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Podcast Episode #23 Challenge Your Bias, But Still Remain Patient Centred

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Jamie Johnston 0:12

You’re listening to the massage therapist Development Initiative. I’m Jamie Johnston. And I’m Eric Purves. This is a podcast by massage therapists for massage therapists. Our objective is to simplify how to be a more evidence informed practitioner, let’s dig into this episode.

Jamie Johnston 0:33

There are times when your beliefs get challenged. And there are times that you have to change the way that you do things.

I’ve been seeing, we’ve been seeing lots online lately, with people that are going back and forth between what the Noy group is saying and what other research papers are saying. And so we decided we would dig into some of this because as science should, we should always challenge our bias.

Eric Purves 1:37
Yes, and I agree that this, you know, I’ve been reading some of these guys, papers, and I’ve been reading some of their blogs for a while now, just because it provides a different thing than the normal echo chambers that we get stuck in. But it seems to me that

Jamie Johnston 1:00
So with that, we will look into a couple of papers that are both from Quintner and Wiseman. One called pain medicine and its models hindering or helping. And then the other one sort of just bringing the title up is pain is not a thing and how that error affects language and logic and pain medicine. So jumping into it, sorry, I’m going back and forth between notes here. I think the the biggest thing that I take from this is words matter, which we believe in anyway.

Eric Purves 1:57
like, it took me a while to really understand what the heck they were talking about. Because it just seemed that they were just kind of basically critiquing everything that was quite common language are quite common beliefs or ideas or ways of practicing in pain care. And so I was like, Well, what do you got? What do you guys saying? And I think it really a lot of it comes down to is the words that yeah, the words that are being used and how things are being described, as well as it seems to be that the things that they that this group in these researchers are arguing against, is I think they’re arguing against how often, like kind of biopsychosocial models are used in practice. But not I don’t see it necessarily as a problem in the I don’t know, they use I prefer framework, they don’t really they’re not really as it’s I don’t think it’s a problem with the framework itself, as much as it is how it’s often communicated to people in pain in practice. That’s so that’s where I see the splitting hairs kind of thing.

Jamie Johnston 3:04
Wandering through, because I looked at as I was reading through it, I was kind of there was some of the challenges that they were making, which is great, because we should challenge things. But I was reading it and going well who’s saying that? Because some of the things didn’t. I’m like, those aren’t the things that I would say to a patient or those that’s not the way that I look at it. So that part of me was wondering like Who exactly are you challenging? Because there’s, there’s some of the things for sure that that are, for lack of a better term splitting hairs. But I, but I’m not sure who it is that’s communicating to patients in the way that they mentioned in some of these things,

Eric Purves 3:48
right. And the thing that I the takeaways I got from reading not just these papers, but some of the other stuff from them, a colleague Monica sent me probably a couple of dozen papers that they had sent her and then she forward them to me and I’ve read not all of them, but I’ve read through most majority of them. And I mean no I grew up and kind of mostly in that group who uses a specific language to communicate the complexity of pain, like they talked about pain being this protective response and pain can be a learned. thing, you know, and and I see the argument from this, this group hear about how that can be problematic. But what I do see from what noi has done, and mostly in their research is they seem to have taken this really complex neurophysiology and this human experience of pain, and they’ve tried to make it something more simplistic for clinicians to think or reason or use in practice. And so it’s shifted that movement away from this pathway, anatomical tissues structural problem explanation more towards a, your system, systemic sensitivity. You know, when there’s like brain and peripheral and spinal cord stuff happening, that’s like the one thing, right? And then they try and put it in a way that’s teachable and use can be used in practice. And I think there is probably some oversimplifications of the words that they use. And I, but I like what you say like I agree with what you say their jammies, I think the, it seems that your average clinician out there, if they are saying those words to people, that can be a problem. Oh, you’ve just learned your pain, oh, you’re just stressed out, you start blaming the psychosocial things, and just trying to discount completely the bio. So I know these guys are talking about the nociceptive apparatus and the nociceptive system, you know, and there’s always going to be an activation of that and every pain experience. And I don’t think that anybody is necessarily really arguing too hard against that. It’s pretty much like they’re saying like, yeah, there’s some type of activation in your system. That’s, and then and then you have a conscious awareness of that. And there’s other psychosocial stress, other things going on around you, which can influence that. Okay, I get that. But when we talked, when, when you’re talking to patients, clients, whatever, like, are you? Like, are you trying to explain away their pain? Because I don’t think that is what people are really doing anymore? And if they are, then I think it’s a misinterpretation of like, analyze teachings. Yeah.

Jamie Johnston 6:37
And I think like, just when you touched on it there, like, that’s one thing that I switched. The way that I explained it years ago, is that, you know, the psychosocial things can influence your pain, it’s not a causative thing. And I know in the one paper they talked about, like the mind body connection, and, and that they’re like, well, that, that my understanding of how I read it anyways, is that it’s it’s not what, what we should be saying to patients, but yeah, they’re also saying the biomedical model doesn’t work either. Yeah. So I get that. I mean, in the, in the one paper, they, you know, you go through and they make some good points, like, you know, they go well, I, when I look at what they’re saying, for words matter, like one of the statements was, when core concepts employed within a field are open, there’s potential for inaccurate or misleading uses of terms, which then can be amplified with the patient. And that talks about like pain, and it saying a stimulus in and of itself is not painful. By contrast, it’s the experience labeled pain that is painful. Yeah. Right. So it’s what the person’s going through is painful. Yeah, it’s not necessarily the stimulus. And then they break it down further with different objections and saying, you know, that it’s a noxious stimuli that causes the pain, that it’s a stimulus that as damaging, or threatens to damage normal tissues, which is the definition of a noxious stimuli that is capable act of activating merseysiders. Yeah, I don’t, I don’t think anyone that Noi group or or others are saying that that’s not true.

Eric Purves 8:15
Yeah, and this is where this is where it gets confusing, right? So what’s, what’s the argument? Their argument is, I think more about the well, they talk about the reification of pain. So pain being a thing. That’s that’s this, you know, this one papers called pain is not a thing, how that error affects language and logic and pain medicine. Well, pain isn’t a thing. I mean, pain is an experience of pain isn’t a tangible thing you can grab your hands on. But I failed to understand and maybe I just need to think about this, reflect on this a bit more, maybe I did just spend more time with this. But we use the term pain, because that’s an experience that people are aware, like, we all know, what pain is a pain for each of us is different. Yeah. And is anyone saying that? It’s not like, you know, and, and there is, there is lots of studies that show that, you know, there’s certain areas of the brain that are activated when someone’s experiencing pain. And then there’s lots of studies that I’ve seen that looked at like the transition from these kind of sensory nociceptive, dominant areas of the brain, and acute and then as things transition to a more persistent, there’s changes, those sensory areas go away, and there’s now activation in the limbic system and other areas of the brain, you know, and these i, and then, what I get from this group here is that they’re saying, Well, you know, you’re, you’re saying that people are thinking differently about their plant or pain or the pain is an output of the brain, you know, and that and they’re saying that that’s not true. And you think, Well, it’s, I get that argument, okay. It’s might not be true, but we do know that there is. If pain is a lived experience of somebody, then there’s going to be something happening in the brain and in the mind of that person. That could be sensitizing the overall system. Whether that’s a peripheral nociceptive or a central or cortical All thing that’s stimulating nociceptive activity? Does it? I don’t know, does it change? How we think does change how we communicate? Is it changing anything that is it something new. And I don’t think that it really is changing anything too much. Because a lot of the stuff that the kind of the last decade of pain information, there might be a little bit too much brain focus. But no one is saying that pain is not a lived experience of the person. I’ve never heard anybody be like, I’ve never I’ve never encountered anything like, Oh, you’re you’re just thinking your pain, you’re making your pain up, or your pain is an output of your brain. Yeah,

Jamie Johnston 10:38
and I know that. We’ve talked about it before where, you know, I’ve been communicating with a with a person, and probably use the long the wrong language where they went. So you’re saying it’s all in my head? And had to backpedal and go? No, no, no, no, no. So you know, if they’re making some very valid points, that the way we communicate with patients is very important. Because we don’t want people believing that it’s all in their head, but the brain is still going to be involved in whatever that pain experience is that the person is going through. And, you know, going through just looking at some of the stuff, they make the argument of the use of the suffix susceptive. They’re saying that that’s the property of a receptor, but it’s often tied to a stimulus. And this leads to an argument that the nociceptive stimulus is one that activates those receptors. But that’s what a noxious stimuli does. But that’s not a language that I would ever use with a patient. No. So I mean, important for us to have that knowledge. And I think one of the big things that they’re saying is, when we’re looking at research papers, this is the language that should be used. Yes. And I can’t disagree with him in that regard. But again, it’s not it’s not ever a way that I would communicate with a patient.

