Are Your Clavicles Where They Should Be For Pain Free Movement?

Many of our lives have been turned upside down resulting in high levels of stress.  It is unclear when our lives will be back to “normal” and this uncertainty results in even more stress. All this stress results in a physical outcome as tension builds in our muslces and fascia. Meditation is a well researched option for effectively reducing stress and anxiety.  So why aren’t we all meditating?  
Many people don’t meditate because they don’t really understand how to do it and they get crazy frustrated when they can’t empty their mind or achieve the appropriate cross-legged posture.  The good news is that you don’t have to do either of those things.  The bad news is that is does take some effort but if you really understand the basics, it can be quite enjoyable and helpful.  The other good news is that it doesn’t just help with stress and anxiety. Meditation can improve focus, improve your mood, give you more energy and help you be more creative.  Those are some great reasons to meditate. 
The true purpose of meditation is two-fold. In the moment, meditation shifts the brain and body into a more relaxed and calm state resulting in an immediate positive change in physiology. Over time, meditation can change your brain and help you respond to stressful situations in a more positive manner.

Here are some practical tips to get started. 
First, you can meditate anywhere and in any position.  You can sit on a pillow cross legged or you can spread out on your lazy boy recliner, what truly matters is what is happening in your head.  As you get started, if your body is more comfortable, you will be less distracted.  You can even meditate standing in line at the grocery store!  Again, what is happening inside is what is most important. 
You can meditate for very short periods of time and get positive outcomes. Even just a few minutes can begin to shift your physiology and start you on the path to shifting your brain. Start with just a couple minutes at a time and slowly add a minute here and there as you gain skill and confidence. Also, time of day doesn’t matter.  Fit it in anywhere you can as you get started.  There are no rules.

Well, there are rules in some styles of meditation and there are many styles out there.  Once you get going you may want to explore what is out there and go down a more specific meditation path, but for now let’s just get over the hurdle of getting started. In ALL meditation styles there are several common ingredients and I’ll cover them all briefly here. I have a video you can watch that explains them as well.  

1. Breathe.  Learn to breath with your diaphragm.  Learn to breathe deeply and slowly.  This one skill can help you make profound shifts in your health and well-being.  The video above also covers diaphragmatic breathing.  You ALWAYS have your breath available as a focus point  Breath well and bring your attention to it often. 
2. Focus.  Your brain must have something to focus on.  We are wired for awareness.  Emptying the mind completely is nearly impossible.  The goals is to bring your attention to the breath, an object or a sensation depending on your choice of meditation style. You can be aware of other thoughts and sensations.  The goal is to learn to let them go and keep returning your attention where you want it and not get pulled down the rabbit hole of your wandering thoughts. 
3. Judgement .  Just let it go.  As thoughts enter your mind or as you notice sensations during meditation, do not judge them as good or bad. Experience them and let them go.  You will find yourself not only judging what is happening externally such as the sound of someone firing up their lawn mover just as you decide to try some meditation, but also internally.  You will get frustrated with yourself when you can’t control those pesky thoughts about what you’ll have for dinner later. Do not judge yourself and your ability to meditate. Rather congratulate yourself each time you notice your attention has wandered and you have decided to bring it back to your object of focus.  Treat yourself gently in the process of learning much like you’d teach a puppy or small child a new skill.  You are gentle, patient and encouraging with them, be so with yourself. This is probably the number one issue most of us struggle with when practicing meditation. 
4. Calm. Learn to soften your body.  Learning to spot tension in your body and continually let it go will help you be more comfortable as you meditate. Soon, this will cross over into daily life. 
5. Mindfulness.  Keep your attention in the present.  Stress and anxiety are typically past or future oriented.  We can’t change the past and can plan appropriately for the future but can’t control it.  Staying in the present is generally much less stressful.  Use your five senses (sight, sound, touch, smell and taste) to pull your mind in to the present. 
6. Process. Let go of any outcomes you are trying to achieve and simply focus on the process of meditation.  It is called a meditation practice.  Practice regularly and focus on the process of continually bringing your mind back to the object of focus.  In a five minute meditation you may have to do this fifty times.  That is OK.  Next time it might only be thirty or it might be fifty-one. If you stick with it, it will get easier.  

