Differences In Graded Exposure And Graded Exercise

November 20, 2017/1 Comment/in Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Therapeutic Exercise/by Jamie Johnston

Sometimes I get confused.

Okay, actually, I get confused A LOT.

There are lots of terms in our profession, some sound alike, but mean completely different things. As a result, I get some of those terms mixed up and can’t always remember the difference between things like isometric, isotonic, or ginandtonic.

Thus the inspiration for this post. To understand the difference between graded exposure and graded exercise, as they both sound the same, but mean different things.

Then comes the question of how do we apply both of these in practice, and are both actually effective?

Graded Exposure

Quite often we get patients who come in after an injury, or diagnosis and are afraid to move because they’re worried it will make the injury worse.

We used to preach to patients that movement was a bad thing during an acute injury, so would always recommend complete rest and immobilization, which also played into this fear that movement was bad. And of course, we’ve all had those times where a patient has been told by another practitioner things like: “if you move your disc bulge will get worse,” or “your pelvis is out of alignment, so we need to stabilize it and reduce movement.”

All these statements do, is put a fear of moving into the patient. Some of these patients have been hearing the same stories for years from various practitioners, so many of those beliefs are deeply ingrained.

Graded exposure is a way to gradually expose patients to those feared movements. It is probably used in psychology (as a means to treat anxiety and phobias), way more than it is in manual therapy, but it has become a valuable tool for us to use in practice. In anxiety or phobia situations, they expose a patient to whatever their fear is in small doses until they can gradually control their fear.

For us as manual therapists, we can use this to gradually expose patients to whatever their feared or restricted movement is. Our biggest role, in this case, is education and helping the patient to understand the ramifications of long-term fear avoidance. One case study showed how using graded exposure as part of a biopsychosocial approach helped a patient who was restricted in spinal flexion (due to concern about disc damage) actually overcome that fear, start to exercise, and return to work.

One of the great ways to do this in practice is to get a patient to move in a different plane of movement, or passively move them during treatment. Imagine a patient comes in complaining of low back pain, and when you ask them to touch their toes, they can’t do it. Try putting them in quadruped on the table, and just have them drop back so their gluts touch their heels. Explain to them how this is essentially the same movement, as their spine has gone into flexion, which also demonstrates that they don’t need to be fearful of the movement. Or if a patient comes in with limited shoulder abduction, passively move that shoulder (gradually) into abduction during the treatment, then show the patient how it is possible for their shoulder to move that far. When they see how the movements are possible it gives positive reinforcement, which you can build upon to continue movement and treatment.

These are just simple examples, but it demonstrates how to start using graded exposure in your practice. Todd Hargrove wrote a great piece on how to start implementing graded exposure in your practice which you can read here. If you don’t follow Cory Blickenstaff, check out his blog forwardmotionpt.com where he talks about this kind of stuff a lot and gives some clear direction on how to use it appropriately.

Graded Exercise

So, this is where I got a bit confused.

Because we can use graded exposure to get a patient moving, isn’t that the same thing as exercise?

Well, the way I read it, graded exposure is more of a method to change belief systems by demonstrating certain movements are possible, thus instilling confidence in the patient. It’s basically a way to get them moving again.

Once you have them moving again, this is where graded exercise comes into play.

If we look at doing any kind of rehab with a patient, exercise and movement should be a fundamental part of getting them back to activity, whether it is an athlete wanting to get back to their sport, or someone who has been in a car accident and needs to get back to work.

Part of my confusion is that graded exposure is actually a part of a graded exercise, as we are going to provide more resistance and load to those feared movements. Graded exercise is where we start the patient moving, then gradually increase it, this could be via increased load or endurance, depending on what is necessary for that patient.

One study shows that when you compare graded exposure to graded exercise, the exercise is more effective in reducing catastrophizing when it comes to back pain, and also points out that catastrophizing may play a part in the transition from acute to chronic pain. The same study had patients do group exercise which consisted of cardiovascular, stretching, strengthening, and functional movement and they saw several functional and objective improvements over an 8 week period. The study also went on to say there is no credible evidence that patients with chronic low back pain should avoid exercise, yet activity restriction is consistently recommended.

So lack of movement and exercise can actually contribute to a patient catastrophizing and making their condition worse, yet because of old habits, this is precisely what gets prescribed to patients!

