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?
Great article Tracy…….
Thank you, Mike. 🙂
So is there a class for clinical thinking?? I do customize massage sessions to each clients needs and medical situations, but, I would love to learn more!!
A class for clinical thinking is a great idea!
Beth and Jill, second that. My focus in that area is contraindications/pathology, and we do teach those skills, but I’m thinking/wondering how each CE course includes this, or doesn’t. For each new technique, or population, or concept, how do we assess when and how to apply it? I would love to know more, as well.
Pam Soule says
Tracy, great article! And relevant! I am experiencing this myself; my head is right here!
I currently work at a spa, but in my own business, I work with seniors with a variety of conditions, along with oncology massage (or massage for people going through infusion. or oral, treatments for cancer and other various conditions). However, when at the spa, I often interview the client with the uncompromised young and athletic body. I have to shift fast in my thinking! But then occasionally, you’ll get an exception. A seemingly healthy person who reports having had a bad headache, but later you find out that she’s had a stent put into a vessel in her brain due to an abnormality that would’ve caused blindness!
So yes, case-by-case.
Besides asking the client “Why do they want a message today?
I have found that, by asking, two basic questions will take me where I need to be as far as assessing what a client can handle (within the short intake period that we have at a spa). These two questions are:
1. Are you on an anticoagulant (aspirin or Coumadin, there are others)?
2. Can you, do you, walk up two to three miles without difficulty?
The answers a client gives to these two questions help. I’m sure that there are other questions that would take us down other paths. But I find that by asking these two questions leads me to ask more and I can determine if a massage is appropriate for a person, and or what type (location, pressure, etc) of service I can give. Because I do not want to give the massage that I would for an elderly woman who has osteoporosis to a young athlete! That’s an extreme contrast but oversimplifies that variants within).
Yes tailoring the massage, so it’s not “for someone else” is hitting the mark!
Thank you, Tracy!
Pam, it’s true we need shortcuts for those abbreviated interview settings. Loved your contrast.
Beth Terhune says
Too right about the clinical thinking piece. Can’t be taught easily but an important element in tailoring care. It’s the same issue that brought me to graduate school years ago… how does one “teach” or elicit critical thought in a world noisily alive with so much else. Practice and dialogue and case studies and mentors and S4OM conferences and postings and blogs like yours… and coming to each session with the mind of a beginner and the treasury of past experience and lessons.
Thank you for this!
Beth, you should know! 🙂
Sandy Fritz says
Right on Tracy. Critical thinking (the process of information gathering, brainstorming, analysis, decision making and justification) and clinical reasoning ( applying critical thinking to an individual situation such as a massage session with a client) should be the foundation of massage education. My goodness, my kindergarten age granddaughter was learning basics of critical thinking in nursery school. I have always constructed my textbooks from a foundation of critical thinking as you have Tracy> There are various models and the decision tree approach is very effect. Unfortunately, over the years I will occasionally here that my textbooks are “too hard” for the students. When I really explore this I almost always discover that the teachers are unfamiliar with critical thinking and that a clinical reasoning approach is “hard to test”. If this is the case then how can we expect graduates to perform responsibly.
Sandy, I wonder what “too hard” means? Need an in-service for teachers? On teaching and testing? Interesting to think about. I do think we’d all prefer simple answers, but the process shouldn’t be that hard to manage. Hmm…
Judy Stahl says
Oh, dear, I get to be the one to mention our litigious society. I think educators are afraid to let students freely think and MT’s in many instances are afraid to go beyond the ‘hard and fast rules’ because somewhere, at some time, someone sued someone because they didn’t follow the proper (whatever that is) precautions for X (hypertension, pregnancy, 1 lymph node removed, what-have-you). I read a fairly popular FB group in which a standard reply to almost any question is, “Don’t do it if you don’t have specific training in that area.” To which I wonder, what is enough training? 24 hours outside of the basic school? 16 hours? a one-day course? When can I say I’m proficient in a particular modality? Then, getting back to case-by-case…You Are So Right. I’ve worked with survivors of Multiple Myeloma, one of whom was along the lines of a Special Forces-trained soldier. Rock solid. Another had peripheral neuropathy and ongoing DVT concerns and ongoing fears of leaving the relative safety of remission. Did I work differently on them? You bet. Did I still modify both massages? Yep. But there’s still a part of me that continues to wonder, as I’m still relatively new to the field (5 years), What If…what if I’m doing it wrong? What if something happens? Would it be my fault? We want to be part of the medical team, we also have to be prepared when someone says, “you went beyond the scope of your training/practice in performing X on that person.” Or, “conventional practice is not to do X when a client has or has had Y.” So, along with modifying our educational tenets, how do we get the medical and legal field to allow us to make such decisions on our own?
