As massage therapists, you have client-related pet peeves. But your clients also have pet peeves when receiving massage. In this episode of The ABMP Podcast, Kristin and Darren are joined by Dr. Joe Muscolino to discuss his top 5 pet peeves when receiving massage and some tips for therapists on how conversations can help reduce these pesky occurrences.
“My Favorite Techniques in Manual Therapy . . . and a Few Pet Peeves,” Massage & Bodywork magazine, September/October 2023, page 58, https://www.massageandbodyworkdigital.com/i/1505456-september-october-2023/60?
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0:00:50.5 Darren Buford: I'm Darren Buford.
0:00:51.4 Kristin Coverly: And I'm Kristin Coverly.
0:00:52.4 DB: And welcome to The ABMP Podcast, a podcast where we speak with a massage and bodywork profession. Our guest today is Dr. Joe Muscolino. Dr. Muscolino has been a manual and movement therapy educator for more than 35 years, he has created several online streaming subscription platforms for manual therapy continuing education, including LearnMuscles Continuing Education with more than 3300 video lessons and more than 320 hours of NCBTMB credit. He has also created Massage Therapy Master Online Curriculum, a full online curriculum for massage therapy schools. He is the author of multiple text books with Elsevier and has authored more than 90 articles. For more information on any of Dr. Joe's content, visit learnmuscles.com. And if that wasn't enough Joe writes for Massage and Bodywork Magazine, which brings us to our discussion today. Hello, Joe and hello Kristin.
0:01:44.7 Dr. Joe Muscolino: Hi there.
0:01:46.0 KC: Hi, Dr. Joe, we're so excited to have you with us, and listeners, Dr. Joe is right here in the ABMP Podcast studio with us because he's here filming some new CE courses. So stay tuned for some more CE greatness in the ABMP Education Center from Dr. Joe Muscolino. Darren mentioned that you are an author for Massage and Bodywork Magazine, and in the upcoming September, October 2023 issue of Massage and Bodywork Magazine, you have the feature article titled, My Favorite Techniques In Manual Therapy, which includes a few pet peeves. Readers if you haven't read that article yet, you can catch that in the digital edition and print edition of the magazine, September October 2023. Your point in the article is to emphasize fundamentals with the intention of promoting critical reasoning in order to creatively employ hands-on assessment. And there's some great content in there when you're talking about your favorite techniques, but of course, today on the podcast, we are gonna talk about your pet peeves, because that's the super fun thing to talk about. So let's dive right in, number one pet peeve is, don't hit my cervical transverse processes.
0:02:58.8 DM: Yeah, this is a big one for me whenever I'm traveling, I'm getting massage from a therapist that I don't know, and I'd love to have neck work done, I really enjoy deep work in my neck, especially on the right side. But when you're doing deep work, you have to modulate that depth based on the tissue that's underneath your finger pads, thumb pad, whatever contact you're using. And very often what I find is that the therapist starts in the laminar groove transverse spinalis, I mean Semispinalis capitis in the back of the neck, right near the spinous processes where there's a lot of thick musculature that really deserves to have work done into it. But as they do their stroke going down the neck, they start to veer more and more anteriorly, and I think it has to do with subconsciously following the sternocleidomastoid. That there's kind of this diagonal and the SCM is so visible that they kinda just follow it, and in the beginning they're over very thick musculature that I want the pressure in, and then they have that same depth and they hit the TPs, the transverse processes. And any tissue deserves to be worked, there are a lot of attachments on to the TPs, but not with very deep work that's just mashing that soft tissue into the pointy transverse processes, pointy bone that does not feel good, and it is an immediate clue to me that they are not visualizing the tissue underneath the skin.
0:04:28.9 DM: That they are not really feeling the response of what they're doing, and that to me only tells me that they're really not clinically-oriented therapists, they're carrying out like a cookbook routine.
0:04:41.3 DB: Yeah, Joe, can you dive into that a little bit? That was one of the points that you make throughout your article, and when you're talking about a cookbook routine versus creative thinking when it's coming to massage and manual therapy. Can you elaborate on that a little bit?
