Soft Tissue Therapy: A Discussion with Anna Maria Mazzieri

We welcome Anna Maria Mazzieri, a soft tissue therapist and educator from the UK. We share our stories and insights that hope to reshape the landscape of manual therapy. Together, we dismantle the problems of outdated therapeutic models so we can build a new framework where evidence-based practice is the core of clinical success. Anna Maria's expertise, cultivated at the Soft Tissue School in the UK, offers a refreshing perspective on the significance of integrating communication, reassurance, and rehabilitation advice into the holistic treatment of clients.

Join us on our journey as manual therapists as we share our experiences from our professional paths and the impact they have had on our approach to care. This dialogue, rich with anecdotes and reflections, is a testament to the power of lifelong learning and the evolution of our clinical expertise. For practitioners, students, or anyone interested by the art and science of hands-on care, this episode aims to  provide you a deeper connection to the nuances of soft tissue therapy.

Transcript

Eric: 0:08

Hello and welcome to another episode of Purves Versus. My name is Eric Purves. I'm a massage therapist, course creator, continuing education provider, curriculum advisor and advocate for evidence-based massage therapy. In this episode, we welcome Anna Maria Mazzieri. She's a soft tissue therapist, a continuing education provider, and she also runs her own school in the United Kingdom called the Soft Tissue School. Over the last few years, anna Maria has become a good friend and professional colleague of mine.

Eric: 0:35

In this episode, anna Maria and I discuss a variety of topics, with our main theme focusing on evidence-based practice and what this means in clinic, and the education for massage and manual therapists. We address the topic of defining expertise in manual therapy, the importance of qualitative research and how important it is for all manual therapists to stop searching for singular causes of pain using outdated models. If you enjoyed this episode, please rate it and share it on your favorite social media platforms. You can also support my podcast by making a donation, so please visit buymeacoffeecom. Slash helloob and Purpose Versus can be found on YouTube, so please check us out there and subscribe. Thanks for being here and I hope you enjoy this episode. Well, hello everybody. Today I get to welcome the most wonderful Anna Maria, my favorite Italian Brit that exists from Devon. Is that correct? Is that where you are?

Anna Maria: 1:29

Correct. Thank you, favorite Italian Brit. I like that yeah.

Eric: 1:35

I was like how am I going to introduce that? I was like, yeah, that's fantastic. So thanks for being here, anna Maria. We've had many great conversations before and I think one of the podcasts that I was on of yours about two or three years ago with I think it was- Was that long ago, was that? Long.

Anna Maria: 1:51

It's time to do another one.

Eric: 1:54

Yeah, that one for me that I did with you was I've had more emails, messages on social media, comments from anybody that listened to that one than any other any other podcast I've ever done. So I don't know if I've ever told you that, but that was that one changed my life. I think it really got my name and kind of things that are important to me, which I think are important, got that out there to the world.

Anna Maria: 2:20

So thank, you, no, no, wonderful wonderful, yeah, yeah. So let's just introduce yourself tell us a little bit about who's Anna Maria and tell and got that out there to the world.

Eric: 2:26

So thank you, no, no, wonderful, wonderful, yeah, yeah. So let's just introduce yourself. Tell us a little bit about who's Anna Maria and tell us what you're all about.

Anna Maria: 2:30

Oh, it's always very difficult, isn't it? Talking about oneself. Well, I always say I identify myself as a soft tissue therapist. A soft tissue therapist is in the UK, is a title that we have adopted from. We have adopted from the origin. They used to be clinical and sports remedial massage. We have adopted, we have adopted this title because we wanted to come out a little bit from clients to identify us only through our modalities. So to us, soft tissue therapy was encompassing a tiny more of a broader skill set, which is about treating the person with different, you know, like, like, with communication, with reassurance, with massage, with rehab advice and so on. So that's why I identify myself as a soft tissue therapist.

Anna Maria: 3:31

I have been in practice for 22 years, although I came to this country, to England, to study archaeology, so still working with the bodies, but these ones are alive. So then I moved on to massage therapy, just as a. I remember I did a course just for interest and literally falling in love with it. All of a sudden things like made sense and I progressed into more clinical aspects of massage therapy and I'm just falling in love with it. And I've been in practice ever since I attended a degree in sports therapy, because I want to go to do my master's in neuroscience and psychology. So hopefully, as long as we don't have another COVID tragedy or anything like that, hopefully 2024 is going to be the the master's year for me, and because I always been very disappointed.

Anna Maria: 4:52

I found that what I was taught at college never, never made sense, or what I was seeing in clinical practice, and so I kept doing courses and courses to try to find a making sense, and I never made sense. In fact, even now it is quite difficult to make sense. And so I started Educating as well, starting teaching, and Really, again, I found a new, new way, another passion of mine to actually share in the room with. I love, when people come into the profession, that they do not have an experience in the profession and they come in with the most amazing, original questions that one doesn't even think about sometimes, you know, and still, even after you know 15 year teachings, I got the students you know coming in and says, oh, but what about this? And I thought, oh, I never thought of that.

Anna Maria: 5:57

So I love these challenges from the students. Um, so now let's say that I I share time between clinical practice, which for me is really important because that's where I truly learn the experience of our clients, but also teaching both courses, qualification courses, diploma courses, but also CPD, which in your country I think you call this CEU. And also I've been very, very lucky, I feel very privileged, that recently I have been part of three studies with an international group of outstanding researchers and clinicians. One study has been published. It's about manual therapy in different pain phenotypes, and the other two they are going through review at the moment. So I felt really privileged, because I do not have any experience in research, apart from being an avid reader of research.

Anna Maria: 7:14

But I think it was wonderful that, in this case, appreciated the value of expertise away from research. And it was great Because when we had to put down our what do you call it? Credentials and paper publications, some of them had 100 plus publications. Mine was a fat zero, but that was interesting because again, then the question comes how do we define expertise? That's expertise, for this case, in manual therapy, is expertise in manual therapy? One criteria to consider oneself an expert is that of having published work. It's years of practice. How, how does one so? That that was was interesting.

Eric: 8:23

so I just a little bit of a shout out about the paper yeah, yeah, I know we should uh send me the the link to that. I know I've read the paper uh, because I believe I was one of the people that uh submitted uh some data for correct, correct.

