Therapeutic Exercise in Massage Therapy: Insights and Challenges with Michelle Smith

Can massage therapists truly prescribe and monitor therapeutic exercise programs effectively? Join us in a conversation with Michelle Smith from Saskatoon, making her third appearance on the podcast, as we tackle this provocative question head-on. Michelle, whose expertise spans kinesiology and exercise physiology, shares her critical insights into the current state of training for massage therapists, particularly when dealing with clients with co-occurring medical conditions. Together, we uncover potential gaps in knowledge and the practical challenges therapists face when integrating therapeutic exercise into their treatment plans.

Our discussion takes a dive into the psychological aspects of exercise, debunking common myths about stretching and its supposed benefits for pain management and athletic performance. We highlight the necessity of customizing exercise recommendations to fit individual preferences and mental readiness. By understanding each client's unique background, lifestyle, and mental health status, therapists can foster more effective and personalized therapeutic interventions. Michelle emphasizes the importance of encouraging positive behavioral changes through tailored exercise plans, moving away from a one-size-fits-all approach.

We also examine the broader implications for the massage therapy profession, discussing the role of therapeutic exercise within RMT scope of practice. Our conversation underscores the need for clearer guidelines and potential curriculum reforms to better equip therapists. Michelle and I stress the significance of continuous learning, critical thinking, and seeking credible sources to challenge outdated practices and advance the field. This episode is a must-listen for anyone passionate about the future of massage therapy and the integration of holistic, evidence-based approaches to client care.

Chapters

• 0:07 Therapeutic Exercise Competency in Massage Therapy
• 15:20 Understanding Therapeutic Exercise and Psychology
• 23:24 Scope of Practice in Massage Therapy
• 37:33 Challenges and Solutions in Massage Therapy
• 46:19 Massage Therapy Competency in Exercise

Transcript

Eric: 0:07

Hello everybody and welcome to another episode of Purves Versus, and we have repeat guests. This is her third time on the podcast and that's Michelle Smith joining us from Saskatoon, so thanks for being here, michelle.

Michelle: 0:17

Thanks for having me again, eric.

Eric: 0:19

One thing that I love is when guests reach out to me and they say, hey, do you want to do a podcast episode about insert topic here? And I said, sure, let's do that. So Michelle wanted to talk about a therapeutic exercise and kind of have a little discussion about is this something that we actually know enough about? Is it actually should it be considered within our scope of practice and what would be obviously a better way forward? What could we do to make sure that we're more competent in therapeutic exercise?

Eric: 0:51

I think this is an interesting conversation, so I'm looking forward to seeing what you have to say about that, michelle.

Michelle: 0:56

Yeah, thanks, I am too, and I'm grateful that you're having me on to share this kind of topic with the rest of the RMT world.

Eric: 1:04

I think, just to start with, this is the idea of therapeutic exercise, is something that we all have a TheraX class and it's something that is in our competency documents. But I think the discussion that Michelle and I want to focus on today is to really pick apart. Do we actually, are we trained well enough to provide exercise prescription, to know enough about the indications or contraindications of when is exercise appropriate? I think you may you make some great points in some of the discussions we had off air michelle about we might, even though it's in our it's in our documents and then we're allowed to do it.

Michelle: 1:49

Should we? Yeah, should we is the question, and I just want to be transparent and say I'm coming to this podcast wearing two hats. Today I have looked into the scope of practice for therapeutic exercise for massage therapists is my original education and career background is as a kinesiologist and exercise physiologist, and so when I was training to be a massage therapist and we did our Therx class and we did our Therx class respectfully it was laughable in terms of the type of information and the amount of information that was delivered to the students wasn't relevant, based on the fact that when clients or patients come to see us for massage therapy, probably 90% of them will have some other co-occurring medical condition and will have multiple co-occurring musculoskeletal limitations. And so to appropriately assess those concerns and provide the you know, the therapeutic exercise that we're taught that to do, I don't necessarily feel being in the massage therapy treatment room is the right space, nor do we have the right time to do so, but again, I'm bringing in my experience working, as you know, a kinesiologist and saying you could bill a full hour of just assessment and exercise prescription on top of your hands-on manual therapy. So there's couple of key things I think that the public are expecting when they see a massage therapist. I mean one is they want hands-on manual work. And then, two, they're going to ask is there anything else I can do at home or outside of the treatment room, you know, for exercise or movement? And our first line of of exercises here do this stretch right? Um, which I'm not saying is wrong, um, any movement is good movement.

Michelle: 4:11

However, um, I would caution the average massage therapist who doesn't have any um extraordinary training in um exercise, health, fitness, fitness, to try to take on that role of having a completely developed exercise therapy program for your patients If you're not aware of the proper contraindications, proper modifications, proper physiological responses that your patient might have if you're giving them this program right.

Michelle: 4:50

And so I guess, for an example, eric, let's say I was seeing you and I'm taking metroprolol for my blood pressure or for my heart rate, sorry, and you're like well, yeah, just start walking. Well, eric, what do I use to evaluate my effort when I'm walking, knowing that I'm on this medication? What are you going to tell me? Right, and that's something we don't learn in massage school.

Michelle: 5:12

But as an exercise physiologist, I'm going to tell you we can't use your target heart rate as a value to assess your intensity when you're on that type of medication, right, we have to use other assessment forms to ensure that you're exercising at a level of cardiovascular fitness that's still going to keep you safe, within those limits of your heart rate, which is being, you know, reduced by a pharmaceutical agent. So I guess that's where I'm sort of looking at the big picture from, because when we talk about our you know our practice competencies, there's that huge section on therapeutic exercise, and cardiovascular exercise is one of them, right, but to what depth are massage therapists being taught the level of knowledge around contraindications and indications around exercise, right?