0:04:56.5 DM: Yeah, I believe you can make a general division of the... It's not just gonna be two categories, but I my forte in working with education in the world of manual therapy massage is to help people do what could be called clinical work or orthopedic work or medical work or rehabilitative work or the United States has a lot of adjectives for this. Almost every other country uses remedial massage, because you're remedying a specific condition with which the client presents, Canada uses registered massage, and this is a higher level of massage in the sense that you cannot just employ an output of something, you have to work based on how the client's tissues are responding to you. You're trying to apply what needs to be done specifically for how they're presenting to you. Most of the time when you go to school, you have an intro course, Massage Therapy One, introduction to massage, and you learn a routine, and I think a lot of people from that point forward, just keep carrying out a routine. They might add in some skill sets they learn in Massage Therapy Two, Three, whatever those courses would be named, but they still tend to go toward a routine. And when I'm laying on the table and they're going down a certain area, and I'm thinking, "Oh, they're gonna get to this area, this is gonna be so good, I can't wait."
0:06:21.4 DM: And then they get to that area and they give it the same pressure and they just run right over it, as if it didn't even exist or didn't have the extra tightness that needed the addressing. And actually, all it does to me is it reminds me of an itch that needs to be scratched and then they don't scratch it, and it's very frustrating to me. Now, having said that there are times I'm traveling, I'm jet-lagged all I want is a general relaxation massage, it is fabulous, it's moving fluids, it's parasympathetic, it's relaxation. I'm not trying to knock that kind of massage, there's a definite place, but given there's no such thing as a muscle doctor, when it comes to someone who has a musculoskeletal condition, a neuromyofascial skeletal condition, who can help with that? Massage therapists can help with that, but that takes being incredibly aware of anatomy, knowing where the transverse processes are, being incredibly aware of the response of the tissue of the client. I'm very fond of saying that there are only three requirements to be an excellent orthopedic, clinical orthopedic manual therapist. One, know your anatomy, two, be able to critically think, because if you can critically think, you can figure out from anatomy physiology, from that you can figure out pathophysiology, from that you can figure out assessment, from that you can figure out treatment.
0:07:45.5 DM: And therefore you can creatively apply the skill sets, as you said, Kristin. And then the third is feel tissue tension mechanical barriers, feel the response of the tissue, if you're outputting a pressure of on a zero to 10 scale, I don't know six and a half, in the back of the neck. And then you hit the TP and you're still at six and a half, ouch, that's not helping anybody, that's not good effective work.
0:08:15.0 DB: Alright, Dr. Joe, let's transition to pet peeve number two. Don't shampoo my head. Tell us about that.
0:08:21.3 DM: Okay, this is truly a pet peeve, no one is going to be hurt if this pet peeve circumstance occurs, it's just a real pet peeve for me. But I can bring it to a place of value, very often I'm getting a massage and people are doing wonderful pressure for what I like, which is moderate to deep work, and they're working up my neck, and then they get on to the occiput and suddenly they start moving their hands. And this is a podcast, you can't see it, they're like shampooing my head, and I don't need my hair to be shampooed, there is a muscle in there called the occipitalis, and it is tight and it deserves work. And in fact, most tension headaches are due to tension of the poster extensor cervical cranial, cervical cranial neck musculature that creates tension in the scalp. And there's the occipitalis, and then that connects via the galea aponeurotica to the frontalis in front. And in fact, you see someone who has a headache and you'll very often see them put their hands on your forehead where the frontalis is and they're pressing in and they're kneading, you see that naturally. As a kid, I saw that in the 1960s in TV shows and in real life and commercials for probably aspirin or something, these muscles in the scalp deserve appropriate pressure. Don't shampoo my head.
0:09:44.9 KC: Okay, pet peeve number three, Dr. Joe, this is another one where it's a little less just pet peeve and more, this could be a caution, yellow sign, flashing. Number three, don't work my hamstring and then stretch my quadriceps or vice versa.
