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Separating Fact From Fiction With Pregnancy Massage

 

Walking into the waiting area, my new client is sitting with a smile and a sizeable baby bump. I offer congratulations along with, “If you’re ready, let’s head this way…”

On the short jog to the massage treatment room, I go over my mental checklist of items I’ll want in the room: body pillow, extra bolsters, support wedge. I close the door and ask my standard, “So, what brought you in for massage today?”

She replies, “I’m seven months pregnant, and my feet are killing me. But I’ve heard massaging feet can be risky, so maybe just focus on my shoulders?”

My mood deflates somewhat as I’m faced with a choice I’ve made countless times with pregnant clients: get on my soapbox, or just get on with the massage? Share facts, at the risk of causing friction, or just provide what she requested, and perpetuate fiction?

A spiral of unknowable, anxiety-amping questions pop into my head:

  • What if I make her uncomfortable by “correcting” what she thinks is true?
  • What if instead she’s glad to not have to worry about ankles anymore?
  • What if she’s actually open to learning about what research says?
  • What if she in turn gets really offended and then tells all her friends?
  • What if it’s the ethical thing to do and her reaction doesn’t matter?
    What if she complains to my boss and I’m told to stop educating clients?
  • What if…

As the thoughts spiral, I land back to the original dilemma: do what’s right or stay quiet?

Is Massage Therapy Safe During Pregnancy?

Many Massage Therapists who provide prenatal massage have run into situations like the one above. 

There are several rooted old wives tales and myths surrounding massage and pregnancy. As Massage Therapists, we have a great opportunity to provide context, debunk pseudoscience, and encourage our clients to enjoy the benefits of massage during their pregnancy.

Yet in doing so, we may cause friction.

Especially with new clients, where rapport has not yet been established, confronting or correcting personal beliefs could be a bit touchy.

Simply put, there’s no evidence that effectively demonstrates massage can induce labor, cause miscarriages, or create complications. Just because someone’s great aunt said so, or a neighbour went into labor after a pedicure, doesn’t make it true.

Physiologically, there’s no reason a pregnant woman couldn’t enjoy the same massage as someone who is not pregnant would. Pregnant women are not sick; nor (in general) do they have a condition that can be worsened through massage.

They are often understandably sore, tired, or uncomfortable, but pregnancy itself is not an illness. Additional pillows, supports, or body positions may be required, but those types of accommodations should come naturally to any client-centered massage practice.

A few times, I’ve been asked if I hold some type of prenatal massage certification?

I reply that I do not, and do not believe it is necessary. Which is normally followed up by, “So what exactly is your prenatal massage?” My honest answer is, “It’s my same great massage… but with more pillows.”

While countless changes occur in the body during pregnancy, in general, the body is not altered to the extent that licensed/registered professional Massage Therapists need additional credentials in order to provide their own same great massage. Muscles are still muscles, joints remain joints, nerves stay nerves. The effects of massage on those tissues remains the same.

However, just as you would with any client, if there’s a health condition, or a known complication, defaulting to having massage ran by their doctor is prudent. 

Examples include diabetes (diagnosed before or during pregnancy); high blood pressure; cancer; and heart, kidney, lung or liver disease. Those conditions are not always contraindications, and clients with them may really benefit from massage, but they may act as cautions and reasons to alter your typical protocol.

What About Massaging The Feet And Ankles?

Do a quick Google search and you’ll come across countless articles, blogs, and opinions that warn pregnant women against ankle massage because it could induce labor. 

Chances are, many women may have at least heard of this myth, and some may become apprehensive or avoidant of massage because of it.

When you try to locate legit sources for such claims, you’ll hear crickets chirping. 

There’s no evidence that applying pressure to points on the feet or ankles will in turn cause uterus contractions. This wide-spread myth stems mostly from Reflexology.

Reflexology is a belief system that points on body relate directly to various internal organs, and by pressing or massaging those points, we can stimulate those organs. The claimed points for the uterus and ovaries are on the ankles.

Two separate systematic reviews in 2009 and 2011 concluded there’s not sufficient evidence to support the use of reflexology for any medical condition, let alone inducing labor.

But if that’s not enough, there was a great study in 2014 where researchers attempted to induce labor in 221 post-due date women by applying acupuncture needles to the specific labor-inducing points. Even when poking these gals every other day for a week, none of the findings supported reflexology claims. If they couldn’t induce labor with that amount of poking, general massage of the ankles is never going to do the trick.

Not only is there no evidence to back up the myth, there’s also no plausible reasoning to explain how it might work. What biological function is present in the ankles that would influence the uterus so? A super long nerve?

If pressing on ankles did influence labor, it would be risky to wear high top shoes, or even walk about daily life, for fear of bumping into or tripping over something with the feet.

Lastly, if it were just that easy to kickstart the birth process, docs and nurses would be spending much more time on women’s feet in the delivery room, and the use of hormones to induce labor would be obsolete.

Benefits Of Massage Therapy During Pregnancy

Moving beyond the fiction and into the facts, research has shown some positive preliminary evidence of the benefits of pregnancy massage.

Everyone can benefit from being less stressed, but for pregnant women in particular, less stress for them also translates into less stress for the growing baby.

A 2010 systematic review concluded that pregnant women reported decreased depression, anxiety, leg and back pain post-massage. Cortisol levels (the stress hormone) also decreased, excessive fetal activity decreased, and the rate of prematurity was lower.

Many of my clients have expressed how taking time to relax has also given them an opportunity to “check in” and more deeply appreciate their changing body. It’s provided time for reflection and appreciation for the child they are eagerly anticipating to meet soon.

A 2015 randomized control trial concluded that massage therapy can reduce lower back pain during the first postpartum month.

Narratively, I have treated pregnant clients for symptoms also expressed by the vast majority of my non-pregnant clients. Swelling, achy joints, nerve pain, sore muscles and compensation due to shifts in weight and posture, tension headaches, etc.

By applying the same anatomy and evidence-based training we would with any client, Massage Therapists can effectively address the aches and pains pregnancy can bring.

