Concussion Management For Massage Therapists

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

– Mark Lovell

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

– Keith Primeau

The sound from the hit echoed through the arena.

He laid there motionless on the ice.

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

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

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

Thank god…he’s breathing.

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

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

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

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

“No, it’s good, just my head”

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

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

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

Everything bothered him and his headache was getting worse.

Even the lights in the room were causing an issue.

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

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

Some of the questions made sense.

Do you remember the hit?

Do you know what day it is?

Do you know approximately what time it is?

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

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

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

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

First Aid Protocols For Acute Concussion

As research develops so does concussion protocols.

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

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

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

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

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

Eye Opening

Open Spontaneously (4)

Open To Speech (3)

Open In Response To Pain (2)

Do Not Open (1)

Verbal Response

Communicates Normally (5)

Confused (4)

Inappropriate Words (swearing) (3)

Confused Sounds (groaning etc) (2)

No verbal response (1)

Motor Response

Obeys Commands (6)

Localizes Pain (swats your hand away) (5)

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

Abnormal Flexion To Pain  (3)

Extension To Pain (2)

No Response (1)

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

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

SCAT3 A Valuable Tool For Massage Therapists

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

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

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

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

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

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

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

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


Photo by: University of the Fraser Valley

Massage Therapy Treatment For Concussions

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

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

Was it a car accident?

Sports injury?

A fall?

Has the person suffered a concussion before?

Which direction did impact come from?

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

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

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

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


How Massage Therapists Can Recognize And Deal With A Heart Attack

“I have had a few times in practice where I’ve caught a myocardial infarction and called 911, if this has yet to happen to you, be forewarned, it will” – Robert Libbey RMT


I’ll never forget that day walking into the hospital.

He didn’t look like himself and wasn’t acting like himself.

He was too young for this to happen and I was too young to really understand it.

Years later he told me the story about, feeling chest pain at home and thought there was something wrong so he jumped in the car and headed to the hospital.

Halfway there he lost the use of his arms and had to steer with his knees.

My dad was in his thirties and had a heart attack. I use this story whenever I teach a First Aid course. You wouldn’t think an otherwise healthy guy in his 30’s would suffer a heart attack, let alone one with two young boys and a wife at home.

Thankfully he survived but had an issue with his heart a couple years later.

We had to change the way we did things, the way we ate and the way we lived.

He wasn’t sure how to recognize what was happening that day or even acknowledge that it was a heart attack.

How about you?

Could you recognize it if this happened in your clinic, or to one of your family members?

Differentiating Chest Pain In Your Massage Therapy Clinic

I’ve said it before and will continue to harp on it.

As healthcare professionals this is something we really need to be able to pick up on, which isn’t always easy to do.

If someone is having a heart attack, they really don’t want to admit it. Their mortality is staring them in the face at this point and realizing that something major is going on isn’t an easy thing to face, in fact most people will completely deny the possibility they are having a heart attack.

That day my dad didn’t want to admit things might be worse.

It would have been fatal if things has progressed anymore on the drive to the hospital. Thankfully he didn’t drive off the road when he lost the use of his arms.

We need to realize the differences in pain to understand whether someone is having a heart attack, indigestion or if something muscular is going on.

If you are going through your typical assessment before a treatment and your patient is having brief chest pain as a result of bending or breathing deep, it’s probably not a heart attack.

Some even feel that it is, or starts as indigestion. However, if it is a heart attack it will continually get stronger over time.

If someone is having a heart attack I have heard it described as “an elephant sitting on my chest”.

While writing this post, I called my dad to ask what the pain was like. He said:

“It felt like someone drove a sword through my chest, pain down both arms and through to the back, it was ten times worse than having any kind of indigestion”

The pain can range from mild to a description of squeezing, or tightness and constricting to a crushing feeling in the chest.

If one of your patients is having chest pain and it lasts longer than ten minutes, it’s time to get them some help.

Signs And Symptoms For Massage Therapists To Recognize

These are going to be a bit different between women and men.

As my dad mentioned he had pain going down both arms. Generally, it will be in the left arm as well as going up the neck and into the jaw. These signs are pretty much the norm when it comes to men.

With women, they quite often get low back pain. Women can also exhibit some soft signs, which are a little harder to pick up on, but just as important to understand and read because it sometimes goes unrecognized.