Eric: 6:08

Those are some great points, michelle, and one of the dangers with education is knowing a little bit can sometimes be more harmful. We could say that with a lot of the things in massage school and anyone that listens to the podcast or knows me. I'm always critical of the curriculum because, you know, it's not because I hate us, us, it's because I want us to be better and I think if we don't challenge and we don't ask hard questions, then we're never going to improve. And when we look at therapeutic exercise, for example, we get so like. I remember I mean it's a long time ago and it was over 20 years or 20 years ago now when I went to massage school and we learned we had a therax class, but I don't remember anything in the class learning about cardiovascular or learning about optimum dosages or or anything more than like this is how you do a stretch.

Michelle: 6:58

This is how you do a strengthening thing.

Eric: 6:59

It was usually just linear, like flexion, extension of this joint. It was very, very rarely was exploring functional movements, whatever functional movement is like, like task specific movements it was. It was never. It was always very like you broke it down these little pieces and it was like, oh, you do five or ten of these and then repeat it times three and then do it every second day or whatever, and it was so generic and even when you did your exams and your board exams, that's all they were looking for. Going back to what I said about knowing a little bit of knowledge might be dangerous is that you learn this and you think, ok, I guess that's all I need to know, right? Yeah, you don't even and you know it's not even addressed that there should be or there could be more specific to that.

Eric: 7:40

You have, like I said, kinesiology, exercise, physiology yeah, physiology, yeah, you know that's what you do right so and I'm just curious though, because obviously this is not my area of knowledge I know a little bit, but I think I know a little bit, so I don't know enough. And this is great that you wanted to have this conversation. When you took, when you said that you went to massage school and you said that you had your therics class, and it was laughable. What kind of things were they teaching you that were that you feel you can remember were shouldn't even have been addressed because it was just so insufficient.

Michelle: 8:18

Probably the first thing that comes to mind is, yeah, giving somebody a stretch or an exercise using a soup can as their weight without even assessing their, their movement or their strength first. Right, so you've had a chance to treat this person on your table. And let's say you know they're coming in with a sore shoulder and and you've done your, your treatment on the table, and then your home exercise program is, you know, do a deltoid stretch and then do some front raises with, with a soup can to add some strength to that shoulder. But how do you know the shoulder is weak if you haven't even tested it? Right, and I know strength testing there's evidence to support that. It isn't really all that great. It's kind of very subjective. But anytime you pursue advice or you pursue giving people some sort of take home exercise prescription or exercise program, home exercise prescription or exercise program, you also have to think of what are you basing that program on? What have you done to demonstrate or to determine they need this front raise with a soup can or they need this stretch? If all you've done is the hands-on manual work, right, because there is a protocol in place that you should do to to measure and evaluate. You know how this person's functioning, how they're moving, what their strength is, what their deficits may be, and then, based on that, okay, is this, is this? Is this something that is, you know, preoperative, postoperative, is this arthritic? Right? Then you decide what type of exercise to prescribe, as well as the frequency and intensity of that exercise, right? So I just think.

Michelle: 10:16

I think the world thinks exercise is just so easy and so basic that anyone can like tell somebody to go and do a front raise with a soup can or a deltoid stretch. But in actuality, in a therapeutic setting, there's a lot of information that you have to gather first and a lot of critical, critical thinking you have to do in order to provide effective and evidence based and and safe, quality therapeutic exercise, right? Um? So just diving in and saying, okay, go, do these soup can raises at home now and do 10 repetitions for three sets a day, every day, until I see you next. What are you doing with that? Right?

Michelle: 11:02

And the other thing that was not taught was how are you going to evaluate the progress of this person? Right, because in my world, in my original profession, you would see this person every week or sometimes every day, and so you would like create a huge program for this person and design a program for this person in all these macro cycles and micro cycles so you could progress their um, their improvement along the way, or even progress their decline, right. And so I think, um, given the space and the context that we as massage therapists have in the treatment room when we're in school, I think the, the level of exercise education we're given is just to be kind of like band-aid fixers or like just a little cherry on top of of the of the treatment, just so we can say we've given them some, some education on here's how you do a stretch and here's how you do like a dumbbell, front or front raise right, which I'm not saying at all is bad or nor is it harmful. I'm just saying it's not going to be as effective as I think we were taught to believe when we were in massage school. Right, even stretching. There's so much research about stretching and how really ineffective it is. That why, why are we stretching things right? Or, you know, people come with us with sore muscles, while those muscles could be sore not because they're tight, but because they're weak, right, and unless you really understand the analysis of those muscles of how to determine is this tightness from weakness versus tightness from being tight and needing a stretch? Why are we giving people rhomboid stretches when they're feeling tight? Because those rhomboids are already so overstretched to begin with from their habitual movements throughout the day. So, in my opinion, you know always, always advising some movement is a benefit for people.

Michelle: 13:07

But when it comes to those laughable moments in my Fairx class, really, it was just here's how, here's how you teach your patients how to stretch right, um, which may be good for somebody who's never done any movement to begin with and it's very unfamiliar with their body, um, but then, once you deliver that message to those patients, what are you doing with it? What are you doing to monitor the results? What are you doing to modify the results? If they come back to you in a month's time saying I've been stretching every day and that neck still is tight and still as cranky, well, what does that mean? What is that telling you? Stretching every day and that neck still is tight and still is cranky, well, what does that mean? What is that telling you right? And so I think that's where, um I'd mentioned to you earlier.

Michelle: 13:51

Sometimes I felt like doing Therax in massage school was akin to when physicians do medical school and they take like a five-hour class on nutrition and all of that you know education they take and they're only given a small chunk of education on nutrition and all of that you know education they take and they're only given a small chunk of education on nutrition.

