Dear LyndaLMT,

I am from the Midwest and have a successful massage therapy practice. What advice do you have on steps I can take to grow my practice, including adding a physical therapist and an acupuncturist? Do you know of massage therapists who work with both? If so, do you know if they work as employees, independent contractors or partners? Enjoy your column.

- Steve from a Midwestern state

Dear Steve:

Talk to other therapists who have taken this step to find out how it is working for them. I also suggest you contact Maria Turk. She owns the Center for Massage and Clinical Therapy in Winter Park, Fla., and works with both a physical therapist and acupuncturist. Here is what she had to share:

It is wonderful to hear that you have a successful practice. I had a massage practice for five years, with a staff of four massage therapists as employees. I brought a physical therapist on board as a part-time employee. After two years, I determined he was a team player and self-motivated - he went out to market the physicians and insurance companies to develop the physical therapy department - which is when I decided to make him my partner. Soon after I hired the physical therapist, I brought on an acupuncturist as an independent contractor. Consider hiring physical therapists or acupuncturists as part-time employees or independent contractors. They can complement your practice. As independent contractors, they pay rent for the space they use. If you find they are working well, you may want to consider bringing them on board as partners after you have worked with them for at least one to two years. During this time, you will find out whether they work as a team and help grow your practice. If you find they work well, start working with a CPA and corporate lawyer to define your practice with the potential partner(s). Please feel free to contact me for more information at marialmt@aol.com.

Wishing you much success,

Maria Turk, LMT, NCTMB

DearLyndaLMT,

Can a registered nurse and massage therapist perform perineal massage for urinary incontinence in the state of Wisconsin?

- Shirley

Dear Shirley:

I forwarded your question to Wisconsin resident Seth Will, a certified massage therapist and acupuncture student currently on staff with David Kent Seminars:

The scopes of practice of both a registered nurse (RN) and a certified massage therapist (CMT) in Wisconsin can be found at www.drl.state.wi.us. The statutes are unclear regarding nursing and performing perineal massage. For massage therapy, the bylaws state that a massage therapist is a person who can and does use manual actions to palpate and manipulate the soft tissues of the human body. The perineum is a soft tissue, albeit a sensitive area. Clear explanations must be provided prior to treatment. The state wants to ensure therapists are able to validate the reasons for treatment with whatever procedure utilized in treating soft tissues. The most important aspect of manipulation of this region is communication, particularly clear explanations. I've learned from working with students and patients that as long as procedures are presented in a manner that unmistakably expresses the rationale, there is a high level of compliance.

Generally, patients who desire the end of a painful or debilitating condition are almost always willing to try anything. Although the willfulness is there, such an emotionally charged area cannot be treated without complete patient agreement and acknowledgement of the methods to be used. Anatomical models are wonderful tools for demonstrating techniques to be utilized. You may want another staff member present; if possible, the treating therapist should be the same gender as the patient.

There are several points to consider for treating the perineum for urinary incontinence. In adults, incontinence can be precipitated by various causes: "Unconsciousness, injury to the spinal cord or nerves controlling the urinary bladder, irritation due to abnormal constituents in urine, disease of the urinary bladder, damage to the external urethral sphincter, and inability of the detrusor muscle to relax due to emotional stress" (Tortora and Grabowski). Many of the causes can be treated with massage therapy, in conjunction with pelvic floor retraining exercises (Kegel). The primary innervation of the muscles of the perineum is that of the perineal branch of the pudendal nerve (S2, 3, 4). The pudendal nerve, along with the pudendal vessels, exit the pelvis through the greater sciatic foramen, next to the lower border of the piriformis, only to cross the ischial spine and re-enter the pelvis via the lesser sciatic foramen. "The internal vessels and pudendal nerve cross the pelvic surface of the obturator internus and are enclosed in a special canal (Alock's canal) formed by the obturator fascia" (Gray's). They continue from there anteriorly, becoming the perineal vessels and nerve, completing their destination after perforating the urogenital diaphragm. Throughout its course, the pudendal nerve and vessels have a few significant entrapment likenesses to ponder.

At its exit through the sacral foramina, almost all sacral nerves are in intimate relation to the anterior sacral attachments of piriformis. Abnormal tension of the piriformis has the ability to put strain on the nerves exiting here. Piriformis hypertonicity can also compress the pudendal nerve as it passes through the greater sciatic foramen. Once the pudendal nerve and vessels re-enter the pelvis, they are enclosed within the obturator fascia, which is adhered to the obturator internus - yet one more entrapment consideration. Also, any sort of pelvic girdle asymmetry has the ability to put adverse strain on the pelvic diaphragm, so thorough evaluation of the entire pelvis is essential.

A second consideration is the effect of trigger point involvement with perineal dysfunction. We all know nerves can cause muscle inhibition and atrophy in severe cases, but one commonly overlooked reason is the action of trigger points. The first sign of a trigger point is not pain, but muscle weakness. Trigger points that commonly refer to the perineum are the coccygeus, levator ani, obturator internus, adductor magnus, piriformis and internal obliques (Travell and Simons). Constant bombardment of referral patterns into this region can produce satellite trigger points, resulting in neuromuscular inhibition

The pelvis and perineum comprise a complex region, deserving of respect and precise knowledge of anatomical/functional considerations. One should not attempt to treat this region without prior instruction and experience. Within the field of neuromuscular therapy (NMT), the above-mentioned muscles are commonly treated externally for pain and dysfunction of the pelvis and perineum. Clear, concise communication and respect is of utmost importance.

Seth Will can be reached at info@davidkent.com. (Write "Attention: Seth Will" in the subject line.)