As Massage Therapists, we could start with some contract-relax stretching/movement while the patient is on the table, then depending on tolerance, increasing load with specific movements after treatment is done. I know prescribing exercise is out of scope for some MT’s, yet it’s okay to do passive and active range of motion. If this is the case for you, start your patients with passive movement on the table, then progress them to active ranges of motion. When they get off the table, just have them do bodyweight movements that load whatever portion of the body they are having difficulty with. You’re not prescribing exercise, you’re just having them move in specific ways, which is part of your treatment. The evidence is mounting on how effective this is, especially when combined with manual therapy, so while you may have to be creative, start incorporating it into every treatment.

Now I have to go do some research on ginandtonic movements.

Don’t Let Ego Influence Your Massage Therapy Practice

November 13, 2017/3 Comments/in Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

“We can’t work with other people if we’ve put up walls. We can’t improve the world if we don’t understand it ourselves. We can’t take or receive feedback if we are incapable of or uninterested in hearing outside sources. We can’t recognize opportunities – or create them – if instead of seeing what is in front of us, we live inside our own fantasy.” – Ryan Holiday

I’m sure we’ve all been on courses with them.

They’re the ones who show up hungover, sit at the back of the room with their sunglasses on and have to make regular breaks outside, disrupting the class.

Then at the end, they fill out the feedback form and where it asks why the took the course, they just put “because I needed the credits.”

Okay, yes, I’ve been hungover at a course, but I really did want to be there!

I always wonder why this happens, and if the college didn’t require us to take CEC’s would these therapists even bother to take a course? What got someone to the point, where they didn’t think they needed to learn anymore, or really just didn’t give a shit!?

More importantly, how does it reflect on them as therapists, and on our profession as a whole?

Preventing Ego-Based Feedback

It can be looked at as both a positive and a negative that we are a somewhat self-regulated profession.

Yes, we may have a regulatory body, college, or some other organization that says we have to take “X” number of continuing education each year and they may even give guidance on what courses are appropriate to take. However, the real onus is on each practitioner to decide which courses to take, and which direction they would like to push their career.

While taking continuing education is a pathway of learning, it is also a means of feedback. These courses can confirm or deny certain biases you may have, and then, of course, you can allow those biases to shape your thinking and even your approach to practice.

One literature review shows that seeking feedback is a valuable resource to promote adaptation, learning, and performance. It also shows that we can discover opportunities for skill improvement and higher goal attainment compared to individuals who don’t seek feedback. But there are factors that influence feedback seeking behaviour:

Learning goal orientation: the person sees that certain abilities can be improved over time and see task failure as a way to increase effort without any threat to their ego, so they seek feedback frequently.
Public vs private context: in other words, they will seek feedback less in a public setting as they are nervous about losing face in front of others.
Leadership style: essentially if the clinic you work in has good leadership, you are more likely to ask for feedback from colleagues or the clinic owner.

The same literature review (although it points out more research is needed here) highlights three motivations for feedback seeking:

Instrumental motive: seeking feedback to meet goals and regulate behaviour.
Ego-based motive: to seek feedback in order to bolster the ego and avoid feedback that may threaten it.
Image-based motive: to protect and enhance their public image.

One of the cases in which they say more research is needed is with regard to the ego-based motive. The old belief was that feedback can contain unfavourable information which could hurt self-esteem, however, they point out newer studies had both positive and negative results in this regard. Of course, all of this information depends on how the person receives the feedback. If they automatically dismiss any negative feedback and only take the positive, there isn’t much of a chance for growth and change.

So herein lies one of the challenges for each of us professionally.

Do we allow ego to get in the way when we take courses, and only actively participate in the ones which promote our own bias? Or do we take some courses that challenge our bias, regardless of how it may affect our ego?

I would like to think that if you have been following this blog for a while, or are just new to it, you’d choose the latter. The only way we can grow personally and professionally is to challenge our own bias or old thoughts and welcome new ideas and research to allow our practice to change accordingly.

Photo by: Goumbic

Becoming The Expert

Who of us wouldn’t like to be called an expert in our field? Okay, maybe there’s some ego there too.

When we look around our therapy world there are certainly those who boast about what they do and put on continuing ed courses claiming their technique is “the only thing that works,” and some have put themselves on some sort of pedestal as being an expert. The reality in those cases…you guessed it…ego.

What we’re talking about is working to grow as a therapist, but it doesn’t happen overnight.

It takes time, but there is a bit of a framework we can look at in developing yourself and your practice to become what could be considered an expert. Think about the difference in how you practice today, compared to the year you graduated college. Is there a difference in your decision making? Do you treat differently? How about communication with patients, is that different?

