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Getting To Yes. Using Negotiation In The Therapeutic Process

 

 

In this article, I want to dive deeply into options available to the therapist, explicitly using a patient-centered, negotiation-driven model of care. A model such as this becomes a therapeutic partnership, an alliance set up for a common goal. Contrast this model to a therapist-centered model. While therapists immersed in their expertise may take umbrage to my characterizations, I ask a bit of patience to allow this explanation to play out. While we may be making changes in the tissues, our in the periphery, we know that the central nervous system is picking up our manual care and shuttling it to the brain.

I believe in using negotiation throughout the process of patient evaluation and negotiation.

Without negotiation, the application of intervention becomes one-sided. Without negotiation, intervention derives from the beliefs and experience (ego) of the therapist, possibly missing out on an outcome that has better meaning to the patient. Negotiation is the core principle I use in my process of manual therapy. While learning manual therapy, or more specifically myofascial release (MFR), may seem like an entirely new intervention, I see it as quite parallel to your current skillset. We are all working toward improving function. MFR is simply another road to explore. Please note that I consider myofascial release a subset of manual therapy, as are the many styles of intervention available to therapists. One might include manual circumlaryngeal treatment as a separate subset, though all are not so dramatically different to warrant their classification. Manual therapy is a common denominator in all of these approaches. 

Getting to Yes,” by Roger Fisher, was a best-selling business book published in 1991. The Amazon.com summary states, “­­­­­­­­­it is based on the work of the Harvard Negotiation Project, a group that deals with all levels of negotiation and conflict resolution. Getting to Yes offers a proven, step-by-step strategy for coming to mutually acceptable agreements in every sort of conflict.” I remember hearing of it earlier in my career, and the memory surfaced recently as a potential frame of reference with regards to the work I teach. While the phrase, getting to yes, might be somewhat narrowly focused, with regards to the outcome of manual therapy, I do see it as a productive and necessary step to fulfill before determining treatment. The concepts presented in “Getting to Yes” have meaning today.

The timeline of a therapist’s inclusion of manual therapy/MFR has a typical pattern, one that I’ve witnessed since beginning my MFR training in 1992. The applications matter little, whether the commonly seen problems of and movement disorders faced by the PTs well as trying to reduce the severity of the impact of dysphagia, dysphonia, trismus, or the full range of other diagnoses facing the SLP.

The timeline often proceeds as follows: when first exposed to a new type of intervention strategy, typically through continuing education, the clinician conservatively doses the therapy, not quite sure of its value or their level of skill. As they gain experience and pursue additional training, therapists use the modality with greater comfort. An illusion is formed, thinking that their expertise and knowledge improve the ability to determine the cause of a problem better.

With that confidence often comes the belief that they have a better ability to determine both what is wrong with the patient and that they know what to do to remediate the issue.

These seem logical conclusions based on principles of advanced learning, but might moving into such certainty begin to minimize the patient’s perspective and preferences? No matter our profession, we are seen as experts in our respective fields, well-prepared to understand the deeper issues underlying a disorder and knowing which intervention to choose to apply. This line of reasoning seems standard practice in most of healthcare and typically meets with success; however, are there ways to improve outcomes? Are there ways to enhance patient by-in? Are there ways to better honor the three aspects of the evidence-based model (EBM)? I ask readers to keep in mind the three equal elements of EBM: 1. The published evidence, 2. Clinician’s experience applying the evidence, and 3. Patient perspectives and preferences with regards to the evidence and the clinician’s perspectives.

I believe that patient perspectives and preferences are given far too little emphasis and respect across the broad spectrum of healthcare, though recent trends in narrative medicine and other more-patient-centric approaches are beginning to create changes. I propose a method that elevates patient perspectives and preferences to carry equal weight with both the evidence as well as clinician experience applying said evidence.

In my years learning and applying MFR, I’ve been exposed to many models of learning. Being encouraged to pursue additional MFR course work was a given and actively encouraged and, at-times required. Working from an intuitive approach was highly stressed, though ill-defined. I was invited to develop my intuition; to work toward having a deeper understanding of processes that, in essence, allowed me to see inside; to be able to determine what was wrong with my patient by merely looking at them. These skills involved conventional evaluator methods, such as postural assessment and movement observance. Still, I was also encouraged to “read” the body, seeing patterns, colors, and holding patterns that would lead me into knowing what treatment needed to be done.

If all of this sounds far-fetched, welcome to the world of pseudoscience. To many, these concepts are logical but are often merely logical fallacies. Using the approach as taught did seem to result in positive outcomes and armed with such power, why would I have stopped believing in the basic tenants of the MFR approach?

In the typical manual therapy intervention, the clinician is tasked with determining if their preferred style of treatment might be useful. That task alone is biased, especially if, in the eyes of the therapist, manual therapy is one of their go-to tools. I recognize this bias as my own, though I try to see through it. For nearly thirty years, myofascial release has been my bias, my tool, my belief. People come to me daily in pain or living with dysfunction, and I apply my biases toward their issues. Over the years of using MFR, I saw the trend I sank into, objectifying their condition as a simple set of fascial restrictions set in place from injury, trauma, surgery, or other conditions; conditions that my skillset was especially good at remediating. Every patient became the nail, well-suited for my hammer. My biases were reinforced by success with many of the patients who sought me out. If the theories behind my fascial training were correct, then my interventions should be helpful, which they were. No dilemma existed, even though many outside my MFR family saw significant problems with the explanatory narrative utilized in MFR, as well as many other modalities targeting tissues and pathologies. 

