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Articles Of The Week March 11, 2018

March 10, 2018/in Article, Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Sport Massage/by Jamie Johnston

Is yoga effective for managing chronic pain? Maybe, but then again maybe we just need to look at safe, non-threatening movement as a way to cure or manage chronic pain.

“Yoga, Mice, Pain and Your Brain” – Sarah Haag

There are some great points in this article about doing aggressive psoas work on patients, but there’s some things I don’t like about the article. To say that only those trained in visceral work should be doing this kind of work (because there’s not much evidence to say visceral manipulation is effective), is a bit of a stretch. However, I like the overall gist, that only trained professionals should be doing the work, and to be careful, there’s no need to do “aggressive” work.

“Serious Warning – If You Do Any Releases To Your Psoas or Abs, You Must Read This” – Antony Lo

Load management in athletes is an important factor in making athletes available for, and being in the best shape possible for competition. This post reviews three factors related to load management to help your athletes.

“Load Management Is Not About Decreasing Minutes” – Tim Gabbett

I love sleep, so I hate this part of the year where I lose an hour of it putting the clocks forward (why are we still doing this!?). A lack of sleep can lead to a host of health conditions and can affect brain health. Fortunately, massage therapy helps with sleep, so this could be a good article to share with your patients as another reason to get a massage!

“Why Are We So Sleep Deprived And Why Does It Matter?” – The Conversation

I’ve been asked many times if I would ever open up a practice at home and while it’s not for me, I know plenty of therapists who do. This post lays out several things to consider if you are wanting to open a home-based practice.

“Opening A Home Based Massage Business” – Allissa Haines

The Adolescent Female And The Athlete Triad

March 5, 2018/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Sport Massage/by Valerie Bobb

Many RMTs, Athletic Therapists and Physios start their career wanting to work with athletes, I know I did.

I had dreams of spending my days in the locker room and on the field, being part of a team and sharing in the glory of winning (having never been talented enough to compete myself!).

For many years, I did just that.

I worked in a sports clinic with my physical therapy “hat” on treating sports injuries and my evenings and weekends covering athletic events wearing my athletic trainer “hat.” During my time at an all-girls high school, I became involved in female athlete triad research and bone stress injuries.

It opened my eyes to how athletics can affect females differently than males.

Since then, how we view the triad and how we treat it has changed.

Can you recognize and screen for the signs of the triad? Do you know who is at risk?

What Is The Triad, And How Do We Recognize It?

Adolescent girls should participate in sports. I want that to be clear.

Girls participating in sports have better communication with their parents, are less likely to get pregnant, have more positive body image and are 20% less likely to get breast cancer later in life.

But they are at risk for injury, 48% of female athletes will have injury severe enough for them to miss playing time.

Bone stress injuries are common in adolescent females, occurring in up to 21% of competitive females. Injuries can range from a stress reaction to a stress fracture and occurs from a disturbance in osteoblastic bone formation and osteoclastic resorption. The most common places are the foot, lower leg and pars in the spine. Risk factors include endurance sports, sudden changes in training (duration, intensity, equipment) and inadequate recovery time.

90% of peak bone mass is gained by 18 years of age and research shows athletes have approximately 10% more bone density than non-athletes. So any non-traumatic bone injury is cause for concern.

It is imperative that the underlying cause is investigated and treatment includes resolving more than just the fracture.

Any time there is a bone stress injury, the other components of the Female Athlete Triad should be considered.

The Female Athlete Triad was first described in 1992 as disordered eating, amenorrhea (specifically missing more than 3 periods in a row) and osteoporosis. The triad has now been expanded to include a spectrum of each pathology. Screening should include having less than 6 periods a year (not necessarily consecutive missed cycles), dietary counselling and a DEXA bone density scan that compares the Z-scores, which matches the athlete to others her age. A -2.0 standard deviation or greater is concerning.

The crux of the triad seems to be low energy availability due to disordered eating.

The athlete doesn’t necessarily try to restrict their calories, although some do in body-conscious sports, or if they are concerned about their weight. Many are just unaware of the amount of food it takes to fuel their daily activity. Sometimes they are just eating poorly: fast food, processed food, you know….they are teenagers! This low energy availability leads to hypoestrogenism and disrupts menstrual cycles.