One study showed that experts in a variety of fields had many of the same characteristics. They included:

Differences in content, self, and procedural knowledge.
Differences in personal qualities, characteristics, technical skills, interpersonal skills, motivation, and commitment.
Experts are highly self-regulated and skilled in directing their attention to things that matter.
They possess clinical knowledge that allows them to use the most critical and relevant information.

Now, this part is pretty cool. The same study found that as expertise increased, therapists adopted more of a supportive, educational, functional, strengths-based approach which included; realistic self-expectations, heightened humility, and increased self-confidence. When a therapist implemented these things, something else happened. They were able to use customizing strategies to create a better therapeutic relationship with the patient!

When that relationship is improved it created a better environment of change for the patient. The study points out that for all of this to happen, the therapist had to have some other qualities like open-mindedness, a non-judgemental stance, and wait for it…the ability to listen.

One other benefit of this line of thinking is a therapist will actually benefit by seeking out and accepting more feedback from managers, peers, clients, and mentors. So, not only does having less ego mean a better relationship with patients, it does with fellow practitioners as well. When we look at these traits, doesn’t that seem like someone we could look to as an expert in our field?

In Leadership Roles

When I got my first chance to work with a national team in sports, I was required to sit in on a conference call with the other therapists, trainers, and coaches before actually getting to camp.

On the call, we were told that we were invited to camp because we had an ego, and were good at what we did in our own careers.

Then came the next comment: “leave your ego’s at the door!” We were told how we each had a specific role to fill with its own job description. Those were the roles we were to fill regardless of what our roles were with our individual teams or sport at home.

On the leadership side, this did two things.

It set us up for success as a team.
It set the parameters of what you were to do before you even got there, so there would be no misunderstandings.

That is good leadership.

Another example of great leadership that happened in this experience was when I reached out to a couple of individuals. One was the Athletic Therapist who gave me my first chance to work in sport. I called him to say thanks for that opportunity and giving me my start, as it led to this opportunity on the national level. The other was the call to say thanks to the person who hired me for that position. In both cases, they turned it around to put the focus on me. When thanking them, both came back with comments like “you got yourself there, no need for thanks,” and “it was your resume and the work you put in that got you there.”

Great leaders empower others, they don’t make it about themselves.

Think of how this is applicable to us as therapists. We don’t just have people in positions as leaders because they are a clinic owner. Others may sit on the board at the college, or association level. They are massage college teachers, event planners, practice group chairs, or CEC providers. In any case, the ones who will be good in those positions are the ones who look at their job descriptions and realize it’s not about them. It’s about empowering their group, their class, their profession, it’s about advancing collectively, not individually. The practitioners who will be good leaders, become experts, and develop therapeutic relationships will be the ones who leave their ego at the door. Although there still might be times when they’re hungover at a CEC.

Sleep Disorders And Massage Therapist Safety

October 30, 2017/1 Comment/in Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

The best part of college was the first two terms of school.

We had two classes a week where we would work on each other and practice draping, how to landmark certain areas of the body and learn new massage techniques. It was a new massage treatment twice a week.

All you would hear in our class were students saying “I love school” as they received their massages from classmates.

The other thing you would hear, was me snoring!

Every time I got on the table I would fall asleep. Teachers regularly came up to me saying “you have to stay awake to give your therapist feedback!”, my response: “I’m sleeping, I’d say they’re doing a good job!”

When we got into the student clinic, we would wear it like a badge of honour when a supervisor asked how the treatment went and we could say: “well, they fell asleep, so pretty good”.

But is that really the best thing? I know it’s great for the patient and it’s an obvious sign they’re relaxed, but what about for the therapist? Is it in our best interest? Is there an issue as far as our safety?

Sleep Disorders & Parasomnias

There are 81 major sleep disorders which are then put into eight major categories.

Some of them you’ve probably heard of, maybe even experienced and more than likely have a few patients who deal with sleep disorders like insomnia, sleepwalking, and sleep apnea.

Within those eight classifications, the fifth one is called “parasomnias”.

Parasomnias are undesirable physical or experiential events that happen during entry to sleep, within sleep, or during arousal from sleep. Those events can be sleep-related movement, behavior, emotions, perceptions, dreaming, and autonomic nervous system functioning and are typically associated with arousal from non-REM sleep. There are several parasomnias that are associated with REM sleep, but since it takes 90 minutes to actually get into REM sleep, those ones probably aren’t much of a concern for us.

Confusional arousal is one of those disorders associated with non-REM sleep and involves the person being mentally confused or having confused behavior after waking up. These are most common with kids but are common with 6% of 15-24-year-olds and present in 1% of the population over the age of 65.