To the uninitiated, those new to manual therapy, this dilemma seems pointless. But to those who’ve spent time exploring the various modality rabbit holes, the dilemma is real. How can so many modalities have the answer? Can each tissue/pathology-based manual therapy model truly singularly and selectively access and intervene in that dysfunction? Can there be so many unique tissue-based problems in the body that lies in wait for the therapist specially trained in a model devoted solely to that problem?

These questions are often seen as heretical by devotees of tissue and pathology-based manual therapy modality families as they question the fundamental underpinnings that are taught. Such talk is often squelched. However, these are conversations that are needed. 

Manual therapy is often helpful for a wide range of disorders, whether in the niche of voice and swallowing, or the larger body of conditions impacting human existence. But does it work in the manner described by its champions? Diving deeply into the evidence pulls out a relative lack of irrefutable proof of both the tissue-based dysfunctions said to be responsible for the disorders which we treat as well as our ability to selectively impact those tissues for intervention. Such omissions are lacking in nearly all of the published scientific literature that studies the efficacy of manual therapy, though many readers of the evidence fail to see the problem. In most manual therapy papers, there is a conflation of the mechanism of action and efficacy. Proving efficacy is often allowed to be sufficient proof of the stated mechanism of action. In a recent article I wrote, Anatomy matters…but which anatomy?, I speak to this problem and how time and research have moved the bar from tissue-based explanations of causation and therapeutic impact to brain-based models. The complexity of the human condition is seldom reducible to problems in one tissue, be it muscle (tension or spasm) or fascia (restrictions), especially within the context of a biopsychosocial model of dysfunction. 

Despite enormous progress in scientific understanding of pathologies and models of care, we are still not at a place of full understanding. Instead of choosing a tissue or pathology-based model of manual therapy, I’ve modified my process toward one of allowing the patient to be the focus of care rather than my skill and beliefs.

While I fully admit I am unable to completely abandon my knowledge, training, and experience (ego/bias), I attempt to temper it and foster a relationship where my patient plays a more active role in determining treatment. In my seminars, I speak to this as a point of demarcation between many other modalities. In many trainings, whether it is a model teaching manual circumlaryngeal treatment (MCT) or more broadly applied myofascial release and manual therapy training, the clinician is tasked with locating the problem, which is often based on palpation. The clinician’s training strongly biases this palpation. While one therapist, trained in MCT, for instance, may feel excessive muscle tension, another clinician, trained in myofascial release, may feel fascial restrictions. It is quite possible that what they are feeling as a result of their palpatory expertise is indeed the same “thing,” though the therapeutic diagnosis/assessment will differ significantly.

These palpatory findings are typically the determinant for intervention; in essence, “I’ve found the problem that needs to be addressed.” Patients seek us out for this skill and is simply a derivative of the standard model of medical care. They give over trust to us, hoping that we can help. The evaluative findings are turned into treatment dosing. 

In my view, this common model lacks one major component; no matter how much I know, how much training I’ve had, I am unable to determine what a patient is feeling. I am unable to palpate when a patient feels might be helpful or harmful. I am unable to palpate or evaluate a patient’s expectations, preferences, and perspectives. None of these are possible when evaluation evolves into an intervention without including the patient in this process. So, with all of this uncertainty, why do I strive to get to yes? How does using a patient-centered model, one that instills ownership to the patient’s perspective and preferences, a matter within the uncertainty mentioned above? I believe that it matters because of the uncertainty. In the future, more will be understood about how manual therapy impacts the local tissues, though I would predict it will be an indirect effect, that is, one mediated by and through the brain and central nervous system. Those who inform my views are researchers such as Roy (1) and Holzman (2), who point to higher levels of control in terms of why changes might be elicited in the periphery.  

I continue to use palpation in my intervention and teach it during each of my seminars. But instead of palpating to locate the cause or even the actual location of a condition, like most other manual therapy models, I use palpation to begin a process of communication with my patient.

In older models, palpation leads to the conclusion; “I’ve found your (muscle tension, fascial restriction, etc.); let’s see what we can do about this.” Treatment typically follows the findings of palpation. I propose a model that uses that same palpation, though not to conclude, instead I use it to begin a conversation with my patient. I cannot discard all of my experience, as I’ve been through these steps thousands of times in the past, most probably in cases nearly identical to the one facing me at that moment. But I’ve also seen sufficient numbers of patients to know that many times I get it wrong. I do believe that our ego tends to dismiss those memories quite easily and hold on to the times that we were correct. But I try to temper my successes with the knowledge that I do not know what my patient is feeling, what they hope for, and what they might fear unless I ask. I have no way of truly knowing if they will ask me to move into pain, which could mean more aggressive work because they feel it must be helpful or because they’ve been told to expect it unless I ask.

I have no way of knowing what sort of threshold to pressures that they might have, whether it is wide or narrow unless I ask. I have no way of knowing if the things that I’ve located through palpation, or other evaluation means, feels like it could be significant, could feel useful, or could feel harmful unless I ask. Despite all of my training and experience, I can never know the answers to these and countless other questions, unless I ask. But most manual therapy training is built on a process that doesn’t ask; the input of the patient is often minimized or at least deferred to the clinical expertise of the therapist. Many times, this all works out well in the end, but are they ways to improve upon this process? 

Coupling our expertise and training with the expectations and perspectives of the patient is the crux of my approach. It is what gets us to yes. It brings the therapeutic process into a partnership, an alliance.

