Sensory Approach to Manual Therapy
Sensory Approach to Manual Therapy
Optimizing Pain Care Through Placebo Integration
Unlock the potential of placebo effects in clinical care with insights from our special guest, Guillaume Leonard, a leading physiotherapist and researcher. This episode promises a deep dive into how integrating placebos, especially within manual therapy and pain management, can enhance treatment outcomes when combined with active components. Guillaume discusses the ethical conundrums and the balancing act of setting realistic expectations without fostering false hopes, all while navigating the intricate landscape of pain diagnosis and treatment.
Explore the critical distinction between diagnosis and prognosis through compelling real-world cases. Guillaume and I dissect the psychological ramifications of diagnoses like fibromyalgia, emphasizing careful communication to prevent nocebo effects. We also highlight the transformative power of effective patient education and the nuanced role of language in shaping patient perceptions and recovery trajectories.
Discover the comparative benefits of massage therapy and transcutaneous electrical nerve stimulation (TENS) for chronic low back pain, backed by evidence from a guideline study by the Ottawa panel. We tackle the challenges of translating research into practical clinical applications and underscore the importance of maintaining hope and positive conditioning. This episode is a must-listen for anyone interested in merging evidence-based medicine with patient-centered care to optimize pain relief and improve quality of life.
Hello everybody and welcome to another podcast of the Sensory Approach to Manual Therapy. I'm here today with Guillaume Leonard, who is a physiotherapist here in Sherbrooke and an associate professor at the University of Sherbrooke. He's also a researcher for the aging population at the CHUS right here in town and also the founder or organizer of the Neuro Show.
Speaker 2:I actually took part in the Neuro Show, but I did not. Yeah, absolutely, and maybe I can. I can say here I'm at the Research Center on Aging, just to, okay, make things more and more precise. So I'm full professor at the rehab school and a researcher at the Research Centre on Aging.
Speaker 1:That's fantastic. So I want to talk to you today because we met a few times and those of my listeners will notice that I just put a podcast and it's on placebos and the times I met with Selj about that. You were there as well, and we talked about a lot of the same stuff and I found it was really interesting. And now SELJ is a researcher only, and so he had some really interesting insights from a scientific point of view from you know, the possibilities seem limitless, right? Science is about not should we it's, can we right? So there's there's this whole conversation around that. But you're a clinician as well and you still have clinic hours.
Speaker 2:And so.
Speaker 1:I really wanted to get since you work with Selj quite a bit and you know his passion around placebos and pain and you specialize in pain as well I really wanted to get a good understanding of how you see placebos being integrated into clinical care as an intervention and also if it's ethically appropriate for us to be bringing it into an intervention, because it's kind of this struggle that I am having and then the more I look into placebos in research, the more I'm seeing the rest of the world is having a similar struggle of great potential, but ethically where do we fall? So I just wanted to get your feedback on that.
Speaker 2:Yeah, well, it's interesting you mentioned that, fred, because you know what. I had the same struggle several years ago and I can say I still have sometimes a bit of that struggle again. It's maybe the answer, the quick answer to your two questions are yes. So we we need to use that. Uh, certainly, in clinic we have to potentiate, actually, um, placebo effects are a nice way to potentiate the effect of our treatments. We have to use placebo effects.
Speaker 2:From a medical point of view, I think the problem is when all the intervention is solely based on placebo effects. This is problematic. But if we have a true active effect let's say we were able to reduce pain by 25% with our active part of the treatment and we can add to that a 20 percent more pain reduction with placebo effects I mean it comes down to 45 pain reduction instead of 25. So certainly we have to build on that. We have to use placebo effects. But again, the problem is if our intervention is is, uh, if our intervention is I was about to say bullshit, there's nothing working on it that's problematic. But if we have an active part of our intervention and we can play with the beliefs and the expectations of our patients without maybe another problem is to create unrealistic expectations. That's a problem for several reasons. We can perhaps discuss that a bit later. But if we can build realistic expectations and we can increase the efficacy of our interventions via the placebo effect, we certainly should use that.
Speaker 1:So it brings me to. I mean, there's a few things there that we need to unpack, but I think one of the first ones that's really important that you bring up that's something that I've been, you know, I've just been traveling in North Carolina and New Hampshire, I'm going to Colorado next week and in Calgary, and a bunch of the stuff that I'm teaching right now is about when a client comes to us in discomfort and we may not have mentioned it in the intro, but you specialize quite a bit in pain and pain research as well and when clients come to us in discomfort, we might, as clinicians, come up with a list of probabilities. We look at our treatment protocols and we go okay, in all likelihood they come in representing these symptoms. They say it's sharp and they're still bruising, but in our head we can go ahead and say, okay, it's probably still acute. Versus they go it's dull, achy and warm. We can probably move towards subacute, chronic phases.
Speaker 1:So they lift off their discomforts, they lift off their problems, how it's affecting their lives, and as clinicians we create a list of probabilities and causes and then we go ahead and said, okay, well, I think it's X, y, z, let's say it's your herniated disc, it's your broken bone, it's your you know your shin splints, it's your. Whatever your whiplash, it's your tension headaches. And because we give it a title, we then look at the pathology of it. And most of these pathologies have very well documented structural, biomechanical components to it, like, let's say, whiplash. Well, we know, in whiplash the head moves forward, the ligaments are stretched, the ligament causes instability, the muscles get fatigued, the muscles are fatigued, they cause tension headaches. You know on and on and on.
Speaker 1:And so when it comes to treatment, often it gets reduced into this theory of because the pathology says your ligaments are weak, that's why you have pain. But we know from pain sciences that their ligaments are weak, which takes up more brain space, because they don't feel like they have a good proprioceptive understanding of reality and their movement within reality. Therefore their vigilance is increased, so they have less capacity to handle change. So now, when they have pain, is it because their ligaments are weak or is it because their threshold, their window of tolerance, is being surpassed?
Speaker 1:And obviously it's a mixture of many components, it's multidimensional, but yet somehow, when it comes to treatment, we become reductionist and we go it's only your ligament. We don't sit there and say it's not just your ligament, it's also the fact that you're stressed today and the fact that you didn't sleep well and the fact that you feel imbalanced in the world around you and gravity is placing forces on your head and we try to isolate it to one thing that can fix you and that, for me, is where I think placebos has so much potential is that we don't know what. We don't know which treatment component is the one that makes our clients feel better. We know one of them does, we just don't know which.