Estrogen normally inhibits bone turnover and maintains a balance between resorption and formation. When there is a nutritional deficit and a lack of estrogen, this balance is disrupted.

Back when we started the research, we thought the best thing to do was replace the estrogen. Makes sense right? Studies now show that using oral birth control does not change the bone density, even with prolonged use. The first treatment should be nutritional counselling and improving caloric intake. There are great resources online at www.femaleathletetriad.org that includes a nutritional calculator to get you started.

Also, find a nutritional counsellor in your area used to working with athletes.

Photo by: KeithJJ

What Can We Do?

So what do you do as a healthcare professional?

Know the signs….an athlete presenting with even one component has a 3x greater risk to develop one of the other components. The Female Athlete Triad Coalition has a great screening tool that is non-confrontational and can easily be done as part of pre-participation screens.

Have information available. Adolescent females need 1300mg of calcium a day and the best source is spread out throughout the day with food. Raw green leafy vegetables, broccoli, almonds, canned sardines with bones, low-fat milk products are the best sources. Certain medications can also impact bone health and may predispose your athlete to bone injuries.

Antiseizure medications (also used for migraine control), prednisone, SSRIs, thyroid medications are common medications for adolescents to be taking for a variety of disorders.

Female Athlete Triad is primarily hormonal and dietary driven. It’s important to have a multidisciplinary approach to diagnosis and treatment. It’s also important to be a nonjudgmental place for your athlete. Athletes are a lot of fun to work with and you are part of a much larger team, especially when dealing with the triad.

References:

Goolsby M, Boniquit N. Bone Health in Athletes: The Role of Exercise, Nutrition, and Hormones. Sports Health[serial online]. November 7, 2016
Gibbs JC, Williams NI, De Souza MJ. Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc. 2013;45:985-996
De Souza MJ, West SL, Jamal SA, Hawker GA, Gundberg CM, Williams NI. The presence of both an energy deficiency and estrogen deficiency exacerbate alterations of bone metabolism in exercising women. Bone. 2008;43:140-14
Liu SL, Lebrun CM. Effect of oral contraceptives and hormone replacement therapy on bone mineral density in premenopausal and perimenopausal women: a systematic review. Br J Sports Med. 2006;40:11-24
Nazem TG, Ackerman KE. The female athlete triad. Sports Health. 2012;4:302-311
O’Connor D, Blake J, Bell R, Bowen A et al. Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause and Beyond. J Obstet Gynaecol Can 2016;38(6):508-554
femaleathletetriad.org

Articles Of The Week March 4, 2018

March 3, 2018/2 Comments/in Article, Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

This one is really interesting as it is several small interviews with different pain experts on different aspects of pain.

“Trust Me, I’m An Expert” – The Conversation

Next isn’t so much an article, it’s a video. But, it’s a great video you could use to help explain pain to patients (or anyone else for that matter). In less than five minutes you could give a simple explanation to patients about what’s going on with them.

“Understanding Pain In Less Than 5 Minutes” – Get PT 1st

Scientists have found “anxiety cells” in the hippocampus which regulate anxious behaviour. They have even found ways to silence them!

“Scientists Just Identified The Physical Source Of Anxiety In The Brain” – Peter Dockrill

It turns out the gut-brain connection is starting to show that certain foods influence the bacteria in our gut, which in turn can influence the mental health. The brain and serotonin are also directly influenced by the gut and dietary improvements may be a strategy for managing mental health.

“Is Your Diet Fighting Depression – Or Intensifying It?” – Natalie Shoemaker

Wow, it seems there’s lots on pain this week, but this is pretty cool! New fitness machines called Jymmin combine a mixture of working out and free musical improvisation, and they make us less sensitive to pain.

“Jymmin, How A Combination Of Exercise And Music Helps Us Feel Less Pain” – Neuroscience News

Massage Therapy, Communication, And Helping Trauma Survivors

February 26, 2018/in Article, First Aid, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jennifer Stelzer

I’m one of those people that nod and smile to the person next to me on the bus and 15 minutes later I have heard most of their life story. You might be nodding and thinking “mmmhmm” right about now. In fact, I think if there was a group of massage therapists gathered and a similar question was asked, many would raise their hand at being “that person”.

