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Self-Care: Getting Better Faster

Clients recover more rapidly and completely from an injury or condition if they participate in an appropriate self-care plan. From a massage therapist’s perspective this means putting a plan together for the client that includes activities such as hydrotherapy (use of heat and cold applications) stretching, resistance exercises, breathing exercises, self-massage and referrals to other practitioners, exercise programs or self-help groups.


September 29, 2009
By Fiona Rattray RMT

Topics

Clients recover more rapidly and completely from an injury or condition if they participate in an appropriate self-care plan. From a massage therapist’s perspective this means putting a plan together for the client that includes activities such as hydrotherapy (use of heat and cold applications) stretching, resistance exercises, breathing exercises, self-massage and referrals to other practitioners, exercise programs or self-help groups.

better1.jpgBut the client could broaden this definition of self-care to include other things that increase his or her well-being such as meditation, proper nutrition, adequate sleep, spirituality, laughter and so on. I know several people who consider their daily hour-long dog walking through the woods to be vital self-care.

Self-care is not just for recovery from injuries; activities such as stretching and breathing exercises can be used to maintain the client’s existing relaxation and good health.

Creating A Self-Care Plan
Assessment First
Before you can create a self-care plan tailored to the client, you need to do an assessment, which includes health history questions, observations, palpation and special tests.

It can’t be said enough: the more specific you are with assessment, the more specific the self-care plan can be.
For example:

  • Test specific muscles for shortness or weakness, not muscle groups.
  • Choose tests and palpation to differentiate the source of any symptoms. Is numbness due to a compression syndrome or trigger point referral?
  • Test for hypermobile or unstable joints as well as restricted ones.
  • Is there an underlying condition such as diabetes or rheumatoid arthritis that may indicate modifications to the plan?
  • What is the client’s overall fitness level?

Ask the client to perform the movement or position that creates any symptoms. This gives a good indication of the structures affected so you can more easily choose the special tests.

Create the Plan
Armed with your assessment results and the client’s goals, you create the self-care plan. Often, less is more: give a client two self-care activities for one week to get comfortable with a self-care routine. Add more activities on subsequent visits after you’ve evaluated how effective the initial plan has been.

Several factors are considered when choosing activities to make the plan appropriate and effective. These are:

  • Stage of healing of any injury (acute, subacute or chronic)
  • Severity of any injury or postural dysfunction (mild, moderate, severe)
  • Modifications for any pre-existing health care concerns
  • Client’s goals and motivation (if injured, the client may only want to return to previous levels of function; on the other hand she may want to improve flexibility or strength, or decrease stress)

After you’ve developed the plan

  • Record the suggested plan in your ongoing notes.
  • Before you send the client home, make sure that she can do the self-care activity safely and correctly. You demonstrate what to do, then have the client try it.
  • Invoke kinesthetic awareness: have the client focus on how it feels to stretch or strengthen the specific muscle so he can reproduce the exercise at home.
  • It’s good to have a handout of the exercise or hydrotherapy application for the client to take home.
  • If the self-care plan happens over several weeks or months, progress from exercises that need minimum tissue length and strength to those that require maximum flexibility and strength.
  • Inform the client that if pain and swelling happen the day after exercise, the exercise was too vigorous: he should stop and apply ice. You should re-evaluate and modify the self-care plan.

Example of Progressing a Self-Care Plan for Stage of Healing

  • Acute, moderate injury: pain-free range of motion to maintain range, cold hydrotherapy and diaphragmatic breathing are appropriate.
  • Chronic, moderate injury: stretching and strengthening to regain full range and strength, hot hydrotherapy and self-massage would be helpful.

Teach Self-Massage
The importance of teaching safe and effective self-massage was brought home to me by a client who used a wooden mallet (for tenderizing meat) to treat the tight muscles in her shoulders …

  • Demonstrate how to do specific techniques on yourself, then have the client do the same.
  • Ask the client to do some diaphragmatic breathing at the same time as self-massage.
  • Stress that techniques like fingertip kneading, muscle stripping and skin rolling are more effective when done slowly.
  • Show clients how to palpate for and treat trigger points, including how to use a tennis ball (not a wooden mallet!) for gentle ischemic compression.

Develop a list of referral experts
When you think that a client may benefit from a self-care activity that you have no formal training in, pull out your referral list. One of the client’s goals may be to take up yoga, meditation or swimming. Maybe she wants to get in touch with the MS Society or Migraine Foundation. Perhaps she wants a referral for nutrition counselling or to a homeopathic practitioner. Having your community’s resources available can be very helpful for your client.

RE-assess the plan

After your client has been doing self-care activities for one or two weeks, check with the client to see if the plan needs modification. Reasons for modification include:

  • Stage of healing has progressed (needs more challenging activities)
  • No improvement in condition (re-assess to see if self-care plan is appropriate, or suggest a less challenging plan
  • Client’s goals have changed (suggest new activities)
  • Client doesn’t like an activity (suggest an alternative)

Compliance Tracks
How motivated is the client? From a therapist’s point of view it sometimes seems that clients who follow a self-care plan to recovery are in the minority.

When someone comes in for massage to treat a condition, there may be an assumption that the client is a good candidate for self-care. But for this client, getting to the appointment may be as much as the client is willing or able to do.

