5 Ways You May Be Increasing your Client's Disease Burden, pt. 2 of 3

written by Robert Truax, DO

What is disease burden?

If you had a disease(s), you'd endure the challenges directly impacting your body which could be mild to substantial. That's not all you'd endure. You'd also manage:

• the side effects of the treatment,
• the logistics of ensuring you consistently get the treatment,
• the burden that others have to take on in order to get you to treatment,
• the expense of the treatment,
• the loss of income caused by needing to take time to get the treatment.

Your health is impacted by more than the sum of the disease symptoms. 

One of the main tasks of the physician is to reduce the burden of the disease.

• When you have cancer, tumors are usually removed to reduce the tumor burden so that chemotherapy and radiation don't have as much cancer to fight. 

• An orthopedic surgeon will drain an abscess in an infected bone prior to starting antibiotics so there's less bacterial burden for the antibiotics to fight.

• In diabetes, eating plenty of vegetables, limiting processed foods, and exercising decreases the metabolic burden that diabetic medications have to fight in order to get blood sugars under control. 

Prior to relieving someone’s disease burden, the full extent of the disease burden needs to be identified. 

Be careful. You can overdo this pursuit.

In this Touchpoint, I described that one of the problems with diseasification is that a treatment plan could be created for something that may not actually be a problem.

For instance, when a physician gives you antibiotics for your cold, the physician is telling you that you are sicker than you really are, since 99% of colds are due to viruses which are self-limiting and won't respond to antibiotics.

However, if your cold is destined to last 10 days, but you're no better after three days of antibiotics, then you might return for a better antibiotic. 

If the second physician tells you “It's just a cold,” your response could be, “The first doctor thought it was more serious . . . he gave me an antibiotic.”  

So, you see, a physician has to be very careful and deliberate in their diagnoses and prescriptions.

The prudent physician appreciates working with other medical practitioners who are as careful and deliberate in what they say because they don't want other practitioners adding to their patients’ disease burden.

The goal of this Touchpoint is to help you avoid adding to your clients' disease burden.

Medical massage therapists work in the dysfunction zone - the zone between health and disease of the musculoskeletal (MSK) system. 

You help the client by reducing the number of dysfunctions or muscle imbalances that contribute to the clients’ overall disease burden. 

Where might you be adding to the disease burden even unwillingly?

 

 Stress

I often do muscle energy with my patients, which means I instruct them to gently contract a particular muscle, hold for a few seconds, and then stop contracting.

When I do this, I usually say “relax” instead of “stop contracting.” 

So, I say, "Relax your hip."

Quite often, they let me know, “I have a hard time relaxing.”

They just used my request to “relax your hip” to explain that the reason they didn't fully stop contracting the muscle was due to their stress.

They take a simple request to stop contracting a muscle and globalize it to their stress problem.

I could overlook this as a mere communication issue, but I don’t. I point out that they just turned a simple request to stop contracting a muscle into a self-declaration that they are very stressed and I must have noticed it in their muscle contraction.

I choose to bring this to their attention because if I didn’t, they could walk out of my office with the idea that I just reinforced their increased stress level because they thought I called attention to it.

Rather than reinforcing their belief they are highly stressed, I ask them to notice that while they were contracting one muscle, the rest of their body WAS relaxed on the table. 

I encourage them that it might not be helpful to look for reasons to reinforce the notion “I am stressed.”

This is diseasifying stress.

Another frequent comment is: “I hold my stress in my shoulders.” 

All humans to one degree or another, and at different times, hold stress in their shoulders. When a client says this, I hear a silent cry of “I'm stressed, I don't know what to do about it, so I'm bringing it up to you.” 

I attempt to demystify this and tell them everyone has stress and that they're not unique in being stressed in the neck. Everyone is stressed to some degree. Stress is a part of life we can never fully avoid.

Your role as a medical massage therapist isn't to reinforce their stress by making a big deal about their “tight muscles.”

Your job isn't to suggest things that are causing stress . . . because how much control do they really have over these causes?

Rather, your goal is to help them through their stress by making space for restfulness in your presence. 

By massaging their muscles while they're passively relaxing on your table, you have the opportunity to reduce their overall stress burden.

In many ways, we stress over our stress and this just worsens our disease burden.

Communicate that you're a respite for relaxation rather than a place all of their stressed-out muscles are identified. By being this, you can decrease their disease burden.

 

Posture

There's a lot of information about posture, and good posture is . . . good.

But, there are too many humans in the world to believe there's a single perfect posture to attain and anything less is a cause of pain.

