Graded Exposure

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Graded exposure is a key concept in understanding how to reduce pain caused by movement.It’s a very common sense idea, and one that most people kind of know at some level, because there is profound truth to it.

But it’s also an idea that most people will probably fail to put into practice in a systematic way. Here’s a brief discussion of what it is, why it works and how to do it.

What is graded exposure?

Graded exposure is a process by which you slowly and progressively expose yourself to some form of stress, in order to make you less sensitive to that form of stress.

In the context of movement, it means the progressive introduction of threatening movements, in the right dosage and timing, in a way that makes them less painful. This might happen in one of two ways – through causing a change in the body, or a change in the way the nervous system perceives threats to the body.

Tissue Adaptation – Make Your Body Stronger

There is some physiological truth to the idea that what doesn’t kill you makes you stronger.

According to the SAID principle, the body will adapt to get better at withstanding specific forms of stress, provided they are experienced to a sufficient degree.

For example, when the muscles are stressed enough by lifting weight, this causes micro damage that stimulates changes in muscle physiology. These changes will make the muscles stronger and less likely to get damaged by the same weight in the future.

With this principle in mind, you can get stronger and stronger by progressively overloading your muscles over time.

The trick is to expose yourself to stress in a graded manner – enough to stimulate adaptation, but not enough to cause injury or prevent healing.

The same principle can be applied to rehab injuries, especially overuse injuries like tendonosis.

The difference is that in this context, getting the right timing and dosage is much more difficult, because the likelihood of injury or incomplete recovery is greatly increased. This makes it harder to find the “sweet spot” where you apply enough stress to cause adaptation, but not enough to cause or worsen injury.

A careful and systematic approach is required.

For example, if you are currently experiencing pain in your foot after running a mile, you could try running just short of a mile, and then slowly inching your way upwards in distance, making sure that you are not making the pain worse.

If you succeed, this might be a sign that you are applying enough stress to the tissues to get them to beneficially adapt, but not enough to cause injury or prevent them from healing.

Most clients find this strategy fairly easy to understand, if not to apply.

The more complicated explanation for why graded exposure might reduce pain associated with a particular movement is that it makes the nervous system less threatened by the movement, even though the tissues are not really adapting in any meaningful way.

Nervous System Adaptation – Disassociate Pain And Movement

We experience pain in relation to movement when the nervous system perceives that the movement is threatening to the body.

Like other perceptions, the perception of threat is an interpretation that is subject to change based on a wide variety of information. A program for graded exposure can offer the nervous system new information about a movement that might cause a change in perception.

If you can find a way to perform a currently painful movement at a low enough intensity that it does not hurt, you are sending the nervous system feedback that the movement is safe.

If you do this repeatedly, perhaps the nervous system will start to disassociate the movement from the pain.

This is the same rationale underlying many treatments for anxiety and phobias.

Here’s an analogy to illustrate. If a child wanted to convince his overprotective mother that it was safe to play at the playground, he would first need to show her that he can play without getting hurt.

A good strategy would be to start slowly with the safest activities, and then move to more dangerous ones, all the while showing Mom he is safe from injury or threat.

Hopefully Mom will eventually chill out.

You can go through a similar process of graded exposure to show your nervous system that a particular movement is safe. If running three miles causes panic, try running just one and see if that is acceptable.

Then slowly inch the mileage upward and monitor the response.

Summary: Graded Exposure Sends Good News

A major goal of any program for movement health should be to send as much “good news” to the nervous system as possible about the state of the body, and its ability to withstand the stress of movement.

Whether this is done by making the body stronger, or making the nervous system less concerned about the strength of the body is sometimes irrelevant.

Either way, the formula for movement success is the same.

Start moving how you want to move, make sure you’re not in pain during the process, and then move a little more next time. That’s graded exposure, and it’s how we get better at anything. Like many other ways to improve health, it’s simple but not easy.

Can Massage Therapy Help Scoliosis?

