The Thinking Practitioner Podcast:
Episode 50: A View Across The Border (with Jamie Johnston and Eric Purves)

©Copyright The Thinking Practitioner Podcast, Til Luchau & Whitney Lowe

Til Luchau:

Welcome to The Thinking Practitioner Podcast, a podcast where we dig into the fascinating issues, conditions and quandaries in the massage and manual therapy world today.

Whitney Lowe:

I'm Whitney Lowe.

Til Luchau:

And I'm Til Luchau.

Whitney Lowe:

Welcome to The Thinking Practitioner.

Til Luchau:

Welcome to The Thinking Practitioner.

Whitney Lowe:

Hi, this is Whitney Lowe and ABMP is proud to sponsor The Thinking Practitioner Podcast. ABMP membership gives massage therapists and bodyworkers exceptional liability insurance, numerous discounts, and great resources to help you thrive like their ABMP podcast, which is available at abmp.com/podcasts or wherever you happen to listen. Even if you're not a member, you can get free access to Massage and Bodywork Magazine, where Til and I are frequent contributors and get special offers for Thinking Practitioner listeners at abmp.com/thinking.

Whitney Lowe:

So welcome everyone. This is Whitney Lowe and I am here by myself as an interviewer today. Til is off this episode and I've got two fine gentlemen from Canada that are going to be joining me here today, so I would like to say hello and welcome to Jamie Johnston and Eric Purves from British Columbia and thanks so much guys for coming to hang out with us today on The Thinking Practitioner.

Jamie Johnston:

Oh we appreciate you having us. We can't thank you enough.

Eric Purves:

Yeah, it's an honor to be here.

Whitney Lowe:

Great, yeah. So let me get a little bit of background. Tell me a little bit about you guys, you have a wonderful podcast that you do, you're doing some wonderful publishing work, co-writing articles, teaching stuff. Tell me a little bit about what you guys are doing. Jamie, why don't you go first and then we'll hear from Eric as well?

Jamie Johnston:

Sure. So I graduated from massage therapy school in December of 2010 and got certified in 2011 and in addition to just working in private practice I've been working in sport with different sports teams and athletes throughout my career. So I started out with our local Junior A hockey team and spent seven years with them and spent one year as the head trainer and medical director with them. Spent a year with Rugby Canada with the Men's 7s program and for the last six years have been with Hockey Canada in the Women's Development program. So in addition to all that private practice in sports, been ... Had my blog, the MTDC, the Massage Therapist Development Center for ... I think I've been doing it for six years now and then a couple years ago Eric and I started teaching together, so we teach a course about pain science and therapeutic exercise and then earlier this year we decided to start doing a podcast together. So we launched that, so it's been a busy number of years.

Whitney Lowe:

Yeah, wonderful, and it's an excellent podcast. I would certainly recommend it to people. That is the Massage Therapy Development Initiative podcast, so yes, for sure, take a listen over there. Eric, tell us a little bit about your background history.

Eric Purves:

Yeah. So I've been a massage therapist since 2006. I own a clinic in town here, it's a multidisciplinary clinic. I've had that for about 11 years now. So in addition to practice, I've been teaching continuing education to massage therapists since about 2015. That first started, the first contract I had doing that was with an organization here called Pain BC. They're basically a government-funded organization for basically education. They provide education to other healthcare providers about best practices for managing chronic pain as well as they have part of their organization is actually providing resources and support to people that are living with chronic pain. So I started with them and I kind of expanded since then and then done some of my own things as well including teaching with Jamie. We've been teaching our course I think since 2018, and a few years ago I decided, "Hey, I don't have enough things to do, so let's go do some graduate work." So I went to do a master's degree at UBC in rehabilitation science and yeah. And so I've been basically trying to balance my life with all these things the last few years and I still haven't found that balance yet but that's part of life.

Whitney Lowe:

I listened to one of these business podcasts some time recently and someone was like, "That whole work-life balance thing, that's a load of crap."

Jamie Johnston:

That's not a thing.

Whitney Lowe:

This is not a thing, yeah. So I think for so many of us too, especially a lot of people in this field get kind of passionately obsessed about the work that we're doing, it's kind of hard to find and maintain that balance sometimes. So how did you guys hook up with each other? What brought you together to start teaching together?

Jamie Johnston:

I think it was because I was teaching a first aid course, because I teach a bunch of first aid courses for massage therapists and Eric took the course, I think that was the first time we met.

 

Eric Purves:

I think so, yep.

Jamie Johnston:

Yeah, and then we kind of just started hanging out and then he got me addicted to going to the San Diego Pain Summit and we're just spending a lot of time together and we kind of came to the conclusion or it was my opinion anyways and when I approached Eric with it he agreed that we don't do enough therapeutic exercise as massage therapists so that's kind of my passion and he knew so much about the pain science and he educated me and I think I educated him and we came together and said, "Well let's put this course together."

Whitney Lowe:

Yeah, sounds excellent. Yeah, it sounds like you;'re bringing those strengths together to the different things that you're doing. Yeah. So I want to kind of focus a bit of our attention today on looking at some comparative things about the profession world in both of our different countries because I always think it's valuable to look at different perspectives and we have listeners all over the world, so some of this is relevant for some of the people outside of both these countries as well, but I can only speak sort of from what I know here in the U.S. and you guys are obviously very well-knowledgeable about what's happening there in the Canadian world and I think there's a lot of relevance in some areas. But my passion is really as an educator, so I've watched a lot of what has happened in British Columbia over the years and I think you all have really led the way in a lot of educational innovations, in particular your move to start using competencies for your entry-level training requirements compared to ours because if I remember correctly, British Columbia, was it like a 3,000 hour requirement, is that right? A number of years back and then they moved to dropping the hours and going to competencies, is that correct?

Eric Purves:

Correct.