Anna Maria: 8:38

so we said yes, and what I really liked? There were already some, let's say, limitations, even the fact that it's divided into pain phenotypes. I have some reservations with it, but we decided you know, it was decided to take the IASP, the National Association of Stylian Pain definitions, and then work from there. So that's fine. But what was really interesting is the type of study. So we are trying to find more qualitative studies and becoming better qualitative studies, and that, I think, has to be uh, praised, credited for sure yeah, yeah, I I.

Eric: 9:28

I like that the, the, the paper, and I've read it when it came out, but it was a couple months ago now, so I can't really remember what, what, what came out, what the findings were. But I do. My bias is towards qualitative stuff. You know the um, some of the work that I did in my graduate studies was qualitative and it just to me I mean, okay, you need both. Right, you need quantitative, you need numerical data, but you also need the stories and the experiences to kind of get a better picture. Personally, though, I feel like in soft tissue massage, manual therapy, qualitative to me seems to make more sense because it's more about what somebody's experience who? Maybe they have this type of pain phenotype, but what's? And then so say you could study like, well, what's your experience when you get manual therapy? You know what's that mean to you and how valuable is that to you, and you can ask kind of I feel, more clinically relevant questions in a qualitative study than you can.

Anna Maria: 10:28

Yes, but also because according to what you want, to what question you want to have answered. So, obviously, if we want to find cause, rct is the best. Of course, yes, rct is the best Of course yes.

Anna Maria: 10:50

However, and obviously of course, in our profession, RCTs are still valuable. However, we know that there is so much. There is limitations, because it's very complex in our profession to mitigate some of the contextual factors and so on. So that's why I think qualitative has we can look at different things with qualitative, and this is the point and please tell me if I'm going a little bit off track, because I think this is quite important Do we need to change the way we research?

Anna Maria: 11:25

Do we need to change the way we research? Do we need to change the questions we are asking? Because, you see, do we really need to know now what the cause, in this case, the exact mechanisms? I don't think that. Yes, a part we need to know, but shouldn't we focus a little bit more on actually, let's move away from the mechanism and see what is the person's experience within the context that create a positive outcome, instead of looking what is the causation of that particular effect, why providing a deep type of stroke or high-velocity thrust will affect pain. No, let's have a look instead. This is one or the other side. What are the gaps in research? And this is the other study that is going to come out soon, hopefully as soon as it's been reviewed, but this is another one. Shall we start changing the question we're asking?

Eric: 12:40

I would think that's a great idea. Sorry, I didn't mean to interrupt there.

Eric: 12:43

No, I think it's a great idea, because so often, right, we see this and you know, I know you and I spend probably more time than you want to me anyway, I see to see that as leading us kind of down this path. That can never be, that it's never going to end, you know, because we can't fix it right. So let's, I like what you said, like what's their experience, and that's what we should be, what our focus is on predominantly for what we do clinically.

Anna Maria: 13:22

So ask you know, absolutely I. I was on it on this conversation very recently, one of the forum, with lovely lovely I think he's a mctimony chiropractor, lovely, lovely man, phil greenfield. And what he did say we're talking. He said but anna, how do you, how you, how can you communicate? She said, you know, if we're not looking for cause, how do we communicate that? Then to the client I said you know, I actually feel what I'm, I'm trying, you know, in the last few years I'm trying to do with my clients, is moving them away to wanting a cause for the problem.

Anna Maria: 14:02

What I'm saying, what I'm trying to explain to them, that that that experience of pain or injury is come because different risk factors which have been building up at a certain time, all of a sudden, boom, boom, they got together at the right time, in the right amount to create, to drive that particular experience. So it's not a cause, because I think that's where our responsibility we need to get away to. We need to help our clients to get away from wanting that singular cause to to validate, being able to validate because they want the singular cause. This is what I make sense in myself, because having the singular cause validates the pain or their experience, but we need to make them realise or help them to make sense of the experience without being validated by one cause, especially not being needed to be validated by one physiological cause. This is why it's really important to me that we talk about risk factors.

Eric: 15:22

This is something we see all the time clinically about risk factors. Yes, and this is something we see all the time clinically and I saw this for years and years and always in clinical practices people would come in and they would be like, oh, I hurt because of an insert, the narrative here, this, this causal thing. And then they would and then you say, okay, well, you know, how have you know, have you had been treated for that and how does it make you feel? And you kind of get to try to tease some of the stuff out of there. Oh yeah, I go to see my chiro, I see my physio, I see my other massage therapist or whatever. I get injections, and but they still had pain, even though their cause.

Eric: 15:54

And so then I found that it allowed us to have a conversation. Well, maybe it's, maybe that's not the cause, like, maybe it's, that's just that there's some, there's other things going on that may be part of it. So you never want to dismiss it because you want to validate them right. But and and and people had most people have never had those type of conversations or never have had a clinician. Try to explore something outside of this singular cause, because what we see a lot in the chronic pain population. So you said, talking expertise earlier, our clinical expertise and my clinical experience suggests that what most people that are given a singular cause for their pain and they're treated ongoing, they still in pain. So it can't be that singular cause unless it's, you know, some type of inflammatory condition or disease process yes, so obviously there is.

Anna Maria: 16:39

There are some some very strong nociceptive drivers which that that's where. That's where, coming back to the AISP differentiation, I don't mind it. There are some limitations, because sometimes the main driver of the pain it's nociception, but the experience of it that affects the suffering that comes out of it, it's still multifactorial and this is where, especially as massage therapists I do think everybody in our care, especially as massage therapists our role is to make them, help them to make sense of the complexity of it, of the, and supporting them through that. Yes, I often also say some of my let's say, let's call it speciality is to help you through the biomechanical risk factors. I'll help you to build the load, reduce the load, you know, improving range of motion.

Anna Maria: 17:51

So that is a little bit more my specialty, still psychologically um kind of um driven practice, but that's where you know I, I probably work more is with the exercise, with the massage. So a little bit more those biomechanical factors, but at the same times I bring them awareness that actually you probably are feeling the pain more today, because you just said to me that you could not sleep last night because you had all this, you know, thinking about having to go back to work after having the child and you know also the fact that your child doesn't sleep very well at night and it's not feeling very well. So you know these are part of the pictures that creates irritates your system. That's how I often so, going back to the causality, I love the work that Cause Health did years ago. It's about let's try to go away from one single cause in healthcare. We are too complex for it.

