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Q Morgan in Oshawa asks: I’ve started working with a client who has persistent referred pain after gallbladder surgery—this has been bothering her for months. She believes that scar tissue is the root of the problem, given the experience she had after a c-section years ago (massage helped then). The issue we’re facing is this: each time I begin to work on her abdomen, she starts to hyperventilate and get really “panicky”. These episodes catch her off guard because she’s not aware of any past trauma that might explain this triggering.
A Alison: I'm glad you brought this up, Morgan. In bodywork, it’s not uncommon for clients to have emotional releases that seem to come out of nowhere. It might be helpful to reassure your client that her experience is normal and quite common. Fortunately, we don’t always need to know the specifics behind these emotions (or any thoughts our clients might be having) to support their nervous system to stay well regulated during treatment. Trauma-informed strategies aren’t trauma-specific; they can be effective when sensitivity arises, even if we don’t fully understand its origins. First things first, it’s important to confirm that her surgeon has cleared her for massage in and around the surgical site. Only the surgeons know what internal structures (sutures or stents) might still be in place. When it comes to positioning, I’d suggest not having your client flat supine. Instead, try having her flex her knees and hips so her feet are resting flat on the table; you can place a few pillows beneath her knees for support. This takes some of the tension off the abdominopelvic tissues, allows the low back to rest more fully against the table, and feels less vulnerable to the nervous system compared to lying flat. (Think of how newborns often seem relaxed when they’re curled up, but cry when laid flat on their backs.) For clients with nervous systems that need a bit more support, I like to treat sensitive areas through a sheet on a first attempt. While this may be less effective than treating directly against the skin for certain techniques, our client’s sense of comfort and safety takes higher priority, for both our therapeutic alliance and the efficacy of treatments. A client with a highly activated sympathetic nervous system isn’t in a conducive state for meaningful healing to occur. When your client is ready to try treatment directly on her skin, involve your client in the process of securing the draping. She can help tuck the sheets snugly so that she really feels the boundaries they create. For example, she could tuck one sheet into the band of her bra and another into the waistband of her underwear. You can also offer to place a heating pad (turned off) or a folded sheet or towel across her chest and upper thighs for some reassuring pressure. This is a consent piece; while some clients find pressure to be soothing, others may feel claustrophobic or "stuck". Collectively, these sensory cues are intended to reinforce the draping boundaries, helping her nervous system clearly understand which areas are being treated and which are off-limits. For a highly sensitive client, another strategy is to start by having her rest her own hand on her abdomen. Our sensory processing centers perceive self-touch differently than touch from others, so this approach can help her nervous system gradually acclimate to therapeutic touch. Once her hand is in place, you can gently rest your hand on top of hers and invite her to take a few slow breaths as she gets used to this contact. When she feels ready, she can slide her hand out from under yours, so that only your hand remains. At that point, cue her to again take a few slow, easy breaths, allowing her nervous system to settle before you move on to specific manual techniques. The nervous system can take time to adapt, so I’d suggest trying these strategies over 2 or 3 sessions to let that process unfold. If, after that time, your client is still experiencing the same level of sensitivity, it might be time to refer her to a colleague who specializes in helping clients process these kinds of emotional responses.
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Q Carleen in Portland asks: I’m a physiotherapist specializing in women’s health, and many of my patients are referred for pelvic floor work. I’ve noticed that pelvic exams can be particularly challenging for patients who’ve experienced sexual violence. Beyond clear communication around informed consent and what to expect, what can I do to make these exams easier for the women I work with?
A Alison: I’m glad you brought this up. Pelvic exams can be inherently stressful, particularly for patients who have experienced trauma. Let’s start with your intake form. Since pelvic exams are a routine part of your practice, it may be helpful to include a section about them on your intake form. You can ask new patients if they’ve had pelvic exams in the past and, if so, what they would like you to know about their experiences. Were the exams comfortable for them? Challenging? If they were challenging, did they find any specific strategy or approach helpful? By understanding what has worked for your patients in the past, you can offer more personalized care rather than relying on a one-size-fits-all approach. It’s also important for patients to know that they don’t have to face challenging appointments alone. You can address this on your intake form by letting clients know they are welcome to bring a support person to their appointment. To ensure clarity, explain how the exam room is structured to accommodate a support person while still maintaining your patient’s privacy. The interview portion of the appointment provides a key opportunity to empower your patient by letting them know they’re in control of the pace. If they need to take a break or defer part of the exam to another day, those options are available. Before starting the pelvic exam, establish a nonverbal signal (like raising a hand) that your patient can use if they need to pause or stop the exam. This proactive approach can make a significant difference in your patients' experiences, fostering a sense of safety and control. This, in turn, can help ease anxieties, particularly for survivors, and improve their overall experience of accessing care. One of the inherent challenges of pelvic exams is the exposure from the waist down. This can feel vulnerable for most people and may be particularly triggering for survivors of sexual violence. I worked with a patient who used to wear a pair of thick, long socks whenever she had to undergo a pelvic exam. These socks reached well above mid-thigh and helped her feel less exposed, allowing her to focus on her breathing and stay calmer during the exam. You might consider keeping a selection of long socks in your clinic for clients to use, similar to how some physiotherapists provide gym shorts. If you decide to offer long socks for pelvic exams, they can be sanitized after each use following the same protocol as other clinic laundry, such as table linens and towels. |
Practice Q&AEach week we'll dive into some of your practice-related questions - from Big Picture considerations, like how to incorporate a more trauma-informed approach in your intake process, to the finer points of specific case studies. We're here to support you in your practice, so send us your questions! Questions can be submitted through our Contact form here:
*Please protect your clients' privacy! When asking about a specific case you're navigating, please don't share any identifying information.
**I also respect your privacy, so please let me know if you'd like to remain anonymous and I'll make this happen. Alison Fraser, RMTAlison Fraser, RMT, is the author of Touch After Trauma, a book that offers manual therapists a new clinical framework, presenting the neuroscience of trauma in plain language and weaving in principles of trauma-informed care. ArchivesCategories |
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