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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.

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