Michelle: 14:08

And then when they counsel their patients, they really don't know as much in-depth knowledge as, say, the dietician you know who has her four-year, his four-year nutrition degree.

Michelle: 14:19

So, circling all this back, I think that I think we can do better in the world of education for massage therapists and we need to do better, especially if it is in our practice standards. I still don't know if, if we interpret our scope of practice of massage therapy, I mean right, we talk about it being within our scope of practice, but when you read a scope of practice of massage therapy, I mean right, we talk about it being within our scope of practice, but when you read a scope of practice it doesn't actually state exercise, right. So I think our practice standards need to put a put a microscopic lens on the exercise and the therapeutic exercise and up the ante on it when it comes to the education component. But I also think our scope of practice needs to either stop misinforming us that it is within our scope of practice, or it needs to clearly state that it is actually within our scope of practice.

Eric: 15:20

Thanks for saying all that, majoka. We're going to talk about that. I'll read the National Standards of Practice definition in a minute. I. Just before we do that, I just want to go back to what you're saying, too about, about the stretching thing, because I think you brought some interesting things there. You know, the idea is like why do we stretch and what is the purpose? Right, and this is a thing that massage therapists across, let's say, across the world across canada.

Eric: 15:42

Anyway, where we are, that's the kind of the go-to home care oh, just do some stretching. And then when people do all their stretches and they come back and they're still in pain, they're like oh, we just gotta stretch more than, or you gotta stretch harder, whatever it might be.

Eric: 15:56

And there is this misunderstanding that stretching actually does more than it really does, because we know that stretching doesn't actually really change the length of tissues for a very long, very short period of time, right, and we know that stretching isn't strongly associated with injury prevention. We know that stretching is not necessarily related to increased athletic performance. But we know that there's some the the data on it is all over the place, right, there's some things say does something positive, some say it does nothing, and then probably the truth is probably somewhere in the middle. But I say the way I interpret the stretching literature and the way I communicate it with patients is would you like to stretch? If the answer is yes, then yeah, go ahead, stretch if you like it. If you don't, don't feel bad, because a lot of people feel bad, right.

Michelle: 16:58

Do you know I didn't do all my stretches, I know.

Eric: 17:01

And oftentimes you hear that and you see cruising through social media. You see people be like oh patients, they don't ever do the stretches and they come back and wonder why they're still in pain. I'm thinking it might still be in pain even if they do the stretches every day. Maybe stretching isn't the thing for them.

Michelle: 17:14

Yeah, exactly.

Eric: 17:15

It goes back to that little bit of knowledge. I think in our profession we feel that stretching for example, does more than it should or than it could, and so I just wanted to bring that back. And because the purpose oftentimes is oh, we need these things to be longer, well, does a longer or more flexible muscle is that more associated with? Is that associated with with less pain? Is a stronger muscle associated with less pain?

Michelle: 17:42

not, necessarily necessarily.

Eric: 17:43

Not necessarily right. Like their bodybuilders, have pain and they got tons of muscle. Yep, right Gymnasts and figure skaters and you know people that and dancers that have tons of flexibility they still can have pain. Yeah. And they don't need to stretch. Yeah. I think that these are, these are good, good things to kind of call out and really stop and reflect on what's the point yeah, it needs to be meaningful to the person well, exactly, and that's I liked your, um, your comment of asking the person well, do you like to stretch, right?

Michelle: 18:16

um, we need to also take this back to a psychological level, um, where I mean and that's that's a huge component of my kinesiology education is trying to encourage or support, or convince a person to adopt a healthy lifestyle and to exercise is as difficult as trying to have a 10-pack a day or lifelong smoker trying to quit, right. There's a significant psychological component that we have to be familiar with and very understanding of when it comes to exercise prescription. First and foremost because if I come see you and I have zero experience with movement period, whether it's going for a walks or whether it's being in a recreational dance class, um, and movement period is not in my wheelhouse because I'm just not a movement based person you need to understand that, first and foremost, right. And so by asking me do you like to move? Do you know any exercises? Do you know any stretches right? What do you do for recreation?

Michelle: 19:30

If my answer is nothing and no, no, no, right, there is the first indication that, okay, I got some work to do with this patient. And how do I elicit some positive stages of change within this person to help them believe that what I'm telling them about exercise is actually going to be a benefit. Right and that's what I've experienced across the board, regardless if it's with personal trainers or massage therapists is that the psychological component to movement and exercise is always overlooked in our clients and we just think, well, because we're the professional and what we say goes, that they're just going to adopt this and go with it. But the reality is they aren't, and we have to be very cognizant of what their lifestyle is like and if they're even open to wanting to learn about different types of stretching or different types of therapeutic exercise, and so the psychology of exercise is also an evidence-based practice that we're not taught in in massage school.

Eric: 20:40

Not at all, and that's such a great point I mean, you brought that up of the psychological aspect because we're dealing with humans, we have to be knowledgeable of psychology. It's ridiculous for us to think that might be out of scope. We're dealing with a human, you have to be appreciative of their psychology. Learned in my sport coaching education is you know, the first thing that that you're supposed to focus on is the, the psychological and mental health of the athlete, and that's just. We're speaking specifically sports. But it would be the same thing with when you're treating a human in a massage therapy or exercise therapy environment is is what is it? Where are they coming from, what do they want to do and what are they capable of doing?

Eric: 21:27

and recognizing that yeah, exactly rather than just throwing the same process or the same prescription or the same advice at everybody, it has to be tailored it has to be completely tailored and you have to also know which, by that point, you should.

