Thrown for a curve - litterally

[NHK]

Hey all. I'm looking for any advice on a client a had today.

Quick introduction first though. I graduated from the Chicago School of Massage Therapy last march (last of the CSMT grads before the Cortiva switch.) I started working at a health club last november doing mostly relaxation, but some sports and therapeutic massage as I can get it. Sadly, the MT department REALLY needs some work in it's record keeping, and I'm currently working with my supervisor to make client intake health forms available (and get them used) as well as starting to use SOAP notes. The current therapists have maintained their own clients long enough that apparently they haven't felt the need for keeping records. Because of this, I was REALLY thrown for a loop today.

My client who made her way into my room today was an elderly lady, on oxygen, using a walker with very limited mobility, and with an extremely hyperkyphotic thoracic curve with some spinal twisting. She stood about 4'10", and explained that over the years she's lost about 5" in height... along with her neck. She's suffered from osteoporosis, a broken hip, and 2 hip replacements, and is on blood thinners. Due to the lack of appropriate intake forms (there's just a release that the clients sign when they pay for the appointment at the front desk - the therapists never see those) and previous SOAP notes (she's been a client for a couple years, but her previous therapists never kept SOAP notes, and are no longer employed there, so I can't check with them) I winged it and did my best today, but she's scheduled for 2-3 more massages in the next couple weeks, so I want to try to be more prepared on friday when she returns.

Her main complaint was lower back pain, and wanted the hour spent only on her back - not her neck, because "anytime someone touches my neck, they make it worse". I was able to use pillows to make her comfortable, and we shifted her a couple times during the massage because of her difficulties breathing. She kept insisting that I use more pressure, because "it's got to hurt if it's going to do any good - that's what I was told." I tried to let her know that massage doesn't have to hurt to be beneficial, and that deep work can be accomplished through warming and appropriate techniques, but because of the blood thinners I didn't want to risk bruising or other injury. She was very insistent that I "dig out those pressure points"... I wish I knew what others had been doing to this woman... Anyway, the massage consisted of lots of warming and working my way through the layers of muscle carefully, with a light to medium amount of pressure. I did some specific work (erectors and QL were very tight) but worked with the intention that I wasn't going to try to change anything on this first visit, other than to hopefully offer her some comfort. I think she left a little unsure today, concerned that she hadn't gotten her money's worth since it didn't hurt enough, but I told her that friday we'll discuss how she's feeling and go from there.

I was really caught off guard today, but I want to be better prepared for friday. What other questions should I be asking? What other cautions should I be taking? Her goal is pain relief for her lower back. For that, she waits till she can't stand the pain anymore, then buys a 3-pack of massages and uses them over about a 2 week period. It seems she does this every 2-3 months. I know she would benefit from more of a regular maintenance schedule than to wait for the pain and go in such spurts... but what else can I do? I'm open to suggestions.

Thanks

 

[tigris]

It is late, and I will ponder over this more tomarrow, but wanted to throw my 2 cents in.

I work on my own, if this woman would have come into me, I am not sure if I would have felt competent to work on her.

Sure, yeah yeah, I could have given her a massage, but her condition would have intimidated me a bit. I would have felt over whelmed by the combination of her curvature, the oxygen, the hoses, she wants it to hurt, her age, the blood thinners, she waits until it gets so bad and then comes in for 3 quick sessions, etc... Seriously, I think I would feel like she would be better in someone elses hands, I probably would refer her out to someone a lot more skilled with NMT.

And as for the lack of soap notes, even if they were there doesnt always mean you will get a clear picture of what was done. I find I personally have a difficult time translating what I do during a session to paper. Massage is an art, and so is good SOAP note writing. I confess I am much better at massage than SOAP note writing. I dont think so much about what I am doing, I just put my hands on a clients body and they just seem to know what to do without me thinking much about it, kind of like a mini trance.

In a perfect world, I would have a tiny microphone on my collar and I could talk into it during a session as I am working on a client. I dont think that would go over very well though.

I remember seeing soap notes in school that looked like books. Some would be the whole page long. These can be just as confusing as soap notes that are not detailed enough.

