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Articles Of The Week June 14, 2020

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This is a PHENOMENAL resource for both practitioners and patients alike. Not only does it provide some education on the current research around Osteoarthritis, it provides exercise recommendations, and exercise programs…it’s FREE.

“OA Optimism” – Greg Lehman

Over the past couple weeks, I have taken some time to reflect and have conversations with friends who are far more educated and experienced than me on race and diversity. This is a great resource we can all use to help educate ourselves so we can all have a better understanding.

“Race, Diversity and Cultural Competency Resources for Massage Therapists” – Meg Donnelly

This is a great resource you could share with your patients around some of the myths of low back pain. The best part is it’s presented by people who have lived with chronic back pain!

“10 Facts Every Person Should Know About Back Pain. Presented By Patients” – Pain Ed

Much like the last article, it is always important to understand the patient’s perspective when it comes to pain. With this small blog post, a chronic pain patient shares their thoughts on overcoming fear and movement.

“A Path Forward” – Keith Meldrum

I honestly didn’t know that ankylosing spondylitis may be portrayed as a ‘man’s disease’. According to this article, there are hundreds of thousands of women living with it, many undiagnosed. Here are eight things to understand about AS and how it affects women.

“Ankylosing Spondylitis in Women: 8 Key Facts to Stop the Stigma” – Lauren Gelman

 

Crossed Arm Syndrome

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I understand the trend toward patient-empowerment, trying to build self-efficacy without risking dependency on the clinician. This has elevated the interventions of education and exercise over manual therapy in terms of best-practice recommendations for physical therapists.

As a long-term PT, I can understand this movement, but the trend comes at a price.

First off is the belief that manual therapy, viewed as a passive intervention, should be dosed sparingly as to not encourage dependency. In contrast, I contend that if manual therapy allows movement with less fear, pain, and caution, this, in itself, builds independence.

I do accept that more common view of PT is the exercise-based model, though I have HUGE issues with intellectual lazy PTs who blame weakness on pain. What I don’t and will not accept is an apparent lack of engagement on the part of my profession.

I have great respect for the time, patience, money, and emotional investment that a budding PT student makes to become a DPT, as it is not an easy path. But what are we building?

Recently I had dropped my car off for a service at a local repair facility. Rather than join the squad impatient chair-sitters, waiting for word of the bill in need of payment, I chose instead to take a long walk. This walk afforded me an opportunity to cruise through the nearby picturesque village, able to see the sights while getting my exercise. My walk took me past the village PT clinic…twice, once on my outbound journey, and again on my way back to the garage.

On my first pass, I was easily able to view a good handful of patients dutifully working out on at their respective stations, all seeming to be completely engaged in their tasks. But at the center of the facility, I viewed two individuals who I am assuming where the resident PTs. How did I know this?

Apparel, for one. They were the only ones NOT engaged.

Instead, they stood side by side, talking with each other, in the dreaded arms-crossed posture. Argh! OK, I thought, as I passed, maybe I caught them at a bad moment. Maybe it was a fluke. I’ll take a look on my way back, hoping that they would not be caught in such a compromising position.

The walk took me through the rest of the village and, with a bit of a divergence, along a roaring creek. Quite lovely. But as I again approached the PT clinic my suspicions rose and, sure enough, there they stood. Maybe they have moved and returned to the exact same spot to converse again…or maybe not. But there they stood, arms-crossed and conversing, while their patients dutifully went through their paces.

A PT may argue that those patients were engaged in self-helping behaviors, learning self-reliance, and building upon their own potential. Quite possibly.

But why did the PTs need to be standing there so unengaged? We can be more than arm crossers, we can be cheerleaders, encouragers, coaches, teachers, and, yes, occasionally, applying manual interventions. Self-reliance is key, but what has the PT profession become; a bunch of arm crossers? Manual therapy PT has its own skulls in the closet, but that’s not what this post is about. It’s about arm crossing.

My bias is toward using manual therapy as a primary intervention and evidence exists for this as a viable treatment strategy. I strongly discourage dependency of any sort and abhor it in other professionals. My work is set up to empower my patient to feel like they can move and with less fear. I teach them to self-treat, based on my examples, and make it a strong encouragement to engage in the movement of their choosing. I recognize that a good majority of patients seen for exercise-based PT improve, though those that don’t often come through my door.

As a profession, PT and other similar professions, the view of us by the public matters. Arm-crossing and spending a good amount of your time conversing with your peer instead of your patient is simply a lame way to spend medical dollars, not to mention a very expensive education.

Next time I make that walk, my hope is to see PTs engaged with their patient. They may not be touching, using manual therapy as I do, but I hope to see them spending time speaking to their patients, coaching and encouraging, aiding and correcting, prescribing, and adapting. I hope to see them doing the things our profession(s) are capable of and not resorting to the stereotypes that pockmark our profession.