Jamie Johnston:

Yeah.

Whitney Lowe:

Yeah. So what's your take on the impact or effect of that? Have you been able to  measure yet the ... Does that have any impact on the quality of practitioners that are coming out or has that been a hard adjustment for people getting off the clock so to speak?

Jamie Johnston:

That's a loaded question.

Eric Purves:

Yeah.

Whitney Lowe:

There's a whole podcast there.

Eric Purves:

Yeah, that's a whole podcast there. I'll start with this one. So I think in a synopsis it was the wrong move. Because what ended up happening, when you went from the hours-based program to a competency-based program, it basically became a rush to the bottom as quick as possible. So what the schools did is it used to be a seven semester program that was 3,000 hours. Now 3,000 hours is kind of irrelevant in the fact that if you have 3,000 hours of stuff that's not good, then it's zero plus zero equals zero, right? But what they did is they got rid of a bunch of the material. They said, "We don't really need to know this because this isn't essential for our competencies," and so what they did is they reduced it from a seven semester program to a five semester program.

Eric Purves:

So even though maybe the competencies were the same, you were pumping students out as fast as you could and I would argue, and I know I'm not alone in this and Jamie would probably agree, is that you really ... This is at least ... My experience in B.C. is going to be different than a lot of other people's experiences where their program already is really short anyway, was that people ... You don't have enough time to integrate the material, you don't have enough time to really kind of go through and interact with your classmates or with the public and go through your clinical mentorship or your clinical program that you have to go through when you're working with the public. It just seems so rushed that I think that people are coming out, I would say not as prepared as they could be. I never want to say inadequate because there's lots of great therapists that I know that have come out of that program, but I think that you are running a risk of just pushing people out into the public that might not have ... They might not have all the skills necessary, not only technical skills but also maturity and cognitive and kind of reasoning skills to be as effective as you could.

Whitney Lowe:

Yeah. So is that kind of true across ... Did that happen with multiple schools that they sort of did that whole process? Or was that just a few of them that kind of cut the programs back like that?

Jamie Johnston:

I think all of them.

Eric Purves:

All of them. Yeah.

Whitney Lowe:

Oh really?

Jamie Johnston:

I think ... What, is there six schools across B.C. now?

Eric Purves:

There's nine.

Jamie Johnston:

Nine?

Eric Purves:

Nine. I hear there's a tenth one coming. So when we went to school, when I went to school, there was two schools here, and that was 15 years ago. Now there's nine, maybe ten. So it's become a business.

Whitney Lowe:

Oh yeah.

Jamie Johnston:

Yeah, and I think like Eric said, once we went ... I think I was one of the last classes that did the 3,000 hour program and I remember it being a big deal when the schools and the college came out and said they were going to do that. Part of it was so that we'd be on par with the other provinces that were regulated in the country, and I know part of the frustration was, "Well why didn't those provinces come up to 3,000 rather than us going down to 2,200?" But I think in addition to what Eric said, now you've got ... You're spending six months less time in school so you've got six months less hands-on experience, you've got six months less review of information, six months less tutorials from good instructors that are maybe out helping you at outreaches and things like that. So I think a lot of what Eric said was right, you're now coming out a lot less experienced and maybe a lot less mature and ready to go on and be as effective as you could be.

Whitney Lowe:

Yeah. One of the arguments that we hear a lot in the States, and some of this may be also related to the way that massage is perceived differently is that there's a lot of practitioners who feel like they don't want to necessarily be perceived as a healthcare professional and they really don't want to work in that model. They want to work more in a spa type of environment or something like that and they just say, "That's just way too much training time. It's costing me way too much money to go into that kind of training." So was that argument part of what drove some of these decisions, of people feeling maybe they were spending too much time, too much money?

Jamie Johnston:

I don't know.

Eric Purves:

This is something that we've noticed and I've noticed over the years is that how our profession in B.C. where we live views itself as they themself ... And most other provinces I would say that are regulated because every ... I think in the States every state has a different kind of regulatory requirement and hours or training, right? Is that correct, Whitney?

Whitney Lowe:

Yeah. Well yeah, there's ... I think 50 states and I think right now we're up to something like 46 of them have state licensure. But the requirements range from around ... Most of them average at 500 to 650 hours and then there's a couple that are up to 2,000. But there's no clarification about what's in that 2,000 hours, so it's very different.

 

Eric Purves:

Yeah, and so I would say ... So in the provinces here that are regulated, and only about half of them are, which means they have a government body, like a licensing body. The ones that are regulated, if you ask a massage therapist there and I'm generalizing here but if you ask them how they view themselves, they would want to view themselves as a healthcare professional, in line with physical therapy and chiropractic and osteopathy and other such similar professions. So I think if you view yourself as wanting to be in the wellness industry and you just want to go work in a spa or something, you don't need all the schooling. But if you want to view yourself as a healthcare professional, I think you really should, to call yourself that title, you need more education just to be on line with all those other allied professions.

Whitney Lowe:

So would you say that there's also a sense of people wanting to perceive themselves as healthcare professionals in the unregulated provinces as well?

Eric Purves:

Oh yes. I think there's definitely.

Jamie Johnston:

I think so, and I know that ... That was the reason for the drop in hours. It had way more to do with regulation across the country to get those regulated provinces, it was so that basically they could approach government and say, "We're all on par, we're all doing the same thing. Let's push and push and push." Since then, I think PEI has become regulated, so one more province, and then there's the whole thing of how much tax we charge that is involved in that too. But the biggest thing was regulation.

Whitney Lowe:

Right. One of the other things that we have been hearing a lot about for quite a long time, and there's more discussion about it as time goes on here in terms of we don't really have a good standardized educational curriculum for entry-level training. Like I said, we have a number of hours in a lot of schools but it's all over the map in terms of what they actually do there. But there's a lot of people here who have been feeling that massage should move to a traditional degree program in colleges or universities for those people that want to work more in a healthcare environment. So is there a same or similar type of push there to move towards academic degree programs in Canada?