Michelle: 21:43

Are they seeing other health providers? Right? Because many of my clients come to see me and they're already connected to a physical therapist, or they're going to the gym and they're seeing a personal trainer Fantastic, you know what I'm just going to say continue doing what your physio or your kinesiologist has you doing, or your personal trainer has you doing, kinesiologist has you doing, or your personal trainer has you doing? Because, again, within our scope of practice, we have to have, we have to refer to the people who are the experts first and foremost. Right, I'm not gonna. I'm not gonna say, oh well, I think you should change these three exercises that your physio has given you. I'm not gonna step on their, their toes, not at all. I'll collaborate with them, absolutely.

Michelle: 22:26

But if my client's telling me, yeah, this one stretch my physio has me doing or my trainer has me doing, I really don't feel comfortable or I really get some pain, okay, well, let's, let's talk about some alternatives and then take that information back to that person and and see if there's something you guys can come up with, kind of halfway in between, based on the recommendations I've given you. Right is a more. I mean is directly within their scope of practice and they have an extensive volume of education and experience around it. Then let that person do the exercise prescription and let that person address the therapeutic exercise, so that you're not clouding the water per se.

Eric: 23:24

It's nice actually when patients come in to see you and they've already have somebody else doing that stuff.

Michelle: 23:30

Yeah, it's great. Do you like doing that? Does that work for you? Yeah, great, perfect Carry on Right.

Eric: 23:36

And then sometimes be like did you, you know, can you share with me, kind of what they're doing, yep. And then I'm like okay, that sounds great, thanks for sharing. And then, yeah, and then I'm like okay, that sounds great, thanks for sharing. And then sometimes I'll ask yep, that sound good.

Michelle: 23:48

I'm like sure.

Eric: 23:49

Yeah, it sounds great, yeah yeah, keep doing it, yeah, keep going right, keep going.

Michelle: 23:51

And then you're their motivator, you're their, their mentor, to say you're doing a great job, right? I'm proud of you, and they want to continue doing it.

Eric: 23:58

So it's amazing. Yeah, that's amazing. Uh, so I, a few minutes ago I mentioned I wanted to read the national standards of practice, just to, so we can have a conversation about. You know, is therapeutic exercise, you know, is it part of our scope? Now, this is from the, the cmta, the canadian massage therapist alliance, and you know, I don't, I don't know why, but there are so many organizations and stakeholders out there. There are so many different acronyms that are involved in the massage therapy profession. I, to be honest, I kind of forget what they all do. But anyway, that's maybe a different conversation, but this here says so.

Eric: 24:34

Massage therapy is the practice of. The practice of massage therapy is the assessment of the musculoskeletal system of the body and the treatment and prevention of physical dysfunction, injury and pain pain by manipulation, mobilization and other manual methods to develop, maintain, rehabilitate or augment physical function, relieve pain or promote health. And there's another sentence after that, but I don't think it matters as much, and the key point that you highlighted with this is nowhere in here does it say exercise, right, you know, the practice of massage therapy is the assessment of the msk system of the body and the treatment and prevention of physical dysfunction, injury and pain by manipulation, mobilization and other manual methods. So it's interesting, isn't it, that, based on this definition, that therapeutic exercise is even within our scope, right?

Eric: 25:29

I think it I like that it is I think we probably agree but if we're going to be like, let's ask some hard questions here, it shouldn't be actually based on this. So I wonder how they get away with that. That's really interesting in bc, in our. Our scope of practice here in bc is a little bit different than, say, ontario, even though, and other regulated provinces, because here manual means by hands and if anyone listening goes online, you google like manual, it's going to say to be done by the hand or done by the hands. One reason why we're not allowed to do a lot of things like cupping or use other non-hands-on interventions is because it's not done with the hands, right? Somebody reached out to me the other day and was saying oh, you know why can't I?

Eric: 26:20

you know why, in BC can't you guys use your feet? And I was like, because it's not your hands. That's the way it's defined doesn't mean I could care less if someone massages you with your feet. Uh, probably feels nice, but the the manual thing. So when we look at this and we take even a bigger look at it, it still says here, you know, manual. What are your thoughts on that?

Michelle: 26:42

I'm confused, to be quite honest, um, because I think, as I said earlier before we were recording, if you were to read that through the lens of, say, a lawyer or an insurance company, if someone had, for whatever reason, said, oh, the exercises Eric gave me caused me to have X, y and Z problem.

Michelle: 27:05

When you read that statement, it does not explicitly define exercise you know, prescription or exercise recommendation as our scope of practice, because it is of, you know, the manual treatment or assessment of a person's musculoskeletal system.

Michelle: 27:26

So it I mean right, as a practicing massage therapist. It makes me confused, then, what does that mean for us? Is it really within our scope of practice, based on how, you know, the regulatory colleges define it, or what this paragraph had said? And I think there needs to be more clarity around it, and I also would challenge that. The clarity around it also needs to then be passed on to the practice competency standards and the schools who are, you know, writing the curriculum for their x classes. But from from on first glance, from my perspective, reading that statement, no, exercise would not be within our scope of practice, even though we all know we are taught it and we are doing it and it is what it is, but if someone were to ever challenge that, I don't know how much clout it would have right To say that it is in our scope of practice.

Eric: 28:34

It would be nice to have a lawyer to answer that one or somebody that works in that, because the way I would see this is now the CMTA they could kind of probably put in here. I mean, they can seem like they can kind of make this up as they go, because they are they don't. I don't think they answered anybody Right. If I understand correctly, I remember correctly, I believe the professional associations are all part of the CMTA. Yes, is that right?

Michelle: 29:01

But one thing you could change here is is you could get.

Eric: 29:04

Rather than saying mobilization and other manual methods, you could just say mobilization and other physical methods or just get rid of manual altogether and say other methods.

Michelle: 29:12

Other methods right. Other evidence, informed or other therapeutic methods yeah or other therapeutic methods.

Eric: 29:19

You know you could get rid of that, get rid of the word manual.