BAN ARM-CROSSING

Articles Of The Week June 7, 2020

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We published an article earlier this week about the therapeutic alliance. What we didn’t talk about in that article is how it is our responsibility to build and maintain that relationship. Fortunately, there are other therapists out there blogging and covering why this is important.

“Welcome to My Practice: The Rules of Conduct” – Jennifer Fleming

We preach regularly about evidence-based practice around here. This article lays out not only the importance of this, but also how to be reasonable about it when taking into account our clinical experience.

“Science versus Experience in Musculoskeletal Medicine” – Paul Ingraham

This past couple of months have been hard on everyone’s business. As a result, many of us could be experiencing some self-doubt regarding their progress and business success. This self-doubt can have major impacts on how we do things, but there are ways to curb this thinking and get back on track.

“Why Questioning Yourself STOPS Your Business – & How To Fix It!” – Vicki Marsh

If you’ve been following this blog for any length of time, you know how strongly we feel about exercise. While the findings and studies are new and limited still, there is emerging evidence to show how important exercise is an effective way to manage stress during to local public health restrictions.

We have published many an article showing how to do graded exposure with patients. While this article is directed towards mental health professionals, the same arguments can be made about exposure therapy in a massage clinic setting. But, if we buy into misconceptions we’re less likely to use something that’s REALLY effective, however, we should be using this with all the confidence that its evidence base deserves.

“Myths About Exposure Therapy” – Dr. Carmen McLean

Creating Sustainability With Therapeutic Alliance

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As different parts of the world start to come out of isolation and begin pondering what work will look like, we have to acknowledge that things are going to be different…forever. 

I’ve seen the question asked “who in this profession is going to make it”? 

There was some debate around this and a few comments I’ve seen are things like:

  • “massage is a luxury, only those who have money are coming back”
  • “Only medical massage therapists will pull through”
  • “Only those who work in a clinical setting will be able to recover” 

Well, the reality is, none of that is true and it quite frankly doesn’t matter what setting you work in. 

What truly matters most is how you’re going to treat your patient. No, I don’t mean what modality are you going to use, I’m referring to the relationship you have built, and will continue to build.
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This is what determines who will be successful after this pandemic, or any other one we may face down the road.

Using Trust To Create Sustainability

It’s not often I say this, but I have to give some kudos to our college. 

While they put in the effort to put together a return to work document1 for our reference and give us some direction on how we should handle things, there was a central point they made in the direction. 

Build trust with your patients. 

They outlined cleaning procedures, PPE protocols, and new consent instructions, yet at the heart of it all was the direction to do or wear these things in front of your patient, if for no other reason than to build their trust in you as the healthcare professional. 

It’s honestly the first time I’ve seen something like this from our regulatory body, and I applaud them for it. 

Along with this was a perspective piece written in the New England Journal of Medicine2, although it was written from a doctor’s perspective, I couldn’t help but see how this is applicable to us as therapists. 

In the article, they talk about the importance of relying on evidence-based practice. While this is always important, at a time like this that importance is amplified as patients and therapists alike could be making decisions based on fear and emotion, which in turn can result in falling prey to cognitive bias and making therapeutic errors. 

Since our role as therapists is to provide safe, effective care we need to have what this article calls a “healthy skepticism” and keep our clinical equipoise when considering any intervention. 

If we don’t retain this healthy skepticism we run the risk of relying on personal anecdotes where all too often in our profession we see people saying things like “I know it works because I’ve seen it work” while at the same time refuting and even sometimes refusing to accept research into their practice. 

When things like this happen it is usually a result of what the article calls “the intense desire to try new and unproven remedies”. Think about how this applies to many of the continuing education courses we see in our profession. Many of them don’t have research to prove their unsubstantiated claims and yet we look to try this new intervention possibly making therapeutic errors.

Of course, all done with the absolute best of intention trying to help our patients. 

If we are going to be successful once this is all over and we want to build sustainability in our practice, this has to change. 

As tough as this whole shutdown has been, it has also created an opportunity for change. As we move forward trying to build trust with our patients while also gaining sustainability in this profession, there’s one other golden nugget we need to look at. 

Therapeutic Alliance

There are many things that influence our treatment outcomes that go well beyond whatever our favourite modality is. 

Some of these are referred to as non-specific or contextual factors.3

Part of these factors is the therapeutic alliance we have with our patients which can be defined as: 

“The working rapport or positive social connection between patient and therapist”3 

 

And

 

“Established between therapist and client through collaboration, communication, therapist empathy, and mutual respect”4

 

This systematic review4 showed there were 8 major themes associated with therapeutic alliance: 

  • Congruence
  • Connectedness
  • Communication
  • Expectation
  • Influencing factors
  • Individualized therapy
  • Partnership 
  • Roles and responsibilities 

Now, we could probably write an entire article on each one of these 8 themes, how it applies to us in practice,  and how we could effectively use them, but let’s leave that for a later date.

For now, let’s just consider what was most important to the patients. 