Eric: 19:04

Yeah, yeah.

Eric: 19:05

And this is where this is where we I mean the theme of what we want to talk about today was kind of evidence-based practice. I think this kind of fits into that is that, you know, is the, the evidence-based kind of ideals, which is where we should be going as a profession. What I seem to feel and understand from reading the arguments that others make, is that there's a lot of people that say, oh yeah, evidence-based practice is good, of course, but some people are like, yeah, but it's too recipe-based, it's too prescription based, and I was like, well, that's not, that's actually is not what it is, but there's that misunderstanding. And so to kind of further on this conversation here is that you have your clinical expertise. There is these causative factors, there is these risk factors. If you are having an evidence-based practice, you are looking at all of these things, not just a singular thing, and I think that's something that is misunderstood amongst many Massively, massively.

Anna Maria: 20:06

Massively and it really kind of saddened me because they use that explanation of recipe cut. I love what you just said as a justification for saying oh, in a person-centered care, you know we don't want recipes. Therefore, you know how can you support evidence-based practice? My my argument with that is that, with all due respect for those people that says that, I think they have a deep misunderstanding of what evidence-based practice is. You partly mentioned it there about the three key elements of the judicious application of clinically relevant current evidence good quality evidence with current evidence. Good quality evidence with therapist expertise to cater for the client needs. But actually I think we need to go a little bit further. We need to go further in thinking how can we use what we know in evidence to cater for this person?

Anna Maria: 21:32

So often people ask the wrong question. That's why one of the major things that I teach when I main, things that I teach when I teach the evidence-based modules, is the pico question. You know how to to the. You need to learn the right question to ask to the evidence. What I find often is that people are seeking support for what they already do, while instead the way I would love us to be thinking it is. I have somebody coming to me with Achilles tendinopathy. Okay, let's have a look. What does evidence tells me about one the Achilles tendinopathy to the lived experience of the person? Three, the communication regarding the therapeutic encounter, for in in our case is touch. Put all of that together. How can, through my expertise because again some people think putting together what they learned over the years no, how do I translate all the beautiful evidence and actually put it together a little bit with my clinical experience? How do I translate it so that he actually fulfills the client's needs?

Anna Maria: 22:59

And this is why we are just too narrow when we seek an answer to a question for evidence. We still think that it is about going and reading a paper about the efficacy of one intervention. It's more than that, it is way more than that. It's things like, for example and this is why you know, when they say manual therapy or touch, you know is short-lived, yes, but short-lived. We know also that there is body of evidence that's saying to us that for responders, that a short-lived pain relief, short-lived symptom modification, is a diagnostic of better outcomes. So even that, if I know that somebody you know, I know the evidence is telling me that. If I know that. I know that maybe with that person I know in the past, might have responded to touch. I might want to use touch. So it is complex. It is up to us educators to make it less complex to our therapists. But it's more complex than the cookie cup.

Eric: 24:16

No yeah.

Anna Maria: 24:18

Ultimately. Oh sorry, no, no go ahead.

Eric: 24:20

No, so go ahead, I'll intervene after.

Anna Maria: 24:22

Ultimately, this is the best we have at the moment and although we need to try, so to me the limitations of evidence-based practice, they're not strong enough to vouch for people not using it. Yes, so we cannot find those you know drawbacks or the limitations and say, oh, because of that I'm not using. I don't think it's a good enough excuse.

Eric: 24:51

What I was going to say, too, when you're talking about the people who get short-term pain relief after manual therapy too, it's also important, too, for us to understand in using taking that person-centered approach, approach which is part of evidence-based practice. Right, there's always, there's always these, these catchphrases, right, that we're all, everyone throws together, um, and I think word salad yeah, word, there's, there's.

Eric: 25:13

yeah, I mean, that's maybe a different conversation. We could talk about all that stuff, uh, but is that meaningful to the person? And that's the thing that needs to to, um, to be understood or asked as well, as it's like okay, so I'm, I'm going to give you this, this treatment, this is these are some some techniques or an approach that has worked in the past, when I've seen this, you know, and if they get some relief, but is that meaningful to them? Is that, is that helpful to them? Do they care? You know, and that and that's something that we is is missed. I think too often is that we're like, oh, this person didn't respond to to what I did, so therefore they can't be helped. And I've heard that a lot from clinicians and it's like, well, maybe it's just what, maybe it what you tried didn't help on that day, but maybe tries a different and maybe you should try and find something else that works for that person.

Anna Maria: 25:55

So maybe you know what you said there. It's really made me think of something that's great, eric, great um eric. Or maybe for that day, the primary outcome wasn't the pain relief. Yeah, you know, this is the point. We should always ask what is your primary outcome? Because sometimes I might not be able to reduce the pain with my touch, but I might be able to hold the space of safety, which that on that day, is more meaningful for them than being pain free. That, I think, is a really, really powerful thing.

Eric: 26:28

You said there actually yeah, and how many times too, I'm sure yourself and others that are listening this podcast has somebody come in and you're like, oh, tell me what's going on. They tell you this big story about their shoulder, their neck or their back, and and, and then you're all of a sudden your clinical reasoning hat goes on you, you're trying to figure it out and ask them questions, and then you're like I know I've done this before and you kind of stop yourself and be like is this something you want me to to, to something you address? No, I can I just get like a nice massage for you know it, just to just to chill out for a little bit. And and you're like, oh, you just want something. You don't even want me to address, that concern, because that's not what they're looking for, their objective for that day. So that's something, too, I think we need to ask, because that used to happen to me all the time.

Anna Maria: 27:12

That made me really think, eric, about going back, about the misunderstanding of people about evidence-based practice. I've recorded a podcast quite recently and for a group that, let's say, it's not known for um following evidence-based practice because all they're they're very modality based, okay, very modality based, and so I was trying to uh, we want, me and my colleague Emi, we wanted to do a podcast with them because we wanted to make them understand that it didn't matter what level of practice they were, it didn't matter what modalities they practiced. Having been evidence-based or at least been evidence informed, it would have been very refreshing and liberating and indeed open up so many more options for them and understand the limitation of the experience they provide. And maybe using a different language could have provided much more, let's say, provided much more, let's say you know how can you say much more, create better outcome for the client, even if they are experiences that did nothing to do with healthcare. Anyway, so the host, he said to me so we're talking about evidence-based practice, and he said, oh, but what about if all those therapists don't want all these big words and they just want to give a massage? And all of a sudden and I really like the host and I really like the host. He's the kindest and the most caring therapist. But that really triggered me. Triggered me because to me, all of a sudden in my head came well, it's not your choice.