Furthermore, no studies have found a clear connection between supposedly good posture, bad posture, and the presence or absence of pain. 

As a massage therapist, do you think

• they have bad posture so their muscles are tight? 
• or their muscles are tight so they have bad posture? 

This is the dilemma.

Furthermore, if we diseasify posture, and they have a skeletal structure that will preclude them from having “good” posture . . . they carry the burden of  “I have bad posture” with them their entire life.

I have a kyphosis in my spine and yet, I don't suffer from chronic back pain. I don't see back pain as my destiny.

I recall seeing a new patient and she was discussing her previous treatments for back pain. She said physical therapy didn't help much, “but the physical therapist did tell me I need to work on my posture.” 

Consider if you were in her situation:

You walk into this physical therapy clinic with the disease burden of back pain and then you're discharged with the same back pain AND a posture problem. 

The physical therapist not only didn't help with the back pain but gave them a new problem to add to their overall disease burden.

To be clear, I'm not suggesting we discourage a client from doing posture-based exercises in an effort to improve their posture. However, I prefer to say that it's to improve overall spinal health and fitness, not to necessarily improve posture or reduce pain. 

Posture exercises can initiate an exercise program, and even people without pain can benefit from posture exercises. 

So, I do address posture in my clinic and when I do, I reinforce that most people have a posture issue, so it’s not necessarily an issue unique to them.

I give them simple maneuvers to address the compensations caused by their posture or perhaps counteract what's causing the posture. 

I help to restore and maintain health to their posture and not blame them for their posture.

 

Inflammation

It's very common to attribute pain to inflammation. 

In my experience, inflammation is over-diagnosed.

Practitioners of both traditional and alternative medicine over-diagnose inflammation. Since massage therapists shouldn't be addressing this, I won't go into too much detail. 

Inflammation can be a cause of pain – especially when someone has an acute traumatic event, an infection, or an autoimmune disease.

In traditional medicine, it's tempting to claim inflammation as the primary cause of pain because they can prescribe anti-inflammatory drugs.

In alternative medicine, it's tempting to claim inflammation as the primary cause of pain because they can recommend their version of an anti-inflammatory diet.

When you have a solution for inflammation, everything can seem like inflammation.

There are commercials showing someone grabbing their back and then getting much better after taking an anti-inflammatory drug.

In the alternative medicine world, a battery of supplements are sold to solve inflammation.

The reality is that unless someone is actually tested for inflammation, determining that musculoskeletal pain is due to inflammation is purely guesswork. 

I often have people frustratingly explain that they have changed their diet and still have "inflammation causing pain".

Hmmm . . . maybe it's not inflammation then. 

Do this experiment right now:

Hold both arms out to your side as if you are a “T”. Hold this until it becomes uncomfortable. I will wait.....

Was the discomfort you felt due to a

• mechanical/physical issue or
• an inflammatory issue? 

I can't prove the discomfort you felt was NOT inflammatory but, the fix to the problem was mechanical . . . drop your arms. 

Muscle physiology studies have shown that the pain you felt was due to fatigue in your muscles, caused by being held in an imbalanced position. Fatigued muscles can cause discomfort/pain.

Do you think an anti-inflammatory supplement/medicine could have reduced your discomfort so you could have kept your arm up longer?

Do you see the problem in thinking that every pain is due to inflammation?

If the pain isn't due to inflammation but a musculoskeletal imbalance, the practitioner won't reduce the patient's disease burden, they will increase it. In some cases, the increase is a pretty steep increase in wasted time, effort and expense. 

Had they gone to an experienced manual therapist, a mechanical issue could potentially be resolved quickly, oftentimes with 2-3 appointments along with an exercise regimen which when done gradually, is never a waste of time.

When you read about anti-inflammatory diets or supplements, check to see what other modalities the author uses. 

Do they do manual therapy?

If they don't do manual therapy, they have likely never seen someone who presents with what seems like an inflammatory process but after a strictly mechanical/physical treatment, they improve.  

Now, I'm all in favor of some anti-inflammatory diets as they can be an overall healthy eating pattern. It probably does no harm for a person to use their painful situation to prompt a healthy diet change. 

But, the issue might be mainly mechanical/functional and not restoring balance to the painful musculoskeletal issue will likely lead to a more sedentary lifestyle, loss of efficiency at work and home, unnecessarily adding to their disease burden.

Our job is to not add to their disease burden.

As a guiding rule, I try to get my patient in good muscle balance within 3 – 4 visits. 

If they're not improving and even as they're improving, as a physician with an unrestricted license, I encourage consistent exercise, sleep hygiene, and a diet change if necessary.

