CHAPTER 1 expected to affect the care the individual Because virtually all state licensing authorities, ETHICS AND STANDARD V – or other clients receive or the health care certifying/accrediting agencies, and ROLES AND BOUNDARIES IN professional’s relationships with colleagues – professional associations establish their own or when they give the appearance of doing so. standards of conduct and ethical guidelines for MASSAGE THERAPY their members, you will need to refer directly This chapter examines the concept of ethics in (6 CE Hours) to the organizations and academic or training massage therapy and the role-based obligations institutions with which you are affiliated, as Learning objectives of professionals in their relationships with ! well as state, local, and national associations, ! Define the concept of power dynamics and clients. It clarifies the concept of boundaries to review the ethical guidelines that apply discuss how psychological processes shape and boundary violations, and analyzes specifically to you and your practice. You may the therapeutic relationship. examples of potentially problematic actions ! also want to refer to the literature or websites ! Trace the history and philosophy of ethical to help massage therapists identify and avoid of prominent professional organizations like standards and conduct, and explain the professionally inappropriate conduct. necessity of abiding by these principles. the American Massage Therapy Association !! Describe your role and limitations in Section I: Concepts in professional ethics (AMTA) and the National Certification Board facilitating client health and welfare, Formal ethical codes and standards of conduct for Therapeutic Massage and Bodywork including appropriate scope of practice. have a long history in medicine. Many of the (NCBTMB), both of which post their ethical !! Explain the critical role communication values, obligations, and rights we have come codes and standards of conduct on their web plays in the therapeutic relationship and to identify with contemporary health care site. are rooted in the Hippocratic Oath, a 2,400- identify some principles that facilitate This course: year-old ethical code that directs physicians, effective communication. Examines the value and function of ! above all else, to “do no harm.”1 Today, ! Recite the basic tenets of the NCBTMB’s ethical codes and professional standards medical ethics is a vast field of study, with Standard V – Roles and Boundaries, listing of conduct in the day-to-day business of categories and subcategories relating to every each point and explaining its significance massage therapy. conceivable topic and issue. Many medical in an ethical massage therapy practice. Emphasizes the important boundaries ! and health-related disciplines establish their ! Define and provide three examples defining the therapeutic relationship, own ethical codes and standards of conduct, of a prohibited dual or multiple role and helps distinguish appropriate from which encapsulate the compiled wisdom of relationships. questionable behavior. ! countless individuals and years of professional ! Explain the relationship between patient Addresses areas of common concern in the experience. Their study offers practitioners the autonomy and agreements, including the field of professional massage, and equips opportunity to learn from their predecessors’ client’s bill of rights, informed consent, practitioners with basic tools for navigating mistakes instead of their own. and right to refuse treatment. potential dilemmas. ! ! Define beneficence and nonmaleficence, Unlike personal ethics, which are flexible and Discusses the role of communication in provide an example of each, and explain open to debate, professional ethical codes the therapeutic relationship and introduces how they relate to bioethics. are formally defined, mandatory standards of principles for effective communication in ! ! Contrast personal and professional conduct established by and for members of the context of massage therapy. boundaries and provide an example of each professional associations to ensure quality and Defining your role in the therapeutic from your practice. integrity in the profession. Professionalism ! relationship ! Distinguish between a boundary violation is a combination of individual responsibility- In the past 40 years, the role of health care and a boundary crossing and provide an personal responsibility on the part of each professionals and the relationships they share example of each. member of the professional community with their patients have changed dramatically. combined with the collective responsibility of Introduction Some decades ago, physicians commonly a formal group or association of practitioners. Massage therapists are committed treated their patients in a paternalistic, or Ethics refers to principles of right or good to promoting the welfare and well- parental, way, sometimes keeping details conduct. Professional ethics in massage being of the client over and above any of the condition or illness from the patient, therapy is the application of guiding principles personal consideration. Indeed, this and making medical decisions with little of right conduct to the study, practice, and fiduciary obligation is one of the defining or no patient input. Today, physicians are business of massage therapy. characteristics of a “profession” as such. encouraged to speak openly with their patients This concept of a profession gives rise to the This chapter addresses a range of issues regarding their health and treatment options, notion of boundaries in client-professional of concern to the professional massage and patients are encouraged to ask questions relationships, that is, to the notion that there therapist and introduces a number of concepts and discuss their concerns with health care are limits of ethically appropriate professional important to the ethical practice of massage professionals. Both are emblematic of a health behavior. therapy. Successful completion of the course care system fraught with potential liability, and A boundary violation occurs when a health will equip you with the basic concepts and the realization that patients who take an active care professional’s behavior goes beyond rationale for ethical decision-making in your interest in health concerns tend to make better, 2 appropriate professional limits. Boundary practice, to help to navigate unknown ethical more informed health and medical decisions. territory, identify questionable behavior, and violations generally arise when a personal Ideally, your relationship and interactions develop a sense for “red flags” of potential interest displaces the professional’s primary with the client are a partnership that ensures conflict, as well as take steps to resolve these commitment to the patient’s welfare in ways the client’s voice is heard and promotes issues. Equally important, it will help you that harm the patient or the patient-practitioner healthy behaviors and sound, informed, know when to seek professional guidance relationship. Interactions between health health care decisions. Encourage reluctant or with a supervisor or mentor, or turn to care professionals and clients are ethically shy clients to become well-informed, active other appropriate resources for professional problematic when they can reasonably be participants, rather than passive observers, assistance. in their own health care decisions. You can www.ILmassageCE.com Page 1 play a significant role in ensuring your clients client and practitioner. An important part behavior. If you overreact, are preaching or understand their medical conditions and of this dynamic is a power differential; the lecturing or are uncomfortable, unsure of treatment options, their questions and concerns imbalance in authority or power that results yourself, or dissatisfied in your interactions are heard and addressed, and their voices and from your greater expertise in the area of with a specific client, you may be experiencing votes are part of the decision-making process. massage therapy. Your education, skills, countertransference, bringing emotions and experience in the field, and professional reactions from your personal life into your Some clients will welcome the opportunity certification give you an authoritative professional environment. to take a more decisive role in their health advantage over your clients. care decisions; others may be intimidated or Professional obligations and overwhelmed by the responsibility. Remember With any position of power comes the responsibilities that your client’s best interests should always potential for abuse. Massage therapists, like Although practitioners and clients may be be your primary goal, and the guide for all many health care professionals, forge close similarly affected by these psychological your actions and decisions. If you suspect relationships with people in their care. The processes and equally capable of showing any other interest is taking priority over your combination of physical and social interaction poor judgment or acting irrationally, licensed client’s welfare, review your rationale. For between practitioner and client can trigger practitioners are bound by their professional example, are you recommending frequent strong emotional responses in one or both affiliation to act responsibly, even when the massage because it benefits your client and is parties, leading to small improprieties as well client does not. appropriate to his condition, or because you’re as egregious misconduct. strapped for cash? When in doubt, ask: What is Boundaries Asking your client, who is a lawyer, for free optimal for my client’s health and welfare? Remember that you are responsible for legal advice; requesting a church donation or maintaining the protective boundaries that Beware of corrupting influences and selling your daughter’s Girl Scout cookies at ensure your client a physically and emotionally motivations that jeopardize your professional the office; mentioning personal details about safe environment. Part of your responsibility relationship with the client. Remember that a client or repeating what was said during a in that role is to protect the client from you, you best facilitate the client’s good health session to a friend or spouse: All are subtle should you act or speak inappropriately, or be through respectful and courteous discussion. ways practitioners take unfair advantage of motivated by anything but your client’s best Never bully or argue with a client. Never their relationships with clients. Even when interests. impose an unwanted solution or proceed with clients appear to welcome, rather than resent, any course of action that is not agreed to by the such requests or behavior, they are never Inappropriate behavior tends to make people client. Instead, involve the client in health and appropriate and do not belong in a professional uncomfortable. If you notice that a client is wellness conversations, and develop health- environment. It is equally inappropriate for not responding positively to massage therapy, related strategies and objectives together. If practitioners to accept favors, free merchandise make sure your behavior or comments are you suspect you are acting out of an unhealthy and services, or confidential information (such not a contributing factor. Relieving stress and need or motive, or feel your interactions or as stock tips) from a client. These interactions physical stiffness or pain should be a relaxing relationship with the client are impeding can distort the therapeutic relationship and and comfortable experience. If your behavior rather than facilitating the therapeutic process, obscure its primary objective. is appropriate but your client appears anxious seek assistance and/or supervision. Consult or uncomfortable in the session, discuss your It is not unusual for clients to unintentionally a professional massage therapy organization concern with the client. test professional boundaries, or practitioners with which you are affiliated for assistance, to unknowingly relax them. When Appropriate behaviors reinforce professional supervision, and other professional resources. practitioners and clients are motivated boundaries. Try to maintain the same structure Interpersonal dynamics and power in the by countertransference and transference, and rules of conduct in each session, with each therapeutic relationship respectively, they are more susceptible to client. Examine the rationale and potential repercussions of any changes or exceptions Professional massage therapists have serious inappropriate impulses that can lead to you make for specific clients, even at their responsibilities to their clients, colleagues, misconduct. Transference refers to all the request, before you implement them. Bending and the profession. The focal point of these feelings experienced by the client, related to a rule may not always endanger the therapeutic interrelated responsibilities is a relationship his or her past experiences and relationships, process, but impropriety can be a “slippery of trust, or fiduciary relationship, in which the stirred up by or in the session. Transference is slope.” If you uncharacteristically deviate client puts his or her trust in a professional neither negative nor positive, but is “always a from normal session structure or protocol, practitioner with the expectation that both distortion; a projection of emotions from the 3 suspect your impulses may be motivated by client and practitioner are working in the past to current objects.” Countertransference self-interest, or are having strong emotional client’s best interests. refers to all the feelings experienced by the practitioner, related to his or her previous responses to a client, seek peer support or This expectation is the foundation of a relationships and experiences, that are supervision. therapeutic relationship. While the practitioner stirred up during the session, including the Accountability and client share the same primary concern practitioner’s conscious and unconscious and objective – the client’s welfare – it is the Professional organizations protect public safety response to the client’s transference of by certifying the competence of their members practitioner, by virtue of his or her professional emotions. status, who is ultimately responsible for the through licensing and continuing education client’s safety, security, and well-being. The Be aware that transference and requirements. Accreditation and professional practitioner bears the burden of accountability countertransference can activate strong affiliations maintain quality control and show because he or she is in a position of authority emotional reactions and/or feelings of sexual your accountability to clients, colleagues, or power in relation to the client. attraction, raising unrealistic expectations on and the profession, as a whole. They confirm the part of clients and practitioners. Learn that you abide by prevailing health and safety Interpersonal dynamics exist in all to identify emotional red flags of blurred standards, conduct yourself in accordance relationships, and are a normal and necessary professional/personal boundaries in your with relevant legislation and/or professional part of a therapeutic relationship between Page 2 www.ILmassageCE.com regulations, and possess the specialized Choosing to provide services for which you practice and their health. If you pursue new knowledge and skills of your field. are not appropriately trained or competent is a educational avenues, update your resume dangerous personal decision that undermines to reflect current study and expected Once you’ve successfully completed an the profession and may carry weighty completion dates, but do not claim the approved training course, written examination legal implications. Your personal level of academic standing or associated credentials (state and/or national) and, in some cases, discretion and ethical standards will largely until after you have written confirmation of a practical evaluation, you are deemed determine the manner in which you advertise successful completion. “competent” in the subject area of massage your services, describe your education and Develop relationships and referral therapy, despite the fact that your specific professional experience, and list credentials. networks with colleagues who are highly skills, training, and knowledge base may be You will have to decide for yourself if you skilled in alternate areas of expertise, so very different from that of other practitioners can rightfully claim substantive experience you can refer your clients to them without in your neighborhood, state, or country. in a discipline for which you’ve attended reservation, and they can do the same. Licensing agencies and professional societies a three-hour workshop or watched a series Knowing other approaches to massage are able to maintain basic standards of quality of instructional videos, or when you can therapy can help you develop your own and professional expertise in the field and properly call yourself an expert in one areas of specialization or focus, and ensure that licensed individuals are keeping modality or another. define what you do and do not want in pace with recent developments through your practice. Conferences, association continuing education requirements. You have an additional obligation to your meetings, or professional get-togethers are clients and the profession to keep pace Crediting course work is offered in a diverse a good time to compare notes and learn with new developments in the field and range of formats (traditional classroom about useful resources and opportunities in maintain skills at a professional level. This attendance, correspondence courses or distance your own field and related disciplines. obligation is partly fulfilled through formal education, weekend workshops, professional Don’t be tempted outside your scope of continuing education requirements, but can be seminars and conferences) that vary widely in practice by clients asking for an informal supplemented by attention to industry journals, scope, practical value, length of study, and fee. opinion, diagnostic guess, treatment and seminar, workshop and conference Opportunities for advanced study in massage recommendations, or any other statements attendance. Make sure any information or therapy outside of continuing education are you are unqualified to make, especially suggestions you pass along are supported also abundant, offering the practitioner a when there is any possibility of risk to the by the professional community and recent diverse range of possibilities in certification, client. Develop a standardized response research findings, and are appropriate and safe titles, and credentials, all associated with that explains your lack of formal training for the client. varying degrees of validity. Checks and in the area, what sort of credentials and balances on this system are minimal; those Use the following guidelines to avoid experience are required, and suggest a that exist are fueled in great measure by the misrepresentation of your professional referral to a qualified professional in the personal accountability, honesty, and integrity experience or credentials in promotional area. of individual practitioners. materials or discussions with clients and Safety colleagues: Scope of practice Practitioners are required to abide by industry List your education, training, work history, Scope of practice refers to your area of standards of safety and hygiene. Client degrees and credentials as accurately as competence, usually obtained through draping, towels, the table surface, and other possible in resumes and biographical formal study, training, and/or professional relevant materials must be cleaned according statements. Include your experience in a experience, and one for which you’ve received to accepted standards of sanitation and meet all different field of study only if it benefits or certification or other proof of qualification. legal health and safety requirements (including enriches your current practice and clients. Unlike other standardized training programs universal precautions relating to communicable Review licensing and regulatory standards or fields of study, schools of professional diseases). Practitioners should know how to for massage therapy practitioners in your massage therapy and state requirements vary cover cuts and use sanitizing supplies such as area, and keep up with legislative issues, significantly in the number of necessary hours disinfectant hand wipes effectively. current events, and research related to your of study and curriculum. Some schools provide field. Confirm that your practice adheres to Practitioners must have the skills and substantial training in specialized procedures, current legal and regulatory requirements. knowledge to assess a client’s condition such as lymphatic-drainage techniques or Note your capabilities and strengths, and provide safe and appropriate therapy. hydrotherapy, while others may only touch including any modalities, techniques, Be attuned to verbal and non-verbal upon these subjects if they are discussed at all. special knowledge, area of specialization, client feedback, and alert to possible Your scope of practice is circumscribed, in or skills you employ on a regular basis contraindications for massage. Sometimes part, by local licensing restrictions, which or have made a focus. Do not overstate these decisions are less than clear-cut, are sometimes very general. Within this legal your level of ability or training, but revise requiring a bit of research or consultation parameter, massage therapists have some the list regularly to reflect any change in with medical personnel more familiar with the latitude in determining what modalities will educational status or experience. client’s condition. Never allow the client, the constitute their practice. Misrepresenting your Note any areas in which you’ve received client’s relatives, or even the client’s doctor to educational achievements, credentials, or training but have had little or no practical pressure you to proceed if you have any doubts abilities is a serious breach of responsibility experience among your weaknesses, regarding the safety of a specific procedure for that endangers client safety and reflects poorly unapologetically. Being realistic about a specific client. You are ultimately responsible on the profession as a whole. If a subject is your abilities and honest with your clients for any injury sustained by the client during or outside your area of expertise, don’t hesitate is the best way to ensure their health and resulting from massage and the medical and to say so, and direct the client to appropriate safety. Pretending familiarity or expertise legal liability associated with it – even if the informational resources or professional in an area is unfair to your clients, at best, client’s physician specifically recommended or services. and likely to be hazardous to both your prescribed the bodywork. www.ILmassageCE.com Page 3 If you have strong concerns about the client’s Refrain from bad-mouthing any Accessibility: Refusing to adapt your health related to medication or procedures procedures, services, or therapies that are office (or making some reasonable received through another source, suggest part of your client’s health regime, or the accommodation) for those with physical that the client have a trusted health care individual who provides them. challenges. professional review the course of treatment. Do not make psychological assessments Bigotry: Refusing to work with someone Pronouncements like this should not be made or counsel the client regarding emotional due to race, religion, size, or sexual flippantly, as they could be the basis of legal matters or interpersonal relationships orientation. action against you for practicing medicine unless you have a degree in counseling and Inappropriate advertising: Using without a license. If you believe your client are advertising your services accordingly. a provocative picture in advertising; has a serious medical condition or may have Never impose your religious or spiritual presenting misleading qualifications. suffered an injury, tell the client immediately beliefs on a client. Leave evangelical Dual relationships: Dating a client. and refer him/her to the appropriate health care literature and discussions outside the Violation of laws: Practicing out of your professional. Do not discuss the condition with office. home, when it is not permitted by law. the client’s doctor or anyone else unless you Even if you are in great shape, resist the Confidentiality: Name-dropping famous have explicit permission from the client to do urge to recommend muscle strengthening clients; telling a spouse details about his so. Be sure to document your referral and the or toning exercises, unless you are also partner’s session. reasons for it in the client record. qualified as a physical therapist, athletic Contraindications: Treating a client when trainer, or related occupation with you are sick/infectious; ignoring signs of Keep scope of practice in mind when you give appropriate credentials. conditions that preclude physical contact. advice or make recommendations to clients. Informed consent: Working on a minor While listening attentively to your client is Misconduct without parental knowledge; treating a relatively risk-free venture, sharing your Misconduct has been a persistent and someone’s injury without permission. opinions is not. Depending on the topic of troubling issue in health care and medical Practicing beyond scope of practice: conversation and your specific comments, professions since the early days of modern Doing spinal adjustments, massage or you may be engaging in high-risk behavior medicine. Written more than 2,000 years ago, counseling without appropriate training. whenever you have casual conversations with the Hippocratic oath urged members of the Sexual misconduct: Watching a client a client. Resisting requests for “advice” in any medical profession to refrain from “mischief, undress or hugging a client in a sexual way. subject outside your areas of expertise is your and in particular, sexual relationships with safest option, but it is natural to be drawn into both female and male persons.”4 In recent Harassment discussions with a client, especially one you’ve years, accusations of misconduct in the health Harassment is a specific kind of misconduct come to know well. care and personal service industries have or boundary violation in which an individual become increasingly common, due in part to of equal or greater authority is inappropriately Advice can be a dangerous and slippery slope formal regulation of the complaint process familiar with a co-worker or junior employee. for practitioners in large part because they and greater awareness of the issue among the Harassment can manifest itself in abusive may have some knowledge and experience general public. remarks or behavior, belittling statements regarding a topic that is health-related, but not and actions, and discussion or commentary strictly within their scope of practice. If you Misconduct takes many different forms of an overly personal or offensive nature. have found an effective nutritional supplement that vary considerably in type and degree Sexual harassment is abuse of power, or exercise program that relieves the same of severity. The following examples of typically exercised within the context of symptoms your client is experiencing, you may misconduct demonstrate the need for ethical work, containing a sexual or gender-specific have a strong impulse to share that information vigilance in every aspect of business practice, component. with your client. Or, you may want to warn from organizational matters, to billing, to your client away from a health regime that you social interactions. Even in cases where Sexual harassment, like sexual misconduct, consider ineffective or potentially dangerous. inappropriate behaviors are the unintended is not defined by any specific sexual result of thoughtlessness, errors in judgment, interaction between two individuals. While When giving your point of view, make sure or improper planning, they risk potentially the prototypical case involves a coercive you delineate a professional recommendation, serious repercussions for the client and heavy exchange of sexual favors for job benefits or based on years of experience and study, from penalties for the practitioner. Victims may face advancement, the sexual dimension in sexual suggestions or opinions of a more personal or emotional and physical scarring with lifelong harassment and misconduct can be subtle, as general nature. Help your client distinguish implications, and allegations of misconduct much a matter of sexual connotation or subtext between subject matter in which you are, and – even false ones – wreak havoc with than any one explicitly sexual act. Abuse of are not, professionally qualified. If a health or practitioners’ lives and livelihoods.5 the power differential can manifest itself in medical issue is outside your scope of practice, a hostile or difficult work environment, not recommend that the client see a qualified Misrepresentation of educational status: easily perceived by outsiders. The Equal health professional regarding the matter. Identifying yourself as a craniosacral Employment Opportunity Commission defines therapist after taking a two-hour course. Resist the appeal of being an authority on sexual harassment as any unwelcome advance, Financial impropriety: Charging a topics outside your scope of practice, and put request, verbal statement, or physical conduct cash-paying client a different fee than an strict limits on comments, opinions, and claims of a sexual nature, including visual displays, in insurance-paying client. that relate to the following points: which:6 Exploiting the power differential: Asking Never recommend that a client stop Submission is made a condition of an a stockbroker for financial tips during a receiving treatment or medication. individual’s employment, either explicitly treatment. Do not recommend medications, herbal or implicitly. Misleading claims of curative abilities: mixtures, or nutritional supplements to the Submission forms the basis for work- Telling a client you guarantee her pain will client, even if the item does not require a related evaluations, such as decisions be gone in two sessions. prescription.
