How Can Massage Treat Patellofemoral Syndrome Knee Pain?

Patellofemoral syndrome is a term used to describe knee pain caused by improper movement, or tracking, of the kneecap over the femur. This condition often results from muscle imbalance in the quadriceps, or thighs. Massage therapy is useful in addressing this muscular imbalance, resulting in decreased pain and increased function of the patellofemoral (knee) joint.

The patellofemoral joint specifically refers to the articulation of the femur and the patella. The patella, or knee cap, is a sesamoid bone and is located within the quadriceps tendon. The patella glides over the boney prominences of the femur, or the femoral condyles, as the quadriceps contract or tighten during extension of the knee.

The quadriceps (aka, quads or thigh muscles) is really a group of four muscles, consisting of the rectus femoris, vastus lateralis, vastus intermedius and vastus medialis. The muscular imbalance which may be one cause of patellofemoral syndrome occurs when the vastus lateralis is stronger than the vastus medialis, and pulls the kneecap to the outside of the thigh during movement. This imbalance is often seen in athletes such as runners, though it is not limited to athletes, and may be caused by posture.

Pain occurs when the quadriceps tendon tightens during movement and pulls the kneecap “off track” – meaning that the underside of the kneecap articulates improperly with the femur. If left untreated, this misalignment can cause inflammation and degeneration of the bony surfaces, eventually leading to arthritic changes.

The treatment

Massage therapy is very useful in reducing the tone and myofascial trigger points of the quadriceps, specifically that of the vastus lateralis. Trigger points in this muscle, which refer pain to the lateral thigh along the iliotibial band area, as well as the lateral knee, may contribute to altered gait. During a massage therapy treatment, the therapist will address the involved and compensating muscle groups, as well as stretching and using hydrotherapy during treatment (heat) and post treatment (ice or cold). The application of cold post treatment will assist in the reduction of inflammation in the patellofemoral joint and surrounding muscle tissue.

Another important aspect of rehabilitation is the strengthening of the vastus medialis, specifically the lower, oblique fibres medial to the patella, known as the vastus medialis oblique (VMO). By strengthening this muscle, the normal position of the patella is regained and it will interact correctly with the femur.

The duration and frequency of the treatment will depend on the presentation of the condition, and how long it has been present.

© Copyright 2010
Jodi Forsythe
www.whymassagetherapy.com
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Low Back Pain and Disc Herniation

The discs located between vertebrae are vulnerable to injury, and can cause debilitating pain when injured.  Disc herniation most commonly affects the lumbar spine, but it can also occur in the cervical spine, and rarely, in the thoracic spine.

What is disc herniation?

Disc herniation is a term that refers to displacement of the nucleus pulposus of the intervertebral disc, due to injury or weakening of the external portion of the disc (annulus fibrosis).  The term “slipped disc” often refers to this type of injury, as does bulging disc.

There are four stages of disc herniation, with various degrees of displacement of the nucleus pulposus. The final stage occurs when the annulus fibrosis is completely ruptured and there is a complete loss of integrity of the external structure.

Pain occurs due to increased pressure on the nerves exiting the spinal cord. Symptoms such as pain, numbness and tingling will occur in the area that is supplied by the affected nerves.

How does disc herniation occur

Disc herniation most often occurs due to injury, sometimes from a seemingly innocent action such as bending over or twisting to pick something up. These actions of sudden flexion or rotation often cause an increase in pressure which forces the nucleus pulposus in a posterior (toward the back) direction.

Signs & Symptoms of Disc Herniation

If you’ve ever had an issue with a disc, it is an unforgettable experience.

1. Sudden, excruciating pain – into the legs and buttocks if the herniation occurs in the lumbar spine; into the arms and hands if the herniation occurs in the cervical spine.
2. Muscle spasm will occur in the injured area – this is the body’s protective mechanism to prevent further injury by immobilizing the area.
3. certain actions will increase pain and symptoms, such as bending forward from the hips, side bending, or twisting. As the action causes the pain, a therapist can tell where the bulge is happening by the pain distribution.

How is disc herniation treated?

