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Indications/Contraindications for Massage
Transcript of Indications/Contraindications for Massage
Student will be able to: •In this chapter, students will explore indications and contraindications to massage.
•They will be introduced to three treatment approaches—therapeutic change, condition management, and palliative care—and they will use clinical reasoning to determine the appropriate intervention process for selected case studies.
•Students will have the opportunity to demonstrate a basic understanding of pathology and will learn when the stress response, inflammatory response, and pain response are indications for massage.
•At the same time, students will have the opportunity to learn when massage is contraindicated and how to refer clients for evaluation by a licensed health care professional.
Indications for Referral Indications for Referral Get to know health care providers:
Referring clients to their personal providers:
Provide a list if client doesn’t have a provider
Explain that observations you’ve made should be evaluated
Supply client with contact information Referral Endangerment sites include
Avoidance or light pressure is indicated when working over an endangerment site. Endangerment Sites Warning Signs of Cancer Tumors—benign (usually localized and slow-growing) or malignant (can metastasize)
Detection of cancer
Cancer not always a contraindication
Massage can support immune function as part of comprehensive treatment program
Important not to overtax body’s systems Tumors and Cancer Massage and medications can interact synergistically or antagonistically to
Over-the-counter medications, herbs, and vitamins should be assessed. Medications Massage therapists recognize indications and contraindications, not diagnose
Types of contraindications:
Regional—conditions related to a specific area of the body
General—possible serious underlying condition; physician’s approval required before massage is indicated Contraindications for Massage 71 Massage can physically influence mental state though compassionate touch:
Work in conjunction with mental health providers Indications for Massage 69 Massage can reduce pressure on nerves:
Soften and stretch connective tissue
Normalize muscle tension patterns
Restore normal resting length to shortened muscles Indications for Massage 67 Lumbar plexus
Symptoms: pain in lower back, belt area, lower abdomen, genitals, thigh, and medial lower leg
Origins of pressure can include quadratus lumborum, psoas, and lumbar dorsal fascia Lumbar Plexus 64 Two types of nerve impingement:
Impingement classified by plexus affected Impingement Syndromes 63 Pain is a complex problem.
Match the treatment plan to the type of pain.
For acute pain, intervention to support healing process
For chronic pain, symptom relief or therapeutic change process Indications for Massage 62 Sources of information for assessment:
Sympathetic responses to acute pain:
Areas of increased or decreased sensitivity Pain Assessment 60 By location—localized, projected, radiating, referred
By type—pricking or bright, burning, aching, deep (pain-spasm-pain cycle), muscle Evaluation of Pain 58 Referred pain is felt far from its origin.
Visceral pain and deep somatic pain can refer.
A diagnosis must be obtained from a physician. Referred Pain 57 Phantom pain after an amputation
Pain or other sensations seem to originate from amputated extremity.
Brain misinterprets stimuli from proximal portions of sensory nerves. Phantom Pain 56 Intractable pain is persistent with treatment or without demonstrable disease.
Poses greatest challenge to health care providers
Massage provides temporary relief through distraction. Intractable Pain 54 Acute pain is a disease symptom or a temporary treatment aspect.
Warning signal that arouses sympathetic nervous system
Temporary, sudden onset, localized
Client is often able to describe it
Arouses sympathetic ANS Acute Pain 53 Acute
Referred Types of Pain 51 The pain threshold is the point at which a stimulus is perceived as painful.
Pain tolerance is the duration or intensity of pain endured before relief is sought.
Varies widely among individuals Pain Sensations 49 Pain transmission to cerebral cortex
Neospinothalamic tract carries type A (fast pain) nociceptors to thalamus
Paleospinothalamic tract carries type C (slow, chronic pain) nociceptors to brainstem Pain Sensations 47 Nociceptors – receptors for pain
Found in almost every tissue of body
Sensitive to any type of stimulus
Little to no adaptation
Adaptation – decrease or disappearance of the perception of a sensation even though the stimulus is still present Pain Sensations 45 Pain mechanisms are very important to understand.