Michelle: 29:23

Right, yeah, absolutely Right. I don't yeah, absolutely right um, yeah, these things.

Eric: 29:27

I don't know where that comes from?

Michelle: 29:29

I don't know either, but it definitely. I see two sides to this because I see, like those therapists who are all like it's, it's in our scope of practice and this is the way you know, we're taught and we can do this. And and then I see other healthcare providers who are like no, stay in your own lane, it's not your scope of practice, let these people do the work because it's within their scope of practice and it's within their level of education and competency, right. And then you see the general public who is like let's be honest, when people book in for a massage, they're not expecting, they book for 60 minutes.

Eric: 30:24

They're not expecting 20 minutes of manual therapy and then 40 minutes of instructed exercise prescription, unless that therapist clearly identifies that is how they operate their practice.

Eric: 30:32

Right, there's a few out there that do that, but it's not the norm. Yeah, exactly. So where does that leave us? I guess the thing is, too, is if we look at it and how the standards of practice are defined. And I don't have that in front of me in terms of like in BC, in our bylaws, like you're only supposed to be able to work within your scope of practice, within your competency level. So if we're going to say, okay, you know what our competencies, personal competencies, for most of us is pretty low when it comes to therapeutic exercise prescription, because we're not exercise physiologists, we're not kinesiologists, we're not strength and condition um, trainers some of us are, but most of us probably aren't. If we don't have that extra level of education, then we should hopefully, at least according to the bylaws, say stay in your lane, don't do too too much. Yeah.

Eric: 31:26

But I guess the question is is how do we know what too much is? Or how do we know, do we recognize that we don't have enough information or enough education? Goes back to my earlier point is a little bit of information can be a bad thing. So I think we need to accept that we just we actually don't in the entry to practice education. We don't have enough exposure or training to be good at therapeutic exercise other than basic stretches, basic strengthening.

Eric: 31:54

I hear what you're saying and I think that a lot of times people probably go above and beyond, thinking that they know more. Like, so say, like you use a cardiovascular one example, right? Like if someone comes in, they're on a bunch of different medications, maybe they've had heart surgery, maybe they have a pacemaker and they're taking beta blockers, how are they supposed to know? Like, how are you supposed to know if you don't have the education or training what's good or not good? Right, you're supposed to refer out. And do we? I'd like to say we do. I'd like to think we do. I'd like to think we do, but we might not, I don't know.

Michelle: 32:32

I think. I think we need to know, like you said earlier, just to refer out when it's over and beyond our competency, right. But then that's where I would question and or challenge when curricula is being created and they use the practice competency standards, the practice competency standards, why do they not create more time and more in-depth information then for TheraX in the program, knowing how in-depth the therapeutic exercise competency standards are?

Eric: 33:04

Yeah, and that's a good point, and we'll talk about the PCPIs in a minute here, because I think that that would be worthwhile and we can kind of probably move from that into talking more about kind of curriculum. But before we do that, I wanted to just highlight a couple things that I find are concerning about this National Standards of Practice document. Like I said, I don't really know who writes these or who approves them, but I look at these things and I think whoever is writing these actually doesn't have a strong understanding of the literature. And this is the thing that keep I keep finding everywhere, everywhere I look, I'm thinking who's coming up with these things? Because you're making statements in these national standards that are non-evidential, right, and so the one like the one where you brought up about other manual methods being like okay, well, manual means by hand, so why are we allowed to do exercise? They should change that Right.

Eric: 33:59

But one thing here it says to it says the prevention of physical dysfunction. So again, again. This is interesting because two questions here. One is what do they mean by physical dysfunction? What is dysfunction? Dysfunction if you ask most people in the msk world, they'll come up with, like you know, some type of physical diagnosis which is kind of made up. You've got, you know, scapular dyskinesis or you've got a rotated this or a hypertone, hypotone, this, like they're looking for, like things that are broken. You're like that's what most people hear when they say dysfunction, which we know is that's kind of like nonsense and that stuff doesn't really exist, uh, the way that a lot of people want it to. So that's one thing. And then the other one here that really kills me is prevention. There's actually I've never seen one thing and I hope, if someone listens, and maybe I'm wrong, but I don't think so I've never once seen that massage or manual therapy prevents anything.

Michelle: 34:59

I 100% agree with you and ditto I can say evidence-based exercise has a huge, huge wealth of research to show the prevention of multiple um conditions down the road in a person's lifespan. But I've never come across any research that says massage therapy um prevents physical dysfunction.

Eric: 35:22

Exactly and then what is dysfunction? You know? It says it prevents your physical dysfunction, exactly. And then what is dysfunction? It says it prevents your physical dysfunction, injury and pain.

Eric: 35:29

Now I can guarantee that somebody's listening to this being like my people come to see me and I treat them as part of their treatment plan and it prevents them from having pain flare-ups. We could say, okay, maybe in certain populations, and we're never going to argue your clinical experience as being wrong. But if we're looking at population-based stuff, not just individual experiences, the statement that massage therapy can prevent physical dysfunction or can prevent injury or prevent pain is not evidence-based, a hundred percent. Not that there's no way that's evidence-based. Now, if we move down to another section on here and this is why I wanted to bring this up, because it's so contradictory it says massage therapists ensure that the patients receive the highest quality, evidence-based care in the treatment, management and prevention of MSK dysfunction and disorders. On the previous line, they call it physical dysfunction. The next paragraph, they're calling it MSK dysfunction and it says that we ensure that people receive the highest quality, evidence-based care. Well, your statement is not evidence-based.

