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Articles Of The Week June 30, 2019

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Ever have patients come in dealing with, or have questions about plantar fasciitis? Here is everything you need to know about the etiology, related conditions, diagnosis, and treatment options.

“Save Yourself From Plantar Fasciitis” – Paul Ingraham

We have discussed many of the things in this article, on this blog before, but it’s good to keep sharing good info on treatment for low back pain. Even more encouraging is how good science is being promoted on mainstream media, hopefully, this means more positive change for patients is coming.

“A Comprehensive Guide To The New Science Of Treating Low Back Pain” – Julia Belluz

There are several contributing factors to how we each experience pain and culture can be an important one. This is important for all of us to learn about as we can have patients of varying backgrounds, culture, religion and even family history that affects how they deal with pain, so we may have to alter how we help each one of them.

“How Different Cultures Experience And Talk About Pain” – Roland Sussex

Unfortunately, there was an article making the rounds last week with some fear mongering information in it regarding kids cell phone use causing them to “grow horns”. Fortunately, someone came up with an excellent answer to the article, so we can provide an accurate response should our patients ask us about it.

“No, Your Kids Evil Cellphone Won’t Give Them Horns” – Kristina Killgrove

We all know how important touch is and it turns out the way we touch others are shaped by our personal and generational affective history. I wonder if this alters treatments between therapists as well?

“Touch Biographies Reveal Transgenerational Nature Of Touch” – Massage Therapy Canada

All Hands On Deck

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Bell Let’s Talk has come, with all it’s social media fanfare and buzz, then gone taking with it the conversation that hardly ever happens. In a few days, the social media world falls quiet again.

The awareness raising campaigns do their thing and for a brief window, it is hip and popular to pay lip service to mental health problems… meanwhile, people living with mental health disorders continue to live with these disorders, quietly, privately, knowing full well the reality of living with mental disorders does not go away after a day or two of token buzz.

At first, I wanted to try and get on board with the bandwagon, jump in when the chatter was hot but something didn’t feel quite right about it so I did not push it.

Maybe it is my own mental disorders I live with getting in the way, maybe it is an as-yet unarticulated sense of “this isn’t the way I want to do it” thing. Whatever it is, I did not write a blog, a series of blogs or long-winded post on social media about mental health and mental disorders.

Probably because it is so damn important to me; if I am going to write about it at all, I MUST do it justice.

You see, I’ve been wrestling with this thing for years, this feeling, this itch, in my career.

When I first chose this path, I couldn’t quite articulate it, but now, I can. I became a Massage Therapist because I want to comfort people when the shit hits the fan. I wanted to provide a space where a person could arrive with armfuls of pain, gritted teeth and hunched shoulders and just put that down for a minute or 90, have a moment where they could just… breathe.

No hard questions, no pushing for deep thinking, no demands for change or healing, only kindness, compassion, acceptance and attention. I wanted to help people find a sense of peace and safety in their bodies. I wanted to help people learn that their bodies could be nice places to be, that it was possible to feel good being in a body. To me it seemed obvious; that’s what Massage Therapists do.

Our scope of practice is clear; we treat the soft tissues of the body to relieve and prevent pain.

We now know that pain and mental health problems can and do travel together [1,3], that childhood traumas (ACEs) are a strong predictor of negative adult health outcomes [2]. And while I may be extrapolating a little bit here, I think it is fair to say that trauma can be an outcome of severe pain experiences, especially those that persist.  

Taking all of this into account, I can’t help but feel certain in my firm adoption of the idea that all healthcare providers, and especially those who choose to work within an evidence-based, biopsychosocial framework, need to learn how to navigate the therapeutic alliance with awareness for managing the intersections of psychological and somatic health problems.

Canadian Mental Health Stats

When I look at the numbers, I wish I could say my heart breaks but the fact is, I see myself in the stats. I see my friends and my family members.  

In any given year, ⅕ Canadians are living with a mental health problem [5], it could be anxiety or depression, it could be an addiction, bipolar disorder or schizophrenia, it could be PTSD.

