November 13, 2025 • 54 mins
We question whether it is ethical to cause pain during manual therapy and unpack what nociception, tissue insult, and consent truly mean. We challenge heuristics like no pain, no gain and ground decision-making in evidence, context, and patient autonomy.
• defining pain and nociception as signals of actual or potential tissue damage
• challenging bruising and discomfort as therapeutic proof
• critiquing hurt does not equal harm as a blanket rule
• considering acute movement without adding insult<br>• separating clinical experience from mechanisms
• identifying knowledge gaps and outcome bias
• using informed consent beyond a checklist
• acknowledging identity, change, and humility in practice
• recognizing social determinants and inequities in pain care
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Eric (00:12):
Hello and welcome to the Massage Science Podcast.
My name is Eric Pervis.
I'm an RMT, course creator,educator, researcher, and
advocate for evidence-basedcare.
Today is episode 2 of myseven-episode series with Monica
Noy.
In this episode, we discussmore of her course content,
including important knowledgegaps, definitions, and social
(00:33):
determinants of health.
Monica's new course, which isthe first of its kind, Pain
Education NoScript Provided, isnow available for purchase on my
website, the CEBE.com.
Thank you for being here, andwe hope you enjoy this episode.
Part two, I'm excited.
Last week's episode I thoughtwas really great.
We had a great conversation.
(00:53):
It was a whole week ago.
I can't remember what we talkedabout, but something about
pain?
Something about pain.
It was fantastic.
And one of the things that Iwanted to start this
conversation off with today wassomething we briefly touched on
last week, and it's somethingthat I touched on in a webinar
(01:15):
that I was delivering last nightabout the question of is it
ever ethical to try to hurtsomeone?
unknown (01:22):
Right.
Eric (01:23):
When so we the we are delivering a treatment or an
intervention.
What are your thoughts aboutthat?
Monica (01:31):
It's a really challenging question because I
think that one of the thingsthat has been accepted in manual
therapies is that it'stherapeutic treatment is going
to be uncomfortable.
Right?
That we are that we it thatit's okay for us to cause
discomfort because ultimatelywe're helping.
(01:51):
And then you'll hear that beingsaid vibaticians is better.
So on an ethical level, it'slike when we look at when we
start looking at what isinvolved, the neurophysiological
aspects of pain and what thatactually means when someone's
(02:15):
saying that they feel then whatthat means is that we are that
we have then deliberately, it'slike during treatment, that we
are deliberately activated.
Sufficient to cause thatsignaling to reach the person's
(02:37):
awareness through the peripheraland central nervous system.
And no susceptors as part ofthat apparatus related to the
sensation of pain, that meansthat we're actually engaging a
sensory element that is relatedto tissue damage or damage of
(02:59):
some.
And that's what we're lookingat with the current definition
of pain.
We're looking at thatassociation between tissue
damage.
And then so the challenge is ifwe're causing someone's pain,
at what level do we know or notknow that we have caused actual
(03:21):
tissue damage?
In which case, like on a blackand white level, so whether or
not they feel better afterwardsmay simply be because we took
our hands off and we stoppedcausing them tissue damage.
So ethnically, it's it's reallyit's quite an interesting thing
(03:44):
to think about on a manualtherapy level.
On a surgical level, maybethat's something different.
Surgery is an absolute insultonto the tissues.
Tissue damage is being caused.
That is the consent that you goin with.
I mean you someone's cuttinginto you.
(04:06):
Like that's an absolute thingthat's happening.
We don't have anywhere nearthat level of uh consent that
we're giving people aboutcausing them pain if we're
causing them pain on a pain forsound.
We've never got that consent tosay we might possibly be caused
of tissue damage.
(04:26):
It's just me like doing the judja generation.
Eric (04:32):
And that is part of the dilemma, uh, from what I
understand, is that because thedefinition is actual or
potential tissue damage with thedefinition of pain, and also
the definition of breaking atpain from uh we know that no
susception is involved in pain.
And I know the ISP has anosyceptive pain definition as
(04:53):
well, which says that painarises from actual or threatened
damage to non-neural tissue andis due to the activation of
nosyceptors.
unknown (05:00):
Yeah.
Eric (05:01):
It's got that actual or threatened or actual or
potential, it's it's a verysimilar overlap.
So, by the definition, we don'tknow, is what you're saying,
whether or not we're doingtissue damage or not.
All we know is that we'reactivating, we're adding enough
noxious stimuli into theirapparatus that they're becoming
(05:21):
aware of it, but we don't knowthrough our touch if what it's
actually.
unknown (05:29):
Where does potential yeah, where does potential
become actual?
Yeah, that's so if you'reputting pressure on someone and
that's pressure enough for themto report to you that that
hurts, like where was that linebetween potential or actual?
And we know in manual therapythat bruises have been created,
(05:53):
like after manual therapy, thatpeople sometimes actually work
to create those bruises, andthat that is actual tissue
damage, that is a evidence ofactual tissue damage.
So for us to then say that thatis therapeutic is like that we
(06:16):
can't have that ethicalsituation both ways.
You either have to have astance in it, or you are you or
you're okay with potentiallycausing some tissue damage or
causing someone actual potentialtissue damage if it leads to
them reporting pain to you withwhat you're doing.
(06:36):
As a manual therapist, ifyou're okay with that to me,
that's possibly ethicallyreprehensible, right?
Like when you you're you'regetting into a place now where
you're okay with doing becauseit's not at the same level as
(07:02):
say a surgeon or someone who'sdoing something, even like a PRP
injection or something alongthose lines.
The description for that is weare actually irritating the hell
out of you for these reasons.
This is what this injection isdoing, or this is what this
surgery is doing.
We're removing something,changing something, we're
(07:22):
cutting through skin.
So all of that is within thedescription of it, within the
consent process.
On a manual or physical therapylevel, we don't have that same
level of consent.
We don't have that same abilityto describe what it is that
we're doing and to actually say,yeah, no, we're gonna give you
(07:43):
painkillers after this becauseit's gonna hurt like health,
because you're gonna go throughhealing.
Eric (07:48):
I would like to say it was rare, but I've heard many, many
stories from other therapistsover the years of teaching and
working in the profession, aswell as stories from patients
when I was working full-time inthe public, was that a lot of
people that took ibuprofen orTylenol before treatment or
right after a treatment, butmany people said that they would
(08:09):
take them before many people,therapists, I know we can't
prescribe drugs, but would tellme that like they're oh yeah, I
always patients, they all I haveall these patients and they
take these drugs before theycome in because they don't want
to feel the pain because theyhave the expectation that the
treatment's gonna hurt.
And then if they don't feel thepain, then they're the
therapist is gonna be able to dobetter work in air.
unknown (08:29):
Or to create more damage.
Eric (08:33):
And that mindset is and that belief system is so common
in our profession and in cultureand society here.
And I'd like to say outside ofNorth America, it probably is
too, for here in Canada andwhere we are for sure.
That's that belief that itneeds to hurt to help, or the no
pain, the no gain.
(08:54):
If it's hurting, it's it'shelping.
That aggressive technique issupposed to be a better
technique.
unknown (09:00):
And or even this, even this sort of notion that we have
of that hurt doesn't equalhurt.
Eric (09:07):
Yeah.
unknown (09:08):
Like that that's a big one that that occurs now with
some of the pain educationstuff, where it's like, oh no,
just because you're hurting, itdoesn't mean that you're harming
yourself.
Whereas, in fact, if it hurts,and if we go by the definition
of pain, then you cannotabsolutely say that you are not
(09:32):
being harmed or that there isnot some harm occurring.
Is it ultimately detrimental toyou on a larger scale?
Maybe not.
But is it ultimately helpful?
We don't necessarily know thateither, right?
We can't actually say, yeah,we're gonna we're gonna give you
(09:52):
an exercise that's gonna hurtwork through the pain because
you'll be better afterwards.
You may be better despite that,or it may take longer to be
better because yeah, you'veadded some things onto that.
We can give whatever twine thelonger we want.
So it's gonna take longer thanyou expect.
Because someone's actuallyundergoing more damage.
Eric (10:16):
Yeah, and that's such interesting point.
There's two things there.
So one that I wanted to hit onwas one was yeah, the hurt
doesn't equal harm, and that's avery common explain pain type
of thing.
And there's a part of that thatI like and agree with, and
there's a part of that that Idon't.
I'm kind of torn between thatbecause I find in my own
(10:37):
personal experience, my clinicalexperience, is having people
say, hey, you know what, thismight hurt a little bit, but as
long as it's manageable, we'veprobably ruled out any red
flags.
It's probably gonna laying downand doing nothing's probably
not the best.
But can you work through thatin a way that's comfortable and
doesn't make you feel worse thenext day?
I for me, I feel that I couldstand behind that.
(11:00):
But the oh, just ignore it ifit hurts because you're not
doing harm, I think is is so Ithink there's there's an extreme
that it can be taken to thatmight be unhelpful.
And what are your thoughts onthat?
unknown (11:14):
Well, so I definitely understand what you're saying in
terms of where if someone comesin in an acute situation and it
hurts to move, it's prettyexpected, actually, that it's
gonna hurt to move if you're inan acute situation.
And that there's a process,perhaps, for you to like start
to feel better.
But part of that process willbe you have to move.
(11:35):
Like you have even if it's ayour back's and spasm, you still
got to get up and go to thetoilet.
So there's some level at whichyou have to negotiate movement
with this.
And that acute state is notnecessarily providing any more
harm than you're already in,because something's happened.
There's something going onthat's activating nose deception
(11:56):
that's having these effects.
And but I think when we startto blanket that in terms of it's
like the way clinical practiceguidelines often get used, where
it's here's your guide.
And then suddenly this guidebecomes the sort of overarching
umbrella that everyone must fitinto in some way.
And so when it's taken out ofthat kind of context and then
(12:21):
perhaps placed into a largercontext where any hurt doesn't
equal harm, because that'sbecause that's just a heuristic.
That's just a little sayingwhere it's hurt does not equal
harm.
There's no context with that.
There's no instruction withthat as to like where do you
apply that situation?
(12:42):
It just becomes this blanket,no pain, no gain, did all of
that sort of thing.
So it just becomes somethinglike that, where it then gets
applied to all aspects withoutcaveat or without association.