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Effective Communication About Pregnancy Massage Myths

Back to the example with my client at the beginning of this article, that day I did opt for the soapbox.

I took a long deep breath and rolled the dice, “Before we begin your massage, can you tell me a bit more about why massaging your feet may be risky? If they’re causing discomfort, I may be able to provide you with some relief today…”

I’ve found it’s helpful to ask a client to clarify their concern. Their response gives me more information to work with when attempting to tactfully dispelling potential myths:

What have they heard?

  • Are they concerned about the entire foot or just specific points? If only specific points, perhaps there’s room to compromise. I can offer a massage of the foot but avoid ankles.

Where have they heard it from?

  • What’s the context? If a client saw a Facebook post warning about ankles and pregnancy, information in that context is typically much easier to confront as false.

How convinced are they?

  • Can they be persuaded or not? If their source is a favorite reflexology practitioner they’ve been seeing for various ailments for years, I may cause considerable friction attempting to counter those beliefs. However, if their source or conviction is uncertain or weak, that may be a door open for continued conversation.

In the few cases I’ve experienced where a client is just not convinced, it has carried some friction (not the beneficial kind) into the massage and I did not see those clients again. Although I hate to lose a client, I take some comfort in knowing perhaps they will at least second guess the myth, maybe do research of their own, and in a best case scenario, perhaps allow another Massage Therapist to relieve their achy feet in the future. I hope others will join me in leaving this particular massage myth behind, continue to help women feel better, and support the on-going pursuit of further evidence to advance massage. In the case I’ve cited, my client’s source and conviction was weak, so I took the chance and briefly recapped the evidence-informed perspective I had to share. I’ll never forget her response: “Then this isn’t an old wives tale, it’s an old husband’s tale. My husband’s got a foot massage backlog to catch up on now.”

Self Care For Massage Therapists With Shoulder Injuries

 

My shoulder started to hurt.

Was this actually happening to ME? Was this the beginning of nagging symptoms leading to the end of my favourite career?

Those thoughts certainly crept into my mind.

One of the most frustrating things a Massage Therapist can experience: an injury.

I imagine a lot of Massage Therapists, as well as many other hands-on health care professionals, experience some form of discomfort or injury during their career. We spend hours each week using our body: our strength, our endurance, our flexibility, our knowledge, our emotion and our passion to help others feel better.

But what do we do for ourselves?

How do we keep ourselves healthy and able to help others?

Those of us who have been therapists for a few years have probably figured out the maximum amount of people we can massage in a day or week and other ways to keep ourselves healthy.

But even when you think you’re keeping yourself healthy, injuries occur.

So what do you do when a nagging, overuse injury creeps up on you?

Possible Reasons For Massage Therapists To Have Shoulder Pain

About two years ago the front of my right shoulder started to burn while I was working, especially when providing downward pressure and while moving client’s limbs.

It also hurt whenever I flexed or abducted my shoulder joint and when I lifted anything with my right arm (groceries, weights). It didn’t get bad enough that I couldn’t work but it didn’t get better either.

After a week I started feeling nervous. After two weeks I was annoyed. I received a few massage therapy treatments that were focused mostly on my pectoralis, deltoid and bicep muscles. While the treatments felt amazing and alleviated some symptoms for a day or two, it didn’t change my problem.  

After a month, the symptoms were no better so I decided to start using my own knowledge to rehab myself!

Thinking about my symptoms, I came up with three main reasons why I might have been getting this injury:

  • I had been feeling tight and stiff through my upper back. Perhaps this was creating dysfunction in my shoulder?
  • I was using a lot of strength during pushing movements and a lot less during pulling movements. Was there some imbalance between the front and back of my body?
  • I had been working hard for many years. Maybe I just needed a bit of a break?

Here’s how I addressed each of these questions and how it helped.

Therapeutic Exercises For Increasing Thoracic Spine Mobility

Have you heard of the stability vs. mobility joint by joint approach?

Michael Boyle (Strength and Conditioning coach) and Grey Cook (Functional Movement Systems) have promoted the idea of the joints of the body needing to be either stable or mobile. Starting from the lower limb and working superior here are some of the main joints and their basic need:

  • Ankle – mobility
  • Knee – stability
  • Hip (Acetabulofemoral joint) – mobility
  • Lumbar spine – stability
  • Thoracic spine – mobility
  • Scapulothoracic – stability
  • Shoulder (Glenohumeral joint) – mobility

If you think about it, this approach makes sense. For example the hip and the shoulder are very mobile joints, while the lumbar spine does not have much range of motion and therefore should be stable.

From the list above you can see the joint requirements alternate. Now think about what happens if one of the mobile joints loses some of that mobility. For the body to move there will be some compensation occurring. Where is the necessary movement going to come from?

It’s probably going to cause the joint(s) above and/or below to be more mobile that they should be. Here are a few examples:

Decreased ankle mobility -> Increased movement through the knee -> knee pain

Decreased hip mobility -> Increased movement through knee and/or lumbar spine -> knee and/or lumbar spine pain

Could it have been in my case that the tightness I was feeling through my thoracic spine was causing pain in my shoulder? With the stability vs. mobility approach in mind here was my thought on my own situation:

Decreased mobility in my thoracic spine -> decreased stability in my scapulothoracic joint -> dysfunction in my Glenohumeral joint -> shoulder pain

From this thought, I decided to spend time working on increasing thoracic spine range of motion.

Each day before I went to work, and each time I warmed up for a workout, I would go through these mobility drills for my thoracic spine: Thoracic spine windmill, Quadruped extension and rotation, Lunge with touch down and rotation.

Here are the descriptions and pictures for these three exercises.

Thoracic Spine Windmill:

    • Lie on your Left side, a pillow placed under your head, arms out in front
    • Bend Right hip and knee and place on a pillow, bolster, foam roller, etc.
    • Right hip should be above 90 degrees of flexion
    • Take a deep breath in
    • When breathing out, rotate through the thoracic spine bringing your arm across your body to the other side
    • Both shoulders should be in contact with the ground
    • Return to starting position and repeat 6-8 times on each side

 

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This is a great exercise you can do with massage therapy clients right on your massage table. I have had success with clients in increasing their thoracic spine mobility by massaging through the thoracic and pectoralis areas and then adding this exercise at the end of their massage session.