If there are a number of MT's working where you are, you may have gotten a client that isnt a favorite among the rest of the staff. Since you are the new one, you got her. Dont worry so much about what you cant change (lack of soap notes) and just go on from where you are.

If you are confident you can help this woman, tell her so,tell her the benefit of coming in more regularily, as well as give her a time frame to get her situation under control. Perhaps 3 appointments in the span of 3 weeks, and then gradually ween her down to once every 3 weeks or so. If within the given time frame, you are doing all you can, and she isnt getting better, then I would refer her out. I have done this already.

Best of luck with your new job. Keep us updated.

 

[Ronan]

Congrats on graduation- one of my favorite teachers went to CSMT a way back.

Anyway- sounds like (as Greatlakes mentioned) that even if you had SOAPs, they may have done you little good. I certianly don't claim to be the best source of info on this, but it seems that Osteoporosis and massage that is to point of pain, as she seems to have gotten in the past, is not a good combo.

Personally, I again agree with Greatlakes, that her medical situation would point me toward a referral- someone who specializes in working with the elderly or more complex cases.

If there is no one there who does that, I would call up one of your favorite teachers, and ask them for help. Additionally, I am sure some on here may have some great advice as well. I do think that your choosing to do lighter work and trying to educate her about massage and pain was a great way to start things.

 

[Ruby]

I work with the elderly. I think you handled it very well by working lighter and explaining that you can get deeper without hurting her as much. Remember, working slower feels deeper, as does working with less oil. But you are correct, you can work your way down through the tissue and get quite deep without diving in for the kill.

I have found with the elderly, especially those in pain and with multiple medical conditions, I can have a lot MORE effect by working lightly. Coaxing the tissue has a much quicker and greater effect than intimidating it! Explaining that to someone who is "set in her ways" can be tricky, though. If you can convince her to give it an honest try, maybe even to chart how she feels immediately after her massage, a day later and two days later, she can convince herself that she just found the SMARTEST MT. : Congratulate her persistence in determination to find the therapy that works, and let her know that she can find the schedule that works best for her, too - so experiementing is in order. Then I'd suggest the schedule Greatttlakes suggested, keeping treatments more consistent so that she can continue to make progress rather than waiting until what progress she has made comes all the way undone.

The blood thinners *are* contraindicated for NMT or any hard-and-fast depth. Deep work is fine, but your way - slowly easing your way in. You could also explain fascia to her, and how releasing that may have an even greater effect for long-term relief, and that is slow, gently work.

Referring her out should always be an option for you, even though you work in a place that stands to lose a little profit. She may very well be best served elsewhere, and if they balk at that idea, remind them of their liability factor. And if their liability doesn't concern them, you can let them know yours concerns you, and you can't risk your whole career for that bit of money you make on her occasional set of three massages!

 

[~ Dan ~]

JaeMarie,
I think considering what you had to deal with you did an excellent job. I have taken a few classes with Earl Conner and Bob King (Pre and Post Cortiva) and love the MFR work that they teach. I would be inclined to approach her from a MFR point of view, stressing that the work is slow though it can be both deep and very profound.
I think getting her to schedule her treatments consistently and to do some self-care would be an important "hurdle" for you to cross with her. I would stress that it may take time but do chart her results so you can show her they can be measurable and tangible. (Rome wasn't built in a day and all that.)
As others have suggested if you feel that you need to refer out you can always contact one of your instructors from CSMT for ideas on who to refer to... or you can post a request in the referrals needed section of this board.
I know we have a few Chicago area MTs. Some other grads from CSMT and at least one John Barnes trained MFR therapist on the board from the Chicago area.
I look foward to seeing more posts from you in the future!

 

[Smiling]

Thanks for the support .

I met with the client again today, and our session went MUCH better than the last. I was more prepared and focussed (less deer in the headlights ) and we had better communication. It turns out that the "lower back" pain she wanted me to work on is really in glute medius and minimus (*lightbulb* hip replacements?) I warmed and worked her low back and posterior hip gently, and she was thrilled.

We'll see how she's doing come monday, and hopefully I'll be able to talk her into more regular work instead of the sporadic schedule she's been keeping.

