How To Get More Traffic To Your Website

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Getting more traffic to your website isn’t voodoo.

It doesn’t take a miracle and it’s not rocket science either.

The secret ingredient – which isn’t that secret – is to give people a good reason to visit your site.

Combine that with a strategy and a consistent approach and before you know it, you’ll begin to see more visitors to your website.

This article will show you, in 3 key areas, how you can go about getting more traffic to your website.

These 3 areas are:

  1. Optimize Website Content – Increasing traffic to your website starts with optimizing the content on your website for both people and search engines
  2. Connect on Social Media – Being active on social media plays a major role in developing a consistent stream of traffic to your website
  3. Leverage Content Outreach – Reaching out to the key influencers in your industry will further grow your website and attract new audiences

So now that you have an idea of what we’ll be looking at, let’s dive right in!

Optimize Website Content

The first leg of increasing traffic to your website is to make sure the content on your website is optimized and performing at its best.

Here are some things you should consider:

Set Up Analytics on Your Website

Getting more traffic to your website starts with having in place an analytics and tracking system.

Without one, you have no way to measure the amount of traffic to your website.

Luckily for you, this system already exists and it’s free!

You’ve probably already heard of it: Google Analytics.

Google Analytics will give you both the insights you need to know what’s working and what’s not, as well as a clear picture into your current traffic numbers.

Some of the more important metrics to pay attention to in Google Analytics are:

  • Users – The number of unique visitors to your website
  • Bounce Rate – How frequently people “bounce” off of your website and back to the search results page
  • Sessions Duration – How long people spend on your site
  • Top pages – Which pages receive the most traffic
  • Pageviews – How many pageviews your content received
  • Exit % – The percentage of people actively exiting your website from a particular page

As you begin to analyze these metrics and compare them to actual pages on your website, you’ll start to realize valuable information that you can use to tweak and refine your traffic growth strategy – which leads to the next step:

Develop a Content Marketing Strategy:

Having a plan in place will make it much more likely that you’ll see success as you strive to increase your website traffic.

Here’s what should go into an effective Content Marketing Strategy:

  1. The goal of the strategy – What are you hoping to gain with more website traffic? Do you want more people to subscribe to your mailing list? Are you trying to sell more products? Start your strategy off by defining S.M.A.R.T goals.
  2. A definition of your audience – Knowing who your audience makes it that much easier to send the right message and reach the right people for your business.
  3. The types of content you intend to produce – This could be blog posts, videos, podcasts, infographics, e-books, a combination of all or some.
  4. What is your edge? – How do you plan to add value and separate your content from your competitors? What makes your content unique and valuable?
  5. Frequency of posts – How often do you intend to post new content?
  6. Getting your content out there – How do you intend to reach people with your content? (We’ll be taking a closer look at this later on)

You may find your strategy changes over time; your goals may change or you might discover new insights about your audience.

That’s alright and is to be expected.

The important thing is to remain focused on your goal yet remain flexible enough to course-correct as required.

Keywords

Now with a way to track website traffic and a strategy in place for getting more visitors, it’s time to look at the actual content itself.

You may already have a good handle on the topics that matter most to your audience.

If that’s not clear to you, you can turn to tools such as Google’s Keyword Explorer, another free tool that lets you see the search volumes for a particular phrase or keyword.

This is a great tool that will give you a sense of how many people are searching for a particular phrase and what the competition is like for that keyword.

For additional ideas, try plugging your candidate keywords into Google and scrolling down to the suggested searches section:

These are related search terms that Google also gets high volumes of search queries for that may give you additional inspiration about what content to produce.

Write More Compelling Headlines

People have short attention spans. That means you have to hook them quickly!

One of the most sure-fire ways to do that is to write catchy, compelling headlines that people just can’t help but click on.

Here are a few quick tips for writing catchy headlines:

  • Use numbers in your headlines (“7 Tips to Reduce Belly Fat”)
  • Create curiosity (“How I Managed to Quit My 9-5 Job and Travel the World”)
  • Use compelling language (“The Definitive Guide”, “The Secret to..”)
  • Add something in brackets (“The Top Cities in the World to Visit [Infographic]”)

Keep your headline length below 70 characters to avoid them being cut off by Google and other search engines/devices.

Great headlines alone aren’t enough to create sustainable website traffic.

Write Better Content

Without content to match, you might get visitors to your website but they’ll quickly “bounce off.”

Without content to match, you might get visitors to your website but they’ll quickly

Here are some things you can do to keep readers sticky to your page:

  1. Perfect your introduction – Learn how to write a good introduction that hooks your readers early on and entices them to read on.
  2. Use shorter paragraphs – Shorter paragraphs are easier for readers to scan and digest. A good rule of thumb is to try to keep your paragraphs under 5-6 lines, ideally 2-3.
  3. Provide data – Real facts are much more compelling than opinions and speculation. Surround your content with data and link to it with images and descriptive link text.
  4. Use multi media – Images and other multimedia are a great way to break up chunks of text and engage readers further.
  5. Proofread – Typos and other inconsistencies weaken credibility, so make sure content is error-free before you hit the ‘Publish’ button.

