Date: 20.11.19

Duration: 1300-1700

Individual with whom I worked with: Mick Smirthwaite

Before my placement:

Aims from today’s placement:

To observe Mick treating his clients and to be invited to get involved with some hands on soft tissue massage techniques.

To see a variety of different conditions and observe how Mick approaches each condition.

I know it is going to be a busy afternoon because Mick’s diary is full.

During my placement:

I felt positive today.  I am embracing the new challenges that this placement opportunity presents.  I am trying to be confident in my ability to perform massage techniques. I have been practising my palpation skills on my son and have performed more STM whilst supporting the swimming and water polo teams.

It is difficult to plan a specific action because I do know how the history of all of Mick’s clients and all of the cases are different.  My intention was to be confident in my ability to perform massage, regardless of how different the techniques that I use are from those that Mick uses.  He is a very experienced masseur and sports therapist.  I can learn new techniques and that is what I am looking forward to especially when I am invited to participate.  I also intended to ask questions about how Mick would apply those techniques to protect his hands, using the client’s own energy as much as possible.  Massage can be very physical and it is important for therapists to protect themselves by adopting a good posture and ensuring that the massage table is at the appropriate height to facilitate this.

After my placement:

I didn’t have time to talk about the clients that were scheduled to see Mick today.  The first client had arrived early to we went straight into the consultation.

Client 1 – A female runner, in her mid-forties.  She had major abdominal surgery 6 months ago.  She is currently attending spin cycling, boxing and pilates classes once a week.  She is also doing light running but says that it still feels uncomfortable.  She is unable to lie on her front.  The client gave her permission for me to take photos of her abdomen pre and post massage.  The photos were taken to demonstrate the positive effect of the massage on the scar tissue.  The colour of the scar was lighter after the massage:

Figure 1 – Pre-massage photo of scar and abdomen

Mick mixed aromatherapy oils: primose, geranium and sage mixed with a base oil and applied superficial effleurage to the abdomen.  I was invited to palpate the client’s abdomen.  The right side felt firmer than the left side.  There was more scar tissue between the fascia and abdominal muscle.  Mick used light pinching movements to breakdown the scar tissue.  The massage helped to ease the scar tissue and also lightened the colour of the scar.   Mick invited me to palpate the client’s abdomen.  I could definitely feel that the tissue on the right side of the abdomen was not as firm as it was before the massage.

Figure 2 – client’s abdomen post massage

Client complained of pain in the neck/shoulder area.  Mick palpated both sides of the neck.  I palpated deeply into the top of the shoulder on the right side and invited me to do the same.  The palpation was deep into the first intercostal rib. He explained that there are usually trigger points in this area and that STR can be applied to ease tension in the neck using a pin and stretch technique.  He demonstrated the technique which involved palpating deep into the tissue of the neck to find the first rib and to slowly turn the head slightly.  The technique is repeated until the trigger point eases and the client visibly relaxes.  I was invited to practise the technique on the client.  Mick also demonstrated on how to apply a traction stretch of the neck.  He showed me where to place my hands underneath the upper back and neck, to keep the thumbs relaxed and rest the forearms and elbows on the couch before lengthening the client’s neck.  I practised the technique a couple of times.  It looked a nice stretch and the client appeared to enjoy it.

Client 2 – has been a client of Mick’s for about 5 years.  He has a history of issues in his lower back and hip after a car accident.  He also suffered whiplash as a result of the accident.  He regularly sees a Personal Trainer to help him building up the muscle strength in his back and hip.  He currently has an issue with his hip flexor.  He also has a DVT in his lower left leg.  The strength in his left glute his reduced – the right hip is stronger.  He also has a tight iliopsoas.

Upon inspection it was clear that there was a slight misalignment of the hip due to tight glutes on the left side of the body.  Mick applied massage and STR at the insertion (Greater Trochanter) for the Gluteus Medius muscle on both left and right side of the body.  A ball was placed between the client’s feet and the client was instructed to squeeze the ball and lift legs, when the STR was applied.  This was a very good example of the therapist using the client’s energy rather than his own.  Mick also performed joint mobilisation of the hip.

Mick massaged the client’s left upper back which was visibly more raised than the right side.  I was invited to massage the right hamstring.  Upon effleurage the hamstring felt tighter on the medial side (semimembranosus).  I applied effleurage, petrissage and STR.  Mick suggested that I apply the STR from the opposite side of the couch, as it would give me easier access to the medial side of the upper leg.   He demonstrated the technique and I applied it solo.  The muscles felt much looser.

The client moved into supine position and Mick applied STR at the insertion point of the Rectus Femoris on the right leg, which was very tight.  He also performed fascia release because the client’s right leg was turning out.

Client 3 – was a regular weekly client and I met her last week for the first time.  She is a female weightlifter.  She asked Mick to give her legs some attention because they were sore focusing on the TFL, hamstrings, lower back, quadriceps, hip flexors.  I observed Mick apply STR at the insertion point for the gluteus Medius to ease the tightness in the glute muscle and the TFL.   The technique was applied on both Right and Left side.  Mick massaged the calves and hamstrings using effleurage, NMT and deep tissue massage.  I was invited to massage the client’s right quadriceps after observing Mick massage the left quads.  I applied effleurage and NMT because there was a large trigger point on the lateral side of the thigh.  I felt quite confident massaging the client’s legs as I have performed many massages on the legs because the majority of my models were runners or cyclists.