Page 4 www.ILmassageCE.com regarding employment benefits or indirect physical contact between practitioner therapy, and practitioners cannot ethically advancement. and client intended to sexually arouse one or continue treatment in cases of lingering or The individual is subject to intimidating, both individuals. While women are less likely persistent sexual arousal. offensive, or hostile environmental than men to be accused of sexual misconduct, 4. Acting on a sexual impulse in the context elements that interfere with the individual’s they are not immune to such allegations. of massage therapy is always inappropriate ability to work effectively or productively. and unacceptable. Some practitioners employ strategies of Harassment may include the discussion of avoidance, ignoring the issue of sexuality If the client indicates sexual interest or sexually explicit topics of conversation at a entirely, either consciously or unconsciously, continues to show signs of sexual arousal after place of business, unnecessary or inappropriate due to their own embarrassment or discomfort you have moved to a different region of the references to specific body parts or functions, with the topic. While this approach may body, you will need to address the situation and visual depictions of a provocative or save you an awkward moment or two, an immediately. The same is true if the client offensive nature, such as posters or calendars inability or refusal to address the subject when verbally or tacitly expresses sexual interest, featuring photos of nude or scantily clad necessary (ignoring signs of sexual arousal, for regardless of physical arousal. Intervention can models. Sexual harassment can occur between example) may not only be inappropriate, but take a variety of forms, depending on the client men and women, women and women, men professionally irresponsible and a breach of and context of the incident, but should include and men, or any other combination of sexual ethical conduct. the following points: or gender identity. Sexual harassment may feel 1. A clear declaration that sexual interest or Human sexual response is influenced humiliating or shameful, making the victim arousal, regardless of cause or intent, is by a complicated mixture of biological, reluctant to report the incident. inappropriate in the context of massage social, and psychological forces that vary therapy. Liability, in cases of sexual harassment, enormously from person to person. Each 2. That it is unethical for the practitioner to depends on the plaintiff’s ability to prove that individual responds differently to the continue treatment if the client is sexually specific positive or negative repercussions tactile stimulation of massage, and may be aroused. were the result of the individual’s submission more or less susceptible to changes in the or lack of submission to the power-holder’s human nervous system, limbic system, and If sexual arousal or interest persists, you will demands. Legal liability, in cases of a hostile parasympathetic nervous system. Physical need to terminate the session. Avoid entering or oppositional work environment, requires arousal can occur unexpectedly because nerve into debate or discussion with your client the plaintiff to prove a pattern of inappropriate impulses associated with massage are not regarding this point. Simply state that you are behavior or series of incidents involving confined to just the immediate area receiving terminating the session because it is unethical offensive language, behavior, or physical tactile stimulation, but radiate outward, over for you to continue. Tell the client to get contact. While legal liability is not dependent a more widespread area. Massage of the dressed, and leave the room. on intention of the power-holder to offend or lower extremities, buttocks, and abdomen are Strategies for client safety intimidate, a determination of such intent can particularly likely to produce the unintended The emotional, financial, and legal consequences influence the nature and severity of penalties “side-effect” of sexual response because of professional misconduct for both the client associated with an incident. these areas of the body share the same nerve and professional community are profound. pathways as the genitals. An incident of In cases of sexual harassment, the plaintiff is Preventive policies should include an educational sexual arousal during massage is typically required to prove that a random “reasonable component explaining power dynamics in the experienced as a momentary surge of sexual person” would consider the incident(s) in therapeutic session, what constitutes appropriate energy that dissipates almost immediately. question “sexual harassment,” based on and inappropriate conduct with individuals of their understanding of the incident(s). This Determining if arousal is an unintended the same and opposite genders, and strategies for can be problematic in that one individual’s by-product of nervous system processes or speaking and acting in ways that delineate and “reasonable person” may interpret certain the sign of sexual interest can be a difficult reinforce appropriate boundaries. behavior, statements, or displays as abusive, assessment. If physical signs of sexual arousal, Ensuring your clients’ safety requires while another might find them inappropriate, such as an erection, occur, but are momentary more than not being sexual toward them, and another might consider them acceptable. and are not associated with other signs of or avoiding overt sexual behaviors with Courts typically weigh the type of misconduct, sexual stimulation, intervention may be a them. It means actively and consciously its context [including factors such as the extent matter of moving to a part of the body less “desexualizing” the experience of massage; of deception or cover-up that accompanied the prone to sexual response, such as the upper that is, making something with potential incident(s)], and its frequency of occurrence, body or head, or using different massage sexuality no longer sexual, or de-emphasizing when making a determination of liability. If movements that encourage response in the that dimension. Desexualizing massage is the accused practitioner’s employer was made sympathetic nervous system. If the incident a process of deconstructing the experience aware of the incident(s) in question – either passes momentarily, further intervention can into its component parts, acknowledging at the time or after the fact – the employer’s take place some time after the fact, such as at human sexuality as a given, and accepting the institution may also bear legal liability for the end of the session. When you address the practitioner and client as sexual beings. harassment. incident, include the following points: 1. Brief incidents of physical arousal are Sexuality and massage It is best to address the issue of sexuality involuntary byproducts or side effects of and client safety early in the therapeutic Sexual misconduct, one of the most egregious specific physiological processes activated relationship. Practitioners can incorporate the examples of inappropriate behavior, by massage. subject into the intake routine by providing the refers to any sexual activity between the 2. Such momentary or fleeting incidents client a brief written statement explaining that massage therapist and client. It includes are not abnormal or inappropriate in the therapeutic massage is a nonsexual experience, obvious transgressions such as intercourse, context of massage therapy. what constitutes appropriate conduct, and masturbation, fellatio, cunnilingus, anal 3. Incidents of sustained sexual arousal are the ethical necessity of these statements or intercourse or oral sex, but also any direct or inappropriate in the context of massage discussion. Tackling the topic of sexuality www.ILmassageCE.com Page 5 proactively, rather than in reaction to a specific leave the room (even if they say it is not feedback from coworkers and clients incident, can prevent or avoid potential necessary), closing the door or curtain behind regarding relevant skills and “table-side misunderstandings and disabuse a client with you. Always knock and/or ask the client’s manner.” ulterior motives. permission before you re-enter the area. Reporting misconduct Draping should cover all clients’ genitals and Desexualizing massage requires a substantial If you believe another practitioner is buttocks and the breasts of female clients. degree of self-awareness and honesty. Only acting unethically or illegally, you have a by acknowledging one’s own sexual nature Avoid ambiguity or the appearance of responsibility to report it. Contact your state can one begin to control when, how, and with impropriety in your words and manner. board to file a complaint, or, if the individual whom it is expressed. The sexual component Dress appropriately in a professional manner, is licensed by the National Certification of massage must be acknowledged and avoiding any outfit that could be construed Board of Therapeutic Massage and Bodywork understood, but channeled and expressed as revealing or provocative. Your demeanor (NCBTMB), contact the organization at appropriately. Practitioners must be able should approximate that of other professional 630-627-8000 or [email protected]. to realistically appraise their own potential health care personnel. Use appropriate A complaint must include the following for sexual response during massage, and language; avoid cursing or indelicate information: acknowledge not only how their own or their comments. Use medical terminology when 1. The name, address, and telephone number coworkers’ sexual natures might affect clients, referring to physical conditions or parts of the of the individual filing the complaint. but also the impact of clients’ and coworkers’ body. Never discuss sexual topics with or in 2. The name, address, and telephone number sexual natures on them. Think about the way front of the client, joke about sexual matters, of the NCBTMB-certified massage you interact with clients and colleagues and make sexual remarks or jokes, or use sexual therapist/bodyworker against whom the how you are perceived. Do you send out mixed innuendo. complaint is being made. messages? Are your intentions absolutely 3. A detailed description of the facts Maintain a comfortable and professional honorable? Are you a flirtatious person? Be supporting the complaint. environment. Avoid meeting new clients at clear about your intentions. Any attempt to 4. A description of any steps that have been unknown locations, at hotels, or in the client’s pursue a sexual or romantic relationship with a taken to address the situation explained home, where your personal safety may be at client is grossly inappropriate. in the complaint, and the results of those greater risk. If you meet the client on-site, steps. It’s natural for clients to feel some degree of set up the massage table in a neutral location, 5. A list of the specific sections of the Code anxiety or insecurity related to the process of rather than a bedroom. Encourage relaxation of Ethics and Standards of Practice alleged disrobing and draping. Minimize anxiety or through your client’s visual, auditory, and to have been violated. concern by stating and/or providing written olfactory senses, but keep the look and smell 6. The complainant’s approval for the Ethics information regarding disrobing. Before the of your environment subdued and professional. and Standards Committee to disclose client undresses, state that a draping procedure Avoid creating an overly perfumed, romantic, all information in the complaint to the is required for purposes of modesty and or sensual atmosphere. Remember that a massage therapist/bodyworker named in physical comfort. Mention or have a written client may be allergic to certain odors, have the complaint, the members of NCBTMB’s notice that explains draping; that it will cover strong negative reactions to certain smells, Ethics and Standards Committee and all parts of the client’s body except the specific or associate a given odor with an unpleasant Investigative Panel, NCBTMB staff, area receiving attention. Once you finish work memory or incident. Music should also be NCBTMB legal counsel, and experts in that area, you will recover it, and move soothing and subtle, and played only after involved in handling the complaint. to the next area. Tell clients to let you know you have asked your client about his or her 7. The signature of the individual filing the if they have a question or concern, or are preference for music or silence during the complaint. uncomfortable in any way. If you encounter massage. a client who prefers not to be draped, explain In addition, you can also file a complaint with Your place of employment should support that you are unable to proceed with the session the Agency for Healthcare Administration client and coworker safety by: until the client agrees to this customary (AHCA), which analyzes complaints and Developing institutional or companywide procedure. reports involving potential misconduct anti-harassment policies for all employees of a licensee and initiates investigations. Explain to clients what can and cannot be and posting them in public locations The boards and councils within statewide removed or left on without impeding your throughout the workplace. organizations determine probable cause and access to those parts of the body; reassure the Having clients read and sign a Client’s Bill disciplinary action in cases involving the client that it is not necessary to remove any of Rights (discussed later in this chapter). misconduct of the licensee. You may obtain more clothing than their personal comfort or Providing informational materials and complaint forms by calling (888) 419-3456. modesty will allow. Request that clients do not a mandatory educational session for begin undressing until you have left the room. all employees to raise awareness about Usually, after a board hearing, if the Never allow the client to dress or undress in workplace harassment and misconduct, practitioner is found to have violated the your presence. Inform your client before you discuss what constitutes it, and how to law, the regulatory board will impose one or begin what areas will be your focus and ask address it. more of the following penalties: reprimand, permission to proceed. Expose and work on Establishing a protocol for reporting fine, administrative cost, probation, only one area of the body at a time, and cover complaints and investigating allegations license suspension or license revocation. the exposed part before moving on to another of misconduct that ensures timely The individual making the complaint will area. and responsive follow-up, and the be notified in writing of the status of the 7 confidentiality and safety of employees complaint throughout the process. Keep the room comfortably warm and give and clients. clients adequate time to disrobe and dress. Business management and promotion Establishing a formal system of checks Make sure the client is able to change without Conducting your business in an ethical and balances and review process assistance or is given the needed help, and manner is not only good for your clients, it’s to evaluate employees and provide Page 6 www.ILmassageCE.com good for your business. In 2001, over two- statements made by your client (regarding use clearly written and recognized thirds (71 percent) of prospective clients an injury, for example), use quotation abbreviations. Remember that you and surveyed (defined as Americans who report marks to demarcate the client’s words. other people may need to refer to these receiving massage and bodywork treatments Keep a separate file for personal notes or notes years in the future. Make sure they each year) considered ethics an “extremely any material of a speculative nature. are easy to read and understand. or very important” criteria in their choice of Make sure the forms you use to collect client File records promptly and accurately. practitioner.8 information are appropriate to your practice Establish a strict filing system and adhere and cover all pertinent areas. Make sure to it, and be sure other staff members know Conducting your business in an ethical manner forms are free of errors and are easy to read the system and the importance of using it. is largely a matter of treating people fairly and and understand. Questions should be stated The following guidelines were established decently, using your skills and time effectively, simply. Avoid jargon or complicated medical for litigation purposes and should be and adhering to high standards in your work. terminology, or define terms, as needed. standard practice in all health care Your promotional materials, record keeping, Review forms on a regular basis, and revise environments: financial dealings, and conduct in day-to-day or simplify confusing formatting or content. Alter records as minimally as possible, business matters should also be able to pass Take a comprehensive case history and only when necessary. ethical scrutiny. Maintaining your practice in and review it with the client before If you find something in error, do good standing means: beginning treatment. This should include not erase. Cross out the error using Filing local, state, and federal taxes. an overview of the client’s general state a single line, so as not to conceal Discussing and/or displaying fee schedules of health and thorough medical history, what is written underneath, and write and billing practices prior to a first his or her reason(s) for seeking massage the word “error” above the incorrect meeting. therapy, onset and duration of problematic statement. Making the client’s welfare your symptoms, medical history of family If you review your records and feel the paramount concern. members (if appropriate), and occupational need to clarify a point, write the date Following generally accepted accounting background. and the additional comments with the practices. Train staff members to record client note (labeled “addendum”). Keeping accurate financial records. histories and other important information If litigation is threatened, do not make Maintaining patient confidentiality. properly and thoroughly, and to ask any kind of change to the records. Respectful and cooperative collaboration appropriate follow-up questions if there is with other professionals. Not all file contents are subject to the same any ambiguity in a response. Implement Appropriate referrals, if necessary. retention times. Keep records for current some structure or mechanism to ensure this and former clients for as long a period as is As a representative of your profession, any information is complete for every client practically possible, but at least the length of negative perceptions of your marketing and answers are recorded in sufficient time specified by federal and state regulations materials or advertisements tend to reflect detail. Review any personal or medical as the legal minimum. Retain children’s poorly on your colleagues and the profession information taken by other staff members records after they turn 18 for a length of time as a whole. Promotional materials should: in a personal interview with the client to that equals the state’s statute of limitations. Include your license number, place of ensure information was recorded properly business, and phone number. and in adequate detail. Confidentiality Refrain from using fear or guilt as Areas that do not apply to a specific client Keep all original records in your possession. motivational tactics. should be marked “N/A” (non applicable) Provide copies of x-rays, notes, and records Avoid unrealistic, misleading, or rather than left blank. documenting client care for clients or health sensational claims, or promises to cure Develop a short, simple form that clients care facilities requiring their own copies. Share specific conditions or ailments. can use to note their progress (or lack of information only in cases where disclosure Avoid using any wording or image that progress) at each visit. is required by law, court order, or another might be construed as sexual in nature. Document any client non-compliance appropriate, professionally approved manner, Adhere to truth-in-advertising standards. with the care plan, including canceled according to legal requirements. appointments (dnka = did not keep Documentation and records appointment), refusal or failure to Impress the importance of confidentiality and Proper documentation and record keeping is a follow health care instructions and/ retaining original file copies upon all staff critical, if mundane, dimension of a successful or take needed medication, activities or members. Institute the following procedures practice. Keep notes legible and accurate. If behaviors that pose a risk to the client’s when providing copies, and make no it is ever necessary to refer to files some time health. Communicate the rationale for exceptions: in the future (in a medical emergency or legal your opinion and do not proceed with any Have the client sign and date a release proceedings, for example), the context and action that conflicts with your professional authorization form. details of your notes should be clear. Other judgment. Keep a copy of the release authorization health care personnel will need to know the If you feel the client’s disregard for with the client’s records. background, presenting status, actions taken professional recommendations is putting Copy only the information requested. and the results, with some discussion of him or her at risk, have the client sign Note in the client’s file: the party treatment strategies and expected objectives. a form acknowledging that he or she requesting the copy, what specifically was Adhere to the following guidelines for has been informed of the potential requested, and the date, to whom, and preparing and maintaining records:9 consequences of their action or inaction, where the copy was sent. Maintain accurate and truthful records: and is choosing to refuse recommended record only factual information, All information and matters relating to a treatment. observations, and actions. Don’t record client’s background, condition, and treatment Notes should be legible as well as accurate. your opinions, or conjecture about the are strictly confidential and should not be Pay attention to your handwriting and client or his/her condition. When recording communicated to a third party (even one www.ILmassageCE.com Page 7 involved in the patient’s care) without the be used and whether the information will be In massage therapy, informed consent usually client’s written consent or a court order. identifiable or anonymous. takes the form of an agreement between the Treat clients with respect and dignity: Handle practitioner and client that states their shared New clients personal information with sensitivity and keep objectives, proposed treatment plan, expected It is generally a good idea to assume that a the content of written records a private matter. outcome(s), and anticipated time frame for new client knows nothing about massage Practitioners who can’t resist telling secrets or results. It may also refer to the client’s medical therapy. Many massage therapists develop an repeating gossip in their personal lives should history, asserting that the client has informed information sheet to acquaint the client with be aware of the heavy penalties associated the practitioner about all known physical or basic massage concepts. Office personnel, with jeopardizing client confidentiality in a medical conditions and current medications, customary procedures, and other useful points professional context. and will inform the practitioner if any of these regarding their place of business, such as conditions change. During the past decade, the traditional medical bathroom locations, and what to expect in a ethical principle of confidentiality, that is, typical session, can be distributed to clients The notice of informed consent in massage the health care provider’s duty to protect in the waiting room before their first session. therapy typically includes a statement the patient’s personal health information, Providing basic instructions and answers to explaining the role of massage therapy in pain has come into increasing conflict with common questions in a brief information sheet and stress reduction or other specified purpose, a perceived need for health information can be very effective in putting new clients at and its limitations: databases serving administrative, planning ease, especially when clients are new to the Massage therapy does not take the place of and research purposes. Computerization experience and unfamiliar with a facility’s medical examinations, care, or treatment. has greatly facilitated the establishment personnel and way of conducting business. The practitioner is not a doctor and and linking of such databases and, thereby, does not diagnose medical conditions or Uncertainty tends to increase clients’ feelings has made breaches of confidentiality much prescribe medication. of vulnerability and loss of control, while easier. In response, many governments have Clients should continue to consult their familiarity, structure, and predictability adopted laws to regulate health databases. primary caregivers or other specialists tend to increase clients’ feelings of security These laws have generated much controversy. for ongoing health care and medical and comfort, and a greater sense of control. Privacy advocates complain that they are conditions. Establish a set routine and session protocol more about facilitating access to personal Clients should consult their primary to which your clients can grow accustomed. health information than protecting privacy, caregiver to review health care Ideally, sessions should be held at regular whereas administrators, researchers and some recommendations before making intervals, at a single location, for a specific, medical associations criticize the bureaucratic significant changes in their health and limited amount of time. Sessions should requirements that the laws impose on routine exercise regimen or diet. begin and end punctually, and should not be medical and research practices. interrupted by phone calls or intrusions from Both the practitioner and client are ensured Professional caregivers have strong reasons for staff or other clients. the “right of refusal.” For a client, this means preserving confidentiality. In order to receive the right to refuse, modify, or terminate medical care, clients have to reveal personal Intake interview and documentation treatment regardless of any prior agreements or information to physicians and others who may Have clients fill out an intake form on their statements of consent. For a practitioner, this be total strangers to them, information that first visit. It should be fairly formal in structure means the right to refuse to treat any person and include the following information: they would not want anyone else to know. or condition for just and reasonable cause. They must have good reason to trust their Client’s name, address, and telephone or These rights safeguard a client’s freedom to caregivers not to divulge this information. other contact number(s). choose any practitioner, and a practitioner’s Reason for visit. The basis of this trust is the ethical and legal freedom to terminate treatment, if necessary. standards of confidentiality that health care Medical history. These rights might come into play in cases Insurance/payment methods (if applicable). professionals are expected to uphold. Without of negligence or abuse. For example, a an understanding that their disclosures will Person to call in case of emergency, with practitioner can refuse to work with an abusive be kept secret, clients may withhold personal their contact information. or unstable client, and a client can refuse information. This can hinder caregivers in their The client should also sign and date the treatment from a practitioner he or she suspects efforts to provide effective interventions or to following statements: is practicing under the influence of alcohol, attain important public health goals. Release of medical records. drugs, or any illegal substances. However, there is also a need for limited Notice of informed consent with scope and A Client’s Bill of Rights typically includes the limitations of practice. disclosure of their clients’ health information following information: to other health care providers to assist in the Client’s Bill of Rights. Name of practitioner. care of the clients, to insurance companies and The concept of informed consent came out Details of practitioner certification and list other agencies for reimbursement of payment of the “patient’s rights” movement of the of credentials. for health services, and to database managers 1960s. Now a customary procedure both Practitioner’s area of expertise, for public health, health system administration inside and outside of health and medical care, philosophy, and/or approach to massage. and research purposes. As a general rule, informed consent refers to a patient’s right to Fees and service schedule. health care professionals should give priority be informed about his or her health care or Payment terms. to the patient’s interests over those of others. medical condition and participate in decisions Filing procedures for written complaints. Disclosure of personal health information regarding that care or condition. The patient, A right to information statement, asserting should protect patient confidentiality as much or patient’s guardian, is required to sign a the client’s right to the following as possible. Where confidentiality cannot be written statement acknowledging agreement to information: maintained, clients should be informed about proposed treatment terms and awareness of the Practitioner’s assessment of the client’s how their personal health information will known risk factors associated with them. physical condition.
Page 8 www.ILmassageCE.com Recommended treatment, estimated Make sure the client understands the context Summarize what you have heard, duration of treatment, and expected of your questions and reasons for asking reviewing the most significant points and results. them so he/she can provide the most specific, relevant implications. Copy of client’s health forms/records relevant information. Evasive, vague, or Nonverbal communication held by practitioner. incomplete responses to sensitive questions Pay attention to nonverbal signs and seek Statement of confidentiality. may be common and should be reviewed, clarification if you suspect that you and the Statement of refusal, explaining the client’s then clarified as delicately as possible with client aren’t “on the same page.” Fatigue, right to terminate a course of treatment at open-ended or closed-ended questions, as disability, language difficulties, and cultural any time and choose a new practitioner. appropriate. issues are some of the many factors that Clients’ right to invoke, explaining client’s Open-ended questions such as, “How have complicate communication between right to invoke these rights without fear of you been?” “Why are you seeking treatment?” practitioner and client. Many clients have an reprisal. and “Tell me about your health in general,” initial period of difficulty speaking their mind; Ask the client to sit down and review the invite the client to address a topic in their they may feel rude, awkward, or vulnerable intake form with you in a treatment room or own words and at greater length than closed- expressing disagreement, making specific other private area. This discussion should take ended questions such as, “What is your age?” demands of you, revealing pain or physical place before the client changes clothing. Ask “How much do you weigh?” and “Do you weakness, or effectively communicating their the following questions: smoke cigarettes and, if so, how many per fears, concerns, or treatment needs. As you Why are you seeking massage therapy? day?” Closed-ended questions tend to elicit and the process of massage therapy grow more Are you experiencing pain/discomfort? shorter, more specific responses, but risk the familiar, your interactions will likely become Where is the location of the pain/ possibility of missing significant details about more natural and comfortable. Assist clients discomfort? [Have client mark diagram] an individual’s health or behavior. by asking clear, direct questions that are easy How and when did the pain/discomfort to answer. If, after some time, your client still Questions should be phrased in a neutral or begin? What were you doing when you appears uncomfortable, or the poor quality of unbiased way to avoid “leading” the client first noticed it? communication is impeding treatment, discuss in a particular direction. Seemingly minor What level of pain/discomfort are you your concerns with the client. differences in wording can encourage wildly experiencing? [Use scale from 0 to 10, different responses from clients. Examine with “0” meaning “no pain,” and “10” Session protocol your phrasing to avoid any language that meaning “unbearable pain”] During the session, be sure to inform the might cue the client to respond in a particular Is the pain/discomfort constant, or does it client when you move from one area to way, such as suggesting by your words or vary in intensity? another, especially when the movement is tone that one answer versus another is right, Do you associate the pain/discomfort with to a particularly vulnerable area, such as the wrong, or preferred in any way, or expressing a specific movement or activity? abdomen. a preconceived notion or assumption about the Have you ever sought medical attention for Assess sensitivity and tolerance and client. For example, “Are you experiencing this condition? [Describe treatment history] inform the client as you progress to deeper any pain?” is preferable to “You’re not Do you have tingling, numbness, or pain movements. experiencing any pain, are you?” The second anywhere else? [Have client mark diagram] Perform tapotement only with client question is more likely to skew the client’s permission, and after you are certain the Review the answers to these questions and the response because it suggests the practitioner’s individual is adequately informed about the client’s medical history with him or her. Ask anticipation or predisposition to hearing a process. follow-up questions, as needed, to acquaint negative response. Take care not to startle a client in a relaxed yourself with the client’s current state of Active listening state. health and assess potential contraindications to Inform the client regarding potential Give clients your full attention and apply massage. massage aftereffects, such as tenderness or principles of active listening to increase the soreness, and their expected duration. Communicating effectively accuracy and reliability of shared information: Ask the client as you near the end of the Professional communication should be brief Don’t “multitask” when you speak with session if any area in particular needs and precise. One rule of thumb suggests the a client, in person or on the phone, or further attention. following strategy, known as the “5 S’s”: let competing business matters, calls, Invite feedback and implement changes Sincerity, simplicity, shortness, specificity, paperwork, or other aspects of your based on client comments. and summary.10 Adjust your tone and style to practice keep you from listening attentively match that of your client and be receptive to to what your client has to say. While good communication is integral to questions or comments. Always explain your Give your client adequate time to the therapeutic relationship, the practitioner actions as you work and ask your client if he or contemplate your question and consider an should never confuse or misrepresent it as she has any questions. answer. Never interrupt or rush a client’s their area of professional competence or response. specialization. Conversational topics should Asking questions Paraphrase your client’s response. never venture outside of your scope of Poorly worded questions invite Accurately restating the client’s comments practice and experience. Unless you have the misunderstandings. Keep questions specific, in your own words is a way to confirm appropriate training and degree, do not attempt direct, and clear. Avoid technical jargon and that you interpreted the client’s statements to act or make recommendations akin to a define any specialized lingo in simple terms correctly. psychological counselor or therapist, even if to assure your meaning is understood. Ask Address any inconsistencies or the client requests it. questions in a logical order, and don’t combine misunderstandings; identify areas in which a number of related questions in one sentence; At the end of each session, discuss the client’s the client’s intended message or meaning instead, ask one question at a time, and clarify treatment plan and health objectives. Ask the and your understanding or interpretation of each answer before moving on. client to assess his or her progress or lack of it differ, and clarify any ambiguities. www.ILmassageCE.com Page 9 progress toward treatment goals. Answer any Consult appropriate information resources Avoid dual or multidimensional questions the client may have, and note the and supervising personnel. Contact a relationships that could impair following information in the client’s record: professional colleague or supervisor professional judgment or result in If the client feels bruised, nauseated, or about your situation with the client, post exploitation of the client or employees lightheaded (check blood pressure and a question on a professional massage and/or co-workers. monitor). therapy website, or refer to professional Not engage in any sexual activity with The length of the massage session. organizations with which you are affiliated. a client. When the client should return for another You may be able to find an alternative Acknowledge and respect the client’s session (session intervals/frequency). to terminating the client, or a sensitive freedom of choice in the therapeutic Anything the client can do to accelerate way to present the issue to him or her. session. progress toward treatment goals. If you appeal to any of these resources, Respect the client’s right to refuse the Anything the client should do or not do be absolutely certain that you maintain therapeutic session. between sessions. strict rules of confidentiality and privacy, Refrain from practicing under the What results the client can expect, and ensuring that the client’s name or other influence of alcohol, drugs, or when. identifying information is never revealed. any illegal substances (with the Do a reality check. Make sure you and exception of prescribed dosage of Practitioners who recommend clients replenish the client are “on the same page” by prescription medication which does not fluids after a session may want to provide comparing your understanding of a significantly impair the certificant). bottled water at their office. therapeutic relationship with theirs, and Have the right to refuse and/or Terminating a professional relationship discussing disparities in the way you terminate the service to a client who If you feel it is appropriate, either because a and the client perceive your relationship, is abusive or under the influence specified, finite course of treatment with a including difficulties and desired of alcohol, drugs, or any illegal client is concluding, or because you believe objectives. This kind of clarification substance.” your relationship with the client has become can help you determine the scope of the Looking more closely, one can see that this dysfunctional, unproductive, or emotionally problem and whether it is the result of standard encompasses a number of distinct damaging, it may be necessary to terminate miscommunication or misinterpretation, but related points. The first 5 points prohibit your professional relationship with the client. something that can be remedied, or boundary violations, that is, the misuse of While this can be a difficult and uncomfortable requires termination. the power differential between the therapist task, it is important that it not be postponed If it is necessary to terminate the client, be and client, while the last four relate to client out of a desire to avoid confrontation or sure it is done when you have sufficient time autonomy and the rights and responsibilities discomfort. to discuss the subject fully. Take the time to of the client and practitioner. While this Terminating a potentially damaging respond to any questions the client may have, information was introduced in Section I, this relationship is an important professional and give the client sufficient time to react to section elaborates on these basic concepts, obligation with specific responsibilities. the news, respond to it, and regain composure. examining boundary violations, dual Practitioners must be able to realistically Do your best to leave the client with positive relationships, patient autonomy, informed assess their own limitations and/or their feelings about you and the practice of massage consent, and issues of substance abuse in client’s potential for therapeutic benefits, and therapy. Provide referrals to other massage more detail, and providing decision-making make a determination in their client’s best practitioners or health care professionals, as information to help you navigate ethical interests, without feelings of failure or guilt. appropriate. dilemmas associated with these topics. They must develop a plan for termination that Section II: Standard V – Roles and Boundaries in the patient-practitioner is considerate of the client, with attention to boundaries relationship12 the possibility that it will be received with The National Certification Board for Boundaries define the limits of appropriate emotion or distress. Therapeutic Massage and Bodywork behavior by a professional toward his or Informed consent provides a framework for (NCBTMB) requires recertifying massage her clients. By establishing boundaries, a termination because it specifies the need for therapists to focus special attention on health care professional creates a safe space an ongoing discussion between the client and Standard V – Roles and Boundaries,11 which for the therapeutic relationship to occur. practitioner regarding the expected goals and reads: Concerns about professional boundaries in the anticipated time-line for therapeutic benefits. “The certificant or applicant shall adhere relationship between clients and health care Involve your client in the process so he or to ethical boundaries and perform the providers – and the damage that results when she is aware of treatment objectives and can professional roles designed to protect boundaries are transgressed – usually captures ask questions and make determinations about both the client and the practitioner, and public and professional attention following his or her progress toward them. Discuss safeguard the therapeutic value of the reports of inappropriate sexual relationships obstacles to client progress as they come up, so relationship. In his/her professional role the between health care professionals and clients, your client is not surprised by an unexpected certificant or applicant shall: but relatively little attention has been paid to pronouncement or abrupt changes in your Recognize his/her personal limitations the “boundary question” outside this context, assessment of the client’s condition from and practice only within these and many other interactions raise concerns one session to the next. Be sure to follow limitations. about boundaries as well. Massage therapists customary procedures for client assessment, Recognize his/her influential position need guidance if they are to avoid engaging in and document relevant information about the with the client and not exploit the interactions with their clients that may prove client’s progress or lack of progress toward relationship for personal or other gain. ethically problematic. treatment goals. Recognize and limit the impact of The notion of boundaries in the health Before terminating the client, be sure to: transference and countertransference care setting is rooted in the concept of a between the client and the certificant. “profession.” While this concept is understood Page 10 www.ILmassageCE.com in several different ways in the health care giving rise to special obligations for health It is important to note that personal and literature, there is consensus regarding one care professionals. The practitioner-client professional interests are not inherently in of the defining characteristics of professions relationship entails special obligations for conflict with one another; in fact, they often and professionals: commitment to serve the the practitioner to serve the patient’s interest coincide. A practitioner’s personal desire to profession’s clients. That is, professionals are because of the specialized knowledge that the be compassionate is compatible with his or expected to make a fiduciary commitment practitioner holds and the imbalance of power her professional obligations. It is natural to to place their clients’ interests ahead of their between practitioner and client. want to earn money through one’s professional own. In exchange for faithfully applying activity. That desire becomes problematic The ethics of professional boundaries their unique knowledge and skills on behalf only when the personal interest in earning a Boundaries define the professional relationship of their clients, members of a profession are livelihood interferes with one’s commitments as fundamentally respectful and protective of granted the freedom to practice and to regulate and obligations as a health care professional. the patient and as dedicated to the patient’s well- themselves. being and best interests. A boundary violation Standards regarding professional boundaries Thus for practitioners, professionalism is the occurs when a health care professional’s are found in a variety of sources. Directly basis of the health care system’s contract with behavior goes beyond appropriate professional or indirectly, professional codes of ethics, society. It demands placing the interests of limits. Boundary violations generally arise when consensus statements, position papers, clients above those of the practitioner, setting the interaction between parties blurs their roles policies, and laws define the boundaries of and maintaining standards of competence vis-à-vis one another, or creates a “double bind” appropriate behavior. These various codes, and integrity, and providing expert advice to situation in which a personal interest displaces consensus statements, and position papers can society on matters of health. The principles the professional’s primary commitment to the assist practitioners to maintain boundaries and responsibilities of medical/health care patient’s welfare in ways that harm – or appear in their professional relationships with professionalism must be clearly understood to harm – the patient or the patient-practitioner clients. Some standards are concrete, setting by both the profession and society. Essential relationship, or might reasonably be expected specific thresholds for professional behavior, to this contract is public trust in massage to do so. often by proscribing particular activities or therapists, which depends on the integrity of relationships, such as sexual relationships, The intimate nature of massage therapy both individual practitioners and the whole for example. Often, the standards set by includes practitioners in important and profession. professional organizations carry sanctions for sometimes highly stressful life events, and professionals who violate acceptable behavior. Clients who come to health care professionals the mutual dependence of colleagues working when they are ill and vulnerable bring with in close concert all present the potential for Other standards, however, set out only general them expectations about this interaction and blurring of limits to professional relationships. values and principles that should guide the how practitioners should behave toward them Remaining within the bounds established professional’s conduct and decision making, as health care professionals, though clients are by the purpose of the relationship can be and rely on health care professionals to use not always able to articulate those expectations especially difficult in prolonged or long-term good judgment in applying those values clearly. Clients should be able to trust that relationships. Even so, in all encounters, and principles. Thus, standards for massage their interests and welfare will be placed above practitioners are responsible for retaining their therapists prohibit them from engaging in dual those of the health care professional, just as professional boundaries. or multiple relationships with clients or former they should be confident they will be treated clients in which there is a risk of exploitation A variety of standards establish the limits of with respect, and be informed so that they can or potential harm to the client and broadly appropriate professional behavior, whether make their own health care decisions to the define “dual or multiple relationships,” but those limits are explicitly enumerated in greatest extent possible. do not suggest criteria by which professionals standards of conduct, codes of ethics, or law, or should assess the nature or level of risk a Professionals, as such, are held to different tacitly conveyed through professional training particular dual relationship would pose for a standards of conduct from other persons. and widespread acceptance. Individuals who client. The implicit message is that being a Relationships and interactions that seek help must rely on the professional they professional entails forgoing some interactions may be ethically unproblematic among consult to be trustworthy: When practitioners or relationships in which one might otherwise nonprofessionals may be unacceptable behave in ways that call their professional wish to engage in order to protect the interests when one of the parties is a professional. An judgment and objectivity into question, the and well-being of clients. individual may have a personal interest that is trust on which the relationship depends is perfectly acceptable in itself, but that conflicts compromised. And when trust is compromised, In addition to professional codes of ethics, with an obligation the same individual has as the efficacy of the therapeutic relationship is various legal and regulatory requirements a health care professional. For example, under adversely affected. address boundaries in patient-professional circumstances in which it would normally interactions. Note that ethics and law are not Boundary violations harm not only individual be acceptable for one person to ask another the same. One way to describe the difference patients, they carry consequences for others individual for a date, it is not acceptable for is that law is generally geared toward when they erode trust and confidence in a health care professional to ask a client for a making sure that behavior conforms to a the profession more broadly. Practitioners’ date, because doing so might compromise the floor of appropriate conduct established by obligations to society parallel their obligations professional’s fiduciary commitment to the requirements imposed by case law, legislation, to individual clients. Practitioners’ conduct patient’s welfare. and/or regulation. Ethics is generally as professionals should merit the respect concerned with defining and promoting what The nature of professions is such that they of the community. Clear and scrupulously is right and what should be done in relation demand expectations of a higher morality and adhered to boundaries thus protect health care to broader moral values, and that may not a greater commitment to the good of others professionals as well as clients, helping to be clearly defined by law. Employees of the than in most other human activities. The health sustain the public