There are many strategies you can use to help yourself let go of those pesky intrusive thoughts that will continue to interrupt your meditation process.  I will share those in the next post.  For now, you may want to watch the introductory video, Practical Meditation.  This will also introduce you to a simple meditation.  My follow up video cleverly titled Practical Meditation #2 will introduce you to a few other styles of both sitting and standing meditations.  Happy meditating! 

We commonly refer to clavicles as collar bones. The clavicle bones are the two long thin bones beneath your shoulders on the front of your body. You can easily feel them with your fingertips. The clavicles connect the sternum (breastbone) to each scapula (shoulder blade). They are far more important than you might think. Five muscles (pectoralis major, sternocleidomastoid, subclavius, deltoid and trapezius) attach to each clavicle supporting complex three-dimensional motion. The clavicles and the attached muscles supply the support and motion required for complex shoulder and arm function. If one or both of your clavicles are not in proper alignment, your shoulders and arms are likely unable to achieve their full range of motion. This misalignment is very likely to lead to an injury or pain that seems to come out of nowhere.

Why might one or both clavicles be out of alignment? This is most likely due to tight muscles or fascia. Tightness is often a result of past injuries, repetitive awkward movements, chronic poor posture, or a combination. So, how do you know if you are at risk? Look in a mirror or have someone take a photo of you with your clavicles in full view. If your clavicles don’t appear to be horizontal or near parallel with the ground, you likely have some tightness pulling your clavicles out of alignment. The more angled one or more clavicle is, the more out of alignment it is. It is far more common for the slope of the clavicle to be lower toward the center of your body and higher on the shoulder side. You may also have one or both clavicles out of alignment from front to back as well. If your shoulders are slouched the shoulder end of the clavicle may be farther forward than the other side.

In the photo above, the model has very horizontal well-aligned clavicles.  The model below has very angled clavicles.  This position may indicate an imbalance of tension in her muscles and fascia.  The third model at the end of this article has her shoulders pulled up and forward creating both a slope and a forward position of the clavicle.  This is a very unhealthy position.  Hopefully this was just a pose for the camera and not a permanent position of her clavicles!  

Another clue when you look in the mirror is noticing where your arms hang in relation to your body. When everything is in good alignment, the tip of your middle finger should be able to feel the side seam of your pants. (This may also be affected by lower body alignment but we’ll stick with the clavicles for now.) If your arms are hanging forward from your body, the muscles and fascia around your clavicles are probably very tight.

Here’s what can you do if your clavicles are not in the best possible alignment. Notice what muscles you need to engage to exaggerate the angle of your clavicles. The upper trapezius muscles pull the shoulder end of the clavicle up and the pectoralis pulls it forward. Lengthening these two muscles is a great place to start. You can start by doing the shoulder stretch on my website.  mayerwellness.com/stretch-and-mobilize-your-fascia They key to stretching with the intent to address tightness in the fascia is to go slow , be gentle, and hold the stretch for at least a minute or two.

Taking your muscles and joints through their full range of motion on a regular basis is another way to keep your body healthy. This helps to maintain range of motion, muscle balance, and good blood supply to the area of the body you are moving. A wonderful simple and fun exercise you can do anywhere is the Paint the Bubble exercise. Look for it on my website. mayerwellness.com/stretch-and-mobilize-your-fascia This will take your shoulders through their full range of motion. Notice how your shoulders feel before and after this exercise. You will be amazed that you can actually feel a difference!

Now go look in the mirror and check out your clavicles!

