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Subpoena’d As An Expert Massage Therapy Witness

I have been fearing this day since I graduated college.

The envelope looked different than any other mail I’d ever gotten.

I opened up the registered letter and there it was, a cheque for $20 and a subpoena.

It read:

“TAKE NOTICE that you are required to attend and testify as a witness in the place, date, and time set out below. You are also required to bring with you all documents in your possession or control relating to the matters in question in this proceeding.”

What was I going to do?

I don’t want to go to court and testify!

At the end of the letter it clearly states:

“if a person, contrary to these Supreme Court Civil Rules and without lawful excuse, refuses or neglects to obey a subpoena or to attend at the time and place appointed for his or her examination, is guilty of contempt of court and subject to the court’s power to punish contempt of court.”

Looks like I have no choice.

I am not looking forward to this.

Compensation For Being A Massage Expert Witness

I really wasn’t sure what to do.

It was quite insulting that a lawyer would send a cheque for $20 (the requisite witness fee) to force you to be a professional witness in an insurance claim that was being fought in order to achieve a settlement for the claimant and themselves.

Not only would I have to take time off work and lose pay, but there is also prep work to be done.

Before I called the lawyer in question, I figured I would talk to our provincial association for some advice first.

The association had some good advice as far as what should be charged in cases like this.

  • Testimony in court $700 per half day
  • Court prep time $93/hour
  • Production of records $100 or $.50 per page.

I had no idea if I was just supposed to demand this or if it was assumed. I was told just talk to the lawyer and explain what was recommended to me.

Calling their office, the lawyers assistant answered.

I laid out what I thought compensation should be.

She responded and said, “okay you can bill us for the $93/hour, but no judge is going to pay you $700, that’s the kind of money they give brain surgeons”.

As we chatted about what would happen, I told her this scared the crap out of me.

Her response set me at ease: “Don’t worry about it, it’s not like TV. You’re a good person, as long as you don’t rob a bank in the meantime you have nothing to worry about. All you have to do is just show up and be honest, they’re not going to try and trip you up.”

Now it’s time to prep.

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Photo by: Medill DC

Prepping A Massage Therapist For Court

The lawyer had me come in to the office for an hour to prep.

We went through all my notes to make sure he could understand them and of course to see what I could remember.

Scouring over the notes, he asked for explanations on what he was reading. Deciphering what different orthopedic tests meant and what I was testing for. Looking for explanations on why there were missed appointments, why would I work on one area one day and a different area on another.

Some of those treatments were three years ago!

Then it was time to tell me what to expect and what was expected of any Massage Therapist called in as a witness.

Just be honest. If you don’t remember something just be straight up about it.

While the opposing lawyer is working for the insurance company and wants to win, they will not cross examine you like you see on TV. They will ask you questions more to try and discredit the patient, not you as a therapist. Just be honest with them.

If you’re asked a question, you answer the judge. While it may be either lawyer asking, you look at and direct all answers to the judge.

Dress appropriately, wear a suit.

Show up early and look for directions as to which room the case will be argued in.

While you are scheduled to be there, you may not be called. It will depend on how the case goes. If the case is settled before hand, you’ll be informed that you don’t need to show up that day and although the case could go on all week, you will only be called for the scheduled day and time that we ask for.

We discussed compensation.

He confirmed that $700/ half day was more than would be given, he did agree that $100/hour for time spent was appropriate as long as I was fine with that.

Two days before the case went to court, they settled. I was fortunate to not have to go. Although I will admit there was some disappointment, I ended up really wanting to see what it was like. Overall it didn’t end up being as scary an experience as I thought (even though I didn’t have to go to court) and as the lawyer and I talked I thought he was fair. He paid the $100/hour for the hour I spent with him and for the hour to get any extra paperwork together, in addition to the bill I had given them months earlier for sending them my charts.

The experience also made me realize that my charting should be better than it was. The lawyer wasn’t totally sure if he’d be able to use them. Some treatment notes were more detailed than others and not all of them were specific enough. Make sure that if you’re ever working with patients who are involved with insurance companies that your note taking is top notch. This is another way for us to prove not only our worth as Massage Therapists, but also our professionalism as one.