trust on which the freedom federal government, for example are intended care relationship is one of both great intimacy to practice rests. to safeguard and foster public trust through and great disparity in power and knowledge, the promotion of transparent and ethical www.ILmassageCE.com Page 11 behavior. The rules cover the acceptance of boundary, thereby increasing the chances of and the awkwardness that can result. Also, gifts, prohibited financial interests, and the use boundary violation. Boundary violation is a there is the risk of taking time and attention of public office for private gain, among other significant and potentially harmful breach away from your client’s treatment and topics. where the practitioner overrides the client’s burdening him/her with knowledge of your rights or actually does harm to the client. own problems. Self-disclosure signals that the Massage therapists are subject to guidelines Some examples are: affectionate or flirtatious relationship is becoming more personal and for professional conduct in health care communication; self-disclosure about the can be interpreted as an invitation for your promulgated by state licensing boards. Some practitioner’s personal problems; or breaking client to ask further personal questions or seek state board guidelines offer specific guidance confidentiality. friendship with you. Exactly where should you to help practitioners avoid inappropriate draw the line? It is helpful to ask yourself two conduct, such as recommending that Personal boundaries and self-disclosure questions before self-disclosing: (a) how will professionals restrict contact with clients to Massage therapists should have clearly it benefit the client? and (b) how will it affect appropriate times and places. Violations of delineated professional and personal boundaries. your professional boundaries? You should these guidelines could result in probation, While professional boundaries, as discussed, also consider your own privacy. For example, limitation of practice, and suspension or are based on social or legal requirements, and what if you and your client attend the same revocation of licensure. Practitioners should formalized into a professional code of ethics, Alcoholics Anonymous meeting? Would this be aware, moreover, that inappropriate sexual personal boundaries also are a way of “letting make it hard for you to get the full benefits of or physical contact can result in clients suing someone in” or keeping them at a distance. attending the meeting during times of stress or practitioners. Self-disclosure is the process in which the relapse? practitioner reveals personal (rather than general Institutional policies are another source of or professional) information about him/herself Whenever there is an interaction between guidance regarding the ethical boundaries to the client. Inappropriate self-disclosure is you and the client, personal information is of patient-professional relationships. done for the benefit of the practitioner rather shared, some intentionally, some accidentally. “Relationships between Employees and than the client, and may burden the client Boundary crossings may be more likely Patients, Former Patients, and Patients’ unnecessarily. Sometimes self-disclosure leads to occur in situations of transference (the Families” implemented in 1998 by the to role reversal, a case in which, for example, client’s personalizing of the relationship) Veterans’ Health Administration, clarified the client feels he or she must take care of the and countertransference (the practitioner’s the conduct expected of all staff and provides practitioner. This unnecessary disclosure is a personalizing of the relationship). You may specific guidance for addressing instances of boundary violation. have a momentary incident in which you share inappropriate behavior, which may prove a something, that later, you wish you had not. useful model for massage therapy. There are many different motivations for and Of course, it is impossible to take words back. types of self-disclosure. Self-disclosure may Boundary crossings Self-disclosure is not always conscious and be deliberate or accidental, initiated by either The professional boundary defines the extent deliberate. Words can be blurted out, poorly the client or the therapist, and can be spoken or and limitations of the relationship with your thought out, or tinged with emotion. When in unspoken. An example of unspoken intentional client. It preserves your client’s confidentiality doubt, do not self-disclose. self-disclosure is how you choose to decorate and creates a “safe space” for your client to your workplace (with careful selection of In a similar vein, it is usually best to keep receive professional services. Boundaries are a meaningful poster or picture, or a family emotional responses or judgments (both signified by the temporal and spatial routines photo, for example). Some self-disclosure is negative and positive) to yourself. A good of the treatment process: regular appointment unavoidable, as your presence communicates rule of thumb is to monitor your own feelings times, consistent length of sessions, and a facts about you such as your gender, and without imposing them on your client. If you dedicated treatment room. approximate age, etc. are distracted by a strong feeling, mentally put You will sometimes need to respond to it to one side. Wait until after the session, then Some disclosure is accidental because it is situations where the boundary becomes less talk with a peer or supervisor or deal with it not meant to be shared but is communicated defined. These situations may seem ordinary personally. As with other boundary crossing, through body language or tone of voice. and potentially harmless. For instance, would self-disclosure should be client-focused, based Accidental self-disclosure also occurs in you accept a gift from your client? Your on the welfare of the client. Different clients cases where a practitioner bumps into a client answer might depend on the context. An and practitioners have different personal unexpectedly, when both are sitting in their inexpensive token of thanks at the last session boundaries, so appropriate boundaries must doctor’s waiting room, for example. You may may be different than a gift on your birthday function within the client’s comfort zone. or may not want to disclose information about or offered by your client at some other point in why you are there, and it may be difficult to Remember that those personal and professional treatment. Explain and discuss the benefits of find a safe middle ground, revealing enough boundaries exist for the benefit of both the keeping your relationship professional so that to be professional and friendly, but not enough practitioner and the client. Changing or you can both focus on the client’s treatment to compromise your own personal space and moving boundaries, which are the limits within needs. privacy. Consider personal and professional which the therapeutic relationship occurs, Boundaries are breached in two ways. Some boundaries when you develop a website or results in an unclear or ambiguous relationship breaches are inadvertent or not intentionally promotional materials. The Internet is a great that is a risk to the safety of the client, exploitative. These are known as boundary way to get information “out there,” but it is although it may not appear to have negative crossings. Commonly cited examples are a difficult to take back, so consider that content repercussions at that time. Transgressions goodbye hug initiated by your client at the carefully. often have delayed consequences that do not completion of treatment; non-sexual physical appear harmful initially. Detecting boundary There is some debate regarding the extent that reassurance at times of extreme stress; violations is complicated by the fact that practitioners should disclose personal things running a session overtime; or selective self- transgressions are more often a process than to their clients. We all know someone who disclosure. Repetitive boundary crossings an individual event or occurrence. Boundary self-discloses too easily or inappropriately are potentially harmful because they blur the Page 12 www.ILmassageCE.com violations may be subtle, or masked by the Prohibited dual relationships can include, but Does the client understand the significance professional/patient relationship. are not limited to: of the dual relationship, and did he/she Accepting as a client anyone with whom give informed consent regarding the risks Dual role (multiple) relationships you have had a prior sexual relationship. associated with the relationship? A dual or multiple role relationship occurs Forming a sexual relationship with a when an individual either at the same time The following examples describe potential current client or someone who has been or different points in time engages in two ethical dilemmas relating to dual relationships. your client. role categories, for example, in addition to In each case, dual relationships cause boundary Treating clients to whom you are related by the professional therapeutic relationship, confusion because the two relationships have blood or legal ties. there is also another relationship, such as different boundary rules. Consider how you Bartering with clients for the provision of relative, friend, student, business partner, would handle this scenario: services. or instructor. While it is perhaps best to You need some painting done in your Entering into financial or business avoid dual relationships, it is not always a office. Your client is unemployed, short transactions with clients (other than the possible or practical ideal. In small towns, for of money and underconfident. You are provision of massage services). example, it may be more difficult to avoid dual thinking about hiring your client to do relationships. Other situations that complicate the massage the job since it could have therapeutic therapy relationship are lending and benefits. What if your client does a bad There is a great range of opinion regarding borrowing money, meeting at inappropriate painting job? How would this impact on the propriety of dual relationships. While places or times, giving or receiving gifts, the therapeutic relationship? What if your some feel that not all dual relationships soliciting donations, inappropriate self- client discloses that she has been drinking are negative, all have that potential. Some disclosure, socialization with clients, and heavily? What impact might this have on organizations suggest that dual relationships inappropriate use of language. your trust in her as a painter? are acceptable, if not exploitive. To ensure that the relationships do not cross the line Before engaging in a dual relationship, ask What about these unexpected encounters? into exploitation, it is important to follow yourself this series of questions to determine Consider how you might react to some of the recommended procedures including informed if the dual relationship is in the best interest of following scenarios: consent, open discussion, consultation, the client and practitioner: Your child becomes friendly with your supervision, and examination of personal Is the dual relationship necessary? client’s child. motivation, all of which should be Unnecessary dual relationships are You bump into your client while you are documented. associated with unnecessary risk. both drinking alcohol at a party. A mutual friend introduces your client as Some professionals consider it unethical to It is usually in the best interests his new date. work on friends, while others consider it of the professional to avoid a dual acceptable to proceed as long as appropriate relationship, if possible. If the dual Many kinds of interactions potentially interfere measures are taken to ensure there are no relationship is deemed necessary, ask: with the primary therapeutic relationship detrimental effects to the therapeutic or Who benefits from the dual between practitioner and patient and pose preexisting relationship. It is always best to relationship? concerns about acceptable conduct for massage avoid multiple relationships if it appears likely Will the dual relationship cause risk therapists. that the relationship might interfere with the to the client? Becoming socially involved or entering into therapeutic relationship. However, existence Will the dual relationship disrupt a business relationship with a patient, for of a dual relationship is not necessarily the therapeutic relationship? example, can impair, or appear to impair, a violation of boundaries. This is usually These questions should be revisited the professional’s objectivity. Accepting referred to as a “prohibited dual relationship.” throughout the treatment process, to ensure a gift is sometimes an appropriate way to This means a dual relationship which might that the relationship remains in the best allow a client to express his or her gratitude, impair objectivity or effectiveness, or permit interests of the client. and at other times is problematic. Showing exploitation, or create an actual, apparent or Am I conflicted or objective in my favoritism, by giving a particular patient potential conflict of interest. reasoning? Because objectivity is an ideal that we can extra attention, time, or priority in scheduling It is your responsibility, not your client’s, only approach, it is useful to discuss this appointments, for example, can cross the to maintain appropriate boundaries in your subject with a supervisor or peer counselor. boundary between action that is appropriate professional relationship. If a complaint advocacy on behalf of a particular client and is filed, it will be your responsibility to Review this list of questions and the action that is unfair to others. Such interactions demonstrate that a client has not been answers in consultation with a trusted or activities are ethically problematic when exploited or coerced, intentionally or advisor, and document the discussion. they can reasonably be expected to affect the unintentionally. Be especially vigilant Documentation should record each portion care received by the individual or by other regarding any conduct that could impair of this decision-making process, reflecting clients or the practitioner’s relationships with your objectivity and professional judgment the choices that led to the dual relationship. his or her colleagues, or when they give the in serving your client, and any conduct that Good documentation acts like a witness to the appearance of doing so. Yet not all behavior carries the risk and/or the appearance of event, and should, in retrospect, support the that might be considered inappropriate exploitation or potential harm to your client. practitioner’s choice. Evaluations of boundary necessarily violates professional obligations. Although it is frequently difficult to draw clear Recognize and avoid the dangers of dual violations in professional practice usually lines, the examples below highlight some of relationships when relating to clients in more occur long after the fact, often arrived at the considerations at stake. than one context, whether professional, social, retrospectively by an ethics committee, so the educational, or commercial. Dual relationships rationale should be clear. Health care professionals should be alert to can occur simultaneously or consecutively. Finally, if you proceed with treatment, ask: situations in which they may be likely to be motivated to behave in ways that violate www.ILmassageCE.com Page 13 accepted ethical standards. Ambiguous Mrs. O’s daughter has been Ms. K’s client or compromise the care available to other interactions and relationships, for example, for many years. The O’s have a cottage clients, or appear to others to do so. Just have the potential both to impair the several hours from the city where they what activities might constitute a violation of professional’s objectivity and compromise his spend the summers, and where Mrs. O professional boundaries depends very much on or her judgment, and to give rise to conflicting is an avid gardener. At the end of every the specific context in which such actions take expectations on the client’s part, which can season Mrs. O makes sure to bring flowers place and their foreseeable likely consequences contaminate the therapeutic relationship and home-grown tomatoes for both Ms. K for others. For example: and potentially undermine the client’s trust. and the office staff. Mr. J is ready to be picked up after a Multiple or ambiguous relationships raise treatment session. His daughter calls the Gifts from clients may be problematic if other concerns as well. Consider the case of office complaining of car trouble, and they carry with them an expectation of return Mr. D and Mr. H: saying she won’t be able to pick Mr. J up. favors, or might influence a practitioner’s Mr. D, an independent contractor, has Ms. K (the massage therapist) is thinking judgment, even when there is no expectation been the massage therapist’s (Mr. H’s) about driving the client home herself. of return. But like Mrs. O, many clients wish patient for three years. During a visit, Mr. to express gratitude to their practitioners Giving Mr. J a ride home would probably D overhears Mr. H talking to a colleague and allowing them to do so accords them a be acceptable if it did not place additional about some remodeling for Mr. H’s home. measure of empowerment and mutuality in the burdens on other staff, or mean that Ms. K is Later in the visit he hands Mr. H his patient-practitioner relationship and can foster not available to other clients. Obviously, if business card and tells him that he will do greater trust and a stronger clinical bond. In Ms. K were regularly to extend the kindness the remodeling for a great price because he other situations, however, gifts are ethically of a ride home to certain clients she would be appreciates the care he has received from problematic. For example: compromising her professional commitment Mr. H. The patient’s offer of discounted Ms. M sits on the board of a nonprofit to be fair to all of her clients and potentially service may contain an implicit quid community group that serves inner city impede the efficient functioning of the clinic. pro quo: Mr. D may now expect Mr. H adolescents through after-school and to provide special services or reduce his The basic general principle underlying all summer activity programs. Mr. G, a fees, for example. An implied quid pro these guidelines is that the practitioner must local businessman, has been her patient quo changes the patient’s expectations give priority to the client in any conflicts of for some time. When Mr. G comes for a of the patient-practitioner relationship, interest. This requires maintaining professional routine visit during the group’s annual and puts the practitioner’s objectivity in and clinical independence from commercial fundraising drive, Ms. M asks him for a question. The patient may perceive that interests and ensuring that relationships with contribution. Soliciting a gift in this way the therapist’s personal interests can be companies do not lead to any action that takes advantage of Mr. G, who may feel appealed to for care that is outside accepted is not in the best interests of the patient. In uncomfortable declining a request from his professional norms. particular, practitioners should not rely on massage therapist, or worry that he won’t company representatives or industry-sponsored It is not always feasible for a massage therapist receive the same attention from Ms. M if promotional events for their knowledge of to bracket his or her interactions with a patient he doesn’t contribute to the community products, and not endorse or attempt to sell from other interactions he or she may have group. Conversely, practitioner’s gifts to these products to clients. with the same individual outside the health clients may create confusion about roles or care setting. While any practitioner may engender a sense of obligation on the part Health care professionals should beware of face the challenge of navigating multiple, of the client that adversely affects his or interacting with any patient in ways that could overlapping, or ambiguous relationships, her openness in the therapeutic encounter. reasonably be expected to create awkward the problem may be particularly acute for situations for either party, compromise Not all gifts are the same (and a gift is not practitioners in small communities, many the professional’s primary commitment to always valued in the same way by giver and of whose clients are also the tradespeople, patient welfare, or call the professional’s recipient), and some can actually benefit the shopkeepers, bankers, or others with whom objectivity into question. While not every patient-practitioner relationship. Thus whether they must do business regularly. But that does business or social interaction or relationship a gift or gift relationship violates ethical not obviate the professional’s responsibility between a health care professional and a professional boundaries should be evaluated to be sensitive to the ethical concerns at stake client necessarily violates ethical professional on a case-by-case basis. Small gifts of food and take appropriate action to withdraw from boundaries, professionals should critically may be acceptable because they are unlikely to or manage social or other relationships in examine their own actions by considering the affect a practitioner’s objectivity or judgment, ways that minimize the possibility of harming following: while larger gifts may do so. It is always clients, interfering with the care of others, or Is this activity a normal, expected part of the practitioner’s responsibility to safeguard disrupting relationships with colleagues. practice for members of my profession? professional objectivity by being cautious Might engaging in this activity Defining what counts as a violation of when accepting or giving gifts. compromise my relationship with this professional boundaries simply by referring Finally, seeming to “play favorites” by client? With other clients? With my to “dual relationships” or to the kinds of accommodating individual clients in special colleagues? With my institution? With the relationships between clients and health care ways can also raise concerns about ethical public? professionals (e.g., business or social) may professional boundaries. Health care Could this activity cause others to question cast the net too widely. Determining whether professionals commit themselves to treating my professional objectivity? any given interaction is or is not appropriate all clients fairly. Clients often need more than Would I want my other clients, other behavior for a health care professional calls just clinical care, and it is not necessarily professionals, or the public to know that I for careful, critical reflection on the particular inappropriate for professionals to provide help engage in such activities? circumstances. Consider the following in other ways. But their actions on behalf of scenario, for example: a particular patient must not adversely affect the therapeutic relationship with that client Page 14 www.ILmassageCE.com If the answers to these questions indicate that g. Respect the client’s right to refuse the incapacitated may require protecting them an activity may violate professional ethical the therapeutic session. as they mature or while they are incapacitated. boundaries, the massage therapist should: A broader context: Bioethics (medical Some persons are in need of extensive Determine if there are applicable standards. 13 protection, even to the point of excluding Consult a trusted and objective peer for a ethics) and decision-making them from activities which may harm them; second opinion about the activity. Bioethics grew out of concerns about the other persons require little protection beyond Seek assistance from a supervisor or ethics disproportionate power that physicians have making sure they undertake activities freely committee. relative to clients in therapeutic decision- and with awareness of possible adverse Communicate his or her concern to the making and physician research practices consequence. The extent of protection individual involved. involving human subjects. Thus, what we afforded should depend upon the risk of harm Transfer the patient to another now think of as “bioethics” was originally and the likelihood of benefit. The judgment practitioner’s care if the professional conceived of more narrowly as “medical that any individual lacks autonomy should relationship has been compromised, or ethics” and limited in scope to ethical be periodically reevaluated and will vary if avoiding the violation will damage the considerations involving individual medical in different situations. Respecting persons, relationship. practice. From medical ethics evolved “clinical ethics” (now sometimes referred to as “health in complicated cases, is often a matter of As well, it is imperative that health care care ethics”), which expanded somewhat the balancing competing claims urged by the professionals be familiar with: scope of concern to reflect diversification principle of respect itself. Relevant professional codes of ethics, in health care to include a health care team. The principle of autonomy (self-rule) is based standards of practice, guidelines, and Bioethics extends the scope of ethical analysis, on the principle of respect for persons, which position statements. more broadly, to include whatever comes to holds that individual persons have the right to Applicable policies in their facilities. bear on matters of health. make their own choices and develop their own Laws pertaining to relationships between life plan. In a health care setting, the principle clients and health and personal care Ethical dilemmas occur when two ethical of autonomy translates into the principle of professionals. principles clash. One of the most successful approaches to health care ethical dilemmas informed consent: You shall not treat a client Drawing distinct lines is possible only with is that of principlism. Principlism is a form without his/her informed consent. In order to regard to the most egregious transgressions of of bioethical analysis in which caregivers affirm autonomy, every effort must be made to professional ethical boundaries, and health care attempt to resolve ethical problems by drawing discuss treatment preferences with clients and professionals must always exercise judgment upon four principles or values: autonomy, to document them in written records. in their relationships with clients. Consultation beneficence, nonmaleficence, and justice. (We Beneficence and nonmaleficence with a more experienced colleague is an will only discuss the first three.) Persons are treated in an ethical manner excellent way of getting support and guidance not only by respecting their decisions and to help you make competent, ethical decisions. Respect for persons (autonomy) protecting them from harm, but also by Peer supervision and case conferences also Respect for persons incorporates at least two making efforts to secure their well-being. offer opportunities to discuss and clarify ethical convictions: first, that individuals should Such treatment falls under the principle of ethical matters. be treated as autonomous agents, and second, that persons with diminished autonomy are beneficence. The term “beneficence” is often We have focused on obligations that flow entitled to protection. The principle of respect understood to cover acts of kindness or charity from the notion of “profession,” but the for persons thus divides into two separate moral that go beyond strict obligation. In this context, analysis offered here is equally relevant to requirements: the requirement to acknowledge beneficence is understood in a stronger sense, all caregivers, whether they are licensed autonomy and the requirement to protect those as an obligation. Two general rules have been practitioners or other staff. Understanding with diminished autonomy. formulated as complementary expressions of and respecting professional boundaries is beneficent actions in this sense: (1) do not part of professional competence. Maintaining An autonomous person is an individual harm and (2) maximize possible benefits and those boundaries is an essential part of capable of deliberation about personal goals minimize possible harms (beneficence and compassionate, effective, and ethical massage and of acting under the direction of such nonmaleficence). therapy practice. deliberation. To respect autonomy is to give weight to autonomous persons’ considered The principle of beneficence requires us, other Patient autonomy, informed consent, and opinions and choices while refraining from things being equal, to do good, or what will right to refuse obstructing their actions unless they are further the patient’s interest. The principle of The following section reviews the concept of clearly detrimental to others. To show lack nonmaleficence requires us, other things being patient autonomy, an integral part of Standard of respect for an autonomous agent is to equal, to avoid harm to the patient, or what V – Roles and Boundaries, and particularly repudiate that person’s considered judgments, would be against the patient’s interests. Both relevant to points f and g: to deny an individual the freedom to act on principles rest on the fundamental importance The certificant or applicant shall adhere those considered judgments, or to withhold of what is in the patient’s interest. The first is to ethical boundaries and perform the information necessary to make a considered the positive requirement to further the patient’s professional roles designed to protect judgment, when there are no compelling interest. The second is the requirement to both the client and the practitioner, and reasons to do so. refrain from doing what damages the patient’s safeguard the therapeutic value of the However, not every human being is capable interest. relationship. In his/her professional role, of self-determination. The capacity for self- There is no way to use these principles to the certificant or applicant shall: determination matures during an individual’s make decisions in the abstract, but with these f. Acknowledge and respect the client’s life, and some individuals lose this capacity qualifications in mind, we can assert that the freedom of choice in the therapeutic wholly or in part because of illness, mental least controversial treatment is one that accords session. disability, or circumstances that severely with the interest of the patient, is consistent restrict liberty. Respect for the immature and with the standard of care within the profession, www.ILmassageCE.com Page 15 is agreed to by the patient, consistent with his In addition, Lavelle-Jones found that elderly Consent for multiple treatments: However, or her informed consent, and satisfies both the patients (over 60 years of age) had poorer to say that consent is always specific is not principle of nonmaleficence and beneficence. recall than younger patients. Patients with the same as saying that separate consent As with all hard cases, the different claims internal locus of control – those who believed is always required for every episode of covered by the principle of beneficence may their health was in their own control – were repeated treatment. When the plan of care come into conflict and force difficult choices. better informed than those with an external for a given diagnosis involves repeated locus of control. treatments or procedures, practitioners Barriers to informed consent should ensure the patient understands that he Clients have a fundamental right to direct Patients with above average IQ exhibited or she is consenting to multiple episodes of what happens to their bodies, grounded in better recall. These findings could indicate “at- treatment. Separate consent is not required the principles of autonomy and respect for risk” groups that interventions may target. for each individual episode. If a patient’s persons. In turn, health care professionals have Several methods of improving the procedures condition changes enough to warrant a an ethical obligation to involve clients in a of obtaining informed consent have been change in the plan of care, the practitioner process of shared decision making and to seek proposed, including improving the readability must explain to the patient how the situation clients’ informed consent for treatments and of consent forms, asking clients for recall to has changed, establish goals of care in light procedures. Good informed consent practices, establish understanding, adding additional of the new situation, recommend a new plan thus, are an essential component of ethics stimuli, such as multimedia presentations and of care, and obtain informed consent for quality in health care. And that means more providing written information. The following the new plan or for specific treatment(s) or than getting a patient’s signature on a consent section discusses “best practices” for informed procedure(s) now recommended. form. consent forms, but also applies to other written Notification versus consent: Informed While informed consent is a well-established material intended for the client. consent is also different from “notification,” practice, it often fails to meet its stated Best practices for written materials that is, providing general information relevant purpose. Recent research findings strongly In order to ensure that clients understand the to clients’ participation in health care. suggest that procedures to obtain informed procedure to which they are consenting, it Similarly, every patient entering a health care consent may not adequately promote the is important that all materials be presented facility must be notified that his or her records patient’s comprehension of the information in a comprehensible manner. Written health will be used for purposes of routine health provided, rendering the consent not truly care materials, such as consent forms, are care operations. Likewise, each patient should “informed.” often written with a relatively complex be notified that his or her information may In a study by Lavelle-Jones, 69 percent of sentence structure and vocabulary, making be used for quality improvement purposes to patients admitted that they did not read a it difficult for the average adult to interpret enable the organization to fulfill its obligation consent form before signing it, and it has the information. In addition, providing these to monitor the quality of care it delivers and been estimated that less than half of the U.S. materials in the language the client finds most to carry out quality improvement activities for population understands commonly used familiar is likely to increase comprehension the benefit of all clients. Notification informs medical terms. This “health literacy” problem substantially for many individuals. clients not only about their rights, but also may impact the ability of the patient to about organizational activities and processes Providing written information to clients understand any attempts to obtain information. that shape how care is delivered. Like regarding their diagnoses, proposed treatments, Since the definition of adequate informed informed consent, notification serves the goal and other information given during informed 14 consent is debatable, the number of individuals of respecting clients as moral agents. consent discussion allows the patient to refer currently not receiving interventions to obtain back to such information, which promotes Informed consent should: adequate informed consent is likely to be quite comprehension. Some investigators have Explain the patient’s condition and high, but is not known. proposed that clients should receive written diagnosis clearly and concisely, in Clients with limited reading ability are consent forms days before receiving a language he or she can understand. at increased risk for medical errors, due procedure. Inform the patient about the treatment(s) or to problems reading medication bottles, procedure(s) you recommend, including: Informed consent is always specific: The appointment slips, self-care instructions, and The name, nature, and details of goal of the informed consent process is to health education brochures. These clients may the recommended treatment(s) or ensure that clients have an opportunity to be also have trouble reading materials intended to procedure(s). informed participants in decisions about their aid in obtaining informed consent. Indications for the recommended health care. To achieve that goal, practitioners course of action. According to the National Adult Literacy must explain the patient’s condition and Likelihood of success of the Survey of 1993, approximately 40 million inform the patient about treatment options recommended treatment(s) or to 44 million Americans were functionally and alternatives, including the risks and procedure(s) for this patient. illiterate, defined as the inability to complete benefits of each, providing the information Describe the expected benefits and known basic reading tasks required to function as that a “reasonable person” in similar risks of the recommended treatment(s) or a member of society. In addition, even in circumstances would want to know in making procedure(s). educated adults, the highest grade-level the treatment decision. A key element of the Describe reasonable alternatives to the completed may not reflect actual reading process is that the practitioner explains why recommended treatment(s) or procedure(s), comprehension level. A study of 100 adult he or she believes recommended treatments including the expected benefits and known cancer patients found that most read at a mean or procedures will be more beneficial than risks of each alternative. grade-level equivalent of between 10th and alternatives in the context of the patient’s Identify the practitioners who will be 11th grade. The authors suggest that forms and diagnosis. Thus informed consent is always involved in performing the treatment or educational materials be written at a grade- specific: to the individual patient, the clinical procedure. level three levels below the highest level of situation, and the recommended plan of care education completed by a patient. or recommended treatment(s) or procedure(s). Page 16 www.ILmassageCE.com Advise the patient if the recommended Using “teach back” to improve Name/type/general nature of treatment, treatment or procedure is novel or communication service or procedure, including what unorthodox. “Teach back” is a simple method of receiving it will entail. Encourage the patient to ask questions. determining whether a patient understands Risks, benefits, and alternatives to the information regarding a procedure by asking treatment, service, or procedure. The communication challenge the client to recount what he or she has been Health care practitioners have an ethical When told. The National Quality Forum (NQF) responsibility to promote shared decision- Ask for “teach back” early in the care process. identified teaching back as one of 50 essential making. They have a professional obligation “safe practices” to improve health care. Clients Why to work with clients to negotiate treatment who are asked to teach back may have better Many clients have difficulty understanding plans that respect the patient’s values, recall and understanding of procedures, and basic health information. Asking clients to preferences, and goals for care. To meet that may follow treatment plans more carefully. “teach back” helps you gauge how well they obligation, practitioners must ensure that they Teaching back can also improve efficiency in understand. communicate effectively with clients. clinical practice. For example, the NQF found Communicating effectively is an important that initiating teach back in a large academic How aspect of showing respect to clients, and medical center led to fewer surgeries delayed Clients should be able to show they understand has practical benefits, as well. Effective or canceled because clients hadn’t understood and not just be asked to pass a “quiz” or to communication promotes greater satisfaction instructions. repeat what you said. and helps ensure better adherence to Practitioners can use teach back to identify Don’t ask: treatment plans, with better health outcomes patient-specific barriers to communication, for “Do you understand?” or for clients. Good communication also example, low health literacy, which includes “Do you have any questions?” reduces the likelihood of lawsuits even when more than just difficulty reading. Cognitive clients don’t have good outcomes. Yet poor Do ask: impairments, such as early stage dementia, communication remains a significant problem “I want to be sure I was clear. Can you tell me, and, especially, limited proficiency in English in health care. Many practitioners are not in your own words, how you should take this (possibly indicating the need for a medical well trained in basic communication skills, medication?” or interpreter), also contribute. Nearly half of all such as asking open-ended questions to elicit American adults have difficulty understanding “To be sure I’ve explained your treatment information (“What brings you to the clinic and acting on health information. There can be clearly, please tell me, in your own words, how this morning?”), reflecting clients’ comments other barriers to effective communication as you’d describe it to your wife/husband.” or back to them (“I hear you saying your new well, for example, when clients have hearing medication makes you sleepy”), or using “It’s important that we’re on the same page problems. other active listening techniques. And formal about your care. Can you tell me, in your own training rarely focuses on the communication Asking clients to recount instructions for words, what our plan is?” tasks that must be completed in patient- taking medication or to describe a proposed As we have reviewed, informed consent provider encounters. procedure can alert practitioners to individuals’ is the process through which a health care particular needs and challenges and help Moreover, practitioners tend to underestimate practitioner informs a patient about the risks practitioners tailor communication more clients’ needs for information, and and benefits of a proposed therapy and allows effectively. Learning to ask for teach back overestimate their own effectiveness in the patient to decide whether the therapy will in ways that don’t intimidate clients is key. conveying information. For example, one be undertaken. It is based on the moral and Practitioners can also use teach back as a tool recent study found that 37 percent of clients legal premise of patient autonomy, and is for assessing their own communication skills. reported understanding what they were told the formal application of the client’s right to Using teach back to communicate more during a medical visit — but their physicians make decisions about his/her own health care. effectively does take time. But facilities that thought that 80 percent of clients understood In addition to being an ethical obligation of were early adopters of NQF’s safe practice the information conveyed. Many clients caregivers, legislation in all 50 states requires found that teach back typically took less than a aren’t comfortable disclosing that they don’t that clients be informed of all important minute to complete once practitioners became understand what practitioners are saying and aspects of a treatment and/or procedures, accustomed to using the technique, and asking point blank, “Do you understand?” although the details of these laws and statutes improving communication helps practitioners puts them on the spot. And a nod in response differ greatly. Failure to obtain adequate get the most out of each interaction they have doesn’t guarantee they’ve actually heard and informed consent renders a health care with their clients, to the benefit of patient and understood what’s been said. To make it easier professional liable for negligence or battery provider alike. for clients to understand health information and constitutes medical malpractice. (and thus to give informed consent), Teaching back Legislation governing the requirements of, practitioners must establish conditions for Ask clients to verbally “teach back” and conditions under which, consent must effective communication. Among other things, information they’ve received about proposed be obtained varies greatly from state to state. they should provide a safe environment, treatments, services, and procedures. General guidelines, such as those proposed in which clients feel comfortable asking by the AMA, require clients to be informed of questions. Who Professionals who communicate with clients the nature of their condition and the proposed Practitioners should use plain language – e.g., about health care decisions. procedure, the purpose of the procedure, the “sore” or “wound” instead of “lesion”; “bad” risks and benefits of the proposed treatments, the instead of “adverse” reaction. And they should What probability of the anticipated risks and benefits, use the technique of “teach back,” asking the Have clients explain, in everyday words: alternatives to the treatment and the associated patient to recount what he or she has been told, Diagnosis/health problem for which they risks and benefits, and the risks and benefits of to help gauge the level of understanding. need care. not receiving the treatment or procedure. www.ILmassageCE.com Page 17 Substance abuse Changes in work performance overwhelming evidence that not only do Standard V – Roles and Boundaries relate to Absences and tardiness, especially on drugs interfere with normal brain functioning the issue of substance abuse and professional Mondays. creating powerful feelings of pleasure, but practice: Declines in quality, timeliness, and they also have long-term effects on brain The certificant or applicant shall adhere quantity of work. metabolism and activity. At some point, to ethical boundaries and perform the Length of the lunch break and changes in changes occur in the brain that can turn drug professional roles designed to protect mood observed in the afternoon. abuse into addiction, a chronic, relapsing both the client and the practitioner, and Disorganized behavior. illness. Those addicted to drugs suffer from a safeguard the therapeutic value of the Increased number of errors or customer compulsive drug craving and usage and cannot relationship. In his/her professional role the complaints. quit by themselves. Treatment is necessary to certificant or applicant shall: end this compulsive behavior. Physical changes Refrain from practicing under the Change in appearance/poor hygiene. To get help for substance abuse, contact the influence of alcohol, drugs, or Looks tired, reports insomnia. National Drug and Alcohol Treatment Referral any illegal substances (with the Frequent shaking and/or sweating. Routing at this toll-free telephone number: exception of prescribed dosage of Loss of appetite, weight loss. 1-800-662-HELP (4357). prescription medication which does not Slurred speech. When you call this toll-free number, a significantly impair the certificant). recorded message (English or Spanish Guidelines for coworkers Have the right to refuse and/or language) gives you the following options: terminate the service to a client who Be attentive. Be ready to recognize 1 – Speak to a representative is abusive or under the influence of problems that may or may not be related to concerning substance abuse treatment alcohol or other drug abuse. alcohol, drugs, or any illegal substance. or to request printed material on Observe. Focus on specific aspects of alcohol or drugs. The following section introduces the topic behavior and determine the effects of those 2 – Local substance abuse treatment of substance abuse, with warning signs to behaviors. referral information in your state. help you recognize when substance abuse is Be thoughtful. Stay nonjudgmental and disrupting the therapeutic relationship, and recognize the individual’s point of view. Alcohol abuse where to turn for help. Be consistent. Follow the same procedures The following section recounts frequently for all coworkers and clients. Regardless of asked questions about alcoholism, with Massage practitioners are no more or less your personal relationship, it is important answers from the National Institute on Alcohol vulnerable than others in society to substance to treat each person the same when Abuse and Alcoholism (NIAAA).16 These abuse or addiction. Addiction affects people addressing performance and/or conduct answers are not meant to provide specific at every level. Many addicted professionals problems. medical advice, but to provide information to graduate near the top of their class and tend Maintain confidentiality. Discuss problems better understand the health consequences of to be hardworking, efficient, and respected by in private and keep the discussion between alcohol abuse and dependence (alcoholism). the community. the two of you. Please consult your physician or other health Perhaps that is why many professionals try so care provider if you or a loved one has an hard to keep their addictions a secret. Understanding substance abuse and alcohol problem. addiction15 There is often a reluctance to step in and Many people view drug abuse and addiction as What is alcoholism? actually say anything to a colleague about strictly a social problem. Parents, teens, older Alcoholism, also known as alcohol suspected substance abuse or addiction. adults, and other members of the community dependence, is a disease that includes the Although you may not be sure a problem tend to characterize people who take drugs as following four symptoms: exists, it is important to realize that in many morally weak or as having criminal tendencies. Craving – A strong need, or urge, to drink. cases, your colleague cannot overcome his They believe that drug abusers and addicts Loss of control – Not being able to stop or her substance abuse and addiction unless should be able to stop taking drugs if they are drinking once drinking has begun. you are willing to help with the first step of willing to change their behavior. Physical dependence – Withdrawal recovery. symptoms, such as nausea, sweating, These myths have not only stereotyped those shakiness, and anxiety after stopping What are the warning signs? with drug-related problems, but also their drinking. Supervisors and co-workers can play a vital families, their communities, and the health Tolerance – The need to drink greater role in helping a colleague or friend take care professionals who work with them. amounts of alcohol to get “high.” the first step toward recovery. Thus, it is Drug abuse and addiction comprise a public important to recognize the warning signs and health problem that affects many people and Is alcoholism a disease? know where to refer practitioners who may has wide-ranging social consequences. The Yes, alcoholism is a disease. The craving that have problems with alcohol or drug abuse or National Institute on Drug Abuse (NIDA) an alcoholic feels for alcohol can be as strong addiction. The following warning signs may be exists to help the public replace its myths and as the need for food or water. An alcoholic helpful in identifying a problem: long-held mistaken beliefs about drug abuse will continue to drink despite serious family, health, or legal problems. Behavioral changes and addiction with scientific evidence that addiction is a chronic, relapsing, and treatable Irritability and/or mood swings; extreme Like many other diseases, alcoholism is disease. temper, anxiety, or depression. chronic, meaning that it lasts a person’s Loss of memory/blackouts. Addiction does begin with drug abuse when lifetime; it usually follows a predictable Withdrawal from friends and social an individual makes a conscious choice to course; and it has symptoms. The risk for activities. use drugs, but addiction is not just “a lot of developing alcoholism is influenced both by a drug use.” Recent scientific research provides person’s genes and by his or her lifestyle.
