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Tools to Succeed for Massage Therapists to Build Your Practice

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By: David Kent, LMT, NCTMB

In these tough economic times, how can you stand out above the competition so that clients will continue to spend their time and money on treatments with you? Well, it often depends on your ability to determine the root of your clients’ complaints coupled with the effectiveness of your treatment and your ability to educate your clients about the muscular components of their pain.

This article will review effective, time-proven methods that work together to educate and empower your clients so that they’ll not only want to continue their treatments, but also play an active role in their own healing process. All massage modalities can be integrated with the tools discussed in this article in any type of setting, including spa, clinical or outcall practices.

Education is a necessary component of a client’s overall treatment plan. Although one treatment may be helpful, perhaps a series of four, six or more would provide greater benefit. But in order to communicate this to your clients and help them recognize why committing to follow-up treatments makes sense, it is necessary for them to understand the processes of their body.

Using Forms

A client’s initial visit should always include a detailed intake form that provides an overview of his/her current and past health conditions. Often this paperwork reveals clues by listing prior accidents, injuries, surgeries and chronic conditions. Additionally, maintaining written accounts of a client’s health history helps protect you in the unlikely and rare event of a client lawsuit. Professional liability insurance covers you as a therapist in case you are ever sued. Remember to always seek authorization from the client’s medical doctor if you are unsure about potential contraindications.

Visual Pain Scales allow clients to specify and document regions of discomfort, the type and intensity of the pain, and other complaints. I suggest you take the Visual Pain Scale into the treatment room, review it with your client, and place it on a stand so that you can reference it throughout the session. This also helps ensure that you remember to address all of your client’s complaints, which a key factor in retaining a steady flow of returning clientele. Without the aid of documentation, it can be easy to slip into a massage routine and forget to address the very reason the client sought treatment in the first place (Photo 1).

Taking Pictures

It is said, “A picture is worth a thousand words.” Postural analysis photos only take a moment to snap, but they can go a long way in helping you explain the stresses on various muscles and to show which muscles are shortened and over lengthened. Keep it simple, the camera and screen built into a cell phone would even allow you to show client’s their forward head or high shoulder posture. Remember to always get permission to take postural analysis photos and treat them confidentially—as you would any other medical records (Photo 2a and 2b).

Relying on Charts

Charts can help you explain to clients the function of muscles and demonstrate why some are stressed and painful. Portable flip charts provide a professional presentation in any environment and are easily moved from one location and/or treatment room to another. The best flip charts on the market are easy to use with logical formats and laminated pages to prevent oils and lotions from damaging them over time. (Photo 3)

Wall charts are also useful and easy to reference. If you are limited on wall space, you can invest in an inexpensive wall chart hanger system that allows you to hang and access up to 10 wall charts in a single space. Muscular and skeletal charts are useful in showing the symmetry that exists in the body. And a Postural Analysis Grid chart makes it easy—even for the layperson—to see the body’s asymmetries in postural photos. And a muscle movement chart also gives the degrees of normal range-of-motion for each joint, which aids with the assessment and development of a treatment and self-care routine.

Trigger point charts, depending on their design, can assist in developing a comprehensive treatment plan that is both based on medical research and specific to your client’s pain.  (Photo 4 ). If trigger points are identified during the treatment session, a trigger point flip chart can also help you show clients their trigger point patterns while they are still on the treatment table. The formation of trigger points is often the result and/or cause of postural distortions that can be identified in the postural analysis photos, as well.

Using and Selling Topical Analgesics

Topical analgesics can help generate additional income without spending extra hours in the treatment room. Many clients use topical analgesics between treatments. There are several types on the market. One company offers free samples attached to a flyer with your name and contact information printed on it. This is also beneficial in promoting your business. Integrate the use of topical analgesics into your treatment routine and give your clients a few sample packs to use at home. Free samples often lead to future sales. If your clients want to buy a topical analgesic, it’s better for you to make a few extra dollars selling it than sending them to the drugstore down the street.

Review

At the end of each treatment, take a minute to review your findings with the client. Use their pain scale, posture photos, skeletal, muscular and trigger point charts to create a treatment plan. This would also be an excellent time to offer your client a package of treatments that has a financial incentive for them to commit.