Eric Purves 11:55
Yeah. Well, and this is goes to a lot of the stuff that we have in research and in our, in our world of pain, and rehab, and movement and all that stuff, is that there’s really cool information. Yeah, but how much of it is really clinically relevant? You know, so based on, you know, like, this is some of the some of the stuff we talk about in our courses, and we teach and, you know, we communicate with others about it. But in terms of like, how relevant is that to us clinically? Is this providing new? Not really, I mean, I would say maybe I’m, I am maybe a little bit more aware of being less brain centric, but still, you’re still like neuro immune centric with this information, because that information coming from the nociceptive activity is being received within the system. And then that is that awareness of that. And meaning of that is, comes from the person and their experience. So I, it’s good, I think it’s good to get out of the echo chamber and think it’s good to challenge stuff, but it’s just I still don’t see it hasn’t changed, how I would do a lot. But I want it to like, I would love to read this and be like, I’m open book, what do I do differently? What do I do better? What do I get throw away? What do I adapt? Very slight, very slight.

Jamie Johnston 13:13
And, you know, as we look through like, does it just because I made a whole bunch of notes on this, when they’re talking about like pain sensitivity, insensitivity hypersensitivity and pain threshold, things like that, because you know, we we’ve all had those, those people on the table, that I’ve got a high pain threshold, you can dig your elbow into me, and I like that. So one of the points that they they made is, is the threshold, the quality of the stimulus or the quality of the response. So if the person has a low threshold, which means the person’s which actually means a person’s ability to tolerate the experience, they’re saying we should use descriptions like pain inducing stimulus and intensity, with more specific terms that refer to the type of stimulus which would be like mechanical, thermal, thermal or chemical. But again, that’s that probably has less to do with us digging our elbow into them more to do with how they’re experiencing pain in the outside world. And what what things are inducing pain for them or creating pain for them? Yeah, yeah.

Eric Purves 14:12
And this goes, this goes back to what we talked about all the time, is in is, there’s not a right or wrong, like a person has a high or low or insensitive to touch. What’s the right touch for that person as us as massage or manual therapists? Well, the one and the person likes the one that they can tolerate. So it doesn’t matter what their level of sensitivity is, or is it maybe just it like it just as a clinician, if you understand that there’s these different sensitivities and everyone’s going to respond differently and there’s a world around this person, there’s a person who’s experienced that might be sensitizing their system. Then all we need to really understand from this is that you always are adapting your your touch or your treatments or your you know, interventions and strategies to what fits best for that person. That day, just to help the person have a better lived experience.

Jamie Johnston 15:04
And then always, yeah, like you said, that comes back to their experience. So whether the painful experience that they’re having when they’re not with you, that’s their experience and the experience they’re having while they’re on the table with you, is their experience. So that’s where that communication aspect comes in. Of does this feel good to you? Is this a good experience for you? Those kinds of things when we’re doing manual therapy with somebody always comes back to that patient centered care. Yeah, what experience is important for them? What is it valued? experience to them was a meaningful experience for that person on the table? Yeah. Easy. It’s interesting, though, because some of the things that we’ve talked about so many times like pain catastrophizing, they they make the point that is catastrophizing, a part of the pain experience or a reflection upon the experience. And is this purpose to serve the experiencer or the observer? So if we’re talking if we think as the observer that somebody is catastrophizing? Is that more important to us? Or is it more important to the person? Person? Yeah, yeah. But it’s something that we should try to take into account. But it doesn’t also doesn’t necessarily mean we’re going to look at them and be like you’re catastrophizing right now. No, right. Yeah.

Eric Purves 16:27
And that’s a really, I mean, yeah, that’s a really important distinction, because we like that kind of moves. Like we want to move away from that operator. perspective, or we’re putting our judgment or beliefs onto the person, which would be so if we said, oh, you’re catastrophizing, that’s us putting judgment onto onto the person. It can provide us insight into thinking well, yeah. So say you’re doing the pain catastrophizing scale, and it says they have a high score on that. What it’s how is that going to that is actually can be useful information for us, because it lets us know, as a clinician, this person is suffering from their pain, and how they how they feel about how they’re experiencing their pain. But it doesn’t tell us what their level of pain is. It just tells us how it’s impacting them. So I don’t again, I don’t see how that really, you know, unless you told somebody you’re catastrophizing. Yeah. Which you wouldn’t that which

Jamie Johnston 17:39
could have a massive impact on somebody? Yeah.

Eric Purves 17:41
Then it’s just we have to be mindful of using our words, for sure. Yeah.

Jamie Johnston 17:45
Yeah. Yeah. Which leads us into also, the comments that they make on kinesio phobia or fear avoidance, they make the kind of make the same point that is that a judgement of the observer or judgment of the person who’s experiencing it. Just reading here for it says it doesn’t deny the importance in challenging challenge of interpreting the behavior of a person experiencing pain. So they suggest that we explore the person’s cognitive appraisal of their own predicament in their words. So listen to them, and whatever they tell you is what they’re going through. Yes, so comes back to that patient center character.

Eric Purves 18:25
Yeah. And that’s what we’ve I mean, that we’ve learned that before from you know, having interviews with people like like Keith Meldrum, who it’s, you know, talking about the, you know, the lived experience, the dog was every year at San Diego Pain Center, they always have the pet or the almost not always, but many years, they have that panel of people their lived experience. And that’s always emphasized as being the most important thing, like you can know all your stuff about pain, you can know all your treatments and all the things to say and do and not do. But what what matters most is really trying to be in that safe space for that person for their lived experience, and not taking that away from them or not trying to replace that with your own views.

Jamie Johnston 19:09
Yeah. And so I like how they put some of those things in there that you know, is it the role of the observer, or the role of the person who’s going through it? And there’s definitely going to be some instances where it’s our responsibility as the observer to recognize that something might be going on. But it also doesn’t mean that we have to communicate that specifically to the person in front of us.

Eric Purves 19:33
Not unless we get their permission now, unless they want to know, which is person centered again. Yeah.

Jamie Johnston 19:40
So it’s, I know this very interesting because I’ve seen this big, these big debates and arguments online. And the Yeah, I mean, the the people make some great points in these papers, but I think in the long run, we’re all saying the same thing.

Eric Purves 19:58
Yeah, and It is, you know, I know in this this this pain medicine and it’s models paper, which is a bit old now I think it’s 2010 or eight or something, it’s a while ago, it’s really an argument against the linear process of bio cycle socialism. Right and that is true that you know, in the bio psychosocial when you first encountered as a clinician, you’re often looking to be like, is this bio is a psycho is a social and you’re looking to explain pain via one of those domains. And it becomes and so they’re like, oh, no, the bio psychosocial is more inclusive, whereas traditional biomedical if the Descartes Cartesian model was very linear, so that whole was explained. And Biomedicine is very linear. But biopsychosocial is just as linear. You’re just looking to find something new to caught to blame. And I’m thinking, well, maybe it may be that some people are applying it. But that’s not how I don’t think how it’s supposed to be implied. I’ve never understood it to be applied that way. It’s more like holistic, like whole with a W like looking at the overall person, their experience, and how is the world and the person how is everything around this person is shaping their experience? That’s how I see biopsychosocial. I don’t see it as this linear process, but maybe how it’s taught or maybe how the people understand it is different. And maybe, you know, if I think back to my early days, maybe I thought it was different, too. But I know you can. It’s hard to remember we used to think not yesterday. Yeah, where am I?

Jamie Johnston 21:28
Yeah. However, and we can, I think we can go off on a little bit of a discussion about this, as well as at the end of one of the papers I there’s a statement that they made that I absolutely loved. Because I think it’s applicable to so many more things in our profession than just this one topic. They said one of the more powerful therapeutic tools available to the clinical pain practitioner, irrespective of their background discipline, is to present a clear and honest explanation that is as close to accurate as possible in the current state of knowledge. Yeah, I think that is beautiful. And I think that we, we have to take that and almost apply it for lack of a better term globally to what we do. And for those that are that are out there saying, I don’t need to look at research because I know what I do works. Ones that are still using old narratives of how their technique works. This right there, it if that doesn’t tell you that you need to change. I don’t know what else could because we have a responsibility as healthcare practitioners, to give as honest an explanation of what’s going on with the person in front of us as we can with the most updated current state of knowledge.