Anna Maria: 29:28

There is a point where, if you want to work with people, that they are in pain and they have an injury, so in the moment in which you open your doors to public, to to members of the public who actually come to you because they say I have a shoulder pain and I would like you to help me with this shoulder pain, the decision of what and how to approach, or if you are evidence-based practice or not, is taken away from you. Rightly so, because actually, the moment you're working with people in pain, you are becoming health care. Yes, it might be non-registered healthcare practitioner, it might be complementary healthcare, but still healthcare In the moment, which is healthcare. We have an absolute duty of care again towards those people. Or do harm harm? Now we know it doesn't come with what we do with our hands, but it will come with what we do with our words.

Anna Maria: 30:36

So if I say to somebody you know your reflexology, doing a reflexology session, which might feel absolutely beautiful, I've got nothing. You know, it's a beautiful experience, it's brilliant. But if you're starting saying, oh, you know, you've got sciatica, let me do a reflexology session, because you know the reflexology session will help with your sciatica, that's a little bit creating a symbol. The other thing is and this is to me it's even more important by having somebody on your couch that should be on somebody else's office, where they can be treated more efficiently and effectively. Therefore, the experience of suffering or pain reduces in the moment in which we keep them in our couch and we don't give them the choice to go to somewhere else.

Anna Maria: 31:28

That, to me, is my practice. I said last night at the red flag course I run. I said don't you think that every single client that comes to us, they think, well, I trust the therapist, I trust that the therapist know, I trust that the therapist keep up to date and I trust that the therapist has my absolute best interest at hand. And if they think that there is something out there that it is tested and tried to be more effective or quicker effective, then surely the therapist will refer it to me. I think every single person that comes through our doors, they think that.

Eric: 32:23

And they should.

Anna Maria: 32:24

They should, yeah. So the fact that the therapist says, oh know, let's try this, let's try now, what do you know about the particular condition? Is there anything we know that can work better? Is there anything that we know that could? Because it doesn't mean that you don't need to be part of this and you know, eric, tell me if I'm going a little bit off. You know off-cut here, but it is okay.

Anna Maria: 32:53

In the moment in which we want to, as I said, in the moment in which we want to work with people in pain, we take on a responsibility and we have to. However, it is also okay to say to somebody look, you come to me because you have sciatica and you found reflexology really helpful before. Look, I am very, very happy to provide a reflexology session because this is the experience that you want and it's beautiful. It's the time for yourself. However, for the sciatica itself, I refer you to my colleague, the physiotherapist down the road, or the chiropractor, or the osteopath, or back to your GP. They're going to take care of that. However, I'm going to give you an experience which is so powerful for their stress, they even their you know an experience of reflexology.

Anna Maria: 33:58

Somebody likes that is will down, regulate the fears will down, regulate the the nervous system. So there is value to that, but a value that is not health care. This is, for me, it's really important, it's leisure and it's good, and I even said in in the podcast if doing ceremonies with crystals is what ticks, you, go and do the ceremony with crystals, but do not use them for people in order as a therapeutic intervention. You know. Use it as somebody wants to expand their consciousness, somebody wants to have an experience, a different experience. This is just. It's enough to wanting, you know, a beautiful experience. This is just is enough to wanting, you know that, a beautiful experience, but it's very different from our care. This is where there should be a very no fine line anymore, a strong line if somebody's going, yeah, I know I love that sorry yeah, no, sorry.

Eric: 35:05

Uh, I love that, annarie, I think because this is something that I think you and I have had conversations about this before, but it's a conversation that's not had very often about the ethical dilemma of the kind of pseudo-scientific approaches that are so common in in our our world, and so often when we call that stuff out and you talk about crystal, you talk about reflexology or you talk about any other type of narrative or understanding that is common in the profession, when you challenge that, people get very defensive, because the ethical thing too, about the like do no harm and informed consent, is something that we should talk more about and it's so important for people to understand that. And you know, this is something else that probably I mean we could talk forever about this would be things like the informed consent. So you talked about the fine line between healthcare, right, so you're selling something or a fixed or some therapeutic value that doesn't have evidence to support it, even though maybe you have clinical experience and say, oh, I do this thing and people feel better, right, but you don't have a plausible, biological, biologically plausible explanation or you don't have evidence to support that. And if you want to be a health care provider, you cannot make those claims of therapeutic benefit. You can say, hey, this is something that might help, but we don't know why, we don't know how.

Eric: 36:34

Do you want to give it a try and see if it helps with your experience? That's a fine line. I could get behind that, as long as you're not selling it as some optimum therapeutic benefit. And this kind of goes with what you're saying too about these modality industries, those modality empires, and this kind of goes with what you're saying too. But these modality industries, those modality empires, where they are definitely wanting to sell their approach as being this is the best approach, this is the only way, and they're making a killing selling that. But ethically, right the people. If you're selling that and that's what you're telling your clients, you're not getting informed consent. They have a duty to understand what you're doing, why you're doing it that's my point with what the what the client believes of us.

Anna Maria: 37:15

I bet they believe that we are totally up to date with knowledge. Call it evidence, call it knowledge, but we are not. That's where I think actually there is no informed consent there then yeah, and that's a big problem.

Eric: 37:29

That's something I'm surprised that doesn't get talked about enough, and that is something that I have been on about for quite a few years, and most people have just looked at me with glazed eyes and have no idea what I'm talking about. So I'm really happy that you have similar thoughts.

Anna Maria: 37:44

Yeah, because I bet if he goes to court, god forbid, god forbid. But if he goes the or at least that what you're offering me, it's equal to something else that is effective, because I do not mind somebody like you just said, you know the clinical expertise, blah, blah, blah, blah. The first, we try some. First we work evidence-based. First, we try some, first we work evidence-based. Sometimes because of context, we know that very well, especially with touch, things might not respond very well. That's why I use massage and touch and manual therapy, because manual therapy just provides me that kind of change of context and then the same approach, the same exercise might work better because of the change of context. In those situations I'm quite happy to say look in my experience. This is so important because then the client makes the choice. It's, you know, I can say in my experience, so they can weigh the knowledge in the right way, knowing that it's only one person's experience. If they're happy with that, we can try that, as long as that experience doesn't take away the person's choice to go somewhere else where they will end the suffering earlier. And this is where for me is the biggest, absolutely the biggest, as I say, and do you know what I absolutely loved talking about.

