Posts

Myofascial Release: An Evolving And Simple Definition

December 3, 2018/1 Comment/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Myofascial Release/by Walt Fritz

Urged on my peers on both sides of the argument, here is an initial version of what I hope becomes a more permanent way to describe the work I use and teach. Comments, suggestions, and criticisms are always welcome (post below). Edits will be made to this post as comments come forward, both here as well as from social media.

Myofascial release (MFR) is one style of manual therapy that uses slow, still, prolonged stretching through clothing or directly on the skin to facilitate change in the patient. Whether having its primary effects on fascia, as historically believed, or on skin, muscle, other tissues, or the nervous system in general, it is realistically a more complex direct and indirect interrelationship of overlapping systems. The goal of MFR is most often to reduce the feeling of tightness and to lessen pain, allowing for more freedom of movement and improvement in functional abilities. While other forms of MFR vary, The Walt Fritz, PT form of MFR relies on direct patient feedback to drive evaluation and treatment, assuring that interventions are patient-specific. (edit 5/13/18)

Myofascial release (MFR) is a style of manual therapy most typically associated with its historical roots, which relied on perceptions that one could label pain and various movement disorders a result of tightness/restriction within the fascia/connective tissue. Most therapists using MFR were taught that they were able to selectively and singularly impact these fascial restrictions to the exclusion of other tissues, with the goal of reducing pain and restoring more normal movement patterns, with any mention of the nervous system added as afterthoughts. While MFR has been a popular and effective form of manual therapy for decades, the claims made by its proponents have yet to be proven, though these issues exist for nearly all forms and brands of manual therapy and massage.

Most brands of MFR, manual therapy, and massage claim that pain/movement problems are due to one specific tissue and make claims to be able to specifically impact that particular problem, all while having remarkably similar styles of engagement as the next type of therapy.

While it may be possible to be able to target one tissue under the skin for intervention, more plausible explanations come from neuroscience-based explanations, as well as the potential impact of contextual factors. These models look at more central mechanisms to explain the local effects of manual therapy, including MFR. Using such principles as neurodynamic technique, where nerve tension is reduced, allowing more freedom of movement and less pain, as well as skin/superficially embedded receptors that can signal the effects of MFR at the local level, with changes in pain/movement problems being an outcome of brain output via the central nervous system. These ideas work from the knowledge that the nervous system is in ultimate control, though in partnership with, the remainder of the soft and bony structures in the body. Though neuroscience-based models also lack full proof, they may be “less wrong” than many of the various other models.

Briefly, MFR has a typical style of engagement that uses slow, still, prolonged stretching to facilitate change in the patient. Whether having its primary effects on skin, fascia, muscle, nerves, or other tissues, its goal is to reduce the feeling of tightness and to lessen pain, allowing for more freedom of movement. I call my work MFR in reference to a very recognizable style of hands-on engagement typically associated with myofascial release, rather than due to thoughts that it is fascia that I am selectively engaging.

With such uncertainty, where does that leave the therapist and consumer? Therapists still treat in the manner they were taught, with hands-on interventions typically very helpful. The best choice may be to keep explanations simple. While it may be the fascia, muscle, joints, knots, trigger points, or a host of other tissues and pathologies are responsible for our problems, we can only work through the skin. Everything else is a stretch (pun intended!).

Articles Of The Week December 2, 2018

December 1, 2018/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

This is a great post, not just because it discusses low back pain, but rather because it discusses change. Change is important for us practitioners, in fact (as the article points out) it is required of us. When new research or data shows there is a better approach to what we are doing, we are required to change. The beauty part of this article is that the researcher is actually having to adapt and change their own research and adapt for better outcomes in patients.

“Explaining Pain For Acute Back Pain – Reflections On Traeger et al. Part 2” – Lorimer Moseley

It has been proven that the language we use with our patients can have a lasting impact. This makes it our responsibility to stay on top of current information so we can convey proper information to those patients. Here we learn about the role our intervertebral discs play and the reality around pain and the “slipped disc” we’ve heard so many patients worry about.

“Discs Don’t Slip DAMMIT!” – Jarod Hall

In response to an article published by an insurance company this past week (which essentially denounced massage therapy and compared it to a good nap), Richard compiled this list of systematic reviews proving the value of what we do.

“A List Of Systematic Reviews Of Massage Therapy” – Richard Lebert

This one isn’t an article, but rather a video. In it, Rob discusses the intimidation massage therapists seem to experience with assessments and a simple way to address it.

