Client self care: Does it work?
“There’s only one corner of the Universe you can be certain of improving and that’s your own self.” -Aldous Huxley
As a manual therapist it is tempting to think that getting effective results is all about your hands on work. After all the use of those awesome healing hands is our prime ‘raison d’etre’ and many of us devote a lifetime to pursuing the massage ‘Holy Grail’ –in other words, the latest technique or modality that will best help our clients out of pain. As a result, client self care it is often pushed to the back burner; a desultory 5 minutes at the end of the session where you give a photocopy of a few stretches
Yet what if you were missing a trick? What if spending time teaching your client self care suggestions was one of the biggest single cost and time effective ways to improve your results with chronic musculo-skeletal pain conditions? Research suggests that devoting some thought to incorporating self- care as part of an overall treatment plan is a wonderful way to quickly improve your results. Conditions as diverse as herniated disc pain, whiplash, headaches and nagging sporting injuries all respond to a healthy dose of self care – and who better to support this than a friendly massage therapist? Massage and self care are wonderful bed fellows; outcomes for low back pain are improved if combined with self care and exercise (Furlan 2002) and studies also suggest that receiving bodywork makes people more likely to carry out self care suggestions (Long 2009)
The psychology of self care: Power to the People!
To understand why self -care can be so powerful we need to look at the psychology behind it – the so- called “locus of control”. You will know from your own experience that the world tends to be divided into 2 types of people: those that believe they can alter their circumstances by their actions and those who believe they are at the mercy of outside forces such as chance, fate or the whims of authority. Psychologist Julian Rotter (1966) came up with the concept of locus of control to explain this tendency. People with an internal locus of control believe they can control events that happen to them whereas those with an external locus of control believe they are powerless to control outside events. (FIG 1). Crucially the sense of locus of control is not fixed and can be altered through education or experience.
So what does this sense of control have to do with helping your client’s persistent bad back? Actually everything, as research shows that the locus of control is highly correlated with successful treatment outcomes. For example headache sufferers with a high internal locus of control respond better to treatment and are less disabled by their pain (Nicholson 2007). On the other hand, believing that relief from low back pain is determined by factors outside of individual control (such as chance or the interventions of health care professionals) is related to higher levels of disability and poorer quality of life (Sengul 2010).
Following the logic of this research suggests that if we are able to empower our clients to believe they have some control over their pain condition then we are more likely to achieve better treatment outcomes. This is why self care approaches can be so effective as clients are literally taking back some of the responsibility for healing into their own hands– a true case of “power to the people!”
Doctor Doctor what are the best exercises to do?
Patient: “Doctor Doctor, what are the best exercises to do.”
Doctor: “The ones that you do.”
This old joke neatly summarises the best approach to prescribing self care. The truth is that the best exercises to suggest are the ones that your client will actually do. There can be a big gap between “knowing” what is good for you and actually doing it and studies show that as many as 70% of physiotherapy clients do not do their prescribed exercises (Beinart 2013) (FIG 2). Therapists often get cross and blaming about clients who “don’t help themselves”; you know – those pesky people who “don’t do their exercises”. (Totally unlike our good selves who never sit and eat cake or watch TV as we are busy spending every moment in unrelenting self- improvement. Hang on a minute while I turn off the mung bean stew so I can go and meditate…..).
The point here is that motivating your clients to become involved in their recovery is an art in itself and requires a number of skills and strategies beyond simply “telling them”. Unsurprisingly, research has shown that some of these strategies are very similar to the motivational tools used in business or personal training. DeSilva (2011) drew out 3 key features of initiating successful self management of musculoskeletal pain conditions:
- Agenda setting: Jointly setting health goals with your client
- Goal setting: Clients choosing their own small and achievable goals
- Goal follow up: Proactive follow up is vital to maintain momentum and provide engagement and support.