Some of these can be stomach pain, flu symptoms and some chest pain that changes with the level of activity. These symptoms are also common in those with diabetes and the older population.

There are a few other signs that usually don’t get talked about much (at least in basic First Aid courses).

Here are a few of the other things that you may see:

While you won’t see this every time, they are all signs that can help you make a decision as to what is happening with someone or how severe their condition is.


Photo by: Alessandro Bonvini

What Massage Therapists Can Do To Help

The first thing we need to do as Robert mentioned is call 911.

Stay calm!

When you call 9-1-1 the dispatcher needs some information from you and the calmer you stay, the better!

They need your address and this is the most critical piece of information because if they can’t get that from you, they can’t get help to you.

They will also ask for your return phone number. They need this to be able to call you back and get more information or to help the crews on their way locate you. It is also so that if you need help they can coach you through what you’re doing.

They will also try to get as much information about the patient as they can. Age, sex, physical condition, level of discomfort, pain and surroundings are all critical information for the arriving crew to have before they get there, so they know what they are getting into.

After that call is made, getting the patient into a position that provides them with the most comfort is the best thing we can do for them. Usually, this is going to be in a seated position leaning forward, but just go with whatever position they say is most comfortable.

Now I know most clinics aren’t going to have this on hand, but getting them some aspirin is going to help things out. And it has to be Aspirin, not Tylenol or Ibuprofen…Aspirin.

It works as a blood thinner so it can help relieve tension on the heart as well as help diminish clots. 

All too often this goes unrecognized or people don’t want to admit it, so they don’t ask for any help. Unfortunately, this could be fatal as it leads to cardiac arrest and the need for CPR.

The more you can do to recognize and be aware of what’s going on with your patients, the more you’ll be able to help and prevent things from getting to that point. Being able to recognize and differentiate the pain a person is experiencing is key to understanding what’s going on with them. Also knowing that the signs and symptoms can be different between men and women can go a long way to recognizing that there is an emergency happening. And remember, this is the only time it’s okay to ask about erectile dysfunction drugs!

“Heart disease is no laughing matter. After my father suffered a massive heart attack, I realized just how serious heart disease can be” – Cheryl Hines

The One Thing Every Massage Therapist Should Have In Their First Responder Bag

Blood is leaking from his left leg.

The players get him to the bench and throw one arm over the AT’s shoulder, I grab the other one and we hobble him down to the treatment room.

Once he’s on the treatment table we start cutting gear off.

He’s been cut by a skate over the Extensor Retinaculum on his left ankle with the tendons exposed. The AT immediately grabs gauze and puts pressure over the cut to control the bleed. He’s gonna need to go to the hospital.

Let’s back up a few hours.

Pregame Warmup, Massage And Treatment

That day started like a  typical Saturday afternoon.

Stop at Tim Horton’s to grab coffee’s around 4:45, at the rink by 5pm.

Step into the dressing room, talk with a few of the players, then into the treatment room.

Have a quick chat with the Athletic Therapist about some injuries etc. going on with players and have our coffee’s.

One by one players came in for treatment.

I do some pre-event massage and help players with their warm up. The A.T. gets to work taping and working on some nagging injuries.

One of the management team comes down to inform us there will be a first aid company in the stands tonight, since none of the Dr’s could make it to the game (it was league rules to have a doctor or a certain number of First Responders in the building for every game).

The first aid company is there to help with any fans at the game and back us up if we need any help.

Pregame skate starts at 6:35, we go and watch one of the players to see how he’s skating with a chronic groin injury.

7:15 puck drop.

Halfway through the 1st period there’s a crash into the boards that resulted in the injury from the beginning. But dealing with the injury wasn’t the difficult part.

The Inexperienced First Aid Attendant

In walks a young man who works for the first aid company, he looks about 18 years old, accompanied by an older gentlemen that just kind of sits back and watches.

The young man immediately attempts to take control of the situation pushing his way around. Me and the AT look at each other somewhat dumbfounded by what’s going on.

He tries to take a pulse (dorsalis pedis) on the injured side. He can’t get it and exclaims “we need to cut the other skate off so that he can compare”.

Of course he can’t get a pulse, the AT is holding pressure on the injury right above to stop the bleeding. He cuts the other skate off while we tend to the injured leg.

