Ep 179 – Keeping Clients Safe with Dr. Ben Benjamin

0:00:00.2 Speaker 1: The Elements Massage brand believes massage therapists deserve a supportive team, business and marketing resources, linens, lotions, and the chance to learn as much as they want, so many Elements Massage studios offer continuing education too. What's better, they're hiring. To get your foot in the door, let them know we sent you by visiting elementsmassage.com/abmp. That's elementsmassage.com/abmp.

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0:00:41.3 Speaker 2: I'm Darren Buford, and welcome to The ABMP Podcast, a podcast where we speak with the massage and bodywork profession. Our good friend and co-host, Kristin Coverly, is out the day on some well-earned vacation time, so we'll fight the good fight today without her. Listeners, our guest today is one of our favorites, Dr. Ben Benjamin. Dr. Benjamin holds a PhD in Sports Medicine and owned and ran a massage school for over 30 years. He studied with James Cyriax MD, widely known for his pioneering work in orthopedic medicine. Dr. Benjamin has been teaching therapists how to work with injuries for over 35 years, and has been in private practice for over 50 years. He works as an expert witness in cases involving musculoskeletal injury and sexual abuse in a massage therapy setting. And he is the author of dozens of articles on working with injuries as well as these widely used books, Listen to Your Pain, Are You Tense? And Exercise Without Injury. For more information, visit benjamininstitute.com. Hello, Ben.

0:01:40.3 Speaker 3: Hi there.

0:01:42.5 S2: Today we're talking with Ben about his three-part series in Massage and Bodywork magazine titled, Keeping Clients Safe. You can find these feature articles in the May, June, July, August and September, October 2021 issues of the magazine available online at massageandbodyworkdigital.com... Ben, why was writing these articles, this series of articles, so important, and what's your history and background with these topics?

0:02:06.5 S3: Well, it's kind of my version of the Hippocratic Oath, like do no harm. In these three articles, that means do no harm physically, emotionally and sexually. In my work as expert witness, I've seen those types of harm because of the lack of knowledge, sometimes bravado, lack of experience, as well as, criminal behavior. The overwhelming majority of cases that cause physical injury are due to lack of sufficient education of the therapist. The topics in these articles are important to me because I value safety; safety for the client, safety for the profession, as well as the therapist. And I wanna help therapists not harm their clients, and I think all of the therapists that I've met feel the same way.

0:02:56.5 S3: When you work as an expert witness, you get a chance to see and hear things that most therapists are never aware of: There are lots of clients with cracked ribs because a therapist used too much pressure, there are clients who have gotten multiple surgeries to fix the damage that a massage or body work therapists inflicted. And there are hundreds of women who have been sexually assaulted in the massage room, who struggled for years and years with the consequences, and some of these people have been damaged for their lifetime. I've seen so many people in pain because they've seen a health care provider, including a doctor or physical therapists and massage therapists who tried to help them but only made them worse because they did not have the expertise to either evaluate them, advise them, or treat them appropriately.

0:03:50.9 S2: Okay, let's start with part one of your series, avoiding client injuries. What are the important things practitioners can do to prevent injuring clients, and what do they need to know to help the client with an injury?

0:04:02.8 S3: Well, if you're not trained in how to assess and treat a particular injury, just work gently on the painful area and don't try to actually treat the injury, but let's start from the beginning. What do therapists need to know to help a client with injuries? The short answer is a lot. First they have to know how to take the history for that particular part of the body. A low back history is quite different from a knee history, for example. Second, the therapist must have a detailed knowledge of anatomy. And that detailed anatomy can't be identifying muscles in a book or on a model.

0:04:39.2 S3: The therapist must be able to put their finger on the structures of the body that are commonly injured. And there are several hundred of different injuries that occur in the body. For example, can the therapist put their finger on the supraspinatus tendon at the distal end where it's attached to the bone? Most therapists I know can't do that. Can a therapist locate the exact attachment of the iliolumbar ligament? Can a therapist put their finger on the anterior tibiotalar ligament in the ankle? This is the one that's most injured in the ankle. If you can't put your finger on it, you can't really treat it very easily or very effectively. This is an area of knowledge that very few massage therapy schools train people in.