Link Internally

If done right, linking internally to your own content is great for SEO and the User Experience.

From an SEO perspective, it increases time-on-page. It also promotes loyalty and increases the odds that your content gets shared on social media.

When linking internally, make sure you:

  1. Use descriptive link text – Descriptive text not only tells visitors what they can expect to find if they click on the link but also indicates to search engines the content of the link.
  2. Link to relevant content – Don’t link for linking sake but instead link to content that will augment the User Experience and enhance the value that you’re already providing to your readers.
  3. Don’t overdo it – A page full of links looks spammy and takes away from the impact that good internal linking can have; it also cheapens the SEO power with every additional internal link you add.

Employ Basic SEO Best Practices

You don’t have to be an SEO expert to execute on some of the basics.

Including these tips will ensure that the search engines know how to understand your content:

  • Have one main heading that includes your keyword phrase, usually the h1 heading
  • Include the keyword phrase in the URL of your page, remove any stop-words like ‘and’ or ‘the’ and separate words with hyphens to make sure the URL is the most search engine-friendly it can be
  • Include your keyword phrase or semantically similar words in the meta description of the page and somewhere within the first 100 words of your content
  • Remain on topic and put secondary keywords into secondary headers as content unfolds
  • Link internally and externally throughout your content when it makes sense to do so from a value-added perspective

Track Content Traffic

Remember when you set up Google Analytics on your website?

As you publish your content, make it a habit of checking in every week or so to see how your content is developing.

Take a look at the metrics we mentioned above and see how your content is faring.

Sometimes you’ll find that one piece of content, in particular, is receiving the most amount of traffic while another isn’t doing as well.

In cases like these, don’t get too precious about the content that isn’t doing so hot.

Instead, think about what you can do to leverage the traffic you’re already getting.

Make Sharing Super Easy

It probably goes without saying but your content should be easy to share.

In the next section, we’ll be talking more about social media but remember that it’s critical that you include social sharing widgets alongside all your web content.

Build Up Your Mailing List Subscribers

Email marketing has one of the highest success and conversion rates versus all other content marketing.

That said, developing your email subscribers can have long-term rewards for your business.

One way to gain more subscribers is by using what’s called a Lead Magnet.

This is essentially the exchange of something valuable for the visitor’s email address.

You’ve probably encountered these a thousand times, usually in the form of an offer to receive a free e-book or a special piece of content.

Lead Magnets can supercharge your mailing list subscribers so consider what you can offer readers to sign up for your mailing list!

Connect on Social Media

Now that we have a solid handle on how to approach creating content and strong methods in place for ensuring our content will hit the mark with both people and search engines it’s time to spread the word on social media.

Identify Your Key Social Media Channels

Each social media network has its own set of characteristics, each attracting uniquely different audiences and demographics.

Depending on your business and which market you’re looking to attract, the social media channel you choose to focus on will vary.

Ideally, the best way to learn which social media channel you need to be on is to ask your audience.

In case you don’t have that info handy, here’s an overview of the types of audiences the major social media networks attract:

Facebook is the dominant social media platform with a majority demographic ranging from 18 to 49 all the way up to 65. It sees a daily 1.15 billion active users and leads the pack among all other social media platforms.

YouTube gets more viewers than any cable network on TV. It attracts users between the ages of 18-34 as well as a large portion of people aged 35-49. As YouTube is owned by Google, your content will benefit from being tied into the Google search engine algorithm.

Instagram is the fastest growing social network. Geared more towards images and videos, Instagram tends to have a younger demographic (with most of its users under 35). If you have a business that can make use of this heavily visual platform, then this might be a strong fit for you.

Twitter is perhaps the most over-saturated and transient social network, leaning more towards being a social feed than content posting platform with more than 50% of its users never posting an update. Twitter is most popular among millennials and people under 35.

Pinterest has a wide spread across age demographics ranging from 18-64. Interestingly enough, this visually-oriented social network is made up of about 80% women.

LinkedIn is unique in that it is mainly geared towards professionals and B2B. It has a significant amount of active users so if you’re targeting business professionals, you shouldn’t ignore LinkedIn.

Develop Your Social Media Followers

Now that you’ve identified which social networks you should be targeting, it’s time to develop your social media followers.

Developing an audience on social media takes time and a commitment to sticking to and executing your Content Marketing Strategy but here a few a things you can do to maximize your efforts and speed up the process:

  • Fill out your social media profiles completely and be consistent with your company image
  • Link to your social networks from your other social networks
  • Include social links in your email signature, website, and published content
  • Share and engage with other people’s content
  • Post your content regularly
  • Engage with your social media followers

Maximize Your Post for Each Platform

As you begin to post content to social media, it’s important that you maximize your efforts by optimizing the way you post to each platform.

For example, if Twitter is one of the social media platforms you intend to be on, you will want to understand how to use hashtags effectively and the syntax for targeting users and key influencers on the platform.

Each platform offers its own unique set of characteristics so once you know which social media platforms your business should be on, do your research and find the most effective way to post your content.

Stick to a Schedule

When it comes to social media, there is something to be said for when you choose to post your content.