Once he gets the skate off he continues to follow protocol, takes the pulse and has the player wiggle the toes on his good leg. He continues to follow protocol and asks the player to wiggle the toes on his bad leg.

Now we’re getting angry!

In as stern a voice as possible I yell out “DO NOT WIGGLE YOUR TOES!”.

The kid looks at me like I’m from outer space (since I’m not following his first aid protocol), the AT looks at him and says: “who the hell is in charge here?”

A little stunned the kid looks and says “well I’m the first aider” (meanwhile his partner, the older gentlemen is just standing watching).

The AT says “there’s over 30 years experience between the two of us, now smarten up and get the hell out of our room”.

I had a big grin on my face.

After he leaves, another team volunteer comes down and we ask him to call an ambulance. The first aid kid comes back and tells the volunteer (who is at least three times his age) to go outside and wait for the ambulance and direct them in.

If looks could kill, he would have been dead three times over.

He was directed to go outside and wait for the ambulance and was shocked that he would have to do such a thing.

Ambulance arrives and we package the player up and pass on all the information they need. The first aid kid continually tries to put his two cents in while the ambulance attendants give him a look like they wanted to pat him on the head and feed him a cookie for a good job.

The player is sent off and we are cleaning up the room.

The kid comes back in and says “good job guys, thanks a lot”. I’m pretty sure I had to restrain my AT buddy… and yet the kid never did thank me for saving his life that night.

As much as I know the kid was just trying to help, it taught me a valuable lesson.

Our anatomy knowledge is one valuable tool. When he took his First Aid course he never had to memorize the Origin, Insertion, Action of muscles.

Your average First Responder isn’t going to know terms and structures like:

Things just aren’t taught that much in detail in a First Responder course (heck I had to open the textbook, just to make sure I was naming things right).

I went through three of my First Responder Instructor books and the best I could find is that students would learn:

I don’t say all of this as an insult to First Responders or the program, it’s just they don’t need to know that much (even though some go on to higher level paramedics and learn more) because their biggest job is to stabilize someone until more advanced help arrives.


Your Massage Knowledge Makes You A Better First Responder

When the player got to the hospital he immediately went into surgery. I don’t recall which tendons were repaired but it required surgery nonetheless.

It’s hard to know if it was just the initial skate blade cut that did it, or if it was once the player started wiggling his toes that caused the most damage.

If you’re working at sports events (or anywhere else for that matter) remember:

  • The people you are there for are YOUR responsibility  and you are in charge (along with other AT’s, Chiro’s, Physio’s that are working)
  • The average first responder or paramedic does not have the anatomical knowledge that you have
  • Put your knowledge to good use and don’t be afraid to help out, even when things are a little unsettling
  • Always keep your first responder license up to date

At most emergency scenes paramedics are in charge but in this case, when it comes to your players, you are the first line of care.

You have probably noticed at most big sporting events, the team trainers and doctors rush out onto the field, ice or track before any ambulance is there.

This is your scene and you pass it off to the paramedics or first aid team after your assessment and treatment, or when you need more help.

Remember to always be respectful when you’re dealing with first responders at these kind of events, it’s best to work together for the safety and outcome of your patients.

Knowledge is a powerful thing. Using your anatomical knowledge will make for greater success in any emergency medical situation. However there should always be one person in charge of a scene. Usually whoever is most experienced should take control and direct the other medical team members what to do. Or whoever’s license is higher (I’m not about to tell one of the team Doctors what to do) since they will have far more training and experience. If you’re dealing with people who are less experienced, don’t be afraid to respectfully take control.

Looking at them and saying “who the hell is in charge here?” may not win you any points with them, but sometimes you just need to get your point across!

How Massage Therapists Can Deal With Compartment Syndrome

The cracking sound echoed through the arena.

He went down to block a shot and when the puck hit him, we knew it was bad.

He couldn’t put any weight on one leg. Once he started to get up a teammate helped him to the bench.

We carried him to the treatment room and started stripping and cutting gear off.

He had severe pain around his shin, where he had blocked the shot. We carefully cut away his shin pads and compression socks.

The area was getting swollen and red throughout his shin. We couldn’t feel a pulse in his foot.

I thought it looked bad, but didn’t realize just how bad. Fortunately I was surrounded by people with more experience who are much smarter than me (yes I know, that’s not difficult to find!). They immediately realized that the player had to go to the hospital.

