Each time I teach a new group of students, it takes me a day or two to learn their names, and to straighten them out in my mind. The first day of a course finds me squinting at name tags and mouthing their names as I move through the room. When there are two students of the same height or skin tone, my brain merges them into one person. I’ve embarrassed myself many times, shouting a name confidently at the wrong student.
One student stood out of the crowd, right away.
This student approached me the first morning of an oncology massage CE course. She wanted to tell me something about her own health.
She hadn’t had cancer, but she had a stroke history, and wanted to know how we would adapt any hands-on work she would be receiving throughout the course. We talked for a bit, and planned out a few massage modifications.
That settled that.
Except it didn’t.
An hour or two later, another student of the same height and hair color approached me to talk about her stroke history. For a moment I was confused. Hadn’t we just had this conversation? No. This was someone new.
I did a double-take as the second student recited some of the same details as the first. I lost track of who was what, with whom and what. Once composed, I did a quick intake-on-the-spot, then replayed many elements of my earlier conversation.
I asked each student if she wanted to share her story, and the two women found each other that day. They stared at each other in disbelief. They had nearly identical histories, a stroke thought to arise from a rare cause: a blood clot on the venous side. They were both young. They had both struggled through rehabilitation, and come out of it on the other side. After coming through such harrowing experiences, they were both determined to help others, and massage therapy was the vehicle.
They quickly partnered up for the afternoon’s hands-on session, and became fast friends.
I learned their names.
We worked with them safely through the next 4 days, taking care with pressure and with the lower extremities in each case, but I’ll save the specifics–the DVT Risk Precautions–for another day.
Massage contraindications can run in packs.
This exact “separated at birth” situation has not happened since, but as I teach and practice massage, I notice pathology questions coming through in pairs or themes. The topic of scleroderma came up twice within a couple days. One week, hepatitis came up three times in class and clinic. And common conditions such as diabetes emerge often enough in the clinic that I practically press “play” when I supervise students.
But playing the recording is not usually enough. Each client is unique, and we always consider the individual person inside the long medical name. We look at how the diagnosis plays out in the body.
A wide range of complex medical conditions can darken the door of a massage studio, especially as our population ages. Faced with condition X, massage therapists may struggle to find massage guidelines, in part because the name of the condition is not enough.
A diagnosis is not enough. A presentation is much better.
Unlike the two students with similar stroke histories, in many cases, two complex cases of X might look very different. There can be a broad range of scenarios. Likewise, there is seldom a single massage “rule” for all clients with X, whether X is diabetes, cancer, lupus, or another disease. A handful of intake questions are necessary to learn the client’s presentation of a condition.
A presentation includes specific signs and symptoms, and whether any complications have developed. It describes the severity of the condition and the effects of the condition on the tissues and organs. It may include the treatment for the condition, and any side effects or complications of treatment.
This constellation of factors can be overwhelming. To simplify it, often in a few minutes between talk and table, a therapist may be tempted to revert back to a strict, blanket rule for that condition. “Massage is contraindicated for X.” “Work gently with anyone with Y.” “Avoid increasing circulation in a case of Z.”
But there are drawbacks to those blanket rules.
Like the massage that was meant for someone else.
I saw one drawback in action, working with a recent grad from MT school. She was taught, “Always work gently on someone with hypertension.” Always.
In our CE practice clinic, I noticed her offering a delicate touch and gentle pressure to a client with mild high blood pressure. The client who was clearly hoping for a bit more. I encouraged the MT to add in some stronger elements, but she refused. I pressed her a bit, but for various reasons, I let this student stay within her comfort zone.
Unfortunately, it was not the best fit for the client on the table, who was quite physically active and healthy, and could handle much more pressure than the student’s delicate touch. Another client at the other end of the scale, with severe or even malignant hypertension might require a cautious approach.
But not this client.
This MT’s guideline was too inflexible for actual practice. Based solely on the name of the client’s condition, the rule didn’t capture all of the presentations of hypertension. The client did not receive a customized massage, he received a massage meant for someone else–someone with a much more serious presentation of the condition.
In massage therapy education, we have a problem. And it is not Pretty.
This is just one story of a clinic training session, and I don’t mean to single out this young MT. She was sticking to the rule as best she could.
I raise this example because I have encountered many, many similar situations. After thousands of hours teaching basic massage school science, and training many thousands of MTs in CE settings, I know our temptation to grasp at simplistic rules. I struggle with the temptation, myself.
Yet, after basic massage coursework, many MTs still struggle with what to ask their clients in the interview, then how to work safely and effectively with common conditions such as hypertension, heart disease, and cancer. Many are following oversimplified rules for conditions that affect huge numbers of our population. Many MTs have asked me, “How do I do better for my clients? How do I move beyond these basic guidelines?”
Even with great books on pathology and growing resources in this area, we tend to link our massage approach directly to the name of a client’s condition rather than her presentation.
Why is it a problem? Because we can lose clients.
A client is unlikely to return after a massage that is not tailored to her tolerance or needs, especially without an adequate explanation from the therapist. Blanket, “catch-all” rules do not serve our clients or our practices. Without thoughtful precautions, we can cause injury, for sure. But when we are too careful, we come off as overly cautious and out of touch with our client’s needs.
We would never drill massage down to a single session for everyone. Instead, we mix up our techniques to meet an individual client’s needs. Massage contraindications are no different. A single rule does not usually capture all presentations of condition X, Y, or Z.
Thinking works better than following a rule.
This is why clinical thinking is so important in massage training: teaching the range of presentations for a given condition, and the range of massage adjustments to adapt to them. More pressure for this scenario, slower speed for that one. Avoid joint movement for this client, but not for that client. Take care with positioning for this liver condition, but not necessarily that one.
Clinical thinking takes more time and effort to teach than it takes to teach rules. It takes time and thought to sort through presentations and get specific about our hands-on work.
Yet, to truly grow into health care, we need to embrace the words, “case-by-case.” To move beyond one-dimensional massage contraindications. By considering a client’s presentation, we honor the nuances of his or her condition. In doing so, we honor the client, as well.
Are we ready?
In the US, the Affordable Care Act is rocketing toward us, along with an invitation to massage therapists to become more involved in healthcare and insurance reimbursement. As a profession, we may finally have that seat at the table we’ve been yearning for, lo, these many years. We want to be taken seriously. We want referrals from physicians. We want to be part of the team.
But we’re uncertain about what to ask, and what to do with the client with shingles, COPD, a mastectomy, or a complicated pregnancy. We still struggle to outline a specific approach, specific contraindications for a specific client.
Of course, some therapists, instructors, and training programs are better at this than others. But my casual sampling of US massage therapists and teachers suggests that in order to move forward in this area, we need more from our basic massage education. Even MTs with much more education behind them, such as some of our Canadian neighbors, complain that the massage contraindications (CIs) they learned are diagnosis-based rather than presentation-based.
We have a problem.
How do we solve it?