We’ve all heard babies should have time on their tummies. Tummy time is not about their    bellies. It is about their back and helps them develop a spine strong enough to help them lift their heads, sit up and prepare to stand and walk. Imagine a toddler trying to walk with their spine and hips still in the fetal position. The prone or tummy position stretches out the front of the body and strengthens the hips and back. This creates the strength and balance necessary for continued development and healthy alignment. If you’ve been around babies who are just starting tummy time, you know that it isn’t always welcome at first. But, as the baby gets stronger, it becomes another fun way of exploring and interacting with their environment. Adults need tummy time too, but for entirely different reasons. 

When I recommend tummy time to my teen and adult clients, I often get “the look.” That “what you talkin’ about Willis?” face. I laugh, then explain. 

Adults (let’s include kids and teen in this conversation too) rarely spend time laying on their stomachs. Some health professionals also recommend not sleeping on your stomach, which in my opinion, only makes sense when there is a medical issue, injury, or significantly limited range of motion in the neck. For many of us, it is just fine and actually a good idea. It promotes neck range of motion and helps us get back what we lose during the day from looking forward constantly. Sleeping positions could take up another entire article. If you are interested, you may want to check out my blog on pillows.

Back to getting prone during the day…

Our culture is set up so that we are almost always sitting. Toileting, eating, working, driving, relaxing, etc. all involve chairs of varying structure and   comfort. Chairs didn’t become common until the 16th century. Since then, we’ve kept making them more and more cozy and   comfortable. Our bodies have become very accustomed to chair sitting. Chair sitting isn’t necessarily bad, but most of us are using them irresponsibly. We collapse into the chair, letting the chair do the work of keeping us upright. We allow our tailbones to tuck under and our head to sink forward. What does this look like? The fetal position!

Our bodies become sticky in the positions we are in most, especially if we don’t move them regularly through a full range of motion in different planes (think yoga, tai chi, dancing or similar). Add up the hours you sit in a day. For many of us that will be 12 plus hours. Ouch! Not only does our fascia thicken and tighten with lack of movement. This habitual positioning creates muscle imbalances. Some are far longer than they are intended to be, and others are short. Both are probably tight. What to do? The good news is that our bodies are very resilient.

To get on the path to tummy time, the first thing you should know is proper pelvic positioning. There are a variety of landmarks, but this is probably the easiest for most people to find. Stand sideways in a mirror. Feel the bones that stick out the furthest in front on both sides of your hips. These are known as the anterior superior iliac spine or ASIS. Now, find the pubic bone. Put your fingers just under your belly button. Press in and slide down until you feel a bone. That is the top of your pubic bone, which is also part of your pelvis. These three bony landmarks are all connected. Now try this movement that will remind you of The Rocky Horror Picture Show. Tilt your hips, so the pubic bone is further forward than the ASIS landmarks. Now try tipping the ASIS points back and your pubic bone forward. The goal is to line them up in the same plane as shown in the picture. This is the position where your lower back is the strongest. It is also the best position for diaphragmatic breathing and pelvic floor function!  This position also  allows the upper body to stack up in best alignment. So if you can’t get rid of your neck or shoulder pain, check your hips!

You may be able to feel the landmarks better if you get on the floor on your tummy. A floor is best to try this. A bed is too soft and will skew your results. Make sure to have your chest and shoulders close to the floor also. Can you feel those three points touching the floor? If not, reach your hand to feel the landmarks.  What isn’t touching? Can you tilt your pelvis back and forth to get there? If you can’t your fascia, muscles or joints are probably sticky. Don’t force it. Instead, stay there and see if your body will slowly adjust. Give it time. It may take a few minutes or a few months. But moving toward proper pelvic alignment is a huge step to better overall health and less pain. If you have trouble achieving this position with gravity helping you, you will have a tough time working against gravity while standing. 

If this is too hard, start on the bed, but move to the floor when you can. You can take your tummy time further by adding a ball to stretch your abdominal fascia and muscles. See more in my video Belly Stretch.

While in tummy time, you probably won’t have anyone entertaining you or cheering you on like you may have had as a baby during tummy time. But you can entertain yourself. Read, play a game, listen to a book or music, watch the news or some Netflix or better yet, meditate. Get your family and friends doing it too!