Anna Maria: 39:39

I absolutely loved going to the psychedelic conference in Exeter quite recently in June, and it was amazing because they give so much respect to the naturalistic approach of psychedelics. So the psychedelics conference was a very academic conference for psychedelics in mental health but also in pain. There is research coming up but you know we need to weigh. So it was a really good, but what they did they showed tremendous respect for the more naturalistic approach to psychedelics. Now I'm not talking just, you know, taking magic mushrooms to go and having a good time talking about more about plant medicine and I really enjoyed how this very high level academics they looked at the naturalistic way, like the shamans and so on, and I said what can we learn from those ways of using psychedelics? And I think we can do the same. So how can we learn from the use of certain modalities, what the certain modalities provide that might help in health care? It's a very different thing to say.

Anna Maria: 40:59

I use those modalities for health care right because the fact, the line of I want to get better and therefore I'm going to go to somebody that I'm hoping they know best about that particular problem, it's very different than, oh, I just want to go somewhere because I want a good experience and that's a big line to be made. It's us needed to make the client aware that that is a big line to be made. It's us needed to make the client aware that that is a line and that they can come to us for having a really great experience if they want, or to therapists to have a great experience, and that's very beneficial as part of something, but not as healthcare.

Eric: 41:47

And this comes down to something I've been on about for years. It is a failing of the kind of entry to practice education, and I know things aren't regulated in the UK like the same they are here. You know all these problems we're talking about the lack of evidence and practice, these ethical dilemmas, kind of fix it causative approaches, all these things we've talked about today. These are not things that I would say people are making up on their own. These are an industry problem because this is the kind of narrative that people are taught in their entry to practice program and so people are spending a lot of money and time to learn and they're basically will be taught a bunch of different modalities and some anatomy and physiology and kinesiology and some pathology. So there's stuff in there that you need to know, but there's also what do we do with this information?

Eric: 42:37

And it almost always comes down to what modality do I choose to help to fix this problem or to correct this dysfunction? The problem for me starts like, from day one you're in your, your massage or soft tissue training, and then it just gets built on from there. You have an entire industry. So, like these modality empire industries that are built on this framework that is we know now, is incorrect what modality do I choose?

Anna Maria: 43:05

this is you just hit the nail in the head. This is where, when before I said about changing our perspective of evidence-based practice this is where we need to change our mindset we should not think what modality should I use. We should think how can I support and facilitate that person to achieve the primary? Whatever the primary goal is it could be pain relief, it could be improved, injury could be going back with playing rugby, whatever, with one evidence tells me to my skill set. So what? How can I support that?

Anna Maria: 43:50

So we some of and this is where we need to be looking at the clients like we look our in education what are the needs? How does that particular person learn or understand? Because I also say and you know that you know it's when people come through our doors, when they see people, they are self-selecting. So the people that already have taken the choice to come to you because they already know that they won't touch. So for us it's a little bit easy. We know they already are expecting touch because and therefore we know that most of the time they will respond that their responders.

Anna Maria: 44:35

So you know we have to to think what? What is the person? How is the person going to better make sense of the pain and how to you know, then recover from the pain, from the injury. This is this is our skill set. It's not the modalities. Our skill set is recognizing the person, what they need, how they need it. Some clients need to actually have less of a massage and more of a the discussion when they come in. Some of my clients they enjoy more the movement aspect of it. So I have the conversation during the movement and some of them I have the conversation that encounter the interaction during the massage itself. It's about the client in front of us, yeah, and that's something.

Eric: 45:24

that is, that I find that when in all the like, when I teach my courses, when I do my live courses, you know we often talk about, you know, communication and touch and movement, exploration and all these things, and people often like, well, when, like, how much do you talk to the person? Like, you know, do you do, you do like a long intake and or whatever, or, and I'm like, well, it really depends on the person, right, like, we can do a lot of these things while we are, while they're on the table or while we have them doing some movement stuff. But there is this thing in our profession that we feel that we're not providing value unless it's all hands on. Someone pays for a 60 minute appointment, like some people are like, well, I give, I have to give 60 minutes hands on. And I'm thinking, well, maybe if the person comes in and they just want a great massage, then yeah, give them as much as they paid for.

Eric: 46:13

But maybe the person comes in and they come in because they want pain relief or they want to improve their function and their ability to do some specific activity.

Eric: 46:24

They want to be able to look over their shoulder or raise their arm above their head so they can grab things from the top shelf, and maybe that's going to require not just an hour of hands-on stuff. So we should ask those questions and say, well, what is it? What would it be that? What would a successful treatment today look like for you? You know, and they're like, oh well, I would like to be able to, you know, reach above my head. Okay, does that require 60 minutes of hands-on? Because if the person told you that's what they want to do and they leave the appointment being able to do that thing a little bit better, then they don't care how many minutes of hands-on they had and that, okay, this is. This is very anecdotal, this is my experience. But when people tell you what they want and you help them achieve it, they don't care how they get there I couldn agree more.

Anna Maria: 47:07

It's about exposing the client to what their outcome could look like. And the other thing is, from a clinical perspective, we need to stop saying 60-minute treatment. They're booking 60-minute appointment. In that appointment we decide together with our client what that looks like. This is, again, is where our skill set is. If I know that there is a client that they're expecting that, I might create a let's call it an environment where on the first appointment, I might deliver some of the information while they're having the massage and then slowly, slowly, I'm taking them out of it Because actually, if they come in for pain and you know particular injury, I want them to get away from thinking I just need to come in for a massage to get my pain or the range of motion or you know, going back to function. I want people to see I'm very you know I'm bang on about it, but massage or maniotherapy is only the context.

Eric: 48:18

It's a great context.