Pain is a complex, private, and abstract experience.
Effective management is a major challenge.
Pain has physiologic, psychologic, and social aspects.
The client defines the pain experience. Pain 43 Contraindications for therapeutic inflammation include:
Suppressed healing mechanisms
Conditions of impaired repair and restorative functions (unless carefully monitored)
Use of antiinflammatory medications Therapeutic Inflammation 41 Theories about how massage benefits prolonged inflammation:
Activates release of body’s antiinflammatory agents
Triggers completion of process
Increases lymphatic flow to dilute and remove irritant Indications for Massage 39 Productive local inflammation
Productive systemic inflammation
Inflammation that is persistent without benefit Inflammatory Disease 37 Heat and redness
Swelling and pain
Edema results from increased permeability of vessel walls.
Increased pressure triggers pain receptors.
Inflammatory exudate is the fluid that accumulates. Inflammatory Response 35 Massage especially beneficial for:
Somatization – anxiety disorders related to the ANS that manifest with physical symptoms Pathologic Conditions and Indications for Massage 33 Generalized stress conditions
The hypothalamus acts on the anterior pituitary to release adrenocorticotropic hormone.
This stimulates the adrenal cortex to secrete glucocorticoid.
The ANS is stimulated by the adrenal medulla’s release of epinephrine and norepinephrine. General Adaptation Syndrome 32 A prolonged or excessive “fight-or-flight” response can disrupt normal functioning throughout the body. General Adaptation Syndrome 31 Three stages:
Alarm (fight-or-flight response) – body’s initial reaction to stressor
Resistance reaction – secretion of hormones allows body to continue fighting or to endure a stressor after effects of alarm reaction have dissipated
Exhaustion – occurs if stress response continues without relief General Adaptation Syndrome 29 Genetic or inherited traits
Age-related or biologic factors
E.g., poor diet, smoking, alcohol consumption, sedentary lifestyle, physical risk taking Risk Factors 27 Acute diseases develop signs and symptoms quickly, last only a short time, and then disappear.
Chronic diseases develop slowly and last for a long time.
Communicable diseases can be transmitted from one person to another. Development of Pathologic Conditions 25 Healing taxes the body’s reserves.
Massage for injuries can address edema, pain, circulation, approximation, scar tissue formation.
Illness and injury:
Inflammation is a factor.
The therapist must refer clients for diagnosis and/or treatment. Development of Pathologic Conditions 24 Injury:
Incorporate aspects of general constitutional massage:
Reflexive in nature
Reduces stress load so the body can heal
Supports the body’s healing responses Development of Pathologic Conditions 23 Illness
Occurs when a body process breaks down
Tends to indicate general cautions and contraindications Development of Pathologic Conditions 22 Health, wellness, and injury continuum Functioning Limits 21 Massage intervention right after a first event can be an effective support for repair and restoration of function.
After dysfunction has set in, an intervention should be applied at the point where ROM limits were first observed.
A more complex intervention plan is necessary. Functioning Limits 19 Limits may be anatomic and physiologic.
The body signals fatigue, pain, or strain when limits are reached.
Extraordinary events can push the body’s limits.
Functioning reserves are available and are replaced by the body. Functioning Limits 17 Homeostasis – the relative constancy of the body’s internal environment
Acute – homeostasis restored quickly
Chronic – homeostasis may never be restored; compensation develops Disease 16 Maximal conditioning and function to a particular action
Injury, depletion, and illness can result:
If the lifestyle does not support recuperation time
If anatomic or physiologic limits are exceeded Peak Performance 12 Pathology – study of disease
Trauma – abrupt shock or injury to the body or psyche Pathology 10 Palliative care – attempts to relieve and reduce the intensity of uncomfortable symptoms, but does not produce a cure
Massage aimed at reducing suffering Approaches to Care: Palliative Care Therapeutic change – modification of physical form or function
Practitioner – must have appropriate knowledge and skills and network of support from other professionals
Client – must have the motivation and resources to complete a change process Approaches to Care: Therapeutic Change Anatomic benefits are measured objectively.
