Thoracic Outlet Syndrome Types, Causes and Symptoms

What is thoracic outlet syndrome, what causes it, and what are the symptoms?

Thoracic Outlet Syndrome, also known as TOS, is a compression of the brachial plexus and subclavian artery and vein. The brachial plexus supplies the upper limb with both sensory and motor nerve fibres, and the subclavian artery supplies the blood supply. There are four areas where the plexus and artery may be compressed and in each instance, the symptoms will present differently.

The part of the brachial plexus most likely to be affected is the medial cord, which orginates from nerve roots C8 to T1.

Symptoms of Thoracic Outlet Syndrome:

Due to involvement of the medial cord of the brachial plexus, the ulnar nerve is most impacted by this compression syndrome. Muscles affected will be the Flexor Carpi Ulnaris, the ulnar aspect of the Flexor Digitorum Profundus, as well as most intrinsic (small) muscles of the hand. As a result, there will be some weakness or altered sensation on the ulnar aspect of the forearm, the hand and little finger. Signs and symptoms will vary, however, depending on the location of the compression and the structure involved.

Compression of a nerve will result in pain, loss of sensation and in chronic cases, muscle wasting or weakness. (this is known as denervation atrophy) Compression of blood vessels (subclavian or axillary arteries, depending on site of compression), will result in pain, paleness of the skin supplied by the artery, possible cyanosis (blue coloring) and decreased skin temperature. Prolonged decrease of blood supply can result in trophic skin changes, emboli (blood clots) and gangrene. Compression of a vein will result in edema, and the blood is unable to be carried back to the heart and lungs.

There are 4 main areas where compression may occur

1) The anterior and middle scalene, a.k.a. the interscalene triangle. The brachial plexus and subclavian artery pass through here, but it is the medial cord of the plexus, arising from the C8-T1 nerve roots, which is most likely to be affected. (*note: the scalenes are classified as secondary muscles of respiration because they attach to the ribs and contract during respiration)

2) Pectoralis minor – compression will occur between the pectoralis minor and its insertion on the coracoid process of the scapula. A person who presents with hyperkyphosis (rounded, slumped shoulders) may be more inclined to have compression here, especially when the muscle is stretched (for example, when they straighten up). The pectoralis minor, by attaching on ribs 1-8, may be affected by any respiratory disorder, leading to hypertonicity of the muscle and subsequent compression of the subclavian artery as it becomes the axillary artery when it passes deep to the clavicle.

3) Costoclavicular – compression occurs between the 1st rib and the clavicle. This is most likely to be a result of injury to the clavicle, such as a break or dislocation, and is prone to affect the vasculature (as the axillary vein becomes the subclavian vein)

4) Presence of a cervical rib - the presence of an extra rib is determined by an x-ray, and it interferes with the size of the interscalene triangle, therefore allowing less room for the plexus and vasculature.

The borders of the thoracic outlet are:

posteriorly (the back) the body of vertebrae T1 laterally the 1st rib bilaterally
anteriorly – manubrium of the sternum

Structures passing through the Thoracic Outlet
The brachial plexus, subclavian arteries and veins.The muscles involved in this syndrome are the anterior and middle scalenes, pectoralis minor and the subclavius.

Who is at risk for Thoracic Outlet Syndrome?

Thoracic Outlet Sydrome usually affects people whose posture tends to be very forward and slumping. Think of a person who sits at a desk all day, or who does a lot of work moving forward (or a massage therapist!). Others at risk may also have “military posture”, extreme retraction of the shoulders which pulls the pectorialis minor tight over the plexus and artery, thus compressing it. Also at risk are people who have had a broken or dislocated clavicle, especially those with a more complicated or compounded break. Due to the attachment of the scalenes and pectoralis minor on the ribs, people who have a respiratory disorder and difficulty breathing often recruit these muscles, thus increasing the incidence of hypertonicity, and the presence of myofascial trigger points.

Thoracic Outlet Syndrome or Raynaud’s Disease?

The therapist, during the course of performing orthopedic tests for TOS, will look for a positive test of a decreased or absent pulse, as well as numbness and tingling or fatigue in the ulnar distribution of the forearm and hand. Raynaud’s Disease presents similarly, but is a peripheral vascular disorder which occurs due to vasospasm and results in decreased circulation. For Raynaud’s disease to be diagnosed, it must be followed closely by a physician for 2 years and manifest as decreased circulation and increased sensitivity of the arms and hands.

How can massage therapy be used to treat Thoracic Outlet Syndrome?

Massage therapy can provide valuable assistance to someone suffering from TOS, either as a stand-alone treatment, or in conjunction with other modalities (i.e. physiotherapy or chiropractic).
Wherever the location of compression, the therapist will attempt to decrease hypertonicity and myofascial trigger points of the involved muscles as well as stretching. Manual lymph drainage can assist in the reduction of fluid build up post treatment. It will also be necessary to retrain the client concerning proper posture.After the treatment plan concludes, it would be wise to encourage the client to continue stretching, and also to schedule maintenance appointments to prevent a relapse.