If you need help finding proper alignment and deciding how to get there, make an appointment. I’m happy to help!

This is a common question with a complicated answer.

I taught at Creighton University for 20 years.  Before my students asked almost any question, they already knew the  answer I would give them. It became a running joke.  The answer to almost every question about how to treat an injury or a diagnosis is…

…it depends.

A good healthcare practitioner (Western or Eastern medicine) knows they are not treating a diagnosis or an injury.  They are treating a person. We are all very similar, but we are all extremely different. There are no clear answers.  There is good solid research out there for many issues we face, but what we have is really a drop in the bucket.  And, the answers often change as new knowledge is always emerging.

Dr. Gabe Mirkin coined R.I.C.E. in 1978. This stands for rest, ice, compression and elevation. It has been a commonly accepted practice for treating injuries but there has never been great evidence to support it.  It has also led to many common misconceptions about what to do for all types of pain.

In this short article, Dr. Mirkin discusses how icing or cooling actually delays recovery. Our natural response to injury is inflammation.  It is a natural part of the healing process.  Icing constricts blood vessels and prevents healing. However, he does say that icing may help prevent pain, but we should only do it for short ten minute periods immediately following an injury.

The Cochran Library provides us with a systematic review of heat and cold for low back pain. There is moderate evidence for heat and very little evidence for cold.

What about the R. or the rest in the R.I.C.E. protocol? The NIH provides a fact sheet on low back pain. There is strong  evidence that you should not stop moving. You should move gently within a safe range of motion respecting your body’s pain limits.  This movement pumps the muscles pulling healing blood deep into the tissues.  This pumping also mobilizes the lymph which is critical for healing. If you are not sure how much you should move based on your injury, talk to your healthcare practitioner.

What should YOU do?

• Discuss your options with your healthcare provider. There may be other variables you should consider when deciding how to treat your pain. For example, if you have a condition that decreases your ability to feel, it may not be safe to use either heat or cold.
• If you are not experiencing an acute injury, the evidence points to heat. But, heat doesn’t mean hot.  Gentle warmth is best.
• Everyone is different. Even though the evidence might point to heat, if you are in pain and ice enables you to decrease your pain enough to move and complete your daily tasks, ice may be the better option for you.  Life keeps on going despite our pain but use it sparingly.  Keep in mind that cold decreases your ability to feel so move with caution after using cold.
• If your goal is to move or stretch your muscles and fascia, the evidence points to warmth.
• You can do both. Alternate heat and cold.
• Remember that both should be used with caution. Don’t put either directly on the skin. Place a layer between the modality and your skin such as a bath towel.
• The American Chronic Pain Association provides a Resource Guide addresses many options including heat and cold.

Gardening is full of risks, especially when you are going from being very sedentary during the winter to all the bending, squatting, lifting and walking on uneven ground yard work and gardening require.

I created a short video to provide several tips for transitioning safely into this wonderful activity that is so good for your whole body and soul.

Find the video at: https://www.youtube.com/watch?v=qG9pvygvrBY or search Gardening Tips to Reduce your Risk Factors on YouTube.

Here is a quick summary.

• Stretch your feet, calves and hamstrings before you head outside.
• Practice squatting to prepare your joints. Use a door handle for balance until your legs are ready to support you.
• Regardless of your body position (standing, bending from the hips, squatting, kneeling, sitting), always maintain a good low back curve.
• When bending over build a bridge with your hand or elbow to take some strain off your low back. (see photo)
• Balance your body from front to back from a plumb line that begins at your ankle. Keeping the weight in your heels will help. (see photo)
• Switch hands frequently when weeding.
• Wear well fitting gloves with a non-skid surface on the palms to reduce the grip forces required for grasping.
• Keep your tools in good working order.

