Concussion Management For Massage Therapists

“The tricky part is that concussion signs and symptoms are not always straightforward and the effects and severity of injury and safe return-to-play can be difficult to determine”

– Mark Lovell

“That’s kind o the line I’ve got to walk now. I think the difference is the post-concussion is light-headedness, where I get that disconnect. Anything else is working and getting your heart rate up. I’m still a little nervous. It’s still a little scary”

– Keith Primeau

The sound from the hit echoed through the arena.

He laid there motionless on the ice.

The other players stared at us with a look of disbelief on their face.

As we opened the door to the bench to step on the ice, two players grabbed me and the AT to help get us to their team mate.

We crouched down beside him trying to get as good of an assessment as possible.

Thank god…he’s breathing.

Getting as close as I could to him to speak, to block out what was happening around us I simply asked “are you there?”.

He responded “yeah my head hurts, I just got my bell rung”.

“Can you move your legs?” Glancing down, they moved.

“Does it hurt if you try to move your neck?”

“No, it’s good, just my head”

As we stood him up and took him back to the bench, it was immediately noticeable, he wasn’t acting like himself.

Once in the treatment room, we could set up for a better more thorough assessment.

He was groggy and lathargic. He lost his usual jovial attitude.

Everything bothered him and his headache was getting worse.

Even the lights in the room were causing an issue.

So was it just a headache? Does he remember what happened? Is there something more going on?

The AT went to work with his assessment. He started asking the player a bunch of questions as I sat back and watched.

Some of the questions made sense.

Do you remember the hit?

Do you know what day it is?

Do you know approximately what time it is?

Then he gave the player a list of words and asked him to repeat it back.

Elbow, apple, carpet, baby, saddle, bubble.

I sat there with a dumb look on my face trying to remember the words too, couldn’t do it.

Afterwards the AT explained what he was doing and showed me this document called SCAT2. I had never seen it before.

First Aid Protocols For Acute Concussion

As research develops so does concussion protocols.

People of my generation probably remember as kids the only thing we were asked was: “how many fingers am I holding up” as if we were Billy Bob on Varsity Blues.

Back then there was talk about “degrees, grades or severity” of concussions, but that thinking is out the window now. There is no such thing as a “minor” concussion anymore.

When I started working in sport the SCAT2 document was the more commonly used method for concussion protocols. It has since evolved into the SCAT3.

Part of the SCAT3 is using the Glasgow Coma Scale (GCS) to assess level of consciousness before you decide to move an injured person. The GCS has been around as an assessment tool for years and if you take advanced levels of First Aid it is incorporated into those courses.

The GCS is used to decide if an injured person requires immediate transport to advanced medical care. It assesses the person on three different types of response (eye, verbal and motor) and gives them a numbered grade according to response.  It looks something like this:

Eye Opening

Open Spontaneously (4)

Open To Speech (3)

Open In Response To Pain (2)

Do Not Open (1)

Verbal Response

Communicates Normally (5)

Confused (4)

Inappropriate Words (swearing) (3)

Confused Sounds (groaning etc) (2)

No verbal response (1)

Motor Response

Obeys Commands (6)

Localizes Pain (swats your hand away) (5)

Flexion To Pain (elbow flexes in direction of pain) (4)

Abnormal Flexion To Pain  (3)

Extension To Pain (2)

No Response (1)

Once you designate a score for each level of response you add the scores together for a total. If it comes out to less than 15, the person should be transported to hospital for more advanced care due to the possibility of a brain injury. There is a great video you can watch here to see how it is done.

The player in the story above scored a 15, his eyes opened spontaneously, he obeyed movement commands and could communicate just fine so we were okay to take him to the dressing room.

SCAT3 A Valuable Tool For Massage Therapists

 Once the GCS is complete and determined it is okay to move someone, the rest of the SCAT3 can be used for assessment.

The document goes through several other assessment tools that include symptom evaluation, cognitive assessment, neck examination, balance and coordination examinations.

This is where those memory techniques of saying five words to the athlete and having them repeat the words back is completed to get an idea of their cognitive function.

Symptom evaluation is assessed by noting things like headaches, pressure in the head, sensitivities to light and noise along with feelings of anxiousness and sadness. Few things are tougher than watching a young athlete cry uncontrollably because of a head injury and being frustrated by not being able to understand what’s going on.

The SCAT3 also goes through return to play protocols for athletes. Most importantly is that once an athlete (or anyone for that matter) has been diagnosed with or assessed a concussion, they must be referred to a doctor (preferably a sport med doctor) to receive clearance to start physical activity again.

Typically with a sports team each player is evaluated on the SCAT3 at the start of the season. This gives training staff a baseline to compare in case someone sustains a head injury. If the original is kept on file, it can then be used as a comparison during the acute injury and also as part of the return to play.

While this document was intended for athletes, it could be a valuable tool to be used in a clinical setting with anyone who comes in that has suffered a head injury whether in the workplace, MVI, or as the result of a fall.

