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Articles Of The Week April 7, 2019

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All too often when the term biopsychosocial comes up, people think it’s out of the scope of Massage Therapists because we aren’t a psychologist. Well, you don’t have to be a psychologist to work this into your practice, and making this part of your practice is quite frankly a must. Fortunately, it’s broken down well for us in this article.

“The Biopsychosocial Model: What It Means For RMT’s” – Eric Purves

When patients hear they have a “bulged, or herniated disc” it immediately causes concern in regards to back pain. and the very thought of lifting anything heavy could strike fear into people. But, like so many other things in the body, when things are under load, the disc will adapt and get better.

“Why You Can And Should Lift Weights With A Herniated Disc” – Alex Kraszewski

Massage therapy is beginning to gain more acceptance within the medical community and in some cases is becoming a demand. Such is the case in some hospice care facilities as the public begins to demand massage become available for their loved ones.

“The Comfort Of Hospice Massage At Life’s End” – Bill Ward

Not sure what to listen to on your morning commute? Here’s a list of podcasts for massage therapists on various topics around rehab, business, education, and science.

“Podcasts For Massage Therapists” – Richard Lebert

Do you ever treat, or are worried about treating people with MS because you don’t have any training working on that condition? Well, you don’t really need extra training, just a better understanding of the condition and the knowledge that massage therapy can help.

“Multiple Sclerosis, Massage, And Me” – Sharon Livingstone

A Novel Mobilization for Acute Ankle Inversion Sprains

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The case in the video was a severe ankle inversion sprain on the left and moderate on the right. The patient is a high-level gymnast who injured herself tumbling during a floor routine.

The video below was taken almost a week after the sprain. She had significantly decreased mobility with pain in all planes. Normally I would try a posterior glide to the lateral malleolus and ankle inversion/plantarflexion, which has worked on her in the past with great results. This time, that was too painful as was lateral malleolus contact.

Instead, I tried slacking the irritated skin and ligaments while gradually moving the forefoot/ankle into dorsiflexion and eversion. This was pain-free and after working my way to end range, her active/passive non-weight bearing range was much better and her gait was nearly pain-free. This got her started with loading and was easily replicated for an hourly home exercise program to modulate pain.

https://www.facebook.com/modernmanualtherapy/videos/2021019021246533/

Articles Of The Week March 24, 2019

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How often has a patient come in and said “I have a slipped disc!” and they’re freaking out about it? Well, the reality is, discs don’t slip and this article gives some great insight you can use with your patients to reassure them they will be okay.

“Discs Do Not Slip” – Minki Kim

Is the removal of tissue really the best option for some areas of pain? Probably not, yet this remains an option for those experiencing Vulvodynia. However,  shouldn’t we be looking for the source of pain rather than just cutting something off?

“No Better Than The Flip Of A Coin?” – Sandy Hilton

New research (although it was done on mice), shows that weight-bearing exercise on the legs is vital for the production of healthy nervous system cells. It shows how critical movement is along with implications around sedentary lifestyle and maintaining a healthy lifestyle.

“Leg Exercise Is Critical To Brain And Nervous System Health” – Technology Networks

If you’ve never had a chronic illness, you’ve probably never thought about the mental and emotional strain associated with it. This is a great story of someone with diabetes and how it has taken a toll mentally and emotionally. I’m sure we all have patients with diabetes and this can help our empathy, but I’m sure it can help our empathy for any of our patients with a chronic illness.

“My Chronic Illness Totally Changed The Way I Think About Mental Health” – Ashley Batz

Do you have patients that are constantly trying the newest exercise and diet fads? Here’s the history behind some of them (and some go WAY back) so you can keep your patient updated on the not so newest fad.

“11 Diet And Fitness Trends That Are Not Actually New” – Jerilyn Covert

Models Of Pain And Movement

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There are various models used to understand pain: the neuromatrix model, the biopsychosocial model; Louis Gifford’s Mature Organism Model; the Onion skin model, the biomedical model. And for motor learning and physical training, there is the constraints based model, or dynamic system theory, the various Russian sports science models, non-linear pedagogy, etc.

 

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I often see debate as to the relative merit of these models, which is a good thing. But what I think is not such a good thing is when people argue that because a model has a certain flaw or limitation, it is fatally deficient. Or that using this model will always lead to error. Or that existing problems with current models require a complete and radical revolution in our thinking. These arguments are particularly common in regard to models about the brain because let’s face it, the brain is pretty hard to model.

The way I look at it, all models are necessarily wrong, at least to some extent. But some models are still useful. We need to be aware of how a particular model might lead us astray, but we also need to appreciate how it can provide insight.

