July 11, 2024 • 61 mins
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and I stress the significance of continuous learning, critical thinking, and seeking credible sources to challenge outdated practices and advance the field.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.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Eric (00:07):
Hello everybody and welcome to another episode of
Purves Versus, and we haverepeat guests.
This is her third time on thepodcast and that's Michelle
Smith joining us from Saskatoon,so thanks for being here,
michelle.
Michelle (00:17):
Thanks for having me again, eric.
Eric (00:19):
One thing that I love is when guests reach out to me and
they say, hey, do you want to doa podcast episode about insert
topic here?
And I said, sure, let's do that.
So Michelle wanted to talkabout a therapeutic exercise and
kind of have a littlediscussion about is this
something that we actually knowenough about?
Is it actually should it beconsidered within our scope of
(00:42):
practice and what would beobviously a better way forward?
What could we do to make surethat we're more competent in
therapeutic exercise?
I think this is an interestingconversation, so I'm looking
forward to seeing what you haveto say about that, michelle.
Michelle (00:56):
Yeah, thanks, I am too , and I'm grateful that you're
having me on to share this kindof topic with the rest of the
RMT world.
Eric (01:04):
I think, just to start with, this is the idea of
therapeutic exercise, issomething that we all have a
TheraX class and it's somethingthat is in our competency
documents.
But I think the discussion thatMichelle and I want to focus on
today is to really pick apart.
Do we actually, are we trainedwell enough to provide exercise
(01:25):
prescription, to know enoughabout the indications or
contraindications of when isexercise appropriate?
I think you may you make somegreat points in some of the
discussions we had off airmichelle about we might, even
though it's in our it's in ourdocuments and then we're allowed
to do it.
Michelle (01:49):
Should we?
Yeah, should we is the question, and I just want to be
transparent and say I'm comingto this podcast wearing two hats
.
Today I have looked into thescope of practice for
therapeutic exercise for massagetherapists is my original
education and career backgroundis as a kinesiologist and
(02:13):
exercise physiologist, and sowhen I was training to be a
massage therapist and we did ourTherx class and we did our
(02:36):
Therx class respectfully it waslaughable in terms of the type
of information and the amount ofinformation that was delivered
to the students wasn't relevant,based on the fact that when
clients or patients come to seeus for massage therapy, probably
90% of them will have someother co-occurring medical
(02:58):
condition and will have multipleco-occurring musculoskeletal
limitations.
And so to appropriately assessthose concerns and provide the
you know, the therapeuticexercise that we're taught that
to do, I don't necessarily feelbeing in the massage therapy
(03:22):
treatment room is the rightspace, nor do we have the right
time to do so, but again, I'mbringing in my experience
working, as you know, akinesiologist and saying you
could bill a full hour of justassessment and exercise
prescription on top of yourhands-on manual therapy.
(03:42):
So there's couple of key thingsI think that the public are
expecting when they see amassage therapist.
I mean one is they wanthands-on manual work.
And then, two, they're going toask is there anything else I
can do at home or outside of thetreatment room, you know, for
exercise or movement?
And our first line of ofexercises here do this stretch
(04:06):
right?
Um, which I'm not saying iswrong, um, any movement is good
movement.
However, um, I would caution theaverage massage therapist who
doesn't have any umextraordinary training in um
exercise, health, fitness,fitness, to try to take on that
(04:26):
role of having a completelydeveloped exercise therapy
program for your patients Ifyou're not aware of the proper
contraindications, propermodifications, proper
physiological responses thatyour patient might have if
(04:46):
you're giving them this programright.
And so I guess, for an example,eric, let's say I was seeing you
and I'm taking metroprolol formy blood pressure or for my
heart rate, sorry, and you'relike well, yeah, just start
walking.
Well, eric, what do I use toevaluate my effort when I'm
walking, knowing that I'm onthis medication?
(05:07):
What are you going to tell me?
Right, and that's something wedon't learn in massage school.
But as an exercise physiologist,I'm going to tell you we can't
use your target heart rate as avalue to assess your intensity
when you're on that type ofmedication, right, we have to
use other assessment forms toensure that you're exercising at
(05:27):
a level of cardiovascularfitness that's still going to
keep you safe, within thoselimits of your heart rate, which
is being, you know, reduced bya pharmaceutical agent.
So I guess that's where I'msort of looking at the big
picture from, because when wetalk about our you know our
practice competencies, there'sthat huge section on therapeutic
(05:50):
exercise, and cardiovascularexercise is one of them, right,
but to what depth are massagetherapists being taught the
level of knowledge aroundcontraindications and
indications around exercise,right?
Eric (06:08):
Those are some great points, michelle, and one of the
dangers with education isknowing a little bit can
sometimes be more harmful.
We could say that with a lot ofthe things in massage school
and anyone that listens to thepodcast or knows me.
I'm always critical of thecurriculum 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'tchallenge and we don't ask hard
(06:30):
questions, then we're nevergoing to improve.
And when we look at therapeuticexercise, for example, we get
so like.
I remember I mean it's a longtime ago and it was over 20
years or 20 years ago now when Iwent to massage school and we
learned we had a therax class,but I don't remember anything in
the class learning aboutcardiovascular or learning about
(06:51):
optimum dosages or or anythingmore than like this is how you
do a stretch.
Michelle (06:58):
This is how you do a strengthening thing.
Eric (06:59):
It was usually just linear , like flexion, extension of
this joint.
It was very, very rarely wasexploring functional movements,
whatever functional movement islike, like task specific
movements it was.
It was never.
It was always very like youbroke it down these little
pieces and it was like, oh, youdo five or ten of these and then
repeat it times three and thendo it every second day or
(07:19):
whatever, and it was so genericand even when you did your exams
and your board exams, that'sall they were looking for.
Going back to what I said aboutknowing a little bit of
knowledge might be dangerous isthat you learn this and you
think, ok, I guess that's all Ineed to know, right?
Yeah, you don't even and youknow it's not even addressed
that there should be or therecould be more specific to that.
(07:40):
You have, like I said,kinesiology, exercise,
physiology yeah, physiology,yeah, you know that's what you
do right so and I'm just curiousthough, because obviously this
is not my area of knowledge Iknow a little bit, but I think I
know a little bit, so I don'tknow enough.
And this is great that youwanted to have this conversation
.
When you took, when you saidthat you went to massage school
and you said that you had yourtherics class, and it was
(08:02):
laughable.
What kind of things were theyteaching you that were that you
feel you can remember wereshouldn't even have been
addressed because it was just soinsufficient.
Michelle (08:18):
Probably the first thing that comes to mind is,
yeah, giving somebody a stretchor an exercise using a soup can
as their weight without evenassessing their, their movement
or their strength first.
Right, so you've had a chanceto treat this person on your
(08:40):
table.
And let's say you know they'recoming in with a sore shoulder
and and you've done your, yourtreatment on the table, and then
your home exercise program is,you know, do a deltoid stretch
and then do some front raiseswith, with a soup can to add
some strength to that shoulder.
But how do you know theshoulder is weak if you haven't
even tested it?
(09:01):
Right, and I know strengthtesting there's evidence to
support that.
It isn't really all that great.
It's kind of very subjective.
But anytime you pursue adviceor you pursue giving people some
sort of take home exerciseprescription or exercise program
(09:23):
, home exercise prescription orexercise program, you also have
to think of what are you basingthat program on?
What have you done todemonstrate or to determine they
need this front raise with asoup can or they need this
stretch?
If all you've done is thehands-on manual work, right,
because there is a protocol inplace that you should do to to
(09:46):
measure and evaluate.
You know how this person'sfunctioning, how they're moving,
what their strength is, whattheir deficits may be, and then,
based on that, okay, is this,is this?
Is this something that is, youknow, preoperative,
postoperative, is this arthritic?
Right?
Then you decide what type ofexercise to prescribe, as well
(10:08):
as the frequency and intensityof that exercise, right?
So I just think.
I think the world thinksexercise is just so easy and so
basic that anyone can like tellsomebody to go and do a front
raise with a soup can or adeltoid stretch.
But in actuality, in atherapeutic setting, there's a
(10:32):
lot of information that you haveto gather first and a lot of
critical, critical thinking youhave to do in order to provide
effective and evidence based andand safe, quality therapeutic
exercise, right?
Um?
So just diving in and saying,okay, go, do these soup can
(10:53):
raises at home now and do 10repetitions for three sets a day
, every day, until I see younext.
What are you doing with that?
Right?
And the other thing that was nottaught was how are you going to
evaluate the progress of thisperson?
Right, because in my world, inmy original profession, you
(11:15):
would see this person every weekor sometimes every day, and so
you would like create a hugeprogram for this person and
design a program for this personin all these macro cycles and
micro cycles so you couldprogress their um, their
improvement along the way, oreven progress their decline,
(11:37):
right.
And so I think, um, given thespace and the context that we as
massage therapists have in thetreatment room when we're in
school, I think the, the levelof exercise education we're
given is just to be kind of likeband-aid fixers or like just a
little cherry on top of of theof the treatment, just so we can
(11:58):
say we've given them some, someeducation on here's how you do
a stretch and here's how you dolike a dumbbell, front or front
raise right, which I'm notsaying at all is bad or nor is
it harmful.
I'm just saying it's not goingto be as effective as I think we
were taught to believe when wewere in massage school.
(12:19):
Right, even stretching.
There's so much research aboutstretching and how really
ineffective it is.
That why, why are we stretchingthings right?
Or, you know, people come withus with sore muscles, while
those muscles could be sore notbecause they're tight, but
because they're weak, right, andunless you really understand
the analysis of those muscles ofhow to determine is this
(12:42):
tightness from weakness versustightness from being tight and
needing a stretch?
Why are we giving peoplerhomboid stretches when they're
feeling tight?
Because those rhomboids arealready so overstretched to
begin with from their habitualmovements throughout the day.
So, in my opinion, you knowalways, always advising some
(13:04):
movement is a benefit for people.
But when it comes to thoselaughable moments in my Fairx
class, really, it was justhere's how, here's how you teach
your patients how to stretchright, um, which may be good for
somebody who's never done anymovement to begin with and it's
very unfamiliar with their body,um, but then, once you deliver
(13:29):
that message to those patients,what are you doing with it?
What are you doing to monitorthe results?
What are you doing to modifythe results?
If they come back to you in amonth's time saying I've been
stretching every day and thatneck still is tight and still as
cranky, well, what does thatmean?
What is that telling you?
Stretching every day and thatneck still is tight and still is
cranky, well, what does thatmean?
What is that telling you right?
And so I think that's where, umI'd mentioned to you earlier.
(13:51):
Sometimes I felt like doingTherax in massage school was
akin to when physicians domedical school and they take
like a five-hour class onnutrition and all of that you
know education they take andthey're only given a small chunk
of education on nutrition andall of that you know education
they take and they're only givena small chunk of education on
nutrition.
And then when they counsel theirpatients, they really don't
know as much in-depth knowledgeas, say, the dietician you know
(14:14):
who has her four-year, hisfour-year nutrition degree.
So, circling all this back, Ithink that I think we can do
better in the world of educationfor massage therapists and we
need to do better, especially ifit is in our practice standards
(14:36):
.