What I thought was a contusion, could actually have been a life threatening emergency if not handled properly. After things calmed down and we got him sent to the hospital, I asked why this was such a big deal. In unison the team Doctor and head Therapist looked at me and said:

“Compartment Syndrome”

Recognizing Increased Compartment Pressure

When this happened I was still a student and honestly a pretty fresh student Massage Therapist.

I was fortunate enough to be able to start volunteering with a hockey team to get some sports experience. I had never heard the term “Compartment Syndrome” (aka: Volkmann’s Ischemia) at that point, or if I had, I didn’t remember it.

Later in Massage school we briefly talked about it, but more from the standpoint of how to treat it post surgery.

When we learned about it in school, we only talked about Compartment Syndrome happening around the shin. Turns out that it can happen in other compartments as well.

I learned that the forearm is another common place for it to happen because the Athletic Therapist used to quiz me on things like that.

Also, did you know that part of Scaphoid doesn’t have vascular supply, so if it gets broken the bone can die? More things he used to quiz me on.

Anyway, in researching for this article, I came to find out that any osteofascial compartment can have a Compartment Syndrome. Areas with deep fascia that is very strong that enclose compartments can be subject to a Compartment Syndrome.

The most common areas are the flexor compartment of the forearm and anterior tibial compartment of the leg. The hand, abdomen, glutes, thigh and upper arm can also be affected.

Acute Compartment Syndrome is a buildup of pressure in one of these compartments due to an injury. It can be both limb threatening and life threatening if not treated properly and in a timely fashion.

As swelling increases in a compartment, blood flow creates more pressure on the structures inside, causing capillaries to collapse and begins to starve the area of oxygen and nutrients.  The nerves can hold up for two to four hours and the muscles can only survive for six hours before becoming permanently damaged.  

Photo by: Hernan Pinera

Photo by: Hernan Pinera

What Causes Compartment Syndrome

There are a number of things that can cause Compartment Syndrome to take place. So having a good knowledge of the mechanism of injury is our biggest help in recognizing what’s going on:

If any of these things have happened and you’re not quite sure if this is a medical emergency, better safe than sorry, have the person sent to the hospital.

But there are some tell tale signs to look for that will help make your decision.

Pain is going to be your first indication that something is wrong. But the pain may not seem to be normal compared to the injury.

Now that you’ve established that this is a medical emergency, it can’t be treated the same way you would typically think to do it.

If there is a long bone fracture in place you can’t put a splint in place as you normally would for a fracture. Anything restricting the area must be cut away to allow the area to swell. Putting on a splint or bandage is only going to make the Compartment Syndrome worse.

However any movement is going to aggravate the pain, so you will have to manually support the injured limb/area as best you can with the help of others around you.

If there is no fracture to the area then it can be treated as you would other soft tissue injuries.

Immobilize the limb as best you can (without bandaging it) and apply ice to the area. If possible, elevate the limb above the heart to help decrease circulation to the area.

But the most important thing you can do is call 9-1-1 and get the person to more advanced medical care as soon as possible.

Once in the care of the hospital, surgical interventions will take place in order to relieve the pressure. A “fasciotomy” is performed, where surgeons cut the muscle and fascia in order to back off the pressure and hopefully save the surrounding tissues.

Massage Therapy And Compartment Syndrome

I actually wrote this article with some encouragement from a former student (thanks, Chelsea).

I wasn’t sure what topic to write on and she told me Compartment Syndrome would be a good topic because we didn’t learn a lot about it in college.

Holy was she right!

Just in doing research on this one I came to learn more about the different compartments that can be affected. I had no idea that the glutes, thigh and upper arm were also at risk. Nor did I know much about Chronic Compartment Syndrome and how it is an overuse injury from excessive vigorous exercise.

The biggest takeaways are just to remember the mechanisms of injury that can create a Compartment Syndrome. Much like the player in the story at the beginning, blocking that shot caused a bad bruise that led to Compartment Syndrome of the anterior lower leg. Always be careful and check (especially with traumatic injuries) if there is a long bone fracture or circulation impingement.

As you assess the injured area, look for pain that doesn’t seem suitable to the injury, increases with muscle stretching and burning/tingling sensations around the area. If you follow your First Aid protocols and take things step by step, you should have no problem figuring out exactly what is wrong. 

