates on, and then you know, we looked at it and some of it is doing like yoga type movement with Dan’s different things like that. But I think from what I understand of it, is it’s quite often with somebody and you’re being coached on how to do it, which I know is the same for the McKenzie method, because they look that up. And it’s like providing an assessment working with the person giving exercise plus homecare. So I’m wondering, things that they didn’t address in this paper is the contextual factors of being, you know, people having this extra training, that they’ve done neither McKenzie method or Pilates or whatever, and that you’re more engaged with the person. And you’re being Yeah, and the person is being coached by you, as opposed to like, go home and stretch. Yes. Right. So how much of an effect and awesome that it’s in a positive manner. But how much of an effect is because of the contextual factors as opposed to the other exercises that they were looking at?

Eric Purves 27:42
Yeah. And there’s, yeah, we look at these things, too. And one thing I thought that was really interesting with this paper, which you don’t see is they talked about Pilates, McKenzie and functional restoration as being the most expensive.

Jamie Johnston 27:58
And yeah, how much does that play into it? Yeah. And

Eric Purves 28:00
then he talked about how socio economic status might play a role those things when they’re looking at the the studies. The people that could afford to do those things, were more likely to are probably in a higher socio economic status. And there’s loads of research. And of course, I can’t remember top my head, but we know is a lot of research out there, that suggests that the lower your Setia socio economic status is, the lower your outcomes are wellness is on pretty much all measures of health related things. So, you know, the postal code that you live in a country you live in is, is gonna have a big influence. So that is something that should be I think, is important. This isn’t this has to take with this as well as that, from the study, it says Pilates is the best. But not everybody is gonna be able to afford to go to a Pilates class, or hire someone to teach them how to do it. But if you can, then it’s this is a good option for you.

Jamie Johnston 29:00
Yeah, yeah. And I mean, even, you know, you looked at I Know, Like, we’re so lucky in BC, because people have, you know, so much continuing, or extended health that pays for treatment, you know, and if you’re living in a place that doesn’t have any of that, what a profound impact that can make as well. Right? That goes back to that socioeconomic if you if you can afford to pay for 10 treatments, and go in and have them then likely to have a better outcome as opposed to maybe somebody who can afford to pay for one and then it’s gone. I can’t afford to keep coming back. But I still need to deal with this pain and which could lead to more disability. So yeah, there’s just so many other factors, but I just found it interesting that, you know, we look at the things that they found had the best outcomes were also the things that required more training and more personalized, individualized care, with the person who’s coming

Eric Purves 29:49
in. I think a really important thing to acknowledge with this, though, is that just because those ones had the best outcomes, everything else it was That was in the study had a benefit. Yeah, it just wasn’t as great. So even if it’s stretching seemed to be the one that was like kind of the one they talked about how wasn’t very effective, but it’s still more effective than doing nothing. Yeah. So if the only if you liked and this and they also mentioned this too, which, which is great to see is doing something is better than doing nothing. Right? And if you’re going to do something, they talked about this in the paper, as well as you need to do it at a higher intensity or higher load. Yeah, yeah, the lower that wasn’t as effective. Yeah. So the more and they didn’t really go into too much detail now. But my interpretation of that would be either more into that point of fatigue, right. So you’re doing to the point of where it’s, you’re, you can’t do any more either, like, it’s starting to get uncomfortable, and you’re gonna back off, because you don’t want to flare it up too much. Or you do it to the point of is, I can’t do any more, because I’m shattered. Yeah. Which is going

Jamie Johnston 31:02
to be different for everybody. Yeah. So that’s where you have to have that clinical decision making in place to go, okay, you know, my first person of the day is going to be completely different from my second, third, fourth, and fifth. So, you know, load them differently, do it to their capabilities. And that really comes back to that whole patient centered approach, right?

Eric Purves 31:21
Yeah. Yeah. Yeah. And this is, this is this last sentence they had here to the section of paper called implications for clinical practice. And this just summarizes what you just talked about. The author’s say, if the observed pain and function outcomes align with the patient’s goals, it may be appropriate to recommend these types of exercise programs, if they are available and financially feasible for the patient.

Jamie Johnston 31:45
Back to everything we’ve been talking about.