Making the SCAT3 part of your intake, combined with regular communication with the patients doctor could give you a better idea how the patient is progressing.

https://flic.kr/p/fpZHhE

Photo by: University of the Fraser Valley

Massage Therapy Treatment For Concussions

Most people dealing with Post Concussion Syndrome will experience a variety of symptoms ranging from dizziness to headaches and balance issues as well as depression.

In order to help any patient that comes to you who has suffered a concussion, one of the biggest things we need to understand is the Mechanism of Injury that caused the concussion.

Was it a car accident?

Sports injury?

A fall?

Has the person suffered a concussion before?

Which direction did impact come from?

Most concussion treatment revolve around aerobic exercise (after periods of complete physical and mental rest) and then return to play protocols for athletes working up to full contact practices (depending on which sport).

When a patient suffers an injury significant enough to cause a concussion it is likely that they have also suffered an injury to the neck which can contribute to headaches as well as dizziness. It is important for us to try and differentiate where the patients dizziness is coming to discern if it is cervicogenic dizziness or a vestibular issue.

I asked a sportmed doctor why they always refer their concussion patients to a Massage Therapist and he said “it’s because there is usually a whiplash injury associated with the concussion, so getting treatment for anything associated with the neck helps in the concussion treatment”. One study showed that Massage Therapy helped a 23 year old athlete by having two 45minute treatments focused around the pelvic girdle, neck and atlanto-occipital and atlanto-axial joints one month after injury.

The SCAT3 (or any other acute concussion assessment tool) is important for Massage Therapists to understand because it will give the therapist better insight, not only on what was done to help a person immediately, but also as a tool to see how a patient is progressing. Above all when it comes to treatment, your clinical experience is going to be the best guide on how to treat someone with post concussion syndrome. While these tools were intended for athletes, it can also be a great tool in dealing with MVI and workplace injured people who are referred to you. Quite often these ones will be dealing with issues like depression, lack of focus, irritability and not understand why they feel this way. Using these tools can be a great method of tracking their progress and helping you refine or change your treatments according to their needs. There is always a concern around Second-Impact Syndrome where someone sustains a second head injury before the initial concussion symptoms are gone. There are companies starting to develop new protocols and services to help with concussion management like imPACT, King-Devick Test, Shift and axonsports but these all come with a cost. Using free resources like the SCAT3 and CATTonline are widely recognized and may be more suitable for sideline and clinical settings for you until the others are more affordable. Take it from someone who has suffered major head injuries in the past, this needs to be managed properly for successful outcomes, the delay in recovery can be frustrating and depressing. But hey, at least when it happened to me I thought I was in Hawaii, and my dad said it knocked some sense into me!

 

The Benefits Of Massage Therapy With The Elderly Population

When I was in school I knew I didn’t want to work with this population.

Weren’t they always grumpy, complaining about life and fragile in their movements and abilities?

With these thoughts in mind I entered my career as a RMT thinking I would steer clear of the elderly population.

I haven’t had a lot of experience working with or being around people over 75 years old. My grandparents passed away when I was a child and even though I have older parents (my dad is 70 but you would never guess that) they have never acted ‘old’. 

For this reason I felt extremely nervous about massaging my first almost 90 year old client.

A few years ago, I was working alone as a locum in a lovely space. Many of the clients there were loyal and dedicated to that clinic, including a mother and daughter who usually received a massage after one another.

At the time of our first appointment together the mother was 89 years old and I was unsure how things would go.

In she walked with the help of her cane, her hair a gorgeous shade of white and perfectly combed. She wore mascara showing off her bright eyes and blush accentuating cheekbones that any girl would die to have.

She had a clear voice but a shy smile and I could tell she was as nervous as I was. She was used to her regular Massage Therapist, who I was locuming for but our first treatment went well and we had a blast getting to know each other.

After my locum was complete this lovely lady became my regular client.

She drove herself to the clinic where I worked, every second Friday for a 45 minute massage. During the years I got to massage her she turned 90 and then 91 and to my knowledge still receives her regular massage.

Giving Respect To Your Elderly Massage Patient

I learned a lot from this lady not only massage wise but life wise.

Can you imagine out living your husband by 30 years? How about out living a son?

She has seen the world change drastically and told me all about it. To say you cannot and should not become attached to clients is crap! She was one of my favourite clients and one of the best people I knew (and still know). I made sure to treat this lady well and to help her out when possible.

If she didn’t give me 24 hours cancellation notice, I didn’t mind. 

If she forgot an appointment, I would call to make sure she was ok but never charged her for a missed appointment.

I often parked her car for her if it was a tricky parking spot to get into and always stood near the massage room outside the door while she was getting undressed and redressed. 

If she needed help I would be there.

I ALWAYS walked her to her car after her massage to make sure she got there ok. She would put one hand on my arm and use her cane to shuffle along the sidewalk.

If she had to park a long distance away, I would run to the car and drive it back to the clinic.

I also gave her my cell phone number in case she needed to get in touch.

