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Using Massage Therapy For PTSD Treatment

My jaw dropped and I had to apologize.

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

Turns out we didn’t.

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

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

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

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

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

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

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

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

What Is PTSD?

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

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

Post Traumatic Stress Disorder is a type of mental illness.

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

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

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

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

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

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

Either way they will feel a loss.

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

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

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

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

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

PTSD, A Counsellor’s Point Of View

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This can be overwhelming for the therapist as well!

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

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

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

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

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

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

Useful resources for more information on this:

https://flic.kr/p/99qH5R

Photo by: Mark Warner

Massage Therapy Treatment And PTSD

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

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

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

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

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

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

 

Myofasical Release And Massage Therapists

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

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

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

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

Fascial Anatomy For Massage Therapists

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

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

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

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

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

What is Fascia?

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

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

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

DSC_1882_edited-1

What Are Massage Therapists Doing With Myofascial Release?

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

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

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

  • Contextual Responses to Myofascial Release
    • This is likely to play a role in any therapeutic intervention, the way we present ourselves and present our techniques has influence on the treatment. The magnitude of a  response may be influenced by mood, expectation, and conditioning.
  • Neurological Responses to Myofascial Release
    • Fascia is highly innervated by mechanoreceptors, this was document by Robert Schleip in 2003. His article Fascial plasticity – a new neurobiological explanation Part 1 Part 2, this is an interesting and very readable two-part article laying out a possible neurological explanation for the beneficial effects of myofascial release.
  • Mechanical Responses to Myofascial Release

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

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

-Fascial plasticity – a new neurobiological explanation: Robert Schleip

Are Massage Therapists Breaking Adhesions?

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

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

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

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

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

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

Is a fascial densification the same thing as fibrosis?

Stecco makes a distinction between a pathological fibrosis and densification:

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

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

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

Nerve Entrapment

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

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

  • Contextual Responses
  • Neurological Responses
  • Mechanical Responses

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

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

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.

https://flic.kr/p/fpZHhE

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!

 

The Benefits Of Massage Therapy With The Elderly Population

When I was in school I knew I didn’t want to work with this population.

Weren’t they always grumpy, complaining about life and fragile in their movements and abilities?

With these thoughts in mind I entered my career as a RMT thinking I would steer clear of the elderly population.

I haven’t had a lot of experience working with or being around people over 75 years old. My grandparents passed away when I was a child and even though I have older parents (my dad is 70 but you would never guess that) they have never acted ‘old’. 

For this reason I felt extremely nervous about massaging my first almost 90 year old client.

A few years ago, I was working alone as a locum in a lovely space. Many of the clients there were loyal and dedicated to that clinic, including a mother and daughter who usually received a massage after one another.

At the time of our first appointment together the mother was 89 years old and I was unsure how things would go.

In she walked with the help of her cane, her hair a gorgeous shade of white and perfectly combed. She wore mascara showing off her bright eyes and blush accentuating cheekbones that any girl would die to have.

She had a clear voice but a shy smile and I could tell she was as nervous as I was. She was used to her regular Massage Therapist, who I was locuming for but our first treatment went well and we had a blast getting to know each other.

After my locum was complete this lovely lady became my regular client.

She drove herself to the clinic where I worked, every second Friday for a 45 minute massage. During the years I got to massage her she turned 90 and then 91 and to my knowledge still receives her regular massage.

Giving Respect To Your Elderly Massage Patient

I learned a lot from this lady not only massage wise but life wise.

Can you imagine out living your husband by 30 years? How about out living a son?

She has seen the world change drastically and told me all about it. To say you cannot and should not become attached to clients is crap! She was one of my favourite clients and one of the best people I knew (and still know). I made sure to treat this lady well and to help her out when possible.

If she didn’t give me 24 hours cancellation notice, I didn’t mind. 

If she forgot an appointment, I would call to make sure she was ok but never charged her for a missed appointment.

I often parked her car for her if it was a tricky parking spot to get into and always stood near the massage room outside the door while she was getting undressed and redressed. 

If she needed help I would be there.

I ALWAYS walked her to her car after her massage to make sure she got there ok. She would put one hand on my arm and use her cane to shuffle along the sidewalk.