For example, the best times to post on LinkedIn are in the mornings before work, at noon, and after work midweek, Monday to Friday.

Each social media platform is different, so do your research to discover the best times to post.

Photo by: geralt

Leverage Content Outreach

You’ve optimized the content on your website and are now connecting to your audience on social media.

The next step to really take your website traffic to the next level is to connect to key influencers in your niche and get your content published on industry-leading websites through guest posting and content republishing.

Doing this puts your content in front of large, highly-targeted audiences. It also helps your website rank better on Google by linking your website to these publications.

Republish Your Content on Larger Websites

Large content publications generally have huge content needs and are actively looking for content to post to their website.

Here’s how you can get your content on these large publications:

Step #1: Find websites that accept and/or republish content

Websites that accept content will have pages detailing their guidelines for content republishing and guest posting.

To find these pages, start by searching Google for your industry keyword plus “guest posting”, “write for us”, or “submit an article” (many other variations exist, so you’ll want to employ smart search tips for finding guest blogging opportunities).

Step #2: Choose content you are going to pitch to these websites

Once you know who’s accepting content, it’s time to figure out how you can add value to these publications.

In the beginning, it’s easier to pitch an original piece of content than it is to pitch content that already exists on your site, so it’s a good idea to start off by understanding the publication that you’re targeting.

Are there opportunities for your content? Is there a gap in their content that you can fill with your knowledge or expertise?

Also, familiarize yourself with the tone and style of the publication so that your content will be a more natural fit for their audience.

If you find that your content isn’t a great fit off-the-bat, you can always tweak your style a little bit to match.

Step #3: Pitch your article

Once you know what content ideas you’re bringing to the table, it’s time to pitch them to the publication.

Pitching your ideas is where the rubber meets the road, so it’s important to bring your A-game and to do it right.

Here are some tips for crafting a winning pitch:

  • Write an engaging subject line – Content editors get boatloads of pitches so stand out by crafting an engaging subject line
  • Know who you are pitching to – Do your homework and find out who you’re pitching your idea to and, if possible, address them by their first name in the pitch
  • Understand their readership – Large publications are in the content business, so make sure you’re giving them stuff their audience will find valuable and be sure to include in your message how your contribution will benefit their readers
  • Include options – Your first idea may not be accepted, so have 2-3 additional ideas to offer in your pitch
  • Be patient – It may take up to a week before your pitch gets seen so don’t be too eager to follow up right away

Step #4: Prepare your content

Once you get the green light from the publication that your content idea has been accepted, it’s time to prepare your content for publishing.

Here are a few pointers:

  • Review the content and publication guidelines of the publication to make sure that you are following them correctly
  • Include at least one link back to your website in your content; aim for 2-3 links to your own content if it makes sense to do so
  • Provide your professional bio and a headshot along with your finished content

Conclusion

We’ve now broken down the three key elements to getting more traffic to your website:

We looked at optimizing the content that is already on your site so that it connects better to your readers, creates engagement and more social shares, and does well with search engines from an SEO standpoint.

We talked about using social media to find the right audiences for your business and stimulate more visitors to your website by making the most out of the content you post.

Finally, we discussed how connecting to large content publications in your industry can provide you with huge boosts in terms of website traffic and SEO and how you can find and approach these publications about republishing and guest posting opportunities.

All that’s left to do now is to get to work.

Good luck!

“Pain Is In The Brain” – Is It A Load Of S**T?

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“Pain is in the brain” is by far and away one of my least favourite phrases and in my opinion unhelpful in understanding a modern view of pain.

Why….?

Well, there are a number of reasons.

  1. It implies (to me anyway) it is not IN the body. This for many people is tough to get their head around, and rightly so.
  2. This may also imply that it is “all in my head”. Again not a helpful message for many and could potentially create more problems than it attempts to solve.
  3. Has created polarisation. As pain obviously has a good part of its genesis within the body we now get the “pendulum has swung too far” fight back. This is a completely warranted stance against this argument. The problems potentially lie in the perception of those who think that anyone who believes the brain is a major player in the pain experience is suggesting pain is all “in the brain”. It is easy to create a counter-argument against a polarised opinion.
  4. That it is idiopathic and spontaneously erupts. Whilst this may be true in some isolated cases for many it is a maladaptation of the system in response to a more physical Genesis.

 

Human brain

 

PAIN IS AN OUTPUT OF THE BRAIN

‘Pain is an output of the brain’ seems a much more sensible way to explain the pain process in my opinion. This allows a model that incorporates both inputs from the body and a modulation of that input in the brain.

The more pain persists then the more it may be driven by top-down rather than bottom-up influences although we must remember that we can get changes, or plasticity, in the nociceptive (noxious stimulus) or danger processing system further down the chain in the periphery and the spinal cord as well.

Stimulus (danger!) processing within the brain can actually be used to turn the output or emergence of pain down as well as up. We have cleverly named ‘on’ and ‘off’ cells in our rostral ventromedial medulla (RVM) that do just that. ‘Off’ cells exert descending inhibition on nociceptive transmission while ‘on’ cells facilitate it.

