The Louis Gifford Episode

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Play Involves Risk

[The following is an adapted excerpt from my new book Playing With Movement.]

Play often involves risk. When kids play, they learn how fast they can run without falling, how hard they can fight without getting hurt, and how much they can bother Mom before she gets mad. They learn where the lines are by crossing them repeatedly. There’s risk in stepping too far, but also risk in not stepping far enough, and failing to discover the limits of potential. As we age, we start with games that are very safe, and then progress to games with more risk. Many people graduate to doing things that are truly stupid. If they survive, they learn some very valuable lessons (hopefully).

But in the beginning, playful exploration presents little risk. When babies are learning to roll over and crawl, there is no way to get hurt if something goes wrong. Without fear of injury, it’s easy to engage in many trials and many errors, and to learn a ton about how to get coordinated. But they are learning nothing about how to protect themselves. As soon as babies stand up and start walking, their education in the potential risks of movement begins. 

Toddlers taking their first steps will fall many times a day. This is unlikely to cause injury because they are close to the ground and have a nice layer of protective fat over their butts. But falling creates nociception, which is the sensory signaling that can result in pain. This puts the nervous system to work in reading evidence about physical threat and deciding whether pain is necessary for protection. Has the butt been injured? Is this a dangerous situation?

There are other important questions raised by falling. Is backward better than forward? Is it a good idea to cry to get Mom’s attention? Should we give up on walking for now and return to crawling? Confronting these questions is a form of training in weighing the risks and rewards of various kinds of movement. 

As kids get older, they start playing with movements that can cause minor injuries. Jumping off couches or benches, running on sidewalks, or going down slides will frequently bruise knees and scrape hands. Each fall is a learning opportunity — did I get injured, how long will it hurt, will I need a band-aid? If I cry enough, will I get ice cream?

Kids who fall after running often don’t know exactly what to think or feel. They were running along without a care in the world, and now they are face down in the dirt. They usually look around for the face of a parent. If Mom is looking panicked and sprinting over, the kid will probably start crying. And if Mom plays it cool, gives a bit of a shrug and smile, the kid usually gets back up and continues to play. Pain always has a social dimension, and kids start learning about it through play.

After getting some significant experience with scraped knees and bruised elbows, kids will start to refine their movement strategies related to self-protection. Some will become cautious, avoiding climbing, contact sports and roughhousing. Better safe than sorry. Other kids take the opposite path: no guts, no glory. They make several trips to the ER before their 6th birthday, but are rewarded by superior skills in skateboarding. 

I recently did some soccer coaching for eight-year-old girls, most of them novices. I watched something interesting happen on at least three occasions. A girl got hit with the ball unexpectedly in the thigh, or trunk, or arm. She would look startled, confused, and then start crying about 10 seconds later. She would leave the game, settle down, and then return to the game feeling fine. I think what happened was that she experienced a completely novel and surprising feeling and didn’t know what it meant. Eventually she learned that it was not really a problem — the body is pretty tolerant to getting smacked with a soccer ball, and this isn’t something that should cause pain.

As kids (especially boys) approach the teenage years, they may start playing with some seriously risky stuff, like fighting, extreme skiing, and football. Some of these “games” may be more in the nature of contests intended to establish dominance hierarchies. Either way, there are important lessons for the players. First, there are many occasions to differentiate between minor and more serious injuries, and this can increase body awareness and refine a sense of threat perception. Scrapes and bruises are very different from sprains and breaks. The former should be pretty much ignored, and the latter requires a trip to the doc. With this sense of perspective in place, minor injuries become more tolerable, and may not even be noticed. Another lesson from risky activities relates to fear management. For example, proper skiing technique (much like asking someone for a date) requires that you lean forward with confidence. You may fall flat on your face, but you need to forget about that for the time being. In many situations, worrying about a bad outcome will make it more likely. Fear is the enemy, and playing with risk is a way to learn to master it. Further, handling a risky situation builds confidence, and a sense of self-efficacy. These qualities are protective against chronic pain and disability.

Peter Gray argues that young mammals have an instinct to “dose” themselves with risky situations as a way to inoculate themselves against the disease of anxiety:

In their motor play and rough-and-tumble play, juvenile mammals appear to put themselves deliberately into awkward, moderately frightening situations. . . . When they leap, for example, they twist and turn in ways that make it difficult to land. They seem to be dosing themselves with moderate degrees of fear, as if deliberately learning how to deal with both the physical and emotional challenges of the moderately dangerous conditions they generate.

