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Breathing and Neck Pain

Have been seeing a few clients lately with neck pain with trigger points present in their scalenes muscles. These muscles are side of the neck (more towards the front than the back) and they are used to tilt the neck and also stabilise the ribs when breathing.

Typically this arises when the person is what is known as paradoxically breathing or thoracic breathing when we should be diaphramatically breathing.

Some people can diaphragmatically breathe in one position but not in another. For example, many of us fail when we are sitting typing on a computer. Yet, We should be able to breathe correctly whether standing, sitting or lying.

One technique that is often used to train our breathing patterns is to put your right hand on your chest and left hand on your stomach. With your eyes closed then breathe in through the nose to a count of around 4 and then exhale via the mouth. This exhalation is also performed to the count of four. Whilst this exhalation is taking place then the abdomen should be returning to the original position.

This exercise should be practiced for around 60 seconds at any one time and should be repeat during the day whilst standing, sitting and lying down.

A demonstration of breathing exercises is shown in the video below.

  

Free Massages – How Not to Give Them

When you are a student massage therapist then providing a free massage for Sydney family members and friends is considered part of the training. In return for you giving them a massage then you get the chance to practice strokes and techniques that you may have learnt in class. In addition, you can solicit feedback from the recipient of the free massage.

It is a win-win situation.

However, once you have qualified and start working as a massage therapist then this synergistic situation changes. You are confident of your skills and how your bodywork is received by clients and client feedback is less important for you.

If you have been working hard at a clinic, doing mobile massage or at a spa then the last thing you want to be doing when you get home is to give away a freebie.

free massage in SydneyUnfortunately from the therapists point of view though friends and family don’t necessarily see it this way and many therapists are frequently asked to give them a few minutes of time to massage their stiff neck or sore shoulder.

A question that is often posed is how can I, as a therapist, politely decline to work on them?

On a recent Facebook posting, therapists gave suggestions on how to deal with this issue. The most common response was along the lines of handing the person your business card and asking them to call to make a booking.

Here of some of the other answers.

I say in a funny sarcastic yet friendly way, “I have all my free massages when I was in school for two years. I have to pay off my student loans before giving anymore free massages.”

I’m just honest. I tell them that I don’t have the stamina on my days off and they always understand. If I can tell someone is just trying to get a freebie, I tell them they can have a business card. They laugh and say, “Smart answer”.

Tell them you’ll trade if they work on you first

When family and friends come crying to me about what is hurting on them (hinting about wanting me to work on them) I always reply by telling them what is hurting on me. They usually get the hint

It seems that people think that because we are MT’s, that we never hurt. Typically don’t like it when I say… Yeah, my neck and back are killing me too!

Sometimes if my friends say “Oh, my back hurts so badly!” I answer with, “I’m sorry, I wish I knew someone who could help”

Make an appointment, today’s my day off.

“Sure! I’ll trade you. I can always use a massage! 5 minutes for 5 minutes?” “Uhh.. uhh… uhh… “

  
But probably my favourite is

If you know someone who is a mechanic, and says “My back hurts, can you help me?” answer: My car needs brakes, can you help me later tonight?
If you know someone who does daycare and they ask for free massage, ask them in turn to babysit your kids for free when they get off work.
You get the point. If they wouldn’t work for free, why should you?

By Richard Lane

Massage Client Behaviour
– What Bugs Us

Although massage therapists always try to give the best experience they can to all clients, they are only human. Some client behaviour can impact on the mood and general psyche of the therapist and you may be surprised at some of the things that may annoy your therapist. Most of these apply whether you are visiting a massage clinic or having a Sydney mobile massage.

Recently an online massage discussion talked about client behaviour that winds up therapists.

Open Eyes
Lying on your back with your eyes open is kind of freaky for us. It gives the impression that you are not relaxing and/or enjoying the massage. Some therapists commented that they were a little unnerved and felt like they were being watched.

“Helping Us”
When we move a particular part of your body such as a limb or leg, then we like to have the muscles relaxed and loose. If you are helping us by holding your arm or your head up then muscles will be contracting which we don’t want contracted.
However, some people can be too loose. To quote from one therapist:

what I refer to as “bobble heads”, there is a difference between relaxing your neck for me to work on it and letting it go completely limp so every time I touch it, you just bobble around.

Try to relax and switch off. Let the therapist do the work – that’s what your paying them for.

massage behaviourCutting it fine
Some people will arrive right on the designated appointment time (or a few minutes late) but then trundle off to the loo and spend 5-10 minutes there whilst the therapist paces up and down waiting for them. Massage therapy is a business so time is money and many therapists operate a tight schedule and cannot afford to run behind time.

