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Self-Efficacy A Well Used Term But Well Understood?

March 4, 2019/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Ben Cormack

Self-efficacy is a term banded around in therapy quite regularly at the moment especially as more active approaches to rehabilitation are being embraced.

So we have to ask exactly what does it mean, why does it matter and how do we improve it?

In fact, my twitter friend/colleague Jerry Durham asked me this question whilst I was in the process of writing this blog, talk about great timing! It also shows that we often don’t have a well-defined definition for a well-used term.

Let’s Start With What Does It Mean?

It was a term first coined by Bandura in the 70’s, he described it is the ‘belief of an individual on whether they have the ability to perform behaviours relative to a specific activity’. Self-efficacy has also been described as a ‘resilient self-belief system’.

I like to describe it as a sense that ‘I have got this’ or ‘I can do this”.

This could be self-efficacy in relation to pain, such as the perception of the ability to remain functional and perform activities of daily living whilst you have pain, or it could be treatment-related activities such as a specific activity or exercise.

So let’s say that your kind therapist has suggested that you go to for a walk to help out with your back pain, do you think that you will be capable of doing this?

Maybe you don’t feel motivated?

Perhaps you don’t feel confident that you physically can?

Could be that you feel you can’t fit it into your busy life?

Low self-efficacy may result in challenges, such as changes in behaviour, being seen as threats to be avoided rather than things that can be overcome. Bandura identified a number of psychological processes involved with self-efficacy, these being cognitive, motivational and affective (emotional). Having valued goals and activities appears to be associated with these factors as well and self-efficacy and resilience literature points towards valued activities being an important part of this process HERE.

Bandura also identified four main sources of self-efficacy.

Mastery

Previous mastery of an activity or action influences our future perception of capabilities. We are starting to learn that human beings use prediction based on past experiences to navigate the uncertain nature of the world around them. If we have been successful at something in the past then it is likely we will perceive that we can overcome it again. This is also related to the ease of successes.

If our successes have been easy then we may be quickly dissuaded by obstacles. If the successes have been tough then we may also be used to overcoming any obstacles that come our way.

In line with this view, we see that previous adherence and participation in exercise has been shown to be important in future exercise adherence HERE.

Experiences

The world around us also influences our perception of capabilities. If people surround you that you perceive as similar, who are achieving similar things that you are being required to achieve, then you will also be more likely to see these things as attainable. This could be from the media that we consume to the involvement in social activities or our family circle, this underlines the social aspects of pain that appear to be pretty important.

This is a great recent paper on social factors in pain HERE

Persuasion

Now, this can be both positive and negative, and of course, it is easier to be influenced negatively than positively! But those that are persuaded, both verbally and experientially, that they are capable of achieving a task are more likely to be able to do so especially if we see previous success as a key factor.

Negative Emotions

Strong negative feelings towards an activity or the negative perception around an activity also will influence the level of self-efficacy someone has. Self-doubt is often an emotion that influences behavior negatively.

So We Have To Also Ask, Why Is It Important?

It appears that self-efficacy has been linked in multiple papers to worse outcomes across various measures of pain and disability. Now we cannot suggest it is causative or even that improving it will simply improve outcomes at this moment in time. But if I were to go out on a limb I think it probably would : ), especially if we are promoting more active approaches to therapy.

Certainly exercise as a treatment relies on it being performed and evidence-based medicine falls flat on its face if we cannot apply the treatment to the patient.

Foster, in 2010, found that for people with low back pain, low confidence in their ability to perform normal activities, or low self-efficacy, was predictive of a worse outcome in terms of disability at 6 months, in fact, better than fear avoidance, catastrophizing or depression HERE.

Keedy, 2014, found that those without the ability to engage in pain management related behaviours, pain self-efficacy, is related to the outcomes for back pain rehabilitation HERE.

Greater passive behaviour scores were also found to be associated with worse outcomes at a five year follow up for lower back pain by Chen, 2018 HERE. Passive coping strategies rely on external resources for pain control rather than internal resources such as our belief systems HERE that also influence self-efficacy.

Self-efficacy has also shown to be fundamental to the adherence of exercise interventions. These studies found that low self-efficacy was a predictive factor for poor adherence to a home exercise program HERE & HERE. For all the focus on the nuts and bolts of exercise, it is a pretty redundant process if the person does not feel capable of doing it. Time spent in this area rather than a focus on sets and reps may drastically improve adherence and therefore outcomes.

