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Special Conference Edition
Summer 2023 Issue


Amanda Cooke

Erin Stanley

Mark Chee-Aloy

Monica Pasinato-Forchielli, RMT

Scott Dartnall


Amanda Cooke, Samuel Jarman,

Stuart Wakefield, Nikita Vizniak,

Paul Kohlmeier, Troy Lavigne

As we develop future issues, we want
your input. We want to hear about the
great things you’re doing and about the
things you’d like to learn about through
this magazine. Tell us what you have
been doing or simply email us your
ideas for future articles and features.
We’d love to hear from you!




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Sam has his BA in Kinesiology , MOMSc as an osteopathic practitioner and MSc in Health Science Education. It is the confluence of clinical experience, teaching experience, and expertise in educating health professionals that Sam draws on to provide high quality patient care, continuing education content, and training osteopathic professionals.

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R. Kin. / Personal Trainer

With over 10 years of experience, Stuart uses evidence based barefoot training techniques to improve movement longevity through sensory stimulation, fascial health and foot stability. Stuart graduated from the University of Guelph with a Bachelors of Applied Science in Kinesiology and is the Director of Education in Canada for EBFA Global.



Dr. Nik is an author, clinician, professor of clinical cadaver anatomy, exercise therapy, orthopedics, joint mobilizations, and a globally recognized expert. He is certified by the National Academy of Sports Medicine as a Corrective Exercise Specialist, practitioner at prohealthclinics com and has authored many textbooks, YouTube videos and CE courses.



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Paul is an RMT and Practitioner of Chinese Medicine . A clinician first, he is also a self professed research nerd. He likes to read research articles and is keen to add evidence and supporting ideas into his practice and courses. He and his wife Michelle are the owners of supply and education companies Cupping Canada and Cupping USA.



Troy is the author of many continuing education programs, including ‘How Massage Therapy Works’, ‘Pain! The other 4 letter word’ and is the creator of ASMR massage techniques. He is a contributor to many podcasts as well as ‘The Advanced Healing Journal’. Troy holds specialized certifications in Orthopedic / Sports and Pediatric massage.



BA (Sp. Hon), RMT

Amanda has a degree in Kinesiologyand is a Registered Massage Therapist. She has practiced in multidisciplinary settings, corporate settings, and has been a clinic and outreach supervisor for Massage Therapy Students. Amanda and her partner Mark own ConEd Institute in Toronto which is a continuing education company for Manual Therapists.

Editor's Note

Editor’s Note

Amanda Cooke, RMT

Why Attend an Educational Conference?

When I was a Massage Therapy Student 16 years ago, the Canadian Massage Conference that we know now was in its inaugural year with the current organizers, One Concept Group. I remember the conference being advertised at my school because there was a free student day. They had amazing discounts on products and equipment as well as some pretty huge prizes to be won. I remember some of my classmates being super excited to go learn from some very experienced therapists and the opportunity to shop for their upcoming careers. For some reason, I didn’t have the desire to go. Seemed like something I would do once I began my career, not while I had anatomy, physiology, and palpation exams to study for! As I reflect back, I not only understand why my classmates were so excited, I also realize the potential missed opportunities that I may have experienced as a result of my former mindset.

Conferences are common in a lot of professional careers. Chiropractors, surgeons, dentists, scientists from many disciplines, all have conferences within their industry to learn, examine new developments and research, and to network with others in their profession that they may not have regular opportunities to meet and have a conversation with. I cannot speak for any other career, but for massage therapists I now see massive value in conferences. We all have professional development requirements of course and that is often the motivation for therapists to attend a conference, and it is often the reason therapists choose not to attend- they have taken enough courses already or prefer to take individual courses. I completely understand that mentality as that was the real reason behind my decision not to attend as a student. I didn’t need continuing education credits yet, so why would I go? I failed to recognize the real reasons for attending conferences- networking with other therapists, exposure to what is happening in the profession, getting outside of your treatment room and comfort zone, reigniting the fire you once felt for your chosen career, getting to see what exists in terms of products and equipment that could help our patients, ensuring you don’t become stagnant, complacent, or restless in your practice so you can have a long and fulfilling career, and of course, to learn from some of the most passionate and experienced therapists in our field. How do conferences accomplish this? Well, this past year I have attended 3 conferences across Canada hosted by associations in those provinces, as well as 2 of our own- CMC Toronto in September 2022, and CMC Halifax that just wrapped up this month! Here is what I have experienced as well as what I have learned from other organizers, educators, vendors, and attendees.