Legs Up the Wall pose is wonderful for so many reasons. I frequently recommend it to my clients who have low back pain, tight hamstrings, tight calves, leg cramps or foot pain. This pose is also great for calming your nervous system and pairs well with a short meditation.  It is such a simple looking pose but offers the body and mind so many benefits.

Below are some additional benefits this position offers:

• Stretches the hamstrings (back of the thighs)
• Stretches the calves
• Stretches and retrains the low back curve
  • It stretches all these areas (legs and back) in combination which is important in functional movements such as walking, bending and reaching.
• Facilitates blood circulation
• Facilitates lymphatic circulation
• Relaxes the pelvic floor
• Stretches the shoulders

But, what if I can’t get on the floor (and back up again)?

I encourage all my clients to practice getting up and down from the floor. Doing Legs Up the Wall Pose is a very purposeful reason to practice this skill.  Getting up and down from the floor uses many muscles and joints in a way we generally don’t during the day (and night). It is a skill we all need, especially as we age.

If you can’t get up and down without assistance, place a chair beside you to help with getting up and down. Take your time and do it mindfully. But, work toward being able to do it without a chair.  You never know when you might need this skill.  If you drop something important and it ends up bouncing a few inches under the couch, you may need to get on the floor.  If you have grandkids who are begging you to play picnic with them, you may need to get on the floor. Hopefully, you never need this skill because you fell, but if you do and there is no one around to help, you will be glad you have this skill. The process of getting down on the floor and up again is a good movement for your body.

Tools You’ll Need

Technically, you don’t need anything to do the pose, but there are a few items that can make your experience more comfortable and help you get the most from the pose.

• A yoga mat can soften the surface you are laying on and encourage you to stay longer. You must be patient when stretching the back of the legs.
• A towel can be folded or rolled up to support the low back curve. You should always maintain a healthy low back curve when doing the pose, so you are stretching with the back in a functional position.  If you can’t tolerate the towel, even with just one fold, you are too close to the wall. Work towards a combination of adding folds in the towel to increase the curve and getting your tush closer to the wall.  Be patient.
• A yoga strap can be placed around the thighs or the calves to keep your legs and feet in line. If you find your feet tend to roll out or in, the strap will keep them pointing in the right direction and allow you to soften into the pose fully.
• Therapy balls can be an excellent addition to the pose. You can place them under your back or shoulders for a little added release during the pose.
• Thick socks may be helpful if your heels are tender. The added cushioning may make it more comfortable.
• A book, music or a podcast can help you be more patient with your pose. Try just breathing for five to ten minutes, but if you’re not there yet and need some entertainment to get the physical benefit from the pose, that is absolutely fine.

You may want to visit my Self-care Products page to find the items you may need.  You’ll find helpful links to the tools. Let’s get started.

Doing Legs Up the Wall Correctly

• Start with your hips 10-12 inches (or more as needed) from the wall, so you are not placing too much tension on the back of your legs. Wiggle yourself closer or further from the wall until you feel a mild to moderate tension in the back of your legs. You may feel the tension in your calves, your thighs, your hips, back or all. There is not a right or wrong. You will feel it where you are the tightest first.  The sensation may shift around. You are stretching fascia as well as muscle. 
• Keep your legs hip-distance apart and your toes pointing forward. If you have trouble keeping your legs and toes in this position, use a strap around your calves. This allows for even deeper relaxation.
• Place a rolled-up towel under your low back to keep your low back curve from flattening. Start with a small roll and increase it to stretch this area.
• Once you have the legs and low back in place, breathe deeply using your diaphragm. Be very patient. Continually scan your body from head to toe and soften any part of your body that has tensed up.
• If you noticed that you are no longer feeling mild tension in the back of your legs, hips or low back, you might be ready to move closer to the wall. Try gently pressing the bottom of your tailbone closer to the floor. If this creates a pulling sensation, you’re ready to move a little closer. If the feeling was intense, just move a little closer, maybe half an inch.  If it wasn’t very intense, you could try moving an inch or more toward the wall. You can do this by placing your feet on the floor and walking your hips toward the wall.

