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Mapping it out


*This article adapted from a forthcoming book, Medical Conditions in Massage Therapy, copyright Wolters Kluwer Health, Lippincott Williams & Wilkins.

Years ago I was teaching a continuing education (CE) course on massage and pathology when a question came up about a medical condition. The therapist asked whether a certain modality was contraindicated for that condition. A second therapist jumped in, said he thought not, and described his practice of that modality, which always employed the gentlest pressure. A third therapist jumped in and described her practice of the same modality, which used very deep pressure.

Soon, everyone was arguing. There was not enough agreement on the modality to answer the question. The modality name itself was too vague. The trade names of some modalities don't necessarily describe the range of techniques within each, nor the way the hands travel over the body. With each therapist's signature on the work, and each employing a variety of modalities and techniques, there can be marked disagreement about the meaning and application of different massage terms. Not even the term "massage" is universally understood. Massage theory and practice are rich, diverse and far from consistent across the field. The argument was growing louder by the minute. I restored order in the classroom, pointing out that it is rare for an entire discipline or modality to be contraindicated for a condition.

Instead, we spoke to specific elements of massage therapy-such as pressures, speeds, movements or areas to avoid or adjust in a given condition. We looked at specific features of the medical condition itself, and how different elements might interact with them. There was no single, categorical statement—"massage is contraindicated"—that captured all of these clinical possibilities.

Simplistic Rules

The discussion that day reflected the state of massage education at the time, before massage curriculum and textbooks began to hone our understanding of contraindications. Many of us learned a one-dimensional approach to massage and pathology: "massage is contraindicated for X" was a common phrase. Students studied long lists of such contraindications. We had simplistic, reflexive responses to conditions: "don't massage" or "don't touch."

This single decision-making step rarely reflects clinical reality. A classic example was the blanket contraindication of massage in cancer, and that contraindication was followed for decades. Among other things, this reflexive response produced isolation and pain for clients who needed care, heartbreak for therapists and a poor image for the massage profession.

It shows what can happen when people bend too easily to simplistic rules for contraindications. Fortunately, the profession is moving away from this approach (see Cancer and Massage: Essential Contraindications" in the Summer 2006 issue of mtj, with many references, for more on this).

Cancer is one example of how a simplistic rule-based approach to contraindications failed the profession. There are other examples, too. In general, the simple flow chart, "If X, do this" fails to capture our clinical reality in the following ways:

  • Condition "X" can manifest very differently in different people.
  • All "massage" isn't the same; it's a collection of elements mixed differently for different clients.
  • Touch in some form is almost always possible, and it's usually not necessary, nor professional, to simply deny massage to a client with condition "X.

A Clearer Approach

From spending years in massage therapy classrooms focused on the nitty-gritty of massage contraindications, I've heard a lot of client cases, including people with multiple sclerosis (MS), diabetes, prostate cancer, bladder infections, eczema, or histories of heart attack and stroke. How do you work with them? What do you avoid and where? In response to each case, try answering two simple questions:

1. What is it about the medical condition that contraindicates massage?

2. What is it about massage that is contraindicated?

Both of these questions must be explored. Identify the elements of a medical condition that are red flags for massage therapy. Then identify the elements of massage therapy that should be adjusted or avoided. In my experience massage therapists tend to be visual and kinesthetic learners and decisionmakers, so I prefer to organize questions one and two in a visual, left to right format-a "decision tree."

The Decision Tree

When faced with the question "what is it about "X" that contraindicates massage?," you need to sort the information and make good clinical decisions. This thinking process is shown in a visual decision tree, which sorts complicated medical problems into smaller, more manageable ones. In the decision tree, the elements of the clinical problem are spelled out and sorted into easy-to-use boxes. You can see information about "X"—or the client's condition—on the left side of the tree. Possible adjustments in massage are shown on the right side.

In this generic tree, arrows show how any of the medical information might lead to any of the massage responses. In a decision tree for a condition such as neuropathy (Figure 2), there are many more arrows, linking specific health information on the left with specific massage changes on the right. The decision tree is not a new concept in health care. In fact, more elaborate "clinical algorithms" exist in medicine. In this case I've adjusted the format for use with massage contraindications.

