SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717

Massage in the Medical Delivery System

I encounter many massage therapists in the field who want to increase their massage skills in order to treat painful conditions by using medical, therapeutic, sports or rehabilitative techniques. This desire to move to a more educated level of massage is indicative of the place massage is taking in the medical arena. Also, many massage clients, who are fed up with the medical establishment that does not adequately address their conditions or symptoms, are contacting massage therapists themselves because they have heard from friends and acquaintances that massage is very effective in relieving painful conditions. Other clients are bypassing the medical establishment entirely, and showing up at massage therapists’ office with a number of maladies in the hopes that maybe massage might be the answer. This creates a tremendous challenge for the massage therapist. At what point do the clients need a medical evaluation before massage treatment should be applied, and under what conditions is massage and soft tissue therapy the safe and obvious form of treatment.

Let’s look at this issue from several angles: 1) clients who regularly see a physician and choose to go to a massage therapist for additional relief, 2) clients who are referred to massage therapists by their doctors, and 3) clients who bypass the medical profession entirely and contact massage therapists directly for pain relief.

THE THREE SCENARIOS:

1) Clients who regularly see a physician and choose to go to a massage therapist for additional relief. The optimal working situation here would be for the massage therapist to contact the physician: 1) to be sure there are no further contraindications for massage, 2) to educate the physician as to the benefits of soft tissue treatment as an intervention at this point, and 3) to have the physician prescribe massage as a specified treatment for the client’s pain. Within the normal medical model, if a client’s symptoms continued to escalate, there could have been further testing and invasive procedures. However, with the timely application of effective therapeutic medical massage and body work there most likely would be measurable improvement which would prevent further degeneration into more serious problems. This is an excellent opportunity for therapeutic medical massage and bodywork to be applied in conjunction with the prescribed medical treatments to facilitate a more complete recovery for the client.

2) Clients who are referred to massage therapists by their doctors. The optimal working condition here would be for the therapist to contact the physician to inform him that the client is being seen for therapeutic medical massage and bodywork treatments for the conditions that the physician prescribed, and to assure the physician that he will be kept abreast of the patient’s progress. This is a fortunate case in that the physician already believes in and is familiar with the benefits of therapeutic medical massage. When the physician sees the client again, the appropriateness of his decision will be reinforced, and the effectiveness of massage therapy will be proven by the client’s improvements. Here the massage therapist fits very nicely into the medical delivery system in that a physician made the initial evaluation, prescribed the necessary medication, and recognized soft tissue complications that could be effectively treated with therapeutic medical massage and bodywork as an intervention before the conditions developed into a more significant or dangerous situation for the client.

3) Clients who bypass the medical profession entirely and contact massage therapists directly for pain relief. Hopefully the massage therapist will have the client complete an intake form indicating lifestyle, type of work, previous doctor visits, and list medications and symptoms. The therapist is now faced with several challenges: a) are there any medical conditions that a doctor recognized in the past that the client did not include on the intake form which would contraindicate massage, either because he did not have the medical information, or because he didn’t like the medical diagnosis? b) Is there any pathology that a physician would consider to be a contraindication for medical massage? c) Does the massage therapist have the appropriate skills to apply medical massage techniques for the client’s current condition.

Addressing these challenges:

a) Are there any medical conditions that a doctor recognized in the past that the client did not include on the intake form which would contraindicate massage, either because he did not have the medical information, or because he didn’t like the medical diagnosis? Obviously, since a physician did not refer the client, it would appear to be a good idea to contact any physician the client had seen in the past for other health problems. However, with today’s confidentiality, the security that is set up to protect the patients rights often makes it difficult to get information from a physician about a client’s condition, and sometimes the client must make a visit to the doctor’s office for this information to be available. Many times requests for faxed release forms from physicians’ offices are low on the list of their priorities.

The challenge for the massage therapist here is to assess the client’s ability to have an adequate understanding of his medical condition, and determine whether the client truthfully listed all medications – there are some dangerous ones, i.e. blood thinners, that would contraindicate therapeutic medical massage and bodywork treatment. This can be a gray area. It is necessary for massage therapists to become educated about medications and their reactions in order to make accurate assessments in cases like this. It is advisable to have an up-do-date PDR (Physician’s Desk Reference) where unfamiliar medications can be researched and evaluated based on the recommendations made in the PDR studies.