Remember, people will spend money on care they feel will make the difference in the quality of their lives. You just need to give them the knowledge and the reasons to make an educated decision. Using the tools and systems outlined in this article will enable you to revolutionize and protect your practice in these tough times.

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.

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Back Pain Caused by Rectus Abdominis Trigger Points

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By: David Kent, LMT, NCTMB

When clients schedule a treatment session, they expect results and regardless of which massage modality or technique you’ve mastered, you want to deliver.

Back pain is a common complaint among massage clients, and symptoms such as pain across the mid back or low-back pain over the sacrum below the iliac crest in the gluteal region could be the result of myofascial trigger points in the rectus abdominis. (Photo 1) According to Simons & Travell, “An active trigger point high in the rectus abdominis muscle on either side can refer to the mid-back bilaterally, which is described by the patient as running horizontally across the back on both sides at the thoracolumbar level”1. The authors also state that “In the lowest part of the rectus abdominis, trigger points may refer pain bilaterally to the sacroiliac and low back regions”1 (Photos 1).

Although many trigger points have been identified in the rectus abdominis muscle, this article will cover two primary trigger-point patterns that cause back pain in these regions, as well as tips about how to treat them and how to educate your clients about the nature of their pain.

Clues:

Trigger points can form in the rectus abdominis muscle due to visceral disease, direct trauma, emotional stress, poor posture and over-exercise, to name a few. Examples of trauma include surgery in the area or injury to the muscle during a motor vehicle accident. These muscles can also become overstressed by everyday activities, including certain exercises or rigorous housework.

Before treating the rectus abdominis, however, it is important to rule out other muscular possibilities. Referred pain from myofascial trigger points into the lower thoracic region can also be produced by muscles in the back, such as the latissimus dorsi, serratus posterior inferior, illiostalis thoracis, multifidi, intercoastals and insterspinales.

Lower lumbar, sacral and gluteal pain often includes trigger points from the quadratus lumborum, gluteul muscles, piriformis and the hamstrings. In addition to the rectus abdominis, the iliopsoas is another muscle that refers pain into both of these regions.

Encourage clients to reveal important clues about their pain by having them complete a thorough health history and intake form. This useful tool also enables you to ask intelligent questions relevant to the possible causes of the client’s pain.

In addition to the health history and intake forms, have your clients complete a visual-pain chart to specify and document the regions of their discomfort; this tool will help you easily spot the trigger-point patterns and treat them accordingly. (Photo 2)

And before getting started, remember to communicate with the client to rule out potential contraindications, such as recent surgery, abdominal aortic aneurysms, or pregnancy, for example. This information should also be documented on the intake form.

Analogies:

Using analogies can help your client understand the cause and effect of trigger points and their pain. For example, some trigger points are similar to a gun and bullet. When pressure is applied to the “trigger” of a gun, it shoots a bullet, which produces an effect at the point of impact. Likewise, when a therapist applies pressure to a “trigger point” in myofascial tissue, it produces referred phenomena (shoots a bullet) to another area of the body; that effect is usually described as pain, numbness, tingling, weakness or other like complaints.

Communication:

Therapists and clients must communicate with each other to determine the presence of trigger points. Instruct your client to let you know if you reproduce the pain when you palpate a myofascial trigger point. Only the client can tell you if the region being palpated is tender and referring pain elsewhere. Once you have identified the culprit, you can treat the appropriate muscle.

Treatment:

Place the client in the supine position with support under the knees and the arms at the side to avoid tightening the skin over the abdomen. (Note: these same techniques can also be used with the client in a side-lying position).

Determine the borders of the rectus abdominis by asking the client to tense the muscle; he can do this by moving into a semi sit-up position as you palpate the region. Make sure that the client relaxes the muscle before you start treatment. Check for muscle sensitivity by palpating with your fingers using static compression.

Release the attachments around the xyphoid process (Photo 3) and costal margin (Photo 4) with your fingers or thumbs. The pubic attachments can be easily located by asking the client to place their thumb over their belly button and extend their middle finger down until they palpate the pubic symphysis. Use static pressure initially. If the area is not too sensitive, add a combination of friction movements in the direction of the muscle fiber (superior and inferior) and across the muscle fiber (medial and lateral). It will be more comfortable for the client if the intention of your pressure is more dominant in one direction.

