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Red Flags For Low Back Pain, Or Clinical Decision Making?

November 6, 2017/1 Comment/in Article, Emergencies, First Aid, First Responder, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Sport Massage/by Jamie Johnston

It’s only happened a couple of times in my career.

You know that feeling you get when something just isn’t right? You’re not quite sure what it is, but something just seems off?

Twice I’ve had people come in where their pain and limited mobility had me questioning if they needed a trip to the emergency room. In one instance I called a family member who took the patient in, and everything checked out fine.

The other instance, the persons low back pain was so extreme, it just didn’t add up. There was no history of trauma or anything else that suggested the hospital was necessary, but I could barely touch the patient during the treatment because their low back was so sensitive. Afterward, I recommended seeing a doctor, or emergency room, but they refused. I never saw them again, so I’m not sure what the outcome was.

So how do we know when low back pain is an emergency, or just really painful?

Traumatic Injuries And The RTC

In old First Aid terms, there were criteria we would use at the scene of an accident to quickly decide if a patient had to have spinal immobilization used and if they needed to be immediately sent to the hospital.

It was called the RTC (Rapid Transport Category), and it was a simple list which made it easier to decide how to provide the appropriate care to a patient. While this isn’t as useful in a clinical setting, it could be invaluable in a sport, or outreach setting if some type of emergency were to happen and you are required to provide care. In a clinical setting, it would be helpful during your patient interview in case you weren’t quite sure why a patient is having the issues they are presenting with.

The RTC criteria include quite an extensive list of things to watch for. Not all of them would be applicable to us, but here are some that would be:

Mechanism of injury
- Fall from greater than 20ft
- High-speed accident
- Pedestrian struck at speeds higher than 30 km/hour
- Broken windshield damaged steering wheel, or airbags deployed
- A rollover accident
- Severe crush injuries
- Any other people involved in the accident that result in a fatality
- Electrical injuries (we always assume spinal damage with electrocution)
Anatomy of injury
- Severe brain injury
- Penetrating injuries to anything but the limbs
- Depressed skull fracture
- Pregnant woman with fairly moderate trauma
Findings in the Primary Survey
- Decreased level of consciousness
- Cardiac arrest
- Suspected heart attack
- Poisoning
- Status Epilepticus

Particularly for us in the clinical setting the mechanism of injury should be one category to take note of. Hopefully, if someone has been through an accident that traumatic, they have already been to the emergency room, or at least a doctor to be checked out, but this doesn’t always happen. Sometimes a patient may play it off and just think they need to see a chiro, physio, or massage therapist and book in with you before ever seeing a doctor, or even calling 9-1-1 after an accident.

I’m sure we all see patients on a regular basis who have been in a car accident. Knowing those above criteria and being able to ask some of those specific questions in your interview may give you a better idea as to how severe their injuries could be. Or, if they played it off and haven’t been checked out, you may want to refer them to a doctor just to be safe.

Whenever I teach a first aid course we talk about the signs and symptoms of a heart attack. This is where there could be a bit of a red flag, as it is quite common for women to experience back pain associated with a heart attack. However, it would be back pain combined with other symptoms like chest pain, nausea and vomiting, sweating, and shortness of breath.

This is certainly part of our role as healthcare professionals to recognize and help our patients if this is happening.

Photo by: Lucina Medina

The Red Flags Of Low Back Pain

There seems to be a wide array of information on the red flags of acute low back pain.

Most of the concern is driven toward four issues:

Malignancy
Infection
Fracture
Cauda Equina Syndrome

One red flag that is unrelated to specific disease was the onset of pain in patients under 20 years old. However, one study actually calls this a “dubious distinction” and shows that age alone combined with pain is not enough to be considered a red flag, as most of the participants in the study were diagnosed with non-specific mechanical spinal pain.

When we look at the risk factors associated with spinal fractures, most information cites major or significant trauma, age, a history of osteoporosis, and the use of corticosteroids as the red flags to look out for. A systematic review showed that all of the above combined with the presence of a contusion brought the probability of a fracture up from 4% to a range between 9 and 62%. An Australian study showed that when three red flags (female, over 7o years of age, severe trauma, and use of corticosteroids) were all present, the chance of a fracture went from 4% to 90%. So, when looking at red flags for fractures, one red flag alone is not likely an issue, but a combination of the red flags is more likely to result in a fracture.