When I was instructing at the Massage Therapy College I always referred to this client as my “90 year old” when providing examples of massage clients and treatments to my students. Eventually my students would start asking about her and referred to her often.

Massaging The Elderly

Each massage treatment was similar.

She had been diagnosed with stenosis of her lumbar spine and complained about weakness, numbness and tingling and cold lower limbs and feet.

Spinal stenosis is a narrowing of the vertebral canal, where the spinal cord runs. The most common cause of spinal stenosis is wear and tear changes such as degeneration of the facet joints and intervertebral discs and the formation of bone spurs within the canal.

Photo from: OHP Kelowna

Photo from: OHP Kelowna

While massage therapy cannot change or reverse the progression of spinal stenosis, it can help to decrease pain and tight musculature around the affected area.

She also had scoliosis, which I believe was caused by degeneration, and resulted in her leaning more to one side. 

She was always sore though her hips and lumbar spine and really enjoyed the relaxation of thoracic spine and upper trapezius work. Would I ever truly help with these conditions of a 90 year old woman? 

No, but I certainly know she felt good during the massage (she would honestly tell me if she didn’t) and if I could help ease some pain or make her feel good for 45 minutes then I would do my best.

She was able to get onto the table and lie prone (face down) herself. I would use a moderate amount of pressure to massage through her gluteus medius and minimus, quadratus lumborum and lumbar erector spinae muscles. 

I always did a general treatment for her mid and upper back and neck, then would do a lot of circulatory work for her posterior lower limbs.

It was a slow process, but I would always ask her to turn supine without my help

In my opinion if she wanted to stay independent she needed to be able to move on her own. She wouldn’t  benefit anything from me helping to turn her on her back. She never asked me for help but if she really couldn’t turn over, she would have told me.

Once supine, I would massage her arms for relaxation and circulation, then finish each treatment with  circulatory work on the lower limbs and feet.

Once the massage was finished I would stay in the room until she was in a seated position. Again, I didn’t help her get up off the table but was there in case she needed me. After I left the room she would dress herself.

Communicating With The Elderly In A Massage Clinic

She always asked the same questions. 

I assume she would forget the answers that I told her the weeks previous and often had to repeat myself due to her forgetting her hearing aids, but she always understood what I told her.

“Do you feel my legs tingling like that?” – No only you can feel that!

“Do my feet feel cold?” – always!

“Why do my legs feel this way? My doctor doesn’t tell me much.” – I always gave her an honest answer of what spinal stenosis is.

“Do you think my muscles are still in my leg?” – yes absolutely! 

She had amazing looking legs for 90 years old. While strength and stability was decreasing quickly, the shape and tone of her leg musculature would make a 20 year old jealous.

https://flic.kr/p/7BzwNQ

Photo by: Fechi Fajardo

What The Elderly Can Teach Their Massage Therapist

She would often make hilarious statements followed by her huge laughter:

“Meaghan, I thought instead of getting a massage today that we could just trade legs! No? Oh fine…rub away then. I guess I can’t have everything in life!”

“I only come here because you laugh at my jokes!”

Then there were statements about life. I often wrote these quotes down and called them ‘wisdom from my 91 year old client’:

“I don’t understand how people get bored! Go do something! Go dancing, play cards, have sex! How can you get bored doing those things?”

“When you get to my age, you watch most of your friends go…and it makes you realize how great it was to love them and to laugh with them”

“I think people think life is like a bowl of cherries. They take, take, take, chew up and enjoy half and spit the rest out like it’s useless. We should be eating life like it’s seedless grapes! Enjoy the whole thing!”

“I’m 91 and I’m not ready to go yet! I want to see how things turn out. Life is too short even at 91.”

Was she grumpy? Never. I have not laughed with a client as much as I did with her.

Did she complain about life? Not once. She told me beautiful stories of times with her husband and kids. She talked about her grandkids and great grandkids. She asked me about my love life and gave me hilarious advice.

Was she fragile? Not in my eyes. She was more on the ball than most people I know who are a third of her age! She had more wit than most. She was blunt and honest. Massage wise, she could take a good amount of pressure and rarely said anything felt too sore. 

Movement wise, she was slow and unsteady. She fell at home a few times and once had a hard time getting back on her feet but she continued to live on her own and drove herself around the city. In most ways she was not fragile at all.  

Unfortunately, as we age we see a decrease in function in many areas: strength, stability, mobility, memory, physiological processes, metabolism and even mental health. While massage therapy may not regain anyone’s youth, I am a firm believer that it can help with mobility and stability issues and can have an incredibly positive impact on one’s state of mind. The elderly may have to deal with disease processes, slowing bodily function, loss of partners, friends and memory, but a Massage Therapist can provide a quality of life that helps them to feel better, be more positive and in my case get a ton of laughs. I moved away from the city where my 91 year old client lives but I get updates from colleagues about her. She taught me a lot about how amazing life is and that you should do the things you love and be around the people who make you smile. Since working with her, I haven’t felt nervous being around elderly people or massaging them. I learned how much the elderly can still do, their abilities and what they have experienced in life. Embrace every client and experience you can! You never know what you will learn!