0:05:24.4 S3: Most chronic injuries actually do not occur in the muscles, they occur in the tendons, the ligaments, the fascia, bursas, nerves and joints, so the massage therapist must be trained in assessment testing if they're going to work with people who have injuries. Fourth, they must be skilled at various treatment modalities and how to approach various injuries in the body and with which modality. Fifth, they have to know the exercise programs to help rehabilitate the client after the injury heals. But most important of all, it's important to know exactly what you can treat and what you can't. Sometimes referring the person to a physician or other healthcare provider is more appropriate for the injury that the person is experiencing, it's not something that hands-on work can do.

0:06:16.6 S2: Okay, Ben, that was a lot of information. Let's go back and clarify each point. You said the history for each part of the body is different. What do you mean by that?

0:06:25.4 S3: Each injury has a unique set of questions that give you the information you need to decide if this person has something that you can treat or if you need to refer the person to someone else. So let's take a look at a low back history, for example. I would ask about 25 to 30 questions. Sometimes the answer to one question leads to another question that you didn't plan on, and that's why the number of questions varies.

0:06:53.5 S3: But there are a series of questions you always ask. What you're looking for in a low back history is a pattern of increasing pain. You're looking for where the pain is, and is it a referred pain or is it a local pain. For example, does it hurt right on the spine or does it hurt in the buttock and down the leg and into the foot or just in the foot? Does it switch from the right side to the left side and back again? Or does it stay on one side? All of these questions give you an indication of something you can treat, like a muscle or a ligament injury, or something you can't treat, like a disc pressing on a nerve. A knee history is quite different.

0:07:37.9 S3: Here what you're looking for is if the pain is deep inside the knee or on the outer surface of the knee. If the pain is deep inside the knee, it's likely to be a torn meniscus, a sprained cruciate ligament, an inflamed bursa, or let's say an erosion of articular cartilage in the knee. All of these injuries cannot be treated with manual therapy and must be referred out, and it's important to know that. If the pain is on the outer surface of the knee, it could be the patella tendon, it could be the medial collateral ligament, the lateral collateral ligament, it could be coronary ligament injury or a retinaculum injury, all of those can be treated by hand with manual therapy.

0:08:19.7 S3: You asked if the knee tends to collapse or if it feels like it's going to collapse, but never does. Each of those questions means something different. If the knee collapses and gets stuck, it means there's a ton meniscus or what's called a loose body in the knee joint. If it feels like it's going to collapse and it doesn't, it generally means it's a ligament called the coronary ligament that can be treated with manual therapy. There are over 20 different injuries that are common in the knee alone, and if you know them, assessing and treating them is one of your skills. And a shoulder history is totally different. Here, you have to know the questions to ask that let you know if it's something that you can treat.

0:09:02.5 S3: Like subscapularis tendon, supraspinatus tendon, infraspinatus, teres minor or biceps or triceps. There are different questions to uncover when it's an acromioclavicular joint or a ligament sprain, like the joint you can't treat, the ligaments sprain, you can. Or a bursitis or a frozen shoulder, which you can't treat, knowing how to differentiate those things is incredibly important. And the history gives you one part of that, the testing gives you another...

0:09:32.6 S2: Ben, you talked about assessment testing, can you explain that?

0:09:36.1 S3: Before you ever touch an injury, you wanna do a series of assessment tests to determine exactly what's injured. For example, if it's an injury in the foot and ankle, there are multiple structures that could be causing a problem. It could be tendons that cross the top of the foot or the bottom of the foot or the sides of the foot. It could be one of seven primary ligaments in the ankle. It could be a bursa or a joint inflammation, or it could be one of the 14 joints of the toes. So you wanna be able to test all those. If you know all the tests for the foot, toes, ankle, etcetera, and you can figure it out fairly easily, then you know what to do or if you can treat it or not, but if you don't and you just sort of... You're kind of wandering about in the dark. In the shoulder, there are about 30 different tests that you do that are useful and to help you differentiate which structures of the shoulder are damaged, and if it's something that you can work with effectively, like a tendon injury, or if it's not, like an inflamed bursae.

0:10:43.3 S3: Now, if you don't have the skill, you waste a lot of time and a lot of the clients money and time. If you do have the skill, you can help the person get better in a very reasonable period of time, if it's a tendon injury. And if it's a bursa injury, you know who to refer them to, and you know that you can't work with it. In the neck and low back, there are many tests that let you know if it's something that you can treat or something that you have to refer out. If a structure is damaged, let's say, two inches inside the body, body work is not gonna do much. But if the damage is near the surface, which most neck and low back injuries are, you can do a lot to help this person, and sometimes the person has one injury you can't help and three injuries that you can. So if you have the skill, you know, which is which. The knee has about 18 tests that fairly accurately tell you if you can help the person or not, so assessment testing is a crucial skill that every therapist who works with people in pain should have.

