Positive Health Online

I entered the field of massage in 1987 with my first massage qualification and a sheet of paper headed 'Contraindications'. This informed me that I wasn't to massage a woman during the first three months of pregnancy, anyone with cancer, an infectious condition, skin disorder or inflammation, to avoid scar tissue, and that I had to get the doctor's permission before I massaged anyone else with a medical condition. Fortunately, most of my clients were young and well, wanting massage for relaxation or self-care. Nearly 20 years later many things have changed, one being the sort of client population that seeks massage as a therapy. The Foundation for Integrated Health states that increasing numbers of people are seeking to combine the best of complementary and conventional healthcare. Massage is no longer only a therapy of indulgence and pampering but also one that people with chronic medical conditions choose to complement their medical care. I think this change began when massage was found to be an effective method of pain relief in palliative care for patients for whom the doctors could no longer cure; people with terminal cancer and AIDS. As the massage profession has taken up the challenge from orthodox medicine to prove its effectiveness through conventional research methodology, and funding has become available to do this, the scientific community has become more accepting of massage and complementary therapy in general. In fact, one of the key principles behind the work of the Foundation for Integrated Health is to promote familiarity with complementary therapies among all health professionals (for example doctors, nurses and midwives). We are no longer 'alternative' but 'complementary' to the medical profession.

Consequently, the massage practitioner today requires a basic understanding of common medical conditions, the systems of the body that are affected, the underlying causes, signs and symptoms, and indications and contraindications for massage, to help her/him make good choices about a safe treatment plan for any client, to have the confidence to work with clients who are not well and healthy, to know when it might be sensible to refuse treatment and when to refer to another professional. All awarding bodies for massage training in the UK provide modules within the curriculum which teach pathology and contraindications. The General Council for Massage Therapy (GCMT) has produced guidelines for the massage profession that aim to unify this information. These are available on their website. For a more comprehensive list of pathological conditions, it is a good idea to have a simple medical dictionary and a copy of the British National Formulary (BNF) or information about medication. Randal Persad's book on massage and medication is extremely helpful too.

A Case Study

When Mrs K was referred to me for massage a few years ago by a local acupuncturist, who was treating her for 'all sorts of things', I knew that I needed to take a detailed case history. Mrs K, then 70, had some hearing loss, chronic asthma and a tendency to bronchitis in winter, intermittent sciatica, lower back pain from wear and tear in her lumbar vertebrae and episodes of IBS-type symptoms. She had high blood pressure controlled by medication. She'd had a hysterectomy 30 years previously and minor surgery on an eyelid two weeks just before our first meeting. Unusually for her, she'd suffered from insomnia for the past few months. She also had a great sense of humour. Having been thin, fit and strong all her life, she was fed up with being overweight and having so many ailments, and wanted to see if a whole body massage might help her feel better. She was taking medication, but didn't know the names of her drugs. I asked her to write them down and bring them to the next appointment, which she did. She had an inhaler for her asthma and had been prescribed Bendrofluazide for oedema and Doxazosin for hypertension. Later, I looked these up in the BNF and made a note of possible side-effects, and anything that might be relevant to massage. Doxazosin, for example, can cause vertigo and dizziness, so it made sense to ensure that Mrs K always sat up slowly after treatment.

What did I decide to do, with all this information? Chronic respiratory problems indicated tight intercostal muscles, which massage might be able to help, and possible difficulties lying prone for too long. Lower back pain and sciatica indicated work on the relevant muscle groups, but I wouldn't be sure how deep until I began to palpate them, and I'd need to negotiate with her about comfortable ways of lying and use of supports. Her hearing loss meant that I'd need to tap her arm or speak clearly when I wanted to communicate during the treatment. High blood pressure, if stress related, indicated that relaxation massage would be beneficial, but also that deep work on her abdomen should be avoided. The unknown abdominal complaints also made me decide to avoid abdominal massage. At the first session I couldn't offer her a face hole because of the recent eyelid surgery. Her back and sciatic pain seemed to be the priorities, so we negotiated a treatment focusing on these areas, with some attention to the rest of her body. Once on the couch, various factors became apparent that hadn't come up in the initial consultation, but needed to be taken into account: her legs were slightly swollen and some veins were varicose (local contraindications), and her shoulder muscles were solid (massage definitely indicated). She also had the loveliest smooth and healthy skin.