Now, I'm not saying that thepeople are stupid and can't
actually figure out where thatmight be a reasonable thing, but
(13:03):
I'm gonna put myself in thiscategory.
We don't always think throughall of the depth and the breadth
and the complexity that goesalong with having these little
heuristics that say, oh, here'sa little tool that you can use
and that use for your thoughtprocess, for your clinical
(13:24):
reasoning.
And now you're using it in ablanket way to reason when
someone comes in.
And you're gonna apply that toeverything or to a lot of
things.
And then you stop thinkingabout it.
This is where I have someissues with some of the ways in
(13:45):
which we uh we can approachreally complex issues.
And in this case, complexissues that across the board we
don't know enough about.
Eric (14:43):
And that's a big thing for us as a profession or anyone in
the manual or massage therapyworld is to say we don't know
enough to make these definitivestatements.
And there's so often aoversimplification, the no pain,
no gain is one, or that hurtdoesn't equal harm, like these
two kind of extremes often gettaken.
unknown (15:04):
But they're sort of the same thing as well, which is
that's that's how I put themtogether.
Eric (15:07):
They're kind of both sort of the same thing.
But we often will hear thesethings, then we said we apply
that to everything.
Like you said, it's a blanketstatement that gets used.
And the key that I find to, andthis is I think where we would
both agree, is that the abilityto reflect and think about our
thinking and say, does that makesense for this person right
here, right now, this situation?
unknown (15:30):
And maybe do I know enough?
Yeah, do I know enough in thissituation to be confident that
if I cause this person harm, ornot harm, but if I put enough
pressure on this person that ithurts them, that I have enough
confidence to say it will helpthem in this particular way.
(15:54):
Without any of the other thingsthat go on.
But if we're talking aboutlooking at then the definition
of pain and the definition of nosusception and what that all
entails, I would have to say noto that question.
I would have to say, I couldnot have enough confidence.
I don't have the measuringtools, I don't have the ability
(16:16):
to have enough confidence to sayif I hurt you in a manual
therapy aspect, that is a thatis a therapeutic treatment.
That that will ultimately helpyou.
Eric (16:32):
Yeah, we don't know.
unknown (16:35):
No, but I think it's safe for us to assume if we're
going on our consensusunderstanding of these
definitions, that we shouldn'tbe doing it.
Eric (16:47):
Yeah, that would be the less wrong kind of understanding
or approach.
unknown (16:52):
Or I'd like to think of it as the more right
understanding.
Eric (16:55):
The more yeah, the more right, yeah.
The more right approach.
Yeah, I like that better.
Yeah, more right.
I often use the term lesswrong, but I I think I like more
right.
I think that's better.
unknown (17:06):
Yeah, because we have we have a certain level of
knowledge.
Yeah.
And that knowledge tells us ifwe're really looking at what it
is, that knowledge tells us ifwe cause someone pain on a
manual or physical therapylevel, we are possibly causing
them harm.
Eric (17:24):
Yes.
unknown (17:26):
And we don't know the line.
Eric (17:29):
Yeah.
And that makes perfect sense.
I 100% appreciate that.
I like how you've said that.
So, question here then to keepgoing on this ethical
discussion, because I think thisis important for people to
listen to.
I find it helpful to talk thisthrough with somebody too.
If he's thinking out loud andhaving this conversation to try
and put my thoughts together aswell.
So, looking at those principlesof ethics, one of them is
(17:50):
autonomy.
So the person is respected andthey consent.
Very simplistic definition ofautonomy.
And say they consent to youhurting them.
And they're okay with that.
What are your thoughts?
Like the reality, how much harmcould we do?
I know there could be a lot ifwe're really aggressive, but
what would be the level of harm?
So say someone did consent toit.
unknown (18:11):
I'm not sure that we're ever gonna, you know, that
there's that silly cartoon wheresomeone's doing a massage and
then all the skin just comes offand you see the the skeleton.
I there was a fascial one, Ithink.
But it it's like we're notobviously we're not doing that
level of harm.
However, are we doing enoughharm to impede healing or to
(18:34):
create another level of healingthat that person didn't need to
go through?
Yes.
So I don't think we have theanswer to those questions
because we think, oh, that'sgoing to be really helpful, but
we might be doing a small amountof so a person's still gonna
(18:57):
recover because time and naturalcourse of the condition and
regression to the mean and allof those different things that
occur, but we may actually beimpeding their process.
Again, you or on a long-termbasis, perhaps impeding their
process, because we're doingthis repeatedly.
Eric (19:18):
And that's something I actually wanted to touch on with
what you said there, because itis unfortunately common that
people have an acute injury orlike a motor vehicle accident or
sports or workplace accident,they go for therapy right away
and they get treated like dayone, day two, day three, while
there's still those in thatacute stage of tissue healing
(19:40):
where there's inflammation andthe fibroblast formations and
things are neuroimmuneprocesses, all those fun things
that I'm sure someone can nerdout about.
I think it's cool.
But anyway, and I think thatwhat you're saying, and this is
what how I understand it too, isthat if some if you go in and
you do a treatment that ishurting them while those
(20:01):
processes are happening, wecould actually be having a we
could be slowing down orimpeding that natural healing
process.
Is that correct?
unknown (20:09):
Yeah.
I mean, well we're adding toit.
Right.
Providing a level at whichtheir healing is is impeded or
slowed in some way, becausewe've just added another tissue
insult.
Yeah.
So now we're all of thosethings that you're talking about
are being activated every timethere's a tissue insult.
Yeah.
Eric (20:29):
And that would be increasing inflammatory
molecules.
unknown (20:32):
Yeah, all of those things come toward for healing.
There's neurophysiologicalprocesses that go on.
We can look at what it means tohave these same metabolic
stresses or various otherlifestyle stresses that are also
the equivalent of tissueinsults on a day-to-day basis.
And there's this, there's thisconstancy within our systems
(20:56):
where there's homeostasis, butthat involves, like homeostasis
involves a level ofinflammation, just on a on a on
a sort of a functional level,that's part of the process, a
level, a low level ofinflammation.
And now we're adding adifferent kind of maybe a
physical tissue insult alongwith that.
So now there's a another levelat which inflammation is
(21:19):
required or other kind ofmolecules are drawn to that
area.
Yeah, I don't see how, when youlook at it in that way, how we
wouldn't, in some way, beenimpeding a process at that
particular time.
Eric (21:34):
Yeah.
And this is why it's soimportant, I feel, for us to
really understand and appreciateneurophysiology and tissue
healing timelines and thoseneuroimmune processes that
occur.
Because if we learned that inschool, or if that was common
knowledge throughout ourprofessions, when we start to
ask these questions that we'reasking right now, the answer
(21:55):
becomes a little more clear thatof course we don't want to add
more insult.
We don't want to impede,because we're we have a better
understanding of what'shappening and how that's gonna
impact the person and theirsystem.
And so hopefully that'sinformation.
unknown (22:08):
And we also claim, we also we claim a healing
profession, but are we claimingthat we're providing the insult
from which someone would behealing?
Because should we not alsoclaim that as well if we're if
that's one of the things that wedo, if we cause someone to hurt
during that therapeuticprocess, then we need to make
(22:30):
that claim as well.
You're gonna heal, but I'mgonna give you something that
needs to heal.
Eric (22:36):
It just doesn't make sense.
unknown (22:37):
Yeah.
No, and like it's not overttissue damage, but we also know
that you don't have to witnessit.
You don't have to see the, as Icurrently have now, a massive
ankle swelling and bruising.
You don't have to see that tounderstand that tissue damage
has or is occurring.
Eric (22:56):
Oh, if someone has, so just for people that are
listening, just maybe there's alittle thing to think about is
that if someone comes in andthey are in pain, we're not
saying don't treat them.
We're just saying don't addmore harm or insult to the
tissue.
So we can still treat thosepeople, but we should, I would
(23:17):
say there should be a caveatthat we're trying to not amplify
their sensation of pain.
We're trying to calm down theirexperience of pain or calm down
the nociceptive system as bestwe can.
unknown (23:33):
Yeah.
And I think for people who,even for people who deliberately
cause someone pain, ultimatelytheir goal is the same.
Their goal is towards healing,towards less pain, towards
better function, all of thatstill exists.
What causing someone pain in atherapeutic context means is a
fundamental misunderstanding ofthe neurophysiology of the
(23:58):
sensation of pain.
Right.
And so that's where we start tosee that huge knowledge gap
that exists, where we've alwaysdone this, we have these
outcomes, people feel betterafterwards.
Do we actually track them?
Because how many times have weseen on social media where
people have been like, thistherapist bruised me and now I'm
(24:19):
in pain or whatever it mightbe?
So those things exist as well.
All of those outcomes willexist.
We're only gonna reallyremember the good ones for the
most part.
But yeah, where do we drawwhere do we draw our own line
for that and our ownunderstanding?
And if we don't understand orif we don't consider that the
(24:45):
definition of pain is what itis, because that's the current
consensus understanding rightnow, even though it's it's
debated, sure, it has it hasn'tchanged at this point in time.
But if we're not willing tolook at that, if we're not
willing to follow the science,then that means we are treating
(25:09):
on faith.
And that's the other ethicalquestion that we talked about as
well.
It was like, didn't did I talkto you about that one?
Is it ever is it is it everethical to clinically reason for
a healthcare context based onfaith?
Because faith is a belief youhold in the absence of evidence.
Eric (25:38):
We may have talked about that off-air.
I don't think that made it tothe recording last time, but I I
think that is a reallyimportant thing to talk about
belief-based or faith-basedtreatments.
unknown (25:51):
And we're not talking like religious faith here, we're
talking about anything that isanything that is a belief in the
absence of evidence is a faith.
Um, so we want justified those.
And if we cannot justify ourbelief that causing someone pain
(26:12):
on a therapeutic, you know,therapeutic context leads to
healing in some way.
And I'm talking manual physicaltherapies, then we don't have a
justified belief.
Right?
We have a faith.
We're hoping that it helps.
(26:33):
We're hoping that, and we'rebasing that on heuristics, we're
basing that on our hurt doesn'tequal harm, no pain, no gain,
whatever our culturaltherapeutic understanding is.
I've seen people feel betterafterwards, so therefore it must
(26:54):
be helping.
Eric (26:57):
That's a problem, too, that is so common.
You mentioned this briefly aminute ago, we forget or ignore
the ones that did help, but weremember, we're biased, remember
that the people that we didhelp.
