(Originally publish in Spring 2019)
Current Evidence Does Not Support Heavy Backpacks Cause Back Pain in Children, But Something Else Does
Research in the last 20-plus years finds a poor association between posture and back pain among children and teens, yet they are told the exact opposite of what science says.
By Nick Ng
(Originally publish in Spring 2019)
You may have seen plenty of ads on social media that tout heavy backpacks as a major cause of back pain or neck pain among children and adolescents, which often is followed by a type of service to “fix” or “correct” their posture. However, parents and therapists must realize that numerous research in the past 20-plus years fail to find a strong and convincing causation between heavy backpacks, posture, and back pain among the youth population.
Independent Contractor or Employee? Common Mistakes in Massage Therapy Invite Government Scrutiny and Penalties
By Erin Jackson
(Originally published in Fall 2017)
“Our therapists are 1099 employees.”
“I’m an independent contractor, but without the independence.”
“My independent contractors have all signed a non-compete agreement.”
“They’re not employees because they choose their own hours.”
These statements misconstrue the distinction between employees and independent contractors. An employee cannot agree to be treated as an independent contractor, and employers can be harshly penalized for misclassifying their workers. (1,2) The overlapping and synonymous titles used for different types of workers further confuses this issue.
“Which designation is better?”
By Bryan Quesnelle
(originally published in Fall 2016 of Massage & Fitness Magazine)
Of course, not all research is designed rigorously. We’ve already discussed some tips for reading massage therapy research, including identifying strengths and potential red flags. One important distinction that seems to be missing in these conversations is the difference between outcomes studies, and mechanism(s) of action studies in manual therapy.
Outcome studies serve to measure the outcomes of a particular treatment protocol or comparing several treatment protocols, ideally against control groups and shams treatment groups. In other words, they are focusing exclusively on the observable results of the treatment(s) for patients experiencing a particular impairment or condition.
Mechanism of action studies focus more on whether a particular physiological response, which may plausibly cause or strongly influence the outcome, is observed during or after a treatment. Examples include the increased or decreased presence of a particular hormone in the bloodstream, or greater or lesser local blood volume in the anatomical area being treated. The idea is to see if a particular response exists, is reliably and measurably initiated or affected by the treatment, and could plausibly be responsible for the outcome.
The outcome of a treatment, and the proposed mechanism of action behind the outcome, are two completely distinct phenomena.
It’s entirely possible to be wrong about the proposed mechanism of action behind a treatment and still have positive patient outcomes. For example, a therapist might believe a treatment “removed toxins”, which are causing the patient’s symptoms. Many of their patients may report feeling better after a treatment, even if “toxins” weren’t plausibly involved at all. The positive outcome isn’t reliant on that specific mechanism of action being accurate – it just means the actual mechanism (or combination of mechanisms) is very likely something else. The outcomes of the treatment don’t validate the proposed mechanism of action for that treatment.
In a manual therapy setting, we can only observe outcomes. We can collect information on how our patients report feeling and moving after treatment. We don’t have the tools or the skills to measure mechanisms of action behind the treatment, since the vast majority aren’t directly observable on a macroscopic level without specialized equipment. We really only get half the picture.
The “Tooth Fairy Science” Argument
Dr. Harriett Hall, a retired M.D. and well-known skepticism and critical thinking advocate, coined the expression “Tooth Fairy Science” to describe doing research on a phenomenon before that phenomenon is shown to exist.
The argument goes: “You could measure how much money the Tooth Fairy leaves under the pillow, whether she leaves more cash for the first or last tooth, whether the payoff is greater if you leave the tooth in a plastic baggie versus wrapped in Kleenex. You can get all kinds of good data that is reproducible and statistically significant. Yes, you have learned something. But you haven’t learned what you think you’ve learned because you haven’t bothered to establish whether the Tooth Fairy really exists.”