Jamie Johnston:

Yeah, and we were very hopeful because a public college here in Victoria started a massage program a year or two ago, and they teach a bachelor of athletic therapy program and we were hoping that that was going to push towards having a bachelor degree incorporated into massage. So there's a lot of interest here in it from people, but I don't know how much the uptake is going to be. Because again, those schools are making a ton of money with the way they're doing things now, so I can't see them wanting to change, but ...

Whitney Lowe:

So would they make less money in a new model like that?

Jamie Johnston:

I don't know. If it became a four-year program, because when we went to school, they would say it was similar to a four-year program because we worked right through summer and we got ... I think a week off in the spring, a week off in the summer and two weeks of Christmas or something like that whereas a typical school takes a full summer off. So I'm not sure. I'm not sure how much Camosu is charging the athletic therapy program compared to the RMT program or if it's the same.

Eric Purves:

I think they're very comparable, but I would assume though that if you put it in a public system, then the public universities and colleges are all ... Like they're funded, a good amount of them is funded by taxpayers, and then the students kind of make up the rest of it. I'm pretty sure the Camosun program is what, 30,000 to 35,000, which is the same as the private schools as well. So yeah. I think the schools are going to make money.

Whitney Lowe:

Yeah. Do you have an idea of how many schools are associated with a traditional academic college or university versus freestanding proprietary massage schools across the college?

Jamie Johnston:

I'm not sure across the country, but here I think Camosun is the only one that's a public school. The rest are all private. Or is Langara a college? Are they considered a private school or -

Eric Purves:

Yeah, actually I guess there would be two because there's one called Langara College here which is ... It is a public university or public college, but they run the massage therapy program I believe out of what they call their continuing education department, so it's not part of the standard kind of campus. It's like an extra add-on type thing. I know in Ontario, there is a handful of public institutions that do have massage programs and they seem to be the ones that seem to have the best ... At least when you look at kind of their programs, their curriculums, if you look at some of the people that are running them, like you actually have people with master's and PhDs that are running those programs. So I would make the assumption, I don't know for sure and I know some of the people that are involved in those things are quite knowledgeable and quite passionate about advocating for promoting the profession. But if you have a province of Ontario with 10 million people and you've got, I don't know, 50 massage schools or something and two of them are really good, then it's just a drop in the bucket.

Whitney Lowe:

Yeah. Well we certainly have run into that kind of problem here I think a good bit in the States because the largest, majority of our schools are proprietary freestanding businesses as opposed to being associated with a major traditional academic training institution and I think that's one of the things that's really halted the move towards academic degree programs is it just would cause all kinds of really logistical problems for a lot of those training institutions, and we have had .... During the height of the boom of massage therapy schools in the country, this was some time around 2005, 2006, we had upwards of 1,400 schools in this country. The big problem is that it really left us unable to get good training in those schools too. It's just very difficult to find an adequate number of teachers for those programs.

 

Jamie Johnston:

Yeah, and it makes it really hard to have any consistency about the education across the country when ... I know quite often what happens here is somebody teaches a course and they decide to step away and they just have all the course material to the new teacher coming in and then they take that and start teaching it again. So if you've got 1,400 schools across the country, how do you know that you're consistently being taught, the students are being consistently taught the same thing? To have regulation and things like that.

Whitney Lowe:

Yeah.. Yeah, go ahead Eric.

Eric Purves:

Sorry, I didn't mean to interrupt. Just to say with what Jamie was saying, it's a problem when you have no ... Even if you have a standardized kind of competency document, which we have here in Canada, but how that document is interpreted is so different from school to school or from instructor to instructor. The schools get given this kind of, "Here's your competency document and here's your guidelines for foundational knowledge," they call it, and then basically it's up to the instructor to figure out, "Well how do I teach this material?" So what ends up happening is people are not necessarily educated with the best, most kind of current evidence or best practices. It's like they're being taught how to pass an exam. Which I think is the wrong mentality because it should be about, "How can we best help those people that come to see us?" People that are seeking our care, let's learn how to best help them rather than, "How do I pass this exam?" I just think it's backwards thinking.

Whitney Lowe:

Yeah. That brings up an interesting thought about this is that I've spent a lot of my career studying education in addition to all the other things in the massage world because I'm fascinated and passionate about good quality education and so I get the whole idea with the competencies and I'm very much behind that idea of we should be looking a lot more to outcomes than we are at just butt in seat clock hours which don't really tell us anything. But one of the problems that I think occurs with something like this, this move is the competencies themselves are a good idea but if you don't have people who understand a lot of those more in-depth facets of education and how to build a curriculum around competencies, you may end up doing a lot of what you're just talking about there.

Jamie Johnston:

Yeah. Totally.

Eric Purves:

And I think that's exactly what's happening is ... Because I'm not against the competencies either. I think it's just ... Like you said, it's a matter of how they're applied or how they're educated. How they're taught I think is the biggest problem. Yeah.

Jamie Johnston:

When they're still teaching a whole bunch of modality courses with outdated narratives, the competencies don't really matter because then they're coming out and they're still 20 years behind.

Whitney Lowe:

Yeah. Right. Another thing I'm curious about, this is something that's pretty significant here still in our country, I'm curious if it is the same way there, that it seems like in the massage therapy world, because we don't come from a traditional academic environment through the university system like a lot of other healthcare professions, we are still highly reliant on this kind of lineage model of teaching, where there's oftentimes a central teacher that did something really significant and then everybody is like a mentor underneath that teacher and they teach that teacher's methodology, more so than looking at traditional methods of content curriculum backed up by research. So do you think that that kind of ... Well first of all, my question is that lineage model pervasive also in Canada and then how does that impact education do you think?