Quadruped extension and rotation:

  • Begin in a quadruped position – on hands and knees with hips placed above the knees and shoulders above the hands
  • Place Right hand on the back of your head
  • Rotate your thoracic spine bringing your Right elbow towards your Left elbow
  • With a smooth movement, Extend and rotate leading the elbow towards the ceiling
  • Return to the start position and repeat 8-10 times on each side

 

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Lunge with Touch Down and Rotation:

    • Take a large step back with the Right leg into a lunge position
    • Reach down with your Right hand and place it on the ground beside your Left (front) foot
    • Rotate towards your Left side bringing the Left arm up
    • Rotate your head to follow your hand
    • Hold for a breath
    • Return to the lunge position and stand up tall
    • Repeat, taking a large step back with the Left leg
    • Alternate legs for 6-8 repetitions on each side

*Bonus – you get some great hip mobility in this drill as well!

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Along with these three thoracic mobility exercises, I also worked on scapular stability through drills such as wall slides, windmills, Turkish getups and scapular push-ups.

I highly suggest being trained on these exercises if you’ve never done them before as they have a lot of important cues. Perhaps this will be in a future blog post! Stay tuned!

Strengthening A Massage Therapist Back To Help Correct Overuse

I’ve loved going to the gym since about 13 years old and have had a passion for strength training for over 10 years. I enjoy being strong and fit.

Strength training is important to me because it allows me to be strong for my career as a massage therapist, and it also is an amazing outlet for any stress or emotions I pick up. I love everything about strength training!

While injured I was probably over using my body, massaging 5 days a week and strength training 4-5 days a week. Since my career required a lot of pushing strength, I needed to compensate by spending more time in the gym on pulling strength.

I increased the amount of time and energy spent on large pulling movements such as deadlifts, hip thrusts, chin-ups and rows.

Four days a week I would do a rowing type exercise: band pull-aparts, dumbbell rows, face pulls, seated cable rows. I would only choose one rowing exercise each day, but made sure to incorporate them into my workout to fix or prevent any imbalances occurring between the front and back of my body.

A rowing movement targets the rhomboid, trapezius, latissimus dorsi and biceps muscles.

Here’s an example of how I would incorporate more exercises to target my posterior body, and especially rowing movements, into my workout each week:

Day 1: 

  • Assisted Pull-ups – 3-4 sets of 10-12 repetitions (reps)
  • Heavy single arm dumbbell row – 3-4 sets of 5-8 reps

Day 2: 

  • Deadlifts – 5 sets of 5 reps  
  • TRX, or other suspension trainer, rows – 4 sets of 15-20 reps

Day 3:

  • Body weight Chin-ups – as many as possible (usually only 2-3 reps)
  • Face pulls – 4 sets of 15-20 reps

Day 4:

  • Hip Thrusts 4 sets of 10-12 reps   
  • Bent over Dumbbell or Barbell rows – 3 sets of 10-12 reps

*Note: these are not my complete workouts, but an example of specific exercises (deadlifts, hip thrusts, pull-ups and rows) that I used.

There are many ways to add exercises that strengthen the back of your body.

This is what worked best for me! The take away from my experiment: if you have anterior shoulder pain (or even if you don’t) and work in a job that requires you to have your arms in front of you or overhead often, it is beneficial to work the back of your body far more frequently in the gym then your pecs and shoulders!

Massaging Less

Something I did not do at the beginning of my symptoms, or even before having symptoms, was give myself sufficient rest.

I would massage for many hours a day and still work out. Wasn’t massaging someone a workout in itself?! However, I didn’t want to give up my love for strength training, so I just changed how I trained, as explained above.

The change in training certainly helped, but I would notice if I had a few busy weeks that the pain would creep back again.

Last May, I moved to Iqaluit, Nunavut to spend an adventurous year in the Arctic with my fiancé. I am taking a short break from massaging full time and have been using previous schooling, training and skills in a different job. I still massage part time and also have gotten back into personal training and teaching fitness classes at the local gym. It has been wonderful using my previous education while still being able to practice what I love.

Since moving and massaging less I have felt AMAZING! No pain and no worrying about my body breaking down. Perhaps all I needed was a break?

But what happens when you can’t afford to take a break?

I remember constantly feeling like I couldn’t take time off. I wouldn’t be getting paid for any days off, I was paying off students loans and didn’t have any other income. How do we manage to take some well deserved rest?

Try to find other avenues of income. I started supervising the student clinic and assisting a teacher at the local massage therapy college. Soon I was lucky enough to teach some of the courses myself. I also taught anatomy courses for fitness professionals on weekends. There are lots of ways we can use our knowledge to gain other or extra income.

While I am looking forward to moving back to my hometown and being back into massage therapy full time, I am also going to be more aware of needing rest or time off.

So What Worked?

As mentioned above, I spent a lot of time working on increasing and, now, maintaining my thoracic spine mobility.

I added more strength exercises for the back of my body to compensate for the amount of pushing I did during massage work. I took a break from massaging full time.  

I still do the same, or similar, mobility drills for my thoracic spine daily. I still work on scapular stability. I still deadlift, hip thrust, row and try hard to perform chin-ups (Why are they so challenging!?!!). I still massage and hope to for many years to come.

Since incorporating thoracic mobility exercises into my daily routine I have found that I no longer feel tight through my back nor through my neck (an added bonus!). More movement through my thoracic spine allows for my other joints around it to function as they are intended. As hands-on therapists we need to figure out what is best for our own health so that we can continue to help others. Use your own knowledge to create a plan to keep yourself healthy and injury free so you can have a long, rewarding career. Don’t give up on what you love!

5 Things You Need To Know About The Business Of Being A Massage Therapist

 

It’s not like any of us set out to be a colossal failure in our business adventures, but it happens.

An average of 7000 businesses file for bankruptcy in Canada each year.

