Emergency Action Planning For Sport Massage Therapists

January 5, 2016/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Sport Massage/by Jamie Johnston

I felt like a deer in the headlights when she asked me.

“Can I get a copy of your Emergency Plan to give to the other team’s trainer?”

My what?

“Your Emergency Plan, you’re supposed to have one ready, or on file before each game to give to the other trainer.”

I had NO idea.

I had volunteered with the team for the previous five years and had never heard of this. However this time I was the head trainer, which came with a whole group of responsibilities I didn’t yet know about.

Part of the league rules were that each team head trainer had to have an Emergency Plan in place in the event that a player was badly injured and needed medical attention beyond what we could provide.

I had yet to do my first road trip and receive one of these documents from another trainer.

All I could do was apologize and promise to have one ready for the next game.

I felt like an idiot.

Massage Therapists As Part Of The Team Within A Team

Even though I felt like an idiot, I was fortunate.

I’ve had to do this kind of thing before and have some experience with it.

There is more to this than just printing up a document. It designates you as a leader, a professional, an expert and a damn good communicator.

When it comes to working in sport, your athletes are your responsibility, but there are times when trainers of opposing teams must work together (actually most of the time it’s important to work together).

I won’t go so far as to speak for other sports (although I’d assume it’s much the same), but in hockey the trainers are almost like their own little team, within the teams. On road trips, it’s not uncommon to forget equipment and have to borrow tools or get help with injuries from the other team’s medical staff. There are constant favors being done back and forth to help each other, whether it’s laundry, equipment trades or holding coaches back from attacking each other (yes it happens).

The same applies when someone is hurt in a game. While your athletes are your responsibility, if they get hurt bad enough that you have to go out on the field, ice or playing surface to help, everyone is on edge.

If the trainer puts their fist up into the air, that’s typically the signal they need more help. At this point, what team you’re on doesn’t matter, it’s all about THAT athletes safety. When it’s done right, it can be seamless, when it’s done wrong it can be a complete cluster…well you know.

There has to be one person in charge and it’s not a time to start second guessing things. When the trainers are working together as a team, in the best interest of the athlete, there can’t be any ego’s. If the athlete is on the other trainers team, they have started first aid protocols before you get there and you may get assigned a somewhat menial task.

If all you are asked to do is call 9-1-1 or go and direct paramedics to the scene, that’s all you need to do.

**Why You Need To Develop An EAP**

The preparation for these kinds of emergencies starts long before the injury or the game even starts.

Making sure you have a well prepared Emergency Action Plan will give the proper steps to ensure a positive outcome for both trainers and athlete. Also making sure your medical equipment is in good working order and properly stocked prior to game time is crucial.

Like I mentioned before when it’s done properly it can be seamless almost like watching an orchestra of movement. The people who are really good at it, can direct with confidence, which in turn instills confidence in the people they are directing.

I’ve been fortunate to watch several people who excel at it and watch how seamlessly they can direct people to do what they need while still tending to injuries and dealing with a patient.

Being able to direct one person to help deal with injuries, one to lead paramedics in and others to get extra equipment doesn’t come naturally, or easily and it must be practiced.

Part of the reason why it’s important to develop an Emergency Action Plan is because of your knowledge of your environment. When teams come from other towns or cities they don’t have the intricate knowledge of the area like you do. Nor do they have the knowledge of the idiosyncracies of your building or area of play.

Every little thing you know that could possibly delay more advanced medical help arriving is crucial information to be able to share with the other trainer.

For instance:

Is there a preferred entrance for paramedics to use?
Is there a better entrance/exit to take the athlete away from the playing surface?
Are there gates or doors that would have to be unlocked for paramedics to gain access?
Where do you keep extra medical equipment stored?
Are there more staff/people on hand trained for medical emergencies that can help?
Is there an AED stored close by?
Where is the closest hospital or medical clinic?
Are there any slang names that are used for common areas of the building/sport area?

While these things might seem simple, to someone who isn’t familiar with the area, it can be crucial.

Having a face-to-face with the other trainer before game time to review your Emergency Action Plan is not only beneficial but can be life saving.

Photo by: Jon Candy

Setting Up An Emergency Action Plan For Sport Massage Therapists

I’ll never forget the first time I was in command of an accident scene with the fire department.

I was beyond nervous.

On the way a senior officer was driving and giving me tips on what to do before we got there. But I had never been in command before and was totally unsure of myself.

Midway through the call, one of the chiefs arrived on scene. He calmly came up, grabbed me and pulled me out of the accident. We walked up a hill about 15 feet from the accident and he told me “here is where you need to start”.

His point was to take a deep breath, take a step back and look at the entire scene, not just the middle of it. Look at what things could possibly go wrong, take a broader view to make sure everything is safe.

Undoubtedly, you will be in the middle of the emergency if this is your scene. Before anything ever happens, take a step back. When you’re making up your Emergency Action Plan, try to envision everything that could possibly go wrong when your athlete has to be taken off the playing surface, or is seriously hurt on it. Anticipate as much as possible. While you will never be able to come up with everything, it’s a good start. If an emergency does happen and something you didn’t think of occurs, go back, review and update your EAP.

There are several things that need to be included on your Emergency Action Plan. Remember, this should be shared with the visiting trainer before game time:

Level of First Aid that is available during the game (team doctors, first responders, paramedics, and how many of each).
Location of any First Aid equipment and supplies (AED, spine board, clamshell).
How to get more help if needed (the fist in the air is fairly common).
How you will respond if needed.
Methods of transport if needed.
Any prearranged routes out of the area and to medical treatment (you can just copy and paste in a picture from google maps).
The role you want the trainer to follow.
The roles other team members will follow (ie: equipment managers, coaches)

If possible, make this a one page plan that can be handed off to anyone. You can make it as detailed or as simple as you want, but the above points should all be included. I’ve heard some trainers say theirs is a 4-5 page document. It’s fine if you want to be that detailed, but in an emergency situation, it’s not practical to have to review something that long.