Recognizing all of the above could possibly save a limb or a life, the next time you have to treat a Compartment Syndrome.

Now if I could just get that Athletic Therapist to keep quizzing me on things, I might get a little smarter!

How Massage Therapists Can Deal With Panic Attacks And Hyperventilating

It was 3:32 on a Tuesday afternoon in Myofascial II class and I was confused.

I couldn’t believe what the instructor was saying.

She was talking about people having an emotional response while having certain areas of the body treated.

Specifically she mentioned SCM (Sternocleidomastoid) and how it can sometimes be upsetting for people to have treated, and actually having people cry from treatment.

I didn’t believe her.

As we worked through our trades in class, I remember looking across the room and seeing it happen. People quickly wrapping sheets around their body and hopping off Massage tables.

Head down, tears rolling down their faces and heading to the bathroom to get away from the class.

I looked down at my buddy, with a dumb look on my face and said “What the hell are we going to do once we’re in clinic and someone starts crying on the table?”

I don’t want to see that, I hate seeing women cry.

Fortunately I went through the rest of college and the student clinic without ever having someone start crying. So glad, made it through never to have to deal with this again

When Someone Hyperventilates In Your Massage Clinic

Yeah, I wasn’t off that easy.

Years later I had a new patient come in to the clinic. In a recent car accident and she needed some work for limited range of motion and neck pain.

She had never had Massage before and was excited that treatments would help out with things after her car accident.

Starting with her face down on the table and things were going well. When she turned over and I started working through the neck, it all started to change.

She started getting a little agitated and couldn’t explain why she was feeling that way.

Her head lifted off the table in an attempt to breathe easier.

She wanted to continue with the treatment, but couldn’t quite catch her breath.  She started breathing faster and was getting a little light-headed, anxious and scared.

Her breathing increased. It was more difficult to catch her breath. Her previously calm demeanor shifted to fearful and agitated.

Now I’m starting to get worried.

What Is Hyperventilation?

Someone getting this anxious can turn into a medical emergency, right on your table.

When someone starts breathing this rapidly it’s called hyperventilating.

It becomes a medical emergency if they can’t calm down because if it goes on too long, it can render the person unconscious.

Because they are breathing so fast, it actually starts to change the pH levels in their blood. With too much oxygen coming in, the blood starts to become too alkaline (respiratory alkalosis) and proper nutrition is not making its way to the rest of the body.

This is also the reason that the persons fingers and toes can start becoming numb and tingling.

Having this happen will only compound the scared feelings the person was having initially, so we need to deal with it.

In this case we know that something is happening in our treatment that is causing the person to hyperventilate, but there are a few other causes that we should know about:

This is important to know, just in case you ever see this happening with a person and you don’t know the underlying cause that is making them hyperventilate.

If the underlying cause isn’t apparent, you need to dig deeper to see if you can find out. It may be the only way to actually deal with the problem at hand.

Remember your Secondary Survey? Great way to use the SAMPLE questions to dig deeper.

Photo by: Jaoie

Photo by: Jaoie

How To Treat Hyperventilation And Panic Attacks

The biggest thing we need to do is calm the person down.

Give them as much reassurance as possible, especially if they are becoming more anxious and scared.

You have to become their coach.

Coach them on their breathing.

Use whatever cues you find appropriate to begin calming them down. If you know them well, talk to them about whatever is important to them, or some memories/thoughts that would start to calm them down.

Have them mimic your breathing. If need be, take their hand and place it on your diaphragm. Breathe normally so they can feel it. Coach them to breathe with you, let them feel the rhythm and consistency of your breathing.

The more you can do to calm them down and get them back to normal breathing again, the better success you will have.

I used to think it was an old wives tale to get a person to breathe into a paper bag, but like so many other times…I was wrong.

I looked up hyperventilation in my Anatomy and Physiology textbook and it’s actually recommended as a method of treatment. As the person breathes into the bag, it helps to get more carbon dioxide back into their system to balance the pH level and help the person calm down.

Who knew a paper bag should be part of a First Aid kit?

Why Massage Therapists Should Not Fear Patients Who Hyperventilate

Fortunately knowing how to deal with someone hyperventilating helped in more ways than one with my patient. She was able to continue treatments after she understood why she was becoming upset and scared during that first treatment.

