Education In Rehab – WTF Does It Mean…?

Education, education, education. How often do you hear this term in relation to modern MSK practice?

Sorry, I got that wrong. Education & exercise, Education & exercise, Education & exercise : )

All the bloody time is the simple answer!

But education, just like exercise, suffers from the issue that we talk about it in very general terms but have little in the way of actual frameworks for application. Every guideline going seems to point towards these as core treatments but often without any real direction. I can see why therapists fall back on more traditional perspectives faced with uncertainty.

So education about what? When? How? To who? The usual questions come out when we unpick it a bit. Education has been hijacked by PAIN education over the last few years but in reality, its formed a backbone of MSK practice…..well forever. Education is something I talk about in class A LOT,  but I do feel people are like hurry up and get to the REAL treatment Ben, i’m getting bored over here.

Is education seen as PROPER treatment? I am not convinced yet.

People Always Have Wanted Information


This is nothing new!

How often have you had someone come in and say “My back pain has been going on a little bit longer than usual and I thought I had better have it checked out”.  We know back pain, as an example, can last for 2-6 weeks and it’s perfectly normal for this to happen. But if someone has only ever had the problem before for a few days it’s probably a bit worrying and they want to know what is going on to decrease the worry that can flourish in stressful situations.

People definitely come to see us to get rid of their pain, but they also want to understand their problem, the implications and know how to manage it as well.

Louis Gifford highlighted a few things that is fairly universal amongst people. What is it? How long will it last? What can we do about it? Another question I get asked regularly is “Can I still do….”. People still want to do things but not to make the problem worse but often get scared into reducing activities rather than receive knowledge to sensibly manage them.

Education Or Knowledge Transfer?


We use the term education, but for me, that can conjures up images of stern teachers in front of naughty school kids and does not really reflect what we often do with people.  Maybe it is really about helping someone make coherent sense of the issue, decreasing the uncertainty and danger around the problem and providing paths forward. This is more of a partnership perspective that incorporates knowledge transfer than traditional didactic models of teaching. So maybe knowledge transfer or sense-making is a better term?

What Can We ‘Educate’ About?




What Is It?

Probably the most important thing that people want is a diagnosis. If we know what it is we can effectively treat it, right? Er…maybe as we know in so many MSK issues that are simply not possible from a structural perspective. In the absence of this, we need a positive & coherent narrative around the problem. That could include pain ed but information about pain does not need to dominate.

“Cases of nonspecific musculoskeletal pain where, although the source of the pain is unclear, diagnostic imaging is not indicated, and the pain may not always be completely alleviated with treatment. In such cases, concrete, clear, and consistent information can help the recovery process, even in the absence of a specific diagnosis” Carroll et al 2016

How Long Will It Take?

Prognosis and the factors that influence it can be really helpful with often unclear diagnoses like back, knee or shoulder pain. Setting realistic expectations is important as well. Too high and it can lead to disappointment when they are not reached, too low and the motivation to engage in the process can limit the outcomes.

What Can I Do About It?

Health and lifestyle, exercise, activity and self-management are all areas that we can help people with. Helping people to effectively create management plans is sorely missing IMO. Again perhaps this is not seen as treatment?

What Does The Person Want To Know?


For a really effective transfer of knowledge maybe taking the time to find out what the person WANTS  to know is important. Just throwing out information might lead to important questions remaining unanswered. There are so many questions that people have that we may not have considered or we feel are not important. If they are important to the person they should be important to us!

“What concerns you the most about your problem?”

“Do you have any major concerns you would like to talk to me about?”

“What’s your biggest fear about this?”

“What’s the most important question I can answer for you today?”



It needs to make “biological and biographical sense” as my friend Joletta Belton would say. This was the great failing of pain education IMO, it does not automatically integrate with the person’s story, it’s like talking to a stranger in a pub when they are telling you about their life story and you are being talked AT without the conversation ever relating to YOU. A friend that just talks about themselves is another example, you just want to get the hell out of there, or . So make sure your knowledge transfer actually fits the person and their story in a way that relates.