Let me use Halifax to address the first point- conferences allow therapists an opportunity to network and gain exposure to what is happening in our profession. The Canadian Massage Conference had never been taken outside of Ontario and we have decided that every spring we will hit up a new city across Canada and Halifax was the first. We had no idea what the response would be, we had little to no contacts on the east coast, and there are multiple associations in Nova Scotia. What we found was that the schools, associations, and therapists were ecstatic to have a conference as big as the CMC coming to their neck of the woods. Being in a smaller location, the response I was receiving from therapists there is that they felt that there was not enough of a variety of education offered. Maybe educators prefer to stick to bigger cities? I am not sure of the reason but I was thrilled to be able to bring 5 educators who do not normally teach on the east coast, as well as bring in 2 educators that are local to give them more exposure. The conference attendees really enjoyed the variety of topics and the chance to see things that they normally aren’t exposed to. We had classes in taping, cupping, perinatal care, end of life care, fascia, working with the diaphragms, cranial sacral, concussions, and more. Only conferences allow for the unique opportunity to “dip your toes in” to see what you may or may not be interested in. The ability to take 2–4-hour classes with various topics was invigorating. Especially for students! As it turns out, like myself all of those years ago, the massage therapy students had no idea what their career path could look like beyond exams and student clinic. It really warmed my heart to see the students getting exposure to how many opportunities exist in this profession. Aside from that, I witnessed so many connections being made. Some of our sponsors were employers and associations. It was wonderful for the students to have the chance to ask questions and meet with potential associations and employers. For the experienced therapists, the benefits were slightly different but equally valuable. They have been working hard, many in isolation, and it was so cool to have them all together, sharing ideas, and working alongside each other no matter their area of focus or years of experience. The community vibe was palpable. 

Let’s talk about getting outside of your comfort zone and keeping your spark alive. I am not super active on social media to be honest, which is funny since I am co-owner of a media company. Our social media team does an excellent job at keeping the rest of us up to date about what conversations are taking place in the massage community, what people want to see more or less of, new research, and industry news. Here at Massage Therapy Media, we do our very best to keep you all up to date with everything massage related. One lingering theme in massage discussions is career longevity and burnout. We have had therapists speak on our podcast about these topics, and we ourselves have been involved in the online discussions about it. Some key components of burnout in our profession seem to be employment mismatches, feeling unfulfilled and/or unappreciated, and physical and mental exhaustion. What if I told you that attending these types of events can impact how one copes with career burnout? Our most recent conferences have prioritized variety. One major reason that therapists start to feel restless in their current situation is that they are either not in the right environment or not serving the right population. A career change may not be the answer, but a career shift might do the trick.

It’s easy to leave school, take your exams or join an association, and get a job at a chain, clinic, or spa. But did you take time to determine what type of therapist you want to be? Who is your ideal patient? And what type of practice setting would you thrive in? There is massive potential when you go to a big conference to meet out of the box thinkers, network with clinic owners who serve a niche population, and again, dip your toes in before taking a dive. Aside from that, the opportunity to explore new products, tables, treatment techniques, and tools, that are designed with therapists in mind to help ensure career longevity. 