Massage Therapy For Children With Developmental Disabilities

 

“I am also a believer in an integrated treatment approach to autism” – Temple Grandin

”Don’t think that there’s a different, better child “hiding” behind the autism. This is your child. Love the child in front of you. Encourage his strengths, celebrate his quirks and improve his weaknesses, the way you would with any child. You may have to work harder on some of this, but that’s the goal. – Claire Scovell LaZebnik

 

I was nervous and unsure.

There was no one to talk to who had experience working with a child with developmental disabilities..

Although I had already met him, how was I going to handle this?

I knew what I wanted to achieve, but could I actually attain any of the goals for my patient that I had set?

Due to my past experience I felt fine working with this child, but no one had ever mentioned or taught me to manage a Massage Therapy case like this.

When I talked to my teachers, they never heard of anyone doing anything like this, and I never realized how much work or how much learning it would take to pull this off.

It was hard to find any good research on the topic, so I had to figure out a lot on my own.

All the goals I set had to be broken down into tiny steps accomplishing little goals in the grand scheme hoping things would add up to the greater good for my patient.

This was a huge learning experience and I hope what I learned can make a difference for kids with developmental disabilities and other Massage Therapists who want to help them.

Massage Objectives With Developmental Disabilities

Before pursuing a career as a registered massage therapist, I worked as a community support worker/ care assistant in a group home setting with people who had developmental disabilities.

I worked with people of all ages that had mild to severe developmental disabilities.

Giving medications and providing support for our clients was all we could do to assist them, however I felt more could be done to improve quality of life.

I found it difficult the only way I could help kids with developmental disabilities was through medical intervention and emotional support.

Although those interventions did help, I felt more could be done to improve the lives of these kids.

I wanted to do a case study to determine the effects of Massage Therapy for these people in need, particularly a developing child who was nonverbal with autism spectrum disorder and global developmental delay.

Developmental disabilities are common in children and occur in all racial and socioeconomic groups.

Some developmental disabilities may include: Attention Deficit Disorder (ADD), Autism Spectrum Disorder, Cerebral Palsy, Downs Syndrome, intellectual disorders, hearing loss, vision impairment, learning disabilities, and other development delay.

Children with developmental disabilities may experience impairments in social interaction, communication, speech and language, general physical development, behavior, learning, cognitive skills, motor control, coordination, balance, and emotional stability.

I found in my case study that Massage Therapy benefits children with developmental disabilities by improving their physical and emotional well being while they are still developing.

My objective was to determine if the effectiveness of Massage Therapy could improve their focus, behaviour and motor function.

Massage Therapy, A Case Study

My participant was a nine year old male with a diagnosis of Autism Spectrum disorder, Pervasive Development Delay (PDD), Moderate Intellectual Disability, asthma, seizure disorder, and an educational designation of physical disability or chronic health impairment (PDCVH).

He also experiences challenges with focus, aggression, and functional movements as a part of his diagnosis and would elicit a rigid rocking behaviour when he became anxious.

When I first met this patient, it turned out in the past he had been turned down by other RMTs when his guardian sought treatment for him. I was nervous at first to take on this case as I was only a Massage student, but put those feelings behind and decided to take it on as the well being of this child meant way more to me than staying within my comfort level.

I performed this case study over the course of three months and was broken into fifteen treatments, seventy minutes in duration, which were divided into three phases:

Treatments consisted of manual modalities to the lower extremities and back such as:

  • relaxation techniques including general swedish massage
  • rocking
  • full limb vibrations to trick the nervous system (helping to relax muscle contractions)
  • deep pressure stroking
  • myofascial release techniques
  • joint mobilizations
  • passive range of motion

Measurement tools included:

  • postural assessment
  • gait analysis
  • orthopedic tests
  • range of motion (ROM) for the motor function aspect of the study  
  • focus tests and qualitative feedback from the patients guardian for the focus and behavior aspect

The results from the study concluded that the patients focus and behaviour had improved, became more social with other children, less aggressive at times of frustration, less anxious, and his balance, motor function, gait and posture had improved.

The patient also completely stopped the rigid rocking behaviour and was able to follow direction when asked to perform simple tasks.

In just three months, a young child’s quality of life had significantly improved.

This proved that more can be done for these people to help improve their lives.

It just takes health care professionals like RMTs to take a risk and work beyond their comfort levels to improve the health and wellness of people of all ages at all stages of physical and mental development.

So what are some rules I created for working with children with developmental disabilities?

