Massage Therapy Body of Knowledge

Comment

Comment by Keith Eric Grant on November 11, 2009 at 4:31pm

Mike,

You're mixing up separate discussions again in a manner that simply creates a distraction. There are very limited data on harm from massage and, as I said, little development of specific training protocols to mitigate any hazards. What we are discussing is that, in moving part of the practice of massage from a context of general massage to one seriously embedded within health care, that it is wise to consider comorbidities in a manner largely unnecessary for massage as a relaxation facilitation or to facilitate the efforts of health athletes. If you look at the recommendations I made in my 2003 article on massage safety (preprint version), you will see that I made similar cautionary statements there. It is not, by the way, a matter of hours but of identifying specific hazards, their methods and contexts of occurrence, and creating training and protocols specifically identified to mitigate such hazards. If such notices of hazard and mitigation have been created, then we need to get them into much greater awareness and circulation. I have yet to find them.

As to time required, it likely could be done in a series of web videos of about 2-4 hours and required biannually to maintain currency. The review could also include refreshers on universal precautions and blood borne pathogens.That is exactly the kind of training currency requirements I experienced while working at a national research lab. I would currently consider awareness of cervical arterial dissections, stroke symptoms (goes with CADs), deep vein thrombosis, and whatever develops in specific drug interaction protocols to be on the list. There may be programs assuring sufficient competence in these areas, but I'm not aware of any states or regulatory agencies using hazards management methods for massage. Please point me to them if I'm wrong.

If such materials are developed and widely accepted and used within a profession, then those teaching and using them should have lower risk. That is one of the purposes for the guidelines development process I'm involved in with my work with the Massage Therapy Foundation. Read the paper.

Comment by Mike Hinkle on November 11, 2009 at 3:35pm

Guys, all this in... 100 hours of training, besides an elective (ie: Swedish) for 250 hours and they have all this to consider on top of it? Do you have to be a doctor now to do massage? And they can't graduate until each KSA is met in each category according to an instructor. Wonder what liabilities the instructor or school will be under by passing students?

What happened to "no harm can be caused by massage?" A lot of harm can be done. You are proving it.

Comment by Keith Eric Grant on November 11, 2009 at 3:19pm

Carl,

I believe it requires some level of collaborative effort and interactive discussion, if only because the massage side needs to specify different "levels" of intervention, as in about of pressure, depth of work, tension on tissue, range of movement, .. Then within that the need for consideration of both systemic and local cautions and contraindications. So I would frame it as a petition for a collaborative effort rather than a petition and wait for the results.

BTW, for those who haven't seen it, Mitchell Batavia did a review on the often ambiguous state of massage contraindications in the January 2004 issue of JBMT.

Comment by Carl W. Brown on November 11, 2009 at 2:54pm

Keith, I believe that is it worth a try to have our associations petition the NIH NCCAM to develop the guidelines for contraindications and precautions. Massage is a major player in CAM an how better to spend taxpayer dollars? We should not be doing this and the NIH would be an ideal body with access to professional resources to do the proper research needed.

Comment by Keith Eric Grant on November 11, 2009 at 2:31pm

Bert,

This is one of my frustrations with massage organizations. One used to hear about the potential for the "untrained" to do harm. That presupposes several things. 1) That there is substantial potential for harm. 2) That the mechanisms and context by and in which the harm occurs have been specifically identified, and 3) that training uniformly address knowledge and protocols needed to mitigate harm, and 4) that we are able to measure/estimate the effectiveness of the mitigation and make changes as needed. I've never been able to find anything that comes close to this within the culture of massage organizations, even though what I've just outlined is standard industrial hazards control.

In the drug interaction arena one has both the action of the drug.and the dose dependence. With Coumadin, for example, there may be a higher dose post-"event" treatment and a longer-term, lower-dose management phase. The contraindications will vary between the two as, likely, will the medical restrictions on patient activities.

This is not something that should be left to the individual practitioner to sort out. Nor should it be left to the individual educator. I also don't think that its reasonable to expect outside agencies to be motivated to clarify this area for the massage profession on their own initiative. Rather, this is the kind of context that the professional organizations should pursue, bringing together both the pertinent research and the needed expertise from other professions. Strangely, for all the hue and cry about standards, such obvious areas for development seem largely ignored. In my book, credibility comes from dealing with such specific, not from erecting facades to create the look of a health care profession. The devil is in the details. One could do worse than the follow the example of the FAA in investigating the causes of aviation "incidents" and the promulgating changes in hardware, training, and protocols.

Comment by Carl W. Brown on November 11, 2009 at 2:21pm

Bert I had a very close friend of over 35 years who lost all of his fingers, 1/3 of one foot and 2/3 of the other because Coumadin actually CAUSED clotting. He had a heat attack and they gave him Coumadin to stop clots and it took the experts too long to figure out that he was getting clots form it and gangrene has set in. BTW is was not the bad Chinese Coumadin either.