Disc herniation is a condition that must be managed in the initial stages, with a focus on removing pressure from the affected nerves and pain control.  As the condition progresses, the focus turns to strengthening the supporting structures – if the herniation has occurred in the lumbar spine, core muscle strengthening will be incorporated into a rehabilitation program.

Massage therapy itself is not a standalone therapy for disc herniation – it can help with pain control and removing some of the excess muscle spasm. It must be noted that removing all of the hypertonicity (excess muscle tone) in the muscles surrounding the injured area is not wise – the excess tone in this case is used to stabilize the area, and if it is completely removed, the area can become very unstable and make the injury worse.

If the injury to the intervertebral disc is severe, the condition can become chronic and progress to degenerative disc disease.

For more information, please see The Anatomy of Low Back Pain.

© Copyright 2009
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The Anatomy of Low Back Pain

Understanding the anatomy of the lumbar spine is key to understanding and managing low back pain.

The lumbar spine, commonly called the “low back”, consists of 5 vertebrae, and is located between the thoracic spine (which articulate with ribs) and the sacrum. The vertebrae themselves are given numbers by which they are identified, for example – Lumbar Vertebra 1 = L1, Lumbar Vertebra 2 = L2 and so on.

The normal lordotic curve of the low back is known as a secondary curve, and starts to develop in infancy due to weight bearing caused by learning to sit up and walk.  The low back is especially vulnerable to injury due to its weight bearing task and mobility.

Between each vertebrae throughout the whole spine (except for C1 and C2) is a intervertebral or fibrous disc. The purpose of the disc is to provide cushioning and shock absorption from weight bearing and movement. The intervertebral disc is comprised of the annulous fibrosis and the gel-like centre called the nucleus pulposus – these structures are work together to provide the shock absorption, and are both implicated in disc dysfunction and neurological symptoms.

Facet joints are the articulating surfaces of bone between vertebrae. These synovial joints are known as “plane” joints because their flat surfaces glide over each other. These joints may become inflamed due to injury to the joint or joint capsule itself, or due to compression of the intervertebral discs, forcing them to interact in a “close-packed” position. This close packed position means that the joint surfaces are forced closer together than normal, and will irritate the bone and cartilage during movement as they contact each other and create friction.

During an acute injury, the inflamed tissue in the joints may irritate the nerve roots as they exit the spinal cord via the intervertebral foramina. Eventually, if facet irritation is untreated, bony spurs may develop due to chronic inflammation and cause spinal stenosis – a decrease in the size of the “vertebral foramen” or spinal canal.

In the case of a “bulging” or herniated disc, pressure is exerted on the nerve root as it leaves the spinal cord via the intervertebral foramina. This pinching or pressure on the nerve root will cause sharp, shooting pain, especially when the patient leans forward (flexes) from the hip.  Symptoms will present in the areas that the compromised nerves supply.

© Copyright 2009
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UN Climate Change Conference – Speak Up and Get Involved!

“The ultimate test of a moral society is the kind of world that it leaves to its children.” Dietrich Bonhoeffer

From December 7 to 18^th, 2009, world leaders will be meeting at the United Nations Climate Change Conference in Copenhagen to ratify the Kyoto Protocol – an agreement of 37 industrialized countries that is based on the United Nations Framework Convention on Climate Change.  The Protocol was agreed upon in 1997 in Kyoto, Japan, and entered into effect in February, 2005.

The goal of the Protocol is, in a nutshell, to hold industrialized nations accountable for reducing carbon emissions and introducing environmentally sustainable industrial practices.

In researching Canada’s contribution (or lack thereof) to the Protocol’s compliance, I was dismayed to see on the website Climate Justice (under the auspices of Friends of the Earth) that as of October 31, 2006,

“The Kyoto Protocol Compliance Committee and the Canadian Environment Minister have today been informed that Canada is violating the Kyoto Protocol and the UN Framework Convention on Climate Change (UNFCCC), thus legally requiring action under the Canadian Environmental Protection Act (CEPA) to control greenhouse gas (GHG) emissions.