Eric: 36:41

Exactly, it's so contradictory it's so contradictory and I just read this I think this is a problem that we have with our profession is that even the people leading leading the ship don't really understand the literature, the science, yeah, the best practices and yeah, I'm sure if you ask any massage therapist there, everyone's going to want to say court, I want to provide evidence-based care. Evidence-based care is the best. It's going to provide me the highest chance of having more positive outcomes for my patients, my clients. Any rmt would say, anybody in health care would say, of course I want to give evidence-based care, I don't want to give make-believe care. I said at least that's what. But we know, and just kind of going. Let's go back to the conversation we're having about, about therapeutic exercise. With therapeutic exercise education we're getting it's not evidence-based, correct. So the whole it's just filled with so many problems yeah, it's like a big slice of swiss cheese.

Eric: 37:49

Tons of holes everywhere, right, tons of holes everywhere right, tons of holes everywhere and I'm not going to read this whole document, but it's.

Michelle: 37:56

But, yeah, it's disheartening. But on the positive side, that's where these conversations bring forward, that shed some light to our colleagues about. Hey, it's okay to ask these questions, right, how can we be confident in what we do if we're just following the herd? Right, let's start asking these questions and every facet of our scope of practice, of our you know what your bylaws say, not just around exercise, but you know everything else. So the people who even wrote this, do they even know what evidence based means if they've made the statement ahead of time that you know isn't evidence-based, right?

Eric: 38:42

so these are such important conversations to have. Some people might hear it as us kind of whinging a little bit and you know, you know there's all the problems but there is solutions always solutions there's always solutions and they're easy solutions and I have lots of solutions. I'm sure you have lots of solutions.

Eric: 39:00

I know you have lots of solutions as well, uh it's just a matter of of having the people, the stakeholders and the curriculum creators and and all the associations and colleges involved to actually say, hey, you know what the public deserves better, most importantly, and our profession deserves better. The amount of times that I do a webinar or do a course where people are like so basically, what I'm hearing is that kind of everything I learned in school is incorrect, I'd say, well, not everything, but a lot of it is, and you deserve better no-transcript.

Michelle: 40:01

Don't play the victim, right? School was intended to give you, to give us the basic entry to practice knowledge that we needed. So what we know is evidence-based, are the anatomy, the physiology, the pathologies, and it's given us that platform, then, to move further and our responsibility is to seek out more education, to seek out better standards of practice, because even a physician who went to school 30 years ago would say the same thing. Oh, so what they taught me in med school 30 years ago is just a load of crock. Probably a good chunk of it could be, because we're in a health care, health science field. Everything is always evolving, right? What we talked about today, in five years from now, there might be some new evidence coming out about exercise that maybe says we shouldn't be giving people therapeutic exercise. Right, we don't know that.

Michelle: 41:01

So when we went to school, those people at that time and that curriculum and those instructions or instructors and institution did the best they knew of for that time and nobody was calling them out because it was just smooth sailing. Everybody was doing that, you know now for sure, we're picking apart that, that level of education, and we're saying, yeah, a lot of the stuff we learned was not evidence-based or best practice, but without that diploma that you earned but without that diploma that you earned, you wouldn't be where you are today, right? So be grateful for the people right now that you're taking these webinars from and these lessons from and saying, hey, at least I have the foundational knowledge that I need in anatomy and physiology and systems and pathology to understand what Eric is telling me about pain. Right, because if you didn't get that information when you were in school, how would you be able to compute the neuroscience of pain when Eric's talking about it? Right? So I'm going to be transparent and probably ruffle some feathers.

Michelle: 42:09

It annoys me when people are like, well, so school taught me nothing. There's always something school taught you, and the most important thing is that school is meant to be a safe construct and they have to teach within the confines of whatever curriculum they've sent to their provincial governing body, their Ministry of Education, that gets approved and gets sent back, so they can only do what they do within those confines because somebody else has approved it, right? Everything else outside of that, it's your responsibility to keep challenging and keep learning and keep growing. Right? Could it have been done better? Absolutely, but 20 years ago, there wasn't an Eric, there wasn't a Michelle hanging out, we weren't challenging these things. So school is a good thing and school is a reflection point.

Michelle: 42:58

For you to say, aha, then maybe I need to stop believing everything I hear and see Right, ie, instagram, ie, tiktok, right, and that, bringing that back to this whole exercise conversation, there's so much garbage in the world of social media about exercise that those people who consider their school experience to be negative and not good. I also challenge you to stop watching TikTok and stop watching Instagram and learning about exercise, because it's garbage. Right. Take the classes, do the webinars, learn from the people who actually have the experience and the education, and don't learn from the influencers who are online when it comes to, when it comes to those important topics that we're responsible for pursuing evidence based education from. So that's my soapbox. I'm going to leave it there.

Eric: 43:51

Thanks for saying all that, michelle. I love it, that's true. Going to leave it there. Thanks for saying all that, michelle. Yeah, I love it, that's true.

Eric: 43:59

It is frustrating when people start to they they don't like that to, they don't want to admit or they don't want to hear that what they've learned might not be enough. But you make such a good point there about people you know you wouldn't be having this conversation if you didn't go through that and there is a lot of good foundational stuff in there and I think one of the best things that we learned, I remember learning from massage. You learn how to give a good massage. They're gonna make people feel good. You learn how to feel comfortable. You know touching different bodies and different body types and you know meeting different. You know trying to help people who have different expectations, or you know goals from from their massage. So you learn a lot of good stuff and obviously the anatomy, the physiology and the the basic kind of foundational sciences is great, um, yeah, so I think that's we just need to. We need to challenge the challenge things, but you also need yeah, there's stuff in there that is important.

Eric: 44:56

There is, yeah, a lot of stuff that may not have been important, but focus on what was important, and it's what's brought you to where you are today, right, yeah, exactly, and I think I'm going to do another episode on this actual standards of practice document Because I think there's a lot of things in here I want to talk about, but as soon as I do, we're going to this will be like a seven hour episode, so I'll I will just go on to the next one. But you I think you did mention too about massage therapists respecting their roles and responsibilities and working with healthcare professionals, and you kind of mentioned earlier the importance of referring out and knowing and knowing who right.

