my first client conundrum

[chuckstervandam]

this is for josh or anybody else who wants to take a stab, poke, or glide into it!



ok, this is my first time asking/posting something like this, and as a student in clinic still, i'm not sure if i'll be explaining this right (considering i'm a total newbie and on and on...)

so i have a client that has specifically returned to see me, and has booked out for weeks ahead with me, as well. this is very exciting for me! but i'm not sure if i know what i'm doing!

here is the situation/condition:

my client wants work only on her upper back and neck, and particularly wants focused work on her right shoulder/neck.

she has been coming to the clinic regularly (before i ever started) and has constant issues with her right shoulder being tight, and just from simply looking it is extremely elevated. i've seen her twice, and the second time seemed was more elevated and restricted/tight than the first.

she is very active and does water aerobics most (if not all) mornings. i found out after last session that she has a condition on the right metatarsal of her second toe that prevents her from putting any pressure on it. i only discovered this condition because i suggested that she could roll some tennis or raquet balls under her feet to loosen up the fascia and perhaps in some way impact it's spread all the way up even to her neck. i didn't say it would cure anything, but i was trying to find some way that would at least provide some temporary loosening for her throughout the week while i dig/research to try to find some kind of way to work with her that might provide better results. she has not listed this foot/toe condition on her intake form anywhere! then after i found this out, she told me that her doctor has told her she needs to stretch her "ankle ligament" by doing calf stretches off of a stair, but that she can't do it on the injured foot because the pain of any pressure on it makes such a move unrealistic for her. i had also suggested that perhaps sometime she'd like me to work on her feet during a session. just the thought of that foot being touched made her cringe. so it causes her considerable pain.

my first thought was that something was going on in her pelvis. when i was warming up her back i tried to evaluate her pelvis and the levels of her psis. i actually could not find any imbalance there, but i might not be knowing exactly what to look for. my thumbs on each side of the psis seemed to be at the same level? is that how i'd check that? gosh, i just feel like i'm fumbling in the dark!

so i proceeded with the massage and worked on her traps, rhomboids, levator scapula, supraspinatus, and teres minor area posteriorly and then in supine i worked SCM and scalenes and also did some holds/tension on the suboccipitals.

also, prone and supine i did some trapezius stretches where i lunged forward from standing behind her head to stretch the shoulders down.

i didn't do a lot of ROM with her arm/shoulder. i feel like i need more learning when it comes to stretches to really know what i'm doing.

ok, so at the end of the massage her right shoulder was less elevated, but i know for a fact that i'm not getting to the root cause of her discomfort and imbalance. and that's frustrating! i want to have a clue and this has been ongoing for this lady!

my gut feeling says that it's a structural issue that needs to be addressed first, possibly by a chiropractor or somebody who does structural massage work stuff like rolfing type stuff or something.

in addition, this client has repeatedly stated verbally and in writing, "You can't hurt me!" and wants a lottttt of pressure. I found a huge knot/TP in her trapezius and as i tried to address it she would not give me a number on a 1-10 pain scale!!! she just said she didn't care how much it hurt and that it didn't matter, she just wanted the pain to go away. i can't seem to get across the idea that her muscle tissue might not agree with her thinking and that it possibly will not release in that way, by me digging to the death.

and i am not the type of therapist with this sort of approach, so it bothers me to inflict pain with out any sort of gauge from the client. does this make sense? it concerns me, and i don't think it would be right for me to just dig into her trouble spots like this, and i don't think it would be effective anyway.

i try to incorporate really warming of the fascia and myofascial stretches (the extremely limited amount i know of anyway, at this point)

it seems like this client's issues should be something fairly approachable and resolvable from a muscular/structural POV, but as a student my knowledge is on a severe learning curve, lol. so here it is, presenting it to the masters! my intuition/gut tells me there's possibly more going on at an emotional level though that might require some time before body/mind are in agreement here?

anyway, so thank you for reading! i hope any of this makes a bit of sense!

 

[a.s.a.p.]

First you need to explain to her how causing pain in the body causes the body to create more tension. I hope that has been explained to you in school. Even if she feels she can "take it" there is still unconscious "fight or flight" tension being created and if she feels any kind of "real pain" at all, anything that she is "tolerating" it could actually be creating more problems. It can take a lot of education to get that point across. You may also want to say that you have been disregarding this for awhile in order to please her, so she doesn't think you're contradicting yourself (since you gave her very deep pressure before).

As for telling about her hips, sometimes you can tell on the table, but most of the time you need to view them standing up to see any real imbalance in the pelvis. For instance, if the legs are different lengths, the pelvis could appear balanced on the table, yet one let would be longer.

I would also suggest to work on her foot, no matter how light you work on it. Challenge yourself and your client that light work can be beneficial. She may feel that only deep work is beneficial and the deep work on her foot would be too painful. After you explain to her the usefulness of moderate work, she may be more open to it.

Finally, with the pain scale, you need to emphasize that you really don't care how much she is hurting (she obviously doesn't!) but you need to be working at a certain level of pressure for maximum effectiveness (and working at a level of pain is not effective), and you need her feedback for that. Sounds kinda backwards, but that's the psychology I'd try on that one.

Good luck! Let us know.

 

[deelell]

hi shivashiva! thank you for your response

yes, i've learned that causing too much pain in the body will cause more tension which is one reason i really don't want to do that! i just wanted to clarify that i have not (knowingly anyway, i check in on pressure) been causing her excessive pain. i've also only worked on her two times. (i've only been in clinic for 4 weeks)

she told me the first time before i started working on her that she could take any sort and lots of pressure, so i did work deep, but not excessively (from what i could tell and from her feedback, but i'm thinking i might not be able to rely on her reviewing because she seems to be in the mindset that the more pain the better.) then she gave me a great written eval. and rebooked for weeks out.

next session she came in and again told me that she could take lots of pressure, go as deep as possible, etc, but then she also said that she came back because i seemed to know all the little tricks (i don't know what those are! lol, so i just said, i hope so! i want to be able to help!)
this is the session where i really found a very tender spot in her right trap. there were actually multiple spots but on big one in particular. i worked on it, had her take a deep breath and asked about pressure. i worked on it, went and warmed up/worked another spot and then returned to the pain a few times. i was told in TP work to only take a go at it 3 times or so? and then let it be??

after the session we talked and that's when i mentioned her feet and learned what i did about it...and then she gave me another great written eval, but emphasized about pressure and exclaimed that i couldn't hurt her.

i know i was using quite a bit of pressure during the massage, and i did feel tissue melting, but i wouldn't dig and dig into that knot past what seemed reasonable to me because she wouldn't give me a pain scale. i should have tried to explain to her right then about the body's response but i didn't. i wasn't sure if i should start talking and conversing and also in clinic we are supposed to keep quiet because there is someone on the other side of the curtain getting a massage. i think next time i see her i'll talk about it before she gets on the table.

for what it's worth, both times i've worked on her she's fallen asleep for portions or the massage and i can always tell (aside from her breathing and the noise) because the tissue starts to work with me a lot better. i find myself communicating with her muscles and tissues reassuring them that it's really ok to let go, and that they can. lol. (i do this silently in my head )

again, thank you so much for the help!!! also next time i'll see about checking out her hip height first thing before she gets on the table too. and yes, i love working on the feet and really see a benefit in it. it would be cool to be able to be the student that helps her find benefit in non-painful touch!

 

[iamalsotim]

Healingtime,

Sounds like you are doing some good work with your client. I believe your client is returning to you because you are showing genuine concern for her well being and recovery, not just giving her a massage for clinic.

I will support the philosophy of not going too deep. Do not allow a client to dictate to you how you should perform a massage... ever. Yes, take time to listen to their concerns, desires and physical issues and build your treatment plan around that consultation, but do not allow a client to dictate how you should actually proceed. YOU are the professional who has been trained to appropriately give a massage. Please DO listen to her feed back during the massage, but consistently let her know that too much pain is counterproductive. It sounds like you have wonderful instincts. Trust them.

I believe you are on the right track looking to her hips and feet being potential sources of her shoulder issue. If the client's doc is encouraging her to stretch her calf, check for hypertonicity of her peroneus, gastrocnemus and soleus. Her foot pain can definately alter her gait to throw off the structural balance of her hips and affect her shoulder.

Do not be too concerned with her shoulder seeming more tense the second time you saw her. This may not be indicative of how good a job you did. She could have had experiences that caused more tension before that second session.

One more thought, you may want to research plantar fasciitis and talk to your client to see if that might apply to her situation.

Good Luck and much encouragement to you.

 

[the showstopper]

my first client conundrum

(Disclaimer: sorry this got so long! Grab a cup o' tea, take a bathroom break, and settle in if you wish )

I agree, your client is in very good hands coming to see you. I'm excited that you're already thinking along lines like this, viewing the whole body, and differentiating soft tissue issues from structural ones and whatnot.

This part kinda bothered me, more for your sake.

my client wants work only on her upper back and neck, and particularly wants focused work on her right shoulder/neck.

This bothers me because these types of clients like to try to dictate their treatment, and they don't have the proper information or training. They don't know what you know. They don't know how everything is all connected. It also bothers me that someone with no training is going to tell a licensed professional where to work.

I've almost gotten to the point where I don't exactly let someone tell me where to work. I know that sounds bad, so please let me clarify. I certainly do listen to their chief complaint. I look carefully at their intake form and I completely respect them and their opinions and experiences. After all, many clients know their bodies quite well.

What I have an issue with is when someone comes to a therapist with a certain problem and then tells them how to address it. I understand that someone may have a preference for a particular technique or maneuver they might have experienced, and I welcome them to share that information with me. I also respect that the session is their time and money. However, we are the ones with the license and the training. When someone tells us where to work and exactly what to do for the whole session time, they're tying our hands behind our backs in terms of what we can do to help relieve their condition. And then, if their condition doesn't resolve, we are almost implied responsible for that, when they rub their area of complaint and complain that the pain/tenderness/problem is still there.

What I do is this (and this may not work for everyone)... During an initial consultation, I ask the client to tell me more about their problem...describe it to me, when did it start, does it come and go, etc. I gain information about what the cause might be and if massage might help, and there's an added benefit in that the client feels they're being validated and cared for (which they are--we all care deeply about our clients). Then, I explain to them what it is I specialize them (NMT) and I tell them a brief couple of sentences about how it can help. I explain that I combine that with some traditional mainstream massage and also some non-traditional newer therapies like cold laser, in order to help them reach the goal of minimizing the pain and restoring the function of the body part. If I've seen this condition before, I tell them this, and I let them know what usually works best, and then I spell out my treatment protocol. Armed with this info, they almost always agree to doing things that way. My aim is to work WITH them to come up with a plan of attack that best meets their goal. I know things that they've never thought of, and they're pleased to learn that. Hehe...just in case that helps.

she has been coming to the clinic regularly (before i ever started) and has constant issues with her right shoulder being tight, and just from simply looking it is extremely elevated. i've seen her twice, and the second time seemed was more elevated and restricted/tight than the first.

Definitely sounds like a lower cervical vertebral misalignment (which will cause postural compensations like you described) or a first rib fixation.

my first thought was that something was going on in her pelvis. when i was warming up her back i tried to evaluate her pelvis and the levels of her psis. i actually could not find any imbalance there, but i might not be knowing exactly what to look for. my thumbs on each side of the psis seemed to be at the same level? is that how i'd check that?

Good thought about the pelvis. Most people have imbalanced pelvises, whether they're active people or sedentary. This will indeed cause compensation patterns further up the spine/ribs (including the neck). Trouble is, you wouldn't really be able to check that much, other than analyzing posture or palpating. This would be more of a bony palpation, which we're not taught in massage therapy. But, you can certainly palpate the surrounding soft tissues. I'd zoom in on the glutes, the TFL, the sacral ligaments (although be careful...don't want to disrupt those too much) and whatnot. You can often get some relief by doing some deep slow compressions on the sacrum, if you're OK with getting on the table (tell your client first, make sure it's OK LOL )

so i proceeded with the massage and worked on her traps, rhomboids, levator scapula, supraspinatus, and teres minor area posteriorly and then in supine i worked SCM and scalenes and also did some holds/tension on the suboccipitals.

also, prone and supine i did some trapezius stretches where i lunged forward from standing behind her head to stretch the shoulders down.

i didn't do a lot of ROM with her arm/shoulder. i feel like i need more learning when it comes to stretches to really know what i'm doing.

Good call Also, I would work the pecs. These are common culprits of shoulder problems, especially pec minor. You may have to start out with some gentle sustained myofascial release type techniques first, because the fascia is often so tight (due to long periods of slouchy posture) that you may try to go deep but the tight fascia won't let you access the muscles underneath.

my gut feeling says that it's a structural issue that needs to be addressed first, possibly by a chiropractor ...

Go with that. She can see a rolfer, but they can't move bones. She could see an osteopath, but they do long-lever adjustment moves that are less specific. Chiropractors get a lot more adjustment training, and they learn short-lever moves that are more specific to the problem area, and they're a lot more comfortable. Make sure she sees a good one, though, as is true for any professional. If you can, do some homework first. Chiropractors that do Motion Palpation or Gonstead or Thompson techniques get sweeeet results usually. I'm more leery of those who practice Diversified technique (unless they swear off rotary moves!) And make SURE they don't do what's called "The Flying 7" which means the same seven moves on every patient, regardless of their chief complaint. Most chiropractors are good, but there are a few lazy ones out there, like any profession.

in addition, this client has repeatedly stated verbally and in writing, "You can't hurt me!" and wants a lottttt of pressure. I found a huge knot/TP in her trapezius and as i tried to address it she would not give me a number on a 1-10 pain scale!!! she just said she didn't care how much it hurt and that it didn't matter, she just wanted the pain to go away. i can't seem to get across the idea that her muscle tissue might not agree with her thinking and that it possibly will not release in that way, by me digging to the death.

Be very, very careful with these people. I've seen people like this, and they've been one of several types:
1) They have actual undiagnosed nerve issues where they can't feel pain as well. Whether they can feel it or not, if you go deep enough, that will traumatize her tissue. This sets up Type 2...
2) She could be the litigious type, looking for an establishment to sue. Not to be paranoid, but as the economy gets worse, we'll see more of this. I've seen it already. Not in my own practice, but in general.
3) They've got psychological issues, where they confuse pain with pleasure, or pain with healing. Not a type you want to walk into uninformed.
4) Some of these people are energy vampires. They want to work you to death, for whatever reason. I've actually heard of people who are only happy when they see the therapist wearing him/herself out. Yeah, I know it's campy and hard to believe. But it's dead-on true. It's almost as if they can't be happy so they want to wear out those around them, too. Or they get a little power trip when they see someone over-exerting themselves for them.

I've encountered clients like this before. I remain at least on psychologically equal ground with them, asserting my position when necessary, mildly flexing the arm of my training and expertise when I need to. I try to work with them, but not FOR them. I tell them, this is what I can do for you. NEVER EVER EVER EVER overexert yourself. NO ONE person is worth your whole career, and yes--you can hurt yourself enough in one session to cause PERMANENT DAMAGE. Also please don't feel bad if you can't satisfy this woman. So many people simply cannot be satisfied no matter what you do, because their real root issue is not physical pain at all, but rather mental/emotional/psychological issues. Many of these people have the poor-me syndrome. Believe in what YOU know, for you know more than you think you know. Realize your own limitations, physically, mentally, and educationally, and do your best, but don't kick yourself for not being able to do anymore. All you can do is all you can do. If necessary, refer her to someone who specializes in deep tissue. Please don't attempt to do deep tissue if you haven't been properly trained. You run a big chance of hurting yourself. Listen to your own body when working on her, and don't try to push your own limitations. If it's still not enough, don't feel bad. No one is able to please everyone. Someone people are just impossible to please. Many of these people are drawn to nice, generous, helpful people like you, and it's a bonus if you're inexperienced because then you're unsure of yourself and more likely to listen to everything she wants and put her wants before your needs. I know cuz I've been there Chances are good that as you maintain your own assertiveness and set boundaries, she may not return. Please know that others, who are more receptive to the lot that you have to offer, will fill her space.

Please know that I didn't mean for any of this to be harsh or judgmental to the client in question; it's just that she sounds so much like so many ppl that I've encountered myself or heard stories about from other therapists, and I've seen the damage it has done to other therapists (physically and mentally--some have left the field because of their experiences with these ppl and the aftermath) and I've also experienced what some of them had almost done to my own practice and all of my energy before I cut them loose. I also remember how uncertain I was and how much guts it took to let them go, but I remember how much happier I was when I changed my approach to clients.

Heh, thanks for getting through my ramblings. I really hope it helped!
Good luck with this situation!
Hugs,
~Jyoti

 

[Pompal 09.]

hi Gerry and jyoti,

thank you both so much for responding and your help...
this all gives me VERY much to think about! (jyoti, the tea break was good too, so thank you! hehe )

if it is ok, i will take some time to think on all this and then come back. i just wanted to say thank you so much for taking out so much of your time to respond to this! the stuff you have shared here is going to be stuff i carry with me as a therapist forever, and just in general life!

thanks much much much, and i will return to respond (and give updates hopefully, if you're interested)
healingtime

 

[? ??so? ?]

All good stuff. Thanks peeps.

 

[Nikolai]

hi again jyoti,

i did indeed see "my client" again today. today it was so dead-on close to everything you wrote that i'm hesitant to post anymore here about this situation because it seemed to go almost point by point through your advice and warnings to me. (maybe she's reading here!)

i am sooo thankful for what you share with me about this situation though, because i would have been totally lost and overwhelmed had i not had your words of support and experience. still i was totally dumbfounded. i can pm you the specifics of it if you're interested, but i'm paranoid to write anymore about it here.

what you shared in general about working with clients may have actually saved my whole career though. thank you so much!!

 

[ms manners]

If you are in massage school and working on this person in clinic there you should be discussing this with your clinic supervisor and peer group.

Since you don't have training in structural work forget about trying to figure out what it is - even if you have structural training forget about it.

I would just do what the client wants. It is her money and her session and you are making it all about you and what you want- you want to make her feel better and when you can't you feel frustrated. People like this just need to be in pain believe it or not. You can't save people from their pain. You can work with them to get them to feel it more and when they feel it more and can accept it - it will go away. Maybe she doesn't really want it to go away. If she did wouldn't she go to a more experienced therapist - nothing personal...

You can make guesses about what it might be or might not be. I would guess that it has more to do with her diet and the alignment of her hips. 20 more massage therapists will have 25 more different guesses.

I do think believe that where the pain is is usually not the problem but you won't be able to tell that to someone until you earn their trust by doing what they ask you to do.

Thinking people are wanting to just slap a law suit on you is really a diservice to the client. You are projecting your fears onto the client. Just be with the person and really listen to her through her words and through what you feel in her body. People can't often feel pain because the tissue is too tight. When you get get it to feel painful that is actually good and then you can work with her more.

She is not ready to deal with the pain in her foot even if it could be causing her shoulder pain. Get her trust and you will be able to work on it.

There are just so many ways to look at this - take in what people say here and then just try what you feel is right for your client.