This argument is a good metaphor of conflating outcomes with mechanisms of action. The money received is the observable outcome, and all the data being collected relates to that outcome. None of the data shows that the proposed mechanism of action, the tooth fairy, actually exists and is responsible for the outcome. We can only reliably gather data on the outcome, there’s nothing in the outcome alone that justifies a particular mechanism.
Many people (massage therapists included) tend to point to outcomes studies as evidence of that a particular mechanism of action is accurate. For instance, pointing to a study on Reiki outcomes as evidence that the “universal life energy” Reiki proposes must exist in some format. This is akin to pointing the money under the pillow and saying “so the tooth fairy must exist!”
This is especially prevalent when the actual mechanism of action is unknown, which is often the case in health and medicine. Sometimes we don’t know why a particular therapy had (or has) an effect, or even whether the therapy itself is responsible for the outcome. However, this unknown doesn’t make any implausible or unproven mechanism any more likely to be true, and so we shouldn’t assume them to be true. If we don’t know where the money comes from, that can’t be used as evidence the Tooth Fairy really exists insofar as science goes.
Limitation of the “Tooth Fairy” Metaphor
Hall’s “Tooth Fairy” metaphor is great at demonstrating the need for distinction between outcomes and mechanisms of action, insofar as research goes. However, in practice, the patient’s goal is arguably always the outcome, not the mechanism. They care about the money earned, not whether the Tooth Fairy exists, or however else the money got there.
This is why outcomes studies and measurements are still very important in manual therapy (and other forms of healthcare), even in the absence of a definite mechanism of action. If a particular therapy demonstrates positive outcomes (superior to sham, placebo and no-treatment) in research and with patients in a real-world setting, there is no reason it should be discontinued on that limitation alone.
A lack of evidence for a particular mechanism does change the way we should communicate with our patients about the therapy, though. We need to be honest with our patients. Not only is it the ethical thing to do, but informed consent requires that we provide accurate information about the therapy insofar as is possible. Sometimes, that means telling a patient that while we have had good outcomes with a particular treatment protocol (which is ideally backed up by research), that we aren’t sure why the outcomes occurred.
It’s OKAY to tell a patient that the mechanism of action behind a treatment is unknown or hasn’t been proven empirically. What’s NOT okay is telling a patient a particular mechanism of action is responsible for the outcome when that mechanism is unknown or not reliably proven to be empirically measurable.
We also have to factor in the lack of empirical evidence for a mechanism against the risks inherent to the treatment. For instance, if a particular therapy has a risk of injuring a patient or being a significant burden to them, financially or otherwise, the need for justification for applying that therapy is greater. If there are comparable outcomes using treatments which have a lesser risk of harm, and with better understood mechanisms of action, it is often more appropriate to apply those treatments instead. Sometimes that means recommending no treatment, or a free home care activity, or otherwise.
Why Studying Mechanism of Action Matters
It’s true that our patients care about outcomes more than mechanisms of action (in most cases). However, researching and understanding the most plausible mechanism of action (or combinations of mechanisms, there isn’t always just one) whenever possible is important for several reasons. The narrative we share with our patients should be as accurate as possible. If a mechanism of action is known and well- researched, it may be important to share the mechanism with the patient, especially if there are any risks associated with that mechanism.
Complicated health histories and current medications may play a role in the outcomes of a treatment. Understanding how the treatment works can help us predict how that treatment may interact with other forms of therapy the patient is undergoing, and whether cautions or contraindications are in effect. If we are basing our understanding on mechanisms which are implausible, we may alter treatments unnecessarily, or miss something that puts the client at risk.
If we understand the underlying mechanism(s) of a treatment, we can potentially apply those principles in other forms of therapy and home care to maximize the outcomes of those activities. Having a greater understanding of how our therapies work also helps us in dealing with other health care providers, insurance companies, and other stakeholders in massage therapy. It also helps us to create a larger body of valid research for our own practice, as well as lobbying efforts.