0:10:00.6 DM: Oh, this point is all the time, all the time. So let's start with a general rule, stretching is meant to lengthen tissue, if you try to stretch a muscle when it's not ready to be stretched, if anything, you will kick in a muscle spindle stretch reflex, which will make the muscle spasm. Because that's the protective reflex to keep the muscle from being over stretched and torn. So my rule is I never stretch a muscle if I have not first warmed it up, how can you warm it up, you can warm it up with massage, you can warm it up directly with heat, maybe they were active before they came in and just had physical activity. The other is that if it hasn't been warmed up, you could actually over stretch it and tear it, so there's a definite danger here, it's so common that you start a massage and you're lying on your stomach, and there you start... You're probably with your face down and they work, most of the time they start in the back area to the neck, they go down, they might work the pelvis, they get into the lower extremity, they work the thighs next could be hamstrings. And they finish working the posterior body wall, then they take my foot and they bring it to my buttock, and what are they doing? They're stretching my quads, they haven't touched by quads, my quads are tight, I'm a guy, I'm an older middle-aged guy, my quads are gonna be generally tight, and they're trying to bring my foot to my buttock, they never touched it.
0:11:21.6 DM: Maybe occasionally you start face up, there are a lot of people who feel that before you work the back, you should work the pecs in front so you can open up the back, maybe they work with you face up for supine. And they're working in the front of your body and they're massaging my quads, and then they take my... They go into a hamstring stretch, they lift my lower extremity up in the air, keeping my knee straight, the heel up, and they haven't massaged my hamstrings at all, and they're stretching them. Many people are tight in their hamstrings, please warm them up before you stretch them.
0:11:58.7 DB: I've never had that happen, ever in a massage.
0:12:02.3 KC: You haven't?
0:12:02.8 DB: No.
0:12:03.1 KC: I know have.
0:12:03.8 KC: Oh yeah.
0:12:04.2 DB: Okay, so you can totally resonate with Dr. Joe there. Okay.
0:12:05.8 KC: Absolutely. And also, I can... I'm thinking back, it's been a long time, I'm trying to dust off some memories here. We may have been taught that in massage school, I'm not 100% sure, but because you're there and it's available and like, hey, if I'm gonna stretch the quads, this is the position I'm gonna do it in. So I can see where it happens, but you're absolutely right, that's not the way to go.
0:12:27.3 DM: Oh, logistically, it absolutely makes sense if you're going to stretch the quads they should be face down, if you're gonna stretch the hamstrings they should be face up. And you don't wanna necessarily make the client turn over lots of times, I can understand that fully, but it is risky, you could tear something and you could certainly defeat your purpose by... If your purpose is loosening tone of musculature and you kick in a muscle spindle spasm, you have defeated your purpose.
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0:14:17.9 KC: Let's get back to our conversation.
0:14:20.5 DB: Alright, Dr. Joe pet peeve number four, don't use bony contacts over bony areas.
0:14:26.8 DM: So there is not just... There are many therapists that are concerned about the health and stability of their joints of their thumbs, of their fingers, many therapists like to employ the Olecranon process of the elbow, and I'm not against that, I certainly will use it myself at times. It will never be as sensitive as smaller contacts, but you can certainly become more and more skilled with it and use it. But it's not just a quantitative issue to say, I need more strength, I'm going to use the Olecranon process, it's also a qualitative issue, it is a hard contact. Now, a hard contact digging into my gluteus maximus and piriformis and fleshy areas, thick meaty areas with a lot of muscle tissue is wonderful, I've got no problem with it. But to relate a specific story I can think of, I was... I traveled to Asia, I was in Japan and I got a massage when I first got over there and the therapist did not speak very much English, understandably so I'm in Japan. And she was using... I'm face down and she was going in the interscapular area between the spine and the medial border of the scapula, and she was using her elbow, her Olecranon process, and she was going up. If you look at the tissue that's there, the skin, the subcutaneous fascia the superficial fascia, then there's, let's say in the middle of it, there's middle trapezius, rhomboids, maybe some serratus posterior superior.
0:15:57.9 DM: And there's paraspinal muscles running vertically retrospining transversospinalis, but there's also ribs and ribs are hard and bony. And she ran over my ribs, the periosteum of the ribs, like, bang, bang, bang.
