Treatment plan decisions

[jusjokin12]

I am wondering how other MTs devise treatment plans for individuals who present with multiple complex issues, such as perhaps hyperkyphosis and hyperlordosis - how do you decide which aspect to treat, when, and for how long, before moving on to the other area? Does anyone find particular success in choosing one area to focus on for a certain number of sessions, then switch, back and forth until problems are resolved? Or do you seem to get the same results by choosing to focus on a couple of spots in each area during each session?

And what advice works well to give that client if he/she cannot (due to career responsibilities) stop performing activities that contribute to the dysfunction?

I'm just feeling a bit stuck. Progress seems (is) much slower in addressing the deeper tissues.

(edit) FYI, client sessions last 90 minutes once a week.

 

[aladdinwa]

I can speak to this a bit as I tend to attract clients in these situations - I think becuase of my years at the chiro clinic and myoskeletal release training, etc.

So - When I have a client with whom I will be doing an intensive Body Balancing Sequence as I call it I will arrange it for three weeks of work - one session per week. I do a complete assessment before and after each session using various forms depending on the situation (I might be able to scan and send you some) and be sure to keep SOAP notes, etc.

In terms of behavior modification to prevent future injuries it usually isn't necessary to tell the client "quit your job" but to teach them how to help their body cope with the stress created by their job.

For example - A truck driver with severe lowback/hip pain cause by hypercontracted hip flexors from hours of sitting in the truck PLUS contractures in the calf muscles from working the pedals. Obviously this is his lifelong career - he WILL spend hours a day sitting behind the wheel of his truck. So I can get him in a more balanced body through the sessions we do and then teaech him how to better STAY that way.

I teach a series of stretches he will do at each truck stop to help counter act the shortening effect in the hip flexors. This will help prevent them from tightening up and pulling the hips out of alignment. Once a month massage sessions keep everything in balance.

Now - having said that - I can devise a complete treatment plan, have something in mind to accomplish that particular session and get going and the muscles are telling me something completely different. You have to listen to that!

I have a client who travels a lot and always has hip/low back issues - getting better but I've never been able to get him in three weeks in a row without travels keeping him away so it's been slower going (I find that three sessions in a row tends to be the turning point for most minor chronic issues) with him. I started working but everything was saying neck/shoulders/pecs. So I moved him on his side and worked to open up that rib cage. Later he said "I can't believe you knew exactly what I needed today!" *laughing*

So yes - plan, study, assess - don't ever just work random muscle tissue with no idea what effect that will have on the tissues surrounding it. But also be very open to what the body is saying.

In terms of long term care many times clients have a weakened muscle group opposite the contracted muscle group that can be strengthened through specific exercises to allow the client a better balanced body overall.

Angela

 

[Johncenazgurl88]

Thanks, AngEngland. I like that term "Body Balancing Sequence" - very concise. I probably should do more specific assessment tests, and would be interested to know which you use most often.

Don't worry, nothing I do is random. Always assessing, trying different approaches and reassessing. Having no post-school specialized training in any myofascial or musculoskeletal release, though, is something that I believe inhibits quicker results. 3 weeks is a pretty amazing turnaround time! However, you did say that was regarding minor issues. My one client - formerly had a high-stress desk job and now is a personal trainer - has had these dysfunctions for at least 6 years. I understand that the longer a condition is chronic the longer it takes to rebalance the body. But it seems that whatever gets "fixed" doesn't seem to last very long. It's a crazy cycle - I concentrate work on a specific area and its counterpart for a couple of weeks, discomfort subsides, I start work on a different area with very little attention to the former, and bam! the discomfort is back!

Is this a fairly common occurance with a challenging client who has long-term chronic conditions? I just worry that my work isn't the most effective for him. However, he has been coming to me religiously for 6 months, and does claim to feel relief directly after our sessions, and sometimes for a number of weeks later, so the work I do must be helping him enough for him to feel satisfied with his progress. Maybe I'm just going through a slight case of new-therapist-lack-of-confidence...and frustration that I don't know everything I want to know yet!!

But still...suggestions are always welcome!

 

[Wallace]

When the symptoms keep returning it means the crux of the matter hasn't been reached. This may be something seemingly unrelated to any other issues, for instance--an abdominal surgical scar that is active. Once the base issue has been worked everything else will fall into place.

Sometimes it is difficult to figure this out and then you just work until you discover it by chance--I've had that happen a couple times--and there is immediate relief from everything else.

Emotional issues have also been shown to be at the base of physical symptoms. However, unless you have enough training when to recognize these issues so you can refer out, there's not much else to do about that.

Taking a very thorough health history is really helpful. Although clients aren't always upfront about past health problems especially if they don't feel it is relevant so it is important to listen to the client and ask lots of questions.

And the most obvious thing, which can be the hardest to see sometimes, is that he has a postural habit contributing to his symptoms that he has yet to change.

 

[manu4live]

When the symptoms keep returning it means the crux of the matter hasn't been reached. This may be something seemingly unrelated to any other issues, for instance--an abdominal surgical scar that is active. Once the base issue has been worked everything else will fall into place.

(Bolding mine) When this is true, it's a beautiful thing. Although I have found over time that sometimes it is true (sometimes there is a "lynchpin" issue blocking all other progress), and sometimes it isn't. Searching for a root cause has unfortunately not helped all my clients - although I wish it did!

Emotional issues have also been shown to be at the base of physical symptoms. However, unless you have enough training when to recognize these issues so you can refer out, there's not much else to do about that.