Regardless of the diagnosis, it’s COMMON; 3.5 million Canadians seek services from hospitals and physicians for mood and anxiety disorders annually [4]. Mood and anxiety disorders are the most common mental illnesses in Canada and worldwide. The highest prevalence is among men and women aged 30-54, with the 55+ group bringing up a close second. Youth and adolescents are the most rapidly growing group of people affected by these disorders. Possibly most painful of all is the fact that an average of almost 11 people dies from suicide PER DAY.

After accidents, it is the 2nd leading cause of death among young people aged 15-24 [5].

Our Role In Human Health Care

So what is a Massage Therapist doing talking about these things, seemingly drifting from out of her lane?

I firmly believe that, currently, the mental illness crises our communities have been living with for decades (upon decades) demand an all hands on deck approach. We can no longer afford the luxury of letting it be someone else’s problem.

It’s a problem that affects us all.

1/5 Canadians will experience a mental disorder, including addiction, in their lifetimes. That means every single one of us knows someone who is presently – RIGHT NOW – dealing with something that can make everything else that much more difficult. And they are often trying to do it privately because either they don’t want to burden you OR they are afraid you will drop them.

Stigma prevents 40% of Canadians living with a mood disorder from seeking medical help [6] risking unnecessary consequences to their mental health. As an RMT, I am a front line health care provider. As a member of those professionals governed by the RHPA, I have a responsibility to care about all of the health of my patients.

As an RMT I may even have a better opportunity to note changes in the health presentations of my patients, including changes in mental health. This reality behooves us, all RMTs and other health care providers, to learn about mental disorders, pursue mental health first aid training, and to destigmatize our practices.

Often when discussing these ideas with my colleagues I encounter pushback; the worry about crossing a scope of practice line emerges, obstructing progress towards a health care system that is fully capable of addressing human health concerns. Our scope of practice is focused on the somatic experience. Given the relationship between mental health and physical health that is emerging, it is clear that, for some people, their ability to access care, follow through with home care plans and overcome the mental hurdles of dealing with a pain problem can be impeded by mental health problems.

Practitioners who work with the soma exclusively may need to consider these additional hurdles, ensuring that they are:

  1. not contributing to the fear of stigma or retraumatizing in their conduct and language and
  2. recognizing when a mental health problem may be a barrier or yellow flag to the patient’s ability to move forward with their pain management strategy, and when it might actually move them backward.

This is no easy task; stepping into a new level of discomfort, digging deep into your humanity to find compassion, understanding, and the ability to walk with your patient through the discomfort, fear, and shame that health problems, mental or physical, can bring requires a great deal of mental and emotional labour. It asks for empathy and boundaries held in close proximity and it asks us to be much better connected to the health care community we are oft surrounded by, but isolated from. And it asks us to address our own biases about mental health and pain and uncover the ugly heads of the stigma that exist within us and our practices.

The time for us to start giving a shit about these problems and SHOW UP to the table has come and gone, over and over again since the days of Freud. It’s time for All Hands On Deck, because we all, ALL of us, need each other if we’re gonna make it through this at all.

Resources

If you’re still with me here then thank you for reading. Below are resources I have been using to inform my own practice and dismantle the barriers of stigma and incompetence when working with mentally ill and traumatized populations. These resources are all free as of this writing.

Trauma + Trauma-Informed Practice:

Trauma Informed Practice Guide

Handbook on Sensitive Practice for Health Care Practitioners

Trauma and Recovery by Dr. Judith Herman M.D. (1992)

ACEs

Sexual Assault:

Addressing Past Sexual Assault in Clinical Settings

Recognizing and Responding to Commonly Misunderstood Reactions to Sexual Assault

Stigma:

Addressing Stigma – CAMH (scroll to the bottom)