You can download the one I made up by clicking here, if you want to see a simple example of one.

Whether you’re the head trainer or there strictly as the team Massage Therapist, you should have a working knowledge of the EAP. If you’re not the head trainer, ask if you can review it and ask what role you can play if there is an emergency. More importantly ask if you can be part of a practice to make sure things run smoothly if you are going to be part of the emergency medical team. If you are the main medical person for a team, make sure you conduct a practice every once in a while to make sure all staff members are familiar with their role in the case of an emergency. Go back and review your EAP every once in awhile. Every year, equipment needs, First Responder protocols and athlete medical conditions will change. Make sure the EAP reflects everyone of those changes. Just try to avoid being like me and feeling like an idiot!

Using Your Massage Therapy Skills To Travel In Australia

December 30, 2015/28 Comments/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Alicia Doll

Has one sentence ever changed your life?

One night, I stumbled across a single woman’s blog on conquering Australia.

She was easy to relate to, her fear and worries were so similar to mine. She calmed my inner fear as her blog resonated with me on a personal level. She was exactly right, “You’re either going to do it or you’re not”.

These little words strung together geared me up and I was moving to the land down under… Australia!

Alone!

My problem, was I didn’t find any support when I googled BC RMT traveling to Australia.

I knew I wasn’t walking on the moon, someone from Canada had surely already done this. I just couldn’t find them, and I felt alone in my search.

There was too much fear of the unknown! The only option I had was to get as much information as I could to alleviate any negative thoughts about starting my adventure.

There was a place called Magnetic Island and Townsville, Queensland that a friend and I had been conversing about for years. I felt a connection to Magnetic Island even before I even arrived.

My friend and I talked about these places so often that I naturally wanted to see them with my own eyes.

This was my first major overseas experience alone. Thankfully, Australia is a lot like Canada and both countries have a lot of similarities which helped the cultural transition.

The best part, I could chase summer all year round. As I thought about the white sandy beaches and clear turquoise water I knew this was something I really wanted to do.

Prior To Departure

For two years after my board exams, I started taking control of my finances by paying off lingering debt, saving, and also organizing my accounts.

I stopped commission rates at the clinic, paid a set monthly rental and took on my own third party accounts. This gave me control over daily and monthly expenses, and by having a set rental cost I increased my treatment times without losing a percentage each hour.

I earned approximately $1500.00 more per month in doing this.

I had a vision for change and big goals in mind.

This motivated me to get out of town as fast as I could. With this vision, I sat down and put a plan into place to get all of my ducks in a row and make this happen.

These are some of the things I had to get figured out before I could go to Australia.

My Passport.
An Australian Working Holiday Visa.
Research Massage Therapy regulations.
Talk to the one person I knew & find a job.
Where to land & start?
Accommodations.
Banking & Taxes.

Ensure your passport will be valid for the duration of your trip. Get it renewed before you leave if it is going to expire while you’re abroad.

Before entry into Australia you need to have an Australian working holiday Visa.

There are multiple types of Visas and finding the right one can be confusing. Here is a rundown of the different types:

Working Visas should not be confused with a Working Holiday Visa. There are two types of Working Holiday Visas: 417 and 462.
The Working Holiday Visa is based on your passport. Because I am a resident of Canada I applied for the Working Holiday Visa 417.
Working Holiday Visa 462 is for passport holders in countries; Argentina, Bangladesh, Chile, Indonesia, Malaysia, Poland, Portugal, Spain, Thailand, Turkey, USA, Uruguay. Only USA passport holders can apply online for this this visa.

To be eligible for a Working Holiday Visa 417 you:

Must be at least 18, but not yet 31 years of age.
Do not have a dependent child accompanying you at any time during your stay in Australia.
Have a passport from an eligible country.
Your partner can accompany you to Australia, but they will need to apply for their own visa.

This Visa allows you to:

Stay in Australia for up to 12 months.
Work in Australia for up to six months with each employer.
Study for up to four months.
Leave and re-enter Australia any number of times while the visa is valid.

Approx. Fee : $420.00 AUD

Massage Therapy In Australia

This PDF file will provide you with the information you need to know about scope of practice, types of massage, education standards, continuing professional development and health fund provider recognition. It is an easy read, but lengthy.

Helpful Translations:

Health Fund = A benefit plan or extended health plan

Health Fund Provider = A person that is reliable to provide treatment for reimbursement to health fund, this person has “provider status”

Remedial = Therapeutic style treatment

RTO = Registered Training Organization

RPL = Recognition of Prior Learning

There are three nationally recognized Massage Therapy qualifications.

Certificate IV

Competent to perform general health maintenance, can be associated with Spa Therapists.

Diploma Remedial

Competent to perform treatments involving specific remedial techniques to alleviate common musculoskeletal presentations such as low back pain.

Advanced Diploma Levels

Competent to treat complex musculoskeletal presentations with a more extensive range of treatment protocols.

Both Diploma & Advance Diploma:

Provided by Registered Training Organizations (RTOs)
RTO’s regulated by the government.
Qualifications sit within the Australian Qualifications Framework (AQF)

There are two Massage Therapy Associations, Australian Massage Therapy (AMT) and Australian Association Massage Therapy (AAMT). Both offer classified ads and advertisements for work on their site, so it can also be a good starting point in looking for jobs.

If you’re not sure what your training is like compared to the Massage Therapy training in Australia, there are two schools that I looked at, Evolve college and NSW School of Massage, they can give you an idea of what Australian tuition and schedules look like.

Tuition range from $7,000 to $11,000 AUS Dollars.

Duration of study is dependent on courses; average 20 weeks – 2 yrs.