Sleep-related dissociative disorders happen during the transition from wakefulness to sleep or after waking up during the first or second stage of sleep (the first five or ten minutes) and involves a disruption of integrative features of consciousness, memory, identity, or perception of the environment.

One study showed these sleep disorders to be more prevalent among the general population than was previously thought and also showed it is not uncommon for a person to have more than one parasomnia. However, there is no real treatment for these type of sleep disorders as they are considered benign and quite often are due to a lack of good sleep. An example given was a sleep-deprived doctor being woken up from a deep sleep, may have confusional arousals and can possibly make errors in judgment.

Most of these things disorders during the first 1/3 of the night when people are going to sleep, but can also be quite common during daytime naps. So, when we look at the example just given, think about your practice and how many shift workers you treat? How many police officers, firefighters, nurses, city workers, or any other night shift workers do you have that come in?

People could have parasomnias and not know it, especially those who are sleep deprived before they even come and see you.

When we look at patient safety, it’s important to know about these kinds of things as someone could wake up during or after a treatment and be very confused about where they are, what they are doing, and even what just occurred while they were on the table.

Paralysis And Lucid Dreaming

Have you ever had a moment where you woke up from sleep and couldn’t move? Or you felt like there was an intruder in the room, pressure on your chest, or the feeling of an out of body experience?

Well, that is sleep paralysis, and part of sleep paralysis is the hallucinations that occur while in this state. It can happen when you are falling asleep, or when you are waking up from sleep, and is divided into three classifications:

Intruder Hallucinations (hearing voices, sensing something evil is in the room)
Incubus Hallucinations (chest pressure, difficulty breathing, perception of pain)
Unusual Body Experiences (flying/floating sensation, out of body experiences, emotional bliss)

In one of the oldest known accounts of sleep paralysis, a woman described the events as the devil laying on her chest, as well as being choked by a great dog. Another study done with Mexican adolescents found that 27.6% of the subjects had experienced the phenomenon of “a dead body climbed on top of me”, which was determined to be a form of sleep paralysis. Some descriptions of this kind of hallucinations even go to the extent of people being fearful of being killed or raped in their bed. These “incubus” hallucinations are more likely to occur when entering a sleep cycle.

Interestingly one study looked at the relationship between sleep paralysis and lucid dreaming. When we are lucid dreaming (which happens more during REM), we actually have the ability to control the dream or wake up from it, because we are aware that we are in a dream state. In the study, lucid dreaming had more of a connection with the third class of sleep paralysis (unusual body experiences) and actually had a positive effect and showed a positive association with imagery. However, the study also pointed out that sleep paralysis has more to do with poor sleep, and increased stress and anxiety.

How many patients do you have that come to you because getting a massage helps them with sleep, stress, and anxiety? Probably quite a few of them, and as it turns out, sleep paralysis is pretty common. One systematic review estimated 7.6% of general population, 28.3% of students, and 31.9% of those who deal with things like depression and anxiety, also deal with sleep paralysis.

Imagine if one of your patients had this happen on your table when entering a sleep cycle. Through no fault of their own (and none to you as well) they could have this type of a hallucination and possibly feel you were involved or part of the hallucination. The important thing is to make sure you protect yourself. Make sure you keep a journal or notebook around to document if something seems strange after the treatment. Keep detailed notes on what occurred in the treatment as a protection for you and your practice…just in case.

Photo by: kellepics

Consent For Massage Therapy

Before any treatment starts, part of the interview process with a patient is getting consent for treatment, especially if you need to work in sensitive areas like the gluts or adductors.

Just recently in Ontario, it was made mandatory to have this documented before each treatment whether you have a previous therapeutic relationship with a patient or it was the first time. Many saw this as a hindrance in practice and felt it would just be annoying for a patient to have to do this every time!

While I can see that side of the argument, why not look at it on the other side and think about what it does for the practitioner rather than the patient (don’t get me wrong, it should be done as a protection for the patient as well).

Studies have shown how the sleeping brain can still interact with its environment. One study showed that not only can movement be triggered by nociceptive stimulus during sleep, but also behavioral responses can occur. Again, think about what could happen if your patient falls asleep on the table and you have to work on the sacrotuberous ligament (or any sensitive area). If for whatever reason they normally wouldn’t allow someone or typically did not want to be touched in this area (even though they initially gave you consent), when that nociceptive stimulus is applied, the patient could have a behavioral or movement response without actually realizing it.