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Her text read: “Hey old man, I’m going to invoke my ‘you’re family so I need your professional opinion’ rite”

My cousins’ oldest daughter was diagnosed with scoliosis and was told that spinal fusion surgery was the only option, it was progressing fast.

On a daily basis her pain was a 6-7 out of 10.

She was experiencing a lot of hip pain and had issues raising her arms above her head.

The scoliosis had gone undetected until she started having some TMJ issues and the family chiropractor discovered it.

At the time of diagnosis she said it was a 41/43 curve.

When I asked if they were told the cause, they said it’s usually hereditary but there is no family history, so it may just be a random condition.

In her case it is a curve to the left (levoscoliosis), however the most common is a curve to the right (dextroscoliosis) which is another reason why doctors had chalked it up to a random occurrence.

Types Of Scoliosis And Surgery

There are six different types of scoliosis and most of the time the cause is unknown (as in my cousins case) but can also come on because of a neuromuscular condition or as part of a separate syndrome a person is dealing with.

They will typically present where the spine has “S” curve or a “C” to the right or left side.

In cases of idiopathic (unknown) scoliosis they are grouped into three different categories:

  • Congenital
    • you are born with the condition
  • Early onset
    • occurs between birth and 10 years of age
  • Adolescent idiopathic
    • happens between the ages of 10 and 18

Now when she told me the curve was a 41/43 I didn’t know what that meant, so I reached out to a couple of chiropractor buddies of mine to see how this they come up with that number and what it means.

This is done by using an assessment tool called the “Cobb Angle” and according to clear-institute.org this is how the measurement is done:

Lines are drawn along the top of the superior tilted vertebra and the bottom of the inferior tilted vertebra. Two more lines are drawn at an angle of 90 degrees to these lines, perpendicular so that they intersect. The resulting angle is measured, and the number is expressed in degrees.

The main methods of treatment in these cases is through bracing or surgery.

Bracing is used when the curve is small in children that are still growing.

Surgery is recommended when the curve is 45-50 degrees or more and depends on how much growing is left for the child to do. Metal rods are fused to the spine to limit the how far the curve can further develop and the use of bone grafts fuses together with the existing bone to form one unit with the spine.

There are two types of surgery, one is done from the back of the spine and the other is done from the front.

One review of scoliosis surgery showed that idiopathic had an average of 6.3% complications, 0.8% neurologic deficits and a 0.02% mortality rate and encouraged this data to be used in the decision making process before agreeing to surgery. (1)

New developments in surgery have seen the use of growth friendly implants instead of a full spine fusion, which allows the spine to grow while correcting the deformity, however it requires multiple surgeries and in turn more complications. (2)

But is surgery the only solution?

https://upload.wikimedia.org/wikipedia/commons/3/3b/Medical_X-Ray_imaging_AOX02_nevit.jpg

Photo by: © Nevit Dilmen [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

Scoliosis And Massage Therapy

There is definitely some differing opinions on the best form of treatment, especially as the scoliotic curve progresses.

Some research says the only solution is surgery as it is the most permanent form of intervention and physical therapy will be a constant work in progress.(3)

However there is an argument being made that a more conservative approach that would include observation, scoliosis specific exercises and bracing is effective. The mini review showed that the use of  exercise and proper bracing can reduce a curve larger than 45 degrees in 70% of adolescents which could alter surgery indication to above 50 degrees.(4)

There is a great resource outlining exercise and bracing approach from seven different scoliosis schools and their approach, which you can look at here.

Overall there isn’t a ton of research I could find based on massage therapy and scoliosis, dealing with treatment around the adolescent idiopathic level. However there is strong evidence on the use of massage and reduction in pain with adults who have scoliosis.