As she would say, “Isn’t everyone so much more beautiful when they smile.”

Massage Therapy And High Ankle Sprains

The story was told to me a couple of months after this happened.

An unlicensed person who was loosely affiliated with the team went through the back door of the dressing room when he saw a player was injured.

The AT had taken him off the ice, helped him into the room and went to get the team doctor.

When the doctor walked in, he immediately threw his hands up in the air and said he would have no part of this.

This unlicensed person was vigorously massaging an acute high ankle sprain.

I was a student at the time and the rest of the medical staff were trying to impress upon me why they always tried to keep the care of all the players in house.

Although it wasn’t the point of the story all I could think was: “what the hell is a high ankle sprain?”

Massage Assessment And Grading Of A Syndesmosis Sprain

I remember through college talking  and learning all about ankle sprains.

The difference between an inversion and an eversion sprain, how the deltoid ligament is so strong it usually prevents an eversion injury, that the anterior tibiofibular ligament is the most commonly injured, since it happens with inversion injuries.

I don’t remember ever learning about a “high ankle sprain” (which is partially why I was so bewildered the first time I heard the name).

A “high ankle sprain” is an injury to the distal tibiofibular syndesmosis. The injury is caused by the foot being dorsiflexed and externally rotated which widens the ankle joint, stressing the syndesmosis.

Initially it can be hard to determine the difference between a typical sprain or a high ankle sprain, but mechanism of injury can be one thing to help differentiate. There are four other tests that help prove the difference:

  1. Passively moving the ankle into dorsiflexion.
  2. Pressing the tibia and fibula together while asking about pain level (squeeze test).
  3. Palpating the syndesmosis ligament.
  4. Externally rotating the ankle while stabilizing the leg (external rotation test).

Acutely this can be managed like any other ankle sprain depending on degree of injury.

The injury is graded from I-III according to it’s severity.

  1. There is injury to the anterior deltoid ligament and palpation of ATFL is quite tender.
  2. Causes disruption to the other deltoid ligaments and tearing of the syndesmosis.
  3. Complete disruption of medial ankle ligaments, possible fracture to the fibula and separation of the syndesmosis. In this case the mechanism of injury is a possible hint to the extent of the injury, since the external rotation and abduction will be pretty severe.

Fortunately in the acute stages, management of this injury should be pretty straightforward if you’re working the sidelines at a sporting event.

As with any acute injury we want to take the swelling down at the start, so implementing a R.I.C.E protocol will be necessary. Then we need to figure out how severe the injury is. Using the testing noted above will help, but a much easier way is to just check out the stability of the joint. If the joint seems unstable at all, then the injury is a Grade II or III. Another sign is that pain will be felt through the lower half to one-third of the leg  (thus the term high ankle sprain).

If your patient is experiencing any of this, you need to immobilize the ankle with proper splinting and remove any weight bearing on the ankle by assisting with crutches.

Then refer them to more advanced medical care.

https://flic.kr/p/Ni6sD

Photo by: soccerkrys

 

Massage And Rehab Guides For High Ankle Sprain

It’s tough to find any research (at least it was for me) indicating the best approach as far as Massage Therapy to treat a high ankle sprain.

Most of what I could find deals with the exercise end of things as opposed to the actual treatment of the ankle. Starting the person on progressive resisted exercise and then challenges on balance and sport specific drills is the most common forms of treatment.

I can remember having one of the players on our team years ago having to deal with a high ankle sprain. One of the exercises the AT would do is hold up a hockey stick between him and the player, they would both hold the stick and the AT would essentially wrestle against the player pushing him back and forth in order to draw his attention away from the ankle, but still have him moving and strengthening it in the process.

Unfortunately it can take up to 12 weeks to completely heal depending on the degree of injury. And will obviously be different if surgery is involved. There is debate over whether a grade II should be a surgical repair, but without surgery it can be difficult for an athlete to return to play.

Because the injury involves a widening of the ankle joint between the fibula and tibia, keeping inflammation down will be important in order to allow the joint to return to proper function again. Depending on the degree of separation and wether the ankle had to be splinted for any length of time will also shape your treatment.

If the leg has been splinted, watch for any muscle wasting compared to the opposite leg and start strengthening once swelling has come down.

Working in some passive and active range of motion will help to keep the joint moving. Because pain is felt further up the leg, working the muscles through the entire area will help in the recovery process. Treating gastrocs/soleus and tibant will help with ankle mobility, but you may have to work further up the leg into the quads, hamstrings and glutes because of the change in gait due to the injury. Be patient with the treatment because it’s a long healing process, especially once activity or return to sport happens. Sometimes athletes can start activity again in six weeks, but can have symptoms for six months. Above all, whether its acute or subacute your assessment is going to tell you what you need to do. Make sure to touch base with their doctor or surgeon in the cases of grade II & III injuries and get a little guidance from them if necessary. And for god’s sakes, please don’t vigorously Massage any acute injuries!

