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Providing Post-Surgery massage to clients

Clients seek massage therapy for many reasons, and one of the most challenging for a therapist is chronic pain following surgery.

It’s a tough spot – here we are dealing with tissues that have had a direct surgical intervention – moved, touched, cut or compressed. We also are dealing with structures altered when the body’s healing response forms scar tissue and adhesions.

Massage therapy, thankfully, is low-tech when it comes to post-surgery pain. When I first began treating clients for this type of problem, I referred to muscular patterns of pain and overlapped them with “dermatome” patterns – meaning areas where disturbed nerves can cause pain.

Often stabbing or sharp pains can come from nerves that have developed adhesions or stress patterns from scar tissue pulling on them. These changes may occur far above the area where pain is felt. The massage is always gentle and soothing, following the course of nerves through plexuses and their redundant branches.

Another technique is pain mapping – each time the client returns we again map the pain areas to see if they have changed. If has altered or lessened the pain then the areas treated may be part of the disturbance.

Abdominal breathing is also an important part of these recovery massages. The diaphragm is inhibited by pain and restoring its function – awakening the “bellows” of the body allows for gentle stretching of muscles, organs and nerves. Ultimately diaphragm breathing is the gentlest massage of all.

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Helping your clients set goals for their massage sessions

I always like to check in with new clients on their goals for massage. Do they want to improve sleep, performance, reduce aches, release stress, etc.

I like to give people a few choices on my intake, plus the opportunity to mark “all of the above.” Lots of “aota’s” later, I have come to see what it truly means to some clients. One such new client put it so well:

“I would like to do what I want to do, when I want to do it.”

His statement made us both laugh, because it often sums up what we all want in life: freedom. We want freedom to enjoy activities without thinking about consequences.

I have to admit that massage cannot deliver that goal.

“When I get to that place myself, I’ll let you know,” I said.

Meanwhile, it made me think about what am I really selling as a massage therapist. When I find, treat and track dysfunction I am perhaps vending exactly the opposite: Allowing people the opportunity to choose after careful consideration of their abilities and consequences.

We all have choices, and we make them sometimes a bit too quickly. Choosing to stay at a job that is no longer fair or fun is a choice: people make those decisions for other kinds of rewards. When they come in for massages, I try to help them survive and feel better about that choice.

Massage can’t fix a lot but it can set the mood for people to adapt and make better choices when it comes to stretching, exercise, foods or sleep.

If I think back to my sandbox days, it was all about trying to have things my way – and I was guided to make a better choice for myself and for the future. Human nature, in deed.

Perhaps I would suggest this goal instead:

I would like to be able to do what is good for me, I would like to enjoy doing good for me, and I would like to do it when it is best for me to do it.

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Starting Choices, Massage Therapists

As they graduate from education programs, massage therapists have many choices for employment. Yet finding that perfect job can be elusive.

The venues have expanded in the past few years but the economics remain the same: work a lot for less pay, work a lot less for more pay.

For recent graduates looking to pay their bills – and their student loans – the pressure is quite high. How do newbies balance reliable income with recognition of their skills? start

As an experienced massage therapist, I don’t have all the answers. But let me suggest some strategies that can help graduates maneuver through the first years of their massage careers.

Use your Advantages – Most massage therapists are women, and often female therapists who are attractive can build a book of clients more quickly. So put that picture on your resume, business card, website, whatever, and prepare to get busy.

Better yet, Use Your Disadvantages – Male, muscular and big? Men who do massage face discrimination from clients both male and female. The reasons, trust me, are very unfair. But why not make it an advantage? A male can be a strong, resilient chair massage therapist. Chair massages are done fully dressed, often in public places such as conventions. That eliminates a lot of objections clients have to male therapists. Those practices bloom.

Gender politics can be an advantage in other situations. I also know a female therapist who looks and acts non-feminine. Is that a problem? Heck, no, she told me. “No trophy wife ever has to worry about me making a play for her husband.”

Have more than one source of income – My friend’s career strategy was simple – her income was secondary to the family breadwinner. Her husband handled the bills and worked the long hours of a tax accountant. That left her time to groom and select her clientele without a lot of money pressure. She also had time to volunteer and market herself. She worked at high-end spas and targeted her favored client type – professional athletes. It took years to build a clientele, but she got there. She has a great elevator speech, and the more she practiced it, the more it became her practice.

Do more than massage alone – Another of my friends runs her own day spa and has a cosmetology license. along with a massage license. She can wax; do facials and other cosmetic treatments to fill her book. A slow massage day can be a busy wax day, etc. She didn’t like cutting and coloring hair, but she loves doing facials, massage and waxing.