‘PATHOLOGICAL’ PAIN

There does seem to be situations where pain itself becomes more of a pathological process. Phantom limb pain is an example where potentially the mechanism for pain is more about the representation of the limb in the brain than nociceptive signals from the limb and is very prevalent with amputees at between 60 & 80% HERE it is also worth reading Melzack and Katz’s opinion on this HERE.

Harris has suggested incongruence between motor intention and movement as a source of pain HERE and sensorimotor incongruence exacerbates the pain of chronic whiplash sufferer’s HERE although this is not a consistent finding HERE.

Moseley & Valyaen HERE and Zusman HERE have both proposed coupling between proprioceptive information, pain responses and memory within the brain that no longer requires nociceptive input from the body.

HERE we see that the visual distortion of a limb can actually affect the processing of pain!

These pieces of research and theory help us understand that pain is a complex process and a ‘pain’ signal is not just simply relayed from the body but it also does not mean that pain is only ‘in the brain’.

So if someone was to ask “is pain in the brain?” My answer would be no, it is much more likely that it is a complex interplay between bottom up and top down influences modulated by many factors and that the sensitivity of the systems involved in the experience of pain has the potential to change over time at peripheral, spinal and cortical levels.

SEMANTICS

Some might, and have, suggested that this is simply semantics. I would agree completely with this because semantics matter. How people interpret meaning is a huge great big deal when it comes to pain and to not recognize that is a problem. This is a great paper by Darlow HERE and another by Barker HERE

‘Pain is in the brain’ seems open to being misconstrued by those in pain and also those who realize it has a great deal of its genesis within the body too.

IS THE ‘ISSUE IN THE TISSUE’?

Is the ‘issue in the tissue’?

Well, of course, it can be, just sometimes a bit more and sometimes a bit less. This does not mean there has to be a pathological state of the tissue however or if there is that getting better is contingent on a change in the state of the tissue. HERE & HERE.

Although we are realizing that pain and damage are not one and the same, local biochemical processes are likely to be very much at play. Whilst there may not be pathology we may have a pathophysiological process occurring, this being a physiological process that has gone a bit haywire!

An example might be if I go out and run a bit more than my body is used to and the normal reparative processes, such as tissue regeneration, becomes replaced by a different cellular expression such as pro-inflammatory chemicals like neuropeptides. This has been documented with tenocytes (fibroblastic like cells) as they transduce mechanical force (mechanotransduction) into cellular processes such as the expression of substance P potentially creating a peptidergically driven inflammatory state in the tissue HERE and HERE we see an elevation of substance P in vivo in response to load.

So we may have a situation where the local tissue state is chemically sensitized due to activity, perhaps previously under loaded tissue and this could potentially be turned up by changes in sensitivity in the systems involved in pain peripherally, spinally or cortically dependent on individual previous pain experiences.

PHYSICAL CHANGES IN THE EXPERIENCE OF PAIN

Changes in the systems involved in the emergence of pain don’t have to be ‘in the brain’ either. The subcortical bits can play their role too with actual physical changes occurring to the peripheral nervous system (PNS) within the tissue. These changes to the PNS include an increase in the number of ion channels in the terminal endings of nociceptors making it easier to get sodium ions into the cell, depolarise it and send a signal (action potential) to the CNS. We also see an increase in the number of receptors and previously silent receptors becoming active.

The signal processing at the dorsal horn can also be ‘turned up’ with more NMDA/AMPA channels making it easier for the peripheral signals to be sent up the chain and an increase in excitatory neurotransmitters, such as glutamate and aspartate, and a decrease in inhibitory chemicals such as GABA and endogenous opioids.

We can also get long-term potentiation of spinal neurons in response to repetitive stimulation or a sustained ‘volley’ of signals from the C-fibres.

Basically put, the more noxious stimulus we receive the more sensitive the dorsal horn becomes to it.

HAS THE PENDULUM SWUNG TO FAR?

That probably depends on your bias and opinion but if someone was to suggest that pain is solely ‘in the brain’ then I would suggest yes it has!

An inclusive model that allows physical, physiological, neurological and psychological processing changes probably fits with what we know about pain at this point in time. Sometimes the pendulum may have to swing big firstly to overcome the inertia of previously held beliefs and then hopefully comes to rest somewhere in the middle.

Back Pain And Pregnancy

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Many women think back pain during pregnancy is very normal.

With the literature reporting as many as 72% of women experiencing pain(1), it seems extremely common.  Women seek out relief through physical therapy, chiropractic care, massage therapy or sometimes can’t find any relief at all.

But would you know what is safe and what isn’t if a pregnant client came into your practice?

As healthcare providers, we took an oath to do no harm.

When we receive a client that is pregnant, we should be fully aware that everything we do to mom, we are doing to the baby.  A recent Clinical Practice Guideline was published that reviewed all the literature regarding pelvic girdle pain in pregnancy and has some great guidelines from diagnosis to treatment.(2)

Understand What Is Causing The Pain

According to Vleeming et al (3) “Pelvic Girdle Pain arises in relation to pregnancy, trauma, arthritis and osteoarthritis.