Jamie Johnston:

Yeah. I think it still does because we're ... Just like you said, we're still teaching outdated narratives to these modalities within class and quite often it's people that have taken X method and they're teaching it 20 years later with what they learned from like you said this person who developed a modality or whatever. So that's still very pervasive up here.

Whitney Lowe:

Yeah.

Eric Purves:

Yeah, I mean oftentimes what you see in school is you see a note package that somebody created or they've just basically taken like, "Oh, I took this weekend workshop," or, "I took a series of levels one through five," with no names, but some provider and they basically took that and now they're teaching a version of that to students and that becomes the curriculum and yeah, it just gets passed on.

Whitney Lowe:

Yeah. I saw a good example of that. One of your podcast episodes that I think was relatively early on, you all did a focus on the psoas, and you were asking the question like where did all this obsession/focus on the psoas come from and I have a at least theory idea of I know where it's kind of came from in my background was that two of my main massage schoolteachers had been exposed to somebody who was a very heavy duty structural integration practitioner, trained at the Rolf Institute, and the psoas was just like the holy grail muscle in structural integration in the 70s.

Jamie Johnston:

The muscle of the soul.

Whitney Lowe:

So that seems ... Yeah, it was, and that seems like that's a great example of how something like that has become almost mythical, just through that whole transmission process that doesn't necessarily get borne out when we start looking at a lot of biomechanical or neurophysiological research, it just doesn't seem to be the kind of thing that sometimes is made but that seems to happen so much when you have that kind of lineage tradition.

Jamie Johnston:

I think I had some teachers in college that learned from the same people that you're talking about, because it was ... It was preached the same way.

Eric Purves:

Yeah. We were all taught, I think it doesn't matter when you went to school, I think the psoas has always been given a huge emphasis because it goes to that most recent podcast that Jamie and I did about science versus beliefs, is there's a strong belief and it just gets passed on, but even like you said, when you look at the neurophysiological or the biomechanical side, it doesn't support it. But people have this belief that something is really important and they don't really care about the factual nature of it. That creates a problem in our profession where we see a lot of this unhelpful kind of banter and camps that people put themselves into, they identify by I'm a psoas therapist for example kind of thing. Then any challenge to that is a challenge against them and then it creates ... You end up arguing dogma, and you're not actually helping people. You're just arguing with each other and I think that's a problem that we see anyone that spends too much time on social media, like Jamie and I do.

Jamie Johnston:

Yeah, you'll never, ever for lack of a better term win an argument when you're arguing dogma, because the people just shut down and it doesn't go anywhere.

Whitney Lowe:

Yeah, I find that fascinating just that we have this ... Part of it is part of a larger overall social culture that we seem to be trying to struggle through right now with this whole thing of tribalism and just fundamentalists on certain types of theories or models or gurus that people are still bowing down to and it just ... People take it so personally of just like ... when I'm confronted with something that confronts my existing belief system or thoughts or ideas, I like to try to stop and think about it and think, "Wow, that's interesting. Let me think about that," and it's caused me a lot of challenge many times because there's a lot of things that I know that I've taught for years and things that I've written in books that are going to be out there forever that now are just wrong, and I feel like people get really attached to certain types of narratives to the point of feeling like it's almost like you're attacking their religion kind of thing sometimes.

Eric Purves:

Yeah. It's exactly the way it feels. Yeah.

Jamie Johnston:

Yeah. A little while ago we did one where we talked about some of the hate mail that we've gotten and I remember this one person, the mail they sent me, they basically were saying, "How dare I ever question some of these people," that were the founders of a certain modality. The gall that I would have to question that they were wrong. But it's just like what you're saying, right? It's almost like a religion, that when it gets confronted, they shut down the conversation and they don't want to advance with it. So it's strange, yeah.

 

Eric Purves:

Yeah.

Whitney Lowe:

Somebody posted something one time on  Facebook, I think it may have been Jason Erickson, I don't know if you know Jason. You guys probably ran into him at the San Diego Pain Summit but I think it might have been him that posted that but anyway, he was talking about one of these long Facebook threads that was getting into this and he said, "Sometimes I'm in the middle of getting ready to write a response to this kind of stuff and I just think nah."

Jamie Johnston:

If you do you're going to be stuck there for the next few days responding.

Whitney Lowe:

Yeah, that one's going to go. I'm just going to let that one go, and I have to remind myself oftentimes too, the saying or whatever it is that it's not at all sensible to try and engage in a logical argument with somebody who didn't use logic to get to their point of view in the first place.

Eric Purves:

That's brilliant.

Whitney Lowe:

That's really true, yeah.

Eric Purves:

Yeah, that's brilliant.

Whitney Lowe:

Yeah. So I want to talk about a couple other things. Eric, you mentioned that you had done this master's degree at UBC and I have to tell you I have college ... I almost went to that program many, many years ago, because it looked really fascinating, and I'm curious about your experience with that in terms of how much of the kinds of stuff that you learned in that program or studied there do you think is really relevant and would really help push our profession forward if that kind of stuff was more available to massage therapists and do you see a way in which that might become more prevalent to us through additional continuing education, that sort of thing?

Eric Purves:

Yeah. I mean I loved it. I mean it's been a couple of years now. If you would ask me two years ago I would have said don't do it, what a waste of time. I was burnt out, but no. It was really good, and when I reflect on it, I gained so much information, so much knowledge. A lot of the skills that I've learned about kind of research and critical thinking and kind of being reflective on your own learning and asking better questions and all that kind of academic stuff. I never would have had it if I hadn't gone through that program, like I felt it really helped refine kind of my thinking and my abilities to teach. It was really good for the education and the teaching I do, but as a general, if you're just a practicing clinician, if you just want to go to work every day and you're just working one on one with people, it's not essential. Because it's all kind of big idea, big picture academic research stuff.