Room for Medical Information

The disease or condition "X" does not look the same in every client. One client with lymphoma may show only a painless lump. In another, lymphoma can cause breathing difficulty or gastrointestinal bleeding. Still another may be profoundly affected by fatigue, intense itching and reduced blood counts.

Since the massage should be geared to what is actually going on with the client instead of a condition name, a single, flat contraindication for "X" may not apply to all three clients. My own work in the field of cancer and massage therapy bears this out. At one time I had two clients with pancreatic cancer coming in on the same day every week, with two vastly different clinical pictures. There was no single, simple contraindication for "X" that would serve those two clients. Instead, I made many massage adjustments and substitutions for one of them, and just a few for the other.

The Left Side of the Tree

On the left side of the tree, the condition "X" is sorted into smaller bits of relevant information. There are four boxes on the left side, containing typical features of a condition. These are essentials, complications and medical treatment. Medical treatment is followed by the effects of the treatment on the body.

Some essentials are listed in the essentials box. Here, characteristics of the condition, signs and symptoms, and relevant medical findings are noted. Information to go in this box could include the basics of what it is-an infection, a tumor, trauma to a tissue, or an impairment in organ function. Signs and symptoms could include a rash or fever. Findings could include a mass found in the lung on the last MRI or even a fracture. In this box are "things that make condition 'X,' condition 'X.'"

In the middle box are complications: significant effects on organ or tissue function that occur once the disease has been around long enough to complicate things. Items in this box might include liver function impairment, heart disease, breathing difficulties or infection. A common cold in the essentials box may lead to bronchitis or pneumonia in the complication box. A hepatitis C infection may lead to cirrhosis and portal hypertension. An open fracture may lead to infection in the bone. Cancer of the pancreas may spread to the bones over time, and so on. In the complications box are things that have worsened the client's condition. In fact, sometimes there may be some overlap between the essentials and the complications, as complications give you the symptoms and signs that are considered essential to the disease. The perfect box doesn't exist for all medical information; however, it's important to put it somewhere to make sure it's handled in the session.

The two boxes at the bottom left hold medical treatment and the effects of treatment. These are important facets of a client's experience, as sometimes medical treatment itself changes the body in ways that require massage adjustments. The medical treatment box holds everything from splinting to chemotherapy, and includes surgery, antibiotics, inhalers and hormone therapy. Some of these are associated with unintended negative events such as side effects, adverse reactions or complications. For example, a side effect of chemotherapy is nausea. One complication of surgery is infection. Some hormone therapies result in hot flashes or joint pain. A severe rash may occur as an adverse reaction to a drug.

With the left side of the tree filled out for a given condition, you've begun to answer the question, "What is it about 'X' that contraindicates massage?" Now you can turn to the question, "What is it about massage that's contraindicated?"

The Right Side of the Tree

If the left side of the decision tree is the information side, the right side of the tree is the action side (Figure 1). It holds actions you take as a massage therapist. I suggest that several elements of massage therapy go in the right-hand box. These elements are the "ingredients" of massage therapy. When divided into its elements, it's much easier to discuss whether something is contraindicated, neutral or even indicated. These elements are contact, lubricant, pressure, joint movement, friction, site, position, draping, speed, rhythm, length of session, scheduling of session and intention.

In addition, there are two other actions you might take in response to the client's medical picture: 1) a medical consult (seeking more information from a client's physician or nurse); or 2) a medical referral, sending a client to a physician for more help than you can provide.

Massage Substitutions

Analogous to the elements of massage are the ingredients of a recipe. For example, you might avoid eating cake because of an allergy. Perhaps it's the wheat, the gluten, the egg or the sugar that you can't tolerate. To say that "cake is contraindicated" in this scenario is too absolute a statement, since only individual ingredients are contraindicated. Usually you can substitute ingredients; in fact, egg-free or flour-free cake recipes abound.

Of course, massage therapy modalities, techniques and approaches abound, too, and substitutions may be made. Rather than a fixed recipe, there is flexibility in massage. Elements of massage include the contact of the hands with the tissues, the movement of joints, the application of pressure. In her book, Medicine Hands: Massage Therapy for People with Cancer, Gayle MacDonald first identified the massage site, pressure and position as the most common massage modifications for people with cancer or medically frail clients.