According to last month’s report by the Canadian Commissioner of the Environment and Sustainable Development, the gap between Canada’s GHG emissions and its Kyoto commitments is growing: Canada’s GHG emissions in 2004 were 26.6% above 1990 levels, resulting in a gap of 34.6% from Canada’s Kyoto target of a 6% reduction by 2008-2012. Per capita, Canadians are amongst the highest emitters in the world, with the production and consumption of fossil fuels accounting for 80% of these emissions.“

As it is 2009, and the UN Summit is less than 8 weeks away, I would like to think that we have improved in the last 3 years, but somehow I have my doubts.

What I don’t understand is, that in a wealthy and prosperous country that is my home (Canada), we are failing our obligations to meet the carbon reduction targets. Climate change seems to be the elephant in the room – everyone knows it’s an issue, but so few wish to acknowledge it.  The argument I typically hear, unfortunately by some people close to me, is that enforcing the protocol, (to which we are legally bound, by the way) will hurt existing industry.

What is my opinion on this? (you knew it was coming). I say “bullshit“ – existing industry which violates the standards may slow down in the short term and eventually end, but Canada can and should be at the forefront of not only carbon emission reduction, but also the development and implementation of alternative, clean energy sources. After all, if our country built the Space Arm, how hard can it be to develop solar panels, wind energy and the like?  And think of the jobs that can be created in these industries! The economic and environmental potential is endless, and we cannot sit by and complain about how hard things are if we haven’t stepped up to the plate and acted on our own behalf and that of future generations.

I hate to think of myself and my fellow countrymen as complacent, but it appears that if we don’t recognize that we are at the 11^th hour environmentally, there is little hope for future generations. I don’t have children, but I really hate to think of my niece and the children of my friends living in an environmental wasteland that we could have prevented had we not been so lazy and complacent. How pathetic is that? And, for my American readers, don’t get high on yourselves, either. Hopefully now that Obama is in the White House, you’ll get your act together, too.

What I recommend is that you get online and check out the following links:

UN Climate Summit – Backgrounder for Canadians – read this even if you’re not Canadian but would like more information on the topic.

UN Climate Summit -  Countdown to Change
Canadians – get involved, and send a message to our Prime Minister and Leaders of the Opposition – make your voice heard NOW.

United Nations Climate Change Conference – December 7 to 18^th, 2009

For general environmental information, check out the David Suzuki Foundation website – David Suzuki is a true environmental hero.

If you don’t want to do this for yourselves, the polar bears or the planet, please do it for future generations.  Our generation might not be around to benefit in 100 years or so, but we will be remembered as the generation who had the courage to step up, make difficult choices and make a change in the face of adversity.  Wouldn’t that be a great legacy to leave?

© Copyright 2009
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Warm Hydrotherapy for Chronic Injury Pain

The use of warm hydrotherapy, also known in therapeutic massage as deep moist heat, is an excellent way to control and alleviate the pain and achiness associated with chronic injuries.

Most of us have experienced at one point or another the nagging achiness that comes with a chronic injury. Deep, moist heat is an excellent way to help control this pain as a part of homecare, and is also used pre-massage treatment to prepare and warm up the tissues.

Often when an injury has been long-standing, previously damaged muscle fibres have been replaced with tough collagen fibres, aka scar tissue, which reinforce and strengthen a muscle that has been damaged. Collagen fibres do not have the blood vessels that muscle has, and this avascular quality means that decreased blood flow in this tissue interrupts or decrease cell metabolism, oxygen delivery and metabolic waste removal. While scar tissue development is a normal part of the healing process, when collagen fibres are laid down, the muscle becomes more inelastic – unable to elongate and then return to its original length. This affects not only the comfort of the client, but also the power and strength of the affected muscle.