We won’t be able to correct a curvature, but providing pain relief and improving quality of life is important to anyone who has this condition. In college we were taught massage should be provided to the concave side of the curve, due to the tightness and tension of the muscles pulling the spine in that direction. Stimulatory techniques were to be applied to the convex side to promote strengthening those muscles to assist in correcting the curve. Overall the use of massage/physical therapy and exercises can be a beneficial treatment which could possibly delay a surgery, or possibly prevent surgery. However as the Scoliosis Association of the UK points out, the need for surgery usually isn’t urgent and the more important consideration is how the child and the family feel moving forward. If we can be a source of pain relief through the use of massage and movement exercises, as well as a source of information for anyone dealing with this, then perhaps we can help improve that quality of life whether the family chooses surgery or not, because no kid should have to live with pain everyday.

 

References:

  1. Reames D, Smith J, Fu K, Polly D, Ames C, Shaffrey C, et al. Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society Morbidity and Mortality database. Spine [serial on the Internet]. (2011, Aug 15), [cited December 18, 2016]; 36(18): 1484-1491. Available from: MEDLINE with Full Text.
  2. Yang S, Andras L, Redding G, Skaggs D. Early-Onset Scoliosis: A Review of History, Current Treatment, and Future Directions. Pediatrics [serial on the Internet]. (2016, Jan), [cited December 18, 2016]; 137(1): Available from: MEDLINE with Full Text.
  3. Greene J, Sallee D. Scoliosis in teenagers and common treatment and intervention methods – a systematic review of SportDiscus and AMED literature. Virginia Journal [serial on the Internet]. (2015, Fall2015), [cited December 18, 2016]; 36(2): 13-18. Available from: SPORTDiscus with Full Text.
  4. Sy N, Bettany-Saltikov J, Moramarco M. Evidence for Conservative Treatment of Adolescent Idiopathic Scoliosis – Update 2015 (Mini-Review). Current Pediatric Reviews [serial on the Internet]. (2016), [cited December 18, 2016]; 12(1): 6-11. Available from: MEDLINE with Full Text.

Can Saline Injections Augment Massage Therapy?

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“I’m not going to be able to get a massage for a few weeks because I’m getting saline injections done”.

For some reason I’ve been hearing this a lot lately, mostly from patients who have been in a car accident.

I get the feeling it’s being promoted as a “cure all” when I talk to patients about it, especially for those who are experiencing pain from a complicated issue (ie: car accident) for the first time.

So far I have seen patients who are experiencing chronic pain (a year or two post accident) to those who are only a few weeks/months after, who are giving this a try.

It has been described a few different ways as well, saline injections, sugar injections and nerve blocking but could never make heads or tails as to what was actually going on, or whether it actually works.

Some patients have had the therapy done and I don’t see them again for ages, while others are back within weeks for more massage.

So I figured it was time to take a hard look at what’s happening.

Saline Injections And Prolotherapy

Like most of you I’m sure, the first I heard of saline injections was from the Travell & Simons textbooks we got in school to learn trigger point therapy.

Most of what I remember in those books were images of trigger point injections with referral patterns etc., and as we know our understanding of what trigger points are has changed.

But the use of saline injections is still being used and has developed into further applications called Prolotherapy.

Turns out there are three different types of Prolotherapy:

  1. Growth factor injection: injecting a growth factor (plasma) to stimulate growth of certain cells.
  2. Growth factor stimulation: injecting something in the body that produces growth factors.
  3. Inflammatory prolotherapy: inject something that causes inflammation and tricks the body into thinking there is an injury and begin healing again.

From looking into research and checking things out online, it looks as though Prolotherapy is used more to work on ligaments and tendons (is also being used with osteoarthritis), compared to trigger point therapy which is focusing more on muscle.

So my question is whether these kinds of therapy are actually effective for the patients who are being referred out to have it done?

Well, like so many other things in therapy…it depends.

Low Back Pain And Whiplash

There are frequent statements in the research I could find that mentioned the effectiveness of these treatments as “unclear”, and tough to find any resounding positive studies to prove the effectiveness of injections.