The commonly used red flags for infection were:

Fever/chills
Use of corticosteroids or immunosuppressant therapy
IV drug use
Pain worse at night
Night and rest pain
Tenderness over the spinous process

But the same systematic review showed that there is a lack of standardization with these red flags, and the risk of serious disease in patients with low back pain is less than 0.1%.

The same can be said for malignancy, as the one big red flag, in this case, is a history of cancer. Yet “history of cancer” isn’t clear enough as it doesn’t specify how long ago the person was diagnosed or the type of cancer they had. There are several cancer types that apparently put a person at greater risk for spreading to the spine, but if the person didn’t have one of those types, or had it 20 years ago, the likelihood of spinal malignancy is probably a lot less than someone diagnosed recently.

The two most common red flags with Cauda Equina were saddle anesthesia (perineal numbness) and sudden onset of bladder dysfunction. Either way, I’d be referring out for that!

One thing that came out of most of the studies I could find was one resonating point. Clinical decision making and judgment of the therapist to determine if the patient needs to be referred out is more reliable than the list of red flags. So in other words, when in doubt, refer out! There are some other things to take into account with this whole red flag discussion and one review makes a great point as to why screening for red flags isn’t reliable. As practitioners, we don’t actually screen, we manage low back conditions. They actually encourage watchful waiting for changes in symptoms, as evidence is showing that early intervention with low back pain may actually be more harmful.

One thing I hadn’t ever heard of was “yellow flags,” however, I found it encouraging that it was mentioned in a paper from rheumatologists. They listed these yellow flags as:

A belief that back pain is harmful or disabling
Fear of pain and movement avoidance
Tendency to low mood and withdrawal from social interaction
Expectation of passive treatments rather than believing active participation helps

Biopsychosocial approach anyone? It’s great to see these “yellow flags” being mentioned with the same importance as the dreaded red flags.

Overall, it is probably good to be aware of those red flags to help guide your clinical decision making, but they aren’t the be all end all like we once thought they were. The valuable thing will be your judgment call and also making sure to monitor your patients progress. If your spidey senses start tingling, and something doesn’t seem right, don’t hesitate to refer out, it’s better safe than sorry.

Sleep Disorders And Massage Therapist Safety

October 30, 2017/1 Comment/in Article, Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jamie Johnston

The best part of college was the first two terms of school.

We had two classes a week where we would work on each other and practice draping, how to landmark certain areas of the body and learn new massage techniques. It was a new massage treatment twice a week.

All you would hear in our class were students saying “I love school” as they received their massages from classmates.

The other thing you would hear, was me snoring!

Every time I got on the table I would fall asleep. Teachers regularly came up to me saying “you have to stay awake to give your therapist feedback!”, my response: “I’m sleeping, I’d say they’re doing a good job!”

When we got into the student clinic, we would wear it like a badge of honour when a supervisor asked how the treatment went and we could say: “well, they fell asleep, so pretty good”.

But is that really the best thing? I know it’s great for the patient and it’s an obvious sign they’re relaxed, but what about for the therapist? Is it in our best interest? Is there an issue as far as our safety?

Sleep Disorders & Parasomnias

There are 81 major sleep disorders which are then put into eight major categories.

Some of them you’ve probably heard of, maybe even experienced and more than likely have a few patients who deal with sleep disorders like insomnia, sleepwalking, and sleep apnea.

Within those eight classifications, the fifth one is called “parasomnias”.

Parasomnias are undesirable physical or experiential events that happen during entry to sleep, within sleep, or during arousal from sleep. Those events can be sleep-related movement, behavior, emotions, perceptions, dreaming, and autonomic nervous system functioning and are typically associated with arousal from non-REM sleep. There are several parasomnias that are associated with REM sleep, but since it takes 90 minutes to actually get into REM sleep, those ones probably aren’t much of a concern for us.

Confusional arousal is one of those disorders associated with non-REM sleep and involves the person being mentally confused or having confused behavior after waking up. These are most common with kids but are common with 6% of 15-24-year-olds and present in 1% of the population over the age of 65.