Speaker 2:And I mean just the effect of care. Just being taken in charge makes a big difference and we actually just published an article on this with two of my students and one colleague showing that following people, they don't even have an intervention. We're having questionnaires with them, mri, and you know what they're improving just following this, no intervention whatsoever, just paying attention to them.
Speaker 2:Exactly exactly. But you're right, troy, and you know what. What I'd like to say, maybe one of the first thing, is there's a very poor relationship between the structural damages and the pain that people expect, and we know that, but we tend to forget that.
Speaker 2:Absolutely, and there's a lot of research on that, so we tend to forget it, or maybe we have that in mind, but what do we tend to do when we have patients in front of us? Maybe we know that stress and anxiety and all those things play a role sleep and all those things. Maybe we say a few words on this to our patients, but what do we do for the rest of our interventions?
Speaker 1:You just touch their physical body, thinking Exactly yeah.
Speaker 2:And so the message that is sent to the patient is well, I mean anxiety, interest. You know I'm going to put a lot of attention to your mechanical so how things move, and so what the patient is thinking is that's the main thing and that's why I'm having. I'm having pain, so I had a.
Speaker 1:Yeah, I had a client two weeks ago who came in for epicondylitis and I did about 25 minutes of work and then he said, are you not going to do any more work?
Speaker 1:I said no, no, we're going to keep doing work, but we're done with the physical treatment. Now it's about education and exercise and he was a little disappointed until he felt better. But in the beginning, you know, being a massage therapist, they assume it's a dollar for a minute kind of concept, even though that I've moved away from that a long time ago and it was just one of those things where you could see it took him a moment and he had already seen before. He knew I'm an educator, he knew I like talking about pain science and about the effects, and it just took him a minute to sit there and say, okay, this session isn't about me feeling good, relaxation wise and getting touched, or is it about me treating my discomfort? And if it's about treating my discomfort, I need to go down that pathway and I need to trust that this therapist, who I have confidence in, is going to do good work and it was. It was a big shift in their mind to move away from.
Speaker 2:That's awesome, that's, and I'm curious how did it went for the? How did it?
Speaker 1:went great, like I mean, I've seen him on and off. I saw him last year for a different problem and then this year for this one, and it's already improving. And you know, I don't, I don't think I see him for another three weeks because his pain is almost completely diminished. Acupuncture, massage, chiropractic, osteo, whatever whatever title you have as a manual therapy, touch therapist, touch based therapist it's still like you said. You know, we we talk about the effects of pain, education and exercise, and yet we spend the majority of the time touching them, and that's a hard thing to move away from, especially when we, when we see our services based on money for time, when clients still see that as the key component.
Speaker 2:Absolutely, I totally agree with that. And maybe one other thing I could add to that is when we evaluate our clients and our patients, what I tend to do now is to reassure them. So this is what I've tested. Right now, let's say I've done a compression and traction to look at the intervertebral discs and so the test is negative, so we don't see any problems with your disc. Just to mention that to the patient, it's probably very helpful, because what we tend to do is do all these tests and maybe say, not explaining exactly what we're testing and what are the results and for the patients that might be stressful and even just the names we're giving to the pain and all the syndromes.
Speaker 2:I remember when I was a PT student. At that time I was studying in Ottawa and one of my friends actually was my co-loc, my roommate, yeah, exactly. So his aunt actually came to the apartment and she was actually in tears. She was completely lost and stressed and anxious and she was actually coming back from a visit with a clinician and stressed and anxious, and she was actually coming back from a visit with a clinician and she received a diagnosis like I think it was a, say the home, facetar, so facetar syndrome or something like that. And I mean for us it means nothing, this is really not serious, but for her to receive that type of diagnostic syndrome it's serious when you have a syndrome For her to receive that type of diagnostic syndrome.
Speaker 1:It's serious and when you have a syndrome it's an interesting conflict that exists between, I think, the nature of a diagnosis and the nature of a treatment, Because it's important to have diagnosis. Like I had a lady come in just her first visit ever was yesterday. And she comes in, she tells me about her health history. She taken a misstep. The moment she misstepped she had shooting pain down both sides of her legs. You know, traditional we would consider sciatic type from a compressed disc or herniation, something like that. And she had. She hadn't had an x ray, she hadn't had an MRI and it'd been over six months and she'd seen physios, massage therapists and she'd even seen her doctor. All of them had just brushed it up saying you'll be fine, which is interesting to start with.
Speaker 1:I'm not thinking those are the best clinicians in the moment. Then I asked her. I said okay, well, when you have your sharp pain in your low back, do you lose strength in your legs and do you lose control of your bladder? And she said yes to both and I'm like okay, well, we're going to treat you, but the moment treatment's over you have to go to the doctor Because a loss of bladder and a loss of leg strength. Those are much more alarming signs of potentially permanent nerve damage. You know we don't want a nerve to be severed, kind of thing. So she takes it seriously.
Speaker 1:She was supposed to go today, don't know, but during the treatment I remember talking to her and saying this diagnosis is important. But the reason it's important is not to understand what you have, it's to understand what you don't have. I want to know that what you have is not dangerous. I actually don't care what you have. It's good to know if you have a herniation, it's good to know if you've lost disc space, but that's not what's good to know. If you have a herniation, it's good to know if you've lost disc space.
Speaker 2:But that's not what's valuable to me. What's valuable to me is to know that it's safe to treat. My intervention will be the same, exactly.
Speaker 1:Exactly. You're still going to be doing touch therapy, exercise therapy, you're still going to have to do movement, all these other things. And I think that's one of the hardest things that it comes to when it comes to the doctors is that all they're looking for is the diagnosis. But even though the diagnosis is good to have, it doesn't actually affect my treatment too much.
Speaker 2:Totally agree. I totally agree with you and I think and people also. I actually really like the way you're presenting things to your patients and I would say people also like to know what they have. So if we don't say, if we don't give a clinical impression or diagnosis, they'll probably be disappointed. So I think we have to communicate this type of information, but it's the how we do it.
Speaker 1:I'm lucky I'm not allowed giving a diagnosis.