Lubricate the muscle belly; then stabilize the skin with the non-treating hand. With the other hand, treat with the muscle fiber using a scooping movement with the fingers (Photo 5), followed by cross fiber (Photo 6).

Pressure:

Make sure to check in with the client frequently about the level of pressure. The body is reflexive, and it responds automatically to stimulation. For example, when you touch a hot surface with your hand, you automatically, or “reflexively,” pull away to avoid burning the skin.

This concept is also true in massage therapy. If the client is reflexively protecting him or herself by pulling away, tightening the muscle, holding his breath, squinting his eyes or clinching his teeth, then you are applying too much pressure. Additionally, if the tenderness in the area and/or the intensity of the referred pain does not ease up within 8 to 12 seconds of holding static pressure on the trigger point, again too much palpation pressure is being applied, leave the area and return later; and then use considerably less pressure.

Other Concerns:

Emotions and Sensitivity – The abdominal region can be a sensitive area for clients. Use good judgment and educate your clients to ensure that they are comfortable with having the abdomen treated.

Positioning and Draping – The client must be positioned comfortably on the treatment table in order for the muscle to fully relax. Additionally, your client’s privacy must always be protected and respected. There are a host of factors that determine the draping technique that you use. If the client is not comfortable with his/her abdomen exposed during treatment, you can still effectively treat the area through the draping itself.

Ice or Heat – If the injury or trauma is acute and/or swelling is present, avoid the injured area, and use ice when appropriate. Otherwise, a moist heat pack can be placed over the muscle prior to therapy.

Topicals – Topicals can help relieve the client’s pain between treatment sessions. You can earn additional income without being in the treatment room. One topical company offers free samples and will even print your contact information on the accompanying promotional materials.

Staying informed by reading articles, textbooks, watching DVDs and taking hands-on seminars to keep your knowledge and skills sharp while helping you perform at your best in the treatment room to meet your personal goals and your clients’ expectations. A percentage of the back pain you treat will be from myofascial trigger points in the rectus abdominis. Watch for the clues and patterns, educate your clients, and use all of the tools at your disposal. Wishing you much success.

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.

1      Simons DG, Travell JG. Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1, Upper Half of Body, Second Edition, Lippincott, Williams and Wilkins: 1999 Page 943

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Back Pain from Gluteus Medius Trigger Points

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By: David Kent, LMT, NCTMB

Each week, I treat several clients who complain of “low back pain.” For many patients, however, the primary cause of pain is not the lower back but the gluteus medius muscle. No matter what kind of massage practice you have, a great deal of your success will depend on how quickly you are able to determine the origin of a patient’s complaint and your ability to produce measurable results. This article will review some ways to identify when the gluteus medius muscle is responsible for causing pain.

Anatomy:

The gluteus medius muscle lies superficial to the gluteus minimus muscle and deep to the gluteus maximus muscle. Proximally, it attaches along the external surface of the ilium between the anterior and posterior gluteal lines. Distally, it attaches to the lateral surface of the greater trochanter of the femur (See Photo 1).

The gluteus medius muscle “abducts the hip joint; the anterior fibers medially rotate and may assist in flexion of the hip joint; [and] the posterior fibers laterally rotate and may assist in extension.”1 It also helps to keep the pelvis level when the opposite leg is raised during activities such as walking, running, or standing on one leg.

Intake and History:

The first step to designing and implementing an effective treatment plan is to understand the client’s medical history and current circumstances. Utilizing health history intake forms will help you gather the appropriate information; they will also reveal important factors that could be relevant to a patient’s condition.

Using pain scales to document a client’s pain patterns are beneficial, as well. Ask the client to color the diagram form illustrating where on the body he/she experiences pain. Then ask the client to add modifiers that adequately describe the pain, followed by a number from 1-10 to rate its intensity (See Photo 2 ). This diagram provides a helpful visual tool that you can reference during the session. You will also see how pain patterns often match common trigger point patterns, which are discussed in more detail below.

