Massage & Bodywork

JULY | AUGUST 2020

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In addition, the hemostatic disruptions seen with COVID-19 may also cause blood clots in tiny blood vessels on the trunk or extremities. Readers may have seen reports of "COVID toes"—this is a consequence of microvascular obstruction with resulting skin damage. This can also take the form of skin bumps, swelling, and redness on the toes, and petechiae on the extremities or trunk, with dark, flat, discolored patches of skin where microvascular bleeding has taken place. DISSEMINATED INTRAVASCULAR COAGULATION A condition called disseminated intravascular coagulation (DIC) is a serious complication that is identified when a specific type of disordered blood clotting accompanies some other major health challenge. It's a complicated situation involving both excessive levels of clotting in some areas and excessive levels of bleeding in others. This is because in the hypercoagulable areas, platelets and clotting factors are used up—leaving inadequate supplies to deal with tissue injuries elsewhere. This is why DIC is sometimes called consumptive coagulopathy— clotting factors are consumed. DIC is identified when blood tests show low levels of platelets (this is called thrombocytopenia), delayed clotting times, and high levels of D-dimer, a substance that indicates fibrin breakdown, or the degradation of blood clots. Is DIC the situation we see with COVID-19 patients? It's not entirely clear. Some medical professionals are moving forward with that assumption, while others find some differences between classic DIC, another clotting disorder called antiphospholipid syndrome, and what is now called COVID-associated coagulopathy. For our purposes, it doesn't matter, but understanding this phenomenon will make a difference in treatment options and survival rates for patients. MASSAGE THERAPY IMPLICATIONS It's hard to make confident recommendations about massage therapy in the context of a situation that is so complicated and fraught with unknowns. As I processed mountains of information and held conversations with many generous people who helped talk me off the cliff of confusion, I boiled down my remaining questions to a few primary ones, some of which I was able to answer: 1. Can you have COVID-19 and not have coagulopathy? (Yes) 2. Can you have COVID-19-related coagulopathy and not be hospitalized? (Yes) 3. Can you have coagulopathy and not have obvious symptoms? (Yes) 4. Could massage lead to embolization in a client with symptomatic or asymptomatic coagulopathy? (UNKNOW N, but we have to assume YES) 5. At what point is it safe for a person with a history of coagulopathy to receive massage? (UNKNOW N) Up until this point, our main goal in the context of COVID-19 has been to minimize the risk of catching or spreading the virus in a massage therapy setting. Now, we have an entirely different risk factor, with the possibility of contributing to blood-clotting complications by way of hands-on bodywork. In the final analysis, we must decide if the risks related to massage therapy for people who might have COVID-related coagulopathy are any greater than the risks we see with other hidden disorders. Is COVID-related coagulopathy different? This topic is a moving target, and our understanding of blood-clotting problems in the context of COVID-19 evolves quickly. In the short run, I propose that the best choice is to avoid working with people who are at risk for a current COVID-19 infection and to screen for blood-clotting problems in general. That might mean adding three new questions to a COVID-specific intake form: • Can you exercise to get your heart rate and respiratory rate up without any problem? (This would indicate whether their cardiopulmonary function is unimpaired.) • Have you had a new onset of muscle aches and pain since the emergence of the virus? (This is a possible early sign of coagulopathy, and a reason to defer treatment until the person has been tested and cleared of coagulopathy risk.) • Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin? (This indicates the possibility of microvascular clotting, and is reason to defer treatment until the person has been tested and cleared of coagulopathy risk.) In terms of clinical decision-making, we can start here: Any new signs of skin lesions or discoloration need to be fully resolved before we can be sure that massage is safe. Any signs of pulmonary or cardiovascular strain needs to be resolved. And any client using an anticoagulant to treat complications related to COVID needs to delay massage until they are no longer at risk for blood clotting. As we learn more about this situation, guidelines will change. This is a snapshot in time, and I dearly hope that in a year we will look back on this and say, "Yes, we've learned a lot since then." But until that time, we must be cautious and conservative, so that we can keep to our promise to "do no harm." Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology (available at www. booksofdiscovery.com), now in its seventh edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com. PATHOLOGY PERSPECTIVES N e w ! A B M P P o c k e t P a t h o l o g y a t w w w. a b m p . c o m / a b m p - p o c k e t - p a t h o l o g y - a p p . 37

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