Articles Of The Week December 17, 2017

If I’ve heard this once in life, I’ve heard it a thousand times, (Work Smarter, Not Harder!) however, this is the first time I’ve heard it from a fellow therapist. And what’s cool, is that it’s from one of my heroes in this profession. She’s one of the few who will tell it like it is (and honestly, when I first started following her, she pissed me off but I realized she’s pretty amazing), which is rare for us. So take her words to heart!

“How Massage Therapists Can Work Smarter, Instead Of Harder” – Alice Sanvito

I’m sure we all have patients who are dealing with fibromyalgia. For me, I sometimes wonder what advice to give as far as home care. This article comes straight from someone with the condition and gives some sound advice for this holiday season that you could share with your patients.

“Banish The Word Should For The Holidays” – Christine Lynch

Rajam Roose gives some quality advice on client retention and building relationships in this post. I promise if you even do one of the things she recommends you will see a return on your investment, because if we’ve said it once, we’ve said it 1,000 times, building relationships is crucial in this business.

“Retain Your Massage Clients” – Rajam Roose

This one is a conversation piece. A conversation with Lorimer Moseley so you can understand the difference between pain science education, and understanding pain science. And let’s be honest, anything with Lorimer in it is worth reading.

“Lorimer Moseley WOW Chat: Pain Science Education Vs. Understanding Pain. What’s The Difference?” – Shelly Prosko

This is a great post on pain and why it persists. Everything Rachel writes in this post, you could easily use as an explanation to your patients. Please give it a read and use the info she has shared, and talk to your patients about what meaningful touch is!

“Why Does Pain Persist?” – Rachael Scott

 

Articles Of The Week December 10, 2017

 

Great article about pain and why we experience it. One of the great things about this article is that while we are becoming more aware of pain science in massage therapy, not all industries are as aware of the new research. So Elie Somers is bringing it to the strength training industry.

“What Is Pain And Why Do We Experience It” – Elie Somers

As we all heard about the Massage Envy stuff last week, there were blogs everywhere writing about it. But I found this one especially interesting. Is it possible that the Massage Envy debacle is our fault?

“An Open Letter To The Massage Therapy Profession: Massage Envy Is Our Fault” – Lauren Cates

There are many facets to our massage therapy and business. One facet is our massage schools and education. Apparently, some organizations expect schools to show up and have their students provide free work. But is this right, or should everyone have to pay for students to provide massage?

“Free Student Chair Massage? Nope!”  – Jill Berkana

I liked this one because there is a lot we can liken to being massage therapists. While our scope is different, there is a lot Paul is saying in this post we could look at as well. There is so much massage therapy can do to be part of healthcare, but WE have to evolve and develop in order to be looked at that way.

“Physiotherapy, Come Forward! (It’s Time To Step Out From Behind The Curtain)”  – Paul Lagerman

How is the culture in your clinic? Is it an open and psychologically safe place where comments and new ideas are easily presented? While it’s intended for companies with employees, this is something that could be applied in our clinics as well to create a culture of psychological safety.

“How To Create A Culture of Psychological Safety” – Jake Herway

 

Articles Of The Week December 3, 2017

After the big news about Massage Envy and sexual assault cases, Irene Diamond wrote a post to start some discussion on how to deal with this. She opens the discussion around a “Professional Personal Boundary Agreement,” and whether it should be used.

Sexual Assault & Massage Therapists: What To Do To Protect Yourself – Irene Diamond

We posted something about being prepared with business cards this week and we, in turn, got some great advice about mobile marketing from Allissa Haines.

Online Marketing as an In-Person Networking Tool for Massage Therapists – Allissa Haines

Recognizing and awareness around concussions has come a long way in the last few years. However, there is lots we still don’t know and we need to continue to improve on treatment.

Everything We Know About Concussions Is Wrong – Quartz Media

Just like so many other things in our profession, there are many things that have myths around them. Pregnancy and many things about pregnancy have lots of myths surrounding it. This is a great article to help dispel some of them.

What To Expect When You’re Expecting – American Physical Therapy Association

A great anatomy review of peripheral nerve roots, along with an explanation of what they do, with this post from Diane Jacobs.

Anatomy Of A Peripheral Nerve Root – Diane Jacobs

Client-Centred, Or All About You?

*This post was originally posted on Laura’s blog on June 28, 2016

This morning I saw a FB post from a practitioner mentioning all the things he throws into a massage…Reiki, toning, spiritual healing, and Qi Gong. When I questioned him, he assured me that his clients know before getting on his table what they’re in for. This is the only way of working with integrity. 