Biochemic benefits can be both objective and subjective.
Physiologic benefits must be reported subjectively. Indications for Massage Based on objective and subjective health-enhancing benefits or results:
Objective results can be measured and observed.
Subjective results are assumed effective based on experience.
Effects of massage are physical (objective) and mental (subjective). Indications for Massage Indication – condition for which an approach would be beneficial
Contraindication – condition for which an approach could be harmful
Types of contraindications:
General avoidance of application
Regional avoidance of application
Application with caution Indications for Massage Mosby’s Fundamentals of Therapeutic Massage 5th edition CHAPTER 06 INDICATIONS AND CONTRAINDICATIONS FOR THERAPEUTIC MASSAGE All paperwork and notations should go into the client’s file.
Follow directions and recommendations of health care professionals exactly. Referral Nervous and Cardiovascular System Endangerment Sites Caution – condition that requires the massage therapist to adapt the massage process so that the client’s safety is maintained
Type of massage lubricant used
Depth of pressure
Duration of the massage
Avoidance of a type of massage application Cautions Lesson 6.3 Identify contraindications to massage and develop massage adaptations to support any cautions identified. Adapting Massage for Contraindications and Cautions 70 Mind/body link—interaction and interdependence of physical and mental processes
Major types of mental health dysfunctions:
Posttraumatic stress disorder (PTSD)
Pain and fatigue syndromes
Anxiety and depressive disorders
Stress-related illness Psychological Dysfunctions 66 The brachial plexus is situated in the neck and axilla.
Symptoms include pain in the shoulder, chest, arm, wrist, and hand, and thoracic outlet syndrome.
Origins of pressure can include scalenes, pectoralis minor, subclavius, and arm muscles. Brachial Plexus 65 The cervical plexus includes the phrenic nerve and the ventral branches of four upper cervical nerves.
Symptoms: headaches, neck pain, breathing difficulties, and pain sensations in neck, ear, and shoulder (transmitted by cutaneous branches of nerves)
Origins of pressure can include suboccipital and sternocleidomastoid muscles and shortened connective tissues at cranial base Cervical Plexus 61 Pain-Spasm-Pain Cycle 59 Referred area and origin innervated by same spinal nerve
Usually, both structures from same dermatome Referred Pain 55 Chronic pain persists or recurs for indefinite periods, longer than 3-6 months
Major health problem for many
Character and quality can change
Anxiety, sleep disturbances, depression common
Multidisciplinary approach to treatment Chronic Pain 50 Influences on perception of pain:
Emotional interpretation—hypothalamus and limbic structures
Rational interpretation—frontal cortex
Neurotransmitters and neuromodulators (substance P, acetylcholine, norepinephrine, epinephrine, dopamine, serotonin)
Endorphins Pain Sensations 46 Four processes involved in pain sensation:
Pain transduction—noxious stimuli lead to electrical activity in pain receptors
Pain transmission—pain impulses travel through PNS to CNS
Pain modulation—neural activity can influence pain transmission at spinal cord; also involves activity in primary afferent pain receptors
Pain perception—subjective experience Pain Sensations 42 Therapeutic inflammation creates a controlled, localized area of inflammation to jump start healing processes.
Types of therapeutic inflammation include:
Connective tissue stretching
Moxibustion: burning the skin
Acupuncture Therapeutic Inflammation 40 Acute inflammatory conditions
Systemic inflammatory conditions
Avoid any approach that adds any more adaptive strain than the client can manage
When in doubt—don’t massage Indications for Massage 36 Inflammatory response—processes that minimize tissue injury and promote healing
Active, important part of healing process
Four primary signs: heat, redness, swelling, and pain
Occurs in response to injury and may also accompany specific immune system reactions
Can be suppressed if more intense or prolonged than desirable Inflammatory Response Lesson 6.2 34 Develop a basic understanding of pathology and use the knowledge to determine indications and contraindications for massage. Using Pathology to Determine Indications and Contraindications 30 Environment
Preexisting or primary conditions
E.g., any substantial change in routine or any activity that forces the body to adapt Risk Factors 28 Risk factors are predisposing conditions that make disease or injury more likely, including:
Genetic or inherited traits
Age-related or biologic factors
Preexisting or primary conditions
Stress Risk Factors 26 Signs are objective abnormalities seen or measured by someone other than the client.