I call this focusing on the hole rather than the donut (the whole!)

What Can We Do To Alter It?

Success

The first steps may simply be to create a successful experience!

Previous successful adherence and progress have been associated with increased self-efficacy and this ties in with a Bayesian perspective of human function. So perhaps our aim for those that display low self-efficacy should be to set a low threshold for activity that can lead to easy adoption and fast progress. We often aim for a dosage of activity that leads to some kind of physical overload and adaptation. This could potentially lead to a negative experience for some and limit increased participation, without a positive initial experience they may not achieve longer-term sustainable success. So essentially good for psychology but not so much for physiology in the short term but hopefully leading to greater longer-term physiological impact through sustained participation.

It could be that just making an exercise session fun and not boring could be a very beneficial outcome. We often don’t place much importance on these things within medicine though. Why do people play sports? Maybe because they enjoy other aspects beyond just the physical exertion component.

People are often driven by challenge, fun & competition, how often do you incorporate these aspects into your training?

Some questions I often ask to gauge self-efficacy around exercise & activity are:

“Would you describe your self as confident around moving and exercising?”

“Do you feel you are currently capable of increasing your activity levels if required?”

“Would you describe yourself as motivated with regards to activity and exercise?”

Motivation

Motivation also appears to be a key aspect of self-efficacy. Helping people find something that actually motivates them could also be important and this could be through a goal-setting process that identifies valued activities. We could then break it down into more perceived manageable chunks that create little wins to help motivate the person.

I call this helping them find their ‘why’.

Lots of exercise programs don’t resonate with people, especially if they have not really participated in one before so exercise in itself is not enough of a ‘why’ for them.

We might ask “what would your perfect day look like with regards to activity?” or “what are some things you love to do that you don’t or can’t?”.

Autonomy is another factor associated with successful exercise, HERE, so also giving choices and options rather than a ‘this is the exercise you have to do’ approach.

Planning

Sitting down and planning with people when they might do things and how much might also have an impact on self-efficacy. Being able to do this for themselves might be a limiting factor and the participation in activity may feel like too great a challenge without some guidance.

What days might be best?

What time of day?

What type?

For how long?

What kind of effort level?

Set a reminder on the smartphone?

How to progress?

Alternative options if you do not succeed?

Takeaways

Previous experiences with behaviours are involved with future self-efficacy
Social environment and support is important
Self-efficacy can make or break an active approach to treatment
Self-efficacy is involved in outcomes for pain and disability
Self-efficacy is important for exercise adherence
Create behavioural wins and good experiences
Your input in terms of planning and motivation is vital if self-efficacy is low

Testing, Graded Exposure, And Reassurance For Low Back Pain

February 25, 2019/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Jamie Johnston

Over the past couple of weeks, we have been looking at and discussing the clinical guidelines for treating low back pain.

We have covered how important reassuring our patients their tissues are safe is a crucial component in their recovery from pain as well as building our therapeutic relationship with them.

We also discussed how important using graded exposure as part of that reassurance is, along with its importance in getting them moving again. So, this week we’ll cover how you can do some simple and effective graded exposure right in your massage therapy treatment room.

But first, we’ll have a look at the orthopedic test that was commonly recommended throughout those clinical guidelines and how to do it. There is a bit of controversy between papers as to how effective this test is, but it is the one that was most commonly recommended, so we felt it important to review.

Here is how to do an SLR (straight leg raise).

Even though the more common use of an SLR for low back pain is to look for a disc issue if you get a positive it is still important to reassure your patient they are okay. Use terms like “it just shows us the area is sensitized right now, so we just need to calm it down”. Try not to alarm them or instill any fear around there being a damaged disc or tissue.

Quite often when patients with low back pain come in, there will be some movements they are fearful of doing. Commonly forward flexion is the one I’ve seen in practice that most people have an issue with, so we’ll look at how we can do some graded exposure to help with that.

If you have a hydraulic table here are some simple things you can do to not only reassure the patient movement is okay, but also to help build up their trust in you:

If you don’t have a hydraulic table, here’s how you can do the same thing with some of the furniture most of us have in our treatment rooms.

The biggest takeaways:

Provide reassurance to the patient that they are not “damaged”.
Make them feel safe with the movements.
Gradually expose them to an increased range of movement.
Encourage, encourage, encourage your patients!

Learn How Movement Will Change Low Back Pain

February 19, 2019/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Jamie Johnston

Last week we posted an article discussing some of the research around the clinical guidelines of low back pain.