I still don't know if, if weinterpret our scope of practice
of massage therapy, I mean right, we talk about it being within
our scope of practice, but whenyou read a scope of practice of
massage therapy, I mean right,we talk about it being within
our scope of practice, but whenyou read a scope of practice it
doesn't actually state exercise,right.
So I think our practicestandards need to put a put a
(14:59):
microscopic lens on the exerciseand the therapeutic exercise
and up the ante on it when itcomes to the education component
.
But I also think our scope ofpractice needs to either stop
misinforming us that it iswithin our scope of practice, or
it needs to clearly state thatit 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 NationalStandards of Practice definition
in a minute.
I.
Just before we do that, I justwant to go back to what you're
saying, too about, about thestretching thing, because I
think you brought someinteresting things there.
You know, the idea is like whydo we stretch and what is the
purpose?
Right, and this is a thing thatmassage therapists across,
let's say, across the worldacross canada.
(15:42):
Anyway, where we are, that's thekind of the go-to home care oh,
just do some stretching.
And then when people do alltheir stretches and they come
back and they're still in pain,they're like oh, we just gotta
stretch more than, or you gottastretch harder, whatever it
might be.
And there is thismisunderstanding that stretching
actually does more than itreally does, because we know
(16:06):
that stretching doesn't actuallyreally change the length of
tissues for a very long, veryshort period of time, right, and
we know that stretching isn'tstrongly associated with injury
prevention.
We know that stretching is notnecessarily related to increased
(16:28):
athletic performance.
But we know that there's somethe the data on it is all over
the place, right, there's somethings say does something
positive, some say it doesnothing, and then probably the
truth is probably somewhere inthe middle.
But I say the way I interpretthe stretching literature and
the way I communicate it withpatients is would you like to
(16:49):
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 ohpatients, they don't ever do the
stretches and they come backand wonder why they're still in
pain.
I'm thinking it might still bein pain even if they do the
stretches every day.
Maybe stretching isn't thething for them.
Michelle (17:14):
Yeah, exactly.
Eric (17:15):
It goes back to that little bit of knowledge.
I think in our profession wefeel that stretching for example
, does more than it should orthan it could, and so I just
wanted to bring that back.
And because the purposeoftentimes is oh, we need these
things to be longer, well, doesa longer or more flexible muscle
is that more associated with?
(17:37):
Is that associated with withless pain?
Is a stronger muscle associatedwith less pain?
Michelle (17:42):
not, necessarily necessarily.
Eric (17:43):
Not necessarily right.
Like their bodybuilders, havepain and they got tons of muscle
.
Yep, right Gymnasts and figureskaters and you know people that
and dancers that have tons offlexibility they still can have
pain.
Yeah.
And they don't need to stretch.
Yeah.
I think that these are, theseare good, good things to kind of
call out and really stop andreflect on what's the point yeah
(18:06):
, it needs to be meaningful tothe person well, exactly, and
that's I liked your, um, yourcomment 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 Imean and that's that's a huge
component of my kinesiologyeducation is trying to encourage
or support, or convince aperson to adopt a healthy
lifestyle and to exercise is asdifficult as trying to have a
(18:42):
10-pack a day or lifelong smokertrying to quit, right.
There's a significantpsychological component that we
have to be familiar with andvery understanding of when it
comes to exercise prescription.
First and foremost because if Icome see you and I have zero
(19:04):
experience with movement period,whether it's going for a walks
or whether it's being in arecreational dance class, um,
and movement period is not in mywheelhouse because I'm just not
a movement based person youneed to understand that, first
and foremost, right.
And so by asking me do you liketo move?
Do you know any exercises?
(19:26):
Do you know any stretches right?
What do you do for recreation?
If my answer is nothing and no,no, no, right, there is the
first indication that, okay, Igot some work to do with this
patient.
And how do I elicit somepositive stages of change within
this person to help thembelieve that what I'm telling
(19:47):
them about exercise is actuallygoing to be a benefit.
Right and that's what I'veexperienced across the board,
regardless if it's with personaltrainers or massage therapists
is that the psychologicalcomponent to movement and
exercise is always overlooked inour clients and we just think,
(20:10):
well, because we're theprofessional and what we say
goes, that they're just going toadopt this and go with it.
But the reality is they aren't,and we have to be very
cognizant of what theirlifestyle is like and if they're
even open to wanting to learnabout different types of
stretching or different types oftherapeutic exercise, and so
(20:32):
the psychology of exercise isalso an evidence-based practice
that we're not taught in inmassage school.
Eric (20:40):
Not at all, and that's such a great point I mean, you
brought that up of thepsychological aspect because
we're dealing with humans, wehave to be knowledgeable of
psychology.
It's ridiculous for us to thinkthat might be out of scope.
We're dealing with a human, youhave to be appreciative of
their psychology.
Learned in my sport coachingeducation is you know, the first
(21:07):
thing that that you're supposedto focus on is the, the
psychological and mental healthof the athlete, and that's just.
We're speaking specificallysports.
But it would be the same thingwith when you're treating a
human in a massage therapy orexercise 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?
and recognizing that yeah,exactly rather than just
(21:30):
throwing the same process or thesame prescription or the same
advice at everybody, it has tobe tailored it has to be
completely tailored and you haveto also know which, by that
point, you should.
Michelle (21:43):
Are they seeing other health providers?
Right?
Because many of my clients cometo see me and they're already
connected to a physicaltherapist, or they're going to
the gym and they're seeing apersonal trainer Fantastic, you
know what I'm just going to saycontinue doing what your physio
or your kinesiologist has youdoing, or your personal trainer
has you doing, kinesiologist hasyou doing, or your personal
(22:05):
trainer has you doing?
Because, again, within ourscope of practice, we have to
have, we have to refer to thepeople who are the experts first
and foremost.
Right, I'm not gonna.
I'm not gonna say, oh well, Ithink you should change these
three exercises that your physiohas given you.
I'm not gonna step on their,their toes, not at all.
I'll collaborate with them,absolutely.
(22:26):
But if my client's telling me,yeah, this one stretch my physio
has me doing or my trainer hasme doing, I really don't feel
comfortable or I really get somepain, okay, well, let's, let's
talk about some alternatives andthen take that information back
to that person and and see ifthere's something you guys can
come up with, kind of halfway inbetween, based on the
(22:48):
recommendations I've given you.
Right is a more.
I mean is directly within theirscope of practice and they have
(23:08):
an extensive volume ofeducation and experience around
it.
Then let that person do theexercise prescription and let
that person address thetherapeutic exercise, so that
you're not clouding the waterper se.
Eric (23:24):
It's nice actually when patients come in to see you and
they've already have somebodyelse doing that stuff.
Michelle (23:30):
Yeah, it's great.
Do you like doing that?
Does that work for you?
Yeah, great, perfect Carry onRight.
Eric (23:36):
And then sometimes be like did you, you know, can you
share with me, kind of whatthey're doing, yep.
And then I'm like okay, thatsounds great, thanks for sharing
.
And then, yeah, and then I'mlike 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 agreat job, right?
I'm proud of you, and they wantto continue doing it.
Eric (23:58):
So it's amazing.
Yeah, that's amazing.
Uh, so I, a few minutes ago Imentioned I wanted to read the
national standards of practice,just to, so we can have a
conversation about.
You know, is therapeuticexercise, 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
(24:20):
are so many organizations andstakeholders out there.
There are so many differentacronyms that are involved in
the massage therapy profession.
I, to be honest, I kind offorget what they all do.
But anyway, that's maybe adifferent conversation, but this
here says so.
Massage therapy is the practiceof.
The practice of massage therapyis the assessment of the
musculoskeletal system of thebody and the treatment and
(24:42):
prevention of physicaldysfunction, injury and pain
pain by manipulation,mobilization and other manual
methods to develop, maintain,rehabilitate or augment physical
function, relieve pain orpromote health.
And there's another sentenceafter that, but I don't think it
matters as much, and the keypoint that you highlighted with
this is nowhere in here does itsay exercise, right, you know,
(25:07):
the practice of massage therapyis the assessment of the msk
system of the body and thetreatment and prevention of
physical dysfunction, injury andpain by manipulation,
mobilization and other manualmethods.
So it's interesting, isn't it,that, based on this definition,
that therapeutic exercise iseven within our scope, right?
(25:29):
I think it I like that it is Ithink we probably agree but if
we're going to be like, let'sask some hard questions here, it
shouldn't be actually based onthis.
So I wonder how they get awaywith that.
That's really interesting in bc, in our.
Our scope of practice here inbc is a little bit different
than, say, ontario, even though,and other regulated provinces,
(25:50):
because here manual means byhands and if anyone listening
goes online, you google likemanual, it's going to say to be
done by the hand or done by thehands.
One reason why we're notallowed to do a lot of things
like cupping or use othernon-hands-on interventions is
(26:13):
because it's not done with thehands, right?
Somebody reached out to me theother day and was saying oh, you
know why can't I?
you know why, in BC can't youguys use your feet?
And I was like, because it'snot your hands.
That's the way it's defineddoesn't mean I could care less
if someone massages you withyour feet.
Uh, probably feels nice, butthe the manual thing.
So when we look at this and wetake even a bigger look at it,
(26:36):
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 beforewe were recording, if you were
to read that through the lens of, say, a lawyer or an insurance
company, if someone had, forwhatever reason, said, oh, the
exercises Eric gave me caused meto have X, y and Z problem.
(27:05):
When you read that statement, itdoes not explicitly define
exercise you know, prescriptionor exercise recommendation as
our scope of practice, becauseit is of, you know, the manual
treatment or assessment of aperson's musculoskeletal system.
(27:26):
So it I mean right, as apracticing massage therapist.
It makes me confused, then,what does that mean for us?
Is it really within our scopeof practice, based on how, you
know, the regulatory collegesdefine it, or what this
paragraph had said?
And I think there needs to bemore clarity around it, and I
(27:49):
also would challenge that.
The clarity around it alsoneeds to then be passed on to
the practice competencystandards and the schools who
are, you know, writing thecurriculum for their x classes.
But from from on first glance,from my perspective, reading
(28:10):
that statement, no, exercisewould not be within our scope of
practice, even though we allknow 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 howmuch clout it would have right
(28:30):
To say that it is in our scopeof 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 kindof probably put in here.
I mean, they can seem like theycan kind of make this up as
they go, because they are theydon't.
I don't think they answeredanybody Right.
If I understand correctly, Iremember correctly, I believe
(28:55):
the professional associationsare 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 saymobilization and other physical
methods or just get rid ofmanual altogether and say other
methods.
Michelle (29:12):
Other methods right.
Other evidence, informed orother 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 rightum, 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 becauseI see, like those therapists
who are all like it's, it's inour scope of practice and this
is the way you know, we'retaught and we can do this.
And and then I see otherhealthcare providers who are
like no, stay in your own lane,it's not your scope of practice,
(29:49):
let these people do the workbecause it's within their scope
of practice and it's withintheir level of education and
competency, right.
And then you see the generalpublic who is like let's be
(30:19):
honest, when people book in fora 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 instructedexercise prescription, unless
that therapist clearlyidentifies that is how they
operate their practice.
Right, there's a few out therethat do that, but it's not the
norm.