Mrs K enjoyed her massage, particularly the foot massage, which she found very relaxing, and the stroking on her upper intercostals for the beneficial effect on her breathing. She made a decision to come once a fortnight and I asked her permission to inform her medical doctor that I was treating her. I wrote the following letter, and showed it to Mrs K at her next appointment before sending it to the health practice.

Dear Dr X,
I am seeing your patient, Mrs K, every two weeks for massage, for the purpose of relaxation and general pain relief. I am observing the usual cautions for high blood pressure. If you have any concerns about the advisability of massage, please let me know.

Medical Liaison: Reasons for doing it

If I'd met Mrs K when I was just starting out in massage, I probably would've looked at her list of ailments and told her to go away and get a letter from her doctor giving permission for me to massage her. And I probably wouldn't have seen her again. Imagine making an appointment with a strange professional for a treatment that you've never had before but, based on what you'd heard about it, think you'd probably enjoy it and then, once you'd given your medical history, being sent away. However, while there are several very good reasons for contacting the client's doctor or consultant if he or she is undergoing medical treatment, or has a chronic medical condition, there's also a big difference between asking permission, which implies that the medical professional knows best and should always be deferred to, and informing or liaising with, both of which suggest a mutuality of knowledge, skill and expertise. None of us would think about asking permission from an osteopath before massaging a client with back pain, so why ask permission from a doctor? If one of my clients also has osteopathy it makes sense for both of us professionals to know what the other is doing so that we can tailor our treatments, and the scheduling of the client's appointments, to work in her best interests. Communication is for information sharing, and out of professional courtesy.

Mrs K had a complicated medical history, and was taking a number of medications, for which she saw her doctor fairly regularly. I considered it courteous to let the doctor know that I too was going to be treating her patient. Communicating in a responsible manner helps to build good relationships between the massage and medical professions. It indicates that we, practitioners of massage, are aware of the potential impact of the various techniques we use on healthy tissues, despite the scarcity of research evidence at the moment, and that, while we know how to adapt our techniques to work competently and safely with people with a range of minor ailments, we also recognize that our knowledge of pathology, and the effect of medication, is limited. We know about massage, the doctor knows about medicine. Communication is a two-way process, as I discovered when I next visited my doctor. Mrs K and I were registered at the same surgery and somehow a copy of my note to her doctor had been attached to my file. The doctor expressed appreciation that I'd bothered to let them know that Mrs K was having massage, but also that she was unqualified to comment on the advisability of massage, having no knowledge of it. Until medical professionals are better informed about complementary therapies and a larger body of evidence based research exists, we cannot expect much help from the medical profession when it comes to the advisability or otherwise of massage with certain clients.

However, there is another very good reason for liaison with the medical profession, and this is for insurance purposes. The GCMT guidelines point out that "students and practitioners of massage therapy should note that at all times they hold clinical, ethical and legal responsibility for the effects of their treatments on clients." None of the main British insurance companies exclude any medical conditions from massage treatment, but they do all recommend that a full medical history is taken, including treatments and medications, and that a doctor's consent is obtained. Litigation is very rare in this country, but were a client to take a massage therapist to court claiming that massage had aggravated a medical condition, the practitioner's legal standing would be much better if he or she had informed a medical doctor that the treatment was taking place. In this respect, liaison is a safeguard for the therapist.

Another reason for liaising with a doctor or consultant is to ask for specific advice. A pregnant woman wants you to be present to massage her during labour and you're uncertain how acceptable this would be for the midwife and don't want to wait until the baby is on the way to find out, so you contact the delivery team beforehand. You wonder about a client with vague muscular aches and pains that haven't improved after a few sessions of massage. You know that she takes an anti-depressant, and you also know that a side-effect of some antidepressants is muscular aches and pains, so you decide to write to her doctor for her opinion on the matter. An elderly client who loves having her head, neck and shoulders massaged has been having a number of transient ischaemic attacks (mini strokes) and you want advice about whether or not just holding her neck could possibly precipitate an attack.