There are several modalities commonly used that aren’t recommended like Tens, laser therapy, imaging, and corticosteroids, but when we look at what is recommended we have an opportunity to make a real difference for those suffering from back pain.

One of the big things recommended is a biopsychosocial approach along with education. In order to start this kind of approach, patient reassurance is critical in order to help the patient feel safe (as we talked about last week).

In addition to reassurance, supervised exercise is also a crucial part of helping patients deal with their back pain. However, these two go hand in hand as it will quite often take a considerable amount of reassurance to convince a patient that it is okay to move.

One way to help is by looking at what the research says for exercise and low back pain, which you can use as a tool to convince (and reassure) patients this is the best course of action.

Exercise For Low Back Pain

Remember the old days when bed rest was the main prescription for low back pain?

Well, now bed rest is actually discouraged unless the pain is too severe, then only two days of bed rest are chosen. In contrast to this, we now understand that staying active has far better outcomes than the way we used to manage this.

And I know many of you might be saying “exercise is out of my scope of practice” and while this may be true, active and passive range of motion probably is within your scope, so there is no reason you can’t incorporate some of this into your treatments.

I know there is probably some concern over being able to recommend “specific” exercises (or movements) but don’t worry it doesn’t have to be all that complicated…in fact, it shouldn’t be! Supervised movement without the use of expensive equipment is one of the specific recommendations, so you can do this right in your treatment room.

This is especially true in the acute stage, where strengthening, extension, and specific exercises are not recommended. Rather, in this case, we want to use graded exposure to physical activity. Graded exposure is essentially getting a patient to move (gradually) into a feared or painful movement (we’ve had articles about this before which you can read HERE for a more detailed description).

For example, when it comes to acute low back pain, if your patient is scared, or experiencing pain with a certain movement like standing forward flexion, have them change the plane of movement and try flexion again. Try having them sit comfortably in a chair, then lean forward. This is still spinal flexion, it’s just in a more supportive position. When they can move in this position comfortably, point out how capable they are of the movement and reassure them that flexion is safe. You can then gradually work up to standing flexion until this feels safe again.

There are many ways to do this, it just takes a little experimentation on your part.

When it comes to chronic low back pain there is no evidence that one exercise is superior to another.

However, recommendations show that remaining as physically active as possible along with an early return to work is well supported by evidence (probably why some workplaces have a gradual return to work program). While there are no specific exercises highlighted as more effective than others, the exercises that work are simply the ones your patient will do. Find out what’s important to them and encourage them to do it. Whether it is strength training, going for a walk, playing with their kids, or playing hockey, the intent is to build confidence in their bodies as opposed to fixing a problem.

Inevitably the question of dosage comes up and the research shows that too much, or too little exercise with some patients can run the risk of developing persistent pain. This is where it’s important to experiment a little to see what works best for the patient, we don’t want them to overdo it, but also want to avoid not doing enough (one of the reasons bed rest has been eliminated).

Overall since we know a biopsychosocial approach is most effective, encourage things like movement in general, getting back to work, staying connected with the things and the people they enjoy. Just make sure these things are done gradually. If we can address peoples fear of movement by using graded exposure early on, we have a better chance of avoiding prolonged pain and disability. So, don’t stress about ‘specific’ exercises, the overall goal is to get our patients moving and keep them moving. Movement along with some education and reassurance can go a long way in not only improving low back pain but also the patients quality of life.

Altered Skin Colour And Circulation, Result Of Massage Or Nervous System?

October 28, 2018/8 Comments/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Sport Massage, Therapeutic Exercise/by Jamie Johnston

This is one of those topics that inevitably comes up on a regular basis.

The last time I taught our course on pain science and therapeutic exercise, there was some resistance to the idea that massage therapy does not increase circulation and last week there were some big discussions on the topic on one of the massage groups on facebook.

This was a harsh reality for me when I realized we don’t have any effect on circulation and I remember the day in college when I started to question it (I’d love to say it was because I was some sort of forward-thinking genius, but I digress). I was working with a hockey team and one of the players had an episode in the summer which required him to be on blood thinners. I was super worried that if I did any massage I’d have an adverse effect on him, so I approached one of my teachers to ask if massage was contraindicated and what I should do as I was worried about the increase of circulation with his condition.

My teacher simply looked at me and said: “you’re not going to increase his circulation any more than him playing hockey!”

It was like a light bulb of astonishment went off, I wish I had a picture of my face.