Don’t Conflate Outcomes and Mechanisms
Before sharing that next piece of research or making a claim about how a treatment works, think about whether the author (or you) are conflating the outcome of a treatment with the mechanism of action. If a piece of research does make a claim about how a therapy works, read through the paper in detail and see whether they can support that claim reliably, or if it is based on assumption.
And remember, it’s OKAY if we don’t know why a particular outcome happens!
Bryan Quesnelle leads a double life as a registered massage therapist and a web developer in Kitchener, Ontario. When he's not treating patients or developing products for ClinicWise, he is usually building websites and applications for other businesses and organizations. Bryan received his 3-year RMT training at Fleming College in Peterborough, Ontario. In his spare time, Bryan enjoys camping and nature walks, playing video games, and experimenting in the kitchen.
Further Reading: Outcome measures measure outcomes, not effects of intervention on PT Think Tank
By Nick Ng
This morning, I had a barrage of various blogs, infographics, and PubMed articles on my Facebook feed on various myths and outdated ideas about pain from Jarod Hall, Lars Avemarie, and Andres Cepeda. There was even a rant from Bodhi Haroldsson who asked why dogma in massage therapy education and culture still exist, (even among Canadian RMTs).
Bodhi, friends, you're not alone. It appears that this is prevalent throughout the world. However, there are a few who want to shake the foundations of an outdated, crumbling structure that make up for their healthcare system and education. With so much solid research behind pain, movement, and psychology of care, why aren’t they taught much in schools and continuing education? If I were to spend five to six figures on medical or manual therapy school, I want the best education, training, and guidance possible, and many patients in pain would agree.
So I asked three manual therapists from three different countries to share their expertise on the application of pain science with their practice and what they are doing to help improve their patients’ care and peer education.
By Nick Ng
Recently, I had a client who told me that not only his right shoulder felt “tight" and sometimes painful when he retracts it, he also “could not retract" as much as his left side could. Although I could not find any significant differences between both sides (he could almost pinch a ping-pong ball with his scapulae), he said that his right shoulder felt like it doesn't want to move back. Any attempt to retract further back elicits a numbing pain in his shoulder near the AC joint. He blamed his desk job is causing his tightness and pain where he used the mouse a lot.
Having ruled out injuries and pathologies, instead of telling him that his tightness and pain comes from "muscle knots" or one side of his pelvis is higher than the other or another biomechanical “fault,” I simply told him, “You seem fine for now and I’ll check in with you during the session. Afterwards, we’ll see how you feel. Cool?” He agreed and we proceeded to the session. I did not mention anything about how tight he was or say stuff that I would have said ten years ago when I believed posture and structural “abnormalities" have a direct causality to pain. He already came in to see me with physical and emotional discomfort that has been nagging him for many months. I don't need to drip kerosene to his fire.
By Nick Ng
Could a simple foot massage (or any massage on another body part) make your brain produce its own supply of oxytocin to help reduce the symptoms of autism spectrum disorder (ASD)? Some researchers think so.
A recent study from The Clinical Hospital of Chengdu Brain Science Institute in Chengu, China, explored non-invasive and non-pharmacological ways to increase a person’s endogenous production of oxytocin, a hormone that is known for building trust and bond between one or more individuals. What better way to do so than “old-fashioned," affective touch. (1)
Lead researchers Dr. Keith Kendrick and Dr. Weihua recruited 40 healthy, heterosexual male university students in their early twenties, who had at least two experiences with Chinese style foot massage (pressure only, no strokes). Previous research on massage and oxytocin concentration in the bloodstream or saliva among children, the researchers reviewed, did not explore its effects on autistic children or adults.