Julie

 

[Sarah M]

hi julie,

thanks for taking the time to respond here...i also am discussing this at school. i will do what the client wants--up to the point of my clinical judgement. if the client wants to be injured, or if how the client is requesting that i work will lead to injury or more damage unknowingly to themselves, i will not obviously do that for my client. also, if a client is requesting i do something i am not trained in, or is asking me to perform a maneuver that will injure me, i have to consider that too. just boundaries and limits. i do have to say that i agree that i would definitely like to help this client feel better and feel some frustration with not being able to, but my client also expresses the same frustration, so i'm not making it all about me and what i want. i can only do what i can do though. i'm just posting here to search out that i am actually doing all i can do (with consideration of my training level and that i'm a student (for 12 more weeks, in school anyway! woohoo. ))

i'm sure there are many theories and guesses and suggestions for how to work with many clients, i just know as a student my knowledge base is significantly lesser than the great stores here so i appreciate everybody's feedback. it's helping me learn a lot, and i can take it into future sessions with this client and future ones. thanks so much for the feedback!

 

[cristelle R]

I would just do what the client wants. It is her money and her session and you are making it all about you and what you want- you want to make her feel better and when you can't you feel frustrated.

With all due respect Julie, I have to disagree with you on this statement. I can recall many situations in my personal practice where if I did "what the client wanted" I could have placed myself at risk in liable and/or ethical areas. Each massage situation is unique and a good therapist will use their common sense and knowledge gained by their training to assess a client session and determine what will be the best course of action.

It's been my experience that a client rarely knows what is going to be best for them in regards to treatment and technique. Most come in just wanting to feel better, and at least come out feeling more relaxed. More often than not, educating my clients on what is in their better interests on how the session proceeds has resulted in many satisfied clients. Those that have chosen not to return were the ones that would have sucked me dry if I allowed them to.

In this case I feel that healingtime just wants to be the best massage therapist she can possibly be, and do what is right for her clients no matter what level of experience she may currently have. I agree it is a bit early for her to address structural imbalances. I also agree that she should address her concerns regarding the client in question to her instructor(s) and peer group. I still encourage her and everyone else to come here and seek out opinions. I thought that is what this forum is for.

Healingtime, keep on caring. Doing everything you can to help a client resolve a pain issue is what will make you an exceptional massage therapist and set you apart from the masses out there you will be competing with. There is nothing more gratifying than to hear a client walk out of your room and say "the pain is gone!" In your massage business it IS all about you and your desire to help people. Lose that, and it will only be a matter of time before you burn out and get sick of it.

Keep in mind that we can't help everyone. It is true that there are people out there that just don't want to heal, use their pain to gain attention. With experience you'll learn to recognize these people much more quickly and gain the ability to steer them away from you. May you find peace, happiness and much success along your path.

Happy Holidays

Gerry

 

[The physician]

I want to give another possibility here that I just thought of, due to a client I had a couple days ago. I get clients on occasion, usually females on the smaller side, who specifically request deep tissue and sometimes say "you can't hurt me" and sometimes say "I can never get a deep tissue massage" and look at me like they are questioning whether I will be able to do it. My theory on these women (and it's not just a theory, it's partially from what they have told me) is that they have not been able to get deep work from most therapists out there for one of several reasons. The most likely reason, I think, is that they are getting a (relatively) new therapist who is afraid they will hurt the client and therefore won't go deep enough for their needs. From my experience teaching, most students do not "get" how to give deep pressure until near the end of school, or later. Most students are afraid of hurting their client, even with moderate pressure.

I am not saying this is whats going on with you, healingtime, I'm just pointing out another possibility, to give balance to the other perspectives. I know there are clients who *do* ask for way more pressure than is necessary.

Also, some therapists see a small woman and think that woman can't possibly take deep pressure and don't or can't assess their actual tissue to feel what kind of pressure the tissue can take and needs. From my experience, I've found that most petite women can take and need more pressure than a lot of the larger people I work on, even muscular men. They may have less tissue overall, but it can be denser and thicker. Also, several of these women have told me that they repeatedly asked for deep tissue or more pressure and were over and over given medium to light pressure (and I have experienced this myself as a client). When I gave each of these women a satisfactory massage, I found it was on the deeper side, but not dangerous in any way, and they were very happy with the results.

Just a thought! It sounds like you are really investigating this thoroughly which is great. I'm sure you'll come to a place of peace with this client.