Establish Trust With Your Massage Therapy Patient

When working on children with developmental disabilities (or any client really) it is important to establish trust and better yet, a therapeutic relationship.

In our typical practice, we meet a client and establish a trusting therapeutic relationship on the first appointment. If that trust is met, they will typically rebook and come back for a following treatment.

In this case, it wasn’t that simple.

I had to work slowly at introducing massage and creating that therapeutic relationship. Before starting the treatments, I met the patient and his parent guardian. I interviewed the parent about triggers, behaviours, things that he enjoys, and tips on communication.

When the treatments finally took place, it was important to introduce everything slowly.

The first treatment was conducted on the floor, while the patient cuddled with his guardian. I slowly introduced touch to the legs and feet. By the next treatment we were able to introduce the table using support from his parent.

As the treatments progressed I slowly introduced massage to different areas of the body.

To put things in perspective, finally after a year and a half of treatment, I am able to work on his arms and hands without him pulling back showing there is now enough trust to let go.

Keeping a constant routine was also important.

I found that if he missed an appointment one week, we would lose progress in comfort with receiving massage. If we made any changes to duration, treatment techniques, or the number of treatments per week/month, it had to be done slowly and only changing one thing at a time to decrease the chance of  effecting progress.

Keeping a routine and working slowly will allow the client to maintain trust in you as a therapist.

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Photo by: hepingting

Gaining A Thorough Massage Health History For Developmental Disorders

It was important to have the full picture on the patients health history, not only for treatment safety but also to fully understand why the patient presented as he did and how I could create a care plan that would be effective.

In order to understand the full picture I collected documents from other health care professionals about his condition and did some research. I also did an extensive interview with his guardian to gather more in depth information on the child’s condition as well as information and tips on how to work with the child.

It is our duty as RMTs to take an in depth health history to ensure the safety of any patient.

Medications, current (and past) medical condition, emotional or behavioural status, assistive devices, activities of daily living, and other therapies a patient is taking part in are all examples of things you should know to create a safe and effective treatment plan for them.

These things are not just important for working with a special population but for every patient you see in your practice.

Massage Treatment And Developmental Disabilities

As mentioned before, ease into treatment.

Slowly introduce touch and ease into longer duration treatments. When it comes to technique choice, I began with general techniques and experimented with techniques until I found what worked.

Once massage was comfortably accepted by him, I was able to use more specific techniques.

Pay attention to the little things.

Starting on the treatment table may be too much too soon. You can start out treatments with a patient in a chair (or wheel chair) or on the floor on a mat or blanket.

Massage may also not be accepted by the patient right away, you may also need to spend the first couple of treatments getting to know the patent.

Utilizing  tools may help the patient feel less anxious, for example they may have a special toy they enjoy. When introducing massage for the first time, having certain objects act as a distraction may help significantly. Using toys, music, books, and sensory stimulation objects may help greatly.

I found that a thermaphore worked excellent as tool to help calm the patient.

Include Your Patient.

Note their mood.

Are they tired or playful?

This may affect how the treatment goes. During the case study, if he was acting playful, I would create a treatment that would suit his mood.

For example, one technique that he enjoyed was a bilateral leg pull.

When he was in a playful mood, I would make the technique more playful by exaggerating that he was growing tall like a tree during the pulling component then shrinking small during the compression portion.

This typically resulted in excitement and laughter. I would also typically use more stimulatory techniques like shaking and jostling when these playful moods were present.

Creating Home Care And Remedial Exercise For Developmental Disabilities

Be creative and realistic.

Utilize the patients hobbies and interests to ensure that the patient will enjoy doing their home care. Another factor to keep in mind is their home life. Quite often home life is very busy so you have to make sure to create a home care plan that will actually be obtainable by the family or care workers.

With this in mind, make sure that the home care you give is therapeutic and effective.

Be patient!!

Improvement may happen very quickly or very slowly. To get the results during my study, it took quite a bit of time and things slowly progressed. When I first began my treatments, the patient didn’t feel comfortable on the table so it was done on the floor. During this treatment, he moved around the whole time. Finally after a few treatments, the next step of progress was having the lower limb remain still for 3 minutes! By treatment 10, the patient actually fell asleep and remained still on the table for the whole hour long treatment.  Results may seem minor, but really are a big deal! The whole point of this Massage Therapy case presentation was to help improve focus, behaviour and motor function. I managed to use Massage Therapy to obtain these goals and truly believe that Massage Therapy would benefit other children dealing with these difficulties.