Lastly, the educational opportunities! I cannot express enough gratitude that there are therapists out there that have dedicated their careers to not only helping their patient population but the massage therapy community as a whole. The role of educator is extremely vulnerable. We all know the feeling of putting ourselves out there, open to scrutiny and possible criticism, and how much conviction and self-awareness this takes. I have had the pleasure of meeting dozens of educators from Canada, USA, and over-seas. These therapists all come from different backgrounds, different educational experiences, and different treatment philosophies. We have this very unique career where there are many different styles of therapy and even some conflicting views. In recent years, the move towards a more evidence-based approach has really helped educators in their classes be able to show research and clinical outcomes when teaching other therapists their material. There are courses out there for everyone and getting the chance to see what aligns with your specific treatment philosophy is invaluable. This edition of Massage Therapy Media Magazine has 5 articles written by CMC presenters to give a glimpse into some of the research and developments in their specific area of focus. Here you will have the opportunity to read about assessment philosophy, what tools to consider if you use IASTM, what effects cupping therapy has on the body, the importance of feet when it comes to therapy, and a little about chronic pain and how much of it is a learned behaviour. These are just a few of the great minds that will be presenting at the CMC Burlington coming up in September 2023. We will have close to 30 different educators offering classes in 1, 2, 3, 4, and 7 hour formats, as well as a short lecture series, informal demonstrations, panel discussions, networking events, and a tradeshow jam packed with deals on supplies, employers, educators, and associations. Each conference that Massage Therapy Media attends, whether as the media team covering the event, or as the producers at the CMC, we are always excited to meet you all, learn from you, listen to you, and continue to offer digital content and in-person events that will keep you engaged in the greatest profession in the world. 





With the largest known IASTM instrument collection in the world, we have definitely “test drove” enough tools to come up with these 5 rules to choosing the right IASTM instrument for you.

Rule #1: Ensure the instrument is suitable for the type of IASTM you want to perform

Every IASTM instrument is designed differently and every design dictates the efficacy of your treatment protocol.

Choosing the right design is like choosing whether you want a sports car or a mini van. There’s no right or wrong, it all depends on what you need it for – zipping around the country side at 100 km/h or packing up soccer balls and the kids to drive them to soccer practice.

Generally, the design optimizes the instrument for two different categories:

1. Diagnostic feedback/mechanical force transmission
Just as a stethoscope improves vibration sensation from the heart, IASTM improves your tactile feedback. For this purpose, you will want to choose an instrument that gives you feel and precision.

Generally, lighter instruments give better feedback and heavier instruments or sharper edges give better force transmission.
Note: Biomechanics and technique also play a huge role!

2. Neurological stimulation/myofascial mobilization
For this purpose, the treatment goal and outcome are more important than a possible subtle loss in tactile vibration. Often instruments with slightly heavier designs have better feeling of quality and reduce practitioner fatigue by letting the tool do the work.

Rule #2: All-in-one instruments can work for you

All-in-one tools are best suited for soft tissue mobilization/neurological stimulation. Generally, more organic shapes tend to better fit body parts and offer a larger number of treatment edges. However, it is important to ensure you have safe and effective biomechanics during your treatment application.

An example of this tool can be:

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Pro: Single instruments are easier to carry around and lower cost (vs. carrying around a whole instrument set) and you become extremely proficient with that instrument

Con: You may be limited to very specific uses and patient body shapes; however, it has been our observation that most practitioners who buy multi tool sets typically only use their 1 or 2 favourites – why spend money on something you do not use?

Rule #3: Watch out for cheap materials

Plastics, Jade, Ivory, “training tools” all fall under the category of cheap materials.

Although they can still give some result, they cannot provide the efficacy that a precision-made stainless steel instrument can provide. This is because the materials cannot provide the same feedback, durability, and consistency of application.


Pro: Cheap

Con: Will not provide good feedback, Will not provide quality, effective treatment, Will not allow you to learn proper IASTM technique

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Rule #4: Treatment edges count! Not all stainless steel IASTM instruments are made the same

The more treatment edges and variability of bevels results in more treatment options.


  • Single bevels give better penetration but are generally used in one direction

  • Double bevels give slightly less penetration but can be used in both directions.

Many of the lower quality instrument sets sold by companies offer 1 or 2 treatment edges per tool, this greatly limits the usefulness of the instrument. More edges and variability give you more options for different regions & different sized patients. Some instruments are less than ~10% efficient based on this measure.