Yeah, exactly.
So where does that leave us?
I guess the thing is, too, isif we look at it and how the
standards of practice aredefined.
And I don't have that in frontof me in terms of like in BC, in
our bylaws, like you're onlysupposed to be able to work
(30:45):
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 mostof us is pretty low when it
comes to therapeutic exerciseprescription, because we're not
exercise physiologists, we'renot kinesiologists, we're not
strength and condition um,trainers some of us are, but
(31:09):
most of us probably aren't.
If we don't have that extralevel of education, then we
should hopefully, at leastaccording to the bylaws, say
stay in your lane, don't do tootoo much.
Yeah.
But I guess the question is ishow do we know what too much is?
Or how do we know, do werecognize that we don't have
(31:32):
enough information or enougheducation?
Goes back to my earlier pointis a little bit of information
can be a bad thing.
So I think we need to acceptthat we just we actually don't
in the entry to practiceeducation.
We don't have enough exposureor training to be good at
therapeutic exercise other thanbasic stretches, basic
(31:53):
strengthening.
I hear what you're saying and Ithink that a lot of times people
probably go above and beyond,thinking that they know more.
Like, so say, like you use acardiovascular one example,
right?
Like if someone comes in,they're on a bunch of different
medications, maybe they've hadheart surgery, maybe they have a
pacemaker and they're takingbeta blockers, how are they
supposed to know?
(32:13):
Like, how are you supposed toknow if you don't have the
education or training what'sgood or not good?
Right, you're supposed to referout.
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 wemight not, I don't know.
Michelle (32:32):
I think.
I think we need to know, likeyou said earlier, just to refer
out when it's over and beyondour competency, right.
But then that's where I wouldquestion and or challenge when
curricula is being created andthey use the practice competency
standards, the practicecompetency standards, why do
(32:53):
they not create more time andmore in-depth information then
for TheraX in the program,knowing how in-depth the
therapeutic exercise competencystandards are?
Eric (33:04):
Yeah, and that's a good point, and we'll talk about the
PCPIs in a minute here, becauseI think that that would be
worthwhile and we can kind ofprobably move from that into
talking more about kind ofcurriculum.
But before we do that, I wantedto just highlight a couple
things that I find areconcerning about this National
Standards of Practice document.
Like I said, I don't reallyknow who writes these or who
(33:26):
approves them, but I look atthese things and I think whoever
is writing these actuallydoesn't have a strong
understanding of the literature.
And this is the thing that keepI keep finding everywhere,
everywhere I look, I'm thinkingwho's coming up with these
things?
Because you're makingstatements in these national
standards that arenon-evidential, right, and so
(33:48):
the one like the one where youbrought 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.
But one thing here it says to itsays the prevention of physical
dysfunction.
So again, again.
This is interesting because twoquestions here.
One is what do they mean byphysical dysfunction?
(34:10):
What is dysfunction?
Dysfunction if you ask mostpeople 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, scapulardyskinesis or you've got a
rotated this or a hypertone,hypotone, this, like they're
(34:30):
looking for, like things thatare broken.
You're like that's what mostpeople hear when they say
dysfunction, which we know isthat'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 herethat really kills me is
prevention.
There's actually I've neverseen one thing and I hope, if
(34:51):
someone listens, and maybe I'mwrong, but I don't think so I've
never once seen that massage ormanual therapy prevents
anything.
Michelle (34:59):
I 100% agree with you and ditto I can say
evidence-based exercise has ahuge, huge wealth of research to
show the prevention of multipleum conditions down the road in
a person's lifespan.
But I've never come across anyresearch that says massage
therapy um prevents physicaldysfunction.
Eric (35:22):
Exactly and then what is dysfunction?
You know?
It says it prevents yourphysical dysfunction, exactly.
And then what is dysfunction?
It says it prevents yourphysical dysfunction, injury and
pain.
Now I can guarantee thatsomebody's listening to this
being like my people come to seeme and I treat them as part of
their treatment plan and itprevents them from having pain
flare-ups.
We could say, okay, maybe incertain populations, and we're
(35:45):
never going to argue yourclinical experience as being
wrong.
But if we're looking atpopulation-based stuff, not just
individual experiences, thestatement that massage therapy
can prevent physical dysfunctionor can prevent injury or
prevent pain is notevidence-based, a hundred
(36:05):
percent.
Not that there's no way that'sevidence-based.
Now, if we move down to anothersection on here and this is why
I wanted to bring this up,because it's so contradictory it
says massage therapists ensurethat the patients receive the
highest quality, evidence-basedcare in the treatment,
management and prevention of MSKdysfunction and disorders.
(36:26):
On the previous line, they callit physical dysfunction.
The next paragraph, they'recalling it MSK dysfunction and
it says that we ensure thatpeople receive the highest
quality, evidence-based care.
Well, your statement is notevidence-based.
Exactly, it's so contradictoryit's so contradictory and I just
read this I think this is aproblem that we have with our
(36:47):
profession is that even thepeople leading leading the ship
don't really understand theliterature, the science, yeah,
the best practices and yeah, I'msure if you ask any massage
therapist there, everyone'sgoing to want to say court, I
(37:09):
want to provide evidence-basedcare.
Evidence-based care is the best.
It's going to provide me thehighest chance of having more
positive outcomes for mypatients, my clients.
Any rmt would say, anybody inhealth care would say, of course
I want to give evidence-basedcare, I don't want to give
make-believe care.
I said at least that's what.
But we know, and just kind ofgoing.
(37:32):
Let's go back to theconversation we're having about,
about therapeutic exercise.
With therapeutic exerciseeducation we're getting it's not
evidence-based, correct.
So the whole it's just filledwith so many problems yeah, it's
like a big slice of swisscheese.
Tons of holes everywhere, right,tons of holes everywhere right,
tons of holes everywhere andI'm not going to read this whole
(37:54):
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 somelight to our colleagues about.
Hey, it's okay to ask thesequestions, right, how can we be
confident in what we do if we'rejust following the herd?
(38:19):
Right, let's start asking thesequestions and every facet of
our scope of practice, of ouryou know what your bylaws say,
not just around exercise, butyou know everything else.
So the people who even wrotethis, do they even know what
evidence based means if they'vemade the statement ahead of time
that you know isn'tevidence-based, right?
Eric (38:42):
so these are such important conversations to have.
Some people might hear it as uskind of whinging a little bit
and you know, you know there'sall the problems but there is
solutions always solutionsthere's always solutions and
they're easy solutions and Ihave lots of solutions.
I'm sure you have lots ofsolutions.
I know you have lots ofsolutions as well, uh it's just
(39:03):
a matter of of having the people, the stakeholders and the
curriculum creators and and allthe associations and colleges
involved to actually say, hey,you know what the public
deserves better, mostimportantly, and our profession
deserves better.
The amount of times that I do awebinar or do a course where
(39:24):
people are like so basically,what I'm hearing is that kind of
everything I learned in schoolis incorrect, I'd say, well, not
everything, but a lot of it is,and you deserve better
(39:56):
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 weneeded.
So what we know isevidence-based, are the anatomy,
the physiology, the pathologies, and it's given us that
(40:21):
platform, then, to move furtherand our responsibility is to
seek out more education, to seekout better standards of
practice, because even aphysician who went to school 30
years ago would say the samething.
Oh, so what they taught me inmed school 30 years ago is just
a load of crock.
Probably a good chunk of itcould be, because we're in a
(40:44):
health care, health sciencefield.
Everything is always evolving,right?
What we talked about today, infive years from now, there might
be some new evidence coming outabout exercise that maybe says
we shouldn't be giving peopletherapeutic exercise.
Right, we don't know that.
So when we went to school, thosepeople at that time and that
(41:07):
curriculum and thoseinstructions or instructors and
institution did the best theyknew of for that time and nobody
was calling them out because itwas just smooth sailing.
Everybody was doing that, youknow now for sure, we're picking
apart that, that level ofeducation, and we're saying,
yeah, a lot of the stuff welearned was not evidence-based
(41:28):
or best practice, but withoutthat diploma that you earned but
without that diploma that youearned, you wouldn't be where
you are today, right?
So be grateful for the peopleright now that you're taking
these webinars from and theselessons from and saying, hey, at
least I have the foundationalknowledge that I need in anatomy
(41:50):
and physiology and systems andpathology to understand what
Eric is telling me about pain.
Right, because if you didn'tget that information when you
were in school, how would you beable to compute the
neuroscience of pain when Eric'stalking about it?
Right?
So I'm going to be transparentand probably ruffle some
feathers.
It annoys me when people arelike, well, so school taught me
(42:12):
nothing.
There's always something schooltaught you, and the most
important thing is that schoolis meant to be a safe construct
and they have to teach withinthe confines of whatever
curriculum they've sent to theirprovincial governing body,
their Ministry of Education,that gets approved and gets sent
back, so they can only do whatthey do within those confines
(42:33):
because somebody else hasapproved it, right?
Everything else outside of that, it's your responsibility to
keep challenging and keeplearning 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 andschool is a reflection point.
(42:58):
For you to say, aha, then maybeI need to stop believing
everything I hear and see Right,ie, instagram, ie, tiktok,
right, and that, bringing thatback to this whole exercise
conversation, there's so muchgarbage in the world of social
media about exercise that thosepeople who consider their school
(43:19):
experience to be negative andnot good.
I also challenge you to stopwatching TikTok and stop
watching Instagram and learningabout exercise, because it's
garbage.
Right.
Take the classes, do thewebinars, learn from the people
who actually have the experienceand the education, and don't
learn from the influencers whoare online when it comes to,
(43:39):
when it comes to those importanttopics that we're responsible
for pursuing evidence basededucation 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.
It is frustrating when peoplestart to they they don't like
that to, they don't want toadmit or they don't want to hear
that what they've learned mightnot be enough.
But you make such a good pointthere about people you know you
(44:15):
wouldn't be having thisconversation if you didn't go
through that and there is a lotof good foundational stuff in
there and I think one of thebest things that we learned, I
remember learning from massage.
You learn how to give a goodmassage.
They're gonna make people feelgood.
You learn how to feelcomfortable.
You know touching differentbodies and different body types
and you know meeting different.
You know trying to help peoplewho have different expectations,
(44:38):
or you know goals from fromtheir massage.
So you learn a lot of goodstuff and obviously the anatomy,
the physiology and the thebasic kind of foundational
sciences is great, um, yeah, soI think that's we just need to.
We need to challenge thechallenge things, but you also
need yeah, there's stuff inthere that is important.
There is, yeah, a lot of stuffthat may not have been important
(44:59):
, but focus on what wasimportant, and it's what's
brought you to where you aretoday, right, yeah, exactly, and
I think I'm going to do anotherepisode on this actual
standards of practice documentBecause I think there's a lot of
things in here I want to talkabout, but as soon as I do,
we're going to this will be likea seven hour episode, so I'll I
will just go on to the next one.
(45:19):
But you I think you did mentiontoo about massage therapists
respecting their roles andresponsibilities and working
with healthcare professionals,and you kind of mentioned
earlier the importance ofreferring out and knowing and
knowing who right.