Now, surely that story can be taken anecdotally if you choose to, so the question will remain: “what does the research say?”

Heart Rate And The SNS

I remember in college while working in the student clinic, part of each treatment we had to develop three goals prior to treatment to be reviewed by one of the clinic supervisors.

Most of the time my goals would look something like this (they got more specific as school progressed):

Increase circulation.
Decrease SNS firing.
Patient education.

I think the reasoning behind “decreasing the sympathetic nervous system firing” was more to just a way of saying we calmed the patient’s stressors down and essentially helped them relax. As we know the SNS is responsible for our “fight or flight” response, which is essentially used when we are scared because we’re being chased by a bear or something. In order to have a “fight or flight” response, it would require our heart to start pumping hard and feed blood to the necessary parts of our body to get us moving and run from the said bear.

One of the assessment tools we would use to prove whether we actually had an effect on the patients SNS was to check their pulse before and after treatment to see if there was a change. Inevitably their pulse rate would be slower post-treatment than it was prior to treatment, thus justifying how we “relaxed” our patient.

So how in the world did I think I could simultaneously increase circulation, while both decreasing sympathetic nervous system activity? My assessment was literally proving me wrong. The sad part is I only thought of this example last week, at no point during my education did I ever question this, I just habitually put them as goals.

One thing we know for sure (and we’ve written about it before, you can read it here), is that massage therapy can help with hypertension and actually decreasing blood pressure. Some articles argue this entirely depends on the type and depth of massage technique used. One study showed using trigger point therapy and sports massage actually increased BP, however, the article wisely ackn0wledged this was due to the pain caused during a trigger point treatment. In this case, the treatment would be causing a sympathetic nervous system reaction to withdraw from pain, thus temporarily increasing blood pressure.

With everything we know about modern pain science and the knowledge around old theory of trigger point therapy, I hope we aren’t going in and causing pain with our patients anymore, as we know it’s not effective. In turn, it’s also not a technique we should use to fight the argument about an increase in circulation. As far as sports massage causing an increase, we’ll get to that in a bit.

Sport Massage

In the sport massage world, there has been a long time practice of using tapotement techniques to help with warm-up and increase blood flow before a competition.

While this can be an effective way of helping an athlete warm-up, there is probably more of a psychological aspect to it than anything about bringing circulation to a specific body part or tissue (this may be part of the reason that a typical warm-up involving exercise is always recommended before seeing a therapist to assist with warmup).

There is also the argument about doing a “leg flush” post-competition to help clear out lactic acid as part of recovery.

While there are several studies showing that blood flow is increased with massage (to help prove the above theories), most of the methods used to try and prove this theory wasn’t very reliable. However, more recent studies have shown that massage has little effect on arterial blood flow.

There were theories that reported a 50% increase in circulation after a vigorous massage, but later studies (which used somewhat unreliable measurement tools) showed not only smaller increases, but some showed no increase at all.

The above-cited study actually did tests post-exercise to see if massage would still have any effect when it comes to circulation. They used one group who would take regular rest post-exercise and one group who would receive massage. There was no significant difference between the two groups on femoral artery blood flow and massage performed on the quadriceps.

So what does this tell us? The only real way to increase blood flow is through movement and exercise. As our friend Alice Sanvito stated in a forum not too long ago: “If we mean there is more blood to an area, we run into another problem. The circulatory system is a closed-loop. There is a relatively fixed amount of blood. If more blood is shunted to one area, then there must be less blood somewhere else.”

The body would not let this happen, so we cannot actually alter circulation to bring more or less to any area of the body, without significant injury, which would result in shock, or blood loss.

Changes In Skin Colour

The question came up, “if we don’t increase circulation why does the skin go red!?”

Great question!, so I had to do some research on that as well.

We have all seen it in our clinic, we work on a specific area of the body and the skin changes color and gets a little bit pink, or maybe even red. Well, there are two possible mechanisms at work here, either the friction created doing, say, an effleurage stroke is irritating the skin, or a change in temperature from touch is the culprit. What about the clients you treat where the skin doesn’t change colour? Does this mean the massage is having less of an effect on them?

Well, studies show that skin friction can increase heating which causes hyperemia in the local massaged area. But the same thing happens when I put a cold pack on my arm and isn’t cold actually supposed to cause vasodilation and a decrease in circulation?