If she had to park a long distance away, I would run to the car and drive it back to the clinic.

I also gave her my cell phone number in case she needed to get in touch.

When I was instructing at the Massage Therapy College I always referred to this client as my “90 year old” when providing examples of massage clients and treatments to my students. Eventually my students would start asking about her and referred to her often.

Massaging The Elderly

Each massage treatment was similar.

She had been diagnosed with stenosis of her lumbar spine and complained about weakness, numbness and tingling and cold lower limbs and feet.

Spinal stenosis is a narrowing of the vertebral canal, where the spinal cord runs. The most common cause of spinal stenosis is wear and tear changes such as degeneration of the facet joints and intervertebral discs and the formation of bone spurs within the canal.

Photo from: OHP Kelowna

Photo from: OHP Kelowna

While massage therapy cannot change or reverse the progression of spinal stenosis, it can help to decrease pain and tight musculature around the affected area.

She also had scoliosis, which I believe was caused by degeneration, and resulted in her leaning more to one side. 

She was always sore though her hips and lumbar spine and really enjoyed the relaxation of thoracic spine and upper trapezius work. Would I ever truly help with these conditions of a 90 year old woman? 

No, but I certainly know she felt good during the massage (she would honestly tell me if she didn’t) and if I could help ease some pain or make her feel good for 45 minutes then I would do my best.

She was able to get onto the table and lie prone (face down) herself. I would use a moderate amount of pressure to massage through her gluteus medius and minimus, quadratus lumborum and lumbar erector spinae muscles. 

I always did a general treatment for her mid and upper back and neck, then would do a lot of circulatory work for her posterior lower limbs.

It was a slow process, but I would always ask her to turn supine without my help

In my opinion if she wanted to stay independent she needed to be able to move on her own. She wouldn’t  benefit anything from me helping to turn her on her back. She never asked me for help but if she really couldn’t turn over, she would have told me.

Once supine, I would massage her arms for relaxation and circulation, then finish each treatment with  circulatory work on the lower limbs and feet.

Once the massage was finished I would stay in the room until she was in a seated position. Again, I didn’t help her get up off the table but was there in case she needed me. After I left the room she would dress herself.

Communicating With The Elderly In A Massage Clinic

She always asked the same questions. 

I assume she would forget the answers that I told her the weeks previous and often had to repeat myself due to her forgetting her hearing aids, but she always understood what I told her.

“Do you feel my legs tingling like that?” – No only you can feel that!

“Do my feet feel cold?” – always!

“Why do my legs feel this way? My doctor doesn’t tell me much.” – I always gave her an honest answer of what spinal stenosis is.

“Do you think my muscles are still in my leg?” – yes absolutely! 

She had amazing looking legs for 90 years old. While strength and stability was decreasing quickly, the shape and tone of her leg musculature would make a 20 year old jealous.

https://flic.kr/p/7BzwNQ

Photo by: Fechi Fajardo

What The Elderly Can Teach Their Massage Therapist

She would often make hilarious statements followed by her huge laughter:

“Meaghan, I thought instead of getting a massage today that we could just trade legs! No? Oh fine…rub away then. I guess I can’t have everything in life!”

“I only come here because you laugh at my jokes!”

Then there were statements about life. I often wrote these quotes down and called them ‘wisdom from my 91 year old client’:

“I don’t understand how people get bored! Go do something! Go dancing, play cards, have sex! How can you get bored doing those things?”

“When you get to my age, you watch most of your friends go…and it makes you realize how great it was to love them and to laugh with them”

“I think people think life is like a bowl of cherries. They take, take, take, chew up and enjoy half and spit the rest out like it’s useless. We should be eating life like it’s seedless grapes! Enjoy the whole thing!”

“I’m 91 and I’m not ready to go yet! I want to see how things turn out. Life is too short even at 91.”

Was she grumpy? Never. I have not laughed with a client as much as I did with her.

Did she complain about life? Not once. She told me beautiful stories of times with her husband and kids. She talked about her grandkids and great grandkids. She asked me about my love life and gave me hilarious advice.

Was she fragile? Not in my eyes. She was more on the ball than most people I know who are a third of her age! She had more wit than most. She was blunt and honest. Massage wise, she could take a good amount of pressure and rarely said anything felt too sore. 

