Issue link: https://www.massageandbodyworkdigital.com/i/1276187
C h e c k o u t A B M P 's 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 . 47 COAGULOPATHY Blood-clotting disorders connected to COVID-19 are the focus of my July/ August 2020 Pathology Perspectives article, "COVID-19-Related Coagulopathy: Blood Clotting Through Thick and Thin" (page 32). This situation is complex, nuanced, and obviously has big implications for decisions about massage therapy. Coagulopathy may affect tiny capillaries or major vessels, and it is a factor in some of the other situations on this list. Many bodywork practitioners are legitimately nervous about the risks of hidden clots in veins, which may lead to pulmonary embolism, or in the arteries, which may lead to heart attack, stroke, or other injuries. This is why we must always gauge our massage to fit within our clients' ability to adapt to environmental challenges. This is called allostatic capacity, which is discussed in detail at www.abmp.com/ updates/blog-posts/staying-stable-being- variable. Working within the limits of a client's daily activities isn't a new concept, but it takes on fresh importance in the context of COVID-19 survivors and their potential for subtle blood-clotting problems. Implications for Massage Therapy Get the clearest possible sense of the client's typical activity levels, and keep bodywork challenges within their allostatic capacity. Watch for skin signs (COVID-toe, petechiae, or other rashes). If the skin is injured, these are local contraindications, and only the gentlest massage is appropriate until these have resolved. Ask about signs of cardiopulmonary distress (edema, shortness of breath, chest pain, headache, cramping in a new pattern), and encourage—or insist—that the client report these to their doctor before proceeding with massage. A hematologist familiar with our work also suggests asking and looking specifically for signs of deep vein thrombosis: unilateral pain, heat, swelling, and/or redness in one leg. This is also a reason to delay massage and refer the client to their health-care team. ACUTE LIVER INJURY Some post-COVID patients have elevated enzymes that indicate liver damage, especially in the aftermath of severe infection. It is not clear whether the liver damage is from direct viral attack, an Massage therapy could be a supportive and life-affirming part of the recovery process—with the caveat that it must be done with great care and in incremental steps toward pre-COV ID levels of intensity. extreme inflammatory response, or other factors. One possibility is liver toxicity related to medication use—this is called drug-induced liver injury, or DILI. At this point, we don't know whether preexisting chronic liver disease (specifically hepatitis B or C, or nonalcoholic fatty liver disease) increases the risk of long- term liver damage related to this virus, but some liver problems make patients more-than-usually susceptible to DILI. COVID-19 patients who develop mild liver problems may not require treatment, and can probably expect full recovery of liver function. But in more severe cases, drugs that support the liver may be prescribed. Implications for Massage Therapy Because the liver is a keystone for healthy fluid management, liver dysfunction is an important factor in making decisions about massage therapy. If the client is using liver- supporting medications, find out whether this is a temporary measure, and consider delaying any challenging bodywork until this part of their recovery is over. If their liver dysfunction limits normal activities or causes edema in the abdomen or elsewhere, then massage therapy needs to be especially gentle, and prone work may not be possible. Also, be aware that liver-supporting drugs may have side effects, and these may also influence choices about massage therapy.