Australian Provider Status and Liability Insurance For Massage Therapists

To gain provider status valid for a health fund Australians must have:

Certification from RTO.
100 Continuing Education points per year, which roughly equates to around 20 hours or three days per annum.
Membership to a professional organization/association such as ATM & AAMT.

Applying for provider status in Australia takes some organizing. This checklist will help you understand what is required, and you can download the word document here to print off if you need it:

? Have your qualification overviewed.

This is called Recognition of Prior Learning (RPL). A Registered Training Organization (RTO) does a review of this.

? Provide your transcripts to RTO

Include units studied and hours to each unit.

The RTO will compare all the information against the Australian Qualification.

? Provide current resume and include:

? Qualifications

? Work experience

? Letters of endorsement from clients & other professionals to enhance your opportunity.

? Hold Australian First Aid certificate and knowledge of Australia’s Occupational Health & Safety legislation.

Remedial Diploma requires Senior/Level 2 First Aid.
HLTFA301B/C – Use this code when searching for the appropriate course information.
Check in with your first aid certificate to see if it is internationally recognized. You may have to get your certificate compared to the Australian standards.
This is a one or two day course, approx. $110.00-$200.00 AUD.
Make sure your First Aid Course is approved by your RTO and is appropriate for the state you chose to live in .

? Set up an interview with the RTO

all the evidence you supply must be verifiable.

? Ultimately you will be awarded the current qualification

HLT50307 Diploma in Remedial Massage.

There are costs involved and vary from College to College / RTO

There is a list of RTO’s on the AAMT website.

Whether you plan on getting a provider number for Australia or not, you’ll need Liability Insurance. Some companies may provide it, but most require you have it already. This company is commonly used for insurance coverage in Australia, www.aon.com.au.

Finding A Massage Therapy Job In Australia

Before I left Canada I knew one person in Australia.

Luckily my friend on Magnetic Island was neighbours with the owner of Massage on Magnetic. We emailed each other and I had confirmed a Massage Therapy job before I landed in Australia.

I stayed with Massage on Magnetic for five glorious weeks. I had 47 weeks left in Australia and I was on the search for a new job.

Two sites that were helpful in searching for job postings were seek.com.au and gumtree.com.au.

I had not written a resume in over 10 years. Preparing a couple of resumes before you leave will be helpful, preferably one resume for Massage and one for another skill set if available.

Is your email appropriate and professional?
Can you get a personalized email? ie: info@yourname.com
Use and have an Australian phone number that works.
Make electronic copies of your college transcript, RMT diploma, continuing education and first aid, these are excellent additions to your resume.
Why should they pick you?
What makes you unique and stand out?
Get a few testimonials together.
Prove your experience don’t just state it.
Use a comparison profile. List what they require from you and specifically how you do that. This can be in addition to your resume and should change or be modified to suit each employer’s requirements.

Be persistent in applying for a job and do not get discouraged! If you are not responded to right away do not take it personally.

Businesses in Australia are bombarded by hundreds of emails responding to job postings. A lot of those emails are from struggling backpackers and travelers looking for part time work.

Working In A Spa vs A Clinical Setting.

Spas can be more accommodating if you do not have a provider number for Australia. I found numerous postings available for spa practitioners, especially in tourist areas.

If you desire a clinic setting, it will be valuable to gain provider status. Large cities and multidisciplinary clinics are looking health fund providers.

Either way, pick an area you would like to live and work in (search this area on seek.com.au and see what positions are available) and then create a resume at home that will appeal to an Australian Spa or Clinic Owner/Employer and email it to them.

From seek.com.au I found a rocking job out on the Great Barrier Reef as a Massage Therapist.

Massage Therapy On The Great Barrier Reef

While searching seek.com.au I came across a posting by Calm Experience. This was a massage therapy company that was owned by by Intuitive Massage located in Airlie Beach, Queensland.

In conjunction with Cruise Whitsundays, the local ferry system, Calm Experience is contracted to provide Massage treatments on Reefworld.

Reefworld is a permanently located pontoon that sits adjacent to the coral reef walls of Hardy Reef. This pontoon is accessible by Cruise Whitsundays for day and overnight tours. The pontoon itself is home to the Harmony Hut (where Massages are given), the dive centre, snorkelling equipment, underwater semi-submersible sub and underwater viewing chamber.

It was an excellent tour to see nature at its finest. You could spot turtles, humpback whales during migration, reef sharks, hundreds of fish, dolphins and of course Nemo.

Watching this video will help you to understand the Reefworld Tour.

I was persistent in applying for this position.

It took four emails before I received a reply. I called three times and I didn’t stop until we spoke on the phone. My persistence paid off as I landed this job during my first telephone conversation.

The whole team would arrive by 7:30am to prepare Seaflight; the guests would arrive on board at 8:00am sharp.

Seaflight is a 37m vessel ideally suited for outer reef cruising, each tour started with a short announcement of activities available at Reefworld. Announcing my Massage Therapy skills to a boat full of international strangers was the last thing I thought I would be doing in Australia, so I was a little nervous at first but eventually it was a stress free routine.

My accent seemed to work in my favour.

I was often the only Canadian and my ‘slow’ accent made it easier for people to hear. My approach was:

Practice my script each morning on the walk to work
Address the audience with a clear and precise message of the Massages I offered.
Review, reflect and re-write as needed.
Be the first on the microphone.
Described my uniform, all black, I was easily found.
Speak in an enthusiastic tone.
Leave the audience with a call of action and urgency.

“Book your appointment now. I have a limited amount of time and I do not want you to miss out.”

Aside from this small presentation that took only minutes of my day my duties were to:

Prepare seated chair massage with fresh towels & face pieces.
Book appointments for my day, after my announcement.
Provide seated chair massage on Seaflight, to & from Reefworld.
Provide Table treatments at Reefworld, 4 hours available.
Record daily sales with payment.
Return used linens to main office once back at shore.
Help provided memorable experience for guest.
Work as a team member.