Massage therapists have an intimate connection with their clients. Many of us work on clients who are only one sheet away from being naked in front of us. That means we need to be exemplary in our treatment of someone on the table. It’s not only a body, but a mind with varying experiences we are working with everytime we touch a client.

Let’s go back to questioning a group of MTs. If the question asked was “How many of you are survivors of trauma” there would no doubt be hands in the air. A lot of MTs came to the profession because of their experience with massage during a traumatic recovery, or, seeing how it positively affected a loved one.

But for the hands that remained down, does this mean they have not experienced trauma?

Absolutely not.

Many people prefer not to share their stories, which is understandable and acceptable. Do not expect that your client will share their personal past or trauma with you. Do treat everyone with the knowledge they may well be in the middle of a traumatic event, or have past event(s) that continue to have an impact on their lives.

When we speak of treating a client with a past trauma we usually think of a physical injury or PTSD. PTSD often brings to mind those who served in the military, but in fact many situations may cause PTSD, as well as C-PTSD, Growing up in poverty, being adopted, survivor guilt, sexual abuse/rape, confinement of any sort (prison, residential treatment centers) repeated injury such as childhood physical and sexual abuse.

The person currently in the middle of a divorce or custody situation. The one who just found out they cannot birth their own children. The client who spent part of their life living with abuse-whether verbal, physical or both. The one who has been body shamed by loved ones. A person who may have spent time in confinement. A former or current member of the military or someone who has seen the effects of war firsthand.

The stories are different, sometimes similar, but affect every human in a very personal manner, consistent with their other life experiences.

Nurturing, Ethical Standards, And Trauma

A few years ago, a client of mine I thought I knew well opened up after a year of sessions.

The client told me they were glad that I worked through the sheets when doing gluteal work, as they had always felt uncomfortable having this type of work done, but enjoyed the benefits post massage.

They told me about being aggressively assaulted by a group of people earlier in their life. This news was of course stunning. All I could do was stutter “I am so sorry” and continue with the session. At the end of the session, the client thanked me for listening and not offering any advice, and again for providing the additional draping. This incident opened my eyes to the knowledge that as massage therapists we rarely know more than the basic details of a client’s history.

After working so closely with the public, I realized that most people have many hidden faces underneath.

I changed my outlook to try and recognize that when someone comes in and says they are ‘not doing great’, there is no need for me to ask why. I am here to provide bodywork. If the client decides to share information with me, it stays in the room. I will not bring it up in another session (unless it is health related to their treatment) and will acknowledge that sometimes people need an ear, but that isn’t a request for feedback.

What we do is nurturing, but we are not “healers”. We must hold high ethical standards that go well beyond not dating clients. All clients must be treated equally, and strict adherence to scope of practice is mandatory. With this in mind and the knowledge that we cannot know if someone currently is experiencing, or has been affected in the past by trauma, all clients should be treated as though trauma has affected their life in some way.

When clients do indicate “PTSD” on their health history, do not inquire about specifics.

Usually, boxes for anxiety, depression and insomnia are also checked as PTSD comes with a host of comorbidities. Some, such as depression and anxiety, have been shown to be alleviated by massage therapy to some degree. Other symptoms like sleep disturbances may also benefit from the use of massage.

A common side effect of PTSD are panic attacks. Some of us have already experienced a friend, family member or coworker have a panic attack. It is a scary and debilitating experience both for the person having the attack and the others present. I have personally witnessed several clients experience a panic attack during a session. I have found it is best to stop the bodywork, redrape the client and allow them the opportunity to end the session at that time. Every experience is different. Some clients need a few minutes, a sip of water, some need to have the therapist leave the room so they can regroup, or get dressed and end the session for that day.

Be sure to ask them if they are aware if this is a panic attack. If not, symptoms can be similar to cardiac events, so familiarize yourself with the symptoms of each, or call for emergency assistance if necessary.

While studies suggest that massage therapy may be beneficial for symptom management of PTSD, it is a priority to ask all clients about their comfort of level of undress, areas of the body to be worked or not touched- and informed consent. Remind each client this is their session, and as a therapist, you are willing to work within their boundaries.