Symptoms are subjective abnormalities felt only by the patient.
Syndromes are groups of signs and symptoms, usually from a common cause. Development of Pathologic Conditions 20 Dysfunction results of depleted reserves:
Dysfunction is related to attempts to maintain a higher energy reserve.
Overstretched muscle patterns are reset to prevent further strain, slightly limiting ROM.
Continuing dysfunction leads to compensatory habits. Functioning Limits 15 Dysfunction – the in-between state of “not healthy” but “not sick”
Prepathologic states often are not apparent using Western diagnostics.
Effective approaches to dysfunction include mind/body medicine, stress management, and prevention methods.
Active pathologic processes often require more aggressive treatment. Dysfunction 14 Health—optimal functioning with freedom from disease or abnormal processes
Factors that influence health:
Inherited (genetic) and constitutional traits
Lifestyle (diet, exercise, rest, stress level)
Beliefs and attitudes, self-esteem, loving relationships
Authentic personality and freedom from self-hindering patterns Health 13 A basic understanding of pathologic processes and pharmacology is helpful:
to refer appropriately;
to recognize contraindicating symptoms;
to recognize general types of disorders, specific signs and symptoms, and the development of disease processes; and
to understand possible interactions between medications and massage. Pathology 8 Condition management – support for clients unable to undergo therapeutic change process for various reasons:
Chronic health condition
Life circumstances that create chronic stress
A situation for which change is not viable
Need to postpone time frame for change Approaches to Care: Condition Management 7 Therapeutic change might be unrealistic at a particular time or under a certain set of circumstances.
Condition management or palliative care can be offered instead.
Because athletes are looking to improve their physical qualities to compete, massage could improve flexibility, enabling them to push off more efficiently and run faster. Approaches to Care: Therapeutic Change Lesson 6.1 Define the terms indication and contraindication.
Define therapeutic change, condition management, and palliative care as therapeutic approaches.
Define pathology and explain the causes of disease. Approaches to Massage Care and Defining Pathology 68 The sacral plexus includes the sciatic nerve and serves the pelvic structure, buttocks, and lower limb.
Symptoms: gluteal, genital, leg, and foot pain
Origin of sciatic pressure can include piriformis muscle and ligaments of the sacroiliac joint Sacral Plexus 48 Fast pain
Felt in deeper tissues
Burning, throbbing, aching
Usually associated with tissue damage Pain Sensations 44 Utility of pain sensations:
Cue us to protect ourselves from further hurt
Initiate a search for medical assistance
Help pinpoint underlying cause Pain 38 Tissue repair is a combination of two processes:
Healing process goals:
Promote regeneration, minimize replacement
Slow the formation of scar tissue
Keep scar tissue that does form pliable Tissue Repair 18 Homeostasis – the relative constancy of the body’s internal environment
Disease or pathology occurrence
Homeostatic and restorative body mechanisms break down or can no longer adapt
Illness usually requires a series of events
Stress levels and lifestyle are contributing factors Disease 11 Questions to ask:
When is change appropriate?
When is change not desirable and condition management and palliative support are more appropriate?
How does the massage professional determine what type of care is appropriate: therapeutic change, condition management, or palliative care?
How does the massage professional know when transitions occur in types of care? Determining the Type and Timing of an Approach 9 Massage benefits:
Managing existing physical compensation patterns
Sometimes slowing progression of chronic conditions
Preventing a situation from becoming worse
Can assist in the management of physical stress symptoms allowing client to cope better
Accounts for the largest client base for therapeutic massage Approaches to Care: Condition Management 52 Origins of pain
Cortex accurately locates origin of most somatic and some visceral pain Origins of Pain