I was paid on commission which relied on my ability to connect with passengers and close a sale. Marketing myself on Seaflight pushed me out of my comfort zone so far I felt like I was going to fall overboard.

I came from a healthy practice where in house referrals fuelled my success.

This job spoke volumes on how much I relied on others for referrals, so this was my time to learn how to market myself and successfully gain clients.

My daily sales ranged from $200-470.00 AUD, minus commission. Averaging $800-1000/week. I made more money in Canada but I was travelling, not making my fortunes; I was just fortunate enough to be there.

I earned a good living, built community support around me, saved money and moved onward to travel the East Coast for nearly three months without working.

This was success for me.

Reflections Of My Massage Therapy Jobs In Australia

I honestly didn’t need a provider number for the two places I worked at.

I chose to live in tourism based places where having a provider number did not separate me from another, my resume and education stood for itself.

If you choose to not have a provider number, get your insurance and start applying to spas and vacation destination places. You might get paid a little less, but the scenery will most likely make up for it.

If you want a provider number for a health fund it shouldn’t be too difficult, especially now that you are informed.

This would be an excellent advantage if you chose to live in a larger city. If you were planning on staying for a long period of time in cities such as Melbourne, Sydney, Gold Coast, Sunshine Coast and Brisbane you would have a greater chance of finding work with a provider number.

Be mindful when applying for jobs as a Massage Therapist in larger cities, be aware of job postings with bad verbiage, late working hours and low fees. This is not to scare you off, only to inform you.

I went to a job interview in Melbourne that never mentioned it was above a pawnshop (not that there is anything wrong with that, BUT… let’s just say they were surprised I had a resume) the girl working there got her techniques off YouTube and if I was honest, I’m pretty sure it was for prostitution.

I thought, what was I doing?

I knew it was wrong and I left.

I had a little cry with a great friend who helped me overcome the situation and it was onward and upward from there.

I eventually had a really beautiful time in Melbourne, not to mention all the lovely friends I met, but also I worked for a family that owned a small children’s toy shop called, Saraghi.

This was where my other resume came into play.

My child care and reception skills made me the perfect candidate to help people purchase gifts for baby showers and birthday presents, it was cute, fun and I drank a lot of coffee.

Just to touch back on the Massage Therapy side of my life, I resisted the idea of a working at a spa in the beginning, I was a clinic-based practitioner. My patients were recovering from motor vehicle accidents, work related injuries and serious limitation issues. I resisted the idea of a spa and in the end working at them helped me find more love for massage. I was uplifted because people were on holidays and they were happy. Their energy transferred on to me, so I was happy too. There you have it… all the information you need to start your journey as a Massage Therapist in Australia. I am going to say to you now…there are no excuses and “you’re either going to do it or you’re not”. All the best, I believe you can achieve your dream and I am here when you need me. If you would like more information and useful links, click here. Now that you have decided you are going, Yippee!

Corrective Exercises For Scapular Winging That Every Massage Therapist Should Know

December 17, 2015/4 Comments/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jon Cain

The frustration was getting to her.

Connie is a dedicated gym-goer with a 6-day/week workout routine.

She’s a personal trainer and yoga instructor, follows her own regiment religiously, never misses a day, and embodies the image that many women would kill for.

Connie’s struggle of late has been difficulty in getting better at wide-grip pull-ups.

She added assisted pull-ups to her weekly back and bicep workout, trying to see improvement.

The result:

FAIL! After four months, she was still stuck maxing out at four pull-ups, assisted! This raises a flag, we can assume she has a thorough understanding of muscular training adaptation to be able to structure her workouts and see the desired result.

This tells us there’s a glaring discrepancy somewhere in her body mechanics preventing her from achieving her goal which needs to be addressed, much like we’ll almost always see when treating clients for musculoskeletal injuries.

After hearing her complaints about the lack of progress being made, I took notice of her shoulder blades. If you saw them at the time, you would have seen her scapulae winging out during any shoulder retraction, cueing us to some kind of bio-mechanical error that needed to be addressed.

Shoulder Mechanics And Massage Therapy

With a working knowledge of anatomy and physiology, we know that the scapular muscles (most significantly the serratus anterior, but consisting of several other muscles of the shoulder girdle) are meant to stabilize the scapulothoracic joint.

These muscles should be active in maintaining the position of the scapula against the rib cage during posture and to control its movement during ranges of motion at the shoulder.

When those muscles get weak, we see this winging, causing a change in the total angle of the shoulder girdle and improper recruitment of larger muscles which are now attempting to compensate for the lack of stability.

If that sounds complicated, just know that if scapular muscles get weak, big shoulder muscles get overworked, shoulder strength and health deteriorate.

I see this problem arise quite often in individuals who follow traditional weight-lifting programs, whether it’s team-sport athletes, body-builders, or average-Joe’s. What’s happening is that the nature of your traditional weight-lifting routine (isolated exercises, weight-machines, supported shoulders against benches) remove the use of the small, stabilizing muscles from the equation.

High end body-builders who receive proper training subvert part of this problem by properly adding isolation of those smaller muscles into their routines, effectively strengthening the scapular stabilizers and preventing the winging of the shoulder blade that would ruin the aesthetic appearance they need.

However, these individuals are still prone to chronic shoulder injuries such as rotator cuff tendinopathies and biceps tendon impingement.

Why is that?

It’s because the strength of those muscles may be well-trained, but the stability is still lacking. (Note: This is a tendency, not a rule. Don’t hate.)

We see errors quite often in the clinical setting when it comes to retraining muscular stability.

In much the same way traditional weight lifters will train themselves, a therapist can easily get caught up in prescribing basic isolation exercises in either excessive amount or for too much time.

True, if there is severe weakness and inactivation of a particular muscle, then of course it needs to be targeted specifically at the start of a rehab plan. But as we progress an individual to the more advance stages of returning to function, synergistic muscular training is key.