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

Massage Therapy Client Obligations and Responsibilities

Massage therapy is unique in that it is a profession with one foot in health care and another in the service industry. This bridging of worlds brings a certain set of responsibilities to not only massage therapists, but also to their clients.

In keeping with my previous postings concerning the therapeutic relationship, I have decided to enlighten massage therapy clients as to what constitutes behaviours which massage therapists appreciate and those which we don’t. A little give, take and understanding of what massage professionals go through on a daily basis might help you establish a better relationship with your therapist, putting you on the top of the pile for preferred days and times, as well as getting “squeezed in” on short notice.

Here are the top things you can do to establish a great relationship with your therapist:

1) Show up on time. Massage therapists really appreciate a client who arrives on time and ready for treatment. It helps our day go smoothly, ensuring we don’t get behind. It also demonstrates to us that you respect our time and profession, which we really appreciate.

2) If you are late, expect that you will pay the full fee even if your therapist can only treat you for the remaining time. And, some therapists will not treat clients at all who are more than 15 minutes late for the appointment.

3) Please call 24 hours in advance if you have to cancel. We understand that life happens, and if you don’t give 24 hours notice and this is an isolated incident, it’s not usually too big of a deal. However, do expect the cancellation policy to be enforced, and if you fail to pay the balance owing, you may be “discharged” from your therapists care.

4) Know your insurance policy, if you have one, before the treatment. There are many different plans which may or may not cover massage therapy treatments, sometimes even within one organization, such as the government. It is your responsibility, not ours, to know how much coverage you have, if a medical referral is required, if direct billing is allowed etc. A therapist, even if he or she does permit direct billing, has the right to ask for payment up front if you are not sure of what is covered or don’t have the appropriate information. A therapist may also only direct bill for certain insurance companies. While most therapists do their best to accommodate clients (within reason), It is our prerogative to decide how to run our business.

I advise calling your insurer well before your appointment and asking them things such as 1. to what association does my therapist need to belong for me to get reimbursed, 2. do I need a medical referral to get my treatments covered, 3. how much coverage do I have and how much will I get reimbursed per treatment, 4. is direct billing permitted, or do I have to pay up front and submit my receipts? If you do need to get a medical referral, do so before your treatment, as massage therapists and doctors cannot “fudge” treatment or referral dates so your treatment is reimbursed.

5) Comply with the treatment plan and recommendations, especially if you are going in for a specific reason, such as an injury. While massage therapists are not permitted to diagnose, and are only permitted to form a “clinical impression“, we usually have great suggestions for treatment plans and exercises to ensure the best possible outcome. Remember that as great as massage therapy is, it is a passive therapy and only part of the health management equation. If you suffer from tight hamstring muscles, but don’t do the recommended stretching between your bi-weekly appointments, then there is only so much your therapist can do to help.

In the case of a client who is receiving insurance coverage for a motor vehicle accident, he or she has to realize that massage therapists are obligated to report to the insurer if the client is “non-compliant” with treatment and home care recommendations. I have seen many people discharged for “non-compliance”, and I have discharged patients myself for this reason. In a rehabilitative setting it is our job to attain certain treatment goals which may not be reached if the client doesn’t hold up his or her end of the bargain. By discharging a patient, I am preventing insurance fraud and freeing up my time so someone else can benefit from treatment.

6) This may hit a nerve with some people, but I’m going to say it anyway – client hygiene is really important. I am not talking about someone who had a shower in the morning and goes to see their therapist after work needing to worry about hygiene. I’m talking about someone for whom hygiene is generally an issue. After all, if a therapist is obligated to maintain a certain level of hygiene to treat clients, the therapist should be able to expect that clients show up presenting a certain level of hygiene. Think about it like this, would you want to be in a small room in close proximity to, and touching, someone who hadn’t had a shower for a few days? I didn’t think so.

And a side note: refrain from using cologne or perfume or tons of hair and body products. It’s really hard to work in a closed spaced with someone who smells like they tried every perfume in the local drugstore. No scent is the best scent, and this ensures that your therapist doesn’t get a migraine or has a flare up of allergies.

7) This is a business, and for most of us, our livelihood. A lot of massage therapists have a hard time reconciling the business aspect of the profession with the “caring” and healing aspect of the profession. But, make no mistake, this is how we pay our mortgages and buy our groceries, not to mention everything else that we need to live.

Someone (I can’t remember who, but I thought she was brilliant) stated in a cartoon “the caring is free, but the service is ($80.00) per hour”. We may choose to do pro-bono work, or may offer reduced fees to long-time clients if there is sufficient reason, but these cases are exceptions that are made of our own volition. I have had potential clients argue and tell me how much I should be charging – the key word being “potential”, I refused to book them. I also won’t negotiate “deals” with people or give them bargains just to get them to be my client – this is devaluing my own professional worth and undercutting my colleagues. Kind of like buying groceries, the price is what it is, and payment is due when the transaction happens.

8 ) Be prepared to pay with the massage therapists preferred method of payment. Find out when you are booking your appointment what is accepted, and don’t expect to run a tab.

Massage Therapists also have obligations to their clients – please check out Massage Therapy Client Rights if you are unsure of anything.

Following these simple steps will ensure that you establish a great relationship with your therapist, and that you get the most out of your treatments.

