Monday, September 17, 2018

Making Win-Win Decisions And The Value Of Relationships

In the past, we’ve had several posts talking about the importance of building relationships and business.

While this is a crucial part of the therapeutic relationship with our patients, it’s just as important in our communication and in building our practice with other practitioners.

However, not everyone sees this or treats it with the importance they should.

With this post, I’ll go into why it’s important and two different circumstances where this has made a massive difference in my life, and in my practice. If spending time building relationships with patients and other practitioners aren’t something you’ve been focusing on, I suggest you start.

Here are two examples where this has helped me in the past two years.

The Job

Back in 2009, it was my third term of massage therapy college.

I knew from the start, I wanted to work with athletes and teams. I was fortunate enough to have a friend from my hometown playing for our local Junior A hockey team, so I asked if they had a Massage Therapist working with them. They didn’t, so he helped get me in touch with their head trainer, and my start in hockey as a therapist began.

The first game I was introduced to the team chiropractor, he instantly started getting players to get treatment from me. I was astounded at how supportive the medical staff was.

For the next seven years, that chiropractor and I worked together on the team. Once I was certified and in practice, we referred patients back and forth. A year or two into my career, I looked at the schedule and half of the people booked in with me one week were referrals he had sent.

There are patients who I’ve been seeing for the past seven years of my career (obviously only when they need it, not weekly or anything) because they were referred from that chiropractor.

About three years ago, he referred another patient to me, and the relationship building with that patient started. He spoke fondly of our chiropractor friend every time he came in. As our relationship built, I mentioned how I was a volunteer firefighter and hoped to get a career job one day. He immediately told me about one of his best friends who worked at one of the fire departments in town (and it was the department I really wanted).

Skip ahead a year and that department started a hiring process.

My patient got a hold of his buddy and said: “you gotta help this guy, he’ll fit in perfectly.”

Then the text messages started. His buddy was giving me advice on what to study, how to get ready, exactly what steps to take. As the hiring process unfolded, he texted me every step of the way with advice on what to do. The advice was invaluable and helped me with the process in ways I can’t even explain.

AND I HAD NEVER MET THE GUY! However, based on his friend’s recommendation, he was willing to help!

After volunteering for 16 years, applying to several departments, spending thousands of dollars on hiring processes, this past June, I was the first person hired off the hiring list and started a career that I worked so hard to get.

None of that wouldn’t have happened if nine years ago, I hadn’t started building a relationship with my chiropractor buddy, or with the patient he referred.

The Win-Win

Back in 2005 a good friend and I invested in a franchise business for repairing dental equipment.

Whenever people bought a franchise, they would have to go down to Oregon to receive training on how to repair the dental equipment and learn the business etc. The man who owned the parent company would always have the new franchisees attend a two-day workshop that was basically a self-improvement kind of thing.

We honestly scoffed at the idea initially, but it turned out to be a pretty good two days. One of the key messages we learned was that whenever we made decisions both personally and professionally we would always try to make the decisions a win-win. Each decision had to be made so it would always be something that would benefit us both.

We worked that business together for two years until we came to the realization it was only going to make enough money to support one of us. After some discussion, we decided he would buy me out, and that was what paid for me to go back to college to become an RMT. The decision was truly a win-win as he still runs the business, I’m clearly enjoying my career, and we’ve remained good friends ever since.

Fast forward 11 years to 2016 and I was faced with another business decision.

Do I take a chance and move on to another clinic to pursue my interest in exercise with patients, or continue with the clinic where I was given my first real chance to build a practice. Part of the difficulty for me was the stories I’d heard about people leaving clinics and there being a fight over patient clinic files between the owner and contractor. Plus the clinic owner and I had built a solid relationship and a great friendship over my five years there, how was that going to work out?

Over a three day period, I kept trying to ask her to grab a coffee or go for a drink or something so we could chat about it, but our schedules didn’t work. On the third day when I tried to arrange something, she looked at me with a smile on her face and said: “are you breaking up with me!?”

When we actually sat down and talked she said it would never be held against me for chasing after the career I wanted and to make sure and email all my patients so they knew where I was going so they could find me and book in.