While there is a minor increase in blood flow to the capillaries of the skin, the increase in blood flow has been measured and shows that the amount is so arbitrary, there is no way it is being diverted away from local musculature. So, while this is p0ssibly a minor increase to the skin, we can’t assume we are increasing circulation to the muscle because the skin is changing colour.

As we mentioned before, what about those clients whose skin colour doesn’t change? Does this mean there is something wrong with their circulatory system, and we aren’t influencing circulation to that area? I’d venture to say no, it probably has more to do with skin sensitivity, or it’s a true measure of how minimal the circulation increase actually is.

Our friend Alice Sanvito also made a stellar point about this:

“What were we taught about the sympathetic and parasympathetic nervous systems? The sympathetic “fight or flight” nervous system diverts blood away from the skin and internal organs and towards the muscles. The parasympathetic “rest and digest” nervous system diverts blood away from the muscles and towards the internal organs and the skin. Since massage tends to relax people, it is probably safe to assume it is downregulating the sympathetic nervous system.”

Like it has been with so many other things in our career, we really have to take a step back sometimes and critically look at the things we were taught. This has been a huge learning curve for me during my career, but there is also a refreshing side to being able to give honest and logical answers to patients. While we may encounter arguments from others on these points, it’s important to keep educating ourselves and others to stay on top of current research and evidence-based practice. We’ve said it before on this blog in regards to circulation, there’s more of an increase happening by your patient walking into your clinic and getting on your table than from anything that happens during the treatment. And you know what? That’s okay because what you are doing for them on the table is FAR more important than worrying about increasing their circulation.

Predictive Coding: Why Expectation Matters For Movement And Pain

October 22, 2018/1 Comment/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Todd Hargrove

Predictive coding is a hip new model for perception that I have been studying lately. In some ways, it is very common sense and intuitive, and in others, it is very challenging and mind-expanding. Here’s a post describing what I’ve learned that I find interesting and practical. Before getting into that, let’s review why any of this should be interesting to anyone concerned with movement and pain.

First, good movement requires good perception. The skill of moving your body with coordination is inseparable from the skill of perceiving where your body is in space and how it is moving. We perceive to move and move to perceive, and that is why we often say that great movers have amazing “body sense” or “proprioception.”

Second, pain is in the nature of a perception. It depends on the brain’s interpretation of whether the body is in danger and what needs to be done to protect it. If your foot hurts, that means your brain perceives, rightly or wrongly, that it is damaged. Perceptions about the body (like anything else) can be mistaken, which is why we can have pain in areas that aren’t damaged, and damage in areas that aren’t painful. By learning more about the science of perception, we necessarily learn more about pain and how to treat it.

The Conventional Model For Perception: Bottoms Up

The conventional model of perception works roughly as follows. We collect sensory information through nerve endings in the eyes, ears, skin, muscles, etc. This information is relayed to the brain, which processes the information, interprets its meaning, and then creates a perception about the cause.

For example, when I see my wife’s face in front of me, this is because light bounced off her face, the pattern of the light was registered by my eyes and sent to my brain, which recognized the pattern as coming from my wife’s face, so it created the perception of her being there (so I would know who to take orders from.)

Or, if someone feels pain in their knee when they take a step, this is because the mechanical force of the step triggered nociception (nerve signals about potential damage), the signals reached the brain, the brain concluded the knee was under threat, and it created pain to encourage protection (maybe by limping). This model is therefore very “bottom-up” or “outside-in.”

It emphasizes the flow of information from the outside world to the periphery of the body, and then from the periphery to the brain. What’s missing from this story? What the model fails to explain very well is the role of past experience in determining how the brain interprets the meaning of the incoming sensory information.

This is where the predictive coding model adds value – it explains how “top-down” factors modify incoming sensory input.

Predictive Coding: Expectation Matters

According to the predictive coding model, the brain is always building and refining its representations or models of the outside world (and our bodies). Our perceptions depend in large part on these models, not just incoming sensory data.

For example, I have an internal model of my house that includes only one four-legged creature – my dog Levi. So if I walked through the living room in low lighting and glanced at a wolf, I would probably literally see my dog, Levi. In other words, my perception would be determined by more by my expectations than by actual sensory data from my eyes.

Check out the pictures below for some other examples of how expectation can determine perception.

In the first two images, you perceived something very different from what your eyes told you, based on your prior assumptions about how words are usually ordered or spelled. In the third picture, you saw two normal looking faces, based on your prior experiences with face parts being arranged in certain ways. (Turn the picture upside down to see a very different arrangement.)