30% of small businesses won’t survive two years, and only 50% make it to year five. That’s a high failure rate when you consider that 98% of Canadians work in small businesses.

Many healthcare professionals graduate college only to discover the running of their practice is in fact another full aspect of their career that they are ill prepared for.

When I started college I had envisioned a lot of candle light and Enya music.

Reality hit me like an avalanche; the pace and volume of information I ingested was like inadvertently entering an eating contest every day for three years. It was much the same when I decided to be self employed, a sole proprietor, upon graduation.

The reality of my situation was vastly different from the mental picture I had.

I thought I was ready to take on the role of a sole proprietor, that my education had prepared me for life as a healthcare professional.

It became blindingly obvious that there was a whole other side to being a RMT, a side that I was unprepared for, the part where I actually had to run a business. The first 5 years in business would show me how much I had yet to learn and teach me some tough lessons about running a small business in the healthcare industry.  

The business of being a healthcare professional comes with it’s own set of rules in addition to all the other more traditional rules of running a business.

There are layers of rules, processes, procedures, variations of business plans and models.

Why did I not know about this? Why did no one seem to know about this? Why did we not learn about this in professional development?

I really had no idea how to get started as a business woman, a sole proprietor, how my proprietorship fit into an existing clinic,  or how to open my own clinic based on what I had learned in college.

So, I paid for that education too…eventually.

But first, I jumped into deep waters without a plan or a personal floatation device. I realize retrospectively that there was an easier way, but some people have to experience the shark tank for themselves. And I assure you, my first few years as a clinic owner were akin to swimming in shark infested waters.

I made a plethora of mistakes along the way and witnessed other therapists make their own host of mistakes as well.  There were so many things I was just not prepared for, and an equal amount of things I didn’t know I needed to plan for.

After much floundering, I decided to take some business classes, read Business For Dummies, and hire a consulting company to help me stabilize the business.  

Those years of change were rough.  

I felt like Captain Jack Sparrow, shouting “Stop blowing holes in my ship!”.

The combined efforts of the consulting company I hired, business specific education, a ton of reading, and a collaborative group that I belong to, helped me get my business shipshape and under way.

I just wish that I had been better prepared for the business aspect of my career coming out of college.

I also wish there were more resources and maybe even some continuing education courses about the business for Massage Therapists. As a profession, we quite simply need to learn more about business.

1.The Myth of “Fair Rent”

The question often arises in conversations and on social media around what is “fair rent”.

I honestly think we’re asking the wrong question, and it articulates our collective lack of understanding of the business aspect of our profession. Although, in some situations we might actually be talking about “rent”, such as when a therapist leases/rents a commercial space.

It seems more accurate to describe the fees paid to a clinic as “association fees”.

It’s possible that the relationship between the therapist and the clinic is a straightforward room rental arrangement, but it’s equally possible the relationship is more of an association, like in a law firm or a real estate agency. In which case, there is so much more going on than just simply renting a room.

In order to determine value, we need to distinguish between rent and association, and itemize what services are offered in exchange for the fees. It means we can ask questions that more accurately determine what would be a fair fee based on the services offered.

Consider it this way, what is a fair price for a car?

We would need to consider several things about the car in order to determine it’s value, such as: Make, model, age, features, accessories, mileage, past, maintenance records, tires, etc. It is similar when we inquire about compensation as a sole proprietor/contract worker as well.

The questions could be:

  • What services are included in my association fees with the clinic?
  • What services are not included in my association fees but are necessary for me to conduct business?
  • What services are negotiable, which are not?
  • What fees are negotiable and which are not?

There are a variety of different clinics to choose from, with variations of administrative structure, clinic management services, policies, procedures, and unique business models.

Because there are so many variables and differences between clinics, it means there are a variety of association fees that are fair. So, it seems that the correct answer might be something we, as Massage Therapists, are all too familiar hearing…it depends.

2. Cost Benefit Analysis, Profit & Loss Statements: Putting It Into Perspective (know your numbers)

You’ve attended school for 2 + years, graduated, passed your board exams, and now you’re looking for a place to hang your shingle.

Or maybe you’re a seasoned therapist, and you just want to go to work, treat your patients, and go home.

And possibly, you’re one of those entrepreneurial marvels and you fancy opening or owning and managing your own clinic. Whichever business model you’re interested in, a solid cost benefit analysis (CBA) or Profit & Loss Statement (P&L) is a good place to start.

“It costs money to make money” is one of my least favourite expressions in business, however true it is.

If you’re a new graduate you’re already wracked with debt, and the thought of start up costs can be overwhelming. Let’s be honest, the risk of loss can be overwhelming for all of us, even successful clinic owners.  The object is to plan for success and manage your cash flow.

A CBA will weigh the costs against the benefits in a chart, and should give you a better idea of what you can and can’t afford. The CBA is a technique that is a systematic approach to estimate and compare the benefits and costs of a project or business.

It will help you determine the feasibility of a business decision.  It could prevent you from getting  into a situation where you hemorrhage cash, and the risks outweigh the potential benefits.

A CBA can morph into, but should not be confused with, a profit and loss statement, which is a financial statement designed to summarize and assess the actual revenues, costs, and expenses incurred during a specified time period, usually a fiscal quarter or year.  

This technique may help assess the bottom line by identifying any hemorrhaging of cash or assets in the business, and improving prudent financial planning for the future stability of the business.

3. Massage Therapist Contracts

Contract law is a mirky quagmire to navigate on your own.

It is always a good idea to consult with legal counsel before you sign anything, or if you have any questions or concerns.

Check with your professional association to see if they offer legal advice to their members (The BC association has a legal retainer for members.) I suggest that it is worth the expense if you’re signing a contract in relation to your Massage Therapy practice. This field has a unique language and is too complex for the average Massage Therapist to traverse on their own.

A contract is an agreement between two or more parties, and should be mutually beneficial. It will itemize the exchange of services, goods, or promises.

Contracts are a part of our life in many ways. Everytime you go skiing you sign a contract. When we buy a cell phone plan, lease a car, take out a loan or mortgage, buy insurance for our home or vehicle we are signing a contract. When we go to our physician we sign a contract to agree to receive medical treatment.  

