Flipping the Script: Shared Decision-Making

Hi new patient, I’m the expert. I am a physical therapist (no DPT, sorry) with 35 years of experience. Those years include a ton of continuing education and independent research. They include tens of thousands of patient-contact hours. I’ve been an educator in the continuing education field since 1995. With all that experience, I should know a thing or two. Right?


I do know a lot and have seen various models of intervention work quite nicely for a range of disorders, so much so that I feel I can reach for a certain tool (metaphor) when you come into my office with a certain complaint. But a wise person once told me that if you already know what you would do or what you would use with a certain patient and their problem before they come into your office, then you don’t know what you are doing. You are complex. I’m complex. Put the two together, and you have double complexity.

While I know a lot, there is one thing missing when you walk in my clinic door. I don’t know what you are feeling, fearing, expecting, and hoping for until I ask. If you don’t tell me, assuming I know what to do, we are missing a unique opportunity to help you in ways I alone cannot accomplish.

I could wow you with a bunch of research citations that speak to just why you need to speak up, but you are looking to feel better, not to be bored with what seems like my ego telling you about a cool study or two. I know that you expect me to determine what is wrong with you and to know what to do to help you. However, while I might have some ideas, I need your help. I need your help to determine if what we do, be it manual therapy or movement-based work, feels useful. Not from a theoretical perspective, but to your body and brain. For instance, does it feel like the stretch we are doing is replicating or calming your symptoms? Does it feel like I am doing something that might be helpful? If not, does it feel like what we are doing right now could be harmful? If so, I’m going to stop immediately. I’m not going to try to talk you into biting on a stick while I dig your pain out of your body with my manual therapy or tell you the No Pain, No Gain crappy story many like to believe.

What’s that? You say that you like deep pressures? You think it needs to hurt to help? OK, then let’s negotiate this whole pressure thing. I’m not going to hurt myself just to help you, nor am I going to do so much pressure or use so much resistance with movement/exercise to put you at risk, but maybe we can meet in the middle. How’s that? Do you feel like I’m having a conversation with your symptoms? Is the pressure enough? What, you’d like a little less? No problem, is this better?

So right now, with the exercise or stretch that we are doing, do you feel the connection to your problem? Yes? OK, does it feel like this exercise/stretch might be helpful for that? Great, then let’s spend some time with it.

This is what I meant about sharing decision-making. I told you that how I treat patients is different, as if you left it up to me, I may have never done something that you found perfectly useful and potentially helpful. What’s that? Why don’t other clinicians ask you to take part? Dunno, though I think that they should.

Articles Of The Week January 16, 2022

So normally these posts are full of articles we’ve scoured the internet to find. However, this link is a really useful tool we can all use for research papers. This google chrome extension actually makes it so you can get access to research papers you may not have been able to access before. Download it and see how many more papers you can get access to.

Unpaywall: An open database of 31,026,169 free scholarly articles. – Google Chrome

We talk lots about the benefits of movement when it comes to helping patients dealing with pain. This is an inspiring story of someone who has RA and finds that going to the gym and lifting weights is helpful in their pain journey. While we always want to take an individualized approach (as this story may not work for every person who has RA) this is a great story of resilience and someone not letting their diagnosis define them.

Rheumatoid Arthritis and Strength Training – Starting Strength

Do you have any patients who need help with TMJ pain? This is a great youtube video that not only gives a great description of how the TMJ works, pain referrals, reasons for extraarticular problems, and even some massage and exercise. This could be a good resource to share with patients.

Exercises and massage for temporomandibular joint dysfunction – Dr. Andrea Furlan

There is a big push in our profession towards evidence-based practice (which I’m clearly a fan of). In order for us to do this there are some things we need to recognize like, where did our beliefs come from, do we need evidence, and why research evidence? Then of course there are logical fallacies and other things we need to unpack. This article has some great takeaways we can use and also does this from a very humble standpoint.

On Beliefs vs. Evidence – Michael Rey

A lot of therapy is now going online and this is a great new program out of Ireland helping people reduce the risk of falls. “Our programme teaches people how to analyse their falls and what caused it and gives them management strategies to prevent future falls.” While it is only a pilot programme they are getting some good results, so down the road, we may be able to refer some of our patients to a program like this.