One systematic review showed that in the case of whiplash, symptoms were better when sterile water was used compared to saline and was more effective in the short term (3 months) compared to long term (8 months).

It showed that trigger point injection was successful at reliving symptoms when used as the sole treatment, but could be better used as something to augment additional therapy like stretching. But since there wasn’t an additional study group that did stretching alone, it is hard to determine how much of a difference trigger point injection would make.

One study showed that intracutaneous injections of sterile water was beneficial both in pain reduction and improving function in patients with acute low back pain.

The study ruled out anyone who had any major back injury or condition like fracture, stenosis or osteoporosis as it would be inappropriate. Another study with the same exclusion criteria showed that saline injections are not recommended for patients with chronic low back pain due to nerve issues.

Those with chronic non-specific low back pain there can be a reduction in pain when injections are made into ligaments, but it does not appear to matter if saline or another prolotherapy solution is used.(1)

When an epidural is done to manage spinal pain, a saline injection is shown to have a lack of effectiveness when compared to using local anesthetic alone and when local anesthetic is used in conjunction with steroid. (2)

However research has been done to show that saline injections are equally as effective as conventional drugs for treating low back pain and other myofascial pain syndromes in a hospital emergency room setting.(3)

Now I know this is a lot of different types of low back pain to discuss, but research is showing that sterile water and saline injections are helpful in acute stages of injury, but not as effective in chronic conditions.

Photo by: Army Medicine

Photo by: Army Medicine

Tendinopathy And Arthritis

The best information I could find was for treatment of tennis elbow as far as a tendinopathy.

One study compared the use of a saline injection against a corticosteroid. It showed that in the short term there was better pain reduction with the corticosteroid, but after 24 weeks the saline injections were working better.

In a comparison between corticosteroid, autologous blood injection and saline for tennis elbow, there was no real improvement compared to the placebo saline injections.

When it comes to arthritis, I found a study and a systematic review on the affect of saline injections for knee Osteoarthritis.

The study said that using a saline injection did not significantly reduce pain in the knee compared to a saline placebo. (4)

Whereas the systematic review makes the argument that due to the pain relief shown in the studies, we should be considering the effectiveness of saline injections.

32 studies involving 1705 patients showed improvement in short term knee pain from saline injections. And 19 studies involving 1445 patients showed improvement in long term knee pain.

While saline injections were originally used as a control or placebo in studies, research is starting to challenge that it does have a therapeutic benefit. Most of the studies cited in this post argued that in the acute stages there is a pain relief and functional benefit to using saline injections. While this isn’t something we are going to be doing as massage therapists, it is important for us to know what could be happening with some of our patients. Any one of our patients who is dealing with chronic pain, whiplash, osteoarthritis or a tendinopathy could be referred by their doctor to have some of these treatments done. It is important for us to understand what and how this is done, so we can better support and stay informed with our patients. Remember, one of the studies showed that trigger point injection might be better as a way to augment additional therapy…like maybe massage therapy!?

 

References:

  1. Yelland M, Glasziou P, Bogduk N, Schluter P, McKernon M. Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial. Spine [serial on the Internet]. (2004, Jan 1), [cited December 12, 2016]; 29(1): 9-16. Available from: MEDLINE with Full Text.
  2. Manchikanti L, Nampiaparampil D, Manchikanti K, Falco F, Singh V, Hirsch J, et al. Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials. Surgical Neurology International [serial on the Internet]. (2015, May 7), [cited December 12, 2016]; 6(Suppl 4): S194-S235. Available from: MEDLINE with Full Text.

  3. Bakunas C, Bayona A, Roldan C, Rehrer S, Leoni J, Hu N, Banuelos R/ University of Texas Health Science Center at Houston, Houston, TX

  4. Lundsgaard C, Dufour N, Fallentin E, Winkel P, Gluud C. Intra-articular sodium hyaluronate 2 mL versus physiological saline 20 mL versus physiological saline 2 mL for painful knee osteoarthritis: a randomized clinical trial. Scandinavian Journal Of Rheumatology [serial on the Internet]. (2008, Mar), [cited December 12, 2016]; 37(2): 142-150. Available from: MEDLINE with Full Text.