If you don’t like the terms of an agreement, or have concerns about a specific term, negotiate them to be something you can agree to.  But, don’t ever sign an agreement you don’t understand or don’t agree with.

Contracts are a good idea in any business relationship. They clearly detail the services, expectations, rules, boundaries, and consequences.

They protect not only the investment of the clinic, but also the investment of all the therapists that work in association with, or under the umbrella of the clinic.

A well written contract is beneficial for all parties. Contracts are everywhere, they shouldn’t be a scary or threatening thing for Massage Therapists.

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Photo by: NobMouse

 4. Sole Proprietorship: The Good, The Bad, And The Ugly Truth

From new graduates to seasoned therapists, I hear the woes of business and ensuing conflicts from poor management practices, poor communication and misinformation running rampant in the Massage Therapy world.

We are taught the value of our service, but not the costs associated with facilities and amenities needed to conduct such service. We are pumped and primed with what we should expect in compensation, how in demand our services are, and what we’re entitled to.

We were even lured into the programs of Massage Therapy with the enticing expectation of making a six figure income with less than 2 years of college education.

The cold hard facts about proprietorship, association with an existing clinic/associates, or contractual work and the risks associated with this business model were briefly touched on, if at all.

Canada Revenue Agency (or other international regulatory bodies for business) have definitions and expectations for those who would define themselves as sole proprietors.

Understanding that the freedom associated with proprietorships comes at a risk of loss is an important shift in paradigm for many healthcare professionals. We want the benefits of proprietorship without the risk of loss, and who can blame us right?

The ugly truth is, there has to be risk of loss if you want to be considered a sole proprietor.

Personal liability is greater in a sole proprietorship also.  

If something should happen in a sole prop. business, if the business should be sued, or if it comes into financial trouble, you’ll be personally on the hook and creditors and lawsuits can come after your personal assets.

If an associate or clinic is audited, and the government determines that the relationship was closer to that of an employee/employer rather than a sole proprietor/contractor, the clinic owner will be at risk of having to back pay the government both the employee and employer portions of CPP, EI, and WCB (taxes and benefits).

The decision is not defined alone by what we say we are, but by how independent the associate is, the autonomy, and the risk of loss. I encourage all sole proprietors to understand how their government distinguishes between proprietorship and employment.

Even an unreasonable client, colleague, or clinic can sue you for breach of contract and you’d be personally liable. It’s important to think about how much risk you’re willing to incur in all your business decisions.

What a proprietorship is not, is a partnership.

Being a sole proprietor working and practicing in a clinic does not entitle the proprietor to a share in the company or make them a business partner. This may seem like a “thank you Captain Obvious” moment, but anecdotal evidence over the last 10 years in business suggests that this is a more common paradigm for registrants than not.  

How does proprietorship of individual therapists fit into the business model of modern clinics?  

The business model for the Massage Therapy profession is closer to that of a law firm or real estate agency than it is to a tenancy agreement.

While some clinics may choose to remain a tenancy styled model, and some may reflect a limited liability partnership, most clinics are like real estate agencies or law firms in their contractual relationship with their associate therapists.  

They offer various associate packages and services in exchange for commision splits or flat fees, but it’s not just based on the splits or fees, there’s a lot more to consider.

For example:

  • What training and education do you need/does the clinic offer?
  • Does the associate require a lot of time and new patient leads provided by the clinic?
  • Is the clinic new/is the associate new?
  • Is there an existing network of referrals and marketing infrastructure to support an additional associate?

To summarize, being a sole proprietor has many benefits, such as flexibility, autonomy, and higher potential revenue. But, it comes at a cost of increased liability, responsibility, and risk of loss.

5. Business Models: Choosing A Clinic Or Practice Model That Meets Your Needs And Plays To Your Strengths.

There’s no single right answer that applies to all circumstances and individuals when it comes to deciding what clinic or practice model is best for you.

You might decide that working alone is what suits you best; A micro business would be your best option if you love the idea of doing it all, the admin, the paperwork, and the practice. Perhaps you are interested in building a huge corporation or franchise with hundreds of therapists and staff members.

Maybe you don’t want to think about the business side of your practice, you just want to go to work, treat your patients, and have administrative staff do all the paperwork for you. Maybe you would like a small local clinic with a solid team and tight knit network of professionals. Or, perhaps you’d prefer a huge integrated health centre with multiple healthcare providers to collaborate with. Maybe your preference is for corporate, sports teams, or mobile services.

From single person micro businesses to huge corporations, there’s really no wrong decision, except to choose a work environment that you don’t enjoy or that doesn’t meet your needs.

It’s critical to be able to analyze the financial viability of your business, project future expenses, plan for success, and understand how to calculate the value of associate fees/packages. Having a well written contract that is clear and fair will give you security and stability. It’s also important to choose a clinic model that meets your individual needs, it will set you up for success and growth. It’s crucial that you appreciate the role, responsibility, liability, and benefits of proprietorship, and how it fits into a clinic environment.  These five things are fundamental to the success of a Massage Therapy business, whether it be a proprietorship, partnership, or corporation. Of course, there’s always the option to jump overboard and take your chances in the shark infested waters of small business. 62% of small businesses in Canada launch without a business plan. In the meantime, I’ve attached a P&L excel spreadsheet from a small Massage Therapy clinic. It itemizes the expenses of a small clinic for 2016 without any of the figures. You can use the list of potential expenses like a draft/template to create a personalized CBA or P&L for your own proprietorship. And, here’s a link to a quick and simple small business startup plan available online through Quickbooks

Back Pain Myths: Posture, Core Strength, Bulging Discs

It is an article of faith among many mainstream experts that poor posture, lack of core strength, and/or structural abnormalities such as bulging discs are major causes of pain, especially back pain. A further assumption is that by working to correct these issues, through stretching or strengthening, or postural retraining, or surgery, pain will decrease. It is probably fair to say that the majority of physical therapy and corrective exercise done in this country is based on exactly these assumptions. Although these ideas have a common sense appeal, there is significant evidence questioning this approach. Here’s a brief review of the conflicting evidence.*

Posture

You have probably heard the claim that bad posture causes back pain, or that you should try to improve your posture to get rid of low back pain.