Building models is a fundamental part of trying to understand the world in any systematic or organized way. The world has too many details and complexities to be taken in all at once. In order to really understand a particular phenomenon, we need to focus on certain essential details while ignoring others.

For example, to understand the movement of large objects in response to forces, we focus on the mass and velocity of the object and the magnitude and direction of the forces applied to it. But we ignore non-essential but very real details like the color of the object, the shape of the object, or even the effects of friction. The result is a model with simple equations like force equals mass times acceleration.

We can test the accuracy of the model by seeing whether it makes accurate predictions. If it does or leads to better understanding and control over the events we are trying to explain, it is a success. Further progress can be made by noting the limitations of the model, arguing about whether other models are better, making improvements to existing models and so forth.

Although we can improve the accuracy and utility of models, they can never be complete or accurate representations of the world. In order to fully model the world, we would have to build another world! That’s impossible, and it wouldn’t really help anyway. So models are not mirrors of reality, but simplified reflections. They are, therefore, to at least some extent, “wrong.” But again, they can be incredibly useful.

Newtonian mechanics allows us to make amazingly accurate predictions about the movement of large objects like planets. But it fails to describe events accurately when objects are very small or moving near the speed of light. Under these circumstances, we need different models – the theory of general relativity or quantum mechanics. So Newton’s “laws” are not universal, but they remain accurate in the “middle-sized” world that is our usual area of concern.

Here’s a relevant quote from Sean Carroll (a very smart physicist) in his new book The Big Picture:

Our best approach to describing the universe is not a single, unified story but an interconnected series of models appropriate at different levels. Each model has a domain in which it is applicable, and the ideas that appear as essential parts of each story have every right to be thought of as “real.” Our task is to assemble an interlocking set of descriptions, based on some fundamental ideas, that fit together to form a stable planet of belief.. . .

Our fundamental ontology, the best way we have of talking about the world at the deepest level, is extremely sparse. But many concepts that are part of non-fundamental ways we have of talking about the world — useful ideas describing higher-level, macroscopic reality — deserve to be called “real.”

 

The key word there is “useful.” There are certainly non-useful ways of talking about the world. In scientific contexts, we refer to such non-useful ways as “wrong” or “false.” . . . Every scientific theory is a way of talking about the world. The world is what exists and what happens, but we gain enormous insight by talking about it — telling its story — in different ways.

I agree!

The human body is one of the most complex organizations of matter in the known universe. To understand it, we must build models, use metaphors, and deal in abstractions. This necessarily involves ignoring certain details, creating simplified pictures, and relying on metaphors that have the potential to mislead. But we have no choice! Models and metaphors are indispensable thinking tools for understanding the body. Is the brain a computer? The heart a pump? The kidney a filter? The nerves telephone wires? In some ways, yes, and others no.

Each model is a different perspective from which to see the world, with its own unique insights and blind spots. For example, you can look at movement or pain from the perspective of the musculoskeletal system, the nervous system, the metabolic system, the immune system, or the endocrine system. You can take a microscopic view to consider the behavior of individual cells, or zoom out for a big picture of the relationship between larger systems. Some perspectives might be highly informative for a wide variety of purposes, and generally, foster an accurate perception of the viewed object. These perspectives are great. Others may get you looking in completely the wrong direction. These perspectives suck. But there is no one perspective that can offer a complete understanding of a multi-dimensional phenomenon like pain, movement, or any other event in the human body.

Articles Of The Week March 17, 2019

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I would say as a profession, we are a compassionate group. However, it turns out compassion can be trained in your brain and can be enhanced with training and practice.

“Brain Can Be Trained In Compassion” – Alison DeShaw Rowe

This is a REALLY good article to share with your patients who are dealing with pain. All too often they are referred for imaging, which only increases pain when patients see the result. However, if we changed things and patients were educated about their pain properly, we would probably have better outcomes.

“Do You Know The Risks And Rewards Of Pain Treatments?” – Kal Fried

Communication matters, however, sometimes communication can be tough and sometimes we are left wondering if our communication was done the right way. If you feel like you’ve been in a situation like this before, you’re not alone, but it is something we can work on. 

“The Enemies Within” – Benjamin Stevens

As business owners, the way we present our business can make a massive difference in our success. This is a great article about what to look for and create when it comes to designing your logo.

“What Makes A Strong Logo For Your Massage Practice (With Examples)” – Michael Reynolds

We have written about imposter syndrome before and as this article shows, it’s not just an issue with people in manual therapy. One of the things that is a little surprising, is those who have imposter syndrome are quite often top performers. While this article is directed towards doctors, it provides some great advice for all of us who may be doubting our skills.