How to Simultaneously Empower and Manage Your Therapists

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Managing a massage therapy practice can be challenging; especially when some, or all, of your therapists are independent workers that get paid by appointment.

To confuse matters further, each therapist has their personal schedule, and often a schedule at another clinic or spa to accommodate.

So how do you ensure your business runs smoothly under these awkward conditions all while being professional in the eye of the customer?

Luckily, there are a wide range of cloud-based software applications that can help you manage your massage clinic more efficiently, and boost results. In particular, online scheduling applications have tons of useful features that streamline the appointment booking process between you, your receptionist, and your Massage Therapists.

Here’s a list of 4 pain points commonly faced by massage clinic owners and things you should look for when choosing a scheduling application.

1. Managing Your Therapists Sporadic Schedules

Massage therapists are frequently hired as independent contractors on an appointment basis and only come in when they are booked.

As you may not be able to provide them with enough appointments, often times they will also work for themselves and/or another massage practice. Knowing when they are available to work can be an overwhelming task.

Do any of these situations sound familiar?

  • The therapist isn’t actually available on the given date and time, you must then scramble to find another therapist to fill the already booked appointment.
  • You may have no choice but to call back the client and embarrassingly ask to reschedule the appointment if he or she absolutely wanted the specific therapist or you cannot find a therapist for that slot.
  • The therapist may just, not show up if there is a conflict in his or her schedule that you were not aware of.

Making sure you know if and when a therapist is available to work is essential.

Many scheduling applications allow you to configure a regular, recurring weekly staff schedule.

However, you should also inquire whether it is possible to program irregular and/or upcoming schedules.

It is also a huge time saver if therapists can update their own schedules through their unique user login for last minute changes to specific calendar dates.

 

2. Educating Your Therapists About the Client While Protecting Your Client List

From talking to massage therapy business owners, it is clear that protecting client data is a tremendous concern as therapists need to easily access data to better serve clients.

However, depending on the employment relationship, (and depending on rules and regulations with your specific college) therapists may not have the right to solicit clients post employment and/or automatically walk out with client files.

You can therefore take steps to ensure therapists don’t just leave with your entire client list including phone numbers and e-mail addresses.

Even when therapists are not employees, you can protect data and ensure confidentiality of personal information by limiting access to their patients only – not the entire clinic’s database (again, depending on rules and regulations in your area).

Some features to look for in a software that help protect your client data:

  • Make sure you can create different types of users with different levels of access and privileges.
  • Absolutely make sure only administrators can export your client database.
  • If allowing therapists to book their own appointments, see if you can limit client database access to their clients only.
  • See if you can also hide client info like telephone numbers and e-mail addresses.
  • Verify if there are any logs available to track general user actiity.

And DO NOT SHARE YOUR ACCOUNT OWNER ACCESS with any of your staff.

Take the time to create an additional profile for your receptionists and therapists. This makes it easier to terminate access to your client data when someone leaves.

3. Enabling Therapists to Manage Their Own Appointments

If you own a multi-practice clinic whose main services are not massage therapy, but still want to offer massage therapy as an added service without adding to your administrative workload, then empowering your therapists as much as possible can save you a lot of time and make you more money.

Many software applications with different user types include a profile that allows the therapist to book, cancel and/or modify appointments for themselves.

This enables the therapist to fully manage his/her schedule and appointments securely while allowing you to still oversee everything.

In addition, why not encourage a therapist to book the client’s next appointment after their massage treatment has been completed by using a tablet connected to your cloud-based software application.

Photo by: FirmBee

Photo by: FirmBee

4. Reducing No-Shows

No-shows are another major issue for any massage therapy business as this leads to lost revenue and idle time for your therapists.