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0:12:24.0 S4: Now, let's get back to the podcast.

0:12:29.8 S2: Ben, what about the treatment skills, what are they?

0:12:33.4 S3: Well, the primary cause of chronic pain in the soft tissues of the body is adhesive scar tissue, and that sometimes forms in the client's body when you're trying to heal and the body tries to heal well, but sometimes it does and you get better, and sometimes it doesn't, and you have it for a very long time. The first task, as we described, is to find the injured structures through assessment testing. Now, when you get to the treatment part, you have to find exactly where the place is on that particular tissue, where that scar tissue is that's causing the pain. For example, if you have determined that it's the achilles tendon that's injured, you have to use your palpation to see exactly where the strain is. Now, it can be on the posterior tendon, it could be on the medial or lateral sides, but it can also be on the anterior surface of the tendon, which can be much more challenging to palpate if you haven't been trained on how to do that. Once you've located the exact area or areas of the injury on the structure that you determined is injured, then you can proceed to treatment and know that you're in the right place, you're doing the right thing, you're gonna help the person.

0:13:44.9 S3: At a minimum, I recommend friction therapy, myofascial therapy, active assisted stretching, muscle energy techniques, cranial sacral therapy and exercise therapy. So let's take them one at a time, and I'll briefly describe them, so you know what I'm talking about. You don't have to have all of them, but if you have most of them or half of them, you can help a lot of people. So first, friction therapy. So cross fiber friction therapy is a very precise form of treatment that's remarkably effective in treating most muscle, tendon and ligament injuries. Friction therapy was developed by Dr. James Syriac, a British physician, who has since become known as the father of orthopedic medicine because he wrote the book on how to work with pain and injuries that were non-surgical.

0:14:35.1 S3: Friction therapy addresses the problem of adhesive scar tissue formation in the muscles, tendons, ligaments and fascia, which is the cause of a great deal of chronic pain. In a healthy healing process, scar tissue really serves as the biological glue that holds the torn fibers together, but in proper alignment. However, in many cases, this process goes awry and adhesive scar tissue builds up in an indiscriminate fashion, so the resulting tissue has much less integrity and uniformity of structure than the original tissue that it replaces. This frequently occurs in the muscles, tendons and ligaments, and the fascia that enveloped those structures. Friction therapy breaks down poorly formed scar tissue and prevents its return.

0:15:24.7 S3: It also promotes the formation of properly aligned and mobile tissue, encouraging normal healing to occur. In addition, by introducing mild control trauma at the injury site, friction therapy increases the collagen production and blood supply to areas that normally have very little circulation. So next, myofascial therapy. So, myofascial therapy is used for many different injuries. Sometimes the fascial covering of the injured ligament tendon or muscle is riddled with adhesive scar tissue, so treating the fascia is really essential. Every structure in the body is wrapped in fascia.

0:16:06.7 S3: When you work on these fascial coverings, you must know how to pinpoint every structure with your fingers. You then work in multiple directions when you're working on fascia. It is unlike friction therapy, which strives to work at a 90 degree angle to the injured fibers. Fascia can and should be worked at least in four directions, that's with fibers, against the fibers, across the fibers in both directions. Think of it as working in north, south, east and west. Active-assisted stretching is another very useful technique. It differs from most other types of stretching programs in several important respects. I'll describe seven defining characteristics of active assisted stretching techniques, each is supported by established principles in human physiology. And I'm gonna spend a little more time on this one modality because I think it's incredibly useful and relatively unknown.

0:17:02.1 S3: So, for specificity, active-assisted stretching movements are precisely targeted to stretch individual muscles and parts of muscles rather than larger groups of muscles. For instance, in contrast to a simple forward bend that provides a general stretch for all parts of the hamstring muscle, active-assisted stretching uses three different stretches to focus on different combinations of the medial lateral oblique, proximal and distal fibers. This enables the practitioner to independently evaluate and then work to maximize the flexibility of each section of the muscle. Using different combinations of these stretches, we can develop customized regimens tailored to the specific needs of any client.