Eric Purves 22:47
100% And we have an ethical obligation to do that as healthcare providers, right, we should have, you know, as you learn new information, even if you look at our, like our competency documents and stuff that they have here in BC, the you’re supposed to use research and incorporate into your practice regularly. And as as you learn, you’re supposed to be able to adapt your knowledge based on your current on, on adapt your practice based on your current knowledge. And the and as we learn more if we learn stuff that contradicts or challenges what we used to know or what we used to do, then we have to, we have to change, you have an ethical obligation to change and people come to seek our care deserve that.

Jamie Johnston 23:30
And which is the exact reason why we wanted to discuss these two papers. Yeah, is in the hopes that it will either challenge or make us change. And it probably has to a degree but probably not to the degree that I thought it was going to.

Eric Purves 23:46
Yeah, and I think so too. I agree with that as well. I was trying to really my reading through these things before really trying to really trying to challenge my bias. And but as I read through this, I’m thinking No, that’s kind of what I already that’s kind of what we already say and what we already do. And and it’s good to question the stuff obviously, like we said before, it’s good to not just sit in an echo chamber but the one issue I have with these guys writings is that they don’t really they don’t really give you any further information about like here’s things moving forward. You’re fine you can fix that. Yeah, it’s very philosophical and very like well this other way is not right. But I would like to see them come up with like an idea or like a like a Knowledge Translation plan or something moving forward that says this is how this information could change your practice or could could be applied to your practice. I would love to see that because when you when it’s just challenging and saying like, this is this is wrong bla bla bla but without a que What do you replace it with? Then then it becomes harder to to incorporate into your to your practice. I think the message is gonna get lost. I think that’s why In like the, you know, RC world that we live in, is that when you’re teaching stuff, you have to find something else to replace it with. And I know, early in my career trying to just give people information hoping they would change. They don’t change, you just try and give them some information and be like, and this is how we try and use this in practice. This is how it shapes what we say and what we do and how we think. But with the absence of like, what do we do with this information? I think he gets lost in a lot of people. I think that’s probably part of the problem, at least from my anecdotal observations of this, how this stuff works in social media, when people are arguing about it. It’s like, Yes, so what do you tell me then?

Jamie Johnston 25:41
Yeah, yeah, I agree. But I would say one thing, looking at it is my impression was that they were saying this is how, like, these are the terms that should be used in research, these are the team terms that should be used in papers. So perhaps, if, if that’s the approach is if they’re saying, well, from now on, when a research paper is done, this is the term that should be used, then gradually that would start to change, perhaps how we’re communicating with a with a patient or with the person in front of us. Yeah. But that was that was just my impression of what they were trying to say.

Eric Purves 26:15
Yeah, and that’s, and that’s, I think that’s a really valid point. Because we, I think one of our first podcast we did was about like, words, the power of beliefs and stuff. So yeah, if there’s better ways of kind of communicating the similar ideas or similar or same things, then, of course, let’s change it now become the new normal.

Jamie Johnston 26:32
Yeah. Yeah. But I, but I still don’t think it would change how I communicate with the person in front of me, because I would never look at a person and use words like noxious stimuli. And, and those kinds of things. No, unless, like you said before, unless they asked and wanted to get really educated on this stuff. You know, but I see the value of using it properly and research.

Eric Purves 26:57
Yeah. Yeah. And maybe that’s maybe that’s where this stuff will be beneficial. Moving forward, is maybe there will be some changes in how the researchers are doing the things. Yeah. Rather than clinicians and I mean, we look at all this stuff through a clinicians lens, not through a researcher lens. Yeah, I mean, these guys are, you know, Quiner and Cohen are retired. And Assaf is I think he works at a university in Israel. So yeah, yeah. Israel, I

Jamie Johnston 27:26
think witness Australia.

Eric Purves 27:28
Yes. I think Cohen is too. But anyway, yeah. So there’s, but it’s interesting, because I would like we get so caught up in the details about things like these like minutiae of the neurophysiology and the language and stuff. But I would, I can be very bold. I’m gonna say if you took this information to a psychologist who treats people in pain, terms like, yeah, who cares? It’s always with the lived experience. It doesn’t matter what this other stuff.

Jamie Johnston 27:58
Yeah, if you were talking to like a millennial, well, yeah, you would probably look at this and like, okay,

Eric Purves 28:04
yeah, they’re like you, they’re gonna say, Well, why are people arguing with this? Like, doesn’t matter, like, what matters most is the person is experienced? And how can we help shape that experience? And through their, obviously through the psychological interventions or ways? You know, this? So I think this, this stuff here is very, very, there’s a lot of people out there that treat people that help people hurt. Yep. This information, I would say would be specific to maybe more physiotherapy or medicine. But I would say, I would say a lot of these guys criticism, a lot of it comes towards the physiotherapy professions, because that is going to allow us directed towards NY and mostly is stuff and Butler stuff. So psychologists and other people are, who cares?

Jamie Johnston 28:51
What we do, because then that’s why we looked at the papers. Yeah, exactly.

Eric Purves 28:54
I think I mean, I think it’s interesting. It’s,

Jamie Johnston 28:57
yeah, so I think the I think we can look at the overall message of this specific podcast is that we can come to agreement that it’s the person’s experience, that’s going to be the most important thing for us to take into account. And just communicate well with your patients. And there are certain times where we need to be the observer and just listen to what it is they’re saying to us. Yeah. Which is

Eric Purves 29:22
good quality. person-centred Care. Yeah. And we don’t need to impart our beliefs on to people without their permission or without their wanting to.

Jamie Johnston 29:33
Unless, unless they ask, unless they ask. Yeah, and, you know, and, of course, the other thing is to always be open to challenging your bias and looking at new things and, and seeing how you can improve as therapists. Brilliant, perfect. That one actually went a lot quicker than I thought it was going to. Because it took me a long time to go through those papers. But yeah, I think that’s a that’s a good way to wrap it up and thanks for listening, everybody. We’ll see you next time. We hope you enjoyed this podcast. These kinds of topics are what we’re all about. If you’d like to learn more, go to our websites,

Eric Purves 30:12
themtdc.com or Ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.

 

Podcast Episode #21 Allowing Research To Challenge Our Beliefs

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James Johnston RMT 0:12
You’re listening to the Massage Therapist Development Initiative. I’m Jamie Johnston. And I am Eric Purves. This is a podcast by massage therapists for massage therapists. Our objective is to simplify how to be a more evidence-informed practitioner. Let’s dig into this episode.

You ever have one of those moments where you get faced with a piece of research that challenges, something that you’ve been saying for a long time?

We’re going to talk about that today. Because I’ve been long saying how going for a walk is one of the best things you can do for low back pain. And while it’s can still be an effective thing, we’ve come apart come upon some research that tells us otherwise. So we’ll get into that today. But I think before we get into that one, we’ve got one paper that we’re going to look at, it’s talking about the superior and middle cluneal nerve entrapment as a cause of low back pain. So we had a quick little discussion about this before we came on. And I think some of the points that you were making right away about the anatomy and things like that are probably a good place to start.

Eric Purves 1:26
Yeah, yeah, it’s good to actually come back and do some more recordings of these because it’s been too long. A few months. Yeah. Been busy start to the 2022.

Yeah, the both of things I think will be it will be interesting to discuss, because there is, you know, and this is a debate, I think that’s never going to go away. The belief is that super detailed anatomical knowledge is necessary to be a good quality therapist. And I would argue that that is a belief, that’s an opinion. But that’s not supported by research, by biological research. Now, I think it’s it makes sense for us as clinicians is that we have to understand anatomy, we have to understand, you know, kinesiology, how things move, but I think it do, we really need to know the specific font, like fine details of the human body in order to be better therapists. And I would say that goes against research. And that goes against a lot of, you know, what we know, in practice is that you can get people getting get better. There, they can become have less pain, they can be more functional, without having to like be super, super, super-specific.

James Johnston RMT 2:36
And that applies to treatments to exercise to just about everything that we do.

Eric Purves 2:42
Yeah, yeah. And the people can hear that and feel threatened. Like it makes them think that oh, well, you know, my palpation skills, what’s the point of going to school, I’m useless. And that’s not what we’re saying at all we’re saying is that, that’s, that’s important, but it might not be as important or as necessary, as you think. And there’s other people out there. They’re teaching courses, and they’re like, You need to know these specific interventions to get the specific results. I’m thinking, well, that’s your anecdotal experience. But that is your belief. You know, and you that’s only supported by your own clinical experience. But maybe people are getting better for completely different reasons. And maybe we can treat somebody more generally, and get the exact same outcomes.