And so often, I know it worksfor me, it works for my clients,
so therefore there's a itworks, therefore it works.
Yes, and it and people use thatclinical experience to justify
(27:18):
the potential mechanisms or tojustify the approach.
And I know that if we'retalking about evidence, yes,
part our personal experience ispart of that evidence, but your
personal experience doesn'tjustify the mechanisms of the
outcome.
unknown (27:32):
No, and your clinical experience should be an
illustration of something thatyou have used before to support
your understanding of themechanism.
And then you may be able to usethe clinical experience as an
illustration of that, but not asa justification of it.
Right?
It does it, it is an evidencein itself.
Eric (27:51):
It can't be and I'm so glad that you brought that up
because that's a conversationI've seen and heard and been a
part of before, where people,well, evidence-based practice
includes clinical experience andthe patient.
unknown (28:05):
Research and evidence and the patient, yeah.
Eric (28:07):
And they're like, but two out of three ain't bad.
I'm I'm kind of flipping onthem.
So we don't have the evidence,but we have we have the
patient's needs, wants, goals,values, and we have clinical
experience.
So that's evidence-basedpractice.
Well, no, it's not, it doesn'twork that way, right?
Right.
People will say, well, it's66.6%, so it's it's more
evidence-based than not.
unknown (28:27):
But I like what you said that it's 60% of the time,
it works every time.
Eric (28:31):
Every time I love the anchorman reference, thank you.
So the point being that yes,clinical practice or your
clinical experience is valid,patients' values are valid, but
them in themselves are should bean illustration of the bigger
picture.
And it needs to be based on theunderstanding of the evidence.
And if the evidence is notbeing considered, then those
(28:53):
other two don't really fit.
unknown (28:56):
Yeah, then you have information, but you still don't
have justified information tobase a therapeutic treatment on,
which I think is I I think ispart of the main issue.
It's very interesting when weget into this understanding of
evidence because people seethings that they want to be able
(29:19):
to explain with the treatmentthat they did.
And they say, Well, I did thisand this happened, and therefore
this is the mechanism, or it'sthe outcome, or whatever it
might be.
And any evidence to thecontrary, like uh like studies
that may show that all of theseoutcomes are just data blips,
(29:42):
right?
Once you start to get thebigger numbers, it's none of
it's really super clinicallysignificant.
And you have perhaps as manyharms as you do helps in terms
of quality of life and how muchof this is longevity, all of
those kinds of things.
So on a manual therapy basis,we don't necessarily have this
awe-inspiring mic drop kind ofevidence for anything that we
(30:05):
do.
But we do use basic science,which is evidence, and we do use
research, which again is partof our evidence collection.
We do use thought processes andclinical understandings.
And what is often missing is ormaybe what was too present is
(30:33):
desire.
It's this desire to be thehealer, it's this desire to be
the helper, it's this desire tosay, well.
Yes, what I did made thismassive difference to this
person's life.
And therefore, it can't bewrong.
And I can't be wrong, and theycan't be wrong.
(30:55):
And to and to say that that iswrong, but that's not the actual
sort of average outcome that weget with people, or that these
techniques don't actually havethat mechanism.
So there's some other perhapsthing that had gone on.
To take that into accountquestions identity, and it
becomes very challenging, itbecomes uncomfortable for people
(31:18):
to say, well, we have thisknowledge.
This knowledge does not explainthe miraculous outcome that I
saw.
But when you look at all thevariables, neither does that
take me to that treatment.
Because we spend in a person'slife.
(31:43):
Maybe you see them six times.
Six hours in a person's wholelife.
And for us to claim that whatwe do is some sort of be-all and
end all has these amazingcurative properties or whatever
it might be is just hubris.
(32:04):
We want to be good people, wewant to be we want to be the
helpers, we want to be thehealers, that's what we're
trained to do.
We have knowledge, we do haveknowledge and expertise that the
average lay person doesn't.
But we are also educated in ourtherapist's expert paradigm.
(32:30):
And if we're to question ourexpertise on this matter, then
where does that leave us?
Where do we actually fit into ahealthcare context?
Are we actually doing anything?
Like I can understand thatpeople then get to a place where
where they're like throw theirhands, I was about to swear that
(32:52):
I'm not gonna where they throwtheir where they throw their
hands up in frustration and say,Well, what am I even doing?
I've done that.
But I think maybe what'smissing is is a different kind
of an an a lot, like a differentkind of uh understanding of
(33:15):
what evidence is and what itshows.
It's like, yes, this shows alimitation only in comparison to
the claim I've made.
And if that's how I seeevidence, then that's always
going to be inferior.
So I have this claim over herethat says I can do all these
things.
The evidence over here says Ican, but this evidence provides
(33:40):
knowledge, it provides reality,it's a grounding, and it means
that we have to change somethingabout how it we think, what we
do.
Once we start layer on layeringon character building traits
like ethics and honesty andintegrity, we have to start
looking at what it is that we'resaying in relation to what it
(34:02):
is that we can support.
Go off on a tangent.
Yeah, not even sure this ismaking sense.
Eric (34:11):
I one reason why I was so excited to and and wanted to do
these episodes with you wasbecause I wanted to hear
Monica's tangents.
I wanted to hear you go off,just share.
So thank you.
Thank you for feelingcomfortable to do that.
unknown (34:23):
Well, I'll put a caveat here because everyone hold it
lightly, because I've changed mymind many a time based on
evidence.
So even hurting people, like Ihave done that in my therapeutic
life.
Eric (34:38):
The same here.
unknown (34:39):
I have hurt people, I have caused people pain when I
have treated them.
I have reported pain and I'vebasically told them to suck it
up.
Like I didn't necessarily usethose words, but kind of close
because there's this idea of nopain, no gain, and then that
changed, and then so there's adifferent thing, and then that
changed again, and there's adifferent way of approaching.
(35:02):
And I have made some massiveerrors in my engagement with
people on a therapeutic level.
And I know that mostly we liketo hold the successes, I tend to
hold the failures, and thefailures are where we learn the
(35:22):
most because it's not theirfailure, it's mine.
I was the one who failed them,and I think that is where we
start to get that kind ofhonesty thing is I failed them.
This is a process where I haveto look at myself and I have to
(35:44):
look at what I'm doing.
And so I have changedsignificantly over the years in
terms of how I approach people,in terms of the claims I make,
in terms of the teaching that Ido, the courses I've done for
this and for Sheridan and forother things, have been fairly
steadfast over the past fewyears.
(36:04):
They've been updated, butthey've not been fundamentally
rock solidly changed.
I've had courses before where Iliterally trashed them.
I did all this research, I didall this putting together
information, and there wasevidence.
Oh, I can't just buy any ofthis.
And I just stopped.
(36:25):
So this has been a little bitdifferent.
And I think it's probably thesame for you, where you start to
see these things that you canbuild on rather than have to
break down to a considerate.
Eric (36:38):
100%.
And that's very overlaps a lotwith with my experience.
And of if I think of back inthe early 2000s when I went to
massage school and what Ithought and felt about massage
and what it was and what itwasn't.
And then through the first oh,probably close to 10, 7, 8, 9
years of my career, where I washeavily involved in
(37:00):
structuralism andpathoanatomical thinking, and
and which was kind of laid inthose thoughts were laid into my
brain in school, because that'swhat we thought.
And I was heavily invested inthe fascia narrative, and I was
took all those types of courses,and I went to the fascia
research congress.
But the more I learned aboutthat that way of thinking, the
(37:25):
less sense it started to make tome because it didn't translate
into what I was seeing in theclinic.
I wanted it to, I tried to makeit.
I I just and it, but it justdid it stopped.
It didn't, and it particularlydidn't make sense with those
people that had I don't want toI don't want to say this in a
way that sounds too flippant,but like people that had like
(37:49):
strange pain stuff, like paintthings that didn't make any
sense.
It didn't fit into a box, andthey've had pain for a long
time, and they reacted reallystrange to the touch that you
put on them.
You're killing me, and you'rethinking, what am I doing?
Or the other end where youcould touch them and they
wouldn't fit, they were numb.
Like it was the stuff didn'tmake any sense.
And so that started getting measked these questions, and yeah,
(38:09):
went into like explain painstuff and looking more about the
role of the nervous system andthe brain and thoughts, blah
blah blah, and thenbiopsychosocial and now where I
am now, where I'm don't reallyknow where I am, but feel more
comfortable in my level ofuncertainty now than I did at
any point in time.
And the stuff that seems, andlike I said that seems to make
(38:31):
the most sense to me is thestuff that we're talking about,
about these kind ofneurophysiology, and if we base
things on pain, no seception,complex experiences, we don't
know enough.
Person, the person's individualexperience matters more than
anything else.
I feel like thinking that way,I don't have all the answers,
(38:58):
whereas I I wanted all theanswers before, but I feel now,
at least in practice and also inthe teaching, is that we don't
need to have all the answers.
We just need to, I think, becurious and explore and see what
it is that we can do for thatperson on that day to hopefully
make them feel better than theycame in.
(39:18):
And we have lots of differentoptions to try to do that
without having to we havedifferent, we have different
boxes now too.
unknown (39:26):
Yeah.
So there's a little bit betterunderstanding, especially with
relation to pain, where we couldput someone into a category.
And I say kind of because thesecategories are not definitive.
They don't have any sort ofabsolutely necessary, well, some
of them may have some necessarycharacteristics to be in that
(39:47):
category.
But there are variationsbetween with and within the
categories with relation to painof being able to make some sort
of assessment of the personbased on it.
Doesn't necessarily even haveto be an in-depth neuroscience
knowledge.
Like don't have a reasonableamount of neuroscience
knowledge, but it's this idea ofconfidence in reason and
(40:10):
confidence in foundation.
So we have this foundationscience, and there may be
changes within it to somedegree.
Pain is something you'll see,start to see some changes within
in terms of some of thesemantics around some of the
term terminology.
But it's not gonna be soextraordinary that it's gonna
(40:34):
overturn all of the pain sciencethat has gone before the basic
pain science that has gonebefore it.
What might be overturned ismore of the bias psychosocial,
where it relates to pain, whereit relates as forces.
That doesn't havejustification.
(40:55):
It's very, very challenging tojustify that when you have other
kind of foundational sciencethat that doesn't really match
those patterns.