Because kids are so adaptable to change, there is greater benefit in using Massage Therapy to help them. After treating him for a year and a half this has developed into a rewarding experience that I never thought I would have. For all of us involved we have seen a huge difference in his development, behaviour and body awareness. Remember to be patient, and don’t forget why you became a RMT… to help improve the quality of life to the people who need it!

If you would like to read Chelsea’s full Case Presentation, you can download the word document here. 

A Summit On Massage Therapy

 

When I got the invitation I didn’t know what to expect.

I was even more surprised that I was the only one in the clinic who got one.

When I phoned the association to find out what it was about, I was told:

“We are hosting a summit where there will be a roundtable discussion on what needs to change and what can be done to improve the profession. There will be several other RMT’s and members of the public participating.”

Okay, I’m in.

I walked into the room on Saturday morning and started to see faces I had only ever met online.

More and more people started to look familiar.

I’ll admit, I was a little star struck.

There were between 40-50 people in the room. We were told that the invite was because those in attendance were considered to be thought leaders in the province.

There were no ego’s in the room and everyone was there for one purpose.

Improving the profession.

Massage Therapy In Patient Centered Care

The BC Ministry of Health is setting new priorities for our health system by setting eight new priorities.

While I understand that if you don’t live in British Columbia, it doesn’t really matter to you there are still take-aways from this that can apply to the profession everywhere.

  1. Provide patient-centered care.
  2. Implement targeted and effective primary prevention and health promotion through a co-ordinated delivery system.
  3. Implement a provincial system of primary and community care built around inter-professional teams and functions.
  4. Strengthen the interface between primary and specialist care and treatment.
  5. Provide timely access to quality diagnostics.
  6. Drive evidence-informed access to clinically effective and cost-effective pharmaceuticals.
  7. Examine the role and functioning of the acute care system, focused on driving inter-professional teams and functions with better linkages to community health care.
  8. Increase access to an appropriate continuum of residential care services.

I don’t think anyone can argue, these are great priorities (especially the portions that are in bold) and we as Massage Therapists should be involved.

However the sad truth is that we are not.

When we looked at the BC labour market for therapists and talked about the Provincial Priority Health Professions, this is what the list looks like:

  • Audiologist
  • Medical Laboratory Technologist
  • Medical Radiation Technologist
  • Occupational Therapist
  • Physical Therapist
  • Physician-General/Specialist
  • Registered Nurse
  • Registered Nurse-Specialty
  • Speech Language Pathologist
  • Ultrasonographer

We didn’t even make the list as a Priority Health Profession.

When you look at the National Occupation Classification we are under “Major Group 32 Technical occupations in health” and within that grouping are classified as “323 Other technical occupations in health care.” Within that group we are listed along with Opticians, Practitioners of natural healing, Licensed practical nurses, Paramedical occupations and Other technical occupations in therapy and assessment.

Under Major Group 31 Professional occupations in health (except nursing) is the realm and classification given to Occupational Therapists, Physiotherapists, Chiropractors and are called “Therapy and assessment professionals”

RMT’s and Physiotherapists in the BC labour market both are in demand, but RMT’s are listed as having “Some Post Secondary” education and  Physiotherapists are listed as having a “Masters Degree”.

The group we are in has significantly less education than we do and with some of those occupations the schooling can be done online. Really!?

In order for us to be recognized as a priority health profession some things need to change.

We need to establish our legitimacy as a profession.

Level of education has been an issue since I became a Massage Therapist and I’m sure it started long before. If we want to be recognized and given increased legitimacy we need to start looking at improvements to our education.

One of the big issues is price of education. For a Physiotherapist or an Occupational Therapist the average tuition is only $13,000 but we know to become a RMT it’s around $30,000.

All because their programs are offered through public universities instead of private schools.

There is a significant decrease in the amount of physical therapists and occupational therapists in the province that are able to fill necessary jobs within the public sector. Most are working in private practice, which creates a substantial need in the public sector working within the health authority.

So where can we start to help fill that gap and be involved?

First off the government needs to fully understand what we do. They are projecting our annual salaries to be in the range of $11,000 – $33,000 a year.