Page 18 www.ILmassageCE.com Can alcoholism be treated? What you say may range from refusing The three “C’s” Yes, alcoholism can be treated. Alcoholism to treat an obviously intoxicated client, to Finally, if you have a family member, friend, treatment programs use both counseling and refusing to go with a spouse or friend to or client with a substance abuse problem, you medications to help a person stop drinking. any social activity where alcohol will be may find this information from the Children of Treatment has helped many people stop served, etc. Do not make any threats you Alcoholics Foundation useful: drinking and rebuild their lives. are not prepared to carry out. It is important for you to understand the “three Get help. Gather information in C’s of addiction”: How can you tell if someone has a advance about treatment options in your You DIDN’T CAUSE it. Addiction is problem? community. If the person is willing to get not something that one person can do Answering the following four questions can help, call immediately for an appointment to another. An unhappy childhood, an help you find out if you or a loved one has a with a treatment counselor. Offer to go unhappy marriage, or problems with drinking problem: with the family member on the first visit to children, for example, do not cause a Have you ever felt you should cut down on a treatment program and/or an Alcoholics person to become a substance abuser. Even your drinking? Anonymous meeting. if you yourself had a substance abuse Have people annoyed you by criticizing Call on a friend. If the family member still problem when your children were young, your drinking? refuses to get help, ask a friend to talk with it is not your fault. While some people may Have you ever felt bad or guilty about your him or her using the steps just described. be born with an inherited tendency toward drinking? A friend who is a recovering alcoholic addiction, and some life experiences may Have you ever had a drink first thing in the may be particularly persuasive, but any make it more or less likely, neither genes morning to steady your nerves or to get rid person who is caring and nonjudgmental nor experiences alone cause addiction. of a hangover? may help. The intervention of more than Rather, the path to drug use, abuse, and one person, more than one time, is often One “yes” answer suggests a possible alcohol addiction are actions that the substance necessary to coax an alcoholic to seek help. problem. More than one “yes” answer means abuser chooses. Simply stated, the Find strength in numbers. With the help it is more likely that a problem exists. If you addiction is the result of a series of bad of a health care professional, some families think that you or someone you know might choices made by the substance abuser. join with other relatives and friends to have an alcohol problem, it is important to You CAN’T CONTROL it. If an addict confront an alcoholic as a group. This see a doctor or other health care provider wants a drug, nothing and no one will stand approach should only be tried under the right away. They can help you determine if in their way. Forget pouring the wine down guidance of a health care professional a drinking problem exists and plan the best the sink, or flushing pills down the toilet; it who is experienced in this kind of group course of action. won’t make a difference. In truth, the only intervention. way to limit being around substance abuse If an alcoholic is unwilling to get help, Get support. It is important to remember is to limit your time around the substance what can you do about it? that you are not alone. Support groups abuser. This can be a challenge. An alcoholic can’t offered in most communities include You CAN’T CURE it. Much as you be forced to get help except under certain Al-Anon, which holds regular meetings may want a substance abuser to get help, circumstances, such as a traffic violation or for spouses and other significant adults you can’t make it happen. Love and arrest that results in court-ordered treatment. in an alcoholic’s life, and Alateen, which understanding won’t do it, and neither But you don’t have to wait for someone to is geared to children of alcoholics. These will begging or threatening. Recovery “hit rock bottom” to act. Many alcoholism groups help family members understand will come, if at all, only if and when the treatment specialists suggest the following that they are not responsible for an substance abuser truly decides to seek steps to help an alcoholic get treatment: alcoholic’s drinking and that they need another life. Just as the addiction was the Stop all “cover ups.” Family members to take steps to take care of themselves, result of a series of bad choices by the often make excuses to others or try to regardless of whether the alcoholic family substance abuser, so must recovery begin protect the alcoholic from the results of member chooses to get help. his or her drinking. It is important to stop and be maintained through a series of good How can a person get help for an alcohol choices by the substance abuser. covering for the alcoholic so that he or problem? she experiences the full consequences of The three C’s can be a great comfort. Suppose There are many national and local resources drinking. you find yourself worrying, saying: If only that can help. The National Drug and Alcohol Time your intervention. The best time I’d been a better mother, perhaps my son Treatment Referral Routing Service provides a to talk to the drinker is shortly after an would never have started drinking. Repeat to toll-free telephone number, 1-800-662-HELP alcohol-related problem has occurred – like yourself: I didn’t cause it. Or tell that nagging (4357), offering various resource information. a serious argument or an accident. Choose inner voice – Maybe if I found a really good Through this service you can speak directly to a time when he or she is sober, both of you treatment program and took her to meet with a representative concerning substance abuse are fairly calm, and you have a chance to the counselor – that you can’t cure it. It’s a treatment, request printed material on alcohol talk in private. hard message to remember at times, but it or other drugs, or obtain local substance abuse Be specific. Tell the individual that you really can help your own peace of mind. You treatment referral information in your State. are worried about his or her drinking. cannot control substance abuse, cure it, or Use examples of the ways in which the Many people also find support groups a helpful cause it. But you can learn to cope with it. drinking has caused problems, including aid to recovery. The following list includes Section III: Improving ethics quality in the most recent incident. a variety of resources: Al-Anon/Alateen; your organization State the results. Explain to the drinker Alcoholics Anonymous (AA) National Only about 10 percent of an iceberg is actually what you will do if he or she doesn’t go Association for Children of Alcoholics visible above the waterline — the greatest for help – not to punish the drinker, but to (NACOA); National Clearinghouse for part of its mass lies hidden below the ocean protect yourself from his or her problems. Alcohol and Drug Information (NCADI). surface. Mariners ignore that submerged mass www.ILmassageCE.com Page 19 Endnotes & Bibliography at their peril. Ethics quality in health care can shown to improve quality of care and 1. Hippocratic Oath translation discussed at http://www.geocities.com/ever wild7/ noharm.html be described in much the same way: Some reduce length of stay and cost. Supporting 2. MIA Professional and Ethics Seminar (Manitoba) June 9, 2002 ethical practices are readily visible; others patients’ rights to forgo life-sustaining 3. The Ethics of Touch [Benjamin and Sohnen-Moe, 2003] 4. http://classics.mit.edu/Hippocrates/hippooath.html become apparent only when we make an effort treatment meets an important ethical 5. The Ethics of Touch, Benjamin, Ben E. and Sohnen-Moe, Cheree, 2003] 6. http://www.eeoc.gov/types/sexual_harassment.html to see them. But what is usually unseen is standard, and at the same time can have the 7. www.doh.state.fl.us/mqa/massage/ma_home.html. Saturday, August 3, 2003 8. NCBTMB Consumer Survey. Harris Interactive, October 2001. Complete survey often the most important determinant of ethical effect of avoiding costs. questions/results are available on line at http://wwwncbtmb.com/Press_releases/ SurveyResults.html:citation at: www.massagetoday.com/archives/2001/12//02.html practice overall. Improving accreditation reviews. As 9. www.cbsmalpractice.com/report/articles/ jul 1801.htm Monday, July 21, 2003 (CBS Malpractice Report: “Tips for Better Record Keeping”) of 2006, the Joint Commission on the 10. Quintrell, N 1994, Communication Skills: Pharmaceutical Society of Australia, At the surface of health care ethics we can Canberra. Accreditation of Healthcare Organizations easily observe decisions and actions, and the 11. http://www.ncbtmb.com/standards_of_practice.html includes 24 standards explicitly pertaining 12. http://www.ethics.va.gov/ETHICS/docs/necrpts/NEC_Report_20030701_Ethical_ events that follow from them, in the day-to-day Boundaries_Pt-Clinician_Relationship.pdf to ethics, patient rights, and organizational 13. http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.htm#xbasic practices of practitioners and administrators. 14. President’s Commission for the Study of Ethical Problems in Medicine and responsibilities. A strong ethics program Biomedical and Behavioral Research, Making Health Care Decisions. Washington, DC: Beneath this, however, organizational systems U.S. Government Printing Office, 1983. can help ensure that the organization meets 15. http://www.nida.nih.gov/Infofacts/understand.html and processes drive decision-making. Not or exceeds those standards. About Massage, Bodywork, and Somatic Therapies, Associated Bodywork and immediately visible in themselves, these Massage Professionals (ABMP) Professional code of Ethics, 2003. Reducing ethics violations. An effective Alternative Therapies: Journal of Alternative Therapies in Health and Medicine organizational factors become apparent when American Massage Therapy Association; AMTA Massage: Definition of Massage, ethics program can help address Code of Ethics, 2003 we look for them, for example, when we Ashton, Joseph, and Cassel, Duke, Review for Therapeutic Massage and Bodywork deficiencies relating to patient privacy Certification, Lippincott, Williams &Wilkins, Baltimore, Maryland, 2002. examine patterns and trends in requests for Beck, Mark F., Milady’s Theory and Practice of Therapeutic Massage,” 3rd edition, and confidentiality, advance directives, Milady Publishing Company, Albany, NY, 1999. ethics consultations. Benjamin, Ben E., and Sohnen-Moe, Cheree, The Ethics of Touch, SMA Inc, 2003. withdrawal of life-sustaining treatment, Burnum JF. Preventability of adverse drug reactions. Ann Intern Med 1976;85(1):80-1. Deeper still lie the organization’s health and informed consent. In health care Calvert, Robert Noah, The History of Massage, Healing Arts Press: Rochester, care ethics environment and culture, which Vermont, 2002. as in the business world, an effective Cohen-Horwitz, B. (1991). “The nurse as defendant.” Trial Lawyer 14(8):39-47. powerfully, but nearly imperceptibly shape its Commonwealth Department of Human Services and Health. Review of professional ethics program can help prevent the sort indemnity arrangements for health care professionals. In: Compensation and ethical practices overall. This deepest level Professional Indemnity in Health care: A Final Report. Australian Government of practices that can lead to findings of Publishing Service, Canberra. November 1995. of organizational values, understandings, Consumers Guide to Therapeutic Massage and Bodywork, National Certification Board material weakness, or even sanctions for Therapeutic Massage and Bodywork (NCBTMB) assumptions, habits, and unspoken messages Consumer Survey Fact Sheet, 2003 Massage Therapy, report commissioned by the or fines, and damage an organization’s American Massage Therapy Association, Survey was conducted August 2003 www. – what people in the organization know but amta.massage.org reputation. Fritz, Sandy, Mosby’s Fundamentals of Therapeutic Massage, Mosby Inc., Second rarely make explicit – is critically important Edition, 2000. Reducing risk of lawsuits. Organizations Fritz, SC and MJ Groenbach, and K Paholsky, Informed Consent, Massage Magazine, since it is the foundation for everything July/August 1997. that make strong commitments to ethical Fritz, SC and MJ Groenbach, and K Paholsky , Scope of Practice, Massage Magazine, else. Yet because it is only revealed through March/April 1997. health care practices, such as being Greenman, Philip E., Principles of Manual Medicine , Second Edition. deliberate and careful observation, it is often honest with clients, can reduce the risk of Griffith, Brenda L. Massage Therapy Has a Role in Pain Management, Practical Pain overlooked. Together, these three levels – Management Magazine, Jan/Feb 2003 litigation and liability. McConnellogue, Kieran, The Courage of Touch, Massage & Bodwork Magazine, Dec/ decisions and actions, systems and processes, Jan 2000 Sustaining corporate integrity. McIntosh, Nina, The Educated Heart: Professional Guidelines for Massage Therapists, and environment and culture – define the Bodyworkers, and Movement Teachers. Decatur Bainbridge Press, 1999. Ambiguity about values and priorities Millenson ML. Demanding Medical Excellence. Chicago: The University of Chicago ethics quality of a health care organization. Press; 1997. is one of the major sources of corporate National Certification Board of Theraapeutic Massage and Bodywork (NCBTMB), Code of Ethics and Standards of Practice, 2003. A strong ethics program can reap many deviance. Making ethics a clear priority National Institutes of Health, Alternative Medicine: Expanding Medical Horizons; A Report to the National Institutes of Health and Alternative Medical Systems and concrete benefits for a health care organization, in corporate culture helps to ensure Practices in the United States, NIH Publication Number 94-066, 1994. NCCAM: Research Citations by the National Center for Complementary and from increasing patient satisfaction, to good business practices throughout the Alternative Medicine; One Body: Information on Massage and other Somatic and Complementary Approaches to Health improving employee morale, to conserving organization. Oxford Textbook of Palliative Medicine, Edited by Derek Doyle, Geoffrey Hanke, and Neil MacDonald 2nd Edition Published by Oxford University Press, Publication date: resources and saving costs. Here’s some of Safeguarding the organization’s future. April 1999 Polseno, Diane, “Say it Ethically; Responding to Sexual Misconduct” Massage Therapy the evidence that doing the right thing is also Lack of an effective ethics program can Journal, Fall 2003. Reilly, E. (1984). “Nurses and the law.” New Hampshire Bar Journal 26(1):7-23. doing the smart thing: seriously jeopardize an organization’s Salvo, Susan G., Massage Therapy Principles and Practice, Massage, Inc. Cotati, CA Schneider, Steven L., MD, Agency for Health care Research and Quality (AHRQ), from Increasing client satisfaction. When reputation and even its survival. Creating www.LaurusHealth.com; Illnesses & Conditions: Work in Partnership with your Doctor structures and processes by which an to Prevent Medical Errors organizations support ethical health care Tappan, Frances M. Healing Massage Techniques – Holistic, Classic, and Emerging practices – for example, by encouraging organization can hold itself accountable to Methods – Second Edition Thiroux, Jacques, Ethics Theory and Practice, Prentice Hall, 1995 practitioners to actively involve clients in its core values and to ethical practices is an Thompson, Diana L., Hands Heal, Lippincott, Williams and Wilkins, 2002. Tideiksaar, R. (1996). “Preventing falls: How to identify risk factors, reduce decisions about their health care – clients investment in the organization’s future. complications.” Geriatrics 51(2):43-55. Woods, Diana Lynn PhD RN and Margaret Dimond PhD RN The University of do better clinically and say they’re more Arkansas for Medical Sciences College of Nursing and the University of Washington Biobehavioral Nursing and Health Systems School of Nursing; Originally published in satisfied with the care they receive. Biological Research for Nursing; Vol4, No. 2 October 2002 pgs 104-114 www.acsu.buffalo.edu/~drstall/karnofsky.html Improving employee morale. www.AmericanMedicalMassage.com www.cancer.org: Complementary and Alternative Methods: Types of Bodywork • www. Organizations that support ethical decision cdc. gov/ncidod/hip/sterile/sterilgp.htm Tuesday , June 03, 20033 www.qwl.com/mtwc/ articles/hiv.html May 27, 2003 making – especially organizations whose www.geocities.com/everwild7/noharm.html www.Holisticonline.com: Massage Therapy ethics programs focus on achieving high www.thebodyworker.com: Julie Onofrio standards instead of simply complying with policy or law – can expect to have happier, more dedicated employees. Enhancing productivity. A strong ethics culture can improve not only employee morale but also performance, and help to improve an organization’s efficiency and productivity. An effective ethics program also makes it easier to recruit and retain quality staff. Conserving resources/avoiding costs. Effective ethics programs have been
Page 20 www.ILmassageCE.com ETHICS AND STANDARD V - 4. In a fiduciary relationship, the client 9. Which of the following is not a guideline ROLES AND BOUNDARIES IN puts his or her trust in a professional to avoid misrepresentation of your practitioner with the expectation that professional experience or credentials in MASSAGE THERAPY both client and practitioner are: promotional materials and discussions Final Examination Questions with clients and colleagues? a. Subject to interpersonal dynamics. Choose the best answer for questions b. Accountable in the therapeutic a. List your education, training, work 1 through 10 and then mark your answers relationship. history, degrees and credentials as on the answer sheet found on page 59 or c. Equal in the power differential. accurately as possible in resumes and proceed to www.ILmassageCE.com to d. Working in the client’s best interests. biographical statements. complete your final examination.. b. Note your capabilities and strengths, including any modalities, techniques, 1. Many of the values, obligations, and 5. A power differential is: special knowledge, areas of rights we have come to identify with a. The amount of force you exert in specialization, or skills you employ contemporary health care are rooted in massage. on a regular basis or have made a the Hippocratic Oath, a 2,400-year-old b. The imbalance in authority or focus. ethical code that directs physicians, power that results from your greater c. Develop relationships and referral above all else, to: expertise in massage therapy. networks with colleagues who are a. Be at peace. c. Egregious misconduct or highly skilled in alternate areas of b. Do no harm. improprieties. expertise, so you can refer your c. Benefit the patient. d. Always unprofessional. clients to them without reservation, d. Soothe the body and mind. and they can do the same. 6. Transference and countertransference d. Respond to clients asking for an 2. Because virtually all state licensing can: informal opinion, diagnostic guess, treatment recommendations, or any authorities, certifying/accrediting a. Activate strong emotional reactions agencies, and professional associations other areas in which you have strong and/or feelings of sexual attraction. feelings. establish their own standards of conduct b. Raise realistic expectations on the and ethical guidelines for their members, part of clients and practitioners. you will need to: c. Keep you from overreacting. 10. If you believe your client has a serious d. Identify red flags. medical condition or may have suffered a. Memorize the AMTA and NCBTMB an injury, which of the following is not ethical codes. recommended: b. Ignore external ethical codes and 7. If you uncharacteristically deviate from create your own. normal session structure or protocol, a. Tell the client immediately and refer c. Refer to the literature or websites suspect your impulses may be motivated him/her to the appropriate health care of prominent organizations in other by self-interest, or are having strong professional. fields of study. emotional responses to a client, you b. Discuss the condition with the d. Refer directly to the organizations should: client’s doctor even if you do not and academic or training institutions have explicit permission from the a. Seek peer support or supervision. with which you are affiliated, as client to do so. b. Discuss your concern with the client. well as state, local, and national c. Document your referral and the reasons c. Provide services outside your scope associations, to review the ethical for it in the client record. of practice. guidelines that apply specifically to d. Keep scope of practice in mind d. Defer responsibility for maintaining you and your practice. when you give advice or make protective boundaries. recommendations to clients. 3. If you suspect you are acting out of an 8. ______refers to your unhealthy need or motive, or feel your area of competence, usually obtained interactions or relationship with the client through formal study, training, and/ are impeding rather than facilitating the or professional experience, and one for therapeutic relationship, you should: which you’ve received certification or a. Respectfully and courteously discuss other proof of qualification. the topic with your client. a. Relevant legislation. b. Encourage the client to take an active b. Misrepresentation. interest in health concerns. c. Scope of practice. c. Seek assistance and/or supervision d. Slippery slope. with a professional massage therapy organization. d. Explain your fiduciary responsibilities to the client.