Eric Purves 31:47
Yeah, exactly. And then if we, if we look at the, you know, that kind of evidence based framework, right, you’ve got like relevant research, you’ve got your clinical expertise, your clinical experience, and you’ve got kind of patient values. And then you also have kind of that fourth part, which you don’t read too much about, it seems to be the ignored part is basically the contexts and the availability of exercise for interventions for people. Now, I would say that that will be where the financial feasibility of it is, you know, what can you do? Yeah, no. And so if we’re looking at, we’ve got evidence to suggest that research, or the research suggests that, you know, these type of exercises are good, any kind of exercise for low back pain seems better than none. And your clinical experience, what works for you, what do you like to do? What do you feel comfortable, and instructing people on if you don’t know, McKenzie therapy, and you don’t know, pilates, and you don’t know, functional restoration? Well, what other type of things can you recommend that you feel comfortable with? And what’s the person want? There we go. Yeah.

Jamie Johnston 32:58
I mean, the other side of that, too, is I could also be, you know, maybe another good thing is to make some professional referral relationships with people who do these specific things. Because I, I mean, looking around here, I don’t I only know of maybe a few Pilates Studios, where we live. Yeah, like for where I live, I think there’s one call one and it’s the only, you know, which is a couple minute drive from here, but it’s the only one I can think of, but there’s, you know, there’s a manual therapy clinic on every corner and like Starbucks around here. But, you know, that specific thing, there’s not that many. So, you know, maybe if we’ve had a patient that we’re doing some movement and exercise with, and maybe they aren’t progressing along to the point that we would like them to, or they would like them to then maybe having that professional referral relationship with, with somebody where you can get them these things. If, if the patient is able to do it, or if the person is able to do it, then then that’s a good thing for us to do as well. Yeah.

Eric Purves 33:54
I guess brilliant. Yeah, exercise is good. manual therapy is good. Combine them is better,

Jamie Johnston 33:59
even better. Yeah. So I think the big messages, for me anyway, is don’t be afraid to incorporate more movement into your treatments. The more that we can do that, I think the more disability we prevent, which is really our main goal with with anybody who comes to see us so make sure you’re incorporating movements in your treatments. Perfect. Alright, see you next time, everybody.

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 websites,

Eric Purves 34:35
themtdc.com or ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.

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.


Three Therapeutic Exercise Progressions For Lateral Movement Of The Hip

Last week we posted some hip exercises called the “Monster Walks” which were some great exercises you can do

right in your treatment room with a simple exercise band to help with balance and general exercises for the hips.


This week we’re going to add to those movements with some extra focus on lateral movements to help with

abduction and adduction.


Let’s start with just some simple lateral movements that will work the hip really well for abduction/adduction.


Once those more static movements get easier for your patients we can ramp up the intensity a little

by providing some more variability to the movement.

Now we’re going to increase that variability by adding some forward and backward walking movements.



  • Make sure your patient is part of the decision-making process for when to progress the exercises.
  • Use the least amount of resistance to start and then add more when the person you’re helping is ready.
  • If you’re giving this as homecare make sure they can give you a good explanation of what they’re supposed to do.
  • Find ways to make this fun and incorporate it into things they already enjoy doing.

Three Therapeutic Exercise Progressions For The Hip

I joined a great gym last year and quite often when we are doing lower body exercises, they take us through a great warm up.

I have to give them credit because I can’t help but think these would be a great therapeutic exercise progression for the hips that we can easily use in our clinical setting.

It doesn’t take much room and all you need is an exercise band (and maybe something to hold for balance) and you can easily take your patients through this.


Here is the first progression you can use.


Here is the second progression, a little bit tougher.


And the third progression, a little bit tougher again.




  • Make sure you start with the easiest exercise first.
  • Let your patient be part of the decision-making about when to progress and make it harder.
  • Start with the least resistance first.
  • It doesn’t have to be complicated, just get them started.

Education In Rehab – WTF Does It Mean…?

Education, education, education. How often do you hear this term in relation to modern MSK practice?

Sorry, I got that wrong. Education & exercise, Education & exercise, Education & exercise : )

All the bloody time is the simple answer!

But education, just like exercise, suffers from the issue that we talk about it in very general terms but have little in the way of actual frameworks for application. Every guideline going seems to point towards these as core treatments but often without any real direction. I can see why therapists fall back on more traditional perspectives faced with uncertainty.

So education about what? When? How? To who? The usual questions come out when we unpick it a bit. Education has been hijacked by PAIN education over the last few years but in reality, its formed a backbone of MSK practice…..well forever. Education is something I talk about in class A LOT,  but I do feel people are like hurry up and get to the REAL treatment Ben, i’m getting bored over here.