James Johnston RMT 3:19
What’s funny I had, I probably shouldn’t go off on too much of a rant about this. But I had a bit of an epiphany the other day that, like, we’ve talked so many times about why people are resistant to change. And I was reading some stuff the other day and came to the my own realization, maybe that we’re doing it because our brain just wants us to feel safe. And our brain is always going to choose the thing that makes us feel safe. And when we look back at our college education we had, I don’t know how many classes that were just manual therapy technique classes. So you look at general Swedish massage, myofascial release, spinal ortho piece, orthopedics, regional orthopedics, cranial sacral, therapy, all these things. And yet, we only had one class on therapeutic exercise. We only have one small class on research with one small class on these other things, there was so much of a focus on assessment and treatment and touching people that we were actually ingrained to believe that that is the most important thing that we can do. And there’s actually I’m looking at some research on it now about how our brain interacts with that and how it’s always going to opt to the thing that is most safe or feels most safe. So that’s what we’re going to focus on. And it takes a little bit of a change in belief system and a change in a way of looking at things in order to get our brain to start going. Okay, maybe I should start looking at more things. So that’s kind of What we’re going to talk about,

Eric Purves 5:01
yeah. And that’s and that’s actually a really good point you make because of how we’re educated. That’s how we’re primed. That’s what we’re that’s what we that’s the beliefs that we take upon us. And what I always like to think though is that if what we were taught, and if what physios and Cairo’s were taught, and osteopaths and act, like if everything that we were taught in school was as effective as they made it think that we were a fixer, we can assess, we can fit, we can fair, what’s the problem, we can palpate it accurately. And we can provide a very specific treatment for if that if it was that easy, then the burden of chronic pain, which is like 20% of the population would be non-existent,

James Johnston RMT 5:44
wouldn’t exist, there wouldn’t be an opioid crisis, yeah, there

Eric Purves 5:47
would not be a pain crisis problem. And I think we need to really understand that we have massive value in what we do. But the value is not what we’ve been led to believe.

James Johnston RMT 6:00
And the thing that I like, as I’ve been looking at this stuff is, and I put a post up on Facebook a couple years ago, that kind of went viral, and it was all about creating a safe space for your patients, is as long as we continue down this path of anatomical and, you know, palpation, and all that kind of stuff is we’re creating safety. In our minds, our brain is creating safety for us, but we’re not creating safety for that person on the table. So we’re actually doing more to make ourselves feel safe, than we are to make the person on the table feel safe. And it’s not until we start to challenge those things and start to change our thought processes, that we’re actually going to start helping the person on the table.

Eric Purves 6:44
While so my friend

James Johnston RMT 6:49
went through this, this thing for the last couple of weeks and looking at some stuff and coming to some profound realizations myself that that, hey, it’s, you know, as much as I think over the last number of years, there’s been so much manual therapy where we get a lot of people feel like we’re pointing the finger at them, saying, You’re wrong for doing this. I think we also have to take a step back and go, Hey, it’s not your fault. Yeah, you were actually primed to think this way, you were primed to believe this. So we just started to have to start changing some of those belief systems.

Eric Purves 7:25
Yeah. And we all were right, we’re all guilty of I mean, we’re all we all have gone through this journey. And we’ve all kind of, you know, gone our own directions and some of his cross to another side. And some of us have stayed where we are, and some have crossed another side and people people change. The one thing I do notice, though, and the reason we wanted to talk about these things today was there has been you know, in the the wonderful social media world there there has been some people out there that I think are without saying it, I think are uncomfortable with what we’re with what we are doing. And the message we’re trying to get out there, which is I said, I mean, I think the messenger trendier is more empowering, and having people feel how give more freedom and be more explore more movement and more touch and, and to not worry about these things which aren’t helpful. Like that’s what the message I think that we’re trying to get across. But other people out there hear that message. And they think, oh, that’s, you know, like myth busting is you shouldn’t be doing that. Or they think that no, you need to be teaching specific things or no, you know, you you have to, you know, certain ways you have to assess, and you have to have these these super specific palpation skills, you know, you have to have these magic hands that can find the root cause of pain. And you have to release this specific tissue this way. And you see this stuff and you and you see these other courses out there, people are teaching them and there’s people putting that information out there and their websites and social media. And it seems like maybe we’re just more aware of it. But seems like a lot of this stuff, I think is is almost in response I just said that we’re doing but others in our kind of community or people that are trying to push our profession forward. And seems like we’re trying to push the profession forward. And there’s those people who feel threatened by that. And they like they’re trying to pull us down. Yeah. And

James Johnston RMT 9:12
that I think goes I mean, I was just talking about how, you know, part of what what happens is that the brain is trying to make us feel safe. So makes us keep doing the things that we’ve been trained to do. And in those cases, I don’t think it’s a matter of maybe it’s a little bit the brain trying to feel safe, but I think it’s also because the finances are getting involved. Yeah. And people are trying to make a living off what they teach and and when it gets challenged. They kick back a little bit harder, because they’re what’s the word their income is depending on what they’re trying to say.

Eric Purves 9:48
Yeah, exactly. Yeah. And that’s and that I think that’s because Who are you right? If you have identified yourself as a clinician that has a specific system similar process and you you teach like a shoulder, pelvis and neck, a lower extremity course and you have like this specific way you do. It’s been two days teaching people all these these things on how to treat this area how to assess that area and how to be, you know, release the tissues a very proper way. And who are you, then when you’ve built a career or a industry or business around that? Who are you when that when that’s been taken away? Like, how do you adapt? And I think that’s the thing is, is if you hold on to these ideals who strongly you don’t tend to adapt? Because yeah, there’s your beliefs are challenged, and how you can earn money.

James Johnston RMT 10:39
Yeah. And I mean, that’s part of your identity. Right? Yeah. I mean, we haven’t I don’t think we’ve talked about it a whole lot on here. But for, for me being raised in a very, very staunchly privileged family that we had a quick little chat about before I came on here. It’s sort of the same thing. It’s your that’s your identify that your identity, you’re identified by a title, you’re identified by what you do. And that’s a really hard thing to take a step away from, and then a really hard thing to change. But it can also be really valuable when you do. Yeah.

Eric Purves 11:14
So the key message here is don’t be scared. Don’t be afraid to change.

James Johnston RMT 11:18
Yeah. And it’s funny, because you used the word uncomfortable. A little while ago, and there’s been so much that I’ve read over the last couple of years that the more uncomfortable you get, the better because that means that you’re changing. And if it feels uncomfortable, it probably means you’re on the right track. Yeah. Oh, get on get uncomfortable. Yeah, be willing to change and start making changes in your practice and changes in your life and things like that. But maybe that’s a maybe a longer rant than we

Eric Purves 11:52
That’s all right, you people are listening. They chose to be here. So they may have turned us off by now. But yeah, those guys going off again. But yeah, let’s, let’s talk about some of this, this colonial nurse stuff there. I mean, there’s two papers that we found recently, one of them was called the anatomical study of the middle cranial nerve, Rajon the study of middle cranial nerve entrapment. And the other one was superior middle cranial nerve entrapment as a cause of low back pain. Both of these were rather interesting, I found was because the, like the superior and middle cranial nerve entrapment was basically to summarize what these without paper was, our Mo was like, this is a sore, this might be a source of common pain complaint to people. But they did like they did it through like, I think they did, like surgeries. They did like imaging to find out where the nerve was. And then they either did like surgeries to kind of release the tissue around it, or they did like injections in it, and nerve blocks and stuff. But what was interesting was, what I felt was not paper was that they were saying that this was a big cause of low back pain, but it was I think it was less than half

James Johnston RMT 13:05
of people. And there’s their sample sizes were small,

Eric Purves 13:09
the sample sizes were quite small. And the results weren’t like they weren’t overwhelming for everybody. That’s not like everybody that had a nerve entrapment that was diagnosed from their medical imaging or surgery. Not every person that had that treated, got better. And so what that always makes me think is, it’s might be a generator of noxious or nociceptive stimuli, and might be related to the pain experience. But, you know, for us as massage therapists, we can change it. But the like, so doesn’t matter.