Speaker 2:I'm a massage therapist. I'm not allowed giving a diagnosis.
Speaker 1:So I get to sit there and say I don't know what it is, even if I'm pretty confident I know what it is.
Speaker 2:But just, I think people need. So it's not I'm not suggesting we're moving away from diagnosis. We need to tell people what we think it is and people, that's it. They need to know what's happening. It's a need that they have, but it's how we communicate the information to them. I will give you another example. It's another clinical example. I had a patient which I've treated, for I was treating that lady for two, three sessions and things were improving, and she went and she saw her doctor and she received a diagnostic diagnosis of fibromyalgia. Exactly things went downhill, exactly, exactly so. So then I had to reassure her and but on her side, receiving this diagnosis had a very negative impact on her clinical evolution.
Speaker 1:So this plays into part of what I want to talk about today. So let's keep down the track of diagnosis versus prognosis. As clients are receiving diagnosis, how much of that regression that we see, because it's quite common, you know, clients are getting better. They receive a diagnosis and we see it.
Speaker 1:I think I remember reading a paper once where it showed that up to 30% of our symptoms can be improved with a healthy prognosis and 30% of our symptoms can be regressed with a diagnosis and that when they get the diagnosis it's almost like a sense of guilt or victimization or reduction of guilt, saying it's not, not my fault, it's happened to me, I have no control over my symptoms anymore. Therefore it's almost like the body just goes into shutdown of protective mechanisms and we just start having more symptoms. But I wonder how much that might be something along the lines of a nocebo because of the way it's presented in the wording, like how catastrophized is the sense, is the diagnostic, and I'm wondering how much of it is just in their head. If placebo can have a positive effect, we know nocebo can have a negative effect and I wonder how much diagnostic might lead to that sensation.
Speaker 2:I think I agree with you again, troy, and I think it is a nocebo or nocebo-like effects. Here we're talking about that type of phenomenon. I'll give you another example. It's a case study that we actually published a few years ago.
Speaker 2:I was seeing this young lady. She had been receiving physio treatment for quite a while actually. She was having pain in her back, thoracic spine and everything, and when I received her and evaluated her, she told me that her physio was saying that she had three displaced vertebrae in her back. I evaluated her and I said oh, you know what? There's three vertebrae that are not moving quite well, but it's not that they're not displaced. I mobilized them a bit and I said you know what? They're moving quite well, but it's not that they're not displaced. I mobilized them a bit and I said you know what? They're moving quite well right now. You can be reassured. Her pain went from I think it was a seven on 10 to zero on 10 in two, three sessions and I never saw her again afterwards and I mean she was back to work and the pain disappeared.
Speaker 2:So often we tend to think that pain catastrophizing and all those things. It's inherent characteristics of the patients and they come to us and they're poor patients. Poor them, they fear, they don't like to move and they catastrophize and all those things and the catastrophizing and all those things. I think that as clinicians often we tend to increase that type of fear, we tend to increase pain catastrophizing just by the words we're saying. I mean the physio probably wanted to make things simple by saying that she had predisplaced vertebra. I'm sure the vertebra were not displaced, but hearing this type of of words from your physio, I mean that's, that's yeah, exactly, it's.
Speaker 1:Pretty common terminology exactly and if you don't know anything about the research around, are we actually able to displace vertebrae? I mean, I think I remember reading a study once where it showed they can move up to five millimeters in every translated direction before you even have any sign of structural changes, let alone if they move further than that. You're actually starting to sever the spinal cord. So like how far can we displace our vertebrae, kind of thing.
Speaker 2:I totally agree with you and I think that probably the physio didn't have that in mind but just wanted to have a simple way of presenting things. But he clearly had a negative impact on the patient by saying that.
Speaker 1:So this moves into the placebo concept. Then, if a nocebo is as affected by diagnostic stuff, how much of you know? Like I said, I remember reading a study I have in one of my classes I can't remember the name of the study, but it's 30% and it was a study in bedside, uh, for doctors, and it was on cancer patients. And it had one where, uh, the same group of same same subjects. One was the control group they were given traditional care for cancer and the other the experimental group. What they were given was a prognosis as opposed to just their diagnostics, and that was it. It was a full prognosis on how soon they could expect to start feeling better and they found that that group had a 30% chance of recovery over the control group.
Speaker 1:And it makes me wonder how and why our language in, not only in medicine, because that's a whole other animal, but even just in complementary alternative medicine, physio, massage, chiro, all these things, any touch-based therapy. Where's the disconnect between the language for patient centered care and the integration of the evidence? You know, somebody come in and say I have three displaced discs. Well, the research shows us that you don't. Well, you know, if you did, you wouldn't be walking into my clinic and yet I don't want to necessarily take the power away from not only other clinicians but the client and say, well, what you think is wrong, because that's demoralizing to the client. So where's the disconnect? As a teacher, as a professor who teaches physio students? Where's the disconnect in how they're going to school, they're learning stuff, and yet when I encounter them in the world, the language is not one of healthy prognosis and education. It's all structural, biomechanical, injury-based language.
Speaker 2:I would tend to say it's easier to blame somebody else, so I will blame somebody else. I think the problem is from the professor at the university. Just kidding here.
Speaker 2:But I think that there's a lot of things just for continuing education and it comes back to what you do with your patient. I mean people, physiotherapists I'll talk for physios because that's what I know more they don't go and have a lot of continuing education on how to talk to your patient, how to your patients, how to present a prognosis, how to reassure your patients, the pain education they do. What's the continuing education on manual therapy and all those things? So again, we're focusing that people are putting a lot of energy on that mechanical aspects of things, putting a lot of energy on that mechanical aspects of things, and I think they're forgetting about all these important other things, about how you speak, how you talk with your patients.
Speaker 1:So, yeah, I would agree I mean my class. That's all we talk about is we talk about how to interact with clients and we do a lot of hands-on stuff as well, because it's relates. But it's like when you do the hands-on stuff, we talk about what we're doing. Keeping clients conscious. Is that unconscious, not as big of a deal in physio, but in massage it's a big deal, especially if they're there for pain management and things like that. So this leads me to stories in your clinical care and manners in which you have found over time yourself changing your interaction with clients and patients so that they do walk away educated, because I've changed my practice over the course of the last 15 years where, like I'll do a good 30 minute intake and evaluation and education on window of tolerance and allostasis, which I to all of my clients learn about the hpa axis and the amygdala.