Is education seen as PROPER treatment? I am not convinced yet.

People Always Have Wanted Information


This is nothing new!

How often have you had someone come in and say “My back pain has been going on a little bit longer than usual and I thought I had better have it checked out”.  We know back pain, as an example, can last for 2-6 weeks and it’s perfectly normal for this to happen. But if someone has only ever had the problem before for a few days it’s probably a bit worrying and they want to know what is going on to decrease the worry that can flourish in stressful situations.

People definitely come to see us to get rid of their pain, but they also want to understand their problem, the implications and know how to manage it as well.

Louis Gifford highlighted a few things that is fairly universal amongst people. What is it? How long will it last? What can we do about it? Another question I get asked regularly is “Can I still do….”. People still want to do things but not to make the problem worse but often get scared into reducing activities rather than receive knowledge to sensibly manage them.

Education Or Knowledge Transfer?


We use the term education, but for me, that can conjures up images of stern teachers in front of naughty school kids and does not really reflect what we often do with people.  Maybe it is really about helping someone make coherent sense of the issue, decreasing the uncertainty and danger around the problem and providing paths forward. This is more of a partnership perspective that incorporates knowledge transfer than traditional didactic models of teaching. So maybe knowledge transfer or sense-making is a better term?

What Can We ‘Educate’ About?




What Is It?

Probably the most important thing that people want is a diagnosis. If we know what it is we can effectively treat it, right? Er…maybe as we know in so many MSK issues that are simply not possible from a structural perspective. In the absence of this, we need a positive & coherent narrative around the problem. That could include pain ed but information about pain does not need to dominate.

“Cases of nonspecific musculoskeletal pain where, although the source of the pain is unclear, diagnostic imaging is not indicated, and the pain may not always be completely alleviated with treatment. In such cases, concrete, clear, and consistent information can help the recovery process, even in the absence of a specific diagnosis” Carroll et al 2016

How Long Will It Take?

Prognosis and the factors that influence it can be really helpful with often unclear diagnoses like back, knee or shoulder pain. Setting realistic expectations is important as well. Too high and it can lead to disappointment when they are not reached, too low and the motivation to engage in the process can limit the outcomes.

What Can I Do About It?

Health and lifestyle, exercise, activity and self-management are all areas that we can help people with. Helping people to effectively create management plans is sorely missing IMO. Again perhaps this is not seen as treatment?

What Does The Person Want To Know?


For a really effective transfer of knowledge maybe taking the time to find out what the person WANTS  to know is important. Just throwing out information might lead to important questions remaining unanswered. There are so many questions that people have that we may not have considered or we feel are not important. If they are important to the person they should be important to us!

“What concerns you the most about your problem?”

“Do you have any major concerns you would like to talk to me about?”

“What’s your biggest fear about this?”

“What’s the most important question I can answer for you today?”



It needs to make “biological and biographical sense” as my friend Joletta Belton would say. This was the great failing of pain education IMO, it does not automatically integrate with the person’s story, it’s like talking to a stranger in a pub when they are telling you about their life story and you are being talked AT without the conversation ever relating to YOU. A friend that just talks about themselves is another example, you just want to get the hell out of there, or . So make sure your knowledge transfer actually fits the person and their story in a way that relates.



Maybe this is why some of the things we expect to be helpful don’t succeed? Without a knowledge of what to do, why they are doing it and how it is going to help, exercise, as an example, does not relate to the person and their problem?

Lots of my failures (professional ones : ) may have come from not aligning in terms of treatment philosophy with the person I am working with. My vision of what to do does not match theirs and in part that might stem from my inability or failure to ‘educate’ about the what, why’s and how’s.



  • Education IS treatment
  • What does it really mean?
  • People have always wanted information from therapists
  • Think person centred rather than teacher style
  • What is it? How long will it take? What can I do about it?
  • Find out what the person wants to know
  • Apply information in context

Things I Wish I Knew About “Rotator Cuff Disease”

It was the first time I’d seen this patient. 

When I asked what brought them in they showed me how they could only get their shoulder to about 90* abduction and it had been this way for two years. 

Digging a little deeper to find out what happened, they explained they had a rotator cuff surgery due to a tear. 

This was life-changing for them. 

Not only could they not move their shoulder correctly, but it also resulted in a change from a job they loved to one they hated due to the lack of mobility. 

So, was surgery the best approach in this case? 

While I’ll never know the true answer to this, I can look at the most up-to-date research and attempt to make an educated guess ( and I think I know where this is going). 

