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Articles Of The Week August 9, 2020

If you’ve been following this blog for any length of time, you know I love this guy. Here’s another great video on being a movement optimist when it comes to the low back and spinal flexion.

“Do You Need To Worry About Spine Flexion And Low Back Pain?” – Greg Lehman

Some new updates on helping people with persistent pain…however, patient centred care remains at the centre of our focus.

“Commonly Used Treatments For Chronic Pain Can Do More Harm Than Good And Should Not Be Used, Says NICE In Draft Guidance” – National Institute For Health And Care Excellence

When we look at some of the causes and issues around pain and specifically low back pain, things can seem fairly complicated. However, when we look at the modern research around this, it really doesn’t have to be.

“Simplifying The Treatment And Management For Low Back Pain– Eric Purves

Inevitably we’ve all had a patient come in asking for “deep tissue massage”. But, what is this really?, it can mean different things to different people. Well, this is a great description and a modern narrative we can use when discussing this with patients.

“What Is A Deep Tissue Massage? A Modern Narrative” – Heather Thuessen

Do you have patients who are regular gym-goers, or athletes who come in for treatment because they’re sore after a hard workout? Well, there may be a dangerous condition result if they push too hard.

“High-Intensity Workouts May Put Regular Gym Goers At Risk Of Rhabdomyolysis, A Rare But Dangerous Condition” – Christopher Gaffney

 

Making Movement More About The Person, Not The Exercise

So I was on Facebook the other day.

And I saw somebody trying to make the argument that this exercise with a Theraband should be retired from anybody’s rehab toolkit.

And their argument was that there’s far better exercises for a rotator cuff injury.

And I’m sure there are, and I’m sure that you could even use this in different planes and do different things in order to help a rotator cuff injury.

But what we have to understand is that it’s not necessarily about the exercise itself.

It’s about the person who’s standing in front of us and we have to make that exercise meaningful to them.

Because maybe their biggest goal is to just be able to put their groceries away pain free, or maybe it’s to pick their child up and if this becomes a meaningful exercise to them that helps build capacity, build resilience and makes it so that they can do those activities we just talked about, then this is just fine as an exercise.

 

 

How Changing Our Habits Can Change Our Practice

Change can be difficult. Like, REALLY difficult.

In fact, we’ve written posts on here a few times regarding different ways therapists are stuck (or refuse to change) the way they practice. Quite often because of not wanting to include research in their practice, or committing to the new narratives around pain science etc.

If we did change, it often feels like a daunting task where the things we have been doing for so long have to change, and in turn there is sometimes fear around how our patients would react when this change occurs.

In the past, I’ve often chalked this up to the methods we use, or techniques we love become part of our identity and thus we don’t want to change.

While I still believe this to be true, it can’t be the only reason.

While reading a book recently, it dawned on me there could be another reason, which most of us probably don’t even realize. Mainly because this occurs subconsciously, it happens routinely, is performed regularly, and most of the time just happens automatically.

What I’m referring to a simple word that most of us don’t realize we are doing with every patient who comes in to see us.

Habits!

Little Seeds Of Change

Quite often when teaching or discussing different concepts around manual therapy with other practitioners, inevitably the topic always comes up “how do I incorporate this in practice”?

I’d say this is especially true with Massage Therapists and discussing how to begin including movement and exercise into treatments (this is just my take on discussions I’ve had with therapists, not the general rule).

There is usually a concern where the patient comes in and just wants to get on the table and get their treatment going. Even to the point of looking at their watch in an attempt to make sure they get their full hour on the table.

This was also true as I started getting interested in pain science and while learning along the way had to change my narrative with patients. I was genuinely worried (also due to my lack of confidence) that patients would think I sounded like I was out to lunch and start seeing a different therapist.

Well, the reality is, when I started doing more of both, not one of my patients ever looked at me and refused to do a movement, or told me they thought I was out to lunch (they may have thought it but never said it to me), and they very well could have because I’m sure it sounded like I was vomiting all this new information at them.

However, there is a way to do this in a much better way than I did when I first started trying to incorporate these things into my practice.

When we are trying to create change with a patient it’s usually about planting little seeds of information and playing the long game. It’s not always about making huge, grand changes all in one session. It’s about incorporating small changes over a longer period.