Speaker 1:Every one of them learns about stressors and stimulus, good and bad, and how they can all instigate pain. All my clients learn about evolution of pain and how it's a positive thing in our life. Even if we don't like it, pain is a very healthy mechanism in our behavior. And then we get into hands-on care, but in a system where you're more reimbursed by insurance companies, there's more protocols set forth for physiotherapy than massage therapy, which is largely unregulated, mainly in Quebec but in quite a few places in the world. How have you changed your practice to bring in some of those components where the clients are walking away with more education, not just go do these exercises, and here's your problem.
Speaker 2:I think one example is what I was saying before when you do your testing and evaluation, explain what you're doing and put things into perspectives, reassure your patient. I would tend to say also that people, they want to hear about all those things. You're saying it right and uh. So you can. And I mean you can do all this. Maybe not as a I don't know how you, uh, you massage therapist really work, maybe it's more relaxing environment. But from our part, I mean you can talk to your patient and explain all these things while you do your manual procedure, when you do your manual therapy thing. So you can talk to your patient and explain all these things while you do your manual procedure, when you do your manual therapy thing. So you can talk with your patient and explain all these things and people. It makes sense to them.
Speaker 2:Maybe one barrier to that is to say you know, I'm not a stress expert, I'm not an expert in sleep and all those things and I don't know how really to work on that.
Speaker 2:But what I've learned from my experience is when you talk about this with your patient, it actually makes a lot of sense. Let's say, they're coming back after a week and they're saying my pain has increased. Pain has increased and you start talking with them. It's a stressful period right now with my sister or with my daughter or whatever it makes sense to them, and now they're seeing that their increase in pain is not because their vertebrae has moved or because something bad has occurred from a mechanical point of view, but it's because of stress and we can help them work with that. You know there's relaxation techniques we can use, having a calm environment and so talking to our patients about that, I think many physiotherapists and other clinicians feel they don't have the tool to really tackle this. It's not true, in fact, just for the individual, the patient knowing okay, now I have more pain, but it's probably because I'm stressed, so I'll try to find a way to decrease that stress right now.
Speaker 1:It's a very helpful way to to see things it's interesting because in physio you guys have dosage dosage in rehabilitation that accommodates for a lot of these concepts, right, like if you're gonna get back to running after plantar fasciitis, you don't run 10 minutes straight, you run what? Two minutes. Then you take a 30 second walk, two minutes, you know, and it increases over time. And, and the biggest like guideline for those capabilities are sharp pain, grimace, types of discomfort and symptoms. And so it's interesting because when it comes to the exercise component, there are a lot of clinicians who already have the tool set. They just haven't bridged that understanding of the reason. Those are your limits is because of pain manifestation, window of tolerance, and those can be instigated by any component.
Speaker 1:Which gets me to that original thing of if pain is multidimensional, we don't know what we do in the clinic. Treatment has to be multidimensional, it can't just be hands-on, that isn't. You know. Treatment has to be multi-dimensional, it can't just be hands-on and stuff like that. It has to be exercised, it's. It's been this long struggling concept that I've had in my mind, which is that I'm not a fan of the idea of manual therapy being broken down into so many subsets of type of care, from chiro to physio, to massage, to acu, like it's in reality. If you're a good clinician, you're integrating components of almost every one of these different types of clinician care. You're you're, you're being there with the individual in front of you, and things like that, and that's that's where the value lies yeah, and you know what that's right.
Speaker 2:that makes it makes me think of, uh of. I remember going to a congress of the IASP International Association for the Study of Pain Congress and they were actually comparing I think it was a massage, acupuncture and manual therapy and in the long term, all these three have the same effect on pain. But when you talk to manual therapists or to acupuncture or to massage therapists, they're convinced that they're really having a larger effect and a better effect than all these others. And I think the reason is that all these extra things you were mentioning the relationship with your patient, explaining education, education that's not really studied and and and it's not specific to a single discipline of care.
Speaker 1:Exactly exactly. Good doctors, good doctors, are doing that, bad doctors aren't. You know exactly?
Speaker 2:exactly so. So I'm not saying that massage therapy and acupuncture and manual therapy and physio is not working they are working. But I mean, I think they have similar effects and when we are depending on the patients and things, but one one part we are neglecting is that this extra stuff education, uh, relationship with your, your patient, and and by doing this you can really improve and and increase the effect of your intervention at the beginning of the podcast when you said your students and you just recently released that article on care, you know, on an intervention without intervention, essentially right, just paying attention to someone.
Speaker 1:It reminded me of a post I saw today from Ben Cormack, who is part of this group called the Better Clinician Project and very smart man, does some really good stuff and I like a lot of his material. But he put up a question today that was really hard to answer and he said if you had to choose between if, if manual therapy and exercise therapy have the same results, the if, if they have the same results, which would? And you could only choose one for life, which would it be? You know, it's like one of those thought of well, one is taking care of myself and one is someone else taking care of me. You know, we know that they're both necessary, but it like that's where I feel manual therapy has such an interesting place in health care is that someone's caring for me. But that can't be your only solution and that's where exercise therapy comes in is that you're taking care of yourself and you know everybody gets tired of taking care of themselves. So manual therapy helps us and everybody hates it when we don't have any strength.
Speaker 2:so there's that little balance and I mean maybe building on that right and coming back to one of the my paper I published it was a few years ago, but you were saying about the guidelines on massage therapy. The massage therapy is that there's a huge uh effects of massage, just decreasing pain and let's say, in the short term, if we can decrease pain in the short term for people and with that they're able to start moving again, doing their exercise again, I mean. So it's not one against the other, it's how we can.
Speaker 1:Yeah, and I actually wanted to ask you about so that you brought it up. That's a good idea. Um, because this is primarily a massage therapy podcast, even though I have a lot of other disciplines who listen to it. Um, I saw that that was a paper that you had done for the Ottawa panel and it was on the effectiveness of massage therapy for chronic low back pain. Correct, absolutely, and was that?
