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Articles Of The Week April 22, 2018

April 21, 2018/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

Where do we go as a profession and as a practitioner if we pursue higher education? Is there an opportunity to stay in the profession and be in research, or in other capacities? This is a great article interviewing some RMT’s who have pursued higher education and what they see as opportunities.

“Preventing Brain Drain: Opportunities And Challenges For Higher Education” – Donald Dillon

Many manual therapists combine meditation and mindfulness into their treatments. A new study is looking at how mindfulness and meditation are helping patients dealing with depression.

“When Science Meets Mindfulness” – The Harvard Gazette

Amazing what communication and education can do for a patient. In this case, it may be more successful in helping people with chronic spinal pain compared to other interventions.

“Neuroscience Education Seen Improving Chronic Spinal Pain” – Judy George

I cherish sleep and have to hit the snooze button every morning. However, according to this article, that may be doing me more harm than good!

“Snoozers Are, In Fact, Losers” – Maria Konnikova

While we can’t necessarily counsel a patient on their nutrition (depending on your scope), we can always share information. Here’s some information backed by data on high-fat diets, that gives a fair bit of info on several topics around it.

“The Truth About High Fat Diets” – Brad Dieter

Tissue Loading For Acute Injuries

April 16, 2018/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Jamie Johnston

As we grow in our careers, there is a lot that can change.

If you’re keeping up with new research and promoting an evidence-based practice, the things you do now, are probably different than it was when you started your career. Whether it’s a technique, communication, your understanding of things, or just how you interact with patients, you’ve probably changed compared to say five years ago.

For me, a big change has come in how we treat and rehab injuries.

With my first aid background, we used RICE when treating injuries, especially in the acute phase. Now while there is still some use for that (I know some of you are yelling at your computer right now, saying the evidence says otherwise), mainly right when the injury happens, and more as an analgesic rather than using ice to reduce inflammation, there is a better approach for us to use clinically.

When we used to rely on RICE for dealing with injuries, a big portion was “rest” and “compression, or splinting” the injury. However, the new research is telling us that loading the injured area does far more to promote healing and rehab the injury.

This of course also depends on the severity of the injury, you can certainly load a sprained ankle, or a muscle strain sooner than a fracture or a shoulder separation. It also depends on what phase of healing the injury is currently at, which also dictates the amount of load that can be used on the affected area.

For this post, we will look at managing an acute injury, and in the next few weeks will talk about the next phases of healing and how to load appropriately.

Inflammatory Phase Of Healing

First off, it’s important to understand what’s going on and what time frames we are looking at for the length of healing.

Acute inflammation is the immediate response to an injury, which for the most part (with some variations) is similar throughout the body in any type of tissue. Chronic inflammation is longer lasting because of an unresolved acute inflammatory response or a persistent injury.

This is the initial phase of injury healing and usually last from 24-48 hours; however, can take up to two weeks. This is when we see pain, heat, redness, swelling and loss of function to the affected area.

There is a whole host of cellular, vascular, and chemical responses that take place which promotes clot formation, cleaning up of dead tissue, and the formation of new capillary beds begin (this is a very simple explanation, it would take me plagiarizing three different textbooks to explain the cellular level of activity).

After this acute phase, the injury switches over to the proliferation phase which begins within the first few days of injury and lasts four to six weeks. Two weeks later the remodelling phase begins, and this is where maximum strength occurs at the injury site. We will talk about both of these phases in upcoming blog posts.

During this acute inflammatory phase, the body has essentially gone into protection mode and is sending danger signals to the area, causing the patient to guard the affected area, which can then result in a loss of function.

The question for us is, how do we manage an injury for a patient within this first week of injury?

Beginning To Load

There are several things to take into account when starting to rehab a soft tissue injury with your patients.

Choosing which interventions would be appropriate; exercise, psychological (careful with your scope of practice), or manual therapy that could influence muscle activation are all possible interventions we can use.

In addition to choosing what intervention to use, your clinical reasoning is a crucial part here. Getting a clear history, assessing for the degree of injury, and getting a defined mechanism of injury can all help in deciding your course of action. For instance, if someone came in with significant swelling around the ankle, couldn’t bear weight on it, and said they heard a “pop” when the injury occurred it would be best to refer to a doctor or medical clinic for imaging. However, if they just rolled their ankle, could walk on it, and there was just minor swelling…well, they’ve come to the right place.