Additional steps to add more benefit.

• With your arms on the floor and your palms up, begin to slide your arms up to 90 degrees or more. This adds a nice shoulder stretch to your pose.
• Use deep diaphragmatic breathing to calm your muscles and promote lymph circulation.
• Make the pose even more beneficial by adding a therapy ball under your upper back. Allowing the ball to sink into your fascia during the pose can relieve tension in this area as well.

Your long-term goal is to be able to easily get down on the floor and do the pose with your bottom against the wall.  This may be in the near future for some of you but pretty far off for others. The short-term goal is to begin.  The benefits are worth the effort.

Thank you to Gessica Stovall, OTS for posing for the photos.

By Amy Mayer OTD, OTR/L, RYT

This fall I have seen a surprising number of teenagers in my practice.  I think most people will say this is not surprising with all the phones and video games teens are using.  I agree.  But, let’s dissect this a bit more because teens are NOT going to stop using technology and devices are getting into the hands of younger and younger children all the time.  As a mom, grandma, and occupational therapist I must implore parents to do the best they can to balance tech time with lots of outdoor and indoor free whole-body play.

The teens I worked with last fall all were injured during exercise.  It was awesome that they were exercising.   I’m sure they and everyone around them most likely thought what they were doing was going to keep them healthy and protect them from injury.

Some of the teens were injured during exercise they were doing on their own, and two believed they were injured during training that was part of a school activities.  In two cases the activity was weight lifting, and one was following a DVD program. In all the cases the students said they had some instruction about how to do the exercise safely.  When I asked them to describe how to do the tasks safely, it was quite superficial and, in most cases, included how to protect your back.  This is good, but it assumes the exerciser is starting with a body in proper alignment and know how to keep their back safe.

The Nebraska Department of Health Education standard related to the use of technology states, “Students will analyze the influence of family, peers, culture, media, technology and other factors on health behaviors”.  This standard is becoming more and more critical as generations of people including kids, parents, and grandparents are using technology.  Our children are observing us.  This is how they learn how to react to stress, grammar and speech patterns, gait (walking) patterns, gestures, posture, how to spend time and energy, etc.  It is not just about how technology affects health behaviors but how our family and culture is using technology. It is much bigger than what I am going to focus on in this short article.

This health education standard is incredibly important.  To my knowledge, there is no direct description related to how this standard must be implemented in a school’s curriculum.  Use of technology affects health in so many ways including mental, emotional, and physical health.  Just in the category of physical health, it can affect eyesight, attention skills, coordination, posture, body weight, etc. With so much to teach related to health education, it would be easy to miss the details of posture and body alignment.

Kids are using technology with rounded backs, tilted hips, rounded shoulders, and flexed necks. They are sitting for longer and longer periods. They are less likely to spend long periods in activities where they are jumping, climbing and running with recess and gym classes being shortened.  All this creates tighter muscles and fascia.  All this tightness continues to pull their bodies out of alignment.  When the human body is chronically out of alignment, meaning the muscles that surround the joints are either overstretched and tight or shortened and tight, the fascia’s job is to thicken up to protect joints. The fascia is trying to protect us and support the function we are asking our bodies to do most.  The problem comes when we ask our bodies to do something very different such as lifting free weights or doing burpees.

You may have heard your teen (or younger) complain of aches and pains, and you know they aren’t lifting weights or doing burpees. If our bodies are chronically out of alignment and stuck, even simple activities can be problematic such as lifting a heavy trash bag, pulling a box out from under the bed, or catching the dog who got out of the yard. It can even be as simple as reaching for the shampoo in the shower.  We should worry if we hear kids complaining of pain from these simple daily tasks.  We should really pay attention when we know our teens are starting to participate in more demanding exercise type activities.