References

  1. Currie, S. R., & Wang, J. (2004). Chronic back pain and major depression in the general Canadian population. Pain, 107(1), 54-60. doi:10.1016/j.pain.2003.09.015
  2. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine, 14(4), 245-258. doi:10.1016/s0749-3797(98)00017-8
  3. Mcwilliams, L. A., Goodwin, R. D., & Cox, B. J. (2004). Depression and anxiety associated with three pain conditions: Results from a nationally representative sample. Pain, 111(1), 77-83. doi:10.1016/j.pain.2004.06.002
  4. Report from the Canadian Chronic Disease Surveillance System: Mood and Anxiety Disorders in Canada, 2016
  5. Mental Illness and Addiction: Facts and Statistics; Centre for Addiction and Mental Health. (https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics) accessed February 2, 2019
  6. Addressing Stigma; Centre for Addiction and Mental Health. (https://www.camh.ca/en/driving-change/addressing-stigma) accessed February 2, 2019

 

Articles Of The Week June 23, 2019

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We hear lots about taking courses where you can add another “tool” to your toolbox. This is usually centered around courses teaching a new technique, or modality. We REALLY need to start challenging that and focusing our efforts into other learning that will be more beneficial to our patients and this article does a great job explaining why.

“Your Hands Are Great, Who Cares?” – Lauren Cates

When I started out in this profession, all I wanted to do was ‘deep’ work and tear people up. However, I was fortunate enough (and so were the patients I treated), to realize how folly this approach was. It’s important that we change and start treating our patients according to up to date research, so an article like this is long overdue.

“To Relive Muscle Tension, Deeper is Not Always Better” – David Lauterstein

We all know how effective massage therapy can be for helping people in pain. Australia is developing a national plan for pain management and as we know, massage therapy should be part of that plan.

“Is Massage Therapy Part Of Australia’s National Pain Plan?” – AMT

I’m guilty of asking each of my patients how they are doing when they come in for treatment. However, I haven’t taken a step back to consider how answering that question may affect them. This is something we should certainly be taking into account, so maybe this article will help you understand this better.

“Answering ‘How Are You?’ As A Person With Chronic Illness” – Adira Bennett

Mental health is constantly becoming more recognized and one of the major things getting more recognition is PTSD. This next article is a great example of how a veteran is using massage therapy to help others dealing with PTSD and has some great takeaways for all of us.

“A Healing Touch: Veteran Provides Massage Therapy To PTSD Patients” – Staff Sgt Kaylee Dubois

Complex Conditions Does Not Mean Complex Treatment

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As a student, I had the opportunity to complete a case study with a client who was living with Multiple Sclerosis.

Multiple Sclerosis (MS) is a chronic, inflammatory disease in which the immune system causes demyelination of nerves within the central nervous system. According to the World Health Organization and Statistics Canada, Canada has one of the highest rates of MS in the world: 2.9% of the population is affected. Fatigue, pain, weakness, spasticity, and paresthesia are common symptoms associated with MS.

I was excited to work on this case study, it was very difficult, in our student clinic or outreach settings, to have continuity of care with a client. To work with an individual every week, over three months, and observe the effect I was having, seemed like a great opportunity.

It also made me nervous.

I was only a student, not only that, I hadn’t received any advanced training at the time – no advanced techniques, remedial exercise, or homecare planning.  I asked my instructors to teach me some advanced techniques that would allow me to address the specific nature of the client’s diagnosis but was encouraged to proceed with what I considered to be a limited skill set. I lacked the confidence that I could make a difference.

I was not convinced but thought it was a good learning opportunity and, so, proceeded.

Help The Person, Improve A Condition

The client I worked with was in her 40’s, a mother of four. She had been diagnosed with MS 20 years prior but it had little effect on her life until the previous few years when she began to experience symptoms of drop foot. She started catching her toes on the stair lip and, by the time I saw her, she was using a walker. She had begun to make decisions that kept her from participating in her normal activities of daily living: driving, walking in winter, and trips with her kids.

At the outset, I had some challenges. I had only fundamental skills as a Massage Therapist and limited experience. The nature of a case study means it is limited in time and scope. Yet the condition itself is quite complex and can present many different symptoms. I took a very straightforward approach to tackle these challenges: listen, focus, and keep it simple.