Remember that consent happens throughout the treatment and it can be taken away at any point even if it was given at the beginning. This could be an instance where a patient is actually revoking or is confused about consent because of an altered state of consciousness, and a behavioral response could be induced even though you technically did nothing wrong. This is where you want to have things documented appropriately to make sure your safety and your practice is always protected.

While I know many of the things talked about in this post might be a rare occurrence, it is possible to have these things happen. I agree that patient safety is of the utmost importance, I also believe therapist safety is just as important. This isn’t to say you should never allow a patient to sleep during a treatment, many of them love the fact that they can get a quick nap in and feel much more relaxed. What I am saying is we all need to be aware of some of the above-mentioned issues to make sure we are kept safe as well. If you’re ever unsure of someone’s reaction during a treatment, or after, make sure you document it so you always have a record to refer to…just in case the worst scenario happens and a patient reports you.

The Power Of Touch And Presence Vs. Modality Specific Beliefs

October 16, 2017/3 Comments/in Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Walt Fritz

Disclaimer: I teach continuing education seminars for a living.

When we touch patients in a therapeutic intervention, how many different “things” or actions can we really be accomplishing? How many different structures can we really make contact with or elicit change?

With higher levels of training come apparent deeper and more precise technique and expectation, while the beginner is viewed as less-than. If your practice is like my own, you receive referrals of people who have seen a multitude of manual therapists of all sorts. At the onset of the initial encounter, they invariably share what others have said about their problem as if all of that information is necessary to get to the bottom of things.

I patiently listen as they rattle off a list of claims made about their problems, with many trending into the catastrophizing mode (the WORST trigger points that therapist had ever seen!).

We are all touching the same body in much the same places, but most are believing we are feeling and finding vastly different structures and problems, both normal and aberrant.

To stay in the first person, my brain filters this information and tries to put it all into a framework of my evaluation findings and beliefs that I was taught and I will typically come up with a different language of what the problem might be. In the past I would have spoken in fascial-based language, calling palpated tightness a fascial restriction and telling a very compelling narrative on how these fascial restrictions, ignored by most in medicine, cause crushing pressures on pain-sensitive structures and only with the application of light, sustained pressures of myofascial release will they ever have a hope of resolving their issues. My language now is quite different, as are my beliefs, and I am much more circumspect about how I explain patient’s problems.

As I teach and travel I have a distinct privilege of meeting with and sharing beliefs with hundreds of therapists and professionals from a wide range of pressures. I am also active on hundreds (yes, hundreds) of niche’ manual therapy groups on Facebook and LinkedIn. Playing the fly-on-the-wall allows one to hear or read conversations that range widely from comparing and contrasting the effectiveness of various modalities to reading people’s suggestions for how to handle a problem case.

Well-meaning inquires regarding how to treat a difficult case are often met with a range of emotionally charged suggestions, most speaking to their favorite modality and citing the “inherited narrative” that goes along with this modality. (Thanks, Phil Greenfield!). As that fly-on-the-wall, I am struck with the hundreds of different modalities and narratives that therapists use in daily conversation.

It takes little effort to see that there really are hundreds of different modalities and sub-classes of modalities available to us as continuing education. But can we really be doing all of the things under the skin that those hundreds of seminar lines profess?

It is beyond the intent of this post to deconstruct any modality in this post. My point is to look at the commonality of our actions. Though our touch can often vary from light to deep, with holds that fluctuate from short duration to long, is there a simpler way to explain our touch rather than the often pained and convoluted models put forth by the various lines of teaching? Is it necessary to invent a new way the body works or a new way to describe how we impact the body in order to sell seats in classes? (A rhetorical question, as it apparently is.)

When we treat, we touch people in a manner that is intended to soothe, to improve the quality or ease of movement. This sounds too simple for many, especially those with advanced training. Many in our shared fields are working to simplify the explanatory model, rather than trying to make it more complex or secretive.

Join the Skeptical Massage Therapists group on Facebook, if you would like to see how this works. Read through the long list of threads and attached links to research and other reference materials. Take a side trip over to SomaSimple for a bit of mental flossing. These are very deep rabbit holes; ones that may cause you not to recognize yourself when you finally emerge. Don’t be surprised if you become defensive or angry as you read how others view your modality or its creator, but give it all time to sink in. How we affect someone when we touch cannot be as complex as many make it seem. Simple, well-meaning directed touch and presence may explain much of our outcomes. And this is not a bad thing

5 Habits To Have To Have Before Disconnecting For The Weekend

October 9, 2017/in Business, Massage Therapist, Massage Therapy, Myofascial Release/by Robert Libbey

Success is determined by what you do after you do what is expected of you.