MIL06ETE12 www.ILmassageCE.com Page 21 CHAPTER 2 ensuring the person’s return for future sessions. treatment room. Complete your interview in CONDUCTING A PROFESSIONAL It also can promote positive word-of-mouth the waiting room only if there are no other CLIENT INTERVIEW AND MASSAGE recommendations to other potential clients. clients present – all information given requires privacy under HIPAA regulations. If other As you greet clients, it is also prudent to THERAPY SESSION clients are present or expected to arrive, take observe their posture and manner of walking as (2 CE Hours) your client to the treatment room to continue they take their seat. Make a mental note of any the interview. Learning objectives skin conditions, postural deviations or signs ! ! List steps in the initial interview protocol. of discomfort as they enter and sit down. You Tell the person you will just take a moment to ! ! Describe the rationale and method for can inquire about this when conducting the look over the information. Before going over establishing client rapport. interview to include in your overall evaluation any physical complaints or medical history, ! ! Describe how to discuss past massage of their condition. This awareness will allow focus on any personal information gleaned experience with clients. you to notice any changes in their condition from the intake. This is the time to get to ! ! Determine the type of session the client is upon completion of sessions. know a client and show an interest in him or seeking and appropriate questions to ask. her as a person, not just another opportunity ! Tell clients before initiating the interview that ! Explain the rehabilitative process for for your financial reward. Explain that before you would like them to fill out the assembled clients needing pain relief. delving into their current physical condition, ! paperwork on the clipboard. Go over it briefly ! Describe the pain scale, palpation you would like to get to know them a little so they understand what you need. These likely application, and necessity for client bit. Take a moment to clarify this part of your will include a client history, medical history, feedback. interview procedure by reassuring the person ! release forms and other such paperwork. ! Explain what to consider in a treatment that his or her pain complaints, if any, are Assure them you are available to guide them plan and session protocol. important and will be addressed. !! Explain body positioning, draping and in completing the forms if they encounter any how to create a setting conducive to client difficulty or have any questions. Ask them to At this point, ask questions that help identify relaxation and comfort. let you know when they are finished. the individual on a personal level. Ask the ! client about his or her occupation, how long ! Explain how to receive a massage. Take this time to finish any room preparation ! has he or she lived here, and where did the ! Describe what clients may expect to feel or other unfinished work. If you are already person move from? Are there children or following a massage session prepared to begin, allow the space and time to ! family here? Note any hobbies listed and ask ! List steps to conclude a successful client fill out the paperwork but periodically check about involvement in them. Anytime you have session. on their progress in case your assistance is something in common with clients, be sure to needed. Greeting and interviewing clients let them know of your mutual involvement – A successful interview and the establishment While they complete their paperwork, use the but be brief. The emphasis should always be of rapport with a new client is an essential time to begin formulating a treatment plan more on the client than you. aspect for retaining clientele. It can be even for today’s session based on your postural Allow clients to express themselves, but be more important to the client than the quality observations and the notes you made of their aware of the time allotted for the session and and expertise of the therapist’s work. Too reasons for booking the appointment. Keep in bring closure by simply saying that you’ll many therapists discount the value of their mind to remain flexible about your treatment look forward to talking about it more later. social and professional interaction skills. Just plan until assessing all verbal and written Taking time for this type of interaction usually as learning a new technique requires practice, medical information acquired along with reduces any initial apprehension or fear and so too does honing one’s skills in conducting palpation examination results, range of motion allows clients to feel more at ease and relaxed, a successful interview that establishes rapport tests and muscle strength testing that may be thereby enhancing the quality of the session. and bonds clients to you. relevant to the session. It also establishes a greater chance of needed If at all possible, before the client arrives, If possible, plan additional time for the client feedback during the treatment. Creating prepare all needed paperwork in the order you appointment when scheduling new clients. a supportive environment in this way, your wish on a clipboard. Familiarize yourself with Otherwise, the client may feel rushed, and ability to build a loyal client base is optimized. any notes you took when the appointment was the therapist will not be able to offer his Clients who have received massage made to use in your initial conversation. Doing or her best session. It will inevitably take Once you have established rapport, the this shows clients you are professional, and longer to complete a professional interview interview focus shifts to clients’ medical that they are important to you. with any new client. Extra time is needed for history and current condition. It is appropriate paperwork, questioning, evaluation, treatment While it may seem like a cliché of proper to know whether clients have ever received a planning, palpation or range of motion testing, behavior, it is extremely important to greet massage therapy session in the past. If so, ask and documentation of session results. clients with a genuine smile, look directly the following questions: into their eyes, shake their hands, speak in You may charge for this extra time; if this is How often have they received massage? a pleasant voice, and offer them a seat. If an insurance-based session, then you can bill When was the last time they received a you are working at a hectic, frenetic pace or for the extra time. Otherwise, explaining that massage? show a lack attention in your greeting, you you will spend this extra time at no additional Have they experienced different types of may seem less friendly and risk making a charge because of concern for the person’s massage from various therapists? poor impression. Practice your greeting in the welfare can be a solid marketing tool for What was the reason for getting the mirror and study your face and smile so you earning repeat business. massage? Relaxation or pain relief? are more aware of it in actual practice. How it was performed? Flowing strokes, Establishing rapport pressure, kneading, etc.? This initial moment with a new client can be When the client has finished the paperwork, What body positioning was used to begin crucial for developing a good relationship and decide whether to interview him or her in and end the session? the waiting room, if you have one, or in your Page 22 www.ILmassageCE.com Was the session effective either by relaxing offset this mentality and transfer a client’s If there are no medical reasons to preclude them or relieving pain? If not, why? loyalty to you requires re-educating the client giving a requested relaxation massage, then the If pain was relieved, by how much? Is the to help him or her accept a new treatment therapist should prepare to begin the session same pain issue still evident today? application. If the client has had multiple with an appropriate explanation of how to Have they ever been hurt by massage? If therapists previously, ask the person to receive a massage, draping, body positioning, so, in what way? describe the differences in the sessions of client feedback, a description of your massage Has anyone ever explained how to receive each therapist. Explain the format you use in application, and what to expect to feel after a massage? your treatments and describe any similarities the massage. If the client does have pain to those the person has experienced with complaints, possible contraindications, or is The answers given determine the other therapists. Ask the person to be open being treated with medications, then further background experience of your client and to experiencing a new method, and after the specific questioning is necessary. what explanations or clarifications may be session is over, give you feedback on it. necessary. If a client’s experiences were Contraindications and medications completely positive with all appropriate It is common for these new “experienced” When contraindications are indicated but do educational explanations previously made, clients to compare your massage treatments not preclude a massage for clients, explain then you can assure the person the past to their past therapist, and it may take them the rationale for avoiding contraindicated treatment was handled professionally and time to get used to your routine. If you areas of their body and how you will work appropriately. However, it is not unusual to speak about this issue with them before their around those areas for their safety and find that even clients who have been receiving session, it may help to create a mindset that security. If the contraindication is one that massage for many years have not been asked acknowledges there will be differences to requires the therapist to adjust pressure, such these or other informative questions, nor what they have been accustomed to in their as with a diabetic whose condition is under have they received pertinent explanations. massage sessions. Bringing awareness to a new control through medication, it is imperative Massage therapists who learn to be well versed experience will generally open people’s minds that the therapist knows how to conduct a in asking about a client’s previous massage and bodies to a positive response. Avoiding safe therapeutic session. In this example, a experiences and who rationally explain their the issue, on the other hand, can encourage a prescription from a doctor authorizing massage treatment protocol are likely to create a very negative response because you may not match therapy is absolutely necessary. favorable client impression. the expectations they had with their previous Some other client medical conditions under therapist. Your attention to the client’s answers allows control through medication that could allow you to determine whether previous treatment To further bolster their acceptance and patience massage to be safely administered are high methods were effective. This information in getting used to your treatment, ask them to blood pressure, heart problems or cancer. clarifies whether your methods are similar experience a few sessions with you and then But any of them would require a prescription or different from past therapists to determine see if they like your methods. Most clients will authorizing massage from a doctor along with what needs to be explained as well as what adjust to your methods over a few sessions, proper adjustments in pressure applications or to expect from your session. If any of these and frequently even prefer them to past the length of the session. questions were not previously addressed, at methods. Some will even find your application Because massage has the potential to alter the this point you have the opportunity to explain preferable to any they’ve ever experienced. effects of medication, it is imperative to know the importance of this information to plan After this trial period, if they have not how to make adjustments to your treatment a session aimed specifically at the person’s developed a preference for your methods, you based on a client’s condition, and you must needs. Further explain that this attention may offer to adjust your treatment protocol. be able to articulate the reasoning for any to detail ensures he or she will receive the Find what pleases them, as long as any treatment adjustments to the client. highest professional service you believe all changes to your routine will still allow you to your clients deserve. Most clients will be It is the responsibility of a therapist to learn perform the session with a positive therapeutic keenly aware of the compassion shown in your proper treatment protocol for any pathological outcome. high regard for their welfare. This can earn condition presented by a client. This you deserved respect and credibility for your Determining the type of session knowledge can be obtained through continuing knowledge and professionalism. The interview focus now shifts to the client’s education classes that focus on pathology in Experienced massage clients new to the medical history and current condition. When relation to massage therapy as well as a few the appointment was made, it should have been written publications. There are several books area established whether they were seeking a stress available on this subject specific to massage It is likely that a new client will come to release relaxation massage or a pain relief therapy that a prudent massage therapist you who has recently moved to the area, has therapeutic massage. Even those who were should keep in his or her library. Internet received regular massage therapy in the past looking for a relaxation session should always searches can identify these publications. or whose previous therapist has moved away be asked whether there has been a change in Before treating any client taking medications, or is no longer in practice. These people have their condition where pain relief may now be checking these sources can quickly inform the come to you seeking a new therapist, but many their choice. therapist on how to proceed or whether the times they are still emotionally attached to session should be terminated. their last therapist and have engrained their When clients are receiving their very first past therapist’s routine methods in their mind massage, take a few moments to go over the Pain complaints and body. That is an important reason why you benefits of massage and provide brochures Assessment of a client’s pain complaints must ask about past treatment methods because or information about massage to read later. requires obtaining a history and current pain they will be used to them, which can make any Regardless of their reasons for getting a status by asking appropriate questions along new treatment protocol less to their liking. massage, you must give attention to their with palpation examination, postural analysis, medical history for any contraindications, range of motion testing, and muscle strength/ It should be understood this is a natural medications to treat a condition, or current weakness tests. Ask the client to tell you response to something new and different. To pain complaints. www.ILmassageCE.com Page 23 about his or her pain issue if the person seeks rehabilitation that can help clients create relieved, or the rehabilitation process may take a therapeutic pain relief session. Appropriate realistic expectations of pain relief from much longer. questions to provide the therapist the massage therapy treatment. Understanding After five sessions, if there is no improvement knowledge to devise a treatment plan include: the rehabilitation process will help them have whatsoever, discuss whether further treatment Does you know what caused the pain to patience in obtaining positive results and is warranted. It would not be unethical to occur? should reduce any doubts about the merits of continue treatment because improvement How long has the pain been going on? massage therapy for their condition. Clients may take longer with some clients, but this is Is the pain acute or chronic? Explain the sometimes do experience an immediate a decision clients must make. Other options difference to the client. reduction or elimination of pain, but chronic for their care may be to refer them to another Is the pain constant or intermittent? or acute soft tissue conditions more often than massage therapist with particular skills you do Does the pain increase when you do a not require repeated cumulative treatment, not possess or to a different type of health care particular activity or movement? with steady pain reduction as treatment provider. Has the pain spread to other body areas progresses. This is especially true of chronic over time? pain complaints. Many clients will experience relief with their On a scale of 1 to 10, can you rate the first session. Most will notice less and less pain Most clients understand that longstanding, intensity of the pain? with regular session work. It is important to enduring pain will not magically disappear Describe the pain: Is it aching, burning and identify a client’s pain scale level before and with a single one-hour massage session, but so on? following each session to gauge improvement. clients who don’t need to have a more realistic Touch any current areas where you are Clients should understand and monitor their expectation of results. While immediate, experiencing pain. pain levels after treatments so they may complete cessation of pain is always a goal, Have you experienced any range of motion provide you with necessary feedback at their if that was always the result, you would have limitations because of pain? next session to determine their progress and people lined up outside your door. Has your pain been diagnosed by a doctor? future treatments plans. Be sure to tell your Did a doctor prescribe treatment? The reality is that rehabilitation of soft tissue clients that it is possible they will see even If so, have you received previous treatment dysfunction is dependent on the severity of greater improvement two hours, six hours, or and by whom? the condition, how frequently treatment is 24 hours after treatment and should report it at Did any previous treatment help or hurt? In obtained, each individual’s physical response, the next treatment. what way? whether the client is engaging in activities that Ideally, during the course of treatment, Are you still receiving treatment? exacerbate the condition, making changes in a person’s pain will continue to subside, If you are receiving treatment, why work or personal habits, postural corrections, sometimes to the point where he or she feels have you come to me? therapist skill level, or permanent physical no pain at the end of the treatment. While the disabilities that exist for a client. If your client has multiple pain complaint pain likely will return later, ask the person to areas, you will need to ask these questions for Explain that client awareness and participation monitor how long he or she remains pain-free each area. in their recovery by performing helpful between sessions before the pain returns. As stretches or strengthening of affected the rehabilitation process continues, people Once you have obtained a written and verbal areas between massage therapy sessions should go longer and longer before the pain description of pain complaints from your may also affect the outcome. It may also returns following sessions. Another sign of client, inform the person that you need to speed the recovery process and should be improvement is that even when pain does complete your assessment through soft tissue encouraged. Educating your clients about these return, it is at lesser levels. palpation and range of motion testing for any characteristics for soft tissue rehabilitation may limitations in movement. The goal is that eventually, improvement will help them provide you with helpful feedback continue until a client experiences no pain You must determine a client’s treatment and garner their confidence by recognizing during, after or between treatments. At this plan according to your own skill level and your professional knowledge as a health care point, a suggestion for maintaining clients’ knowledge of pain relief techniques. Describe provider. pain-free status is to have them continue your preliminary treatment plan to the client When your clients have a more informed to come in for treatment for two additional for approval before proceeding with any pain awareness of the many things that can weeks. If they continue to remain pain-free, it relief session. Describe how you will use the determine their rehabilitation, you can offer the is likely they no longer need further treatment information derived from the person’s answers, following guidelines on how the rehabilitation except for maintenance. If their pain condition written pain history, postural analysis findings process might work. flares up again within a few weeks or a if performed, and any range of motion test month, have them schedule a session as soon results to implement your treatment plan. If massage therapy is effective treatment for as possible. Generally, one or two sessions Make the client aware that your plan may clients’ pain, they should notice a reduction will return them to their pain-free status. change during the session, depending on the of pain levels usually within the first five Suggesting regular massage therapy as often condition of the person’s soft tissue upon sessions, although this is not set in stone. You as they desire or are able to schedule will help palpation and response as you perform the will have more chance for success with your keep their soft tissue in a healthy condition. A treatment. Tell the client that all subsequent clients if they will commit to receiving this rule of thumb is to recommend once-a-month session plans will be determined by the results many sessions. Generally, for massage therapy treatments as a minimum to maintain a healthy of each treatment completed. to have effective pain relief results, clients status. need to be encouraged to receive session work Explaining the rehabilitation process for two to three times a week. Clients should Massage therapy can reduce pain that is pain relief treatment be made aware that if they can only receive not fully caused by soft tissue dysfunction While any improvement or elimination of a treatment once a week, then chances for but not eliminate it. Pain from previous soft tissue dysfunction or pain will vary complete pain recovery will be limited, their injuries, surgeries or physical conditions may with each client, there are guidelines for pain symptoms may only be temporarily be improved to a certain level that can be Page 24 www.ILmassageCE.com maintained. Clients should be made aware of completely. If the client wishes to do that, let clients who don’t provide feedback on their this possibility when it is appropriate. Even so, the person determine what adjustments he or pain – and who instead choose not to return many clients are satisfied with attaining a level she prefers to accomplish the session. for massage treatment again and spread word of rehabilitation that has significantly reduced about their negative experience to others. A widely accepted pain scale ranks it from their pain; frequently, it is the only way they zero to 10, with 8 as the first sensation of It is not uncommon for a client to say, “You are able to manage their pain. actual pain. Explain to clients that 9 is extreme can go deeper than that” as you begin to Pain scales and client feedback pain and 10 is excruciating pain. Tell them to massage any particular area of the body. This Whether the type of massage you perform just say the appropriate number anytime during usually occurs before you have completed is for relaxation and stress release or for the session when they feel pain and that you a body area where you are systematically pain reduction, every client must have an will immediately adjust your pressure to a applying pressure from light to medium to understanding of pain scales in relation to level where pain is not evident and then try to deep. Such a statement indicates the need his or her existing pain complaints and your find a comfortable level of palpation pressure. to explain your palpation methods before palpation pressure. beginning the session. Inform the client that Instruct clients to provide verbal feedback with each new body area, you will initially The client seeking a relaxation massage when they feel the first sensation of pain as apply light pressure to assess the condition who has no pain complaints quite often you reapply your technique of choice gently of the tissue and progressively increase your will recognize tender or painful areas as and slowly deepen your pressure. Tell them pressure deeper and deeper as the tissue you perform your session. Discussing this when they rate the pain as No. 8, you will ease allows. possibility before the relaxation massage your pressure slightly until they no longer feel will ensure the client does not think you pain from palpation. Tell them your goal is to Explain that you will not work any deeper than are creating the tenderness or pain with only use palpation pressure they can tolerate can the client can comfortably tolerate and that your palpation. Skillful application using comfortably, which would be from a 5 to a 7 you will apply your deepest pressure last on progressive deepening of palpation pressure on the pain scale. To describe the appropriate each area treated. Let the person know that if rather than starting your session with feeling, tell clients the area may feel sensitive you encounter any dysfunctional conditions, immediate deep pressure will ensure you do as it is palpated but it will feel like a “good” such as tight muscle fibers, or they tell you not cause or create pain for your client. hurt, not a painful hurt. they have pain, you won’t increase pressure until the tissue softens and releases. Tell the Knowing how to describe what pain scale Explain that the pain scale is also used to client if softening and release does occur, you level the client feels when any such area is describe palpation pressure and that your goal will then continue to increase your pressure located helps the therapist assess the severity is to palpate to between a 5-7 on the pain scale deeper and deeper accordingly. If the soft of any dysfunction and determine proper to achieve effective changes in any soft tissue tissue does not release or pain is not eased, palpation pressure. Making clients aware of condition. Be sure to ask them to let you know explain that the dysfunction may require and able to identify possible sensitive areas if your pressure drops below a 5 on the scale repetitive session treatments to eliminate that are not consciously evident to them helps because too little pressure may not noticeably before you can safely go deeper without them provide accurate feedback to guide their reduce the pain. causing injury to the tissue or exacerbating session and to trust your palpation methods. It is a good rule of thumb to remind returning the problem. Ask the client to be mindful of Explain that such a situation is actually clients about the pain scale and need for any improvement or worsening of the muscles beneficial because it helps find any problem feedback before beginning each subsequent involved between now and the person’s next areas and allows you to give focused treatment session until you are satisfied they will provide scheduled session and to tell you about it. attention to them either during the session or you with accurate and appropriate feedback. After following the protocol of progressively in a future appointment. Further explain that Palpation application deeper palpation pressure, you will be able recognizing and treating these areas now may Many clients erroneously believe that unless to provide deep tissue massage with no eliminate or prevent any soft tissue problems a massage is deep enough to cause pain, they discomfort to the client and allow you to from developing later. However, let clients aren’t getting a “good” massage. This false comfortably sink down all the way to the bone decide before the session whether they want belief might stem from previous therapists of a given area. If a client suggests you still to address any sensitive areas found during who improperly applied deep pressure too can go deeper, press against the bone to show the session. Some clients may not want pain quickly, were incorrectly trained, or never the person you can go no further. He or she relief techniques used, preferring to issue learned how to communicate sound massage usually will be amazed and surprised because as little feedback as possible to maximize therapy practices to their clients. The result this accomplishment came without any pain. the relaxation component of their massage has been far too many members of the public This provides an opportunity to reinforce session. Any soft tissue conditions evaluated expecting pain as a measure of whether they your earlier explanations that it is possible to during a treatment can be discussed after the are receiving a “good” deep tissue massage. receive the deepest of pressure without feeling massage and a determination made whether the pain when proper palpation methods are client wants attention given to them in future Take the time to re-educate these clients by applied. sessions. explaining that deep tissue massage can be accomplished without pain. If your client Re-educating clients who improperly endured If a client does want you to spend extra expects or insists on pressure that causes pain from previous therapists heightens time with any given area during a relaxation pain during your sessions, it may be time to your credibility as a knowledgeable, skilled massage, discuss the need to extend the re-examine your technique or your ability to massage therapist. massage session. This will require acceptance communicate how you perform your sessions. and approval to charge a higher rate for a Treatment plan and session protocol It may also require a clearer explanation of longer session. You may also offer to stay Once clients have an understanding of the how to receive pain-free deep tissue massage. within the initially approved appointment time characteristics of a massage therapy session Aggressive palpation in a hurried manner as by working less time on other parts of the body and you understand their reasons for seeking matter of practice may frequently hurt new or removing some body areas from treatment a session, it is time to discuss your proposed www.ILmassageCE.com Page 25 treatment plan for their approval. Determining Being flexible in your approach may mean Prone position: your plan is based on your interview, clients’ reversing the order of your proposed plan For clients beginning in the prone position, medical history, any stated pain complaints, of treatment. In such cases, explain your explain that you can adjust the face cradle pre-massage palpation, and any range of new protocol and again ask for the client’s for their comfort. In describing the bolster motion tests or muscle strength/weakness approval. If you feel the session would have support for this position, physically testing when appropriate. greater effectiveness by not following a client’s illustrate where the placement of the preference, discuss your rationale after the pillow/bolster should be to support the Your plan is also dictated by what your clients session and ask whether the client would be front of the foot/ankle area. Ensure when are seeking in their session. They may have willing to try your proposed method in the next you return to begin treatment that toes pain complaints but wish to have a stress session. If the client agrees, then after that next are positioned at the edge of the pillow release/relaxation massage rather than a pain session, ask how the person feels to determine for maximum client comfort and not on relief-focused session. After assessment of how future sessions will be performed. the table, bent in a flexed position. Also all the information you have, choose the let them know where the bolster will be techniques within your knowledge base that There are differing points of view among positioned in the supine position when may bring you the best results. Determine therapists on which position to begin a session, changing from prone to supine during whether to focus on certain body areas or and both have merits. But the ultimate decision the session. Explain that in either body provide a full body session. Ask clients should rest upon the client’s comfort. position, you will remove the bolster by whether there are any areas of their body they Supine position sliding your hand under the ankle area prefer not to have treated and remain mindful If the session is to begin in the supine and gently lifting their legs to remove of avoiding theses areas during the session. position, place your hand on the table to and replace the support bolster. Another Advise them of your evaluations, how you show clients exactly where to position consideration for females with large wish to proceed, and ask for their approval. their head. Be sure to emphasize that the breasts is to place pillow support under If they wish for focused pain-relief treatment head should be completely on the table the abdominal area to ease pressure on but also want a full body massage, it may be rather than extending over the edge. Next, the chest in the prone position. This same necessary to explain it is not possible to do illustrate the position of the legs centered pillow/bolster positioning may also be both unless the session is extended for a longer over the bolster. Let clients know you will more comfortable for any client with time period (if available in your schedule). adjust the bolster if necessary. Explain lumbar back discomfort. that the bolster support can alleviate any Another factor in formulating a treatment plan Side lying position lumbar back discomfort, and emphasize is to retain the flexibility to make changes For clients unable to receive a comfortable you will check on their comfort level with and adaptations during your session when massage in the supine or prone position the bolster and add additional support if palpation findings provide more information because of pain or for a pregnancy necessary to achieve comfort in the supine on soft tissue conditions and as you receive massage, an effective session can be position. feedback from the client. achieved in a side lying position. The When clients have neck pain complaints, knees may be brought up enough to flex Upon client approval of your treatment offer a pillow support under the head the hip area with a pillow placed between plan, explain where you will begin on the and check to whether they are more them. Give clients a pillow to hug in front person’s body, where you will subsequently comfortable with or without the support. of them and place a pillow under their transition to, and where you will finish the Ask people who prefer pillow support head. Explain how you will remove the session. Ideally, your session protocol will whether they can comfortably tolerate not pillow between the knees and the one they be performed by moving from one body area having it while you perform any cervical are holding when it is time to roll over to to another in a sequential, systematic order, treatment techniques and note that you their other side and that you will replace providing continuity and flow throughout the will replace the pillow when you complete the pillows in the same positions as before. session. Whether relaxation or pain relief is that area. If removal is uncomfortable, be It is wise to keep a supply of several the goal, explaining the details of how you flexible and treat the neck while on the pillows to accomplish any type of body will proceed can ease any potential anxiety or pillow. positioning. fear, especially with new clients. If applicable, explain when you may ask client to turn over, If the treatment plan dictates changing Arm positioning how you want the person to turn over, and that body positioning, tell clients that just Client should be instructed to have their you will adjust the face cradle, support bolsters before having them turn over, you will arms at their sides on the table in the supine and draping. remove the support and replace it in an position. This is not always possible, appropriate position after they’ve turned depending on the size of the client or width Body positioning over. Explain that you will set up the face of the table. If a client’s hands only slightly If your interviews take place in the waiting cradle before having them turn over as well dangle off the table and do not impede your room of your establishment, once it’s finished, and how it may be adjusted. ability to perform your treatment comfortably take clients to the treatment room. Whether and without incurring contact with your body, Lastly, when it comes time to transition you normally begin your sessions with you may proceed in this position. If this is their body position, describe how you will clients in the supine or prone position, your not the case or the arms or hands extend lift the draping just enough for them to explanation of your approved treatment plan substantially off the table, it will be prudent to roll over away from your side of the table. format will have established the position use the draping to wrap around the hands and Show them how you will perform this so you prefer. However, a client’s past massage tuck gently under the body to secure them on that their body will be unseen during the experiences may have begun with an opposite the table. starting position. As a gesture of concern for process, which will emphasize that your this client’s preferences, you may offer to respect the client’s privacy. This same In the prone position, it is essential to tell begin in the position most comfortable to the method should be described when clients clients the best suitable position for their person. transition from the prone position. arms. First, explain it is not desirable to place Page 26 www.ILmassageCE.com their arms forward with their hands resting their jewelry, and have a robe handy if they unclothed is tied to the physiological benefits on the face cradle or dangling off the front of need to use the restroom during the session. of massage. Tight-fitting clothing or elastic the table. Explain that in this position, their Tell them your choice of lubricant, but have bands put pressure on blood vessels, impeding upper back muscles, especially the trapeziums, other lubricant supplies available if they prefer blood flow. Because one of the main benefits will be in a contracted position that will not another. With female clients, make sure that of massage is enhancing blood flow, thereby allow you to use your techniques as efficiently using lubricant on the neck, which could ensuring that cells better receive nutrients and to relax them. Ask them to place their arms possibly get into scalp hair, meets with their oxygen and more effective removal of toxins, at their sides on the table as a position of approval. If not, be prepared to use techniques eliminating any clothing restrictions provides preference or dangling off either side of the that do not require lubricant or gliding strokes a greater chance for healthy tissue functioning. table. You can always use the tuck draping in this area. Assure clients that whatever level of clothing of the hands next to their body if needed. removal that is comfortable for them is Be careful that your clients approve any use Acknowledge that ultimately, though, whatever certainly acceptable. of aromatherapy scents, candles and so on. position is most comfortable for them is OK, Recognize that using a scent for one client Once clients are on the table, instruct them to even if it means resting their hands on the face may not be wanted by the next, and it could be let go of their body tension, let their body be cradle. difficult to eliminate the smells from the room. limp like a noodle or a ragdoll and to let you Draping If this is the case, have an air freshener ready do all the lifting and moving of their head, Your description of draping can be done before to neutralize odors. arms and legs without their help. Suggest or after you explain body positioning. Most taking a few deep breaths and exhaling fully. Keep your room spotlessly clean. Decorate clients prefer draping that covers their entire Tell them to think of a pleasant thought or your room with pleasing furniture or knick- body. While sheets are the most common place, to drift into the relaxing music, to use knacks that are in no way offensive. Choose material for draping, full body towels are at any meditation practices they may have, to wall and curtain colors in shades that are times preferred because they provide a more think of this time as their sanctuary away from soothing and relaxing. Have water, tissues, secure feeling of coverage and additional all responsibilities and cares of the world. breath mints or cough drops available for warmth for the client. Be sure to have blankets yourself or the client. Be sure their cell phones Let them know that is OK to fall asleep available for client comfort as well. For clients as well as yours are turned off. Your attention and that you will gently wake them when who feel overheated with full body draping, to all these details will enhance a setting of necessary. If during the session they feel a you can tuck the draping between the legs relaxation that your client is sure to appreciate. need to cry or laugh, assure them it is alright exposing the legs as long as genital areas are because massage can sometimes release covered as well as the breast area for females. Explain how to receive a massage emotions, and they will be safe and supported Adjusting the room temperature to a cooler Conducting a professional interview includes by your caring presence. setting is also an option. ensuring that clients know how to receive a massage. Any new client, regardless of Suggest that using the restroom before getting Be explicit when you point to and tell clients whether this is their first, can benefit from on the table is a good idea because massage to cover themselves with the draping upon guidelines on how to receive a massage. Your can sometimes stimulate the need to go. Ask getting on the table. Let them know you instructions can answer any unasked questions them to tell you if a restroom need arises have additional sheets, towels and blankets in their minds and calm any fears. You may be during the session instead of trying to wait if needed for their comfort. Finally, tell them surprised by how many clients with massage until the session is finished. Explain that you you will only uncover each body part being experience have never had this explained by will leave the room and they can use a robe or treated and recover them when finished as previous therapists. When clients follow your wrap the draping around them and can notify you move around their body while always instructions, you will find it easier to complete you when they have returned to the table by respecting their privacy. If you tuck the a successful session. calling out to you. draping under their legs when working there, explain how you will do that. If you will be Begin your explanation by asking them to Remind them to give you feedback if they using techniques that require range of motion remove all jewelry possible. If they wear have pain during the session. movements of the legs or pelvic area, explain contact lenses, suggest removing them if Tell clients you will whisper in their ear when the diaper draping method you will use to possible, or not wearing them when coming to the session is completed and remind them how accomplish that. Inform clients of any special their next appointment. Explain that being in to safely get off the table before you leave the draping methods, such as in a side lying the face cradle could cause lenses to be pressed room. If at all possible, tell them it is okay to position or appropriate draping methods for the against the eye and potentially scratch them. remain on the table for a few minutes after breast area on females if treatment in this area Because some people will not feel free to completing the session to soak in the feeling of is indicated and approved by the client because remove their contacts, ask them whether there relaxation, and then to get up slowly. Describe of pectoral musculature dysfunction or pain. is any discomfort when you place them in the and even demonstrate how to get off the table face cradle and determine whether to use it. If Creating a setting conducive to client by asking them to roll on their side, bring their applicable, use a pillow on the table and have relaxation and comfort knees up to a 90-degree position, letting their clients turn their heads from side to side during Ensuring client satisfaction requires attention feet dangle off the table. Then they should use treatment. to people’s comfort needs before initiating their hands and arms to push them to a seated a session. Explain that you want to provide Next address the removal of clothing. Tell position; explain that this method puts the least a setting that will make their experience a clients that most clients receive massage strain on their back muscles. Instruct them to pleasant one. Ask them their preferences for completely unclothed, although they will be sit at the edge of the table for a few moments, the lighting, room temperature, amount of draped at all times. Avoid using terms like gather themselves, and then gently ease off draping covers and whether they would like naked or nude because they may conjure the table. Stress the need to ease off the table music and if so, choices on music and volume. thoughts of sexuality. Explain that it is also OK gently because clients who quickly push off Provide a place to hang their clothes and to put to keep underwear on if they prefer. Explain the table could actually pull a back muscle in that the rationale for receiving massage the process. www.ILmassageCE.com Page 27 If your client is short or frail and your table is regular treatment, their body’s particular Steps to conclude a successful client set high, provide a fold out step or step stool response to treatment and more. interview and massage therapy session for getting on and off the table safely. If your Once clients are dressed and ready to leave, Advise clients to be aware of how their client is elderly or frail, you may wish to cover conclude the session with a post-massage pain feels before the session so they may them with the draping and help them get off interview by taking these steps: better notice any changes after completion. the table. Offer them a glass of water. Inform them they may feel no change, minor Inform them of the need to ask questions Finally, let clients know you will be waiting differences or dramatic changes in their pain about their session. for them in your office or will come back when levels. Until the session is completed, there is Ask them to relate what they are feeling they are dressed and ready after the session no way to know. Additionally, alert the client now. Avoid questions that predispose is completed. Ask whether they have any that such changes can be felt anywhere from an outcome, such as “Do you or are questions. Tell them you will now leave the one to 48 hours following a session. However, you feeling better now?” Clients may room so they may get off the table and dress. you can tell them that many effects of a session answer affirmatively to that question even Let them know you will knock for permission are generally felt within 24 hours after their when they don’t to avoid hurting your to re-enter the room. Once the session is treatment. Let them know you will inquire feelings. Ask for honest feedback so your completed and you have left the room, give about their response during your post-session assessment documentation is accurate; tell clients at least five minutes before checking meeting. them you are not seeking compliments but on them to make sure they are okay and are It is pertinent to tell pain relief-seeking clients need to determine whether future sessions preparing to leave the room or for permission that they may have an intensified level of pain should be similar to this one or whether to re-enter. up to 24 hours after the session. If this occurs, you need to make adjustments to improve Describe what the client may expect to tell them not to be alarmed because sometimes the outcome. feel following a massage pain is not a bad indicator of session results. Did they notice any areas of discomfort It is just as significant for clients to know what Explain that tissue dysfunctions can build up during the massage? If so, ask them where to expect to feel after a massage as it is to toxins that upon being released can take one and to describe what they felt. know how to receive one. While reactions may or two days for the body to eliminate. This If they experienced sensitivity or vary from person to person, knowing some of sudden release of toxins may have the effect discomfort during a relaxation session, the possibilities will help your clients more of causing feelings of increased pain following ask them whether they would like to focus clearly identify what they are feeling. This the first few sessions until they are eliminated. treatment on those areas in their next awareness allows you to maintain accurate Explain that even though the person may session. documentation regarding the outcome of the feel temporary additional discomfort, this is Ask if they feel the same, worse or better session. Those receiving relaxation or pain actually a positive result because the body after a pain relief session. If the response relief massage may respond similarly or is being cleansed of pain-causing toxins. is better or less pain, ask them what the have completely different results. Take time Clearing of toxins is quite often accomplished pain scale level is now compared to before to explain possible outcomes regardless of in just a few sessions, and post-session pain treatment. If they answer “the same,” whether it is a client receiving his or her very levels usually subside or no longer exist. then remind them repetitive sessions are first massage or a new but experienced client, needed to determine whether massage will Tell clients that people who do feel increased no matter what their reasons for getting a be effective. If the answer is “worse,” ask pain a day after their session frequently report session. them what their current pain scale level is that the second day after treatment, they feel a and discuss the need to adjust palpation dramatic improvement and often say they feel As a general rule, following a relaxation pressure or techniques in the next session. much better than before they received their massage, explain that people tend to feel a Process payment for the session. massage. floating or dream-like sensation. Clients often Book their next appointment. relate feeling a mind- and body high, relaxed, And assure clients that if they still feel Remind them to be aware of any changes a feeling of wellness, or even feeling a little intensified pain two days following the session, they experience in the next 48 hours and foggy but in a good way. Tell them these then you may need to change the amount of that you’ll want to know about them at the feelings generally last about 10 minutes to palpation pressure you use on them or your next scheduled session. an hour following a session. Understand that techniques. Let them know you will make Thank them and walk them to the door. these feelings are the reason many people love adjustments in the next scheduled session until Write documentation notes regarding the getting massage. Explain that massage triggers you find the level of palpation that doesn’t session. a physiological response in the body by increase pain. Prepare the treatment room for your next releasing endorphins from the brain to create client. an elevated sense of mood, triggering these Admit that determining what constitutes an positive feelings. effective session sometimes requires a few Depending on each therapist’s work sessions, depending on their response to environment, conducting a professional Clients receiving pain relief treatment may treatment. Providing awareness of the possible client interview and massage therapy also have these same feelings but may be results of a session increases credibility, session as described may not be possible. focused more on what their pain levels are instills trust in your evaluations, and better Working in a doctor’s office, spa, salon or following a session compared with how they ensures your client will continue to return. cruise ship may limit the time allotted by were before the session. Explain that it is If a client does incur increased levels of pain the employer to accomplish the suggested common for clients to notice a reduction or after a session, instead of deciding not to format. However, discussing the need for elimination of pain, but not always. Results chance another session, most will remember client safety and welfare with your employer depend on many factors, such as the cause of you informed them of these possibilities. by using this interview/treatment method the pain, the degree of injury or dysfunction, Client education in these matters helps may result in changes to the protocol. Private toxicity levels in the tissue, whether this is develop patience and understanding for the client interviews and those seen at massage their first session or they have been receiving rehabilitative components of massage therapy. establishments can certainly be conducted Page 28 www.ILmassageCE.com following the guidelines presented. Attention NOTES to every detail assures client needs are CONDUCTING A PROFESSIONAL considered and affords the therapist the CLIENT INTERVIEW AND potential for a successful session outcome MASSAGE THERAPY SESSION while establishing a professional client/ Final Examination Questions therapist relationship. Choose the best answer for questions 11 through 15 and then mark your answers on the answer sheet found on page 59 or proceed to www.ILmassageCE.com to complete your final examination.