0:16:13.7 DM: Now, let me start with the fact that I respected the fact that she was getting feedback, she wasn't just doing a cookbook routine motor out, she was actually trying to feel what was there by feeling the response to the tissue. But she was mistaking my bones, my ribs for tight myofascial tissue. So she did the typical three and I thought to myself, "It's a challenge for the language, don't say anything, she'll do the three and she'll stop." After she did the three, she did another three and I thought to myself, "Okay, she's gonna be done now, so I won't say anything." And she did another three and I'm staying silent, she did another three and she... I kept thinking, "Oh she's gotta be done now." And she did another three and she got to over 20 and well, fast forward, my ribs were bruised for about three days, right? When I was doing anything, picking up a suitcase, anything rotating my trunk, I was bruised. This was my fault, this was my fault because I was the client, and I should know better than anyone that you need to be proactive and speak out and say. But I just couldn't believe that she would keep going and she did, so that's... I've had other instances of this, but especially over the ribs posteriorly between the scapular and spine.
0:17:37.7 KC: That's tough because as you mentioned, you had the language barrier, I can absolutely see where you would think, okay, now she's done. Like I can see that exact scenario unfolding.
0:17:47.6 DM: I respect greatly what her intentions were.
0:17:50.5 KC: Yeah, yeah.
0:17:51.0 DM: And that's another thing that's tough with language, even without a language barrier is, the therapist could be somewhere and the pressure is too much and I say, "Please lighten the pressure." But then they lighten the pressure everywhere.
0:18:02.9 KC: For the rest of the session, yes.
0:18:04.2 DM: And I don't want it lightened everywhere else.
0:18:05.7 KC: Yes.
0:18:06.1 DM: Or sometimes I want it deep around my right side than my left side for the same tissue, so sometimes I don't say anything when it's a little bit too deep because I don't wanna have to then go back and say, "Now, please increase the pressure." And from their point of view if they don't understand how tissue pressure needs to be modulated, they might start to get confused. I'll add this piece, I've started to develop something with my patients and also when I'm getting massage with therapist, if I'm going to see them more than once. And that's a communication system where I never... I don't ask my patients, "How is the pressure?" Because most of the time they're gonna say, "It's okay, it's fine." They don't wanna criticize you, right? A better question would be, "Would you like more pressure or would you like less pressure?" They can just say, "More, less." Now they have to go out of their way to say, "No, the pressure is fine the way it is." But even better than that, if they have to wait for me to ask, is I've developed a little hand signal thing, so podcast we can't see it, but I put my fingers together really close together, and that means less pressure and if I bring my fingers far apart, it means more pressure.
0:19:14.0 DM: And if I put my thumb up, it means the pressure is perfect the way it is, and then the therapist that works on me simply acknowledges that they see it, they say, "Yes, okay." Because it's also possible I'm face down and I do this signal and they're looking at my feet and they're not seeing, right. So I really like it, 'cause I can't believe it took me nearly 40 years to figure out something like this so that you won't have problems with the pressure.
0:19:40.6 KC: And that it's really responsive as you're working different areas of the body, and like you said, even from side to side, same area, that's great.
0:19:47.2 DM: And it gives the therapist affirmation when it's good, because my therapist will always say thank you when I put my thumb up.
0:19:58.7 DB: I really appreciate that as a client, because so often before a session starts, you'll be asked what type of pressure do you like? And I think it's just my very careful nature to be medium, it's kind of like when ordering the spicy chicken sandwich, you're like medium, I think. And then that's it, we don't have any more conversations about that, so I like your hand gestures. That's a really nice partnership.
0:20:21.5 KC: Yeah, I always say medium plus high minus. So they know because that's how I order my spicy Thai food too, is like I say mild plus 'cause I'm way down on that med scale, but I try to say like... Yeah, medium plus, high deep minus. So that they know I'm in that zone. It's hard because it's so subjective, isn't it?
0:20:40.4 DM: And it so depends on... It's like saying, What do you want to eat? Chicken, okay, I'll give you chicken for the rest of your life. What I want in pressure is so different, like I have... I'm an absolute wimp when it comes to my feet, I do not like... I like a, on a zero to 10 scale, like a one or a two on my feet, but I want an eight and a half in my right semispinalis capitis neck area, but I don't want anything half on the left there, I want around five and a half six. So to have an ongoing conversation, whether it's a verbal, we're not... And because when you're relaxing to some degree, even with deep work, with massage, you're trying to get to a certain zone, speaking, interrupts that, and I think it really disturbs the flow, so this idea of just a simple putting my hand up and just to one the other or the other... And again, I really like the idea that if you're never saying anything to the therapist, the therapist has no idea, if you like their work, putting a thumb up occasionally lets them know that they're on the right track, so I really like that method of communication it's not in the pet peeve area here, but we did transition toward it.