Of course, we can’t just ask our patients what they think is wrong with them, ask them what we should do, and then do it…or can’t we? The way I teach my work is to use palpation only as a place to start a meaningful conversation about what brought them (the patient) into my clinic. As soon as I feel something that, form my past, feels interesting, I see if I am getting the attention of my patient. I immediately try to ascertain if they are feeling something familiar, something they’ve felt before or associated with the condition or issues that brought them to see me. I put them to work in ways many have never experienced. I, in essence, force them to help me help them. I work toward finding a tactile cue that connects with a feeling that they’ve felt before, good or bad, and is somehow relevant to them. I do very little selling of an approach or beliefs. If what I’m palpating does not replicate one of these conditions, then I move on. If it does connect with their experience, I ask them if the stretch that I am performing feels like it might be helpful? If so, I ask them if they would like me to hold the stretch for a while to see if we can change the outcome? If there is anything about my palpation-found stretch that feels like it may not be helpful, I will ask them if it feels like it might be harmful? If so, I immediately stop. I am attempting to get to yes with them; to find a pressure, stretch, or engagement that they feel will be useful; helpful. I let them decide what constitutes a yes, not me. I allow them to decide what level of pressure or engagement is too much or ineffectual, not me. I require them to be a full participant in the therapeutic process and put them in a position of responsibility for helping me help them. Getting to yes, to me, forms a crucial tipping point in the process that moves us from evaluation into treatment. 

Have you ever heard of a patient/client leaving a massage session, for instance, saying something like, “that therapist was so good that they were able to find things I didn’t even know that I had!” I have, and I detest such statements, only because the therapist did a somewhat unethical job of selling pathologies onto a vulnerable public. Nothing I find is meaningful unless confirmed by my patient. All of this is hard work, though I think it to be good work.

Getting to yes. That is my mandate.

The Science Of Placebo

 

What does the word placebo mean?

Does the placebo effect involve actual health benefits or just imagined benefits?

Is placebo “mind over body” or “all in your head”? Is it unethical to provide a client with placebo treatments? And what about nocebos?

In this article, I’ll answer these questions and discuss some fascinating research by Fabrizio Benedetti and colleagues.

After reading this you will have a better understanding of placebo, and you might even stop using the word, because it’s fairly ambiguous, and often a poor explanation for why a treatment helps someone to move better or feel better.

What Exactly Is The Placebo Effect?

Placebo is a confusing term because it means different things when used in different contexts.*

For purposes of this article, it has the following meaning: A placebo is a treatment that reduces symptoms only because the patient expects a benefit, not because the treatment itself has any effect.

For example, a sugar pill can be a placebo that will improve a headache only if the person taking the pill expects that it will provide benefits. But if the person does not expect benefit, it’s no longer a placebo, and does nothing.

The placebo effect is the physiological process by which expectations about a treatment cause changes in the brain that initiate an improvement in symptoms. These changes are real, not imagined.

In other words, if someone experiences a real placebo effect, they are not just imagining some improvement – there are objective and measurable changes in their physiology to prove it.

The nocebo effect is basically the opposite: It causes negative changes in symptoms (e.g. more pain and reduced function) when there is an expectation that an otherwise harmless stimulus will cause harm.

Clearing Up Mind-Body Confusions

Placebo is often described in terms of a “mind-body connection.”

This suggests it involves some sort of mysterious process, or that we need to radically change our way of thinking to understand it.

But in fact, the connection between abstract thought and events in the body should be intuitive and trivially obvious. If I form an intention to reach for a cup, my hand actually reaches for the cup! If I think there is an intruder in my house, my heart will beat faster and I may begin to sweat. If I spend my life worrying, I increase my risk of headaches and heart attacks.

So we already know that thoughts affect the body.

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In other words, the placebo effect does not involve anything magical. It is one of many ways that our cognition affects our physiology. But it is a very interesting and clinically relevant phenomenon because it reveals the mechanisms by which our thoughts and expectations affect the way we move and feel.

What Can The Placebo Effect Do?

Placebos can cause changes in pain level, motor control, muscle tension, strength, endurance, energy level, depression, immune response, heart rate, and glucose level.

They can even make you drunk!

But placebos don’t help with everything. They won’t cure cancer, make you taller, and they probably don’t help with asthma. Placebo effects are often significant. In the case of pain, they can change self-reported pain scores two points on a ten-point scale.

VAS-chart

 

The rest of the article will focus on placebo effects as they relate to pain.

How Does The Placebo Effect Work To Reduce Pain?

The easiest way to understand how a placebo can affect pain is by considering the purpose that pain serves.

Pain is an unpleasant feeling designed to protect you from perceived threat to the body.

Placebos alter the perception of threat and therefore the pain. And that works as follows. The brain is always in the process of unconsciously analyzing threats to the body, based on all the information it can gather. This information comes from a wide variety of sources, including sensory data from the body, visual data from the eyes, memories, opinions, and, importantly, information that is provided by medical authorities.

Thus, when a doctor tells you something about some condition in your body, or the medicine intended to treat it, this becomes part of the evidence base from which your brain unconsciously determines whether pain is needed to protect you from that condition. Put another way, your opinions about the effects of a placebo treatment become one of many cognitive inputs that modify the output of pain.

Neuromatrix-Simplified

 

The research of Benedetti and others has identified three different patterns of mental processes that create the placebo effect: (1) expectations of benefit; (2) reduction of anxiety; and (3) learning through association. Let’s look at each in turn and the associated physiological processes.

Expectation Of Reward

One way placebos work is by creating an expectation of benefit, which activates the reward system of the brain.

The reward system motivates us to engage in behaviors that maximize the spread of our genes, such as eating food, having sex, getting money, and basically doing all the things that humans are generally very motivated to do. The reward system involves release of dopamine. For example, when you experience the reward of getting social approval, you get a little hit of dopamine, which makes you want to do it again.

It’s like a built-in dog trainer. Facebook likes, good boy!

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Here’s how we know the reward system is involved in placebos that reduce pain.