Real clinical practice doesn't feature flat, categorical contraindications, but instead, these substitutions and adaptations. If a certain pressure is contraindicated in an area, a gentler pressure may be substituted. If a given essential oil is contraindicated during pregnancy, an aroma-free lubricant may be used. If the prone position is contraindicated for breathing difficulties, other comfortable positions may be substituted. If bone stability is compromised by osteoporosis or cancer spread, then gentler joint movement or pressure may be used over vulnerable areas.

Massage therapy language, especially the language of contraindications, needs to reflect this reality. The right side of the decision tree lists these flexible ingredients of a massage therapy session. Once massage is described in terms of its elements, contraindications become clearer. These elements, with examples of contraindications for each, are in Table 1.

Using Decision Trees

Decision trees may be used in a variety of ways. One way is to complete a tree for a given condition. Figures 2 and 3 are pre-made trees for two conditions, peripheral neuropathy and MS. They show typical clinical pictures and massage modifications for these conditions.

Trees are fairly easy to construct for a pathology you've seen in practice, or may expect to see it one day. To fill out the left side, draw on massage textbooks such as the references at the end of this article. Search the web for the terms "patient education" and condition 'X.' Go to reliable sites, such as hospital patient education sites, the National Institutes of Health, or reputable medical or nursing schools' sites for information. You can also visit the Librarian's Internet Index for a good source of high-quality websites. Another good resource is the Mayo Clinic site at www.mayoclinic.com. Using the information gathered from these sources, fill in the left side of the tree.

The right side of the tree can be constructed from several massage therapy texts (see bibliography at the end of this article). A completed tree yields the possible client presentations, and the key elements of massage to contraindicate or adjust for all those presentations.

From the completed tree, generate some interview questions: Tell me about your condition? How does it affect you? What kinds of medical findings have there been? Have there been any complications? How is it treated? These are some examples you can start with. The decision tree shows you specific questions: Do you have any breathing difficulty from this condition? Are your legs swollen at all? How does the condition affect your skin? Your muscles? Then you are more prepared for a client with condition "X."

Individualizing a Tree

Another way to use a tree is to create one from the interview and a client health intake form. Put their condition in the leftmost box, and jot down their medical information all along the left side. While they're getting ready for the massage, take a moment to highlight the relevant massage concerns and actions.

While not everyone thinks in "tree" form, doing so can be a useful exercise for clinical practice, or the massage therapy classroom. It's part of the clinical decision-making process, and the tree helps make the process conscious. The decision tree can help prepare you for a current client, or a hypothetical client who might show up in practice one day. Generating a tree is useful in and of itself, honing skills with not just one, but a variety of clinical scenarios.

Examples of Trees

Examples of decision trees are in Figures 2 and 3. Figure 2 shows a decision tree for peripheral neuropathy. Arrows link the medical issues to corresponding massage adjustments. The decision tree in Figure 2 clarifies issues in massage and neuropathy. Scores of massage therapists have told me they were taught "not to massage neuropathy" during their training. Unfortunately, this grew from lists of simplistic, absolute contraindications. Clinical reasoning works better than lists of contraindications. In reality, you can't always massage an area of neuropathic symptoms, but often you can with the right massage elements. For example, massage elements such as pressure or joint movement should be adapted, but it's not necessary to eliminate all massage. This is clear from the tree.

The decision tree shows some fairly simple responses to peripheral neuropathy. Where it gets more complex is in the bottom boxes, if medical treatment causes additional problems. In the medical treatment box, the arrows indicate typical effects of treatments and massage adjustments. It's not necessary for every client on tricyclic antidepressants to rise slowly from the massage table, just the ones who experience dizziness and hypotension from these medications. The arrows suggest possible side effects, and possible massage concerns and actions for those side effects. The decision tree for peripheral neuropathy is a diagram of possibilities, where key issues, such as sensation disturbance, tissue health, infection and some strong medications are depicted. This is a far cry from a flat, blanket contraindication to massage.