However, there is one thing worse than going to the loo when you should be on the massage table and that is
….not going to the loo.

Some therapists describe situations when the client left it too late before using the bathroom……….

Not talking to us
If you are lying on the massage table and not enjoying aspects of the massage then talk to us and let us know. If you want more or less pressure, if you don’t particularly enjoy a stroke or technique, if the room is too warm or cold, if the music is bugging you then please tell us. Whilst some things may be outside of our control, we will endeavour to change what we can so that your massage can be as enjoyable and effective as possible for you.

Talking to us
This can vary from therapist to therapist but some therapists find it distracting if you are constantly talking. It can give the impression that you are not relaxing and not overly enjoying the bodywork.
However, it may be the case that you use your time on the table to wind down and you do this by talking and unloading.
If you want to talk and your therapist doesn’t then maybe it might be time for you to find a therapist who is more open to chatting and conversation during the massage.

Unreasonable expectations
A common theme amongst the discussion was that sometimes clients have unrealistic expectations about what we can do within the one session. If you expect me to release your calf muscles, increase your hamstring flexibility, cure your tennis elbow, address that nagging pain in your lower back, free up your shoulders, loosen a tight neck and get rid of the thumping headache you are suffering from, in one 60 minute session then, sorry, but you will be disappointed.
I’ll do what I can but if you require remedial or medical massages, I can generally only work on a couple of areas effectively with one hour.

Not letting us know what is happening with your health
If anything has happened with your health since we saw you last, please let us know. To quote from one response:

Another time an elderly lady said, while on the table and after saying, “no, no changes this week”, “oh yeah, I had a small stroke the other day”. Yeah…….the MT about had a small stroke…..

  
Other (irritating) behaviours described included:

  • Leaving phones on and talking during a session.
    Cracking knuckles during an entire session.
    Playing games on a phone.
  • ==========

    Please be aware that these are personal comments from individual therapists and ultimately you are the paying customer. However, it might be worthwhile to have an appreciation of the massage from the therapists point of view.

    Want Great Massage
    – Then Speak Up!

    If you regularly experience massage then you know the type of touch you like. Some people like point pressure, some people like flowing strokes. Some people like strong pressure (which they may refer to as deep tissue massage), others like a more gentle nurturing approach. Some people like different techniques and pressures for different muscle groups. Some people like different massages at different times depending on their mood and how their body is feeling on a particular day. Some people like a full body massage including massage to the glutes, abdomen and pecs, others prefer the session to concentrate on specific problem areas such as the neck, shoulders or back for example.

    massageNow whilst many massage therapists may consider that they have a degree of intuition and may modify a particular session based on what they are feeling both physically and intuitively, unfortunately none of us are mind readers. We are only guessing how the massage feels for you.

    To optimise the benefit you receive from your massage then there is an onus on you to communicate your requirements and preferences.

    If there are techniques, strokes and styles that you particularly enjoy (or particularly dislike) then let your therapist know before the session. If there are parts of your body that you want included in the massage then please communicate that to your therapist (similarly if you don’t want particular areas included).

       
    For me personally, I dislike being jabbed or prodded with point pressure with a sudden motion. It does nothing for me (and to be honest I cannot understand how it is supposed to improve the function of the soft tissue). But it is up to me to tell is to the therapist.

    Once the session begins again if there is anything that is bugging you with the way the therapist is working, don’t just lie there but speak up. Tell your therapist that you want more or less pressure. Let them know that you would prefer more gliding/stretching strokes rather than acupressure style or whatever the case may be.

    Although you may not wish to talk too much during your treatment, just a couple of comments to direct the therapist will go a long way to providing you with the bodywork you are after.

    By Richard Lane

    Subscapularis Massage

    I recently posed an online question to other therapists about what muscles they believe do not receive sufficient attention from bodyworkers. My suggestions was the SCM (sternocleidomastoid) muscle at the front of the neck. Other suggestions included the gluteal muscles, the pecs and abs which didn’t surprise me too much. However, a few therapists included the subscapularis muscle in their lists which I have to admit, is not a muscle I would normally spend a great deal of time on.

    Their comments inspired me to have a look at subscapularis, what it does and why it may be important for some shoulder conditions.

    Now the subscapularis muscle is part of the rotator cuff group, along with the teres minor, infraspinatus and supraspinatus muscles. These muscles work together to stabilise the humerus in the glenoid fossa of the shoulder. From a massage therapists terminology it attaches to the anterior surface of the scapula at the subscapular fossa and the lesser tubercle of the humerus. It’s action is to internally rotating and adducting the humerus (along with it’s stabilisation role).