We can’t expect proper shoulder mechanics (which requires stability provided from multiple smaller muscles working together) to arise from training each muscle separately and isolated through range of motion.

Exercise Recommendations To Use With Your Massage Therapy Patients

After realizing the large discrepancy in shoulder stability, I gave Connie two very simple exercises to do.

The first one was a scapular push. This one is hard to explain in written words, so take a look at the video below. This exercise was to be done daily for two sets of 10 reps per side.

The second exercise, the T-curl is an isolation one (as I mentioned is still often important as a supplement) for serratus anterior, one of the major stabilizers. This one was prescribed for 2-3 sets of 10 reps on Connie’s “pull” day at the gym.

Keeping the upper arm parallel to the floor and the entire limb in the frontal place, the cable is curled in with the palm flipping between every rep.

Connie did these two exercises, as instructed, for 8 weeks, without modification.

After four months, pre-intervention, of Connie barely being able to muster out four assisted pull-ups, she is now pushing towards ten reps, unassisted.

The results speak for themselves.

Big lats and biceps are only part of the equation; you need to take care of the small stuff as well. It’s important to not neglect the prime movers, but when attempting to retrain healthy movement, the foundational support needs to be considered first when prescribing exercise.

Exercise rehab like this is clearly vital in the clinical setting. However in Connie’s case, her condition was not yet pathological and causing pain. In the case of clinical clients, we’ll need a bit more intervention on the therapist’s side.

With individuals who have such severe scapular weakness, you’ll also typically find significant spasm and adhesion in those same muscles due to the body attempting to create stability any way it can. It’s also important to look at the antagonistic muscles to what we’re focusing on; in this example that would mean taking some time to work through the pectoralis muscles that, combined with the weak upper back, will likely contribute to a rounder shoulder and t-spine posture. Connie is going to continue her training using these interventions, possibly with some further modification, and I can confidently predict that her progress will not plateau any time soon. Luckily, we were able to target her weaknesses before they became pathological issues, but this won’t always be the case. However, whether or not your treatments in the clinic start with basic exercises or even Massage treatments alone to begin with, the progression that I did with Connie is an excellent example of late-stage rehab that we can use to get our clients above and beyond their pre-injury state.

Acute Quadricep Contusion Management For Massage Therapists

December 15, 2015/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Sport Massage/by Jamie Johnston

He was a little slow getting up.

An opposing player tripped him, he fell to his knees and slid into the boards.

I was following the rest of the play and the student working with me pointed out he was hurt.

Looking down at the end of the bench, he was standing and shifting his weight back and forth from leg to leg and was bearing weight on the leg no problem. The whistle blew, so he went out for a quick skate to test it while there was a stop in play.

When he came back to the bench he was wincing and gave me a look that said he wanted some help.

As we walked into the dressing room, he had a bit of a limp.

Once he sat down, I started taking his gear off and there wasn’t much of an issue pain wise.

There was some tenderness just above the knee cap and his range of motion was pretty good, a bit of pain with muscle testing and some minor swelling in the area. We pulled him from the game and had him ice the quadriceps.

After the game he came into the treatment room and asked what he should do that night? Since we had a game the next night, I advised him to ice the quad, elevate it and take some ibuprofen.

Then the discussion started.

The student I was working with thought it was better to get inflammation to the area rather than prevent it.

After we discussed it, we still decided to go with ice and anti-inflammatories.

Treatment for Acute Quadriceps Contusion

There has been so much debate over this for the last while, it’s no wonder there was some confusion for treatment protocol.

I think Paul Ingraham explained it better than I could with his article titled “The Great Ice vs Heat Confusion Debacle”.

We use ice as a treatment application to reduce pain with acute injuries as well as reduce inflammation. While there is much debate on whether to reduce inflammation, the body has a tendency to over do it, so in the acute stages (in order to manage pain and mobility) ice is a good thing.

As with any other injury, you want to make sure you do a thorough assessment to determine its severity.

If you’re working on the sidelines in sport, your assessment happens immediately on impact or collision that causes the contusion.

Running through a quick checklist in your head can help:

Was the collision severe enough to cause a fracture?
Can the player bear weight?
Did they need help to get off the ice or playing surface?
If they can bear weight, are they walking with a limp?
Are they able to bend the knee?

Once you get them into your treatment room, or away from play, your more concise assessment can start.

In the case of a Quad contusion, they are divided into three grades:

Grade I (mild)
- Mild swelling and pain and able to walk without a limp.
- Passive movement beyond 90° may cause pain.
- A muscle test for knee extension may cause minimal discomfort.

Grade II (moderate)
- Walks with a limp.
- Can bend the knee between 45°-90°.
- Swelling prevents full knee flexion.

Grade III (severe)
- Progressive bleeding and swelling occur within 24 hours.
- Swelling won’t allow knee flexion past 45°.
- Flexing the quads is also painful or not possible.
- They will need to see a doctor.

The easiest way to do this is just by having the person lay prone on your treatment table (if possible) and you’re essentially going to perform an Ely’s test.

Once they are face down on the table just passively flex the knee (within pain tolerance) as much as possible to see what grade you get. Anything past 90° is mild, anything less than 90° is moderate to severe, the person should not bear weight and should be given crutches.

In order to treat a mild contusion an application of ice while the knee is braced in full flexion (this can be done using a large tensor bandage), puts a stretch on the muscle and helps maintain range of motion but the bracing should not be done for extended periods of time because it can weaken the tissues. One study showed that bracing for 24 hours immediately after injury (in addition to stretching and strengthening exercises after brace removal) had people back to full athletic function in 3.5 days.

For the first day or two continue with ice and anti-inflammatories to keep the swelling down. Use passive and active range of motion to keep the surrounding joints moving as well as preventing tissue changes.

With any hip or thigh injury, if the person can’t bear weight (grade II or III) they should be sent for more advanced medical care.