I interviewed the client prior to starting the case study – partly to establish a baseline but mostly to understand what she wanted to address. Listening to her whole story provided context and direction for the treatment. It helped me understand what aspects of the condition were most affecting her life. Together, we identified what to ‘tackle’. 

It was important that was something measurable – not just because I was doing a case study but because the client wanted to understand the cause and effect of her efforts. Because of my limitations, keeping the protocol simple was necessary but it also turned out to be effective. The protocol used basic techniques like petrissage, tapotement, and stroking but it was applied consistently and regularly.

In retrospect, there were other aspects may have influenced the results. In choosing to participate, the client likely already felt hopeful and empowered, the regular break for self-care alone would be a change from her regular routine. Further, it provided an opportunity to get out of the house at a time when that was not easy for her. All of these aspects lie outside our treatment yet can have a significant impact on the outcomes.

Over the course of treatment, the results varied. The intervention used was a standardized massage therapy treatment approximately once a week for 12 treatments. The patient was assessed using the Multiple Sclerosis Quality of Life Inventory (MSQLI) (for the quality of life issues such as fatigue and pain) and measurement of dorsiflexion (as an indication of the degree of severity of drop foot).

The MSQLI is a comprehensive questionnaire that has been developed specifically for patients with MS and subdivided to include: health status, fatigue, pain, sexual satisfaction, bladder control, bowel control, visual impairment, perceived deficits, mental health, and social support. This self-administered survey takes approximately 45 minutes to complete. The raw scores of each section of the survey are scored, according to MSQLI instructions to determine the final representation of data. This case study, based on the patient interview, paid particular attention to Health Status, Modified Fatigue Impact Scale, and Perceived Deficits.

Most of the client’s symptoms improved steadily with a significant improvement in Perceived Deficits, meaning, the client felt she was developing the skills to cope with her symptoms. However, on three occasions, the ability to dorsiflex declined. 

Alarmingly, there were some new symptoms presenting at some points. Just past the halfway point of the treatment the client experienced the ‘worst spasticity of her life’. This was an extremely challenging point in the treatment.

Should I stop? Should I alter the protocol? Because of the random nature of Multiple Sclerosis, it was very difficult to determine how to proceed. On direction from the client, and with input from advisors, we continued. The overall result was positive, the client started with dorsiflexion of 2mm and, after 12 weeks, could dorsiflex 47mm. For her, it meant the difference between tripping and not tripping during her normal daily activities. Although she was not ready to return to driving, she had the confidence to attend a school trip to a museum with her children and successfully navigate the day with the use of a cane.

The important lesson for me was that a complex condition does not require a complex solution. Instead of employing advanced modalities or techniques, I listened, focused, and kept things simple by sticking to the basic principles of massage.

You can download the case study HERE if you’d like to learn more.

 

Articles Of The Week June 9, 2019

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The things that happen to us as children can have a significant effect on our brain and in turn on how we deal with things as an adult. Various types of trauma can have different effects later in life ranging from criminality to drug addiction, and even chronic illness.

“Childhood Trauma Leads To Brains Wired For Fear” – Side Effects Public Health Media

As massage therapists, we take on a lot when it comes to treating our patients. We have to be “on” so to speak when every patient comes in and be willing to help them with whatever it is they have going on in life that day. But, what do we do for ourselves? Here’s some great advice and six different ways to perform self-care.

“Self Care For Massage Professionals: Emotional Wellness & Self Management” – Susan Salvo

How often do you have patients come in with irritated tendons, but you’re not quite sure how to manage it? Well, probably the most important thing is to use progressive loading and this article outlines why.

“Achilles Tendinitis Treatment Science” – Paul Ingraham

It seems in our medical and manual therapy world, there is always a certain amount of pseudoscience that gets shared and promoted whether on social media or in some continuing education courses (fortunately it’s not just in our industry, it is rampant in other areas as well). So, how do we combat it? Well, by practice and training how we think.