Kids have less chance to do this in the modern world. Gone are the days when parents let kids play unsupervised for hours at a time near trees, fields, streets, or large groups of multi-age kids. These activities are now considered dangerous unless parents are constantly supervising, monitoring, encouraging, discouraging, coaching, hydrating, child-proofing and doing almost everything short of bubble-wrapping their kids. If the parents weren’t there, heaven forbid that a child might fall down, get hurt, be exposed to germs, or suffer a temporary drop in self-esteem. Many experts believe this approach actually makes kids less safe, and more fragile, sensitive and anxious. Helicopter parenting pushes kids toward safe spaces like couches, and away from uncontrolled spaces where they might actually engage in some playful activities like climbing a tree, riding a bike or even playing a game of tag. This prevents them for learning that they can control risk, and some argue this is a cause for rising rates of teen anxiety. It is certainly not a good idea to be reckless and irresponsible, but it can be just as destructive to fear and avoid movement that makes you healthy and robust.

All the above points have implications for adults. Perception of threat is at the root of many undesirable conditions in the body. Pain, fatigue, inflammation, anxiety, stiffness, and weakness are all caused, at least in part, by the unconscious perception that the body is weak, under attack, incapable, broken, fragile, damaged, vulnerable to threats. Playing with risky movement is one way to build a self-image that is far more robust, strong and capable. So is disregarding the well-intended but counterproductive advice of many helicoptering personal trainers and physical therapists, who would seek to prevent us from sitting, standing, running, or drawing even a single breath without the “correct” form. 

To learn more about the value of play for movement skill and health, check out my book Playing With Movement. 

 

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Articles Of The Week March 21, 2021

Richard always does a great job compiling resources for us all to learn from. Here’s his list of the best podcasts for Massage Therapists and we’re honoured to be mentioned.

Best Podcasts For Massage Therapists – Richard Lebert

This is a condition I have only seen a few times in practice, so it’s great to listen in on those with a bit more experience. Listen in to learn more about Thoracic Outlet Syndrome.

Thoracic Outlet Syndrome: What You Didn’t Know – Whitney Lowe & Til Luchau

Setting goals and having them come to fruition can sometimes be difficult. That’s where having a playbook might be helpful. Check out how a playbook in life can be a thorough plan of action to achieve your intentions.

Building Your Playbook! – Scott Livingston

A great chat looking at pain from a different approach (at least for us manual therapists). Rachel Zoffness is a pain psychologist, so very interesting to listen to how a psychologist helps people with pain.

Healing Our Pandemic – Dr. Zubin Damania & Rachell Zoffness

Okay for once I’m putting myself in the articles of the week. Had a great chat with Matt Phillips about staying evidence informed. It doesn’t have to be expensive or time consuming, but it is necessary!

How To Stay Evidence Informed – Matt Phillips & ME!

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Don’t Fall For The “Ultimate Modality” Hoax

 

A couple of weeks ago, we looked at a Bialosky paper on the mechanisms of manual therapy. 

I liked several things about the paper; for one, it showed us how all techniques we use result in neurophysiological responses in both the peripheral and CNS to help with pain inhibition. 

Secondly, part of the paper’s reason was to try and find a construct that could be used for future research since we now know there are more than just techniques that influence our clinical outcomes. 

With that, we have developed a framework any of us can use to have better clinical outcomes, so here it is. 

The All-New Modality Framework To GUARANTEE Successful Treatments 

As we all know, every good treatment technique in our industry comes with a good acronym. 

When I think back to college, there was MRF, CST, MET, MLD, and probably a host of other ones I’m forgetting. 

I still use some of these techniques in practice today, essentially because they feel good and my patients like them. 

However, with our new treatment framework, we’ve come up with a four-level system that will get you and your patients the results we’re all so desperately looking for. 

This four-level system has four acronyms: EPN, TPN, MPN, and SFN. 

Let’s take a look at how to implement this in practice. Because 60% of the time, this works every time!

EPN – Educate People Nicely

This is an essential factor to start any treatment. Quite often, people come in with certain expectations for what they want and expect from their visit. 

