Critical 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 Dr.Chernich’s methodology please watch this Boris’ video clip) However, it can happen, that scientist might not be a clinician, but have training and a proclivity to critical thinking and thus make the right recommendation for upcoming research. One can be a 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 a 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 a 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?” 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 figured out that, practically, all that professor Tchaikovsky did in that 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 a 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 Tchaikovsky offered in his interview to New York Times. In this interview to the New York Times, you will find 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 a client, objective data of hands-on soft tissue evaluation, examinations of tensions in 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. Best wishes. Boris ABDOMINAL/VISCERAL MASSAGE IN CASES OF SEVERE BACK PAIN Patient female, 26 years old. Works in finance. Single, but in a committed relationship. MAIN COMPLAINTS 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. The 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 the patient had it periodically. She described the pain as intermittent and it was a minor irritant. A pediatrician, a children’s orthopedic surgeon, and lately gynecologists have concluded that her pain is myofascial 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-to-day 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 a 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 a high dosage of oral corticosteroids consumption provided some relief from it. 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 the physician I had the opportunity to examine the young lady in my office. During the examination of her lower back, she reported slightly increased local pain when a pressure was applied over her left back and the 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, because no acute trigger points at the lower back area, I decided to start with an 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 the 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 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

Abdominal Massage 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 Lymphedema. 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 lumbosacral area combining basic therapeutic massage techniques with the 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 rarer. 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.

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