James Johnston RMT 13:46
When you look at the area, like we’re talking about where that is right over top of the iliac crest. Right, right. There’s we’re not talking about BT tissues, we’re talking about things that are very superficial to wear, like, just simply hitting it could cause pain. You know, we’re not, we’re not talking about anything really deep that’s going on. So to label it. I mean, there’s, there’s no doubt that you can definitely have pain in the area. But because it’s so superficial, we’ve probably got a pretty good odds of when we’re delivering a massage, being able to reduce that pain by just going in and making it feel good. Yeah,

Eric Purves 14:25
exactly. So do you and that’s the thing I would want to ask is does that do you need God specific? Do you need to actually try and target that specific nerve? And if you if the nerve is, say trapped, so to speak in there for whatever might be causing it? Is there value in trying to go and being specific and try to like, release it? Because if it’s a trapped nerve, it’s probably inflamed. It’s probably very tender and sensitive. So does it make sense to try to go work in like poker right in there. I think you You’d want to work around it. And and whether it is joints, whether it’s nerve, whether it’s doesn’t matter what, what might be the, the main contributor to the person’s pain, it shouldn’t really make a difference what it is that because our treatment should still be the same would be to find touch and movement. It feels good.

James Johnston RMT 15:22
Absolutely. And then, like one of the things that I noticed reading through, I only read through one of the papers, the the low back pain. One is that, basically, they’re talking about a lot of cutaneous nerves, and then they’re comparing it a lot to trigger points. And when we look at the research background on trigger points is that it’s likely, like it’s most likely that just cutaneous nerves are having a referral pattern or for real pain. Right. So, because they talked so much about trigger points in it is, is the actual source of the pain coming from the middle clinical nerve, or is it a referral from a trigger point? Right. Right. Like they’re like, there’s so many other things going on. And because it’s so superficial, I just don’t think that we need to give it as much attention as as what it’s being given in these papers.

Eric Purves 16:19
No, no. And and I would say to that thing is always going to kind of bugs me a little bit is that when you’re reading this, this paper that the we’re talking about are things from 2018. So it’s not that old. But they’re still talking about trigger points as being being a thing that they have to accurately palpate. Yeah. And then we look at some the other the wealth of research on trigger points, they show that they’re not always that easily agreed upon when palpated from different clinicians. So yeah, it’s it’s, like interesting anatomy. But so what?

James Johnston RMT 16:54
Yeah, but it’s almost like they’re ignoring the other research on trigger points. Yeah, it’s right to prove their theory.

Eric Purves 17:03
Right. Yeah. No. And here, one thing they mentioned is they talk about how do you assess for how do you like, diagnose it? And one of them is they say, the canal signs, is that tapping over? The very specific part, which is, let’s see if I can find it here. I guess what, right where the nerve goes kind of over around the psis. Find it here. It sounds like science detected at the site of nerve penetration, but three to four centimeters from the midline. So So basically, it’s a tonnelle sign around the area, where the around the iliac crest, and if you get like a nerving a nervy type sensation, then that means that it could be potentially a nerve. But what I always like to say is like, Okay, interesting, but so what so as a massage therapist, right, someone comes in, they’re complaining of pain around the restaurant, they’re low back, it’s radiating a bit. Okay, well might be a bit of a nerve. But do we need to go on being provoked? Do we need to go and provoke it? Like, do you want to go in there and assess it and poke it and punch it? And like, see more? What’s that

James Johnston RMT 18:13
and make it more aggravated than it already is?

Eric Purves 18:15
Yeah, I just did me it just to me seems a little bit. It seems a little bit like does it. So what I guess is why we think like, it doesn’t matter, right, you know, most low back pain regardless what it is, is going to be aggravated by certain movements, positions, or prolonged postures in one way or another or not. And maybe yeah, if there’s more numbness reported, and maybe there’s more of a nerve, than if it’s more kind of like a muscular or joint sensitivity or ligamentous strain or something. But I think your treatment would still be the same. And because when I’ve seen these things in clinic, you’re like, Okay, well, let’s just see what feels good. Let’s find movements that feel good. Let’s find exercises that feel good and just the dark. To make it easier. Yeah. So I know, it’s kind of interesting. But so I just how I feel about some of these ones, but they get a lot of they get a lot of attention. And I think because like you said, we like we started off with, is this comfortable to know the specifics? Oh, your source of pain is this, and I’m the one that can fix

James Johnston RMT 19:17
it. That’s, I think where it comes from? Well, I think we’d pick that apart.

Eric Purves 19:24
Yeah, there’s just one other one too. And this one, this one got a lot of got a lot of press to call the called anatomical study of middle cranial nerve entrapment. This was the one that was there was a the researchers had made an assumption that basically that the middle cranial nerve can get trapped under the long posterior sacroiliac ligament, right, which kind of goes like, kind of between the sacrum and the psis. There, right. And they thought, well, this is an undiagnosed cause of low back or leg pain. That’s what the that was kind of what they’re looking at. So they they actually what they did, they did a cadaver study, where they had 30 pelvises with the mean age You’re 80 years old. So these were seniors senior pelvises, that they were in cadavers, right. But the thing that was interesting was, they did find that about 13% of people in this anatomical study had middle cranial nerve and trauma and under this long posterior sacroiliac ligament, but they don’t know if any of these people have had pain. All they like so because did those 13% of people that had that injury? Did they experience pain? We don’t know. It doesn’t say in the study. So there’s a lot of assumptions here. It’s saying, this is a thing that happens the leg of the 13% of people that the nerve can kind of go through or under this, this, this ligament, and we know that all humans are different, right? And our anatomy is different. So it goes through or under there. But does that mean you’re going to get pain, maybe it increases the chance that you might get, you might experience pain. But this study doesn’t show us anything other than interesting anatomy doesn’t say there’s any relevance to pain. And then again, it doesn’t say if there’s anything you can do about it. With manual therapy. Oh, really?

James Johnston RMT 21:06
It’s all just a big maybe.

Eric Purves 21:07
It’s a big maybe. Yeah. So I just do I see, when I see people commenting on these things, I see that I saw this this paper shared and a bunch of different pages. I thought, Okay, well, maybe I met let’s let’s be skeptical. Maybe there is a thing here. It didn’t really. I it was like interesting. So what, again, great.

James Johnston RMT 21:27
It’s sort of like that. I don’t know if there’s much clinical relevance to it. But remember, in college, they told us that there are certain amount of the population that the sciatic nerve goes through piriformis. Yeah, but there was never mentioned that, you know, and I, somebody can call me out on this. I think the number was 4%, when I was in school that 4% of the population has that. And I could 100% be wrong. But there was never a discussion of those 4% experience more pain or have more disability or anything else. Right than the other. It’s just this is an anatomical difference. Yeah. So.

Eric Purves 22:02
So that’s, yeah, and that’s what I see with these things, too, is that the eye, oftentimes, it seems that people want to find a specific anatomical thing. And then they that can give them a reason or an explanation for why somebody might hurt, which it might be, but us without using a fluoroscopy or ultrasound machine or an MRI, which we don’t have access to in our clinics. If we do then you’re going money and training. But we don’t know.

James Johnston RMT 22:35
Well, they

Eric Purves 22:37
and they even say that too. They say even say here that the gold standard is a fluoroscopy. Where are they? And then they do an injection. And that’s how they find out. But that’s not something that we can do at our clinic. So what do we do if we think that somebody might have a middle middle cranial nerve or superior cranial nerve and treatment, and it’s not getting better with kind of traditional or conservative care, maybe you can refer them to a doctor and maybe they can get sent to a specialist where they can get this diagnosed, and maybe they can try something. But my I’m always concerned, because early in my career, I worked right next door to like an interventional pain management clinic where basically all I did was inject and cut people that and blocked things and ablated things. I didn’t see we didn’t. I didn’t see a lot of people get a lot better.

James Johnston RMT 23:27
Yeah. Well, I mean, even looking at the paper you were talking about, they’re like, they’re they’re doing these studies on cadavers. But there’s no report as to how much pain this person was in. So let’s just say that this person was experiencing pain in the low back, just before they passed away. Well, that the anatomical difference didn’t change a year before they passed away. It’s been like that their whole life. Yeah. Right. They their body grew that way. And they didn’t experience pain through their entire life because of this corneal nerve thing. That is an anatomical difference. Right? So again, why does it matter?

