Note: I am often asked by my students to outline the entire clinical process that I go through with each of my patients. In this post I will do just that, beginning with my first contact with a new client, and ending with my follow-up contact with that client. I hope you find this information useful.
The Guiding Objective
Before we begin the outline, let us remind ourselves of our guiding objective. As a trigger point therapist, your entire correspondence and interaction with a client has one objective: To find the source of their pain. You will achieve this objective by utilizing three analytical tools:
(1) By analyzing the events that preceded the onset of their pain: Using the client’s history, and with Q&A, you need to determine which muscle group (or groups) was initially overloaded. The client may or may not present with referred pain associated with this muscle group, depending on the maturity of their disorder. If this muscle group is not specifically addressed by your treatment, it will likely reactivate the treated trigger points. To review, your looking for a muscle group that was exposed to one or more of the following stressors:
- A sustained contraction over a long period of time
- An unaccustomed workload
- Placed in a shortened state for a long period
- Physical chilling
- Emotional stress
(2) By analyzing dysfunctions in their movement and posture: In regard to client locomotion, you want to identify the muscle groups that are no longer functioning properly. This includes muscle groups that the client avoids using because of pain, and muscle groups that are too weak to perform their usual duties. A therapist might incorporate basic muscle testing to confirm biomechanical observations and/or pain-limited functioning of a particular muscle group. Postural analysis typically consists of identifying overtly tense muscle groups.
(3) By analyzing the nature and location of their pain presentation: This tool is the “bread and butter” of a trigger point therapist. The client’s particular pain presentation is the key to understanding the source of their pain. Referred pain serves to protect the injured tissue from additional trauma. Unfortunately, how a particular referred pain protects the injured tissue is not initially obvious to the client (or healthcare professional), thus the location of the injured tissue is often overlooked or missed completely. To overcome this predicament, a therapist must study and learn the referred pain patterns establish by Dr. Travell. With clinical experience, however, the therapist will intuitively understand the purpose of a particular referred pain pattern and therefore will be able to identify what muscle group is being protected without much effort.
Believe it or not, in the midst of daily practice, it can be easy to overlook the primary objective of finding the source of a client’s pain. It serves both you and the client well to always ask the following questions throughout the clinical process: What is the client telling me? What is the client’s body telling me? What is the client’s pain telling me?
Outline Of The Clinical Process
Step 1: Initial Contact
When you first make contact with a prospective client, whether it is by phone or in person, there are a few questions your going to want to ask them:
- Ask them to describe the type of pain that they are having: where it is located, how long they have had it, what do they think caused it, etc
- Ask how they found out about you: referral, advertisement, flyer, etc
- If needed, ask them to visit your website or your blog here on the TriggerPointTherapist.com Network to learn more about trigger point therapy, what to expect in a session, and about you as a therapist.
Use this information to prepare for the session. Review any protocols that you think you might need to perform.
Step 2: The Client Information and Pain Questionnaire Form
Insist that all new clients fill out a Client Information and Pain Questionnaire Form. This will serve to provide you with valuable clinical and marketing information. The proper application of Clinical Trigger Point Therapy requires a therapist to consistently assess what is working in daily practice and to refine your technique and protocols accordingly. Having a written record of a client’s progress to review is critical to this refinement process. Also it is important to collect client’s personal information for future marketing projects. Create a separate address book (or computer database) with all your client’s names, addresses, email, and phone numbers. This can be time consuming, but you will be glad you did this later.
Step 3: Client Observation
As you meet a client for a session, take a few seconds to observe their posture and movement. Is one of their shoulders higher than the other? Is their head held straight or is it held too far forward or to a side? Is their trunk bent forward or to one side. When they move, can you identify a muscle group that they are protecting (not contracting or stretching)? Do they move their head or just their eyes to look at you? Are they limping? Do they assist their movement with their hands?
Step 4: Pain Presentation
Next, the therapist should precisely determine the client’s pain presentation. Have them physically show you the location of their pain and confirm its location with your own hands.
Step 5: Confirm the Client’s History
At this point you want to review the information the provided on the Client Information Form with the client. Clarify the following points with the client verbally:
- How long have they had this pain?
- What do they think caused the pain?
- What makes the pain worse or better?
- Ask them to rate the severity of their pain on a scale of 1 (no pain) to 10 (extreme pain)
Step 6: Client Q & A
Describe a typical Clinical Trigger Point Therapy session to the client so that they will know what to expect during the session. Inform them that they should expect some discomfort, but that you will work within the pain tolerance that they define. Explain that you will be using their pain as a guide and that you expect them to give constant feedback on the severity of the pain experienced during the session. Answer any questions that they have.
Step 7: Protocol Execution
You should now have a good idea of which protocol(s) to perform. While you perform the protocols keep these factors in mind:
- Client Positioning: Is the client well supported and as comfortable as possible? Is the client warm enough? Can you help the client move into and out of the positions? Is the client breathing correctly?
- Your Biomechanics: Is a part of your body becoming fatigued? Is your stance correct? Are your shoulders down and relaxed? Are you using your body weight or are you using muscular effort? Are you breathing from your belly? Are you incorporating whole body movements into your technique?
- Your Presence: Are you concentrating on your technique or is your mind distracted? If you notice that your thinking about something else, just bring your attention back to your body. Be aware of your kinesthetic sensation. How do your legs feel? How does it feel to inhale and exhale? How does the client’s tissue feel under your contact? Can you visualize the trigger point your working on releasing? What is the client’s body trying to tell you?
Step 8: Supplemental Techniques
After you have performed the protocols are their any stretch-release techniques or exercises you can perform with your client. This is an important step to restore the proper functioning of muscles that have been hampered with trigger points. It also helps the client realize that they can move more easily now. Make sure not to overdue it, just get the client’s muscles moving again.
Step 9: Client Education
Based on the muscles involved with their pain complaint, advise the client on what activities and movements the should avoid in the next few days. Ask them to keep their muscles warm, drink extra water, eat regularly, and rest for a few days.
Step 10: Record Keeping
If possible, create a folder for each new client and place their Client Information Form and some blank paper in it. After each session with the client, jot down some notes on the client’s progress and record any changes in their pain presentation. This information can become very valuable from both a clinical and marketing perspective over time. You might think about keeping and updating these records on your computer, instead of on paper.
Step 11: Follow Up With The Client
In the next day or so, call or email the client to see how they are doing. If you feel the timing is appropriate, this also a good time to schedule another appointment with them.