Sleep-related dissociative disorders happen during the transition from wakefulness to sleep or after waking up during the first or second stage of sleep (the first five or ten minutes) and involves a disruption of integrative features of consciousness, memory, identity, or perception of the environment.

One study showed these sleep disorders to be more prevalent among the general population than was previously thought and also showed it is not uncommon for a person to have more than one parasomnia. However, there is no real treatment for these type of sleep disorders as they are considered benign and quite often are due to a lack of good sleep. An example given was a sleep-deprived doctor being woken up from a deep sleep, may have confusional arousals and can possibly make errors in judgment.

Most of these things disorders during the first 1/3 of the night when people are going to sleep, but can also be quite common during daytime naps. So, when we look at the example just given, think about your practice and how many shift workers you treat? How many police officers, firefighters, nurses, city workers, or any other night shift workers do you have that come in?

People could have parasomnias and not know it, especially those who are sleep deprived before they even come and see you.

When we look at patient safety, it’s important to know about these kinds of things as someone could wake up during or after a treatment and be very confused about where they are, what they are doing, and even what just occurred while they were on the table.

Paralysis And Lucid Dreaming

Have you ever had a moment where you woke up from sleep and couldn’t move? Or you felt like there was an intruder in the room, pressure on your chest, or the feeling of an out of body experience?

Well, that is sleep paralysis, and part of sleep paralysis is the hallucinations that occur while in this state. It can happen when you are falling asleep, or when you are waking up from sleep, and is divided into three classifications:

Intruder Hallucinations (hearing voices, sensing something evil is in the room)
Incubus Hallucinations (chest pressure, difficulty breathing, perception of pain)
Unusual Body Experiences (flying/floating sensation, out of body experiences, emotional bliss)

In one of the oldest known accounts of sleep paralysis, a woman described the events as the devil laying on her chest, as well as being choked by a great dog. Another study done with Mexican adolescents found that 27.6% of the subjects had experienced the phenomenon of “a dead body climbed on top of me”, which was determined to be a form of sleep paralysis. Some descriptions of this kind of hallucinations even go to the extent of people being fearful of being killed or raped in their bed. These “incubus” hallucinations are more likely to occur when entering a sleep cycle.

Interestingly one study looked at the relationship between sleep paralysis and lucid dreaming. When we are lucid dreaming (which happens more during REM), we actually have the ability to control the dream or wake up from it, because we are aware that we are in a dream state. In the study, lucid dreaming had more of a connection with the third class of sleep paralysis (unusual body experiences) and actually had a positive effect and showed a positive association with imagery. However, the study also pointed out that sleep paralysis has more to do with poor sleep, and increased stress and anxiety.

How many patients do you have that come to you because getting a massage helps them with sleep, stress, and anxiety? Probably quite a few of them, and as it turns out, sleep paralysis is pretty common. One systematic review estimated 7.6% of general population, 28.3% of students, and 31.9% of those who deal with things like depression and anxiety, also deal with sleep paralysis.

Imagine if one of your patients had this happen on your table when entering a sleep cycle. Through no fault of their own (and none to you as well) they could have this type of a hallucination and possibly feel you were involved or part of the hallucination. The important thing is to make sure you protect yourself. Make sure you keep a journal or notebook around to document if something seems strange after the treatment. Keep detailed notes on what occurred in the treatment as a protection for you and your practice…just in case.

Photo by: kellepics

Consent For Massage Therapy

Before any treatment starts, part of the interview process with a patient is getting consent for treatment, especially if you need to work in sensitive areas like the gluts or adductors.

Just recently in Ontario, it was made mandatory to have this documented before each treatment whether you have a previous therapeutic relationship with a patient or it was the first time. Many saw this as a hindrance in practice and felt it would just be annoying for a patient to have to do this every time!

While I can see that side of the argument, why not look at it on the other side and think about what it does for the practitioner rather than the patient (don’t get me wrong, it should be done as a protection for the patient as well).