Michelle (45:36):
Look around the community and know who those
people are, so you can developgood professional relationships
with them and send people theirway, 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 otherhealthcare providers who we send
people back and forth all thetime, and that's that's quality
(45:59):
care, that's evidence-based care.
Eric (46:02):
Yeah, that collaboration with other healthcare
professionals and patientsusually like it, you know, when
they they feel that you're havetheir best interests for them,
and that's how we get morereferrals and you, you know, you
get them come back next timesomething else happens with them
.
It's, it's important, yeah,yeah.
So let's talk about the uh,inter-jurisdictional practice,
(46:22):
competency, competencies andperformance indicators, the
pcpis.
My the biggest problem well,god, I can do the whole episode
on these that one of the biggestproblems I have with this
document is it hasn't beenupdated since 2016.
Right, or in 2024.
Yeah, that's a long time and Ilook at this thing and it just
makes me cringe.
And we're not going to talkabout Section 3.2, for example,
(46:46):
which is about all the how to dodifferent techniques.
We'll talk about thetherapeutic exercise component,
which is Section 3.3.
Tell me your thoughts aboutthis.
What do you, what do you feelis good and or bad with, with
this, the competencies?
Michelle (47:02):
with the competencies.
Hey well, like the first one wetalk about is perform a direct
patient client in stretchingdemonstrate knowledge of
indications, safetyconsiderations, effects and
outcomes of stretching, directpatient clients in stretching
and incorporate these differenttypes of stretchings into the
treatment and modify thestretches based on patient or
(47:24):
client history, presentation andresponse.
Um, this to me is a very genericum map and to me, when I read
this, I think of they'reassuming it's the average, not
the average.
I'm assuming it should bedirected to a healthy individual
(47:47):
who has zero, zero diagnosisother than they're there for a
massage, right, completelyhealthy.
They don't have type twodiabetes, they don't have, you
know, osteoarthritis.
So it's just basically sayinghere's your ideal person, with
no other issues, and show themhow to stretch.
(48:09):
But we know that's not the case, right?
So they're not allowing roomfor special considerations,
right?
They're not requiring us toknow all of the different
pathologies as they relate toexercise prescription.
(48:33):
As they relate to exerciseprescription Because, as we know
, when we go through school welearn about the pathologies and
as it relates to massage therapy, right, but we also need to be
looking at those pathologies asit relates to giving people
therapeutic exercise.
Eric (48:47):
And it also says in here too, it talks about, you know,
other things with therapeuticexercise In addition to
stretching.
They talk about range of motionexercises, strengthening
exercises, cardiovascularexercises, proprioception
exercises and exercises torestore capacity and activities
of daily living right.
Michelle (49:06):
So I'm like, oh, there's my physio and my
occupational occupationaltherapy friends, right like it's
.
Eric (49:12):
It's a huge amount of exercise intervention that they
are including in this documentthat I don't even think is
nearly close to being addressedat the academic level for
massage therapists academic orpractical level or practical
correct, yeah, because I don'tknow what other people's
(49:32):
experiences are, but I could sayvery comfortably that probably
at least 95 percent of myclinical hours at school were
predominantly people that justwanted hands-on, and even if you
wanted to do exercise, it wasnever really.
It was always so basic.
(49:53):
Because one thing is you didn'thave the time or the space and
we didn't have the education toassess and prescribe within a
therx type environment yeah and,and like you said too, like I
don't know, the therapeuticexercises.
I think, if I remember correctly, it was like halfway through
(50:14):
the program and it was maybe twoclasses 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 nota lot, you know, and that
includes all of this stuff rightversus Versus an OT, for
example.
So my sister is an occupationaltherapist.
(50:36):
It's a two years master'sdegree where all you're doing is
working on differentpopulations 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'relooking at who's better at it.
Mm-hmm.
What I would look at with thesethings.
Here is one.
Obviously, my go-to solution isincrease the hours, increase
(51:13):
the education.
Right.
Yeah, and I know a lot of peoplefight back on that, but
whatever, that's fine, they can.
I think that's where we need togo.
The other one, though, is say,rather than directing them all
these things, there should be athing on recognizing when to
refer it out.
Yeah fur out, yeah, or somethingin here about.
(51:39):
You know recognize when thisneeds something beyond your,
your scope or beyond your, yourexpertise.
Because how are you supposed todirect a client in
cardiovascular exercises in theclinical treatment room?
At least give them advice, buthow 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 wherethey're starting from Right?
How do you?
How are you?
How are you?
doing that and that's thequestion I pose.
You know, as the exercisephysiologist, is if your client
patient comes to see you andthey've just had a coronary
(52:12):
artery bypass surgery andthey've been cleared to drive to
get to see you, to come formassage, and let's say they
aren't connected to any rehabprograms or anybody else the
first person they see, how areyou going to know what to do to
tell them where they're supposedto start when they're resuming
their cardiovascular activities?
(52:33):
Sorry, but you're not right,unless you have the prior
training, the prior experience.
I mean, I wrote a cardiacrehabilitation program so I can
tell you right now what to do.
But I always am very clear tomy clients.
I say okay, I'm taking off mymassage therapist hat and I'm
putting on my kinesiologist hat.
This is Michelle, thekinesiologist giving you this
(52:56):
information, not the massagetherapist.
Because we're not taught thatlevel of knowledge in our, you
know, in our school experience.
Nor is it clearly stated inthese practice competencies that
we should know, you know, knowabout these special populations
and how to direct the patient orclient in cardiovascular
(53:20):
exercise.
So I think, um, I think, Ithink this, I think the practice
competencies need to define umwhen it comes to exercise, um
say like intermediate orbeginner level movement patterns
(53:40):
, or define the intensity or theappropriateness of the exercise
, and then anything above andbeyond that refer out right.
Um, so if your patient comes tosee you and has no
cardiovascular contraindications, prior history diagnosis, then
you can demonstrate yourknowledge of prescribing some
(54:03):
cardiovascular activity.
Telling someone to go for awalk is perfectly safe,
perfectly fine, easiest thing todo, but if that person is
coming to you and they've justhad this major surgery and
they're on this battery ofmedications, telling that person
to go for a walk, there's moreto it than just that right?
So I think the performanceindicators could be more clearly
(54:24):
defined and scaled back.
So it's reflective of a what Iconsider like a personal trainer
, where you take a weekendcourse and then you're a
personal trainer.
Because they're assuming you'reworking with an average,
healthy individual without anyother complicated health history
(54:45):
, right, and even then probablyyou know, if every massage
therapist took a basic personaltraining certification course,
even then they're probably goingto learn more about exercise
than what we learn in massageschool.
Eric (55:01):
I 100% agree with you there, michelle, because it does
say in the indicators.
It does say demonstrateknowledge of indications, safety
considerations, effects andoutcomes, effects and outcomes.
But I would be hard-pressedbecause I've seen the therax
textbooks that they use in mostschools and it does not really
go into much detail for those atall.
(55:23):
So even though it's in here, Iwould say it's probably lacking
because, I mean, the reality isright.
Michelle (55:30):
Our patients are getting more complex as they
come to see us, with more andmore different health conditions
cropping up and being diagnosed.
That a lot of it is is kind ofnot over our head, but a lot of
it needs to be referred out,right?
Know your lane, stay within ityeah, right yeah, respectfully,
(55:53):
like that's that's what it boilsdown, right yeah, respectfully,
like that's that's what itboils down to, right yeah.
Eric (55:57):
Yeah, I think that's, that's a.
That's a good way to kind ofsummarize a lot of the stuff.
Is that therapy exercise basedon the definition?
It looks like it shouldn't bewithin our scope of practice
based on the massage therapydefinition, but it is in our
PCPI so it's considered we.
It is within our scopePI, soit's considered we.
It is within our scope but weprobably most of us don't have
(56:21):
the required education,knowledge, skills to be very
effective with therapeuticexercise 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 yourschool experience.
I'd like to look at, like, whowrote these documents and what
their level of knowledge is,because just reading the
practice competencies again, I'msorry if I offend the people
who write this, but do you evenknow exercise?
(56:56):
You know when you're writingthis and how do you know how
this correlates to what theschools 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 andorganizations out there across
Canada, I would say most peoplethat are in charge of things
just don't have the knowledgeRight and a lot of that comes
from a profession that has a.
I think it's getting better,but I think traditionally we
(57:30):
have a bit of a culture ofacademic avoidance.
Better, but I thinktraditionally we have a bit of a
culture of academic avoidance.
People just don't.
We don't have enough peoplethat are really wanting to
pursue, you know, academia inthe, in the profession,
unfortunately.
But I can understand why.
Because what's the leave like?
What do you, what do you dowith it?
You know I, I know I've met andwhat searched out a handful of
(57:51):
the rmts that have a phd acrosscan, but very, very, very few of
them are involved at all in themassage therapy profession,
cause they get their PhD andthey go work at a university or
they go work research, doingsomething else it's totally
unrelated to massage, becauseit's kind of there's there's
nothing here for that.
So, you know, until I think westart getting more people in
(58:15):
positions of the have requiredor a higher level of education
and knowledge, particularly whenit comes down to, to research
and knowledge, translation andresearch.
Until we get those peopleinvolved with the stakeholders,
I don't think things are goingto change very quickly, if at
(58:36):
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 theylast did the PCPIs, the
competency document I would say,if this came out september 2024
, I would be surprised if it wasvastly different from this.
I bet you, eight years later,it probably looks very much the
same, because you probably havethe same people or similar
(59:06):
people writing it, and so Idon't know if anyone's listening
.
I have a whole list of peoplethat I could recommend that
would be very well suited tohelp push these things into a
higher standard and still staywithin our scope 100% right, and
how fantastic would that be tofor our profession and to
(59:29):
elevate the up and coming.
Michelle (59:30):
you know massage therapists who are in school or
who are considering you knowgoing to school for massage
therapy amazing, awesome, yeahwell, thanks for that today,
michelle, that was.
Eric (59:43):
That was really fun.
I really enjoyed thatconversation.
I hopefully the listeners gotsomething out of that.
We covered a lot of a lot ofthings, yeah.
Michelle (59:51):
Yeah, it was great and I think I think it's a good.
It's a good perspective toconsider for everybody.
We always have a role inhelping our patients and we
always have a role with respectto promoting movement and
activity.
I would just caution thelisteners not to use blanket
(01:00:13):
prescriptions.
Don't go tell everybody to gotry yoga.
Yoga classes can do a lot ofharm.
Not saying yoga is bad, but youknow a blanket statement of go
do some yoga isn't going to helpyour person.
But the easiest thing to do issay, hey, when was the last time
you went for a walk, right, andjust breaking it down, getting
(01:00:56):
down to the basics of thingswith people and just have going
to be more beneficial than youtelling them to go and stretch
their neck for 30 seconds.
So give them that pat on theback instead.
Eric (01:01:05):
Well done, michelle.
Good summary.
Thank you for that today, Untilnext time.
Michelle (01:01:09):
Yeah, thanks so much again, eric.
I appreciate the time.
Eric (01:01:11):
Thank you, thanks for listening.
I appreciate all of you fortaking the time to be here.
If you enjoyed this episode,please give it a five-star
rating and share it on yourfavorite social media platforms.
You can always follow me onInstagram or Facebook at
EricPervisRMT, and please headover to my website,
ericperviscom, to see a fulllisting of all my live courses,
webinars and self-directedcourse options.