Since then I’ve referred patients to her clinic, she refers patients to me and there has never been an instance where a disagreement occurred about a patient file. In fact, I still have access to all of the files for when the lawyer requests records for one of my patients.

Even better, that clinic owner refers her family members to me and comes to me for treatments herself (and yes she gave me permission to write that, so I’m not breaking confidentiality). So, when I hear those rumours (I hope they’re just rumours) about owners and contractors bickering over patient files, I can’t help but wonder WHY!?

Why is this an argument?

The patient has the right to choose where and to whom they go for their treatment, it’s not up to the practitioner or the clinic to decide that. I get there might be an instance where there is a monetary value to the file if a lawyer or insurance company etc requests the file, but it’s not so great a value that is worth ruining a relationship over. There are many patients who followed me to the new clinic when I moved and just as many who stayed behind and continued at the old clinic because all of them had the right to choose. The most important thing in that whole experience is the relationship that remained between myself and the clinic owner. Because the decisions made between us were done on a win-win basis, the patients win, both the clinic owner and I win, and our relationship has never been better. And to be honest, that relationship is far more important to me than the monetary value of a file, or whether a patient followed me. 



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Saturday, September 15, 2018

Articles Of The Week September 16, 2018


As business owners, there are many things we need to take into account. Malpractice claims are certainly one of the things we need to be concerned about. However, maybe not, if you follow the advice in this post. It covers both how to avoid malpractice claims in person and on social media.

“How To Protect Your Practice Against Malpractice Claims” – Rajam Roose

Not all see manual therapy as a form of primary care in the healthcare system. Yet, it can be a low cost, low risk, and proven effective for many conditions. So, could modern healthcare take a few lessons from the military?

“Primary Care And The Physical Therapist: Lessons From The Military” – Jason Silvernail

Turns out exercise is more important than ergonomics in preventing neck pain! According to this study, exercise-based interventions halved the incidence of neck pain compared to ergonomic interventions/

“Exercise More Important Than Ergonomics In Preventing Neck Pain” – Haley Williams

This is an interesting post, that I’m sure will generate some discussion. It’s a look at how our thoughts and how we manage them could possibly generate pain. Do we repeatedly tell ourselves stories, or ruminate on things that generate a negative response?

“Clean Pain And Dirty Pain: The Two Types Of Emotional Suffering” – Rory

I’ve been wanting to write something about this for quite some time, (and I still might). This one is quick and to the point on the matter of whether massage therapy releases toxins or not. Give it a read and share if you agree.

“Massage Releases Toxins, Fact Or Fiction?” – Custom Bodies Fitness And Massage



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Monday, September 10, 2018

Fear Instilling Behaviours

A recent post in one of the many groups here to which I belong got me thinking about how easily swayed a  patient can become to accept the views of the clinician.

These views often conflict with what the patient’s primary MD or medical specialist might put forth and often stem from the results of testing unique to that particular line of intervention. I am working hard not to cast shade on one particular group or sub-group, as many different professions can be seen as guilty of such sins.

The post which got me thinking was one where the health professional warned the patient not to look up or fully turn their head to either out of fear of damage to their spine. If they did do so, they were instructed to return to the clinician immediately to see if they knocked things out of place and needed more treatment. This despite having been seen by a spine specialist (MD) who ran enough tests to assure that the pain was not overtly pathology-driven, with no fracture or overt spine/nerve compression issues.

I do realize that many patients trust the word of MD’s less than others in the medical profession, but why allow FEAR to drive you?

Are we so fragile that looking up or hitting a pothole with your car (another one of my favourite fear-building warnings..ARGH!!!) that we cannot hope to live a quality existence without the constant oversight and (expensive) micromanaging by a healthcare professional? I cannot hope to know the rationale from which all different healthcare professionals are trained, but with what is known about pain and it is often not an indication of damage/injury/pathology, building a model of fear in our brains could make us more vulnerable to future problems, not to mention paying for the boat of that professional who planted the FEAR SEEDS.

My N=1 story. 20 years ago I suffered two spiral crush fractures of my lumbar spine, all while riding on a pasture horse named Sweetie (true story, true name). Sweetie was actually a fairly old horse who happened to be grey…an old grey mare. I had 2-3 years of regular, daily pain, attributed to the secondary issues of what was at that time diagnosed as disc herniation-type pain.