That's not saying biosexual isirrelevant.
That's just saying that whenit's applied, when it's been
taken and applied to health andpain in various ways, it's gone
(41:17):
into those heuristics thatnegate the meaning of the
research.
Eric (41:25):
Today we're going to talk about deck two, module two for
the course, and we haven't evenreally touched on.
unknown (41:30):
No, I know.
Eric (41:31):
But I think that this is maybe next, maybe we'll see that
for now.
unknown (41:34):
This is a good, yeah, but this is actually a good,
like just the understanding ofthe biosarocial is a good intro
into that.
One of the decks is very muchabout the the health, what do I
call it?
Health inequities and socialdeterminants of health.
Because biasecosocial issupposed to encompass that.
And because of the and but butsocial determinants of health
(42:00):
and health inequities are socomplex.
And I'm providing anintroduction, but you can go
into each of them in a really,really complex way that has to
do with sectionality between allof these social determinants
and all of other characters,other characters is cultural and
(42:21):
social and various otherfinancial, economic, race,
gender, all of those kinds ofthings will come together in
some ways.
So it's not just that theyexist, it's that they exist and
they interact and they interactin particular ways.
And what biosychosocial hasdone to some degree is
(42:43):
simplified them so much down toone word that has a very sort of
minimalistic meaning associatedwith it.
These social determinants ofhealth are supposed to be
considerations withinbiosychosocial.
And what I find is that thatoccurs minimally.
(43:04):
And so we are missing massiveamounts of information if we're
not actually considering thedepth and the breadth to which
these social determinants,health inequities dictate to
some degree, how we might bethinking of a therapeutic
(43:24):
intervention or how we mightclinically reason to treat
somebody in any particularsense.
Eric (43:35):
Yeah, it's an important topic that doesn't get discussed
enough.
And love how you without givingaway too much, because we don't
want to tell everybody.
But when we're looking at thesocial determinants, it it is
it's very important from myunderstanding and from looking
through the research that you'veincluded.
(43:55):
We're looking at racism andgender and sex differences and
poverty or income wealth orincome levels and how those
things shape the experience ofpain, but also the treatment
that's available or not.
unknown (44:09):
And how they shape research as well, yeah.
And they shape researchquestions and how things are set
up to be disadvantageous tocertain people, and that we
don't that we live within that.
We live within this system thatis set up to disadvantage
people, and we are part of it.
And we we act as part of it,not necessarily as people who
(44:33):
are understanding of that andcan take any kind of action that
might change something aboutthat.
So it's very easy to just bewithin the system that we're in
and not question that because insome ways it's uh beneficial
for us, but uh it's going to bedisadvantageous to somebody
(44:55):
else.
Eric (44:57):
Yeah, and maybe next week we'll discuss that a little.
We can go into that a littlebit more.
I I think this conversationthough today about uh ethics was
probably something that wasn'tscheduled, but I think I'm glad
that we had it because I thinkit was very valuable, it was
valuable to me.
Hopefully the listeners werefind it valuable too, because
these are topics that so thingslike ethics, things like social
(45:20):
determinants, which we'll talkabout next time, are things that
are so important to understandin the research as well as in
the clinical environments orworlds that we work in, but we
just don't have no these theseconversations aren't happening
enough.
unknown (45:37):
I I I agree.
I don't think they're happeningenough.
I think they're and they'realso happening too late.
So you'll often find thatethics or research or these this
uh understanding of socialdeterminants comes at the end of
a course.
And it's usually an add-on asopposed to something that
actually should be thefoundational component from
(45:57):
which the thought processbegins.
Because we should beunderstanding our context and
understanding the context inwhich another person exists and
how we exist in that contexttogether before we could
actually make some sort ofreasonable determination.
And then you add that of tothat, of course, the knowledge
(46:18):
that we do have of the basicsciences and of our skill set,
and also then the knowledge thatwe're missing.
It's a lot of work for us todo, and that's maybe a lot of
work that people don'tnecessarily want to do at this
stage of life, when people havebeen in the industry for a
little while.
Sometimes that's not where youwant to go.
(46:38):
But there can be other thingsthat you understand that may
help you out with that, withthat, without having to do all
the work.
As long as in in to some degreethere are certain fundamental
things that you may accept, evenif you haven't, because they
can justify, because they canprovide justification for what
you might do on a clinicalreasoning level without
(47:02):
necessarily having to go intoall of that.
But but I think for youngerpeople who are coming up, for
people who are just getting intothe profession or who are like
wanting to move in differentways, these should be our
foundational thought like bricksthat we build our house with.
Eric (47:21):
Which is why we're discussing them in episode two.
unknown (47:24):
Yeah.
Eric (47:25):
Have these discussions for the forefront of knowledge and
of having these conversations tobe aware of them and these
thought processes and to helpshape your thinking.
So as we move on through therest of these podcast episodes,
as well as as you move throughwhen everyone decides to take
this course that you're going tobe presenting.
Exciting, that they will thisstuff is gonna be okay, I'm now
(47:49):
thinking through this lens.
Yeah, it's still gonna befoggy, it still might not be
that clear, but and it's notsupposed to be, but you're
starting to think about it soyou can shape how you how you
take on that further knowledge.
unknown (48:05):
Yeah, and that's why I put these courses together was
for my own understanding, for myown ability to think through
these things.
And that's what I'm sharingwith people.
So I'm also coming at it from aperspective where I also don't
necessarily have enoughknowledge, and we haven't even
gotten into the idea of theautonomy and agency and what it
means to be an agent in theworld with free will, who, you
(48:28):
know, wants other people to alsohave free will.
And what does that mean whenwe're when we're not providing
consent for it, like properconsent for a process that's
causing them pain that couldthat that means actual or
potential to she then?
Yeah.
Eric (48:48):
So one thing I often will try to address in some of my
courses, and I'm glad that youwanted to talk about it, was the
idea of informed consent.
Can somebody actually give youinformed consent when your
treatment is based on a belief?
unknown (49:07):
Exactly.
Yeah, there's that foundationalkind of ethical sort of
question.
Because belief does not requirejustification.
Eric (49:16):
Yeah.
unknown (49:16):
You can justify it to yourself, but you can't justify
it with evidence that will makeit a justified true belief and
and an actual something we couldactually say is knowledge,
right?
Is how we know something is aknowledge that we can have.
Eric (49:34):
Now, I don't know big T truth, but it it's the more
right when it comes to anythingthat has this social component
in relation to these are heavyconversations that I hope people
listening will start to havebecause people that enter the
(49:54):
profession, they just want to goand they learn, they want to
learn how to perform massage anddo assessment and help people.
And that's why I think we allgot in the profession.
But the longer that I'm around,the more I start to realize
that these foundationalphilosophies, these
understandings are justcompletely absent in an
(50:15):
entry-to-practice education.
And uh I don't I'm not saying,and I don't think you're saying
that you need to be a uh aphilosopher, have a philosophy
degree, but this stuff should befoundational in that entry to
practice.
So at least people are aware ofthis because it will shape how
you think and look at yourpatients and how you pursue your
(50:35):
professional development shouldcome through these lenses.
unknown (50:39):
I will say and someone paying you for treatment isn't
consent for you entering intotheir space and touching them in
ways that you believe will helpthem.
Right.
That that's not consent becausethat's a transaction, but that
(51:02):
that transaction involvesbecause you believe you're doing
something therapeutic or theybelieve they're doing something
therapeutic, that involvesjustification.
And if you can't justify thatto yourself, if it's based on
belief, then ethically you're ina no-go zone as far as I'm
concerned.
Eric (51:22):
I hope some of the regulatory colleges and
regulatory bodies out there,stakeholders, are listening to
this.
Because the conversations thatI feel that you should be
exploring at that regulatorylevel.
unknown (51:36):
Yeah.
Yeah, consent's a consent's achecklist, basically.
But it doesn't actually have agood understanding of what it
means to have a an autonomoushuman being in front of you that
you and that that you respecttheir autonomy as much as they
as you respect your own.
Eric (51:55):
Yeah.
Heavy stuff.
unknown (52:00):
I know.
But fun.
But fun.
Eric (52:02):
I know I love it.
This is great.
unknown (52:03):
We can get we can get heavier.
I don't have I don't have asmuch of the philosophical
knowledge that I would like.
I'm doing more of that kind ofexploration, but I have enough
to ask questions that I can'tnecessarily always clearly
answer.
But I know then some of thosequestions, it like it's yes or
no.
There's no middle here.
Like it should you start with aquestion and your answer is
(52:27):
either yes or no.
No is just you would have toreject that it would, it would
probably be morallyreprehensible.
And yes means that you have tonow negotiate something about
what it is that you believe.
These are the these are youroptions, basically.
Eric (52:44):
I am not an expert at all either when it comes to the
philosophy and the healthcarephilosophy, but it's something
that in the last year-ish or so,I've been trying to read more
about and to understand and toto reflect and think of, and
stuff I'm trying to incorporatea little bit into some of the
courses things I do just to sopeople start asking those
(53:04):
questions and start thinkingthat way.
I don't know if people do, butI I I hope that uh there's the
occasional person that maybe isstarting to ask different
questions.
And I think that's when we'restarting, that's all we can all
we can ask.
unknown (53:17):
Yeah.
Yeah.
Eric (53:18):
Well, that was great, Monica.
Thank you for that today.
We will be back next week andwe'll talk maybe a bit more
about module two, and probablywe should talk a little bit more
about module three because it'swe're gonna do module produces.
unknown (53:30):
Are we gonna talk about any of the modules?
Maybe not.
We're probably just getting toall sorts of other questions.
Eric (53:35):
You know what?
That's okay.
They provide I find that the uhjust kind of the general ideas
of some of these modulesactually provide a lot of
information about just for usjust to have conversations and
then ask questions to each otheruh about some of those things.
unknown (53:49):
And we will actually get into some of those knowledge
aspects of pain that peopleperhaps don't know and that will
help us gain more knowledge andfill that gap, right?
We will actually go there.
Eric (54:01):
Yes, promise.
So anyway, thanks Monica.
We'll talk to you soon.
unknown (54:05):
Not a problem, we'll see you later.
Bye, Eric.
Eric (54:08):
Thank you for listening.
Pain Education, no scriptprovided, is now available for
purchase on my website, theCEBE.com.