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

A Massage Therapy Career – What to Know or Do Before You Take the Plunge

Some points to consider before you embark on a Massage Therapy career.

Massage therapy is an interesting, rewarding and fun career. It is also growing considerably in North America – according to the United States Bureau of Labor Statistics, the profession is forecast to grow faster than average (20%!) between 2006 and 2016.

If you are interested in a massage therapy career, this is great news. I would suggest, however, that before you embark on a new career path and undertake the commitment necessary to become a massage therapist, you consider what the profession is really all about.

1. My first piece of advice is to get a massage!

It never ceases to amaze me how many people love the idea of becoming a massage therapist, yet have never had a massage treatment from a professional. Getting a either a relaxation or therapeutic massage is a great opportunity to know what it’s like to be a client, as well as to establish a rapport with a professional in the industry. I would advise that you go for a massage therapy treatment in the type of setting where you think you’d like to work …

2. Speak with several massage therapists currently in the industry.

You will find massage therapists in spas, sports facilities and medical clinics. You may also find them working out of their own home, or perhaps the massage therapist you know will have a mobile service, and go house to house visiting clients. Tell them that you are considering a career in Massage Therapy, and as them for the input. Also ask them to be honest, and discuss a “typical day”, as well as the pros and cons of the profession, everything from work environment to pay rates, and how they fit into the organizations in which they work. Once again, because everyone has a different experience of the profession, speak with several people to get a general idea of what life is like as a massage therapist.

3. Experience different types of massage

From relaxation and therapeutic massage to different modalities under the “massage therapy umbrella”, you have several excellent options, try as many as you can before you make your final decision on whether or not to pursue a massage therapy career. After your basic education is done, it is good to know that you have options where you can specialize as your experience grows.

4. Ask your new massage therapist friends where they went to school, and what their experience was like.

As professional therapists, they will be able to guide you where to go for the education you will require, as well as discuss the licensing requirements for the state or province where you want to practice and live. The massage therapy school you attend is your foundation and will set the stage for years to come, so choose wisely.

5. Don’t let the romance of massage therapy as a healing art mislead you!

To be successful in Massage Therapy, it must be treated like a business, albeit a caring one. You will have bills to pay, so don’t be misled by thinking that the money you charge per treatment is money that goes directly into your pocket. Once again, talk to massage therapists to get a reality check on the business aspect of the profession, it could save you a lot of heartache.

For more information on the realities of the profession, check out the main site, under Massage Therapy Careers. Taking the time to learn about the massage therapy profession before you commit your time, money and energy is effort well spent.

© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.

Massage Therapy and Informed Verbal Consent

What is Informed (Verbal) Consent, and why is it necessary for a massage therapy assessment or treatment?

Ignorance is NOT bliss in the massage therapy profession.

I remember my first few weeks of massage therapy school – making new friends, touching people I didn’t know, and the overwhelming amount of information involved, not the least of which was trying to wrap my head around informed verbal consent.(also known as informed consent) I was more “fortunate” than most of my peers, because I had actually had an awful first experience with massage therapy which, as a student and later a therapist, instilled in me the need to advise my clients of what to expect during treatment.

I swear that the massage therapist who treated me for my very first treatment could have been the poster child for what NOT to do to a new client. He didn’t tell me what to expect, he used pressure so deep I wanted to cry, and he talked about how much he hated his ex girlfriend. Wow, did I ever feel vulnerable, and had I known I could discontinue the treatment I would have. With a first experience like that it’s amazing that I ever went to another massage therapist, let alone became one.

So basically, the definition of informed (verbal) consent is: obtaining client agreement to the impending treatment based on full disclosure by the therapist as to what the client should expect before, during and after the treatment. The client consents on the treatment with full knowledge of what’s going on.

Why is Informed Verbal Consent so important?

There are a few purposes to obtaining informed verbal consent, not the least of which is that the client has a right to know what is going to happen – this is not rocket science. Would you buy a car or a house without knowing the specifications? Probably not. And certainly where a client’s health is concerned, he or she must be presented with sufficient information to make an informed decision concerning the treatment, and then give you permission to do it. Informed consent is about empowering the client through knowledge and trust. This knowledge and empowerment protects the best interests of the client. After all, it shouldn’t take too much imagination to remember how it feels to be lying in a very vulnerable position, mostly undressed, in a closed off room with just you and a complete stranger.

Informed consent helps establish trust between the therapist and the client – which is the foundation of a productive therapeutic relationship. When you say to expect XYZ and the client receives XYZ, then he or she knows you are a person of your word. If a client feels pain during treatment, and you stop whatever you’re doing when you are asked, the client understands that you are there to look out for her best interest.

Informed verbal consent protects the therapist, too. When therapists take the time to advise a client on the various points of informed consent, he or she is ensuring that whatever happens will not alarm, scare or cause undue pain to a client. A therapist should document that he or she received permission to continue with the treatment for each treatment – a simple IVC next to the treatment date should suffice. And therapists should remember that any time any new area or body part is worked on, or different treatment modality is used, consent must be obtained from the client.

What should be included in basic Informed Verbal Consent?