Hello everybody and welcome to another episode of
Purves Versus, and we haverepeat guests.
This is her third time on thepodcast and that's Michelle
Smith joining us from Saskatoon,so thanks for being here,
michelle.
Michelle (00:17):
Thanks for having me again, eric.
Eric (00:19):
One thing that I love is when guests reach out to me and
they say, hey, do you want to doa podcast episode about insert
topic here?
And I said, sure, let's do that.
So Michelle wanted to talkabout a therapeutic exercise and
kind of have a littlediscussion about is this
something that we actually knowenough about?
Is it actually should it beconsidered within our scope of
(00:42):
practice and what would beobviously a better way forward?
What could we do to make surethat we're more competent in
therapeutic exercise?
I think this is an interestingconversation, so I'm looking
forward to seeing what you haveto say about that, michelle.
Michelle (00:56):
Yeah, thanks, I am too , and I'm grateful that you're
having me on to share this kindof topic with the rest of the
RMT world.
Eric (01:04):
I think, just to start with, this is the idea of
therapeutic exercise, issomething that we all have a
TheraX class and it's somethingthat is in our competency
documents.
But I think the discussion thatMichelle and I want to focus on
today is to really pick apart.
Do we actually, are we trainedwell enough to provide exercise
(01:25):
prescription, to know enoughabout the indications or
contraindications of when isexercise appropriate?
I think you may you make somegreat points in some of the
discussions we had off airmichelle about we might, even
though it's in our it's in ourdocuments and then we're allowed
to do it.
Michelle (01:49):
Should we?
Yeah, should we is the question, and I just want to be
transparent and say I'm comingto this podcast wearing two hats
.
Today I have looked into thescope of practice for
therapeutic exercise for massagetherapists is my original
education and career backgroundis as a kinesiologist and
(02:13):
exercise physiologist, and sowhen I was training to be a
massage therapist and we did ourTherx class and we did our
(02:36):
Therx class respectfully it waslaughable in terms of the type
of information and the amount ofinformation that was delivered
to the students wasn't relevant,based on the fact that when
clients or patients come to seeus for massage therapy, probably
90% of them will have someother co-occurring medical
(02:58):
condition and will have multipleco-occurring musculoskeletal
limitations.
And so to appropriately assessthose concerns and provide the
you know, the therapeuticexercise that we're taught that
to do, I don't necessarily feelbeing in the massage therapy
(03:22):
treatment room is the rightspace, nor do we have the right
time to do so, but again, I'mbringing in my experience
working, as you know, akinesiologist and saying you
could bill a full hour of justassessment and exercise
prescription on top of yourhands-on manual therapy.
(03:42):
So there's couple of key thingsI think that the public are
expecting when they see amassage therapist.
I mean one is they wanthands-on manual work.
And then, two, they're going toask is there anything else I
can do at home or outside of thetreatment room, you know, for
exercise or movement?
And our first line of ofexercises here do this stretch
(04:06):
right?
Um, which I'm not saying iswrong, um, any movement is good
movement.
However, um, I would caution theaverage massage therapist who
doesn't have any umextraordinary training in um
exercise, health, fitness,fitness, to try to take on that
(04:26):
role of having a completelydeveloped exercise therapy
program for your patients Ifyou're not aware of the proper
contraindications, propermodifications, proper
physiological responses thatyour patient might have if
(04:46):
you're giving them this programright.
And so I guess, for an example,eric, let's say I was seeing you
and I'm taking metroprolol formy blood pressure or for my
heart rate, sorry, and you'relike well, yeah, just start
walking.
Well, eric, what do I use toevaluate my effort when I'm
walking, knowing that I'm onthis medication?
(05:07):
What are you going to tell me?
Right, and that's something wedon't learn in massage school.
But as an exercise physiologist,I'm going to tell you we can't
use your target heart rate as avalue to assess your intensity
when you're on that type ofmedication, right, we have to
use other assessment forms toensure that you're exercising at
(05:27):
a level of cardiovascularfitness that's still going to
keep you safe, within thoselimits of your heart rate, which
is being, you know, reduced bya pharmaceutical agent.
So I guess that's where I'msort of looking at the big
picture from, because when wetalk about our you know our
practice competencies, there'sthat huge section on therapeutic
(05:50):
exercise, and cardiovascularexercise is one of them, right,
but to what depth are massagetherapists being taught the
level of knowledge aroundcontraindications and
indications around exercise,right?
Eric (06:08):
Those are some great points, michelle, and one of the
dangers with education isknowing a little bit can
sometimes be more harmful.
We could say that with a lot ofthe things in massage school
and anyone that listens to thepodcast or knows me.
I'm always critical of thecurriculum 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'tchallenge and we don't ask hard
(06:30):
questions, then we're nevergoing to improve.
And when we look at therapeuticexercise, for example, we get
so like.
I remember I mean it's a longtime ago and it was over 20
years or 20 years ago now when Iwent to massage school and we
learned we had a therax class,but I don't remember anything in
the class learning aboutcardiovascular or learning about
(06:51):
optimum dosages or or anythingmore than like this is how you
do a stretch.
Michelle (06:58):
This is how you do a strengthening thing.
Eric (06:59):
It was usually just linear , like flexion, extension of
this joint.
It was very, very rarely wasexploring functional movements,
whatever functional movement islike, like task specific
movements it was.
It was never.
It was always very like youbroke it down these little
pieces and it was like, oh, youdo five or ten of these and then
repeat it times three and thendo it every second day or
(07:19):
whatever, and it was so genericand even when you did your exams
and your board exams, that'sall they were looking for.
Going back to what I said aboutknowing a little bit of
knowledge might be dangerous isthat you learn this and you
think, ok, I guess that's all Ineed to know, right?
Yeah, you don't even and youknow it's not even addressed
that there should be or therecould be more specific to that.
(07:40):
You have, like I said,kinesiology, exercise,
physiology yeah, physiology,yeah, you know that's what you
do right so and I'm just curiousthough, because obviously this
is not my area of knowledge Iknow a little bit, but I think I
know a little bit, so I don'tknow enough.
And this is great that youwanted to have this conversation
.
When you took, when you saidthat you went to massage school
and you said that you had yourtherics class, and it was
(08:02):
laughable.
What kind of things were theyteaching you that were that you
feel you can remember wereshouldn't even have been
addressed because it was just soinsufficient.
Michelle (08:18):
Probably the first thing that comes to mind is,
yeah, giving somebody a stretchor an exercise using a soup can
as their weight without evenassessing their, their movement
or their strength first.
Right, so you've had a chanceto treat this person on your
(08:40):
table.
And let's say you know they'recoming in with a sore shoulder
and and you've done your, yourtreatment on the table, and then
your home exercise program is,you know, do a deltoid stretch
and then do some front raiseswith, with a soup can to add
some strength to that shoulder.
But how do you know theshoulder is weak if you haven't
even tested it?
(09:01):
Right, and I know strengthtesting there's evidence to
support that.
It isn't really all that great.
It's kind of very subjective.
But anytime you pursue adviceor you pursue giving people some
sort of take home exerciseprescription or exercise program
(09:23):
, home exercise prescription orexercise program, you also have
to think of what are you basingthat program on?
What have you done todemonstrate or to determine they
need this front raise with asoup can or they need this
stretch?
If all you've done is thehands-on manual work, right,
because there is a protocol inplace that you should do to to
(09:46):
measure and evaluate.
You know how this person'sfunctioning, how they're moving,
what their strength is, whattheir deficits may be, and then,
based on that, okay, is this,is this?
Is this something that is, youknow, preoperative,
postoperative, is this arthritic?
Right?
Then you decide what type ofexercise to prescribe, as well
(10:08):
as the frequency and intensityof that exercise, right?
So I just think.
I think the world thinksexercise is just so easy and so
basic that anyone can like tellsomebody to go and do a front
raise with a soup can or adeltoid stretch.
But in actuality, in atherapeutic setting, there's a
(10:32):
lot of information that you haveto gather first and a lot of
critical, critical thinking youhave to do in order to provide
effective and evidence based andand safe, quality therapeutic
exercise, right?
Um?
So just diving in and saying,okay, go, do these soup can
(10:53):
raises at home now and do 10repetitions for three sets a day
, every day, until I see younext.
What are you doing with that?
Right?
And the other thing that was nottaught was how are you going to
evaluate the progress of thisperson?
Right, because in my world, inmy original profession, you
(11:15):
would see this person every weekor sometimes every day, and so
you would like create a hugeprogram for this person and
design a program for this personin all these macro cycles and
micro cycles so you couldprogress their um, their
improvement along the way, oreven progress their decline,
(11:37):
right.
And so I think, um, given thespace and the context that we as
massage therapists have in thetreatment room when we're in
school, I think the, the levelof exercise education we're
given is just to be kind of likeband-aid fixers or like just a
little cherry on top of of theof the treatment, just so we can
(11:58):
say we've given them some, someeducation on here's how you do
a stretch and here's how you dolike a dumbbell, front or front
raise right, which I'm notsaying at all is bad or nor is
it harmful.
I'm just saying it's not goingto be as effective as I think we
were taught to believe when wewere in massage school.
(12:19):
Right, even stretching.
There's so much research aboutstretching and how really
ineffective it is.
That why, why are we stretchingthings right?
Or, you know, people come withus with sore muscles, while
those muscles could be sore notbecause they're tight, but
because they're weak, right, andunless you really understand
the analysis of those muscles ofhow to determine is this
(12:42):
tightness from weakness versustightness from being tight and
needing a stretch?
Why are we giving peoplerhomboid stretches when they're
feeling tight?
Because those rhomboids arealready so overstretched to
begin with from their habitualmovements throughout the day.
So, in my opinion, you knowalways, always advising some
(13:04):
movement is a benefit for people.
But when it comes to thoselaughable moments in my Fairx
class, really, it was justhere's how, here's how you teach
your patients how to stretchright, um, which may be good for
somebody who's never done anymovement to begin with and it's
very unfamiliar with their body,um, but then, once you deliver
(13:29):
that message to those patients,what are you doing with it?
What are you doing to monitorthe results?
What are you doing to modifythe results?
If they come back to you in amonth's time saying I've been
stretching every day and thatneck still is tight and still as
cranky, well, what does thatmean?
What is that telling you?
Stretching every day and thatneck still is tight and still is
cranky, well, what does thatmean?
What is that telling you right?
And so I think that's where, umI'd mentioned to you earlier.
(13:51):
Sometimes I felt like doingTherax in massage school was
akin to when physicians domedical school and they take
like a five-hour class onnutrition and all of that you
know education they take andthey're only given a small chunk
of education on nutrition andall of that you know education
they take and they're only givena small chunk of education on
nutrition.
And then when they counsel theirpatients, they really don't
know as much in-depth knowledgeas, say, the dietician you know
(14:14):
who has her four-year, hisfour-year nutrition degree.
So, circling all this back, Ithink that I think we can do
better in the world of educationfor massage therapists and we
need to do better, especially ifit is in our practice standards
(14:36):
.