The placebo effect is greater in people who get more dopamine release when rewarded. It’s also stronger in people who experience more rewards from receiving money. Further, nocebo effects are associated with dopamine reduction. Also, the improvement in motor control that a Parkinson’s patient experiences after a placebo is correlated with release of dopamine in parts of the brain related to motor control.

So how exactly does activation of the reward system reduce pain?

One mechanism for reward-based analgesia is descending inhibition of nociception. This involves the brain sending opioids or other drug-like substances down the spinal cord to block nociceptive signals (danger signals that often result in pain) from getting to the brain. David Butler calls this system the “drug cabinet in the brain.

How do we know this system is involved in the painkilling effects of placebo? Because when you give people drugs that block the operation of this system, they don’t get any placebo effect from expecting a reward. Here’s a cool example to illustrate.

Researchers put tourniquets on the arms of subjects and asked them to squeeze a ball for as long as possible, to the limits of their pain tolerance. One group was told the procedure would benefit their muscles, and the other was told nothing. Not surprisingly, the group expecting benefit was able to tolerate the pain longer. Here’s the cool part: increased pain tolerance from an expectation of benefit was completely eliminated by drugs which prevented activation of the descending inhibition system.

So we know that descending modulation is involved in placebo effects related to expectation of reward. I think it probably plays a role in the pain relief we often see from exercise, foam rolling or trigger point work. Interestingly, many common chronic pain conditions such as fibromyalgia, chronic fatigue, and IBS are characterized by the relative inefficiency of the descending inhibitory systems. We should expect that these groups are less likely to experience placebo effects based on the expectation of reward.

Anxiety Reduction

Another mechanism by which placebos work is reduction of anxiety. Anxiety basically means the state of expecting a future threat. (It can be distinguished from fear, which is the perception of a current threat.)

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Research shows that placebos can reduce anxiety, which tends to decrease pain.

Nocebos do the opposite – they increase anxiety and pain. For example, in one study, researchers told volunteers that a very low-intensity electrical stimulus would be painful. And so it was, even though it shouldn’t have hurt much at all.

Again, the effects are real not imagined – researchers measured the increase in anxiety and pain not just by subjective report, but objective measures of activity in relevant brain areas. Further evidence that nocebos have real physiological effects comes from research showing that it can be eliminated by drugs that reduce anxiety, such as benzodiazepine and diazepam.

In other words, if you can’t be made anxious by false suggestions that something will hurt you, it won’t hurt any more than it should. Anxiety also works to antagonize the dopamine and opioid networks that cause placebo pain relief.

Learning

If you consistently experience pain relief right after a certain stimulus, you will learn to associate the stimulus with reduced pain.

For example, if you regularly take aspirin to help with a headache, you will begin to associate the appearance of the pill with feeling better. If someone then gives you a fake aspirin that looks like the real one, you will get a much better placebo effect than without the prior conditioning.

Thus, past experience can make you “expect” benefit from a particular stimulus, even if that expectation is purely unconscious and based on past associations.

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These associations can be “unlearned” as well.

If you ring a bell for a Pavlovian dog, he will salivate – but if you keep ringing and never bring dinner, at some point he will figure it out and stop drooling.

And if you keep taking that same placebo aspirin without its active ingredient, it will eventually lose any learned placebo effect.

Here are some interesting experiments that demonstrate how learning through association can create placebo effects.

Rats who learn to associate a favored liquid with receiving an immunosuppressive drug will experience immune suppression after drinking the liquid, even if the drug is removed. Similar results have been obtained in humans. A tasty beverage will improve runny noses in people with allergies if it is first consistently paired with an antihistamine.

Unconscious learning can also create placebo effects in the endocrine system. A fake insulin injection can lower blood sugar after a conditioning process with actual insulin.

This is all very interesting to be sure, but why should a manual or movement therapist care? 

We are (hopefully) not in the business of giving our clients drugs during treatment to cause them to associate our care with pain relief.

Here’s why we should care: This research gives insight into what is probably a major player in pain relief related to movement therapy – “unlearning” negative associations between movement and pain. These associations can arise after an injury, and remain to cause a big fat nocebo effect even after the injury heals. Imagine you injure your back, and then experience nociception and pain whenever you forward bend into full lumbar flexion. You will start to consciously or unconsciously associate this movement with pain, and you will gradually learn to expect pain when you do the movement.

After a while, the back injury heals but the association remains. 

Forward bends are now a nocebo that can create pain even without the “active ingredient” of nociception. How do we stop this nocebo effect? By breaking the learned association between forward bending and pain.

If you repeat the forward bend enough, especially in ways that are slow, novel and non-threatening, your brain will eventually realize that the “active ingredient” of nociception is no longer present. You will start to unlearn the association between movement and pain, and eventually recover full pain free flexion.

But what if you don’t fully go through this unlearning process?

Maybe the injury heals and nociception is gone, but you avoid the movement completely because you’re too scared to revisit it. The nocebo effect remains because you never break the association between pain and movement. This is perhaps one of the reasons why fear of movement (kinesophobia) is a good predictor of when acute injuries will develop into chronic pain. I think the one of the main ways that movement therapy can help us get rid of chronic pain is to progress slowly and carefully into movements which we expect either consciously or unconsciously to cause pain.

For an amazing and dramatic example of this process, check out this video by Peter O’Sullivan.

Conclusion

The science of placebo is very interesting and informative.

It is not unreasonable to suppose that a good degree of the success seen in movement-based therapies is through placebo-like effects, or through getting rid of nocebos.