1) The nature of the treatment – tell the client what body parts you’ll be working on, as well as how much pressure you’ll be using. I like to explain to my clients how the will be undraped (uncovered) and that the only part of the body that will be uncovered is the part that I am working on.

I also tell clients to undress to their comfort levels, though it is more effective if I work directly on the skin. If my new client looks unsure, I usually tell him he can leave their underwear on, and I will leave the room so he can undress and get on the table in privacy. I also make sure before I do leave the room that my client doesn’t need any assistance with either.

2) The benefits of treatment – If your client comes in for a relaxation treatment, then a benefit should be that she will be more relaxed and may sleep better. If a person comes in specifically for treatment of an injury, then the benefit of treatment should be the same as the treatment goals – i.e. decreased pain, increased mobility etc.

3) What are the risks and side effects of the treatment? A risk is generally more long term in nature, whereas a side effect is more immediate. For example, a side effect is that a client may be a little “woozy” when he or she gets off of the table, but a risk of a more vigourous treatment is that your client may be a little sore the next day.

4) Advise your client of alternatives to treatment. This is described in the context of massage therapy – for example, if a client presents with scar tissue, you can advise your client that you will be performing Frictions (aka friction massage therapy). In the event that this is too much for your client to tolerate, you should advise that an alternative is to do petrissage and deep kneading to the area.

5) What are the consequences of not having treatment? If a client doesn’t have treatment, then he or she can expect to NOT achieve the goals and aims of treatment and not improve. So, if a client presents with limited range of motion of the right shoulder, and opts out of treatment designed to increase the ROM, then a consequence of not getting the treatment would be no improvement of shoulder range of motion.

6) The client ALWAYS has the right to stop or modify the treatment. Period.

Sometimes clients look a little confused when I say this, so I tell them “if anything makes you uncomfortable in any way, please let me know and I’ll stop what I’m doing. If you feel that you have had enough of the treatment, then we can finish.”

7) Ask the client if she understands what you have told her AND if she has any questions. This presents her with the opportunity to speak up if she is unsure about anything.

8 ) Ask the client if you have her permission to proceed with the treatment as you have described it. This might seem obvious, but you don’t ever want to get caught on a technicality. This gives her the ability to “Yes” or “No” the treatment, enabling you to carry on with confidence.

This is basic informed consent that every therapist should use when treating a new client.

For those candidates preparing for the College of Massage Therapists’ of Ontario (CMTO) certification exams (i.e. the MCQ and OSCE exam), informed consent is a little more involved. (OSCE = Objectively Structured Clinical Evaluation).

Though informed verbal consent (aka informed consent) may seem tedious, once you establish your own way of doing it, it should become second nature to you. And remember, it serves both you and your clients, and builds the therapeutic relationship on a foundation of trust.

© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.

Massage Therapy Client Rights

Question: At my first massage therapy appointment, I asked the therapist some questions concerning the treatment. I found her to be evasive, and a little impatient with me. As a client, don’t I have right to know what is going to happen?

Yes, you certainly do. Here is a list of some of the rights you have as a massage therapy client.

1) Get some advice on how to find a licensed massage therapist – you have the right to know what qualifications your therapist holds. Ask where he or she went to school, to what professional association or college he or she belongs, and if they have any additional training. And remember, don’t discount a therapist just because he or she has recently graduated – there are some really fantastic new therapists who begin their careers every year.

2) You have the right to be informed about what to expect during and after a treatment. This is known as Informed Verbal Consent and is a set of statements designed to make the client aware of expectations concerning the treatment, as well as his or her rights as a client. Informed verbal consent goes above and beyond some typical quesitons, such as “do I have to take off all of my clothes” or “is it normal for the treatment to hurt?”. For any Canadian massage therapist who practices in compliance with the CMTO standards, informed verbal consent is mandatory before assessment or treatment begins and provides the client an opportunity to ask questions.

I have been disappointed to hear from clients who, when they’ve seen me for the first time, tell me that no
massage therapist has ever gone over informed consent with them. I cannot speak for students educated in the US, but Canadian massage therapists should really know better. We are obligated to advise clients what is going to happen. Period.

3) You have the right to receive treatment in a safe and hygienic setting. This is everything from the entryway of the clinic, to the bathroom and waiting facilities, and most certainly extends to the linens, towels etc that come into direct contact with the client. Linens should only be used with one client, and anything that comes into contact with the client’s skin needs to be washed after each use.

Equipment should also be safe, clean and in good repair, and there should be nothing on the floor on which a client could trip or lose footing. If the linen looks dirty, the equipment is wobbly or obviously broken or the
clinic is obviously unhygienic, you have every right to turn around and leave. (and I suggest you do)

4) You have the right to receive treatment from a massage therapist who is clean and hygienic herself. If there appears to be “hygiene” issues, you have the right to voice your concern and leave, you are not obligated to receive a treatment from someone who makes you uncomfortable or is unclean. I can pretty much guarantee that if a therapist doesn’t pay attention to his or her personal hygiene, that the linen and equipment will be lacking in this department as well.