The goals, therefore of deep moist heat in the form of a hydrocollator or thermaphore are:

-         to warm up an area by increasing blood flow
-         increase the delivery of oxygen and nutrients to muscle cells, and speeding up metabolic processes. This decreases pain and achiness.
-         the heat itself will decrease the viscosity of the “ground substance” in muscle tissue, allowing the massage therapist to break down any scar tissue and realign the affected muscle fibres with those of the surrounding tissue

Contraindications for using heat:

-         uncontrolled high blood pressure
-         diabetes or any conditions with neuropathies or altered sensation – the client won’t be able to tell if the application is too hot, and tissue could be damaged
-         any condition where tissue is fragile or circulation has been compromised (i.e. immediately after a cast is removed) – the circulation may be too impaired for extreme heat, so mild applications can be used until the condition of the tissue improves
-         tissue is broken (i.e. a cut, or skin condition such as psoriasis – the tissue is likely already inflamed – heat will make it worse,  and infection can be introduced)
-         metal implants – pins, plates, rods, wire – these will heat up quickly and can really injure a client
-         heat sources should NEVER be placed over major arteries or over the heart

How to use heat properly

You may have never heard of a thermaphore or a hydrocollator, but if you have used a gel pack or grain-filled bag you can heat in the microwave, these same principles apply:

-        heat should only be left on for 20 minutes maximum – any longer and the tissue can get very congested and be even more painful.  You can take it off and use it on another area, or reapply after an hour or so.
-         For hygiene and to prevent burns, the heat source should always be wrapped in a clean towel. For a gel pack (I boil mine on the stove in a cooking pot), I wrap a clean, damp dishcloth around it when it is hot, then a thicker cloth over top. I get the benefit of the moisture that way.
-         it is a good idea to do any stretching that needs to be done after a heat application – you muscles will be much more pliable and stretch more easily.
- use caution if you have taken any analgesics (pain killers), your perception of heat and pain may be off and you could get burned.
-         NEVER lie on a heat source – in the case of a gel pack, hydrocollator or grain-filled bag, it could burst from your weight and you could get seriously burned.

The use of heat in this manner is a great way to control pain from a chronic injury, as well as prepare the muscles in the area for stretching.

© Copyright 2009
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Massage therapists – Stop Complaining and Participate in Your Associations.

To really affect change in the massage therapy industry, therapists must stop being so complacent and exercise their democratic rights as association members. Much the same as voting for the leadership in your country, if you don’t make yourself heard by attending industry meetings, you don’t have the right to complain.

Yesterday I went to the SAGM of the Massage Therapists’ Association of Nova Scotia (MTANS). I admit I hadn’t been for a while, since the last one I went to 3 years ago was poorly run, unorganized, and really turned out to be a fiasco. All in all, it was very frustrating and unproductive. However, a lot has changed since that time, and since there are winds of change brewing in our profession, I felt the need to get involved again.

The most unfortunate thing about yesterday’s meeting, other than the whole insurance fraud issue wasn’t on the agenda, was that there weren’t even enough members present to reach quorum. This is really disappointing, as many of us, including and especially Board and committee members, had taken time out of our weekends and away from our families to be present and vote on critical issues in our profession. As it turned out, it was a great social occasion, but it looks like we’ll have to attend another meeting on yet another Sunday.

As I left the meeting with one of my friends and colleagues, she made a really great point – some of the people we know who didn’t attend are always the ones to criticize the association. It happens every year, and while these same people spend lots of energy complaining and criticizing the association board, they can’t be bothered to show up at meetings or sign the proxy forms.

Hmmm … it reminds me of politics, because in reality, it is. One look at world history has demonstrated that a vote can change the course of history, for better or for worse. One vote could make the difference to your association, your industry and your future. So, the next time I hear a complaint about policy XYZ, let’s just hope you were at the meeting, because if you weren’t, I don’t want to hear it. You have lost the right to complain.

© Copyright 2009
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Cryotherapy, Acute Injury and Pain Control

Cryotherapy is also known as “cold hydrotherapy” and can take the form of ice, frozen gel packs (or a bag of peas) or submersion into cold water. It is most beneficial when an acute injury occurs, and will assist in pain control and reduce swelling and bruising.

Disclaimer:  If you are unsure if or how you should use a cold application, please consult with a medical professional who can take into consideration your personal health history.

We have all felt the pain of sprains, strains or bruises, but did you know that most massage therapists are trained in hydrotherapy applications? These applications enhance the effects of treatment and can be used by clients at home. It is important, though, to know how to use cold applications properly.

