Use Your Case History to Reduce Risk of Harm

There are a number of reasons to conduct a case history for a new or returning massage therapy patient/client.  The case history helps to identify:

  • the source of the symptoms or dysfunction, and how to best intervene
  • contributing factors: environmental, emotional, behavioural, physical and bio-mechanical
  • precautions or preclusions (yellow or red flags) in conducting the assessment or treatment
  • Prognosis ie: how a person’s response to your intervention is determined by general health, extent of injury, expectations, lifestyle, and personal resilience

Probably the most important reason is to reduce risk of harm.  The case history is an essential tool for teasing out precautions and preclusions.  Here’s an excerpt from Charting Skills for Massage Therapists:

Precautions and Preclusions – Yellow and Red Flags

In the sports arena, a yellow flag indicates pre-caution when proceeding – a red flag precludes further action…stop!

As practitioners, when yellow or red flags present in the case history or assessment, they provide us “cause for pause” to ensure our care will not be harmful.  Primum non nocere... “First, do no harm.”

Fairly basic and common symptoms might have more serious underpinnings.  It’s important to attach additional questions to any yellow flags – including pain – that present themselves, and identify red flags that may require immediate medical attention.

Nicola J. Petty and Ann P. Moore describe the dangers of underestimating pain:

Since (manual therapists) are now ‘first contact’ clinicians, we have assumed greater responsibilities.  While those interested in manipulation and allied treatments energetically improve their competence in the various techniques and applications, we might profitably spend a little time considering what we are doing all this for…. Pain distribution might confuse unwary or overconfident therapists, who may assume familiarity with a syndrome they recognize and then perhaps find themselves confronting the tip of a very different kind of iceberg.[1]

Martha Costello reiterates the importance of rigorous screening in the case history.

Bodyworkers should be cautioned—often, when a patient has seen a medical professional prior to consultation with the bodyworker, it is assumed that all organic or pathological causes for symptoms have been ruled out.

 Unfortunately, this often is not the case, as the prior medical examination may have been cursory, and a thorough history may not have been conducted.  It is not uncommon for even a review-of-symptoms questionnaire to have been extremely brief, painting a very incomplete picture of the patient’s current and past health history. [2]

[1] N. J. Petty. A. P. Moore: Neuromusculoskeletal Examination and Assessment.  Churchill Livingstone 1998  p 28

[2] Martha Costello, DC: Chiropractic Rehabilitation: Journal of Bodywork and Movement Therapy, April 1998

Are you using your case history as a tool to reduce risk of harm?  Would you like to build more competence in this skill?  Have a look at the Charting Skills for Massage Therapists program.

CEUs have been granted in NFLD/LAB, PEI, NS, NB, ON, MB and SK, with others pending.

Your Practice, By Design…and You Are the Designer

Are you overwhelmed with the operations-side of running a practice?  Have you inherited a mixed bag of useful practice tips coupled with antiquated and even incorrect guidance?

Would you benefit from a how-to manual from start-to-finish, coaching you along the way in the development of your practice?  Can you use a resource that bridges to the higher level you aspire to?

Building on my 28 years of experience in practice, coupled with speaking to hundreds of practitioners across North America, I’m putting together a progressive Practice Operations workbook for massage therapists.

Each module provides theoretical constructs, real-life examples and reflective exercises to move you forward while honouring your past.

The best resource, of course, would be designed by you…for you.  Even if you’ve been in practice for many years (and perhaps especially for you), I want to reconfigure your feelings of isolation and frustration.  If you’re closer to the entry-level part of practice, all the better.  You can start off on the right foot and fast-track your progression.

Here’s what I need from you:  Have a look at this rough outline.  Would this progressively meet your needs, at whatever stage you’re at?  What specifically would you like to see included in the program?

What have been your practice challenges?  What pearls of wisdom would you like to share with others?

Entry-Level: Practitioner Physical and Security Needs

1) Profile – We start with you.  Reflective exercises tease out personal and professional talents that demonstrate your unique competence, experiences and skillsets as you lay the foundation upon which to build your professional career.

2) Provisions – Account for all assets you bring to the table – capital, contacts, business competence as commitment to see it through.  Evaluate if you have sufficient resources to launch your own practice, or would instead excel apprenticing in an established enterprise.