    Pain and dysfunction in the subscapularis muscle often manifests as an inability to lift the arm above the shoulder (although it should be mentioned that not being able to lift the arm above the shoulder does not necessarily indicate that there is an injury to the muscle as there are other conditions which have the same impact on lack of shoulder mobility). It is often the case that someone who spends a lot of time in front of a computer may very well have some dysfunction of the subscapularis, such as trigger points (this applies to anyone who works with their arms out in front of them including massage therapists!).

    Pain that is due to dysfunction of the subscapularis can manifest in a number of different ways, it can be sharp and located in the shoulder, deeper or at the top of the shoulder. It can refer down the arm. There can be impingement of the brachial nerve which can lead to numblike sensations or tingling down the arm. The pain can gradually appear over time or, in the case of an acute incident, it can happen at an instant (throwing or pitching a ball is commonly cited as a major contributer to subscapularis injuries). Subscapularis therapy is often indicated when a client is recovering from frozen shoulder.

    Massage for the Subscapularis
    Access to the subscapularis is limited particularly when a client is lying prone and most therapists prefer to do their subscapularis bodywork with the client either supine or in a side-lying position. Examples of supine and sidelying subscapularis massages are shown in the videos below.

    Supine Massage

    Sidelying Massage

    Dr Ben Benjamin advocates using friction treatments to address subscapularis tendon injuries and claims that it can be a remarkably effective treatment for most muscle, tendon and ligament injuries. Friction massage for the subscapularis can be mildly unpleasant and should be performed from 5 to 15 minutes and is demonstrated on the video below.

      

    Pain Between Shoulders

    Although there are any number of reasons that people call for remedial massage, probably one of the more common is for pain between the shoulder blades. This can be an isolated pain or it can be in conjunction with neck pain and stiffness or headaches. The pain can be persistent and chronic or it can appear acutely after a particular activity or movement.

    Many people will believe that the root cause of the problem lies in the muscles between the shoulders blades, namely the rhomboids. If they book in for a massage then they will expect that the therapist pays particular attention to these muscles and the muscles around the area to reduce the tightness and tension.

    MHowever, often the problem is not associated with tightness in the area but weakness. Tightness in other muscles is causing the muscles such as the rhomboids to become irritated because they are over-stretched not because they are overly tight. A massage therapist that tries to eliminate the tightness by stretching and adding length to the muscles may even be adding to the problem.

    Often postural professionals will refer this condition with terms such as forward head posture or upper cross syndrome. The pain between the shoulders actually results from the complex interaction of the muscles around the shoulder girdle. It comes about from an increase in tightness in the muscles at the front of the neck and upper chest and weakness with the upper back and back of the neck (technically muscles such as the levator scapula, pectoralis major, suboccipitals, SCM and upper trapezius tend to be tight whereas the lower trapezius and rhomboid muscles tend to be weak).

    Typically when you have your posture checked, a therapist would notice that the shoulder blades (the scapulae) are depressed lower than they should be and they are spread apart towards the sides of the body. When the shoulder blades are in this position, the traps and the rhomboids are stretched to their maximum and they struggle to hold the weight of the arms. The force of gravity leads to a constant pulling on the muscles and nerves in the area. The results is pain in and around the neck, between the shoulder blades and even down the arms.

    Postural awareness is the first starting point for reducing the impact of upper crossed syndrome or forward head posture. Left untreated it can lead to degenerative changes in the upper back and result in constant neck pain, back pain and contributes to the formation of the Dowager’s Hump and be implicated in TMJ dysfunction.

      
    Being mindful of when you are performing repeated tasks with you arms extended in front of you (such as typing on computers or driving) is a good starting point. However, restoring the balance between the muscles of the shoulder girdle is of prime importance and this can often be quite a challenge as normal movement patterns may have been compromised by persistant pain.

    Massage can help to address some of the issues associated with these problems, in particular by releasing those muscles that are pulling the shoulders blades forward and down. Your therapist can also suggest stretching exercises for the upper chest and strengthening exercises for the upper back.

    Celebrity Massages

    celebrity massagesA recent ebook has been published which discusses various aspects of the massage industry (often salacious) – Touchy Subjects: Tales from the Massage Table by Steve Capellini. Included in the book is apparently detailed reference to a named celebrity that he massaged (I say apparently as I have not read the book and am only going on what people who have read the book have said). The report is that the story does not paint the celebrity in a good light.