0:17:48.0 S3: Then there's active initiation. Although the stretchers are supported and assisted by the practitioner, each movement is initiated by the client. This enhances the stretch since contracting a muscle on one side of a joint causes the muscle on the opposite side to relax, this is a principal known as Sherrington's Law of reciprocal inhibition. And that relaxation helps the muscle to stretch more efficiently. Also having the muscles actively working, helps to increase the temperature of the muscles and the fascia which enhances flexibility even further. Then there's the incremental assist of the therapist. At the end of the client's active range of motion, the practitioner provides just enough assistance to push slightly beyond what the person could do on his or her own. In this way, it's possible to increase flexibility incrementally.

0:18:43.0 S3: Typically adding one or two degrees with each repetition, the movements involved in this technique are quite gentle, never approaching the maximum sustainable force that a muscle can handle. Laboratory studies confirm that to avoid injury, it's important to use 50% or less of maximal force for muscles being stretched. Gradual gentle motion also helps to delay activation of the stretch reflex, which is a defensive mechanism in the nervous system that's designed to prevent muscles from stretching too far or too fast and getting injured. A movement that is sudden, severe or too long will cause the muscle being stretched to reflexively contract, and it's also done in brief duration.

0:19:31.9 S3: The key to avoiding the stretch reflex, which is a contraction against the stretch, is to hold the stretch for only a really short time, no more than two seconds. Traditionally, exercise specialists have recommended holding stretches for much longer periods, like up to 60 seconds, and if you do that very gently, it also works. But in this technique, you can move much more quickly by not doing static stretching, but by doing this kind of active stretching for very short periods of time. However, research has shown that such prolonged stretching initiates the stretch reflex, decreasing blood flow to the tissues and leads to a build-up of waste products, such as lactic acids that contribute to muscle fatigue and soreness.

0:20:13.9 S3: When people stretch in this way, they're working against themselves, causing a contraction of the very muscles that they're trying to lengthen. Sort of like trying to drive a car with the parking break on. As a result, the tendons and ligaments get stretched more than the muscles, which can lead to tendon and ligament irritation and even laxity and predispose the person to getting further injured, and then there are multiple repetitions. Static stretching relies on a principal known as stress relaxation. When muscles and connective tissues are held at a constant length, they eventually fatigue, release and lengthen, in addition to promoting muscle fatigue, this type of action is also relatively slow. Active-assisted stretching achieves results much more quickly by using 5 to 10 repetitions of shorter stretches. This method can help increase the range of motion in a particular area by as much as 50 degrees in a relatively short period of time.

0:21:16.5 S3: So now onto a different modality called muscle energy techniques. Now, muscle energy technique is a technique that was developed in 1948 by Fred Mitchell, who was an osteopath. It's a form of manual therapy that uses the muscles own energy in a form of gentle isometric contractions to relax the muscles via reciprocal inhibition and it lengthens the muscle. Muscle energy technique is an active technique in which the client is also an active participant. It's based on a concept called autogenic inhibition and reciprocal inhibition. The difference between autogenic and reciprocal inhibition is that autogenic inhibition is the ability to relax the muscle when it experiences a stretch or increased tension. While reciprocal inhibition is the relaxation of muscles on one side of a joint to accommodate contraction on the other side of the joint.

0:22:17.3 S3: In muscle and energy work, the contraction of the muscle is followed by a stretching of the same muscle and is known as autogenic inhibition. And if a contraction of a muscle is followed by stretching of the opposite muscle, then it's known as a reciprocal inhibition. Muscle and energy work combines these two different techniques. And then craniosacral therapy, which many therapists are studying these days. Cranial therapy originated in the field of osteopathy. Osteopathy was developed by Dr. Andrew Taylor Still just after the Civil War. His work became known as cranial osteopathy. Now, in the 1970s, an osteopath named Dr. John Upledger developed craniosacral therapy as an offshoot of cranial osteopathy. He trained thousands of therapists who were not osteopaths. Craniosacral therapy uses light touch to examine and treat the membranes and movement of fluids in and around the brain and central nervous system.

0:23:20.9 S3: It takes a long time to learn and really be good at, but worth the effort to master it, if that's something that you're interested in. And then exercise therapy is another type of skill that is very useful in working with people who have pain and injury. As an injury is healing, it's important for the person to build back their strength. If it was a tendon injury, the entire muscle tendon unit has likely atrophied as well as the surrounding muscles because they can't do certain actions without pain. So there are two jobs: Strengthen the injured structure first, then integrate all of the muscles that act together. For example, if you injure one of the rotator cuff muscle tendon units in the shoulder, let's say the subscapularis, after you have successfully reduced the pain producing scar tissue, first you build up the structure that was injured with a targeted exercise, then you build back the entire shoulder, which uses exercises that integrate all the muscles of the shoulder together.