But I think the word placebo can be confusing. It refers to a wide variety of different phenomena that have different effects through different mechanisms. Some placebo effects work through anxiety reduction, others through activation of the reward system, and others through descending inhibition of nociception. The common thread is they are all created by cognitive inputs – information that changes what the patient expects or believes about their health.

And this relates to another problem with the word placebo – it suggests that treatments which work through changes in client expectation are somehow inert, or ineffective, or not meaningful, or unethical, or even a scam. Of course this may very well be the case when the treatment is a sugar pill, or based on pseudoscience or quackery. In these instances, the clients’ expectations and beliefs are changed because they are deceived, and this is in most cases unethical.

But what if a treatment works primarily through changes in belief and expectation, but in a way that changes those beliefs to be more accurate? Consider the following scenarios, all of which might be described as involving placebo effects, but none of which involve deception:

  • a client is given accurate information about the poor correlation between back pain and objective MRI findings. This lowers his anxiety and pain.
  • a client is shown through passive and active movement that it is possible for her to bend forward without pain if she does so in a different manner. This reduces her anxiety, makes her expect benefit from therapy, and this reduces her pain.
  • a client receives compassionate and empathetic treatment from a caring therapist. This lowers his anxiety, makes him expect benefit, and thereby reduces his pain.
  • a client has had many past experiences with massage causing pain relief, and this learned association contributes to further pain relief from massage.

Are these all placebo effects?

It is true that they all work in large part by changing the client’s beliefs. But that was the whole point of the treatment in the first place! So there should be no suggestion that the treatments are inert, ineffective or deceptive. Using the word placebo in these cases can be stigmatizing and confusing.

I prefer to look at it this way: pain results from perception of threat, and it can be treated by providing the client as much good news as possible about the threat in question. Does this present an ethical issue? Only when that good news is built from lies and not the truth. Fortunately, I think there are many optimistic truths that clients can learn from therapists through touch, movement, and conversation.

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*Another meaning for placebo is used in the context of research trying to determine whether some treatment is effective. This meaning includes various reasons the data reflects that a subject feels better after a treatment, such as spontaneous remission of the disease, data error, or regression to the mean. In this context, if my headache was about to get better in the next hour, and I took a pill right before that, my improvement would be attributed to “placebo.” Yet another meaning for placebo is something that causes a subject to think that they feel better, or to report that they feel better, even when there haven’t been any real objective changes in their symptoms.

Articles Of The Week January 26, 2020

All too often we are blaming back pain on things like degeneration, aging, injury, and using surgery and opioids in treatment. But, as he usually does, Dr. Peter O’Sullivan sheds some better light on back pain.

“A Refreshing Take On Back Pain With Peter O’Sullivan” – Steve Katasi

We discuss pain around here quite a bit and there are many arguments that can be made regarding different aspects of pain. In this post wants to put the sensation vs perception debate to rest.

“Sensation Vs Perception Debate” – Richard McIlmoyle

He has taught us a lot about pain science over the years, but with this post, he shares his own experience with pain (which is really important for us to understand as clinicians).

“Personal Chronic Pain Update” – Paul Ingraham

Researchers have identified a new target of alcohol in the brain. A new study reveals alcohol blocks the KCNK13 potassium channel within the membrane of dopamine-releasing neurons in the ventral tegmental area.

“New Target Of Alcohol In The Brain Identified” – University Of Illinois

You may not deal with head injuries every day in your practice but you will probably see a few in your career. This article shows how football players can be affected by CTE (and it’s symptoms) as the case history of 111 NFL players demonstrates

“111 NFL Brains: All But One Have CTE” – Joe Ward, Josh Williams, and Sam Manchester

6 Steps In Preventing Harassment From Happening To You

 

“ If you let me go and leave, I’ll pick up the phone and tell the police I accidentally hit the panic button with my leg.” This was me, negotiating my safety with a predator who was a regular patient of mine. 

I was given the opportunity to pair up with theMTDC after reading posts that I feel are becoming more of an unfortunate regularity on Facebook. Those posts about therapists being subject to disgusting behavior or uncomfortable situations and I wanted to share my experience of being a female massage therapist, the situations I have had to deal with, and tactics you can use if (hopefully never) those times occur. 

Before we jump into details, just want you the reader to be aware some of these experiences may deal with sexual content and nonconsensual/ forceful touching. Read at your own discretion. 

 The Protection Of School

When you are a fresh RMT, building a practice takes priority and when uncomfortable situations come up, it can be really hard to confront those patients. I know when I was a recent RMT, I didn’t want to lose out on a patient; I wanted people to like my treatments so I would get referrals. 

A lot of the time when patients said off-color things, I would just awkwardly laugh and redirect the conversation. When I got asked out on dates, I would use the CMTBC by-laws or “I have a boyfriend, sorry,” as an excuse. I wasn’t well versed in establishing and maintaining my boundaries as a young therapist because school made me more fluent in muscular anatomy and postural dysfunction than it did with establishing boundaries. The tactics I remember vaguely were; redirect the conversation, get them to focus on their breathing, and if things were really bad, tell them the treatment is over and why, and leave. Instructors often shared their experiences, but unlike MTAR, there was no specific protocol if severe situations were to arise. 

As a student, I had male patients rub my legs when I was treating, make lewd comments about happy endings, and in one case, I had a male patient grab my face and kiss me as I was trying to help him put his shirt on after the treatment was over.

My instructors were great, always there to jump in and deal with patients, but this didn’t set me up for practice when I would be by myself. I was met with remarks like “ This kind of stuff you’ll very rarely have to deal with in practice. The general public has a way better understanding now that massage therapy is health care and not something sexual.” Said from a male instructor. In his experience, I’m assuming, that is probably true. My experience speaks differently though.