“Assessments And Pain Science” – Rob Haddow

There always seems to be debate around applying new research and what “we’ve seen work” when it comes to treating our patients. The reality is, both have a place in what we do, and both should be used. Here’s some advice on how to apply both along with a few extra tips in using science to get results.

“Four Ways To Use Science To Get The Best Results For Your Clients” – Alex McBrairty

When The Holidays Aren’t Happy; How Do We Help Our Patients?

November 26, 2018/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Mental Health/by Valerie Bobb

Last week I was working with a patient when she started getting emotional about the upcoming holiday season. She was struggling enjoying her 8 month old’s first holidays and the sadness that she was also feeling. “Why am I not just happy and enjoying this time?” she asked me.

I perked up for a variety of reasons.

One, I knew she struggled with postpartum depression immediately after her daughter’s birth.

Two, it is not unusual for people to have feelings of sadness and stress during the holidays, and then guilt for feeling that way!

So I listened; why was she feeling this way? She was overwhelmed by demands from family to see the baby, juggling an infant’s sleep schedule while keeping them happy, and starting traditions of her own. I told her this was completely normal, but also reminded her that she only needs to be responsible to herself, her daughter and her husband.

“How do I do that?!?” she responded a bit exasperated at the idea of telling the in-laws that no, they were not staying for 12 hours on Thanksgiving Day.

Every year I have similar conversations with patients.

So what do we tell them? While we all need to stay in our scope of practice, and our own comfort zone, the following will help us navigate the conversation.

There are many reasons why people experience a range of anxiety/depression/stress during the holidays. Symptoms can be anywhere on the spectrum from “holiday blues” to a more serious depression. The good news is, the vast majority of people will have a mild case of the blues. In spite of long-held beliefs and even occasional media coverage, suicide rate and depression-related hospital admissions do not go up during the holiday season. The U.S. Center for Health Statistics shows that November, December, and January actually have the lowest daily suicide rate. However, that does not mean that the holiday blues are not a real concern.

No systematic reviews exist regarding mental health around the holidays.

However, the American Psychological Association has conducted surveys with some interesting information:

While the majority of people report feeling happy, loved and in high spirits during the holidays, they also report feeling fatigue, stress, and irritability.
38% of the people said their stress level increased during the holidays.
56% of people said their stress was the worst at work, while only 29% said the stress was experienced at home.
53% of people said their stress had a financial component.

So what do we tell our patients? The American Psychological Association recommend several coping strategies:

Most importantly, remember the holiday season does not banish reasons for feeling sad or lonely. There is room for all feelings and anything the person is feeling should be acknowledged and validated.
If they have experienced a recent loss or a loss around the holidays, grieving may be strong and surprising, even years later. Reassure them all feelings are valid and sharing them is the best way to positively grieve. Encourage them to share with trusted friends or a counselor and prepare to celebrate their loved one’s life in a positive manner.
Spend time with supportive and caring people.
Save time to take care of themselves. No guilt. Do whatever activity they wish.
Be aware of excessive drinking and excessive junk food. There isn’t consistent evidence that one particular food staves off depression, but there is some research to suggest an overall healthy diet is helpful in treating depression.
Go to bed! Getting plenty of sleep will help manage anxiety and stress.
Get some light. Exposure to light, especially in the morning is important to anybody at risk for depression.
Exercise. There is a lot of research that movement, any kind, can help with general mood.
Identify the source of the pressure and make priority lists. Don’t feel bad if something doesn’t make the list.
Don’t be afraid to say “No” if occasions are not on your priority list. Or say “Yes, but” as in “Yes I would love to see you but right now is not a good time and I really want to be fully engaged. How about we arrange that end of January?”
If feeling lonely, reach out or try other activities to make friends.
Finances are often the source of stress. Set a budget, communicate intentions well ahead of time with loved ones and concentrate the larger reasons for the seasons. Do a group outing or volunteer for a charity as a family instead of focusing on gifts.

It is important we know and recognize the signs for a more serious depression. Past posts on The Massage Therapist Development Centre have done an excellent job of describing the signs and what we can do. Find the link here. For most of our patients, listening, validating, and giving them permission to be a priority will help them thrive, not just survive the holidays. Reassuring them all feelings are normal and the stress is short-lived goes a long way to have the happiest of holidays. And remember—that goes for us caregivers as well! Remember to not just take care of your patients, but take care of yourselves and have the happiest of holidays!

References:

https://www.apa.org/helpcenter/holiday-stress.aspx

https://www.apa.org/pi/women/resources/news/holiday-blues.aspx

Day-Calder M How to beat the post-holiday blues. Nurs Stand. 2016 Sep 14;31(3):37-38.