0:21:54.5 KC: I'd like a thumbs up every once in a while, so great. Tell us about Number Five: Don't work on my anterior abdomen at the very end of the massage.
0:22:05.4 DM: So I'm gonna put this somewhere around and don't shampoo my head, it's not really going to create damage, it's not really a major issue. But it's a pet peeve of mine. So massage creates increased circulation, it moves lymph it moves venous, you're going to have more circulation through the arterial system as a result more renal filtration or fluid in your bladder, I'm getting an hour massage, let's say, and we're 50-55 minutes into it. And now they ask if I want my anterior abdomen to be massaged. Well, at this point, the first thing I'm thinking of is going to the bathroom to urinate to pee afterwards, I don't want anyone pressing on my lower anterior abdominal wall at that point in time, yet I do Pilates every day and I do a lot of work on my anterior abdomen and I would like it worked, but not at the end. No, I realize if they start the massage face down, they can't work my anterior abdomen when I'm face down, but when I first turn face up, that's when I would like them to offer the massage and especially because I usually get an hour and a half massage, so I'm even more prone to it and look, it could be men, I'm 64 years old, you get a little older right?
0:23:25.2 DM: A lot of people don't have the ability to be comfortable with a fuller bladder for long periods of time and massage just amplifies it by increasing fluid circulation. So most of the time I refuse the anterior abdomen work, but with regret, because I would have liked it earlier in the massage.
0:23:44.1 DB: I think the key there for me... I agree with you, Dr. Joe, I think the thing, the key phrase there for me is the very end of the message, which you mentioned, that's just not how I want the massage to close, I really want the massage to close either on my feet or on my head, and that's where we transition from the deeper work, to the lighter work and maybe some breathing exercises together with a therapist and the client, then we're coming to a close. The abdomen is so abrupt. So that's where we're gonna end the massage. I've actually come out of the massage at that point because it's not an area that I just associate with closing the massage right? I'm just thinking other areas of the body that are more prone to slowly bringing me awake, and if perhaps if it's asked at the beginning in the intake session, if I would like abdominal work, at least I might know that's gonna happen, but there have been many, many times and I've talked about on this podcast before where it's not mentioned or it's asked in the moment, so at the 59th minute of the 60-minute massage, I'm now asked and I'm like, I'm already brought out of the massage or even worse, therapist's just dive into a possibly pretty sensitive area, and it can be really uncomfortable.
0:24:54.6 KC: And I like something you said, they're Darren too, just as great awareness for all of us when we're in the client role, is that if a practitioner does ask us in the intake session at the beginning, 'Would you like abdominal work?' It's great awareness for us to say, yes, but please don't do that as the very last thing, and I think that just always being educated as a client and asking for what we want and don't want, and feeling empowered to do that.
0:25:19.4 DB: I feel like so much of the wisdom that both of you brought to the podcast today has been about communication skills, especially as the client, to not just receive the message and to then walk away, there's so many instances where you could walk away and never book again, and honestly couldn't, it may not be the massage therapist's fault, it's because you didn't communicate your likes or dislikes during the session, and then the massage therapist is left clueless and doesn't understand potentially why you didn't book again.
0:25:47.2 DM: Of course, it's up to the massage therapist to create that communication though in the beginning. So yes, if you have a client that is not communicative, not responsive, it is much harder. I know that working manual therapy for many, many decades, but it is my job to create that communication, maybe this is slightly out there for an example, but when I teach a workshop, I say I will always learn something, even teaching this workshop, but I'm not here for me, I'm here for you. That's why I'm here, if you have questions you need to ask. Please, if you're thinking of a question there's probably three other people thinking it, and they're gonna thank that you ask it.
0:26:26.3 DM: Right? It's a similar thing. I'm working on someone, I'm doing manual therapy, I'm not there for me, I'm there for them. So they need to feel empowered to proactively be able to communicate with me at any point in any time in any way, so how you ask a question very often dictates what the answer will be, how often you ask can dictate the communication, how you set it up. So yeah, we really did come to communication for so much of this, because if you want that client to come back beyond the fact altruistically, you want to help them, you want to have a thriving practice so that you can pay your electric bill and your mortgage or your rent, then it doesn't serve you well to set up the circumstance where the client does not have a good experience and you don't even know it.