The client has come to the massage office expecting to receive a massage right away. If the massage therapist feels comfortable applying therapeutic massage techniques in this situation, then there is no problem proceeding. However, if there is any question as to the appropriateness of applying therapeutic massage or the credibility of the client, it is best to play it safe and refer the client to a physician prior to doing a session – even if it means losing that client. The well-known phrase "above all else do no harm" will protect the therapist as well as the client.

b) Is there any pathology that a physician would consider to be a contraindication for medical massage? Obviously, the massage therapist needs to spend significant time becoming educated in medications and pathologies, and developing a good understanding of how pathologies relate to the indication or contraindication of massage. The more educated the massage therapist is, the easier it will be to make an accurate assessment. When a client who is not under a doctor’s care consults a massage therapist, the massage therapist needs to be able to assess the appropriateness of applying therapeutic medical massage and bodywork by evaluating client symptoms, swelling, inflammation, redness, range of motion, type and amount of pain, and the possible existence of serious pathology that would contraindicate massage. Understanding the relationship of symptoms to pathology and the severity of pathologies is very important in being able to recommend the appropriateness of massage. The good news here is that very few pathologies have adverse or dangerous reactions to the application of massage techniques. The national certification and state licensing has helped move massage more into the medical arena, and required more advanced education and training for the massage therapists giving them a broader foundation of information on which to make proper assessments of the appropriateness of massage.

c) Does the massage therapist have the appropriate skills to apply medical massage techniques for the client’s current condition. Another challenge for the massage therapist is having the proper skills to apply therapeutic medical massage treatments that will positively address the client’s condition. This again is a gray area since the length and depth of the education and training for massage therapists varies so greatly.

Advanced training in therapeutic rehabilitative massage, i.e. medical massage, focuses on evaluating symptoms and conditions, and determining possible causes. Additional information can be gained by using structural body reading, measuring range of motion, and using kinesiology and palpation to determine the condition of the musculoskeletal system. Integrating all this with the information from the client interview and intake form will give the massage therapist a good foundation on which to build a treatment plan for effective therapeutic medical massage and bodywork.

Once this full evaluation has been made, the final challenge is determining which therapeutic techniques would best serve to rehabilitate the condition. Again, the more highly educated massage therapists will be able to apply an effective treatment protocol, based on their education from books, training and experience, which will result in rehabilitation and recovery for their clients.

The final challenge for the massage therapist is the client who fails to show improvement within a reasonable amount of time. This could be several sessions, or up to 10-15 sessions depending on whether the condition was acute or chronic, minor or severe.

An acute condition should show improvement within four to five treatment sessions. If this doesn’t happen, there may be underlying medical conditions that have yet to be diagnosed, and the client needs to see a physician for further evaluation. The physician will be able to rule out any complications and then suggest continued massage treatment, add some other form of treatment in conjunction with massage (prescription medication or physical therapy), or may recommend other medical treatment based on their medical judgment.

If the condition is chronic, it will often take 10-15 sessions of therapeutic medical massage to achieve a lasting positive change. This is due to the fact that there will be a larger build-up of adhesions, lactic acid, scarring, compensations, and structural distortion. The more highly skilled the massage therapist will be able to effectively treat the more complicated chronic conditions.

Conditions that have minor dysfunction and pain should show improvement within four to five sessions. If this doesn’t occur, referral to a physician for further evaluation is appropriate.

If the condition is severe, it is important to have an evaluation done by a physician before the application of therapeutic medical massage treatments. This will rule out conditions that contraindicate massage therapy or could very possibly be aggravated by its application. Because of the severity of certain conditions, 10-15 treatments may be necessary before significant change is noted. After 10-15 sessions, if there is only minimal improvement, it is best to re-evaluate the condition from the massage standpoint, the client’s goals, and the physician’s diagnosis. It is never appropriate to tell the client they can’t get better, but sometimes it is necessary to refer them to someone more skilled, or with advanced medical training and experience for the client’s best good.

I hope this has helped to clarify massage therapy’s place in the medical delivery model. Keep up the good massage therapy.