I DID live in fear for many years, even after the primary pain subsided, fueled by 3-4 time per year reoccurrences of some pretty bad back region pain. I heeded my health practitioners’ advice, initially from my MD as well as the other people who helped me return to function, but some of this advice was avoidance warnings as well as predictions of limitations in mobility and function for the remainder of my life.

I’m not always the best patient, at least when it comes to heeding warnings.

Yesterday I shovelled 4 yards of dirt into a wheelbarrow and moved it to a job site on a different part of my property. I woke up this morning stiff, but not my low back, which feels as strong as before Sweetie and I met. There was a period of time when I would hear those health professional’s words in my ear, warning me not to do such work as I would injure myself further, risking permanent damage. But I had a life to live and I worked my way to a point where I can live a fully healthy and active lifestyle.

I ignored the warnings which did not come from my MD. He basically told me to stay active and see what happens. He told me to let pain be my guide but not my master.

I am not at all trying to say that you are me. Maybe you have a condition that truly should cause you to live and act with caution. But ask yourself a question: is the health professional who is planting these fears telling you a story that contradicts all of the other health professionals you have seen? Even if that person is seeming to help you, might you be better served finding a provider who does not use fear as a primary motivator?

Pain does not always equate to damage and “damage” can be overcome.


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Saturday, September 8, 2018

Articles Of The Week September 9, 2018

The way we communicate with patients is a crucial factor in their treatment and recovery from whatever their injury may be. There may be times when the language we use can leave a scar on our patient and actually harm them with our words. What kind of scar do you want to leave with your patients?

“Words Have Power – What Kind Of Scars Are You Leaving  Your Clients?” – Antony Lo

I think we all like to learn (otherwise, why would you be reading this?) and Richard has put together an awesome resource for all of us to learn from. Everything from podcasts, to blogs, and youtube channels, this could be your own personal learning network.

“Personal Learning Networks For Massage Therapists” – Richard Lebert

Considering getting into a debate online? This article outlines some better ways to “argue” that may help in your debating endeavours.

“How To Disagree Well: 7 Of The Best And Worst Ways To Argue” – Paul Ratner

I had a discussion with someone on the facebook page this week about this very topic. It seems there is an epidemic of people out there who’s “glutes aren’t firing”, but is this really even a thing? Fortunately, this article explains the pitfalls of this issue far better than I will ever be able to.

“Are Your Glutes Really Not Firing?” – Greg Lehman

There are many factors to our patient’s mechanism of pain. Part of what we as therapists need to do is figure out which mechanisms are the greatest contributor and provide our treatments accordingly. This is a great post which outlines some of the ways we can accomplish that.

“A Mechanistic Approach To Pain Management: Applying The Biopsychosocial Approach To Physical Therapy” – Laura Frey Law, Ruth Chimenti, and Kathleen Sluka


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Sunday, September 2, 2018

4 Tissue Loading Progressions To Help With Knee Pain

We have discussed therapeutic exercise/movement many times on this blog before.

Not too long ago we went over the different phases of healing and discussed appropriate measures to take in loading tissues to help with healing. Movement is a great way to reinforce the manual therapy you help your patient with while they’re on the table, so we encourage you to start making a practice of tissue loading and movement once they’re off of it.

After you’ve done your interview and concluded it is safe to begin loading (which you can read about here), here are some progressions for the knee you can do right in your treatment room. These are good for someone with anterior knee pain, a quad contusion, patellar tendinopathy, or a quad strain. 

If the injury is more severe like a ligament tear, more specific interventions and movements should be chosen.

In the acute stage, (the first 24-48 hours) these isometric exercises (joint angle doesn’t change during contraction) would be appropriate. You’ll notice there is some movement to get into a bent knee, but then the contraction is actually a hold with the knee kept bent. 


When your patient comes in for their second treatment, you can start to progress the movement as you are now in the proliferative phase of healing.

In this case, you can progress to an eccentric load, but make sure to stay within the patient’s pain tolerance.  A little bit of discomfort is okay, but we don’t want to aggravate the injury by causing any significant pain.

