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I've just had my most successful year so far with people suffering chronic pain. Thoracic outlet syndrome 9yrs , Migraine 20 yrs , Back Pain 8 yrs and many more.

I wish to state how important your clients first visit is, and how you might attempt to set yourself apart from "other professionals " in the eyes of your new client.

You must allocate extra time to their first visit to enable them to relax and tell you everything thats on their minds in relation to their complaint, stress levels and previous treatments and medications.
You the therapist should fill out the intake form for them, whilst asking the questions on it, so that they can freely engage in conversation without the distraction of form filling themselves. Allow your higher self a free hand to engage/ask the right questions/Empathise with your client. Carefully explain the type of massage you will be doing, its effects and hoped for outcome. Empower the client, make sure they know this is teamwork and that feedback re pressure/pain 1 to 10 is very important. Make sure they are happy they have told you as much as possible related their problems before inviting them to change and get on your couch. = time

On this, the first visit, do not do, a postural/muscle length/strength assesment unless guided/instructed by the client. This may sound somewhat controversial but they already had this done umpteen times before and may associate it with previous failed treatments/professionals or time wasting.
The sooner you can start to soothe their condition and directly palpate/treat the chronic tissues the more quickly the clients confidence will grow in your ability to resolve their condition.

The chronic/depressed client may well be beyond being told they = have hammer toes, leg length discrepencies, tilted hips, scoliosed spine, one ear higher than the other ....! Right now they just want a good nights sleep, less pain, to feel human again ! do what you do best, get your hands on them and get on with the massage. Give them what they are most in need of, time and treatment.

Regards steve

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Comment by Stephen Jeffrey on September 29, 2010 at 9:48am
Hi Janet, the proposed 1 to 10 is to encourage a sense of teamwork and feedback without which the client may feel they should stay quiet.
"Assess as you treat" :) totally agree. .......Even with the client horizontall on the couch, I think you can develope an eye that can identify alot(not all) of postural problems ............ anyone teach this ?
Comment by Stephen Jeffrey on September 29, 2010 at 9:01am
Hi Noel and Rachel
Firstly when I was a newby, I started treating athletes at my local running club. These were fit population with mostly non chronic injuries, this allowed me to develope the skills I had been taught without being overly pressurised regarding chronic pain and referal dicisions.Any clients presenting with problems that make you feel awkward or out of your depth, you must refere on. You will gain much more respect doing that, than giving in to your wanting to help your client.

Every therapist starting out, has gone through simular feelings of fustration but we must learn to walk before we run, and this takes time.

I can't recommend any CE classes in the US as I am in the UK, but Clair Davies Triggerpoint therapy workbook would be a good place to start.

Here is an article that suggests the above approach may be more appropiate for a wider range of clientel.
Comment by Noel Sumbad on September 29, 2010 at 6:15am
I wish you'll publish more info, it helps me a lot being new in massage
Comment by Janet on September 22, 2010 at 12:16pm
As a client I hate having to give a 1-10 number. I'd much rather do ROM and have a chat. It is such a relief when the therapist fills out the intake form. And it is annoying when you don't know that your intake assessment is part of the time you thought you paid for treatment. F/U assessments shouldn't take long. I keep thinking, "I wish they would just get their hands on me." I think you can do a lot of assessment as you treat.
Comment by Jeff Sims on January 1, 2010 at 10:03pm
excellent discussion. like many questions, i think the answer to the question "how much assessment should be done prior to the first treatment?" is "it depends."

communicating with the client at the first appointment is very important and establishes the client-therapist relationship. i like your approach Steve of interviewing the client rather than asking them to fill out forms. interviewing is not an easy skill, but takes practice. as LMTs, we have the benefit of palpation and passive ROM stretches in our practice -- these kind of assessments (even active listening) are treatments. when done carefully, or in a heart-felt way, assessments build trust, soothe and calm the client and help us to focus our energies with our precious resource time.

happy New Year!
Comment by Ken Elwood on January 1, 2010 at 5:35am
Many of my clients have discussed massage therapy many times prior to getting on my table. They have trouble believing that massage therapy may help when pain medsand physical therapy have failed to help. I have clients complete a intake form. I observe them walking, standing, sitting for postural imbalances. I ask what is most important for them (which is usually sleep) and develop a plan as I work during the massage. The first appointment many times takes 11/2 hours, I suggest they set up to come back in two weeks for a follow up appointment before they leave. I call the next day to follow up with how they slept and pain level.
Comment by Kelly Grounds on December 30, 2009 at 6:49am
This is such good information. Like many newbies, I over analyzed my clients and overwhelmed them with information. Now, I let them tell me, rather than another intake form, and get them on the table so I can listen to what their body is telling me. I work with many in chronic pain, like you do, and my clients want relief...not another series of 'tests' and a a lecture.
Comment by Stephen Jeffrey on December 23, 2009 at 4:06pm
Thankyou everyone for your positive replies.

I had no idea how this blog would be received as my own associations guidelines emphasise postural examination as being of prime importance.

However, the greatest teachers are our clients, and as experienced MTs we must allow our intuition the flexability to create the ideal environment in which a chronic client feels comfortable enough to allow us privilaged access for affective healing.

These clients have suffered for years, on meds that incapasitate straight thought.The original complaint pales into insignificance in comparison to where they are now. Using your skills, touches their body in a language that only massage can deliver, and this needs to be the main focus of the first session not assesment!.
Comment by lee kalpin on December 23, 2009 at 12:38pm
This site usually allows me to edit my comments and fix any typos. For some reason that is not happening this time, so I apologize for the numerous typos.
Comment by lee kalpin on December 23, 2009 at 12:35pm
I think most therapisst are taught in school that they should do a thorough assessment at the first treatment. It takes a while for them to learn How to modiify that advice, taking into consideration the individual client and what that client's experience has been, Newbies often don't have the concept that assessment is an ONGOING process and doesn't all have to be done at the first treatment.
For people with chronic pain problems I use the Pain and Disability charting (used by Pain Clinics). There are some that are specific to back pain, others for whiplash and others for generalized pain conditions.
They ask questions about how the pain affects the client's lifestyle, such as
Pain Intensity at the monent (from 1 - 10)
Ability to do personal care: Ability to lift: Frequency of Headaches: Ability to concentrate: Ability to work/ drive /use a computer; can you sleep through the night? How many times to you wake? Are you taking medications and how much/ how often?
This type of questioning gives you a more accurate picture of how chronic pain is impacting ont the client's life.
Some conditions (such as fibromyalgia and many of the immune system discorders) do not typically cause loss of range of motion, so there is nothing to see, and nothing to test, but the client has disabling pain.
This type of questioning is also effective for measuring progress. If the client, for example, said he could never sleep through the night and wakes at least 3 times, and has headaches every day that require Tylenol 3 to releave them - then we can ask those questions again in a month or 2 months and see if there are any changes. If the client can now sleep through the night 3x week, and only gets headaches once a week, there is major progress being made. This is very affirming to both the client and the therapist.
Some useful forms are
Neck Pain and Disability Index (Vernon-Mior)
Low Back Pain and Diability Questinnaire (Roland-Morris)
Fibromyalgia Impact Questionnaire (FIQ)
Fibromyalia Pain and Function Index

I'm not sure where to find these questionnaire, but no doubt they can be found online. It is up to each therapist how they might want to use them - either to have the client fill them out or to ask the questions verbally

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