Sometimes they have been to other practitioners who are still using old narratives, leading to specific belief systems around the pain they are experiencing. They may even believe their pain is a result of their hip or rib being “out”. 

Perhaps they’ve been told a specific muscle needs to be “released”, or a ligament on their liver is twisted (yes, I’ve been told this). 

Whatever thing it is, we have a responsibility to educate the person on what is going on and start changing their belief system around those narratives. 

However, those beliefs are often deep-seated, and attempting to blow it out of the water on the first visit may not lead to a solid therapeutic relationship. 

So there are a couple of ways we can handle this. 

Just giving little bits of information with each session and gradually changing their beliefs is one way. As pointed out to me by some colleagues, another is to ask them: “how can I support you”? 

Once you have offered support and helped them, they may ask you for advice or what you think is going on. This opens the door to deliver some education and gives them control over this framework. The more control they have helps in building their resilience, which we should be shooting for. 

Now that we have provided a bit of education, next comes the treatment part.

TPN – Touch People Nicely

I have to give Eric Purves credit on this one.

Give people what they like. 

One of the great things about many of those techniques we learned in school is how great they felt. Since we know that every technique is just a neurophysiological input that helps create change let’s figure out how to touch people in a way that feels best to THEM. 

For some people, a nice light touch feels great; for others, they like a firmer or deeper treatment. 

It’s essential to ask them if they like this because of how it feels or because they think deep is necessary for the treatment to work? 

If it’s the latter, we may have to go back to EPN and demonstrate that a deeper painful treatment isn’t necessary and gradually show them how we can make a difference by doing something else that just feels really good. 

If it’s because a deeper treatment feels excellent to them, this is TPN for them, so continue on. 

MPN – Move People Nicely

I’m a huge fan of movement and graded exposure. 

As my career goes on, I’ve come to my own realization that most orthopedic tests are simply a version of graded exposure. You get a person to move their shoulder a certain way, then get them to do it again right away or after treatment, and sure enough, that body part goes a bit farther. 

Whether you do this before, during, or after treatment and the person can now move a bit farther, it feels nicer; this helps build confidence in that movement. 

The more encouragement we can give them that movement is safe and actually helps their pain experience, this will contribute to MPN and a better outcome. 

SFN – So F@!*ing Nice

So now that we’ve done EPN, TPN, and MPN and we know what feels really good for the person on your table, next comes SFN. 

This happens when we’re using the patient’s favourite technique (and they are quite possibly drooling while facedown), and all you hear is the patient say, “that feels sooo f@!*ing nice”!

This is quite possibly the pinnacle of our new framework for a couple of reasons. Patients love it when things feel SFN, and I like swearing. 

The Truth About This Framework

So this post was done a little tongue in cheek, and obviously a fair bit of sarcasm. 

I have no issue with courses that have a great acronym; many of them are great courses. However, the narratives behind them have to change and be brought up to date with manual therapy’s actual mechanisms. 

It would help if you also didn’t have to pay for specific modalities, “five to seven levels of mastery,” to become certified as a “provider.” 

Another issue is that since we know all techniques work the same, we need to stop seeing things like “we guarantee this will get your patients better, faster!” There are so many factors to a treatment that to make this statement is quite simply false, the technique itself will not do this and to advertise it as such is just plain unethical.

What we need to do is look at each patient as an individual. Talk to them about their expectations, what they like, demonstrate how movement is safe, and help them get to the point where they feel SFN in their own body. 

This can take time and a lot of practice to accomplish. 

Still, if we look at each treatment as an opportunity to learn more about the person in front of us, rather than how a new shiny modality can change our practice, we’d probably be a lot better off. I know our patients would be as well. 

Let’s focus on EPN, TPN, MPN, and SFN so we can help people build resilience and confidence in their own bodies. And I promise we’ll never come up with a new modality with seven tiers to change your practice. Just do what feels nice to people and do what feels good to THEM. 

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Articles Of The Week March 14, 2021

The one muscle that seems to consistently create great debate and excitement amongst the MSK professions is the psoas and we really need to start asking why? For some reason, it gets a lot of attention and a lot of the blame for so many problems. However, we really need to start looking at why one muscle could get blamed for so many things.