Maybe this is why some of the things we expect to be helpful don’t succeed? Without a knowledge of what to do, why they are doing it and how it is going to help, exercise, as an example, does not relate to the person and their problem?

Lots of my failures (professional ones : ) may have come from not aligning in terms of treatment philosophy with the person I am working with. My vision of what to do does not match theirs and in part that might stem from my inability or failure to ‘educate’ about the what, why’s and how’s.



  • Education IS treatment
  • What does it really mean?
  • People have always wanted information from therapists
  • Think person centred rather than teacher style
  • What is it? How long will it take? What can I do about it?
  • Find out what the person wants to know
  • Apply information in context

A Good Response To: “Manual Therapy Sucks”

Not too long ago, we did a post about how manual therapy actually works (as opposed to many of the narratives offered in continuing education).

While we know manual therapy can be a very helpful component in helping people dealing with pain, we still see some opposition to this once in a while.

We see people making some bold statements like:

“manual therapy sucks” or

“exercise is the only thing that works.”

In reality, neither of these things are true but using both in treatment will likely give you better outcomes than just one as a singular intervention.

Putting The Human Back In Human Touch

For the past few years, the manual therapy field has paid a lot of attention to the biopsychosocial aspects of pain management.

However, it almost seems like manual therapy has taken a back seat to other interventions like exercise (which I’m a big fan of using in treatment).

But is this the best approach for us to take?

A great new paper¹ outlines several reasons why it is still REALLY important for us to use and incorporate manual therapy into treatments and fortunately, there are a number of things I never thought of.

Firstly, think about the aspects of your clinical encounter when a patient comes to see you, especially when it’s the first time.

Usually, we would start with some orthopedic tests and a good conversation. Part of what is happening during this time is demonstrating your clinical competence

Your hands-on movement of an injured area shows not just that you know what you’re doing, but it also demonstrates compassion and humanizes the treatment for the person receiving it.

This also helps us set up treatment boundaries where we find out what the person is comfortable with while creating a safe space. While it is very important for us to set up our clinical encounter with people to create that safe space (and to show your clinical competence) there are some other really important aspects to touch that are invaluable in helping a person with pain.

Analgesic Touch

Ever hit your shin on the side of a coffee table and then rub it incessantly like Peter Griffin in family guy (obviously after you’ve sworn at the table!)?

Well, there’s a reason we do this because touch feels really good!

There is a pain modulation that happens with touch that feels good. While there are other techniques we use that do things like distraction to take attention away from a painful area, good touch actually helps to downregulate pain signals through various fibres and pathways that are mediated at the brainstem.

Affective Touch

When touch is delivered in a therapeutic setting, it prepares the brain for touch which stimulates C-Tactile fibres which set things up for a positive therapeutic experience. This promotes positive feelings like safety and relaxation while also reducing things like avoidance behaviours and stress.

Now because this is an empathetic touch it helps remove some of the psychosocial barriers that contribute to a person’s pain experience.

Somatoperceptual Touch

We have seen over the past few years how when a person dealing with persistent pain can experience a misrepresentation of how their body actually feels and what it experiences.

Turns out a therapist’s touch can help in this regard as well.

Just by putting our hands on people, we can help to change a person’s body perception by helping to reorganize mental representations of their body. This helps a patient be able to discriminate between safe and threatening stimuli while also showing how their body isn’t damaged.

This also helps to reduce stress, anxiety, and avoidance behaviours around pain.

Does This Mean Our Touch Is Enough?

Well…it depends.

There are certainly times when someone just needs a good old delicious feeling massage and there is certainly NOTHING wrong with that.

If we have those people (say nurses or other first responders for example) who aren’t necessarily dealing with an injury and are using us as part of a wellness plan, then by all means give them that delicious massage.

However, when we have those individuals who are dealing with an injury say from a car accident, workplace, sports, or some other type of injury we need to incorporate more than just hands-on into the treatments.