The no-show rate can easily be reduced by implementing a software application that sends out automated appointment reminders.

It is incredible how a simple e-mail or text message reminder sent out a couple of days before the appointment allows clients to inform you in a timely manner of changes to their availability and eliminates forgotten appointments.

Also, stop wasting time calling all your clients to confirm their appointment as many people of today’s generation do not even answer their phone calls.

Instead find a system that lets clients confirm their appointments themselves either by e-mail or text message. Automating appointment confirmations is a great feature giving you and your therapists the certainty that your client will be attending his/her appointment with minimal to no intervention on your part.

Other features that can reduce no-shows include asking for a credit card number or deposit at the time of the booking. If people know they will lose money, they will think twice about skipping out on their appointment.

All in all, if you are still using paper or an outdated software application, look into a web-based appointment booking system. This will allow you to run your business more efficiently and stay connected with your therapists. The entire team will be happier and experience fewer administrative frustrations. Even Massage Therapists need less stress in their lives.

Treating A Diabetic Reaction In Your Massage Clinic

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It was a few years ago and we were having a great conversation about our favourite topic, hockey.

Being a big Jets fan, he excitedly told me the news that Winnipeg was approved to get their team back.

You could feel the excitement come across the phone: “did you hear the Jets are coming back!?”

Not 30 seconds later, he said it again: “did you hear the Jets are coming back!?”

Umm yeah, we just talked about that.

Then he repeated it again, this time his speech was a little slurred.

Something was off.

Then I clued in and asked: “did you take your insulin this morning?”

“Why would I do that”, his speech was getting more slurred.

“When was the last time you ate?”

“Why would I do that, I don’t need anything!?”

I hung up and started phoning every extension in the office, no one was answering.

I drove to the office and found him slumped over his desk, looking and sounding very confused.

The small sugar drink he had taken wasn’t working, or more likely just wasn’t enough.

I ran next door to the coffee shop and grabbed some food, Coke and orange juice.

When I got back, I held everything up and asked what would work best.

He pointed at the Coke.

I took the top off, handed it to him and he took a sip. He sat up a little, then took another drink. The third drink perked him up some more, with each drink his condition improved.

Then he looked at me and said: “what the hell were we talking about!?”

“Hockey”

“Oh yeah, did you hear the Jets are coming back!?”

Understanding Types Of Diabetes

I’m sure we all know someone and have at least a few patients who have diabetes. However it is important to know which type of diabetes they have.

There are two different classifications, although one kind doesn’t get talked about or recognized as much.

  • Diabetes Insipidus:
    • Results because of dysfunction of the posterior pituitary.
    • Causes defects in antidiuretic hormone (ADH) receptors or can’t secrete it.
    • Neurogenic Diabetes Insipidus makes too much ADH because of a brain injury.
    • Nephrogenic Diabetes Insipidus the kidneys do not respond to ADH which results in too much urination leading to dehydration.
    • This type of diabetes is typically treated with hormone therapy.
  • Diabetes Mellitus:
    • The more common form of diabetes, with classification of Type 1 and Type 2 resulting from an inability to make or use insulin.
    • Type 1 referred to as juvenile diabetes or insulin dependent, the persons immune system destroys the beta cells in the pancreas, so they don’t produce insulin.
    • People with Type 1 typically have to take insulin injections to deal with the condition.
    • Type 2 aka: non-insulin dependent diabetes or adult onset diabetes most commonly caused by cells becoming less sensitive to insulin.
    • Type 2 diabetics may need insulin injections but it is typically managed with checking blood sugar and regulating with diet.

Diabetes Mellitus is the condition we are most likely going to be faced with in our clinic, so it is important for us to understand what is happening and how to deal with this if we are ever faced with someone having a diabetic emergency before or after a treatment.

If someone who requires the use of insulin takes too much (hyperinsulinism) this can cause the body to use up any extra glucose in the blood (hypoglycemia), which then deprives the brain of the sugar it needs.