They hypothesized that hand massage would be more effective at releasing oxytocin than a machine massage, and massage itself increases the response in brain regions that process cognitive and reward effects of social touch of the bilateral orbitofrontal cortex (OFC) and superior temporal sulcus (STS) of the brain, but not in the somatosensory cortex (S1), which responds to to physical touch and its intensity. They also hypothesized that “basal and/or evoked [oxytocin] release and neural responses to hand massage would be positively associated with pleasure/reward ratings and negatively associated with autistic traits and dislike of social touch but not with other personality traits." (1)
By Nick Ng
When I met physiotherapist Rheysonn Cornillia, who practices in Cavite, Philippines, at the 2019 San Diego Pain Summit, I wasn’t too surprised to hear the problems he faces in his profession are the same as most of my manual therapy friends in Canada, US, Europe, Australia, and New Zealand. Given the gradual acceptance and understanding of the biopsychosocial framework and narrative of pain and health (instead of the biomedical/biomechanical narrative) around the world, I was curious if other countries are already changing their education curriculum and practice.
Having seen a few posts about the ISSPCON 2019 in India and ASEAPS Congress Malaysia 2019 recently, I contacted several friends from around the world who are making such small yet steady changes in their country.
Here are their stories.
By Nick Ng
It's still too early for me to say whether my communication skills at work has improved or not after a week-long boot camp at the 2019 San Diego Pain Summit. Nearly all clients I had so far this week had some sort of chronic pain that nagged them. However, I had to bite my tongue many times when my clients shared their stories with me about their pain and current life before the session.
I kept thinking about physiotherapist Tim Beames' patient's story that he presented at one of the Pain Summit's workshops last week regarding how we therapists tend to interject patients' stories and explanations with our biases. While my tongue didn't bleed from all that biting, it reminded me to listen and ask open-ended questions before I started the session.
There was something different about this year’s San Diego Pain Summit compared to previous Summits. It wasn't just because about half of the attendants were first-timers. It wasn’t because it was cold enough to make some Canadians feel like they never left home. Kinda like this guy on the right.
I think it is how the workshops were arranged. The first two workshops leaned more toward the “bio" side of the biopsychosocial framework of pain with physiotherapist Adam Meakins covering shoulder rehab, physiotherapist Erik Meira covering knee rehab, and Dr. Tim Beames covering the philosophical and biological aspects about pain.
The last two workshops leaned toward the “psychosocial" side with Ben Cormack's behavior in movement relating to the lower back and lower limbs and improv patient communication with Dr. Sandy Hilton, Mike Stewart, Keith Waldron, and Alison Sim.
Rajam Roose, the founder of this one-of-a-kind event, placed the workshops and the speakers of the main event like a role-playing game, laying out the setting, connecting the plots, and allowing the participants and the presenters to “play out” the act. For many therapists and other clinicians who are new to applied BPS framework of healthcare, they are like the level 1 to 5 fighter, wizard, or cleric in a Dungeons & Dragons game. And for many like myself, we fall somewhere between level 6 and 20.
By Nick Ng
A recent cross-sectional study from Duke Integrative Medicine in Durham, North Carolina, finds that massage therapy (Swedish) can alleviate pain among people with knee osteoarthritis, better than light touching or “usual care.” However, the benefits of massage therapy lessen after eight weeks, and by week 52, there was “no significant difference” among the groups.
Gender, Emotions, and Knee Stiffness Have Higher Predictors of Getting Running Injury Than Biomechanics, 2-Year Study Reveals
By Nick Ng
A recent study of 300 recreational runners, who were injury-free in the last six months, found several factors that are reliable factors in predicting who would be more likely to get injured. Researchers kept track of these runners for two years and found that that being female, having knee stiffness with excess weight of more than 80 kg, and having higher negative emotions are high predictors of sustaining at least one running injury. Contrary to what many physiotherapists, personal trainers, and coaches believe, most biomechanical and structural factors are not reliable factors.
By Nick Ng
“You don’t speak Dutch?” said the middle-age gentleman who sat in front of me at a bench inside a Starbucks in De Meern, Netherlands, while I was compiling the feature story for the Summer 2018 issue on my laptop.
