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A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 13 READER FORUM HELLO FROM AUSTRALIA! I am a remedial massage therapist and trainer in Melbourne, Australia. I could go on for hours as to the state of our unregulated massage industry here, but suffi ce to say the level of training offered here is sadly lacking and qualifi ed therapists are often working with the best of intentions but with outdated knowledge. I was so excited to read Ruth Werner's article, "Understanding Indications and Contraindications," in Massage & Bodywork [May/June 2018, page 40]. I have recently developed a Continuing Professional Education (CPE) training program for Australian therapists to help them address some of the common side effects of common over-the-counter and prescription medications. I use a "traffi c light" system to create levels of awareness for them. Green is minimal issues for massage, red is extreme caution for some types of treatment (e.g., client on blood thinners = no deep-tissue work.) I know it is not rocket science, but it frightens me that so many therapists worry about the pathology of an issue and don't consider the other factors that may impact the client. I wish that Ruth's work was referenced and taught more in Australia, and that publications like Massage & Bodywork were promoted more to therapists in Australia. I look forward to reading more of her work, and thank her for what her books have taught me and for providing my inspiration for training other therapists. LIZ SHARKEY MELBOURNE, AUSTRALIA WITH GRACE, HUMILITY, AND LOVE I loved reading Cindy Williams's article "How Pain Changed My Life for the Good" in the May/June 2018 issue of Massage & Bodywork [page 74]. It is so beautiful and heartfelt. Very well written, it conveys the range of what chronic pain really entails. In the massage world, we tend to talk so much about "fi xing" people's pain that we forget the person who is experiencing it. Cindy brings her heart and soul to the discussion. I, too, have injury/conditions that contribute to chronic pain. Cindy articulates so well how her experience changed her life forever. I know that my identity was very wrapped up in the things I loved to do—hiking, dancing, cross-country skiing— and when I couldn't do them anymore, the pain of that loss was ongoing too. A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 41 40 m a s s a g e & b o d y w o r k m a y / j u n e 2 0 1 8 education PATHOLOGY PERSPECTIVES I recently had an interesting phone conversation with a friend who is a massage therapy school administrator. She wanted some guidance for a new pathology educator. We had a spirited discussion (which is to say, a friendly disagreement) about whether some condition, I don't remember which, contraindicates massage therapy. I maintained that with appropriate accommodations it would be possible to design a session that could be helpful and safe, even in a situation where the client was frail and their constitutional health was compromised. After a brief silence, my friend asked, "Well if that's true, then what is a contraindication anyway? And how are we supposed to teach it?" That conversation blossomed into this article, which is dedicated to massage therapy pathology educators everywhere, but which is intended for use by every well-meaning massage therapist who sees clients with health challenges—and I'm willing to bet that's the majority. A LITTLE VOCABULARY The terms indication and contraindication are sometimes used a bit carelessly in massage therapy education. To be precise, an "indication" is a situation in which a particular intervention is expected to have a positive effect on the outcome of the disease or condition, and a "contraindication" is the opposite: a situation in which an intervention should be avoided because of risks to the client. We can say some situations indicate or contraindicate massage, but in reality, I believe it is more accurate to say that massage therapy addresses the person, rather than the disease. So rather than saying massage is indicated or contraindicated, it is generally better instead to weigh relative risks and benefits of massage therapy in a particular situation, in order to design a session that maximizes benefits while avoiding risks. And here's where it gets tricky. Massage therapy is a huge term! It can encompass virtually any kind of systematically applied, educated, and outcome-oriented touch. So, it is possible to imagine bringing something useful into almost any nonemergency pathologic situation. ANALYZING THE VARIABLES When we have a client who is not in perfect health, how do we determine how to serve their best interests? Some of the variables that impact our decisions include client goals, stage of the condition, communicability, medications and side effects, and client resiliency. Client Goals It's not by accident that this is at the top of the list—and yet it is amazing how many session plans I read in which what the client wants is not mentioned. A person's reasons for visiting a massage therapist may have nothing to do with their chronic health challenges. Someone who lives with knee arthritis may also have slept funny and have a kink in his neck that he'd like to work out. In this situation, his knee is beside the point and should not be the main focus of the session. Stage of the Condition, Inflammatory State In situations where a person pursues massage therapy to help with a chronic problem, we need to evaluate how the condition affects their health and function, and whether this informs our decisions about bodywork. Examples include things like autoimmune diseases: a client may want massage therapy to help with the pain related to rheumatoid arthritis, but if they are in flare-up when they come to see us, our work needs to be gentler than if they are in remission. Some of these decisions may also be guided by location. A person with one inflamed ankle that needs gentle touch may welcome work that is more challenging on the other side. Communicability In some situations, we may be able to offer some benefits to a client, but the associated hazard to the therapist is not acceptable. Someone with the flu who is coughing and sneezing and achy might enjoy some gentle massage therapy that helps to clear sinuses and improve sleep. But if the client is still contagious, then the Understanding Indications and Contraindications By Ruth Werner risk to the therapist outweighs the benefit to the client. Indeed, acute, contagious, systemic infections are the only situations where I cannot see a way for massage therapy to provide benefits without risks. Medications and Side Effects Medications add an additional set of variables. For a client who uses Lopressor to manage high blood pressure, or insulin for diabetes, or Humira to manage psoriasis, we need to know what the drug is for, what side effects it might have, and how these issues impact the client's quality of life and goals for massage therapy. Some medications affect the integrity of the skin (topical corticosteroid creams, for instance), and that must change the way we work. Other medications sometimes cause dizziness and lethargy, so clients may need stimulating strokes to finish a session. It is important to ask clients how their medications affect them in order to predict how to adjust massage therapy to that situation. Client Resilience and Activities of Daily Living I saved this for last because it's a good bookend to client goals. All of our clients, but especially those who struggle with health, have good days and bad days: days when they feel ready for anything, and others when they feel pretty puny. One of our jobs is to meet people at their current level of energy, and to keep the challenges that our work imposes within their capacity for adaptation. This sensitivity can help keep our work safe, even if we don't know all the details of the other points in this list. Let us know your thoughts about the magazine! Email Others' attempts to "fi x" me, or suggestions for curing the pain just aren't helpful. But my friends and family who accept me for who I am right now are the best! And the massage therapists who listen, and offer respect and comfort, make life so much better too. Accepting where you are is so important—no going back. Health is the ability to adapt to change, and Cindy's personal story is one of doing that with grace, humility, and love. MARY ROSE LONGMONT, COLORADO AH, SHUCKS I was at Lauterstein-Conway Massage School & Clinic in Austin and saw your pub. It's beautiful! WESTON CARLS AUSTIN, TEXAS I want to personally thank you and say how much I've enjoyed your issue on pain and pain science [May/June 2018]. It is wonderful to see such current information in a trade publication. J. HUTCHINSON PACIFIC GROVE, CALIFORNIA I'm consistently impressed by the level of content and writing in your publication. This month, I was most struck by the masterful way that Ruth Werner handled the critical thinking required when parsing contraindications, safety, and client desires and goals. The article was practical, immediately actionable, and delicately handled a few of the sacred cows some (most) of us learned in massage school. I love seeing this! LESLIE FORRESTER RIVERVIEW, FLORIDA

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