Features Continuing Education Education
Practice Management: Spring 2005

Walt Disney is quoted as saying “Do what you do so well, people will come back to see you do it again.” I believe this is a wonderful definition of excellence … to do what you do so well that people will come back to see, or experience, it again.

What makes the service you provide excellent? If you’ve never thought about this before, it may be worthwhile to examine your answers to the following questions: How did you determine what approach to take? How did you interact with the person before, during and after treatment? Did your intuition drive you, or did you combine this with a standardized approach to achieve your outcomes? How did you use your body effectively, so as not to injure yourself or retain unwanted tension? What insights did the person come away from the session with?

Through many years of providing excellent care, and on more occasions than I care to admit not-so-excellent care, I have observed several factors that ensure a fairly consistent and positive result. I approach these seven factors or ‘steps’ as a protocol. At the end of treatment, I evaluate to make sure I’ve covered each step. Perhaps this article may encourage readers to form an effective protocol of their own. Here are the seven steps:

Empathize
Although the intake, or case history taking, is important in identifying barriers to treatment and recovery, it should be much more than a pathology screen designed to identify red or yellow flags. 

The case history is an opportunity to understand a person’s experience, to give them room to air their innermost concerns. One report cited that the average patient is interrupted within eight seconds during their medical intake. The interview quickly shifts from an exploration and a sharing to a decision-making and an intervention. 

This is opposite to what we naturally do when we are empathetically listening – we must create a safe, quiet space for the person to share her or his concern.

To empathize is to feel what another is feeling, to identify with their perspective.  It is challenging, but highly beneficial, if we can truly relate to the trials of the person before us. We can be most effective, and serve to transform our fearful perceptions if we can approach the symptoms as a riddle … a problem to be solved.

Questions can be very helpful in assisting the person to reframe the symptoms as ‘things’ into ‘experiences.’ Once the perspective is shifted, the person is then prepared to problem-solve with you to accept and change these conditions. Open-ended questions, questions that require more than “yes” or “no” can assist the person in kinesthetically grounding themselves in their experience. Examples are: “What results would you like to see from our treatment?  How is this condition affecting your life? How did this first come about? Why do you want to change this?

The person may struggle with descriptions, as our western culture often teaches repression of emotional distress and avoidance of pain and suffering.

You can encourage them with gentle prompts such as “tell me more about that.” Gestures such as nodding the head to affirm understanding, leaning forward to show interest and maintaining eye contact without staring all assist to draw out their experience.

The degree to which a person feels understood often represents the degree to which they are open to your encouragements, physical interventions and health recommendations. The time you spend initially empathizing to a person’s circumstances will yield tremendous results as the treatment plan progresses.

Analyze
Once the person feels thoroughly understood, and your case history questions are answered, you can now test your hypothesis of what the condition may be with your assessment. In the biomechanical health sciences, there
are some commonalities among the assessment process. The first part of the assessment outlines observations
in gait and movement, postural alignment, breathing patterns and pallor.

Observations are followed by range-of-motion testing incorporating active, resisted and passive movements of the affected area.  Orthopedic or diagnostic tests aim at ruling out (or for) a particular condition, and are defined by a positive or negative finding in the test.

Included in the latter group are neurological tests for motor function, reflex response and dermatome or sensory intactness. And finally, palpatory findings, which assess neuromuscular tonus, surface temperature, tenderness, and texture – the tissue’s pliancy and resiliency. 

While massage therapists may have some knowledge and competency at orthopedic testing, I believe a key contribution we can make to the common field of assessment is comprehensive postural assessment and palpation.

Of course, the amount of time spent in analysis depends on your focus. If you are in a spa setting, some joint play and tissue tension/compression tests may be all that is warranted to reach your client’s goals of relaxation and rejuvenation. Clinical therapists will tend to place more emphasis on this area, given they are usually trying to intervene on the cause of pain, and the compromised and compensating structures.

Findings from each section of the assessment should be recorded in a meaningful way so as to, along with the case history information, present a clear clinical picture determining if therapeutic intervention would be helpful and not harmful. The purpose of analysis is to gather information and map out a plan of approach.