Pro: More edges and ergonomic design gives more therapeutic options and should be able to be used right or left-handed (a very important feature to reduce practitioner strain)

Con: With more treatment edges it may be hard to find comfortable holding positions for some practitioners and may cost more to manufacture.

Rule #5: There’s no guarantee that your hands will be saved when using IASTM instruments

Choose instruments that are designed for your hands, ambidextrous in nature (right & left usability), and give better treatment options. There are a lot of companies that sell IASTM instruments and they all state that their products help save your hands. Unfortunately, this isn’t necessarily true.

All decent instruments are highly polished which provides a slicker look, smoother features, and excellent curves and bevels (i.e., they look pretty!). As wonderful as that is, this makes many tools extremely hard to grasp – especially when you apply emollients during your treatment – leading to a natural increase in grip and thus hand fatigue.

They neglect the most important thing – your money maker (no not that one?) – YOUR HANDS. The only way to decrease hand fatigue with these tools is to relax your grip on the tool and have biomechanical forces transmitted through different regions of your hand that are not normally used.

To truly save your hands, choose techniques and instruments that have been ergonomically designed and can be used either right or left-handed (i.e., has not neglected the importance of your hands). The most important instrument in your practice is YOU! So, let’s ensure that your hands are protected for the longevity of you and your practice.

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Consisting of 26 bones (28 if you include the often forgotten sesamoids), 33 joints and layer upon layer of intrinsic and extrinsic muscles, the foot truly is as Leonardo da Vinci called it “a
masterpiece of engineering and a work of art”.


Considering the most functional movement we do on a daily basis is walking, let’s consider the 3 main functions of the human foot during this movement.

Impact Absorption:
While it’s somewhat obvious, our foot, specifically our calcaneus is our first point of contact with the ground. As the largest bone in the foot and comparatively larger than any other primate, this, along with a dense fat pad make the calcaneus an ideal place to strike the ground to assist in shock absorption.

When the calcaneus does strike the ground, our subtalar joint should be positioned in inversion, which is a locked, stable and rigid position. The impact we experience at foot contact creates a medial tilt of the calcaneus (relative subtalar eversion) bringing us to a more neutral subtalar position. This adaptation to striking the ground is a critical aspect of impact absorption. Think of shocks on a vehicle that have become very rusted and rigid - because there is no adaptation, more shock is transferred to the frame of the vehicle, increasing the amount of wear and tear over time. Functional Podiatrist, Dr Emily Splichal often refers to the foot as a “mobile adapter” - one that is both flexible but also able to stiffen and become rigid when necessary.

We can appreciate that there must be a balance between both the adaptation to the ground and the control of this relative subtalar eversion. The control of this motion and the prevention of rearfoot over-pronation following heel strike is highly dictated by soft tissues such as our “spring ligament” (plantar calcaneonavicular ligament) and what I often refer to as the “king of the foot”, our posterior tibialis. Our subtalar joint should continue to maintain a neutral position through midstance, until the push off phase of gait, which we’ll dive into shortly.

Assessing this joint in a closed chain position can provide the therapist with a wealth of information, both with how a patient is interacting with the ground (where most injuries occur) and what will occur through the remainder of the stance phase of gait.

Single Leg Stance:
One could argue this is the most critical part of the gait cycle. The peak point of stability. While our focus is on the foot, we can’t neglect the role of the pelvis here. As one foot leaves the ground, going into the swing phase, the corresponding frontal plane pelvic movement requires gluteus medius activation on the stance leg side to maintain this pelvic stability. This activation assists in driving subtalar joint stability, allowing us to maintain a neutral position as our foot continues to move through the stance phase.

