Takeaway:

Involving the client in treatment approaches can produce better outcomes, while also increasing their sense of empowerment and self-efficacy.

Mr. C. had visited my office with complaints of leg pain in the right lateral thigh. We sat down and discussed his experience.

“When and how often do you experience this discomfort?” I asked.

“I often feel it after sitting for any length of time, and sometimes when I am going up stairs. The pain is on the lateral side of my knee. It’s not a sharp pain, more like a deep ache.”

“How long has this been going on?” I asked.

“Several months. I should have come in sooner, but I thought it would be better by now. It’s not getting worse, but it certainly isn’t getting better either,” he replied.

I asked Mr. C. to stand up and do a squat for me, hoping to replicate the pain. As he did, he was able to point to an area just anterior to the iliotibial band, likely on the vastus lateralis. Transferring to the table, I began to thoroughly explore the area. As I approximated the area of his pain, I saw him react with discomfort.

“I assume this is the sensitive area?” I inquired.

“That’s certainly more tender than I expected it to be,” he said.

“Does this feel like the exact area you described earlier?” I asked.

“It is a very tender area,” he answered.

“Yes, but is it the exact area?” I challenged.

“You know, not really,” Mr. C. replied, after some hesitation. “Close, but that’s not it.”

In response, I moved my finger just a few millimeters in either direction, then made slight pressure changes, guided by his perceptions. When that didn’t produce results, I changed the angle of my pressure without moving my finger. Finally, the pressure and angle were perfectly aligned.

“Wow, that is exactly it,” he said. “Right on it! I can’t believe how painful that is.”

“Now that we have zeroed in on the area, I have a question. Does my pressure feel like a welcome experience to you, or do you feel yourself recoiling from the discomfort?” I asked.

“It’s the strangest thing. Even though it is painful, it feels like I’ve been waiting for weeks for someone to put their finger there. It’s painful, and yet indescribably beneficial at the same time.”

“The first task is to locate the area,” I said. “The next task is to decide the best approach to address it. Let’s explore some options. One option is to hold a consistent pressure, while another approach is to use small movements of my finger. Let me show you how that feels,” I said, moving my pressure about 2 centimeters in either direction.

“Which feels more productive to you?” I asked.

“When you move your finger back and forth, it feels like you are on it then off target again. To me, it feels best when you locate the spot exactly and stay there.”

“Then that is exactly what I’ll do,” I said. I located that spot again, with a bit of guidance from Mr. C. to be exactly on target. I promised to use only the amount of pressure he felt was productive and would hold that pressure steady. I demonstrated the amount of pressure I was putting on his leg by pressing with that same pressure on his forearm.

“No way,” he said. “It feels like you are pushing really hard on my leg, but that feels like nothing on my arm.”

“Yep, that’s how sensitive it is. I’ll just hold pressure and you tell me when the sensitivity is about 75–80 percent better.”

After a short time, Mr. C. said the sensitivity had all but disappeared. He then asked if I could do some larger stroking movements up the entire muscle. Having him lie on his side, he also directed me to the posterior aspects of his vastus lateralis, using both static pressure and movement-based work at his direction. We ended the session soon after.

Our session outcome was excellent; his knee pain all but disappeared over the next 10 days and has stayed that way for weeks.

The important lesson here is the power of client self-direction, involving the client in the treatment approach as much as possible. Having clients direct my hands and then choose what they perceive to be the most productive approach has been a game changer, both in my own practice and as a clinic owner with 20 therapists on staff. Clients feel not only part of the treatment decisions, but also in control of the process.

This approach has also substantially increased client satisfaction scores; the session they receive is one they play a large role in designing, rather than one the therapist decides is best. Clients learn to listen to their body and share that information with the therapist. The therapist’s task is to listen and respond appropriately. The best treatment outcomes are most often produced when the therapist and client are in a true partnership.