In Figure 3, a more medically complex condition is shown-MS. A broad range of effects of MS on the body is shown in the top two left boxes, and the arrows point to appropriate massage therapy concerns and actions for each on the right. The massage concerns and actions box also implies cautions for spa therapies-especially those involving heat that can raise the core temperature-that can aggravate symptoms in some people with MS.

The decision tree for MS is more complex than for peripheral neurop athy; MS has a broader range of disease manifestations. The tree helps sort the volume of information into smaller, useful and manageable categories. Going down the list of what goes wrong in MS, how it's treated and how different massage elements should be changed or avoided, you get a sense of which questions to ask a client. In fact, intake questions can be formed directly from the information on the tree: Do you have any of the following symptoms? How is your MS treated? Are you on any current medications for MS? How do they affect you? These are just some of the questions that flow directly from the tree.

The tree shows real clinical practice for people with MS. The expanded information in this tree allows for individual scenarios of disease and treatment. Space limits discussing each medical and massage element shown on the tree, but the figure aptly demonstrates large, complex conditions broken into smaller problems.

Take Home Messages

A decision tree is not a final dictate of massage protocol. Instead, it's a thinking process, a roadmap of the terrain, showing where to start, what to ask and how to proceed in an initial massage. But like any massage contraindication, it may change. After monitoring the effects on the client over time, you might be able to inch up on the pressure, or move a joint more strongly. Massage is customized to a client, not just a condition. Some clients with MS fatigue can take more pressure and resisted movement than others. Some with sensation changes tolerate less touch over an affected area than others. As a client's health picture on the left side of the tree changes, the right side must adjust, as well.

The decision tree substitutes reasoning for memorization, which may be a welcome change for those who struggle to memorize long lists of contraindications! This scheme makes the process conscious, easier to discuss, reinforce or dispute. You may see things on the trees in Figures 2 and 3 that with which you disagree. Descriptive language leads to more meaningful dialogue, rather than getting mired in arguments over the language itself, as we did in my classroom that day.

With the decision tree, I see massage therapists managing information more easily, swinging almost effortlessly from the left side to the right side of the tree. Where the left side once harbored intimidating medical information, it can now be sorted into boxes and addressed. You can fill in missing or unfamiliar information by using clients, their own resources and even a client's physician. Sometimes the decision tree even clarifies what to look up, or how to follow-through.

When contraindications are made explicit and then handled clearly and completely, safety concerns are laid to rest. Once you manage medical information and link it to sound massage adjustments, your intuition can spring forth. Then there is room for joy and purpose in each massage movement.

Bibliography

  1. Born B. The Essential massage companion. Berkley, Michigan: Concepts Born, 2005.
  2. Burch S. Recognizing health and illness: pathology for massage therapists and bodyworkers, 2nd edition. Lawrence, Kansas: Health Positive Publishing, 2001.
  3. Curties D. Massage therapy and cancer. Moncton, New Brunswick: Curties-Overzet Publications, Inc. 1999.
  4. MacDonald G. Massage for the hospital patient and medically frail client. Philadelphia: Lippincott Williams & Wilkins, 2005.
  5. MacDonald G. Medicine hands: massage therapy for people with cancer, 2nd edition. Forres, Scotland: FindhornPress, 2007.
  6. Newton D. Clinical pathology for the professional bodyworker. Portland, Oregon: Simran Publications, 1995.
  7. Persad R. Massage therapy and medications. Moncton, New Brunswick: Curties-Overzet Publications, Inc., 1999.
  8. Premkumar K. Pathology a to z- a handbook for massage therapists, 2nd edition. Calgary, Alberta: Meducational Skills, Tools & Technology, Inc., 2001.
  9. Rattray F, Ludwig L. Clinical massage therapy: understanding, assessing and treating over 70 conditions. Toronto, Ontario: Talus, Inc., 2000.
  10. Salvo S, Anderson SK. Mosby's pathology for massage therapists. St. Louis: Elsevier, 2004.
  11. Werner R. A Massage therapist's guide to pathology, 3 edition. Philadelphia: Lippincott Williams & Wilkins, 2005.
  12. Wible J. Pharmacology for massage therapy. Philadelphia: Lippincott Williams & Wilkins, 2005.
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