Hopefully, by this point, your patient is getting into more pain-free movement because you’ve been doing lots of great treatment and also getting them to load the tissue. 

So, if they could do the above eccentric movements by the third or fourth visit, you can progress them to concentric movements as they have probably progressed to the remodelling phase of healing.

Here is a final progression you can try if your patient is up for it.

Plyometrics! It may take a bit of encouragement to get them to try, but if they can do this, it’s a great progressive load for athletes who may be on a return to play rehab scenario or a return to work for an injured worker.

If the patient has any balance issues, it might be best to avoid this until they regain more strength and their balance has improved. 


  • Make sure you are monitoring the area for swelling, redness, and heat, or anything else that could indicate chronic inflammation.
  • Encourage the patient to move, they may be apprehensive to start a loading program.
  • Communication is essential both for the instructions you give, and the feedback you get from the patient.
  • Educate them on how a little bit of pain and discomfort is okay during the movement, they just don’t want to overdo it.

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Saturday, September 1, 2018

Articles Of The Week September 2, 2018

This is a great start to our articles from Greg Lehman. The words and language we use with patients matters and some of the language has to stop! The article generated a lot of discussion on our facebook page, so hopefully, it will get more therapists thinking about their communication with patients.

“Watch Your Mouth, The Nonsense Is Breaking Many” – Greg Lehman

This is another article attempting to dispel some myths, however, its about strength and conditioning. Fortunately, some of the topics are still applicable in manual therapy as well.

“10 Strength And Conditioning Practices That Are Overhyped” – Carl Valle

This one is actually a podcast and its a quick listen, so worth your time listening. One of the points I loved, is how the term “pain science,” has taken on its own life when in reality it’s just science. What matters is understanding how to help people who are in pain.

“Massage Therapy Now” – Eric Purves

We all have to prepare for the unknown. Whether it’s an injury, retirement, or just simple issues that could come up with our practice, we need to be prepared. This article shares some ideas on how to prepare, but also some ideas for extra income, or career shifts.

“Who Knows What Is In Your Future” – Sinead Kelly-Barber

Massage is a valuable healthcare modality, but it for some reason when it comes to the financial cost of getting a massage, some companies are undercutting prices, and in turn the value of our profession. This article shares some ideas on how to give your patients an experience they will value enough for you to charge appropriately.

“The Value Of Massage” – Julie Onofrio

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Tuesday, August 28, 2018

10 Evidence Based Reasons Why You & Your Patients Should Exercise

Exercise is great, we know this, right?

Well, sort of.

Many people know exercise is good for us on a general level, but the question is, do they know it’s right for them on an individual level and is it the right fix for their problem?

This is an entirely different proposition, applying that general information to the person. This idea that these things are good for us can be quite vague, one of those things we may have glanced over in a newspaper or half-hearted on the news whilst eating our corn flakes.

People also build up ideas about what is the correct treatment for them. This can be from their own in-depth research on the internet (right!), what they have picked up from friends and family or from previous treatment with a therapist. This can lead to some pretty strong ideas about what should and perhaps should not be done to help them.

These beliefs don’t always align with the best available data we have about interventions. A prime example of this is the belief that exercise risks outweigh the benefits with back pain (55% of folk in New Zealand). This stat was taken from this Darlow paper in 2016 HERE. 

We know that exercise can be effective with back pain, certainly not a magic bullet, but one of the best things we have at our disposable within a comprehensive treatment plan, especially as it is low cost and low risk too.

Beliefs And Expectations

Our beliefs drive our expectations and actions. Predicted expectations are gaining weight as a prognostic factor in recovery over the past decade. They may influence my participation and behaviour in a treatment plan that will ultimately affect the outcome.  If I don’t believe in something I am much less likely to do it.

How can we combat this? Well, in my opinion, the best tool we have is good quality information we can use to combat the beliefs that may hold people back. A key to start affecting beliefs, again, in my opinion, is not to challenge too firmly, but inform people using well-evidenced information. One of my favourite one-liners is “That’s what we used to think but we are learning new things all the time, the latest research suggests…”

Here are some small tidbits of information that we can use to start informing our patients and clients about the role of exercise in pain AND health, which of course ultimately affects pain too!