You can find this claim all over the internet – from physical therapists, chiropractors and personal trainers. If you do a Google search for “posture and pain,” you get 4 million hits.

With so many posture police on patrol, it is a near certainty that you will sooner or later be told by some authority that your posture needs work.

For example, if you go to a physical therapist with low back pain and a large curve in your low back, you may be told that you need to correct this by sucking in your gut, squeezing your glutes, tucking your tail, or strengthening your core. If you have upper back pain and a sunken chest, you may be told to pinch back your shoulder blades, strengthen your scapular retractors, stretch the chest, and raise the sternum.

These ideas have intuitive appeal, and are advocated by numerous experts. But are they supported by evidence? And should you spend time trying to analyze your own posture and make corrections? Let’s look at some evidence that might help us answer these questions.

In one study, researchers looked at the posture of teenagers and then tracked who developed back pain in adulthood. Teenagers with postural asymmetry, thoracic kyphosis (chest slumping) and lumbar lordosis (overly arched low lack) were no more likely to develop back pain than others with “better” posture.

Another study looked at increases in low back curve and pelvic angle due to pregnancy. The women with more postural distortion were no more likely to have back pain during the pregnancy. A systematic review of more than fifty four studies found no good evidence of a correlation between posture and pain. Leg length inequality seems to have no effect on back pain unless it is more than 20 mm (the average leg length difference is 5.2 mm). Hamstring and psoas tightness do not predict back pain.

These results are particularly striking given that many studies have quite easily found other factors that correlate well with low back pain, such as exercise, job satisfaction, educational level, stress, and smoking. Although some studies have found a correlation between back pain and posture, it is important to remember that correlation does not equal causation. It may be pain is causing the bad posture and not the other way around. This is a very likely possibility. People will spontaneously adopt different postural strategies when injected with a painful solution. Big surprise!

Based on the above, there is little evidence to support the idea that we can explain pain in reference to posture or that we can cure pain by trying to change posture. For more articles on posture, click here.

Disc Degeneration, Bulging Discs, And Other MRI Abnormalities

Another common idea is that herniated discs or other degenerative changes revealed by MRI are major causes of back pain. Many people who learn of these structural changes will assume it is the cause of their pain and start to consider surgery as a solution. However, numerous studies show that many types of structural abnormalities are poor predictors of pain.

In one famous study, MRIs were performed on subjects who did not have back pain. Fifty two percent of the subjects had at least one bulging disc or other MRI abnormality for which surgery is sometimes recommended. Given these findings, the authors stated that: “the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.” In a similar study, MRIs on individuals who had never suffered from low back pain revealed that one third had a substantial spinal abnormality and 20% under the age of 60 had a herniated disc.

In a study of pain free hockey players, seventy percent were found to have abnormal pelvis or hip MRIs, and fifty four percent had labral tears. The author stated that “this study shows the limitations of depending too heavily on an MRI. A surgeon may see something in the image, but it isn’t causing a problem.”

In this study, researchers examined forty four volunteers, age 20-68, with no history of knee pain. Sixty percent showed abnormalities in at least three of the four regions of the knee, causing the authors to conclude that “meniscal degeneration or tears…are highly prevalent in asymptomatic individuals.”

Studies of active baseball pitchers or overhead athletes consistently demonstrate very large percentages (over seventy percent) of torn labrums and rotator cuffs.

These are all issues for which surgery is sometimes recommended.

This is not to say that herniated discs, torn labrums or other structural abnormalities cannot cause pain. Of course they can, and you would rather have less damage than more. But if a large percentage of pain free people have bulging discs, then how likely is it that a bulging disc is the cause of your back pain? If you look close enough at almost any joint in the body, you will find something wrong with it. Don’t assume that whatever shows up on the MRI is the source of your pain. For more on the poor correlation between MRI results and pain, click here.

Core Strength And Back Pain

The idea that good core strength is essential for a healthy back is another ubiquitous idea. What is the evidence that poor core strength causes pain or that core strength exercises reduce back pain?

Before reviewing the studies, it is first interesting to note that most of life requires only minimal activation of the core musculature. During walking, the rectus abdominis has an average activity of two percent of maximal voluntary contraction, and the external oblique operates at five percent. During standing, trunk flexors and extensors are estimated to fire at less than one percent. Add more than fifty pounds to the torso and they fire at three percent. During bending and lifting muscular activation is similarly low. Given that daily life seems to require so little core strength, perhaps it is not surprising that research interventions to increase core strength have little effect on pain.

Here’s another quick reality check before moving on to some research: ever noticed a heavily muscled person with massive core strength who has lots of back pain? Or a skinny weak person with none?

Now let’s look at some research. One study showed that core strengthening exercises for pain free persons identified as having a weak core do not reduce the future likelihood of back pain. Numerous studies have been performed to test whether core strength exercises reduce back pain. The thrust of these studies is clear – although core exercise can improve low back outcomes, it is no better than general exercise. The obvious conclusion is that if core strengthening has benefit, it works because of the generally beneficial effects of exercise (or as a placebo), not because lack of core strength or poor firing patterns are a major cause of of back pain. In other words, despite what we are told over and over, the current evidence states that there is nothing magic about core strength as means to prevent or reduce back pain.

Conclusions

The above results are surprising and counterintuitive, and raise many questions such as: why do these approaches seem to work; how can so many people be wrong; and if these aren’t the true sources of pain, then what is?

For more information to answer some of these questions, I recommend clicking on the Posture and Pain links above for relevant articles.

*Most of the studies referenced in this article are from three excellent papers: The Myth of Core Stability by Eyal Lederman; The Fall of the Postural Structural Model in Manual and Physical Therapies by Eyal Lederman; and The Traditional Mechanistic Paradigm in the Teaching and Practice of Manual Therapy: Time for a Reality Check, by Frederic Wellens.