Speaker 1:So I didn't have a chance to look too far into the study and I plan on it because I just I just found it, you know, earlier this week and I've had a busy week, but can you tell us a little bit about that study, and not only how it was done, but what was the goal and from it, from the results that you had, has it? Most studies that are done like that their primary goal is legislative right, like if you can show that it's effective, insurance companies start paying for massage therapy to be included, government agencies start recognizing it as more of a necessity. Isn't a primary service, things like that. So when the study was done, was that part of the goal and how did you guys go about breaking into that study a little more?
Speaker 2:Yeah, it was actually a guideline, so it's not a single study. We actually got to review the evidence on massage therapy, so one was on low back pain and the other was on neck pain, but basically the conclusions were the same. So massage therapy is effective, it's working, and it's mainly effective, I would say, or what we tend to see a lot is this short-term effect on pain. So it's very useful for people to reduce pain. We have the same problem.
Speaker 2:I'm working a lot on neurostimulation techniques, let's say TANS, or transcutaneous electrical nerve stimulations, for just to name one. I don't know if you're familiar with that type of intervention. It's actually electrical stimulation, so it's skin electrodes that we apply on over peripheral nerves, so it's going over the gate control theory. So it's actually working, a bit like massage is working, so we're stimulating the epiphyterins just to block pain, based on the gate control theory principles. So for a long time there were actually a lot of people saying, ah, it's not really working, tens is not really working, blah, blah, blah.
Speaker 2:But what we tended to do in clinical practice but also in research, is to give transcutaneously critical TENS sessions to patients. We continuously attend the sessions to patients, let's say, for three or four sessions a week times during three weeks and afterwards we stop the protocol and a few days after we look at their pain levels. And one month later or three months later we're looking at their pain levels and we're comparing those who have received the real intervention from those who got the placebo intervention. And on the long term it's not that convincing that we're seeing really a big effect. But when we look at the short-term effect of transcutaneous electrical nerve stimulation I mean they're huge. Electrical nerve stimulation, I mean they're huge. I mean when we measure this in our lab we're seeing a 50% decrease in pain To have that kind of effect.
Speaker 1:We would need to give very high doses of opioids. How long is that effect persisting for?
Speaker 2:That's the thing, and so when we use TENS, the main effect is when TENS is working, and it tends to continue a few hours or a few days if we're lucky afterwards, but the big effect is when TENS is working. So what we tend to do now so let's say, on a practical way, how should we conduct research on TENS is to measure the effect of TENS when TENS is working. Would we do the same thing for opioids or any other medication giving people the medication for three, four weeks, stopping the medication and a few days or a few weeks after looking if there's a difference? No, we're comparing the groups. We're measuring the effect on pain when people are taking the medication. So it's the same thing with TENS. We should be measuring its effect when TENS is working.
Speaker 1:That's when TENS is happening. It's one of those really interesting things in research. I just created a class that I'm teaching at the Calgary Canadian Massage Conference in June called Integrating Evidence-Based Medicine and Patient-Centered Care, and it's one of those things that's always been really interesting in research in that it asks really good questions that sometimes have nothing to do with our clients. And an example I just had I just put up a blog post on this there was a research paper that was just in the last pain magazine from the IASP and it was on the uh, the emotions the effect of emotions on pain. But in the study they were inducing pain through uh, the cold method, the, the dad pressure method, they had a few different methods, electric, things like that and the thing that was interesting was, you know they saw that pain has a significant effect, especially in the short term, compared to the control groups.
Speaker 1:But when you read the methodology, no subject inside the study came in with chronic pain or acute pain. Everybody had to be pain free so they could induce pain. So you know it's in a controlled environment and for me I have to wonder like that's a great study and it's cool and it was a meta analysis, so it was a really well, I mean they really evaluated. I think there were a total of 71 studies that were considered high quality and 70 that were moderate quality and really good meta-analysis. But in the end it was also like they excluded every paper that had anything to do buddy with with any symptom of discomfort and I wonder at the effects of that. Me that would be far more important to understand as a clinician how effective it is for someone literally walking in with discomfort and that's the same thing that you're saying with the TENS, like on the research around that like doesn't it only just make, but that's, I guess that's the approach from a clinician.
Speaker 2:You know that's someone who is actually still treating clients, who is actually still treating clients and I think sometimes we for a long time, coming back to TENS we imagined ourselves that TENS was about to cure low back pain. Tens does not cure low back pain. It decreases low back pain. It decreases pain and with that, using that, perhaps the individual can start moving easier, they feel safe. Yeah, Exactly, Do his exercise again on a more regular basis, and all those things. So that's what we have to keep in mind. And so I think massage therapy there's people saying, ah, that's not really worth it. That's the kind of wording discourse I sometimes have. It's only a short-term effect.
Speaker 1:There's a very famous guy on Instagram, Adam Meekin, who talks about how he hates manual therapy.
Speaker 2:Yeah, and I don't agree with them because I mean, if you're relieving pain, just even in the short term for people and they're able to, because of that, start walking again, do their exercise again, they're reassured. They say, oh no, my pain. I have a certain control over my pain. When it's too bad, I can go and see Troy and he can reduce my pain. I can use the TENS machine and I can reduce my pain. That's important for people with chronic pain.
Speaker 1:I think the hardest part is what we see a lot in manual therapy, especially in massage, but I think in other disciplines as well. What we see is one if your clients get better, you're going to be very poor, right, like you're going to eventually run out of clients, right? So there's this marketing component of you have to come back in and see me, and that's a whole ethical conversation that the communities have to have within themselves to say stop doing that because it's not very ethical. It's like if they're not feeling pain, if they want to come in for feel good sessions, there's nothing wrong with that they know what they're coming in for, clear expectations.
Speaker 1:But I think there's a big thing where one, there's the I need repetitive clients and two and not to call therapists callous, but it is definitely a component, it's their livelihood. And then I think there's another component of which is therapists want to feel important and so if they can do something that's valuable, they don't want to then say, or they don't like, if you finally feel good, they don't want you to get hurt, oh, go, exercise. Well, most people don't know how to exercise, so they're going to go and run. If they used to run five kilometers in 30 minutes, they're going to go run five kilometers in 30 minutes the day they feel better from their plantar fasciitis and that might not be the right thing to do, right? So it's about educating them from injury recovery to performance recovery and that phase in between, I think, where people have a hard time.
Speaker 2:And that's important to do. As a physio, as a massage therapist, that's part of our role.