Michelle: 45:36

Look around the community and know who those people are, so you can develop good professional relationships with them and send people their way, and then, vice versa, they will send people your way too, and I can say that direct from experience. I have a whole team of other healthcare providers who we send people back and forth all the time, and that's that's quality care, that's evidence-based care.

Eric: 46:02

Yeah, that collaboration with other healthcare professionals and patients usually like it, you know, when they they feel that you're have their best interests for them, and that's how we get more referrals and you, you know, you get them come back next time something else happens with them. It's, it's important, yeah, yeah. So let's talk about the uh, inter-jurisdictional practice, competency, competencies and performance indicators, the pcpis. My the biggest problem well, god, I can do the whole episode on these that one of the biggest problems I have with this document is it hasn't been updated since 2016. Right, or in 2024.

Eric: 46:37

Yeah, that's a long time and I look at this thing and it just makes me cringe. And we're not going to talk about Section 3.2, for example, which is about all the how to do different techniques. We'll talk about the therapeutic exercise component, which is Section 3.3. Tell me your thoughts about this. What do you, what do you feel is good and or bad with, with this, the competencies?

Michelle: 47:02

with the competencies.

Michelle: 47:04

Hey well, like the first one we talk about is perform a direct patient client in stretching demonstrate knowledge of indications, safety considerations, effects and outcomes of stretching, direct patient clients in stretching and incorporate these different types of stretchings into the treatment and modify the stretches based on patient or client history, presentation and response.

Michelle: 47:27

Um, this to me is a very generic um map and to me, when I read this, I think of they're assuming it's the average, not the average. I'm assuming it should be directed to a healthy individual who has zero, zero diagnosis other than they're there for a massage, right, completely healthy. They don't have type two diabetes, they don't have, you know, osteoarthritis. So it's just basically saying here's your ideal person, with no other issues, and show them how to stretch. But we know that's not the case, right? So they're not allowing room for special considerations, right? They're not requiring us to know all of the different pathologies as they relate to exercise prescription. As they relate to exercise prescription Because, as we know, when we go through school we learn about the pathologies and as it relates to massage therapy, right, but we also need to be looking at those pathologies as it relates to giving people therapeutic exercise.

Eric: 48:47

And it also says in here too, it talks about, you know, other things with therapeutic exercise In addition to stretching. They talk about range of motion exercises, strengthening exercises, cardiovascular exercises, proprioception exercises and exercises to restore capacity and activities of daily living right.

Michelle: 49:06

So I'm like, oh, there's my physio and my occupational occupational therapy friends, right like it's.

Eric: 49:12

It's a huge amount of exercise intervention that they are including in this document that I don't even think is nearly close to being addressed at the academic level for massage therapists academic or practical level or practical correct, yeah, because I don't know what other people's experiences are, but I could say very comfortably that probably at least 95 percent of my clinical hours at school were predominantly people that just wanted hands-on, and even if you wanted to do exercise, it was never really. It was always so basic. Because one thing is you didn't have the time or the space and we didn't have the education to assess and prescribe within a therx type environment yeah and, and like you said too, like I don't know, the therapeutic exercises.

Eric: 50:11

I think, if I remember correctly, it was like halfway through the program and it was maybe two classes a week for one term, so seven hours a week for 12 weeks, whatever how many hours, like you know, you're not, that's not a lot, you know, and that includes all of this stuff right versus Versus an OT, for example. So my sister is an occupational therapist. It's a two years master's degree where all you're doing is working on different populations to restore capacity and activities of daily living.

Michelle: 50:46

Yeah.

Eric: 50:47

Like that's what they do, that's their specialty.

Michelle: 50:49

So yeah.

Eric: 50:50

So we get a class on that? Okay, it's in our competencies, but do we actually have the skills to do it? I don't know. Probably not, not when we're looking at who's better at it. Mm-hmm. What I would look at with these things. Here is one. Obviously, my go-to solution is increase the hours, increase the education. Right.

Eric: 51:15

Yeah, and I know a lot of people fight back on that, but whatever, that's fine, they can. I think that's where we need to go. The other one, though, is say, rather than directing them all these things, there should be a thing on recognizing when to refer it out.

Eric: 51:30

Yeah fur out, yeah, or something in here about. You know recognize when this needs something beyond your, your scope or beyond your, your expertise. Because how are you supposed to direct a client in cardiovascular exercises in the clinical treatment room? At least give them advice, but how are you supposed to monitor? How do?

Michelle: 51:52

you monitor it? How do you? How are you supposed to monitor? How do you monitor it? How do you? How are you supposed to provide, how are you performing baseline testing to know where they're starting from Right? How do you? How are you? How are you?

Michelle: 52:03

doing that and that's the question I pose. You know, as the exercise physiologist, is if your client patient comes to see you and they've just had a coronary artery bypass surgery and they've been cleared to drive to get to see you, to come for massage, and let's say they aren't connected to any rehab programs or anybody else the first person they see, how are you going to know what to do to tell them where they're supposed to start when they're resuming their cardiovascular activities? Sorry, but you're not right, unless you have the prior training, the prior experience. I mean, I wrote a cardiac rehabilitation program so I can tell you right now what to do. But I always am very clear to my clients. I say okay, I'm taking off my massage therapist hat and I'm putting on my kinesiologist hat.

