Adding Value

By Daniel Wonnocott

This is somewhat of mental checklist I run through during my treatment planning process; it isn’t going to tell you what to do but it should help you better appreciate some of the complexities that need to be considered when designing a treatment plan.

Preparing to adapt – support the person throughout the process

Two central discussions worth focusing on with clients are outlined below. The length is determined by the client, as rule of thumb, when things are going well, the conversations are shorter and the focus is on the future.

Discuss and debrief – Why they present the way they do.

• Understand their journey to date.
• Know what they have been up to recently.

Approach and Plan – Get ready for the next step

• What comes next – think of treatment as preparation rather than recovery.
• Enhance their position and mindset to execute the next stage of their journey.

Long term success comes from stacking small victories up every day. Between social media, outdated clinical narratives, infomercials and blogs on the internet sprouting new ways of approaching age old problems, there is ample opportunity for our clients to get sidetracked from making progress. Of the 700 odd hours in a month, we would be lucky to see a majority of clients for more than 1-2 hours. Focus on supporting the person and reflecting on their journey, help them where you can and send the out ready to win the day/s.

Elements of client presentations

This is by no means an extensive list, and it is highly unlikely that only one element will be present. Look at this as a checklist to help identify some considerations you need to make in the way you approach any treatment. Depending on the level and nature of your own training, you may find you are well equipped to manage most of these on your own or you may find you need to refer to other suitable channels.

Stress/Anxiety

Think

• Mental and physiological responses to challenges.
• Can be negative (distress) if left unchecked or poorly addressed, or beneficial (eustress) if framed and managed well.

Do

• Be open, receptive and non-judgmental. Endeavour to understand and consider the way you approach their case to reflect this.

Remember

• We know our professional capability better than our clients, but our clients are the experts on themselves.
• Technical jargon might be normal for us; however, it can be scary for the client.

Treatment considerations

• Where possible, keep things closer towards the minimum effective dose and avoid any undue discomfort. Chasing larger changes in tissue at the expense of stress and discomfort can backfire.
• Maintain communication and accommodate client comfort levels. (Some actually enjoy and respond well to firm treatment – others do not.)
• Be mindful of how you frame your explanations.
• Holding space is tough and tiring as a therapist, but it is one of the most impactful things we can do for someone.

Sensitivity

Think

Irritation, discomfort, pain or perceived threat in the absence of a direct pathology, trauma, tissue damage, disease state or clear loss of function.

May be because of a protective or adaptive response to a pathology, trauma, disease state, clear loss of function or driven by fear and uncertainty.

Do

• Ensure you rule out the big stuff. Most of the assessment skills we have are more beneficial at ruling out serious problems then they are at designing pathways back to normal.

Remember

• Find your minimum effective input and respect your maximal tolerable input.
• Nociceptive signalling is normal – just because we can alter it and provide relief for clients does not mean it needs to be pathologized.

Treatment

You’re managing 3 levels of nociceptive behaviour.

1. Receptor to Spinal cord. Change nociceptive environment. Think A alpha and A beta dominant interventions (not painful). (Bottom up.)
2. Spinal cord to brainstem. Reduce wind up “hypersensitivity”. A delta and C fiber dominant intervention (painful) can backfire. (Top and bottom.)
3. Brainstem to cerebral cortex. Poor sleep, anxiety, stress, depression and NEGATIVE BELIEFS etc. all have the potential to increase the sensitivity of the nervous system. If your treatment narrative isn’t supported and reduces someone’s self-efficacy, you are actually fighting against the body work you provide.

Related article: Read Dan’s article “It Depends” where he explains the top down/bottom up theory.

Introducing D.I.C.K.

I’d like to introduce a 4-letter acronym – all the 3-letter ones have been trademarked.

Dope Input – Crappy Knowledge

Being a D.I.C.K. diminishes treatment outcomes.

Situation

Think

• No tissue issues, no major fears or concerns or roadblocks.
• Looking for advice and guidance to advance and progress from where they are currently.

Do

• Build confidence and plan out a path forward
• Identify referral or recommend resources a client might find useful.
• Educate on what support we can offer and who else they might need to consider having in their circle.

Remember

• Our role is very supportive and flexible, but when it comes to driving the bus, it is often easier to outsource and support than to keep it internal and try to juggle multiple facets.

Treatment

This element is primarily hands off and is more about forecasting and planning ahead.

Serious

Think

• Indications of a pathology, trauma, tissue damage or disease.
• Mostly treat people with these presentations rather than direct treatment for the condition itself.

Do

• Often supporting them with symptomatic relief and helping restore and prevent loss of function.

Remember

• Primary care practitioners exist for a reason. Utilize them.

Treatment

• Recovery and rehab can be a long journey with plenty of ups and downs. Look to be someone and somewhere they can go and have their symptoms relieved (pain, mental health and ROM).
• Support them by helping maintain a healthy body and mind. Let them vent and help them identify the small victories along the way. Aim to help soften the blow of the downs and pick them back up again.

Sustainability

Think

• Nothing specific, general treatment to help keep them on track.
• Big blocks that set them up for the challenges they face.

Do

• Know the big blocks required to keep them on track and establish key baseline tests or feedback measures.
• Focus on what works for them and what they enjoy.
• Build the lighthouse! Reflect on behaviours, attitudes and processes that have been working off the table. Take the opportunity to gain insight as to where they are building a solid base without disruption. When things go off track, reflect on these sessions as a lighthouse to aim for again.

Remember

• Bodywork is just one of many cogs.
• Don’t get caught up on what you are doing to/for the tissue.

Treatment

• Know what movements they need to own and break the components down.
• Develop an understanding of the physical and mental stressors that are unavoidable and acknowledge them ahead of time.
• Explore, reflect and mix up treatments to find what works for them.
• Don’t be scared to throw something different in the mix when things are going well. This is when they are most likely to be able to absorb something new that may not be for them.

In Summary

My role is to help facilitate change rather than to “fix” my clients. I find that having a preparation mindset rather than a restoration attitude helps me to apply manual therapy ethically and in a supportive manner that fosters appreciation whilst reducing the dependency mindset that can unfortunately develop under most traditional approaches.

About the Author

Daniel Wonnocott is a massage therapist based in Ipswich, Queensland who is upset by people’s growing unwillingness to take a guess when asked to guess what?

Dan will be presenting again at the 2021 AMT Annual Conference and this article may be a hint of what is to come in his presentation.

Cover image by steven underhill from Pixabay