My questions about those things, and anything else other than massage that you include in sessions:

1. Did the client ask for it?

I was attending classes in energy work for five years before attending massage school almost 17 years ago. I was taught that you should never impose it on clients who have not asked for it, as many may have religious objections to it or just not believe in it–or just be intent on getting the full hour of massage that they have paid for without other things they aren’t expecting being thrown in. I always adhered to that policy in the interest of being client-centred.

2. Was the client informed before getting on the table that this is the way you conduct all your sessions, and given the opportunity to refuse in the event they just want a massage and nothing more?

If a client books a massage, they are expecting a massage. Particularly in the case of a client who has never had a massage, they are not expecting you to delve into their private spiritual beliefs or perform rituals that they know nothing about.  If you are an “integrative” practitioner and you throw in other things during your session, that needs to be made clear at the very first contact.

It is the same principle as putting nut oil on a client without asking them if they have a nut allergy, or putting essential oils on someone who may have allergies or just object to the fragrance. Just because you love to use peppermint oil during a massage doesn’t mean the client is going to enjoy it.

People have the idea that I am against energy work. I am not against it. I believe anytime you place your hands on people in a compassionate, non-sexual, non-threatening, non-judgmental way, with the intention of soothing their pain, relieving their stress, easing their passing, or whatever, that’s a good thing, and you can do the work without needing some supernatural  narrative that violates the physical laws of the universe to go along with it. A good explanation from Keith Eric Grant, who might be the only physicist in the US who is also a massage therapist of many years, can be found here.

I taught Reiki for ten years myself. One day it struck me that my drawing a few symbols in the air and blowing a puff of my breath on someone is never going to turn anyone into a healer, and I tore up my master certificate. I came to the conclusion that I can lay my hands on someone without needing a story to go along with it, outside of “I just want to comfort you.”

3. Do you wait until they are on the table to spring your plans for the session on them when they are already relaxed and possibly in an altered state of consciousness?

There is an inherent power differential in the therapeutic relationship that is in our favour, and that clients look at us as the authority figure who knows what they’re doing, and who is supposed to have their best interests at heart.

4. Are you client-centred, or is it all about you?

If a client has booked a relaxation massage, and you start digging in because you have decided they need a deep tissue massage, it’s all about you.

I gained numerous clients over the years from massage therapists who thought it was all about them. I’ve heard many comments such as “She was just sitting there with her hands on me not doing anything. I thought she went to sleep.” And “He walked around the table banging a little gong and said he was clearing my negative energy.” And “I kept asking him to lighten up because he was hurting me, but he said he couldn’t because this is what I need.” And “I just can’t stand strong fragrances of any kind. Before I knew what was happening, she had doused me with some kind of oil and I thought I was going to choke.”

A therapist who is client-centred is a successful therapist. A therapist who is not client-centred is going to crash and burn a year or two in and wonder why they just couldn’t make a living doing massage. Being client-centred isn’t optional; it’s our obligation.

Articles Of The Week November 26, 2017

“Your Body Is (probably) Not As Broken As You Think” – Heather Thuesen

The way we talk to our patients is really important, like REALLY important. Heather does a great job of talking about what massage therapy does and does not do. And more importantly, talks about how to talk and educate your patients about pain.

‘It’s Like Chalk On A Blackboard’ My Experiences Researching Patellofemoral Crepitus  – Claire Robertson

This is a great article as it gives lots of research and background on Patellofemoral Crepitus but also shows how a patients beliefs are just as important to acknowledge and treat as the condition itself.

Why I Have Gymnasts Track Sleep Fatigue, And Soreness Every Day – Dave Tilley

If you work with athletes, they really like to track things like progress, success, gains, and almost everything in between. This article is from coaches perspective on why they have their athletes track certain things, so the coaches can alter their training program accordingly.

Shifting Away Nociception And Mesodermalism And Towards “Yesiception,” neurocentrism, and pain science – Alice Sanvito

I’ll admit, this one was written a while ago, but I just came across it this week. It’s a bit of an introduction to pain science if you’re new to it. However, what I love about it is how Alice shows, you don’t have to really change what you’re already doing in practice, you just need to change your description. It’s well worth the read. 

How Important Is Muscular Symmetry For Strength Sports – Greg Nuckols

Our bodies aren’t symmetrical, so do we lift things symmetrically? Is it even important? Well, it probably is for a physique competition, but not so much when it comes to activities like lifting. There may be instances where it could help with injury prediction, but overall it’s not that big of a deal. But if you want to be more symmetrical, or your patient does, the article also gives some advice on that. 

Differences In Graded Exposure And Graded Exercise

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.