11. What is the first step in the interview process after greeting the client? a. Preparing your treatment room. b. Having the client fill out all needed paperwork. c. Making mental notes of the client’s posture, manner of walking, skin condition and so on. d. Offering a glass of water.
12. When asking questions about clients’ past massage experience, which of the following is NOT necessary to know? a. The name of their previous therapist. b. How often they receive massage. c. Were they treated for pain complaints? d. The body position used to begin their massage.
13. Which of the following conditions would require being under control through medication and necessitate a doctor’s prescription authorizing massage? a. Strained quadriceps muscle. b. Tendinitis. c. Diabetes. d. Acne.
14. For effective rehabilitation of a pain complaint, how many times a week should a client receive massage treatment. a. 7. b. 1. c. 4 to 5. d. 2 to 3.
15. In a post-massage interview to conclude your session, which of the following is an appropriate question? a. Do you feel better now? b. Are you feeling good? c. What do you feel now? d. Did I do a good job?
MIL02PIE12 www.ILmassageCE.com Page 29 CHAPTER 3 Researchers and health officials agree that new however, never goes away. A person who is Living with hiv/AIDS drug therapies have helped to slow down the infected with HIV is said to be “HIV positive.” (2 CE Hours) number of deaths attributed to HIV/AIDS in Once a person is HIV positive, that person will the past 20 years. But they fear complacency always be HIV positive. may have developed among people at high Learning objectives What does the virus do? ! risk for the disease. While many more people ! Define HIV, AIDS, their relationship and All viruses must infect living cells to are living with HIV/AIDS, the reality is that the differences between them. reproduce. HIV takes over certain immune ! people continue to be diagnosed with HIV ! Identify how HIV is transmitted from one system cells that are supposed to defend the every day – in fact, one person every 9½ person to another – and how it is NOT body. These cells are called CD4 cells, or T minutes, according to the CDC. spread. cells. !! List risk factors for being infected by HIV. In August 2009, the CDC issued a report When HIV takes over a CD4 cell, it turns !! Describe HIV tests and what they measure. entitled “HIV prevention in the United States the cell into a virus factory. It forces the cell !! Define CD4 counts and “viral loads.” at a Critical Crossroads,” and it noted that its to produce thousands of copies of the virus. !! List ways a person who is HIV positive can latest estimates suggest that more than 56,000 These copies infect other CD4 cells. Infected avoid transmitting the virus to others. Americans are becoming infected every year, a cells don’t work well and die early. Over time, !! Name some common “opportunistic slight increase over recent years of stable rates the loss of CD4 cells weakens the immune infections.” of infection. The report shows that infection system, making it harder for the body to stay !! Explain HIV “drug cocktails” and their rates grew among heterosexual men and healthy. role in treating people with HIV. women – particularly African American and !! List common side effects of HIV/AIDS Hispanic people – as well as men who have What is AIDS? drugs. sex with men. AIDS stands for acquired immunodeficiency Introduction Also in 2009, the Henry J. Kaiser Family syndrome: A – Acquired. This condition is acquired, Three decades ago, when doctors first noticed a Foundation released a report on its survey of meaning that a person becomes infected strange illness that became known as acquired American attitudes and knowledge of AIDS, with it. immune deficiency syndrome, or AIDS, the noting, “A sense of urgency about HIV/AIDS I – Immuno. This condition affects a diagnosis was nearly always a death sentence. has fallen considerably from recent years, and person’s immune system, the part of the While there still is no cure for AIDS or a way personal concern about becoming infected body that fights off germs such as bacteria to eradicate the virus that causes it – the human has declined steadily, including among young or viruses. immunodeficiency virus (HIV) – the number adults.” D – Deficiency. The immune system of people who are surviving the infection has So, in addition to research efforts (in June becomes deficient and does not work consistently risen in the past 20 years. 2010, the government listed more than 800 properly. Two sports legends, NBA star Magic Johnson ongoing HIV/AIDS research projects on S – Syndrome. A person with AIDS may and Olympic diving gold medalist Greg various websites), health officials are trying experience other diseases and infections Louganis, are among the well-known people to put more emphasis on prevention and early because of a weakened immune system. living with HIV or AIDS. Both say that while detection. the virus remains in their bodies, it is now AIDS is the most advanced stage of infection For those already infected with HIV, the future caused by HIV. Most people who are HIV undetectable. Both are known to keep fit, and is brighter for the many who continue to live, both say they owe their good health to their positive do not have AIDS. An HIV-positive and live well, with HIV/AIDS. But with that person is said to have AIDS when his or her medications, the anti-HIV drug “cocktails” that comes the challenges of adapting to lifestyle have helped millions worldwide maintain their immune system becomes so weak it can’t fight and behavioral changes and a new commitment off certain kinds of infections and cancers. health despite having HIV infection. to good health. This course, adapted from “I take my meds and go about my business of information from the U.S. Department of Even without one of these infections, an living,” Louganis told People magazine in a Veterans Affairs and other government HIV-positive person is diagnosed with AIDS February 2010 interview. “I don’t really dwell agencies, presents those challenges and the if his or her immune system becomes severely on it.” reality of living with HIV/AIDS. weakened. This is measured by a lab test that determines the number of CD4 cells a person Johnson, who has become a savvy The Basics of HIV/AIDS has. A CD4 cell count less than 200 in an HIV- businessman as well as an advocate for AIDS What is HIV? infected person counts as a diagnosis of AIDS. education and prevention, told the Washington HIV stands for the human immunodeficiency It can take between two to 10 years or longer Post in 2006: “The only thing that saved virus: for an HIV-positive person to develop AIDS, my life was early detection and taking my H – Human. This virus infects human even without treatment. medicine.” beings. How is HIV spread? But they are hardly alone. In 2006, more than I – Immunodeficiency. This virus attacks HIV is spread though four body fluids: a million Americans were living with HIV/ a person’s immune system. The immune Semen. AIDS, according to the Centers for Disease system is the body’s defense against Vaginal fluid. Control (CDC) in a 2008 report. And thanks infections, such as bacteria and viruses. Blood. to new drug therapies, many people who are Once attacked by HIV, the immune system Breast milk. HIV positive are living symptom free, and like becomes deficient and doesn’t work Magic Johnson after nearly 20 years, they have properly. HIV is NOT spread through: yet to develop the illness AIDS. V – Virus. A virus is a type of germ too Tears. small to be seen even with a microscope. Sweat. Some viruses, like the ones that cause colds or Feces. flu, stay in the body for only a few days. HIV, Urine. Page 30 www.ILmassageCE.com How is HIV spread through sex? to two weeks. The only way to tell whether the 1985 – The federal government licenses an A person can get infected from sexual contact symptoms are from a cold, the flu or HIV is to HIV antibody test, and screening of the U.S. with someone who is infected with HIV. have an HIV test. blood supply begins. Sexual contact that can transmit HIV includes: Who is at risk? Ryan White, a 13-year-old hemophiliac with Vaginal sex. As of 2006, guidelines from the U.S. Centers AIDS, is barred from school in Indiana. Anal sex. for Disease Control and Prevention have Oral sex. recommended that any sexually active person U.S. Total Cases reported: 15,527 12,529 deaths The best thing for sexually active people to aged 13-64 be tested for HIV during routine do is to practice “safer sex” all the time. To do health screenings every year, even if that 1986 – In the first comprehensive report on so, always use a condom or other latex barrier. person is at low risk of contracting the virus. AIDS, the Institute of Medicine states that $2 They should make sure that any lubricant However, health officials say people are at billion is needed annually for AIDS research used with condoms is water based, not oil- above-average risk of getting HIV if they: and care. based. Oil-based lubrications can cause latex Have had unprotected sex with someone U.S. Total Cases reported: 28,712 24,559 condoms to deteriorate. who is infected with HIV. deaths Unprotected sex with someone who is infected Have shared injection drug needles and doesn’t mean a person will automatically be syringes. 1987 – Researchers realize that virtually all infected, too. But there is always a chance. Have had a sexually transmitted disease, cases of HIV infection ultimately lead to full- Using a condom reduces the risk. like chlamydia or gonorrhea. blown AIDS, but only after a long incubation Received a blood transfusion/blood period. HIV is NOT spread by: clotting factor between 1978 and 1985. Hugging or massage. U.S. Total Cases reported: 50,378 40,849 Have had unprotected sex with anyone Fantasizing. deaths who falls into an above category. Dry kissing. 1988 – The federal government mails an edu- Daily living with someone who has HIV. Thirty years of HIV/ AIDS: Snapshots of an cational pamphlet, “Understanding AIDS,” to epidemic How is HIV spread through blood? 107 million homes nationwide. This snapshot provides you with an idea of People can become infected if they have how quickly HIV/Aids became an epidemic. U.S. Total Cases reported: 82,362 61,816 contact with the blood of someone who is deaths infected with HIV. Blood-borne infection with 1981 – Unexplained cases of enlarged lymph HIV can occur through: nodes among men are observed and studied by 1989 – The NIH funds 17 community-based Sharing needles when shooting drugs. physicians and researchers in New York City. AIDS clinical research units as part of a feder- Tattoos or body piercings with unsterilized ally sponsored research program. needles. U.S. Total Cases reported: 159 U.S. Total Cases reported: 117,508 89,343 Accidental needle sticks. 1982 – In addition to cases in men, cases of deaths Blood transfusions. AIDS are reported in hemophiliacs and in a Splashing blood in the eyes. few women, infants and recipients of blood 1990 – Surveillance data indicate that while transfusions. Transmission of an infectious Black and Latina women constitute just 19 HIV is NOT spread by blood passed through percent of all U.S. women, they represent 72 insect bites. agent through blood and sexual contact is strongly suspected. percent of U.S. women diagnosed with AIDS. Can mothers give HIV to their babies? The Centers for Disease Control and Preven- AIDS has claimed the lives of nearly twice the Pregnant women who are HIV positive can tion establishes the term acquired immunode- number of Americans who died in the Vietnam give the virus to their babies in the womb and ficiency syndrome (AIDS) and identifies four War. during birth. Taking anti-HIV drugs during “risk factors”: unprotected sex, intravenous pregnancy and childbirth can help lower Ryan White dies of AIDS. drug use, Haitian origin, and hemophilia A. the risk, but there is no sure way to prevent U.S. Total Cases reported: 160,969 120,453 infection. With proper care, however, most U.S. Total Cases reported: 771 deaths babies of HIV-infected women now are born 618 deaths free of the virus. 1991– The CDC reports that 1 million Ameri- 1983 – A major outbreak of AIDS is reported cans are infected with HIV. What are the symptoms of HIV? among men and women in central Africa. You can’t tell if a person is HIV positive Ervin “Magic” Johnson announces that he is by looking at them. Most people with HIV The CDC warns bloodbanks of a possible infected with HIV. infection don’t look sick. Even so, when a problem with the U.S. blood supply. AIDS U.S. Total Cases reported: 206,563 156,143 person first becomes infected, he or she may cases have now been reported in 33 countries. deaths experience certain symptoms. This period of U.S. Total Cases reported: 2,807 early infection is called acute HIV infection. 2,118 deaths 1992 – President Clinton establishes a new Symptoms can be different for each person, White House Office of National AIDS Policy. and sometimes there are no symptoms at all. It 1984 – Dr. Robert Gallo of the U.S. National U.S. Total Cases reported: 254,147 194,476 might feel like a cold or the flu. A person might Cancer Institute announces that his lab has deaths experience fever, headache, a sore throat, isolated the virus believed to cause AIDS. He swollen lymph nodes (usually on the neck), calls it human T-cell lymphatic virus type III 1993 – AIDS patients start to show signs of fatigue, a rash or sores in the mouth. (HTLV-III). resistance to AZT. If symptoms appear, they usually do so within U.S. Total Cases reported: 7,239 Arthur Ashe dies of AIDS. days or weeks after infection, and end after one 5,596 deaths \ www.ILmassageCE.com Page 31 U.S. Total Cases reported: 360,909 234,225 deaths 1994 – Dr. David Ho and George Shaw show that following initial infection, HIV replicates in the body continuously, producing billions of copies each day. U.S. Total Cases reported: 441,528 270,870 deaths 1995 – AIDS deaths reach an all-time high. The New York Times reports that AIDS has become the leading cause of death among all Americans ages 25 to 44. U.S. Total Cases reported: 513,486 319,849 deaths 1996 – For the first time in the U.S., a larger proportion of AIDS cases occur among African Americans (41 percent) than among whites (38 percent). The first home HIV test is approved by the FDA.
U.S. Total Cases reported: 581,429 362,004 2001- 2010 - Many believe that HIV/AIDS drugs are difficult to take, can cause serious deaths is a thing of the past because you do not hear side effects, and don’t work for everyone. 1997 – AIDS patients continue to live longer much about it in the news media anymore. Even when a drug does help a particular Nothing could be further from the truth. On the person, it may become less effective over time thanks to the new anti-HIV therapies, dubbed following page is a chart that shows that while or stop working altogether. On the other hand, drug “cocktails,” and AIDS deaths in the U.S. the number of deaths has leveled off, the sheer the drugs help keep HIV under control and decline by 42 percent. number of people living with AIDS is growing. let people infected with HIV live longer and U.S. Total Cases reported: 641,086 390,692 healthier lives. How is HIV treated? deaths Many treatments now can help people with Once on medications, patients must work 1998 – Early hope that combination therapy HIV. As a result, many people with HIV are with their doctors to monitor how well the might affect a clinical cure for AIDS fades. living much longer and healthier lives than drugs are working, deal with side effects, if before. any, and decide what to do if the drugs stop U.S. Total Cases reported: 688,200 410,800 working. The good news is that experts are Currently, medicines can slow the growth deaths learning more about the virus and creating new of the virus or stop it from making copies of treatments for HIV that are easier to take. 1999 – Experts estimate that at least half of all itself. Although these drugs don’t kill the virus, new HIV infections in the U.S. (and world- they keep the amount of virus in the blood low. Do people with HIV have to be treated wide) occur among young people under the The amount of virus in the blood is called the for the rest of their lives? age of 25. “viral load,” and it can be measured by a test. Right now, there is no cure for HIV infection U.S. Total Cases reported: 733,374 429,825 The lower the viral load, the longer a person or AIDS. So once a person starts treatment, he deaths can stay healthy and fight off infections. or she must continue it to be sure that the virus doesn’t multiply out of control. 2000 – UNAIDS reports that 3.1 million There are several types of anti-HIV drugs. people are now living with HIV/AIDS, over 13 Each type attacks the virus in its own way. Are there long-term effects? million children have lost one or both parents How are the drugs taken? Over time, people who are HIV positive may to AIDS and nearly 22 million people have Most people being treated for HIV take three experience symptoms from the infection died of AIDS-related causes since the epidemic or more drugs. This is called combination and side effects from their anti-HIV drugs. began. therapy, or “the cocktail.” (It also has a longer Sometimes it is not clear whether the virus or name: highly active antiretroviral therapy, or the medications are causing the problems. U.S. Total Cases reported: 774,467 448,060 HAART.) Combination therapy is the most deaths One long-term effect that some people effective treatment for HIV. experience is a change in the way their bodies 2001 – New study shows that 14 percent of Is it hard to take these drugs? handle fats and sugars. For example, they may individuals newly infected with HIV in the HIV medicines have become much easier gain or lose a lot of fat in unusual areas of the U.S. already exhibit resistance to at least one to take in recent years. Some newer drug body, or they may develop heart disease or antiviral drug. combinations package three separate diabetes. U.S. Secretary of State Colin Powell reaf- medicines into only one or two pills, taken Eventually, people may get sick with other firms the position that HIV/AIDS constitutes a once a day, with minimal side effects for infections or cancers because their weakened national security threat. most individuals. Still, taking medicine for immune system can’t protect the body HIV can be complicated and depends on the particular patient. On one hand, some of the Page 32 www.ILmassageCE.com anymore. They may reach the advanced stage antibodies. The HIV test can detect these Learn about HIV and AIDS of infection called AIDS. antibodies to HIV in the person’s body; they The more people know about HIV and how Is HIV always fatal? are different from antibodies for the flu, a cold to treat it, the less confused and anxious they or other infections. So a person who has HIV and others will be about the diagnosis. And Most people with HIV probably will have the antibodies has been infected with HIV. The test the more they learn, the better they will be at virus in their body when they die because there does not tell whether people have AIDS, how making decisions about their health. is currently no way to get rid of it. Whether long they have been infected or how sick they HIV will be what causes someone’s death, There are many ways to learn about HIV and might be. however, is not always clear. AIDS: The U.S. government has many What many people want to know is whether What does the test involve? informative, reputable websites that it is possible to get HIV and have a normal, The HIV test requires a sample of blood or provide accurate information about living relatively healthy life. HIV is often thought of fluid from inside the mouth. with HIV for patients and caregivers, as an incurable, fatal illness, and it certainly For the blood test, blood is drawn either friends and partners. An excellent place to can be – especially after a person’s immune from the arm or from the finger with a start is at an online centralized site called system is weakened to the point that he or she needlestick. Results from oral-fluid or AIDS.gov (http://aids.gov/), which links has AIDS. Without treatment, most people blood tests usually take one to two weeks. to dozens of federal agencies and outside with HIV will eventually develop AIDS and For the oral-fluid test (called OraSure), a resources for people wanting to learn about die. When someone dies of AIDS, it is usually probe sits in the mouth between the cheek HIV/AIDS. Many of them provide phone because of an opportunistic infection or other and gums for two to five minutes. numbers, hotlines and ways to obtain long-term effect of having HIV. However, there are now rapid tests for both informative brochures in the mail oral fluid and blood that give results in less Since 1996, improved treatments have given Use the local library: The most current than 30 minutes. Rapid tests require special renewed hope to many people who are HIV- information will be in the library’s handling, and not every medical center or positive. While the treatments are not a cure collection of newspapers and magazines clinic offers them. What’s more, positive and are far from perfect, they may help to keep (books about HIV and AIDS may be out of results from rapid tests must be confirmed people with HIV healthy for a long time. date by the time they are published). by another, more sensitive, test – and getting A newly diagnosed person should talk How long? No one knows, really. Some those results can take one to two weeks. A with others who have been diagnosed with people may do very well for many, many negative result from the rapid test does not HIV and AIDS. Doctors may know where years. Others may eventually get sick and die need to be confirmed. despite being treated. Recent studies suggest to find support groups. Or people can go that people who take the treatments can gain, In most people, the body will produce online, where there are message boards and on average, 24 extra years of life. There is a antibodies to the virus between 2 and 12 weeks chat rooms. However, they should always great need for research to find new and better after exposure to HIV. But in some people, discuss what they learn from these sources treatments for HIV. it may take three months after exposure for with the doctor. The information may not the test results to be 97 percent accurate, and be accurate, and even if it is, it may not be HIV and hepatitis C six months to be absolutely certain, meaning right for this person’s particular situation. HIV and hepatitis C, although caused by people whose initial tests are negative should different viruses, are very different illnesses retest. Telling others that are increasingly found together in people People who find they are HIV positive need with HIV. A positive HIV test support from family, friends and colleagues, A positive HIV test does not equal death: It and they must be people who are willing to HIV is spread mainly through the blood and means people need to take care of themselves help them through the emotional and physical through sexual contact. It can wear down the to stay healthy. Many people who have been issues they are going to face. Those who want body’s immune system, making it hard for infected since the 1980s are alive today, to help loved ones and friends who are facing the body to fight off dangerous infections. living healthy and productive lives. The most HIV should: Hepatitis C is a disease that affects the liver. important things people who get a positive Offer support and understanding. It is caused by a virus called the hepatitis C result can do immediately are: Provide assistance, such as running errands virus, and it is spread mainly by blood, but Start seeing a doctor or other health care and helping with childcare, doctor visits rarely by sex. In many cases, hepatitis C never provider. and work. goes away. Over time, it can cause other health Show up at medical appointments. Learn from the person with HIV how it is problems, such as cirrhosis (or scarring of the Follow the doctor’s instructions about spread and spur the discussion on how to liver) and liver cancer. lifestyle, diet, nutrition and treatment. prevent the person from spreading it. HIV affects the whole immune system, Learn about HIV disease and how to take including the body’s ability to fight off care of themselves. Deciding to tell others that he or she is HIV hepatitis C. As a result, a person with HIV Ask for help or support. positive is an important personal choice. It might develop a case of hepatitis C that is can make a big difference in how the person Living with AIDS worse than it would be if he or she didn’t have copes with the disease, and can affect his Understanding the diagnosis HIV. or her relationships with people. People Soon after a diagnosis, a person’s doctor will who decide to share information about their The HIV test run other tests to determine his or her overall diagnosis should tell people they trust or What does the test measure? health and the condition of the immune those who are directly affected. These include The HIV test is designed to determine system. This is key because HIV affects family members; good friends; all health whether a person has been infected with HIV, the immune system, and can make common care providers, such as doctors, nurses and the virus that causes AIDS. When a person illnesses much worse than they would be for dentists; and personal services workers such is infected with HIV, the body produces people who don’t have HIV. as cosmetologists, nail technicians, and facial cells and particles to fight the virus, called specialists. www.ILmassageCE.com Page 33 However, people don’t have to tell everyone Patients have the right to ask questions of a others. It can also protect a person with about their HIV status right away. They might doctor or exercise their legal right to see their HIV from getting other sexually transmitted want to talk with a counselor or social worker medical records. After all, it’s their body. diseases. first. Patients must be encouraged to be honest. If Sometimes it can be difficult for a person with Support groups they have sex with someone of the same sex HIV to explain that they have the virus to Joining a group of people who are facing the or someone other than their spouse, it’s OK to people with whom they have had sex or shared same challenges can have important benefits. tell the doctor. He or she isn’t there to judge needles in the past. However, it is important These include helping people feel better about a patient, but to make decisions based on the those people be told so that they can decide themselves, finding a new life focus, making person’s particular circumstances. The patient whether to be tested. Most city or county new friendships, improving their mood and must tell the doctor about his or her sexual or health departments will tell them for a patient better understanding their own needs and those drug use history, because those behaviors can without using the patient’s name. A doctor can of their families. People in support groups put the person at risk of getting other sexually help arrange this service. often help each other deal with common transmitted diseases as well as hepatitis. When Moving forward with life experiences associated with being HIV the body is fighting off these other diseases, it Life does not end with a diagnosis of HIV. In positive. Support groups are especially helpful will not be able to fight off HIV as effectively. fact, with proper treatment, people with HIV for people who live alone or don’t have family A person who is HIV positive may get sicker, can live very healthy lives. Taking care of their and friends nearby. faster. overall health can help them deal with HIV. Working with the doctor Monitoring health They should: If ignored, HIV can lead to illness and death. Once people are diagnosed with HIV, they Get regular medical and dental checkups. This is why it is so important for people with need to pay closer attention to their health than Eat a healthy diet. There are many sources HIV to get medical care. They should not be they did before. The most important is to track for information on healthy diets for those afraid to seek a doctor or nurse practitioner the condition of their immune systems. First, with HIV. with experience in treating HIV-infected regular lab tests can often show signs of illness Exercise regularly. patients – he or she can help them to stay well. before there are any noticeable symptoms. Avoid smoking and recreational drug use. Many doctors who treat HIV are specialists in Second, they must listen to what their bodies Go easy on alcohol. infectious disease. They work with a team of are telling them and be on the alert for signs Practice safer sex (it can protect others other health professionals who focus on HIV that something isn’t right. from getting HIV, and can protect the as a chronic, or lifelong, disease. Regular lab tests person from other sexually transmitted diseases). Before appointments While many doctors use laboratory tests People with HIV – indeed any patient with to check patients’ general health, they are Understanding lab tests any serious disease – should prepare for an especially important for people with HIV. For Laboratory tests can help keep tabs on patients’ appointment with a doctor by writing down: those people, the tests: health; a doctor will set up a schedule for Any questions they have. Show how well their immune system is patients with HIV. The lab tests look at: Any symptoms or problems they want to functioning. How well their immune systems are tell the doctor about (include symptoms How rapidly HIV is progressing. functioning (CD4 count). such as poor sleep, trouble concentrating, Check certain basic body functions (tests How rapidly HIV is progressing (the viral feeling tired). look at the kidneys, liver, cholesterol and load). A list of the medications they are taking blood cells). How well their bodies are functioning (include herbs and vitamins). Whether they have other diseases that are (tests look at kidneys, liver, cholesterol and Upcoming tests or new information associated with HIV. blood cells). they’ve heard about. Whether they have other diseases that Changes in their living situation, such as a Possible complications are associated with HIV (tests for certain job change. Certain changes can happen to people who are infections). HIV-positive and living longer because of HIV If it seems appropriate, a family member or The most important tests include: medicines. Some people have experienced friend who is aware of the situation might CD4 count (or T-cell test) visible changes in body shape and appearance. volunteer to go with the person and take notes The CD4 count is like a snapshot of how Sometimes these changes can raise the risk of of the answers and facts the person is given. well the immune system is functioning. heart disease and diabetes. For a patient, it can be difficult to take notes CD4 cells (also known as CD4+ T cells) and pay attention to what the doctor is saying Also, by weakening the immune system, are white blood cells that fight infection. at the same time. HIV can leave people vulnerable to certain The more a person has, the better. These During appointments cancers and infections. These infections are are the cells that HIV kills. As HIV Patients with HIV should learn about the called “opportunistic” because they take the infection progresses, the number of these important lab tests that will track their health opportunity to attack patients when their cells declines. When the CD4 count drops and the progress of HIV. They should not be immune systems are weak. below 200 because of advanced HIV afraid to question the doctor about any tests Protecting others disease, a person is diagnosed with AIDS. ordered, and ask the doctor what the tests are A person with HIV can give the virus to others A normal range for CD4 cells is between to measure. If they don’t understand what the by having unprotected sex or by sharing 600 and 1,500. The higher the CD4 count, doctor is saying, they must ask him or her to needles (or if she is pregnant or has an infant, the better. explain it in everyday terms. Friends who are during pregnancy, childbirth or by breast- Viral load (or HIV RNA) part of the person’s support team should be feeding). This is true even if the person feels Viral load tests measure the amount of HIV ready to encourage an HIV patient to do so. perfectly fine. Using condoms and clean in the blood. Lower levels are better than needles can prevent a person from infecting higher levels. The main goal of HIV drugs