Eric Purves:

So I think if you want to be an educator, if you want to be involved or you maybe you want to be some type of thought leader or advocate for the profession, I think it's extremely, extremely important because I think it really provides a great base of knowledge for that. But if you're just somebody that wants to just go to work everyday and you have no interest in that stuff, which is fine, right? Because all professions have that. Physical therapists, they've got PhD programs and some have never worked with patients and some of them all they want to do is go work with patients all day. So I think it's not necessary but I think it's important for more of us to have a higher level of education. I think that program is something I know a number of massage therapists here in B.C. and in Ontario that have done that program, because there's a few of them in Canada, and I think it's been really, really good for those that have gone through it.

Whitney Lowe:

Yeah. Well I certainly do think too that some of the people who are leading the pack as educators and trying to carve a path for the other people who are going to be your students down the road, that's certainly advantageous to you. I had two halfway completed master's programs that I never finished, one in psychology and another one in sports medicine and biomechanics. But they were both really valuable learning experiences and they were ... Both of them were interrupted for other fascinating educational experiences and I've always kind of abided by, there's a saying from Carl Rogers, the psychologist, one time he said, "Don't let school get in the way of your education." That's always been kind of a good motto for me, like I'll use it when it looks valuable and relevant, and there are other times when I'm not going to be taken down too much by the obsession with it. But I do think that kind of thing helps massage therapists or practitioners, whatever your field is, see things more broadly oftentimes. That's one of the more valuable aspects of really getting a bigger picture. That's one of the things that I got out of that training a great deal, so ...

Eric Purves:

I would say the same thing. The big picture ideas stuff was really, really quite profound for me.

Whitney Lowe:

Yeah. Yeah, so ... Well I want to shift gears a little bit here. We've been talking a good bit about education and education strategy. I know you guys have been teaching a lot of different topics and things like that and I wanted to kind of pick your brains a little bit on a few of those things. One of them course that's kind of near and dear to my heart and focus and attention for years has been about assessment of strategies and trying to get better at assessing musculoskeletal problems. I've had kind of a difficult time making some of these adjustments in light of a lot of the current research that's come out about how accurate are some of the methods that we've used for assessment and when a lot of the information was coming out about pain science and things like that, I started questioning like, "Well is this stuff even relevant? Is it necessary? Do we just think that all this pain problems have to do with neural processing in the brain and that sort of thing?"

Whitney Lowe:

But I'm curious about this because I still think there's a lot of value in the clinical reasoning process and the efforts to try to identify the nature of certain soft tissue pain and injury problems, but one of the questions I wanted to start with here was there's been a lot of discussion lately about the use of assessment, special orthopedic tests and assessment and how much energy should we put into this? I heard a lot of people talk about, when they talk about assessment in their training programs, they say, "We learned our assessments," talking about them as if they are a thing that you learn like particular skills, like special orthopedic tests were what they were learning as assessments, and to me, assessment has always been a lot more about the clinical reasoning process and the systematic gathering of information from all different facets of our client interaction.

Whitney Lowe:

But when we look at a lot of these special orthopedic tests, they don't have such great reliability in a lot of the researchers nowadays, what are your thoughts on should we keep teaching this stuff? Should we keep using it? What do you all think about the relevance of that for a lot of what soft tissue practitioners are doing?

Jamie Johnston:

I think there's still a relevance to it. A lot of the research has come out and shown us that they show a lot more sensitivity over specificity. So a lot of them we were told were a specific test to see if this tendon or this muscle or this thing was having an issue. But now -

Whitney Lowe:

And Jamie, if I can interrupt you for a second for those people who don't really know that distinction or what that means, can you explain a little bit about sensitivity and specificity? What that tells us about those?

Jamie Johnston:

Sure, so like a lot of those tests. So let's look at like Speed's Test, which I think was for bicipital tendonitis. So we were told that that was a specific test that would show that specifically this person had bicipital tendonitis. Whereas a lot of the research now has shown us that many of those orthopedic tests don't show us anything specific but they do show us that the area is sensitized. So there's a sensitivity there, and a lot of the tests have been shown to be provocative, so actually causing pain. Whereas I've started to look at it differently, I just look at it as though it's another way, another form of graded exposure. Where I can get a person to do a movement and then gradually move into that movement a little bit more until they can finally do more of said movement and you can actually show them between the beginning of your appointment and the end of your appointment how they can actually move in a better range compared to when you started. So I think there's still a value to it, but again, we need to change the narrative behind it and not tell them that they have bicipital tendonitis when that's not what it's actually telling us.

Whitney Lowe:

Mm-hmm (affirmative). Yeah. Yeah. Eric, what are your thoughts on that?

Eric Purves:

Yeah. I never want to throw away everything. Like you never want to say always or never get rid of something or always hold onto it. I think there's a value to them. I think that the emphasis though on the value of special tests and the orthopedic tests is ... I think it's oversold, especially when we look at the research, which says most of these things are provocative to a specific area but where they're not always specific to a particular structure. A joke we always make when we're teaching and this doesn't apply to all tests because some tests are really good, right? Like some tests, they are like, "Yeah, you have an ACL," the Lachman, it's like yeah, it's you probably have an ACL tear. But sometimes, say the shoulder one, we always make the joke, someone comes in, they got like it hurts with 90 degrees of shoulder abduction and then you put them through a whole bunch of special tests to say, "Yes, it does hurt when you abduct your shoulder 90 degrees," and you've just done a bunch of tests to piss it off and to prove that they're not lying to you.