One study had patients with an acute Grade I or II ankle sprain (less than 7 days) divided into a standardized group and an exercise group. The exercise group was given non-weight-bearing exercises that were to be repeated three times a day for one week. The exercises were focused on improving range of motion and strength. They found that the standard group spent less time walking and took fewer steps which showed that early therapeutic exercise may allow for higher volume and faster speed of walking post-injury.

Another study focused on athletes and overuse injuries (although the study was done on animals, so further study is required with humans) at the bone-tendon junction. They found that for 24 hours post-injury, low-intensity training brought improvement and did not deteriorate the injury, and 48 hours post-injury was an acceptable time delay to resume training.

A randomized control trial conducted on athletes with an injury to the thigh or calf muscle compared those who started exercise and therapy within two days compared to those who started nine days after injury. The results showed a quicker pain-free recovery and return to sports three weeks sooner.

The take away from these studies? Start to load the injured tissue soon after injury.

Part of what we will have to do is educate our patients. There can be fear of movement due to worry about the injury, and of course pain. But if we educate them that a little bit of pain is okay (we don’t want to overdo this as increased pain can cause a delay in healing), and the importance of getting the joint or limb etc. moving again, we can hopefully set them at ease and start loading the tissue.

You can easily start to load the tissue as part of your treatment by starting with some PROM and AROM exercise while the person is still on the table. Use your massage therapy techniques and gentle joint mobilizations to calm the area down, but we also need to start building strength in the tissue again.

In the case of an acute injury, we want to start with an isometric exercise. Remember that an isometric exercise is one in which there is just tension put on the muscle. It doesn’t change in length or have any visible joint motion. So, in the case of an ankle sprain, it can be as simple as using your massage table for balance and standing beside the table, then weight bearing on the ankle within pain tolerances. Have the patient resist the pressure you put against a joint (ie: resist dorsiflexion in the ankle without allowing motion at the joint). If they can do AROM it can also help with decreasing inflammation in the area, which in turn may let you start to increase load on the joint sooner. Remember, part of what you want to do is instil confidence in your patient by showing them that an exercise is safe and appropriate so they will continue to do the chosen exercise as homecare.

In the coming weeks, we will continue to talk about ways to load tissue to promote healing and help rehab patients injuries.

Articles Of The Week April 15, 2018

April 14, 2018/in Article, Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Jamie Johnston

There was quite the buzz over the past couple of weeks about a newly discovered organ. Some groups were jumping all over it, trying to use this as a way to reinforce their modalities. But, maybe this new discovery is not quite as it seems.

“Two ‘Newly Discovered’ Human Organs Aren’t What They Seem” – Andrew Tarantola

If it hasn’t happened to you yet, it’s going to happen eventually. There will be a point in your career, where you learn something that disrupts some of the beliefs you had in certain modalities, or concepts about manual therapy. So, you have a choice to either continue to go along with it or confront it. Here’s a good example of someone who chose to confront it.

“Confronting The Challenges Of A Major Paradigm Shift” – Whitney Lowe

Do you treat many patients who are dealing with a tendinopathy? Here’s some great info on how to progressively load tendons to rehab the injury.

“Lifters Guide To Treating Tendinopathy” – Sean Jacobs

You know how we feel about busting massage myths around here, so this article was of immediate interest. We know that when we give a massage, we aren’t flushing out toxins, but there is still some belief that you can sweat out toxins. Well, you can share this article with your patients to show them, that’s not a thing either!

“Fact Or Fiction: Can You Really Sweat Out Toxins?” – Erika Engelhaupt

Massage is awesome! In fact, it would be great if we had more confidence in it and didn’t try to use so many fancy explanations around modalities, but just use simple defensible reasoning on helping our patients.

“What’s With The Resistance?” – Taylor Laviolette

Pathologizing: Our Words Matter

April 9, 2018/1 Comment/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Myofascial Release/by Walt Fritz

As a physical therapist trained in the 1980’s, biomechanical explanations for pain and movement disorders were the norm.