    An online discussion followed about the merits of discussing celebrity clients. There was fairly clear consensus that just because you have massaged someone who is in the public eye, it does not give you the right to discuss this or use the fact that you have massaged so-and-so to promote your business (unless you have their specific permission). Just normal basic privacy considerations should apply, regardless of who you have had on your massage table.

    Yet there are massage businesses and therapists both in Sydney and in other cities who do use the fact that they have massaged identities to give their business a sense of elitism. Whether they do or do not have the individuals permission, I have no idea. They use phrases such as “the rock star massage therapist” or “massage therapists to the stars”. Whether they are trying to use such phrases to attract other ‘stars’ or to attract people who will be impressed by the fact that they have massaged celebs I don’t know.

    The validity of this approach is very much a personal opinion.

      
    Over the years that we have been operating, we have not divulged who we have massaged nor asked for ‘celebrity endorsements’.

    It just doesn’t sit well with us. Most of our clients are ‘real’ people with ‘real’ issues from their everyday ‘real’ work and life.

    Once you are on our table, it doesn’t matter to us who you are, where you live or what you do. All that matters is your body on our massage table and how we can best give you the bodywork experience that you are after.

    By Richard Lane

    You should always Massage Distal to Proximal. Is this yet another Massage Myth?

    Recently there has been significant discussion about the massage myths that are frequently perpetuated by therapists (and sometimes even taught in massage schools). For example, pregnancy massage being contraindicated during the first trimester and massage releasing toxins are myths that are in the process of being eliminated.

    distal to proximal massage
    Massage therapists are always taught that they must massage distal to proximal, from the extremities towards heart. The argument is that the bodywork can increase the back pressure in the veins and potentially damage the vein’s valves through undue pressure.

    Although it may appear to be logical rationale, is there any evidence that massaging proximal to distal does cause damage?

    If you can imagine a fluid filled balloon inside a second fluid balloon and apply a local pressure to the external balloon, then (without claiming to be a scientist), it is hard to imagine that there will be a significant increase in the local pressure of the internal balloon. Isn’t this the situation in say the hamstrings, the calves or the quads? Would applying a distal force in one of these muscle groups really cause an increase in pressure significant enough to cause damage to a valve in a vein, even if the therapist was performing a strong deep tissue massage?

    Please note, I am not advocating that therapists throw out the mantra that you must always work towards the heart. It is always understandable that there should be caution with working distally with anyone who has varicose veins, risk factors for deep vein thrombosis, potentially weaker veins (ie the elderly), during pregnancy, etc. However, let’s say for reasonable fit and healthy clients, is it true that we can really damage their veins?

    I’m struggling to find any evidence that it can and has happened.

    There are those who argue that working in a distal direction can be effective in achieving your massage goals, particularly if you are performing structural bodywork or the like. If you are massaging with correct intentions and are in tune with the requirements of the client’s, then you should work in the directions that will get the best results for the client.

    According to Art Riggs(1) there are significant advantages of working distally:

    • Since most muscles attach proximally in order to exert force proximally, working distally lengthens short muscle fibers and fascia for lasting relief from contraction which limits joint function and causes discomfort.
    • It frees and lengthens nerves that have shortened along with the muscles.
    • It decompresses joints and releases tight ligaments for better osseous function.
    • Possibly the most important benefit is that working distally helps train our clients to override protective holding and reprograms movement patterns as they release in the direction of lengthening and relaxation.

      
    If you have never tried releasing soft tissues by working proximal to distal then maybe it’s time to consider introducing it to your range of massage strokes and techniques. Just be mindful of normal massage contraindications, what you are doing, why you are doing it and who you are doing it on.

    (1) “Distal vs Proximal Work”. Art Riggs. http://www.abmp.com/textonlymags/article.php?article=91

    By Richard Lane

    Can I Massage your Obturator Internus?

    I recently attended a deep tissue massage course in Sydney where I was introduced to the obturator internus muscle. I probably should have known where it is in the body and what it does but, I have to admit, I didn’t. The reason being is that it is in a pretty personal part of the body that I tend to stay away from during professional massage.

    Now the formal description of the location of this muscle is that it “originates on the medial surface of the obturator membrane, the ischium near the membrane, and the rim of the pubis”. In language a little easier to understand it runs from the pelvic floor muscle, under and around sit bone (the ischial tuberosity) and attaches near the femoral head in the hip. It is one of a group of muscles that laterally rotates the hip (and it also assists in the abduction of the thigh).