Photo by: The US Army

Return To Play For Massage Therapists

Once past that initial 24-48 hours and swelling has started to go down you can look at getting your athlete involved in their sport again.

Massage Therapy treatments can start in addition to functional exercises. As long as the athlete can do the functional movements associated with their sport, pass all functional tests, and range of motion is within 10° of the other leg, they should be good to go.

In the case of a Grade I, this could be the next day, Grades II-III will take longer and if the athlete has been sent for more advanced medical care, their return to play should be coordinated with feedback from the doctor.

There are a couple of complications that should be ruled out with Grade II-III (possible compartment syndrome and myositis ossificans) and this requires a doctor’s care.

It will be rare to see an acute quadricep contusion in a clinical setting, but if you are interested in or are already working in sport, there is the potential to see this all the time. While there are many guidelines that can be used, good clinical reasoning on your part will be the best guideline for whether an athlete can return to play again. The player treated in this story was back on the ice and in the game the next night. Using some ice and anti-inflammatories helped manage his pain when he got home that night, so that he could get a decent sleep. The next day, the swelling had gone down, he was functioning well and we put a bit of extra padding in place for protection. Athletes are a bit of a different breed compared to the general population in cases like this, they will do whatever they can to get back in the game and sometimes to their own detriment. In his most recent book Ron MacLean tells a story about Trent McCleary, a former NHL player who repeatedly used his body to block shots which meant constant swollen and bruised ankles and knees, and the odd charley horse that took him out of a game or two. But he didn’t like to get out of the way because he thought that was putting himself ahead of the team. Besides, he was getting good at managing contusions with ice and flexing.

Using Massage Therapy For PTSD Treatment

December 10, 2015/1 Comment/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

My jaw dropped and I had to apologize.

As he told stories, I mentioned that we had something in common because we both had experience in First Aid.

Turns out we didn’t.

As the stories progressed each was more horrific than the last and I felt bad for speaking out of turn.

The things he had seen and experienced were things no one should be subject to.

There was no way I could understand the pain he was going through, much less what could possibly be going on in his head.

The doctor had prescribed getting Massage Therapy to help treat PTSD.

I had no idea how to effectively manage this, so I just let him talk.

There was nothing great about the treatment, much less anything really specific about it, but for 45 minutes he talked, vented and decompressed.

I’ll admit I was pretty intrigued by the stories as well as learning how something that happened 40 years earlier was still playing on his mind.

While I couldn’t give any feedback or advice, the treatment did make a difference and he left in a better mood.

What Is PTSD?

I used to think that PTSD was something that just veterans were diagnosed with.

Over the past few years I have had a few people come into the clinic who have been diagnosed with PTSD, some were veterans, some were teenagers and not all of them had a background that would suggest a PTSD diagnosis (or so I thought).

Post Traumatic Stress Disorder is a type of mental illness.

The Canadian Mental Health Association gives a definition of the cause:

“It involves exposure to trauma involving death or the threat of death, serious injury, or sexual violence.”

Little did I realize that over the past few years, I have probably treated more people who might have been dealing with this than I thought.

Think about that definition for a second, “trauma involving death, threat of death, serious injury or sexual violence”. Every single person who has come in for treatment after a car accident could potentially have PTSD.

I get called out (with the fire department) to dozens of MVI’s every year and witness first hand how people react in these situations. Even very minor accidents are very traumatic experiences for most people.

If this is the first time they have experienced anything traumatic, it’s hard to know how they will respond.

Either way they will feel a loss.

It could be the loss of a loved one, the loss of their first vehicle, or just that they simply lost control. There is also the addition of how severe an accident is. Even as First Responders, the adrenaline gets pumping a little more when we hear that we are responding to a roll-over MVI, nevermind if you’re actually in the vehicle.

It can seem like a life or death experience (or at least a major injury experience) that can have severe repercussions to a person’s mental health down the road.

As for the topic of sexual violence, unfortunately this is all too common in our society these days. As time goes on, more and more I meet people or have friends admit to me, they have had to deal with this at some point.

I can’t imagine the mental trauma involved, nor am I going to pretend to.

However I have had to use First Aid skills before, in order to help people who are hyperventilating and having an emotional release due to an experience like this in their past.

PTSD, A Counsellor’s Point Of View

I reached out to my friend Tara Miller, she’s a Clinical Counsellor and Psychotherapist who deals with patients who have PTSD on a regular basis, here’s her advice for helping them:

What predisposes someone to PTSD is not the relative severity of the event or threat they have experienced, but rather what’s already in their nervous system.

A person with many overwhelming or traumatizing events in their life can function quite well but can experience symptoms after a relatively minor event because of what’s previously layered in their nervous system.

Knowing this can help your patients deal with any shame about their inability to heal mentally or physically compared to how minor they feel their accident or incident was.

With relationship violence, it’s important to remember that a person hurt them. You, as a therapist can feel just as threatening. Just like how a person bit by a dog can be afraid of all dogs, not just the breed or the dog that attacked them.

In both cases, you might see common symptoms expressed physically including:

Chronic brace/tension.
Repeated injuries to the same area of the body as previously injured.
Gastrointestinal issues.
Difficulty sleeping.
Increase in headaches/migraines.
Sensitivity to light and sound.
Trouble reading/visual disturbances.
Increased startle reflex/jumpiness.

The emotional and cognitive symptoms add to those and you might see your patients in treatment experience crying episodes, panic attacks/anxiety, and even dissociation (a sense of being there but not there, spaciness), and memory lapses.

What can help, is education around all of this – it’ll help reassure them that it’s normal and even expected. Being able to add information about some of their physical symptoms being related to how the brain holds trauma and recommending a trained psychotherapist to work in conjunction with the physical therapy they are receiving is highly beneficial.