Some therapists can increase incomes by doing administrative and billing work at their chiropractor’s offices. Another friend also works as a personal assistant, running errands for people who are too busy or too old to do errands.

Work in Multiple Massage Venues – A doctor, a chiropractor, a spa, a chain, a physical therapy clinic, a hotel, a mall chair-massage store. You may surprise yourself to discover your best fit. And if one venue becomes slow, another may be busy.

Be Productive No Matter Where You Work – I call this the “Joseph” strategy. Like Joseph in the Bible, maybe your brothers don’t like you and you get sold into slavery but you work hard and do so well you end up running your master’s house and businesses.

Where you start does not have to be where you end up. Use your venue as a learning laboratory. Does your chain want you to sign up members? Practice so you can figure out how to do that. Sell products? You can learn how to do that, too. What about upgrades? Some of the more corporate places have quotas for therapists. Instead of stressing about meeting those quotas, can you figure out how to fill them? boybaseball

I met sales quotas at a spa by asking someone who could sell how to do it. I sucked at it, but kept practicing and asking questions until I go it. You can also read up on sales techniques, and you can observe those who are successful at it. The key is practice. Being a productive massage employee is all about trying multiple times. Kind of like baseball, hitting three out of 10 times makes you a superstar.

Tips for Bringing Muscles Back to Life

As mysterious as the workings of the human body is, we massage therapists have learned a few tricks to bring errant, dysfunctional muscles back to working order.

I continue to be impressed by the methods of active release, also known as myofascial release, in reviving elements of structure and function to certain muscles.

I recently had the fun of trying to extricate a “burning” sensation in the left lumbar area over the area we associate with discs L-5 and S-1. This is a frequent complaint of people coming in for massage, and sometimes restoring circulation and tone don’t quite fix this problem.

Active release involves allowing the therapist to palpate the errant muscle and drawing it through a complete range of motion. What people sometimes forget in this venue is that complete range of motion must be done by the client, not the therapist, to truly meet the definition of active release.

This took a good trusting relationship between me, the therapist, and my client. It helped that it was not the first time I have seen this client. It also helped that the client was suffering enough to be gung-ho about trying the step.

First, I demonstrated the full motion range to the client, then I asked the client to go through the motion with my verbal prompts. The actions of the suspected muscle, the multifidus, are varied between spinal stabilization in standing and bending, especially while holding a weight in front of the spine. I usually re-discover the aaaargh-factor of the multifidus muscle when I am trying to lift boxes onto a shelf in the garage. Or take them out.

Clients will come in and report such activity as garage-cleaning, house-cleaning, tub-cleaning, etc., followed by pain in the area later in the evening. If it has been a bad lift, the pain is immediate.

Once in a while a client will report trauma, such as falling off a ladder, or a fall during gymnastics, that will make me believe the mutlifidus is now stabilizing a spinous process or transverse process fracture. Off to the doctor they go. I can do active release for the multifidus after the fracture has healed.

This client was sitting on the massage table, back to me, while I palpated the area of the multifidus, just lateral to the spine and about a half-inch into the myofascial bundle. I kept constant pressure on the multifidus as the client bent forward, bent back and then rotated to the opposite side and bent forward. When the multifidus is particularly out of sync, I may do this with the client on their side and asking them to arch the back in this wobble-toy motion.

Give this technique a try with your massage-trading partner to see how it works for you. It’s another trick to hang onto when the clients present with a big pain in a very small area. Do you have your own version of this technique? I would love to hear some more….

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The Price of Comfort

Recently I walked into a raging discussion among massage therapists over discount pricing. To discount or not to discount is a huge bugaboo for massage therapists.

Prices are subjective, of course, and one can only wonder why people ask for a discount from a single massage therapist when they wouldn’t dream of asking at a big spa. I came up with a list of concerns about prices:

Overhead: Discounting is tough for all therapists, really, because our stated prices and what we get paid are quite different. My asking price includes things that support my practice, such as office rent, website, phones, supplies, education and licensing. A friend who does house calls only has the expenses of phone, linens and oil. Another therapist has few expenses as an independent contractor, other than insurance and licensing, but taxes take a much bigger bite out of her paycheck and she rarely makes tips at her chiropractor’s office. At the end of the year, we all make radically different bottom lines, and our prices are quite different.

Perception: Most of the huffy comments from my friends on this topic come from the feeling that clients who ask for discounts are insulting them or their skills. People don’t haggle over many items, but they do haggle over personal services. My feeling is: do you want to be paid like the maid or the accountant?