With their stats of 3,200 RMT’s where only 26% are working full time (a total of 832 full time RMT’s in the province?) I think we’d all venture to say those stats aren’t accurate.

Here are the stats from RMTBC on a survey that was done regarding income 

It’s time to start lobbying government to educate them on what an RMT does. Show them what our current education consists of and also how effective Massage can be for the patients in hospitals or extended care facilities.

The encouraging side is there are some places where Massage Therapy is being offered in the public sector.

We heard from Liza Dion.

She is a Massage Therapist at the Mayo Clinic. She told us about how surgeons wanted Massage Therapy performed for their cardiac surgery patients. They ran randomized control studies and proved Massage Therapy was effective in helping these patients.

They now have regular Massage Therapy happening in the hospital and is a primary part of the care given. However it’s not just in cardiac patients, they have also done studies with Colorectal surgery, Thoracic surgery, Breast surgery and Cardiology patients. It has even gotten to the point that they have a hospital based Massage Therapy course that is offered twice a year for Massage Therapists to come in and learn how to offer care in the hospital.

Liza also mentioned that she regularly has to educate new nurses and other practitioners in the hospital about what Massage Therapy does.

What if these other practitioners already knew what we did because we all went to university together? At least started out in the same programs and then decided which avenue we were going to pursue.

If we want to join these other therapies in the public sector work, we should also join them in the public sector schools.

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Photo by: NEC

Massage Therapy Education, Professionalism, Practice Support and Resources

As part of the summit we were divided into groups to discuss these topics.

I was fortunate to be part of the Education group.

As expected, there was a lot of discussion and passion on the topic.

Everyone there believed more education was crucial to our advancement as a profession. The common belief (as discussed earlier) was that a bachelor’s or master’s degree in massage was the direction we should start looking at.

I’m sure there are just as many people against the idea as there are people for it, but think about what this could do for us.

We have never been able to say that we specialize in something. I’m sure there are a number of therapists out there that focus their practice into something specific or some particular modality. Having more education is one way to lift this type of boundary on the profession. As we start to set up Professional Practice Groups here in the province, why shouldn’t we be able to say that we specialize in something or some area of interest?

Expanded scope of practice. I get frustrated that we are not allowed to use modalities like IMS, Shock Wave, Ultrasound or any other electrical stimulation. I know that in other provinces Massage Therapists are fully licensed and allowed to use these types of modalities. I think it’s time to make these options standard practice in regulated provinces.

Part of the problem with this goes back to lobbying government and making them aware that this should be within our scope (even though I think it already should be). Having a bachelor program in place, would help take away any doubt on their part.

As someone who loves working in sport, I believe there are many things we could do with our curriculum that would support students who have this interest. I spent last year working with some Athletic Therapy students and there are things we could learn from their program.

Those students come out of school with a few different certifications. Since it is a bachelor degree program, they come out with a list of exercise certifications on top of the AT certification. Right now we could start incorporating a CPT (Certified Personal Trainer) certification into the program. It would give students a much better grasp of exercise prescription for their patients and also give them an extra avenue of making money once done school.

For those that are interested they could have a combination Personal Training and Massage Therapy practice. It would also give those students interested in working with athletes or sports teams a better chance of getting involved.

There were so many other topics that were brought up in that discussion, but I’m writing this from memory so I can’t remember it all.

However when each group came back and talked again, every group mentioned that education had come up as a priority.

The Future Of Massage Therapy In Mainstream Healthcare

Dr. Gurdeep Parhar presented to us a new idea on how we could identify what we want from our profession and how we fit into the healthcare system.

canmeds 1

He talked about the CanMeds framework that physicians had put into practice to see what is expected of a medical expert. This framework has been adopted around the world, where students and medical professionals are graded on the six branches of the model. But the same model has been adopted in Physiotherapy and Occupational Therapy groups as well.

The public expects a doctor to be a medical professional (obviously) but the above six qualities are expected as well.

Communicators. We are judged by other professions and the public on how we communicate. This includes writing reports in response to doctors and other practitioners that we refer to and from. Dr. Parhar also sat in with the professionalism group and spoke with them on how important it was to implement report or communication writing back to doctors.