1. Celebrate Your Wins And Reflect On Your Future

Develop the Habit of reviewing what went well and celebrate it. It reminds you to focus on your growth, to focus on the positive influences you’ve had, the contributions to improving your patients’ quality of life and helps you begin your weekend in an enthusiastic frame of mind.

Now is the time to take 5 minutes, at the end of your day, and really reflect on the good work you are doing and the lives you are touching (pun intended!) I guarantee that along the way, you helped quite a few people. I have no doubts that you changed a few lives by improving the quality of life of some people.

If your weeks are like mine, this week went by so fast, you were so busy with treating patients, you don’t even know what you did, but you got here somehow.

Ask yourself a few key questions: What did I accomplish this week? What do I want to accomplish next week? Next month? Next year? A businessperson should always be aware of his or her recent accomplishments and reflect on them to better plan for his or her future success.

2. Develop The Habit Of Sending Two “Thank-You” Notes!

As a businessperson, you rely on a lot of people; your team, mentors, partners, and Patients to support you each week. All play an important role in our lives, yet in today’s world, thankfulness seems to be on the downslope.

Before you leave the office, recognize at least two people for their continued offerings, positive influences, and referrals with simple notes of appreciation. Doing this shows you care about “your team” and that you recognize their support.

3. Develop The Habit Of Reviewing Your Contacts List For The Week

Before you leave your practice, reflect upon your contacts list and review your calendar (see below).

Throughout the week you may have had certain people you came into contact with that can and possibly will influence the direction of your professional and or personal path. Think about the NEW patients you had. Make a couple of quick notes about what the next step in their treatment may be. This doesn’t have to be a concise treatment plan, just a couple of points to think about and get you started in a direction.

Add any business contacts to your LinkedIn, Twitter and other social media accounts. Doing this now makes sure no one slips through the cracks.

Photo by: Pixelkult

4. Develop The Habit Of Having A Clean Desk

Make sure you have all your daily patient files charted. Ultimately you should have the habit of charting your files as part of your treatment time, but for those of us who chart at the end of the day… get it done now!

If you have any clinical records waiting to be copied and sent to lawyers or insurance companies…get them done and mailed.

Clearing your desk of these tasks is a weight off your mind. You now have the freedom to focus on more important weekend activities, friends, and family.

5. Develop The Habit Of Reviewing Next Week’s Calendar

Make note of any business contacts you met with over the past week and how and when you’ll follow up with them. Review or enter times and dates on your calendar for next week of when you may want to contact them again. Make a short list of who needs to be contacted next week and set a tentative date and time to do so.

Don’t feel bad if you don’t get through all of these. The exercise is to get you into the Habit of ending your week productively and positively!

Everything You Need to Know to Get Awesome Referrals From Personal Trainers

September 19, 2017/1 Comment/in Business, Cardiopulmonary Resuscitation, Massage Clinic, Massage Therapist, Massage Therapy/by Rick Elnor

Marketing is no fun.

For years the word “marketing” conjured up thoughts of sleazy pitchmen and ads full of unsubstantiated claims. It didn’t seem like much fun. In fact, it seemed like something I didn’t want to be involved in at all.

“Marketing sucks,” I thought. But so did my client roster.

With a young child and a single income just surviving wasn’t good enough.

Given I lacked the money for fancy advertising I set out on a journey to find a way of getting the word out about my services to potential clients. There were many options out there but they all had price tags attached and made some rather outlandish promises.

I needed something that wouldn’t break the bank.

Something I could live with. Something that didn’t spread half-truths or make empty promises. Something that worked.

What I soon learned is that my initial impressions of marketing couldn’t have been more wrong. Marketing doesn’t have to suck. You are the one in control. You can market your services ethically and have fun if you put in the work. The work, in this case, consists of building relationships and a referral network which can keep you busy without risky ad campaigns or flashy “click funnels”.

Sustainable marketing efforts all come back to building value for both those in your network and your clients.

The following process is the same process I used as a fitness coach. This process has been refined to help Massage Therapists pull great coaches/personal trainers into their referral networks with the help of my co-author (a former personal trainer and current RMT) Keenan Hollingsworth.

The Benefits of Trainer Referrals

Before we dig into the process of building a referral network let’s first talk a bit about what makes personal trainers a great source of patient referrals for Massage Therapists.