When this happens the brain cannot function properly and the body begins to shut down.

If someone is having this kind of a diabetic reaction, it can eventually lead into a diabetic coma and eventually death if it is not dealt with appropriately.

It is then our responsibility as healthcare professionals to be able to recognize and deal with this, preventing the coma and reversing the reaction.

Signs And Symptoms Of A Diabetic Reaction

If we have a patient with diabetes, chances are it is going to be Type 1 or 2.

Those with Type 2 typically manage their blood sugar with diet and monitoring blood sugar levels (sometimes they use insulin as well). This comes on later in life, usually past the age of 35.

However those with Type 1 (who use insulin) can end up suffering from hyper or hypoglycemia.

If they are experiencing hyperglycemia, there is sugar in their blood, but not enough insulin to allow their cells to be receptive to the sugar.

When this happens the body attempts to get the sugar from other sources, such as fats from within the body. This produces increased waste in the body and knocks pH balance off and the person starts to feel ill.

When the person is experiencing hypoglycemia (not enough sugar), the sugar in the body is used up and in turn affects brain function which can be life threatening.

This can be caused by a few different things:

  • Takes too much insulin.
  • Hasn’t eaten enough, or regularly enough.
  • Exercise has burned off their blood sugar faster than normal.
  • Great emotional stress.

In order to recognize a possible emergency, there are similarities between the hyper and hypoglycemic conditions:

  • An altered level of consciousness, dizzy, drowsy and confused.
  • Rapid breathing.
  • Rapid pulse.
  • Feeling ill as well as looking ill.

If you know one of your patients has diabetes and starts to show any of these symptoms, it is essential to provide the appropriate care.

Photo by: stevepb

Photo by: stevepb

Providing Care During A Diabetic Emergency

There are some specific steps to take when trying to help someone during a diabetic emergency.

If you’re not sure why the person is having an issue, we do what is called a Primary Survey. Check to see if they have their ABCs (Airway, Breathing, Circulation). If they are unconscious, call 911.

If they are conscious and speaking to you, then the ABCs are present and you can go into your Secondary Survey.

During the Secondary Survey we do a quick check of the rest of the body to see if there are any injuries that could be causing the issue. It’s just a quick rapid scan of the persons body from head to toe looking for possible injuries.

This is where you could possibly find a medic alert bracelet or necklace that could tell you they are diabetic. Nowadays some people are also getting them as tattoos, so you may see this as well.

Assuming the person can talk to you, then there is a series of questions to use called the SAMPLE questions. It is just a simple mnemonic which can help you determine what is going on:

  • S – signs and symptoms?
  • A – allergies?
  • M – medications?
  • P – past medical history?
  • L – last meal?
  • E – events leading up to the emergency?

In the case of a diabetic emergency, there are a few questions that can really help you out.

If you didn’t already know it was a diabetic emergency, knowing their medication (insulin), past medical history (diabetes) and their last meal can give you great insight into what is going on.

The person might tell you right away what is wrong and ask for something to help, but just in case they don’t, asking those questions can get you the information you need.

Now that you have determined the emergency, we need to get sugar into their system.

Keeping fruit juice, candy or non-diet soft drinks in your clinic are all great resources to help someone in this condition. After they have some sugar, it will help quickly, actually it’s surprising how quickly it can turn things around.

If the person is unconscious, do not give them anything, you could end up compromising the airway and making things worse.

Just monitor their ABCs until further help arrives.

There is a bit of controversy about determining the difference between hyper and hypoglycemic conditions as there could be a concern about giving someone sugar who already has too much sugar in their system.

While this could cause some more damage, it is not going be as life threatening as it is for someone who has low blood sugar and needs to get sugar in their system.

For our purposes in a clinical setting, we are going to treat the person with sugar because it will be difficult to know which condition is causing a problem.