Eric Purves:

I think sometimes we can ... They can be overused when you don't really need to, right? Like, "Show me what it looks like when you reach to the top shelf." "Ow, that hurts." You need to really go and target is that biceps, is that supraspinatus, is that a labral tear, whatever. Really I think when it comes down to it, the treatment and the management is still very similar. Massage it, move it, load it, to try and make it feel better. I think in some of those cases, you don't need to be as specific. But in certain cases, I mean we could probably go through each region of the body and find out there's a good cluster for tests in one area, but yeah. They have value I think to show people ... Obviously to rule out, red flags in certain cases and I think in some cases you can use them to say, "Actually, you know what? Look, you're really strong here. This is safe. You're okay. Look, I've done all these tests and you're fine." So you can flip that script and turn it into a positive rather than just this provocative, negative situation.

Whitney Lowe:

Yeah. It's interesting too, you bring up the comment of clustering them. I do think that's a value in a lot of instances is using a group of those procedures and saying, "Now does the overall big picture that I'm seeing point to something in particular?" That might give you more information than just a single test alone. I was reading an article about this the other day. I'll pull this up and make sure we put that in the show notes, but this was an article from about 2017 from the British Journal of Sports Medicine from Hegedus, and the title of the article was Orthopedic Special Tests and Diagnostic Accuracy Studies: House Wine Served in Very Cheap Containers. That was an interesting concept.

Jamie Johnston:

I love it. I love it.

Whitney Lowe:

So I read this and there were some really good points. It was not a long article, it was just more of a kind of an editorial thing, Chad Cook was one of the authors, he's done lots of work in the orthopedic testing world. But one of the most pertinent things that really came out of their reading that and I think this is really spot-on correct is that so many people have used those procedures to try to make it simpler to do an evaluation. Because they can just sort of jump to, while doing a couple orthopedic tests, "Oh, you've got lateral epicondylitis," or, "You've got tenosynovitis," or whatever is the condition du jour for them, and it makes it so that they don't really have to go through and be that comprehensive and thorough about their evaluation. I have always been a big advocate about the importance of looking for patterns amongst all different facets of active movement and passive movement, resistant movement, and any pertinent orthopedic test information, icing on the cake maybe. But people put a lot of stock in those, I think too soon and too early, to try to jump to an understanding of what's happening so they don't go through a thorough evaluation.

Jamie Johnston:

I would agree. When we learned special tests in school, it was you learned how to identify the ... The term we were taught was the root cause of the dysfunction or the root cause of the pain, and then if you could identify that, then you could treat it specifically and you could release it or break it down, whatever, you were taught this very fix-it mindset which as we know, that singular kind of causal idea isn't well-supported.

Whitney Lowe:

Yeah. It's tempting because of the allure of it that really makes us be relevant and a real central part of the treatment process and it may be even a necessary or needed part of the treatment process. "Come to me, I'm the knowledgeable expert that's going to help fix you," sort of thing. That's alluring. A lot of people can kind of really get latched onto that but I think it sort of disempowers clients sometimes to really look at the bigger picture of what seems to be happening for them.

Jamie Johnston:

Yeah, I think in some cases, it does more harm than good too, because people are coming in and they're given this diagnosis of something that isn't really going on and then every time that they feel some discomfort or some pain, they associate it with what that practitioner told them, that their X is out or whatever because they've done these provocative tests and led them down a lie to believe that there's something wrong that isn't.

Whitney Lowe:

Yeah. One of the things that they mentioned in this ... The article, the Hegedus article was that the evaluation of a lot of the books now and other papers and things that are publishing information on the accuracy of orthopedic tests, they're trying to come up with these evaluation numbers of their specificity and sensitivity, and that's in comparison to certain other methods that supposedly are more of a gold standard of the nature of this, like either x-rays or surgical exploration or whatever. But they were highlighting in this article that a lot of the methods that were used as the gold standard to compare against are not accurate themselves, and so trying to compare these procedures to something that's inaccurate just magnifies the problem and any instances of finding a degree of accuracy there, so ...

Jamie Johnston:

No real gold standard there at all.

Whitney Lowe:

Yeah. So to continue this a little bit further down another line too, talking about research stuff, because I know you guys emphasize a great deal on your podcast and your teaching the importance of us being evidence-informed practitioners and trying to really focus on a lot of the research space for what we're doing. Of course one of the big problems that we have in our field is that we don't have a really strong base of research supporting a lot of what we do. So how do you kind of encourage people to move in the direction of being more sort of evidence-informed in their practice when we don't have a lot of good resource evidence in many instances to support some of the things that we're doing? Any suggestions or ideas that you have for how people should go about that?

 

Eric Purves:

That's a whole nother podcast.

Whitney Lowe:

Of course it is.

Eric Purves:

I could talk about that all day. You're right, there's such a paucity in the massage therapy specific research. Like we just don't have that academic culture, where we don't have people in colleges and universities as a research chair pumping out studies about what it is that we do. So that is a huge barrier, but what we can do, because rather than just being like, "Oh, put our hands up in the air, let's just forget about it, there's nothing we can do, we're just going to follow this kind of lineage model and this kind of historical model." I think what we need to do is we need to start looking at the research that's closest to what we do. So we know there's a wealth of other research out there by other allied healthcare professionals, particularly the physical therapy, where they have lots of stuff on manual therapy and touch and movement and exercise. There's lots of psychological journals out there and people are looking at the interactions between healthcare providers the patient or the client.

Eric Purves:

There's a lot of stuff I think that really we can use it to inform how we practice and the narratives we use and the way we work, and I also think that if we look, this is something that I've done a lot of doing because this interests me, is if you really look at a lot of the neurophysiology, so peripheral, spinal, brain neurophysiology and you look at the mechanics literature, you look at all the literature on pain and other stuff that's on exercise and movement and you look at things like these contextual factors and all the research that's out there in all these other fields, I think we can easily extrapolate a lot of that and apply it to what we have because we don't have that ourselves. But I think we need to be aware of that stuff and that really forms a lot of the stuff that I teach and a lot of the stuff that Jamie teaches and things we talk about on our podcast is ... If we just looked at massage therapy specific things, we would have a very narrow evidence base.