We also must acknowledge the importance of balance that is required in mid-stance as it is occurring in a single leg stance. Walking speed (or lack thereof), often referred to as the “6th vital sign”, has been shown to predict many different outcomes including cognitive decline, falls and all-cause mortality. (Middleton et al, 2015)

While balance is achieved through multi system integration from our proprioceptive, vestibular and visual systems, we can reference the importance of foot stabilization achieved through musculature such as the aforementioned gluteus medius and more locally in the foot via the soleus, posterior tibialis and flexor digitorum longus. This shows the importance of not only training these muscles individually, but also training these 3 systems together, in all ages, for both fall prevention and longevity.


Often referred to as the “push-off” phase of gait, James Earls in his book, Understanding the Human Foot, refers to this as “toe-off” instead. “Pushing-off with deliberate muscular contraction is not necessarily our default action, it is just one option available to us in response to movement variables, such as walking faster or uphill.”

Often referred to as the catapult effect, the human body has the ability to double the ground reaction forces we take in at heel strike. This demonstrates the incredible elastic potential in our tissues, specifically facia and is the foundation to efficient movement.

Our ability to take advantage of this elasticity is highly dependent on our foot being able to achieve a rigid lever position. As mentioned previously, as our foot makes its way through midstance into late midstance, it must remain in a neutral position. However, during the propulsive phase of gait, in order to take advantage of our elastic potential, we must achieve a locked, stable and rigid foot position. This starts with subtalar joint inversion. While there are many inverters of the foot, the posterior tibialis muscle is a major player here. As the most powerful supinator of the foot, its importance in helping lock the foot for toe-off is critical.

We can also reference the peroneus longus as having a critical importance in the toe-off phase of gait. The ability to dorsiflex our  1st metaphalangeal joint (1st MPJ) is critical to avoid compensation during toe-off. Functionally, our peroneus longus must plantarflex our 1st ray (medial cuneiform and 1st metatarsal), allowing our 1st MPJ to dorsiflex optimally. This adequate dorsiflexion through the 1st MPJ allows us to access our windlass mechanism, the tensioning of our plantar fascia, another locking mechanism of the foot.

Lastly, we must appreciate the importance of metatarsal splay at toe-off. As our body shifts onto the metatarsal heads during toe off, our metatarsals should open up. This creates a tensioning effect in our deep transverse metatarsal ligament, assisting in forefoot stability as our foot is loaded with an immense amount of force through a very small surface area. Assessing and correcting these key components of toe-off can have a profound effect on a patients overall health, movement efficiency and movement longevity.

1. Earls, J (2021). Understanding the Human Foot. Lotus Publishing.
2. Middleton A, Fritz SL, Lusardi M. Walking speed: the functional vital sign. J Aging Phys

Act. 2015

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Cupping Therapy:
Exploring Its Benefits and Applications


Cupping therapy has witnessed a resurgence in popularity ever since the renowned swimmer Michael Phelps sported cupping marks during the Rio Olympics in 2016. This event sparked curiosity and heightened demand for this practice in North America. As a result, numerous continuing education providers began offering courses on cupping therapy from various perspectives. However, this diversity of perspectives has led to conflicting explanations regarding the purpose, techniques, and physiological effects of cupping. Consequently, practitioners have engaged in debates over the most plausible explanations, leading to different stories that shape people's understanding of their bodies. Despite the varying explanations, cupping therapy has demonstrated reliable outcomes, particularly in terms of improving range of motion, reducing pain, and alleviating disability. By focusing on these outcomes, cupping therapy can maintain its relevance and effectiveness, even if its mechanisms are not yet fully understood.

Understanding the Mechanisms

The scientific understanding of how cupping therapy works is still evolving, much like other manual therapy methods. It is likely that cupping exerts its effects through a combination of neurological, circulatory, and tissue changes. While the precise mechanisms are not yet understood, it is important to recognize the consistent outcomes associated with cupping therapy.

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Key Outcomes of Cupping Therapy

Increased Range of Motion: Cupping therapy has been found to improve range of motion in cases where restrictions exist. Creating suction on the skin surface seems to stimulate blood flow locally, decrease muscular tension, and promote better tissue sliding layer on layer. These effects contribute to enhanced joint mobility and increased range of motion, offering clients greater freedom of movement.
Reduced Pain: Clients seeking manual therapy often experience pain. Cupping therapy has shown promise in reducing reported pain levels. It is not understood if this change results from a change in the tissue itself or in the central nervous system.
Decreased Disability: Cupping therapy has been reported to alleviate the feeling of disability reported by clients. By addressing underlying musculoskeletal issues, improving range of motion, and reducing pain, cupping can enhance clients' ability to perform daily activities and participate in physical pursuits. This improvement in functionality can significantly impact their quality of life.

Expanding Applications of Cupping Therapy

Lymphatic Drainage: Cupping therapy has shown potential in the field of lymphatic drainage. Research studies have demonstrated comparable results between cupping and manual lymph drainage in reducing limb volume, particularly in cases of chronic edema. This suggests that cupping therapy could be a valuable adjunctive treatment for individuals with lymphatic issues.
Headache Management: Although headaches are a common ailment, the literature on cupping therapy for headache treatment predominantly focuses on wet cupping or bleeding techniques. This raises questions about the specific effects of cupping alone. Since most manual therapy practitioners are unable to perform wet cupping, and other cupping methods are not commonly seen in the literature, there is little guidance on using cupping to treat headaches. Further research is necessary to determine the effectiveness of non-bleeding cupping therapy for headache relief.


Cupping therapy has experienced a resurgence of interest and demand, driven by its visibility during high-profile sporting events. While there are varying explanations regarding its mechanisms, cupping therapy has demonstrated reliable outcomes such as increased range of motion, reduced pain, and decreased disability. By focusing on these outcomes and emphasizing tangible benefits, cupping therapy can maintain its relevance and avoid falling into disuse due to limited scientific understanding. Furthermore, exploring its potential applications in areas such as lymphatic drainage and headache management could contribute to expanding the therapeutic possibilities of cupping therapy. As research continues to shed light on its mechanisms, cupping therapy has the potential to provide valuable support for individuals seeking non-invasive and holistic approaches to promote healing and well-being.

Chronic Pain
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Let us reflect on memory and its relationship with chronic pain. Gretchen Schmelzer published an interesting article in 2015 on the effects of memory and learning. She discusses how these relate to synaptic behavior development and understanding around chronic pain in the brain. 

The first concept she talks about is urgency. Urgency in learning is one aspect of memory and when it comes to pain, you could equate it to the actual injury or trauma. Urgency creates the ‘urgent state’ in the brain and this releases stress hormones. It creates a powerful wash of chemicals. It strengthens the connections between neurons and synopsis and pre-synaptic behavior.

The trauma or injury and the pain associated with it also determine how and where the brain encodes the information that we're learning for long-term memory interpretation.

This becomes important with chronic pain because based on the threat level and how we determine where it goes in the brain it will  also affect our threat perception in the future. Another aspect to urgency is that it creates a long lasting memory, usually after a single exposure and not with repeated exposure. This is usually when the amygdala will retain the memory, and it can do it for the entire lifespan. This would be something like P T S D, abuse serious car accidents, traumatic moments and experiences that go beyond just simply pain that would be non-traumatic.

When this urgency occurs, one of the downsides to it is that the information gets stored with an emotional component rather than a narrative marker. What this means is that now when we can replicate that emotional state, oftentimes that pain sensation will become induced, based purely on emotional stimulus, not necessarily the narrative of a movement that triggers pain or a behavior that triggers chronic pain.

Another learning is ‘Repetition’ Repetition is one of the most familiar learning tools. Almost everybody knows that repetition has an impact on memory and learning. It creates long-term memories by eliciting and enacting chemical interactions that are both pre synaptic and post synaptic. This really encourages the synaptic pathway to become dominant and more powerful. This is where we associate manual therapy and exercise therapy.

Nerves that fire together, wire together. So repetition really creates a strong presynaptic and postsynaptic behavior. Repetition creates the strongest learning. Urgency learning is ingrained deeply and instantly but we can re-wire these ingrained urgencies with repetition. Trainings like EMDR and IMO are a few of the different types of psychological exercises to help remove the emotional component that urgency creates.