Inflammation is known as a “non-specific” response to injury, and is a physiological process which begins immediately after injury.  Inflammation serves the purpose of isolating and immobilizing the injured area. When an injury occurs, whether it is a sprain, strain, contusion etc, a cascade of events is set in motion:

• vasoconstriction (contraction of the blood vessels) occurs immediately, followed shortly by vasodilation (expansion of the blood vessels).  Vasodilation results from the release of chemicals such as histamine, increasing the size and permeability of capillaries and arterioles

• This increase in size and permeability increases blood flow to area (resulting in warmth and redness) and the leaking of fluid (exudate) from capillaries (resulting in swelling and pain)

• with increased blood flow, white blood cells migrate to area – the presence of white blood cells will inhibit infection

• At this point, further loss of blood and fluid is prevented due to clotting by proteins

Even though inflammation does serve a purpose, it can be very painful. This is where cold hydrotherapy applications come in handy, as they help control pain and bruising of injured tissue.

How does the application of cryotherapy affect an injury?

When cold is applied, the sensation which is felt is Cold, then Burning, Aching and Numb. (CBAN) The general rule when applying cold to an acute injury is to leave the application on until the area is numb, or for 10 minutes, whichever comes first.  This duration of application, which is considered to be a “long” duration, will have the following effects on tissue:

• slowdown metabolism of the affected cells, meaning less oxygen is required for cellular process

• cold will constrict the blood vessels and decrease blood flow, thereby reducing hematoma and contusion formati

• the exudate (fluid) formation will be reduced at the site; less fluid puts less pressure on the pain receptors – therefore, it is less pain

• This effect will last up to 20 minutes after the application has been removed

• pain decreases for 2 reasons:   waste products (cellular debris) is being absorbed and cold has a numbing effect on the nerves (pain receptors or nociceptors)

Cold hydrotherapy applications during this phase of injury may also decrease the amount of scar tissue formed, as the migration of fibroblasts to the injury site is reduced.

Why is there a time limit on how long I can leave a cold application on?

The time limit which is placed on a cold application is there to maintain the health of the tissue. If cold is left on an area for too long (12-15 minutes or longer), Hunting Response is activated to prevent tissue damage from prolonged cold.

Hunting Response is a cycle of vasoconstriction (decreased blood flow), then vasodilation (increased blood flow), and will occur if cold is left on for too long, or when tissue is cooled excessively. The increased blood flow occurs for 2 reasons:

1) to prevent damage to tissue that is peripheral to the injury site and

2) to help remove waste products,such as histamine, which occur in response to the injury and to the cold.

Hunting Response is essential to tissue health as it maintains the cellular metabolism at a rate which assists in healing the injury and surrounding tissue, and ensures that blood, supplying oxygen and nutrients, is delivered in adequate amounts to the cells.

If Hunting Response is allowed to occur from a prolonged application of cold, it can be painful as blood is forced into the area via a process known as “active derivation”.

How do I use a frozen gel-pack on my injury?

Gel packs are just one of several cryotherapy applications, and are a convenient way to address an acute injury.  Here are some tips, precautions and contraindications for using cryotherapy:

1. Any application is contraindicated over an open wound, as it may introduce infection to the area.
2. Cold applications should be left until after your massage therapy treatment, and can be used between visits.
3. Cold should never be applied “proximal” to an injury. (proximal is an anatomical term which refers to how close an area on a limb is to the trunk of the body. For example. the elbow is proximal to the hand.)  Circulation is diverted away from the application site, and blood may pool in the already injured area.
4. Cold is contraindicated if you have had a previous poor reaction to cold, have nerve damage, poor circulation (such as in diabetes or Raynaud’s Disease), fragile skin, plates, pins or wires.
5. Your gel pack should always be wrapped in a damp cloth or towel, and not applied directly to the skin. (you can damage your skin this way)
6. The gel pack can be used in cycles of 10-10-10 – 10 minutes on, 10 off, 10 on again.  Then, give your body a rest and leave it off for up to an hour, then repeat.
7. You should never lie on your gel pack.