Studies have shown how the sleeping brain can still interact with its environment. One study showed that not only can movement be triggered by nociceptive stimulus during sleep, but also behavioral responses can occur. Again, think about what could happen if your patient falls asleep on the table and you have to work on the sacrotuberous ligament (or any sensitive area). If for whatever reason they normally wouldn’t allow someone or typically did not want to be touched in this area (even though they initially gave you consent), when that nociceptive stimulus is applied, the patient could have a behavioral or movement response without actually realizing it.

Remember that consent happens throughout the treatment and it can be taken away at any point even if it was given at the beginning. This could be an instance where a patient is actually revoking or is confused about consent because of an altered state of consciousness, and a behavioral response could be induced even though you technically did nothing wrong. This is where you want to have things documented appropriately to make sure your safety and your practice is always protected.

While I know many of the things talked about in this post might be a rare occurrence, it is possible to have these things happen. I agree that patient safety is of the utmost importance, I also believe therapist safety is just as important. This isn’t to say you should never allow a patient to sleep during a treatment, many of them love the fact that they can get a quick nap in and feel much more relaxed. What I am saying is we all need to be aware of some of the above-mentioned issues to make sure we are kept safe as well. If you’re ever unsure of someone’s reaction during a treatment, or after, make sure you document it so you always have a record to refer to…just in case the worst scenario happens and a patient reports you.

The Power Of Touch And Presence Vs. Modality Specific Beliefs

October 16, 2017/3 Comments/in Article, Business, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Walt Fritz

Disclaimer: I teach continuing education seminars for a living.

When we touch patients in a therapeutic intervention, how many different “things” or actions can we really be accomplishing? How many different structures can we really make contact with or elicit change?

With higher levels of training come apparent deeper and more precise technique and expectation, while the beginner is viewed as less-than. If your practice is like my own, you receive referrals of people who have seen a multitude of manual therapists of all sorts. At the onset of the initial encounter, they invariably share what others have said about their problem as if all of that information is necessary to get to the bottom of things.

I patiently listen as they rattle off a list of claims made about their problems, with many trending into the catastrophizing mode (the WORST trigger points that therapist had ever seen!).

We are all touching the same body in much the same places, but most are believing we are feeling and finding vastly different structures and problems, both normal and aberrant.

To stay in the first person, my brain filters this information and tries to put it all into a framework of my evaluation findings and beliefs that I was taught and I will typically come up with a different language of what the problem might be. In the past I would have spoken in fascial-based language, calling palpated tightness a fascial restriction and telling a very compelling narrative on how these fascial restrictions, ignored by most in medicine, cause crushing pressures on pain-sensitive structures and only with the application of light, sustained pressures of myofascial release will they ever have a hope of resolving their issues. My language now is quite different, as are my beliefs, and I am much more circumspect about how I explain patient’s problems.

As I teach and travel I have a distinct privilege of meeting with and sharing beliefs with hundreds of therapists and professionals from a wide range of pressures. I am also active on hundreds (yes, hundreds) of niche’ manual therapy groups on Facebook and LinkedIn. Playing the fly-on-the-wall allows one to hear or read conversations that range widely from comparing and contrasting the effectiveness of various modalities to reading people’s suggestions for how to handle a problem case.

Well-meaning inquires regarding how to treat a difficult case are often met with a range of emotionally charged suggestions, most speaking to their favorite modality and citing the “inherited narrative” that goes along with this modality. (Thanks, Phil Greenfield!). As that fly-on-the-wall, I am struck with the hundreds of different modalities and narratives that therapists use in daily conversation.

It takes little effort to see that there really are hundreds of different modalities and sub-classes of modalities available to us as continuing education. But can we really be doing all of the things under the skin that those hundreds of seminar lines profess?

It is beyond the intent of this post to deconstruct any modality in this post. My point is to look at the commonality of our actions. Though our touch can often vary from light to deep, with holds that fluctuate from short duration to long, is there a simpler way to explain our touch rather than the often pained and convoluted models put forth by the various lines of teaching? Is it necessary to invent a new way the body works or a new way to describe how we impact the body in order to sell seats in classes? (A rhetorical question, as it apparently is.)

When we treat, we touch people in a manner that is intended to soothe, to improve the quality or ease of movement. This sounds too simple for many, especially those with advanced training. Many in our shared fields are working to simplify the explanatory model, rather than trying to make it more complex or secretive.