Michelle: 52:53

This is Michelle, the kinesiologist giving you this information, not the massage therapist. Because we're not taught that level of knowledge in our, you know, in our school experience. Nor is it clearly stated in these practice competencies that we should know, you know, know about these special populations and how to direct the patient or client in cardiovascular exercise. So I think, um, I think, I think this, I think the practice competencies need to define um when it comes to exercise, um say like intermediate or beginner level movement patterns, or define the intensity or the appropriateness of the exercise, and then anything above and beyond that refer out right.

Michelle: 53:49

Um, so if your patient comes to see you and has no cardiovascular contraindications, prior history diagnosis, then you can demonstrate your knowledge of prescribing some cardiovascular activity. Telling someone to go for a walk is perfectly safe, perfectly fine, easiest thing to do, but if that person is coming to you and they've just had this major surgery and they're on this battery of medications, telling that person to go for a walk, there's more to it than just that right? So I think the performance indicators could be more clearly defined and scaled back. So it's reflective of a what I consider like a personal trainer, where you take a weekend course and then you're a personal trainer. Because they're assuming you're working with an average, healthy individual without any other complicated health history, right, and even then probably you know, if every massage therapist took a basic personal training certification course, even then they're probably going to learn more about exercise than what we learn in massage school.

Eric: 55:01

I 100% agree with you there, michelle, because it does say in the indicators. It does say demonstrate knowledge of indications, safety considerations, effects and outcomes, effects and outcomes. But I would be hard-pressed because I've seen the therax textbooks that they use in most schools and it does not really go into much detail for those at all. So even though it's in here, I would say it's probably lacking because, I mean, the reality is right.

Michelle: 55:30

Our patients are getting more complex as they come to see us, with more and more different health conditions cropping up and being diagnosed. That a lot of it is is kind of not over our head, but a lot of it needs to be referred out, right? Know your lane, stay within it yeah, right yeah, respectfully, like that's that's what it boils down, right yeah, respectfully, like that's that's what it boils down to, right yeah.

Eric: 55:57

Yeah, I think that's, that's a. That's a good way to kind of summarize a lot of the stuff. Is that therapy exercise based on the definition? It looks like it shouldn't be within our scope of practice based on the massage therapy definition, but it is in our PCPI so it's considered we. It is within our scopePI, so it's considered we. It is within our scope but we probably most of us don't have the required education, knowledge, skills to be very effective with therapeutic exercise and a lot of cases it's probably best to refer out.

Michelle: 56:32

Yeah.

Eric: 56:34

Is that a fair summary?

Michelle: 56:35

I would agree. Yeah, and it's funny. You know how we talk about. Don't fall back and blame your school experience. I'd like to look at, like, who wrote these documents and what their level of knowledge is, because just reading the practice competencies again, I'm sorry if I offend the people who write this, but do you even know exercise? You know when you're writing this and how do you know how this correlates to what the schools have to ensure is being taught to their students? And my answer is probably not.

Eric: 57:09

I would agree with you and, based on all the different acronyms of associations and organizations out there across Canada, I would say most people that are in charge of things just don't have the knowledge Right and a lot of that comes from a profession that has a. I think it's getting better, but I think traditionally we have a bit of a culture of academic avoidance. Better, but I think traditionally we have a bit of a culture of academic avoidance. People just don't. We don't have enough people that are really wanting to pursue, you know, academia in the, in the profession, unfortunately. But I can understand why. Because what's the leave like? What do you, what do you do with it?

Eric: 57:47

You know I, I know I've met and what searched out a handful of the rmts that have a phd across can, but very, very, very few of them are involved at all in the massage therapy profession, cause they get their PhD and they go work at a university or they go work research, doing something else it's totally unrelated to massage, because it's kind of there's there's nothing here for that. So, you know, until I think we start getting more people in positions of the have required or a higher level of education and knowledge, particularly when it comes down to, to research and knowledge, translation and research. Until we get those people involved with the stakeholders, I don't think things are going to change very quickly, if at all, because my worry is Sorry, go ahead, Michelle.

Michelle: 58:41

I would agree on that Absolutely.

Eric: 58:44

I would say that if they did this today, if they say this is September 2016, when they last did the PCPIs, the competency document I would say, if this came out september 2024, I would be surprised if it was vastly different from this. I bet you, eight years later, it probably looks very much the same, because you probably have the same people or similar people writing it, and so I don't know if anyone's listening. I have a whole list of people that I could recommend that would be very well suited to help push these things into a higher standard and still stay within our scope 100% right, and how fantastic would that be to for our profession and to elevate the up and coming.

Michelle: 59:30

you know massage therapists who are in school or who are considering you know going to school for massage therapy amazing, awesome, yeah well, thanks for that today, michelle, that was.

Eric: 59:43

That was really fun. I really enjoyed that conversation. I hopefully the listeners got something out of that. We covered a lot of a lot of things, yeah.

Michelle: 59:51

Yeah, it was great and I think I think it's a good. It's a good perspective to consider for everybody. We always have a role in helping our patients and we always have a role with respect to promoting movement and activity. I would just caution the listeners not to use blanket prescriptions. Don't go tell everybody to go try yoga. Yoga classes can do a lot of harm. Not saying yoga is bad, but you know a blanket statement of go do some yoga isn't going to help your person. But the easiest thing to do is say, hey, when was the last time you went for a walk, right, and just breaking it down, getting down to the basics of things with people and just have going to be more beneficial than you telling them to go and stretch their neck for 30 seconds. So give them that pat on the back instead.

Eric: 1:01:05

Well done, michelle. Good summary. Thank you for that today, Until next time.

Michelle: 1:01:09

Yeah, thanks so much again, eric. I appreciate the time.

Eric: 1:01:11

Thank you, thanks for listening. I appreciate all of you 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 platforms. You can always follow me on Instagram or Facebook at EricPervisRMT, and please head over to my website, ericperviscom, to see a full listing of all my live courses, webinars and self-directed course options.