Whitney Lowe:

That pool is pretty thin. It's pretty shallow.

Eric Purves:

Yeah, very thin. But it's huge if we look at all the stuff that really is consistent with what we do. So rather than just the hands-on aspect, which there is research that shows kind of what you do and don't do with your hands and what's happening mechanically and tissue and neurophysiologically, but there's all the other stuff that I think is really important and can really ... We can use that to our advantage so to speak.

Jamie Johnston:

Yeah, there's no reason that we can't piggyback off what other professions are doing. Even if you look at ... I got in kind of a debate online a little while ago between evidence-based or evidence-informed, and evidence-informed piggybacks a lot of their research off evidence-based stuff. So I mean it happens everywhere else, so there's no reason that just like Eric said, we can't piggyback off what physios are doing and psychology is doing and social work is doing because it's all ... What they're doing is all about the person in front of them. That's really what we want to apply, right?

Whitney Lowe:

Yeah, and one of the things that I think is so crucial that we're missing a lot and I'd be curious to hear your thoughts on this too is the development of critical thinking skills to evaluate the quality of some research because there's a lot of stuff out there that's just because something's published doesn't mean it's first of all accurate or really even good research and so we need to get people to become more research-literate and have some critical thinking skills to determine, like is this really, is this telling us something significant or is there really good methodology here? That's kind of difficult to get sometimes. I think I remember hearing this story, I think it might have been Greg Lehman who told me this story one time, this was down at San Diego Pain Summit in fact. He said, if it was him, I think it was him that said this. He said, "You know how they do a lot of biomechanical research? They walk into the lab and they say, "Okay, let's see. We got a force plate. We got a ball. We got this kind of an inclinometer here and we're going to know what can we make up to study that will use these devices that we have?""

Whitney Lowe:

A lot of that is because the pressure in some of these research institutions for publications is so high that it forces you just to go put something out there just because you need to get a paper published, and whether or not it's really good stuff is not always the case.

Eric Purves:

Yeah, exactly, I mean that's 100%. I think I've heard Greg tell that story before too and I think it's what he did when he did a lot of his biomechanics research, they used what was in the room, what they had access to, so yeah.

Whitney Lowe:

Yeah. But they came up with some good stuff. They must have had good stuff in the room.

Eric Purves:

Yeah. Yeah. But that's a really good point you make though Whitney is that thinking about whether ... I think it's more important for educators rather than your average ... I shouldn't say average, it sounds like ... Rather than your clinician that's just, like we said earlier, just somebody who goes to work every day and they have no interest in teaching, they just want to ... But I think if you were taking the role as an educator or as a thought leader or a researcher, teacher, however you want to label yourself in the industry, I think you have an ethical responsibility and a moral responsibility to really have those kind of critical thinking skills, understanding logical errors, learning about how to analyze papers and critique methodology and all that stuff is so, so important because once you understand that, it really helps you to kind of weed through all of the nonsense that's out there and you can really choose the good from the bad so to speak.

Whitney Lowe:

Yeah. So do you have any suggestions for that ... Again, we'll call this person an average practitioner or person who's out there in the trenches working all day, doesn't have a lot of time to spend on the computer delving into stuff, like some people might. Suggestions or ideas, how does that person go about getting better at those things? Getting better at the critical thinking element? Getting better at even finding stuff or knowing what to read or knowing how to interpret things? Any suggestions or ideas you have come across that have been particularly helpful for you all in doing that?

Jamie Johnston:

But I think also just knowing what the research pyramid also, that these studies are at the bottom and then you have to look at systematic reviews and things that are at the top. So if you want to start with systematic reviews, where they looked at thousands of papers and extrapolated the most important things from those papers and how it applies to us, that's probably your best bet to start. I know usually when I'm writing a blog post, if there's information I'm trying to find, I'm usually going to look in systematic reviews first to find out what the best information is on it and then once you're used to that you can kind of work down and then start understanding how other research papers work and if you see that somebody's doing research on a certain topic and they teach about that topic or they have a program around that topic, it's probably not going to be very good research.

Whitney Lowe:

Yeah.

Eric Purves:

That's an important thing though is understanding the ... Being able to judge the quality of the research, and like I said, I was kind of joking. It takes practice though, you have to really put time into it, just like you would put time in massage school learning your anatomy and your physiology and practicing your different palpation and movement and all of your different techniques. It takes time and practice and I think if you want to be more critical and research aware, it takes practice doing that. They key thing is what I learned early days for me was ... The first thing that I found that was really important was the concept of biological plausibility. What we see a lot of in massage and in manual therapy is we see people making these -

Whitney Lowe:

Outlandish claims.

Eric Purves:

These big, outlandish claims on what's happening and so what they're looking is they're ... Maybe they did a specific treatment and there was an outcome that was favorable on how they measured it, but then they make a mechanistic claim for that outcome, and what I found for me is once I really understood kind of the physiology and the plausibility of stuff, that really helped kind of filter through whether a study was valid or not. That was a big one and just surrounding yourself with people that are aware of this stuff and asking questions is really important. I mean I have ... Some of the things I'm involved with and some of the mentoring I do involves this exact thing is just helping people kind of make sense of the evidence.

Whitney Lowe:

Yeah. Yeah, I wrote a blog post a couple years back on something called fantasy physiology. It's just -

 

Eric Purves:

I've read that.