0:24:22.7 S2: Ben, let's shift to working the first time with a client, is it important to do an intake with a new client in person or is it fine to have clients fill out information beforehand or at the appointment and then review it together, and how much time do you dedicate to this?

0:24:37.6 S3: Well, it depends on why the person is there. If the person wants a relaxation massage or a health maintenance session and they're not injured, five or maybe 10 minutes are usually adequate to take the history. Just make sure you ask about any pain they may be experiencing, shoulder dislocations, any surgeries, underlying medical conditions or medications that may interfere with sensation or pain perception during the treatment. If they had an ankle sprain, let's say, and present with a swollen ankle. Did they get an X-ray? I take the history in person or over Zoom in a virtual kind of session where I'm just doing an assessment, and it usually takes maybe 20 to 25 minutes.

0:25:23.2 S3: It depends on how much the person has to say. And I find that I get much more useful information when I do it live. Part of taking the history is beginning to establish a relationship with the person, a connection with a particular client. And you can't do that just by going over a few details you're getting from looking at a form. I tend to work with people for a long period of time. Usually several months for most injuries, or in some cases, actually several years, if they're very active and wanna make changes to their body. And a thorough history is essential to support this, especially working with athletes. The time frame is much longer because they often have multiple injuries and they often get new ones as you're going along.

0:26:07.3 S2: Ben, have you had clients misconstrue their health history or not be forthcoming in relaying injuries or underestimating their injuries. And why is this bad? And if so, how can you get clients to be more forthcoming and truthful when relaying their health history?

0:26:22.4 S3: Doctors who do assessments for insurance companies are much more likely to get this type of person. They're usually trying to cheat the system and not work and get paid. Massage and body work practitioners don't usually see this type of client because the clients are coming to get help and are usually paying out of pocket for the service. Underestimating your injury is a bad thing to do, because you will likely get more seriously injured if you don't stop doing the things that hurt and don't take some action to get the appropriate treatment. Things just get worse and worse. I've seen this over and over.

0:27:00.5 S3: I have seen clients who have ignored the recommendations of health professionals and ignored the signals of their own body only to suffer more and more serious or multiple injuries as a result. For example, I've seen an amateur athletes who had pain in their shoulder or their foot and they ignore it, and they continue to play the sport that they're playing that they love, even though it hurts. And so as not to disappoint someone else, sometimes they'll finish a game even though their foot is killing them or the shoulder. To please someone else these individuals often end up with multiple injuries that are much more serious. And once you establish a strong relationship with a client, I find that they are very forthcoming and truthful when they're relaying their health history, but sometimes more information comes out slowly as you work with them. They remember more details over time, and this is natural.

0:27:54.2 S2: Okay, Ben, we talked about first time or new clients, what about existing clients? How often should you review health intake information?

0:28:02.5 S3: Whenever an existing client comes in, I always ask if anything is different from the last time I saw them, and if there is anything that's painful that I should know about. And I ask that every single time.

0:28:14.5 S2: Ben, what guidance do you have for appropriate pressure, especially with a new client?

0:28:18.8 S3: Well, you just ask. Some clients who have had massage before, know what type of pressure they like, and they tell you; mild, moderate, deep pressure. With a new client, it's always good to begin with mild pressure and be in conversation with the client as you work. Each part of the body may require a different amount of pressure, it's not the same all over. A client may have a lot of tension in their neck and shoulders, but have very little in their legs or vice versa. I always do a muscle tension assessment test, which is detailed at the back of my book, Are You Tense? The amount of pressure a client likes is usually directly related to how much chronic tension exists in different parts of their body.

0:29:03.3 S3: During this assessment test, I apply mild then moderate and then slowly increasing pressure to the neck, shoulders, upper back, mid back, low back, hip, thigh and lower leg. And this tells me how much chronic tension exists in their body. In the history process, I ask the client about their goals, and if they want a relaxing experience, I would use a gentler pressure. But if they want to change the state of the muscle tension in their body, I would work with them weekly and use an amount of pressure to slightly challenge the tissue to release its tension. I would always ask before doing this and always follow the client's direction, unless the client asks for something that I felt would be not be beneficial, and this would be really rare. For example, if a client said...