Some things that can help your PTSD patient is to become familiar with the room, noticing elements they like and giving them time to settle in and feel comfortable.

Checking in on light, sound, even the loudness of your voice and adjusting to their comfort level. You want to avoid the word ‘safe’ – it automatically brings up what is not safe. Use the word “comfortable” – what would make you more comfortable?

Trauma happens quickly, remind them they have all the time they need to settle. From there, when you work on an area where they brace or tense up, ask them what level of pressure they’d like – too much pressure can increase the brace in the injured area and cause more pain.

Pain is activation and their system is already in high sympathetic arousal. These patients might need a gentler approach as you work psycho-physiologically with their injury while being mindful of PTSD.

Another thing to be aware of, when working on an injured area or area of brace is knowing that all activity around the injury brings back their traumatic incident – potentially reliving it each time.

They might start talking about it when you go to the area as well.

What we know about the brain and nervous system is that talking about trauma does not heal trauma.

Clients feel the need to talk about what happened but that light’s up their brain and releases all the same fight or flight chemicals as when they first experienced the trauma. This adds more of a charge to the system we are trying to regulate down.

This can be overwhelming for the therapist as well!

Instead, encourage them to use their imaginations in treatment. Where would be your favourite place to go and relax, have them describe it in detail (see if their muscles don’t start to let go with the visualization at the same time). Ask what would feel best on the injured area, visualizing a warm compress, floating in the ocean or a magic ointment that could seep through the pores and remove all the inflammation.

Notice what happens in their physical body as they imagine the perfect healing, the perfect environment, or what they will do once healed, how it would feel to move their bodies when well again. This works as little brain hacks encouraging the brain to light up and release chemicals that are relaxing vs activating.

Help your patient avoid talking about the worst moments of their trauma if they haven’t worked through their traumatic experiences with a professional. You can explain what happens when we retell and re-live traumatic experiences and how that can cause tension in the body during treatment.

Encourage them to see a psychotherapist or counsellor that is trained in a neuroscience based, trauma-centered modality, like Self Regulation Therapy.

These patients need extra support and are more sensitive to their environment and therapist than others. It might be helpful to book a little extra time for them to settle in. Check their comfort level and help them direct the discussion and imagination into positive directions to get the most benefit from treatment.

Find a therapist that can work with them and collaborate on their care for overall best outcome.

Useful resources for more information on this:

Photo by: Mark Warner

Massage Therapy Treatment And PTSD

It turns out Massage Therapy can and should be a part of therapy for anyone dealing with PTSD.

When someone is suspected of having PTSD, a PDS (Posttraumatic Diagnostic Scale) can be used to determine the severity of the condition. It is used to measure how helpless the person felt during an event and if there are any avoidance or arousal symptoms they are experiencing.

Communication with a patients counsellor or psychiatrist is crucial to understand what measurements they are using in their assessment, so that we may be able to get a better idea of how someone is progressing once they start receiving Massage Therapy.

Studies have shown that incorporating Massage into a patient’s treatment has helped in their recovery.

One pilot study had National Guard Veteran patients do massage with their partners at home to the shoulders, back, neck, head, and feet. They were encouraged to do as much as they wanted each week but were required to do one 20 minute session as a Massage reporting session. The results showed a significant reduction in physical pain, tension, irritability, anxiety, and depression. However, one of the things noticed was how important it was to leverage an existing trusted relationship to initiate care for these veterans.

What is little talked about is the improvement in home life and effect on family members. I have personally seen a spouse insist on regular Massage Therapy treatment because of the improvement in mood at home. I also truly believe that these treatments are not for the faint of heart. While I know that Massage does make a difference and helps, I also believe there is another facet to the treatment (and this is strictly just my opinion). Letting people talk. I’m pretty fortunate because it takes a lot to offend me (okay maybe fortunate isn’t the word) and have had people swear while telling their story, which could be hard for some therapists. People will want to tell their story while on the Massage table, but should only be done if they are working through things professionally with a trained counsellor and feel like they can talk about it, without being impacted by it. If this starts to happen, (just as Tara recommended) try to shape the conversation to something more positive. While we can’t give them advice (other than recommending seeing a counsellor if they aren’t already) we can be a very therapeutic service for anyone dealing with PTSD. Just make sure you can handle hearing a few f-bombs.

Myofasical Release And Massage Therapists

December 8, 2015/22 Comments/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Richard Lebert

Anyone who has spent long hours engaged in a heated discussion over Facebook knows the frustration that comes along with it. These discussions have forced me to question many of my long held beliefs about the fascial system and myofascial release. There is evidence that myofascial release is an effective technique for a number of injuries.

However, when it comes to anything fascia related the professional community is divided with fundamentalist views on both sides.

To some myofascial release is a panacea and others regard fascia as ‘dead tissue’ with no clinical significance.

With some of the research and reading I’ve done, I have wanted to dispel myths and simplify research.

Fascial Anatomy For Massage Therapists

Andreas Vesalius (1514-1564) is often considered to be the first anatomist and is best remembered for publishing the famous anatomy text, De humani corporis fabrica in 1543.

If you look at these early illustrations they present the fascia and muscles as one continuous soft tissue structure.

Fast forward to the 20th century (texts we study) most opt to omit fascial structures in order to depict muscles in a cleaner fashion. Recently there has be a resurgence of this ‘forgotten tissue’ and anatomy textbooks have made an effort to include fascial structures in their depictions and descriptions.

An example of this is The Functional Atlas of the Human Fascial System by Carla Stecco, an Orthopedic surgeon and a professor of human anatomy at the University of Padua in Italy, the same University that once employed Andreas Vesalius in the early 1500’s.

Another example is Anatomy Trains by Thomas Myers, in this book Myers presents conceptual ‘myofascial meridians’, a recent systematic review confirmed a number of these continuous soft tissue structures.

What is Fascia?