I looked at him, mildly surprised that would say that to me, and smiled. “Sorry, I don’t. I’m just visiting.” I could’ve explained to him that I was visiting the Netherlands for a story in my publication, and I already speak two other languages besides English. I could’ve told him that I used Spanish to communicate with the young barista who spoke little English (his parents were from Spain who immigrated to the Netherlands). Well, I just let it go and continued my work while he mumbled something under his breath.
Interestingly, most Dutch I had met in my four-night stay in the Netherlands were also fluent in English, like many Norwegians and some Germans I had encountered during my travels in northern Europe last April. The amount of bilingualism and trilingualism (and sometimes even more!) among many Europeans surprised me a bit. And looking back at my last traveling adventure, I never expected that writing and publishing would take me to many places that I did not expect to go so soon.
With the increase of the awareness and application of the biopsychosocial framework (BPS) of pain and healthcare among manual therapists, I think the “social” piece does not get discussed much on social media, at least within my network. There are a few therapists I know who often include this factors in their discussions, reminding others that we are not just treating pain or structures.
Many of us—including myself—have experienced discrimination in various flavors. In public, we get stares from people because we’re dating someone of a different race, skin color, height, size, gender, etc. We might get rejected in a job application because of how we look and sound—or even just by reading our name. Some of us might even risk getting harassed more often in the streets. For many living in the United States, this is a regular struggle every single day, every breath.
How much does this affect their health and risk of developing chronic pain?
By Nick Ng
A few years ago, I recall seeing many of my friends and acquaintances in physiotherapy talk about how great “Explain Pain Supercharged” was in helping them and their patients understand how pain works. Although I have not yet read the whole book, I had read a few passages when I visited Dr. Sandy Hilton and Dr. Sarah Haag at their Chicago “Mecca” two years ago in November. I loved the way Professor Lorimer Moseley and Dr. David Butler describe and illustrate the concept of pain and its research, written in a way that most fifth graders would understand.
I thought this book was the Holy Grail to help my clients with acute and chronic pain get even better. Pain education. Much of the research said it works! However, a recent study published in JAMA Neurology seemed to challenge the idea that pain education is better than having no pain education. While much of the research in pain education in the past 20 years have demonstrated benefits to those with low back pain of various intensities, pain education “ has never been tested in a placebo-controlled trial. Any benefits observed in previous trials of patient education for acute low back pain could be explained by nonspecific effects of the clinical encounter or the characteristics of the usual care comparison,” the authors wrote.
That caught my attention. I brewed another pot of coffee and continued.
Core Muscle Activation Is Overactive Among Post-pregnant Women With Pelvic Pain Than Those Without Pain
By Nick Ng
For many years, some physiotherapists and other manual therapists have told their patients with pelvic pain to “strengthen their core muscles” to reduce and manage their pain and function. This idea comes from early studies of pelvic pain that the pain is mechanical in nature due to too much strain upon the ligaments in the lumbopelvic region. Co-contraction of the transverse abdominal muscle (TVA) and pelvic floor muscles compresses the region which may protect against strain and lowers the risk of pelvic pain.
However, pelvic pain—or pain itself—is much more complex than just mechanical issues.
By Nick Ng
Earlier this year, a German study found that “back pain patients and athletes did not show a different behavior to asymptomatic non-athletes.” (1) In other words, if you were to examine hundreds of people in a day by looking at their standing posture, you would not be able to accurately identify who has low back pain and who does not. This is because of the many variations that humans have, from standing posture to anatomical structures.