As discussed, we cannot identify trauma in a client and many clients may not feel comfortable enough to discuss trauma, especially during early sessions, so we must do our best to avoid triggers which may result in panic attacks or other symptoms of distress. As your therapeutic relationship develops, it may be more appropriate to discuss things as the patient opens up to you, but when starting out, try to avoid those triggers.

Some suggestions are below.

Do’s And Dont’s

Do: Create and maintain boundaries in your practice

Don’t: Deviate from boundaries

Do: Allow time for a thorough intake

Don’t: Rush your client

Do: Ask for emergency contact

Don’t: Ask marital status

Do: Have a box to check for pregnancy

Don’t: Ask about children

Do: Ask for preferred name & pronoun

Don’t: Assume nicknames or gender

Do: Request current health information

Don’t: Ask about heritage, accents

Do: Ask for surgical/accident history

Don’t: Set time limits (ie: 10 yrs)

Do: Add a box for PTSD

Don’t: Expect full disclosure

Do: Discuss levels of undress

Don’t: Ever adjust bras/underwear

Do: Ask clients about working gluteal areas

Don’t: Ask when client on table

Do: Discuss Informed Consent

Don’t: Make assumptions

Do: Avoid negative words & phrases

Don’t: Talk down to clients

Do: Greet every client with a smile & nod

Don’t: Force a handshake

Do: Respect personal space

Don’t: Initiate a hug

Do: Give advance warning of animals in practice

Don’t: Assume a client likes animals

Do: Ask client about music preference or none

Don’t: Play what you want to hear

Do: Appreciate client’s religious preference

Don’t: Display religious emblems

Do: Treat a body with respect

Don’t: Ask about scars or tattoos

Do: Provide appropriate draping

Don’t: Discuss client weight/height

Do: Acknowledge each client is an individual

Don’t: Council/compare clients

Do: Work in scope of practice

Don’t: Offer nutrition advice or sell other services you provide

Remember, we do not need to walk on eggshells, just work within our scope of practice, treat each client as an individual and understand there are many context layers in each person’s life experience.

Articles Of The Week February 25, 2018

February 24, 2018/in Article, Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

It can be a bit stressful when we think about treating patients with chronic pain as there is a lack of understanding and tools for treating this population. However, the biopsychosocial approach is a framework that can be effective, and this post shows why.

“A Plea To Providers: This Is Why Biopsychosocial Treatment Of Pain Works” – Devra Sheldon

I know there is some research being done at our local university on this exact topic, but can a blood test actually diagnose a concussion? Well, not yet, and this post shows four reasons why.

“Can A Blood Test Diagnose A Concussion?” – Complete Concussion Management

I hate paying taxes, but unfortunately, it’s that time of year again. Maybe next year I will have to use some of the advice from this post to make sure I’m ready at tax time.

“Tis The Season For Taxes (Again)” – Cath Cox

It seems as though the real learning in our industry happens after college and in continuing education courses. However, we need to be careful when choosing which courses to take because they can actually reduce our credibility.

“Fantasy Physiology And The Post Hoc Fallacy” – Whitney Lowe

Have you ever looked at the cost difference between getting a new client, or retaining the ones you have? Over the long term, you’re better off to build solid relationships with your current patients, and since they love your treatments and trust you, they’re more likely to refer their friends to you. While this post is directed at personal trainers, there’s some solid advice in there for therapists too.

“The Importance Of Client Retention” – Michael Anderson

The Difficulty Of Challenging Our Beliefs

February 19, 2018/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

Growing up I was raised with a certain belief system.

It worked well for my parents, family, and most of our friends. However, I always felt like a bit of an outsider. I tended to question things, and couldn’t always get a good answer (or at least an answer that satisfied me).

Quite often when I asked questions, I was told not to question things (and was sometimes reprimanded for it), that there were some things we just didn’t know the answer to. It rarely felt right to me, not to be able to get, or find those answers, to just accept things as they were.

It got to the point, I would just stop asking. Sometimes out of mere frustration, sometimes out of fear, sometimes because I just got fed up with feeling out of place. It was probably just easier to follow along and not try to push the envelope as it were.

Later in life, I took a different direction.

I went back to school to learn something new and would be the first one in my family to go to college. It seemed pretty daunting, but I took the same approach. Don’t ask questions!

I went through college assuming that everything I was being taught was correct, so there was no reason to question it. I knew all the things I was learning was what I would be examined on both in school and at our board exams, so really there seemed to be no reason to question the information.