Psoas Obsession – Eric Purves

I haven’t seen much of this in my practice, so it’s definitely a topic I need to learn more about. Thankfully we have some great people putting content together so we can understand Hypermobility and how to help patients better.

Understanding Hypermobility – Matt Phillips & Bonnie Southgate

For some reason, we are always looking to ‘blame’ a certain thing for a person’s pain. While it’s true that patients like getting a diagnosis, it’s also important for us to realize there are many more factors that contribute to a successful treatment. We need to look past the biomechanical and also try taking a collaborative approach.

Joint Pain Treatment: Beyond the ‘Bio’ and ‘Silo’ – Nick Ng

This is just a REALLY creative and entertaining review of the organ systems in the human body, I applaud their creativity.

How To Learn The Organ Systems In Under Five Minutes – Fundamental Raps

There is many pseudoscience interventions being peddled within musculoskeletal therapy. Now, it’s even being used with animals! If you didn’t see it a zoo used kinesiology tape on an elephant, I’ll let you guess what the outcome was.

Nonsense For Elephants: The Houston Zoo Promotes Kinesiology Tape – Clay Jones

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Unravelling The Mechanisms Of Manual Therapy

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People Don’t Follow Guidelines For Back Pain Because There Is No Path To Follow

I get the opportunity to chat about back pain now and again around the world and one of the things I often talk about is the current guidelines around back pain. I will admit to often feeling a little apprehensive around this subject as the current guidelines run contrary to the way many HCP treat this common problem.

There is always a little gasp when manual therapy, acupuncture and ultrasound get relegated to adjunctive treatments. “Don’t shoot the messenger” is often my get out of jail card.

We know that clinical guidelines around most things within healthcare are not well followed. The big question is why?

We Are Humans!

Healthcare professionals are humans just like the people we are trying to help and suffer from exactly the same issues. For me there are parallels between getting clinicians to follow guidelines and getting people to be compliant, adherent, committed or whatever you want to call it to exercise programs or health improvement or even taking medications.

We all know that getting fitter is good for us as is reducing smoking, drinking and eating crappy foods. But that does not mean we always implement this knowledge. People still smoke and drink too much and don’t get the recommended dosages of exercise. Big societal messages are needed, but so is how to put them into practice at an individual level.

The big problem I see is how gigantically broad the guidelines are around treatment. Let’s take my favourite subjects’ activity & exercise, the guidelines are clear, movement is good, but the evidence base is not really clear when it comes to putting these recommendations into practice!

We might ask ourselves which exercise? How much? How should they do it? What should it feel like? Might it make the problem worse? How to get people to actually do it? If I look back at my clinical education in back pain treatment mostly it was based around Maitland mobilisations with little about exercise treatment and implementation.

So a simple guideline turns into a much greater clinical problem.

Providing A Path

Fundamentally we cannot expect people to implement something without giving them a way to implement it. We need to provide a pathway in much the same way we need to provide a pathway for the patients we work with around exercise.

How can you guide someone in something of you have no idea how to do it yourself?

Imagine getting a bit of flat pack furniture that did not come with any instructions. The pile of pieces that lay in front of you daring you to put them together. Some hardy souls, and probably those with a heap of previous experience, might attempt to put them together. Most normal folk, myself included, would simply put them back in the box and push them to the corner of the room. This conundrum is simply too much to handle.

You have all the pieces of the puzzle, but the problem is putting them together!

Education is another prime example. Education about what? Back pain? Pain? Treatment? Prognosis? All of the above? How to do it? Again there are many questions to unpack within the broad recommendation of education. I received no education in education at undergrad or post grad as I suspect neither have many of you reading this. Again this provides a barrier to implementation at the most basic level.

In the face of uncertainty and low confidence we return to our old habits that are ingrained within us and for many that is not based on current guidelines. Uncertainty provides huge inertia to change.

Support

Support is another factor that is often overlooked. How many people feel they cannot treat how they want to treat because of the working environment they are in and the people around them? This is something I often hear. Support again is a huge part of behaviour change and maintenance of that behaviour. A major part of self efficacy is built around social support and I doubt that it would be different in the work place.

The healthcare system that people work in can be a huge influencer of the way we practice in the same way our social systems affect our overall health and behaviours.