5) You have the right to refuse treatment from a therapist who is ill. Your therapist should advise you in advance (preferably) or when you arrive if he or she isn’t feeling well or has a cold, and should not charge you if you decide to postpone treatment until he or she is feeling better.

6) You have the right to stop or modify the treatment at any time. If you are in a lot of pain, or for ANY reason you are uncomfortable, you do have the right to tell the therapist you want to stop. The therapist should respect your request and allow you to get off of the table and get dressed in privacy.

A massage therapists needs to receive informed verbal consent from you if he or she is going to be working in a “sensitive area” – for example, breast massage is not typically performed unless it is clinically indicated by your presentation or health history. Either way, it is always your choice whether or not to receive or refuse treatment.

If you feel that any inappropriate touching or remarks have been made, whether of a sexual nature or not, you have the right to report the therapist to his or her professional association. Please do so, as therapists who violate massage therapy professional standards and a position of trust do not deserve to call themselves massage therapists. In addition, therapists who engage in sexual misconduct commit a crime for which there should be repercussions.

7) You have the right to be advised of the massage treatment fees when you book your appointment. You also have the right to not be subjected to “upselling” or pressure sales tactics. The College of Massage Therapists of Ontario, and any provincial massage therapy association who follows their guidelines, require therapists and clinics to post their fees in a visible space for all clients to see. Anyone who doesn’t do this is in violation of the policy.

8 ) You have the right to know what products are being used on you. If you have a health issue such as an allergy, or an objection (for example) to products tested on animals, you need to ask this when you are booking your appointment. Remember, though, that a therapist also has the right to know of any issues in advance so he or she can be honest with you, whether or not he can accommodate your request.

9) You have the right to receive your treatment on time. Occasionally a therapist may run a little behind, for example, if the previous client was late; however, if this is habitual, then it shows an issue with your therapist’s time management. While the duration of the appointment will probably be reduced if YOU are late, if your therapist is late, you should receive your full treatment.

If the therapist is so late as to keep you from other commitments, you have the right to leave without incurring a charge. After all, you were ready at the agreed upon time.

The above points are some of your rights, but do realize that a therapeutic relationship between a massage therapist and client is based on mutual respect. If for any reason you don’t feel the situation is working out for you, please consider finding a therapist with whom you have a “good fit”.

© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.

Massage Therapy and Preventing Missed Appointments by Clients

A Massage Therapist’s point on view on preventing and dealing with clients who miss appointments.

It happens to the best of us. Our day is booked solid, and we are all set to go full throttle. At some point during the day, a client doesn’t show, doesn’t even call to say that he or she is going to miss the appointment. Then another one misses an appointment. What is going on here? Our day is ruined by missed appointments and the no show client, and instead of being productive, we are stuck reading the newspaper when we’d either rather be treating, or at the mall/beach/movies. You feel disrespected, and yes, possibly, a little abused.

Let me just start by saying that most of our clients don’t miss appointments on purpose, usually it is a case of life getting busy and they have forgotten about it. I have been on both sides of that fence, and I have some strategies that can help prevent and deal successfully with the dreaded “no show” or “dns” (meaning did not show).

1) To begin with, I suggest that you create and post a cancellation policy and use a standard script when booking a new client. If you use a receptionist instead of booking your own clients, I suggest that you make friends with him or her and encourage them to use it when booking for you. When booking a new client, I ALWAYS advise them of the cancellation policy – you can say something like this:

“Your appointment time is reserved just for you, and if you should need to cancel, I do require 24 hours notice. In the event that you fail to provide the required notice, there is a charge of (i.e. 50%) of the fee. And in the event that you arrive late for the appointment, you will be charged the full fee, even if I am not able to treat you for the full duration of the time you’ve booked.”

This way there are no surprises – your script will become like second nature to you, and it is better to be up
front about your expectations – this way the client can’t come back and say that he or she didn’t know.

2) How you approach this is also going to depend on the situation in which you work. If you are a contractor, then you should have complete control over your clients and how you interact with them, establishing your own policies (within reason, of course). If you are an employee, then the control you have over how you handle these sorts of things may be limited by the policy of your employer – and this may or may not work to your advantage.

The College of Massage Therapists’ of Ontario (CMTO) requires that massage therapists post treatment fees in their place of practice where they can be easily seen by incoming clients. I think this is a really great idea, as there will be no surprises and the expectations will be clear. Also, it is a great opportunity to post your cancellation policy along with your fees, though I did have one clinic owner who had a problem with this (apparently it was “aggressive and tacky”) – I did notice, however, that my clients were very clear and accepting of the policy, and as I was in compliance with CMTO standards, it didn’t really matter what this individual’s opinion was. Ultimately, I had to answer to the professional college first.

Under your posted fees, you can indicate your cancellation and late arrival policy – it can be something like:

Your appointment time is reserved just for you. I respectfully request 24 hours notice to cancel an appointment, or full payment will be required. Full payment is also required if you are late for your appointment, or fail to show for your scheduled booking. Thank-you for respecting my time.