Pain is experienced between the posterior iliac crests and gluteal fold, particularly in the vicinity of the sacroiliac joint.  The pain may radiate in the posterior thigh.”  The sacroiliac joints are the posterior point of load transfer of the pelvic girdle.  Changes in the ability to transfer load may occur during pregnancy due to increase in laxity from hormonal influence or poor coordination and muscle control now that the abdominal muscles are stretched and no longer at their preferred length tension curve.(4)

Pain can persist into the postpartum period for 25% of people with 10% still having pain 1-2 years later.(5)  It’s important to note that patients with a history of previous low back pain or pelvic girdle pain, previous pelvic trauma, increased BMI, hip/lower extremity dysfunction and pelvic floor dysfunction are at higher risk for developing pelvic girdle pain during pregnancy.  A correlation with work dissatisfaction and lack of belief in improvement also exists.(6)

Therefore it extremely important to get an accurate and thorough past medical and social history.

Pain in the low back, buttock, possibly radiating down the leg sounds like a lot of things, doesn’t it? Sciatica, greater trochanteric bursitis, facet dysfunction, lumbar disc derangement.  It is important to do a good differential diagnosis to make sure your patient’s complaints are pelvic girdle pain.

It is important to do a good differential diagnosis to make sure your patient’s complaints are pelvic girdle pain.

Testing to rule out lumbar disc involvement, hip dysfunction (including transient osteoporosis and labral tears), and any other serious disease or psychological factors should be performed.(3)  Specific testing can also be done to diagnosis pelvic girdle pain.

Literature tends to agree that clustering tests yield the highest specificity and positive likelihood ratios, although which tests should be involved varies amongst the literature.  Combining the active straight leg raise for load transfer, posterior pelvic pain provocation test (P4)/thigh thrust, FABERs for posterior concurrent pain, lunge test and manual muscle testing of the hip appear to have the highest likelihood ratios.  Postural changes do not appear to be indicative of the development of or the intensity of pelvic girdle pain.(7,8)

Photo by: Sara Neff

Choosing Your Intervention

What does the literature say about treating pelvic girdle pain?

Well, a lot of the evidence for intervention is conflicting or weak.  Poorly controlled studies or studies where the population and interventions vary greatly makes it difficult to do a true meta-analysis of intervention.  So we need to go back to what we know and what is safe for both our patient and her baby.  Both the American College of Obstetrics and Gynecology (ACOG) and the Society of Obstetrics and Gynecologists of Canada (SOGC) recommend regular exercise during a healthy pregnancy.

I recently wrote a post about the importance of activity during pregnancy.  However, the literature is conflicting regarding therapeutic exercise for treatment of pelvic girdle pain.  Much research has looked simply at group exercise compared to ergonomic/postural education, acupuncture or no intervention.

The research investigating specific therapeutic exercise has been inconclusive.  

A recent systematic review concluded that there is no conclusive evidence to support exercise as a standard treatment for low back pain or PGP after determining only 2 studies to be of “good” quality.(9)  Other individual studies have found stabilization exercises to significantly reduce generalized back pain compared to no intervention.(10)  However, there are no studies that first classified patients (based on a differential diagnosis of the region) and then specifically treated based on the clustered tests.  The clinical practice guideline recommends clinicians consider the use of exercise in the antepartum patient because it is low risk and the RCT and studies have been non-specific.(2)  There is also a call for more studies.

So what about manual manipulation/therapy/massage?

Normal movement in all directions is advocated in our moms.(2)  This can include soft tissue mobilization, myofascial release, massage, muscle energy technique or even manipulation.  Studies have shown that adverse effects from high-velocity thrusts are rare, although several are documented.(11)

Every practitioner needs to decide their level of comfort when treating pregnant women.  Personally, I do not manipulate my pregnant women.  I feel they rarely need it, and I can accomplish the same goal with less aggressive manoeuvres.  Manual therapy continues to be a hotly contested intervention in the therapy world.  There is much discussion regarding what system and how we are actually affecting our patient’s pain and the pregnant population is no different.  The evidence for long-term pelvic girdle pain relief is weak, however, clinicians may consider manual intervention.  There is little to no adverse effects reported from manual therapy and may help back specific function2.

Overall the evidence is strong for predisposing factors and differential diagnosis. Conversely, our intervention evidence remains weak and conflicting at best.  More research is needed!  However, we can definitely do more intervention than we traditionally thought.  An accurate diagnosis is important as is the patient belief system.  If you have those two things, you’ll be in good shape.