For further information on hydrotherapy, the book I used as a reference for this article is An Introduction to Heat and Cold as Therapy by Laurel Fowlie (paperback 2006)

© Copyright 2009
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Massage Therapists – Prevent Insurance Fraud

In my previous article “Massage Therapy and Insurance Fraud”, I discussed at length the situations in which a massage therapist may find him or herself in a case of fraudulent billing.

It’s important to remember that direct billing of an insurance company is a privilege that our profession has worked very hard to achieve. Fraudulent billing not only detracts from the integrity of the massage therapy profession, it also calls into question your integrity as a therapist and person. Your insurance billing identification should be treated like your passport, driver’s license and social security/insurance number, and protected at all times.

Assuming that you yourself aren’t committing insurance fraud, I have some suggestions which may help you avoid this slippery legal and professional slope, and protect your license while working in a business.

1) If you are a contractor, you have the right to establish your cancellation/no-show policy and conduct your business as you see fit (within reason). Ask the clinic and co-worker what their policies are concerning missed appointments and non-compliance. If their policies seem reasonable, then it is to your advantage to be consistent with the business in which you work.

If you are an employee, unfortunately you are pretty much stuck with following the guidelines of your employer.

2) If front-office staff is responsible for booking the appointments on your behalf, ask them if clients are advised when booking appointments of the no-show and cancellation policies. No? This makes it a little more awkward, but I would suggest – if the front office staff will not, or forgets, to mention the policy – creating a waiver which is part of the health history intake. This waiver should state your policies, and you should not only ensure it has been read and signed, you may also want to verbalize this to your clients before treatment.

3) Do you do your own billing? If not, whether or not you have signed a waiver permitting front-office staff to bill for you, you need to keep a close eye on your account.

If the business in which you work has asked you to sign a waiver permitting them to bill on your behalf, you may want to provide your own addendum which states that you do not give permission to bill on your behalf for i) treatments which didn’t occur or not provided by you ii) last minute cancellations or no-shows, iii) treatments other than the accepted massage therapy treatment modalities. (consult your professional association or college to find out which modalities are grouped under massage therapy in your jurisdiction). You may also want to include that the liability lies with the management for any of the above situations. Don’t forget to get the clinic or spa manager to sign the addendum to the waiver.

(realistically, I doubt that many clinic or spa managers will do this, but it’s worth a try. Remember that your billing number is your responsibility, and if no such agreement exists, you will likely take the heat if the insurance fraud allegation comes up)

4) Every week or so, compare your insurance account with the list of treatments you have provided. If you notice that there are charges for treatments that never occurred or you didn’t provide, I recommend that you bring it to the attention of the clinic/business owner, and front office staff in writing. Give everyone the benefit of the doubt, and assume that this was an error. Advise the clinic that you will have to notify the insurance company to reimburse them – note, however, that if you haven’t received the money, you expect the clinic/business to reimburse the insurance. A refusal on their part to do this is not a good sign of their honesty. If this is the case, send them another letter and …

5) Mail yourself a copy for good measure (and don’t open it, put it in a safe place. The postmark can be used to verify dates should the law ever become involved). Use registered mail to send the clinic the letter and print the receipt of when the clinic received it.

6) In the case of 4 & 5, you may need to find another place to practice, so get moving on that – after all, all signs would indicate that perhaps that the business where you work is involved in fraud, or is, at the very least, unethical. Do you really want your name and professional reputation associated with that? I didn’t think so.

Keeping these above points in mind will help you maintain your professional integrity and raise the transparency of the profession. Only by doing so will the massage therapy profession position itself as a health care industry deserving of insurance billing privileges.

© Copyright 2009
www.whymassagetherapy.com
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Massage Therapy and Insurance Fraud

An unfortunate trend seems to be rearing its ugly head in the massage therapy profession in Nova Scotia, Canada. Could fraudulent billing by businesses and massage therapists be the beginning of the end of insurance coverage for massage therapy services?

In most areas of North America, and Canada in particular, the massage therapy profession has long been promoting itself as a viable and legitimate health care modality. For several years massage therapists belonging to professional colleges and associations in Canada have been privileged to have our services covered by private and motor vehicle insurance, allowing us to build our practices upon an expanding base of savvy health care consumers.

In the recent months, however, it has come to the our attention as a profession that BlueCross insurance is rightfully investigating allegations of insurance fraud, and has gone so far to revoke direct billing rights of some businesses found to process fraudulent claims. BlueCross has also gone so far as to re-establish the direct billing Terms of Use agreement by massage therapists – but the general fear is that if this privilege continues to be abused it will eventually be revoked, leaving many of us out in the cold with a client base who will no longer be able to afford, or be willing to pay for, our services.

What is insurance fraud?

For our purposes, a simple definition of insurance fraud (please see my source FraudEducation.com) would be “criminal act requiring a material and intentional misrepresentation in order to obtain a benefit.”

This intentional misrepresentation regarding massage therapy services could possibly encompass:

1) Billing an insurance company for a therapeutic massage treatment that never happened (for example, a therapist or clinic bills insurance for a missed appointment)

As I have mentioned in my previous article Massage Therapy and Preventing Missed Appointment by Clients , I prefer to let one missed appointment go without penalty to the client, but in the event that it happens a second time, you need to be prepared to stand strong in case your client refuses to pay. Under no circumstance should the therapist allow these missed appointments to go by without bringing it to the client’s attention. Clients must understand that a therapist or clinic is unable to “just bill insurance” and you will not commit insurance fraud to let them off the hook. If a client won’t pay the fee, then it is better to discharge the patient from your care and document the events leading up to the dismissal.

In the case of a patient undergoing treatment in a motor vehicle insurance claim, it is necessary to document not only subjective and objective findings, but their compliance to your treatment plan and home care. If you find that a client is always late, misses appointments and doesn’t do suggested home care, you can discharge a patient for “non-compliance”. Clients should be informed up front that being discharged for non-compliance will not work in their favour, and that any further requests for treatment will not likely be granted, as the insurance company will not take the request seriously. After all, if a client is unable or unwilling to follow a previous treatment plan, then he or she is unlikely to be compliant in the future.

2) Performing treatments which are excessive and unnecessary.

There is a difference between what we think is necessary and what is considered excessive treatment – this is difficult, as a massage therapist working on MVA clients may identify a need for more treatments than the insurance tables deem appropriate. However, very few people need treatment more than a couple of times a week, unless you have specialized in a therapy such as Manual Lymph Drainage (aka MLD or Lymphatic Drainage), which is most effective initially in several treatments in a shorter time frame. I would have to say that if you can’t document objective findings which demonstrate an improvement in your client’s condition, or you can’t propose a reasonable treatment plan, you will probably find that your client will get limited treatments approved by insurance.

As massage therapists are not considered primary health care providers, our clinical impression is often trumped by a diagnosis of physician, chiropractor or physiotherapist. There’s not a lot we can do about that, but the reality is that in the past there have been therapists who have treated insurance coverage like a cash cow, instead of a tool to help their clients get needed treatment. (Not only is this fraudulent, but it is also unethical on the part of the therapist.).This quite rightfully has led insurance companies to view the profession with a bit of trepidation and suspicion, which is why a primary health care provider’s opinion will be taken over a massage therapist’s.

3) Billing an insurance company for a “massage therapy treatment” but performing another service (for example, a body treatment, such as a mud wrap. This has been alleged to be happening in Nova Scotia in spa settings.)

4) Using the billing number of a registered or licensed massage therapist by another party to perform services.

In the case of billing spa or esthetic treatments as “massage therapy”, or an unqualified practitioner using a therapists billing number, this is absolutely inexcusable. This practice has resulted in several spas being investigated. To my knowledge, there is at least one spa in Halifax that has had BlueCross direct billing privileges revoked, with several more under investigation.

