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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

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