You can increase client compliance by designing a plan to fit into the client’s day. For example, if the client can do two forearm stretches under the warm water of a morning shower, the self-care may get done on a daily basis.

Some clients flat-out tell you they won’t do exercises. Then the challenge for the therapist is to choose something the client likes to do: no point in recommending swimming if the client doesn’t like it.

‘I’M Doing It And It’s Helping Track’

  • Troubled with neck pain, this client wanted to change his sleeping posture (which was on his stomach, putting stress on his neck); he would start out sleeping on his back but was frustrated to wake up lying on his stomach. I suggested that he put two pillows across the bed at the level of his knees between the mattress and the bottom sheet so he couldn’t kick them away. When he slept on his back, the pillows gave him comfortable knee and hip flexion and his neck stayed straight. If he turned onto his stomach, the pillows caused knee and hip extension and woke him up. It took several weeks to retrain his sleeping posture and reduce his neck pain.
  • A client experienced uncomfortable hip pain and was diagnosed with trochanteric bursitis by another practitioner. I asked her to show me the activity that hurt. Active Resisted muscle testing and palpation revealed a trigger point in the anterior portion of gluteus medius. She was intrigued that the tests reproduced the exact pain she was feeling, and did her self-care stretches, heat and postural modifications diligently. The symptoms did not recur.

Description of stretch for anterior portion of gluteus medius:
Client is side-lying on a bed or sofa, affected leg uppermost; she extends the hip so that the leg can be allowed to slowly drop down toward the floor.

Watch Out For …
Overly ambitious clients: if a five pound weight isn’t challenging enough for strengthening a particular muscle, this client quickly moves up to 10 pounds and courts re-injury. Suggest more repetitions at 5 pounds until it’s pain-free, then move to 8 pounds with pain-free activity before going to the 10 pound level.

Carpal Tunnel Syndrome

• Another client had all the symptoms of carpal tunnel syndrome and her neurologist recommended surgery.
She asked if she could try other things for six months to see if the symptoms diminished, and got the go-ahead.

An assessment showed thoracic outlet syndrome as well as carpal tunnel; a grip strength meter showed the affected hand was markedly weaker. This client and I developed what I at first thought was an ambitious self-care plan; she was determined and stayed with it.

I re-measured her grip strength from time to time. Her symptoms diminished and her strength increased. At the six-month appointment, the neurologist thought she could hold off on the surgery, but should check back if the symptoms ever recurred.

better2.jpgAverage Carpal Tunnel Self-care Plan

  • Apply ice or contrast hydrotherapy applications to wrist/forearm after activity
  • Stretch forearm flexors/extensors daily
  • Self-massage to forearms daily (arm on table, use ulnar border of other arm to muscle strip)

Determined Carpal Tunnel Self-care Plan

  • The average carpal tunnel self-care plan (above) plus these each day:
  • Diaphragmatic breathing
  • Stretches for pectoralis major (picture 1) and minor (picture 2)
  • Stretches for middle (picture 3), anterior (picture 4) and posterior scalenes (picture 5)
  • Self-traction for wrists and fingers
  • Skin rolling for flexors and extensors
  • Fascial spreading over flexor retinaculum, followed by ice

“No, I’m Not Doing It” Track
Few people respond positively to well-intentioned health care nagging. Try a positive and motivating approach, particularly if re-assessment reveals that the client hasn’t been doing the self-care.

• Even with a streamlined self-care plan, some people have a perceived lack of time to participate in helping themselves. Suggest to them that they will be pain-free for longer and have more mobility if they can follow their plan.

• A few clients have a value system that allows them to justify the “luxury” of massage only if they are in pain. This could mean overdoing activities or skipping self-care. Give a gentle reminder that the massage combined with self-care would benefit them.

Watch Out For …

Clients who want you to do all the work: no, the self-care hasn’t been done, isn’t it the therapist’s job to make improvements? Remind the client that the time with you is only one hour, the rest of the week is the client’s time to help themselves.

Self-Care Resources:

  • Anderson, Bob. 2000. Stretching. Shelter Publications. Book, Exercise prescription pads www.stretching.com  
  • Kisner, Carolyn, and Lynn Allen Colby. 2002. Therapeutic Exercise: Foundations and Techniques, 4th Ed. Philadelphia: F. A. Davis
Self-Care For The Therapist
I’ve been in this profession for 22 years. Part of the reason I’ve had such a long work life is my self-care routine. I found this routine through poor biomechanics: in my first two years out of massage school, I habitually stood with my left leg externally rotated.

This was the leg I “pushed off” when doing an effleurage or petrissage technique. Over time, the repetitive action caused my left medial arch to drop.

The metatarsophalangeal (MTP) joint became so inflamed I couldn’t stand the pressure of a shoe on that foot, and the skin began peeling off the joint. I used a cane to get around. I tried cold. I tried heat. I tried ultrasound. I went to a rheumatologist who diagnosed “monoarthritis” and offered surgery.

Finally, a chiropractor suggested orthotics and, in my case, it solved the problem. After that, I got serious about self-care, and took instruction in movement therapy to correct my biomechanics. I’ve maintained a routine of stretching, muscle stripping for my forearms, traction for wrists and fingers, skin rolling and hydrotherapy applications.


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