Again my experience differs a little from this -- although I don't deal directly with clients resolving their emotional concerns, if THEY mention the possibility of emotional injury I do encourage them to be open to the emotion/body connection. I have seen some very good results when a client simply knows that they are supported and heard for considering the possibility. (Not all those results are complete resolution of the physical problem.)


One thing I try to do is approach each client as a completely new person each time I see them, and get the client's agreement to do this. It's understandably easy for the client to show up for session 6 or 10 and just want to hop on the table w/no discussion, a "pick up where we left off" approach. While I don't make them go through their absolute entire history each time, I've found it helpful to assess each time almost as if for the first time.

 

[Gia C]

One thing I try to do is approach each client as a completely new person each time I see them, and get the client's agreement to do this. It's understandably easy for the client to show up for session 6 or 10 and just want to hop on the table w/no discussion, a "pick up where we left off" approach. While I don't make them go through their absolute entire history each time, I've found it helpful to assess each time almost as if for the first time.

When I'm working with someone through the Body Balancing Series I do this and I when someone calls to schedule I always ask what they are hoping to achieve through this session. But I don't always approach it "new" with the client if they are just coming in for a basic stress relief type of session. I always approach each SESSION new however - I feel that is vital to ensuring you give each client what they need at the time they need it.

By the way - it's not three weeks and they are "cured" - it's three weeks and they notice a huge decrease in pain, increase in rom and functionality.

The trick is getting them to come in three weeks in a row - the trend is to come once - notice improvement not show up until a month later when everything is "out of whack" again.

I packaged the Body balancing Series as an attempt to get people to prepay three sessions and go three weeks in a row. it's still a work in progress and mostly an educational process.

Angela

 

[monument]

While I don't make them go through their absolute entire history each time, I've found it helpful to assess each time almost as if for the first time.

I've found this helpful with some of my "project" clients, those who have a specific issue they're working on.

The trick is getting them to come in three weeks in a row - the trend is to come once - notice improvement not show up until a month later when everything is "out of whack" again.

This has been my experience as well. I like your idea of packaging three weekly sessions. How has that been working out?

 

[heybulldog]

Thanks, AngEngland. I like that term "Body Balancing Sequence" - very concise. I probably should do more specific assessment tests, and would be interested to know which you use most often.

Don't worry, nothing I do is random. Always assessing, trying different approaches and reassessing. Having no post-school specialized training in any myofascial or musculoskeletal release, though, is something that I believe inhibits quicker results. 3 weeks is a pretty amazing turnaround time! However, you did say that was regarding minor issues. My one client - formerly had a high-stress desk job and now is a personal trainer - has had these dysfunctions for at least 6 years. I understand that the longer a condition is chronic the longer it takes to rebalance the body. But it seems that whatever gets "fixed" doesn't seem to last very long. It's a crazy cycle - I concentrate work on a specific area and its counterpart for a couple of weeks, discomfort subsides, I start work on a different area with very little attention to the former, and bam! the discomfort is back!

Is this a fairly common occurance with a challenging client who has long-term chronic conditions? I just worry that my work isn't the most effective for him. However, he has been coming to me religiously for 6 months, and does claim to feel relief directly after our sessions, and sometimes for a number of weeks later, so the work I do must be helping him enough for him to feel satisfied with his progress. Maybe I'm just going through a slight case of new-therapist-lack-of-confidence...and frustration that I don't know everything I want to know yet!!

But still...suggestions are always welcome!

As a personal trainer, I spend much time working on training clients to undo dysfunctional body patterning so they can become healthier and achieve their goals. Most of my clients are gained by referral from other trainers as, sadly, most trainers (of my acquaintance) have little to no idea how to work with complex long-term issues. When the person having the difficulty is a trainer, they tend to be more resistant to corrective action, as they tend to assume that whatever they are doing now is probably "just fine" and not contributing to their problems. I see this all the time... *sigh*

While your client is presumably an active person, their exercise regimen may well be reinforcing the negative adaptations you are combating. Pressing movements (such as bench press, pushups) are contraindicated for hyperkyphosis of the upper spine. Back hyperextensions, leg kickbacks, and the like are contraindicated for hyperlordosis of the low back. It's possible to include them in a balancing routine that overcompensates for them, but that takes more expertise.

You aren't in a good position to provide structured advice on this client's exercise regimen, but you can suggest that they take a look at it. Let them know it may be a contributing factor with long-term consequences. It is helpful to have someone good (a trainer) you can refer them to. One way you might make some progress on this front is to have them bring in a copy of their exercise program (many trainers have one). Go over it with them and discuss how some of the movements may be contributing to their symptomology, and encourage them to find suitable alternatives.

Something else to consider: When you move on to a new area, don't stop working on the old one. It's clear that their body needs more in-depth work on those areas even after the pain has subsided. While you may give them less time, continue treating the old areas to maintain the improvements already made.

I've had a lot of success with discussing long-term treatment programs with my clients. When it's a tough situation, I simply tell them we are probably looking at months or years of regular work, and that they need to decide how much of a priority they want to place on their health. Once they understand that I am serious, it's easier for them to contemplate longer treatment programs. We discuss short-term goals like reduction of frequency and/or intensity of symptoms, improved posture and ROM, and the like rather than focusing on becoming symptom-free. Treatment programs of 4-12 sessions are good ways for them to get started and see what kind of difference can be made. My clients generally don't pay in advance, but it's a golden opportunity to offer larger packages as an additional incentive for clients to follow through.

Good luck!