Eric Purves 24:06
Yeah, yeah, that’s fine. Why does it matter? I don’t know if they’ve gone

James Johnston RMT 24:09
their whole life without getting in. These weren’t people that they dissected when when Oh, they’ve been dealing with persistent low back pain for the past 30 years. Let’s look and see what the difference is. This is just oh, that we’ve just noticed anatomical difference,

Eric Purves 24:22
right? And that there may be other studies out there and hopefully someone that’s listening or something, maybe they maybe they do exist, haven’t seen them, but doesn’t mean they don’t, they don’t exist, that maybe they do maybe can have, you know, do cadaver studies on people that had suffered from low back pain, severe pain, and then look to see what you find. You’d always would have to compare that versus somebody that didn’t have low back pain that was around the same age and could do a comparison to see and

James Johnston RMT 24:48
then lifestyle and saying,

Eric Purves 24:50
Yeah, based on other like anatomical studies, it shows that you can have those things and have pain or you can have those things are not happening. So the relevance right doesn’t really matter. I think a lot of times we can get jump into these these these thought rabbit holes where we think all this stuff is, is going to be the reason why we can fix people, which is I don’t think it’s helpful. Okay, next one.

James Johnston RMT 25:24
Yeah. Okay, so the next one is walking, cycling, swimming for nonspecific low back pain, a systematic review. I really liked this, because I will constantly be an advocate that as massage therapists, we need to incorporate more movement and more exercise into our treatments. And I’m starting to lean much more to the side of let’s stop calling it exercise because people don’t necessarily want to do exercise. But typically, people want to do movement, so let’s just call it movement. So this is where my bias has got really challenged, because I’ve long been an advocate of telling people that they can, that going for a walk is one of the best things they can do for back pain. But that may not be the case.

Eric Purves 26:12
Yeah, and this, this was interesting, for sure that the, you know, a lot of the things that you’d want to believe to be true. You’re like, I want this to support my bias. And that’s why I’m set for a walk with my patients. Yeah. And this, this one says, basically, summarize it says, walking is better than doing nothing. Yeah. But it’s not better than doing other more specific low back exercises, more specific meaning, I think they did, like they did some trunk conditioning, they did some of McGill exercise protocols. And then they were they called Pilates was on here as well as, but they called usual physical therapy, whatever that means, which probably means some type of manual therapy and stretching, strengthening kind of stuff.

James Johnston RMT 27:02
pullback stabilization exercises, were one of the things that stood out to me as okay. Yeah. So really interesting, because they, they went through and looked at it. And of course, when they did the study, they ruled out red flags. And they looked at this and said, Okay, we’re, we’re just going to look at the people who are being treated for nonspecific low back pain. So which I’d say is, I mean, I can’t make up the I’ll make the stat up on the spot, but it’s not accurate. I’ll say that 99% of the people that we see that with low back. That’s definitely not an accurate number. But but most of the people that we see, I would say, are dealing with nonspecific low back pain. So and which meant that they had pain or discomfort localized in the posterior aspect of the body from the 12th rib, down to the gluteal. folds. And with or without referred pain into the legs. And if, if we could see everybody who’s listening, put your hand up if you treat somebody like that everybody everyday. Yeah. Yeah, it’s so common. So caught it, probably five people a day who come in, and that’s what they’re dealing with. So they basically looked and said, they compared like swimming, walking, running. And there’s there wasn’t a ton of studies that had been done on swimming, however, or sorry, swimming and cycling. But for walking and running, there was a lot that hadn’t been done. And it basically came down to not one of them is more superior than the other. And I think you can also look at it and go, which one does the person like the most? Yeah, go do that thing.

Eric Purves 28:40
Yeah, and that’s a that’s a great point. And that because that was the question I had to was how meaningful reads intervention is to the person, the right person? Do they value or they enjoy walking, cycling, running, swimming? You know, that would be a question I think worth asking is, if you gave people a certain amount of options, say, these are the things that might help you, which one of these is the one you would like to do, which is, which is the one that you think you could commit to do on a certain schedule that you would set up with a person? Yep. And if they show and they go, they’re probably gonna have the best results and they get to choose the one that they like to do most,

James Johnston RMT 29:16
then but that probably going to be the more effective one. And one of the things that that looking through it. Of course, they did. I don’t know if you notice, but I didn’t notice a whole lot of focus on like, the psychosocial aspects of things. It was more just on the, the bio and the exercise side of it. But in the included trials, they talked about people who use a treadmill, they were supplied Nordic walking poles, or they were doing things in a community setting. And I looked at those and I was like, you look at the site, psychosocial factors involved in both of those. That’s that’s going to have a huge make a huge difference in what the person’s going through. Because if you think about somebody who on a treadmill, they have the support of the treadmill around them that should they trip, they can grab it, you know, if they all of a sudden have low back pain, as opposed to say, being out in the middle of the street where they don’t have a support around them, should they start to experience back pain. Because I know I’d like I have intermittent back pain once in a while, where something happens. And it’s like, oh, it kind of takes your breath away. And, you know, having the psychological side of, Oh, I’ve got the support of the side of the treadmill that I can catch myself on, I’m probably more likely to do that, then going out for a walk by myself. And then I looked at, like, if you’re using Nordic walking poles, then you’ve got a whole lot more upper body involvement in this exercise. And then in a community setting, yeah, if you’re going out for a walk with a group of people, then you’ve got that social support when you’re going out and doing it. So there wasn’t any mention of those factors. But they mentioned that those are things that are effective in helping these people. So I’d love to see some more research or some more looks at how much those social settings make a different sort of psychological social settings make a difference when when people are using walking as a as an exercise for low back pain?

Eric Purves 31:10
For sure. Yeah, that actually would be really interesting, what kind of follow up study because this one was there, basically, it’s looking at outcomes. Right? So for mechanisms not looking for rationale. So I think you make a good point there that, you know, these things are, I mean, all I would say anything, any intervention has a psychosocial aspect it has to. And some might be more so than others. I mean, even coming and getting a massage is has psychosocial, because you’re with somebody in your room, and you’re hanging out with them, and you’re, you know, interacting with them. You can’t. There’s a human there, and there’s two humans interacting, right. And I think that’s a good point with this tool is that people that I was the people that valued the activity, and they they valued doing something with other people or being out in the community, you know, is probably better than sitting at home doing nothing.

James Johnston RMT 32:01
said, Yeah, especially if that was part of your social system before. That there’s people that you went for a walk with everyday, or you went for a run with everyday, and now that’s taken away from you. The quicker you can get back to doing that, I think the bigger difference it’s going to have.

Eric Purves 32:16
Yeah, it was interesting, though, that the there was no I think there’s only been one study each that looked at the effects of cycling. Another one another site that looked at the effects of swimming on low back pain, I thought that was surprising that they these read these, when they did this review, they only found one study of for each of those. I thought there have been more,

James Johnston RMT 32:37
especially to me, like because we there’s so much about aquatic exercise with rehab, you would think there would be 1000s of studies in swimming as part of aquatic exercise. Yeah, but yeah, there wasn’t, wasn’t much at all. Yeah. But I know, like we said before, if there’s one of those things that you enjoy more, it’s probably going to have a more profound effect. Because if I’m having a little back pain, and you told me to go swimming, I’m going to tell you where to go because I sink like a stone and I’m worried about drowning in the pool.

Eric Purves 33:07
I’m a terrible swimmer too. I, I if I if I go and like lie in the water and put my body out and take a deep breath. And like people like you’re supposed to fit this in like no, I will go straight to the bottom of the pool. I’ve always been like, ever since I was a kid hasn’t changed. Even as you get older and heavier. You’re like, I don’t float. Yeah, I still don’t float. I’m like an anchor.

James Johnston RMT 33:30
Yeah, I think we both have the lower body density or something that just makes us sing. But

Eric Purves 33:35
yeah, my legs just go straight down. Yeah. Yeah. So that would work for me. No, I, I can swim. But I’m not a good swimmer. And I don’t

James Johnston RMT 33:46
care for water. Yeah, maybe we’re going to depend on next weekend and the girlfriend wants to go surfing and I’m like, That’s great. You go ahead, I’ll be at the VRBO oven.

Eric Purves 33:59
here and drink coffee or beer or whatever. And yeah. This this study, though, is I think we’ll include this in the show notes. What I did like with this so and you don’t they don’t see this enough in studies, I find it but they actually have at the end there live thing is that key messages for clinicians. For those people and in our industry and those people that are actually working clinicians that want to be mindful of the research and be able to like apply to the practice, I think you need like the synopses that so clinicians can kind of flip through it and they don’t want to have to go through all the results and analyze all the data they want to like what’s like what’s the actionable items and what can I do with this? And I do like that they had this here and I’m just gonna read it because it’s I think it’s it’s important, says under key messages for clinicians, walking, running, cycling and swimming, appear to be slightly less effective than alternative interventions for Treating low back pain. So kind of traditional care, or physical therapy care as well as some, you know, specific low or anxious, I should say specific exercises designed for low back, whatever those might be, are more tended to be more effective. Right? Is walking impossibly swimming provides small benefits when compared to minimal or no intervention for treating chronic or recurrent, nonspecific low back pain. So like we started this off with doing something is better than nothing. But not much better.