Anna Maria: 48:19

I love it, I love providing it, my clients love receiving it. But it's only the context in which the really true interaction takes place, which is therapeutic alliance, communication which provides reassurance and advice on lifestyle and helping them to make sense, and all these other really meaningful and valuable aspects of the therapeutic encounter. Manual therapy is just our, literally it's the environment where it takes place, the context. Some people do understand, do feel more prone to understanding when they get touched. There are reasons for it, which is absolutely fine, and this is why we are in practice, because some people do respond to that Not everybody, but some people do. And that's why, and if we like doing it, so we like providing manual therapy, then you know you're matching people's needs.

Eric: 49:21

Yeah, yeah, that's such a great point and I love these conversations, so thanks, thanks for saying that. What are your thoughts on these modality industries? Do you think it's ever possible that our kind of shared professions here are ever going to be able to move past these kind of modality approaches?

Anna Maria: 49:44

Are they wrong? This is my point, though. Are they? Is the modality that is wrong or is what we use the modality for? So, for example, we still teach in our school modalities in terms of, let's call it, met techniques or a little bit of cupping, but we teach them as part of a varied type of touch, and I differentiate them. So massage is something massage gives that long, long sustained touch, and other techniques like, let's say, cupping, it's a different type of input sensation. So that's how I see them, and I don't dislike that, because sometimes it's nice to have the variability of touch for the person at that time.

Anna Maria: 50:50

What I'm having a little bit of an issue and I am afraid that in this country we don't seem to get away from it is that they see those modalities as the intervention themselves and the intervention itself, and they put so much focus on it and they cherry pick those studies not very high quality either in order to give an explanation of that, and we don't need that. You know you can. You know you can use cupping, as long as it's not the kind of cupping that gives you all that. What do you call it? I don't know what you call, call a dry cap and that gives you all that oh yeah, bruises. No, no, we use a very simple, sometimes little silicone cap just to provide a different sensation, because the client at the time might like a different sensation. That's why I use kinesio tape. But my client knows that I use kinesio tape just to give you a different sensation, not because it does anything particular. You know special.

Anna Maria: 51:59

And this is where I think we're having a little bit of a problem in our industry. We're still considering the, the modalities, the driver of the outcome. I don't think that it is. I think we need to switch the only one part of the communication process and they're not what creates the outcomes. And until we change that mindset, until we we really think, we really understand that it's more than that physiological effect, I don't think we can. It's not even about being evidence-based practitioner here. It's about understanding that the person's pain and injury and experience is very complex. It's way, way beyond the effect that acupuncture might have.

Eric: 52:54

Yeah, and this is such a I'm you. You kind of clarified that a bit because, yeah, I, I often will go off about like all the different techniques and and I'm not against the modalities like. I'm not against like because there's there's different, different strokes for different folks. Right, there's different approaches that you can take. There's different. Some people like the the the like a pokey.

Eric: 53:14

Some people like the, the the kind of like nice flowing sweet we're going to want the more kind of stretch skin stuff which people would call myofascial. You know, like there's some people want the light touch or the met. Like there's different approaches, which I have no problem, because I think it's great to try different things, because a different intervention might uh have a different impact on on person, right? So not everyone's, uh, not everyone's going to respond the same, and we all know that, clinically, like sometimes you feel like you've done nothing to somebody because you've just kind of like held their head for 45 minutes, um, and you know, but that's like the most powerful massage, that's what they needed.

Eric: 53:50

That's, that's, yeah, yeah, yeah but the yeah, the issue I get is when the modalities are sold as doing something magical. Correct and that's why I talk about modality empires is that they're like this is the best approach. But what I am noticing, though, now and I'm sure you notice this too is that a lot of these modality empires are now starting to throw in terms like biopsychosocial, evidence-based, person-centered, you know, pain science, and you start to say they say, they start to use these catchphrases which, um, I mean, we use them too, you and I, I know, because, like it tries to explain what is we're doing. But now I'm starting to see that you put in the last probably three or four years that everybody else is using these too, and I think it's confusing for the customers.

Anna Maria: 54:40

Very recently I noticed somebody uh, let's say that until now they sold their own method. Okay, you use this method for chronic pain and people will get better. So that in itself, you know, using a method for chronic pain and you get better. That is the opposite to what evidence-based practice is, because one of the things that we know from a strong body of evidence that there is nothing superior to anything else for persistent pain. So just somebody that anyway.

Anna Maria: 55:26

But recently, because they realize a lot, a lot of people in the, a lot of therapists are more and more, I think, that they're starting understanding and seeking to be more evidence-based or at least being aware of evidence-based training.

Anna Maria: 55:48

So they are asking that and I think recently they advertised for something and the kid not, it was a word salad talking about. You know, they put within one sentence the biopsychosocial person center and something else, and I thought you just put it in literally to attract, probably for SEO purposes, because you know you're gonna. You're selling a method. They are selling an absolute method to advertise. You know, advertising their own method, which is herbs for, you know, chronic pain, but they're putting their words by vps and the words by some sentence. I think, oh my god, this is what people don't understand, because then, what people do and this is what I realized on the podcast I was recently they're trying to shoehorn modalities into an evidence base and this is it's not. You know, of course you know you can shoe show on anything, but it is the is the absolute mindset. That is different.

Eric: 57:01

And that's one thing I always like to.

Eric: 57:03

One of the things I focus on so much when I'm doing my, my live courses is, you know, bring whatever technique or modality you want to the, to the, the, the workshop, or, and you can use whatever technique or modality you want to the to the, the, the workshop, or, and you can use whatever technique or modality you want in your treatment room.

Eric: 57:19

But what we're going to focus on is we're going to focus on how do we apply the clinical reasoning of whatever it is your favorite technique is, to the population or to the person that's in front of you. So if we're doing a low back and pelvic course, for example, like you know, people often have what techniques do I use? I'm like, well, which ones do you want to use? Right, maybe these ones might work better for depending on the presentation, and we try and have conversations and and uh discussions on that and demos to trying some different things. But you know, I see that if we focus on just like identifying by modality, we're missing the bigger picture of the person and we are attributing every single thing in their experience to some type of dysfunction which that modality can then fix.