Speaker 1:And I think that's probably one of the biggest roles that is neglected. I just started two years ago offering personal trainer sessions to my clients and it's specifically around their injuries. So if they have low back pain and I've been working on them and we've helped get them away from their low back pain, then the personal trainer program exercises are specifically for that client. They're not a cookie cutter thing or their fasciitis or their whiplash, whatever it is, but it's not a personal trainer like a weight loss program performance. It's before you go back to the gym and potentially get too excited that you're feeling good and hurt yourself. I want you to feel safe, even lifting that 35 pound weight over your head and things like that, and then I don't do the program anymore. It's, but it's to get them and I think a lot of people forget that is the recovery phase after your discharge is still valuable.
Speaker 2:And I had that. That's something I often say to my and I. I had clinic yesterday and I said to one or two patients again. I mean I was telling them imagine, for marathon runners, we're not asking them to run 42 kilometers the first time. They're building at the first. They will run two, three, five kilometers. So they're building on that. So this is an important part of our job. Again, just to put things into perspective for our patients You've been not moving a lot for the last few weeks because of your pain. Now the pain has subsided, but start gradually. Don't go back running like you did before your injury.
Speaker 1:So one of the things I wanted to bring this back towards, too is in your clinician aspect, not the research aspect, but more the clinician. Have you found yourself using placebos and, if so, do you have any unique ones that you kind of fall back onto? The one I fall back onto is the one that I heard at the neuro show that you and sarah at where and my listeners have already heard this one about the foot temperature thing, where if you, the way you word which of your feet is warmer as opposed to is one of your feet warmer than the other? And the way you word it makes them make a choice. And so I've I've started using vernacular that encourages clients to fall into that quote unquote trap where when they come in, I say okay, instead of how are you feeling today?
Speaker 1:My question is, how do you feel compared to your last session? And it makes them make a comparative analysis from when they first came in to the sessions after to where they are today, and then we pick apart how they felt on a daily basis and when it was worse, what it was better, and we go through a lot of detail and essentially they're kind of tricking their own brain into saying oh, on session one I came in and I was an eight. And session five I'm coming in and I'm a two on the pain scale. It's obviously working right, kind of like that. Whether it's me or whether it's the fact that they're moving, or whether the fact that it's that started eating oranges again in their life or that they broke up in a relationship, I don't care the reason they're feeling better. I'm not happy as a clinician, I'm just happy they're getting better. Are there any of those kind of tricks that you've started falling back onto that you see are particularly effective?
Speaker 2:Yeah, I would tend to say I don't know if these are tricks, but I would tend to say here perhaps one or two things. It's coming back to expectations. So building expectations, realistic expectations. Let's say I'm giving a TENS treatment for using the TENS again and I'm saying, ah, I'm not really sure it will work. You know what, but I don't know what to use else than that, so let's go with the TENS, but I don't think it will work. You know what, but I don't know what to use else than that, so let's go with the TENS, but I don't think it will really work. I mean, it will certainly decrease the placebo effect and maybe even create a nocebo effect that could eventually even block a real active, real effect from the TENS. So it's building upon realistic expectations, being confident about what you propose. Do not propose unrealistic things, but build on these realistic expectations.
Speaker 2:And the other thing I would say here, maybe, is that the first treatment is very, very, very important. So there's actually studies showing that when it's because placebo is about expectations but also about conditioning. So if you experience a treatment failure, it will probably be difficult to change this, to get over that first hurt Exactly, and we actually have, from a clinical point of view, but from research studies, also in my lab and in other labs, showing that when you experience treatment failure, you're actually not only again decreasing your placebo effects for the next treatments but also potentially creating nocebo effects. Saying, let's say I've seen young before that type of clinic, that type of treatments didn't work. Saying, let's say I've seen young before that type of clinic, that type of treatments didn't work. So even if he changed things the next time and he, he, uh, the treatment is a little different, I probably not will not work.
Speaker 1:I think we see that. I think most therapists will have seen that somewhere in their career where they have a client walk in the door and say, oh, I've already seen everybody under the sun and you're my last hope, and they've already had they come in with this almost resignation and it's, it's almost. I remember I had one client. She came in, she was on week three. She's had a total shoulder replacement. She's eight years post-op. She has very limited movement. It looks like frozen shoulder but it's not. You know they.
Speaker 1:She really doesn't have that, especially on the pain symptoms that with it. It's just her brain for some reason thinks she can't go beyond that movement, even though structurally she seems to be healthy. And she came in and we were doing treatment and she'd started getting all this improvement and I'd even put some Instagram posts for like. For the first time in eight years she took her sweater off over above her head and things like that. And I remember she came in one session and she was super down and all my symptoms are back and the other. And when she left she goes oh, thanks, I needed that.
Speaker 1:It's been three weeks since I was brainwashed and I finally feel happy again that I was brainwashed and I'm walking away happy and it just made me laugh like that. It really sometimes feels like that's the job of a clinician is to remind your clients with so much emphasis that there is hope that even if you have a chronic degenerative disorder like fibromyalgia, like MS, like something that's progressive in nature as well, you can still increase quality of life, you can still diminish symptoms of intensity and have a better quality even with all those things and I think that brainwashing is a hard thing for a lot of them. I'm not a big fan of the term brainwashing, but it seems to be one of the things that happen.
Speaker 2:And I would add to that maybe is to listen to your patient. Let's say your patient comes in and the patient says I've tried TENS or I've tried this type of intervention before. It doesn't work. Probably you're better to try to use something else, something that has never been tried before, or if you use the intervention I'm coming back again to the example of TENS. I got this type of case a few times before. The idea just to say here to mention quickly caffeine blocks, the effect of high-frequency TENS, and this is a really nice study that was published by Serge Marchand a few years ago. People say I've used TENS before. It didn't really work. Did you limit your coffee consumption? No, not really. I didn't know about that. You know what the studies are showing that coffee blocks with. So you're explaining all these things.
Speaker 2:I didn't know that either. That's really cool, yeah exactly so when you explain that to people. So you're putting them into another uh state of mind. So now they're maybe more receptive to uh receiving tens instead of just trying the same recipe again, trying tens without changing anything. So I think we can try the the same intervention even if it has been shown not effective before. But we have to change things. Explain to patients why this time it will work.