Of those 8 themes the most important determinants of a therapeutic alliance in the eyes of the patient were: 

  • Communication
  • Interpersonal aspects
  • Partnership
  • Roles and responsibilities

Another thing the review showed was both patient and therapist agree that effective communication improved treatment adherence. They also found that agreement on goals and tasks, sense of connectedness, positive feedback, genuine interest, individualized care, trust in the therapist, and feeling empowered were all important predictors of exercise or homecare adherence.

The way we communicate, listening, sending appropriate messages and words of encouragement actually has an influence on reduction in pain.4 However, it’s important to note that making inappropriate comments can actually make patient’s symptoms worse (which also demonstrates why communication is so important in the patient’s eyes).

They also came to understand a few more sub-categories important to build this alliance. Included are humour (I can only use a limited supply of this as my sense of humour is pretty offside), emotional intelligence, appreciation, honesty, clarity of information and feedback, support and follow up. 

Are you as excited as I am when looking at these lists?

We are in a place of HUGE opportunity for sustainability in our practice by simply communicating, creating a partnership, showing genuine interest in our patients, providing individualized care, and just simply being genuine!
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I’m sure most of us are already doing many of these things in our practice, but how often do we practice them, get better at them, take a course on them? While they are deemed “soft skills” the research is showing us these things should be at the forefront of our practice. 

And the great thing…we get to spend more time with our patients than most other manual therapists and we can literally practice most of these things during our treatments. This was another one of the things that positively influenced outcomes, the amount of time spent with the patient along with warm, empathic interaction!4 So while there was no way for us to predict this pandemic, there are ways for us to create sustainability in our career. Massage therapy as a profession isn’t going anywhere, people will still need help, and still want to be touched in a therapeutic way. Unfortunately, some clinics won’t recover from this which is an absolute travesty that no one deserved to go through. But the best way to create sustainability is by enhancing and developing strong therapeutic relationships with our patients. With that strong relationship, should something like this ever happen again, those patients will be waiting for your clinic doors to open again because they trust you will do what’s best for them. As we start our clinics up again, while it won’t be the same, there is a genuine opportunity to start building that trust again while creating sustainability in your practice. 

References

  1. https://cmtbc.ca/registrants/interim-guidelines-for-return-to-practice/
  2. Zagury-Orly I, Schwartzstein RM. Covid-19—A Reminder to Reason. New England Journal of Medicine. 2020 Apr 28
  3. Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical therapy. 2014 Apr 1;94(4):477-89.
  4. Babatunde F, MacDermid J, MacIntyre N. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC health services research. 2017 Dec;17(1):375.

 

 

 

Articles Of The Week May 31, 2020

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We did an article on this topic a couple weeks ago, so it’s great to see the awareness being raised around this topic. There is little correlation to “weak glutes” being the reason for a person’s low back pain, so let’s build resilience with people rather than preaching false narratives.

“Gluteal Amnesia: Real, Relevant or Ridiculous?” – Eric Purves

For those of you who treat kids on a regular basis, I’m sure you’ve seen the importance of having the parents appropriately on board with treatments. However, sometimes they may be sending the wrong message, which can make for a difficult conversation. So, here are some tips on how to manage those conversations.

“Sometimes Parents Are The Problem” – Nick Hannah

This could be one of the most beneficial videos you could share with your patients regarding back pain (especially if they’re considering surgery). I’m hoping this will change a lot of minds having people choose rehab over surgery.

“Could The Billions Of Dollars Spent To Fix Back Pain Be Doing More Harm Than Good?” – Leigh Sales

Love this pain analogy and it’s another one you should DEFINITELY share with your patients. Sometimes we experience pain when our “cup” gets too full, or we can’t get a bigger “cup”. The things happening around this can influence the amount of pain we feel and in turn change how we are managing things in life. So maybe we either need a bigger cup, or decrease what’s in the cup.

“What? Pain Is Complex – The Overflowing Cup Analogy Of Pain.” – Greg Lehman

This is a really important topic for both patient and therapist. Everyone involved in this podcast is doing great work to benefit both patients and therapists, so this is WELL worth the listen.

“Self-Efficacy For Patients And Clinicians” – Dave Moen & The Knowledge Exchange

 

Level Up The Prone Press Up

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The Prone Press Up is one of the best ways to prevent and treat acute low back pain. Even if you get a massage, adjustment/manipulation, or other treatment in a clinic, you still need to maintain the improvement at home (unless you want to pay for a passive solution forever).

A patient is more likely to get better if they do a high dosage of repetitions throughout the day of whatever resets their system. If it hurts, they’re less likely to dose or to get to end range. Here are some of my favorite ways to make the prone press up pain-free or to eliminate the perception of tightness at end range

  1. Alternating Isometric Contralateral Arm/Leg raises
  2. Bilateral Isometric Hip Extensions
  3. Diaphragmatic Breathing at End Range

 

Any or all of these strategies should make the press up pain-free or as comfortable as possible so a high dosage should be easier to accomplish.

 

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