Anna Maria: 58:04

In air quotes At the same time, though, eric, I am a strong supporter of of honing in or refining touch, so I do think that it's actually good to attend some techniques courses because it helps you refine your touch. Yes, because actually, and and again, this is total clinical experience. There are some type of touch that are more comfortable than others, like broad, long, slow strokes, and somebody that has been in practice for many years and touched and provided touch with different bodies they would have experienced us, so learning from those people to create an experience. This is the difference. We are creating an experience with manual therapy or massage. In our case, we are creating an experience. In that experience, there is an option for behaviour change to take place, and this is then it's up to the client. We are just there to facilitate an experience, what they do with that. We can help them and support them through that. It's not the experience that creates the change. The experience provides the option. And how can I make that experience absolutely magnificent? It's providing that beautiful touch. Sometimes that gets the person lost in their own body, and this is why I love the link between touch and interoception.

Anna Maria: 59:58

There is some evidence coming out of it, or the Laura case, who is amazing. She's done some fantastic, really good research on touch, on deep touch. She's actually trying to eliminate as many contextual factors as possible and what she had discovered? That not only sitatite fibers gets what do we call it processed into the insular cortex where then they're processed with emotion. That's why sitatite fibers, light touch, feels pleasant, but also deep touch. So what she has found? That the deep touch stimulates the same pleasurable pathways than light touch. And would that make anything different for what we already do? No, but it's really good to know.

Anna Maria: 1:00:51

You know, it's really good to know why the deep touch. And then you wonder to know, you know, it's really good to know why they did the deep touch. And then you wonder why. You know again, this is total personal clinical experience the people that you do those long, long strokes, nice and deep strokes, they say you know, they feel quite, let's say they feel powerful. It's a powerful experience. Of course, if they're nice and long and slow, you have more time to internalize, there is more time to connect the discriminatory touch together with the affective touch. So there are a lot of things happening. So the myofascial people, when myofascial, you know, says oh, wow, you know, I feel so upright. He said you feel upright because you changed the fascia. You feel upright because actually you had time to process the sensations.

Eric: 1:01:51

Yes, and that's a less wrong explanation that you just provided in that and that's, and that, that's wrong, bravo, let bravo, less wrong.

Anna Maria: 1:01:59

It's not what exactly is happening, but it's. This is what research is there to provide a less wrong explanation?

Eric: 1:02:09

and when we have that, less wrong explanation. You know that allows us to be more ethical and allows us to be more evidence based in our approach. And I do like what you did say, though, too. You did say that there was the. You know, you do encourage people to learn different modalities, and I think so too, because it's a matter of comfort, right? If you only know how to do Swedish massage and somebody doesn't respond to that, then you don't have another approach.

Eric: 1:02:32

So I personally for me, I've taken lots of different modality things in my in my career. It's been a while since I've taken one, because I feel like they're all kind of variations of the same thing. If you are someone that just right out of school and you maybe you're totally aware of all the evidence based knowledge that's out there, and you're like, yeah, okay, I know all this, totally aware of all the evidence-based knowledge that's out there, and you're like, yeah, okay, I know all this, I know all the pain, science, I know a person's energy, stuff, and I've had conversations with new grads that are like, come out like fully, like yeah, I've listened to your stuff, I've listened to so-and-so stuff, like I know all this stuff, but I just need more tools and I'm like, yeah, then take those modality courses, learn some different approaches. That's great. Just don't believe the BS that is often not always often being sold, because there's value in that.

Anna Maria: 1:03:20

We run. We run hot stone courses. Yeah, I love hot stone courses, but we're not going to. When we run our hot stone massage courses, we do not build a narrative about the benefit of the heat, it's a narrative about experience. That is enough. We just don't need anything more than check the control indications and make sure that it is suitable for the person. Apart from that, it's all about the experience that provides to the client, because it can be such a pleasant, wonderful, warm, you know, experience that actually down-regulates the nervous system. And then we can go. Then, when I talk to them about, for example let's talk about you, you know challenging that overhead movement.

Eric: 1:04:17

There is more chance they will do that because the pleasant approach establish or reinforce our therapeutic alliance but also created a safe space in the brain to now do something that originally could have been a little bit more challenging the best massage I ever had in my entire life was a hot stone massage by somebody that was not a trained therapist but just somebody who just was good at doing it, and the treatment I got like that was the most delicious thing I've ever experienced. It was so good and it really opened up my mind to realizing that, like the power of a positive clinical presence with a, with a touch that feels good, goes a long ways. Now what's going to be missed, obviously, is pathology or understanding of mechanism stuff, but if you're just looking for something great I mean I, I, I still think that was a couple years ago I like that was the best thing I've ever experienced. I've never been able to find another massage that even came close to that I need an example.

Anna Maria: 1:05:26

So let's say, you know somebody, um, uh, she's suffering with frozen shoulder and it's at acute stage. It's really obviously really suffering and she wants to keep away. She's gone through the GP and she wants to keep away from pain medications. So she comes to to help with maintaining the, the range of motion. She has to help with a little bit of pain, but also to help her with a little bit of pain but also to give herself, like she says, I want a bit of a respite from suffering. So we work with that. I do a little bit of hot stones because on the shoulder it makes her feel really good. Then we can manage to do a bit of mobilization. When we do a bit of mobilobilization, all of a sudden it says I got a little bit more movement than I thought I had. Not because I increased the range of motion, it's because she feels so pleasant you use the beautiful word delicious then actually the contractile mechanism had a little bit switched off, probably so we could see what her potential was. So she accessed that potential. Then she goes home and says look, in the next few hours show your brain that you still got that potential. So for that particular hour that she was in the clinic.

Anna Maria: 1:06:48

Her experience took her away from suffering. Look at, away from suffering. Does she know that the massage doesn't cure frozen shoulder? Of course she does, but does that mean that she should not be using it? No, she has been given all the other options. We looked at all the other options between me and the GP and she actually says I'm okay, I will go through it. I know that it's pain, I know that it can get better. I just want to be supported through this time. This is what we're there for and that makes it powerful too right Like that it's when we talk about liberating you dismissive of kind of some of the stories and the the different things that people learn.