Page 34 www.ILmassageCE.com is to reduce viral load as much as possible opportunity to attack when the immune system and protein to keep from losing muscle mass. for as long as possible. Some viral load is weak. The cancers are called “AIDS-related” Foods to add to meals to do that include tests measure down to 400 or 500 copies of because they appear mostly in people who peanut butter, legumes (dried beans and HIV per unit of blood; others go as low as have advanced, later-stage HIV infection, peas), cheeses, eggs, instant breakfast drinks, 50 or even 25 copies. High levels – from known as AIDS. milkshakes and sauces. People living with HIV 30,000 (in women) to 60,000 (in men) Most people who die of AIDS do not die from can also maintain or increase muscle mass and above – are linked to faster disease the virus itself. They die from opportunistic through exercise, especially with progressive progression. Levels below 50 offer the best infections. Often, people are infected with strength-building exercises. These include outcome for people’s health. The lower the the opportunistic infection long before they resistance and weight-lifting exercise. viral load, the better. become infected with HIV. Their functioning Candidiasis (thrush) CD4 counts and viral load tests are usually immune system keeps it under control, so they Candidiasis (or thrush) is a fungal infection of done every three months. Results can help a don’t have any symptoms of the infection. the mouth or lungs. Most people already have patient and doctor decide when it’s time to Once HIV damages their immune system the Candida fungus in their body, but the body start taking anti-HIV drugs. enough, the infectious disease becomes keeps it in check. Someone whose immune uncontrolled and makes them sick. In fact, system is weakened is more likely to develop Other tests look at whether the person with many HIV-negative people have opportunistic problems. Some people have no symptoms, HIV may be resistant to certain medications, infections but don’t know about it because but others may experience white patches or meaning the drugs don’t work well for this their immune system keeps the infections in smooth red areas on the back of the tongue; person, usually because a disease has mutated check. painful areas in the mouth; changes in taste or changed. Other lab tests look at a person’s and sensitivity to spicy foods; and decreased blood counts, which measure things like Common types of illnesses appetite. whether a person has anemia or a high white Opportunistic infections can be caused by blood cell count, which indicates the body is viruses, bacteria, fungus, even parasites. Herpes zoster (shingles) fighting off an infection; blood chemistries, Common opportunistic infections for people Shingles is caused by a virus, the same one which measure things like cholesterol levels; with HIV are: that causes chickenpox. People with shingles other ailments, such as sexually transmitted usually had chickenpox as a child, and the Tuberculosis (TB) diseases; and screenings for tuberculosis and virus is becoming active again. Symptoms can Tuberculosis is caused by a bacteria passed hepatitis A, B and C. include painful skin blisters on one side of the through the air when someone coughs, sneezes face or body and some vision loss. The skin Body changes or talks. It is spread easily in confined spaces. blisters can be extremely painful. Treatment is People who are taking HIV medicines and Tuberculosis (TB) can occur early in the available to help the blisters heal, but there is living longer sometimes experience visible course of HIV infection, often when CD4 no cure. Bathing them in mild soap and water changes in body shape and appearance. A counts are slightly below normal. Symptoms can help. Antibiotic ointments can help keep buildup of fat is called lipoaccumulation can include fever, night sweats, weight loss, the infection from spreading. (“lipo” means fat). A loss of fat is called fatigue, loss of appetite and coughing. TB can lipoatrophy. be prevented and usually is curable. If left HIV dementia Possible changes in body appearance: untreated, it can kill. Sometimes called “HIV encephalopathy” Increased fat in the abdomen. Pneumocystis pneumonia (PCP) or “AIDS dementia,” this disease is caused Increased fat in neck, shoulders, breasts or An unusual fungus found in many places in the by HIV invading the brain. Symptoms can face. environment causes this kind of pneumonia. include memory loss, depression, unsteadiness Fatty bumps on the body. Nearly two out of three children have been walking, irritability or apathy and personality Loss of fat in the face, legs or arms. exposed to it by age 4. The fungus can affect changes. This condition is less common now that there are drugs available to treat HIV. It Blood sugar levels many organs, the most common being the lungs. Symptoms can include fever, shortness may even be prevented by using HIV drugs The body may become less sensitive to insulin of breath, a dry cough, night sweats and that cross into the brain. because blood sugar levels increase. This can fatigue. Common AIDS-related cancers lead to diabetes. HIV wasting syndrome Kaposi sarcoma (KS) is the most common Exercise may be able to lessen the fat deposits Wasting syndrome refers to unwanted weight cancer seen in HIV. This cancer is caused by around the gut. Diet can help lower the blood loss that is equal to more than 10 percent of a the human herpes virus 8 (HHV-8). The virus fats (cholesterol and triglycerides) that increase person’s body weight. For a 150-pound man, can be spread by deep kissing, unprotected sex the risk of heart disease. this means a loss of 15 pounds or more. Weight and sharing needles. It also can be spread from Experts aren’t sure whether these changes are loss can result in loss of both fat and muscle. mother to child. Symptoms include brown, due to HIV itself or to the anti-HIV drugs. Once lost, the weight is difficult to regain. The purple or pink lesions (or blotches) on the skin, There are no proven cures at this time, but condition can be caused by many things: HIV, usually on the arms and legs, neck or head, there are steps a person can take to reduce the inflammation or opportunistic infections. The and sometimes in the mouth. Sometimes there effects, including treatment by plastic surgeons weight loss may be accompanied by low-grade is tooth pain or tooth loss, weight loss, night with liposuction to remove fat and injections to fever and sometimes diarrhea. The person may sweats or fever for longer than two weeks. KS fill out sunken areas, particularly in the face. get full easily or have no appetite at all. can also affect internal organs, most seriously the lungs. HIV drugs can slow the growth of Opportunistic infections and AIDS-related The condition may be preventable, to some lesions or even reverse the condition itself. cancers degree, by eating a good diet. A “good diet” KS has become less common and much more HIV weakens the immune system, leaving for an HIV-positive person may not be the low- treatable since the development of effective a person vulnerable to certain infections fat, low-calorie diet recommended for healthy combination HIV therapy. and cancers. The infections are called people. Compared with other people, someone “opportunistic” because they take the with HIV may need to take in more calories www.ILmassageCE.com Page 35 Lymphomas associated with HIV include a symptoms of HIV disease, which can be signs the following questions (and make sure they large group of cancers that begin in the cells that HIV is weakening the immune system, and understand the answers): of the immune system. The cancers can go includes things such as weight loss, chronic What dose of the drug should be taken? on to invade different parts of the body, such fevers and opportunistic infections. How many pills does this mean? as the central nervous system, liver, bone AIDS means treatment is needed How often should the drug be taken? marrow and gastrointestinal tract. Symptoms Does it matter if it is taken with food, or on Most experts agree that anyone diagnosed with depend on where the cancer resides. Treatment an empty stomach? AIDS should take anti-HIV drugs unless there varies depending on the specific cancer, but Does the drug have to be kept in a is some reason why doing so would make that can include radiation and chemotherapy. HIV refrigerator? person sicker. Once a person and his or her drugs, by boosting the immune system, can What are the side effects of the drug? doctor have decided the patient should start help the body fight the cancer, too. In fact, the What should be done to deal with the side taking drugs for HIV, the doctor will come up development of effective combination HIV effects? with a personal treatment plan. therapy has greatly improved the outlook for How severe do side effects have to be persons with HIV-associated lymphoma. What kinds of drugs are available? before a doctor is called? Anti-HIV drugs are also called antiretroviral AIDS-defining illnesses drugs or antiretrovirals. They work because Staying on a treatment plan Certain serious and life-threatening diseases they attack the HIV virus directly. The drugs During every visit to the doctor, a patient that occur in HIV-positive people are called cripple the ability of the virus to make copies with HIV taking combination therapy should “AIDS-defining” illnesses. When a person gets of itself. talk about whether he or she is having trouble one of these illnesses, he or she is diagnosed staying on the treatment plan. Studies show with the advanced stage of HIV infection There are five main classes of anti-HIV drugs that patients who take their medicine in the known as AIDS, regardless of CD4 and viral and at least 25 different drugs, with more still right way get the best results: their viral loads load counts. in the experimental stage. Each group attacks stay down, their CD4 counts stay up and they HIV and helps the body fight the infection in The Centers for Disease Control and feel healthier. its own way. Most of these drugs come as pills, Prevention (CDC) has developed a list of capsules or coated tablets. Several of them What are drug interactions? these illnesses. No single patient is likely may be combined into one tablet to make it Anti-HIV medications can be affected by other to have all of these problems. Some of the easier to take medications. These are known as medicines, including drugs people buy over the conditions, in fact, are rare. The list includes fixed-dose combinations. counter at a drugstore. Even herbal therapies 24 different diseases or illnesses. Detailed and some things found in common foods can information on these opportunistic diseases When the HIV virus enters a healthy cell, it affect HIV medicines. can be found online at the U.S. National attempts to make copies of itself. It does this When one drug affects how another drug Library of Medicine, part of the National by using an enzyme; some drugs work because behaves, this is called a drug-drug interaction. Institutes of Health, at http://sis.nlm.nih.gov/ they block that enzyme. Another drug group For example, some drugs become less effective hiv/opportunisticinfections.html#a1. also blocks the enzyme, but in a different way. A third group keeps another enzyme when taken together. Treatment that allows the virus, once reproduced, from When something in food affects how a drug Treatment decisions leaving its cell home and infecting other cells. behaves, it is called a drug-food interaction. HIV is a virus that can multiply quickly in The fourth group of medicines stops the HIV For example, grapefruit juice, taken at the body. Even though no cure exists for HIV virus from getting into healthy cells in the the same time as certain drugs, can boost infection or the later stage of HIV disease first place. To infect a cell, HIV must bind to the amount of these drugs in a person’s known as AIDS, there are many different drugs two types of molecules on the cell’s surface. bloodstream to an undesirable level. People that can slow down the virus, and we know The fifth group of drugs keeps the virus from taking anti-HIV drugs need to be very careful that the slower the virus grows, the longer binding to the molecules. about these interactions. Doctors are familiar people live and the healthier they remain. Anti-HIV drugs are used in combination with with these interactions and can provide patients Most people who take medicine for their HIV one another in order to get the best results. The a list of drugs and foods to avoid, depending infection can now expect to live healthy lives goal is to get the viral load as low as possible on what kind of medicine the patient takes. for many years. for as long as possible. These medicines do Side effects Without treatment, however, HIV can make different things to the virus – they attack it in Among the most common side effects of anti- the immune system very weak. Because the different ways – so using the different drugs in HIV drugs are: immune system is what allows the body to combination works better than using just one Anemia, or a low red blood cell count. fight off bacteria and viruses, the person will by itself. Symptoms include feeling tired, fatigued or have a hard time staying well. Experts haven’t come up with one combination shortness of breath. Deciding to start taking anti-HIV drugs is a of HIV medications that works best for Diarrhea, which can be a minor hassle very personal choice, and one that cannot be everyone. Each combination has its pluses and or a serious medical problem. A person’s made alone. A patient must talk with his or her minuses. doctor should be told if goes on for a long doctor, who can help the person make a wise, time, is bloody or accompanied by a fever, Questions patients should ask doctors or just worries the person. appropriate decision. about all drugs Dry mouth, which can make it difficult Symptoms (the patient’s “clinical One of the most important things all people to chew, swallow and talk. If it is severe status”) can do to make sure they take medications or doesn’t go away, a doctor should be “Clinical status” refers to how well the patient correctly is to talk with their doctors about consulted. is doing in general, including how well he or their lifestyle, such as their sleeping and eating Fatigue, which can cause people to have she feels. Before starting treatment, a doctor schedules. When a doctor prescribes a drug a hard time getting out of bed, walking up normally will look at whether the person has for any illness, patients should be sure to ask stairs or even concentrating on something Page 36 www.ILmassageCE.com for very long. If the fatigue doesn’t go copies of itself, changes (or mutations) under the law. For example, removing an away after a person gives his or her body sometimes occur. These changes may result essential function from an employee’s job and mind time to rest, this fatigue can get in a new strain of the virus that is resistant to description and providing HIV education for worse. the action of the drugs. A blood test can help all employees are not examples of reasonable Hair loss can occur with certain identify other drugs that might still work for accommodations. Similarly, while allowing medications. Stress can make it worse. the person. an employee to work part-time is a type of Headaches can be caused by these Even if a virus is resistant to most or all reasonable accommodation, continuing to pay medications as well as by tension or stress. available drugs, some people can still stay that employee a full-time salary is not required They usually can be treated by over-the- healthy by continuing to take the same by the law. The ADA establishes a baseline – a counter drugs such as aspirin. combination of drugs. floor, not a ceiling. Nausea and vomiting can occur with People who have a strain of HIV that is Specific legal boundaries of reasonable some medications. This usually goes accommodation away a few weeks after starting a new resistant to most or all available drugs could Employers and employees trying to determine medication. Vomiting is cause to call a consider joining a clinical trial that is testing appropriate accommodations should be doctor. new drugs that have not yet been approved aware of the specific legal boundaries of Pain and nerve damage can be caused by by the U.S. Food and Drug Administration “reasonable accommodation.” Many of the HIV itself as well as medications to fight (FDA). General information on participating employers profiled in these case studies HIV. Called peripheral neuropathy, when in clinical trials can be found at http://www. provided assistance and accommodations that these nerves are damaged, the feet, toes clinicaltrials.gov/. went above and beyond what the law would and hands can feel like they’re burning or Workplace accommodations for require. As a general rule of thumb, given stinging, or numb and stiff. A doctor should employees with HIV/AIDS that the ADA governs many of the actions in be consulted. People living with HIV infection and this area, employers should consider the ADA Rashes can be caused by medication. AIDS can be productive workers for many implications of any decisions involving an Often they come and go, but can signal a years. Even in the best of circumstances, employee with HIV infection or AIDS. This bad reaction to a medication. Skin changes, the challenges associated with HIV can be includes any decisions about disclosing an especially after starting new medication, significant. In addition to complex medical and employee’s HIV status. should be reported to a doctor. legal concerns, AIDS raises difficult emotional Weight loss can be the result of many issues such as fear, stigma, death, and dying. The ADA has strict rules about maintaining other side effects. People who are losing confidentiality of such information, and HIV/AIDS is an increasingly important weight without trying should talk to their employers should ensure that they do not issue in workplaces throughout the country. doctor. violate these rules. As awareness of the ADA Two-thirds of large businesses and one in 10 and its employment provisions increases, How do doctors know when a drug is small businesses have already encountered an more and more employees are stepping working? employee with HIV infection or AIDS. More forward to disclose their HIV status to their Doctors will look at how much virus is in a than 75 percent of all AIDS cases occur among employers, managers, coworkers, and friends. patient’s bloodstream (the viral load) to see people between the ages of 25 and 44 – the Disclosure often takes courage and is unlikely how well the drug therapy is working. If the same group comprising the bulk of the U.S. to happen without an environment in which the medicines are working, the viral load goes workforce. disclosure will be met with cooperation and down and there is less of it in the bloodstream. Employment provisions under the support. Because of the stigma still associated The CD4 count also should stay the same or Americans with Disabilities Act of 1990 with HIV, this disclosure – especially in the go up if the drugs are working. Regular health The Americans with Disabilities Act (ADA) workplace setting – too often does not occur checkups should show that the treatment is prohibits discrimination against all people with until a crisis forces the issue out into the open. helping the person fight off infections and disabilities or perceived disabilities, including By this time an otherwise manageable situation diseases and remain healthy. people with HIV infection and AIDS. A can become a crisis, and everyone loses – the HIV-positive employee, the employer, the What if viral load is undetectable? detailed explanation of the ADA is beyond the scope of this publication but can be found manager, coworkers, and the worksite. If a viral load becomes undetectable (doesn’t at www.ada.gov. Similar legal requirements show up on tests), can a person stop treatment? Many employers believe that encouraging have been in place for employers covered by disclosure may not be desirable because it Having an undetectable viral load, meaning the Rehabilitation Act and by certain state creates certain obligations that might not that the virus isn’t showing up on tests, is and municipal ordinances covering disability have otherwise existed. An environment a sign that the anti-HIV medications are discrimination in employment. that discourages or is hostile to disclosure, working. But it doesn’t mean treatment can The employment provisions of the ADA also however, may present altogether different be stopped. If the treatment is stopped, the require employers to provide “reasonable problems, legal and otherwise, just as a virus will start reproducing again, and the accommodations” for employees with company experiences similar problems viral load will increase. Even though the virus disabilities. Reasonable accommodations when it does not encourage employees with is undetectable in the blood, it is still hidden are changes or adjustments in the job or harassment complaints to come forward. in other parts of the body, such as the brain, work environment that permit individuals reproductive organs and lymph nodes. Most human resource professionals agree that with disabilities to perform the essential providing an environment where complaints or What if the treatment isn’t working? functions of a job. The term “reasonable situations (such as the existence of a disability Even when a person has tried different accommodation” is a legal term that refers and the need for an accommodation) can be combinations of drugs, the treatment plan to certain changes and adjustments in discussed and remedied without the fear of doesn’t always work. This often occurs the workplace. An employer may choose retaliation is a sound policy for both overall because the drugs don’t completely stop the to go beyond the ADA and provide an productivity and legal reasons. virus from reproducing. As the virus makes accommodation that would not be required www.ILmassageCE.com Page 37 There is no simple formula for The benefits of accommodating accommodation. Accommodations can be accommodation of employees with HIV employees with HIV infection and AIDS made without the supervisor’s knowing that Infection or AIDS balance the costs the individual is HIV-positive or has AIDS; the The dual goals of accommodation are to ensure Companies that effectively manage HIV/ supervisor may know only that the individual that work assignments are accomplished and AIDS grow stronger. How a company treats is ill. that the individual with HIV infection or AIDS one employee with a chronic illness is a clear Disclosure of one’s HIV status can take place continues working as long as possible. indicator and a signal of the standard it will in many settings. Some employees have Accommodation is a process of ongoing use in managing other employees. Witnessing chosen to disclose it in letters to colleagues problem-solving between an employee support, accommodation, and respect for a or workgroups, others do so in face-to-face with HIV infection or AIDS and his or her coworker with a terminal illness strengthens meetings with individuals or groups. supervisor. Because the manifestations of HIV worker morale, loyalty, and productivity. Coworkers and supervisors share a deeply Intensive workplace AIDS education may infection and AIDS are different in different precede or follow a disclosure. people, accommodation is not a one-time human connection. Employers have the alteration of a job or physical structure. Just satisfaction of knowing they are making a Employees may inform managers of as each person with HIV infection and AIDS contribution to the dignity and well-being their health condition but request that the experiences the disease differently, each person of one of their own employees. Sometimes information be kept confidential; and by law, will also require different accommodations. An companies directly benefit financially from the employer must comply with that request. accommodations as well. One employee, accommodation that is effective for an earlier Over time, however, if coworkers unaware working on commission-based pay, wanted phase of HIV infection may not be effective of these circumstances become suspicious of to reduce the pressure caused by his income for a later phase; an accommodation is an perceived preferential treatment, they may depending directly on his daily sales. His ongoing process requiring ongoing evaluation, become resentful and spend considerable time, accommodation included converting from in part because the manifestations of HIV energy, and effort trying to figure out “what’s commission-based pay to a fixed salary. When infection and AIDS change over time, and in wrong.” part because some attempted accommodations his sales were high, this arrangement benefited Rumors may circulate. When the performance may not work for either the employer or the the company since it kept the commissions he of their work groups is called into question employee. would have received. by superiors, managers may find themselves Companies benefit when employees who Effective accommodation does not require unable to adequately explain the situation. become ill can help train other employees lowering the expectations of the employee. In such circumstances, the employee may be to share and eventually assume some of Rather, it requires ongoing negotiation uncomfortable as well, knowing that rumors their responsibilities. The expertise of a and creative problem-solving to determine are circulating and feeling the unwanted knowledgeable and experienced employee is alternative means of accomplishing work attention from others. At that point, it may be thus passed on to a new employee. This may assignments. This negotiation process helpful for the manager to discuss with the also give ill employees some peace of mind may result in different outcomes in similar employee what, if anything, he or she wants knowing their responsibilities are being taken circumstances. For example, one employee to do to address the situation. The decision care of in their absence. might convert from a full-time job to part time. to disclose rests with the employee, but the Employees who fully disclosed their HIV employee may be willing to risk disclosure Providing accommodation to employees status in the workplace felt relieved and if the manager is not forcing the individual with HIV infection or AIDS is a team strengthened to disclose but, instead, offers support for effort with impact on a company’s Being an employee with HIV/AIDS, as one whatever decision is made. workforce, managers, and policies interviewee described it, is “not for cowards.” Because of the fear and stigma still associated Finally, many employees with HIV/AIDS The employee must manage the overwhelming with HIV/AIDS, accommodating people with believe that continuing to work is critical emotions of facing a terminal and often HIV infection and AIDS affects virtually to their mental and physical health and stigmatizing illness while still continuing everyone in the workplace. A fearful work survival. Work can provide a sense of purpose, to be a productive worker. People with HIV environment is not a productive work financial support, productiveness, continuity, infection and AIDS are challenged to manage environment. In the process of providing involvement, peer support, and the opportunity and plan for an ever changing set of ailments, accommodation of employees with HIV to focus on something other than one’s illness. health care needs, and financial demands – all infection or AIDS, an employer might consider In our culture and society, a person’s work and while maintaining motivation and self-esteem. addressing coworker attitudes. In order profession often hold deep ethical, economic, to dispel unwarranted fears and to ensure HIV-positive employees must decide whom and personal significance. The importance of cooperation in the accommodation process, to inform about their health status, how much work and the workplace context for people managers need accurate information about information to reveal, and when to reveal it. with HIV infection and AIDS should not be HIV infection and AIDS. Confronting AIDS The stigma still associated with HIV/AIDS underestimated. Indeed, for some, keeping a also involves confronting grief. Coworkers makes such decisions all the more difficult. job may mean keeping the “will to live.” and managers in these profiles responded Fear of rejection, regrettably, is a fear based in constructively in a supportive environment reality. where emotional responses to HIV could be The decision to disclose HIV status is the addressed. Leadership is an important part of prerogative of the HIV-positive individual. effective accommodation. A message from the It is illegal for an employer to ask a current manager about how an employee with HIV or prospective employee about HIV status. infection or AIDS will be treated is critical Nonetheless, the HIV-positive employee may because it sets a clear standard. have to disclose some health information to managers or supervisors in order to seek an
Page 38 www.ILmassageCE.com References and Sources U.S. Department of Veterans Affairs: HIV/AIDS for Patients and the Public: http:// NOTES www.hiv.va.gov/vahiv?page=pt-home. LIVING WITH HIV/AIDS Centers for Disease Control: Basic information and statistics on AIDS: (http://www. cdc.gov/hiv/topics/basic/index.htm#aids); “Diagnoses of HIV infection and AIDS in Final Examination Questions the United States and Dependent Areas,” 2008. (http://www.cdc.gov/hiv/surveillance/ resources/reports/2008report/index.htm); additional information, reports and brochures (http://www.cdc.gov/hiv/resources/). Choose the best answer for questions AIDS.gov: http://www.aids.gov/hiv-aids-basics/. 16 through 20 and then mark your answers AIDS Clinical Trials Group: All about research. (http://www.aactg.org/#) U.S. Department of Health and Human Services: ( http://www.aidsinfo.nih.gov/.) on the answer sheet found on page 59 or AEGIS: The AIDS Education Global Information System (http://www.aegis.com/.) Los Angeles Times: “Magic’s Announcement 10 Years Later,” Nov. 7, 2001. proceed to www.ILmassageCE.com to Associated Press: “The Trials and Tribulations of Greg Louganis,” Feb. 8, 2010. People Magazine: “Greg Louganis: His Greatest Victory,” Feb. 8, 2010. complete your final examination.. Kaiser Family Foundation: “2009 Survey of Americans on HIV/AIDS: Summary of Findings on the Domestic Epidemic.” Central Intelligence Agency World Fact Book: People living with AIDS by country. (https://www.cia.gov/library/publications/the-world-factbook/rankorder/2156rank. 16. The Centers for Disease Control’s latest html). estimates suggest that approximately National Institutes for Health: (http://health.nih.gov/topic/AIDS).U.S. Food and Drug Administration: (http://www.fda.gov/ForConsumers/nyAudience/ForPatientAdvocates/ how many Americans become infected HIVandAIDSActivities/defalut.htm). with the human immunodeficiency virus (HIV) every year? a. 125,000. b. 56,000. c. 13,000. d. 203,000.
17. HIV is spread through all of these EXCEPT: a. Semen. b. Blood. c. Sweat. d. Vaginal fluid.
18. Health officials warn that individuals are at an above-average risk of contracting HIV if they: a. Have had unprotected sex with someone who is infected with HIV. b. Have shared injection drug needles and syringes. c. Have had a sexually transmitted disease, like chlamydia or gonorrhea. d. All of the above.
19. What illnesses are increasingly found together in individuals with HIV? a. HIV and Crohn’s disease. b. HIV and diverticulitis. c. HIV and heart disease. d. HIV and hepatitis C.
20. All are common side effects of anti-HIV drugs EXCEPT: a. Weight gain. b. Anemia. c. Fatigue. d. Dry mouth.
MIL02HVE12 www.ILmassageCE.com Page 39 CHAPTER 4 “The wonderful thing about studying This course looks at four chronic conditions Pathology of chronic pathology … is the discovery that much for which massage therapy is indicated to help conditions for massage of the time, even after a serious illness, reduce pain and, in some cases, reduce chronic people get better.” symptoms: cerebral palsy, fibromyalgia, therapists myofascial pain syndrome and chronic fatigue To help those people get better, modern (2 CE Hours) syndrome. The last three affect different body therapists must understand the illnesses and systems, yet can be mistaken for each other their processes that cause problems for people. Learning objectives because of their complexity and overlapping They must widen their knowledge as well as Define pathology and relate it to the symptoms. practice of massage therapy. their skills to accurately and appropriately Describe the different forms of cerebral decide whether their scope of practice can fit An understanding of their pathologies will palsy and how they affect functioning of into the growing use of integrated medicine guide the massage therapist to the way to help people. that has, however cautiously, begun to embrace patients who endure these conditions. massage therapy for chronically ill people. Explain what causes cerebral palsy and Remember: Before each massage session, where its effects are manifested. Massage is an ancient treatment that has gone all patients and clients should be properly List the kinds of treatments that may be in and out of public favor. But today, according assessed for their tolerance for treatment and used to help cerebral palsy patients. to the 2007 National Health Interview whether any changes in the procedures should List the symptoms that people with Survey, an estimated 18 million U.S. adults be made. This is particularly important for fibromyalgia may exhibit. and 700,000 children had received massage clients suffering from pain and the symptoms Explain how fibromyalgia is diagnosed. therapy in the previous year. you will learn about in this course. List the benefits of massage for people with fibromyalgia and the general types of That is partly because of growing acceptance Part I: Cerebral Palsy massage that should be used. of the practice in the mainstream medical About cerebral palsy Explain the differences in symptoms of world. Physicians who once might have Cerebral palsy refers to a group of disorders fibromyalgia and myofascial pain. shunned what is known as alternative medicine that affect a person’s ability to move and to Define trigger points and their relation to now see many professions, including massage, maintain balance and posture. It is due to myofascial pain. as “complementary” medicine that benefits a nonprogressive brain abnormality, which List treatments for myofascial pain, their patients. means that it does not get worse over time, though the exact symptoms can change over a including indications for massage. The National Institutes for Health has created person’s lifetime. Describe the criteria for diagnosis of the National Center for Complementary and chronic fatigue syndrome. Alternative Medicine (NCCAM) to study the People with cerebral palsy have damage to List possible causes of chronic fatigue benefits of complementary and alternative the part of the brain that controls muscle tone, syndrome. medicine and practices. The center has helped which is the amount of resistance to movement List treatment options for chronic fatigue fund research to quantify the benefits and in a muscle. It is what lets you keep your body syndrome. assure the safety of these practices, which it in a certain posture or position. Introduction: What is pathology? calls CAM, and to spread the word to health care professionals and the public. For example, it lets you sit up straight and The Merriam-Webster medical dictionary keep your head up. Changes in muscle tone let defines it this way: Massage therapists must be ready to move you move. For example, to bring your hand to Definition of pathology into this new world with its new and expanded your face, the tone in your biceps muscle at the (pa·thol·o·gy noun \-jē\ plural responsibilities and challenges. They must be front of your arm must increase while the tone pa·thol·o·gies) able to speak – and understand – the medical in the triceps muscle at the back of your arm 1. The study of the essential nature of lingo. They must understand the complex must decrease. The tone in different muscle diseases and especially of the structural systems of the body and how they work to groups must be balanced for you to move and functional changes produced by them. enhance their own practices and techniques smoothly. and protocols. As they do this, they will be 2. The anatomic and physiological deviations What are the different forms? from the normal that constitute disease or ready to become a part of a new kind medical system: integrated medicine, where teams of The specific forms of cerebral palsy are characterize a particular disease. determined by the extent, type, and location 3. A treatise on or compilation of professionals from many disciplines work together in the interests of patient health of a child’s abnormalities. Doctors classify abnormalities . and bridge the division between traditional medicine and complementary and alternative movement disorder involved – spastic (stiff Massage therapy, as it is generally defined, medicine. muscles), athetoid (writhing movements), or is the practice of manually manipulating soft ataxic (poor balance and coordination) – plus body tissues to help the body heal itself to Many physicians on their own have come any additional symptoms. Doctors will often enhance general health and well-being. Indeed, to understand the benefits of CAM and send describe the type of cerebral palsy a child has the greatest reward for most therapists is to their patients to chiropractors, acupuncturists, based on which limbs are affected. The names see a client feel better after a session, to win massage therapists and others for certain of the most common forms of cerebral palsy the battle against pain. That’s where pathology ailments, especially those that are associated use Latin terms to describe the location or comes into the practice of massage. with pain. Massage therapists know – and number of affected limbs combined with the more and more research is officially supporting words for weakened (paresis) or paralyzed Author and massage therapist Ruth Werner the notion – that their practice can truly help (plegia).For example, hemiparesis (hemi = puts it this way in her book “A Massage a patient suffering from the chronic pain of a half) indicates that only one side of the body is Therapist’s Guide to Pathology”: medical ailment. weakened. Quadriplegia (quad = four) means all four limbs are paralyzed.