3) Purpose, Passion, Position in the Marketplace and Workplace – What do you bring to the marketplace?  Why does your product/service matter?  What populations do you serve?  What is your role in the workplace?  What are the values that guide your practice?  We drill down to your core beliefs so you can best position your practice launch.

4) Product, Pricing and Place – Define your “product” and how it will be packaged and presented.  Consider pricing theory and strategies while you contemplate the place (sector/delivery-of-care model) you will incorporate in your practice.

5) Promotion – Learn how to recruit prospective patrons, retain them for the long-term, reward patron behaviour that builds your practice, and re-serve (serve again) those patrons who would buy more from you.

6) Profit – Track key financial metrics, build financial competence, nurture growth and positive cash flow.  Unless your practice is just a hobby, you’ll need profit for growth, contingency and retirement.

Established: Professional Esteem, Relationships and Processes

7) and 8) Practitioner Relations – What role do you play in working with others?  What are your expectations?  Theirs?  Before you sign on the dotted line, consider the implications of the business agreement you’re entering into.  Learn how to strengthen relationships with your work mates and support staff.  If you’re a business owner, effectively scale up to incorporate practitioners into your enterprise.

9) Perspective – Comprehend the extrinsic factors that influence your practice viability – government policy and funding, insurance industry and gatekeeper health practitioner relations, public and media endorsement, competitors and profiteers.  Explore the profession’s culture and essential stakeholders as they exercise influence on your practice.

10) Promises and processes – Set practice policies and processes that deliver on your quality of care.  Consider regulations and laws that govern your practice.

Actualized: Professional and Personal Maturation

11) Potential – Evaluate and entertain delivery-of-care models, discuss how to use tools, team and technology to reduce strain while increasing work capacity and income potential.  Consider how to generate other sources of income.

12) Public & Private Good – Consider your contribution to public health and wellness initiatives, while nurturing the private good in your own well-being.

Write me with your suggestions at don@dondillon-RMT.com.  Let’s elevate the profession together.

What Market Sector Do You Work In?

Salutations my fellow practitioners!

I need your help.  I’m working diligently on a considerable update to the 2010 book Massage Therapist Practice: Start, Sustain, Succeed.  The thoroughly revised manual will have 12 modules, building from entry-level practice to upper-level practice development.

MTP coverI’ll release a table of contents for the book soon, but for now I’d like to get some feedback on the section called “Place”.

Place is one of the 4 variables in the marketing mix theory (the others being product, pricing and promotion) and I’m attempting to capture the nuances between different workspaces / market sectors served by massage practitioners and how services are delivered.

Specifically I write about design differences between the market sectors, plus upside and downside of working in each.  I would greatly appreciate feedback on the following short document to see if I’ve missed or misrepresented anything.  Click here ymtp_place

Write me at don@MassageTherapistPractice.com or visit the Facebook discussion at https://www.facebook.com/Massage-Therapist-Practice-222743724456748/

Thank you in advance for your time and consideration.

don

p.s.  I promise my face will not be on the cover this time…it will be tucked away in the book somewhere, much smaller, hardly noticeable.

Pricing Your Massage Therapy Services

Don 2016 scrubs_web

I’ve been deliberating for some time over whether to raise my professional service fees.  My practice is located in a small city where an automaker – the major industry in this town – laid off thousands of workers years ago.  Tourism and other industries have suffered, and I suspect many shopkeepers and service providers have wrestled with their pricing decisions for fear of customer reprisal.  It causes me to reflect on how I, and indeed my colleagues, set pricing.

How do we set our pricing?  Is pricing based on the type of massage or sector served (rehabilitation, spa, integrated wellness, in-chair massage)?  Time-length of session?  Inputs of labour or added elements like hydro\electric therapies or special hand-tools?  Are some outcomes (pain reduction, better mobility) more valuable than others (reduced anxiety, relaxation, better sleep quality)?

What role does wealth of the local economy, reliance on generous employee benefit plans, competition with peers or other services promising similar benefit play?  What are our own beliefs about the value of our work, our relationship and experiences with money, and what we believe patrons are willing to pay?

Pricing is how the practitioner “captures” the value they offer to the marketplace.  “Price transmits the most important signal to the customer…what the (practitioner) believes the product is worth”, states Ronald J. Baker, author of Pricing on Purpose:  Creating and Capturing Value.  Read the whole article at Massage Therapy Canada magazine

Should Alternative Health Be More Tightly Regulated?