 When Real Life Hits

I have been in practice for 6 years now. I have dealt with the following; male patients ejaculating onto sheets, asking if I have ever had to deal with other men asking for happy endings, patients actually asking for a happy ending or if I knew a place nearby that would offer one, men calling in and asking for “ a petite or Asian female”, patients asking if I did house calls and saying “ don’t worry, I’ll change the sheets when we are done”, telling me “ If my wife ever saw what you really looked like, she would never let me come here again” or flat out asking me out on a date or if I had a boyfriend. I’ve had my butt grabbed and had a patient pull me into his lap during a seated shoulder technique I was performing. 

Most of these uncomfortable conversations ended the same way; I would freeze, maybe let out an uncomfortable laugh or redirect conversation, get them to focus on their breathing and after they left, I would send them an email saying that they were being referred out to someone who could better help them focus on their treatment as we weren’t a good therapeutic fit or something along those lines. I would never see those patients again.  If this sounds familiar to you, keep reading. 

I had the terrible opportunity of dealing with a professional predator. A new patient to me who found me online and became a regular. At first, our interaction was normal and professional, but slowly conversations started to drift into his dating life. I would redirect when this would happen, but one day he asked for my advice on how he should approach women and I said that was out of my scope of practice and that I could refer him to a counselor if he wanted to discuss his frustrations.  

Then he started talking about things that I was interested in, and I thought, “ Wow, what a small world. I never met anyone who liked a lot of the same stuff I do.” And treatment became comfortable with this patient again.  

The night before I was attacked, I called my mom to catch up; I had moved out recently and hadn’t talked to my family in a while. My dad needed to use the phone because someone was parked outside (not in the driveway, but on the road) in front of their house and my dad thought it was a drug dealer and wanted to call non-emergency. (Classic Surrey) 

I said good night to my mom and went to bed. 

The next day, while I was wrapping up with my second to last patient, my last patient arrived earlier than usual. My colleague and patient were just leaving when she said:

“ Have a good night! Can I lock you in with your last one?” 

My last, now knowing we were alone, probably thought this was his opportunity to attack. Now that I look back, he never did earlier because he never actually knew if I was alone because all the treatment room doors would always be shut if they weren’t in use and we had a central music system that would always be playing.

Treatment was typical, but this time he was asking me about hockey, and if I was a Montreal Canadiens fan. Surprised, I said I was, and he suggested, since he was my last, we should catch the game at the pub, he would even drive me home to grab my jersey. 

I froze; I asked, “ How do you know where I live? And how do you know I have a jersey?” 

He looked up at me and I’ll never forget the smirk, “ You tagged yourself in a picture of you and your dad watching the game. You should really talk to your family about their privacy settings on Facebook; Anyone can see everything.” 

I told him the treatment was over and he grabbed my thigh, “ No no no, I’m just kidding, c’mon let’s go watch the game.” I stepped out of his grip and said, “ You’ve breached our therapeutic and professional contract, I’m going to step out and you can leave” 

I run out of the room and the patient is quick to follow. (context here, I was treating his lower legs so he was fully clothed, probably now a thought out reason why he had me work on them, even with his shoes on), I just manage to press the panic button under the desk when he grabs my arm and pulls me in really close. 

“ I’m taking you out for dinner and I’m not taking no for an answer.”

My mind, going a thousand miles an hour through the Rolodex of previous experiences or something, ANYTHING relatable to grab onto and use, goes blank. 

The phone rings. 

I look him in the eyes, “ That is the Police. If I do not take that call, they will be here in 3 minutes. If you let me go and leave, I’ll tell them that I accidentally pressed the panic button with my leg. But you HAVE to leave now.” 

He lets me go, I pick up the phone and tell dispatch I accidentally pressed the button with my leg, and he smiles at me and leaves. 

Knowing Your Rights

It’s easy now, even as I write this to go, “ Jocelyn, tell them this guy grabbed you!” But when you are in an enclosed space with a predator, 3 minutes is too long. I was too embarrassed after that to ever say anything. All I told my colleagues was that I was no longer seeing this patient and if he calls, to refer him to someone else. I didn’t know my rights as to what action I could take, and as a newer RMT, I thought that the College could take away my license because I breached patient confidentiality if I reported this person to the authorities. So I tried to let it go.

It wasn’t until much later when my anxiety was so crippling that I sought counseling, I was made aware of my rights. However, when I was going to pursue legal action, this patient had lied about everything identifiable on his intake form, including his name. He always paid cash. There was no way of tracing him. He was a professional predator who was grooming me and knew from the moment he saw my photo online that I was going to be his target. 

I want to take this opportunity to share with you readers what my actions are and what my plan is when a patient makes me feel uncomfortable or unsafe. 

  1. Always go with your gut. If someone’s behavior, conversation or actions make you feel uneasy or unsafe, don’t shrug it off as just creepy or weird as we tend to do. 
  2. When your gut tells you something is off, don’t deflect or redirect. Address the concern head-on.  “ I would prefer if we moved away from this topic of conversation because it is not relevant to your treatment and is inappropriate for this setting.” Be firm. Don’t laugh it off, because they won’t take you seriously or think that is okay. If they say they are just joking or call you cold or that you are being too sensitive, tell them the treatment is over and you will be following up with an official discharge email. If you give them an inch, they will take a mile.   
  3. Don’t use the College or a relationship ( ie: I can’t go out with you, my college says I can’t date patients, or I’m married/have a partner etc..) as an excuse for why you don’t  want to do or engage in something. It’s easy for someone to follow up and say, “I won’t tell if you won’t”, and then the conversation goes in circles. Decline and say, “ I would like to remind you that this is a clinical setting and if you are seeking anything more than what I offer, which is only therapeutic treatment, I will refer you to someone who can continue your care.” 
  4. Know your surroundings and have a strategy prepared. I had recently posted my strategy on the BCRMT Facebook page. I suggest you meet up with your colleagues and have a plan ready, role-play situations and get used to saying those phrases; that way, they just come out easily when you need them too. 
  5. Never make it obvious that you are alone. Close another treatment room door and put music on in that room. If patients ask if you are alone or if they are your last for the night, say no. Colleagues, if you are locking another colleague in by themselves, don’t announce it to everyone in the office, just leave a note and lock up or have this as a known clinic policy that if someone is by themselves to lock them in. 
  6. Unfortunately, sometimes you can’t avoid when someone decides to attack you, self-defense lessons are a great idea. Under the law, you can fight as hard as necessary to protect yourself and get away safely. Your rights to safety and self-preservation under federal law are above any by-law. 