Movement wise, she was slow and unsteady. She fell at home a few times and once had a hard time getting back on her feet but she continued to live on her own and drove herself around the city. In most ways she was not fragile at all.  

Unfortunately, as we age we see a decrease in function in many areas: strength, stability, mobility, memory, physiological processes, metabolism and even mental health. While massage therapy may not regain anyone’s youth, I am a firm believer that it can help with mobility and stability issues and can have an incredibly positive impact on one’s state of mind. The elderly may have to deal with disease processes, slowing bodily function, loss of partners, friends and memory, but a Massage Therapist can provide a quality of life that helps them to feel better, be more positive and in my case get a ton of laughs. I moved away from the city where my 91 year old client lives but I get updates from colleagues about her. She taught me a lot about how amazing life is and that you should do the things you love and be around the people who make you smile. Since working with her, I haven’t felt nervous being around elderly people or massaging them. I learned how much the elderly can still do, their abilities and what they have experienced in life. Embrace every client and experience you can! You never know what you will learn!

As she would say, “Isn’t everyone so much more beautiful when they smile.”

Massage Therapy And High Ankle Sprains

The story was told to me a couple of months after this happened.

An unlicensed person who was loosely affiliated with the team went through the back door of the dressing room when he saw a player was injured.

The AT had taken him off the ice, helped him into the room and went to get the team doctor.

When the doctor walked in, he immediately threw his hands up in the air and said he would have no part of this.

This unlicensed person was vigorously massaging an acute high ankle sprain.

I was a student at the time and the rest of the medical staff were trying to impress upon me why they always tried to keep the care of all the players in house.

Although it wasn’t the point of the story all I could think was: “what the hell is a high ankle sprain?”

Massage Assessment And Grading Of A Syndesmosis Sprain

I remember through college talking  and learning all about ankle sprains.

The difference between an inversion and an eversion sprain, how the deltoid ligament is so strong it usually prevents an eversion injury, that the anterior tibiofibular ligament is the most commonly injured, since it happens with inversion injuries.

I don’t remember ever learning about a “high ankle sprain” (which is partially why I was so bewildered the first time I heard the name).

A “high ankle sprain” is an injury to the distal tibiofibular syndesmosis. The injury is caused by the foot being dorsiflexed and externally rotated which widens the ankle joint, stressing the syndesmosis.

Initially it can be hard to determine the difference between a typical sprain or a high ankle sprain, but mechanism of injury can be one thing to help differentiate. There are four other tests that help prove the difference:

  1. Passively moving the ankle into dorsiflexion.
  2. Pressing the tibia and fibula together while asking about pain level (squeeze test).
  3. Palpating the syndesmosis ligament.
  4. Externally rotating the ankle while stabilizing the leg (external rotation test).

Acutely this can be managed like any other ankle sprain depending on degree of injury.

The injury is graded from I-III according to it’s severity.

  1. There is injury to the anterior deltoid ligament and palpation of ATFL is quite tender.
  2. Causes disruption to the other deltoid ligaments and tearing of the syndesmosis.
  3. Complete disruption of medial ankle ligaments, possible fracture to the fibula and separation of the syndesmosis. In this case the mechanism of injury is a possible hint to the extent of the injury, since the external rotation and abduction will be pretty severe.

Fortunately in the acute stages, management of this injury should be pretty straightforward if you’re working the sidelines at a sporting event.

As with any acute injury we want to take the swelling down at the start, so implementing a R.I.C.E protocol will be necessary. Then we need to figure out how severe the injury is. Using the testing noted above will help, but a much easier way is to just check out the stability of the joint. If the joint seems unstable at all, then the injury is a Grade II or III. Another sign is that pain will be felt through the lower half to one-third of the leg  (thus the term high ankle sprain).

If your patient is experiencing any of this, you need to immobilize the ankle with proper splinting and remove any weight bearing on the ankle by assisting with crutches.

Then refer them to more advanced medical care.

https://flic.kr/p/Ni6sD

Photo by: soccerkrys

 

Massage And Rehab Guides For High Ankle Sprain

It’s tough to find any research (at least it was for me) indicating the best approach as far as Massage Therapy to treat a high ankle sprain.