Mobilize
Chiropractors know that when joints are fixated or “subluxed,” pressure and pain receptors in the surrounding connective tissues bombard the central nervous system (CNS) with substantial information. The CNS excitability results in a host of sequelae including increased muscle tonus around the affected joint and related structures, antalgic movement, compromised vascular and cellular fluid exchange. Chiropractors, through mobilization of the spine, reduce this nervous excitability relieving pain and guarded movement quickly and dramatically.

I’ve noted in my own practice that if I mobilize involved joints and reduce the noxious stimuli bombarding the CNS first, the change in muscle tonus and nutritive mechanisms affecting the traumatized site reduces the soft-tissue work I’ll need to perform in the rest of the session. I recommend joint play of the affected joints first to decrease CNS excitability, ease pain and muscle guarding, and to pave the way for specific soft-tissue manipulation.

Manipulate
The term “manipulation” has often been used to describe treatment to both joints and myofascial tissues. For the purposes of this article and for ease of understanding, I differentiate here to define manipulation as the purposeful application of manual technique to affect a positive change in pliancy and fluidity of connective tissues, and tonus in muscle tissue. Once joint fixations have been removed, the next step is to remove adhesive barriers and resolve hyper-tonicity in skeletal muscles. This includes application of pressure as in trigger point therapy.

The focus of this step is to remove impediments to musculo-skeletal, neural and vascular structures by reducing pain and deconstructing adhesions.

Irrigate
This is the first point at which lubricant is utilized. Classic Swedish massage techniques such as efflurage, petrissage, and tapotement are effective to irrigate manipulated tissues, increase vascular drainage and reduce pain.

If a therapist works in a spa setting, this step would be given the greatest amount of time in the treatment. A clinical approach would require considerably less of the irrigation step, with more time weighted to the mobilize and manipulate steps.

Integrate
Once the area of focus is effectively treated, the body can benefit from a re-integration with the rest of itself – regardless of whether your approach is spa or clinical.

Integration encourages a sense of completion to the therapy, with a renewed sense of wholeness and a body/mind re-connection more emphasized in bodywork than in other health care “interventions.”

This can be created with a general myofascial stretch, using the person’s forearms/wrists or ankles as leverage points. Shaking and rocking to the torso and hips is also effective. A short foot massage if the shoulder girdle was the focus, or a head and neck massage if the pelvic girdle and lower extremity were worked on. A simple, few short minutes to recalibrate and integrate the body as a whole adds value to the work you’ve completed.

Educate
A very important, yet probably the most under-weighted step is educate. Educate means ‘to draw forth’ – in our context we wish to draw forth the kinesthetic wisdom inherent in each body. If we don’t work on this wisdom, we may be band-aiding the problem, causing the person to continue to seek relief and insight into their problem.

In our clinic, we use musculo-skeletal models, charts, analogies and other teaching aids to clearly explain what the structure at fault appears to be, why it is causing these symptoms, and how we can intervene to solve their problem of pain, decreased movement, or low energy.

We describe cause and effect, and we teach remedial exercise to prevent recurrence of the problem. Taking the time to educate encourages the client/patient to monitor their body for problems, and to take prompt action when problems arise.  People who feel empathized with and have their symptoms clearly explained are far more likely to commit to a treatment plan than someone taken through the process as a ‘widget’. 

The Asian proverb, “Give a man a fish and you feed him for a day.  But teach him to fish and you feed him for a life-time” applies here. I encourage you to take the time to teach people about their health, and their responsibility for keeping it. They will be better clients/patients and your business retention will be fantastic.

In Summary
Consider including the 3 ‘izes’ – empathize, analyze and mobilize – and the 4 ‘ates’ – manipulate, irrigate, integrate and educate – in each and every treatment. Your clients/patients will be so pleased, they will want to come back and see you do it again!

Donald Quinn Dillon established MTCoach to provide seminars, business coaching and tools to massage therapists. He can be reached at the Massage Therapy Canada website via www.mtseminars.com, or through MTCoach at www.mtcoach.com