The Importance Of Curriculum Change For Massage Therapy

When I graduated from massage therapy school in 2005 I had already completed my bachelor of science and felt very comfortable in my knowledge and abilities to become a great therapist.  

It became very evident to me over the ensuing years that there was a lot more I needed to know and understand in order to more effectively treat complex problems, particularly those who lived with persistent pain.

It was through the experience of seeing my wife struggle with disabling pain and realizing the treatments she was receiving from medical doctors and allied health care providers were inadequate.

Something was missing in how myself, and other health professionals were educated.  

The conceptual framework and understanding of the human pain experience and how we conduct our treatments appeared incomplete.

This quest for answers led me on a fantastic journey that completely changed how I view the body, the brain, and how I treat my patients.  Last February at the San Diego Pain Summit I was convinced that the path I was going on was the correct one.

Treating people in pain is what we do, and there is a much better way to do it than what we learn in school.  I felt inspired and realized one of the main problems with our profession is that there are not enough of us with advanced degrees to lead the profession towards the changes it needs.

I decided that in order to help advance our profession I couldn’t sit on the sidelines, I would need to be involved and pursued more education.  In September I started my Masters in rehabilitation sciences at the University of BC.

Already, in a short period of time I feel I have gained invaluable tools for critiquing research, finding and utilizing evidence for practice and critical thinking skills.  These skills need to be fundamental to all health-care professionals.

Changes are necessary for us to evolve.

National Standards For Massage Therapists

The profession of massage therapy in Canada (particularly in British Columbia), has a long history of being leaders in its curriculum, standards of education and licensure that can exceed our colleagues in other parts of the world.

There is a strong desire among our membership in BC to increase our education to that of a baccalaureate program.  Our professional association, the RMTBC has completed great work in attempting to make this happen.  Ideally, it would be great if all education for massage therapists was standardized regardless of what province or state you were educated in, much like it is for physical therapists, nurses, pharmacists, opticians, and medical doctors.

Currently in Canada the regulated provinces are working on a national standard of competencies.  

I applaud their attempts in pioneering this endeavour as it could provide a framework that other massage therapy regulatory bodies throughout the world could follow.  However, the lack of quality research used to support the development of the competencies is embarrassingly evident.

As a regulated health-care profession, the educational curriculum and practice standards of massage therapy need to be based on strong scientific principles and good quality relevant research.  In order to make informed practice decisions and incorporate an evidence-based approach to treatment planning the educational standards of RMT’s must be recreated.

As it currently stands, the Interjurisdictional Competency Document and its companion, the Guidelines for Foundational Knowledge in Massage Therapy Educational Programs, which together form the framework of what is taught in the massage therapy colleges and creates the material for what is required to pass board exams, are both regrettably unacceptable as documents around which an entire profession’s competencies are created.

Creating A Greater Understanding Of Massage Therapy

What is wrong with this document and what is a fundamental problem in our profession?

The primary faults I see is the research on the actual mechanisms of manual therapy are ignored and an inadequate understanding of pain and its bio-psycho-social components are missing.

Unfortunately, manual therapy professions base their treatment models and understanding of pain and dysfunction through out-dated biomedical beliefs, structuralism and connective tissues modalities.  There is a better direction to go, we simply need to follow the science.

Manual techniques exhibit the majority of their effects based on mechanoreceptor input from the skin, not the muscles or fascia.  

The words we use, how we interact with our patients and the explanations we give are more important than any miraculous technique that we learn.  This short article provides a great discussion of the need to move beyond our techniques.

All positive or negative changes our patients have in their pain perception or movements are from alterations in their nervous system.  Nervous tissue is the only tissue in the body that can adapt and change quickly within the confines of a treatment session.

Once a therapist realizes that every effect we have is through the nervous system, primarily the brain, massage therapy becomes much more simplified, more powerful as a therapeutic tool and prevents unnecessary and unrealistic treatment plans that do not serve the best interests of the patient.

Research has shown that connective tissue cannot be altered for any length of time through manual techniques, and we shouldn’t want to alter it anyway.  Here are a couple great articles worth the read that refutes fascia’s importance, here and here.  I could post numerous links to all the research, but these two sum it up succinctly.

Trigger points, another sacred doctrine of massage therapy are likely not a problem in muscle tissue, more plausibly it is referred pain from peripheral nerves.  Posture and biomechanics are not always as important as we think they are either, here is a free full text pdf available worth the read.  

These links are not meant to completely invalidate other ways of thinking.  

They are to identify the science and other opinions in the manual therapy field.  As a profession we need to be more open-minded and become science-based clinicians, and not continue to base our curriculum and practices on historical beliefs.  This is still possible while not forgetting the art of what it is we do.

https://flic.kr/p/bN15Tk

Photo by: BU Interactive News

Three Pillars Of Massage Therapy

The three pillars that guide our profession as outlined by our regulatory Colleges is safe, effective and ethical health care.

By purposely neglecting the wealth of evidence on manual therapy mechanisms we are failing on all three pillars.  This purposeful neglect is unforgivable with the wealth of modern science on pain, fascia, biomechanics and the mechanisms of manual therapy.

By focusing on out-dated beliefs and a biomedical structuralist approach to care, and furthering the pseudoscientific beliefs about fascia, trigger points, cranio-sacral therapy, visceral manipulation, postural asymmetries and adhesions to name a few, we are supporting unsafe, unethical and ineffective practices.  

Our profession needs to move towards an evidence-based model that includes plausible scientific principles of manual therapy.

We do not need to make up stories to explain what we are doing.  Touch is therapeutic, massage and movement is analgesic.  These effects occur because of our interaction with another person’s nervous system.

By adopting a curriculum that includes biopsychosocial approaches to pain management, peripheral and central mechanisms of pain, understanding nonspecific treatment effects, motor control, graded exposure to movement, principles of patient centred care and the pillars of an evidence based practice, we would be much better suited to provide safe, effective and ethical care.  

Those approaches are much more supported by science and encourage a feeling of security, robustness and self-efficacy that can elicit more consistent results and better patient outcomes.