The Massage Therapist Guide To Clinic Management Software

This was an opportune time to make the switch.

Over the past 8 years, our clinic has gone from paper and pencil scheduling, through two different software based management systems, and now we’re switching to a platform that supports online booking and electronic medical records.

Each time we change systems, it involves researching options, exporting and reconfiguring all our data, and then re-training the staff on a new software.

Every few years our needs in a clinic management software seem to change or grow, and unfortunately our past softwares haven’t grown with our needs.

With the high demand from the public for online booking, even though we have full-time reception, this was something we couldn’t ignore any longer.

The other factor that played into our need for change, was that with more therapists and multiple disciplines their files take up A LOT of room in the clinic. They are taking up so much room that we are now archiving files after two years.

Needless to say, a more storage-efficient method was needed.

6 Important Features For Massage Therapy Clinic Management Software

When what you love doing for your career involves working with patients to become pain free, you don’t want to spend all your time with dealing with scheduling, billing, and lots of “front end” duties at the office.

We now live in a time where there’s an app for everything. It feels like overnight we went from not having any choices, to having too many choices in selecting the software to run our clinic.

Being involved in a large interdisciplinary clinic, I’ve recently underwent the arduous task of finding a new clinical management software (CMS) that needed to check more boxes than I have fingers. Since I have finally come to a decision for my clinic, I’m here to share what I learned. My choice will not be your choice, because my boxes are not your boxes, but here is what I learned.

First step is to figure out what you want out of a CMS, which is tricky when you don’t know what they offer or have the capabilities of. So here are the important features I decided to highlight:

  1. Online Booking – even if you have a full-time receptionist, online booking has now become a very important feature that patients look for in order to access their therapist.
  2. Electronic Charting – If you have a large number of therapists and limited number of square feet to devote to file storage, then this is a great option for you.
  3. Integrated Billing – This makes sure that checking out your patient is a smooth and quick process, and with the different reporting options, makes a big difference when it’s time to do your books.
  4. Integrated Wait List – If you are like some Massage Therapists I know, who have a 1-month waiting list, it can be frustrating when you get a cancellation with too little notice to fill it.
  5. Remote Schedule Availability – Having the ability to check your schedule from home is a great asset, especially when patients can book in with you when they wake up at midnight with a kinked neck.
  6. Cost – When it comes down to it, cost always plays a factor, especially when it comes to your business.

4 Online Scheduling Programs Reviewed

I investigated several applications, but I found that only four of the ones I looked at had the right combination of features to warrant getting shared.

There are lots of choices out there, so I could have easily missed some that you may really enjoy.

These options happen to all be cloud-based, which means they are not installed on your hard drive like a typical software program, but hosted online and you log into them via your internet browser. Here they are:

 1.    Jane App – www.janeapp.com

Jane App has a very clean presentation and seems to hit the best on all the features listed above, and many more features not listed.

It’s a Canadian company based in Vancouver, and they make an honest effort to really do things properly; such as hosting your data in Canadian servers in multiple provinces where they are very safe.

If you are running a clinic with only one type of therapist (such as RMTs), they have a feature where you can incorporate into the intake form a “Survey Monkey” style questionnaire for  health history, and inputs it automatically into their patient file for you. Jane App also lets you custom build your template for charting, using both scanned diagrams (or using a stylus to draw on), lists, and general text charting.

Their website is by far the easiest to really understand what you get and what you don’t compared to the other options. My only complaint with Jane is that it’s the most expensive of the options, especially when you have a larger clinic.

Unless you need all those great features, it might not be worth the expense.

2.    Cliniko www.cliniko.com

Cliniko, much like Jane, has a very clean presentation to it and also does well on the features above.

There were little details with how well some of those features function that made them not the best, but overall still great.

They are working on incorporating electronic charting, the ability to use a stylus to draw, scribble, and write in the chart, but it is not set up yet.

They are an international company, which was great as they have help staff that work 24/7. If you have a large clinic with many types of practitioners and lots of needs, Jane & Cliniko seem like the only choice that starts checking boxes after the fundamental needs.

3.    Body Soul www.bodysoulonline.com

Body Soul’s website is hard to find any really definitive answers on without asking for help, which makes me think their software lacks the same forethought.

Their online booking feature seems not as streamlined as Jane & Cliniko, and lacks the waitlist feature.

They are however a local company from British Columbia, and even though they don’t allow the use of a stylus in the charting function, they have done a clean job of streamlining it. They even have a dictation feature for your charts!

Their price was very reasonable, if you’re a single Massage Therapist; otherwise it’s double the cost per practitioner.

 4.    Mind Body – www.mindbodyonline.com

Mind Body seems like it is designed for a yoga studio first, then adapted for a health clinic.

This is the one software that doesn’t include the Electronic charting and as it was with body soul, it lacks a waiting list. It is very focused on social media and lets you even tailor an app to the branding of your business, and have patients book in for a treatment from within Facebook.

The overall design is not as clean as Jane or Cliniko. Mind Body was the only application in addition to Jane that has a feature to customize your practitioners’ access; everyone gets a unique login and password so they can access what they need, but not everything that you can.