Hirthler MA Change of shift. Holiday Blues. Ann Emerg Med 2010 Dec, 56(6);690

Articles Of The Week November 25, 2018

November 23, 2018/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

I’m sure most of us have been through at least a minor version of this in our careers. That moment when we examine evidence and theories, only to realize…we’re wrong. It can make what we do in our profession difficult, but it also brings about new opportunity.

“Reflections:4 Years In” – Tristen Attenborough

Non-specific low back pain is an explanation many of us may shy away from because it’s not really a diagnosis. However, it’s probably the most common type of low back pain and is it really necessary for us to come up with a diagnosis or explanation?

“Non-Specific Low Back Pain Exists, You Just Don’t Want To Admit It” – Greg Lehman

There is lots of discussion in our profession around placebo and it’s effects. There are plenty of modalities out there with grand explanations of what it does, however, research shows those techniques have more placebo effect than the explanations given. However, this article makes the argument that placebo effect is not a thing. Would love to hear your opinions on this!

“The Placebo Myth” – Mark Crislip

We know that research is important but sometimes it can be hard to figure out how to trust the research paper you’re looking at or the research that is being cited. This is a long but important post on how to figure all of that out!

“When To Trust Research Findings” – Greg Nukols

She seems to be making this list quite regularly, but I really like what Raechel is doing with her blog, as it should benefit other Massage Therapists greatly. Here are three legs that shape an evidence-informed massage therapy practice.

“What’s Evidence-Informed Massage?” – Raechel Haller

Pain Education – How Much Neuroscience Do We Really Need?

November 19, 2018/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Ben Cormack

Pain education has for many become an integral part of the treatment process and rightly so, being able to help people understand what is happening to them is a must. One of the most frequently used methods to help people better understand pain is based on the neuroscience and physiology of pain.

In some cases, this can be sufficient to help people understand more about pain but is neuroscience ALWAYS required? Many patients may benefit from explanations that do not include information related to these aspects.

Also, does a neuroscience-based approach adequately explain the EXPERIENCE of pain and acknowledge the person EXPERIENCING it?

The neuroscience of pain could be explained in a standard way involving the various bits of neuroanatomy and the associated physiological processes to a room full of people, BUT if we were to interact individually with the PEOPLE in the room we may find that they have wildly varying EXPERIENCES associated with that pain.

Pain As An Experience

So neuroscience may explain how the sensation of pain is created, and many of the oddities that surround it, but does it fully explain the experience? Human beings, after all, are much more than the sum of their parts, and this is what makes us individuals, and does a generic universal explanation imply that pain is all the same? A neuroscience-based approach could be described as an objective view rather than a subjective one, but perhaps it is subjective that seems to most explain the impact of pain on people’s lives.

A question to ponder is that if structural anatomy, and the damage to it, does not adequately explain pain does neuroanatomy and physiology? It certainly pokes holes in the common belief in a simplistic relationship between damage and pain but does it fall short in explaining the experience and the behavioral responses that have such a profound impact on the wellbeing of the person and those around them?

We could take brain imaging or nociceptor firing thresholds or the dorsal horn sensitivity of anyone and display it on a screen, can I differentiate the different experiences that people have by doing so?

From my perspective I want people to know that pain is MORE than just a sensation to be recorded in a score, rating or questionnaire. It is in an experience that can puncture or our existence in many ways and that many parts of our existence can affect our pain experience as well.

Pain is far more than just physical, it affects our overall well-being and emotional state and this is completely NORMAL. For example, our mental health is part of our wellbeing and goes up and down in the same way that physical health does. We often place a much greater stigma on mental health though and we might need to let people know IT IS OK NOT TO BE OK with regards to this facet of their pain experience.

We can feel low, worry about the implications of the pain and have greatly reduced expectations for recovery. These aspects form our individual experience and addressing these aspects for some people could be the key to their recovery.

The common sense model is a great way to start to understand some of the aspects that make up our individual pain representations

Leventhal – HERE

Hale HERE

Bunzli HERE

Pain Has Meaning

The MEANING that someone associates with pain, the emotions, and changes in behavior, the belief structures, these are the things that make the pain experience unique to the individual. These are the things that differentiate one person’s experience from another and why some can cope whilst others are disabled by pain that might be of a similar intensity.

We could say that neuroscience is merely a process involved in that experience, but instead of putting the person at the forefront of that experience do we now place the therapist and the information they hold as the star of the show?

A very simple analogy ( and please remember that they are never perfect!) I use for helping people understand the different meanings people attribute to pain is that of a Petrol gauge.