Join the Skeptical Massage Therapists group on Facebook, if you would like to see how this works. Read through the long list of threads and attached links to research and other reference materials. Take a side trip over to SomaSimple for a bit of mental flossing. These are very deep rabbit holes; ones that may cause you not to recognize yourself when you finally emerge. Don’t be surprised if you become defensive or angry as you read how others view your modality or its creator, but give it all time to sink in. How we affect someone when we touch cannot be as complex as many make it seem. Simple, well-meaning directed touch and presence may explain much of our outcomes. And this is not a bad thing

5 Habits To Have To Have Before Disconnecting For The Weekend

October 9, 2017/in Article, Business, Massage Therapist, Massage Therapy, Myofascial Release/by Robert Libbey

Success is determined by what you do after you do what is expected of you.

1. Celebrate Your Wins And Reflect On Your Future

Develop the Habit of reviewing what went well and celebrate it. It reminds you to focus on your growth, to focus on the positive influences you’ve had, the contributions to improving your patients’ quality of life and helps you begin your weekend in an enthusiastic frame of mind.

Now is the time to take 5 minutes, at the end of your day, and really reflect on the good work you are doing and the lives you are touching (pun intended!) I guarantee that along the way, you helped quite a few people. I have no doubts that you changed a few lives by improving the quality of life of some people.

If your weeks are like mine, this week went by so fast, you were so busy with treating patients, you don’t even know what you did, but you got here somehow.

Ask yourself a few key questions: What did I accomplish this week? What do I want to accomplish next week? Next month? Next year? A businessperson should always be aware of his or her recent accomplishments and reflect on them to better plan for his or her future success.

2. Develop The Habit Of Sending Two “Thank-You” Notes!

As a businessperson, you rely on a lot of people; your team, mentors, partners, and Patients to support you each week. All play an important role in our lives, yet in today’s world, thankfulness seems to be on the downslope.

Before you leave the office, recognize at least two people for their continued offerings, positive influences, and referrals with simple notes of appreciation. Doing this shows you care about “your team” and that you recognize their support.

3. Develop The Habit Of Reviewing Your Contacts List For The Week

Before you leave your practice, reflect upon your contacts list and review your calendar (see below).

Throughout the week you may have had certain people you came into contact with that can and possibly will influence the direction of your professional and or personal path. Think about the NEW patients you had. Make a couple of quick notes about what the next step in their treatment may be. This doesn’t have to be a concise treatment plan, just a couple of points to think about and get you started in a direction.

Add any business contacts to your LinkedIn, Twitter and other social media accounts. Doing this now makes sure no one slips through the cracks.

Photo by: Pixelkult

4. Develop The Habit Of Having A Clean Desk

Make sure you have all your daily patient files charted. Ultimately you should have the habit of charting your files as part of your treatment time, but for those of us who chart at the end of the day… get it done now!

If you have any clinical records waiting to be copied and sent to lawyers or insurance companies…get them done and mailed.

Clearing your desk of these tasks is a weight off your mind. You now have the freedom to focus on more important weekend activities, friends, and family.

5. Develop The Habit Of Reviewing Next Week’s Calendar

Make note of any business contacts you met with over the past week and how and when you’ll follow up with them. Review or enter times and dates on your calendar for next week of when you may want to contact them again. Make a short list of who needs to be contacted next week and set a tentative date and time to do so.

Don’t feel bad if you don’t get through all of these. The exercise is to get you into the Habit of ending your week productively and positively!

5 Exercises For The Cervical Spine

September 25, 2017/5 Comments/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Erson Religioso

As usual, all of your magic hands hocus pocus means nothing if the patient cannot keep the improvements between visits. Here are 5 ways to self-treat the cervical spine.

Start

Don’t think double chin, think triple chin!

1) The Good Ole Chin Tuck

for central or bilateral complaints
- headaches into the frontal cranium
- bilateral neck pain radiating into upper traps
end range is sternal elevation
last year a little old lady asked me if this exercise would make her double chin worse
I said, “I don’t know, but at least it helps your headaches and neck pain.”
I saw her just this past summer for a completely different condition, the first thing she showed me was the lack of a double chin, she was so happy the chin tucks tightened everything up!