The cost is really hard to argue with too; you can get one of their bigger packages for under $100/month.

I’ve included a handy chart to show you which program has what feature, and in some cases a rank out of 5 on how well they did. These ratings are based on the information I was able to pull from the website and from answers I received from helpful staff, I have not used any of these programs in my clinical setting yet.

If it wasn’t obvious in my review, we chose Jane for our clinic.

Key FeaturesJaneappClinikoBody SoulMind Body
Janeapp.comcliniko.combodysoulonline.commindbodyonline.com
Cost$$$$$$$$$$
Electronic Medical Records544N/A
Integrated Billing5543
Online booking5433
Remote Schedule AvailabilityYesYesYesYes
Wait List FunctionYesYesNo No

The cost for each app has a slightly different structure, so it’s hard to lay it out for you easily here. Your best bet is to visit the websites and calculate your cost based on your clinic size and needs.

Based on what your needs are, you will probably choose different options, from myself and from each others. Most of these apps have functions that would work for your clinic, but based on our needs, Jane App was the solution. It was a challenging decision between Cliniko and Jane App, but in the end the extra details associated with Jane App didn’t equate to a large enough price difference to deter us from using it. Another reassuring fact that help us make this decision is that many large clinics that I respect and trust use Jane App. Our plan is to start using Jane App in the new year, fingers crossed it all goes well. Stay tuned for the 6-month follow-up. 

I’m also just really excited to get to do my charting on a snazzy iPad!

 

 

Subpoena’d As An Expert Massage Therapy Witness

I have been fearing this day since I graduated college.

The envelope looked different than any other mail I’d ever gotten.

I opened up the registered letter and there it was, a cheque for $20 and a subpoena.

It read:

“TAKE NOTICE that you are required to attend and testify as a witness in the place, date, and time set out below. You are also required to bring with you all documents in your possession or control relating to the matters in question in this proceeding.”

What was I going to do?

I don’t want to go to court and testify!

At the end of the letter it clearly states:

“if a person, contrary to these Supreme Court Civil Rules and without lawful excuse, refuses or neglects to obey a subpoena or to attend at the time and place appointed for his or her examination, is guilty of contempt of court and subject to the court’s power to punish contempt of court.”

Looks like I have no choice.

I am not looking forward to this.

Compensation For Being A Massage Expert Witness

I really wasn’t sure what to do.

It was quite insulting that a lawyer would send a cheque for $20 (the requisite witness fee) to force you to be a professional witness in an insurance claim that was being fought in order to achieve a settlement for the claimant and themselves.

Not only would I have to take time off work and lose pay, but there is also prep work to be done.

Before I called the lawyer in question, I figured I would talk to our provincial association for some advice first.

The association had some good advice as far as what should be charged in cases like this.

  • Testimony in court $700 per half day
  • Court prep time $93/hour
  • Production of records $100 or $.50 per page.

I had no idea if I was just supposed to demand this or if it was assumed. I was told just talk to the lawyer and explain what was recommended to me.

Calling their office, the lawyers assistant answered.

I laid out what I thought compensation should be.

She responded and said, “okay you can bill us for the $93/hour, but no judge is going to pay you $700, that’s the kind of money they give brain surgeons”.

As we chatted about what would happen, I told her this scared the crap out of me.

Her response set me at ease: “Don’t worry about it, it’s not like TV. You’re a good person, as long as you don’t rob a bank in the meantime you have nothing to worry about. All you have to do is just show up and be honest, they’re not going to try and trip you up.”

Now it’s time to prep.

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Photo by: Medill DC

Prepping A Massage Therapist For Court

The lawyer had me come in to the office for an hour to prep.

We went through all my notes to make sure he could understand them and of course to see what I could remember.

Scouring over the notes, he asked for explanations on what he was reading. Deciphering what different orthopedic tests meant and what I was testing for. Looking for explanations on why there were missed appointments, why would I work on one area one day and a different area on another.

Some of those treatments were three years ago!

Then it was time to tell me what to expect and what was expected of any Massage Therapist called in as a witness.

Just be honest. If you don’t remember something just be straight up about it.

While the opposing lawyer is working for the insurance company and wants to win, they will not cross examine you like you see on TV. They will ask you questions more to try and discredit the patient, not you as a therapist. Just be honest with them.

If you’re asked a question, you answer the judge. While it may be either lawyer asking, you look at and direct all answers to the judge.

Dress appropriately, wear a suit.

Show up early and look for directions as to which room the case will be argued in.

While you are scheduled to be there, you may not be called. It will depend on how the case goes. If the case is settled before hand, you’ll be informed that you don’t need to show up that day and although the case could go on all week, you will only be called for the scheduled day and time that we ask for.

We discussed compensation.

He confirmed that $700/ half day was more than would be given, he did agree that $100/hour for time spent was appropriate as long as I was fine with that.