By Nick Ng
Should you get a massage before sprinting or any sport that requires bursts of speed? Probably not. A study that was published recently in Complementary Therapies in Clinical Practice found that massage therapy alone is no better than dynamic warm-ups or a sham ultrasound treatment to improve acceleration in sprinting. (1)
For the 12-week study, a team of of researchers, led by Dr. Ryan Moran from the University of Alabama, recruited 25 NCAA Division II athletes that included freshmen and upperclassmen with nearly a one-to-one male and female ratio. There were four interventions that were randomly assigned to each athlete: 1) massage only; 2) dynamic warm-up only; 3) massage with warm-up; 4) sham ultrasound. Each group of athletes are rotated in different intervention group in the next session after the first tests were completed.
By Nick Ng
Oslo. Europe. Across the Atlantic Ocean. Ask me what would I be doing in 2018 last summer, and I would not have predicted that I will be traveling in Europe for the first time in my life. Canada? Sure, it’s just a catapult vault away, but crossing the Atlantic Ocean seemed as unlikely as giving up my diet of tortillas and rice. The second annual PainCloud Convention in Oslo, Norway, seemed too good to “not go,” and last September, I made a strong commitment to crawl out of my southern California bubble.
In some ways, PainCloud is very similar to the San Diego Pain Summit. Presentation, followed by Q&A, break, repeat. But what I was more interested in was how much do most European physiotherapists and other clinicians understand pain, disability, and exercise compared to the U.S. and Canada, and how would they use that knowledge to their practice. Would their way of doing things be similar to what my American and Canadian manual therapy friends are doing? Would language and culture be significant influences in how they apply their knowledge and communicate with their patients? Well, let’ see what they have to say.
By Nick Ng
Foam rolling has been known to create known to help increase range of motion, even for a short time, but little is known exactly how long does this short-term change lasts. Researchers from Coastal Carolina University in South Carolina, USA, recruited 29 young subjects (21 women, 8 men) with various experiences with exercise and foam rolling, from recreational athletes to sedentary ones with no experience with foam rolling. (1)
The subjects warmed up by pedaling on a stationary bike for five minutes and performed a vertical jump test and a sit-and-reach test as a baseline measurement. Then they were randomly assigned to a foam rolling group, dynamic stretching group, combo group (foam rolling + stretching), and a control group (no foam rolling) where they rested for more than 20 minutes before retesting. Subjects in the foam rolling group rolled their glutes, quadriceps, hamstrings, and calves for 3 sets for 30 seconds with a 30 second break between sets.
By Nick Ng
Many studies in the more than 20 years have shown that spinal pathologies, certain types of posture and pelvic tilts, and similar structural “problems” do not always correlate or associate with pain, disability, and daily function. Even among elite Olympic athletes, MRI scans, and other types of scans found similar trends.
A recent American study, led by Dr. Michael Wasserman, who is a resident at the Boston Medical Center, found that 52 out of the sample of 100 athletes who competed in the 2016 Rio de Janeiro Olympic Games had various types of spinal pathologies. These athletes had their spine scanned during the event. Among this sample, athletes who were in “athletics”—track and field, for example—had the highest number of positive findings in the scan, with 15 out of 31 athletes (48%). Judo was the next highest with 5 out of 8 athletes (63%), followed by diving and weightlifting—both with 4 out of 6 positive findings (67%).
But why do these sports have such high number of positive findings?
By Nick Ng
How well patients with chronic low back pain respond to physiotherapy treatment can depend on what and how the physiotherapist explains pain to them. Researchers from the International Spine and Pain Institute in Story City, Iowa—led by Dr. Adriaan Louw—found that their subjects seem to respond better to a single leg raise test after they were given a neurological explanation of their pain than the classical biomechanical one.
Sixty-two patients were randomly assigned to the Neuro explanation group or Biomechanical group, and they performed one survey that measured their perception of low back pain and leg pain (Numeric Pain Rating Scale) and two physical tests—standing lumbar flexion and single leg raise (SLR). These were taken prior to and immediately after the manual therapy intervention (central posterior–anterior mobilization). During the treatment, the physiotherapists gave each patient a neuro or bio explanation, which are summarized in the following: