Critical Thinking vs. Clinical Thinking
The critical thinking is based on: analysis, critique and conclusions. In our field in most cases critical thinking is necessary at the time of meta-analysis. If scientists have an interest in research and development of hands-on protocols/techniques, the purpose of which is to accelerate quantities of lymphatic drainage, scientists analyze huge amount of available data on the subject, including, physiology of lymphatic system, its main duty, etc. The same approach applicable in preparation of research on different subjects, related to lower back disorders, neck and upper back disorders etc.
At the time of meta-analysis unsuitable or unacceptable data should be filtered out. Concurrently, a researcher must choose the related data in order to write down the research protocol. Finally, research should be organized; i.e. the decision should be made on laboratory tests, diagnostic equipment, what type of techniques to apply, etc.
Dr.Chernich was a great meta-analysis specialist and a very good massage therapist at the same time. (If you are not familiar with with Dr.Chernich’s methodology please watch this Boris’ vido clip)However, it can happen, that scientist might not be clinician, but have training and a proclivity to critical thinking and thus make right recommendation for upcoming research. One can be great critical thinker, but have no desire or ability to develop great clinical skills in massage therapy. These are the two different specialists.
Of course, the best combination is when meta-analysis is done by a person who combines both expertise: critical thinking and clinical experience. If the meta-analysis is not done well, then there is a poor chance that research outcome will be up to standards. The resulting theory, having not proved itself clinically, would just remain a theory – not useful in a treatment room.
Lately, in average 50% of research data, cannot be reproduced. Something is very wrong with it – maybe not well performed meta-analysis, contributes to this statistics.
I believe that the following is a good example of how critical thinking was applied. Please take a look at the following New York Times article by titled
“Does Massage Help After Exercise?”
When Dr.Ross Turchaniov and I had the opportunity to read this outrageous interview by Professor Michal Tschakovsky, then by applying critical thinking, we started a step-by-step analysis of this research data. We did figure out that practically all that professor Tschakovsky did in the research and presented in an interview to New York Times, was absolutely wrong. We both came to the conclusion, that he and his team either didn’t do meta-analysis or it was of very poorly quality. We have proposed critiques and explanation in regards to the wrong research data and of course conclusions, that Tschakovsky offered in his interview to New York Times.
You will find within this interview to the New York Times, the reply of AMTA president, sounding something like this: ”more research have to be done.” In this case it wasn’t “more research” that needed to be done but a simple and good analysis, that surely required critical thinking.
Clinical thinking VS. Critical thinking.
As I stated above meta-analysis demands critical thinking which is, analysis, critiques and conclusions. Clinical thinking demands a bit different approach such as analysis of subjective information provided by client, objective data of hands-on soft tissue evaluation such as, examinations of tensions within fascia, muscles, existence of trigger points etc.
As an example of clinical thinking please read below, my case presentation, that first was published more than a year ago in the journal of massage science. I’m happy to report that the client, which case I presented, feels very well, long since off all the heavy addictive medications, and this November will get married. I am invited to share the happy moment.
ABDOMINAL/VISCERAL MASSAGE IN CASES OF SEVERE BACK PAIN
Patient female, 26 years old. Works in finance. Single, but in a committed relationship.
Severe pain at left side lower back. Sitting position and/or changing from a sitting to standing position triggering intolerable pain. Walking slowly for up to 15 minutes has reduced the intensity of the pain, but walking for longer than that would once again increase it. Two-three days before her period the intensity of pain dramatically increased, forcing her to spend a few days in bed. Patient was practically disabled for four months prior to her visit to our clinic.
PATIENT HISTORY AND CLINICAL EXAMINATION
Initially this pain wasn’t severe, and patient had it periodically. She described pain as intermittent and it was minor irritant. A pediatrician, a children’s orthopedic surgeon, and lately gynecologists have concluded that her pain is myofacial in nature.
Over the last five years the pain has gradually increased in its intensity and become chronic. The last four months were especially difficult, because the pain became constant. She couldn’t work and her day-today life was greatly affected. The patient became depressed, anxious, and mentally exhausted.
In a desperate attempt to help her primary care physician referred her to the Multidiscipline Pain Management Center in the hope of addressing her condition with combination of acupuncture, chiropractic adjustments and physical therapy. This approach failed and her pain and disability increased. The pain became so intolerable that she was hospitalized. Strong pain killers didn’t block the pain, but high dosage of oral corticosteroids consumption provided some relief from her pain.
After an intense flair up her pain management physician recommended surgery of electrodes insertion in the spinal cord to prevent pain stimuli reaching the brain. However, the Pain Management center’s psychiatrist insisted that such treatment be postponed and antipsychotic medications, as well as psychotherapy, should be tried first.
The patient was referred to our clinic by a physician who was Board Certified in Physical Medicine, and who had been invited to consult the patient when she was hospitalized. While I was talking with the physician, she informed me that all necessary tests, including CT and MRI, had found no significant spinal abnormalities.
I asked if the patient had any abdominal (including gynecological) surgery. The answer was “Yes”. Her appendix was removed when she was 12 years old. Just out of interest I asked if the CT with contrast which was done. The answer was “No”. The day after my conversation with physician I had the opportunity to examine the young lady in my office.
During examination of her lower back, she reported slightly increased local pain when pressure was applied over her left back and left gluteal area. However, the pain had moderate intensity without obvious presence of acute trigger points in the lower back and gluteal muscles Resting muscle tone on the left side was significantly higher, and the fascia exhibited areas of tension in various degrees. Regardless, these symptoms didn’t match the intensity of the lower back pain, associated with Lumbalgia.
Clinically thinking and because no acute trigger points at lower back area ,I decided to start with abdominal massage in order to accelerate venous blood and lymph drainage. These techniques are gentle and always feel pleasant. After a few minutes of the application of drainage techniques she began to cry. My first thought was that my therapy had increased her pain intensity, and I asked her about it. She replied, “No, it didn’t increase my pain.” At this moment, it was obvious to me that she had released psychological tension and suppressed emotions. This is very common in patients who suffer from intense chronic pain, and such a reaction was great hope for successful rehabilitation.
After application of abdominal drainage techniques she reported a significant decrease of pain intensity in lower back region. I asked her to sit up. To our great surprise, the pain didn’t come back as she sat still for more than 10 minutes. At this moment it seemed clear that her severe back pain was a result of significant venous stasis and lymphedema in the abdominal cavity. Shortly after her visit to me her primary care physician ordered a CT scan with contrast. This test showed significant adhesions and abnormal and abundant post surgical scar tissue in the lower abdominal cavity. This CT test finding increased my confidence, and we began a treatment course using abdominal massage as the main therapeutic tool.
ABDOMINAL MASSAGE (AM). GENERAL INFORMATION
AM starts with the gentle mobilization of the anterior and lateral abdominal walls. These facilitate the more efficient application of drainage techniques, as well as various visceral massage techniques that target the internal organs located in the abdominal and pelvic cavities. At least 35% of the total arterial blood supply is provided to organs within the abdominal cavity. This mean that the same quantity of venous blood must naturally be drained from the abdominal cavity, If drainage is impaired, venous stasis develops and various functional abnormalities may manifest (e.g. Diverticulosis, Irritable Bowl Syndrome, Constipation) genito-urinary system (e.g. Infertility, PMS, Prostatitis) or pre-existing pathological conditions may worsen.
The first goal of AM is to eliminate venous stasis and reduce the Abdominal Lympdema. Secondarily to improve the inner organs’ function and reduce abdominal and lower back pain. The next targets of AM are to address existing (?) so adhesions and affected inner organs using visceral massage techniques.
MEDICAL MASSAGE PROTOCOL
I started with 12 to 15 minutes massage in the lumbo-sacral area combining basic therapeutic massage techniques with a following application of Connective Tissue Massage. This part of the session I finished with lumbar muscle mobilization using at least 50% of the time on the application of kneading techniques.
The next target was the lateral abdominal walls I spent around 7 minutes on their mobilization. I spent up to 15 minutes on the mobilization of the anterior abdominal wall and pelvic region. The successful mobilization of the abdominal wall allowed me to efficiently apply abdominal drainage massage techniques, and finally work on the adhesions in the left lower abdominal quadrant for another 10 minutes. Her lower back pain was almost gone after the first five treatments. In total she received 15 sessions of medical massage. I added stress reduction massage for the back and upper neck to the last 5 sessions. Currently she doesn’t have any lower or back pain, but she still feels anxiety attacks which are becoming more rare. I continue to see her weekly for full body stress management massage, and I still include AM in the treatment. I believe that 5 to 6 weeks of such maintenance will break the vicious circle of stress her body has accumulated during her ordeal, and she will be able to completely recover and have a completely normal and pain free life.
As soon as it was obvious that she was on her way to recovery I insisted that she refuse to go on disability and go back to work. She was reluctant at first but she was glad that she followed my advice and it is already a month since she has returned to work practically pain free. Now she feels her fiancé is ready to propose.
Is it too late to rename “Prilutsky’s method of silicon jars massage” to “Prilutsky’s method of fascia mobilizations using silicone jars?”
Friends, I could have given several titles to this blog.
“Is it too late to rename Prilutsky’s method of silicon jars massage toPrilutsky’s method of fascia mobilizations using silicone jars?”
“Techniques by themselves have no power without deep understanding of what we do, as well as techniques without understanding of the entire concept, including understanding that we are not treating a disease, but treating person, techniques have no power.”
”Teaching seminars are also an ongoing process of learning.”
I just come back from Chicago, where I presented the seminar on utilization of silicon jars massage in cases of fibromyalgia. I have enjoyed many aspects of this seminar. In particular, I’ve gotten a huge satisfaction from a realization that participants are ready to provide a professional procedure, reaching a positive outcome when treating people, suffering from fibromyalgia.
Friends, I’d like to share my entire seminar experience with you, because for me it was just as educational as for its participants.
The class was very eager to start learning techniques. I always love this kind of energy. However, right from the beginning, I cautioned the class that of all painful disorder fibromyalgia produces the most complicated snowball effect and without a thorough understanding of these effects, techniques that they learn would prove useless.
Conceptually, the pathological processes leading to fibromyalgia are easy to understand. Due to the cases mentioned in the article (link to the article is supplied below), muscles all over the body start gradually accumulate tension to the point that microcirculation is disturbed, pH drops, pain-analyzing system activates, causing constant pain all over the body.
As it well known, fascia surrounds muscles, providing pathways for nerves and blood vessels. Constricted muscles also imply constricted blood vessels, decreased blood supply and decreased blood supply to fascia. In turn, this triggers tension accumulation in fascia.
Very tense fascia produces dysfunction and becomes a constant irritant for muscles, fueling low-grade inflammatory conditions, including formation of adhesions.
As a side note, I’d like to add that the concepts presented in the article were the topic of my theoretical presentation. At the risk of repeating myself, I’d like to emphasize that without an understanding of the fibromyalgia snowball effect, one would not be able to change the clinical picture for the better in a short period of time. The article also explains how the gradual accumulation of tension in muscles causes clinical depression. Please read this article to be on the same page with my narrative. Massage Therapy is a beneficial tool in treating fibromyalgia
This is mind boggling that not so long ago patients suffering from fibromyalgia were diagnosed as having a psychosomatic problem. Drs. believed that fibromyalgia is a psychosomatic disorder, not a physical condition because after conducting lab tests and X-rays, they couldn’t find the evidence of rheumatoid arthritis, osteoarthritis and other pathologies such as many different autoimmune diseases that produce pain in muscles and connective tissue all over the body. Of course, with fibromyalgia these tests showed nothing, patients behaving strangely, for example crying, etc.