Finally, my intent for this post is not to scare or alarm you therapists out there; it is to prepare you. We are so knowledgeable in how the body works and can apply critical thinking to our manual therapy, but we need to have that same knowledge and strategies when it comes to our safety and boundaries. Do what you must to get comfortable dealing with uncomfortable situations, as I am not going to tell you that this is a rare occurrence. If it is in your experience, I say, it’s better to be prepared than it is to find yourself negotiating your safety with a predator. 

 

Articles Of The Week December 15, 2019

 

There is many a myth in our industry, and while I’ve written about and tried to change some opinions around them, I haven’t been able to cover them all. Fortunately, people like Daniel Wonnocott are trying to do the same and did a great job busting this myth.

“Mythbusting: Massage Reduces Cortisol” – Daniel Wonnocott

I’m sharing this because it’s simply an amazing cause that involves our profession. A group is Rwanda is training visually impaired people to be massage therapists, providing them with a career they may not have had otherwise.

“Seeing Hands Rwanda” – Seeing Hands Spa

There is no shortage of modality classes you can take to learn a different way to touch your patients. However, what if we paid more attention to the concepts behind a treatment application, rather than just the modality itself? I for one think this is FAR more important than any modality and fortunately, this article agrees with me.

“Modalities vs. Concepts in Massage Therapy” – Tania Valasquez

This seems to be a hotly debated topic at times, but it’s a necessary one. It’s important for our business, but also as this article shows, charging for late cancellations is also important for the therapeutic relationship and our mental health.

“Why I Charge For Late Cancellation” – Megan MacCutcheon

While I know (well, at least I hope) none of us are on our cell phones while talking to patients. However, there’s some good advice here about communication in general, and yes, we can apply this to when we are talking with our patients and improve not only our communication but probably our outcomes as well.

“Put Down Your Phone: Why Presence Is the Best Gift You’ll Ever Give” – Will Aylward

 

The Truth About The SI Joint That You Shouldn’t Ignore

Early on in my career, I’d have people come in with hip pain and like it was a script, I had an explanation ready.

I had a couple of go-to orthopedic tests, (Gillet’s, Standing Flexion, and Supine To Sit) and I’d boast about how their Ilium was rotated to their Sacrum. This, of course, resulted in a leg length discrepancy and had to be the source of their pain!

I’d do a muscle energy technique that would cause a loud “pop” from their pubic symphysis and this look of relief would wash over the patient’s face as if I had just done some sort of magical repair.

But, as time goes on not only have I started to realize that most of the above concepts were wrong, I was SUPER wrong for believing I was doing some magical repair (I’d like to think my ego has shrunk since then).

So, the question begs, what’s really going on with this darn S.I joint!?

Well…here’s what I’ve found out.

Rotation Of The Ilium

Whenever we talk bout the ilium rotating we are discussing nutation and counternutation.

Nutation is when the sacrum is moving in anterior/inferior…think to nod your head. The interosseous sacroiliac ligament (which is one of the strongest in the body) connects the sacrum and the ilium and prevents this movement from happening.

Counternutation is the opposite, moving in posterior/superior…think looking up at the ceiling. The posterior sacroiliac ligament connects the PSIS and the iliac crest with the sacrum and also prevents counternutation.

This is essentially what we were told to test in college and it was all about how the ilium rotated on the sacrum. So, we have to ask the question, how much rotation can there be?

The degree of movement is typically measured through the axis of rotation occurring through the second sacral vertebrae so the sacrum is performing its nutation or counternutation in the sagittal plane (the body in half from head to toe). The amount of movement is thought to be anywhere between 15° and less than 3°.

There is even discrepancy as to the direction of movements as one study showed that when a patient is forward flexing (like we do for some of the SI special tests) the sacrum was just as likely to nutate as it was to counternutate.

However, there are extenuating circumstances that would allow more movement in the joint such as those who have S.I. Joint disorders (which we will get into later), but when we look at healthy individuals who are perhaps experiencing some pain in the area we see much different numbers. One study actually showed in healthy individuals the average total rotation was only around 2°. They even examined 25 patients with sacroiliac joint syndrome and found the movement range to only be 1-3° with no difference between the symptomatic and asymptomatic side.

When we look at a goniometer or a protractor to see what 1-3° looks like, it’s pretty minimal and I dare say REALLY difficult to see with the naked eye.

So, we have to ask the question, are the aforementioned orthopedic tests accurate or valuable for us to use?

Well, a systematic review showed the use of Gillett’s test to evaluate movement of the SIJ to have a 47% intertester reliability, which shows this test to be unreliable. Because the movements are so limited and minute it is even suggested the movement would be impossible to see. 