Two days before the case went to court, they settled. I was fortunate to not have to go. Although I will admit there was some disappointment, I ended up really wanting to see what it was like. Overall it didn’t end up being as scary an experience as I thought (even though I didn’t have to go to court) and as the lawyer and I talked I thought he was fair. He paid the $100/hour for the hour I spent with him and for the hour to get any extra paperwork together, in addition to the bill I had given them months earlier for sending them my charts.

The experience also made me realize that my charting should be better than it was. The lawyer wasn’t totally sure if he’d be able to use them. Some treatment notes were more detailed than others and not all of them were specific enough. Make sure that if you’re ever working with patients who are involved with insurance companies that your note taking is top notch. This is another way for us to prove not only our worth as Massage Therapists, but also our professionalism as one.

Massage Therapy For Children With Developmental Disabilities

 

“I am also a believer in an integrated treatment approach to autism” – Temple Grandin

”Don’t think that there’s a different, better child “hiding” behind the autism. This is your child. Love the child in front of you. Encourage his strengths, celebrate his quirks and improve his weaknesses, the way you would with any child. You may have to work harder on some of this, but that’s the goal. – Claire Scovell LaZebnik

 

I was nervous and unsure.

There was no one to talk to who had experience working with a child with developmental disabilities..

Although I had already met him, how was I going to handle this?

I knew what I wanted to achieve, but could I actually attain any of the goals for my patient that I had set?

Due to my past experience I felt fine working with this child, but no one had ever mentioned or taught me to manage a Massage Therapy case like this.

When I talked to my teachers, they never heard of anyone doing anything like this, and I never realized how much work or how much learning it would take to pull this off.

It was hard to find any good research on the topic, so I had to figure out a lot on my own.

All the goals I set had to be broken down into tiny steps accomplishing little goals in the grand scheme hoping things would add up to the greater good for my patient.

This was a huge learning experience and I hope what I learned can make a difference for kids with developmental disabilities and other Massage Therapists who want to help them.

Massage Objectives With Developmental Disabilities

Before pursuing a career as a registered massage therapist, I worked as a community support worker/ care assistant in a group home setting with people who had developmental disabilities.

I worked with people of all ages that had mild to severe developmental disabilities.

Giving medications and providing support for our clients was all we could do to assist them, however I felt more could be done to improve quality of life.

I found it difficult the only way I could help kids with developmental disabilities was through medical intervention and emotional support.

Although those interventions did help, I felt more could be done to improve the lives of these kids.

I wanted to do a case study to determine the effects of Massage Therapy for these people in need, particularly a developing child who was nonverbal with autism spectrum disorder and global developmental delay.

Developmental disabilities are common in children and occur in all racial and socioeconomic groups.

Some developmental disabilities may include: Attention Deficit Disorder (ADD), Autism Spectrum Disorder, Cerebral Palsy, Downs Syndrome, intellectual disorders, hearing loss, vision impairment, learning disabilities, and other development delay.

Children with developmental disabilities may experience impairments in social interaction, communication, speech and language, general physical development, behavior, learning, cognitive skills, motor control, coordination, balance, and emotional stability.

I found in my case study that Massage Therapy benefits children with developmental disabilities by improving their physical and emotional well being while they are still developing.

My objective was to determine if the effectiveness of Massage Therapy could improve their focus, behaviour and motor function.

Massage Therapy, A Case Study

My participant was a nine year old male with a diagnosis of Autism Spectrum disorder, Pervasive Development Delay (PDD), Moderate Intellectual Disability, asthma, seizure disorder, and an educational designation of physical disability or chronic health impairment (PDCVH).

He also experiences challenges with focus, aggression, and functional movements as a part of his diagnosis and would elicit a rigid rocking behaviour when he became anxious.

When I first met this patient, it turned out in the past he had been turned down by other RMTs when his guardian sought treatment for him. I was nervous at first to take on this case as I was only a Massage student, but put those feelings behind and decided to take it on as the well being of this child meant way more to me than staying within my comfort level.

I performed this case study over the course of three months and was broken into fifteen treatments, seventy minutes in duration, which were divided into three phases:

Treatments consisted of manual modalities to the lower extremities and back such as:

  • relaxation techniques including general swedish massage
  • rocking
  • full limb vibrations to trick the nervous system (helping to relax muscle contractions)
  • deep pressure stroking
  • myofascial release techniques
  • joint mobilizations
  • passive range of motion

Measurement tools included:

  • postural assessment
  • gait analysis
  • orthopedic tests
  • range of motion (ROM) for the motor function aspect of the study  
  • focus tests and qualitative feedback from the patients guardian for the focus and behavior aspect

The results from the study concluded that the patients focus and behaviour had improved, became more social with other children, less aggressive at times of frustration, less anxious, and his balance, motor function, gait and posture had improved.

The patient also completely stopped the rigid rocking behaviour and was able to follow direction when asked to perform simple tasks.

In just three months, a young child’s quality of life had significantly improved.

This proved that more can be done for these people to help improve their lives.

It just takes health care professionals like RMTs to take a risk and work beyond their comfort levels to improve the health and wellness of people of all ages at all stages of physical and mental development.