Whitney Lowe:

It just seems so pervasive sometimes, just ... And some of the things that people come up with is like ... I mean that's like pretty great imagination making the stretch that somebody's pelvis has got this 25 degree range of motion moving in and out like I've never seen a pelvis move like that, but that's pretty amazing that you can do that. But it's both frustrating and at the same time ... I get that a lot of it just comes from lack of really having that sort of critical perspective of what we're doing and challenging some of the things that some of the supposedly knowledgeable folks have been teaching and telling us for years, so ... The big takeaway I'd like to tell people is that always, always, always question authority and if somebody doesn't like you questioning them, then you want to question where you're spending your time with them. It may not be so wisely used perhaps.

Jamie Johnston:

Which is great, because that's ... Every single time we teach, we're like, "Please question us. We're not an authority and sometimes the answer might be “I don't know." But we always say, "If you're going to take a continuing education course, you should feel free to question whoever the instructor is and if they're not happy with that or if they're not cool with that, you shouldn't be taking that course."

Whitney Lowe:

Yeah.

Eric Purves:

Yeah. Be skeptical all the time. I don't believe anything. I'm so skeptical of everything.

Whitney Lowe:

The other thing I was going to say about this too is that I know social media gets a pretty bad rap for a lot of stuff and let's face it, they do a lot of stuff badly and there's just a lot of really not so great things that happen there, but the flip side of that is any day you can open up your computer and go to a Facebook group and have a discussion with some of the world's leading clinicians and researchers all over the world on some of these groups and to me and that's just an amazing capability. When I first started in practice, the internet didn't exist and I was going to the medical library and digging books off the shelves and trying to find journal articles and stuff, when, "Oh, there's this great article I want to go read," and you go look and then somebody's taken the journal off the bookshelf. Where do you get that? There's nowhere else to get it, and now, people don't realize how easy it is to get great information so much more effectively than it used to be in the old days.

Whitney Lowe:

Well again, we can kind of run off and on and on and on on so many of these topics, but I think we've hit on some of the big things that I wanted to zero in on. Anything that you guys want to wrap up with here on any of these topics that we've talked about? Final thoughts for folks?

Jamie Johnston:

I don't really have any. I was just going to say thanks for having us on.

 

Whitney Lowe:

All right.

Jamie Johnston:

I don't know if Eric's got any.

Eric Purves:

Yeah. Yeah, no. I was just going to say thanks again Whitney for having us here. This was great. I hope people enjoyed this episode and if they want to hear more from us, they can obviously, like you said before, we have our own podcast, so check us out. We're The Massage Therapist Development Initiative where we talk about some of these things and talk about some of the other stuff as well, but maybe we should get you on our podcast soon, Whitney.

Jamie Johnston:

Yeah.

Whitney Lowe:

Yeah. I'd love to do that.

Jamie Johnston:

I would love that.

Eric Purves:

I think it's nice to have perspective from educators and clinicians from other parts of the world, so I think you have a unique experience which I think would be great to share to our listeners as well so, we'd appreciate that.

Whitney Lowe:

So where can people find out more about you guys? I know you mentioned the podcast name but you've got websites and other resources and things like that and you've got classes, training programs, things like that. So where can people find out more about what you guys are doing?

Jamie Johnston:

We each have a website. Mine is themtdc.com, so T-H-E-M-T-D-C.com. All the courses that we teach are listed on there. I've got my membership and some online courses and things that are listed on there as well as weekly blog articles that come out and then Eric's got his own.

Eric Purves:

Yep. My website is ericpurves.com, so E-R-I-C-P-U-R-V-E-S, and I have a listing of all of the courses I teach on there and same thing, I've got self-directed online stuff as well as I have a membership community for people to learn together and yeah. I have blogs on there as well, so check out my site and reach out to me. I'm always happy to answer questions and provide resources or support people if they want and if they want to take any courses we'd be happy to have them. We're doing our courses, because of COVID, we've been doing a majority of them online -

Whitney Lowe:

Via Zoom?

Eric Purves:

Via webinar via Zoom and we've kind of tweaked them to make that work and it seems to be going pretty well, so I can't complain too much.

Whitney Lowe:

All right. Excellent. So well thank you both for coming today. It's been great having a conversation here with you. I'm really glad you were able to take some time out and we hope listeners got some good stuff out of there as well. So thank you both here. I would also like to say thank you to our closing sponsor Books of Discovery. They've been a part of massage therapy education for over 20 years. Thousands of schools around the world teach with their textbooks, e-textbooks, and digital resources, and in these trying times, this beloved publisher is dedicated to helping educators with online friendly digital resources that make instruction easier and more effective in the classroom or virtually. Books of Discovery likes to say learning adventures start here. They see that same spirit here on The Thinking Practitioner Podcast and they're proud to support our work, knowing we share the mission to bring the massage and bodywork community enlivening content that advances our profession. You can check out their collection of e-textbooks and digital learning resources for pathology, kinesiology, anatomy and physiology at booksofdiscovery.com, where Thinking Practitioner listeners can save 15% by entering THINKING at checkout.

Whitney Lowe:

So thanks again to all our sponsors. We say a special thanks to all our listeners as well. Great to have you all here. You can stop by our sites for show notes, transcripts and any extras. You can find that over on my site at academyofclinicalmassage.com, and from Til on his site, he will be back in our next episode here, you can find that over on advanced-trainings.com as well. If you've got questions or things you'd like to hear from us, please send us an email. We'd love to hear from you at info@thethinkingpractitioner.com, or you can look for us on social media as well. You can follow the podcast on Spotify, Google Podcasts, Stitcher, wherever you happen to be listening. If you get a chance, rate us on Apple Podcasts. It does help other people to find the show, and anywhere else you happen to listen, you can tell a friend and of course if you are unable to find us in any of those locations, you can tap out TTP on a 17th century Morse code device and you can find us there. All right, ladies and gentlemen, it's been a pleasure. We'll talk to you next time.

 

 

 

 

 

 

 

 

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