If you ever have to deal with someone who’s going through this, remember these steps:

  1. Try to distract them from the fact that they are hyperventilating. Let them talk about whatever triggered this response.
  2. Reassure them, let them know that this type of response can be a reaction to the treatment.
  3. Coach him or her on their breathing.
  4. Have them look at you and try to mimic your slower breathing.
  5. If necessary have them place their hand on your diaphragm to get the feeling and rhythm of your breathing as a tactile response to relate to.

It can be a scary thing, but it doesn’t have to be. As long as you’re prepared and know how to deal with the situation you’ll be successful. Recognizing what’s happening and following the above steps will ensure your patients safety and their trust in you as their therapist.

Always be ready to coach and reassure your patients through whatever is happening in your treatment room. And again if you’re not sure of the cause, going through the SAMPLE questions will get you what you need to know.

While I’m not as scared of this happening anymore, I still can’t handle seeing a woman cry.

I may need to keep a paper bag handy the next time I watch “The Notebook”

Massage Therapists Guide To First Aid At Work


“To be prepared is half the victory” – Miguel de Cervantes

I used to cringe every two years when my First Aid certificate expired.

Great, another two-week course with a bunch of people I don’t know teaching me the same thing I learned the last time. Total crap.

It would drive me nuts that I had to go sit through the exact same course, same textbook, same information, but at least I always got two weeks off work to do it.

Then it happened. Fresh off of taking a re-cert course, we had a major incident at work where someone was seriously injured. I hadn’t dealt with this kind of traumatic head injury before.

As I made my way to the scene, other workers who were First Responders outside of work were helping out. However, the way they handled the person was wrong.

When I questioned them, they simply said “that’s how we were taught the last time we did the course”.

Then it dawned on me, that the new way of handling this person was an update that had come through recently. The type of spinal immobilization they were doing was an old way, but new research had changed and upgraded how to do it.

If I had not just recently done the course again I wouldn’t have known any better.

That’s why it’s important to keep on top of your license and re-certify when it expires.

And yes, I know I’m probably the only Massage Therapist out there that gets excited about First Aid, but I truly believe it contributes to our recognition as healthcare professionals. As I’ve promised before I’ll do my best to keep you up to date on First Aid info, so with this post I’ll review some of the more important points you need to remember.

The Primary Survey In First Aid

Remember back when you did your last course and the instructor was adamant about you checking the scene for safety?

Well this is the first part in your Primary Survey when helping someone in need. Hopefully you remember some mnemonics used as reminders of what to do, but if not here’s what you need to know.

The three C’s. Check, Call, Care. This is the first thing you need to do whenever trying to help someone, but remember it can be modified to fit the situation.


  • Check the scene, is it safe for you to help out? This is where things can be modified, if this is happening in your clinic, chances are it’s a safe environment, so just make sure it’s safe enough that your patient isn’t going to cause you harm.
  • If the environment isn’t safe, back away and call 9-1-1
  • Check the person. Get down beside them and see if they are conscious and breathing.
  • If they are not conscious go through and check the ABCs.
  • If they are conscious ask them what’s happening, let them know you are trained in First Aid and want to help (hopefully they’ll let you)


  • Once you’ve checked the person, determine if this is a medical emergency.
  • If they respond, try and figure out if they need a 9-1-1 call. (however you may find something in the Secondary Survey that requires you call for emergency help)
  • If they’re unconscious, don’t waste time, call 9-1-1 and get the other people in your clinic to come and help.


  • Provide whatever immediate care is necessary for any life threatening injuries.

The ABCs


  • Make sure the persons airway is open.
  • Get down beside them, put your ear as close as possible above their mouth while looking at their chest. Listen for breathing and see if you feel their breath on your ear.
  • Put one hand on the chest, watch for it to rise.
  • This is called look-listen-and feel. Do it for 10 seconds
  • If there is no rise in the chest or signs of breathing we have to try and open the airway.
  • Use the head-tilt-chin lift technique that you learned in your course. This technique moves the tongue out-of-the-way from blocking the airway.
  • If no breathing occurs, attempt to give two breaths and see if air passes through.
  • If air passes through, begin CPR.
  • If you do the head-tilt-chin lift and they start breathing, maintain the position to keep the airway open.