On the Canada Broadcasting Corporation (CBC) program Cross-Country Check-Up May 1st, a discussion on whether tighter regulations for alternative health care ensued. This was prompted on the recent conviction of the parents of Ezekiel Stephan. Ezekiel died when his parents refused to take him to a physician despite life-threatening symptoms and instead administered homeopathic remedies.

You can find the full broadcast at http://www.cbc.ca/radio/checkup/should-alternative-healing-be-more-tightly-regulated-1.3557679

Woman Getting a Massage ca. 1980s-1990s

Part of my submission was read on-air (43:06 into broadcast) and my full submission follows below.

re: Should Alternative Health be More Tightly Regulated?

Yes. Yet, there’s a better question, “Do Canadians have access to the most efficacious health care?” The case of Ezekiel Stephan and his parents is a tragic one, and could have been avoided – not by more regulation per se – but better methods at improving user information (and informed choice) and treatment efficacy.

By linking clinical outcomes via technology and reported patient experience to a national database, the public would clearly learn what methods were working and which were suspect. In an age of user experience, it would be health-care users – not political lobbyists – determining what methods were sanctioned based on efficacy.

It’s very difficult for emerging health professions to receive necessary health care funding or research dollars. These emerging professions are not included in the consideration of public health care, even when they are regulated.

Massage therapy, for example, has been regulated for almost 100 years in Ontario, the last quarter century under the Regulated Health Professions Act. Yet despite the rigors of regulation, massage therapy is not funded by Ontario’s health plan, is subject to the HST (because over half of the other provinces are not regulated), and is precluded from hospital patient care, Community Care Access Centres or public health settings. This preclusion despite evidence showing efficacy in the treatment of conditions such as lower back pain, treatment of anxiety and depression.

Massage therapy was overlooked when the Ministry of Health and Long-Term Care announced its Lower Back Pain Pilot Program. The profession was later thrown a bone when the Ministry agreed to inclusion at only one of the test sites (out of seven), and treatment delivered by students at a training school, not seasoned professionals.

Western medicine has a political choke-hold on funding and government support. But medicine didn’t always have the public confidence. Before the Flexner report (1910) commissioned by the Carnegie Foundation, medical schools of varying quality operated in the marketplace. Hospitals were not seen as places of recovery, but of dying. See Patricia O’Reilly’s book “Health Care Practitioners in Canada” to see how politics played heavily in credibility and funding in health care.

People that pursue medical degrees typically come from wealthy families who provide philanthropic donations to hospitals and medical colleges. Pharmaceutical companies also inject millions of dollars into positioning their products in the application of western medicine, ultimately affecting the type of interventions that are endorsed by government.

Proponents of western medicine may cry “where’s the science?” and bemoan a paucity of research for these rival interventions. This detracts from the problem that small professions just don’t have the money.

Small professions are expected to self-fund research to prove efficacy, while western medicine is supplemented from a variety of wealthy sources. It’s a chicken-and-egg outcome for less resourced disciplines to prove themselves.

Western medicine practitioners are already working with chiropractors, massage therapists, naturopathic practitioners and a variety of what is usually termed “Complementary and Alternative Medicine” (CAM) practitioners. I concur, all these professions can and should do more to demonstrate efficacy in their approaches. But the way the system is set up now, these other professions don’t stand a chance.

The National Institutes of Health branch – National Center for Complementary and Integrative Health – is funded by the US Government to explore efficacy in alternative approaches to western medicine. I would like our government to shift from a “prove it to me” stance to a “let’s prove or denounce it together” approach.

The parents of Ezekiel Stephen made a terrible mistake. That mistake could have been avoided if our health care system truly integrated the best of various forms of medicine, funded research in emerging professions that show promise through reported direct user experiences and measurable outcomes, and governments that determine access to services based not on the politically savvy but on efficacy.

A Common Contract for Health Care Providers

As I was reflecting on Ontario’s Proposed Clinic Regulation, I considered possible solutions.  Regulation can be an expensive process requiring lots of oversight and reach.  Measuring its effectiveness in actually dealing with the problem could be difficult.

What if the profession could influence the RMT culture in a broader way, a way that would give practitioners more agency in their interactions with employers/landlords/practice brokers?

