Updated: Jan 24
My therapeutic approach kind of exists in a realm of honest ambiguity.
Let me explain.
Right now, there are many outdated narratives of manual therapy being reformed or understood differently as modern research and knowledge is shared about the body, nervous system, and psychology – how pain works, what does and doesn’t feel good and why, for example. They ripple through body therapy communities, shifting practitioners’ knowledge about what we know and what we do. Within the massage therapy community, there is a growing number of practitioners moving toward these emerging theories in order to elevate professional therapeutic massage into a progressive, ethical, client-centered health service. We seek to be informed and adapt to knowledge that wasn’t available or taught in training, and we seek to move away from outdated and unsupported ideas about massage therapy. And that is where I am – (trying) to adapt therapeutic choices by what we do know to be supported by evidence, and I am learning to be comfortable in the honesty about that which we don’t know, but are curious.
I’d like to share a couple examples of what this evolving, fascinating realm of ambiguity and learning looks like.
Context is Key
I’ve been shifting in how I approach treatment based on an expanded understanding of the why/how of pain, which has moved from a biomechanical/postural to a biopsychosocial model. For example: we (manual therapists and researchers) previously thought that posture or state of tissue is the direct cause of body pain. However, our evolving understanding of the body and nervous system suggests that pain is a complex amalgamation of lived experience, cultural and environmental context, sensory input, and neural pattern.
Imagine a client has persistent low back pain and believes it is the way she sits at work that is causing this pain. Instead of taking that at face value and assuming that her posture, muscles, and how she carries her body is causing her pain, perhaps I’d like to 1) accept what this client is telling me about her body and her experience, and 2) begin to build enough therapeutic trust to understand other factors relating to her pain. And this trust and sort of gathering of information isn’t something that just instantly happens, but it organically arises as the relationship grows.
I want to go deeper than placing assumptions about her body. I want to explore and know if this client has a history of back injury (or any injury) that was impactful on her life, if she is experiencing a higher level of stress or exhaustion or a significant life/world event, if she feels a high level of fear, anticipation, or fixation on the pain, and whether or not she has been told by another medical practitioner (or raised to believe) that she has poor posture or something physiologically wrong with her back. Does she feel supported enough by herself and those she turns to for relief to believe she can exist without pain or safely manage it? Were her caregivers when she was young attentive to her needs and sense of self? Having a nonjudgmental and curious mindset about these deeper questions allow the layers unfold and tell the story of pain.
Pain is a personal, subjective experience influenced by cultural learning, the meaning of the situation, attention, and other psychological variables…injury or disease produces neural signals that enter an active nervous system that is the substrate of past experience, culture, and a host of other environmental and personal factors (Melzack & Katz).
This client’s persistent low back pain may be associated in some way with her posture. Perhaps, her pain is a personal, dynamic experience that spans across time and is informed by relevant life circumstances, and was at one point associated by an uncomfortable sitting position at work. This is the new way of listening to and serving clients – patiently waiting for and addressing the story beyond the surface.
Great summary and commentary by Diane Jacobs, PT, on Melzack & Katz paper
Relationship Before Modality
Another shift in my understanding of working with clients is that when it comes to helping people feel good and addressing pain, the quality of client/practitioner relationship is at times more important than modality and technique. Diane Jacobs, physiotherapist and founder of the interactive, nervous system-based approach to manual therapy called Dermoneuromodulation (DNM), coined the notion of therapist as “interactor” with the biopsychosocial context of clients rather than simply performing popularized techniques and modalities. When therapists are reconceptualized with clients from operator of modality to interactor of humanity is when opportunity grows for positive outcomes.
Operator: The therapist treats clients as passive receivers of objective modalities and techniques
Interactor: The therapist is a role within the entire treatment that encompasses the client, their biopsychosocial experience, as well as modalities and techniques
Studies suggest that factors within the quality of social contact and relationship between practitioner and client “lead to the final step of receiving the therapy which, regardless of its effectiveness or ineffectiveness, triggers placebo responses” (Benedetti et al). Factors include trust, empathy, compassion, hope, and expectation. A skilled therapist as a respectful and engaged interactor with the client during treatment of subjective pain is more likely to produce positive treatment outcomes, no matter the modality used, than a therapist taking a position of operator treating a client's problem objectively with a fancy toolset of modality and technique.
I continue with education courses and familiarize myself with modalities and techniques - but do not promote and price for them. Therapeutic choices are made based on the relationship I develop with clients and on engaging with their expressed needs, questions, and feedback. This is the foundation of a positive session!
Moving Us Forward
There are many other examples of shifting frameworks and evidence-based approaches to manual therapy, and there are some that are in the limbo of moving into a new place of understanding (more of the ambiguity) such as trigger points (still sort of a medical mystery), the relationship between muscle “tightness” felt by therapist and actual client experience of pain (there appears to not be any predictive relationship), and force of pressure used on the body (there is “good” pain with pressure and there is abuse/tissue damage from pressure). I like to touch on these and the educational aspects of massage therapy as they come up with clients. Sharing something different than the commonly accepted stories about manual therapy and pain will help bring change to the quality of what practitioners can offer and to what people experience when they come to us for help. It also contributes to rehumanizing healthcare, which will bring us forth out of a colonized and machine-like treatment system -
"Decolonizing medicine begins with the project of rehumanization and reconnection, linking scans to people's faces; patients to their families, their cosmologies, communities, and histories; peoples to their lands and mountains and waters; and relatives to one another across the vast web of life...It is the ambition to build a community of respect for the 'animacy of life itself'". -Inflamed by Marya & Patel
I love educating and spreading the word about modern science and evidence, and at the end of the day, I’m here to help people feel better – and skilled hands and engaged presence are sometimes all that is needed.