As I drifted into a myofascial release manual therapy in the early 1990’s, the biomechanical model was reinforced and made more narrow through the beliefs that pain and movement dysfunction stem from issues of fascial tightness/restriction. All had evidence to support their views, as well as well-presented logical assumptions.

Myofascial suffered from testimonial-type of evidence, which seemed very compelling to a casual scientific observer (me), who was unwilling to question the sources of presented information.

Biomechanical still are well represented throughout the manual therapies, as evident by the daily squabbles regarding the importance, or lack of, with such issues as posture, weakness, and asymmetry when it comes to both pain as well as movement disorders.

This post is not intended to address these issues, but to briefly discuss the language we use when conversing with our patients/clients.

The Power Of Our Words

Patients pay us to help them.

This help is most often accompanied by the thorough evaluation, after which we proclaim our findings on both what is wrong with them and what should be done to rectify the situation.

We may call this our assessment or diagnosis, depending on the scope of practice allowances and limitations of your profession. Patients expect it and we feel it necessary to give them what they want and deserve, but is it always in their best interest, especially when there is a lack of consensus on the validity of our assessment’s claims?

Biomechanical factors and judgement, such as poor posture being the cause of pain, are popular and logical assumptions which many of our patients believe and you may believe it to be true as well, but is it always true?

While at the computer, I leave my Facebook notifications turned on, which is probably one reason I am so easily distracted. As I was writing this post a notification came in that I will sanitize and post here:

“I’m new to this group, but curious as to many issues a (named surgical procedure) could help with. My biggest issues are forward head posture – my (type of) therapist once told me it was the worst she had ever seen – neck/shoulder/upper back tension that my chiropractor gave up on treating because he didn’t understand why he couldn’t fix it, jaw clenching, anxiety, etc). Anyway, does anyone have a recommendation for a practitioner in (certain city)?”

The writer of this post was speaking from genuine self-concern and must have found some solace in her therapist’s statement about the severity of her forward head, but what does she now do with that?

If she is the worst case her health professional has ever seen, it would seem to me that makes it less likely that she can be helped. There is information easily available that casts doubt on the degree of forward head posture and neck pain, but that therapist has planted a seed in the patient’s brain that she is one of the worst out there, at least from her therapist’s perspective.

Do we really need to say things like this?

Below are some studies that were recently posted to a thread on one of the many groups there, all speaking to the effect of the power of our words. If you’ve never given this much thought, please read through some of the abstracts and papers.

Our words have power, and often the message conveyed negatively impacts outcomes.

Easy to Harm, Hard to Heal: Patient Views About the Back.

CONCLUSION: Negative assumptions about the back made by those with LBP may affect information processing during an episode of pain. This may result in an attentional bias toward information indicating that the spine is vulnerable, an injury is serious, or the outcome will be poor. Approaching consultations with this understanding may assist clinicians to have a positive influence on beliefs.

The enduring impact of what clinicians say to people with low back pain. (Full-text link)

CONCLUSIONS: Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.

Importance of psychological factors for the recovery from a first episode of acute non-specific neck pain – a longitudinal study. (Full-text link)

CONCLUSIONS: Psychological factors emerged from this study as relevant in the early phase of acute neck pain. Particularly persistent anxiety and depression at baseline might be risk factors for a transition to chronic pain that should be addressed in the early management of neck pain patients.

‘Talking a different language’: a qualitative study of chronic low back pain patients’ interpretation of the language used by student osteopaths.

CONCLUSIONS: The language used by student osteopaths’ influences patient beliefs about LBP in a variety of ways. The current study furthers understanding of how language contributes to these beliefs, identifying ways through which communication can contribute to improved healthcare through enhancing patient engagement.

Words That Harm, Words That Heal. (Full-text link)

Both positive and negative beliefs are important in patients with spine pain: findings from the oioc registry.

CONCLUSIONS: Our study demonstrates that both negative and positive beliefs are associated with perceptions of disability, however, in this study only positive beliefs were associated with treatment outcome.

Do you have any studies to share regarding this topic? I’d love to have a look!