To listen to more of theseepisodes, please subscribe on
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If you enjoyed this episode,please like and share to your
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If you'd like to connect withme directly, I can be reached
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(54:31):
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This can be done by clicking onthe support button or heading
over to buymeacoffee.comslashhelloob.
Hello and welcome to the Massage Science Podcast.
My name is Eric Pervis.
I'm an RMT, course creator,educator, researcher, and
advocate for evidence-basedcare.
Today is episode 2 of myseven-episode series with Monica
Noy.
In this episode, we discussmore of her course content,
including important knowledgegaps, definitions, and social
(00:33):
determinants of health.
Monica's new course, which isthe first of its kind, Pain
Education NoScript Provided, isnow available for purchase on my
website, the CEBE.com.
Thank you for being here, andwe hope you enjoy this episode.
Part two, I'm excited.
Last week's episode I thoughtwas really great.
We had a great conversation.
(00:53):
It was a whole week ago.
I can't remember what we talkedabout, but something about
pain?
Something about pain.
It was fantastic.
And one of the things that Iwanted to start this
conversation off with today wassomething we briefly touched on
last week, and it's somethingthat I touched on in a webinar
(01:15):
that I was delivering last nightabout the question of is it
ever ethical to try to hurtsomeone?
unknown (01:22):
Right.
Eric (01:23):
When so we the we are delivering a treatment or an
intervention.
What are your thoughts aboutthat?
Monica (01:31):
It's a really challenging question because I
think that one of the thingsthat has been accepted in manual
therapies is that it'stherapeutic treatment is going
to be uncomfortable.
Right?
That we are that we it thatit's okay for us to cause
discomfort because ultimatelywe're helping.
(01:51):
And then you'll hear that beingsaid vibaticians is better.
So on an ethical level, it'slike when we look at when we
start looking at what isinvolved, the neurophysiological
aspects of pain and what thatactually means when someone's
(02:15):
saying that they feel then whatthat means is that we are that
we have then deliberately, it'slike during treatment, that we
are deliberately activated.
Sufficient to cause thatsignaling to reach the person's
(02:37):
awareness through the peripheraland central nervous system.
And no susceptors as part ofthat apparatus related to the
sensation of pain, that meansthat we're actually engaging a
sensory element that is relatedto tissue damage or damage of
(02:59):
some.
And that's what we're lookingat with the current definition
of pain.
We're looking at thatassociation between tissue
damage.
And then so the challenge is ifwe're causing someone's pain,
at what level do we know or notknow that we have caused actual
(03:21):
tissue damage?
In which case, like on a blackand white level, so whether or
not they feel better afterwardsmay simply be because we took
our hands off and we stoppedcausing them tissue damage.
So ethnically, it's it's reallyit's quite an interesting thing
(03:44):
to think about on a manualtherapy level.
On a surgical level, maybethat's something different.
Surgery is an absolute insultonto the tissues.
Tissue damage is being caused.
That is the consent that you goin with.
I mean you someone's cuttinginto you.
(04:06):
Like that's an absolute thingthat's happening.
We don't have anywhere nearthat level of uh consent that
we're giving people aboutcausing them pain if we're
causing them pain on a pain forsound.
We've never got that consent tosay we might possibly be caused
of tissue damage.
(04:26):
It's just me like doing the judja generation.
Eric (04:32):
And that is part of the dilemma, uh, from what I
understand, is that because thedefinition is actual or
potential tissue damage with thedefinition of pain, and also
the definition of breaking atpain from uh we know that no
susception is involved in pain.
And I know the ISP has anosyceptive pain definition as
(04:53):
well, which says that painarises from actual or threatened
damage to non-neural tissue andis due to the activation of
nosyceptors.
unknown (05:00):
Yeah.
Eric (05:01):
It's got that actual or threatened or actual or
potential, it's it's a verysimilar overlap.
So, by the definition, we don'tknow, is what you're saying,
whether or not we're doingtissue damage or not.
All we know is that we'reactivating, we're adding enough
noxious stimuli into theirapparatus that they're becoming
(05:21):
aware of it, but we don't knowthrough our touch if what it's
actually.
unknown (05:29):
Where does potential yeah, where does potential
become actual?
Yeah, that's so if you'reputting pressure on someone and
that's pressure enough for themto report to you that that
hurts, like where was that linebetween potential or actual?
And we know in manual therapythat bruises have been created,
(05:53):
like after manual therapy, thatpeople sometimes actually work
to create those bruises, andthat that is actual tissue
damage, that is a evidence ofactual tissue damage.
So for us to then say that thatis therapeutic is like that we
(06:16):
can't have that ethicalsituation both ways.
You either have to have astance in it, or you are you or
you're okay with potentiallycausing some tissue damage or
causing someone actual potentialtissue damage if it leads to
them reporting pain to you withwhat you're doing.
(06:36):
As a manual therapist, ifyou're okay with that to me,
that's possibly ethicallyreprehensible, right?
Like when you you're you'regetting into a place now where
you're okay with doing becauseit's not at the same level as
(07:02):
say a surgeon or someone who'sdoing something, even like a PRP
injection or something alongthose lines.
The description for that is weare actually irritating the hell
out of you for these reasons.
This is what this injection isdoing, or this is what this
surgery is doing.
We're removing something,changing something, we're
(07:22):
cutting through skin.
So all of that is within thedescription of it, within the
consent process.
On a manual or physical therapylevel, we don't have that same
level of consent.
We don't have that same abilityto describe what it is that
we're doing and to actually say,yeah, no, we're gonna give you
(07:43):
painkillers after this becauseit's gonna hurt like health,
because you're gonna go throughhealing.
Eric (07:48):
I would like to say it was rare, but I've heard many, many
stories from other therapistsover the years of teaching and
working in the profession, aswell as stories from patients
when I was working full-time inthe public, was that a lot of
people that took ibuprofen orTylenol before treatment or
right after a treatment, butmany people said that they would
(08:09):
take them before many people,therapists, I know we can't
prescribe drugs, but would tellme that like they're oh yeah, I
always patients, they all I haveall these patients and they
take these drugs before theycome in because they don't want
to feel the pain because theyhave the expectation that the
treatment's gonna hurt.
And then if they don't feel thepain, then they're the
therapist is gonna be able to dobetter work in air.
unknown (08:29):
Or to create more damage.
Eric (08:33):
And that mindset is and that belief system is so common
in our profession and in cultureand society here.
And I'd like to say outside ofNorth America, it probably is
too, for here in Canada andwhere we are for sure.
That's that belief that itneeds to hurt to help, or the no
pain, the no gain.
(08:54):
If it's hurting, it's it'shelping.
That aggressive technique issupposed to be a better
technique.
unknown (09:00):
And or even this, even this sort of notion that we have
of that hurt doesn't equalhurt.
Eric (09:07):
Yeah.
unknown (09:08):
Like that that's a big one that that occurs now with
some of the pain educationstuff, where it's like, oh no,
just because you're hurting, itdoesn't mean that you're harming
yourself.
Whereas, in fact, if it hurts,and if we go by the definition
of pain, then you cannotabsolutely say that you are not
(09:32):
being harmed or that there isnot some harm occurring.
Is it ultimately detrimental toyou on a larger scale?
Maybe not.
But is it ultimately helpful?
We don't necessarily know thateither, right?
We can't actually say, yeah,we're gonna we're gonna give you
(09:52):
an exercise that's gonna hurtwork through the pain because
you'll be better afterwards.
You may be better despite that,or it may take longer to be
better because yeah, you'veadded some things onto that.
We can give whatever twine thelonger we want.
So it's gonna take longer thanyou expect.
Because someone's actuallyundergoing more damage.
Eric (10:16):
Yeah, and that's such interesting point.
There's two things there.
So one that I wanted to hit onwas one was yeah, the hurt
doesn't equal harm, and that's avery common explain pain type
of thing.
And there's a part of that thatI like and agree with, and
there's a part of that that Idon't.
I'm kind of torn between thatbecause I find in my own
(10:37):
personal experience, my clinicalexperience, is having people
say, hey, you know what, thismight hurt a little bit, but as
long as it's manageable, we'veprobably ruled out any red
flags.
It's probably gonna laying downand doing nothing's probably
not the best.
But can you work through thatin a way that's comfortable and
doesn't make you feel worse thenext day?
I for me, I feel that I couldstand behind that.
(11:00):
But the oh, just ignore it ifit hurts because you're not
doing harm, I think is is so Ithink there's there's an extreme
that it can be taken to thatmight be unhelpful.
And what are your thoughts onthat?
unknown (11:14):
Well, so I definitely understand what you're saying in
terms of where if someone comesin in an acute situation and it
hurts to move, it's prettyexpected, actually, that it's
gonna hurt to move if you're inan acute situation.
And that there's a process,perhaps, for you to like start
to feel better.
But part of that process willbe you have to move.
(11:35):
Like you have even if it's ayour back's and spasm, you still
got to get up and go to thetoilet.
So there's some level at whichyou have to negotiate movement
with this.
And that acute state is notnecessarily providing any more
harm than you're already in,because something's happened.
There's something going onthat's activating nose deception
(11:56):
that's having these effects.
And but I think when we startto blanket that in terms of it's
like the way clinical practiceguidelines often get used, where
it's here's your guide.
And then suddenly this guidebecomes the sort of overarching
umbrella that everyone must fitinto in some way.
And so when it's taken out ofthat kind of context and then
(12:21):
perhaps placed into a largercontext where any hurt doesn't
equal harm, because that'sbecause that's just a heuristic.
That's just a little sayingwhere it's hurt does not equal
harm.
There's no context with that.
There's no instruction withthat as to like where do you
apply that situation?
(12:42):
It just becomes this blanket,no pain, no gain, did all of
that sort of thing.
So it just becomes somethinglike that, where it then gets
applied to all aspects withoutcaveat or without association.
Now, I'm not saying that thepeople are stupid and can't
actually figure out where thatmight be a reasonable thing, but
(13:03):
I'm gonna put myself in thiscategory.
We don't always think throughall of the depth and the breadth
and the complexity that goesalong with having these little
heuristics that say, oh, here'sa little tool that you can use
and that use for your thoughtprocess, for your clinical
(13:24):
reasoning.
And now you're using it in ablanket way to reason when
someone comes in.
And you're gonna apply that toeverything or to a lot of
things.