Unfortunately for some of the therapists involved, this fraudulent billing has happened without their knowledge, and while I know this may seem little suspect, I really believe that a lot of therapists have been put in a no-win situation. In most spas and some clinics, therapists do not have access to the system which allows them to process the charges, so they sign a waiver allowing the business to do this admin work on their behalf. If a greedy business owner wants his or her cut of the action, they may instruct admin staff to bill a mud wrap or pedicure as massage therapy. If a client is aware that this is happening, then the client is every bit at fault as the therapist. I would also like to point out that a therapist signing a waiver does not imply that they are in agreement with fraudulent billing practices, and many are not offered a choice of refusing to sign.

Does Fraudulent Billing = Professional Misconduct?

Any one of the above mentioned situations is not only considered fraudulent, but may also be considered professional misconduct by a professional college or association. Part of required client records according to the CMTO is a financial record – this includes not only the date and time of the treatment, but also of the treating therapist, duration, the fee, and how it was paid. Any falsification of client records is considered professional misconduct.

If a therapist’s billing number is fraudulently used, should the therapist have to reimburse the insurance company? Or should it be the spa or business’s responsibility? Who is culpable of fraud?

I have discussed this at length with several friends and colleagues of mine. While I do agree that it is a therapist’s responsibility to oversee his or her account with the insurance company, I do not necessarily agree that a therapist should be held responsible for reimbursing the insurance company if the spa or clinic fraudulently billed it on his or her behalf and the therapist did not receive the money. This places many therapists in a very difficult situation as they often don’t have access to the company system to review the billing. It will be interesting to see how this all unfolds and if it results in criminal charges of fraud for spas and businesses, and professional misconduct of therapists.

For further reading, please go to the post “Massage Therapists – Prevent Insurance Fraud”.

© Copyright 2009
www.whymassagetherapy.com
All Rights Reserved.

How Often Should I Get a Massage – Frequency Guideline

Following my initial blog post on this subject How Often Should I Get a Massage, here is my treatment frequency guideline, for massage therapists and their clients.

Remember, this is just a very generic guide, and will have to be adapted for individual situations.

Here are my general guidelines for treatment frequency:

Relaxation – once a month for an hour, unless you want to come more often.

Acute injury – more frequent treatments of shorter duration should help – for example, 2 times a week for 30 – 45 minutes. This should help relieve pain and congestion in the area, then after a few weeks, switch to deeper, muscular work for longer periods of time. At this point your injury may have moved into a subacute or chronic stage of healing, depending on the severity of the injury, 1-2 times a week for an hour, over a period of 3-4 weeks should get you on the road to recovery.

Treatment for chronic conditions (i.e. headaches or back pain) – one hour twice a week for 4 treatments, then try once a week for 3 or 4 weeks, and try to decrease to 1x in 14 days for 2 treatments. You will then go into maintenance mode. Once again, very individual, and the longer the condition has been an issue for the client, the more treatments will usually be needed to make consistent gains.

Some more general guidelines:

Follow remedial exercise and homecare advice – passive treatments such as massage therapy can only take you so far, it is YOUR responsibility to be proactive in your own health care. This means follow exercise, stress management, nutrition and lifestyle advice. Record what you do and how you feel, try to make a correlation between various factors. If you have a team of health care providers who are willing to work together, use them!

Don’t go too long between treatments! Progress made during a treatment is building on the progress made in a prior treatment. This means that if I’ve treated a client for chronic back pain for a month and we’re seeing some results, if he stretches out the length of time between appointments to 8 weeks instead of my recommended 2 – 4 weeks, it may be like starting all over again. What a waste of money for the client!

Remember, though, that if you start to feel consistently better (and consistent is key), you have the right to say “I’d like to stretch out the time between treatments a few more days, can we try that?” Your therapist can only give you advice and guidance, you have to figure things out what works for your situation.

If the treatment is not helping – find another therapist! Sometimes people feel awkward about ditching their therapist, especially if you have a good relationship with him or her. BUT, it’s your time and money, and you should see results. Sometimes massage therapy is not the be-all-end-all of treatments, I personally find a combination of therapies to be the most effective.

Knowing your rights as a client will prevent you from getting expensive, unnecessary or ineffective treatments, and will enable you to receive treatment that suits your needs.

© Copyright 2009
www.whymassagetherapy.com
All Rights Reserved.

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