0:27:18.6 DB: As we start to bring this podcast to close, we heard about Dr. Joe's five pet peeves. Kristin, let me just turn the microphone to you. Do you have any specific pet peeves when you're receiving work?
0:27:31.6 KC: Absolutely, yes. The first thing that jumped into my mind, what I thought even about pet peeves and that we were going to do this podcast with Dr. Joe, popped into my mind immediately. I have practitioners who do deep linear friction along the borders of the radius and ulna, and they just stick their some and finger in there and go back and forth, back and forth, back and forth from elbow to wrist, elbow to wrist with this deep pressure right on the edge of the bone and to me, it's uncomfortable and painful, and I'm always curious what do they think they're doing, what goal do they have for doing applying that friction there? Any ideas, Dr. Joe, am I missing something?
0:28:14.3 DM: Well, I will first, you remind me of something I like to say when I'm teaching a workshop, and that is that, and maybe this shows me being a little too anal retentive, obsessive compulsive, but whether I'm teaching massage therapist or pilates instructors, yoga people, fitness, I say anybody should be able to stop you at any point during your session and ask you why are you doing what you are doing right now, and if you don't have an answer for it, then that means you're in that cookbook routine that is being with all due respect, maybe it's a great cookbook routine that will be great for seven out of 10 people, but it means that you're not really having a dialogue with the client on the table, you're not having a dialogue with their tissues. So I don't have a specific answer to what they're doing when they're right on there, that doesn't make a lot of sense to me if you're just off it and you're catching where the aponeurotic fibers, tendinous, collagen and tissues going in, that is very often ignored and that can be wonderful. In fact, another pet peeve of mine is the extensor carpi ulnaris is almost always skipped when therapists are working on the posterior forearm, I can't believe how 'cause it's around the bend.
0:29:29.8 DB: One of the things I really dislike, Joe touched on it when people are using their elbow for deeper work, but think of... You probably have a better verbiage that I do here, but when the elbow is held static and then it slips off into something else, that is the worst feeling in the world, first of all, I am out of the massage immediately, and I'm just like, wait, what just happened there, did we need to use the elbow to go that you went so deep that you just rolled off of the muscle.
0:30:03.4 DM: Well, that's poor technique, whether you need to use the deep work there or not, whether it needs to be the Olecranon process, the elbow or not, we can debate, but one should be in control of their contact on the client, much of the time I've gotten comfortable enough with the elbow that I put my thumb web of my other hand over the anterior cubital area antecubital area of the elbow, just to add pressure, but if I'm concerned that I'm going to slip, then my other hand goes around the elbow so that I can't slip, I'm giving myself a thumb web, like 180-degree guide that I simply can't go past and I can't slip because if I'm in a delicate area, it's not good to twine across tissue periods. Whenever that, when I do accidentally do that, I always apologize, but my goodness, if you do it with an elbow.
0:30:58.6 KC: And the way that when we're using an elbow, the way that we adjust the pressure is we change the angle of the elbow joint, so it could be that they had their palm almost touching their shoulder and they were coming in with very point and they could maybe should have been using a much wider angle to have a much broader contact with the muscle.
0:31:16.5 DM: And you can flatten it out to be using the posterior forearm, and then you have a choice of pronating or supinating to actually get the ulna the bone ulna on them versus the fleshiness of the tissue that's around there, so you have choices when you're using elbow to form arm.
0:31:35.2 DB: I'm gonna use this podcast as a reference in the future. If this occurs again. Thank you so much Kristin and Joe for this. This has been amazing. I wanna thank our guest, Dr. Joe Muscolino to find more information about Joe and the good work he's doing. Visit learnmuscles.com. Thanks, Joe, and thanks Kristin.
0:31:53.2 DM: I wanna say thank you very much I'm here live, as you mentioned before, and this is so cool, sitting here while the microphone is in the booth with Collin out there, so thank you very much for inviting me here.
0:32:04.0 KC: Thank you so much for coming in for this really fun conversation, but important conversation about pet peeves.
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