And then you stop thinkingabout it.
This is where I have someissues with some of the ways in
(13:45):
which we uh we can approachreally complex issues.
And in this case, complexissues that across the board we
don't know enough about.
Eric (14:43):
And that's a big thing for us as a profession or anyone in
the manual or massage therapyworld is to say we don't know
enough to make these definitivestatements.
And there's so often aoversimplification, the no pain,
no gain is one, or that hurtdoesn't equal harm, like these
two kind of extremes often gettaken.
unknown (15:04):
But they're sort of the same thing as well, which is
that's that's how I put themtogether.
Eric (15:07):
They're kind of both sort of the same thing.
But we often will hear thesethings, then we said we apply
that to everything.
Like you said, it's a blanketstatement that gets used.
And the key that I find to, andthis is I think where we would
both agree, is that the abilityto reflect and think about our
thinking and say, does that makesense for this person right
here, right now, this situation?
unknown (15:30):
And maybe do I know enough?
Yeah, do I know enough in thissituation to be confident that
if I cause this person harm, ornot harm, but if I put enough
pressure on this person that ithurts them, that I have enough
confidence to say it will helpthem in this particular way.
(15:54):
Without any of the other thingsthat go on.
But if we're talking aboutlooking at then the definition
of pain and the definition of nosusception and what that all
entails, I would have to say noto that question.
I would have to say, I couldnot have enough confidence.
I don't have the measuringtools, I don't have the ability
(16:16):
to have enough confidence to sayif I hurt you in a manual
therapy aspect, that is a thatis a therapeutic treatment.
That that will ultimately helpyou.
Eric (16:32):
Yeah, we don't know.
unknown (16:35):
No, but I think it's safe for us to assume if we're
going on our consensusunderstanding of these
definitions, that we shouldn'tbe doing it.
Eric (16:47):
Yeah, that would be the less wrong kind of understanding
or approach.
unknown (16:52):
Or I'd like to think of it as the more right
understanding.
Eric (16:55):
The more yeah, the more right, yeah.
The more right approach.
Yeah, I like that better.
Yeah, more right.
I often use the term lesswrong, but I I think I like more
right.
I think that's better.
unknown (17:06):
Yeah, because we have we have a certain level of
knowledge.
Yeah.
And that knowledge tells us ifwe're really looking at what it
is, that knowledge tells us ifwe cause someone pain on a
manual or physical therapylevel, we are possibly causing
them harm.
Eric (17:24):
Yes.
unknown (17:26):
And we don't know the line.
Eric (17:29):
Yeah.
And that makes perfect sense.
I 100% appreciate that.
I like how you've said that.
So, question here then to keepgoing on this ethical
discussion, because I think thisis important for people to
listen to.
I find it helpful to talk thisthrough with somebody too.
If he's thinking out loud andhaving this conversation to try
and put my thoughts together aswell.
So, looking at those principlesof ethics, one of them is
(17:50):
autonomy.
So the person is respected andthey consent.
Very simplistic definition ofautonomy.
And say they consent to youhurting them.
And they're okay with that.
What are your thoughts?
Like the reality, how much harmcould we do?
I know there could be a lot ifwe're really aggressive, but
what would be the level of harm?
So say someone did consent toit.
unknown (18:11):
I'm not sure that we're ever gonna, you know, that
there's that silly cartoon wheresomeone's doing a massage and
then all the skin just comes offand you see the the skeleton.
I there was a fascial one, Ithink.
But it it's like we're notobviously we're not doing that
level of harm.
However, are we doing enoughharm to impede healing or to
(18:34):
create another level of healingthat that person didn't need to
go through?
Yes.
So I don't think we have theanswer to those questions
because we think, oh, that'sgoing to be really helpful, but
we might be doing a small amountof so a person's still gonna
(18:57):
recover because time and naturalcourse of the condition and
regression to the mean and allof those different things that
occur, but we may actually beimpeding their process.
Again, you or on a long-termbasis, perhaps impeding their
process, because we're doingthis repeatedly.
Eric (19:18):
And that's something I actually wanted to touch on with
what you said there, because itis unfortunately common that
people have an acute injury orlike a motor vehicle accident or
sports or workplace accident,they go for therapy right away
and they get treated like dayone, day two, day three, while
there's still those in thatacute stage of tissue healing
(19:40):
where there's inflammation andthe fibroblast formations and
things are neuroimmuneprocesses, all those fun things
that I'm sure someone can nerdout about.
I think it's cool.
But anyway, and I think thatwhat you're saying, and this is
what how I understand it too, isthat if some if you go in and
you do a treatment that ishurting them while those
(20:01):
processes are happening, wecould actually be having a we
could be slowing down orimpeding that natural healing
process.
Is that correct?
unknown (20:09):
Yeah.
I mean, well we're adding toit.
Right.
Providing a level at whichtheir healing is is impeded or
slowed in some way, becausewe've just added another tissue
insult.
Yeah.
So now we're all of thosethings that you're talking about
are being activated every timethere's a tissue insult.
Yeah.
Eric (20:29):
And that would be increasing inflammatory
molecules.
unknown (20:32):
Yeah, all of those things come toward for healing.
There's neurophysiologicalprocesses that go on.
We can look at what it means tohave these same metabolic
stresses or various otherlifestyle stresses that are also
the equivalent of tissueinsults on a day-to-day basis.
And there's this, there's thisconstancy within our systems
(20:56):
where there's homeostasis, butthat involves, like homeostasis
involves a level ofinflammation, just on a on a on
a sort of a functional level,that's part of the process, a
level, a low level ofinflammation.
And now we're adding adifferent kind of maybe a
physical tissue insult alongwith that.
So now there's a another levelat which inflammation is
(21:19):
required or other kind ofmolecules are drawn to that
area.
Yeah, I don't see how, when youlook at it in that way, how we
wouldn't, in some way, beenimpeding a process at that
particular time.
Eric (21:34):
Yeah.
And this is why it's soimportant, I feel, for us to
really understand and appreciateneurophysiology and tissue
healing timelines and thoseneuroimmune processes that
occur.
Because if we learned that inschool, or if that was common
knowledge throughout ourprofessions, when we start to
ask these questions that we'reasking right now, the answer
(21:55):
becomes a little more clear thatof course we don't want to add
more insult.
We don't want to impede,because we're we have a better
understanding of what'shappening and how that's gonna
impact the person and theirsystem.
And so hopefully that'sinformation.
unknown (22:08):
And we also claim, we also we claim a healing
profession, but are we claimingthat we're providing the insult
from which someone would behealing?
Because should we not alsoclaim that as well if we're if
that's one of the things that wedo, if we cause someone to hurt
during that therapeuticprocess, then we need to make
(22:30):
that claim as well.
You're gonna heal, but I'mgonna give you something that
needs to heal.
Eric (22:36):
It just doesn't make sense.
unknown (22:37):
Yeah.
No, and like it's not overttissue damage, but we also know
that you don't have to witnessit.
You don't have to see the, as Icurrently have now, a massive
ankle swelling and bruising.
You don't have to see that tounderstand that tissue damage
has or is occurring.
Eric (22:56):
Oh, if someone has, so just for people that are
listening, just maybe there's alittle thing to think about is
that if someone comes in andthey are in pain, we're not
saying don't treat them.
We're just saying don't addmore harm or insult to the
tissue.
So we can still treat thosepeople, but we should, I would
(23:17):
say there should be a caveatthat we're trying to not amplify
their sensation of pain.
We're trying to calm down theirexperience of pain or calm down
the nociceptive system as bestwe can.
unknown (23:33):
Yeah.
And I think for people who,even for people who deliberately
cause someone pain, ultimatelytheir goal is the same.
Their goal is towards healing,towards less pain, towards
better function, all of thatstill exists.
What causing someone pain in atherapeutic context means is a
fundamental misunderstanding ofthe neurophysiology of the
(23:58):
sensation of pain.
Right.
And so that's where we start tosee that huge knowledge gap
that exists, where we've alwaysdone this, we have these
outcomes, people feel betterafterwards.
Do we actually track them?
Because how many times have weseen on social media where
people have been like, thistherapist bruised me and now I'm
(24:19):
in pain or whatever it mightbe?
So those things exist as well.
All of those outcomes willexist.
We're only gonna reallyremember the good ones for the
most part.
But yeah, where do we drawwhere do we draw our own line
for that and our ownunderstanding?
And if we don't understand orif we don't consider that the
(24:45):
definition of pain is what itis, because that's the current
consensus understanding rightnow, even though it's it's
debated, sure, it has it hasn'tchanged at this point in time.
But if we're not willing tolook at that, if we're not
willing to follow the science,then that means we are treating
(25:09):
on faith.
And that's the other ethicalquestion that we talked about as
well.
It was like, didn't did I talkto you about that one?
Is it ever is it is it everethical to clinically reason for
a healthcare context based onfaith?
Because faith is a belief youhold in the absence of evidence.
Eric (25:38):
We may have talked about that off-air.
I don't think that made it tothe recording last time, but I I
think that is a reallyimportant thing to talk about
belief-based or faith-basedtreatments.
unknown (25:51):
And we're not talking like religious faith here, we're
talking about anything that isanything that is a belief in the
absence of evidence is a faith.
Um, so we want justified those.
And if we cannot justify ourbelief that causing someone pain
(26:12):
on a therapeutic, you know,therapeutic context leads to
healing in some way.
And I'm talking manual physicaltherapies, then we don't have a
justified belief.
Right?
We have a faith.
We're hoping that it helps.
(26:33):
We're hoping that, and we'rebasing that on heuristics, we're
basing that on our hurt doesn'tequal harm, no pain, no gain,
whatever our culturaltherapeutic understanding is.
I've seen people feel betterafterwards, so therefore it must
(26:54):
be helping.
Eric (26:57):
That's a problem, too, that is so common.
You mentioned this briefly aminute ago, we forget or ignore
the ones that did help, but weremember, we're biased, remember
that the people that we didhelp.
And so often, I know it worksfor me, it works for my clients,
so therefore there's a itworks, therefore it works.
Yes, and it and people use thatclinical experience to justify
(27:18):
the potential mechanisms or tojustify the approach.
And I know that if we'retalking about evidence, yes,
part our personal experience ispart of that evidence, but your
personal experience doesn'tjustify the mechanisms of the
outcome.
unknown (27:32):
No, and your clinical experience should be an
illustration of something thatyou have used before to support
your understanding of themechanism.