Takeaways

 

• Behaviour change is no different for HCPs than it is for patients

• If we want change we have to provide a path to change and support along the way

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A Simple Guide To Patient Centred Exercise

After ‘pain science’ and ‘biopsychosocial’ the latest buzz word on our horizon seems to be ‘patient centred care’ or PCC for short.

Now for a buzzword it is pretty poorly defined and we don’t really have a strict description, but I think PCC is really how we should be implementing the BioPsychoSocial (BPS) model and what the BPS model was really meant to be about rather than the more pain focused version we have today.

This blog aims to focus on how we might apply PCC in the context of an active approach to treatment but don’t be surprised if it meanders off course a bit.

Patient Or Person?

Most of the available literature in this area discusses “patient centred care” but I much prefer “person” centred care as it turns the patient well ….into a person and a much more ‘real’ entity in a two way relationship.

The term ‘patient’ has long been open to discussion and this is an interesting read on the subject and I picked out a couple of quotes.

“Do we need a new word for patients?”

“Patient comes from the Latin “patiens,” from “patior,” to suffer or bear. The patient, in this language, is truly passive—bearing whatever suffering is necessary and tolerating patiently the interventions of the outside expert”

“An unequal relationship between the user of healthcare services and the provider”

These are interesting perspectives that highlights the potential perspective of the ‘patient’ as a passive recipient to be told what to do and without concern for them as an individual. After all tissues and pathologies really don’t care how they are treated so why the need to worry about it?

What Actually Is PCC?

Maybe by definition PCC is tough to define for all? What is person centred for one may not be for another, but there do appear to be some broad themes and ideas that can be discussed.

Patient (person) centred care has previously been defined as:

“willingness to become involved in the full range of difficulties patients bring to their doctors, and not just their biomedical problems” – Stewart 1995

“the physician tries to enter the patient’s world, to see the illness through the patient’s eyes” McWhinney 1989

“Two person medicine (rather than one person)” – Balint e al 1993

(Quotes in Mead et al 2000)

For me, a good start for PCC is not to see the therapist or technique or method or exercise as the star of the show. It’s about the PERSON that really needs our help. That does not mean fanfares, razzmatazz and pedestals, it really means that we try to think about what THIS person in front of me needs, what is it like to walk a mile THEIR shoes?

Another very simple way to look at it is, how would YOU like to be treated?

Mead et al in “Patient-centredness: a conceptual framework and review of the empirical literature”defined 5 key aspects of a “patient centredness”

• The biopsychosocial perspective (the patients life)
• The patient as a person
• Shared power and responsibility
• Therapeutic alliance
• The doctor as a person (Personal qualities such as Humanness)

Wijma et al explored “Patient-centeredness in physiotherapy: What does it entail?”

They defined PCC as

“Patient centeredness in physiotherapy entails the characteristics of offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient-defined goals, a treatment in which the patient is supported and empowered, and a physiotherapist with patient-centered social skills, confidence, and knowledge”

What PCC Is Not

There are some criticisms of PCC that seem to centre around the idea of consumer driven healthcare and doing ‘whatever someone wants you to do’. Maybe the idea of ‘shared decision making’, intrinsic to PCC, seems to open up this idea of consumer healthcare for some.

These discussions are often dominated by the type of treatment and the application of more passive modalities and we really need to guard against this reductionist perspective of PCC.

Rather than MAKING the decision based on someone’s preference, PCC instead really should be about people being involved in decisions, a key part of PCC, and this should reflect the best information around treatment that we have available and frank and honest conversations around the best course of action. Not simply “what treatment do you want”.

Makoul & Clayman in “An integrative model of shared decision making in medical encounters”discuss a number of steps involved with shared decision making

• Define or explain problem
• Present options
• Discuss pros and cons (benefits/risks/costs)
• Assess patients’ values or preferences
• Discuss patient ability or self- efficacy
• Provide doctor knowledge or recommendations
• Check or clarify understanding
• Make or explicitly defer decision
• Arrange follow-up

What Do People Really Want?

That leads us nicely into “what DO people want” and this does NOT seem to revolve around their favourite treatment type.

PCC is perhaps thinking about what healthcare can do for the end user, the person rather than how do they fit into the broader healthcare world. What better way is there to do that than ask them : ).