Repetition is really one of those things that once it's ingrained, it's very difficult to lose barring some new injury to the brain. Examples of repetition are learning a language, learning an instrument, taking up a new skill set etc. The old adage ‘You never forget how to ride a bike’ seems to hold true. 

Pain, when initially created can be either urgent or dismissive, one will be stored permanently and one will not be, however even dismissive pain, with enough repetition will now become a learned behaviour.

One of the questions that we have to ask ourselves then, in relationship to chronic pain, is why is it so hard to make behavioural changes?


This is difficult because the new behavior (pain free) has to repeated for so long and so frequently that the old behavior (painful) is now held in check, and this is an important component around chronic pain. If chronic pain is the current behavior, then pain-free movement and pain-free manual therapy are essential.

It is important to note that behaviour and therapy are not discomfort free but rather pain-free, they are not the same. There's a difference there. Pain-free movement, pain-free manual therapy must to be repeated so frequently and so often that the pain-free experience becomes the most dominant process. That way the old painful behaviours are held in check.

The secret to change is to focus all of your energy not on fighting the old, but on building the new. -Socrates

If we can focus on non-painful experiences and repeat those experiences more frequently, eventually the pain will become subsided.

The last thing that Gretchen Schmelzer talks about is associative memory, but this will be for another day. 

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Assessment is About Movement, Not Cognitive Interpretations

In hands-on healthcare, especially in osteopathic manual practice, assessment is central to the choice of methods utilized when interacting with a patient (1,2). With the preceding as our starting point, it is important to acknowledge several things that are common in any hands-on healthcare practice with respect to assessment. Broadly, hands-on healthcare is performed with the environment of observation being external to the patient. Stated differently, hands-on healthcare is unable to accurately observe past the skin of the patient. It will be acknowledged that the chiropractors utilize periodic x-ray images with, depending on the particular research cited, a high degree of variance and frequency (3), day to day practice does not include a new x-ray image. Again, stated another way, some hands-on healthcare practitioners have access to the ability to produce radiological images of patients however these images are not taken at every patient interaction. The lack of images at every patient interaction supports the claim that hands-on healthcare is broadly performed at the level of an external environment of observation. 

Following from the argument that hands-on health care is performed from an external environment of observation, it is possible to consider some of the common challenges associated with assessment in hands-on health. Please keep in mind that the vast majority of this argument is based on evidence from osteopathy with a high degree of likelihood that this evidence does generalize due to the external environment of observation common to hands-on healthcare. The first issue to be highlighted is palpatory accuracy. The ability to accurately identify specific structures with palpation has problems. It will be clearly stated that the assessment of reliability or validity of palpation is generally performed on smaller structures (i.e. a spinous process and not a humerus) so it does make superficial sense that accurate identification of structures has problems. If we consider the validity of utilizing palpation to identify lumbo-pelvic structures we are able to identify that low levels of accuracy make it difficult to argue that palpation may be claimed to accurately identify landmarks (4). Along with issues of validity there is further observation that accurate identification of structures is generally low with palpation (5,6). In order to be explicit, prior to furthering this discussion we will note that the term validity broadly describes the level of confidence that a measurement is assessing what it says it is (7) and reliability broadly describes how consistent an assessment is with respect to the normal range of results it provides (8). Please note that the broad definitions of validity (7) and reliability (8) do specifically come from educational assessment; however, the broad sentiment is consistent with any form of testing/assessment. 

With the apparent lack of accuracy to identify landmarks/structures with palpation (4–6) we may predict issues with the reliability of palpation. When considering agreement between individuals with palpatory assessment we are able to note that it is generally poor but does improve on specific types of assessment with consensus training (9,10). Consensus training, essentially training individuals to perform the same tests the same way, does lead to improvement with respect to the identification of tenderness (pain provocation) and tissue texture (variations in yield to pressure broadly) but not in the identification of static asymmetry or dynamic asymmetry of lumbar landmarks (9,10). There is some interesting evidence that expertise (essentially experience across time) far more than specified training improves reliability with respect to palpation identifying the location of a heel lift (11). 