Mick demonstrated STR on the iliopsoas.  He said that it was a particularly sensitive area and is connected deeply to the emotions.  Sometimes after applying STR to the iliopsoas clients are tearful so a therapist has to be careful and mindful of this.  The technique involved palpation from the ASIS, 2 inches across to the medial part of the abdomen and 2 inches up towards the naval.  The client was instructed to breathe in and as they breathed out – Mick pressed deeper into the the soft tissue.  This technique was repeated until Mick could go no deeper.  The client was instructed to breathe in and flex the hip and lower the leg on expiration.  On the third repetition, as the client breathed out Mick released his fingers from the area.  It was really interesting to observe and to be invited to practise on the opposite side of the client’s abdomen.  I really enjoyed practising this particular technique under Mick’s guidance because I felt that he was trusting me more to engage with these difficult techniques.

Client 4 – This client is a car mechanic and spends many hours in a cold garage working on cars.  He was lifting heavy weights in a gym session in October but had to stop because of pain in his lower back.  He also has issues in his shoulder and upper back which could be due to working in a cold garage and standing up all of the time.  He said that sometimes it feels uncomfortable to sit down.  Sometimes he experiences pins and needles when seated and his shoulders ache.

I watched Mick observe the client’s posture when lying prone on the couch.  The hip was not symmetrical due to tight Erector Spinae and Quadratus Lumborum muscles on the right side.  Mick applied mobilisation of the upper back and SIJ joint.  He massaged the left and right side of the upper back and working out trigger points in the Rhomboids with the NMT. A traction stretch was applied to the left leg to ease a tight hip flexor.  I observed the treatment, but was not invited to apply STM because the client has only been to Mick once before and may not have been comfortable with be getting involved.

The client revealed that some of the tightness in the hip could also be credited to the fact that he had a pin in his left hip when he was 16.

Mick gave the client advice on doing flexibility exercises to help improve the ROM of his hip, hip flexors, lower back and upper back.  Working in a cold garage will also have an impact upon his flexibility.  The muscles are stiff when they are cold, so flexibility is reduced.  Regularly stretching will help the client improve his ROM.

How I felt through-out my placement today:

I was pleased that Mick involved me more in the clients’ treatment.  I felt more confident than I did  during the first placement visit.  I am beginning to understand how Mick work’s with his clients.  It is very patient-centred.

Evaluate today’s placement activity:

I felt that I repeated the techniques that were demonstrated, quite well.  Improvements will come with practise.  I am not so reticent about getting involved.  I am enjoying the opportunity to do more.

A deeper, analytical and critical approach to today’s experiences:

Practising palpation skills and massage skills has definitely helped.  Revision of anatomy is also making a difference. I have also been watching videos about massaging different muscles in the body and the different styles and ways in which practitioners apply massage techniques.

Continuing to practise palpation and massage is a priority.  Moving muscle groups whilst palpating them has enhanced my understanding and I am beginning to identify the difference between fascia, muscle tissue and tendons.  My anatomy is helping me to locate origin and insertion points of muscles by feel.

Draw conclusions – what have I learned from today’s activities and my reflections:

I have been watching Mick closely during his treatments.  In practical lectures we are taught a process of Subjective Assessment, Objective Assessment and treatment.  Mick works very differently.  He does a subjective assessment but he knows his clients so well because they have been seeing him regularly for years.  So he doesn’t spend as much time on this part of the process.  He doesn’t go through a detailed objective assessment either.  He observes his clients when they are on the couch and he learns a lot about what is going on by palpation.  He does resisted movements during the treatments.  He knows exactly what it happening with the muscles and the joints.

Action plan – how will I apply what I have learned from today’s activities & my future professional and personal development:

Practise palpations and massage techniques.

Keep up with the revision of the anatomy and different pathologies.

Try to read as much as possible about massage techniques, the fascia, anatomy trains and the kinetic chain.

Have any questions arisen from today’s placement that I need to discuss with my Placement Tutor or University Placement Tutor:

I always have a discussion with my Placement Supervisor at the end of each placement session.  Today he asked if I had any questions.  I didn’t have any specific questions. I did however talk to him about my apparent lack of confidence during the first few weeks.  I explained that because he is such an experienced therapist with a lot of knowledge it is very difficult not to feel inadequate and to wonder whether I will ever measure up to his standard.  I realised that I will improve with experience, but this is the reason for my reticence.  Today’s session has been good and I enjoyed the opportunity to be more involved.

Returning to my reflections:

After observing the effects of the massage that Mick applied on the female client who had had major surgery six months ago, I was interested to find out whether there was any evidence in the research literature regarding the benefits of massage post-major surgery.  Currently there doesn’t appear to be any conclusive evidence (Shin & Bordeaux, 2012) of the effectiveness of massage on scar tissue.

References:

Shin, T. M., & Bordeaux, J. S. (2012). The Role of Massage in Scar Management: A Literature Review. Dermatologic Surgery, 38(3), 414–423.