Reflections: 4 years in

 

I qualified and started up in all this in 2014.  After I qualified I started examining the evidence and theories underpinning my new skills.  This led down a brutally challenging rabbit hole through which I eventually managed to find light.

However, I am deeply concerned about the industry, the quality of service and its future.

Bring the pain science

Learning about research into pain had a massive impact on my development as a therapist.  Our traditional view of pain is that sensors all over our body detect damage, send this information along pain fibres to the brain and we react.  Well that could hardly be further from the truth.  It turns out that our brains create pain to  protect us and the amount of pain, if any, may have little to do with the state of our tissues and more to do with our brain’s perception of what’s going on.  Lorimer Moseley’s TED talk on ‘Why things hurt’ is an excellent and amusing introduction to this remarkable paradigm shift.  Understanding the interplay between the biology, psychology and social context of the experience of pain will be a massive undertaking for researchers.  We refer to this as the biopsychosocial (BPS) approach.

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This is having a massive impact on physiotherapy and other disciplines comprising manual therapy. When we begin to understand pain, we realise that many of the core assumptions on which our manual therapy techniques are based, start to fall apart.  It is hard for an individual therapist to reconcile this.  It may mean questioning much of what we have been taught, but this is paramount otherwise we are failing our clients. But, keeping clients for long periods and at great expense for fundamentally flawed therapy is nothing to be proud of.  Questioning your costly and extensive training is difficult and emotional and has led inevitably to conflicts between the traditionalists and those embracing the BPS approach. 

Progressive, research-driven physiotherapists are on a mission to evolve the profession, yet I cannot see much evidence of this happening in massage.  In particular, sports massage is dependent upon understanding the body as a structure on which you can perform mechanical tests and fix with mechanical techniques.  But this approach is simply no longer tenable.  Pain doesn’t correlate with posture differences, with ranges of movement and not even that well with tissue damage. As hard as this is to accept, we must make the transition which U.S. physiotherapist Dr. Jason Silvernail dubbed ‘crossing the chasm’.  I’ve met physiotherapists and chiropractors, with years of training who have been running large clinics, face up to and embrace this revolution and I respect them greatly.  Challenging your beliefs when you are so heavily invested is a mammoth task worthy of acknowledgement.  

Claims are either:
~ Biologically implausible
~ Unproven
~ Thoroughly debunked

A massage school functioning as a business is going to find it a much bigger challenge to alter its narrative in light of evidence than an individual on a mission.  It’s a huge and precarious undertaking.  What do you teach if your justifications are flawed?  If the teachers lack science degrees or equivalent research and critical thinking skills, and so too the students, you end up with iterations of qualified practitioners who never even perceive the problem, much less engage with it.  This is where I think we are.  I would suggest that roughly half the claims on almost any massage therapist’s website are either biologically implausible, unproven or have been thoroughly debunked and the authors have no idea.  They’re not lying, they just lack the expertise to realise the problem (the Dunning-Kruger effect).  After all, how would they know?

 

When I reflect on my own training, where I’d expected to find evidence, expertise and robust theories I actually encountered anecdotes, gurus and pseudoscientific narratives.  What galled me at the time was not that many of the core assumptions were flawed and techniques on dubious scientific footing, but that it really hadn’t taken much effort on my part to realise this.  Not much at all.

I think it gets worse.  There are now so many courses available offering shorter and shorter training periods and actually marketing this fact.  Some are even online courses, which I can’t imagine.  It’s hard to believe that the quality of training is not degrading in order to sell a readily marketable product.  Friends of mine in the fitness industry paint a similar picture of quick courses promising new careers while the general state of the profession suffers.  One gym manager told me there is no shortage of personal trainers around, but very hard to find even one he would employ.  This means as with the fitness industry, you are going encounter increasingly less capable ‘professionals’ who are inevitably going to miss the amazing evidence-informed pain revolution. 


Just a massage?

a level 3 sports massage therapist may have had only 50 hours of training

I should point out an important distinction here.  If you just want a massage because it feels good, then it doesn’t really matter who does it, or how qualified they are, assuming a basic level of safety and professionalism has been met.  For example, a level 3 sports massage therapist may have had only 50 hours of training and be 16 years of age with no other prior qualifications.  If they give a really great massage, who could possibly have an issue with that?  There are plenty of these around.  If we consider this as a service, there’s no issue.

The problem arises when you have pain and you want help.  The risk is you will be assessed using implausible or debunked methods, such as a posture analysis, or have your pelvic position measured, then told you have a ‘syndrome’ that you don’t really have, or, more commonly told that your actually perfectly ‘normal’ body is abnormal.  You then get a treatment of dubious clinical efficacy for your non-existent problem.  Clearly this starts to cross an ethical boundary. 


Doing harm

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Consider this scenario.  You have lower back pain.  You are told your slouching posture is not good and needs to be corrected and that you need to strengthen your core because your spine is not stable – which is the cause of your pain.  You will need regular massage while we fix this.  Not only is all of this untrue, but the idea is implanted in your head that you, the sloucher (something else to feel guilty about) have a vulnerable spine (which you don’t) and it may put you off normal movement and activities you would otherwise enjoy.  Now you’re dependent on the therapist for the foreseeable.  These ideas actually serve to disempower you.  If fear inhibits you from moving normally this could have an overall detrimental effect on your health.  This is called a nocebo effect, it’s the opposite of a placebo.  Nocebo information is harmful, it is everywhere and massage therapists are among the worse offenders.

What can be asserted without evidence
can be dismissed without evidence.
— Christopher Hitchens

I feel weary and disappointed when I see therapists posting about how ‘text-neck’ is going to ruin your spine because of your dangerously heavy head, and advising you on how they can fix you.  This is a made-up pathology with no evidence to support its existence. Everyday I see social media posts where therapists make claims that are pseudoscientific, nocebos, out-dated or just plain ridiculous. I do wonder how the public navigates this.  These therapists are effectively aligning themselves to an industry of quackery - selling you solutions to problems you simply don’t have.  How much should you entrust your health to, or pay someone who’s reading magazines instead of science?

So now...

Maybe we need to see a divergence of practitioners.  One group provides a service, a massage to your liking, much like you would have in a spa.  This is of great value and respectable.  But here, no claims are made about the benefits of massage unless they are comprehensively evidence-informed and consistent with theories of pain.  You can then have another group dedicated to evidence-based approaches.  This group may include specialisms such as pain management, acceptance-commitment therapy, cognitive-behavioural therapy, cognitive functional therapy, exercise rehabilitation, mindfulness-based therapy or dermoneuromodulation to name a few.  The challenge of this second group is that there is no clear path to becoming this kind of practitioner. 

The last 4 years have been a significant personal and professional challenge.  I’ve had to re-conceptualise everything I do.  People don’t hurt for the reasons we thought, therapy - if it works, doesn’t work the way we think.  Pain science is really hard to understand and using it to inform practice is harder still and requires a broader and nuanced skillset.  Fortunately there are brilliantly clever minds out there leading the way on this.  I’ve taken on a masters degree in pain management to develop some understanding of this complex topic.  Given what I believe paying clients deserve, it’s the least I can do.

Thank you for reading.

Tris