3) You don’t have to be so rigid with this policy as to drive away clients. Find your balance between fairness (towards all of your clients) and firmness (you are running a business, and when you treat it like a business, clients will see it as a business). Without telling clients this, I usually give them one missed appointments grace. This is only fair, as sometimes life just happens – children (or the client) get sick, things are busy at work and it slips their mind, the car breaks down, they get stuck in traffic… you know what I mean. It did work for me, and here is how I let them know that the next time the policy would be enforced …

4) When you call your client to let them know they missed their appointment, you should make it as non-confrontational as possible, their reason for missing the appointment may really be very innocent and legitimate. You can say something like “I am calling to make sure you are OK, you had an appointment booked with me at 3:00 and you didn’t show. Can you just give me a call to let me know all is well, and then we can rebook you?” Usually they will call and be very apologetic, if they’re not, when you document the missed appointment in their file (and when you called them, if you left a message, what was said, etc), you need to note this as well.

When you do speak with him or her, what you can say is “I’m glad you’re OK, and I will waive the missed
appointment fee, as it is the first time this has happened. If you should miss any more appointments, you will be charged the missed appointment fee. When would you like to rebook?” They are usually happy with this, and have gotten the message loud and clear about the expectation the next time they miss an appointment.

5) Your policy enforcement will also depend on the relationship you have established with your client. Is the
client relatively new? Or has your client been loyal to you for a while? A loyal client who has a family member who is ill or has a special needs child, for example, may not show due to a family emergency. If you have already established a good relationship with this client and you know you are not being taken advantage of, then I would let an occasional missed appointment go.

6) The reminder call can work wonders, even though it is a little time consuming. For your own sanity, you may want to get into the habit of doing this the day before the appointment – it can go a long way in preventing a no show, and give you time to book someone else if your client can’t make it.

Another issue which is directly related to massage therapy is fraudulent billing for missed appointments, if you haven’t encountered it, you should read about it, it will be an issue at some point.

These are just some pointers in how to deal with no-show clients, please stay tuned for my upcoming post on Massage Therapy and How to End the Therapeutic Relationship, for those clients with whom you “just can’t seem to make it work.”

© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.

Massage Students – How to Prepare for the NCBTMB Exam

You’ve come so far within the last year, and done everything right – you’ve picked the best massage therapy school for your needs, gone to class (I hope), studied hard and are getting ready to graduate. Congratulations, well done. But now there is one more thing you need to do, and your next big question to yourself is how to prepare for the NCBTMB exam in your state.

Wow, trust me, I know how you feel. It doesn’t matter how hard you’ve worked or studied, you always wonder if you’ve done enough to get you over this last hurdle so you can start your new profession in massage therapy. Well, my friends, there are strategies and tools you can use to help you prepare for the NCBTMB exam. Here’s a list of pointers, some resources and some advice that is realistic (and will hopefully help you lessen some of the stress that comes with this challenge)

1) It doesn’t matter how much you have prepared, it will always feel like it’s not enough.

This is an unfortunate truth in whatever you do. You may find yourself thinking “Maybe I shouldn’t have gone to the movie with my friends last Sunday afternoon” or “maybe I shouldn’t have gone home to visit my grandparents/Aunt Jo/Cousin Felix last weekend”. What I can tell you is this – life is short, and I think it’s better to spend time with people you love – it helps you connect with what is important in life. After all, isn’t that why you chose a profession like Massage Therapy?

2) If you’re still in school, ask the administration if a graduate who recently completed the NCBTMB exam can come in and speak to your class about his or her experience. This is a reasonable request, and most massage therapy colleges love to show off their success stories. If someone does come to speak to your class, don’t be shy, ask questions. Most graduates are more than happy to help out newbies.

3) Start early – let’s say a few months before your exam – and set a schedule.

You may have already done this if your final exams for school are coming up, and that’s great. Depending on the time frame, you need to set a realistic schedule and STICK TO IT. This will allow you some fun time, and it will also allow you some flexibility for unforeseen interruptions. Personally, I like tons of freedom within structure, so setting a schedule keeps me from being overwhelmed while allowing me to make tangible progress and have fun. (I’m all about the fun)

4) Make sure you have the right resources

Mosby’s has a great selection of books which, if you didn’t use them in school, will be a great resource in preparing for your NCBTMB exam and when you start working. Also, there are sample NCETMB, NCETM & MBLEx Practice Exams available which are a great investment, try them out. (Unfortunately, when I did the CMTO exams in Ontario, I didn’t have a tool like this, but it would have been really nice)

5) Study the hard or difficult stuff first.

Trust me on this one. The sooner you get to the tough stuff, the sooner you can identify any issues and address them (darn that Kreb’s cycle). Studying the easy stuff will be a reward, so break it up. If you are studying for 6 hours during the day, spend a couple of hours on the more difficult stuff, then “reward” yourself with subjects you enjoy. And then …

6) Get together with a study group and test each other…

Hopefully you will have found a study group or buddy who is supportive, structured and serious. (Note – it may not be a good idea to study with your friends, you may tend to socialize instead of studying). Get the sample questions for the NCBTMB to help you with this process. Realistically, if you haven’t understood something before, then hearing or seeing the question in a different way may be enough for the lightbulb to go on – trust me, 9 years after writing my exams, this still happens. And, one more thing, the best way to learn a subject is to teach it, so time spent helping someone else is never wasted.