Need: We all have clients who come in with limited means and in need of massage. How do you handle these? I have given people discounts for multiple sessions when they clearly have a need and lack resources. However, there are always a few people who ask for discounts and don’t have a need. In my experience, they are either thrifty or culturally used to haggling. I don’t take offense. If they really want a discount for the sake of a discount, I refer them to one of the $39 chains.

Desire: Another therapist friend had a home-based practice, (sub-rosa, no licensing or insurance) and needed clients, so she offered massages for $25 an hour, cash only. It worked. She did not have to leave her house She is also now very burned out and has no savings.

My friend who is a hair stylist put it this way: when she started her practice, her prices were low. As she built clientele, her prices rose. The clients who stayed valued her services. The others, well, one or two come in every year so she can fix their $8 haircut.

Massage Finger Maps Helps Reduce Numbness

Massage therapists will often have clients ask about foot or finger pain, or a strip of tightness around the knees or hips, but when is this a symptom of something gone wrong?

As we rub away with our talented hands, we may have an opportunity to assess if a nerve root or disc has been pinched or altered by time or trauma.

Recently a client sought help for numbness in the fingertips of the thumb, index and middle finger. Massage therapists are aware that numbness or weakness calls for evaluation by a doctor. This client had already seen her doctor, and an evaluation had shown disc problems in the neck.

My client was hoping for some improvement brought about by massage instead of more drastic measures.

A quick frisk of Google for numbness in these areas yields lots of articles regards dermatomes and myotomes, showing the body sliced into grids labeled with the common nerve root/disc source. The thumb, index and middle fingers are associated with the medial and radial nerves, and with C5-C6. Tingles in these areas might be caused anywhere from the spine and disc to the carpal tunnel.

By tracking the radial nerve from neck to fingers, I used several techniques to warm, stretch and free the nerve from adhesions. I also massaged the scalenes and applied light traction to the head, in hopes of opening the pinched off areas.

Her symptoms were greatly reduced, and my client is hopeful that massages and some physical therapy will keep her out of the operating room. Will my client have neck surgery? I don’t know, but her symptoms took a turn for the better, and that is what clients seek.

If dermatomes and myotomes are new to you, try a Google of them for some great information that will help your massage practice. I also keep a printed chart handy in my massage appointment book.

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Knowing Your Client – What Works For One Person Doesn’t Work For All

In the early days of a massage therapist’s career, discovering which techniques work well in a treatment session can be baffling.

Is it deep tissue? Soothing strokes? Is it short sessions? Long sessions? Is it movement? Breath? Is it the clients’ mindset? Perceived value? Desire?

Somehow fumbling about in our dim-lit treatment rooms we establish our patterns of understanding, and hopefully we can match those up to our clients’ expectations.

But ask a room full of massage therapists what works can be maddening. Folks who otherwise feel compassion for others can get rigid about their thinking. After all, if something works for them, should it not work for everyone?

It’s a hard fact of life that what works for one person doesn’t work for all. Yet we as a profession are constantly trying to define and establish “scientific” protocols for what works. An effort of little reward, it seems, for therapists and their clients. It does seem to fill up chat rooms and discussion groups.

I saw a lot of this discussion in other professions, as I spent much of my first career reporting on medicine and health sciences. People in these professions don’t want to do any harm, but they want to alleviate suffering and improve lives. Complicating that is the fact that outcomes vary widely. Protocols often work far better for one doctor over another, and for one facility versus another.

The human factor, a long-time friend explained, is what drives people a bit crazy in clinical practice. Was it the protocol or the nurse/doctor/therapist/team/facility or the family prayer group in the waiting room? Is the new drug a wonder pill or is it the selection of patients and monitoring of its use?

I suspect the answers in massage therapy may be about as difficult to vet as it is in medicine. Meanwhile, we practice in the dim-lit rooms of our vocation. If lucky, our clients will tell us what we need to know.

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Providing Quadriceps Massage

My massage therapy client has been working very hard to lose weight. She is going to the gym four times a week, training under the watch of two very good kiniesiology trainers, and eating a diabetic diet. She has lost more than 70 pounds in the past year.

That is a little fast to lose weight, but she has been a trooper. This past holiday season she stayed on track, upping her workouts to make up for time spent traveling and enjoying a few extra carbs. I had not seen her for nearly more than 6 weeks when she limped into my office.

“It’s my knee,” she said. “My good knee!”

Sharp pain was curling around her kneecap. I recognized that look of dread. Try losing weight when you have knee surgery and you are going to spend a month on the couch. A few years ago she experienced that with her bad knee.

Knee pain can be anything, a testy sciatic nerve, nerve root impingement, a poorly tracking kneecap, and osteo-arthritis in the joint. But I do massage, so I follow my muse. Chances are, a sore knee is a sore, entrapped quadriceps – or more likely a sore, entrapped group of quadriceps.