Most of what I could find deals with the exercise end of things as opposed to the actual treatment of the ankle. Starting the person on progressive resisted exercise and then challenges on balance and sport specific drills is the most common forms of treatment.

I can remember having one of the players on our team years ago having to deal with a high ankle sprain. One of the exercises the AT would do is hold up a hockey stick between him and the player, they would both hold the stick and the AT would essentially wrestle against the player pushing him back and forth in order to draw his attention away from the ankle, but still have him moving and strengthening it in the process.

Unfortunately it can take up to 12 weeks to completely heal depending on the degree of injury. And will obviously be different if surgery is involved. There is debate over whether a grade II should be a surgical repair, but without surgery it can be difficult for an athlete to return to play.

Because the injury involves a widening of the ankle joint between the fibula and tibia, keeping inflammation down will be important in order to allow the joint to return to proper function again. Depending on the degree of separation and wether the ankle had to be splinted for any length of time will also shape your treatment.

If the leg has been splinted, watch for any muscle wasting compared to the opposite leg and start strengthening once swelling has come down.

Working in some passive and active range of motion will help to keep the joint moving. Because pain is felt further up the leg, working the muscles through the entire area will help in the recovery process. Treating gastrocs/soleus and tibant will help with ankle mobility, but you may have to work further up the leg into the quads, hamstrings and glutes because of the change in gait due to the injury. Be patient with the treatment because it’s a long healing process, especially once activity or return to sport happens. Sometimes athletes can start activity again in six weeks, but can have symptoms for six months. Above all, whether its acute or subacute your assessment is going to tell you what you need to do. Make sure to touch base with their doctor or surgeon in the cases of grade II & III injuries and get a little guidance from them if necessary. And for god’s sakes, please don’t vigorously Massage any acute injuries!

The Massage Therapist Guide To Clinic Management Software

This was an opportune time to make the switch.

Over the past 8 years, our clinic has gone from paper and pencil scheduling, through two different software based management systems, and now we’re switching to a platform that supports online booking and electronic medical records.

Each time we change systems, it involves researching options, exporting and reconfiguring all our data, and then re-training the staff on a new software.

Every few years our needs in a clinic management software seem to change or grow, and unfortunately our past softwares haven’t grown with our needs.

With the high demand from the public for online booking, even though we have full-time reception, this was something we couldn’t ignore any longer.

The other factor that played into our need for change, was that with more therapists and multiple disciplines their files take up A LOT of room in the clinic. They are taking up so much room that we are now archiving files after two years.

Needless to say, a more storage-efficient method was needed.

6 Important Features For Massage Therapy Clinic Management Software

When what you love doing for your career involves working with patients to become pain free, you don’t want to spend all your time with dealing with scheduling, billing, and lots of “front end” duties at the office.

We now live in a time where there’s an app for everything. It feels like overnight we went from not having any choices, to having too many choices in selecting the software to run our clinic.

Being involved in a large interdisciplinary clinic, I’ve recently underwent the arduous task of finding a new clinical management software (CMS) that needed to check more boxes than I have fingers. Since I have finally come to a decision for my clinic, I’m here to share what I learned. My choice will not be your choice, because my boxes are not your boxes, but here is what I learned.

First step is to figure out what you want out of a CMS, which is tricky when you don’t know what they offer or have the capabilities of. So here are the important features I decided to highlight:

  1. Online Booking – even if you have a full-time receptionist, online booking has now become a very important feature that patients look for in order to access their therapist.
  2. Electronic Charting – If you have a large number of therapists and limited number of square feet to devote to file storage, then this is a great option for you.
  3. Integrated Billing – This makes sure that checking out your patient is a smooth and quick process, and with the different reporting options, makes a big difference when it’s time to do your books.
  4. Integrated Wait List – If you are like some Massage Therapists I know, who have a 1-month waiting list, it can be frustrating when you get a cancellation with too little notice to fill it.
  5. Remote Schedule Availability – Having the ability to check your schedule from home is a great asset, especially when patients can book in with you when they wake up at midnight with a kinked neck.
  6. Cost – When it comes down to it, cost always plays a factor, especially when it comes to your business.