This happens with many other kinds of sensations. If you think satanic messages are hidden in rock lyrics, you can hear them if you play Stairway to Heaven backwards. If you come up from behind someone and say “hot!” at the same time you put ice on their arm, they will feel heat. The painkilling effect of a placebo is based purely on the expectation that it will reduce pain. And nocebos work the opposite way – expecting pain can cause pain. To some extent, we perceive what we predict.

Comparing Top-Down to Bottom-Up

The predictive coding model has a great explanation for exactly how expectation affects perception.

The nervous system is arranged in a hierarchical fashion with the brain cortexes at the top and nerve endings at the bottom. Higher levels of the nervous system are constantly predicting the incoming flow of sensory data from lower levels. These predictions create a neural activity that flows downward (top-down) to meet incoming sensory data (bottom-up).

When the meeting occurs, a comparison is made between what has been predicted and what has been sensed and this generates a prediction error. Put another way, top-down “shakes hands” with bottom-up, and disagreements are discussed and compromises are struck. If the error (or disagreement) is relatively small, it is disregarded as being random noise or “close enough.”

Higher levels of the nervous system are not informed of their prediction errors, and the world is perceived exactly as expected. If the error is large, higher levels are notified of their mistake so they can update their model of the world. This creates a subjective feeling that something surprising or important has happened, and attention is automatically shifted to the incoming sensory data so that perception and action can be adjusted accordingly.

The strength or confidence of the prediction has a big effect on how prediction errors are treated.

If the prediction about incoming sensory data is highly confident, (perhaps based on tons of past experience) even significant errors will get ignored. But if the prediction is not confident (perhaps because the context is novel and errors are anticipated), then bottom-up sensory information has a better chance of ascending to higher levels of the nervous system and causing changes in perception.

Attention also matters for how prediction errors get processed.

If I pay attention to a certain stream of sensory information, it increases the chance that prediction errors will be noticed and not dismissed. The system can, therefore, bias perception in favor of top-down or bottom-up factors based on relative levels of confidence or attention to either one. For example, according to my model of the world, the only black SUV in my garage is my car. If you switched it for another one, I would probably get in without even noticing. My perception would be controlled by expectation, not the information from my eyes. But I wouldn’t suffer the same illusion in a crowded parking lot where my perceptions would be controlled far more by bottom-up sensation than top-down prediction.

Now that we have a basic understanding of how this model works, let’s look at how it explains some common and not so common phenomena related to perception.

Pain

The predictive coding framework helps explain why pain is affected by past experiences, thoughts, expectations, and emotions, and not just tissue damage.

For example, if you have a good deal of experience where flexing your low back causes pain, you will start to build an internal model of your back that predicts it will hurt with flexion. This will strongly bias you to feel pain each time you bend, even if the back isn’t actually producing that much nociception.

You can reduce the contribution of top-down factors to your pain by updating the model of your back. To do this, you need to cause a prediction error by violating your expectation that bending will hurt.

A good strategy would be to perform low back flexion in some novel way, perhaps in quadruped or supine, while paying attention to how it feels while bending so that any predictions errors are not disregarded. That sounds like a high percentage of movement therapy in a nutshell.

A more aggressive and risky strategy would be to perform some movement where the back muscles have to work very hard to prevent flexion, say a heavy deadlift. Perhaps you do the deadlifts with good form to prevent flexion. It hurts a little, but nowhere near as much as you expected. In fact, you have a visceral feeling of surprise at how strong you feel. This is evidence that you have violated an expectation that your back was too weak and fragile to handle any significant force, and that your map for the back is being updated to account for the prediction error. Good sign!

The bottom line is this – a great deal of what can help with pain in the short term is violating an expectation that something will hurt. There’s probably a lot of ways to do that – massage, deadlifts, cat-cows, stretching, isometric resistance exercise, active or assisted joint mobility exercises. What they all have in common (if they help with pain) is that they don’t hurt as much as you would expect.

Moving Better – Prediction And Action

According to the predictive coding model, there is a profound connection between perception and movement, because each can help correct a prediction error, and minimizing error is really all the system cares about.

When the system is confronted with a prediction error, it can do one of two things – update models to reflect the new information (change perception) or alter action in a way that gathers sensory information consistent with the prediction (change movement).

For example, let’s say I am squatting to a box with my a barbell on my back. When I squat to a certain depth I expect sensory feedback from my butt indicating touchdown. But there is a prediction error – my butt is silent. I can do one of two things – I can change my perception about the location of the box (oops I forgot to put it in place!) Or I could change my action – move my butt a bit lower or further back until I get the predicted feedback.