    Although I can understand that as a hip rotator that it may be important to release the obturator internus if someone is having hip problems, but given that I was not aware of it before the course, I think it is probably less important than other hip rotators such as piriformis.

    On the course we spent over an hour talking about the obturator internus, receiving demonstrations on how to massage it and then practising working on it. All well and good in terms of improving the knowledge and education of the therapists, learning in a safe and supervised session. There seemed to be a real buzz and energy in the class about this one muscle that unnerved me though.

    Although we are only talking about soft tissue bodywork, working in and around this part of the body is fraught with danger. If I went into see a therapist for the first time and they started massaging my obturator internus, I would be concerned that I was in the wrong type of massage establishment.

    It is a highly personal area of the body that, in my view, the vast majority of massage therapists should never consider working. Yes knowledge of the anatomy and physiology is good but this type of bodywork should only be performed by therapists who are recognised as being experts and specialists in working with hip and pelvic floor issues (releasing and relaxing the obturator internus may be indicated with people who have a dysfunctional pelvic floor).

      
    I would probably include massage to the coccyx in the same category – yes there are times when it may be indicated, yes most therapists could probably do effective body work in and around the coccyx. But in my view, probably best that coccyx massage is left to those who consider themselves to be specialists.

    Maybe I picked up the vibe of the class wrong but just seemed that there was going to be a whole group of therapists targeting this previously unheralded muscle on an unsuspecting public.

    Suffice to say though that you can rest assured that I would never be asking you the title question of this post.

    Massage and Cancellation Policies

    Probably the 2nd most popular topic amongst massage therapists on internet forum and discussion sites is the issue of cancellation policies. Go to any forum and there will be countless posts from therapists asking what is the best cancellation policy and what is the best way to enforce it.

    Cancellation policy for massageThe breakdown of responses tends to be split into two:
    (1) I have a strict cancellation policy and I will enforce it without fail.
    (2) I have a cancellation policy but will take each cancellation on a case-by-case basis.

    Most cancellation policies will only come in force either for same-day cancellations or with less than 24 hours notice. Some will charge the full amount, others a proportion of the fee.

    Those who go for option (1) above will often respond by saying that it is essential for the professionalism of the massage industry that therapist stick to their guns and be firm.

    So long as the client is fully aware of this when making a booking then this is a perfectly fair and reasonable approach. We are professionals so why should we lose out if the client has to cancel for whatever reason. If the therapist is working in a clinic or day spa then there is rent to pay. If they are unable to fill the slot then they will be out of pocket for the cancellation or no-show.

    I personally adopt option (2) and prefer to be a little more flexible with cancellation policies. Sometimes circumstances are simply beyond the clients control and as a business decision then it may be better to waive charges. If, for example, someone wakes up in the morning feeling feverish, then effectively forcing them to have a massage otherwise they would be charged a full cancellation fee, could be considered as borderline unprofessional.

    Formally our cancellation policy is:

    We understand that life is unpredictable and personal circumstances can change at short notice. We prefer not to charge a cancellation fee if there is no impact on the time/scheduling of the therapist. However, we are professional therapists and this is how we earn our living. We reserve the right to charge up to 100% of the fee based on the amount of cancellation notice given and the impact on the therapist(s) involved (for example, travel time/ travel costs/other bookings that have been knocked back)

    which is probably too woolly for the strict ‘cancellation policies must be enforced’ brigade.

    For me, the overriding factor is whether the client respects my professionalism if and when they cancel within the timelines of our cancellation policy. Respect that my time is of value and this is how I make my living and I will respect that you are cancelling because you have to not because you want to.

    However, one of the reasons for cancelling at short notice is that you have to stay back at work or you have been called into work unexpectedly. Whilst this is a part of life that may be unavoidable, I do have to say that it is not a reason for us not to charge you.

    Very occasionally a client may say that ‘well you aren’t paying rent so if I cancel then there’s no impact to you’. However, this fails to respect that we have planned our day around seeing them at a given time and we suddenly have a huge hole in our day (appointment time + travel time). Being out on the road it is not always the case that we go to our home base or use the time effectively. Also we may have had to knock back other clients so we have also lost earning potential or had to make personal arrangements to take the booking (ie some therapists need to arrange childcare or the like).

      
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    By the way, I don’t want this post to sound like a whinge. Cancellations for our mobile massage businesses are significantly rarer than clinics and it is highly unusual for us to charge a fee. The upshot is that we don’t like charging a cancellation fee as it is never a satisfactory outcome for anybody but we will do so when circumstances dictate that it the right thing to do with respect to our business.

    By Richard Lane


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