I still don't know if, if weinterpret our scope of practice
of massage therapy, I mean right, we talk about it being within
our scope of practice, but whenyou read a scope of practice of
massage therapy, I mean right,we talk about it being within
our scope of practice, but whenyou read a scope of practice it
doesn't actually state exercise,right.
So I think our practicestandards need to put a put a
(14:59):
microscopic lens on the exerciseand the therapeutic exercise
and up the ante on it when itcomes to the education component
.
But I also think our scope ofpractice needs to either stop
misinforming us that it iswithin our scope of practice, or
it needs to clearly state thatit 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 NationalStandards of Practice definition
in a minute.
I.
Just before we do that, I justwant to go back to what you're
saying, too about, about thestretching thing, because I
think you brought someinteresting things there.
You know, the idea is like whydo we stretch and what is the
purpose?
Right, and this is a thing thatmassage therapists across,
let's say, across the worldacross canada.
(15:42):
Anyway, where we are, that's thekind of the go-to home care oh,
just do some stretching.
And then when people do alltheir stretches and they come
back and they're still in pain,they're like oh, we just gotta
stretch more than, or you gottastretch harder, whatever it
might be.
And there is thismisunderstanding that stretching
actually does more than itreally does, because we know
(16:06):
that stretching doesn't actuallyreally change the length of
tissues for a very long, veryshort period of time, right, and
we know that stretching isn'tstrongly associated with injury
prevention.
We know that stretching is notnecessarily related to increased
(16:28):
athletic performance.
But we know that there's somethe the data on it is all over
the place, right, there's somethings say does something
positive, some say it doesnothing, and then probably the
truth is probably somewhere inthe middle.
But I say the way I interpretthe stretching literature and
the way I communicate it withpatients is would you like to
(16:49):
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 ohpatients, they don't ever do the
stretches and they come backand wonder why they're still in
pain.
I'm thinking it might still bein pain even if they do the
stretches every day.
Maybe stretching isn't thething for them.
Michelle (17:14):
Yeah, exactly.
Eric (17:15):
It goes back to that little bit of knowledge.
I think in our profession wefeel that stretching for example
, does more than it should orthan it could, and so I just
wanted to bring that back.
And because the purposeoftentimes is oh, we need these
things to be longer, well, doesa longer or more flexible muscle
is that more associated with?
(17:37):
Is that associated with withless pain?
Is a stronger muscle associatedwith less pain?
Michelle (17:42):
not, necessarily necessarily.
Eric (17:43):
Not necessarily right.
Like their bodybuilders, havepain and they got tons of muscle
.
Yep, right Gymnasts and figureskaters and you know people that
and dancers that have tons offlexibility they still can have
pain.
Yeah.
And they don't need to stretch.
Yeah.
I think that these are, theseare good, good things to kind of
call out and really stop andreflect on what's the point yeah
(18:06):
, it needs to be meaningful tothe person well, exactly, and
that's I liked your, um, yourcomment 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 Imean and that's that's a huge
component of my kinesiologyeducation is trying to encourage
or support, or convince aperson to adopt a healthy
lifestyle and to exercise is asdifficult as trying to have a
(18:42):
10-pack a day or lifelong smokertrying to quit, right.
There's a significantpsychological component that we
have to be familiar with andvery understanding of when it
comes to exercise prescription.
First and foremost because if Icome see you and I have zero
(19:04):
experience with movement period,whether it's going for a walks
or whether it's being in arecreational dance class, um,
and movement period is not in mywheelhouse because I'm just not
a movement based person youneed to understand that, first
and foremost, right.
And so by asking me do you liketo move?
Do you know any exercises?
(19:26):
Do you know any stretches right?
What do you do for recreation?
If my answer is nothing and no,no, no, right, there is the
first indication that, okay, Igot some work to do with this
patient.
And how do I elicit somepositive stages of change within
this person to help thembelieve that what I'm telling
(19:47):
them about exercise is actuallygoing to be a benefit.
Right and that's what I'veexperienced across the board,
regardless if it's with personaltrainers or massage therapists
is that the psychologicalcomponent to movement and
exercise is always overlooked inour clients and we just think,
(20:10):
well, because we're theprofessional and what we say
goes, that they're just going toadopt this and go with it.
But the reality is they aren't,and we have to be very
cognizant of what theirlifestyle is like and if they're
even open to wanting to learnabout different types of
stretching or different types oftherapeutic exercise, and so
(20:32):
the psychology of exercise isalso an evidence-based practice
that we're not taught in inmassage school.
Eric (20:40):
Not at all, and that's such a great point I mean, you
brought that up of thepsychological aspect because
we're dealing with humans, wehave to be knowledgeable of
psychology.
It's ridiculous for us to thinkthat might be out of scope.
We're dealing with a human, youhave to be appreciative of
their psychology.
Learned in my sport coachingeducation is you know, the first
(21:07):
thing that that you're supposedto focus on is the, the
psychological and mental healthof the athlete, and that's just.
We're speaking specificallysports.
But it would be the same thingwith when you're treating a
human in a massage therapy orexercise 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?
and recognizing that yeah,exactly rather than just
(21:30):
throwing the same process or thesame prescription or the same
advice at everybody, it has tobe tailored it has to be
completely tailored and you haveto also know which, by that
point, you should.
Michelle (21:43):
Are they seeing other health providers?
Right?
Because many of my clients cometo see me and they're already
connected to a physicaltherapist, or they're going to
the gym and they're seeing apersonal trainer Fantastic, you
know what I'm just going to saycontinue doing what your physio
or your kinesiologist has youdoing, or your personal trainer
has you doing, kinesiologist hasyou doing, or your personal
(22:05):
trainer has you doing?
Because, again, within ourscope of practice, we have to
have, we have to refer to thepeople who are the experts first
and foremost.
Right, I'm not gonna.
I'm not gonna say, oh well, Ithink you should change these
three exercises that your physiohas given you.
I'm not gonna step on their,their toes, not at all.
I'll collaborate with them,absolutely.
(22:26):
But if my client's telling me,yeah, this one stretch my physio
has me doing or my trainer hasme doing, I really don't feel
comfortable or I really get somepain, okay, well, let's, let's
talk about some alternatives andthen take that information back
to that person and and see ifthere's something you guys can
come up with, kind of halfway inbetween, based on the
(22:48):
recommendations I've given you.
Right is a more.
I mean is directly within theirscope of practice and they have
(23:08):
an extensive volume ofeducation and experience around
it.
Then let that person do theexercise prescription and let
that person address thetherapeutic exercise, so that
you're not clouding the waterper se.
Eric (23:24):
It's nice actually when patients come in to see you and
they've already have somebodyelse doing that stuff.
Michelle (23:30):
Yeah, it's great.
Do you like doing that?
Does that work for you?
Yeah, great, perfect Carry onRight.
Eric (23:36):
And then sometimes be like did you, you know, can you
share with me, kind of whatthey're doing, yep.
And then I'm like okay, thatsounds great, thanks for sharing
.
And then, yeah, and then I'mlike 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 agreat job, right?
I'm proud of you, and they wantto continue doing it.
Eric (23:58):
So it's amazing.
Yeah, that's amazing.
Uh, so I, a few minutes ago Imentioned I wanted to read the
national standards of practice,just to, so we can have a
conversation about.
You know, is therapeuticexercise, 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
(24:20):
are so many organizations andstakeholders out there.
There are so many differentacronyms that are involved in
the massage therapy profession.
I, to be honest, I kind offorget what they all do.
But anyway, that's maybe adifferent conversation, but this
here says so.
Massage therapy is the practiceof.
The practice of massage therapyis the assessment of the
musculoskeletal system of thebody and the treatment and
(24:42):
prevention of physicaldysfunction, injury and pain
pain by manipulation,mobilization and other manual
methods to develop, maintain,rehabilitate or augment physical
function, relieve pain orpromote health.
And there's another sentenceafter that, but I don't think it
matters as much, and the keypoint that you highlighted with
this is nowhere in here does itsay exercise, right, you know,
(25:07):
the practice of massage therapyis the assessment of the msk
system of the body and thetreatment and prevention of
physical dysfunction, injury andpain by manipulation,
mobilization and other manualmethods.
So it's interesting, isn't it,that, based on this definition,
that therapeutic exercise iseven within our scope, right?
(25:29):
I think it I like that it is Ithink we probably agree but if
we're going to be like, let'sask some hard questions here, it
shouldn't be actually based onthis.
So I wonder how they get awaywith that.
That's really interesting in bc, in our.
Our scope of practice here inbc is a little bit different
than, say, ontario, even though,and other regulated provinces,
(25:50):
because here manual means byhands and if anyone listening
goes online, you google likemanual, it's going to say to be
done by the hand or done by thehands.
One reason why we're notallowed to do a lot of things
like cupping or use othernon-hands-on interventions is
(26:13):
because it's not done with thehands, right?
Somebody reached out to me theother day and was saying oh, you
know why can't I?
you know why, in BC can't youguys use your feet?
And I was like, because it'snot your hands.
That's the way it's defineddoesn't mean I could care less
if someone massages you withyour feet.
Uh, probably feels nice, butthe the manual thing.
So when we look at this and wetake even a bigger look at it,
(26:36):
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 beforewe were recording, if you were
to read that through the lens of, say, a lawyer or an insurance
company, if someone had, forwhatever reason, said, oh, the
exercises Eric gave me caused meto have X, y and Z problem.
(27:05):
When you read that statement, itdoes not explicitly define
exercise you know, prescriptionor exercise recommendation as
our scope of practice, becauseit is of, you know, the manual
treatment or assessment of aperson's musculoskeletal system.
(27:26):
So it I mean right, as apracticing massage therapist.
It makes me confused, then,what does that mean for us?
Is it really within our scopeof practice, based on how, you
know, the regulatory collegesdefine it, or what this
paragraph had said?
And I think there needs to bemore clarity around it, and I
(27:49):
also would challenge that.
The clarity around it alsoneeds to then be passed on to
the practice competencystandards and the schools who
are, you know, writing thecurriculum for their x classes.
But from from on first glance,from my perspective, reading
(28:10):
that statement, no, exercisewould not be within our scope of
practice, even though we allknow 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 howmuch clout it would have right
(28:30):
To say that it is in our scopeof 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 kindof probably put in here.
I mean, they can seem like theycan kind of make this up as
they go, because they are theydon't.
I don't think they answeredanybody Right.
If I understand correctly, Iremember correctly, I believe
(28:55):
the professional associationsare 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 saymobilization and other physical
methods or just get rid ofmanual altogether and say other
methods.
Michelle (29:12):
Other methods right.
Other evidence, informed orother 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 rightum, 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 becauseI see, like those therapists
who are all like it's, it's inour scope of practice and this
is the way you know, we'retaught and we can do this.
And and then I see otherhealthcare providers who are
like no, stay in your own lane,it's not your scope of practice,
(29:49):
let these people do the workbecause it's within their scope
of practice and it's withintheir level of education and
competency, right.
And then you see the generalpublic who is like let's be
(30:19):
honest, when people book in fora 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 instructedexercise prescription, unless
that therapist clearlyidentifies that is how they
operate their practice.
Right, there's a few out therethat do that, but it's not the
norm.
Yeah, exactly.
So where does that leave us?
I guess the thing is, too, isif we look at it and how the
standards of practice aredefined.