A personal trainer is someone your patient sees very regularly, often multiple times per week, every week, for months or even years on end. One of the biggest reasons people stay with their trainer long-term is the strong relationship they develop; there is trust, camaraderie, and mutual respect. This rapport goes a long way when it comes to referrals. People trust their trainer, and having the trainer’s stamp of approval is going to make it much easier for you to get the patient in the door, and have them buy into the treatment plan.

Personal trainers are told by their clients about all the client’s little aches and pains, old injuries which they felt hadn’t healed properly, or certain exercises they couldn’t perform because their “ _____ is falling apart”.

Unfortunately, the truth is that these complaints often go unaddressed because the trainer hearing them doesn’t have a trusted source they can refer to. Building a strong connection with a personal trainer can lead those “my knee has been killing me lately, I can’t-do squats” comments into new patients for you, and hopefully, in turn, better feeling knees for the client!

A huge benefit of working with a personal trainer is home-care.

We all know patients can struggle with completing their home-care. Whether it’s due to lack of motivation, feeling like they don’t have time, being uncomfortable performing the exercises unsupervised, or any other of a million reasons, “compliance” can be a difficult hurdle. A good personal trainer is a perfect adjunct to this.

If you communicate properly with the patient’s trainer, they can help reinforce the importance of doing the home-care, and help the patient work through it during their sessions. If I think a patient will benefit from strengthening their upper back, what’s going to be more effective, sending them home to do rows with a TheraBand, or working with their trainer to program in a variety of progressively harder upper back movements within the workout they are already going to be doing? Someone who’s going to coach them through every exercise, push them for quality technique and effort, while programming in methodical increases to improve strength and endurance…or their kid watching them fumble around in the kitchen trying to remember exactly how to do an exercise they were taught them 3 days ago? I think the answer is clear (and it isn’t the TheraBand).

A lot of research is beginning to highlight just how important “general exercise” really is, for health, mental wellbeing, and even pain management. Unfortunately saying “just go out and get some exercise” can be a daunting task. If a patient mentions the desire to “get in shape”, or the need to “get back to the gym”, having a personal trainer you can trust to work with them in a safe, effective way is an amazing resource.

Whether they just want one session to learn what to do on their own, or they’re looking for a long-term trainer, being able to recommend someone with a similar philosophy and message as you, is valuable to both you and the patient.

Define Who You Are Looking For

The first step to finding the best referral sources is to define the type of client/patient you are looking for.

Experienced trainers often specialize and target a specific population. This can mean that while some work with the general population others focus on specific genders, ages, sports, levels of athletic performance etc. If you define your dream population it will start to narrow down the list of trainers you should be trying to recruit into your network.

Once the perfect client has been defined it’s time to think about the perfect referral source. Personal Trainers with an approach similar to your own will always provide better referrals than trying to solicit everyone to pass your name along. As a Personal

Personal Trainers with an approach similar to your own will always provide better referrals than trying to solicit everyone to pass your name along. As a Personal Trainer, I want someone in my network who understands the value of exercise, the power of the words we use and the importance of evidence. I also want someone who is used to working with a wide range of athletes. The more my clientele aligns with a Massage Therapist, the more people I can refer to them.

Think of the values that define your massage practice. On a lined scrap of paper record these values. This set of values can function as a checklist which you can quickly refer to, allowing you to decide if someone will ultimately be a benefit to your network or more trouble than they are worth.

Referrals are a two-way street. If you don’t trust a trainer’s expertise enough that you would feel comfortable sending patients their way, it is not worth your time to recruit them into your referral network.

Getting To Know The Locals

Providing a service which revolves around physical contact means local clients are needed.

As such, a strong local referral network is one of the keys to success. Building this network isn’t as complex as it may seem. If you live in a place which is large enough to support your business, you live in a place where there are trainers who want to be part of your network.

Finding them isn’t as hard as it may seem at first.

In my experience the better relationship you have with a potential lead the higher chance you have of bringing them into your network. Due to this, I like to start with the people closest to me and work my way out to new contacts and relationships.

Marketing is all about building and supporting relationships and this task is no exception.

Start With The People You Know

This step seems hard for many people.

To ask those they know if they would be interested in forming a mutual referral relationship takes courage as it opens a person up to rejection, but if you believe in your service (and theirs), not asking is a missed opportunity.

My favorite approach in this situation (especially if you are prone to nervousness), is to write down who and how you are going to ask in advance and don’t over think it. Contact every trainer you can, be it a new relationship or one that has slipped into the past.