James Johnston RMT 35:33
Yeah. What do we look at? Like, let’s talk about the the other interventions, the things I noticed that they mentioned were stabilization exercises, tai chi, general exercise or physical therapy. So all of those are just different forms of movement. Yeah, that we’re using, right? So those forms of movement are just a bit better than what going for a walk or going cycling are. And if you have a patient who hates going for a walk, hates going on a bike and hates going swimming, then use all those other things. Yeah, if you can use some of those other things, but they love one of those other things, then incorporate that into it as well.

Eric Purves 36:15
I would love to see a study that looked at, say, walking compared to getting a massage.

James Johnston RMT 36:25
Yeah, because and that’s one of the things that they talked about in this is they did not compare those things. Yeah.

Eric Purves 36:29
Yeah. Because it’ll be interesting to see, you know, someone values coming from I love massage helps with my low back, someone comes in to get a massage. And another group goes and just goes as low back pain, they just go for whatever 20 minute walks or whatever, 10 minute walks, whatever they decide, you’ll be interesting to see to see how the what the outcomes were for people, if there were if anyone was better or worse than the other? And I would say a lot of it would probably come down to patient preference. Yep, I’d be my guess.

James Johnston RMT 36:57
Yeah. Yeah. But with that, I will constantly advocate that we shouldn’t be constantly doing passive treatment, we should be doing some sort of active treatment as well. Yeah, that could be going for a walk with your patients. And, and I know, you’re like when we look at the industry, you’re you’re commonly thought of as the pain guy. Because you, you know, that’s the stuff that you teach about more. And I think for me, I’m looking more as the Preventing disability guide, because I’m more on the movement side of things. And wanting to encourage encourage more massage therapists to be involved in movement. And, and we looked at the when they looked at the differences, they said compared to no Underbase to no intervention, using these exercises, is better for reducing both pain and disability. Yep. Right. So for for both of the things that we love talking about. Yeah, his exercises work well for him.

Eric Purves 37:52
Yeah, exactly. And I totally agree with you is the being able to incorporate more movement, or movement advice or movement, exploration and treatments is really, I think we really powerful for people. Because I think we all have in our industry, we all have certain types of people in society, and that come to see us. So people just want to get on the table and have massage feels good. Right? Great. You’re not going to force those people to do something, you’re not going to force them to go through a barrage of orthopedic tests and all this movement stuff, if that’s their like, I just want to get I just want to chill out I just want to. But then you have those other people that come in, they’re like, I don’t care. I’ve seen everybody nothing’s working. Just make helped me feel better. Those ones I think those ones there, you probably agree those are the ones that you really want to encourage more than just the passive care, use the massage in conjunction with the movement, and then the exercise or movement. Plan movement program. We don’t want to go and exercise I think is is super valuable. And yeah, I think that’s that’s totally your your niche that you can have a lot to offer to how to incorporate that stuff.

James Johnston RMT 39:03
Yeah. Because Because those people that are coming in, they’re like, I just want to massage. In those cases, we’re typically not dealing with pain or disability. We’re just helping somebody that just wants to feel better. Maybe they need to chill out for an hour. Maybe they just need a break from the family. They need a break from work and they didn’t have it on the table just to have time to themselves. So like you said, in those cases, we’re not going through a whole barrage of different things in order to help them they just need to chill out for a little while. But for those other people that’s that’s where we need to do more for them. For sure. Easy I think that’s a great way to wrap up. Yeah,

Eric Purves 39:40
I think there’s the the two key points in this was low back pain might have something to do with cranky nerves. Yep. And she nerves, but we don’t really know. And it shouldn’t really matter because your treatment interventions would should still be the same and movement Doing something is better than doing nothing. But for pain, but I think overall health moving is better.

James Johnston RMT 40:06
And you’re probably going to have better outcomes if you can incorporate the two. Yeah, you don’t add some movement and help those people who come and see you. Too easy. Beautiful, right. Until next time, everybody. Thank you. We hope you enjoyed this podcast. These kinds of topics are what we are all about. If you’d like to learn more, go to our

Eric Purves 40:31
websites, themtdc.com or ericpurves.com. If you know of any other therapists that could benefit from this, please tell them to subscribe.

 

Education In Rehab – WTF Does It Mean…?

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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?

 

SO MANY THINGS IS THE SIMPLE ANSWER!

 

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?”

Context

 

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.

Failure

 

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.

Conclusion

 

  • 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

Things I Wish I Knew About “Rotator Cuff Disease”

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It was the first time I’d seen this patient. 

When I asked what brought them in they showed me how they could only get their shoulder to about 90* abduction and it had been this way for two years. 

Digging a little deeper to find out what happened, they explained they had a rotator cuff surgery due to a tear. 

This was life-changing for them. 

Not only could they not move their shoulder correctly, but it also resulted in a change from a job they loved to one they hated due to the lack of mobility. 

So, was surgery the best approach in this case? 

While I’ll never know the true answer to this, I can look at the most up-to-date research and attempt to make an educated guess ( and I think I know where this is going). 

Rotator Cuff Disease

A recent paper¹ came out on this topic, and I’ll admit I was surprised to see them refer to this condition as a “disease.”

However, when we look at the dictionary definition of disease² it states: 

“disease, any harmful deviation from the normal structural or functional state of an organism, generally associated with certain signs and symptoms and differing in nature from physical injury.”

So, in this case, the limited function of the shoulder has deviated from its normal functional or structural state, so I guess it can be classified as such. But, I would never want to communicate it to a patient that way as it suggests a more damning diagnosis than it is. 

Now, in order to define this “disease” they put some classification around it which includes: 

  • Pain that is worse at night
  • Pain exacerbated by specific movements which included overhead activities
  • Loss of function and weakness

In addition to the above rotator cuff disease was basically used as an umbrella term to classify issues with the rotator cuff regardless of the cause and would include: 

  • Positive painful arc test (physiotutors gives a great example of how to perform the test HERE)
  • Positive external rotation resistance test

These tests together were the most accurate diagnosis unless it was a full-thickness tear. In this case, the use of a positive lag test was most appropriate. Here is one example of how to do the test, but this can also be done with the shoulder at 90′ rotation, called the “drop arm sign.” 

It is also worth noting that the review found an increased prevalence of this with age, especially in those people who performed repeated overhead activities. 

What Do We Do For Treatment?

So, this paper was a BIG review; there were 3620 participants in 60 different trials with a median age of 51. 52% of these were women and the average duration of symptoms was 11 months. 

What they found was that people were rarely given just one intervention. 

This makes it really difficult to say if just manual therapy, just exercise, or a single other intervention was the best approach as there was always a combination of things offered. 

The average duration of therapy offered was six weeks. When they looked at what manual therapy was offered, this included: 

  • Joint mobilizations
  • Massage
  • Spinal or neck mobilizations
  • PNF stretching
  • Dicutaneous Fibrosis (I had to google this as I’ve never heard of it, but it’s IASTM with a stainless steel hook)

Exercise interventions included: 

  • Strengthening
  • Stretching
  • Progressive resistance
  • Pendulum exercises
  • Eccentric training
  • Postural training
  • Motor control
  • Proprioceptive training
  • Self-mobilization (yay for self-care)
  • Dynamic humeral centring (movement aimed at humeral head depression) 

Interestingly, they compared the above to some other trials that included things like steroid injection, NSAIDs, surgery, naturopathic care, and a few other interventions. 

When it was all said and done, they compared what was seen as high-quality evidence to low-quality evidence. 

Under the umbrella of “high quality evidence,” their findings showed no difference between manual therapy, exercise, and placebo for overall pain, disability, and function. But there was also a risk as manual therapy and exercise were frequently associated with adverse effects like short-term pain (although very mild). 

When looking at “low quality evidence,” it was pretty consistent with the aforementioned high-quality evidence but also showed that the use of glucocorticoid steroid injections helped with global treatment success. 

Overall, this doesn’t sound like a real positive for manual therapy and exercise, but there are some things to consider. Throughout the studies, manual therapy and exercise were always incorporated with some other type of therapy. Also, much of the exercise used was very vague by description and didn’t include whether this was done supervised in the clinic, or at home. Finally, while the comparison to glucocorticoid steroid injection seems like it could be of benefit, this was based on low-quality evidence, so this doesn’t give the intervention much credence. 