Speaker 1:If not, I want to come back to that TENS thing in a moment because that's really interesting and made me think of something else, but it also reminds me that it's one of the reasons why I think pain education is such a good thing, because if a client comes in and they said I've had massage, I've had physical therapy, I've had this, and that I'll look at them and go, it's not like my elbow is more powerful than someone else's elbow. It's not like I have a better understanding of anatomy than other. People are smarter than I am. They definitely know more than I do, but if they've done that and you haven't had success, well, let's try the pain education and take that and take the time to make that valuable instead of just laying you on the table. I think that's one of the interesting potential alternative and I don't know if it should be considered alternative. It should be considered part of basic care, but I think it's one of those things that people have in their tool bag.
Speaker 1:But the TENS thing is interesting for me, for caffeine. So it made me wonder something, because earlier you were saying you were basing the TENS component off the pain gate cycle. So when you're using the TENS theory for the pain gate cycle, are you essentially overriding the pain stimulus through the tens enough in order to subdue it? And if caffeine blocks the effectiveness of tens, does caffeine have an effect on the pain gain cycle?
Speaker 1:I know there's leaps and logics, there's leaps and logics, but I mean why wouldn't, if you're saying one is based off the other and the other one affects the other one?
Speaker 2:And I would say another leap is that is coffee having an impact on massage therapy.
Speaker 1:Yeah, yeah, yeah. People would say yes because too much coffee, they'll be anxious on the table after pee. But I'm a coffee addict, I have ADHD and I don't take Ritalin or Adderall. I used to and I've replaced it fully with caffeine. I do about five cups a day and that's sometimes not even enough. So, yes, it does, but I'm wondering on the pain-gate cycle. I'll have to look to see if there's any studies on that.
Speaker 2:That would be really interesting, because if you're saying… it's not only because it's more stressful. It's a group of researchers in montreal that actually showed, and that it's via pure energetic receptors. So because coffee blocks, uh, exactly these type of receptors, I'm trying to remember the name of it.
Speaker 1:I used to know this because I used to really be a big fanatic of caffeine and wanted to go into roasting. But um, there's a certain receptor that takes in the caffeine and then your body goes well, we need more of these receptors. So you, you produce more, causing fatigue, making you have to consume more caffeine to fill the receptors, and on and on and on, which is why you start with one cup of coffee, but every three or four hours, but then you have to eventually do a cup of coffee every 20 minutes to stay awake, and things like that.
Speaker 2:And I'm not aware of any studies on the effect of coffee on massage therapy. But the good thing to keep in mind and that's the message I give to people who use tans is you know what the half life of coffee is six hours, so you can let's say you want to use your tans in the afternoon, take your coffee in the morning. That's not an issue, but just not take another coffee just before in the in the afternoon, before using your tans.
Speaker 2:And again, that's a study to be conducted just to confirm things. But is the effect of massage therapy decreased when people just had a coffee before coming?
Speaker 1:in. I don't want to do that study because that means I would have to stop the smell of caffeine in my office, and caffeine is in my office all day long. That would be a problem for me personally. I actually don't want that information because I'll listen to it and I won't like that change. That's confirmation bias over here um.
Speaker 2:But again, and coming back to the placebo effect, so I think the it's a lot of pressure on ourselves, but your first treatment is very important uh and I only have the uh. Important uh and I only have the uh. The sentence in uh in french. But we had a um. It was an advertisement and announcement from a shampoo company several years ago saying we only um. So there's only one chance to make a good.
Speaker 1:There's only one chance to make a good first impression.
Speaker 1:Exactly so, I think that's one of the things people ask me, like when I treat, I wear a button-up shirt and I wear slacks and things like that and a lot of. Even when I teach, a lot of my students ask me why and I say first impressions you eat with your eyes. First, a client walks into my door. They see business shirt, business casual and slacks. They're going to go. Oh, this is therapy. Whether it's conscious or unconscious, I don't care. That's the first thing they see. Now, a couple of sessions later, they might see me in my jeans, my flannel plaid shirt or my T-shirt, no problem. But that first impression, you have to lay it on very heavy.
Speaker 2:And we have to, you have to lay it out, lay it on very heavy, yeah, and we have to get success. We're condemned, condemned to success for our first intervention.
Speaker 1:I mean that's, that's very important yeah, so there was another paper I wanted to talk to you about, um and before I let you go here, which was um, a paper you did I I don't think it was for the IASP, I think it was for frontier, but it was, uh, defining low back pain the acute versus the chronic low back pain Um, and personally, I love that. I loved the result. I love the conclusion of the incorporation in papers for them to determine, because it's been one of those confusing things, and earlier on, you said stuff that made me think of this, which was, you know, massage has an effect short term and there are other studies that show that it has an effect on long term pain management, comparatively to opioid medication. That was done by the Department of Defense and the VA back in 2015 with Tripp Bachenmeier.
Speaker 2:And just maybe here, to be sure, I'm not saying that massage cannot have an effect on the long term.
Speaker 1:No, it was just that paper showed that it had an effect, and that's one of the things I talk about in my evidence class, which is research answers a question.
Speaker 2:but your question might be different, and so in this one it was, it said, short-term effect and as a massage therapist, if you're only doing massage, I think probably you'll have mainly an effect on the short term. But if you're doing massage and doing education and reassure your patient and and encourage them to move again and do his exercise. Then you'll have an effect on the long term.
Speaker 1:Yeah, and ideally that's where you work in a team, that's where, okay, you're a massage therapist and I might get them confident moving. And I just like I started working with a group here in Sherbrooke actually Bas Le Planel where they do workouts for the elderly and that's all they do. That's their entire business model. So my goal is okay, pain-free, please go work with them. I don't want to be the reason you keep. I don't want to be the only resource you have. You need to go, but that's about the network. But so this study that you did on defining low back pain, tell me a little bit about it, because I was really interested in the conclusion with acute versus chronic. So tell us a little bit about that.
Speaker 2:It was a study actually just defining chronic low back pain and even in the definition, some people say chronic pain is when the pain persists after the time of healing. Others would say on a more easiest way to define things it's three months after the onset of pain. Others will say no, it's six months after the onset of pain. Others will say no, it's six months after the onset of pain. So there's all different definitions in the literature.