The problem with overcoming this dilemma is the belief systems are so ingrained in the profession.  Too much of what we do is based on faith and not on fact.  Changing the profession will require great force of will and continuous efforts, because it is an entire culture that will need to adapt and change.  

From the top down, national massage therapy organizations, provincial regulatory Colleges’, massage therapy educator’s, current RMT’s, and students will need to adjust.

Changing Massage Therapist Focus

We are so focused on our modalities and learning new techniques to add to our toolbox, that we lose focus on what really matters.

Our profession has made the care we provide more complex than it needs to be.  

If we could focus on having a solid foundation in the core sciences, learn how to interpret research, critically think, and learn advanced skills to more effectively interact and educate patients we would be significantly farther in our progression as a useful component of the health care system.

Patient centred care and evidence-based practices should be the foundation of what we learn in our education.  Assessment and manual skills are important and these skills will always be central to our profession.  RMT’s can still historically do what we have always done, but the time is here for us to adapt and reinvent ourselves.  The regulatory Colleges, professional associations, all the private colleges and most importantly the massage therapists have roles to play in this process and a desire from each organization or individual to implement change is needed for our profession to become leaders in manual therapy education. Change is constant, it is not to be feared, and it needs to be embraced, as change is necessary for the long-term survival and relevancy of our profession.

Visit Somasimple.com, Body in Mind at http://www.bodyinmind.org, the NOI Group at http://noijam.com, www.greglehman.ca, or go on Facebook and interact with clinicians from Skeptical Massage Therapists, Biopsychosocial therapists, Explaining Pain Science or Dermoneuromodualtion among many others and you will find great debate, discussion and heaps of research to sift through that will quickly get you questioning your current practice and beliefs.

Ethics Violation, or Communication Breakdown?

This year I wrapped up five years of service on the North Carolina Board of Massage & Bodywork Therapy. Anyone who has ever sat on a board will probably agree with me that disciplinary hearings involving massage therapists are one of the most stressful parts of that job. It was for me. I estimate that during my time on the Board, I had to sit through approximately fifty of them. It was very distressing to see my fellow massage therapists trying to defend themselves–and in a few cases, just outright admitting to the violation–whenever they were accused of something.

Nine times out of ten, the accusation was of a sexual nature. 99 times out of 100, it involved a male therapist. I’m dead certain there are female therapists out there performing sexual favors every day, but most men won’t come forward to complain about it. Go figure.

My question to myself at those hearings was always this: “Did this person have an intent to do something evil, or was this a communication breakdown or simple mistake that could have happened to you or me?”

If you’ve been practicing longer than a year or two, the chances are good that in spite of your best efforts, you have accidentally exposed a body part. Or you have said something that the instant it left your mouth, you thought “why did I say that?” The very first massage I ever gave, I accidentally touched the man’s penis. I went to tuck in the drape, and all I can say is there it was. He was supine on the table, his eyes were closed, and when my hand grazed it, I saw his eyebrows shoot up. I said “I’m sorry,” and carried on. If I had made a big deal out of it, I could have just made it worse than what it was.

If your only intent is to give a therapeutic massage, then your major obligation is not just about giving the massage; it is clear and direct client communication. This has come home to me again and again, and most recently when one of my friends was accused of a sexual violation. The case has not been settled yet; it hasn’t even been to court, but he has been crucified in the press and by a number of bloggers–none of whom were present in the room and have no idea what truly happened there, but I’ve been watching what amounts to a feeding frenzy by a bunch of sharks who are determined to hang him from the highest tree. He is apparently guilty until proven innocent. And since no one was in the room except for him and the alleged victim, I am fearful of the outcome. Of course I do not want a sexual predator turned loose on the public. But after a career that has spanned about 30 years with no previous complaints, it’s a shame to see that going down the tubes. He has loyal clients who are still patronizing him (including women), but what do you think the chances are of him getting any new ones while this is going on? Zilch.

You can’t be too careful. Let’s be realistic. Most massage tables are set up so that the table is at about crotch-level. That’s a fact. We lean over people. We use our body weight on people. Some therapists get on the table with people. In my younger, skinnier days, I’ve crawled up on the table when someone was prone. I’ve done pelvic work on people of both sexes. I’ve done pectoral work on people of both sexes. I’ve worked on the gluts of both sexes. If you’re performing medical massage, you’re going to find the need to touch those areas–with the client’s informed consent.

Think for a moment about the muscles that originate on the pelvis. If you want to make the belly of a muscle relax, you need to make the origin and insertion relax. That’s just the way it is. If you’re ignoring the origin and insertion, you might be giving a relaxing massage, but you’re not getting to the root of the problem. However, if you abruptly touch someone’s pelvic bone without discussing that with them beforehand, you’re the next disciplinary hearing waiting to happen.The general public doesn’t know squat about origins, insertions, and actions of muscles. It’s up to you to educate them. And it’s up to you to abide by their comfort level. If they prefer not to have their gluts worked on or you getting near their pubic bone, then you don’t do it, period. I have found it helpful to have a muscle flip chart in the treatment room. That allows me to pick it up while someone is on the table and show them the muscle, where it begins, and where it ends. It’s a professional thing, to me.

There is also no excuse for careless draping. The law in my state says that “the drape may be temporarily moved in order to accommodate treatment.” Yours probably says something similar–or not. Working through the drape may not be ideal, but if that’s the law in a your state, then I suggest you abide by it. Don’t expose more than you need to expose, and don’t leave it exposed. If you have moved the drape in order to work on the gluts, that doesn’t give you license to perform the whole massage with someone’s butt shining. Get it done and cover them up.

Be aware of the comments you make. It’s okay to tell someone they have taut bands or active trigger points in the gluts. It is not okay to tell someone they have a tight ass. You might be thinking it, but keep your mouth shut.

You may think you’re all above-board as a therapist and that you’re never going to be accused of anything. Guess what–all those people who have been accused didn’t expect it to happen to them, either. Two things that did become apparent to me during my years on the Board…one, there are indeed predators out there who decided this profession would be a good place to meet a fresh crop of victims, and two, there are just therapists out there who are guilty–of failure to communicate. Don’t let it be you.

Originally published December 31, 2011