Start

Cervical neutral, “yes sir!”

Unilateral nod variation for right-sided HA or upper cervical pain

2) The Good Ole Chin Tuck Part 2

For those who do not tolerate cervical retraction, possibly due to tighter upper cervical spine
this works a bit better for headaches than retractions
a variation for unilateral headaches is the same light nod with neutral cervical spine with a slight 5-10 deg rotation to the ipsilateral side of involvement

starting position, the retracting dead

rotation with self-overpressure to end range, rotate toward the pain

3) Cervical Retraction With Rotation

If the above unilateral nod variation does not work with upper cervical pain or unilateral HA, try this
make sure to rotate but keep the contralateral shoulder from moving anteriorly too early
this works very well to restore lost rotation or keep it after your manual techniques

stock starting photo… “brains….”

end range overpressure to the painful/limited side, welcome to the gun show

4) Cervical Retraction With Side Bending Overpressure

it’s the too simple to work for many upper quarter problems self-treatment!
as always, end range is key here, remember to slack the contralateral upper trap if needed by passively elevating the scapula
try for any hand, forearm, elbow, shoulder, scapula, thoracic pain that is unilateral and not responding to traditional treatments
better yet, try this first for any of the above to rule out cervical involvement

start, triple chin!

finish, forehead parallel to the ceiling

5) Cervical Retraction With Extension

a progression for improvement or plateau for central or bilateral complaints
I do not give this one out too often in lieu of self-generated overpressure into cervical retraction
this may also work for symptoms that are radiating to mid thoracic spine or scapula
make sure they get to end range, which is normally the forehead parallel to the ceiling
also check out this clinical pearl on this very technique

Everything You Need to Know to Get Awesome Referrals From Personal Trainers

September 19, 2017/1 Comment/in Article, Business, Cardiopulmonary Resuscitation, Massage Clinic, Massage Therapist, Massage Therapy/by Rick Elnor

Marketing is no fun.

For years the word “marketing” conjured up thoughts of sleazy pitchmen and ads full of unsubstantiated claims. It didn’t seem like much fun. In fact, it seemed like something I didn’t want to be involved in at all.

“Marketing sucks,” I thought. But so did my client roster.

With a young child and a single income just surviving wasn’t good enough.

Given I lacked the money for fancy advertising I set out on a journey to find a way of getting the word out about my services to potential clients. There were many options out there but they all had price tags attached and made some rather outlandish promises.

I needed something that wouldn’t break the bank.

Something I could live with. Something that didn’t spread half-truths or make empty promises. Something that worked.

What I soon learned is that my initial impressions of marketing couldn’t have been more wrong. Marketing doesn’t have to suck. You are the one in control. You can market your services ethically and have fun if you put in the work. The work, in this case, consists of building relationships and a referral network which can keep you busy without risky ad campaigns or flashy “click funnels”.

Sustainable marketing efforts all come back to building value for both those in your network and your clients.

The following process is the same process I used as a fitness coach. This process has been refined to help Massage Therapists pull great coaches/personal trainers into their referral networks with the help of my co-author (a former personal trainer and current RMT) Keenan Hollingsworth.

The Benefits of Trainer Referrals

Before we dig into the process of building a referral network let’s first talk a bit about what makes personal trainers a great source of patient referrals for Massage Therapists.

A personal trainer is someone your patient sees very regularly, often multiple times per week, every week, for months or even years on end. One of the biggest reasons people stay with their trainer long-term is the strong relationship they develop; there is trust, camaraderie, and mutual respect. This rapport goes a long way when it comes to referrals. People trust their trainer, and having the trainer’s stamp of approval is going to make it much easier for you to get the patient in the door, and have them buy into the treatment plan.

Personal trainers are told by their clients about all the client’s little aches and pains, old injuries which they felt hadn’t healed properly, or certain exercises they couldn’t perform because their “ _____ is falling apart”.