7) Try to find a study partner whose strong points are your weak points.

My study partner in massage therapy school was really good at anatomy – he could memorize muscle origins and insertions like no one I’ve seen. My strength was physiology – I prefer to learn processes. He used to challenge me constantly, and while it was annoying at times, it really did help me remember.

8 ) Surround yourself with positive, proactive friends and study partners.

As a former instructor, there were always a few students who constantly (and I mean they were relentless) found fault with everything, and when they didn’t do well, it was ALWAYS someone else’s fault. I like to call this “swimming against the current”, and these folks wasted time and energy fighting the system when they should have been focusing on learning and taking advantage of instructor knowledge and availability. (side note: my aunt, who has her PhD and has been a teacher for years, calls this type of person a “crazy maker” – they are never happy unless they are stirring up crap, then they like to sit back and watch everyone else freak out. Don’t fall for it, please)

Incredible, really, but you have to choose how you want to live your life, and surround yourself with people who can get you there. So, get rid of the dead weight and the ‘crazy makers’ early on, you’re not responsible for anyone other than yourself. Make the choice to be with people who elevate you (mentally, spiritually and intellectually), not drag you down with them. Harsh, maybe, but so what? These “friends” won’t be paying your student loans, so you need to align yourself with people who have similar goals – which is to pass those exams and get working.

9) Take frequent breaks, completely get away from the books, and move your body. Adequate rest and sleep are really important as well.

My schedule used to go like this – study for 45 minutes, take a 15 minute break, repeat 2 times (that’s 3 hours) – then take an hour or two and step away from the books. Get outside, play with your dog, throw a baseball, get to the gym, do some yoga/pilates/weight training. It doesn’t matter. Reconnect with your body, it really does help.

10) Don’t o.d. on junk food – you will crash and burn mentally and physically.

Remember, junk in = junk out. You need to help your mind retain all of this information by giving your body good fuel – fruit, vegetables, protein, and yes, some fat. Get rid of the deep fried or packaged, sugary processed foods, and the soft drinks.

11) Sign up early so you can have your choice of exam times – you will know by this point when you are able to deliver peak performance, so schedule accordingly.

12) If you have to travel to take your exam, allow yourself time to get there in a stress free state. Stay someplace, or have access to, quiet so you can review before your exam, and where you can sleep well.

13) This is the hardest thing to do, but the night before your exam, don’t study.

Really. Take a break, go to a movie, go for a walk, have a nice dinner and a good sleep. Remember that alcohol can inhibit your sleep, and may make you “wonky” the next day, so you may want to forgo that beer or martini. Feel free to do whatever you want afterwards as a reward.

Best of luck on your exams, and welcome to our profession!

Massage Therapy – treatment option for back pain funded by the NHS?

I recently read an article on the BBC website which states that the National Institute for Health and Clinical Excellence (or NICE) in Britain suggests massage therapy as one treatment option for back pain sufferers. In addition, NICE also suggests that the NHS (National Health Service) fund certain alternative therapies to allow patient access.

In addition to massage therapy, acupuncture and exercise are also suggested as possible interventions for back pain. This is huge for practitioners of complementary and alternative therapies as well as back pain sufferers, that an organization as large as the NICE is, for the first time in its history, is openly advocating such types of interventions.

According to the article, one in 3 Brits suffer from back pain (no surprise there) – a condition where the cause can be very elusive, and which can quickly become debilitating if not treated successfully. For more information on the recommendations, check out the original article on BBC Health News.

This is the first of several posts dealing with back pain causes, symptoms and massage therapy as an intervention. In the meantime, check out the following informational video on managing back pain.

Massage Therapy – is the customer always right? (Part 2)

As a follow up to my post a few days ago – “Massage Therapy – Health Profession or Customer Service? “, I’m pretty sure that you know where I’m going with this.

At the forefront of my thoughts when talking about massage therapists and customer service (as in “is the customer always right?”) is that ultimately because the health and well-being of our clients is our responsibility during treatment, it supersedes the customer service aspect of the profession.

That being said, for the most part therapists will very seldom encounter situations where they have to pull out their “health professional first” hat and decline a customer request. Ultimately, if what you do as a massage therapist during treatment presents a risk of harm to the client, then you need to stick to your decision if you decide to refuse or alter a treatment. Cases where this might happen:

1) Your client refuses to fill out a health history form.

This is pretty basic – I won’t treat a client if I don’t know what is going on with his or her health. End of story. The client may say “my health is fine”, but really, what does fine mean? “Fine” is different between members of the general public and health professionals, and most people, as previously discussed, don’t have the knowledge to have any kind of discernment when it comes to therapeutic techniques. Can you imagine getting a severe diabetic client who wants scar tissue work done, or a client with a history of TIA (transient ischemic attack) or stroke who wants to “work the kinks out” of his or her neck. These are two conditions which require precaution when treating, and for which certain techniques are contraindicated.