“Understanding And Dealing With Imposter Syndrome” – Jocelyn Lowinger

The Negotiation Of Pressures

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  • “Using a soft touch which is generally no greater than 5 grams – about the weight of a nickel – practitioners release restrictions in the soft tissues that surround the central nervous system.” (source)
  • “It has been suggested that ischemic compression therapy using either 90 (seconds) low pressure up to the pain threshold or 30 s stronger pressure up to pain tolerance can create immediate pain relief and MTrP sensitivity suppression” (source)
  • “In the past, it was suggested that you hold pressure the trigger point at the individuals’ pain tolerance of a 7-8/10 (10 being excruciating pain).  It is now accepted that even a 7-8/10 may be to high to get a proper release, so authors and researchers suggest holding the trigger point at a level of a 5/10 until the individual experiences a decrease in symptoms, at which point you can either go deeper into the tissue (look for trigger points that are in deeper muscles) or move to another location and search for trigger points” (source)
  • “Pressure during deep-tissue work must be significant but always stays just below the client’s pain threshold.” (source)

Uncertain as to how much pressure to use? Well, the above statements should straighten things out, right?

Regular readers of my blog know my take on pressures, but if you are new:

In manual therapy/massage literature, there is little, if any credible, repeatable peer-reviewed evidence to show one type of pressure being superior to another. But there is also little that shows static pressures/stretch, of the type often used in myofascial release, to be superior to dynamic/movement stretching/massage.

Sure, you will find published studies showing many different styles of pressure having positive outcomes, which mistakenly leads therapists to feel their work has been validated.

Read enough studies and you may realize that just touching may be sufficient to produce potential positive outcomes, though that is a tough sell to most therapists. Having paid my way through a very expensive MFR curriculum a few decades back, I wanted to be taught how slow, light, static engagement is superior to all other forms of manual therapy/massage. The work I was taught and still continue to use/teach was and continues to be quite effective.

But is it better than others? Probably not.

Successful therapeutic outcomes are far more complex than simply the style and amount of pressure that you use and beyond the scope of this post. So how to decide on the proper amount of pressure?

I recently had a patient in my PT manual therapy practice who had a fair amount of experience as a therapist trained in craniosacral therapy. After hearing this I fully expected the patient to request the very light pressures that are typical of that line of training. (Disclaimer: Using and sticking to using only 5 grams of pressure used to drive me crazy!!! I know the craniosacral narrative quite well and what they say happens if you use more than 5 grams, but attempting to use pressures that do not even let me rest my hand on someone drives me frickin’ crazy! Even when I was taking CST classes I cheated and used more. Things seemed to happen in a positive way no matter what sort of pressures I used, which validated my belief that the CST narrative was less than stellar. Now, with a much better understanding of pain science, indirect/contextual factors, and the potential benefit from very light stretching to the skin I can better understand why those 5 grams of pressure may work for some therapists. Back to my story.) But, instead of requesting/expecting light pressures, this patient wanted me to hammer on them, repeatedly asking for a LOT more pressure than I normally use!

Some pretty scary pressures were requested and I had to recalibrate. Understanding that patient expectation often plays a big role in outcomes I found myself in a bit of a negotiation. Even current models of Evidence-Based Practice allow that fully 1/3 of the model is based upon patient values and preferences (link).

My big take on pressures is that whatever I am doing my patient should feel that my pressures are replicating a familiar aspect of their condition. This could mean bring their pain, etc., to their awareness (NOT hurting them, just making them aware that what I am doing is familiar) or reducing the intensity of the symptom. My pressures should feel helpful to them, or at least potentially helpful. They should never leave a patient feeling that the work we are doing may not be good for them.

Logical, but not always a common approach in manual therapy/massage/myofascial release. I do not think enough therapists ask their patients for input/guidance beyond, “Are you OK with this pressure?”.

During recent sessions with this patient, I found myself trying to draw them back from the ledge a bit but equally found myself taking a look over the edge of the ledge a bit. This patient and I negotiated a pressure that they felt was potentially effective while staying within my beliefs as to what pressure was necessary. I am fairly certain that I’ve done this in the past, but never actively being aware of the negotiations that were occurring at the moment.

The concept of negotiating pressures has taken on new meaning to me. As shown at the top of this page, from statements culled from various websites, pressures are taught in somewhat predetermined ways, mostly based on the inherited narrative or a story used to support the type of therapy/modality. It may have been presented in a manner that sounded well researched and even scientific in origin, but digging deep may prove that to be false. But the pressures may have worked well for you. I must admit that my MFR training seemed to give me permission to use a variety of pressures, but words like, “Intuition” were bantered about when trying to figure out how much to use. I still maintain that light to moderate pressures are sufficient to allow awareness and help to elicit change, but now I allow myself to be a bit of a car salesman, negotiating pressures until we both agree.

How do you determine pressures? Do you think that one level of pressure is superior than others? If so, why?

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