  • Assess their breathing to make sure it is adequate.
  • Make sure they are taking a normal amount of breaths, it’s not just an occasional gasp.
  • If the breathing is not adequate you will need to start CPR soon.


  • With a Standard First Aid course all we do for checking circulation is assess the skin.
  • Do they have pale skin? Or is it full in color?
  • If their skin is pale it’s showing signs of shock and decreased circulation.
  • Take a quick scan of the body to see if there is any deadly bleeding happening.

The Secondary Survey In First Aid

Remember, you cannot move on to the Secondary Survey if the ABCs aren’t adequate or being maintained by another person.

The Secondary Survey is where you find out what else is possibly happening with this person. Its your chance gather as much information possible. Let’s assume you’ve completed your Primary Survey and the person has their ABCs in place.

There are two portions to the Secondary Survey, one is the interview and the other is the head to toe check where you look for other injuries.

Assuming the person is conscious you can start with the interview. If they are not conscious, but have their ABCs you can ask bystanders, friends or loved ones as they may have the answer to some of these questions. The mnemonic to remember for the interview is SAMPLE.

S – Signs and Symptoms?

A – Allergies?

M – Medications?

P – Past medical history? (Anything like this happen before, or family             history?)

L – Last meal? (Might be a hint of diabetic reactions)

E – Events leading up to the incident? (Do they remember what happened? Might be sign of altered level of consciousness)

Once you document the answers to the SAMPLE questions then you can do a head-to-toe check. Start at the head and work your way down the body, palpating each area as you go. Look for any bleeding, bruising, or signs of further injury as you go. As Massage Therapists we should be pro’s at this.

Make sure you never drag your hands down a person while checking them in case there is anything sharp sticking off their body (broken bone, syringes, other objects) as you don’t want to cut yourself, always pat and compress areas as you go.

A very important part of doing a head-to-toe check is looking for medical alert bracelets. They can inform you of conditions like asthma, angina, diabetes and allergic reactions.

If they are conscious but don’t want you touching them, you can do a hands off head-to-toe check by getting them to move for you. Shrugging shoulders, moving limbs and shoulders can tell you a lot about what’s happening with a person.

Photos by: Rocky Sun, Jill Hedler, Steve Jurveston and Melissa Johnson

Photos by: Rocky Sun, Jill Hedler, Steve Jurveston and Melissa Johnson

The Most Common Conditions, What Massage Therapists Should Know


Choking is classified into two categories:

  • Mild – this is where the person is still having some air exchange happening and are just coughing but maybe a little distressed.
  • Severe – when this happens there is a full obstruction of the airway preventing any air exchange from happening. It’s usually recognized by the classic sign of someone putting their hands up to their neck and of course…not breathing.

If someone is experiencing mild choking, all we do for them is encourage coughing and stay with them to make sure they clear whatever they are choking on. You’re staying with them and making sure they don’t suffer a full airway obstruction.

When someone is severely choking we have to step in to help. Make sure you stand in front of the person and tell them you’re trained in First Aid and going to help before you just jump behind them and go to work.

Get behind the person and wedge your knee/leg between their legs so that you have a solid base to support them in case they collapse. Doing this makes it so they won’t pull you down with them and cause an injury in case they do pass out.

Now here is where things may have changed since the last time you took a First Aid course. We don’t go right into abdominal thrusts now. Here are the new steps to take:

If what they are choking on becomes dislodged, accept the hug from the person and go on about your day knowing you just did something awesome.


No, not Massage strokes, a medical stroke. I posted an article on here recently about how to deal with someone having a stroke in your clinic which you can read here, as well as a video to help out which you can watch here.

As it is with so many other things in First Aid, recognition is key. When it comes to someone who has had or is having a stroke, the biggest help you can give is to simply recognize that something is wrong, then get help.

The Red Cross has a great mnemonic to help out with this. If you can do your best to remember it, your chances of helping the person recover increase greatly. If someone has had a stroke, the quicker they get medical help the less damaging the stroke can be. So try to remember this:

F – Face (numb, weak and drooping on one side)

A – Arm  (numbness and weakness on same side as the face)

S – Speech (slurred and confused)

T – Time (time to call 9-1-1, remember the quicker they get help, the less the consequences can be)

Once you recognize that the person has had a stroke, call 9-1-1 and stay with them. The biggest thing you are going to do now is monitor their ABCs and provide appropriate care if they lose consciousness.