Take an interest in what they are doing, ask about both work and life outside of it but eventually come around to explaining that you are open for referrals and open to referring to them. Build on the relationships you have as chances are if you trust in them already they trust in you as well.

Ask The People You Know If They Know Anyone

Trainees are passionate about their personal trainers.

If they think their trainer is amazing they will tell you. Likewise, if they think they need a new one they will tell you that too. Asking friends, colleagues, and family for introductions to their trainers is a win-win-win situation. Not only does the person you are asking feel their opinion is valued but the trainer feels valued to be considered worthy of consideration and you gain a potential lead.

Ask EVERYONE whose opinion you value.

Physiotherapists, Chiropractors, and other healthcare professionals are great sources especially if they are already in a trainer’s referral network but anyone in a highly social profession could be an exceptional source for information about local personal trainers.

Trainers often target highly social professionals as referral sources so real estate agents, lawyers etc. all may have been approached previously by the trainers you are trying to target.

Social Media

Social Media is ubiquitous, it is the perfect tool to find local, proficient and engaging individuals able who are able to provide clientele fitting the criteria you defined earlier.

Almost every trainer has a social media presence and almost every trainer is looking for ways to increase client retention and acquisition rates.

The most effective way I have found to locate Personal Trainers and other referral sources on social media are by using Facebook. Facebook provides query filters which allow the narrowing of friend searches to your current city, hometown, mutual friends etc. This is a powerful tool. Search, pick the people that seem to best fit your desired criteria and start communicating. Posting insightful comments on things that they post, friend requesting them as you build a repertoire and then speaking via messenger is extremely effective. It’s not an immediate payoff but relationships take time. A little effort each day is all that it takes.

It’s not an immediate payoff but relationships take time. A little effort each day is all that it takes.

Of course with local personal trainers, the real goal here is to meet them in person and see if both your clients and theirs would benefit from being part of the same referral network.

Meet, Connect, And Assess

The main task you have in the first meeting with a potential referral source is to get to know them and for them to get to know you.

Finding common ground is a requirement before trying to convince them of your value and bring them into the fold. Most of this should have been done via your messenger conversations but this is a chance to build on it.

Buy them a coffee (or a beer if they so please) and just have a conversation without thinking too much about referrals and such. What makes or breaks your referral chances is the personal connection. Essentially they are buying into you, not just the value of your services. Keep it light, keep it fun, and don’t be a pushy salesman, nobody likes that crap. More than likely work and the purpose of the meeting will come up naturally as it will be a “common thread” which is easy to fall back on when conversation stalls.

Just like a date, if it goes well follow-up, heck even if it doesn’t go all that well follow up. The trainer that doesn’t mesh with your style may know another one who does. Don’t burn bridges if you don’t have to.

The follow-up, continuing to speak to people on a regular basis, and offering support (where you can) is probably the most overlooked variable involved in getting people to refer patients your way. A continued line of communication builds trust, it keeps you in their minds and it shows you are in this for more than just yourself.

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Expanding Beyond The Locals

Due to the rapid expansion of online training and trainers working remotely, the potential for referrals from trainers all over the world now exists.

A personal trainer in Cork, Ireland may have a client in Burbank, California for example. Trainers are no longer limited by geographical location which means they can work with people who are local to you.

If they don’t they probably know someone who does. Bringing trainers from all over the world into your network and expanding globally is the same process as with local trainers.

Sure you can also join mutual Facebook groups, use Twitter, Instagram etc. but the idea is the same. It is all relationship building. Meeting for coffee gets replaced by meeting via video chat or a phone call but the steps remain the same.

The Process in 35 Words Or Less

Define who you are looking for
Ask your existing network for introductions
Search using Facebook’s search modifiers
Comment on their posts to open the lines of communication
Move it to messenger
Video chat
Keep communicating, nurture the relationship

A Word About Incentives

Small personalized gifts are a great way to leave a lasting impression and keep you in their mind but never devalue your services. I’ve sent books, birthday cakes, and cufflinks but I’ve never provided a discount on my services to get people signed up. If you provide value they will pay what you are worth. No discount needed.

Conclusions

In many ways building a referral network is not unlike building a client base. The ideal person of interest must be defined and a search for such a person must be undertaken. This initial phase is followed by building/expressing value over time. It isn’t a “quick fix” but a strategy for long-term growth. Answers to common questions can be pre-written and rehearsed but relationships can’t be automated. In a world of gimmicks and inauthenticity personal connection is what will make you stand apart from the crowd.