Speaker 2:So here we actually wanted to compare. We were comparing the definition of two or three official statements two or three official statements and we also had the definition of actually defining acute pain as non-chronic and we actually came up with very different numbers. Very different people were defined as acute and chronic based on these different definitions acute and chronic based on these different definitions. So maybe the take-home message on this is it's not as many other things. We tend to think that things are very defined and things are clear and it always depends on how we define those things and from one definition to another, people can be classified as acute, non-acute, chronic or non-chronic, and we really have to keep in mind how did the authors or the researchers or the clinicians, how did they define chronic or acute pain?
Speaker 1:Yeah, I think one of the things I liked about the study that you did and when I was reading it, was when, looking at low back pain, you can have somebody come in at six months, at two years, at 20 years where they've had chronic low back pain and they still have acute phases. And the term that I used to use was oh, you have acute, chronic low back pain because you have majority of the time it's just this low back chronic discomfort and then momentarily you have these sharp spasms of discomfort that replicate acute symptoms. And then I remember when I started getting into neuroplasticity and neuroscience, I remember, oh, at three and a half months is when we learn something, that's when the cells start firing together and wiring together. And in my head that's when I started shifting away from that six month window of chronic pain to three month window because, like now, the brain has taken on a component of that discomfort as a learned attribute, not necessarily as a signal of perception, and for me I remember started thinking that, but when you talked about it I really liked that.
Speaker 1:The conclusion essentially was saying papers need to include their definition for the type of pain. I think it goes beyond low back pain, I think it goes into all discomforts because it plays into whether or not it's relevant to our clients and I think that's often overlooked in studies. It's just, oh, I read a study and it said low back pain. But what type of low back pain? Was it neuropathic? What was the reason for it?
Speaker 2:And that's one of the message I'm giving to my students. We have uh courses on on research, and what I'm saying is go beyond the abstract. It's we I, I understand we. We don't have a lot of time as clinician and and we tend to look at the abstract really rapidly and just to but ask yourself question how did they define chronic pain? Or how did how was the intervention given? Maybe you're saying, ah, it's not working. Well, how was it given? Is it that way? It should be given Again. So we often tend to take shortcuts as clinicians because we miss time.
Speaker 1:But one of my key messages here to the people who are listening to us, I think, is take the time to to look how are things defined, how was the intervention given, and make yourself your own opinion of that yeah, it was the there was a placebo meta-analysis that had been done, that I put up a blog where I take a paper and I break it down for my fault, for the people who read my blog who don't know how to read research, necessarily and I break it down and I break down the methodology. And I remember in it it had a section where it said, um, placebos had shown to be 14 percent, uh, clinically relevant and yet statistically insignificant. And I remember thinking, or no, vice versa, it was statistically significant but clinically irrelevant. And I remember thinking how, or no, vice versa, it was statistically significant but clinically irrelevant and I remember thinking how I mean 14% is a pretty important number, it's a pretty good number.
Speaker 1:And then I remember when reading the methodology oh, it was because they had defined clinically relevant as 20% Arbitrarily. There was no reason for it, that was just the number they had arbitrarily given to it. So anything short of 20% would have been seen as irrelevant, even though 14% could be. Maybe that 14% is the 14% that pushes them over the pain boundary into recovery. We don't know.
Speaker 2:Yeah, and on that I would say, Troy, that there are studies saying that we need, for clinically significant changes in pain, we need to have a two-point on a scale from zero to 10. But you know, what For other studies? They're showing, for elderly individuals, for example, that one point reduction is clinically significant. So again, we have to make our own minds. Okay, it's not clinically significant. Based on what actually? And is it applicable to the population we're studying here in this research?
Speaker 1:And it goes to that question of if it was 1%, wouldn't your clients be happy If the 10%, like that one point on the 10 scale? If that 10% was all they got, they'd still be happy with 10% improvement. Sure, they'd want 90% to 100%, but still be grateful for 10%. So it's the relevance becomes a good question mark now.
Speaker 2:And the studies made on clinical significance. I agree with you and the studies made on that. They were looking at interventions. But let's say that you have, because now with placebo, we're thinking differently. Let's say we're reducing pain by 20% and I'm adding to that another 14%. That's worth it. I think it's not the same thing as just looking at the effect of an intervention and saying, oh, it's reducing pain by 14%, or not? You're saying you're adding 14% to something already there.
Speaker 1:I guess that's my last question before we wrap up here, and that's definitely how I feel about placebos, which is we don't know their effectiveness 100%. We're not really sure what's causing a placebo. You know, because everybody might have their own reason. You know, based on your culture, based on your past, your experiences, your history, your gender, your genetics, placebo has a different effect based on whether you come into my clinic Friday at 5pm when I'm thinking of a margarita, or you come in Monday morning and I'm fresh off the weekend. It's going to have an effect on my interaction with you.
Speaker 1:So we don't know where the placebo is necessarily occurring, which makes it complicated, but we do know that there's an effect and so that effect is a bonus to the care, which I think is a big thing that people forget when it comes to placebos. They see it as part of the intervention, like the percentages and the results, when it's actually a bonus to your other results. So, with that in mind, where do you see the future going with placebo and intervention? Do you see it as something that you know? We're going to start looking to actively find ways to integrate placebos into clinical care, not research, because I know in research the goal is to reduce placebos, but clinicians not so much. Is it something that we're going to try to see it removed for protocols to know exactly what's effective? Where's the future for placebos as clinicians?
Speaker 2:I think it's the first option. So we will need to integrate that into our clinic. So we will need to integrate that into our clinic and I would say, maybe, building on what you're saying, before the first studies it was Beecher, one of the first studies looking at the placebo effect, and they were saying actually there are placebo responders and non-responders. We know now that this is not the case. Actually you have somebody who responds? More or less?
Speaker 1:but everybody responds.
Speaker 2:And the same individual will maybe not respond in that context with this type of clinician and this type of intervention, but in other contexts, with another clinician and another intervention, will respond. So, based on that, it will respond because of what? Because the treatment that is proposed is coherent with his expectations, his values, his beliefs. So we have to keep that in mind and, by having that in our mind, try to potentiate the placebo effect to really reduce the pain the more we can in our patients and increase the quality of life.
Speaker 1:Awesome. Well, that's a great way to finish the podcast.