In an article published in Massage Therapy Canada, Spring 2016, I outline such an idea:

contract-negotiations

“Massage therapists are among a number of regulated health professionals that work as contracting “freelancers,” tenants under a larger business, or employees. Cross-contamination of the different working arrangements is common in our profession, and creates confusion, tension and corruption of business models, as well as risk of misclassification by Canada Revenue Agency.

The solution? Ask regulatory colleges and professional associations to hire legal counsel to draft employment, tenant and contractor/freelancer contracts, complete with all provisions regulated health professions must adhere to. Financial compensation, hours of employment and other non-regulatory variables specific to the common employment contract would be added as an addendum to further define the relationship.

Employers are already complicit in privacy legislation and mandatory reporting – if their employed regulated health professionals demonstrate incompetence, incapacity or abuse. A common contract containing all regulatory requirements legally bind both practitioners and the employers they work for, extending regulator influence beyond the practitioners they regulate.”

Read the whole article at:

http://www.massagetherapycanada.com/opinion/proposed-ontario-clinic-regulation-%e2%80%93-an-alternative-3182#sthash.Ns1GEocl.dpuf

Massage Made to Measure

On the heels of my articles featuring top 12 desired practice management software features, and an interview with 6 RMT-software developers , I want to ask you directly, “Can we tighten our assessment and outcome variables in our charting practices?”  I’m wondering if our profession can collectively get tight around what we assess, how we measure it and how we qualify change brought about by our hands.

Here are the variables I suggest we assess, and the standardized, reproducible parameters we use in that assessment:
  1. Posture – (spine) kyphotic, lordotic, scoliotic
    Posture – (shoulder & pelvic girdle) tilt, twist (torsion), protract (draw out) or retract (drawn back)
  2. Range-of-Motion – full, limited, impaired (alternative degrees of motion)
  3. Muscle (motor) test 0 – 5
  4. Palpation: tension, tenderness, texture, temperature
    (3 grades each, see table below)
  5. Numeric Pain Scale 0 – 5 (0 no pain to 5 excruciating pain
  6. Neurologic/orthopedic tests  + or – (positive or negative)
  7. Pain questionnaire – score (Vernon-Mior, Oswestry, DASH, Lower Extremity Functional Scale, etc)
Tension
Texture
Tenderness
Temperature
Minimal
Pliable
Minimal
Minimal
Moderate
Adhesive
Tolerable
Warm
Spasm/strain
Fibrotic
Withdrawal
Inflamed

Why would I suggest doing this?

1) Communication – if we’re all measuring the same variables we can engage in professional inquiry and qualify our experiences within and outside the profession

2) Credibility – using a common lexicon and producing the same outcome measures despite different practitioners contributes to the sophistication of research conducted and results measured.  Credibility is essential to health care funding and gatekeeper HCP confidence in referrals.

Write me at don@massagetherapistpractice.com or join the discussion on Facebook and let me know if you can work within these variables.

For those who attended Work that Charting! at the Canadian Massage Conference this past weekend, here’s a sample of the completed Assessment/Treatment template for you to study.

If you’re interested in the methodology and accessing the templates, the revised self-study workbook will be available in the coming months.  Keep posted on our Facebook page or sign up for announcements.

Response to the Toronto Star – part II

“Hi Donald.  Thanks for your email and comments. You make some good points.  The article was really a look at how we use benefits at different ages and stages and how that has changed rather than suggesting that they aren’t needed or helpful. They are certainly needed and certainly beneficial.”

(regards) Adam Mayers, Personal Finance Editor Toronto Star| 416-869-4821 amayers@thestar.ca

Hello Adam, and thank you kindly for responding back.

I appreciate that your intention was to write the article highlighting how people use their employee health benefits at different ages and stages.  While your article could have referred to more data, and indeed in a more objective way, I suspect many found your intentions arcane and purposefully inflammatory.

I read Mr. Willow’s white paper you referenced, Employee Benefits Plans Not Reflecting Canada’s Health Challenges According to New Study, and Mr. Willows presents a sincere concern with how health benefits are utilized.  We collectively would do well to heed his advice.  However your article focuses on comments not included in the document, and I’m assuming were made in a private conversation.  Mr. Willows is portrayed as skeptical and ignorant when referring to chiropractic, physiotherapy and massage as “the Three Amigos”, massage “as a lifestyle”, “a special treat” and “considered something for the wealthy”.