We could conceptualize both pain and a petrol gauge as warnings. How we respond to these warnings can be very different. In the case of the petrol gauge some people may be quite comfortable to drive on even though they have the gauge on empty, perhaps they know their car and exactly what it is capable of doing. Someone else may rush to get petrol straight away; their response to the same situation is completely different. Perhaps they have run out of petrol before and remember a bad experience? If we changed the context would that have an impact? Would the comfortable people feel different in someone’s car?

Individualize It

Education should be something we do WITH people rather than something that is done TO people.

One of the key aspects in the clinical encounter is the individual journey that someone has had in relation to their pain. How do we use our increasing knowledge of pain to adequately explain THEIR therapeutic journey, story and ultimately their overall pain experience?

Qualitative research tells us that people crave an explanation for their problems, that they want a diagnosis HERE & HERE. This is often not possible and so a narrative becomes vital and this can often involve learning more about their pain and the way it behaves. There is a huge difference between helping generate an alternative positive personal narrative and just the application of information about pain, however.

Rather than an information dump, the selective use of pain-related information should relate to something that is involved in the dialogue that is occurring between two people. A large criticism of and negative responses to medical interactions appears to be HCP’s not listening to people and talking AT them rather than to them. There is a danger of this with any application of information in a generic way.

This is a fantastic paper on the use of metaphor with people in pain HERE

Education Has Many Parts

There are many ways in which we can educate people about their experience. Part of this DOES include neuroscience, especially from the perspective of a clinicians understanding of pain. How much of this needs to be part of the educational experience of the person though?

Basic information about a normal timeline for recovery might influence perception and behaviours. Understanding the lack of association between many physical factors and activities and pain might influence perception and behaviours. There is a recent example of back pain HERE

Some of the factors that are associated with worse outcomes in back pain, such as increased passive coping and low self-efficacy HERE, might actually help change behaviour. Informing people that THEY are the key to their own recovery!

There are many ways in which we can educate people that don’t involve the neuroscience of pain.

Creating A Positive Experience

Regardless of what type of information provided, the most important thing is to create a positive experience for the person and to try to describe pain as a positive part of the human experience. After all, you would not want to live without it!

Another very simple analogy I use, and of course is context dependent, is to compare pain to red wine. A glass of red wine for many is a good experience but have a bottle instead of a glass and that can be too much of a good thing, especially the next day. We would like pain at the appropriate times and the appropriate levels.

With the biopsychosocial model we are opening up many new therapeutic influences and targets for treatments but amongst all these problems we can also work on things that are positive within peoples lives and in negative times, such as during pain, this may be a great way to alter someone’s current experience. This is a fantastic paper on focusing on resilience and sustainability HERE.

As a recap, these are some key patient messages (IMHO of course)

Pain is an experience, not just a sensation
It is more than just physical it affects our well-being and emotional state and that is NORMAL.
It may become more about these affective factors as it persists.
The way that we think and feel directly effects recovery
Human beings are very complex and much more than anatomy that becomes damaged or even sensitized.
Focus on positives factors, not just negatives ones.

Articles Of The Week November 11, 2018

November 10, 2018/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

Quite often people end up living with an issue because they just think it’s a normal reaction their body has to a life experience. Pelvic floor issues are one of those things. People think that because they had kids, or are getting older that peeing a little when they workout, cough, or laugh is just part of life. Well, it doesn’t have to be!

“Does Working Out Make You Pee? Pelvic Floor PT To The Rescue!” – Jenna Jozefowski & Sarah Haag

Educating our patients is a crucial part of the treatment process. But is it more important than other aspects of treatment? Well, it turns out taking the time to listen, while giving your time and attention to patients may be just as important.

“Explain Pain Is Just As Good As Listening And Giving Attention For Low Back Pain Patients” – Nick Ng

It can be exciting to learn a new technique and start to apply them to your patients. At what point do we have enough ‘techniques’ and start to rely on clinical reasoning? This is a great and very important post which addresses this topic.

“Technique Isn’t Enough: The Importance Of Clinical Reasoning” – Whitney Lowe

It is always great to see massage therapy gaining momentum in healthcare and even better when it gains more recognition from other health professions. Great to see that a hospital in New York is making massage a priority.

“New York Hospital Makes Medical Massage Therapy A Priority” – Christina DeBrusk

Massage therapy is useful for many things and chronic pain is certainly one of them. Quite often by influencing anxiety and quality of sleep we can help make a difference not only in pain levels for our patients but also in the quality of life.

“Massage Therapy For Chronic Pain” – RMTAO