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.

Red Flags For Low Back Pain, Or Clinical Decision Making?

November 6, 2017/1 Comment/in Emergencies, First Aid, First Responder, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Sport Massage/by Jamie Johnston

It’s only happened a couple of times in my career.

You know that feeling you get when something just isn’t right? You’re not quite sure what it is, but something just seems off?

Twice I’ve had people come in where their pain and limited mobility had me questioning if they needed a trip to the emergency room. In one instance I called a family member who took the patient in, and everything checked out fine.

The other instance, the persons low back pain was so extreme, it just didn’t add up. There was no history of trauma or anything else that suggested the hospital was necessary, but I could barely touch the patient during the treatment because their low back was so sensitive. Afterward, I recommended seeing a doctor, or emergency room, but they refused. I never saw them again, so I’m not sure what the outcome was.

So how do we know when low back pain is an emergency, or just really painful?

Traumatic Injuries And The RTC

In old First Aid terms, there were criteria we would use at the scene of an accident to quickly decide if a patient had to have spinal immobilization used and if they needed to be immediately sent to the hospital.

It was called the RTC (Rapid Transport Category), and it was a simple list which made it easier to decide how to provide the appropriate care to a patient. While this isn’t as useful in a clinical setting, it could be invaluable in a sport, or outreach setting if some type of emergency were to happen and you are required to provide care. In a clinical setting, it would be helpful during your patient interview in case you weren’t quite sure why a patient is having the issues they are presenting with.

The RTC criteria include quite an extensive list of things to watch for. Not all of them would be applicable to us, but here are some that would be:

Mechanism of injury
- Fall from greater than 20ft
- High-speed accident
- Pedestrian struck at speeds higher than 30 km/hour
- Broken windshield damaged steering wheel, or airbags deployed
- A rollover accident
- Severe crush injuries
- Any other people involved in the accident that result in a fatality
- Electrical injuries (we always assume spinal damage with electrocution)
Anatomy of injury
- Severe brain injury
- Penetrating injuries to anything but the limbs
- Depressed skull fracture
- Pregnant woman with fairly moderate trauma
Findings in the Primary Survey
- Decreased level of consciousness
- Cardiac arrest
- Suspected heart attack
- Poisoning
- Status Epilepticus

Particularly for us in the clinical setting the mechanism of injury should be one category to take note of. Hopefully, if someone has been through an accident that traumatic, they have already been to the emergency room, or at least a doctor to be checked out, but this doesn’t always happen. Sometimes a patient may play it off and just think they need to see a chiro, physio, or massage therapist and book in with you before ever seeing a doctor, or even calling 9-1-1 after an accident.

I’m sure we all see patients on a regular basis who have been in a car accident. Knowing those above criteria and being able to ask some of those specific questions in your interview may give you a better idea as to how severe their injuries could be. Or, if they played it off and haven’t been checked out, you may want to refer them to a doctor just to be safe.

Whenever I teach a first aid course we talk about the signs and symptoms of a heart attack. This is where there could be a bit of a red flag, as it is quite common for women to experience back pain associated with a heart attack. However, it would be back pain combined with other symptoms like chest pain, nausea and vomiting, sweating, and shortness of breath.

This is certainly part of our role as healthcare professionals to recognize and help our patients if this is happening.

Photo by: Lucina Medina

The Red Flags Of Low Back Pain

There seems to be a wide array of information on the red flags of acute low back pain.

Most of the concern is driven toward four issues:

Malignancy
Infection
Fracture
Cauda Equina Syndrome

One red flag that is unrelated to specific disease was the onset of pain in patients under 20 years old. However, one study actually calls this a “dubious distinction” and shows that age alone combined with pain is not enough to be considered a red flag, as most of the participants in the study were diagnosed with non-specific mechanical spinal pain.

When we look at the risk factors associated with spinal fractures, most information cites major or significant trauma, age, a history of osteoporosis, and the use of corticosteroids as the red flags to look out for. A systematic review showed that all of the above combined with the presence of a contusion brought the probability of a fracture up from 4% to a range between 9 and 62%. An Australian study showed that when three red flags (female, over 7o years of age, severe trauma, and use of corticosteroids) were all present, the chance of a fracture went from 4% to 90%. So, when looking at red flags for fractures, one red flag alone is not likely an issue, but a combination of the red flags is more likely to result in a fracture.

The commonly used red flags for infection were:

Fever/chills
Use of corticosteroids or immunosuppressant therapy
IV drug use
Pain worse at night
Night and rest pain
Tenderness over the spinous process

But the same systematic review showed that there is a lack of standardization with these red flags, and the risk of serious disease in patients with low back pain is less than 0.1%.

The same can be said for malignancy, as the one big red flag, in this case, is a history of cancer. Yet “history of cancer” isn’t clear enough as it doesn’t specify how long ago the person was diagnosed or the type of cancer they had. There are several cancer types that apparently put a person at greater risk for spreading to the spine, but if the person didn’t have one of those types, or had it 20 years ago, the likelihood of spinal malignancy is probably a lot less than someone diagnosed recently.

The two most common red flags with Cauda Equina were saddle anesthesia (perineal numbness) and sudden onset of bladder dysfunction. Either way, I’d be referring out for that!

One thing that came out of most of the studies I could find was one resonating point. Clinical decision making and judgment of the therapist to determine if the patient needs to be referred out is more reliable than the list of red flags. So in other words, when in doubt, refer out! There are some other things to take into account with this whole red flag discussion and one review makes a great point as to why screening for red flags isn’t reliable. As practitioners, we don’t actually screen, we manage low back conditions. They actually encourage watchful waiting for changes in symptoms, as evidence is showing that early intervention with low back pain may actually be more harmful.

One thing I hadn’t ever heard of was “yellow flags,” however, I found it encouraging that it was mentioned in a paper from rheumatologists. They listed these yellow flags as:

A belief that back pain is harmful or disabling
Fear of pain and movement avoidance
Tendency to low mood and withdrawal from social interaction
Expectation of passive treatments rather than believing active participation helps

Biopsychosocial approach anyone? It’s great to see these “yellow flags” being mentioned with the same importance as the dreaded red flags.

Overall, it is probably good to be aware of those red flags to help guide your clinical decision making, but they aren’t the be all end all like we once thought they were. The valuable thing will be your judgment call and also making sure to monitor your patients progress. If your spidey senses start tingling, and something doesn’t seem right, don’t hesitate to refer out, it’s better safe than sorry.

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!