Unfortunately, the truth is that these complaints often go unaddressed because the trainer hearing them doesn’t have a trusted source they can refer to. Building a strong connection with a personal trainer can lead those “my knee has been killing me lately, I can’t-do squats” comments into new patients for you, and hopefully, in turn, better feeling knees for the client!

A huge benefit of working with a personal trainer is home-care.

We all know patients can struggle with completing their home-care. Whether it’s due to lack of motivation, feeling like they don’t have time, being uncomfortable performing the exercises unsupervised, or any other of a million reasons, “compliance” can be a difficult hurdle. A good personal trainer is a perfect adjunct to this.

If you communicate properly with the patient’s trainer, they can help reinforce the importance of doing the home-care, and help the patient work through it during their sessions. If I think a patient will benefit from strengthening their upper back, what’s going to be more effective, sending them home to do rows with a TheraBand, or working with their trainer to program in a variety of progressively harder upper back movements within the workout they are already going to be doing? Someone who’s going to coach them through every exercise, push them for quality technique and effort, while programming in methodical increases to improve strength and endurance…or their kid watching them fumble around in the kitchen trying to remember exactly how to do an exercise they were taught them 3 days ago? I think the answer is clear (and it isn’t the TheraBand).

A lot of research is beginning to highlight just how important “general exercise” really is, for health, mental wellbeing, and even pain management. Unfortunately saying “just go out and get some exercise” can be a daunting task. If a patient mentions the desire to “get in shape”, or the need to “get back to the gym”, having a personal trainer you can trust to work with them in a safe, effective way is an amazing resource.

Whether they just want one session to learn what to do on their own, or they’re looking for a long-term trainer, being able to recommend someone with a similar philosophy and message as you, is valuable to both you and the patient.

Define Who You Are Looking For

The first step to finding the best referral sources is to define the type of client/patient you are looking for.

Experienced trainers often specialize and target a specific population. This can mean that while some work with the general population others focus on specific genders, ages, sports, levels of athletic performance etc. If you define your dream population it will start to narrow down the list of trainers you should be trying to recruit into your network.

Once the perfect client has been defined it’s time to think about the perfect referral source. Personal Trainers with an approach similar to your own will always provide better referrals than trying to solicit everyone to pass your name along. As a Personal

Personal Trainers with an approach similar to your own will always provide better referrals than trying to solicit everyone to pass your name along. As a Personal Trainer, I want someone in my network who understands the value of exercise, the power of the words we use and the importance of evidence. I also want someone who is used to working with a wide range of athletes. The more my clientele aligns with a Massage Therapist, the more people I can refer to them.

Think of the values that define your massage practice. On a lined scrap of paper record these values. This set of values can function as a checklist which you can quickly refer to, allowing you to decide if someone will ultimately be a benefit to your network or more trouble than they are worth.

Referrals are a two-way street. If you don’t trust a trainer’s expertise enough that you would feel comfortable sending patients their way, it is not worth your time to recruit them into your referral network.

Getting To Know The Locals

Providing a service which revolves around physical contact means local clients are needed.

As such, a strong local referral network is one of the keys to success. Building this network isn’t as complex as it may seem. If you live in a place which is large enough to support your business, you live in a place where there are trainers who want to be part of your network.

Finding them isn’t as hard as it may seem at first.

In my experience the better relationship you have with a potential lead the higher chance you have of bringing them into your network. Due to this, I like to start with the people closest to me and work my way out to new contacts and relationships.

Marketing is all about building and supporting relationships and this task is no exception.

Start With The People You Know

This step seems hard for many people.

To ask those they know if they would be interested in forming a mutual referral relationship takes courage as it opens a person up to rejection, but if you believe in your service (and theirs), not asking is a missed opportunity.

My favorite approach in this situation (especially if you are prone to nervousness), is to write down who and how you are going to ask in advance and don’t over think it. Contact every trainer you can, be it a new relationship or one that has slipped into the past.

Take an interest in what they are doing, ask about both work and life outside of it but eventually come around to explaining that you are open for referrals and open to referring to them. Build on the relationships you have as chances are if you trust in them already they trust in you as well.

Ask The People You Know If They Know Anyone

Trainees are passionate about their personal trainers.