Get the person into a position that they are comfortable with until Ambulance arrives. They are probably best laying on their side, make sure to position them affected side up. This helps them maintain motor control of their mouth and airway should they begin to vomit, remember to keep that airway clear.

Angina And Heart Attack

This is another one of those cases where your intake form can give you a heads up on a potential issue. Someone who has angina typically knows they have it and is taking a medication called nitroglycerin to deal with it. Angina is essentially chest pain a person experiences that comes and goes. The medication for it comes in a few forms:

  • Tablets.
  • Patches.
  • Oral Spray.
  • Skin Ointment.

If someone in your clinic has Angina and is complaining of chest pain, this isn’t a medical emergency yet. If they are having chest pain it should feel how it usually feels, they take their nitroglycerin and with rest the pain goes away.

It is a condition they manage and know what to handle. If they take their nitroglycerin and the pain doesn’t subside within five minutes, have them take another dose. This is one case where its okay for a Massage Therapist to ask if someone has taken erectile dysfunction drugs. They should not take their Nitroglycerin in this case as they are both vasodilators and can cause further problems.

If after three cycles of Nitroglycerin (spaced five minutes apart) the pain doesn’t subside, or is worse than usual, it is a medical emergency and you must get them to the hospital because their condition has progressed to a heart attack.

If someone is having a heart attack in your clinic it is because of a blockage in an artery feeding the heart. Some of the signs and symptoms of a heart attack are:

There are also some “soft” signs to watch for that occur most commonly with the elderly, women and people with diabetes (another important intake form question). They will have more mild and broad chest pain that:

If someone is having a heart attack, have them rest and call 9-1-1. If they have a predisposed heart condition they may have Aspirin recommended by their doctor, if they have it with them get it for them. Stay with them and monitor ABCs in case they lose consciousness.

Diabetic Reaction

As mentioned above, this is another one of those questions that should be reviewed on your intake form.

Always be aware when one of your patients who has diabetes comes in just in case they haven’t eaten in a while. Once the person goes long enough without food their body begins to shut down until finally losing consciousness if not dealt with properly.

If you know someone coming in for a treatment has diabetes and don’t seem like themselves, it may be your first hint that something is going on.

Once the person has gone long enough without food, the excess intake of insulin has taken up too much of their blood glucose. Their brain is now deprived of the necessary sugar it needs to function effectively, which in turn can cause unconsciousness and shock. 

Once you recognize that the person is not acting like themselves there are some signs you want to look for to confirm a diabetic reaction:

We have to act fast.

Getting some sugar in their system is the biggest thing we can do. Always make sure you keep fruit juice, soda or some kind of sugary drink in your clinic (can’t be diet, they need real sugar). Get it to them as quick as possible.

If this happens and you get sugar in them fast enough, it doesn’t mean you have to call 9-1-1. This is a condition they deal with on a regular basis and should know how to manage. However it does mean that you cannot proceed with your treatment they came in for. They need to get carbohydrates in their system by eating a proper meal.

If they progress to the point of unconsciousness, it is now a medical emergency, make sure you call for help. Stay with the person until help arrives monitoring their ABCs as their condition will progressively get worse. Roll them over into the recovery position to help maintain their airway and continually check on them.

You cannot give them anything orally once they are unconscious, however the paramedics responding will have something to give them to help the condition.

The Common Theme For Massage Therapists

I wanted to outline choking, strokes, angina, heart attack and diabetic reactions because they are some of the more common things that you can see with patients that come to see you on a daily basis. The common theme with all of them is recognition. Recognizing that there is a possible emergency is the number one thing you can do to help someone in each of these cases.

Secondly, staying with them to monitor their ABCs until help arrives is the next step. As long as you do a proper Primary and Secondary Survey you should be able to figure out what is happening in any case and deal with it appropriately.

If you’re ever unsure what is going on with someone, that Secondary Survey is your key to investigating what’s happening. As healthcare professionals knowing how to interpret the signs and symptoms of different First Aid emergencies is key to providing excellent care to our patients.

Whether it’s a stroke, choking, diabetic reaction or angina following the appropriate steps will give you the best chance of success when you’re providing First Aid at work.

So don’t get too upset the next time you have to re-cert your first aid license, there is a reason for it.

And try not to take too much aggression out on the instructor!