References

  1. Albert HB, Godskesen M, Westergaard JG. Incidence of four syndromes of pregnancy-related pelvic joint pain. Spine. 2002;27;2831-2834
  2. Clinton, Susan C.; LaCross, Jennifer. Pelvic Girdle Pain in the Antepartum Population. Journal of Women’s Health Physical Therapy . July 2017 41(2):100-101
  3. Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008; 17(6):794-819
  4. Vleeming A, Stoechart R, Volers ACW et al. Relationship between form and function in the sacroiliac joint: part 1: clinical anatomical aspects. Spine 1990; 15:130-132
  5. Albert HB, Godskesen M, WEstergaard JG. Prognosis in four syndromes of pregnancy-related pelvic pain. Acta Obstet Gynecol Scand 2001; 80:505-510
  6. Kanakaris NK, Roberts CS, Giannoudis PV Pregnancy-related pelvic girdle pain: an update. BMC Medicine. 2001; 9 (1):15
  7. Albert HB, Godskesen M, Westergaard JG. Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain. European Spine Journal. 2000;9:161-166
  8. Cook C, Massa L, Harm-Ernandes I et al. Inter-rater reliability and diagnostic accuracy of pelvic girdle pain classification. J Manipulative Phys Ther. 2007; 30(4):252-258
  9. Lilos S, Young J. The effects of core and lower extremity strengthening on pregnancy-related low back and pelvic girdle pain: A systematic review. J Women’s Health. 2012;36(3):116-124
  10. Kluge J, Hall D, Louw Q, Therone G et al. specific exercises to treat pregnancy-related low back pain in a South African population. Int J Gynaecol Obstet. 2011;113(3):187-191
  11. Khorsan R, Hawk C, Lisi AJ, et al. Manipulative therapy for pregnancy and related conditions: A Systematic Review. Obstet Genecol Survey. 2009;64(6):416-427

Putting Your Safety As A Massage Therapist First

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It was the strangest thing to happen in my career to that point.

Something just felt off, right from the introduction to a new patient. I couldn’t explain it, it just felt off.

The patient came in and was very demanding. Telling me over and over again, “deep pressure is the only thing that works for me, it HAS to be deep pressure.”

Fair enough, I weigh around 215lbs, I should be able to put enough pressure into this.

After they got on the table, I went to work. As I pushed in with more pressure, I would continually check in to make sure they were satisfied with the pressure.

Then about 15 minutes into the treatment the patient abruptly said: “this isn’t working for me, I want to stop!”

I quickly asked if I had done something wrong?

“No, I just want this to stop now, it’s not working for me.”

I ended the treatment and said I would meet them outside when they were ready. As the patient exited the room, their hand reached out with a credit card in it. I said there would be no charge as it was only a 15-minute treatment (they were booked in for 45) and were also dissatisfied with it. But they refused and paid for the treatment.

I sat there even more confused (although happy I would have the next 1/2 hour to figure out what just happened).

As they walked out the door, the patient turned back and said: “thanks a lot for making me feel safe.”

Now, I was even more confused (and convinced the person had been sent in as a test or something), but even in the confusion, there was something that I was concerned with even more.

What about MY safety?

Right Of Refusal

This is where things can get a bit tricky.

When I look at our provincial bylaws (I’m just going to assume most other places are about the same) under the code of ethics there is a wide range of topic and wording that apply to us in practice. And that wording can be read a couple of different ways, depending on your interpretation.

To highlight a few that are applicable to the point of this post:

  • Massage therapists must set and maintain appropriate professional boundaries with a patient.
  • Despite section 23(iii), a massage therapist may immediately terminate the therapeutic relationship with any patient that:
    • sexualizes or attempts to sexualize the treatment or environment, or
    • threatens the massage therapist or otherwise endangers the massage therapist.
  • Massage therapists must protect and maintain personal and professional integrity.
  • Massage therapists must maintain a safe and healthy treatment environment.

Now granted, the colleges responsibility is to protect the public and most of these are probably in place with that thought in mind, as opposed to protection of a therapist.

The reason I bring all of this up is because of the story I mentioned in the beginning but also because, most of the time when I hear of someone who has been falsely accused of something (these are just things I’ve heard in passing, not from anyone directly who has been accused), I also hear, they regret not ending the treatment themselves because something just felt “off.”

Since we are to maintain appropriate professional boundaries with a patient, the responsibility lies with us. If the patient is going beyond a boundary it is up to us to end and or alter the treatment.

As laid out, we can terminate a therapeutic relationship if a patient threatens or otherwise endangers us as a therapist. In this case, I’m sure the intent was if a patient was actually threatening or physically endangering us. But what about when they are doing something that could possibly endanger your career, your mental health, or your overall well being? If something during the treatment happens and our gut tells us something isn’t right, we should have the full right to end that treatment. It won’t be easy to do, but in the long run, it could save not only a career but also mental anguish. This is also a way we can protect and maintain our personal integrity.

Since we are also expected to maintain a safe and healthy work environment, have we taken the time to think how that affects us as opposed to our patients?

In my past career before becoming an RMT, I worked in an industrial setting dealing with health and safety. The one thing that always came up was our right as employees to have a safe work environment. Part of those rights was the ability to deny unsafe work. If you were told to do a job but considered it to be unsafe, you had the right to deny doing it.

While you had to give sound reasons for why you considered it unsafe, the company could not force you to do it until the safety concerns were rectified.

In this case, if a patient is doing something that is setting off some red flags for you, it is your right to demand a safe workplace environment and in turn should be able to deny treatment to a patient if you think your safety is at risk.

Photo by: JESHOOTS

Working Alone

This is another one of those areas that is often overlooked because we are either self-employed or work as contractors.