Eric: 1:07:36

You know, it doesn't mean that what we're doing doesn't work. It doesn't mean that what we're doing isn't helpful, and that's, that's the thing. We need to understand that when we are challenging, uh kind of the status quo of narratives and of beliefs in the profession, it doesn't mean that what we're doing has no value, because that's oftentimes that people hear like, oh, you're telling me I'm useless. I never once used that word. That's what you think when you hear that what you're doing isn't working the way you think you're doing. But you've got 20 years of clinical experience which is showing you that people are getting better. So don't think that what we're saying is telling you that you're useless or that you're not a good therapist. It's just that there's newer, more updated knowledge which needs to be adopted, and we can incorporate that into what we already do, providing these beautiful massages, yes, and even probably more powerful when we understand kind of the, the bigger picture of how our manual interventions can potentially impact a person.

Anna Maria: 1:08:34

And this is if we say you know, my final message would be it's not just changing a narrative because you need to. It's more than changing a narrative by a narrative. Although the client might come out of your room feeling really good, the narrative you give of the treatment, it can provide a nocebic effect on a long term. So the client may come to you and you say oh, yes, it's because your pelvis is rotated right or left, whatever the sacrum, whatever all this rotation, and you treat and they feel better, say yes, because I put the pelvis back then and then they will feel great. Yes, because it's a neuromuscular response. Of course they feel great after massage, after touch, but next time they got the pain again. What are they going to be thinking? They're going to be thinking oh, I'm in pain because my pelvis has gone out again and therefore I need to go and see Anna Maria again, because and that is dangerous we know that the person thinking of fragility in the body and I thinking of the pelvic going out of pain that is fragility does not have a good outcome for them.

Anna Maria: 1:09:53

Well, instead, if you say well, actually you know you're feeling in pain because there are all those risk factors. Some of it is biomechanical ie not previous autoplay but strengths, deficiencies or inflammatory drivers. Some of them are more systemic. You know, actually, biomechanically you could have had those risk factors for 20 years. However, you're feeling them more now because maybe you're starting perimenopausal. So it's actually not the biomechanical risk factors that the driver is the perimenopause. So should we go and discuss with the doctor possibility of HRT? So this is what our role is is to provide those options. Yes, then if it's the driver, we can decrease some biomechanical drivers, but nobody. They're just impaired. So you know, ultimately the narrative, it's the first thing that somebody must change straight away.

Eric: 1:10:58

Yes, and that's a great final thought because, yes, understanding narratives are important, but they aren't the only thing, because we can't justify everything by just changing the narrative. But we'll just leave that thought there, that the narrative is important and, uh, you know, hopefully anyone that listens to this understands that we as educators and advocates for our profession, strongly believe in the power and the wonderfulness of what our profession can do. But we are just pushing for us to realize our potential on opposite sides of the pond to do better.

Anna Maria: 1:11:32

I am still in practice after 22 years. I used to be strongly biomechanic. I used to run all the anatomy training courses, so I used to be very strongly biomechanically based. If somebody like me embraced when evidence-based practice came into my vocabulary and I got my views. Why it didn't beforehand? And I'm not ashamed of it, it's just I went into search change. It actually was liberating because all of a sudden you start realizing all the quirky things you see in the clinical practice, that certain things don't make sense when you are looking at the evidence. All of a sudden you think when you are looking at the evidence, all of a sudden you think that makes sense. And it's so liberating because you realize it's about you and the client and there is no cookie cutter. It's about that. The relationship is the most absolute importance. So so yes, it's liberating yeah, I would agree.

Eric: 1:12:34

That was my experience too, is I? I took all the anatomy trains courses and I was heavily invested in that as well. And then, yeah, once you start to um learn some of the current evidence, it definitely allows you to poke holes in those things.

Anna Maria: 1:12:48

And it starts it starts to make sense now why you had some successes and why you had some failures well, let's say sorry, eric, to stop, because that is something that I feel very, very, because I thought about it very deeply. Why we all embraced the anatomy trains of the fascia movement is because it happened at the time where we all been in practice for a while and we started realizing, you know, what the biomechanical approach is not the beginning of the end. So something was started with. Then we're going to those fascial anatomy training courses and this was at the time where fascial research started having a bit of a resurgence. And what the fascia research showed is that everything is interconnected, which we were seeing in practice. They took it more biomechanically, but already they gave us a bit of a vocabulary and just made us think oh, in fact they used to talk about fascia containing emotions and so on. So it actually gave us a bit of an explanation, a vocabulary, for what we were already seeing. We didn't have any other vocabulary to use because evidence-based practice didn't come into our industry as yet.

Anna Maria: 1:14:11

But then, once evidence-based practice came in, we started realizing oh, actually, that is a way. I'm much less wrong with that. But that's why we all jumped on board of FASHA, because it allowed. It was the first time, it was the absolute first thing that moved us away from the very strict biomechanical perspective and more of a comprehensive integrated movement in the body. So it made sense to all of us because we're starting to think oh yes, I sure see that. But then when the true, you know the biopsychosocial model, which is the closer model to the way we see health and pay we see health at the moment is, or the neuromatrix of pain that makes that is we are again less wrong. So I do understand where people went down onto the fascia route. I totally get it. Yeah, I was one of them yeah, I know, me too.

Eric: 1:15:12

I'm'm the first to admit. You know that I was, and it made more sense to me at the time, and then it's just a constant evolution. I think of thinking and of our clinical, trying to make sense of our clinical experiences. And you know, I mean you know, maybe five, 10 years from now, what we're talking about will be maybe we're completely wrong now.

Anna Maria: 1:15:33

And that's okay.

Eric: 1:15:35

That's okay. That's okay. I think we have to be mindful, um, but I think we will. We know we are less wrong now than we were with with the anatomy train stuff, and that's okay that's the best thing we can do. That's all, absolutely, absolutely so anyway, henry, that was lovely as always. Thank you so much for for taking the time to be here and I look forward to having some conversations with you in the future and hopefully we can make it work. I can come meet you in person next year in the UK.

Anna Maria: 1:16:03

Wonderful. Yeah, we look forward. We're trying to get you over now for the last couple of years. On the third year we will manage to get you over here. Can't wait so it will be fantastic. Thank you very much for inviting me, Eric.

Eric: 1:16:15

I appreciate all you listeners for taking the time to be here. If you enjoyed this episode, please give it a five-star rating and share it on your favorite social media platform. You can follow me on Instagram or Facebook, where you can find me at ericpervis RMT, and please head over to my website, ericperviscom to see a full listing of all my live courses, webinars and self-directed course options. You can connect with Anna Maria via her website, thestschoolcouk. Until next time, thanks for listening.