If they think their trainer is amazing they will tell you. Likewise, if they think they need a new one they will tell you that too. Asking friends, colleagues, and family for introductions to their trainers is a win-win-win situation. Not only does the person you are asking feel their opinion is valued but the trainer feels valued to be considered worthy of consideration and you gain a potential lead.

Ask EVERYONE whose opinion you value.

Physiotherapists, Chiropractors, and other healthcare professionals are great sources especially if they are already in a trainer’s referral network but anyone in a highly social profession could be an exceptional source for information about local personal trainers.

Trainers often target highly social professionals as referral sources so real estate agents, lawyers etc. all may have been approached previously by the trainers you are trying to target.

Social Media

Social Media is ubiquitous, it is the perfect tool to find local, proficient and engaging individuals able who are able to provide clientele fitting the criteria you defined earlier.

Almost every trainer has a social media presence and almost every trainer is looking for ways to increase client retention and acquisition rates.

The most effective way I have found to locate Personal Trainers and other referral sources on social media are by using Facebook. Facebook provides query filters which allow the narrowing of friend searches to your current city, hometown, mutual friends etc. This is a powerful tool. Search, pick the people that seem to best fit your desired criteria and start communicating. Posting insightful comments on things that they post, friend requesting them as you build a repertoire and then speaking via messenger is extremely effective. It’s not an immediate payoff but relationships take time. A little effort each day is all that it takes.

It’s not an immediate payoff but relationships take time. A little effort each day is all that it takes.

Of course with local personal trainers, the real goal here is to meet them in person and see if both your clients and theirs would benefit from being part of the same referral network.

Meet, Connect, And Assess

The main task you have in the first meeting with a potential referral source is to get to know them and for them to get to know you.

Finding common ground is a requirement before trying to convince them of your value and bring them into the fold. Most of this should have been done via your messenger conversations but this is a chance to build on it.

Buy them a coffee (or a beer if they so please) and just have a conversation without thinking too much about referrals and such. What makes or breaks your referral chances is the personal connection. Essentially they are buying into you, not just the value of your services. Keep it light, keep it fun, and don’t be a pushy salesman, nobody likes that crap. More than likely work and the purpose of the meeting will come up naturally as it will be a “common thread” which is easy to fall back on when conversation stalls.

Just like a date, if it goes well follow-up, heck even if it doesn’t go all that well follow up. The trainer that doesn’t mesh with your style may know another one who does. Don’t burn bridges if you don’t have to.

The follow-up, continuing to speak to people on a regular basis, and offering support (where you can) is probably the most overlooked variable involved in getting people to refer patients your way. A continued line of communication builds trust, it keeps you in their minds and it shows you are in this for more than just yourself.

Photo by: StartupStockPhotos

Expanding Beyond The Locals

Due to the rapid expansion of online training and trainers working remotely, the potential for referrals from trainers all over the world now exists.

A personal trainer in Cork, Ireland may have a client in Burbank, California for example. Trainers are no longer limited by geographical location which means they can work with people who are local to you.

If they don’t they probably know someone who does. Bringing trainers from all over the world into your network and expanding globally is the same process as with local trainers.

Sure you can also join mutual Facebook groups, use Twitter, Instagram etc. but the idea is the same. It is all relationship building. Meeting for coffee gets replaced by meeting via video chat or a phone call but the steps remain the same.

The Process in 35 Words Or Less

Define who you are looking for
Ask your existing network for introductions
Search using Facebook’s search modifiers
Comment on their posts to open the lines of communication
Move it to messenger
Video chat
Keep communicating, nurture the relationship

A Word About Incentives

Small personalized gifts are a great way to leave a lasting impression and keep you in their mind but never devalue your services. I’ve sent books, birthday cakes, and cufflinks but I’ve never provided a discount on my services to get people signed up. If you provide value they will pay what you are worth. No discount needed.

Conclusions

In many ways building a referral network is not unlike building a client base. The ideal person of interest must be defined and a search for such a person must be undertaken. This initial phase is followed by building/expressing value over time. It isn’t a “quick fix” but a strategy for long-term growth. Answers to common questions can be pre-written and rehearsed but relationships can’t be automated. In a world of gimmicks and inauthenticity personal connection is what will make you stand apart from the crowd.