Articles Of The Week April 8, 2018

April 7, 2018/in Article, Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

We can all probably look back and remember what it was that made us choose this fine profession. This post discusses what made a fellow therapist choose this, but also some great advice for practitioners, whether you’re a new grad or a seasoned vet!

“Why I Became A Massage Therapist” – Taylor Laviolette

This seems to be a recurring theme. Doctors prescribing opioids and other treatments that don’t really work for low back pain, when looking at social, psychological and other factors do. Great to see more mainstream media spreading the word.

“Ineffective Treatment Often Prescribed For Lower Back Pain” – Rina Shaikh-Lesko.

“It may not be surprising that people with chronic pain don’t necessarily like the idea of accepting it.” But this article shows some research where this could be a valid approach.

“Is Chronic Pain Something More People Should Accept?” – Clare Foran

Ever recommend foam rolling to your athletes as part of their warmup routine? Will it actually make a difference? Well, maybe for a short time, but foam rolling might be better used at other times.

“Foam Rolling May Increase Range Of Motion In The Legs, But For A Very Short Time” – Nick Ng

It’s great to see that some massage therapy associations are getting in on the act of spreading evidence-based information. The AMT (Association of Massage Therapists in Australia) does a great job dispelling the myths around pregnancy massage with this post.

“10 Pregnancy Massage Mythconceptions” – Sharon Livingstone

The #1 Secret And A Jedi Mind Trick To Make Planning Not Suck

April 2, 2018/in Article, Business, Massage Clinic, Massage Therapist, Massage Therapy/by Ann Sutton

“If you fail to plan, you are planning to fail” – Benjamin Franklin

Why am I so resistant to planning?!

I suppose, like most people, I’d rather be “doing” than planning. All that thinking. It doesn’t feel as rewarding as the instant satisfaction that comes from action: even if it’s answering and erasing emails.

And, yes, planning can be hard to do – documenting and prioritizing ideas. Estimating (aka guessing) how much time I need, versus how much time I have, to get work done can be tedious.

And, true confession time, because I see myself as a sort of free-wheeling over-achiever, writing down goals and planning them out, kills the spontaneity and introduces a level of accountability that can be anxiety making. It feels like a set-up for an annual performance review.

The worst – when I do put together a plan I feel good about, it’s out-of-date almost immediately. The sad truth: plans are just that – plans. And, like life, they change. It’s the nature of the beast.

So… why do I persist?

Well, when I first started my coaching practice, I didn’t plan. And, a big product launch for my first group program, in plain language, tanked. It bombed. No registrations. Nada. Crickets.

As the launch was circling the drain, I realized what I’d done wrong. I hadn’t planned. Oh, I was smart enough to plan the daily tasks – the tactics. I engaged a great team, but, I hadn’t adequately thought through the bigger picture, strategic chunks of work. I missed accommodating for a big risk: I’m not that well-known.

As a result, I hadn’t engaged people around me who are considerably better known, liked, and trusted than I am with (much) larger email lists who could have reached out to their audiences to vouch for and promote me. Now, facing disaster, it was too late in the timeline for them to effectively step in and bail me out.

Based on this experience, I realized planning and I had to come to terms – I had to find a way to get over my entrepreneurial ego and accountability anxiety.

My First Exercise In Planning

Here’s my secret (the jedi mind trick).

I sat quietly, closed my eyes, and pretended it was one year from today. I cast myself into the future and imagined I was having dinner with my best friend to celebrate my successes. I thought about what I’d tell her about my accomplishments. What had I achieved? How did it feel? What did I learn? What changes did I make to get the amazing results I was so proud of?

When I opened my eyes, I had more clarity and excitement about my goals for the coming year and the process for achieving them.

But that wasn’t my only discovery.

The imagining exercise changed the story I tell myself about the planning process. I stopped thinking, “Ugh – planning, shoot me now.” Instead, I began asking myself, “How can I make the planning process easy and fun?”

For me, easy and fun means focus.

First, and this step is super important, I describe the qualities of my ideal client. These are the only people I want to serve because they love what I do and I love working with them. It’s not to say, I don’t work with other people, but these are the people I actively seek out.