Your article provides me with the impression that the sharing of data or trends from Greenshield’s study – indeed helpful and useful information for workers, employers, insurers and health care providers alike – is shadowed in a pall of antagonism and distrust for the intentions of these health care providers.

There was so much good information that could have been extracted from the Greenshield paper.  For example, Mr. Willow’s describes how only 1% of benefits are utilized on dietitians and nutritionists.  He hints at the social determinants of health, and sets up an opportunity to discuss how worker benefits could be better prescribed and directed, perhaps in line with personalized medicine.

We must all ask the question; if workers are not making the right choices with their available benefits, how can we ensure best evidence and health policy direct them?  Perhaps there is a way to align the interests of workers, their employers, insurers and health care providers.  This focus is where your article could do the most good.

Mr. Willows references concern for benefits used by people of younger ages.  I think this is reflective of the societal impact on health at younger and younger ages.  I certainly see this in my practice.  Mr. Willows may be interested to learn that, beyond the treatment of strain and pain, massage therapy in implicated for health enhancement and wellness, which contributes lower health costs.  C.K. Andrade in her seminal book Outcomes Based Massage recognizes benefits beyond simply injury rehabilitation, including: improved energy and sleep, better social functioning and family relationships, a sense of well-being, improved mood, relaxation and coping skills, mindfulness and greater life satisfaction, positive attitude and empathy towards others.  Cultivating these health benefits could go a long way to addressing the serious, insidious illnesses Mr. Willows references.

Resources are limited, and more cost-benefits analyses are needed in the utilization of employee health benefits, no question.  I suggest not inflaming the relationship between insurers and health care providers but instead using the media to foster a dialogue on how to better care for workers with the resources available.

Thank you,

Don Dillon

cc David Willows, Vice President, Strategic Market Solutions, Green Shield Canada david.willows@greenshield.ca

Insurance Costs for Massage: Response to The Toronto Star

In the article The Rise of the Three Amigos of Health Care,  http://www.thestar.com/business/personal_finance/2015/04/13/the-rise-of-the-three-amigos-of-health-care.html?referrer=https%3A%2F%2Fwww.google.ca%2F Adam Mayers presents valid concerns for how employer-sponsored benefit plans are utilized.  He describes specifically physiotherapy, chiropractic and massage therapy providing “soft benefits” ie: harder to measure – and the associated costs that could affect money spent on pharmaceuticals.  I’m writing to add additional context to the concerns Mr. Mayer raises.

There is a surprising lack of financial support for treatment of the structural components of the body that help us to move – muscles and connective tissues.  Chiropractic and physiotherapy were removed from the provincial health plan in 2004 – presumably to shunt dollars to treatments for heart disease, cancer, diabetes and other chronic illnesses with some association to lifestyle choices.  Massage therapy – despite being regulated as a health profession in Ontario since 1919 – has curiously never been covered under OHIP.

Provincial funding for orthopedic treatment of osteoarthritis or severely traumatized joints is not extended to strains and sprains affecting the everyday function of people.  It appears these injuries and ailments hold low priority, and employers – rather than our health care system – are mandated to pay for them.  Case in point – a person experiencing soft-tissue and joint injuries in a motor vehicle collision must tax their employer-paid benefits first before applying for claimant-paid auto-insurance benefits.  I’m not sure why employers aren’t up in arms over this and organizing a response to the insurance industry.

I wonder if Greenshield in their data review has considered that rising expenditures in these areas are a shift from drugs to physical/psychological therapies as a reflection of the population preferring less invasive or dangerous interventions to pharmaceuticals or surgery.  Judicious treatment of soft-tissue injuries may preclude or limit the need for more invasive interventions, or obviate the serious side-effects associated with the ingestion of pharmaceuticals such as Non-Steroidal Anti-Inflammatory drugs (NSAIDs).

True, there is a lack of accountability on how employee benefit plans are used.  Employers trust employees to search out practitioners in the open marketplace that can help them address various symptoms affecting health and wellness.  There is currently no measure in place to assure the employer that the benefits have been well directed or effective.