We still need to follow the best guidelines for MSK care and provide education, reassurance, movement…and of course some massage. While a lot of what we do in treatment is communicating with our hands, our communication verbally is still a really important part of the therapeutic experience. This paper ¹ points out how this should also be a responsibility of educators and students alike to veer away from the biomechanical constructs of communication to include the person’s emotional experiences as well when we talk to them. While I will always be an advocate to include exercise and movement into our treatments, it doesn’t mean we need to abandon manual therapy (as some would like to promote) and strictly adhere to an exercise-only program. It’s quite the opposite. To be a better therapist and have better outcomes with our patients, let’s not throw the baby out with the bathwater as it were, let’s include education, movement, and massage. The more well-rounded we are as therapists and the more well-rounded our delivery, the better it is for the people who come to see us. As for those who say manual therapy sucks…well…this paper proves that wrong. There is still a really important place for that delicious feeling massage.



  1. Geri T, Viceconti A, Minacci M, Testa M, Rossettini G. Manual therapy: exploiting the role of human touch. Musculoskeletal Science and Practice. 2019 Dec 1;44:102044.


Articles Of The Week December 5, 2021

We quite often talk about this topic but rarely in the case of athletes. Important for us to take into account how the thought of pain and tissue damage is effecting this population and how we can communicate with them to help.

Why Pain Doesn’t Always Mean You’re Injured – Alex Hutchinson

Well, the holidays are coming and if you’re anything like me you’re probably going to overdo it on the treats and cocktails! However, this shouldn’t discourage us and there are some ways that we can still work to stay healthy during this holiday season.

How To Stay Healthy During The Holidays – Gina Harney

Dec 1st is “World Aids Day”. This is really important because when AIDS & HIV were first known about we had little knowledge about it and unfortunately there wasn’t much in the way of treatment. However, nowadays this is a manageable condition and we are likely to see more people in our clinics with this who could use our help. Thus, it’s really important to educate ourselves on the condition.

World AIDS day | 40 years on – Rehabilitation is Key – Kim Jackson

When I was 19 I got pulled through the wheel well of a tractor and dislocated my patella. Ten years later I had surgery to repair this and my leg was in a splint for 3 months…it was literally 1/2 the size of my other leg when the splint came off. I wish I had access to this article back then!

How to Fight Muscle Atrophy After Injury: A Personal Trainer’s Guide – Michelle Carroll

So it isn’t just the manual therapy professions who deal with poor information getting shared around, it’s rife within the nutrition industry as well. But, there is some really quality, evidence-based information out there…you just have to look for it.

Superstition, sciencestition, and how to stop overthinking food. – John Berardi

Podcast Episode #18 Manual Therapy: Exploiting The Role Of Human Touch.


You can get access to the paper we are discussing by clicking HERE

Articles Of The Week November 28, 2021

We quite often highlight things around mental health but to this day I don’t think we give enough attention to athletes and the toll mental health can take on them. This is a great example of how a professional athlete is using their platform to raise awareness around this.

Tyson Fury opens up on his mental health: ‘I have been unwell all my life. I didn’t know what it was’ – Kevin Garside

No matter what part of healthcare you work in, informed consent is a crucial part of the patient/therapist interaction. What we see here is a healthcare provider giving treatments with no evidence behind them. Unfortunately, we see this regularly in our profession with many of the narratives behind some modalities that are offered as continuing education. This should be a warning to all of us in healthcare about informed consent and proper treatment.

Naturopath who gave vitamin IVs to mental health patient without doctors’ knowledge faces renewed probe – Bethany Lindsay

We often preach about evidence-based practice and the importance of incorporating research into practice. But it turns out this is even an issue with doctors and this questions their ability to deliver effective care. While we often preach that we can do better as a profession, turns out all healthcare professions need to do better as well.

How doctors are betraying the Hippocratic oathIan A Harris & Rachelle Buchbinder

It’s not often that pain science is applied to athletes but in this study (which highlights the work of our friend Morten Hogh) it argues that, in the context of sports medicine, pain and injury are two distinct entities and shouldn’t be lumped together.

Why Pain Doesn’t Always Mean You’re Injured – Alex Hutchinson

What do we do with the initial information we receive when a new person comes to see us? Well, there are several things and this article gives some great advice on how to proceed.

Making First Contact: What To Do With All That Information! Part 1 – Bronnie Lennox Thompson