Perhaps it’s making one small change in an activity of daily living until eventually several changes are made and your patient adapts to a new routine or exercise until it becomes a habit.

So, if this approach can and does work for our patients, what if we took the same approach with our practice?

Changing Our Habits

In his book “Atomic Habits” James Clear breaks down how to build good habits and break bad ones.

One of the things I found really interesting was a quote from the book talking about habit change, I couldn’t help but relate it to how so often our techniques become part of our identity in our practice:

“The real reason habits stick is that it becomes part of your identity, improvements are only temporary until they become part of who you are”

“When you have repeated a story to yourself for years, it is easy to slide into these mental grooves and accept them as a fact. In time, you begin to resist certain actions because “that’s not who I am”. There is internal pressure to maintain your self image and behave in a way that is consistent with your beliefs. You find whatever you can to avoid contradicting yourself”

Just about everything we do in our clinic is a habit without even realizing it.

The way we greet a patient when they come in, the way we sit in our clinic room with them when they first arrive, the way our hands make initial contact with them when they’re on our table…all habits. We’re probably more likely to call it a routine, but these are all habits we’ve created, which is also part of the reason you’re successful.

Your patients REALLY like this routine.

And the thing is, so do we! It’s comfortable and familiar, which makes change all that much harder.

However, if we truly want to grow in our practice, it’s a matter of us deciding we will change, not making the patient change (although this will happen gradually).

This can also be daunting because it can feel like we’ll get left behind (making it all that much easier to stay in our groove), which is overwhelming, I mean, it takes 17 years before research is actually implemented in most medical practices, so it’s not like we’re going to get left behind by attempting to change what we do in our practice.

In this book, James talks about how to create new habits by doing something called “habit stacking”. To do this you identify a current habit you already do each day and then stack your new behaviour on top of the current one. As you begin to master the structure of doing this, you create larger change by incorporating more of these small changes until these new habits are formed.

Could we just start by asking one new question during our intake and do it with each patient one day, then the next, until it becomes part of our normal conversation with a patient? Once this becomes our new normal, we could include one graded exposure movement before each treatment? When this becomes part of the routine, start to incorporate movement into a treatment, then homecare, etc. Even if all we do is just change by a small fraction each day or week, this can have a profound change in our practice and our patients over the long term. As this adds up you can have some breakthrough moments that not only make you a better therapist but can enhance your career. And the best part is, while you gradually make this change, your patients will change with you without them realizing it. These changes will become an expected part of your treatment and hopefully, they won’t be checking their watch at the start of the treatment.

If you’re curious or want to know more about habit change and how it can help you and your patients, I highly recommend “Atomic Habits” which you can get HERE.

 

 

Articles Of The Week July 26, 2020

This is a great podcast from a pain researcher and an exercise physiologist so you can better understand central sensitization and pain. Great stuff!

“Central Sensitization And Pain” – Ben Cormack & Melissa Farmer

You know if there’s something regarding exercise and pain, we’re going to share it. This one I really like as it focuses not so much on a specific exercise, but physical activity, and the person in front of you.

“Exercise And Pain, An Opinion Piece” – Rhyesson Cornilla

I really like this one, as I have a disdain for insurance companies due to my former life before being an RMT. But, this shows us how to help those who have pain, yet no objectionable measure of pain to in turn satisfy said insurance companies.

“Secondary Gain, Really?” – Bronnie Lennox Thompson

We are constantly talking to patients recommending self-care. But, what are we doing for ourselves when it comes to self-care? Here’s some dynamite advice on how to do just that.

“How to Customize a Self-Care Plan That Works For You” – Aleksandra Slijepcevic

This pandemic has changed a lot of things. One of which is the way we provide first aid to people. For me at work, we’ve gone through massive changes in the way we do things at the Firehall. For those of us in sport, this outlines some changes we should take into account.

“Medical Care And First Aid: A Framework For Organised Non-Elite Sport During The COVID-19 Pandemic” – Steffan Griffin

 

Are You All About The Exercise Or The Person Doing It? Making Movement Meaningful

This is the first in the series of a few mini/microblogs of about 500 words (famous last words) and in this first one I wanted to kick off by talking about making movement and exercise meaningful.

This is a term that is being bandied about more and more in rehab but still has the feel of a buzzword rather than something well defined.