So one way or the other, the essential goal is always to reduce prediction error, and it doesn’t really matter whether that is done by changing perception or action. The important thing is that I don’t crash to the ground with a barbell on my back. Either way, good internal models and good predictions are the basis for generating functional perceptions and actions.

Getting better at movement is therefore very much about improving your internal models for movement and your predictions for what kind of sensory feedback you will get during the movement. This means you need a lot of experience, you need to make mistakes, and you need to pay attention to the right streams of sensory information to identify and correct those mistakes through better perceptions and actions.

Of course, we know most of these things anyway, but I think it’s cool to see that application of the predictive coding framework gets us to the right answers. Here’s some cool stuff that we might learn from predictive coding that we don’t already know and is not easily explained by other models.

Schizophrenia, Autism And Babies

Check out this picture of Albert Einstein – is his nose closer to you or further away?

We expect noses to be closer to us, so most people will see this mask as being convex when it is in fact concave.

Interestingly, schizophrenics (and people stoned on marijuana) are actually less likely to make this mistake. This might be because their perceptions are controlled more by bottom-up sensation than top-down models of the world. And maybe this is why they can both tend towards paranoia. Schizophrenia involves delusions where everyday events are regarded as incredibly salient and important.

Imagine sitting in a crowded coffee shop and hearing your name in a nearby conversation. This might get your attention, but it would not probably register in your consciousness as being profoundly surprising.

But if you had a problem whereby the relevance of unpredicted incoming sensory information was massively magnified, then the mention of your name might feel profoundly important, and perhaps contribute to delusions of reference or paranoia. So perhaps paranoid delusions involve assigning too much importance to minor errors in prediction.

Autism can be also be understood as a condition where bottom-up sensation dominates top-down predictions. Even the smallest prediction errors are considered important.

Thus, all incoming sensory information is regarded as “newsworthy” and people with autism are “slaves to sensation”, constantly distracted or irritated by minor inputs like labels on their clothes, or random noises. Interestingly, people with autism often self-soothe by engaging in repetitive rhythmic movements. These create a stream of sensory information that is highly predictable. Better prediction allows the suppression of sensory information that would otherwise be overwhelming.

Maybe this is why babies like rhythmic movements, or to be carried around all the time, or to be swaddled. Because they don’t have much experience in the world, they have no strong internal models to create confident predictions about their incoming sense data, and they just get blown away by all of the information they are getting about the unpredictable movements of their arms and legs, the variations in the way their back is touching the car seat, and the random noises created by the TV, traffic, etc.

Adults are exposed to all of this information too, but we can easily predict it and therefore ignore it. But for babies without good internal models of the world, everything is a blooming, buzzing confusion. Perhaps they are soothed by getting a nice stream of predictable rhythmic sensory information. Aren’t we all? Lots of interesting food for thought here. Here are some further resources if you want to learn more.

Good Articles On Predictive Coding

An Aberrant Precision Account of Autism

Prediction error minimization: Implications for Embodied Cognition and the Extended Mind Hypothesis

Active Interoceptive Inference and the Emotional Brain

The Hard Problem of Consciousness is a Distraction From the Real One

It’s Bayes All the Way Up

(Thanks to Derek Griffin and Mick Thacker for linking many of these.)

Home Care Plans: Instructions Vs. Adherence

October 14, 2018/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Jon Cain

I remember going to physiotherapy when I was in high school and having my exercises prescribed to me for my knee pain. I was instructed to do them every day, which I think I may have managed to do for about a week. Past that, they tapered down to as little as once per week only, followed by lies to my physio about doing them regularly.

Was I just a bad client? Maybe. Let’s fast-forward a decade or so, though.

When I began my career as an Athletic Therapist, I would instruct my patients along the same lines. Do the exercises every single day in order to get better. It’s the standard I wanted and, if nothing else, it would make the clients exercise to some extent.

But my method didn’t work.

Adherence to my instructions was poor and my clients had a difficult time getting better. Truth, maybe there are “bad clients” out there, but at some point, you have to look at the coach rather than the players. Which brings us to the key error so common to many of our practices:

“I tell my clients to do their exercises every single day knowing that they won’t, but at least, then, they’ll do them every other day.”

Does this sound familiar?