So if you really want to get results with your client self care exercises you will need to look at setting time aside within your treatment to set goals, review and – most importantly- cheer-lead! (FIG 3)
Understanding the biopsychosocial model of pain
To properly get to grips with the art and science of prescribing self care it is vital to understand what is really going on in musculo-skeletal pain. The most accepted model of pain is the Biopsychosocial model – a bit of a mouthful hence commonly abbreviated to BPS. If you find the word makes you want to glaze over just substitute the concept of ‘holistic” as this pretty much means the same thing!
In a nutshell the BPS model (Engel 1977, 1980). suggests that pain is due not just to biological issues (the bio bit) but also psychological and social factors (FIG 4). In other words, our experience of pain can be increased by:
- Psychological factors: unhelpful thoughts, feelings or attitudes such as ‘catastrophising’ (jumping to the worst possible scenario about the pain condition – see FIG 5)
- Social context: wider factors such as being unhappy in a job or a relationship
Conversely, positive thoughts and beliefs or a supportive social context generally leads to the pain signals being “turned down” by the brain.
For effective self care it is important to gain some idea of how each of these 3 areas is contributing to your client’s pain situation so that you can target your suggestions accordingly. The hands on portion of the treatment can address any “issues in the tissues” such as trigger points or fascial adhesions that may be contributing to the ongoing pain. However the psychological and social factors can only properly be addressed via self- management suggestions.
The Jing method: The MAPS approach to self care
Choosing the most appropriate self care suggestions for a particular client or condition can seem like a minefield so, as with most things, it is helpful to have a map to guide you through the process.
The MAPS approach to self care (Fairweather 2015) is a simple mnemonic to help you think about the most useful self care suggestions for a particular client and their condition. Most self care suggestions can be grouped under 4 major headings as laid out below. All of these areas have a strong research base to support their use in the management of persistent musculoskeletal pain
Movement and exercise
Research shows that most types of exercise can be helpful to pain conditions. These include:
- General aerobic exercise: For example running, cycling, swimming, walking
Advice and education
Advice and education is a key area that can help change unhelpful beliefs that may be perpetuating the client’s pain state. Self care approaches that fall within this category include:
- Education and information about the pain condition: reassurance that most acute pain situations get better in a matter of days or weeks. (FIG 6)
- Advice on managing and returning to desired activities
- Help with goal setting, action planning and reviews through structured treatment plans
- Advice and referral to classes that would be helpful e.g: yoga, Pilates or Tai chi
Research has shown that practices that help to change unhelpful psychological mind- sets or give mechanisms for dealing with stress can be extremely useful. This is especially the case in chronic pain situations. Useful evidence based approaches include:
- Relaxation, meditation or mindfulness practices (FIG 7 )
- CBT based self help approaches that aim to reduce unhelpful beliefs such as catastrophising
- Reflecting back to the client any social factors that may be perpetuating the pain condition. Common themes in this category include being unhappy in a job or relationship. It is not your job to “sort this out” but helping the client identify these factors as being relevant can be very powerful.
Site specific interventions
Self care interventions that are targeted at the area of pain can include:
- Self trigger point treatment (FIG 8)
- Application of hot and cold
- Specific exercise targetted to help the area of pain. For example stretching, mobilisation or rehab exercises for the low back (FIG 9)
Quite simply your self- care suggestions should draw on each of these categories for a full all round biopsychosocial approach to treatment.
Using the MAPS approach for acute herniated disc
As an example of using the MAPS self care process for a client with pain from a herniated disc we might look at approaches that include:
- Movement based self care: This could be as simple as encouraging walking to work a few times a week
- Advice and reassurance: Reassuring your client that most disc problems heal within 4-6 weeks and do not lead to long term problems. This is because the disc can shrink back from the nerve that it is pressing on and that more importantly our brain can learn to “turn down” the pain signals (and that there are many things they can do to help this process)
- Psychological: Teaching a simple breathing exercise to help your client cope with stress and feel in control of any pain they are experiencing
- Site specific interventions: Teaching some simple mobilisation exercise or stretches for the low back
It is important not to overwhelm your client with too many suggestions at once – we usually recommend between 1-3 exercises a session depending on complexity. Self care suggestions should be reviewed at every treatment to see how successful the client has been at carrying them out and can be built on, week by week.