It is an area that we are not very good at. During discussions later in the day, the feeling was that most thought a report to a doctor had to be complicated and frequent. Dr. Parhar spoke about how much he as a physician appreciates getting communication from RMT’s, but it just needs to be a report at the beginning of treatment and one at the end. Just a report that informs the doctor in areas of treatment and how treatment progressed, so they know what has been done with the patient.

That’s it.

Collaborators. This works with our communication. How are we interacting with the rest of the healthcare team? We can’t work in isolation, we should be communicating with our patients other practitioners and contributing to their healthcare plan.

Manager. Why can’t we be a case manager on behalf of a patient? We can see a recently injured patient 2-3 times a week for an hour at a time. A doctor will see this person once every 4-6 weeks for maybe half an hour. So why aren’t we a piece of this puzzle, or even the primary case managers?

Health Advocate. Access to care is so crucial, especially in a “patient centred” model of care. There is still a difficulty for doctor’s to explain to their patients why Registered Massage Therapy isn’t approved by their insurance company when it is needed. We need to help advocate for the patients because society trusts us as professionals based on our guidelines and standards of care.

Scholar. This is a difficult area for us. There was plenty of discussion throughout the day on research (in fact a guest speaker Dr. Martha Brown-Menard LMT, spoke to us specifically on research) and how important it is. The problem is that research is done at universities and big companies don’t necessarily want to fund research for massage.

As much as we are pushing for evidence based practice, qualitative studies are just as important. But we need to start doing the research if we want to advocate for more resources to back up our profession.

Professionalism. Is Massage Therapy going to continue to have an artistic side to it, or do we start to present ourselves in a more professional manner? Should there be a standardization so that when someone comes in for treatment a person feels like they are dealing with clinicians?

I’m as guilty of this as anyone, I like just going to work in what I’m comfortable in (which is usually cargo shorts and a t-shirt), but would I be more presentable or respected if I made sure to wear a golf shirt instead? While I don’t think this is something that will ever be mandated, it may just be some food for thought when it comes to your own practice.

Listening to all of those points coming from a doctor was more than rewarding. Knowing there are doctors out there that are also advocates for Massage Therapy says that we are at least on the right track.

When I started this blog, the whole intent was to have other therapists collaborate information on how to improve the profession and share knowledge. I was excited when each one of the coaches agreed to be part of it because they were willing to share.

Sitting in a room of other RMT’s that are passionate about their profession and improving it was impressive. It also showed that we have a ways to go in order for our profession to gain more respect. While it is leaps and bounds ahead of where it was 10, 15 or 20 years ago, we can never stop improving. As the CanMeds model increases throughout the world, Massage Therapists need to continue working on being Professionals, Communicators, Collaborators, Scholars, Managers and Health Advocates. As mainstream healthcare continues to develop we need to make Massage Therapy prominent in patient centred care.

No one is going to this for us, it is only through our efforts that we can prove to government and other practitioners that we belong in the public sector and mainstream healthcare. I realize as I write this post that it seems pretty heavy on the education side of things. There was so much more that came out of the discussions that day, it’s just hard to put it all down in one place. If nothing else, I think the discussion was a step in the right direction.

We were asked to bring the excitement that we were all feeling that day back to our colleagues and share in order to keep the momentum going. I hope I have at least managed to do that, although I know it’s just the beginning.

Removing Pec Minor Discomfort From Massage Treatments

 

He winced when I first started trying to dig in to the area.

Palpating along the ribs, I found it.

Getting him to activate the muscle I felt it pop up under my fingers.

Okay, this is going to be a bit uncomfortable.

Treating Pec Minor is always a bit of a daunting task, especially when the patient is hesitant to have it done.

And with good reason, its usually pretty uncomfortable and can be painful.

However, as a therapist that preaches modern manual therapy, there is a less painful way.

Pain Free Massage Therapy Techniques

Yes… absolutely like most manual therapists, I have caused a fair share of pain and discomfort at my hands in the name of tissue deformation.

I have not believed in that for about 3 years now.

Here is my updated Pec Minor Release.

Patient: Supine

Massage Therapist: standing on the involved shoulder side

Test-retest: posteriorly tip the scapula to assess for loss of shoulder internal rotation, make sure you push the scapula into a set position as the involved side is often anteriorly tipped.