Dear massage therapists,

Consider this when you're being advised to put your clients on a treatment plan.

Ask yourself if the treatment plan is a business strategy or a health strategy?

Are you adding to their disease burden by claiming you require them to come to you more than truly necessary?

Massage is only one part of an overall health plan. Do what's best for your client.

Resist the temptation to over-diagnose soft tissue imbalance simply because you offer the solution.

 

Daily Behavior

Quite often I have a patient tell me the reason for his pain is: “I stand all day at work.” 

Then, the next patient explains that her pain is because: “I sit all day at work.”

Then, the third patient tells me: “I walk all day.” 

These patients are diseasifying their daily behavior.

It's possible that a person’s regular behavior may be contributing to their pain but unless there's something obvious like a very large purse or a wallet, I try to steer away from taking part in this diseasification. 

A patient will ask me “what am I doing to cause this pain?” and I wish I could tell them. Each person does hundreds of different movements each day so it's not reasonable for me to guess 1 or 2 things as the cause.

While I will ask them to consider repetitive behaviors that might contribute to imbalances across their muscles, the problem might not be those specific behaviors as much as their overall muscle health.

An improvement of overall muscle health through manual therapy and exercise could address their discomfort in such a way that they don't need to make dramatic changes in their daily behaviors. 

 

 Bed & Pillows

I refuse to diseasify mattresses and pillows.

What we sleep on are pieces of furniture. They're not health care devices.

New pillows and beds are coming out all the time. Simply because a furniture company declares it's good for the neck and back doesn't make it a medical device. It's still a piece of furniture.

I avoid making any suggestions that might make a patient feel compelled to spend hundreds of dollars on merely my guess. 

Simply because someone has pain and discomfort at night doesn't mean it is the bed's or pillow’s fault. 

Muscle imbalances during the day could result in fatigued muscles that feel significantly sore after the lights are out and the room is quiet or when they wake up the next day. It may have nothing to do with their furniture or how they sleep.

If you are selling pillows or recommending mattresses . . . I caution you.

Really think through your marketing and consider if it is adding to your clients' disease burden so you get extra income, or is it simply something you offer that might help them. There is a way to do it ethically.

 

Not Adding to Disease Burden will Make you a Better Therapist

Understanding these common temptations to add to disease burden will make you a better therapist. 

The core issue is understanding what we can control and what we can't control.

Your client may have limited control over the stress in their lives or the job they have or the spine they were born with or the mattress they can currently afford.

Your role is to ensure that what they can't control doesn't have unmitigated impact  such that it keeps them from moving and exercising and building muscle which will help them be more resilient in the midst of what they can't control.

If you're seeking to network within the medical community, this is part of their education.

Physicians will appreciate networking with fellow medical professionals who are as careful about adding to their patients' disease burden as they are.

Look through your marketing and support materials before networking with physicians and consider these common ways of adding to disease burden.

You want to communicate that you're aware of this healthcare commitment and that you seek to be part of a healthcare team that puts your patient before profit or even flattery of your own ability by over-prescribing massage.

 

Touchpoints

This is a longer than typical Touchpoints list but worth it.

Look over your marketing and support materials and ask these questions:

• Are you unnecessarily adding to your client's disease burden?
• Do you communicate your clinic as a place where stressed muscles are identified or as a peaceful place to make room for your body to be restored and healed?
• Does your advertising claim that you identify where your client holds stress as if that is not a normal human thing to do?
• Or do you communicate that stress is a normal part of life and you are the place where your body is rebalanced so you can handle what life throws at you the following week?
• Would your client feel at all shamed for having a stressful life in your clinic?
• How do you communicate the importance of posture?
• Do you normalize having different postures and spines?
• Would your client feel at all shamed for having been born with a spine issue?
• Do you help clients put posture into a larger perspective so that they don't feel destined to have back pain resulting from the spine issues they were born with?
• How do you speak of postural exercises if you are also a fitness trainer.
• When a client comes to you and says they were diagnosed with inflammation, what concerns do you have? (Great question to ask in Mentor Live.)
• Do you offer extended treatment plans beyond 3-4 visits for pain issues? Examine what drives that treatment plan. Is it based on your experience as a medical professional or business building? How do you balance these two motivations? Are they at odds? Where does it cross the line into confirmation bias?
• If you feel uncomfortable with your treatment plans but they've helped your business grow, what else can you do to ensure your business remains robust and healthy without extended treatment plans?
• How do you handle it when clients add to their own disease burden by diseasifying their daily behaviors?
• Do you diseasify daily behaviors in your marketing and support materials?