So what the hell does it mean……..

Firstly lets separate the idea of meaningful from what many describe as ‘functional’. Meaningful exercise does not have to look or recreate movements, mechanics, or even physical qualities that people may need.

Lets PLEASE not go down that road again. PLEASE.

Something being meaningful is much more about the WHY behind doing it or the meaning it holds (as the title suggests : )

Too often it’s the therapists why, but it really should be the PERSON doing it’s WHY! As therapists, we often have a bunch of why’s, ROM, strength, and other outcome measures that are often not really very well aligned with the patients WHY.

Put yourself in the other person’s boots – why am I actually doing this? And ultimately, by doing it, how can it help me? We pretty much do this calculation for a lot of things in life.

What makes this person tick when it comes to moving…..

Now it could be argued getting out of pain should be a big enough WHY. But when it comes to exercise, especially for rehab, we know that is not enough from the data around adherence (commitment is a much better word btw) and this also extends to adherence to drugs and general health advice.

So really we have to consider HOW to get to people’s WHY. Well, I think this really has to come from HOW we as HCPs interact with our patients. Without knowing what they want to achieve or their valued activities it is very hard to create a real relevance, MEANING, or as I like to call it a ‘finding a HOOK’.

Essentially any movement could be framed as being meaningful with the right explanation and the link to a motivating and meaningful goal. Learning more about sets and reps might not improve your outcomes!

Recent research has shown some very good effect sizes for using goal-setting interventions in back pain *HERE*

Here is real life an example from a course I gave last weekend in Melbourne. An attendee was discussing Jiu-Jitsu training. He said 50% of the reason he goes is for the social aspect. Firstly imagine the impact firstly of NOT going on life (more than just pain!), secondly the motivation to get BACK to going.

Rehab should tap into the meaning of that person’s life and what they gain from doing it, not just doing an exercise because someone told me to.

The problem has been one of therapeutic exercise finding an exercise to fix the problem, such as VMO firing for knee pain or core firing for back pain. Potentially we could call this targeting the muscle but missing the person.  So we are now talking about movements not muscles, but how about talking people? Getting people moving perhaps needs a GOAL, a HOOK, a MEANING?

Maybe one of the benefits of working with a sporting or active population is that the WHY is often clear-cut, sometimes people can even be over motivated.  The meaning is built into the process.

The challenge with persisting pain may be the motivation is not so clear cut, we need to dig a bit deeper as pain can narrow people’s focus and reduce the number of options they feel they have available to lead a full life.  This is where ‘finding a hook’ can be really important I feel.

Meaningful movement tips

  • Listen and ‘find the hook’
  • Take time to explain WHY moving will help
  • Relate the explanations back to the ‘hook’
  • Spend time building confidence and positive movement experiences
  • Think person rather than exercise

P.s I was close – 650 words ; )

Articles Of The Week July 12, 2020

 

During a time when gyms, yoga studios…and well, everything else was closed. Many people took to running for their exercise regime. With that, quite often comes new kinds of injuries people have never dealt with before. Fortunately, our friend Laura Dunkley has and sheds some advice on this.

“Running In The Time Of The Coronavirus: Reducing Fear, Tolerating Uncertainty & Promoting Resilience” – Laura Dunkley

This is a phenomenal resource you can download to both use for yourself, but also to educate our patients on pain management.

“Pain Management Guidebook” – The Honest Physio

Most of us aren’t psychologists and yet we look at the biopsychosocial aspects of pain. Sometimes this can leave us wondering how to understand the psychological aspects of this, and how we can help our patients. Well, here’s a great chat from two people who are great at this and hoping to show us what we can do.

“Bronnie & Laura Chat: Compassionate Care, Not Just Clever Care” – Laura Rathbone & Bronnie Lennox Thompson

We all know how important mental health and well being is, some would even say it’s a super power. Here’s six steps you can use to improve your mental health with psychological flexibility.

“Psychological Flexibility: The Superpower of Mental Health and Wellbeing” – The Weekend University

We all know how big a fan I am of Walt Fritz, so I had to include this. In this podcast he talks about the importance of critical thinking and changing our narratives in manual therapy.

“BPS Aspects Of Manual Therapy” – Walt Fritz & Daniel Pablo Arbilla