Thanks again .

BTW - maestra, I had Earl as an instructor for 10 weeks of class. He was a WONDERFUL teacher, who I'd jump at the chance to learn from again.

 

[Mickey K]

Thanks for the support .

I met with the client again today, and our session went MUCH better than the last. I was more prepared and focussed (less deer in the headlights ) and we had better communication. It turns out that the "lower back" pain she wanted me to work on is really in glute medius and minimus (*lightbulb* hip replacements?) I warmed and worked her low back and posterior hip gently, and she was thrilled.

We'll see how she's doing come monday, and hopefully I'll be able to talk her into more regular work instead of the sporadic schedule she's been keeping.

Thanks again .

BTW - maestra, I had Earl as an instructor for 10 weeks of class. He was a WONDERFUL teacher, who I'd jump at the chance to learn from again.

The hip replacements certainly could be the cause of her pain!

I am frequently amused to find that "lower back" is code for "butt" in my older clients. They just can NOT say, "My butt hurts", so just keep saying, "lower, go lower" when I am trying to locate the site of pain. :

 

[Salerio]

LOL - that's EXACTLY what happened!

I think by the second appointment today she finally felt comfortable enough with me to point to where it hurts, instead of saying it was "really low" across her back. Once I got into her glutes she completely stopped talking and settled right in .

 

[Akash]

BTW - maestra, I had Earl as an instructor for 10 weeks of class. He was a WONDERFUL teacher, who I'd jump at the chance to learn from again.

Me too JaeMarie, me too!

 

[Pompal 09.]

I am frequently amused to find that "lower back" is code for "butt" in my older clients. They just can NOT say, "My butt hurts", so just keep saying, "lower, go lower" when I am trying to locate the site of pain. :

I don't think I have a problem saying my butt hurts (could be deep-seated subconscious something) but if I experience pain in my lower back it's usually more butt-related than I expect. I don't realize how tight my glutes are until someone tries to do compressions on them...whooooee! Oh, and I'm not so old quite yet. (24) : So, my point is, my guess is it's a perception thing rather than a prudish thing

 

[doctor frog]

I am frequently amused to find that "lower back" is code for "butt" in my older clients. They just can NOT say, "My butt hurts", so just keep saying, "lower, go lower" when I am trying to locate the site of pain. :

I don't think I have a problem saying my butt hurts (could be deep-seated subconscious something) but if I experience pain in my lower back it's usually more butt-related than I expect. I don't realize how tight my glutes are until someone tries to do compressions on them...whooooee! Oh, and I'm not so old quite yet. (24) : So, my point is, my guess is it's a perception thing rather than a prudish thing

For some, you are right, I am sure. Others, though - will repeatedly come in and say, "It's my 'low back' again." knowing I know exactly where they want me to work!

One lady, though, came in and said, "I think my butt is out of joint". : I loved it.

 

[emaculentge]

I had an 86 year old client on my table today. I said, "You put your tush here, your shoulders here..."
"My what?"
"Your tush, derriere, gluteus maximus, your butt..."
"Oh, ok, I learned a new word today... how do you spell that?"
"Spell what?"
"The word you first used for butt."
"Tush? T-U-S-H."
"You learn something new every day!"
:biglaugh:

 

[xmenarutofan]

Maestra, that is hilarious!! Thanks for sharing! :

 

[Kate C]

JaeMarie!

I was CSMT class 8! :shock:

My son is Cortiva class116 in their remote location...
I predated Earl, but my son has him regularly, and Bob King was one of my main teachers.

My I respectfully suggest that their version of MFR is alot of what Barnes trained therapists (me, for one) call Soft tissue mobilization. IMO and IME Barnes work is far superior. Enough of that.

Sounds like you did good work with your client. She may just come to love you more than her dog!

Because of my MFR work, I have alot of older clients. I love them dearly, they are compliant they do their homework. Try to find out if her irregular treatment schedule is because of money issues. That is what I usually find with older clients. My greatest joy of my own practice in my own space is that I can charge what I want. Massage therapists, not matter our modality, are sometimes the only people who listen to an older person, and we have the skills to keep them independent!