And I don't have that in frontof me in terms of like in BC, in
our bylaws, like you're onlysupposed to be able to work
(30:45):
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 mostof us is pretty low when it
comes to therapeutic exerciseprescription, because we're not
exercise physiologists, we'renot kinesiologists, we're not
strength and condition um,trainers some of us are, but
(31:09):
most of us probably aren't.
If we don't have that extralevel of education, then we
should hopefully, at leastaccording to the bylaws, say
stay in your lane, don't do tootoo much.
Yeah.
But I guess the question is ishow do we know what too much is?
Or how do we know, do werecognize that we don't have
(31:32):
enough information or enougheducation?
Goes back to my earlier pointis a little bit of information
can be a bad thing.
So I think we need to acceptthat we just we actually don't
in the entry to practiceeducation.
We don't have enough exposureor training to be good at
therapeutic exercise other thanbasic stretches, basic
(31:53):
strengthening.
I hear what you're saying and Ithink that a lot of times people
probably go above and beyond,thinking that they know more.
Like, so say, like you use acardiovascular one example,
right?
Like if someone comes in,they're on a bunch of different
medications, maybe they've hadheart surgery, maybe they have a
pacemaker and they're takingbeta blockers, how are they
supposed to know?
(32:13):
Like, how are you supposed toknow if you don't have the
education or training what'sgood or not good?
Right, you're supposed to referout.
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 wemight not, I don't know.
Michelle (32:32):
I think.
I think we need to know, likeyou said earlier, just to refer
out when it's over and beyondour competency, right.
But then that's where I wouldquestion and or challenge when
curricula is being created andthey use the practice competency
standards, the practicecompetency standards, why do
(32:53):
they not create more time andmore in-depth information then
for TheraX in the program,knowing how in-depth the
therapeutic exercise competencystandards are?
Eric (33:04):
Yeah, and that's a good point, and we'll talk about the
PCPIs in a minute here, becauseI think that that would be
worthwhile and we can kind ofprobably move from that into
talking more about kind ofcurriculum.
But before we do that, I wantedto just highlight a couple
things that I find areconcerning about this National
Standards of Practice document.
Like I said, I don't reallyknow who writes these or who
(33:26):
approves them, but I look atthese things and I think whoever
is writing these actuallydoesn't have a strong
understanding of the literature.
And this is the thing that keepI keep finding everywhere,
everywhere I look, I'm thinkingwho's coming up with these
things?
Because you're makingstatements in these national
standards that arenon-evidential, right, and so
(33:48):
the one like the one where youbrought 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.
But one thing here it says to itsays the prevention of physical
dysfunction.
So again, again.
This is interesting because twoquestions here.
One is what do they mean byphysical dysfunction?
(34:10):
What is dysfunction?
Dysfunction if you ask mostpeople 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, scapulardyskinesis or you've got a
rotated this or a hypertone,hypotone, this, like they're
(34:30):
looking for, like things thatare broken.
You're like that's what mostpeople hear when they say
dysfunction, which we know isthat'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 herethat really kills me is
prevention.
There's actually I've neverseen one thing and I hope, if
(34:51):
someone listens, and maybe I'mwrong, but I don't think so I've
never once seen that massage ormanual therapy prevents
anything.
Michelle (34:59):
I 100% agree with you and ditto I can say
evidence-based exercise has ahuge, huge wealth of research to
show the prevention of multipleum conditions down the road in
a person's lifespan.
But I've never come across anyresearch that says massage
therapy um prevents physicaldysfunction.
Eric (35:22):
Exactly and then what is dysfunction?
You know?
It says it prevents yourphysical dysfunction, exactly.
And then what is dysfunction?
It says it prevents yourphysical dysfunction, injury and
pain.
Now I can guarantee thatsomebody's listening to this
being like my people come to seeme and I treat them as part of
their treatment plan and itprevents them from having pain
flare-ups.
We could say, okay, maybe incertain populations, and we're
(35:45):
never going to argue yourclinical experience as being
wrong.
But if we're looking atpopulation-based stuff, not just
individual experiences, thestatement that massage therapy
can prevent physical dysfunctionor can prevent injury or
prevent pain is notevidence-based, a hundred
(36:05):
percent.
Not that there's no way that'sevidence-based.
Now, if we move down to anothersection on here and this is why
I wanted to bring this up,because it's so contradictory it
says massage therapists ensurethat the patients receive the
highest quality, evidence-basedcare in the treatment,
management and prevention of MSKdysfunction and disorders.
(36:26):
On the previous line, they callit physical dysfunction.
The next paragraph, they'recalling it MSK dysfunction and
it says that we ensure thatpeople receive the highest
quality, evidence-based care.
Well, your statement is notevidence-based.
Exactly, it's so contradictoryit's so contradictory and I just
read this I think this is aproblem that we have with our
(36:47):
profession is that even thepeople leading leading the ship
don't really understand theliterature, the science, yeah,
the best practices and yeah, I'msure if you ask any massage
therapist there, everyone'sgoing to want to say court, I
(37:09):
want to provide evidence-basedcare.
Evidence-based care is the best.
It's going to provide me thehighest chance of having more
positive outcomes for mypatients, my clients.
Any rmt would say, anybody inhealth care would say, of course
I want to give evidence-basedcare, I don't want to give
make-believe care.
I said at least that's what.
But we know, and just kind ofgoing.
(37:32):
Let's go back to theconversation we're having about,
about therapeutic exercise.
With therapeutic exerciseeducation we're getting it's not
evidence-based, correct.
So the whole it's just filledwith so many problems yeah, it's
like a big slice of swisscheese.
Tons of holes everywhere, right,tons of holes everywhere right,
tons of holes everywhere andI'm not going to read this whole
(37:54):
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 somelight to our colleagues about.
Hey, it's okay to ask thesequestions, right, how can we be
confident in what we do if we'rejust following the herd?
(38:19):
Right, let's start asking thesequestions and every facet of
our scope of practice, of ouryou know what your bylaws say,
not just around exercise, butyou know everything else.
So the people who even wrotethis, do they even know what
evidence based means if they'vemade the statement ahead of time
that you know isn'tevidence-based, right?
Eric (38:42):
so these are such important conversations to have.
Some people might hear it as uskind of whinging a little bit
and you know, you know there'sall the problems but there is
solutions always solutionsthere's always solutions and
they're easy solutions and Ihave lots of solutions.
I'm sure you have lots ofsolutions.
I know you have lots ofsolutions as well, uh it's just
(39:03):
a matter of of having the people, the stakeholders and the
curriculum creators and and allthe associations and colleges
involved to actually say, hey,you know what the public
deserves better, mostimportantly, and our profession
deserves better.
The amount of times that I do awebinar or do a course where
(39:24):
people are like so basically,what I'm hearing is that kind of
everything I learned in schoolis incorrect, I'd say, well, not
everything, but a lot of it is,and you deserve better
(39:56):
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 weneeded.
So what we know isevidence-based, are the anatomy,
the physiology, the pathologies, and it's given us that
(40:21):
platform, then, to move furtherand our responsibility is to
seek out more education, to seekout better standards of
practice, because even aphysician who went to school 30
years ago would say the samething.
Oh, so what they taught me inmed school 30 years ago is just
a load of crock.
Probably a good chunk of itcould be, because we're in a
(40:44):
health care, health sciencefield.
Everything is always evolving,right?
What we talked about today, infive years from now, there might
be some new evidence coming outabout exercise that maybe says
we shouldn't be giving peopletherapeutic exercise.
Right, we don't know that.
So when we went to school, thosepeople at that time and that
(41:07):
curriculum and thoseinstructions or instructors and
institution did the best theyknew of for that time and nobody
was calling them out because itwas just smooth sailing.
Everybody was doing that, youknow now for sure, we're picking
apart that, that level ofeducation, and we're saying,
yeah, a lot of the stuff welearned was not evidence-based
(41:28):
or best practice, but withoutthat diploma that you earned but
without that diploma that youearned, you wouldn't be where
you are today, right?
So be grateful for the peopleright now that you're taking
these webinars from and theselessons from and saying, hey, at
least I have the foundationalknowledge that I need in anatomy
(41:50):
and physiology and systems andpathology to understand what
Eric is telling me about pain.
Right, because if you didn'tget that information when you
were in school, how would you beable to compute the
neuroscience of pain when Eric'stalking about it?
Right?
So I'm going to be transparentand probably ruffle some
feathers.
It annoys me when people arelike, well, so school taught me
(42:12):
nothing.
There's always something schooltaught you, and the most
important thing is that schoolis meant to be a safe construct
and they have to teach withinthe confines of whatever
curriculum they've sent to theirprovincial governing body,
their Ministry of Education,that gets approved and gets sent
back, so they can only do whatthey do within those confines
(42:33):
because somebody else hasapproved it, right?
Everything else outside of that, it's your responsibility to
keep challenging and keeplearning 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 andschool is a reflection point.
(42:58):
For you to say, aha, then maybeI need to stop believing
everything I hear and see Right,ie, instagram, ie, tiktok,
right, and that, bringing thatback to this whole exercise
conversation, there's so muchgarbage in the world of social
media about exercise that thosepeople who consider their school
(43:19):
experience to be negative andnot good.
I also challenge you to stopwatching TikTok and stop
watching Instagram and learningabout exercise, because it's
garbage.
Right.
Take the classes, do thewebinars, learn from the people
who actually have the experienceand the education, and don't
learn from the influencers whoare online when it comes to,
(43:39):
when it comes to those importanttopics that we're responsible
for pursuing evidence basededucation 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.
It is frustrating when peoplestart to they they don't like
that to, they don't want toadmit or they don't want to hear
that what they've learned mightnot be enough.
But you make such a good pointthere about people you know you
(44:15):
wouldn't be having thisconversation if you didn't go
through that and there is a lotof good foundational stuff in
there and I think one of thebest things that we learned, I
remember learning from massage.
You learn how to give a goodmassage.
They're gonna make people feelgood.
You learn how to feelcomfortable.
You know touching differentbodies and different body types
and you know meeting different.
You know trying to help peoplewho have different expectations,
(44:38):
or you know goals from fromtheir massage.
So you learn a lot of goodstuff and obviously the anatomy,
the physiology and the thebasic kind of foundational
sciences is great, um, yeah, soI think that's we just need to.
We need to challenge thechallenge things, but you also
need yeah, there's stuff inthere that is important.
There is, yeah, a lot of stuffthat may not have been important
(44:59):
, but focus on what wasimportant, and it's what's
brought you to where you aretoday, right, yeah, exactly, and
I think I'm going to do anotherepisode on this actual
standards of practice documentBecause I think there's a lot of
things in here I want to talkabout, but as soon as I do,
we're going to this will be likea seven hour episode, so I'll I
will just go on to the next one.
(45:19):
But you I think you did mentiontoo about massage therapists
respecting their roles andresponsibilities and working
with healthcare professionals,and you kind of mentioned
earlier the importance ofreferring out and knowing and
knowing who right.
Michelle (45:36):
Look around the community and know who those
people are, so you can developgood professional relationships
with them and send people theirway, 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 otherhealthcare providers who we send
people back and forth all thetime, and that's that's quality
(45:59):
care, that's evidence-based care.