It’s not the easiest massage, but opening the quads can bring a lot of relief. I have learned to start slow, with a lot of warming Swedish massage, to reduce the pain and agony of myofascial release and trigger point work on the most adhesed muscles of all.

Quadriceps that have become trapped in their fascia feel like stone. They lack the softness and rubbery bounce of muscle, feeling sharp and bumpy, almost lifeless.

Warming Swedish can get at the overlay of skin and adipose tissue but that will leave the quadriceps unchanged. Trigger point maps of the quads show so many “x” spots it is hard to see the anatomy. I have learned to start at the top of the muscle, near the trochanter and ISIS, using forearm rather than fingers. Both of these moves reduce the pain.

As trigger points fade, the muscles start to soften. Then add a layer of myofascial release, again using forearm to reduce the strain on the therapist and the client. I slowly move down each quadriceps in strips, starting with the medialis. As I work, I using overall Swedish strokes in between to structurally integrate and encourage circulation.

I am used to feeling the major changes in the quads as they soften. What is remarkable is that my client noticed this, too.

“They feel like they are getting softer and warmer,” she said.

The monster trigger points hide in the area of the vastus lateralis nearest to the knee. I work those last as they are the worst. On these points the knee pain finally subsided.

“Those ball squats you have been doing at the gym have been very effective,” I told my client. “We need to do the bad knee, too.”

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The Push

Massage therapists know that when a client has been pulling something – wire or cable, storage boxes, dogs, etc. that they will find a host of sore and overstretched muscles.

Ergonomically, it is not good to pull, but to push. Push we can do much more easily and with much less fatigue. Somehow the design of things and the human body makes push much better than pull.

This concept gets forgotten, here and there, by otherwise wise, experienced and intuitive massage therapists, in this case me. push

Oh my, something was up. I went for my weekly massage, which I hadn’t had for three weeks because my schedule got crazy, and felt what seemed like a loop of fatigued tissue running from my traps to posterior rotators to lats to triceps to forearms to my thumbs.

Funny I didn’t know that bad patch was there until the massage therapist starting rubbing there. How many times has a client told me that they had no idea something hurt until it was touched? It was especially bad on my left side. Lo, I am left-handed.

As my friend and massage therapist trade-partner tried to get the angst out of this area, I suddenly became aware that I had been doing something wrong. Oh so very wrong. Me? In the biz now for 20 years and I have found a new way to feel yucky?

Hey, it happens.

After three massages that week, I began to feel a lot better. The drilled-in fatigue dropped, I felt less looped in the shoulders and back.

But I needed to find out for myself what I had been doing that had run me off the boards.

I was working with a client who had a habit of clutching items – files, purses, children, and etc. when the dawn finally broke over Marblehead.

I had been working on rotator cuffs from the opposite side of the client, pulling up and back on trigger points in the lats / tereses / infraspinatus muscles. One can massage from the opposite side, on occasion, of course without ending up sore. But one must use the weight of the body, mainly one’s assets, to create the pull. Somehow in the frenzy of the past month I had forgotten this and started using my pulling muscles instead of leverage. What are the pulling muscles? Traps, lats, triceps, etc. Somehow I had forgotten to bend my knees and use weight instead of muscle.

Oh, I have been very good this week. Now I work trapped shoulder blades from the same side. I take care to move the arm into flexion to expose the shoulder. And I vow to never, ever, to pull again. Time for another Epsom soak.

They are Called Trigger Points for a Reason…

The nice man who likes to run every day came into my massage therapy office looking for some relief.

I thought I was going to do a massage – but it turned out to be an intervention.

This man had gotten a hold of a trigger point therapy workbook. He had been doing his own trigger points at home – now his aches and pains were so bad he couldn’t sleep.

The points had been overworked to the point that his body was now so tight and armored this was going to be a tough massage.

With his knee bent, I tried to distract the femur from the hip capsule. Nothing doing. The psoas was so tight it wouldn’t move.

I took a teaching moment. “You go through this at massage school,” I said. “You discover trigger points, see them as the answer to all ills, and you come into class one day having set them all afire with your own merciless fingers. You learn the hard way.”

I took another moment to demonstrate a trigger point release on his common extensor. “Really?” he said. “Is that all the pressure you use?”

Uh-huh.

It took a while, but I was able to get some of the psoas unlocked. I see a lot of Swedish in his future.

With some massage therapy clients, assigning a little homework on their own trigger points may be a good thing. But (oh no please!) don’t try this at home without some instruction.

If home trigger point therapy seems like a good idea, I like to tell clients: “You will be very tempted to be much meaner to your trigger points than I am.”

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