The increase in qualitative research is fantastic and really helps us understand what people think, feel and ultimately need.

This is a really interesting paper regarding a two person perspective in back pain Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain

The authors here identified some key areas.

Partnership With Practitioner

“All participants expressed the need for mutual enquiry, problem-solving, negotiation and renegotiation between care-provider and care-seeker to establish mutual therapeutic goals “

‘Ask Me’

“All participants reported that engagement with their health care-provider improved if they were explicitly asked for their opinions and goals.”

‘Understand Me’

“Consideration of life circumstances and preferences was important to all participants in developing therapeutic partnerships and optimising exercise outcomes”

‘Listen To Me’

‘Explain it so I can understand’ – Valuing competent and empathetic listener

I know my own body   – Participants framed the ability to ‘know your own body’ as empowering

This sentence particularly resonated with me however

“Tension existed between patients’ wanting a genuine voice in the partnership and them wanting a care-provider to give explicit diagnosis and best management instruction”

Does It Matter?

A question I often hear asked about person centred care is does PCC actually improve ‘outcomes’? I suppose my response would be does the effect of PPC on outcomes actually matter and which outcomes are we discussing?

Although we know that contextual factors have an affect on outcomes we don’t know if PCC specificaly improves the most common outcome measures , but in my opinion it is the RIGHT way to treat other people regardless of if it changes pain, function or whatever. Although we don’t really have much data currently, my biases say for many it would make a difference, if not to common outcome measure then to the persons experience in healthcare (which might be an outcome measure in itself).

 

The Application Of PCC

Maybe we should NOT see a person centred approach to activity/movement/exercise just about the type of exercise or the sets and reps. Instead it’s about all those things AROUND the moving as well and I will focus mostly on these (you can retain your exercise bias : )

Starting With The End In Mind

Unless we define what recovery might look or feel like it is probably hard for anyone to know if they are actually getting there. Really the role of the therapist should be to see where someone wants to get to, where they are currently and then help them bridge that gap.

The best place to start might be with the end in mind and this first and foremost really involves listening. Listening and understanding, is in my opinion the real essence of PCC but many people don’t feel that this always happens in their HealthCare experiences.

This short excerpt is from the excellent “From “Non‐encounters” to autonomic agency. Conceptions of patients with low back pain about their encounters in the health care system”  

Holopainen 2018

“Patients felt that they were not being heard. They felt that the encounters were expert driven, and the HCP interrupted them and dismissed what they had to say, without listening to their wishes and opinions”

We also have to acknowledge that for some who have had pain for a long time this process of defining goals or recovery can be really tough. It’s often difficult to see outside of the pain and suffering to have a sense of what ‘life’ actually looks and feels like again.

“Patients identified the effects of pain on their lives. They reported that their circle of life had shrunk and they had given up doing things they used to enjoy” – Holopainen 2018

I try to highlight to people that they are not just moving for the sake of moving (although this can be a positive thing), we are moving to get further towards valued activities and goals that we have discussed and hopefully this can tap into people’s intrinsic motivation.

A big problem, IMO, with goals is that we can measure their success via their effects on more generic measures such as pain or function (certainly in research around physical therapies).

We have a wonderfully personal and specific thing, the goal, and we should actually measure the success of a goal by achieving……the goal! If that involves changes in pain then of course with a person centred approach we have to involve pain in the goal. But we might have no changes in pain (our outcome measure) but reach a valued goal that has a huge effect on someone’s quality of life and may not always be captured by the more generic measures.

I do believe that the ‘WHY’ behind action has to be driven by the person. So much of what happens in therapy is driven by the biases of therapists about the best way to get people pain free or functioning better.

Maybe the ‘methods’ employed often fit better with the identity and values of the therapist rather than the patient?

Shared Decisions And Responsibilities

As we discussed earlier, PCC and shared decision making is not just doing what someone wants. We need to present the best available information and our professional opinion on the best course of action to properly inform decision making.

Autonomy has been shown to be have an influence on exercise outcomes “Autonomy: A Missing Ingredient of a Successful Program?” . Perhaps some autonomy and choice might lead to better ‘bonding’ with exercise in rehab?

As there are a whole bunch of ways to exercise, move and load it should be not to hard to present a number of options and allow people some choice on the best way forward. Equally it is a therapists responsibility to give their opinion about the best course of action that they think will ‘fit’ the person based on the best data and a sprinkle of experience.