Instead of simply noting the challenges presented by assessment methods performed by hands-on healthcare practitioners, we will use the same evidence (plus more) to build a model for how to leverage current assessment methods. The initial signal to concern ourselves with does have a negative valence which is accuracy/validity. The current attempts at accuracy in identification of structures is less than ideal (4–6) which would primarily predict that accuracy claims may be worth abandoning. The second signal already presented is that consensus training improves interobserver reliability (9,10) for assessment tissue texture and tenderness which allows for the prediction that consistent assessment methods might improve reliability. Further, in experts who have received specific training, intraobserver reliability has shown improvement for identification of the location of a heel lift (11) which further supports the prediction that consistent assessment methods might improve reliability. The third concern is where a new line of evidence will provide insight. The third concern stems from the issues surrounding palpation such that, instead of maintaining the cognitive paradigm that palpation is the primary assessment method in hands-on health care and that osteopathic practitioners have “seeing and listening hands” (12). In order to shift out of the paradigm that palpation is primary in hands-on assessment we are able to identify observational studies of osteopathic practitioners that note the use of both palpation and vision during assessment (12–14) as well as textbooks which explicitly note the use of both visual and palpatory assessments (1,2,15). It is important to note that observation of practitioners assessing patients in the hopes of generating a classification system of the assessment methods displays that the categories are all based on motion, including deep and superficial palpation which is achieved by applying pressure to soft tissues which will generate yield or resistance as a quality of motion (13).

Both observation of practitioners and textbooks to inform training of osteopathic practitioners suggest assessment is explicitly multisensory and not simply palpatory. Now, we have some evidence to build the framework of a model that suggests hands-on practitioners would be well served to abandon claims of accuracy with respect to specific structures, perform the same set of assessment methods the same way as often as possible to improve reliability, as well as to explicitly utilize at least vision and palpation to generate assessment findings based on motion.

Now that there is a framework for a model to build an assessment some time will be given to make this framework more concrete. The primary features of the framework will be reiterated as the abandonment of accuracy claims, the performance of the same set of assessment methods the same way as often as possible, and the explicit utilization of at least vision and palpation to generate assessment methods based on motion. As an exceptionally simple example we will consider a patient in supine. In order to gain information about the lower limb we will offer a straight leg raise and in order to gain information about the upper limb we will offer abduction of the upper limb in the coronal plane (i.e., a one-armed snow angel). The practitioner should perform both tests the same way as often as they are able to perform those tests (reliability). The practitioner will identify asymmetry between the right and left lower/upper limbs primarily with their eyes while identifying resistance to motion with palpation (multisensory integration). The most important change to current practice with both of these assessment methods will be that the practitioner will not think any deeper about asymmetry or resistance than identifying the limb(s) that display the motion dysfunctions (validity). By utilizing current assessment methods, improving the consistent application of the same tests by the same practitioner (reliability), utilizing at least vision and palpation to identify motion issues as practitioners are already trained to do (multisensory integration), and not thinking any deeper than the identification of motion asymmetry/dysfunction there is a model to improve assessment reliability and validity with very little change to practice or training. The primary problems arising from assessment currently are the claims of accuracy and the observable variable application of assessments by the same practitioner with different patients as observed by Dinnar, et al (13). If, as a group, hands-on healthcare practitioners abandon accuracy claims and improve consistency there will be an acknowledgement of the obvious external environment of observation as well as improvement in reliability and validity of the same assessment methods already in use.

The aim of this article is not to claim there is a problem with current assessment methods. The evidence presented in this article allows for an alteration in perspective to leverage current assessment methods to improve identification of motion issues (asymmetry/dysfunction) from the external environment of observation. Once the motion issues are identified the practitioner is then able to make simple choices about how they will interface with the identified issue (i.e. effleurage, oscillation, myofascial release, post-isometric relaxation) with no requirement to make cognitive leaps to things they are unable to observe.  


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