Remember that giving people information is really designed to change behaviour rather than just show how smart you are so monitoring what happens is pretty important.

1. Exercise Is One Of The Best Evidence-Based Interventions We Have For MSK Pain

This paper HERE from 2017 in PLOS one shows moderate to strong effectiveness of exercise as an intervention for many MSK issues. This is in contrast to the belief that things need to be zapped, needled or popped back into place.

My therapist only gave me some exercises. Yep. Because they followed the evidence!

2. Exercise Won’t Make Your Body Worse

So many people see the body as a bit of machinery. The more it works the more the parts need replacing. Is this true? Absolutely NOT. The body is an organic organism that adapts both positively and negatively to stimulus. The more active we are (within reason) the stronger we become. The less active, well…

A classic common belief is that our intervertebral discs wear out the more we use them. This classic study from Battie HERE (2009) looked at twins to determine the major contributors to disc degeneration. They suggest that the “commonly held view that disc degeneration is primarily a result of ageing and ‘wear and tear’ from mechanical insults and injuries, was not supported by this series of studies”.

This study HERE from 2017 found that if you have a rotator cuff tear, the tear getting worse did not appear to be simply related to activity levels. In fact, they suggest pain development is actually associated with LOWER activity levels. If I had a pound for every time it has been suggested to me that running damages the knees then I would be a rich man. A study of marathon runners HERE showed that they had LESS meniscal abnormalities than non-runners.

3. Exercise Might Actually Make The Discs In Your Back Healthier!

Two recent studies have shown a POSITIVE effect of activity on intervertebral discs. Firstly this study HERE from 2017 showed that MORE vigorous activity was associated with BETTER disc health on MRI. Secondly, in this paper from 2016 HERE. Runners were shown to have intervertebral discs that had increase hypertrophy compared to the non-athletic group. The authors suggest that running actually strengthens the discs, whether we can infer a causal relationship here is unclear but this goes against activity causing wear and tear which is a common belief.

4. Activity Is A Pain Killer

This study HERE showed that older adults who were MORE active also had better endogenous pain inhibitory mechanisms when their conditioned pain modulation (CPM) was tested. Simply put, this means the more active the better their natural pain-killing mechanisms were. Which of course is super cool.

5. Exercise Is An Anti Inflammatory

This study HERE showed that regular physical activity caused an increase in interleukin -10 which is an anti-inflammatory cytokine that can reduce nociceptor sensitisation.

Now the caveat here is this study was performed in an animal population but as we know that there are associations between inactivity and both acute and chronic pain in humans it is a linked that potentially needs to be better explored.

6. Lack Of Exercise Is Associated With Chronic Pain

This large study HERE looked at the relationship between recreational exercise and chronic pain. Both older and younger folk were studied and the researchers found that for both groups exercise participation was associated with reduced chronic pain. A relationship was also present for the frequency, duration and intensity of that exercise.

7. Lack Of Exercise As A Major Cause Of Chronic Diseases

This comprehensive paper HERE makes a case for a lack of exercise being a primary prevention against 35 chronic conditions suffered by us poor humans. This goes beyond what most of us involved in the musculoskeletal field would have to deal with but also shows the importance of exercise for systemic health too.

8. It’s Involved In Mental Health As Well

We are understanding more and more that the mind and the body cannot really be separated. Physical health and mental health are interlinked in the human being and guess what…..exercise plays a role in improving mental health too. This paper HERE explores the mechanisms that may relate to mental health and exercise.

This randomised control trial looked at aerobic exercise and a variety of measures of psychological health HERE. The authors found significant group differences that favoured the exercise group.

9. You Want To Live Longer Right?

Strength training in this paper HERE was found to have a significant association with decreased mortality in adults over 65. But only a minority of this age group actually meet the current guidelines.

10. Have A Healthier Heart

This prospective study of 15 years duration HERE found that physical activity was a predictor of cardiovascular disease.

Summing Up

There are a whole bunch of others studies that relate to these topics but I just picked a few. I think it demonstrates that physical activity and exercise have an effect on us on a number of different levels, from the heart to the head to pain as well.

  • Do it
  • Do it
  • Do it
  • Do it

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