Laying out each others responsibilities in the process is an important step. I always say I am here to guide and help but you have to go and do it and believe in it for it to work. I believe we need accountability towards each other sometimes.

Planning

This for me really is true biopsychosocialism.

We are all people ‘embedded’ in the world with work, family and social pressures. One of the best ways to implement a BPS perspective is to realise that any movement/exercise plan is not going to come at ‘no cost’ in terms of time, effort and sacrificing something else.

People don’t just need a something to do, they also need a plan to be able to do it. A destination is great but we also need a path to get there.

How many things do you never quite get around to doing because you don’t have a clear time, place and structure to get it done?

When’s the best time to do some exercise? Before or after work. How much is OK? What should it feel like? Do they have the required information to facilitate doing it?

Another passage from “From’Non‐encounters’ to autonomic agency” highlights this.

 “A lack of written instruction prevented them from doing prescribed exercises because they were unsure of what they were supposed to do”

Helping people to navigate their own individual social environments is also a beneficial way to help. We cannot often modify many ‘social’ things but we can help people understand and navigate them better. For example, how might someone access community support with getting more active? Are there free or low cost resources that they can use? Are there support groups or family members or friends that might be able to help.

Acting as a guide rather than healer can be really helpful for many!

Support & Motivation

Picking someone’s exercise form apart or highlighting some kind of movement dysfunction really is the opposite of PCC. It shows a complete disregard for how that might make someone else feel and how that might impact on their behaviours. But I suppose if you feel you are just dealing with a pathology then why should that matter?

We could say that view is quite the opposite to walking a mile in someone else’s shoes.

Perhaps we can think about how we might lift someone up rather than pick them apart. Think about highlighting strengths and positives. We entirely underestimate the power of motivation and optimism in healthcare in my opinion. This is a fundamental part of the role of the coach or trainer in the world of fitness but has been lost in the translation of exercise to the world of medicine.

People even say this themselves!

“patients reported that they needed someone to push them, like a personal trainer” – Holopainen 2018

Conclusion

 

• Person centred care is defined by the person
• PCC is not just giving people what they want
• People are people not just patients (passive recipients)
• Think about “walking a mile in someone else’s shoes”
• Think more about shared decisions (within evidence base)
• Start with the end in mind, tie into valued activities
• Help people navigate their ‘world’
• Build people up rather than knock them down

 

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Why You Matter More Than Your Technique

Remember the first two terms of college? 

I remember it being REALLY stressful; in fact, they always said if you could make it through term two, you would be okay because it was the toughest. 

However, this was when we learned most of our technique classes. For us, term two was when we had a class called “Myofascial Release II .”

We learned a technique in that class that I still use today. The “Occipital Hold,” and we were taught how this was releasing the fascia around the occiput. 

Then five terms later, we had two more technique courses. One was MLD, and the other was Craniosacral. I don’t remember who taught us Craniosacral, but I probably owe them an apology. I was a bit of a jerk in that class because…well, I couldn’t feel the rhythms and pulses as it was being taught. As other students would exclaim how they felt these rhythms, I’d look across the room and say, “you’re full of s#*t you can’t feel anything!”

It wasn’t my finest moment; clearly, my ego and lack of palpation skills were at play, and I’m sure I owe some classmates an apology as well. 

The interesting thing is one of the techniques they taught us in that class was an occipital hold. With this technique, we were supposed to be altering the rhythm or flow of cerebrospinal fluid (I’m saying this strictly from memory as I haven’t studied any craniosacral since that time) along with possibly altering sutures in the skull. 

Now, I wish I could say I was some forward-thinking student that realized this at the time, but I only came to this revelation a year or two ago. 

Those two classes taught me the exact same technique but with wildly different explanations of what was going on. 

So, which one was right?

The Mechanisms Of Manual Therapy

An excellent paper was done, which looked at modelling a new approach to how studies in our field should be designed to understand better how to advance what works in our profession and what doesn’t. 

Part of the problem with many of our profession’s modality courses is how there seems to be a one-size-fits-all approach. That one technique can work on anyone for almost anything.⁽¹⁾ 

Well, there’s a lot more to a treatment than just the technique we use. So we can’t justify saying there is a “single thing’, or “single technique” that works exclusively on any given subject.