Pilot online exercise programme aims to reduce risk of falls – David Raleigh

How To Evaluate The Quality Of Evidence In Massage Therapy

One of a therapist’s biggest mistakes when helping our patients are basing their recommendations on personal experience or anecdotal evidence. It’s not that these kinds of recommendations aren’t valuable. 

On the contrary, they’re great in many situations, but it’s essential to understand what you don’t know and to use a bit more of the available evidence to help you determine the best course of action.

In one of our recent blog posts, some of the research cited: “high quality evidence” and “low quality evidence.” This is important for us to understand so we can evaluate the quality of evidence you’re using in your practice; plus, this gives us the most effective ways to communicate evidence to your patients.

The most important part of evaluating the quality of evidence in massage therapy is knowing where to look for it—and what constitutes the best available evidence.

Difficulties In An Being Evidence-Based Massage Therapist


One of the problems we face as Massage Therapists (especially if you’re trying to be evidence-based) is that there isn’t a lot of research done strictly on Massage Therapy, so we are often left to rely on the research being done under the umbrella of “physical therapy” or other manual-therapy professions. 

Where this creates a lot of difficulty for us is actually getting access to quality papers.¹

Part of the reason for this is that we don’t come from a university program (typically) where those students have access to a larger base of papers due to university subscriptions.

Despite this, all hope is not lost as there are many options like google scholar, PubMed, Medline, and other options to gain access to papers online; it just takes a little work to find what you’re looking for. 

Another issue is that most of us were not taught in school how to look at papers and decipher what good quality vs. bad quality papers is, but this can be learned (and is honestly the point of this blog post). 

While these things create a bit of difficulty, we should not look at them as reasons not to embrace being an evidence-based practitioner or ignoring the research. Instead, we should embrace it as a challenge and do what we can to use more research in practice. 

Different Types of Research

Some of the best research we can use are RCTs (randomized control trials), where the patients are randomly assigned to groups where they don’t know if they are getting the designated treatment or not,  and Systematic Reviews. ¹

Systematic Reviews are important as they look at the available literature and use methods to minimize different biases and summarize the information for best practices. While they don’t make recommendations, they look at what is most “correct.” 

This is great as we are essentially always trying to be less wrong in the care we deliver. 

There is a system in place called GRADE that looks at what makes research good or bad ². There are five things they look at which lower the quality of evidence in a study which include: 

  1. Study Limitations
    • those limitations bias their estimation of treatment effects

       2. Inconsistent Results

    • Large differences in estimates of treatment effects

        3. Indirectness of Evidence

    • ie: comparing a drug against placebo instead of against another drug

        4. Imprecision

    • Study is only done on a few patients and few events yet state they have a wide application. 

         5. Publication Bias

    • Investigators/researchers ignore other studies in favour of published trials that are funded by industry.

That last one is crucial for us to consider. There are many modalities used in our profession where research papers were published in favour of said modality by the people who actually developed and taught the modality while citing the positive benefits of their own research. 

So now we can look at what can increase the value of evidence. The same paper ² cites three different factors that can help us out: 

  1. When strong observational studies have large, consistent estimates of treatment effect we can be more confident in the results
  2. The larger the magnitude of effect, the stronger the study
  3. A situation where all bias’ would decrease the effect

Looking at what we know constitutes good or bad research, it should be easier to apply in practice. However, it’s also important to consider that even some of the lower quality evidence can be of use. Primarily, if we focus on a population where there isn’t a lot of research on the one specific thing we are looking for. In these cases, we may have to look at some of the lower quality research to help guide our decision-making while putting out clinical experience to use as well. 

Now What Do We Do?

It is more important than ever for our practice to comply with professional standards. Therefore, ensuring that the treatments we provide meet the standards and ethical guidelines of the profession should always be a priority for us and other manual therapy professionals.

The evidence-based approach isn’t just for the scientific community (although this seems to be regularly debated online). 