Looking at what they considered placebo, they used modalities like ultrasound (which in other studies has been shown to have a high level of placebo). This review doesn’t really talk about the interaction between patient and therapist or other contextual factors of treatment. We might see a more detailed description of the exercises and modalities used as interventions if these were included. 

However, when we look at other papers that discuss the clinical guidelines of MSK care the best steps are typically shown to be: 

  1. Reassurance
  2. Education
  3. Exercise
  4. Some manual therapy

If we were to apply the same to issues with the rotator cuff, we’d likely see better outcomes than if these weren’t used. Even though this review says there is no clinically important benefit to manual therapy and exercise over placebo, it doesn’t mean they aren’t of benefit. But if we used those as a combination in treatment the high-quality evidence shows this to be the best approach. So, with any shoulder issue, continue to use exercise and massage. Just remember there are other factors that contribute to a successful treatment. Things like patient preference, demeanour, education, reassuring them, and providing validation will all help contribute to better patient outcomes. Let’s just remember to incorporate as much as possible.

 

Podcast: Beliefs Vs. Science

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On this episode we look at “Beliefs Vs. Science” and how this functions within our profession.

We are of the belief that if science refutes or proves your belief wrong, we have a responsibility as healthcare professionals to change that narrative.

Check out our upcoming live courses in October that can also be attended via zoom by clicking the link:

http://themtdc.com/courses/clinical-applications-of-pain-science-manual-therapy-exercise-and-rehabilitation-principles-for-rmts/

How Often Should My Patient Do Their Exercises?

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One of the most common questions I get asked, after “which exercise is best to fix back pain?” is….

“How often should my patient do their exercises?”

One of the things we have to remember is that “how often” or FREQUENCY is tied into the INTENSITY and EFFORT and therefore need for REST & RECOVERY, and the one thing under-discussed and often unreported in studies is intensity!! We could do 3×10 or 5×5 or whatever, but without the accompanying intensity, the sets and reps don’t really mean that much.

Intensity and effort often get used interchangeably, if there is a technical difference to discern then intensity is more about the objective measures we make e.g. heart rate whilst running, and effort is more how hard we perceive this to be, so rate of perceived exertion (RPE) would be a subjective measure with the Borg scale designed to relate to current working heart rate. So whilst technically not exactly the same, intensity & effort do have a strong relationship in my opinion and RPE can be used clinically as a simple, rudimentary measure of intensity.

This does not mean that all exercises have to be intense, it might need to fit the current sensitivity of the patient and this lower intensity can often be done more regularly, and for many just moving in a non-threatening way might suffice. But there may also need to be progression and this can be where lots of therapeutic exercise programs can fall down as they are looking for a single exercise/dosage.

Based on the current data with exercise my personal belief is that the dosing such as intensity and frequency are probably more important than the TYPE for some people!

I wrote about this a while back –  “Exercise dosing for pain is not he same as exercise doing for fitness”

What Is The Aim Of The Exercise?

 

Your clinical reasoning should really determine which exercise, how much, and how OFTEN!

Now there is a fair bit of discussion of whether ‘general exercise’ is better than ‘specific’ exercise whatever those two things are exactly, but my personal belief is we should always have some reasoning around WHY we are doing something. Unfortunately, although it’s a simple answer I just don’t really see “just do some exercise” as being THE answer to back pain for example.

So what is the aim? Well, we often have two main types, a more physical adaptation aim or a pain/function-focused aim.

Let’s start with the physical adaptation side of reasoning.

Strength

So strength and strengthening often get used interchangeably but might be different. Actually increasing force production or strength can require some intense exercise and higher effort levels. Sets and reps are often programmed but not the intensity as previously discussed. You could do strength programming variables but without sufficient intensity, and therefore you may not need the same rest as with more intense training but also might not get the same benefit. The load here should really dictate the reps as stopping at 5 reps with another 5 in the bank because the load is too light isn’t really going to cut it.

Our views of programming are changing with regards to strength and hypertrophy but intensity matters here and therefore frequency does too.

Load/Tissue Tolerance

This is a common aim, the concept of ‘strengthening’ an area to take a bit more load or activity.  A common mistake is to assume painful movement or being intolerant to an activity or load is CAUSED by excess load. Load is a very catch-all term and ANY painful movement or joint could be described as being load ‘intolerant’ if it causes pain, this would be a basic correlation NOT causation mistake.

Generally heavier loads are advocated and therefore higher intensities and lower frequencies although we really don’t know that much here, load tolerance I doubt is a solely tissue phenomenon.

In some cases a load tolerance approach might work by actually taking away load as much as a stimulus to increase tolerance, so addition by subtraction. We simply keep the body moving whilst taking away an aggravating load is a plausible rationale especially with exercises of limited intensity.

How does your exercise prescription also fit in with the other stuff the person is doing? This also should tie into your reasoning around frequency. With very active people, where volume might be an issue, sometimes LOWER intensity exercise performed more FREQUENTLY can also be of benefit.

The Spanner In The Works & Graded Approaches

 

It would all be so easy if therapeutic exercise was just about physical variables such as strength, but unfortunately, it’s not. We all know it’s great to get parameters to work with but anyone who has been in clinic knows that the real test is in how the person RESPONDS.

Screen Shot 2020 06 23 At 09.44.41

It’s the interplay between intensity, frequency and PAIN that’s that really should guide us rather than theoretical parameters for fitness. And it’s not just pain as a sensation but the person’s beliefs and behaviours in response to and around pain in general that also need to be considered.

Graded activity and exercise are concepts that relate a bit more to habituating to pain and graded exposure to cognitive factors such as fear or catastrophizing. Here we don’t have ANY real parameters apart from those that are based around physical ability and pain tolerance. So frequency is really a thing that is tough to set BEFORE you work with someone. This is part of the inherent uncertainty in therapy that we have to get used to but can be guided by a thorough history of pain and exercise participation.

Graded Activity & Exercise

These are approaches that originally looked at improving chronic fatigue but are equally applicable to pain too. Again the intensity is important, if we are pushing the level of grading towards the more intense then longer rests and decreased frequency might be important. If more about building a movement HABIT then less intense and more frequent.

Graded Exposure

Graded exposure is slightly different in that it is more about cognitive factors such as fear and anxiety around moving than pain or actually than a physical change. But frequency is NO LESS important. True exposure sessions are mentally fatiguing and because of this physically and emotionally tiring. If we want to reinforce this with additional work at home we would have to consider this in terms of frequency and individual levels of fatigue.

Reasoning In Action

 

Here is how my reasoning might work with the two different aims. I like to use effort level as a guide to intensity as it is a simple subjective measure that is easy to use clinically across a variety of exercises/activities and I find rate of perceived exertion (RPE) is good for this. Now intensity and effort are NOT the same thing but generally the more intense an exercise the more effort is required especially the more of it you do.

Physical

Although the data around adaptation and reps/sets/intensity is definitely changing compared with what I was taught back in the 90’s, I still think that intensity is key for physical adaptation. With more intensity, we need more rest so frequency might only be 2/3 times per week. Bodybuilders were smart at training regions of the body on different days to maximize recovery whilst also getting in their overall training needs.

So we probably need at least a 7/10 RPE.  If you are looking for strength (force production) then I would say we should probably bias heavier mass to create that intensity too.

Tolerance might be different in that intensity could be created by a lighter load but you have to get in more reps to make the intensity. If we think about all the different activities and types of loads coupled with access to loading equipment then adjusting load and reps for intensity helps us a bunch. Remember that all this also ties in with their current level of sensitivity too and we often have to adjust this based on responses.

Graded

My reasoning here would be how can we build a HABIT of moving. HABITS are built more by frequency than intensity.

So let’s identify something that is going to be valued or ties into the values. We don’t always have to enjoy things but we do have to see a worth in doing them to continue to do them. Based on how someone’s pain behaves in terms of types of activities that trigger, severity of pain and how much it takes to do so (irritability) we can start to build a picture and reason a  dose of that activity.

So although we still have to be guided by the person’s RESPONSE, I would aim for intensity lower (3-5 RPE) and a frequency of daily or every other day, remember it does not have to be the SAME activity/exercise that is performed each time.

It is important to remember where you start with frequency and intensity should not be where you finish with it, but sometimes we need to start lower to get higher!

Key Points

 

  • Just go do some exercise might be why lots of exercise programs ultimately fail
  • Sets and reps also need intensity/effort
  • Intensity is relative to what you want to achieve and intensity dictates frequency
  • It’s often about trial and error
  • Get used to it!

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