The moment when practitioners understood the principles of fibromyalgia development, they started treating clients and not the disease. This understanding is crucial, and has to exist before very effective massage therapy protocol will be applied correctly. If you are a clinician, practicing massage on a daily base and is in a position to deliver results in short period of time, you must understand this principle. In other words, if symptoms seem to indicate mental psychosomatic disorder, it shouldn’t be confused with the case of fibromyalgia. As everyone could understand from my presentation, fibromyalgia is not a mental disorder even when patients demonstrate symptoms similar to psychosomatic. If we look at a person as a whole and understand the original reason that caused manifestation of these symptoms, then we should direct our treatment to address this cause. In such a case treating patient and not the symptom results in confidence, different practitioner’s energy status, and leads to great outcome. The lack of evidence within lab tests and radiological examinations used to lead to conclusions of mental disorders. At the same time, using our own hands, we can detect restrictions within fascia, muscular tension, etc. That would support pains all over the body, as well as put us in a position to eliminate mentioned above abnormalities.
So, I will repeat myself stating that in cases of fibromyalgia a practitioner must understand that the snowball effect of this disorder starts at the level of muscles, and therefore it has to be addressed on the level of muscles. At the same time, it is important to understand that a fibromyalgia patient is physically and emotionally exhausted. As you can see, the combination of this knowledge allows one to treat patient rather than a disease, and not to suspect that something is not okay with client’ mental state.
Luckily, the class understood and then practiced techniques with the understanding that silicon jars massage, essentially, is fascia mobilization methodology, but much more intense and powerful than fascia mobilizations (or connective tissue massage) done by hands.
At that moment, it just hit me: ”Why didn’t I call the methodology I have developed ”Prilutsky’s method of fascia release and mobilizations/connective tissue massage using silicone jars?” Maybe because it would sound excessively long. LOL From now on, though, from the very beginning of any seminar on the subject of utilization of silicon jars I will make it clear that what I am going to teach is fascia release and mobilizations using silicone jars.
As you understood from the article, we must eliminate tension in the fascia and adhesions before we are able to sustain normal resting tone in muscles. Silicon jars techniques allow us to achieve fascia releases and adhesions eliminations practically immediately.
As a side note, I’d like to add that receiving treatments and feeling the effect of the methodology, is also shall be considered as an educational component. When one practicing this techniques and know about healing power of it, one performing it much better, because one know about this therapeutic powers, and not just believe in it.
On the second day of training in Chicago, I started asking participants, if they felt any difference after receiving the treatment. To my great satisfaction, people who had pain before the treatment reported that pain was gone after treatment was completed. Practically all participants also reported experiencing stress management affect. Listening to the participants, I felt proud that I was on a way to educate them to deliver results.
During the next day I was pleased to see that, practicing on each other, the participants were having fun, and worked with silicon jars with great interest and enthusiasm. It was obvious that, practically, all of them have demonstrated confidence. In my view, performing a procedure with confidence means that one knows what he or she is doing. Provide intensive treatment and results will come.
Apparently, you can teach old dog new tricks.
Teaching in America, I have always faced the same difficulty. The difficult to convince massage therapists that excessive pressure is not the way to stimulate deep layers of muscles and other soft tissues and that it is premature to learn the techniques before adopting the concepts. In most cases, participants rushed me to put them on tables.
During this Chicago based seminar, I have concluded that the quality of my teaching would not suffer if after a few minutes of introduction I start teaching techniques, and then later teach the concepts. Never have I realized how well this approach could work! Again, I had an opportunity to learn something.
Overall, this was a very successful seminar. Using the opportunity, I would like to thank Lauri Novak and Mike Divo, the organizers of this seminar. Everything that they did was excellent, including walking extra mile and providing breakfasts and lunches. I believe that each of us could have afforded to purchase food, but it was a pleasant surprise to see how well they treated us.
I’m looking forward to come back to Chicago in September to teach a seminar on medical massage in cases of sciatica, neck and upper back disorders, including thoracic outlet syndrome and incorporation of silicon jars into the orthopedic massage procedure.