As health practitioners, we’re used to working with patients who are only partially or completely non-compliant when it comes to their exercise rehab. As a result, we become accustomed to “tricks” in order to get them to exercise and be able to recover.

However, if you’ve used the above trick in the past, I’m sorry to say that you’re terribly misguided. (As I was.)

Let’s consider that by saying this, we’re raising the expectations for a patient to what is, for all intents and purposes, an unrealistic level. (If it was realistic, then we wouldn’t be assuming failure on the client’s part.) Now ask yourself, have unrealistic expectations ever proven to be a formula for success?

We know this to not work with raising children or dieting, so why in the world do we assume this to be effective when it comes to rehab?

Poor exercise adherence has been shown to be, in large part, due to anxiety regarding the process and an expectation of failure. Think about it; if we’re told that we absolutely need to do 100% to recover, but we know we won’t achieve that 100%, are we going to be motivated to do 50% in hopes that it will be enough? Not likely!

More likely, the guilt of not adhering completely will derail the behaviour change altogether.

So, I’m sorry, there is no easy and effective “trick” such as simply telling a patient to perform a mile while expecting an inch. Instead, actual investment in coaching patients through their exercise barriers is required.

Such coaching techniques include:

Helping them understand the starting process and develop a feeling of control
Understanding their hesitations regarding exercise
Finding exercise and time routines that work with their lifestyles
Making small changes at a time
Developing relapse expectation and management

So, let’s look into how we can take those points and put them into action with our patients.

Education

As clinical professionals trying to induce behavioural changes, we need to ensure our patients have a thorough understanding of the recovery process and the importance of exercise. With this understanding, clients will develop a feeling of control over their recovery and become motivated by being able to see the direct benefit of their actions.

Exploring Barriers

If a patient has barriers to physical activity, you’re allowed to dig a little bit to understand them for yourself.

Perhaps it’s that anxiety about the process, which education will address. Maybe it’s a time constraint or limited equipment-availability, which signals the need to carefully strategize with their plan. The patient could simply hate the idea of exercising, and so you might have to come up with something that does not necessarily feel like formal exercise.

Discussing these obstacles with your patient will let them know you’re investing time and energy in creating the right plan for them and create trust between the two of you.

Which brings us to…

Individualizing Their Routine

If you have a go-to-patient that is hyped and happy to set aside 30 minutes per day and run through all of their rehab homework daily, then great. For the rest, we need to explore different methods.

For some patients, requesting their rehab exercises to be done every 2-3 days might be the realistic and attainable option. You can also consider programming them as a warm-up before working out, sports, or even just going out to walk, which is great for those with perceived time-restrictions.

Split-routines are an effective method as well, especially when it comes to combatting boredom or monotony. If you have six exercises you want your patient to do, try splitting them into three on one day and three on the other.

Finally, for those who are averse to traditional exercise, in general, you might have to be a bit more creative and find movements that are fun or don’t resemble the “work” of a workout. What I find beneficial is simply reintroducing the activities that patients want to do upon recovery as graded-exposure therapy.

Throughout all this, though, let’s remember to make small changes to lifestyle at a time. As we know, gradual modifications are much more successful in the long-term than massive overhauls.

Develop A Relapse Plan

Finally, it’s crucial we create somewhat of a risk-management plan with our clients.

A lot of things can potentially derail an individual’s adherence to change. Missing a day or two of exercise might demotivate someone from continuing further. A relapse of pain might be the clincher that causes a patient to give up and think they failed. Even simple life events might throw a wedge into the ability for someone to focus on their health.

In these cases, I drive home the point that relapses and derails are likely to happen. By predicting the possibility, we can create methods of coping and moving on. Let a patient know that it’s ok if they miss a day or even a week of exercise and that they’ll continue to reap the benefits as soon as they get back on the horse.

Pain relapses should be normalized as an expected event, and if the patient can use it as a learning opportunity rather than as a sign of a failed recovery. Like with anything we do in life, recovery will involve ups, downs, and plateaus to work around.

In truth, this ability to work with a client to create longer-term habits and adherence is something that many fitness professionals commonly excel at over medical ones. Personal trainers know that it’s an easy way to lose their client by telling them to do cardio six times per week or that they need to work out for three hours per day. Bringing those expectations back down to a realistic level and adjusting their plans as the client changes are the sure-fire way to success. Cookie-cutting a method for motivating that person to exercise is as bad as cookie-cutting the program itself. We have a duty to individualize our patients routine which includes the frequency basis on which it’s performed. And don’t expect failure; aim for success.