We know the mechanical stimulus from any manual therapy technique regardless of the intervention (joint mobs, spinal manipulation, Swedish massage, myofascial release, etc) results in neurophysiological responses in both the peripheral and CNS to help with pain inhibition. ⁽¹⁾

This helps demonstrate why we can’t take a mechanistic approach to treat patients. As the paper points out, to have a mechanical based approach, there are two prerequisites needed: 

1. A mechanism contributing to a clinical population or subpopulation. 
2. Biological effects of treatment have to be established. 

If both of these are met, a patient could then be matched to appropriate treatment (or technique), allowing for targeted application of that specific treatment. ⁽¹⁾

The issue here is there is no way to identify the main mechanisms of how any technique works. 

Now, I know that will ruffle some feathers as we quite often become attached to our favourite technique (and in no way am I saying you have to stop using the said technique; I encourage you to keep using it). Still, much of the research behind many of these techniques aren’t reliable. Often, the study is being done by the person who created said technique to prove its validity. And most of the time, they have excellent outcomes to prove their efficacy. 

However, what they aren’t taking into account is the contextual effects of what they’re doing. As this paper points out, this is a crucial part of any manual therapy intervention. 

How Our Treatments Are Multi-Faceted

There is far more than just our hands-on techniques that influence treatment outcomes. 

Just some of the non-specific factors to include are:⁽¹⁾ 

• Patient beliefs
• Provider beliefs, confidence, demeanour
• The environment the treatment is provided in
• Therapeutic relationship
• Influence of community factors on the patient

There are many more but with this brief overview, let’s consider how this could influence research outcomes when strictly focused on a technique. 

If a patient believes the technique will help, well, it probably will. 

If the provider is trying to prove the efficacy of a said technique, chances are they are very confident of their proposed outcomes. They have probably also used the technique often, so they are quite capable and confident with the hands-on portion of using it. This would also influence their demeanour during their interaction with the patient, which also helps with a therapeutic relationship. 

Even the setting where the treatment is delivered can influence the outcome. For instance, an athlete would likely have a better result receiving treatment within the facility of their chosen sport. Someone with headaches would probably have a more significant effect in a darker room with less noise. 

So many of these contextual factors come into play; it demonstrates how we can’t strictly focus on one intervention or technique to show its effectiveness. 

As well there is this other wonderful thing called “Clinical Equipose.” 

We have touched on this in the past but essentially, what it means is a clinician having no preference as to what modality or technique they use. 

This is very important because bias towards a treatment is also associated with clinical outcomes. Because if a clinician believes a technique works and their expectation is that said technique always works, their expectations influence the outcome. 

Clinical Equipose is essential in a research setting because if the provider doesn’t care or isn’t invested in a particular technique, there can be no bias towards the intervention. As we have seen, this bias can influence outcomes. 

When we look back to my story from college and ask which technique description was right, the reality is neither one was right, but this is still a great technique. 

We know that what we do with our hands is a mechanical stimulus that results in neurophysiological responses to the nervous system. Everything we do is an influence on the nervous system. When we look at the occiput, this is an area that is HIGHLY innervated with nerves, and being nicely touched in the area feels really good! This is why an occipital hold is such a GREAT technique. So while we challenge the premise of some modalities (honestly, I wasn’t trying to pick on MFR or CST, it’s just a good example), it doesn’t mean we have to stop doing them. 

However, we have to look at the reasons why these work with the people we see. First off, your patients like you, and you do a good job. You’re confident with your skills. They come to your clinic with an expectation that you’re going to help them (and you do!). Their preference is to see you because they like what you do. Their belief system is that you’ve helped them in the past, so you’re likely to do so again. 

What we do have to change is the narrative behind some of these techniques. They’re not doing what many of us were taught, but they feel outstanding. So, if it feels good, you’re confident with them, and your patients believe you will help them, isn’t that better than a description that isn’t really plausible?

Oh, and to all my classmates and that teacher, I apologize. 

 

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References

1. Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unravelling the mechanisms of manual therapy: modelling an approach. Journal of orthopaedic & sports physical therapy. 2018 Jan;48(1):8-18.

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source https://themtdc.com/why-you-matter-more-than-your-technique/