A 21st century approach to massage therapy
For massage therapists to move forward in the 21st century it is important that we embrace all the aspects of our great profession. Long before the coining of the term “biopsychosocial”, complementary therapists had a core belief in holism – defined by the dictionary as “The treating of the whole person, taking into account mental and social factors, rather than just the physical symptoms of a disease”. In the holistic approach, clients are seen as active agents in their path towards healing with the practitioner role being that of a facilitator towards this aim; client and therapist work as an alliance towards mutual goals. Self care has always been an integral part of this approach. With our modern knowledge of how psychology can influence pain states, now is the time to reclaim self- care as a vital part of a successful treatment.
Using the biopsychosocial model as a basis gives us a clear map to navigate different self care options to prescribe the most useful approaches for our clients. Remember that the MAPS (Movement, Advice, Psycho-social aspects and site specific interventions) process helps to ensure that your self care suggestions are addressing all aspects of your clients pain condition:. Ensure you set aside enough time in your hands on sessions to goal set and review successful outcomes with your clients. Motivate, inspire, encourage and watch your results increase!
Further reading and Freebies for Terra Rosa readers
Our philosophy around self care is part of an overall approach to excellence in soft tissue therapy for chronic pain as pioneered through our book “Massage Fusion; the Jing method for the treatment of chronic pain”. For further reading on the subject hit chapter 11 of the book.
For some great FREE self care resources head over to our website http://www.jingmassage.com/category/self-care-resources-for-massage-therapists/ where you will find loads of self care handouts that you can print out and give directly to your clients. From mindfulness to mobilisations, advice to active isolated stretching, feel free to print out, enjoy and share with your clients and other therapists. (FIG 10)
About Rachel Fairweather and Jing Advanced Massage
Rachel Fairweather is author of the best selling book for passionate massage therapists – ‘Massage Fusion: The Jing Method for the treatment of chronic pain”. She is also the dynamic Co-founder and Director of Jing Advanced Massage Training (www.jingmassage.com), a company providing degree level, hands-on and online training for all who are passionate about massage.
Rachel has over 25 years experience in the industry working as an advanced therapist and trainer, first in New York and now throughout the UK. Due to her extensive experience, undeniable passion and intense dedication, Rachel is a sought after international guest lecturer, writes regularly for professional trade magazines, and has twice received awards for outstanding achievement in her field.
Rachel holds a degree in Psychology, a Postgraduate Diploma in Social Work, an AOS in Massage Therapy and is a licensed massage therapist.
Beinart, N.A. et al., 2013. Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review. The spine journal : official journal of the North American Spine Society, 13(12), pp.1940–50.
De Silva, D. (The Health Foundation 2011) No Evidence: Helping people help themselves A review of the evidence considering whether it is worthwhile to support self-management,
Engers, A. et al., 2008. Individual patient education for low back pain. The Cochrane database of systematic reviews, (1), p.CD004057.
Fairweather, R (2015): The MAPS approach to self care; Jing Advanced massage
Furlan, A.D. et al., 2002. Massage for low back pain. The Cochrane database of systematic reviews, (2), p.CD001929.
Long, A.F., 2009. The potential of complementary and alternative medicine in promoting well-being and critical health literacy: a prospective, observational study of shiatsu. BMC complementary and alternative medicine, 9, p.19.
Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement: Psychological Monographs: General & Applied 80(1) 1966, 1-28.Nicholson, R.A. et al., 2007. Psychological risk factors in headache. Headache, 47(3), pp.413–26.
Sengul, Y., Kara, B. & Arda, M.N., 2010. The relationship between health locus of control and quality of life in patients with chronic low back pain. Turkish neurosurgery, 20(2), pp.180–5.