Since we are not authorized to give medications we don’t inject insulin for people. If this happens before a treatment, you cannot carry on with the massage even if the patient has some sugar and starts to feel better. They need to go eat a proper meal to help balance out blood sugar. It doesn’t mean they need to go to the hospital (unless they don’t start to feel better within five minutes of getting sugar in their system), remember this is something they deal with on a regular basis (if they go unconscious, call 911). Since 9.3% of the population has diabetes and a large population remains undiagnosed, as well as the prevalence of gestational diabetes affecting 9.2% of pregnant women, there is a strong chance you will have to deal with this kind of an emergency in your clinic one day. Knowing the signs, symptoms and ways to deal with it will be the biggest way you can help any one of your patients should this happen. And yes, the Jets came back and I still get to talk to my buddy about it regularly.  

How Not To Rub Your Patients The Wrong Way

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Your client is coming to you in order to feel better. They want an experience that is going to relax them or perhaps even energize them. They’re not coming to you to be rubbed the wrong way.

A good client consultation requires more than just technique in massage and the administration of physical therapies.

Your goal should be to give them a complete therapeutic experience not only for their body but their mind as well.

Here are three ways you can avoid rubbing your client’s body and mind the wrong way.

Ask Questions

One of the things I did as a matter of routine at the beginning of any client session was to ask them what they enjoy most about massage.

This might seem like a redundant question when you’re there to provide therapy, but your clients are looking for a rewarding experience.

Knowing their pain points as well as their pleasure points will make you much more sensitive to their needs and far more likely to result in the satisfying massage experience for your clients.

I have been massaged many times by professionals who never asked me anything beyond how I was feeling. All you have to do to win me over is massage my legs.

You can do that all day long, and I would walk out feeling great.

But if you fail to ask questions and just move on assumptions you’re probably going to spend an hour on my neck, and I’m just going to be irritated.

Sure, my neck may be the presenting problem, but part of remedial therapy is to bring the entire body back into a harmonic state.

And one of the best ways to bring the body back into a harmonic state is to compensate the discomfort with a positive experience.

Be Dedicated to Your Client

Your clients want your attention. They want a commitment from you.

A single-minded passion and focus on your profession and your client can take you a long way in the therapeutic and massage industry.

Robert Granter, a leading educator in soft tissue dysfunction and a trainer at the Melbourne Institute of Massage in Australia, entered the profession as a patient. Robert says he was so impressed by the effectiveness of the treatment that he decided to enter into the field himself.

His dedication, which includes a dedication to the clients themselves, has taken him to several Olympics and Commonwealth Games events as a therapist and opened up many doors for him in his profession.

Commitment means a willingness to not only improve your therapeutic and remedial skills, but it also means being entirely focused on the client right in front of you.

Your clients know when you are inattentive. They will sometimes twitch and move in discomfort on the table. Too shy to say anything, they are hoping you will respond by either adjusting your method or asking a question.

If your mind is distracted with the cares of this world and your other responsibilities, that disinterest in your client will filter down into your fingers, and your client will notice it.

They may not say anything but their feet will do the talking and you won’t see them again.

Continue to Develop Your Communication Skills

One of the motivations your clients may have in coming to see you is to unwind through communication. Others want complete silence so that they can let their minds rest.

Your job as a therapist is to know, when, what and how much verbal communication to engage in.

Not only that but when you do speak you want your words to further the therapeutic process, not detract from it.

There are countless therapeutic schools which provide training in the technical aspects of Massage Therapy but nothing else. If you want a thriving practice, one that grows over time, then it is in your best interest to continue your training.

One of the ways that you can do that is to develop your therapeutic communication skills.

I have found the study of things like neuro-linguistic programming (NLP) and other similar therapeutic modalities to greatly enrich my clients experience as well as my effectiveness as a therapist.

Whatever form of remedial massage therapy you are involved in, your goal is to provide the most satisfying experience for your customers and your clients.

Take these tips and find ways to implement them and perhaps even adjust your mode of operation so that both your professional expertise and your business will grow.

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