Typically, if our bodies were in proper alignment, it would be no big deal to grab a couple of 5-pound weights and start pressing them to the ceiling. But, if our shoulders are stuck in a rounded forward position with muscles that are tightened in either a short or elongated position (even just a few millimeters), and we lift those weights, we are asking for trouble.  Our complex shoulder joints are designed for complex movement and need to be moved through their full range of motion regularly to function best.  Regularly doesn’t mean 3 times per week for 20 minutes.  Regularly means daily, several times per day. Instead, the position our neck and shoulders see most is rounded forward grasping a phone or typing on a computer.  This idea applies to our feet, ankles, knees, hips, ribs, neck, elbows, wrists and fingers, too.

We must educate our kids on what proper posture is, and that is it not just standing or sitting up straight.  It starts at the feet and goes to the top of the head with many important details in between. We must take responsibility for our children to help be sure their bodies don’t slowly get stuck in a poor position. We must watch over them, and if we allow lots of sitting time, we demand lots of whole-body movement time.  We must watch to be sure their bodies are not slowly rounding forward at the neck, shoulders, and hips. We are setting them up for injury when they are old enough to decide on their own it is time to move and get fit.  They must understand that body alignment is perhaps the most crucial part of a fitness routine.  They will experience more success and fewer injuries if they pay attention to the details of alignment first.

Every fitness program, regardless of age, should begin with an assessment of your body alignment no matter how young (or old) you are.  If you find details of alignment that need to be corrected, every program should begin with exercises that focus on bringing the body back into alignment.  Once proper alignment is achieved, full-speed ahead.

For details on correct body-alignment visit https://mayerwellness.com/.

I have had a very small private practice for many years and never processed insurance. I have also practiced within larger institutions who did process insurance.  Since I have formalized my private practice into a limited liability company, I have waivered back and forth regarding whether I should become a provider and process insurance, or not. I am in my 6th month of full-time practice, and I still do not process insurance.  Despite this, my practice continues to grow.

Occasionally something happens that makes me rethink my stance on processing insurance.  A client might ask about insurance or tell me they’d come more often if I took it.  They might say to me they have passed my name on to someone who could use my skills, but they won’t come because I don’t take insurance.  It may be because they can’t afford it, or merely because they think I should take it because I’m an occupational therapist. I have talked with people that are baffled by this choice, some that are irritated by it, and others that applaud me.

On the topic of not being able to afford “out of pocket” services… I know there are some who think that only the elite can afford to pay out of pocket for the services I offer.  I was a little concerned about this too. However, I have found that it is less about income and more about where people place their value. I don’t use a sliding scale or ask about salary when I intake a new client, but I do ask about the type of work they do to get a feel for how they use their body. Their job may or may not tell me about their financial status.  I don’t know about their spouse, if they have one, or their savings account, or if they have a health savings account.  (I do make sure to tell them if they have a health savings account, they can use it since I am an occupational therapist.) With high deductible plans becoming common, more clients are expecting to pay out of pocket. Most of my clients don’t question this arrangement.  It is on my website, and I don’t proceed with my evaluation until it is clear that I don’t process insurance. I don’t want any suprises. I also never pressure clients to return.  It is up to them if they find value in my services and want to continue.  If they do, they decide when and how often. I also volunteer my services to be sure I am helping people who can use my skills but can’t afford them.  I do think it is essential to give back to the community and I am working with a local non-profit to do this regularly.

I continually reflect on how I want to grow my practice and how I want to shape my life.  When you own a business, it becomes your life.  I crave a simple life, and processing insurance is NOT simple. There are many rules to follow and tasks to complete that extend far beyond client care. I want as much of my energy, creativity, time, and problem solving as possible to go into client care.  On the flip side, I could charge more and make more if I took insurance.  In the state of Nebraska, if I accepted Medicare, I could make about 40% more per visit.  If I accepted other commercial insurance products, that number would go up. However, with others, it may go down. Some pay based on the service description (CPT codes) and others pay a flat rate often based on their determination of an average treatment time (usually 30 minutes). I have also compared my hourly rate to other practitioners around the country who have the specialized skills I use in my practice. Some practitioners charge more than triple what I charge.  The practitioners are not just on the coasts where the cost of living is higher — many practice in the Midwest.  I recently had a client who found an MFR practitioner in Oklahoma for her mother.  This practitioner has much less experience and charges double my rate. Ultimately, even though I could make more money, I want do not want any insurance company dictating how I interact with my clients, provide therapy and operate my business.