Practitioners – the vast majority ethical, compassionate and competent – are penalized for excessive or unnecessary billing only if there is an investigation by their regulatory body or a criminal conviction.  No question, a few unscrupulous providers are casting a dark pall over the reputations of the majority of these regulated professionals.  As well, more accountability for how these benefits are used is long overdue.

Perhaps designing a system similar to a trust fund – where employees and employers pay in – and health professions provide approved treatment plans substantiated by the best evidence available – may improve the situation.  The current system that pools risk to lower costs creates incentive for employees to use plans without judicious consideration (or accountability to the employer) of where and how the money is spent, and incentive for insurance companies to deny claims or discredit credible services to improve profit margins.  Turn “soft benefits” into hard by establishing clear workplace outcomes – reduced time off work, increased job satisfaction and sense of well-being – and ensure workplace benefits are used toward those outcomes.  Practitioners could be registered and would lose access if outcomes were not reached.

Its unfortunate Greenshield refers to these 3 regulated health professions in a derogatory manor.  Of particular concern is Greenshield’s vice president David Willows referring to massage therapy as “a special treat”.  As mentioned, massage therapy has been regulated in Ontario since 1919 as a health profession, and demonstrates effectiveness in the treatment of headaches, lower back pain, arthritis-related stiffness and pain, muscle discomforts related to pregnancy, and most recently efficacy in the treatment of anxiety.  It appears Mr. Willows is unaware of the evidence favouring massage therapy to address a number of health concerns.  Ironically, employees in the insurance industry – along with the technology and finance industries – are cited as some of the greatest users of employee benefit plans.

It would be helpful if Greenshield and the insurance industry worked in collaboration with research and educational institutions to draft a cost-benefits analysis how physiotherapy, chiropractic and massage therapy may off-set costs that would typically show up in the provincially-funded medical system.  The insurance industry may complain of the rising use in employee benefit plans, and employers are justifiably concerned about shouldering these costs, but is this a red herring?

Without study, we won’t know if in fact expenditures for these “3 Amigos” may actually be saving the provincial health care plan a considerable expense.  Job-related stress, for example is estimated to cost the Canadian economy $16 Billion dollars/year.  As per Mr. Willows claim about the drugs that can “send you from bed back to work”, please elaborate…I’m unaware of such miracle drugs and would be quite interested in their efficacy.

As for the mention of children receiving care, it appears we are seeing children at younger ages developing the same afflictions their parents and grand-parents suffer from.  Perhaps the focus should be on correcting the social-economic mechanisms that affect quality of life and trigger repeated responses to stress rather than precluding populations simply because they appear novel in our consideration of health and quality of life.

You may also like:

Insurance Adjudicators Assume Gatekeeper Position http://massagetherapistpractice.com/insurance-adjudicators/

Insurance Claim Challenges: A Problem More Insidious than Fraud http://massagetherapistpractice.com/insurance-claim-manipulation-a-problem-more-insidious-than-fraud/

Insurance Coverage for Massage Therapy: Going, going…gone? http://massagetherapistpractice.com/insurance-coverage-for-massage-therapy-going-going-gone/

Massage on Demand…Brilliant!

I was reading this morning about Zeel: Massage on Demand.  With an app on your smart phone you can book a same-day, in-home massage, designate the type and duration (60 or 90 minute), and the practitioner comes to you.

Zeel is membership-based, and for $99/month (more in some upscale areas) plus built-in tip and taxes, you receive a monthly massage plus a massage table you retain in your home.  You can purchase more massage sessions at the same $99 price if you choose.  Zeel also offers a corporate chair massage service.

Zeel counters the greatest obstacle to in-home massage…the practitioner having to lug in the table every time.  In using smart phone technology to select, book and pay for your massage, Zeel has maximized convenience and time savings for the user while appealing to our ego’s need to be nurtured in our own space.

How much more often will users book a massage when they’re regularly reminded of the massage table in their home?  I predict this will be very, very big.

Another service, Pager, provides a similar service but by bringing physicians to you.  Home visits by a doctor, no crowded waiting rooms with contagious people, no-surprise fees up front…wow.  Truly service built around the patient.

Delivery-of-service models for massage therapy emerged from physiotherapy and nursing applications during the World Wars, the European Spa, athletic massage and the human potential movement in the 1970’s.  However with the advent of technology and large companies in the rehab and spa sectors brokering massage services and creating new work opportunities for practitioners, it appears change is happening in the profession at break-neck speed.