How to approach this? Tell your client that there are often conditions which require a treatment to be modified, or that treatment may even be unsuitable. You as a therapist are unable to plan and deliver the best treatment possible without this health information. You can also remind them that the health history is fully confidential and their information will not be disclosed. If they are really sticky, you can quite simply say that you are not willing to be liable for any injury caused because you weren’t informed, and that you will not treat them. (

*Any time you have this type of conversation with a client, you need to keep an incident report of it, even if you didn’t end up treating them. This will cover all of your bases in the event that the client feels like accusing you of being unprofessional. (Personally, I haven’t ever heard of this, but it’s better to be safe than sorry))

2) Your (new) client is adamant about getting “really deep pressure”.

This is actually quite common, and I have had to finesse my way around this several times. John (or Jane) Doe may say “My therapist uses really deep pressure, it’s the only thing that works for me.” and you start treating and suddenly your client finds your moderate pressure too much. Why is this? It’s because everything is relative and subjective – what is deep to one person is too light for another, or too much. What feels good to one client may be excruciatingly painful to another. Your colleague’s pressure might be considered deep, but relative to whom? This is a situation where being creative and flexible really comes in handy.

The fact of the matter is that it is always better to use the first appointment as a trial run, so to speak. I’m not saying to just put oil or gel on your client and spread it around so that he or she gets no benefit – that would just be annoying and I can pretty much guarantee they wouldn’t rebook. What I’m suggesting is that you use moderate pressure (I love that word) and check in frequently – and don’t forget to advise your client that he or she may feel a bit sore the next day (informed verbal consent should have done even before getting them on the table anyway).

How to approach this? You can say to your client “Since I haven’t seen you before, I’m not sure how you are going to react to the treatment, or my pressure. What I usually do is use moderate but firm pressure during the first appointment, and then if you react well to the treatment, I’ll use more pressure next time. This is to prevent you from getting really sore in case I use too much pressure – you might not realize this until it’s too late, and you could be sore for days.” This is usually sufficient, but if the client argues further, I will say that I rarely have complaints about my pressure being too light, or my clients being too sore (but this my experience, you’ll have to figure out your own explanation )

3) Your client shows up with a bad cough, fever or chills

Many clients will show up when they are getting ill with acute bronchitis or flu-like symptoms because “everything hurts” and they think that a massage will make them feel better. At this point you should ask them if you can call a cab for them and rebook when they are feeling better. Don’t take “no” for an answer. Seriously.

It’s not just that treating someone with an acute or systemic infection will be really bad for them (after all, they body is already trying to fight off a virus or bacteria – increasing circulation won’t help them at this point) – you are also putting yourself, other clients and your clinic at risk of infection. Remember the SARS epidemic (Sudden Acute Respiratory Syndrome) in Ontario, Canada in 2003? It was absolute chaos for a while, and massage therapists all over Ontario received guidelines from the CMTO concerning protocol in preventing the spread of infection. The last thing you need is to be remembered as the therapist or clinic that was an incubator for infection – even if it wasn’t your fault.

What I would suggest that you say to a client in these or similar events is something like this “Since you are not feeling well, I believe that it is in your best interest to go home and rest until you get better, the massage won’t help you and may make you worse. Let your body deal with the infection, and then call me in a week or so to rebook.

The bottom line is this, a client will 99% of the time appreciate that you are making his or her health as a priority. If a client cannot see reason in your commitment to her health or well-being, then you may risk losing her business. But, in my experience, I would rather have 20 clients who respected my knowledge and professional judgement than 40 who did not.

For more information on building and maintaining a practice, check out a fantastic, tried and true resource – Business Mastery: A Guide for Creating a Fulfilling, Thriving Business and Keeping it Successful

© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.

Massage Therapy, One Million Acts of Green and Father’s Day

A lot of stuff to cover today, a bit of a mish-mash, but here it goes …

I recently jumped on the One Million Acts of Green website, and actually recorded my acts of green – I am so amazed that some very simple things that I do daily can have such a large, cumulative effect on the planet. And what is even more amazing to me is that my conversion has been all very painless and very simple. Who would have thought?

I have thought a lot about massage therapy practice and the environmental impact since my post on Earth Day, and I have always been conscious of how human activity affects the environment and our health. I realize that some people feel that whatever they do won’t make a difference anyway, so why bother? Or, some people think that the environmental impact of our activities is blown out of proportion, and they continue to do as they please with little regard for future generations. But, I am happy to report that bringing even very simple things to the attention of others can be a catalyst for positive, sustainable change. Small changes really do add up, and I am living proof, as my carbon footprint has been reduced by over 280,000 kg/year.

I really do encourage as many people as possible to get on the above website and see not only what they are doing that has made a positive impact, but also what can be done to help out the environment. Check out Green Nexxus – One Million Acts of Green to learn more about what you can do, every day, to help mitigate the impact of human activity on the planet.

And, on a lighter note, since Father’s Day is fast approaching, why don’t you go green when thinking of the men in your life? I don’t know many men who pass up gadgets, so why not make a “gadgety” gift as eco-friendly as possible? I’m talking hemp wallets, solar barbeques – you know he wants it! (or maybe you want it? It’s all good) The products at Exclusively Green are environmentally friendly and sustainable, how great is that?

So, massage therapists and clients, give Dad a green gift, and check out what you can do at the same time to lighten the load on the planet.

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