Ask the client if any of his/her daily activities are affected by the pain. If the answer is yes, ask the client which muscles hurt, what movements aggravate the pain, and what he/she believes caused the pain. Ask if the client has recently started or modified an exercise program. Answers like walking, running, tennis, aerobics and other types of activities may indicate gluteus medius involvement. Has the client had any falls or sustained any hip injuries? What is the client’s occupation? Does the client place a wallet or tools in a back pocket? All of these questions will help you narrow down the origin of pain. (Read “Questions with Direction,”)

Gait & Postural Analysis:

Observe the client as he/she walks. A painful or “weak gluteus medius muscle forces the client to lurch toward the involved side to place the center of gravity over the hip; such movement is called an abduction, or gluteus medius lurch.”2

Show your client the relationship between posture and pain, and describe how you can help. Just like chiropractors advertise free “spinal exams” to attract new patients, you could provide free postural analysis to attract new clients. Market the postural analysis as a value that you include during the initial visit; then include a second postural analysis taken upon completing a series of treatments. This is a great way to sell packages, and it also demonstrates postural progress. (Read “Getting Comfortable with Postural Analysis,”) When conducting a postural analysis, look for signs of gluteus medius muscle involvement. Shortness of the gluteus medius muscle “may be seen as a lateral pelvic tilt, low on the side of tightness, along with some abduction of the extremity.”3

Trigger Points

“Myofascial trigger points (TrPs) in the gluteus medius are a commonly overlooked source of low back pain.”4 There are three trigger points frequently identified in the gluteus medius muscle. TrP1 (See Photo 1) is located lateral and superior to the posterior superior iliac spine (PSIS) just below the iliac crest. TrP1 refers pain and tenderness over the sacrum, above the iliac crest into the lumbar region, and throughout the gluteal region on the same side of the body as the trigger point.

TrP2 (See Photo 1) is positioned midway between the anterior superior iliac spine (ASIS) and the PSIS just below the iliac crest. “Pain referred from TrP2 is projected more laterally and to the midgluteal region; [and] may extend into the upper thigh posteriorly and laterally.”5

TrP3 (See Photo 1) is rarely present and can be located just posterior to the ASIS and just below the iliac crest. Referred pain is primarily produced over the sacrum bilaterally.

Educate your clients about trigger points. Use wall charts or flip charts to demonstrate their location on the body. Using charts and other aids will not only help the client, but it will also build your credibility with the client. This is also an excellent time to explain how the muscle affects posture.

Pain is a symptom. As massage therapists, our job is to address the cause of the pain and work to prevent its return. Educate your clients. Discuss proper ergonomics, stretching and strengthening. Identifying the gluteus medius as a source of back pain is easy once you have the knowledge.

David Kent, LMT, NCTMB

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.

1, 3 Kendell FP, McCreary, et al. Muscle Testing and Function with Posture and Pain, 5th ed.  Lippincott, Williams and Wilkins: 2005.

2 Hoppenfeld S. Physical Examination of the Spine & Extremities. Appleton & Lange: 1976

4 Simons DG, Travell JG. “Myofascial Origins of Low Back Pain, 3: Pelvic and Lower Extremity Muscles,” Postgrad Med 73:99-108, 1983.

5 Simons DG, Travell JG. Myofascial Pain and Dysfunction, The Trigger Point Manual: The Lower Extremities, 2. Lippincott, Williams and Wilkins: 1992

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Simple Answer, Positive Results

Finding the source of your clients’ pain

By David Kent, LMT, NCTMB

Addressing the pain and discomfort associated with trigger points is one of the most common complaints massage therapists deal with in the treatment room. It’s not uncommon, for example, to palpate a trigger point in the upper trapezius, sternocleidomastoid or suboccipital muscles that produces a referred phenomenon to a completely different area of the body, such as the head. When trigger points refer into the head the phenomenon is often described as pain, a headache, pressure, tingling and/or numbness. Although clients are often surprised at this phenomenon, most are thrilled when I am able to isolate and treat the trigger point. Occasionally, however, a client might show distress at this discovery and say something like, “I’m all screwed up,” “I’m wired wrong‚” or “I’m weird.” In this article, I will share simple solutions for addressing these types of comments in ways that will help empower your clients to have a positive attitude and take a more proactive approach to their health care.

To read the full article, click here:

David Kent – Massage Today: Simple Answers Create Results (05/08)