0:29:54.2 S3: And this has happened, "Work with as much pressure as you can. I don't really mind the pain, I think it's good for me." I would not do that. I would explain why this is not a good idea and proceed in a way that I thought was safe.

0:30:09.8 S2: Ben, what are your thoughts on staying informed and educated about various conditions and possible treatments, and what do you know to refer out to other practitioners or healthcare providers?

0:30:20.7 S3: Well, I suggest that therapists try to learn something new every year. There are always new things to learn and new research that challenges us to rethink our old beliefs. It keeps the work alive. Be in touch with the work of the massage therapy foundation, read Massage and Bodywork publications that have a lot of new information to share. Be ready to change your mind about things you've always believed. As new information becomes available, you may need to alter your perspective from what you learned in school 10 or 20 years ago.

0:30:55.8 S3: For example, it was commonly believed that massage was not good for cancer patients, but research has shown that it was not true. And with training in how to work with cancer patients, these clients derive great benefit. There are many beliefs and myths in massage therapy that have to be corrected with facts. And here are a few more: Pain down the leg is caused by pressure on the sciatic nerve. Well, the fact is that the sciatic nerve consists of five separate nerves all wrapped together. And it is rare, very rare, if ever, that there's pressure on all of them at once. One or possibly two nerves could be compressed by one or more injured extruded disks that are popped out of their medium, their...

0:31:43.6 S3: Let me start that again. One or possibly two nerves could be compressed by one or more extruded discs. However, most cases of pain down the leg are caused by injury to structures like sacroiliac or sacrotuberous ligaments, the iliolumbar ligament, the hip joint, or a gluteus medius muscle, not the sciatic nerve or its branches. Another myth is when a tendon is chronically painful, it's tendinitis, because the tendon is inflamed. Well, the fact is that we now know that there are no inflammatory cells when a tendon has been injured over an extended period of time. This is called tendinosis, where the cells are deteriorating. Tendinitis refers to a strain of a tendon in the early stage of injury where there are inflammatory cells that are trying to have a repair response.

0:32:41.5 S3: Conversely, tendinosis is defined as intertendinous degeneration due to atrophy, which means a kind of an aging process, micro-trauma and a vascular compromise of blood circulation. In recent research, many tendonitis complaints have been found to be lacking in inflammatory cells, and the main issue in these tendon disorders, referred to as tendinosis, appears to be collagen degeneration from overuse. Massage therapy, specifically deep friction therapy, is beneficial as it stimulates the production of collagen in damaged tendon fibers rather than only breaking up a fiber scar tissue in chronically inflamed tendons as previously thought.

0:33:25.5 S3: Generally pain does not originate in the muscles. Most people don't know this and assume the pain that they're feeling is coming from their muscles. Pain is often referred to the muscles from injured tendons, ligaments and joints. Massage therapists receive in-depth training on muscles and their function. When something goes wrong in the body or a client presents with pain, it's the first and often only place they look.

0:33:51.4 S3: A therapist might attribute the discomfort to a muscle spasm or an injury to muscle tissue. However, this is often not the case, especially with lasting chronic pain. For example, muscle spasms are frequently identified as a source of pain, yet in most cases muscle spasms are protective mechanisms and a result of an injury to a tissue other than muscles. For example, if a ligament or nerve root is injured on one side of the low back and you begin to move in a way that adds pressure to those structures, the muscles of the low back will seize up in spasm, limiting movement and possible further injury to that ligament or nerve root. The pain associated with an injury to a muscle tissue... Start again. The pain associated with an injury to muscle tissue often diminishes within a day or two or maybe a week.

0:34:47.3 S3: Muscle strains do occur frequently, yet muscle tissue is so highly vascularized it heals very quickly in most cases with any kind of treatment. Where there is ample circulation, there is a larger capacity and efficacy for effective healing. When pain continues for months or years, it is typically indicative of damage to a ligament, tendon, a joint or the bursa.

0:35:11.3 S2: Ben, as we come to a close, is there anything else you'd like to add?

0:35:14.6 S3: Becoming really good at anything takes a lot of work and time. To be good at working with people in pain, I studied for many years. And I was always amazed at how much I didn't know. I kept meeting people who knew things I didn't know, so I studied with them until I could incorporate what they had to teach me. Good luck on your quest to learn.

0:35:37.5 S2: We wanna thank our guest today, Dr. Ben Benjamin. To find out more information about Ben, visit benjamininstitute.com. Thanks, Ben.

0:35:45.8 S3: You're welcome. Glad to do it.

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