And then you may be able to usethe clinical experience as an
illustration of that, but not asa justification of it.
Right?
It does it, it is an evidencein itself.
Eric (27:51):
It can't be and I'm so glad that you brought that up
because that's a conversationI've seen and heard and been a
part of before, where people,well, evidence-based practice
includes clinical experience andthe patient.
unknown (28:05):
Research and evidence and the patient, yeah.
Eric (28:07):
And they're like, but two out of three ain't bad.
I'm I'm kind of flipping onthem.
So we don't have the evidence,but we have we have the
patient's needs, wants, goals,values, and we have clinical
experience.
So that's evidence-basedpractice.
Well, no, it's not, it doesn'twork that way, right?
Right.
People will say, well, it's66.6%, so it's it's more
evidence-based than not.
unknown (28:27):
But I like what you said that it's 60% of the time,
it works every time.
Eric (28:31):
Every time I love the anchorman reference, thank you.
So the point being that yes,clinical practice or your
clinical experience is valid,patients' values are valid, but
them in themselves are should bean illustration of the bigger
picture.
And it needs to be based on theunderstanding of the evidence.
And if the evidence is notbeing considered, then those
(28:53):
other two don't really fit.
unknown (28:56):
Yeah, then you have information, but you still don't
have justified information tobase a therapeutic treatment on,
which I think is I I think ispart of the main issue.
It's very interesting when weget into this understanding of
evidence because people seethings that they want to be able
(29:19):
to explain with the treatmentthat they did.
And they say, Well, I did thisand this happened, and therefore
this is the mechanism, or it'sthe outcome, or whatever it
might be.
And any evidence to thecontrary, like uh like studies
that may show that all of theseoutcomes are just data blips,
(29:42):
right?
Once you start to get thebigger numbers, it's none of
it's really super clinicallysignificant.
And you have perhaps as manyharms as you do helps in terms
of quality of life and how muchof this is longevity, all of
those kinds of things.
So on a manual therapy basis,we don't necessarily have this
awe-inspiring mic drop kind ofevidence for anything that we
(30:05):
do.
But we do use basic science,which is evidence, and we do use
research, which again is partof our evidence collection.
We do use thought processes andclinical understandings.
And what is often missing is ormaybe what was too present is
(30:33):
desire.
It's this desire to be thehealer, it's this desire to be
the helper, it's this desire tosay, well.
Yes, what I did made thismassive difference to this
person's life.
And therefore, it can't bewrong.
And I can't be wrong, and theycan't be wrong.
(30:55):
And to and to say that that iswrong, but that's not the actual
sort of average outcome that weget with people, or that these
techniques don't actually havethat mechanism.
So there's some other perhapsthing that had gone on.
To take that into accountquestions identity, and it
becomes very challenging, itbecomes uncomfortable for people
(31:18):
to say, well, we have thisknowledge.
This knowledge does not explainthe miraculous outcome that I
saw.
But when you look at all thevariables, neither does that
take me to that treatment.
Because we spend in a person'slife.
(31:43):
Maybe you see them six times.
Six hours in a person's wholelife.
And for us to claim that whatwe do is some sort of be-all and
end all has these amazingcurative properties or whatever
it might be is just hubris.
(32:04):
We want to be good people, wewant to be we want to be the
helpers, we want to be thehealers, that's what we're
trained to do.
We have knowledge, we do haveknowledge and expertise that the
average lay person doesn't.
But we are also educated in ourtherapist's expert paradigm.
(32:30):
And if we're to question ourexpertise on this matter, then
where does that leave us?
Where do we actually fit into ahealthcare context?
Are we actually doing anything?
Like I can understand thatpeople then get to a place where
where they're like throw theirhands, I was about to swear that
(32:52):
I'm not gonna where they throwtheir where they throw their
hands up in frustration and say,Well, what am I even doing?
I've done that.
But I think maybe what'smissing is is a different kind
of an an a lot, like a differentkind of uh understanding of
(33:15):
what evidence is and what itshows.
It's like, yes, this shows alimitation only in comparison to
the claim I've made.
And if that's how I seeevidence, then that's always
going to be inferior.
So I have this claim over herethat says I can do all these
things.
The evidence over here says Ican, but this evidence provides
(33:40):
knowledge, it provides reality,it's a grounding, and it means
that we have to change somethingabout how it we think, what we
do.
Once we start layer on layeringon character building traits
like ethics and honesty andintegrity, we have to start
looking at what it is that we'resaying in relation to what it
(34:02):
is that we can support.
Go off on a tangent.
Yeah, not even sure this ismaking sense.
Eric (34:11):
I one reason why I was so excited to and and wanted to do
these episodes with you wasbecause I wanted to hear
Monica's tangents.
I wanted to hear you go off,just share.
So thank you.
Thank you for feelingcomfortable to do that.
unknown (34:23):
Well, I'll put a caveat here because everyone hold it
lightly, because I've changed mymind many a time based on
evidence.
So even hurting people, like Ihave done that in my therapeutic
life.
Eric (34:38):
The same here.
unknown (34:39):
I have hurt people, I have caused people pain when I
have treated them.
I have reported pain and I'vebasically told them to suck it
up.
Like I didn't necessarily usethose words, but kind of close
because there's this idea of nopain, no gain, and then that
changed, and then so there's adifferent thing, and then that
changed again, and there's adifferent way of approaching.
(35:02):
And I have made some massiveerrors in my engagement with
people on a therapeutic level.
And I know that mostly we liketo hold the successes, I tend to
hold the failures, and thefailures are where we learn the
(35:22):
most because it's not theirfailure, it's mine.
I was the one who failed them,and I think that is where we
start to get that kind ofhonesty thing is I failed them.
This is a process where I haveto look at myself and I have to
(35:44):
look at what I'm doing.
And so I have changedsignificantly over the years in
terms of how I approach people,in terms of the claims I make,
in terms of the teaching that Ido, the courses I've done for
this and for Sheridan and forother things, have been fairly
steadfast over the past fewyears.
(36:04):
They've been updated, butthey've not been fundamentally
rock solidly changed.
I've had courses before where Iliterally trashed them.
I did all this research, I didall this putting together
information, and there wasevidence.
Oh, I can't just buy any ofthis.
And I just stopped.
(36:25):
So this has been a little bitdifferent.
And I think it's probably thesame for you, where you start to
see these things that you canbuild on rather than have to
break down to a considerate.
Eric (36:38):
100%.
And that's very overlaps a lotwith with my experience.
And of if I think of back inthe early 2000s when I went to
massage school and what Ithought and felt about massage
and what it was and what itwasn't.
And then through the first oh,probably close to 10, 7, 8, 9
years of my career, where I washeavily involved in
(37:00):
structuralism andpathoanatomical thinking, and
and which was kind of laid inthose thoughts were laid into my
brain in school, because that'swhat we thought.
And I was heavily invested inthe fascia narrative, and I was
took all those types of courses,and I went to the fascia
research congress.
But the more I learned aboutthat that way of thinking, the
(37:25):
less sense it started to make tome because it didn't translate
into what I was seeing in theclinic.
I wanted it to, I tried to makeit.
I I just and it, but it justdid it stopped.
It didn't, and it particularlydidn't make sense with those
people that had I don't want toI don't want to say this in a
way that sounds too flippant,but like people that had like
(37:49):
strange pain stuff, like paintthings that didn't make any
sense.
It didn't fit into a box, andthey've had pain for a long
time, and they reacted reallystrange to the touch that you
put on them.
You're killing me, and you'rethinking, what am I doing?
Or the other end where youcould touch them and they
wouldn't fit, they were numb.
Like it was the stuff didn'tmake any sense.
And so that started getting measked these questions, and yeah,
(38:09):
went into like explain painstuff and looking more about the
role of the nervous system andthe brain and thoughts, blah
blah blah, and thenbiopsychosocial and now where I
am now, where I'm don't reallyknow where I am, but feel more
comfortable in my level ofuncertainty now than I did at
any point in time.
And the stuff that seems, andlike I said that seems to make
(38:31):
the most sense to me is thestuff that we're talking about,
about these kind ofneurophysiology, and if we base
things on pain, no seception,complex experiences, we don't
know enough.
Person, the person's individualexperience matters more than
anything else.
I feel like thinking that way,I don't have all the answers,
(38:58):
whereas I I wanted all theanswers before, but I feel now,
at least in practice and also inthe teaching, is that we don't
need to have all the answers.
We just need to, I think, becurious and explore and see what
it is that we can do for thatperson on that day to hopefully
make them feel better than theycame in.
(39:18):
And we have lots of differentoptions to try to do that
without having to we havedifferent, we have different
boxes now too.
unknown (39:26):
Yeah.
So there's a little bit betterunderstanding, especially with
relation to pain, where we couldput someone into a category.
And I say kind of because thesecategories are not definitive.
They don't have any sort ofabsolutely necessary, well, some
of them may have some necessarycharacteristics to be in that
(39:47):
category.
But there are variationsbetween with and within the
categories with relation to painof being able to make some sort
of assessment of the personbased on it.
Doesn't necessarily even haveto be an in-depth neuroscience
knowledge.
Like don't have a reasonableamount of neuroscience
knowledge, but it's this idea ofconfidence in reason and
(40:10):
confidence in foundation.
So we have this foundationscience, and there may be
changes within it to somedegree.
Pain is something you'll see,start to see some changes within
in terms of some of thesemantics around some of the
term terminology.
But it's not gonna be soextraordinary that it's gonna
(40:34):
overturn all of the pain sciencethat has gone before the basic
pain science that has gonebefore it.
What might be overturned ismore of the bias psychosocial,
where it relates to pain, whereit relates as forces.
That doesn't havejustification.
(40:55):
It's very, very challenging tojustify that when you have other
kind of foundational sciencethat that doesn't really match
those patterns.
That's not saying biosexual isirrelevant.
That's just saying that whenit's applied, when it's been
taken and applied to health andpain in various ways, it's gone
(41:17):
into those heuristics thatnegate the meaning of the
research.
Eric (41:25):
Today we're going to talk about deck two, module two for
the course, and we haven't evenreally touched on.
unknown (41:30):
No, I know.