Even if we’re doing tests to look for some sort of dysfunction, another review showed the most typical tests used were: Faber, distraction/compression test, focal SIJ tenderness, seated and standing Gillett’s, femoral shear, and modified Gaenslen’s were not reliable to show the likelihood of SIJ tenderness unless three or more of those provocation tests were positive, the pain was unilateral, the pain is below L5 without lumbar pain, or if pain increases with rising from sitting. 

Now that’s a lot to take into account especially if there is no history to suggest any kind of a pain or dysfunction disorder.

Of course, some of our patients will be referred for imaging, but even that isn’t helpful in the evaluation of SIJ pain unless looking for tumors, infection, or fracture, but hopefully, you’ve ruled some of this out with your intake by ruling out red flags.

What Should We Be Looking For?

If we look at a broader term, pain around the SIJ can be referred to as Pelvic Girdle Pain Disorders (PGP).

Specifically, when we look at this, the cause is around pregnancy, trauma, arthritis, and/or osteoarthritis, but excludes things like gynecological and urological disorders.

Pregnancy is one of the factors that we know can influence women to experience PGP as the effect of hormones (higher serum levels of relaxin and progesterone) affects the ligaments in the pelvis to increase their laxity, and possibly influences stability of the pelvis, but more research is needed to clarify how the role of hormones may differ in various presentations. However, this decreased joint stability can be compensated for by a change in muscle function. There is also evidence to show some of the risk factors associated with developing PGP during pregnancy is a previous history of low back pain and previous trauma to the pelvis.

When it comes to specific pathological issues like inflammatory arthritis, sacroiliitis, fractures, or infections there’s really not much we can do as therapists as manual therapy can’t address the underlying pain mechanism of the disorder, so, much of what we are doing is most likely helping with symptoms as opposed to rectifying the cause. 

Beyond these specific pathological issues there is another group of issues classified as Non-specific pelvic girdle pain disorders:

  • Non-specific inflammatory pelvic girdle pain disorder
    • constant, disabling, non-remitting pain in SIJ, provoked with weight-bearing, pelvic compression, and SIJ provocation tests.
  • Peripherally mediated (mechanically induced) pelvic girdle pain
    • Localized pain to SIJ that in intermittent and provoked and relieved by specific postures and activities due to directional loads and weight-bearing.
    • Usually, they have a clear mechanism or time of onset due to repeated strain or direct trauma.
  • Reduced Force Closure
    • Associated with excessive strain to the SIJ coupled with motor control deficits of muscles that do force closure of the joints (pelvic floor, transverse abdominus, lumbar multifidus, iliopsoas, gluts).
    • Common with postpartum PGP and a positive ASLR (active straight leg raise) test.
    • Functional impairment associated with, sitting, standing, walking, or activities that induce rotational pelvic strain coupled with spine or hip loading activities like cycling, or rowing.
  • Excessive Force Closure
    • Localized pain to SIJ and surrounding tissues, along with positive pain provocation tests.
    • Result of excessive, abnormal, and sustained loading of sensitized SIJ
    • Negative ASLR
    • Compression and local muscle activation (pelvic floor, transverse abdominal wall, back muscles, glutes, iliopsoas) is provocative.
    • Commonly associated with the belief the pelvis is ‘unstable’ or ‘displaced’ but exercise, massage (although I wouldn’t recommend this for the pelvic floor as massage in this area is out of our scope), stretching helpful for pain relief.
  • Psychological influences on peripherally mediated pelvic girdle pain
    • May be associated with underlying stress and anxiety.
    • It can be associated with faulty beliefs, and passive coping strategies, so we have to promote accurate beliefs, relaxation, and active coping strategies.
    • If associated with positive beliefs, and active coping strategies, then focus can be on physical impairments and work on helping with pain control.
  • Central nervous system driven pelvic girdle pain disorders
    • Associated with widespread, severe, and constant pain that is non-mechanical.
    • High levels of physical impairment, social impact, and abnormal pain behaviours.
    • Dominant psychosocial factors (catastrophizing, fear, anxiety, depression, history of sexual abuse).
    • Requires a multidisciplinary approach with medical and psychological management.
  • Genetics
    • People with PGP are more likely to have a mother or sister affected.
    • Possibly a social influence here as well.

While this may seem like a lot to take in, it actually simplifies things for us.

If there is no history of pregnancy, trauma, or inflammatory issues (which we should be able to rule out fairly quickly in our intake process), then we can look at psychosocial factors influencing their pain. 

Now, I know where many are going with this…we can’t treat psychosocial (or many arguing it’s not in our scope).

Well, maybe we can’t treat it directly (okay for sure we can’t, refer out to a mental health professional for that) but we can recognize their influence and work on our treatment and communication from there. Many of these conditions revolve around beliefs, stress, anxiety, catastrophizing, depression, fears, and social impact. We can most certainly address these things by giving some proper education around what they are experiencing. Explaining to them, their hip isn’t ‘out’, their ilium isn’t rotated, they don’t have an inflammatory disease, and pain is normal. Giving them relaxation techniques, helping with symptom modification, and coping strategies can all have a large impact on helping our patients with SIJ pain. However, more importantly ‘promoting accurate beliefs’, might be one of the most important things we can do. All too often we have patients come in who have been told they’re rotated, out, or misaligned, which puts the responsibility on us to educate and correct those beliefs. Sadly, I used to be one of the practitioners telling them this. If I could go back and apologize to them I would, but many of those people I don’t see in my practice anymore. While I can hope this is because I helped and they’re doing better (and I probably did with some of them), I hope that whoever they are seeing now isn’t reinforcing those old narratives, but is giving them more accurate information. I know the way I treat SIJ now, is different than the way I did 10 years ago and now that you have this information, I hope it changes the way you do because updating our narrative is part of our responsibility as healthcare professionals.