Recently I had an experience that made me reflect on my decision not to process insurance.  Usually, these experiences push me to reconsider processing insurance. Many times, I have reopened my provider application to Medicare, but something always stops me. This recent experience made me dig in my heels and affirmed why I don’t.  I don’t want to share too many details about what was going on with my client, but we had a great discussion about insurance, evaluation, and documentation.

The bottom line, not processing insurance allows me to practice how I want to practice. It allows me to spend 100% of my time with a client addressing their needs exactly how I think is best (in collaboration with them of course).  The insurance company does not dictate how long each visit lasts and how frequently we meet. It cannot cap how many sessions we can work together. It cannot stop therapy if progress is slow or they deem therapy to be medically unnecessary Many clients begin with several visits, trail off, then come back intermittently as they need help.  Each client’s frequency and duration of visits varies widely.  Again, the client decides rather than the insurance company.

Insurance companies want objective information.  They want proof that a person has pain.  They demand objective reproducible, measurable information to prove a person actually has pain, and proof that the therapy being provided is making progress toward an objective, measurable goal. There is not always a clear measurable deficit that accompanies pain.  Most of my clients can do all their daily tasks.  They go to work every day. They take care of their families.  They are happy and interesting people. They have normal range of motion and functional strength. Many have had imaging tests that do not show a problem.  …and yet they have pain. Sometimes the pain is mild and intermittent and sometimes it is severe and chronic. But, they are still functional.  They must be.  Life won’t allow less.  It is the quality of their experience that brings them to therapy.  My therapist friends might ask, “don’t you use a pain scale?”.  I used to.  It just doesn’t work for many of my clients.

A pain rating is a snapshot in time. There are times when a client walks in, and they tell me they are doing great right now, but they had pain during the weekend when working in their garden or while at work lifting boxes or it wakes them up at night.  The nature of fascial pain is that it does change.  It is not always in the same place or the same intensity.  It can increase and decrease depending on the overall tension in the body.  Tension can change with changes in activities and stress.  Both activities and stress change every moment of every day.  Pain can get a little better, then worse, then better again.  The path to healing is NOT always linear. And, some of my clients say they don’t really have pain.  They describe it as tension or tightness in their bodies. So, the pain scale doesn’t really work in my practice, and I no longer use it.

I also don’t typically take measurements or use assessments of any kind.  I may do some testing to pin down an issue, or take a measurement if a client has a specific concern about loss of stretgth or motion.  I do complete an evaluation with every new client.  I get a full history, and I evaluate their body alignment in great depth. We discuss their activities, work and wellness habits. This process helps me determine if there may be a connection between their experience of pain and their life habits. When it comes to them telling me about their pain, where it is, when it hurts and how bad, I simply believe them. I don’t have to have objective evidence (which often doesn’t exist) to prove they need therapy.  If they are spending their own money to get help, I don’t need proof.  I don’t waste any time collecting information I don’t need to help them. I spend 100% of my time collecting data that will help me help them.  The information I collect is often subjective, and part of the person’s lived experience and not a standardized assessment. Each follow-up session is 100% problem solving and treatment.  I don’t need to spend time repeating assessments to prove change is happening. I simply ask my clients how they are doing, and we go from there.

Note: I am not trying to state that health insurance for therapy services is not a wonderful benefit. It absolutely is. However, it comes with many requirements that shape both the business and the services offered.  It is far better suited for diagnoses that come with measurable effects and result in clear funcional deficits.  I want to offer something different for my clients who don’t always demonstrate clear measurable impairments or have functional loss.  The common thread in both groups is loss of quality of life.  That is very difficult to measure.