Eric (41:31):
But I think that this is maybe next, maybe we'll see that
for now.
unknown (41:34):
This is a good, yeah, but this is actually a good,
like just the understanding ofthe biosarocial is a good intro
into that.
One of the decks is very muchabout the the health, what do I
call it?
Health inequities and socialdeterminants of health.
Because biasecosocial issupposed to encompass that.
And because of the and but butsocial determinants of health
(42:00):
and health inequities are socomplex.
And I'm providing anintroduction, but you can go
into each of them in a really,really complex way that has to
do with sectionality between allof these social determinants
and all of other characters,other characters is cultural and
(42:21):
social and various otherfinancial, economic, race,
gender, all of those kinds ofthings will come together in
some ways.
So it's not just that theyexist, it's that they exist and
they interact and they interactin particular ways.
And what biosychosocial hasdone to some degree is
(42:43):
simplified them so much down toone word that has a very sort of
minimalistic meaning associatedwith it.
These social determinants ofhealth are supposed to be
considerations withinbiosychosocial.
And what I find is that thatoccurs minimally.
(43:04):
And so we are missing massiveamounts of information if we're
not actually considering thedepth and the breadth to which
these social determinants,health inequities dictate to
some degree, how we might bethinking of a therapeutic
(43:24):
intervention or how we mightclinically reason to treat
somebody in any particularsense.
Eric (43:35):
Yeah, it's an important topic that doesn't get discussed
enough.
And love how you without givingaway too much, because we don't
want to tell everybody.
But when we're looking at thesocial determinants, it it is
it's very important from myunderstanding and from looking
through the research that you'veincluded.
(43:55):
We're looking at racism andgender and sex differences and
poverty or income wealth orincome levels and how those
things shape the experience ofpain, but also the treatment
that's available or not.
unknown (44:09):
And how they shape research as well, yeah.
And they shape researchquestions and how things are set
up to be disadvantageous tocertain people, and that we
don't that we live within that.
We live within this system thatis set up to disadvantage
people, and we are part of it.
And we we act as part of it,not necessarily as people who
(44:33):
are understanding of that andcan take any kind of action that
might change something aboutthat.
So it's very easy to just bewithin the system that we're in
and not question that because insome ways it's uh beneficial
for us, but uh it's going to bedisadvantageous to somebody
(44:55):
else.
Eric (44:57):
Yeah, and maybe next week we'll discuss that a little.
We can go into that a littlebit more.
I I think this conversationthough today about uh ethics was
probably something that wasn'tscheduled, but I think I'm glad
that we had it because I thinkit was very valuable, it was
valuable to me.
Hopefully the listeners werefind it valuable too, because
these are topics that so thingslike ethics, things like social
(45:20):
determinants, which we'll talkabout next time, are things that
are so important to understandin the research as well as in
the clinical environments orworlds that we work in, but we
just don't have no these theseconversations aren't happening
enough.
unknown (45:37):
I I I agree.
I don't think they're happeningenough.
I think they're and they'realso happening too late.
So you'll often find thatethics or research or these this
uh understanding of socialdeterminants comes at the end of
a course.
And it's usually an add-on asopposed to something that
actually should be thefoundational component from
(45:57):
which the thought processbegins.
Because we should beunderstanding our context and
understanding the context inwhich another person exists and
how we exist in that contexttogether before we could
actually make some sort ofreasonable determination.
And then you add that of tothat, of course, the knowledge
(46:18):
that we do have of the basicsciences and of our skill set,
and also then the knowledge thatwe're missing.
It's a lot of work for us todo, and that's maybe a lot of
work that people don'tnecessarily want to do at this
stage of life, when people havebeen in the industry for a
little while.
Sometimes that's not where youwant to go.
(46:38):
But there can be other thingsthat you understand that may
help you out with that, withthat, without having to do all
the work.
As long as in in to some degreethere are certain fundamental
things that you may accept, evenif you haven't, because they
can justify, because they canprovide justification for what
you might do on a clinicalreasoning level without
(47:02):
necessarily having to go intoall of that.
But but I think for youngerpeople who are coming up, for
people who are just getting intothe profession or who are like
wanting to move in differentways, these should be our
foundational thought like bricksthat we build our house with.
Eric (47:21):
Which is why we're discussing them in episode two.
unknown (47:24):
Yeah.
Eric (47:25):
Have these discussions for the forefront of knowledge and
of having these conversations tobe aware of them and these
thought processes and to helpshape your thinking.
So as we move on through therest of these podcast episodes,
as well as as you move throughwhen everyone decides to take
this course that you're going tobe presenting.
Exciting, that they will thisstuff is gonna be okay, I'm now
(47:49):
thinking through this lens.
Yeah, it's still gonna befoggy, it still might not be
that clear, but and it's notsupposed to be, but you're
starting to think about it soyou can shape how you how you
take on that further knowledge.
unknown (48:05):
Yeah, and that's why I put these courses together was
for my own understanding, for myown ability to think through
these things.
And that's what I'm sharingwith people.
So I'm also coming at it from aperspective where I also don't
necessarily have enoughknowledge, and we haven't even
gotten into the idea of theautonomy and agency and what it
means to be an agent in theworld with free will, who, you
(48:28):
know, wants other people to alsohave free will.
And what does that mean whenwe're when we're not providing
consent for it, like properconsent for a process that's
causing them pain that couldthat that means actual or
potential to she then?
Yeah.
Eric (48:48):
So one thing I often will try to address in some of my
courses, and I'm glad that youwanted to talk about it, was the
idea of informed consent.
Can somebody actually give youinformed consent when your
treatment is based on a belief?
unknown (49:07):
Exactly.
Yeah, there's that foundationalkind of ethical sort of
question.
Because belief does not requirejustification.
Eric (49:16):
Yeah.
unknown (49:16):
You can justify it to yourself, but you can't justify
it with evidence that will makeit a justified true belief and
and an actual something we couldactually say is knowledge,
right?
Is how we know something is aknowledge that we can have.
Eric (49:34):
Now, I don't know big T truth, but it it's the more
right when it comes to anythingthat has this social component
in relation to these are heavyconversations that I hope people
listening will start to havebecause people that enter the
(49:54):
profession, they just want to goand they learn, they want to
learn how to perform massage anddo assessment and help people.
And that's why I think we allgot in the profession.
But the longer that I'm around,the more I start to realize
that these foundationalphilosophies, these
understandings are justcompletely absent in an
(50:15):
entry-to-practice education.
And uh I don't I'm not saying,and I don't think you're saying
that you need to be a uh aphilosopher, have a philosophy
degree, but this stuff should befoundational in that entry to
practice.
So at least people are aware ofthis because it will shape how
you think and look at yourpatients and how you pursue your
(50:35):
professional development shouldcome through these lenses.
unknown (50:39):
I will say and someone paying you for treatment isn't
consent for you entering intotheir space and touching them in
ways that you believe will helpthem.
Right.
That that's not consent becausethat's a transaction, but that
(51:02):
that transaction involvesbecause you believe you're doing
something therapeutic or theybelieve they're doing something
therapeutic, that involvesjustification.
And if you can't justify thatto yourself, if it's based on
belief, then ethically you're ina no-go zone as far as I'm
concerned.
Eric (51:22):
I hope some of the regulatory colleges and
regulatory bodies out there,stakeholders, are listening to
this.
Because the conversations thatI feel that you should be
exploring at that regulatorylevel.
unknown (51:36):
Yeah.
Yeah, consent's a consent's achecklist, basically.
But it doesn't actually have agood understanding of what it
means to have a an autonomoushuman being in front of you that
you and that that you respecttheir autonomy as much as they
as you respect your own.
Eric (51:55):
Yeah.
Heavy stuff.
unknown (52:00):
I know.
But fun.
But fun.
Eric (52:02):
I know I love it.
This is great.
unknown (52:03):
We can get we can get heavier.
I don't have I don't have asmuch of the philosophical
knowledge that I would like.
I'm doing more of that kind ofexploration, but I have enough
to ask questions that I can'tnecessarily always clearly
answer.
But I know then some of thosequestions, it like it's yes or
no.
There's no middle here.
Like it should you start with aquestion and your answer is
(52:27):
either yes or no.
No is just you would have toreject that it would, it would
probably be morallyreprehensible.
And yes means that you have tonow negotiate something about
what it is that you believe.
These are the these are youroptions, basically.
Eric (52:44):
I am not an expert at all either when it comes to the
philosophy and the healthcarephilosophy, but it's something
that in the last year-ish or so,I've been trying to read more
about and to understand and toto reflect and think of, and
stuff I'm trying to incorporatea little bit into some of the
courses things I do just to sopeople start asking those
(53:04):
questions and start thinkingthat way.
I don't know if people do, butI I I hope that uh there's the
occasional person that maybe isstarting to ask different
questions.
And I think that's when we'restarting, that's all we can all
we can ask.
unknown (53:17):
Yeah.
Yeah.
Eric (53:18):
Well, that was great, Monica.
Thank you for that today.
We will be back next week andwe'll talk maybe a bit more
about module two, and probablywe should talk a little bit more
about module three because it'swe're gonna do module produces.
unknown (53:30):
Are we gonna talk about any of the modules?
Maybe not.
We're probably just getting toall sorts of other questions.
Eric (53:35):
You know what?
That's okay.
They provide I find that the uhjust kind of the general ideas
of some of these modulesactually provide a lot of
information about just for usjust to have conversations and
then ask questions to each otheruh about some of those things.
unknown (53:49):
And we will actually get into some of those knowledge
aspects of pain that peopleperhaps don't know and that will
help us gain more knowledge andfill that gap, right?
We will actually go there.
Eric (54:01):
Yes, promise.
So anyway, thanks Monica.
We'll talk to you soon.
unknown (54:05):
Not a problem, we'll see you later.
Bye, Eric.
Eric (54:08):
Thank you for listening.
Pain Education, no scriptprovided, is now available for
purchase on my website, theCEBE.com.
To listen to more of theseepisodes, please subscribe on
your favorite podcast network.
If you enjoyed this episode,please like and share to your
favorite social media platforms.
If you'd like to connect withme directly, I can be reached
through my website or send me aDM through either Facebook or
(54:31):
Instagram at EricPurvis RMT.
If you want to support mypodcast, please consider making
a small donation.
This can be done by clicking onthe support button or heading
over to buymeacoffee.comslashhelloob.
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