Methods of Liaison

Having considered the reasons for liaising, the next question is how you go about it. Bearing in mind that all information a client gives you is confidential, if you decide to communicate with another practitioner you must discuss this with the client, giving clear reasons for your decision, and you must have your client's consent. You could then ask the client to inform her doctor verbally, at her next appointment, that she has started to have massage treatment. This is a very informal approach. The problems are that you have no evidence, apart from the client's word, about the doctor's response and no written evidence, for legal requirements. Another way is to write to the doctor with the information that you are currently seeing her patient for massage, and to request that if she has any observations or reservations, to let you know. You could have a standard letter for such purposes. Keep a copy on file and a copy of any responses. A third approach is to write a more detailed letter requesting information about the advisability of massage from the doctor. If, for example, a client has had a stroke, you might want the go-ahead from his doctor about when it is safe for him to receive massage.

If a client refuses permission to liaise you have two choices; if you have serious doubts either about the advisability of massage for a particular medical condition, or about your own experience and competence to massage safely, then don't. Explain your reservations and possibly refer to another practitioner; the other choice is to ask the client to sign a medical disclaimer, to the effect that he refused permission to consult with his doctor and takes full responsibility for his medical condition and any changes that arise as a result of having massage. However, as the professional, you still have total responsibility for the treatment, including anything detrimental that could happen, and a written disclaimer holds no legal weight were the client to bring a malpractice case against you.

General Guidelines

Should we inform the client's doctor every time she or he has a cold? This would be ridiculous. But how are we to decide when to inform, when to ask about the advisability of massage, and when not to bother? The following lists, taken from my book Practical Pathology for the Massage Therapist have been adopted by the GCMT as guidelines.

Medical consent is not required if the client has…

• Mild to moderate strains and sprains, and cramp;
• Common complaints, for which the client is not receiving medical treatment including upper respiratory infections, such as colds, coughs, sinusitis, common allergies such as hay fever, jet lag, constipation/diarrhoea (unless part of an underlying condition);
• Localized skin conditions unless they are severe or undiagnosed;
• Visual and hearing impairment;
• Conditions that have resolved or are in remission, and there is no on-going medical treatment;
• Common menstrual or menopausal symptoms;
• Pregnancy, unless there is a history of miscarriage. Inform the medical practitioner if the client has…
• Unhealed fractures, all types of arthritis and osteoporosis;
• RSI, muscular dystrophy, fibromyalgia;
• Severe or widespread skin disorders for which the client is receiving medical treatment;
• Severe respiratory conditions like emphysema, chronic bronchitis and pneumonia;
• Most nervous system disorders affecting motor and/or sensory function if the client has on-going medical treatment;
• Clients who are emotionally vulnerable and taking medication – but be sensitive to the client's wishes;
• Cancer, if in remission;
• Diabetes, thyroid and other endocrine disorders;
• Disorders of the large intestines, such as Crohn's disease, or IBS;
• Gall and kidney stones.

Request input or guidance about the advisability of massage if the client has…

• Had recent major surgery;
• Cancer, if in treatment;
• HIV/AIDS, if seriously unwell;
• Most cardiovascular conditions;
• Conditions that are infectious for a certain period during the acute phase, such as pulmonary TB. Hepatitis and cirrhosis.

These lists are intended as helpful guidelines only and not as absolute criteria. Every individual case is different, and the decision to liaise also depends on the practitioner's professional maturity, experience with particular client groups and confidence.

References

British Medical Association and the Royal Pharmaceutical Society of Great Britain. British National Formulary. BMJ bookshop. PO Box 295, London WC1H 9TE. www.BNF.org
The General Council for Massage Therapy www.gcmt.org.uk
Fox S. Practical Pathology for the Massage Therapist. Corpus Publishing Ltd. Gloucester. ISBN 1 903333 19 9. 2005.
Persad RS. Massage Therapy and Medications. Curties-Overzet Publications Inc. Ontario. ISBN 0-9685256-2-8. 2002.
The Prince of Wales' Foundation for Integrated Health. www.fihealth.org.uk