Technique:

  • lightly place your fist or a ball into the pec major under the coracoid
    • no you don’t need to go underneath it or anything ridiculously painful
  • have the patient move actively into elevation until extra tension or discomfort is felt, then have them resist into elevation to activate the scapular stabilizers
  • this will reciprocally inhibit the pec minor and they (or you) should be able to elevate the shoulder into the next barrier
  • continue until the shoulder is at full elevation if possible
  • re-test shoulder internal rotation, if they are a rapid responder, this should change after 4-5 reps

If done correctly, this should not hurt at all, unlike most other passive or movement based “releases”

Give the repeated shoulder extension reset for home care exercises

With modern manual therapy, we don’t need to cause pain and discomfort to get positive results. Make sure when you’re treating pec minor that you test and retest before and after the treatment to see the difference you have made in the patients internal rotation, not just for yourself but also to prove to them the difference the treatment has made. After 4-5 reps in the treatment you should be able to tell the difference you’ve made, the difference is that you’ll do it pain free.

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.

https://flic.kr/p/5ZsuFK

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

How Massage Therapists Can Treat The Thorax Part 2

In our last post Robert discussed how the assessment and treatment of the thorax was far from acceptable.

He went on to outline the importance of gaining informed consent from patients will help them feel more comfortable with treating this sensitive area. The more you can tune in to the area and ask for information with your palpation, the better we can develop the treatment.

Here is the follow up with Robert’s instructions on how to assess and treat the thorax:

 

In the previous post I had hoped to serve you by discussing my general thoughts and perspective on the Anterior Thorax. This section will be a discussion on some basic assessment techniques and perspectives I regularly utilize for the anterior thorax.

When looking at treatment for the anterior thorax, the manual therapist must have a good knowledge of the anatomy of the exterior and interior thoracic cage. One book I recommend is “The Thorax” by Jean-Pierre Barral. It is a great resource and I refer to it on a regular basis.

From Amazon:

“Barrral begins by describing the thorax as an area of conflict and contrast: it must protect the organs thoraxenclosed within, yet must also allow exchanges with the neck and abdomen. Problems with either of its dual roles of protection and exchange lie at the root of most thoracic disorders. Detailed descriptions and illustrations are provided of tests for dysfunction and treatment of the nonaxial joints, fasciae and viscera of this important area of the body.

Among the special topics contained in this volume are global and local listening of the thorax; utilization of the completed Adson-Wright test; cervical attachments of the pleura; intrasternal tests and treatment; utilization of various access points to the phrenic nerve; and stretching along the orientation of the coronary arteries.”

I couldn’t agree more with this description.

Complaints Massage Therapists Will Hear

There are a number of patient complaints that we see every day; shortness of breath, tight exterior chest and or back, sharp specific and or shooting pain, deep pain, referred pain/tension, the inability to breathe deeply etc… There are also complaints from condition such as asthma, post surgical trauma, post unforeseen trauma such as MVA, strains, sprains, fractures, contusions etc…

As with all patients complaining of dysfunction in the thorax, a detailed thorough history must be done to rule out conditions that are outside our scope of practice and may require immediate emergent care.

I have had a few times in my practice where I’ve caught a Myocardial Infarction and called 911. If this has yet to happen to you, be forewarned, it will. Most of the time though, the complaints are well within our scope.

A future article will deal with information gathering during history taking.

Massage Therapists And Orthopaedic Tests

So, the question is how do we assess and come to a treatment plan for a patient in discomfort? There are a number of assessment tests that are available to utilize. There in lies the problem. There is much research that shows that these tests are unreliable due to user perception, testers reliability and testers education on the application of the tests.

Therapists perform the same tests on the same patients and come to completely different conclusions. This happens more often that we would all like to believe.

So do we throw out all the tests, books written on the tests and our education?

Well… not yet!

My suggestion is to have a few books written on orthopaedic testing in your library. Refer to each of them on a regular basis and compare/contrast the application of the tests.

Once you have become familiar with them, choose 3/body part that you feel you are capable of performing. These should be committed to memory and should be practiced on a regular basis. Make these part of your regular routine diagnostic assessment portion of your treatments.

Your goal is to become very skilled in the investigative art of attempting to understand what possibly is causing your patients complaint.

In my office I created orthopaedic assessment paper that had a list of my commonly used tests and expected positive and negative outcomes for each region of the body. I did this to make it easier to remember the tests and before long, this list was imprinted in my mind through my eyes.