There was an article being circulated a month or so ago, which highlighted a massage therapist getting killed on the job as she was doing mobile, home care work (I think it later came out that she was working under less scrupulous employment) with no one else around.

If someone was working as a mobile therapist by themselves, or even working alone in a clinic, there are certain safety guidelines set out through WorkSafe or department of labour that stipulate conditions that are to be met to protect someone in this case.

Some of the guidelines that are set out in order to protect someone working alone or in isolation are as follows:

  • Develop and implement a written procedure for checking the well-being of a worker assigned to work alone or in isolation.
  • Procedure for checking a worker’s well-being must include the time interval between checks and the procedure to follow in case the worker cannot be contacted, including provisions for emergency rescue.
  • A person must be designated to establish contact with the worker at predetermined intervals and the results must be recorded by the person.
  • Time intervals for checking a worker’s well-being must be developed in consultation with the worker assigned to work alone or in isolation.

So, if you are a clinic owner, think of how this applies to some of the people working in your clinics. Are there times in the day when they are at the clinic alone? Is anyone calling in to check on them? Are there emergency procedures in place if something were to happen to one of them?

How about for those of you who do mobile massage on your own? Do you have a check in system before and after your treatments? Does someone know your schedule for the day and the addresses you’ll be working at? Do you have a contact in case of emergencies?

This doesn’t have to be an expensive complicated endeavour, even if it is regular contact throughout the day to a loved one or co-worker, who can regularly check in with you, as long as there is constant contact with someone.

However, there are companies out there who offer this kind of check in service. When I used to work alone I would have to call in to a company every two hours. If they didn’t hear from me, they would try to make contact. If contact failed they would dispatch emergency help to come and check on me (fortunately this never happened). There are now even some phone apps available like this one to handle these types of scenarios. The whole point of this post was not intended to scare anyone, but as self-employed people, we rarely take the time to think about possible safety issues within our work. We are trained to constantly think about what is safe and appropriate for our patients, when in reality isn’t our safety just as, if not more important?

Therapeutic Exercise And Inversion Ankle Sprains

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When she came in, you could see the pain on her face.

Wincing with each step toward the treatment room, her limp was noticeable as she was protecting the ankle.

As I helped her sit down, of course, my first aid protocols popped into my head first, so I ran through the typical questions:

“What happened?”

“Did you hit your head at all?”

“Did you hear a pop in your ankle?”

“How are your pain levels?”

Fortunately, she didn’t hit her head and there was no “pop.”

She had just rolled her ankle and had a pretty typical inversion sprain, the swelling was already noticeable. What made it worse for her was the stress and worry of whether she could run as it was her favourite thing to do.

She wanted to get that ankle back to her normal activities ASAP.

Helping Protect The Injury

As I mentioned, the first thing I thought of was the first aid protocols when it comes to an injury.

This particular incident was obviously in the acute stage, so all the RICE protocols are the first thing I thought of. While there has been lots of debate online about using ice and rest, I still believe that in the acute stage it’s the best way to go.

Where I have changed my opinion is how long to use RICE.

In the past, we would use ice and rest for way longer (at least I did) than was probably appropriate. During the inflammation phase, (which is the first 48 hours) it is important to rest and support the tissues involved in the injury but still, keep up with some movement and continue to load the tissue within pain tolerances.

Since most of you probably already know how to rest, ice, and elevate I thought we would go over the compression portion and demonstrate how to properly wrap and inversion sprain, to give it some support and help control swelling over that first 48 hours.

Properly wrapping an ankle like this can give it that little bit of extra support (and confidence) in order to help the patient continue to move and also help with pain management.

Loading The Tissue

More and more over the past few years, we have been hearing and seeing more research on the importance of loading tissues post injury.

I’m sure we’ve all heard the stories about how they get patients up and moving almost immediately after surgeries.

Research is showing that loading the tissue or causing mechanical tension (muscular force) is actually a way to help influence wound healing. As the injury enters into the repair phase we can start to load the tissue even more.

This, of course, depends on pain and weight bearing abilities. If the patient can do full weight bearing pain-free you should be able to load the tissue more than if they can’t do full weight bearing. If they can’t bear full weight, giving the patient something to hold for balance will help decrease the amount of weight we are loading into the tissue and help with a decrease in pain, but still have the ability to move and load the tissue.

Here is an example of how you can begin some weight bearing exercises and load for an inversion sprain.

Once the patient feels more comfortable and pain has decreased, you can then progress them to this kind of exercise in order to load the tissue more:


As the patient continues to progress, here is a 3rd progression you can use to load into the injury more:


It is important to work within your patients pain tolerance when doing any kind of exercise, but one study showed that doing isometric contractions actually helped to decrease pain in patients with a tendinopathy. While an inversion sprain isn’t a tendinopathy, we can use it as a reminder that it is okay to load the tissue early in the healing process. So, in addition to doing some massage therapy, actually loading the tissue will not only help strengthen the area but also assist in decreasing pain for the patient. However you decide to set up your treatment plan, these are movements that can be taught in the clinic and incorporated into your treatment but also given as homecare exercises to help the patient progress. For those of you who don’t have “exercise” in your scope of practice, let’s just call it “therapeutic movement!”