I believe that we should not be in the business of trying to attempt to make decisions that are too complex for the experts to do a good job. If we put pharmacology not the BOK we then become responsible to know it and make the right decisions. Bad idea.

If we ask a client if they have clotting problems, thrombosis, etc. That makes sense. Asking for their drug list so that we can determine if they missed something on the list puts us into an area that is not part of our scope of practice.

Comment by Bert Davich on November 11, 2009 at 1:52pm

Hi Carl,
If the National Institute of Health would provide a set of contraindications and precautions, it would be a great boon for out profession. That would solve the problem of knowing which authority should be adhered to and would eliminate potential frivolous lawsuits and place the problem of updating changes in research and experience based side effects into the hands of the NIH.

This is exactly what I was referring to; an Rx issue from a medical authority that is adequately prepared to deal with the 'heat'. Again the PDR is a poor and potentially dangerous tool for massage therapists. It could take a therapist hours to determine contraindications or precautions from the PDR as contraindications or precautions are not spelled out. This also emphisizes my problem with the BOK referring to the PDR (which it does)

Here are perfect examples quoted from the PDR of Rx that require precautions or contraindications, none of which are mentioned in the PDR.
What should I avoid while taking Coumadin?
Do not take or discontinue any other medication unless directed to do so by your doctor. Avoid alcohol, salicylates such as aspirin, larger than usual amounts of foods rich in vitamin K (eg, liver, vegetable oil, egg yolks, and green leafy vegetables) that can counteract the effect of Coumadin, or any other drastic change in diet. Avoid activities and sports that could cause an injury and bleeding.

Coumadin is a powerful blood thinner that demands mindful precautions or possibly contraindication. This is not even mentioned in the PDR. So a therapist would have to already have the knowledge or make a medical decision based on what the PDR actually states.

Norvasc- Hypertension.... nothing about massage

What should I avoid while taking Insulin?
To avoid infection or contamination, use disposable needles and syringes or sterilize your reusable syringe and needle carefully. Always keep handy an extra supply of insulin as well as a spare syringe and needle.
Use alcohol carefully, since excessive alcohol consumption can cause low blood sugar. Don't drink unless your doctor has approved it.....
Nothing about precautions for massage.

In short the therapist would have to make a medical interpretation to make a decision regarding contraindications or precautions from the PDR. This is simply not acceptable from a legal and liability view point.

Comment by Carl W. Brown on November 11, 2009 at 12:47pm

Bert, I don’t think we should be making medical decision within our scope of practice and training. As you said we cannot agree on contraindications. I think once we have that the RX issue is simpler because the PDR for example will indicate what drugs are use to treat the conditions or can produce side effects that cause the conditions.

This is what the NIH says. Maybe we should ask them to provide a definite set on contraindications and precautions:

Safety
Massage therapy appears to have few serious risks—if it is performed by a properly trained therapist and if appropriate cautions are followed. The number of serious injuries reported is very small. Side effects of massage therapy may include temporary pain or discomfort, bruising, swelling, and a sensitivity or allergy to massage oils.
Cautions about massage therapy include the following:
· Vigorous massage should be avoided by people with bleeding disorders or low blood platelet counts, and by people taking blood-thinning medications such as warfarin.
· Massage should not be done in any area of the body with blood clots, fractures, open or healing wounds, skin infections, or weakened bones (such as from osteoporosis or cancer), or where there has been a recent surgery.
· Although massage therapy appears to be generally safe for cancer patients, they should consult their oncologist before having a massage that involves deep or intense pressure. Any direct pressure over a tumor usually is discouraged. Cancer patients should discuss any concerns about massage therapy with their oncologist.
· Pregnant women should consult their health care provider before using massage therapy.

Comment by Bert Davich on November 10, 2009 at 10:41pm

I think an RX list may not be a good idea for the BOK due to the lack of consensus on contraindications. Those writing the BOK are not physicians or medical researchers, so how will they determine how to handle a drug that may be contraindicated by one expert and not by another? To be lawsuit safe(er) they will have to go with the contraindication which may result in denying massage to many who need it. Then who will keep up with the changes in contraindications due to new research studies? And how about the parade of new pharmaceuticals that have not been around enough to have compiled a track record of negative side effects the Rx may have with or without massage thrown into the mix. I think this is a"tar baby" that will not result in benefit to the public or massage therapists. If the BOK is going to tackle this one, I would recommend the BOK refer to some specific recognized expert sources, and not the PDR which does not lend itself particularly well to indications and contraindications of massage.

Comment by Carl W. Brown on November 9, 2009 at 12:56pm

Noel what is the point of looking at pharmacology if we do not have a definitive guideline of contraindications?

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