To make more informed decisions, we can use the information available to evaluate the quality of evidence supporting the techniques and practices we use. The information from the papers we cited can help practitioners and educators identify which therapies and techniques are supported by a high level of evidence. While there are limitations and difficulties associated with this, we need to rise to the challenge of incorporating research and evidence into our practice. This is not only good for the people we see, but it’s beneficial for the profession as a whole. While there is concern about the extra time it takes to do this, we could start with choosing just one research paper a week to read in our spare time; you could start with the ones cited below?

Why not use this as an opportunity to see how you can use evidence-based practices to improve your practice.


  1. Maher CG, Sherrington C, Elkins M, Herbert RD, Moseley AM. Challenges for evidence-based physical therapy: accessing and interpreting high-quality evidence on therapy. Physical Therapy. 2004 Jul 1;84(7):644-54.
  2. Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schünemann HJ. What is “quality of evidence” and why is it important to clinicians?. Bmj. 2008 May 1;336(7651):995-8.

Articles Of The Week January 9, 2022


Quite often we have people who experience persistent pain where we can’t necessarily help their pain but can make a difference in their disability. Sometimes it isn’t about taking pain away but rather helping their quality of life.

STUDY: Treatment for pain versus disability – Paul Ingraham

While this article is aimed at convincing science deniers on bigger topics like climate change, we could use the same information when it comes to other therapists in our industry who deny what current research has to say about what we do.

How to convince a science denier to reconsider their beliefs – Lee McIntyre

There seems to be a theme here this week! Reflexology is one of those techniques that are commonly used in our profession, yet there isn’t any good research behind its use, other than some anecdotal evidence. The reality is that using something like this can do more harm than good with the people we are trying to help.

Reflexology Research Doesn’t Put Its Best Foot Forward – Jonathan Jarry

I’d love to say that I’m some sort of out of the box thinker, but alas..I am not. However, there are ways that we can learn to become a more lateral thinker, so maybe there’s hope for me yet!?

The most undervalued skill? Lateral thinking – Matt Davis

Richard does a great job of putting together lists of research papers for Massage Therapists and he’s at it again. Here is a list of papers from the past year that could be beneficial for your practice.

10 Impactful Open Access Papers for Massage Therapists – Richard Lebert

Podcast Episode #19 The Epic Fails Episode

On this episode, we chat about some of the failures we’ve had in our careers.

It’s important to talk about failures because you can’t succeed without failing. Also because we all make mistakes in practice but we’re not alone, the more we discuss them, the greater growth we can have.

And as always, check out our websites.


and our emails:


Articles Of The Week December 19, 2021

Most of the time when someone is dealing with pain, they want to know why. However, when it comes to healthcare, it’s a business and sending people out for more imaging etc. is part of that business. So, it’s great to see a doctor putting out the kind of information that is presented in this article.

Sometimes our joints just hurt, and it’s ok not to know why – Howard J. Luks MD

With all the information being thrown at us on a daily basis (especially in the last couple of years) we can get pretty overwhelmed. So, how do we know what works well for us personally in all this information for sustainable well-being? Here are some tips:

Nailing The Basics Is Simple Not Easy—The Growth Equation Manifesto – Brad Stulberg & Steve Magness

There is many a “myth” around our profession (in fact we’ve written about several of them). However, quite often when we learn that some of the things we’ve been telling patients isn’t true it can be quite disheartening. But as this ebook tells us…don’t lose heart, we are still doing some great things.

5 Myths and Truths about Massage Therapy Letting Go Without Losing Heart – Tracy Walton

Is the medical system lacking humanity? Well, with this article coming from someone who has dealt with persistent pain for most of their life and being put through the medical system, I listen when they talk about healthcare. So, yes, I’d say we need to put more humanity back in healthcare.

We Need to Put Humanity Back Into Healthcare – Keith Meldrum

Getting a good health history is a really important part of what we do. However, there are times where even with a good history we may not be able to rule everything out and in turn could have something confusing happen with a person on our table. This is just one of those situations:

Medical Mystery: A spa day with lasting consequences for US professor – Sandra G Boodman