Sarah, SOMEone’s got to mention litigation. Your question about enough training is a great one. I think if our decision making is a conscious process, it’s easier to defend. But making it conscious can be a challenge.
Janet Kemper says
Tracy, this article was right on.
Mark W. Dixon says
I believe it’s more important to know how to think than what to think. Thanks Tracy. I value and appreciate your work.
Alfredo Araujo says
l like the approach of the text above. Just to endorse Tracy. l am MT but also Physical Education Teacher and black belt in Judo and Brazilian Jiu Jitsu. I am instructor in both martial arts as well. Either in Physical Conditioning itself or in Judo and Brazilia Jiu Jitsu we should customize the practice even if the martial arts student are in the same class. For example l can teach to a white belt (beginner), and a brown belt (more advanced in knowledge and experience) in the same class and at the same time. And watch both students growing technically in the same way, Therefore massage is not different should be considered the client personal rythm, desire and intention. I would say that massage is like food. The client choice of food is based on in what he likes or in what he chooses. It is of course necessary to consider that there are medical cases that we can not follow only the desire of the client. But for that we MTs should clarify to the client why in such clinical circumstance heavy massage does not fit. For example if the client wants the MT to strike hard in a inflamed joint. That can harm more than help. But the MT can massage around inflamed joint area and this massaging aroung the inflamed joint are will bring blood to the joint which is going to help fight the inflamation. Everything in life depends on “Time, Place and Circumstance” Thanks.
Nedlands Pilates says
I believe as a massage therapist, you already know so much things with regards to it. And even if there are hundreds students to ask you, you can answer them. You already have the answer with you. All you have to do is speak. 🙂
Tracy Walton says
Mark, Alfredo, thank you for your comments. Alfredo, I think the food analogy is very effective, and have used it in teaching! Nedlands Pilates, so cool to hear from you–I think it’s best when we DO speak. Then it becomes a conscious process.
julie ackerman (Flow Therapies) says
Great article… I came away from ‘assisting’ at an Intro to Onc. Massage this weekend thinking about this issue indeed!!! Such incredible enthusiasm and thrill at learning about Oncology Massage. But I couldnt help but think that after 13 years in hospital based and Oncolgy centered massage, my need for peer based dialogue and a venue for sharing our process is endless. The continued developement of critical thinking in and of our profession is vital. I found myself listening to a few of first timers (to a class on Onc. Massage) discuss the clinics they want to open for people with cancer now! (With the knowlegde of one 3-day class!) As the teacher stated – “one 3-day lass does not an Oncology Therapist make” As you beautifully stated in this blog- the balance is so delicate between facts we need to learn and the time and effort spent in pure discussion and critical thinking. Beginner mind… and all the opportunities Beth mentioned above and absolutely a fuller grounding in critical thinking in our basic massage education!
Tracy Walton says
Yes, Julie, thank you. 23 years in MT and I still relish the beginner’s mind.
John Wackman says
I’d like to bring up the subjuct of Supervision Groups. Good friends who are psychologists and psychotherapists are all active in monthly Supervision Groups–and highly value the information and insight they receive regularly from their respected peers. In fact they consider it essential to their professional practice. Why are we MTs not doing this?
Great article. Currently the bulk of healthcare dollars in this country is spent on managing and curing diseases, not on prevention.In fact, only 3% of all healthcare dollars are spent on public health which main role is identifying threats both environmental and social to public health. However, while it’s still being debated, there are provisions in the ACA that lend more towards massage and other holistic and preventative care practitioners, or as additional care for people dealing with acute and/or chronic disease. It will be interesting to see how much this law increases accessibility to non-medical therapies such as massage and chiropractic.
Trevor Chisman says
Thank you for a wonderful, thought provoking article Tracy.
Some much of what we do comes down to listening to our clients and adapting our service to best suit them and their requirements.
Evangeline Maah says
Excellent article, Tracy! Yes, we should consider everyone’s needs in a case-to-case basis.