To better understand the possible actions of myofascial release, there is a need to clarify the definition of fascia and how it interacts with various other structures: muscles, nerves, vessels.

Simply speaking all fascial tissue is connective tissue, but all connective tissue is not fascial tissue.

The primary job of connective tissue is to support, connect or separate different types of tissues and organs in the body. For the purpose of brevity, connective tissue proper can be divided into dense connective tissue and loose connective tissue. Simply put fascia is a combination of dense and loose layers of connective tissue. As, for the definition of fascia, there are many different ways that fascia is defined, see What is ‘fascia’ A review of different nomenclatures. In this article the definitions of fascia that I use is “Fascia is fibrous collagenous tissue which are part of a body wide tensional force transmission system”

What Are Massage Therapists Doing With Myofascial Release?

The thing is, myofascial release is not well defined, it is a broad term covering a wide variety of techniques.

This includes osteopathic techniques, rolfing, structural integration, massage therapy, cupping and IASTM. My interpretation of myofascial release may differ from others, but in this post I am referring to myofascial release as a manual technique that tensions soft tissue structures and is accompanied by active or passive movement, to promote relative tissue motion.

I have divided the response to myofascial release into three categories, in reality the response likely represents a response of multiple overlapping systems:

Contextual Responses to Myofascial Release
- This is likely to play a role in any therapeutic intervention, the way we present ourselves and present our techniques has influence on the treatment. The magnitude of a response may be influenced by mood, expectation, and conditioning.
Neurological Responses to Myofascial Release
- Fascia is highly innervated by mechanoreceptors, this was document by Robert Schleip in 2003. His article Fascial plasticity – a new neurobiological explanation Part 1– Part 2, this is an interesting and very readable two-part article laying out a possible neurological explanation for the beneficial effects of myofascial release.
Mechanical Responses to Myofascial Release
- The literature of Robert Schleip, Carla Stecco, Antonio Stecco and Thomas Findley support the idea that along with the neurological response and contextual response massage therapy has a mechanical effect on the fascial system. A summary of the proposed mechanisms includes but is not limited to

Any type of massage therapy is actively engaging the nervous system by stimulating mechanoreceptors at the level of the skin, as well as at deeper level fascial layers. Deep slow myofascial release techniques stimulate sensory ending known as the ruffini endings. Stimulating these slow adapting sensory receptors has the ability to alter the motor output and the experience of pain.

“Fascia and the autonomic nervous system appear to be intimately connected. A change in attitude in myofascial practitioners from a mechanical perspective toward an inclusion of the self-regulatory dynamics of the nervous system is suggested.”

-Fascial plasticity – a new neurobiological explanation: Robert Schleip

Are Massage Therapists Breaking Adhesions?

With such a lengthy post on myofascial release I would be remiss if I did not address the notion of breaking down adhesion. “An adhesion is an attachment of tissue at unusual non-anatomic sites which can be, vascular or avascular, innervated or not innervated.”

There is little to no research that I am aware of that would indicate that massage therapy can manually break down mature adhesions. There is however literature to support the idea that massage therapy may be able to break down immature postoperative adhesions.

Research by Geoffrey Bove and Susan Chapelle has demonstrated that manual therapy has the ability to break down immature adhesions. A recent case study demonstrated the effect of manual therapy on immature postoperative adhesions. Susan Chapelle has posted a well put together summary of the latest evidence of massage therapy and the effect on scars and adhesions Susan Chapelle- Understanding and Approach to Treatment of Scars and Adhesions.

What is the Clinical Relevance Of The Fascial System In Massage Therapy?

The “fascial system” serves to provide a conceptual model by which to explain the function of the global fascial net during movement, including the interconnections of fascial tissues with joint capsules, nerves and intramuscular connective tissues.

One of the proposed dysfunctions is an alteration of loose connective tissue that may adversely affect the sliding motion of fascial layers, this may be due to age, trauma or inflammation. This alteration of loose connective tissue is described as a densification In The Functional Atlas of the Human Fascial System.

Is a fascial densification the same thing as fibrosis?

Stecco makes a distinction between a pathological fibrosis and densification:

Densification refers to an alteration of the loose connective tissue (adipose cells, glycosaminoglycans and hyaluronic acid) Densification can involve an alteration in the quantity or quality of the components of loose connective tissue and an alteration in fascial viscosity.

“Densification may affect the sliding and gliding of tissue. The different layers of the body contain viscous loose connective tissues that allow a gliding, sliding function, protecting sensitive neural structures, as well as facilitating pain-free, efficient movement and force transmission. Gliding function may be lost because of trauma, inflammation or aging, resulting in fibrosis, thickening, densification.” -Pavan et al 2014

Fibrosis is defined as an alteration of dense connective tissue, specifically a rearrangement of the composition and structure of the dense connective tissue.

Nerve Entrapment

Many cases of peripheral nerve entrapment occurs following a traumatic injury, this is often the case with the sciatic nerve in proximal hamstring syndrome. It could be argued that this thickening and entrapment of peripheral nerves is a development process, could manual therapy play a role in slowing or reversing this progression?

Conclusion
Over the last couple of months I have spent a lot of time reading and reviewing fascial research, this has changed the way I that I communicate with therapists and patients. Myofascial release is an effective treatment technique, the catch is that it may not work in the way some were taught. Over time the supportive theories behind techniques evolve or change completely, myofascial release is an example of this. Is the name myofascial release better used as an analogous term to describe a palpable change in tissue that is likely due to many overlapping responses? Namely:

Contextual Responses
Neurological Responses
Mechanical Responses

These combined responses results in an increased pliability of soft tissue structures that often translates clinically into improved proprioception, increased range of motion and decreased experience of pain.

I am no longer frustrated when I get in heated discussions on Facebook, if someone can present a convincing argument I am willing to change some of my long standing views. Something I am still frustrated with is that there is a lack of resources available for massage therapists, hopefully this will change over time.