4 Online Scheduling Programs Reviewed

I investigated several applications, but I found that only four of the ones I looked at had the right combination of features to warrant getting shared.

There are lots of choices out there, so I could have easily missed some that you may really enjoy.

These options happen to all be cloud-based, which means they are not installed on your hard drive like a typical software program, but hosted online and you log into them via your internet browser. Here they are:

 1.    Jane App – www.janeapp.com

Jane App has a very clean presentation and seems to hit the best on all the features listed above, and many more features not listed.

It’s a Canadian company based in Vancouver, and they make an honest effort to really do things properly; such as hosting your data in Canadian servers in multiple provinces where they are very safe.

If you are running a clinic with only one type of therapist (such as RMTs), they have a feature where you can incorporate into the intake form a “Survey Monkey” style questionnaire for  health history, and inputs it automatically into their patient file for you. Jane App also lets you custom build your template for charting, using both scanned diagrams (or using a stylus to draw on), lists, and general text charting.

Their website is by far the easiest to really understand what you get and what you don’t compared to the other options. My only complaint with Jane is that it’s the most expensive of the options, especially when you have a larger clinic.

Unless you need all those great features, it might not be worth the expense.

2.    Cliniko www.cliniko.com

Cliniko, much like Jane, has a very clean presentation to it and also does well on the features above.

There were little details with how well some of those features function that made them not the best, but overall still great.

They are working on incorporating electronic charting, the ability to use a stylus to draw, scribble, and write in the chart, but it is not set up yet.

They are an international company, which was great as they have help staff that work 24/7. If you have a large clinic with many types of practitioners and lots of needs, Jane & Cliniko seem like the only choice that starts checking boxes after the fundamental needs.

3.    Body Soul www.bodysoulonline.com

Body Soul’s website is hard to find any really definitive answers on without asking for help, which makes me think their software lacks the same forethought.

Their online booking feature seems not as streamlined as Jane & Cliniko, and lacks the waitlist feature.

They are however a local company from British Columbia, and even though they don’t allow the use of a stylus in the charting function, they have done a clean job of streamlining it. They even have a dictation feature for your charts!

Their price was very reasonable, if you’re a single Massage Therapist; otherwise it’s double the cost per practitioner.

 4.    Mind Body – www.mindbodyonline.com

Mind Body seems like it is designed for a yoga studio first, then adapted for a health clinic.

This is the one software that doesn’t include the Electronic charting and as it was with body soul, it lacks a waiting list. It is very focused on social media and lets you even tailor an app to the branding of your business, and have patients book in for a treatment from within Facebook.

The overall design is not as clean as Jane or Cliniko. Mind Body was the only application in addition to Jane that has a feature to customize your practitioners’ access; everyone gets a unique login and password so they can access what they need, but not everything that you can.

The cost is really hard to argue with too; you can get one of their bigger packages for under $100/month.

I’ve included a handy chart to show you which program has what feature, and in some cases a rank out of 5 on how well they did. These ratings are based on the information I was able to pull from the website and from answers I received from helpful staff, I have not used any of these programs in my clinical setting yet.

If it wasn’t obvious in my review, we chose Jane for our clinic.

Key FeaturesJaneappClinikoBody SoulMind Body
Janeapp.comcliniko.combodysoulonline.commindbodyonline.com
Cost$$$$$$$$$$
Electronic Medical Records544N/A
Integrated Billing5543
Online booking5433
Remote Schedule AvailabilityYesYesYesYes
Wait List FunctionYesYesNo No

The cost for each app has a slightly different structure, so it’s hard to lay it out for you easily here. Your best bet is to visit the websites and calculate your cost based on your clinic size and needs.

Based on what your needs are, you will probably choose different options, from myself and from each others. Most of these apps have functions that would work for your clinic, but based on our needs, Jane App was the solution. It was a challenging decision between Cliniko and Jane App, but in the end the extra details associated with Jane App didn’t equate to a large enough price difference to deter us from using it. Another reassuring fact that help us make this decision is that many large clinics that I respect and trust use Jane App. Our plan is to start using Jane App in the new year, fingers crossed it all goes well. Stay tuned for the 6-month follow-up. 

I’m also just really excited to get to do my charting on a snazzy iPad!