Rotator Cuff Disease

A recent paper¹ came out on this topic, and I’ll admit I was surprised to see them refer to this condition as a “disease.”

However, when we look at the dictionary definition of disease² it states: 

disease, any harmful deviation from the normal structural or functional state of an organism, generally associated with certain signs and symptoms and differing in nature from physical injury.”

So, in this case, the limited function of the shoulder has deviated from its normal functional or structural state, so I guess it can be classified as such. But, I would never want to communicate it to a patient that way as it suggests a more damning diagnosis than it is. 

Now, in order to define this “disease” they put some classification around it which includes: 

  • Pain that is worse at night
  • Pain exacerbated by specific movements which included overhead activities
  • Loss of function and weakness

In addition to the above rotator cuff disease was basically used as an umbrella term to classify issues with the rotator cuff regardless of the cause and would include: 

  • Positive painful arc test (physiotutors gives a great example of how to perform the test HERE)
  • Positive external rotation resistance test

These tests together were the most accurate diagnosis unless it was a full-thickness tear. In this case, the use of a positive lag test was most appropriate. Here is one example of how to do the test, but this can also be done with the shoulder at 90′ rotation, called the “drop arm sign.” 

It is also worth noting that the review found an increased prevalence of this with age, especially in those people who performed repeated overhead activities. 

What Do We Do For Treatment?

So, this paper was a BIG review; there were 3620 participants in 60 different trials with a median age of 51. 52% of these were women and the average duration of symptoms was 11 months. 

What they found was that people were rarely given just one intervention. 

This makes it really difficult to say if just manual therapy, just exercise, or a single other intervention was the best approach as there was always a combination of things offered. 

The average duration of therapy offered was six weeks. When they looked at what manual therapy was offered, this included: 

  • Joint mobilizations
  • Massage
  • Spinal or neck mobilizations
  • PNF stretching
  • Dicutaneous Fibrosis (I had to google this as I’ve never heard of it, but it’s IASTM with a stainless steel hook)

Exercise interventions included: 

  • Strengthening
  • Stretching
  • Progressive resistance
  • Pendulum exercises
  • Eccentric training
  • Postural training
  • Motor control
  • Proprioceptive training
  • Self-mobilization (yay for self-care)
  • Dynamic humeral centring (movement aimed at humeral head depression) 

Interestingly, they compared the above to some other trials that included things like steroid injection, NSAIDs, surgery, naturopathic care, and a few other interventions. 

When it was all said and done, they compared what was seen as high-quality evidence to low-quality evidence. 

Under the umbrella of “high quality evidence,” their findings showed no difference between manual therapy, exercise, and placebo for overall pain, disability, and function. But there was also a risk as manual therapy and exercise were frequently associated with adverse effects like short-term pain (although very mild). 

When looking at “low quality evidence,” it was pretty consistent with the aforementioned high-quality evidence but also showed that the use of glucocorticoid steroid injections helped with global treatment success. 

Overall, this doesn’t sound like a real positive for manual therapy and exercise, but there are some things to consider. Throughout the studies, manual therapy and exercise were always incorporated with some other type of therapy. Also, much of the exercise used was very vague by description and didn’t include whether this was done supervised in the clinic, or at home. Finally, while the comparison to glucocorticoid steroid injection seems like it could be of benefit, this was based on low-quality evidence, so this doesn’t give the intervention much credence. 

Looking at what they considered placebo, they used modalities like ultrasound (which in other studies has been shown to have a high level of placebo). This review doesn’t really talk about the interaction between patient and therapist or other contextual factors of treatment. We might see a more detailed description of the exercises and modalities used as interventions if these were included. 

However, when we look at other papers that discuss the clinical guidelines of MSK care the best steps are typically shown to be: 

  1. Reassurance
  2. Education
  3. Exercise
  4. Some manual therapy

If we were to apply the same to issues with the rotator cuff, we’d likely see better outcomes than if these weren’t used. Even though this review says there is no clinically important benefit to manual therapy and exercise over placebo, it doesn’t mean they aren’t of benefit. But if we used those as a combination in treatment the high-quality evidence shows this to be the best approach. So, with any shoulder issue, continue to use exercise and massage. Just remember there are other factors that contribute to a successful treatment. Things like patient preference, demeanour, education, reassuring them, and providing validation will all help contribute to better patient outcomes. Let’s just remember to incorporate as much as possible.