So what are some rules I created for working with children with developmental disabilities?

Establish Trust With Your Massage Therapy Patient

When working on children with developmental disabilities (or any client really) it is important to establish trust and better yet, a therapeutic relationship.

In our typical practice, we meet a client and establish a trusting therapeutic relationship on the first appointment. If that trust is met, they will typically rebook and come back for a following treatment.

In this case, it wasn’t that simple.

I had to work slowly at introducing massage and creating that therapeutic relationship. Before starting the treatments, I met the patient and his parent guardian. I interviewed the parent about triggers, behaviours, things that he enjoys, and tips on communication.

When the treatments finally took place, it was important to introduce everything slowly.

The first treatment was conducted on the floor, while the patient cuddled with his guardian. I slowly introduced touch to the legs and feet. By the next treatment we were able to introduce the table using support from his parent.

As the treatments progressed I slowly introduced massage to different areas of the body.

To put things in perspective, finally after a year and a half of treatment, I am able to work on his arms and hands without him pulling back showing there is now enough trust to let go.

Keeping a constant routine was also important.

I found that if he missed an appointment one week, we would lose progress in comfort with receiving massage. If we made any changes to duration, treatment techniques, or the number of treatments per week/month, it had to be done slowly and only changing one thing at a time to decrease the chance of  effecting progress.

Keeping a routine and working slowly will allow the client to maintain trust in you as a therapist.

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Photo by: hepingting

Gaining A Thorough Massage Health History For Developmental Disorders

It was important to have the full picture on the patients health history, not only for treatment safety but also to fully understand why the patient presented as he did and how I could create a care plan that would be effective.

In order to understand the full picture I collected documents from other health care professionals about his condition and did some research. I also did an extensive interview with his guardian to gather more in depth information on the child’s condition as well as information and tips on how to work with the child.

It is our duty as RMTs to take an in depth health history to ensure the safety of any patient.

Medications, current (and past) medical condition, emotional or behavioural status, assistive devices, activities of daily living, and other therapies a patient is taking part in are all examples of things you should know to create a safe and effective treatment plan for them.

These things are not just important for working with a special population but for every patient you see in your practice.

Massage Treatment And Developmental Disabilities

As mentioned before, ease into treatment.

Slowly introduce touch and ease into longer duration treatments. When it comes to technique choice, I began with general techniques and experimented with techniques until I found what worked.

Once massage was comfortably accepted by him, I was able to use more specific techniques.

Pay attention to the little things.

Starting on the treatment table may be too much too soon. You can start out treatments with a patient in a chair (or wheel chair) or on the floor on a mat or blanket.

Massage may also not be accepted by the patient right away, you may also need to spend the first couple of treatments getting to know the patent.

Utilizing  tools may help the patient feel less anxious, for example they may have a special toy they enjoy. When introducing massage for the first time, having certain objects act as a distraction may help significantly. Using toys, music, books, and sensory stimulation objects may help greatly.

I found that a thermaphore worked excellent as tool to help calm the patient.

Include Your Patient.

Note their mood.

Are they tired or playful?

This may affect how the treatment goes. During the case study, if he was acting playful, I would create a treatment that would suit his mood.

For example, one technique that he enjoyed was a bilateral leg pull.

When he was in a playful mood, I would make the technique more playful by exaggerating that he was growing tall like a tree during the pulling component then shrinking small during the compression portion.

This typically resulted in excitement and laughter. I would also typically use more stimulatory techniques like shaking and jostling when these playful moods were present.

Creating Home Care And Remedial Exercise For Developmental Disabilities

Be creative and realistic.

Utilize the patients hobbies and interests to ensure that the patient will enjoy doing their home care. Another factor to keep in mind is their home life. Quite often home life is very busy so you have to make sure to create a home care plan that will actually be obtainable by the family or care workers.

With this in mind, make sure that the home care you give is therapeutic and effective.

Be patient!!

Improvement may happen very quickly or very slowly. To get the results during my study, it took quite a bit of time and things slowly progressed. When I first began my treatments, the patient didn’t feel comfortable on the table so it was done on the floor. During this treatment, he moved around the whole time. Finally after a few treatments, the next step of progress was having the lower limb remain still for 3 minutes! By treatment 10, the patient actually fell asleep and remained still on the table for the whole hour long treatment.  Results may seem minor, but really are a big deal! The whole point of this Massage Therapy case presentation was to help improve focus, behaviour and motor function. I managed to use Massage Therapy to obtain these goals and truly believe that Massage Therapy would benefit other children dealing with these difficulties.

Because kids are so adaptable to change, there is greater benefit in using Massage Therapy to help them. After treating him for a year and a half this has developed into a rewarding experience that I never thought I would have. For all of us involved we have seen a huge difference in his development, behaviour and body awareness. Remember to be patient, and don’t forget why you became a RMT… to help improve the quality of life to the people who need it!

If you would like to read Chelsea’s full Case Presentation, you can download the word document here.