“The Cure For Pseudoscience? Clear Thinking” – Helen Lee Bouygues

This article goes well with the first one in this list, as we look at how concussions can affect children later in life. Unfortunately, a concussion diagnosis is often missed, so we have to be diligent in recognizing when a concussion could have happened.

“Hidden Epidemic? Childhood Concussion May Lead To Long Term Cognitive And Behavioral Problems” – The Conversation

Movement That Gives You the Feels

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A baseball player walks into the batter’s box. He shifts weight from front foot to back while circling the bat. Rotates his right heel into the ground. Orients his gaze to the pitcher while pointing his bat to center field. Slowly swings his bat three or four times to an imagined contact point with the ball. Then crouches lower to wait for the pitch, still shifting weight from foot to foot. What’s the point of all this seemingly useless motion?

You can see similar routines in any sport that allows an athlete a few free seconds before taking action.

Waggling the club before a golf shot.

Bouncing the ball before a free throw or tennis serve.

Doing all manner of bizarre shit before a deadlift.

 

Are these rehearsals for the upcoming action? Sure doesn’t look like it. Do these movements get you in the groove? Maybe so but why? And, did you actually watch the deadlifting video? Go back and watch please, show Jujimufu some respect.

Epistemic Actions

I think these movements might be what are called “epistemic actions.”

David Kirsh and Paul Maglio introduced this term as a way to distinguish between physical movements done directly in the performance of a physical task (“pragmatic actions”) and movements done to reduce the difficulty of the information processing necessary to control the task (“epistemic actions”).

Accurate motor control requires you to have information about the moving parts in the body and environment. You also need to interpret the meaning of that information so that it helps you plan the right movements. An epistemic action is one that either delivers the right information at the right time, or assists in the interpretation of that information. You might say it is a movement that gives you a good sense of “feel” about how to move.

Here’s an example of an epistemic movement that is trivially obvious – turning the eyes or head to see objects in the environment. Check out this video of Frank Lampard playing soccer with his head on a swivel.

 

 

Part of the reason he is turning so much is that he needs updates on a changing environment. But even when analyzing a static scene, such as a room full of objects, you must constantly shift your eyes back and forth to make any practical sense of the information (for example, finding where you left your keys.) The information won’t arrive passively just by staring in the right direction. Vision is therefore a very activeprocess – you need to move to perceive, and you need to move the right way to perceive the right things.

Proprioception is the same way, it is an active process, not a passive one. Many of the our movements have a primarily epistemic purpose – they are not done so much to directly accomplish a physical goal, but to create proprioceptive information that optimizes or simplifies motor control.

I think this is what the batters are doing in the box while waiting for a pitch. They are moving in a way that actively seeks all the sensory information that will help them hit the ball. They are looking for the “feel” of the position of the feet relative to the plate and the pitcher; the angle of the head; the place where they will contact the ball; and the orientation of the hands, shoulders and hips relative to the bat.

Of course these players have already built, through many years of practice, maps or representations inside their brains that have information about all of these factors, and this allows them to “feel” the right stance even in the absence of these preparatory movements. But all this representing and mapping places a burden on memory and information processing. “The best map for the world is the world itself”, therefore it is far more efficient to gather information about the body and environment right when it is needed, as opposed to constantly maintaining an internal model of that information. Epistemic actions are a way to check in with the state of the world through movement.

(By the way, the idea of “offloading” the demands of information processing to the body or environment is very consistent with the ideas about “extended mind” that I discussed in my previous post.)

Conclusion

So why is this interesting? Well it just is. Here’s a few more reasons.

I think a good deal of the movements seen in various forms of corrective exercise are much more epistemic than pragmatic. That is, their value consists more in feeling your body than in rehearsing actual movements you might do some day. And remember that this feel is temporary – you need to keep refreshing it through movement.

Another reason epistemic action is interesting is that it should be a caution to analyzing the technical merits of a movement with too much reliance on its biomechanical “pragmatism.” What appears to be a pragmatic bug in someone’s movement technique might actually be an epistemic feature. Put another way, some ways of moving just “feel” better, and this might be more important than how it looks to the coach. 

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