Eric (46:02):
Yeah, that collaboration with other healthcare
professionals and patientsusually like it, you know, when
they they feel that you're havetheir best interests for them,
and that's how we get morereferrals and you, you know, you
get them come back next timesomething else happens with them
.
It's, it's important, yeah,yeah.
So let's talk about the uh,inter-jurisdictional practice,
(46:22):
competency, competencies andperformance indicators, the
pcpis.
My the biggest problem well,god, I can do the whole episode
on these that one of the biggestproblems I have with this
document is it hasn't beenupdated since 2016.
Right, or in 2024.
Yeah, that's a long time and Ilook at this thing and it just
makes me cringe.
And we're not going to talkabout Section 3.2, for example,
(46:46):
which is about all the how to dodifferent techniques.
We'll talk about thetherapeutic exercise component,
which is Section 3.3.
Tell me your thoughts aboutthis.
What do you, what do you feelis good and or bad with, with
this, the competencies?
Michelle (47:02):
with the competencies.
Hey well, like the first one wetalk about is perform a direct
patient client in stretchingdemonstrate knowledge of
indications, safetyconsiderations, effects and
outcomes of stretching, directpatient clients in stretching
and incorporate these differenttypes of stretchings into the
treatment and modify thestretches based on patient or
(47:24):
client history, presentation andresponse.
Um, this to me is a very genericum map and to me, when I read
this, I think of they'reassuming it's the average, not
the average.
I'm assuming it should bedirected to a healthy individual
(47:47):
who has zero, zero diagnosisother than they're there for a
massage, right, completelyhealthy.
They don't have type twodiabetes, they don't have, you
know, osteoarthritis.
So it's just basically sayinghere's your ideal person, with
no other issues, and show themhow to stretch.
(48:09):
But we know that's not the case, right?
So they're not allowing roomfor special considerations,
right?
They're not requiring us toknow all of the different
pathologies as they relate toexercise prescription.
(48:33):
As they relate to exerciseprescription Because, as we know
, when we go through school welearn about the pathologies and
as it relates to massage therapy, right, but we also need to be
looking at those pathologies asit relates to giving people
therapeutic exercise.
Eric (48:47):
And it also says in here too, it talks about, you know,
other things with therapeuticexercise In addition to
stretching.
They talk about range of motionexercises, strengthening
exercises, cardiovascularexercises, proprioception
exercises and exercises torestore capacity and activities
of daily living right.
Michelle (49:06):
So I'm like, oh, there's my physio and my
occupational occupationaltherapy friends, right like it's
.
Eric (49:12):
It's a huge amount of exercise intervention that they
are including in this documentthat I don't even think is
nearly close to being addressedat the academic level for
massage therapists academic orpractical level or practical
correct, yeah, because I don'tknow what other people's
(49:32):
experiences are, but I could sayvery comfortably that probably
at least 95 percent of myclinical hours at school were
predominantly people that justwanted hands-on, and even if you
wanted to do exercise, it wasnever really.
It was always so basic.
(49:53):
Because one thing is you didn'thave the time or the space and
we didn't have the education toassess and prescribe within a
therx type environment yeah and,and like you said too, like I
don't know, the therapeuticexercises.
I think, if I remember correctly, it was like halfway through
(50:14):
the program and it was maybe twoclasses 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 nota lot, you know, and that
includes all of this stuff rightversus Versus an OT, for
example.
So my sister is an occupationaltherapist.
(50:36):
It's a two years master'sdegree where all you're doing is
working on differentpopulations 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'relooking at who's better at it.
Mm-hmm.
What I would look at with thesethings.
Here is one.
Obviously, my go-to solution isincrease the hours, increase
(51:13):
the education.
Right.
Yeah, and I know a lot of peoplefight back on that, but
whatever, that's fine, they can.
I think that's where we need togo.
The other one, though, is say,rather than directing them all
these things, there should be athing on recognizing when to
refer it out.
Yeah fur out, yeah, or somethingin here about.
(51:39):
You know recognize when thisneeds something beyond your,
your scope or beyond your, yourexpertise.
Because how are you supposed todirect a client in
cardiovascular exercises in theclinical treatment room?
At least give them advice, buthow 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 wherethey're starting from Right?
How do you?
How are you?
How are you?
doing that and that's thequestion I pose.
You know, as the exercisephysiologist, is if your client
patient comes to see you andthey've just had a coronary
(52:12):
artery bypass surgery andthey've been cleared to drive to
get to see you, to come formassage, and let's say they
aren't connected to any rehabprograms or anybody else the
first person they see, how areyou going to know what to do to
tell them where they're supposedto start when they're resuming
their cardiovascular activities?
(52:33):
Sorry, but you're not right,unless you have the prior
training, the prior experience.
I mean, I wrote a cardiacrehabilitation program so I can
tell you right now what to do.
But I always am very clear tomy clients.
I say okay, I'm taking off mymassage therapist hat and I'm
putting on my kinesiologist hat.
This is Michelle, thekinesiologist giving you this
(52:56):
information, not the massagetherapist.
Because we're not taught thatlevel of knowledge in our, you
know, in our school experience.
Nor is it clearly stated inthese practice competencies that
we should know, you know, knowabout these special populations
and how to direct the patient orclient in cardiovascular
(53:20):
exercise.
So I think, um, I think, Ithink this, I think the practice
competencies need to define umwhen it comes to exercise, um
say like intermediate orbeginner level movement patterns
(53:40):
, or define the intensity or theappropriateness of the exercise
, and then anything above andbeyond that refer out right.
Um, so if your patient comes tosee you and has no
cardiovascular contraindications, prior history diagnosis, then
you can demonstrate yourknowledge of prescribing some
(54:03):
cardiovascular activity.
Telling someone to go for awalk is perfectly safe,
perfectly fine, easiest thing todo, but if that person is
coming to you and they've justhad this major surgery and
they're on this battery ofmedications, telling that person
to go for a walk, there's moreto it than just that right?
So I think the performanceindicators could be more clearly
(54:24):
defined and scaled back.
So it's reflective of a what Iconsider like a personal trainer
, where you take a weekendcourse and then you're a
personal trainer.
Because they're assuming you'reworking with an average,
healthy individual without anyother complicated health history
(54:45):
, right, and even then probablyyou know, if every massage
therapist took a basic personaltraining certification course,
even then they're probably goingto learn more about exercise
than what we learn in massageschool.
Eric (55:01):
I 100% agree with you there, michelle, because it does
say in the indicators.
It does say demonstrateknowledge of indications, safety
considerations, effects andoutcomes, effects and outcomes.
But I would be hard-pressedbecause I've seen the therax
textbooks that they use in mostschools and it does not really
go into much detail for those atall.
(55:23):
So even though it's in here, Iwould say it's probably lacking
because, I mean, the reality isright.
Michelle (55:30):
Our patients are getting more complex as they
come to see us, with more andmore different health conditions
cropping up and being diagnosed.
That a lot of it is is kind ofnot over our head, but a lot of
it needs to be referred out,right?
Know your lane, stay within ityeah, right yeah, respectfully,
(55:53):
like that's that's what it boilsdown, right yeah, respectfully,
like that's that's what itboils down to, right yeah.
Eric (55:57):
Yeah, I think that's, that's a.
That's a good way to kind ofsummarize a lot of the stuff.
Is that therapy exercise basedon the definition?
It looks like it shouldn't bewithin our scope of practice
based on the massage therapydefinition, but it is in our
PCPI so it's considered we.
It is within our scopePI, soit's considered we.
It is within our scope but weprobably most of us don't have
(56:21):
the required education,knowledge, skills to be very
effective with therapeuticexercise 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 yourschool experience.
I'd like to look at, like, whowrote these documents and what
their level of knowledge is,because just reading the
practice competencies again, I'msorry if I offend the people
who write this, but do you evenknow exercise?
(56:56):
You know when you're writingthis and how do you know how
this correlates to what theschools 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 andorganizations out there across
Canada, I would say most peoplethat are in charge of things
just don't have the knowledgeRight and a lot of that comes
from a profession that has a.
I think it's getting better,but I think traditionally we
(57:30):
have a bit of a culture ofacademic avoidance.
Better, but I thinktraditionally we have a bit of a
culture of academic avoidance.
People just don't.
We don't have enough peoplethat are really wanting to
pursue, you know, academia inthe, in the profession,
unfortunately.
But I can understand why.
Because what's the leave like?
What do you, what do you dowith it?
You know I, I know I've met andwhat searched out a handful of
(57:51):
the rmts that have a phd acrosscan, but very, very, very few of
them are involved at all in themassage therapy profession,
cause they get their PhD andthey go work at a university or
they go work research, doingsomething else it's totally
unrelated to massage, becauseit's kind of there's there's
nothing here for that.
So, you know, until I think westart getting more people in
(58:15):
positions of the have requiredor a higher level of education
and knowledge, particularly whenit comes down to, to research
and knowledge, translation andresearch.
Until we get those peopleinvolved with the stakeholders,
I don't think things are goingto change very quickly, if at
(58:36):
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 theylast did the PCPIs, the
competency document I would say,if this came out september 2024
, I would be surprised if it wasvastly different from this.
I bet you, eight years later,it probably looks very much the
same, because you probably havethe same people or similar
(59:06):
people writing it, and so Idon't know if anyone's listening
.
I have a whole list of peoplethat I could recommend that
would be very well suited tohelp push these things into a
higher standard and still staywithin our scope 100% right, and
how fantastic would that be tofor our profession and to
(59:29):
elevate the up and coming.
Michelle (59:30):
you know massage therapists who are in school or
who are considering you knowgoing to school for massage
therapy amazing, awesome, yeahwell, thanks for that today,
michelle, that was.
Eric (59:43):
That was really fun.
I really enjoyed thatconversation.
I hopefully the listeners gotsomething out of that.
We covered a lot of a lot ofthings, yeah.
Michelle (59:51):
Yeah, it was great and I think I think it's a good.
It's a good perspective toconsider for everybody.
We always have a role inhelping our patients and we
always have a role with respectto promoting movement and
activity.
I would just caution thelisteners not to use blanket
(01:00:13):
prescriptions.
Don't go tell everybody to gotry yoga.
Yoga classes can do a lot ofharm.
Not saying yoga is bad, but youknow a blanket statement of go
do some yoga isn't going to helpyour person.
But the easiest thing to do issay, hey, when was the last time
you went for a walk, right, andjust breaking it down, getting
(01:00:56):
down to the basics of thingswith people and just have going
to be more beneficial than youtelling them to go and stretch
their neck for 30 seconds.
So give them that pat on theback instead.
Eric (01:01:05):
Well done, michelle.
Good summary.
Thank you for that today, Untilnext time.
Michelle (01:01:09):
Yeah, thanks so much again, eric.
I appreciate the time.
Eric (01:01:11):
Thank you, thanks for listening.
I appreciate all of you fortaking the time to be here.
If you enjoyed this episode,please give it a five-star
rating and share it on yourfavorite social media platforms.
You can always follow me onInstagram or Facebook at
EricPervisRMT, and please headover to my website,
ericperviscom, to see a fulllisting of all my live courses,
webinars and self-directedcourse options.
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