Challenging More Beliefs

For some reason, I’ve been seeing a lot more discussion online lately about some of the old theories around Massage Therapy (specifically about pregnancy and massage for some reason). I’ve even heard of a patient being denied treatment because they were pregnant and a therapist thought it was contraindicated.

I still find it remarkable that some of those ‘myths’ are still being spread around and believed.

But then I think back and realize just how hard it is to challenge our beliefs. If there are certain modalities or contraindications we have been using for long periods of time and we’re having a reasonable amount of success treating this way, why would we ever question it?

The difficulty isn’t just within our own practice, sometimes it means challenging the establishment, and even other colleagues. There can be significant kickback from those same colleagues, especially if you’re starting to challenge their belief system.

Part of the issue is that when our beliefs are challenged, we feel threatened. Look at any of the many facebook groups about massage therapy, and watch how people react when certain modalities are challenged (and even proven wrong with research). It is usually met with harsh denial from some parties, quite often to the point of getting quite angry.

Regularly I have people comment on blog posts or unsubscribe, then send emails citing their complete disagreement with an article, and their years of experience proving the article wrong as the reason. And for a long time, I was that guy! I took it as a personal attack when going through various facebook threads, or seeing comments challenging what I had learned in school. I had to leave some of those facebook groups because they got me so angry.

Then for some reason, I started to reflect on those experiences growing up when I would ask questions and people would get upset. It didn’t seem reasonable to me then, so why was I reacting like this?

I started taking courses where the instructors were challenging the old ways of thinking and didn’t mind being challenged by students in the class. Usually, they were able to come back with reasonable explanations to the students who were challenging them. And the best part was, they never got upset. They took it in stride and were able to change the students view with updated relevant information.

I started to go back to some of those groups watch, learn, and try not to take things personally. Turns out lots of good information was being shared and there was never any ill intent behind the discussions taking place, they were just that…discussions. While some debate takes place, I came to realize there is such a thing as healthy debate, and debate causes progress. What I always thought was just people arguing and puffing their chest out, was actually just people challenging beliefs and literally trying to help advance professionally. While sometimes better language and communication could have been used, I don’t think anyone was ever trying to personally attack anyone.

Rather than expecting others to change, I had to step back, look at those groups and say “it’s not you, it’s me,” but rather than it being a break-up, I was trying to stay in!

The Results

While there is always the chance of repercussions when we start to challenge things, there is a positive side to it as well.

If I hadn’t challenged my beliefs all those years ago, I would have never gone back to college, never gotten the chance to work in sport, and most certainly wouldn’t be sitting here writing this blog. However, there were major repercussions I had to consider when challenging things, mainly around relationships with family and friends. Even though there was a real possibility those relationships would fade away or end, to my surprise (for the most part) they didn’t. The ones who mattered are still around today.

The same thing happened over my concerns with colleagues. The more I started to challenge ideas within our profession, the more relationships actually grew, became stronger, and new ones developed. The kickback I expected (because of the way I was interpreting things online) didn’t really happen, and I noticed more people started questioning things as well.

The other thing that happened…my interaction with my patients got better.

When we start to challenge things and leave those old ideas in the past, there is a certain amount of freedom that comes with it. So many of the things I thought were contraindications with massage aren’t, so I don’t have to worry about those things anymore. I also don’t have to give my patients fancy explanations around what I do, because I’m not wrapped up in explaining biomechanical things that aren’t relative to a treatment, or trigger points, innominate rotations, and certainly not worried about touching a pregnant woman’s ankles! What’s even better is the simpler explanations I give now, make more sense to the patient.

In a conversation I had with Alice Sanvito last week, she made a really great point about this kind of communication. If we are using the explanations around some of these old beliefs we aren’t actually getting proper consent from our patients when treating them. How could they consent to treatment when what we’re describing isn’t actually an issue, or the modality isn’t backed by evidence?

I hope as a profession we start to question things more, in fact, to become more respected and evidence-based, we HAVE to start challenging information more. While there will be resistance from some (and probably some anger), with any hope it will also bring us all a little bit more freedom. I also hope no one will be left feeling like an outsider, worried about the reactions of others, but rather open to asking questions and finding appropriate answers.