Remember that we don’t just perform tests willy nilly. There has to be an underlying reason.

The patient must have some complaint that leads you to testing. Pain, tension, loss of AROM/PROM, headache, referred pain/tension and so on must be investigated. Initially attempting to investigate the complaint with orthopaedic testing is the logical starting point.

One main problem I find is that there are too few orthopaedic tests for the thoracic cage.

There are Specific AROM tests for vertebralcostal joints, Sternochondral joints, and you can usually feel for a decreased intercostals space and there are tests for extremity’s with neurological/vascular complaints, loss of AROM etc… but what about torsional strain feelings behind the sternum?

What of pain over the heart where the heart has been ruled out?

What of pain within the chest sometimes described as being in between?

What of respiratory challenges?

Sure there are medical tests that can confirm what the patient is complaining of, but why?

In cases such as these and many more, you must rely on your sensing/palpatory abilities and patient observational skills to make the determination of what a possible cause may be.

How Massage Therapists Can Acquire Information

In my previous post “The Thorax Part 1”, I very briefly suggested that you commit yourself to not palpate, but to “sense” for information your patients body is attempting to relay to you. I find these listening skills come into place more and more with concerns of the thorax.

Develop your “allknowingseeingthinkingfeeling” hands.

I utilize a combination of palpatory and sensing techniques together. Try the following:

Standing above your supine patient at their head, placing your full palm onto their sternum. Slowly and firmly load down into the table and inferiorly through the sternum.

sternum-1-300x200What to you feel? Does the tissues take you straight, or is there something that takes you into either a rotational or diagonal direction or a combination of both? Come back out and this time perform the same action with less force of compression. Do this over and over until you get to the point where you can feel the direction of ease of the tissue using the minimalist amount of compression …ounces. You are now on your way to sensing! This is a great technique for any body part.

“Co-operate with the tissues, you’ll get more with less!”

Now move to one side of the table. Working cross body, place both of your hands onto the chest wall, one sternum-2-300x200placed on the upper ribs 1-4, and one place on the lower ribs 6-10. If you patient is female, the breast tissue will be in between your hands, but our focus is still the thoracic tissues. Perform this exercise once again. Does the tissue take one hand in a different direction than the other? Does the whole cage move easily down into the table or is there some kind of diagonal/rotational torque. Do the upper tissues move differently than the lower tissues?

Information acquired can change with small movements of the head, neck & arms.

Don’t be afraid to move your patient or have them move. Load into the sternum once again with either of the techniques described above and have the patient rotate their head one direction then the other. Look for subtle changes not only in what you can sense, but also in feedback from the patient.

What are you feeling; Skin, Superficial fascia, muscle, deep fascia, bone, ligament, joint capsule, endothoracic fascia, parietal/visceral pleura, lung, mediastinum, neurovasculature, pericardium, oesophagus, trachea, vertebral rotations, fluid dynamics, tissues of the same side or opposite side?

I find it’s always a good idea to have a Netter Anatomy around when trying to be specific as to what tissues are speaking to me.

Don’t forget to monitor to your patients heart rate and thoracic respiration. These are great systems that let you know when you are close to the source of a patient’s complaint(s).

“The quieter the mind, the stiller the hands, the less movement we make, the more we are able to perceive involuntary movement.”

– James Jealous, DO

Look for health!

Where is the health, where is the restriction?

We all seem to be very focused on finding the restrictions, tension, pain, but how often do you look for the health in the tissue?

How often do you look for what is working pain free?

Look for the health in every patient at some point. It’s quite refreshing to watch the physiology work as a well sounding orchestra! Music not only to your hands, but to your physiology also. Time seems to stop in this place… enjoy it.

Always make sure give extra attention to a patients complaints when it comes to the thorax. Get that detailed history from them so you can rule out anything that may be out of your scope of practice and may require emergency care. In addition, make sure you are comfortable with orthopaedic tests while also relying on your palpation and observation skills. Continue to look for health in your patients and see how you can help them to start working pain free. As always, I hope that I have been able to serve you in some way with this information, be it a completely new perspective into your patients, be it some new thoughts about how to approach a treatment or provide you with a review and acknowledgement that what you are doing, as far as I’m concerned, is having an amazingly positive impact in improving the quality of life for your patients.