The 4-Step formula I use to describe my ideal clients works like this: “I help people who are [characteristic #1] and [characteristic #2] to achieve [immediate outcome #1] so that they can achieve [big outcome].

For example, in a massage therapy practice, this formula could become: “I help people who are [active in sports] and [have sustained a sports-related injury] to [return to health] so that they can [play competitive hockey again].” Another example could be: “I help women who are [35-45] with [chronic back pain] to [provide stretching/strengthening exercises] so that [they can enjoy the freedom that comes with living pain-free].”

Once I’ve defined who I’d love to work with, I think about what I need from them. For example, I love to work with people who are committed to doing the exercises I suggest, show up on time, happily pay my fee, and provide referrals.

Next, having identified my ideal client, I think about ways to reach out to them. And, of all the ways I identify, I focus on only 2-3 (instead of 5-6) Big Hairy Audacious Goals or opportunities that are exciting, inspiring, and challenging enough to carry me through the year.

If you love sports and you’d love to work with athletes who are challenged by sports injuries, you’re going to want to build relationships with people who work with them: coaches, trainers, and sport med doctors to establish your reputation and obtain referrals. You may even want to volunteer with sports teams to help players recover from, or mitigate injuries.

On the other hand, if your ideal clients are office workers who suffer from neck and lower back pain because they sit at desks all day working on computers, you may want to build relationships with corporate health and wellness coordinators and offer “lunch and learn” sessions or chair massages to build relationships with prospective clients.

Then, I identify what Brendon Burchard, a leading high-performance coach and best-selling author, calls the “needle movers” – the five big steps needed to move each goal forward. These five big moves, or chunks, can include many activities but they keep me from getting too lost in the details.

Photo by: image4you

Making Big Moves

If one of the opportunities I identified was “relationship building”, my five steps might be: identify relationships (successful massage therapists, doctors/chiropractors, team coaches, corporate health and wellness coordinators); speak with key people; identify opportunities (volunteering or speaking engagements); create an offer (e.g. a free consultation); and, develop support materials (e.g. a website or a Facebook page where people could learn more about the benefits of massage therapy, how to select a reputable massage therapist, and get to know, like, and trust me).

For example, when Burchard wanted to produce a best-selling book, he chunked the project down into five steps: finish the book; cultivate an audience; get an agent; create an offer (e.g. an online promotion that could include a free webinar); and, develop a partnership-focused launch (i.e. engage people who are influencers with email lists to promote the book).

Planning Hack Alert! Research.

In Burchard’s case, he researched and interviewed authors to learn the process they followed to attain best-seller status for their books. As you can imagine, this helped him benefit from their learnings, avoid mistakes, and build his network. In my case, I find ways to research the level of interest my clients have in the product(s) I’m considering launching to support each Big. Hairy. Audacious. Goal.

Flexibility is the last thing I now build into my planning process because… life happens. Once I decide on my chunks or my “needle-moving” five steps, I plan the first 3 months of my year carefully and I review how I’m doing each week so I can make adjustments. The rest of the year is loosely planned. I know what “chunk” – or big accomplishment – I want to focus on or complete every 3 months but the daily and weekly tasks remain to be fleshed out.

This level of flexibility is important.

I think many people get frustrated with planning because they try to get too detailed too quickly. They spend a lot of time – and do an amazing job – plotting out every little task. Then, circumstances change. They get overwhelmed at work, a task takes longer than anticipated and they get discouraged.

I leave room in my plan to “breathe”.

For example, Mondays are research and writing days. I set aside Friday or Sunday afternoons to reflect and readjust. I’ve learned to accept that planning is a fluid, ongoing process. Once you decide where you’re going, it requires a series of adjustments to stay on track – and that’s ok.

A final big change – I don’t check email (or Facebook) first thing in the morning anymore. Instead, I take a close look at my day and take Burchard’s “needle-moving” approach one step further by identifying the “needle-moving” activities that need to happen. Is there someone I need to call? An article I must complete? In this way, my annual Big Hairy Audacious Goals get “baked in” to daily tasks, reviewed weekly, and assessed quarterly. Planning has become an ongoing review rather than a one-shot horror show that only takes place once a year – or under duress. And, it’s more engaging because it’s designed to be easy and fun.