What Is Really CI’d With Hypertension?

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Was it 140/90 or was it less than that?

Wait, 160/95 is what’s too high?

I always had a hard time remembering what was CI’d and what wasn’t. Positioning, heat, which blood pressure numbers were too high?

Many of these CI’s were based on massage increasing circulation, making it too hard on the heart when blood pressure was already too high.

But what about now that we know that massage doesn’t increase circulation and move fluids around like we once thought?

Are these things still a contraindication?

And do we really need to take every patients blood pressure before treatment?

Do We Really Need To Take Blood Pressure?

Part of the problem with hypertension is that it quite often goes unrecognized.

It has been called the “silent killer” because of the damage it can cause to the blood vessels, heart, brain and kidneys before any other noticed symptoms occur.

Where we need to pay attention is the degree of hypertension the person is experiencing.

  • Normal blood pressure: 120/80
  • Prehypertension: between 120-139 systolic over 80-89 diastolic.
  • Stage 1 high blood pressure; 140-159 systolic over 90-99 diastolic.
  • Stage 2 high blood pressure; 160 or higher systolic over 100 or higher diastolic.
  • Hypertensive crisis, a medical emergency; 180/110 or higher.

Looking back over my notes from college, we were told that 160/95 was contraindicated for a massage. This is probably true in the case of someone who doesn’t know they have hypertension and should see a doctor. If they are under the care of their doctor, they’re probably coming to see you for help with this very thing.

Which leads us to why we should be taking a patients blood pressure in the first place.

One paper examined the role of manual therapists taking blood pressure prior to treatments as an aid to their clinical reasoning, risk assessment, and vascular profiling. The paper presents three case studies where patients were having either neurological or musculoskeletal pain in the neck and/or thoracic chest area.

In each case blood pressure was taken, two of the cases were abnormally high, and one was low. Once the patients were referred out to appropriate care and the issues causing the rise or drop in BP was corrected, the issues they were experiencing decreased and manual therapy could continue.  The only way these issues would have ever been recognized was by the manual therapist taking blood pressure readings as part of their treatment protocols.

Also important is another study which showed a difference in blood pressure measurement depending on the position the patient was in. Systolic blood pressure decreased in semi-fowlers and sitting positions compared to being taken when the patient was supine. This stressed the importance of making sure measurements were being taken with the patient in the same position before and after treatment to get a true reading on whether therapy was effective.

If you took the initial measurement when the patient was sitting before the treatment started, then took a second measurement at the end of the treatment while they were laying on your table, your comparison before and after treatment wouldn’t be accurate.

So even if you think the patient you’re treating doesn’t fit the profile of someone who would be dealing with high blood pressure, it should still be part of your routine, especially if it’s the first time you’re seeing someone.

Photo by: Gadini

Shortening Strokes And Positioning

As we have discussed on this blog before about massage and circulation, many of the contraindications we learned in school probably aren’t as applicable anymore.

We were taught to shorten our strokes when it comes to hypertensive patients, but as research has shown, we aren’t increasing total body circulation, there is just a bit of circulation increase locally to the tissue we are working on. So, we probably don’t need to worry about specifically shortening our strokes with a hypertensive patient.

We were also told that positioning of the patient on the table could be a concern as well, we were instructed to not leave the person in the prone position for extended periods. Looking back through the textbooks and notes as I wrote this article, there was some good advice from one of the texts, the gist was that if the person could sleep in this position (eight hours sleeping compared to an hour on your table), they’re probably fine. Keeping communication open with that patient would be important, to see if they start feeling dizzy, or lightheaded during the treatment, but otherwise, you’re probably safe.

One study showed that just lying prone can actually help decrease blood pressure just as much as lying prone with a massage (however this study was done on healthy people and those with hypertension were excluded from the study).

Another systematic review(1) showed that massage therapy combined with antihypertensive drugs was more effective than just using the drugs alone. While researching for this, I found several articles and studies that show massage therapy to be an effective complimentary treatment for hypertension.

So with all this evidence, it’s safe to say there is a lot we can do to help patients with hypertension. Keeping in mind a few different things, like when pressure is high enough to dictate an emergency, communication with your patient and knowing that a regular length stroke is okay, there shouldn’t be too many issues with your treatment. As we continue to try and gain respect as healthcare professionals, this is one easy step we can use to add to our clinical reasoning and risk assessments when dealing with our patients. If one of your patients is coming in for this specifically, take their blood pressure before and after the treatment (with them in the same position), so you can prove what you are doing is helping them, and communicate that information with their family doctor as well. I guess I’ll have to go buy one of those digital blood pressure cuffs now, they’re probably more accurate and less of a chance I’ll screw it up when using it.

References

  1. Xiong X, Li S, Zhang Y. Massage therapy for essential hypertension: a systematic review. Journal Of Human Hypertension [serial on the Internet]. (2015, Mar), [cited July 10, 2017]; 29(3): 143-151. Available from: MEDLINE with Full Text.

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