Page 40 www.ILmassageCE.com Spastic hemiplegia/hemiparesis. This to any single type of cerebral palsy. Their 10,000 10-year-old children had cerebral palsy. type of cerebral palsy typically affects symptoms are a mix of types. For example, Eighty-one percent of the children had spastic the arm and hand on one side of the body, a child with mixed cerebral palsy may have cerebral palsy. Seventy-five percent had one or but it can also include the leg. Children some muscles that are too tight and others more other disabilities (epilepsy, intellectual with spastic hemiplegia generally walk that are too relaxed, creating a mix of disabilities, hearing loss or vision impairment). later and on tiptoe because of tight heel stiffness and floppiness. What causes cerebral palsy? tendons. The arm and leg of the affected How common is cerebral palsy? Doctors use the term cerebral palsy to refer to side are frequently shorter and thinner. The United Cerebral Palsy (UCP) Foundation any one of a number of neurological disorders Some children will develop an abnormal estimates that nearly 800,000 children and that appear in infancy or early childhood curvature of the spine (scoliosis). adults in the United States are living with one and permanently affect body movement and Depending on the location of the brain or more of the symptoms of cerebral palsy. muscle coordination but aren’t progressive damage, a child with spastic hemiplegia According to the federal government’s Centers – in other words, they don’t get worse over may also have seizures. Speech will be for Disease Control and Prevention (CDC), time. The term cerebral refers to the two delayed and, at best, may be competent, each year about 10,000 babies born in the halves or hemispheres of the brain, in this but intelligence is usually normal. United States will develop cerebral palsy. case to the motor area of the brain’s outer Spastic diplegia/diparesis. In this type layer (called the cerebral cortex), the part of cerebral palsy, muscle stiffness is In a study, CDC used data from the National of the brain that directs muscle movement; predominantly in the legs and less severely Health Interview Survey – Child Health palsy refers to the loss or impairment of motor affects the arms and face, although the Supplement to find the number of children function. hands may be clumsy. Tendon reflexes are with cerebral palsy in the United States in hyperactive. Toes point up. Tightness in 1988. The survey asked parents or other adults Even though cerebral palsy affects muscle certain leg muscles makes the legs move whether children in the home had cerebral movement, it isn’t caused by problems like the arms of a scissor. Children with palsy. The study showed that 23 of every in the muscles or nerves. It is caused by this kind of cerebral palsy may require 10,000 children 17 years of age or younger had abnormalities inside the brain that disrupt a walker or leg braces. Intelligence and cerebral palsy. the brain’s ability to control movement and language skills are usually normal. posture. Spastic quadriplegia/quadriparesis. Despite advances in preventing and treating This is the most severe form of cerebral certain causes of cerebral palsy, the percentage The part of the brain that is damaged palsy, often associated with moderate- of babies who develop the condition has determines what parts of the body are affected. to-severe mental retardation. It is caused remained the same over the past 30 years. There are many possible causes of the brain by widespread damage to the brain or Improved care in neonatal intensive-care damage. Some causes affect how the child’s significant brain malformations. Children units has resulted in higher survival rates for brain develops during the first six months will often have severe stiffness in their very low birth-weight babies. Many of these of pregnancy. These causes include genetic limbs but a floppy neck. They are infants will have developmental defects in conditions and problems with the blood supply rarely able to walk. Speaking and being their nervous systems or suffer brain damage to the brain. Other causes of cerebral palsy understood are difficult. Seizures can be that will cause the characteristic symptoms of happen after the brain has developed. These frequent and hard to control. cerebral palsy. causes can occur during later pregnancy, delivery or the first years of the child’s life. Dyskinetic cerebral palsy (also In the Metropolitan Atlanta Developmental They include bacterial meningitis and other includes athetoid, choreoathetoid and Disabilities Surveillance Program (MADDSP), infections, bleeding in the brain, lack of dystonic cerebral palsies). Slow and approximately 2 percent of 8-year-old children oxygen, severe jaundice and head injury. uncontrollable writhing movements of the had at least one of the five developmental hands, feet, arms or legs characterize this disabilities monitored. MADDSP tracks the Children who are born prematurely or who type of cerebral palsy. In some children, number of school-age children living in five are very low birth-weight (less than 1,500 1 hyperactivity in the muscles of the face counties of metro Atlanta who have cerebral grams or about 3 /3 pounds) are more likely and tongue makes them grimace or drool. palsy, hearing loss, vision impairment, to have problems that might lead to cerebral They find it difficult to sit straight or intellectual disabilities and/or autism spectrum palsy. However, children who are full term walk. Children may also have problems disorders. and normal birth weight can also have cerebral coordinating the muscle movements palsy. required for speaking. Intelligence is rarely In 1996, an estimated 3.6 per 1,000 8-year-old affected in these forms of cerebral palsy. children in metro Atlanta, or about 1 in 278, A small number of children have acquired Ataxic cerebral palsy. This rare type of had cerebral palsy. In 2000, the prevalence cerebral palsy, which means the disorder cerebral palsy affects balance and depth was an estimated 3.1 per 1,000, or about begins after birth. In these cases, doctors perception. Children will often have 1 in 323, 8-year-olds. In 1996 and 2000, can often pinpoint a specific reason for the poor coordination and walk unsteadily respectively, 55 percent and 60 percent of problem, such as brain damage in the first few with a wide-based gait, placing their feet children with cerebral palsy also had one or months or years of life, brain infections such unusually far apart. They have difficulty more other developmental disabilities tracked as bacterial meningitis or viral encephalitis, or with quick or precise movements, such as by MADDSP. head injury from a motor vehicle accident, a fall or child abuse. writing or buttoning a shirt. They may also The CDC also studied how many children have intention tremor, in which a voluntary in metropolitan Atlanta had cerebral palsy in What causes the remaining 90 to 95 percent? movement, such as reaching for a book, is the mid-1980s. This project was done as part Research has given us a bigger and more accompanied by trembling that gets worse of the Metropolitan Atlanta Developmental accurate picture of the kinds of events that the closer their hand gets to the object. Disabilities Study (MADDS), which studied can happen during early fetal development or Mixed types. It is common for children how common certain disabilities were in 10- just before, during or after birth, that cause to have symptoms that don’t correspond year-old children. It found that 23 of every the particular types of brain damage that will www.ILmassageCE.com Page 41 result in congenital cerebral palsy. There are even though a newborn’s blood is equipped Blood type incompatibility. Rh multiple reasons why cerebral palsy happens – to compensate for short-term low levels of incompatibility is a condition that develops as the result of genetic abnormalities, maternal oxygen, if the supply of oxygen is cut off when a mother’s Rh blood type (either infections or fevers, or fetal injury, for or reduced for lengthy periods, an infant positive or negative) is different from the example. But in all cases, the disorder is the can develop a type of brain damage called blood type of her baby. Because blood result of four types of brain damage that cause hypoxic-ischemic encephalopathy, which cells from the baby and mother mix during its characteristic symptoms: destroys tissue in the cerebral motor cortex pregnancy, if a mother is negative and her Damage to the white matter of the brain and other areas of the brain. This kind baby positive, for example, the mother’s (periventricular leukomalacia [PVL]). of damage can also be caused by severe system won’t tolerate the presence of The white matter of the brain is responsible maternal low blood pressure, rupture of Rh-positive red blood cells. Her body for transmitting signals inside the brain the uterus, detachment of the placenta or will begin to make antibodies that will and to the rest of the body. PVL describes problems involving the umbilical cord. attack and kill her baby’s blood cells. Rh a type of damage that looks like tiny holes incompatibility is routinely tested for and What are the risk factors? in the white matter of an infant’s brain. treated in the United States, but conditions Just as there are particular types of brain These gaps in brain tissue interfere with in other countries continue to keep blood damage that cause cerebral palsy, there are the normal transmission of signals. There type incompatibility a risk factor for also certain medical conditions or events that are a number of events that can cause cerebral palsy. can happen during pregnancy and delivery PVL, including maternal or fetal infection. Exposure to toxic substances. Mothers that will increase a baby’s risk of being born Researchers have also identified a period who have been exposed to toxic substances with cerebral palsy. Research scientists have of selective vulnerability in the developing during pregnancy, such as methyl mercury, examined thousands of expectant mothers, fetal brain, a period of time between are at a heightened risk of having a baby followed them through childbirth and 26 and 34 weeks of gestation, in which with cerebral palsy. monitored their children’s early neurological periventricular white matter is particularly Mothers with thyroid abnormalities, development to establish these risk factors. sensitive to insults and injury. mental retardation or seizures. Mothers If a mother or her baby has any of these risk Abnormal development of the brain with any of these conditions are slightly factors, it doesn’t mean that cerebral palsy is (cerebral dysgenesis). Any interruption more likely to have a child with cerebral inevitable, but it does increase the chance for of the normal process of brain growth palsy. the kinds of brain damage that cause it. during fetal development can cause brain Low birth weight and premature birth. There are also medical conditions during labor malformations that interfere with the The risk of cerebral palsy is higher among and delivery and immediately after delivery transmission of brain signals. The fetal babies who weigh less than 5½ pounds that act as warning signs for an increased risk brain is particularly vulnerable during the at birth or are born less than 37 weeks of cerebral palsy. Knowing these warning signs first 20 weeks of development. Mutations into pregnancy. The risk increases as helps doctors keep a close eye on children in the genes that control brain development birth-weight falls or weeks of gestation who face a higher risk. However, parents during this early period can keep the brain shorten. Intensive care for premature shouldn’t become too alarmed if their baby has from developing normally. Infections, infants has improved dramatically over the one or more of these conditions at birth. Most fevers, trauma or other conditions that course of the past 30 years. Babies born of these children will not develop cerebral cause unhealthy conditions in the womb extremely early are surviving, but with palsy. Warning signs include: also put an unborn baby’s nervous system medical problems that can put them at risk Breech presentation. Babies with cerebral at risk. for cerebral palsy. Although normal- or palsy are more likely to be in a breech Bleeding in the brain (intracranial heavier-weight babies are at relatively low position (feet first) instead of head first at hemorrhage). Intracranial hemorrhage individual risk for cerebral palsy, term or the beginning of labor. describes bleeding inside the brain caused near-term babies still make up half of the Complicated labor and delivery. A baby by blocked or broken blood vessels. A infants born with the condition. who has vascular or respiratory problems common cause of this kind of damage Multiple births. Twins, triplets, and other during labor and delivery may already have is fetal stroke. Some babies suffer a multiple births – even those born at term – suffered brain damage or abnormalities. stroke while still in the womb because are linked to an increased risk of cerebral Small for gestational age. Babies born of blood clots in the placenta that block palsy. The death of a baby’s twin or triplet smaller than normal for their gestational blood flow. Other types of fetal stroke further increases the risk. age are at risk for cerebral palsy because are caused by malformed or weak blood Infections during pregnancy. Infectious of factors that kept them from growing vessels in the brain or by blood-clotting diseases caused by viruses, such as naturally in the womb. abnormalities. Maternal high blood toxoplasmosis, rubella (German measles), Low Apgar score. The Apgar score is a pressure (hypertension) is a common cytomegalovirus and herpes, can infect the numbered rating that reflects a newborn’s medical disorder during pregnancy that has womb and placenta. Researchers currently condition. To determine an Apgar score, been known to cause fetal stroke. Maternal think that maternal infection leads to doctors periodically check a baby’s heart infection, especially pelvic inflammatory elevated levels of immune system cells rate, breathing, muscle tone, reflexes disease, has also been shown to increase called cytokines that circulate in the brain and skin color during the first minutes the risk of fetal stroke. and blood of the fetus. Cytokines respond after birth. They then assign points; the Brain damage caused by a lack of to infection by triggering inflammation. higher the score, the more normal a baby’s oxygen in the brain (hypoxic-ischemic Inflammation may then go on to cause condition. A low score at 10-20 minutes encephalopathy or intrapartum asphyxia). central nervous system damage in an after delivery is often considered an Asphyxia, a lack of oxygen in the brain unborn baby. Maternal fever during important sign of potential problems such caused by an interruption in breathing or pregnancy or delivery can also set off this as cerebral palsy. poor oxygen supply, is common in babies kind of inflammatory response. Jaundice. More than 50 percent of due to the stress of labor and delivery. But newborns develop jaundice after birth Page 42 www.ILmassageCE.com when bilirubin, a substance normally abnormal muscle tone as infants. Decreased as quickly or as long as those on the found in bile, builds up faster than their muscle tone (hypotonia) can make them appear normal side. livers can break it down and pass it from relaxed, even floppy. Increased muscle tone Spinal deformities. Deformities of the the body. Severe, untreated jaundice can (hypertonia) can make them seem stiff or rigid. spine – curvature (scoliosis), humpback cause a neurological condition known as In some cases, an early period of hypotonia (kyphosis) and saddleback (lordosis) – are kernicterus, which kills brain cells and can will progress to hypertonia after the first 2 to associated with cerebral palsy. Spinal cause deafness and cerebral palsy. 3 months of life. Children with cerebral palsy deformities can make sitting, standing and Seizures. An infant who has seizures faces may also have unusual posture or favor one walking difficult and cause chronic back a higher risk of being diagnosed later in side of the body when they move. pain. childhood with cerebral palsy. Impaired vision, hearing or speech. A Parents who are concerned about their baby’s large number of children with cerebral Can cerebral palsy be prevented? development for any reason should contact palsy have strabismus, commonly called Cerebral palsy related to genetic abnormalities their pediatrician. A doctor can determine “cross eyes,” in which the eyes are is not preventable, but a few of the risk the difference between a normal lag in misaligned because of differences between factors for congenital cerebral palsy can be development and a delay that could indicate the left and right eye muscles. In an managed or avoided. For example, rubella, or cerebral palsy. adult, strabismus causes double vision. In German measles, is preventable if women are What other conditions are associated children, the brain adapts to the condition vaccinated against the disease before becoming with cerebral palsy? by ignoring signals from one of the pregnant. Rh incompatibilities can also be Many individuals with cerebral palsy have misaligned eyes. Untreated, this can lead managed early in pregnancy. But there are still no additional medical disorders. However, to poor vision in one eye and can interfere risk factors that can’t be controlled or avoided because cerebral palsy involves the brain with the ability to judge distance. In some in spite of medical intervention. and the brain controls so many of the body’s cases, doctors will recommend surgery to For example, the use of electronic fetal functions, cerebral palsy can also cause realign the muscles. monitoring machines to keep track of an seizures, impair intellectual development and Children with hemiparesis may unborn baby’s heartbeat during labor and the affect vision, hearing and behavior. Coping have hemianopia, which is defective use of emergency cesarean section surgery with these disabilities may be even more vision or blindness that blurs the when there are significant signs of fetal of a challenge than coping with the motor normal field of vision in one eye. distress haven’t lowered the numbers of babies impairments of cerebral palsy. In homonymoushemianopia, the born with cerebral palsy. Interventions to impairment affects the same part of the These additional medical conditions include: treat other prenatal causes of cerebral palsy, visual field in both eyes. Mental retardation. Two-thirds of such as therapies to prevent prenatal stroke Impaired hearing is also more frequent individuals with cerebral palsy will be or antibiotics to cure intrauterine infections, among those with cerebral palsy than intellectually impaired. Mental impairment are either difficult to administer or haven’t yet in the general population. Speech and is more common among those with been proven to lower the risk of cerebral palsy language disorders, such as difficulty spastic quadriplegia than in those with in vulnerable infants. forming words and speaking clearly, other types of cerebral palsy, and children are present in more than a third of those Fortunately, acquired cerebral palsy, often due who have epilepsy and an abnormal with cerebral palsy. to head injury, is preventable using common electroencephalogram (EEG) or MRI are Drooling. Some individuals with cerebral safety tactics, such as using car seats for also more likely to have mental retardation. palsy drool because they have poor infants and toddlers and making sure young Seizure disorder. As many as half of all control of the muscles of the throat, mouth children wear helmets when they ride bicycles. children with cerebral palsy have seizures. and tongue. Drooling can cause severe In addition, common sense measures around Seizures can take the form of the classic skin irritation. Because it is socially the household, such as supervising babies and convulsions of tonic-clonic seizures or unacceptable, drooling may also isolate young children closely when they bathe, can the less obvious focal (partial) seizures, in children from their peers. reduce the risk of accidental injury. which the only symptoms may be muscle Incontinence. A common complication twitches or mental confusion. Despite the best efforts of parents and of cerebral palsy is incontinence, caused Delayed growth and development. physicians, however, children will still be born by poor control of the muscles that keep A syndrome called failure to thrive is with cerebral palsy. Since in many cases the the bladder closed. Incontinence can take common in children with moderate-to- cause or causes of cerebral palsy aren’t fully the form of bed-wetting, uncontrolled severe cerebral palsy, especially those with known, little can currently be done to prevent urination during physical activities, or slow spastic quadriparesis. Failure to thrive it. As investigators learn more about the causes leaking of urine throughout the day. is a general term doctors use to describe of cerebral palsy through basic and clinical Abnormal sensations and perceptions. children who lag behind in growth and research, doctors and parents will know more Some children with cerebral palsy have development. In babies, this lag usually about how to prevent this disorder. difficulty feeling simple sensations, such as takes the form of too little weight gain. In touch. They may have stereognosia, which Signs and symptoms young children, it can appear as abnormal makes it difficult to perceive and identify The early signs of cerebral palsy usually shortness, and in teenagers, it may appear objects using only the sense of touch. appear before a child reaches 3 years of age. as a combination of shortness and lack of A child with stereognosia, for example, Parents are often the first to suspect that their sexual development. would have trouble closing his eyes and baby’s motor skills aren’t developing normally. In addition, the muscles and limbs sensing the difference between a hard ball Infants with cerebral palsy frequently have affected by cerebral palsy tend to be and a sponge ball placed in his hand. developmental delay, in which they are slow smaller than normal. This is especially to reach developmental milestones such noticeable in children with spastic Symptoms as learning to roll over, sit, crawl, smile or hemiplegia because limbs on the The symptoms of cerebral palsy vary from walk. Some infants with cerebral palsy have affected side of the body may not grow person to person. Symptoms can also change www.ILmassageCE.com Page 43 over time. A person with severe cerebral palsy allow severely impaired individuals to personal determination are two of the most might not be able to walk and might need communicate with others. important factors in helping individuals with lifelong care. Spasticity (rigidity of muscles) cerebral palsy reach their long-term goals. Doctors use tests and evaluation scales to may cause impaired motor organization and determine a child’s level of disability and While mastering specific skills is an important functioning, including deficits in sitting, then make decisions about the types of focus of treatment on a day-to-day basis, the standing, locomotion and daily living skills. treatments and the best timing and strategy ultimate goal is to help children grow into A person with mild cerebral palsy, on the other for interventions. Early intervention programs adulthood with as much independence as hand, might walk a little awkwardly, but might typically provide all the required therapies possible. not need any special help. People with cerebral within a single treatment center. Centers also As a child with cerebral palsy grows older, palsy can have other disabilities as well. focus on parents’ needs, often offering support the need for therapy and the kinds of therapies Examples of these conditions include seizure groups, babysitting services and respite care. required as well as support services will disorders, vision impairment, hearing loss and The members of the treatment team for a child likely change. Counseling for emotional and intellectual disabilities. with cerebral palsy will most likely include the psychological challenges may be needed following: How is cerebral palsy managed? at any age, but is often most critical during A physician, such as a pediatrician, Cerebral palsy can’t be cured, but treatment adolescence. Depending on their physical and pediatric neurologist, or pediatric will often improve a child’s capabilities. Many intellectual abilities, adults may need help physiatrist, who is trained to help children go on to enjoy near-normal adult finding attendants to care for them, a place to developmentally disabled children. This lives if their disabilities are properly managed. live, a job and a way to get to their place of doctor, who often acts as the leader of the In general, the earlier treatment begins, the employment. treatment team, integrates the professional better chance children have of overcoming advice of all team members into a Addressing the needs of parents and caregivers developmental disabilities or learning new comprehensive treatment plan, makes is also an important component of the ways to accomplish the tasks that challenge sure the plan is implemented properly, and treatment plan. The well-being of an individual them. follows the child’s progress over a number with cerebral palsy depends upon the strength and well-being of his or her family. For parents There is no standard therapy that works for of years. to accept a child’s disabilities and come every individual with cerebral palsy. Once An orthopedist, a surgeon who specializes to grips with the extent of their caregiving the diagnosis is made and the type of cerebral in treating the bones, muscles, tendons responsibilities will take time and support palsy is determined, a team of health care and other parts of the skeletal system. An from health care professionals. Family- professionals will work with a child and his orthopedist is often brought in to diagnose centered programs in hospitals and clinics and or her parents to identify specific impairments and treat muscle problems associated with community-based organizations usually work and needs, and then develop an appropriate cerebral palsy. together with families to help them make well- plan to tackle the core disabilities that affect A physical therapist, who designs and informed decisions about the services they the child’s quality of life. puts into practice special exercise programs need. They also coordinate services to get the A comprehensive management plan will pull to improve strength and functional most out of treatment. in a combination of health professionals with mobility. expertise in the following: An occupational therapist, who teaches A good program will encourage the Physical therapy to improve walking and the skills necessary for day-to-day living, open exchange of information, offer gait, stretch spastic muscles and prevent school and work. respectful and supportive care, encourage deformities. A speech and language pathologist, who partnerships between parents and the health Occupational therapy to develop specializes in diagnosing and treating care professionals they work with, and compensating tactics for everyday disabilities relating to difficulties with acknowledge that although medical specialists activities such as dressing, going to school, swallowing and communication. may be the experts, it is parents who know and participating in day-to-day activities. A social worker, who helps individuals their children best. and their families locate community Speech therapy to address swallowing What specific treatments are available? assistance and education programs. disorders, speech impediments and other Physical therapy, usually begun in the first A psychologist, who helps individuals and obstacles to communication. few years of life or soon after the diagnosis their families cope with the special stresses Counseling and behavioral therapy to is made, is a cornerstone of cerebral palsy and demands of cerebral palsy. In some address emotional and psychological needs treatment. Physical therapy programs use cases, psychologists may also oversee and help children cope emotionally with specific sets of exercises and activities to therapy to modify unhelpful or destructive their disabilities. work toward two important goals: preventing behaviors. Drugs to control seizures, relax muscle weakening or deterioration in the muscles An educator, who may play an especially spasms and alleviate pain. that aren’t being used (disuse atrophy), and important role when mental retardation or Surgery to correct anatomical keeping muscles from becoming fixed in a learning disabilities present a challenge to abnormalities or release tight muscles. rigid, abnormal position (contracture). Braces and other orthotic devices to education. compensate for muscle imbalance, Resistive exercise programs (also called Regardless of age or the types of therapy improve posture and walking, and increase strength training) and other types of exercise that are used, treatment doesn’t end when independent mobility. are often used to increase muscle performance, an individual with cerebral palsy leaves the Mechanical aids such as wheelchairs and especially in children and adolescents with treatment center. Most of the work is done at rolling walkers for individuals who are not mild cerebral palsy. Daily bouts of exercise home. Members of the treatment team often independently mobile. keep muscles that aren’t normally used moving act as coaches, giving parents and children Communication aids such as computers, and active and less prone to wasting away. techniques and strategies to practice at home. voice synthesizers or symbol boards to Exercise also reduces the risk of contracture, Studies have shown that family support and
Page 44 www.ILmassageCE.com one of the most common and serious with a voice synthesizer or a special board drugs are easy to use, except that dosages high complications of cerebral palsy. covered with symbols of everyday objects and enough to be effective often have side effects, Normally growing children stretch their activities to which a child can point to indicate among them drowsiness, upset stomach, high muscles and tendons as they run, walk and his or her wishes. blood pressure and possible liver damage move through their daily activities. This Speech interventions often use a child’s family with long-term use. Oral medications are ensures that their muscles grow at the same members and friends to reinforce the lessons most appropriate for children who need only rate as their bones. But in children with learned in a therapeutic setting. This kind of mild reduction in muscle tone or who have cerebral palsy, spasticity prevents muscles indirect therapy encourages people who are widespread spasticity. from stretching. As a result, their muscles in close daily contact with a child to create Doctors also sometimes use alcohol “washes”– don’t grow fast enough to keep up with their opportunities for him or her to use their new injections of alcohol into muscles – to reduce lengthening bones. The muscle contracture skills in conversation. spasticity. The benefits last from a few months that results can set back the gains in function Treatments for problems with eating and to two years or more, but the adverse effects they’ve made. Physical therapy alone or drooling are often necessary when children include a significant risk of pain or numbness, in combination with special braces (called with cerebral palsy have difficulty eating and and the procedure requires a high degree of orthotic devices) helps prevent contracture by drinking because they have little control over skill to target the nerve. stretching spastic muscles. the muscles that move their mouth, jaw, and The availability of new and more precise Occupational therapy. This kind of therapy tongue. They are also at risk for breathing food methods to deliver antispasmodic medications focuses on optimizing upper body function, or fluid into the lungs. Some children develop is moving treatment for spasticity toward improving posture and making the most of gastroesophageal reflux disease (GERD, chemodenervation, in which injected drugs are a child’s mobility. An occupational therapist commonly called heartburn) in which a weak used to target and relax muscles. helps a child master the basic activities of diaphragm can’t keep stomach acids from Botulinum toxin (BT-A), injected locally, has daily living, such as eating, dressing and spilling into the esophagus. The irritation of become a standard treatment for overactive using the bathroom alone. Fostering this kind the acid can cause bleeding and pain. muscles in children with spastic movement of independence boosts self-reliance and Individuals with cerebral palsy are also at risk disorders such as cerebral palsy. BT-A relaxes self-esteem and also helps reduce demands on for malnutrition, recurrent lung infections contracted muscles by keeping nerve cells parents and caregivers. and progressive lung disease. The individuals from over-activating muscle. Although Recreational therapies. Recreational most at risk for these problems are those with BT-A is not approved by the Food and Drug therapies, such as therapeutic horseback riding spastic quadriplegia. Administration (FDA) for treating cerebral (also called hippotherapy), are sometimes Initially, children should be evaluated for palsy, since the 1990s doctors have been using used with mildly impaired children to improve their swallowing ability, which is usually it off-label to relax spastic muscles. A number gross motor skills. Parents of children who done with a modified barium swallow study. of studies have shown that it reduces spasticity participate in recreational therapies usually Recommendations regarding diet modifications and increases the range of motion of the notice an improvement in their child’s speech, will be derived from the results of this study. muscles it targets. self-esteem and emotional well-being. In severe cases where swallowing problems The relaxing effect of a BT-A injection lasts Speech and language therapy. About 20 are causing malnutrition, a doctor may approximately three months. Undesirable side percent of children with cerebral palsy are recommend tube feeding, in which a tube effects are mild and short-lived, consisting unable to produce intelligible speech. They delivers food and nutrients down the throat of pain upon injection and occasionally mild also experience challenges in other areas of and into the stomach, or gastrostomy, in which flu-like symptoms. BT-A injections are most communication, such as hand gestures and a surgical opening allows a tube to be placed effective when followed by a stretching facial expressions, and they have difficulty directly into the stomach. program including physical therapy and participating in the basic give-and-take of a splinting. BT-A injections work best for normal conversation. These challenges will Although numerous treatments for drooling children who have some control over their last throughout their lives. have been tested over the years, there is no one motor movements and have a limited number treatment that helps reliably. Anticholinergic However, therapists (also known as of muscles to treat, none of which is fixed or drugs – such as glycopyrolate – can reduce the rigid. speech therapists or speech-language flow of saliva but may cause unpleasant side pathologists) observe, diagnose, and treat effects, such as dry mouth, constipation and Because BT-A does not have FDA approval some communication disorders associated urinary retention. Surgery, while sometimes to treat spasticity in children, parents and with cerebral palsy. They use a program of effective, carries the risk of complications. caregivers should make sure that the doctor exercises to teach children how to overcome Some children benefit from biofeedback giving the injection is trained in the procedure specific communication difficulties. techniques that help them recognize more and has experience using it in children. For example, if a child has difficulty saying quickly when their mouths fall open and they Intrathecalbaclofen therapy uses an words that begin with “b,” the therapist begin to drool. Intraoral devices (devices that implantable pump to deliver baclofen, a may suggest daily practice with a list of “b” fit into the mouth) that encourage better tongue muscle relaxant, into the fluid surrounding words, increasing their difficulty as each list positioning and swallowing are still being the spinal cord. Baclofen works by decreasing is mastered. Other kinds of exercises help evaluated, but appear to reduce drooling for the excitability of nerve cells in the spinal children master the social skills involved in some children. cord, which then reduces muscle spasticity communicating by teaching them to keep Drug treatments throughout the body. Because it is delivered their head up, maintain eye contact and repeat directly into the nervous system, the intrathecal Oral medications such as diazepam, baclofen, themselves when they are misunderstood. dose of baclofen can be as low as one one- dantrolene sodium and tizanidine are usually hundredth of the oral dose. Studies have shown Speech therapists can also help children with used as the first line of treatment to relax it reduces spasticity and pain and improves severe disabilities learn how to use special stiff, contracted or overactive muscles. These communication devices, such as a computer sleep. www.ILmassageCE.com Page 45 The pump is the size of a hockey puck and and how much improvement in gait can be and may only achieve small improvements is implanted in the abdomen. It contains a expected. in function. Although recent research has refillable reservoir connected to an alarm that The timing of orthopedic surgery has also shown that combining SDR with physical beeps when the reservoir is low. The pump is changed in recent years. Previously, orthopedic therapy reduces spasticity in some children, programmable with an electronic telemetry surgeons preferred to perform all of the particularly those with spastic diplegia, wand. The program can be adjusted if muscle necessary surgeries a child needed at the whether it improves gait or function has still tone is worse at certain times of the day or same time, usually between the ages of 7 and not been proven. Ongoing research continues night. 10. Because of the length of time spent in to look at this surgery’s effectiveness. The baclofen pump carries a small but recovery, which was generally several months, Spinal cord stimulation was developed in the significant risk of serious complications if doing them all at once shortened the amount 1980s to treat spinal cord injury and other it fails or is programmed incorrectly, if the of time a child spent in bed. Now most of neurological conditions involving motor catheter becomes twisted or kinked or if the the surgical procedures can be done on an neurons. An implanted electrode selectively insertion site becomes infected. Undesirable, outpatient basis or with a short inpatient stay. stimulates nerves at the base of the spinal cord but infrequent, side effects include Children usually return to their normal lifestyle to inhibit and decrease nerve activity. The overrelaxation of the muscles, sleepiness, within a week. effectiveness of spinal cord stimulation for the headache, nausea, vomiting, dizziness and Consequently, doctors think it is much better treatment of cerebral palsy has yet to be proven constipation. to stagger surgeries and perform them at times in clinical studies. It is considered a treatment As a muscle-relaxing therapy, the baclofen appropriate to a child’s age and level of motor alternative only when other conservative or pump is most appropriate for individuals development. For example, spasticity in the surgical treatments have been unsuccessful at with chronic, severe stiffness or uncontrolled upper leg muscles (the adductors), which relaxing muscles or relieving pain. muscle movement throughout the body. causes a “scissor pattern” walk, is a major Orthotic devices Doctors have successfully implanted the pump obstacle to normal gait. The optimal age to Orthotic devices – such as braces and in children as young as 3 years of age. correct this spasticity with adduction release splints – use external force to correct muscle Surgery surgery is 2 to 4 years of age. On the other abnormalities. The technology of orthotics has hand, the best time to perform surgery to Orthopedic surgery is often recommended advanced over the past 30 years from metal lengthen the hamstrings or Achilles tendon is 7 when spasticity and stiffness are severe enough rods that hooked up to bulky orthopedic shoes, to 8 years of age. If adduction release surgery to make walking and moving about difficult to appliances that are individually molded is delayed so that it can be performed at the or painful. For many people with cerebral from high-temperature plastics for a precise fit. same time as hamstring lengthening, the child palsy, improving the appearance of how they Ankle-foot orthoses are frequently prescribed will have learned to compensate for spasticity walk – their gait – is also important. A more for children with spastic diplegia to prevent in the adductors. By the time the hamstring upright gait with smoother transitions and muscle contracture and to improve gait. Splints surgery is performed, the child’s abnormal gait foot placements is the primary goal for many are also used to correct spasticity in the hand pattern could be so ingrained that it might not children and young adults. muscles. be easily corrected. In the operating room, surgeons can lengthen Assistive technology With shorter recovery times and new, less muscles and tendons that are proportionately Devices that help individuals move about more invasive surgical techniques, doctors can too short. But first, they have to determine easily and communicate successfully at home, schedule surgeries at times that take advantage the specific muscles responsible for the gait at school, or in the workplace can help a child of a child’s age and developmental abilities for abnormalities. Finding these muscles can be or adult with cerebral palsy overcome physical the best possible result. difficult. It takes more than 30 major muscles and communication limitations. There are a working at the right time using the right Selective dorsal rhizotomy (SDR) is a surgical number of devices that help individuals stand amount of force to walk two strides with a procedure recommended only for cases straight and walk, such as postural support or normal gait. A problem with any of those of severe spasticity when all of the more seating systems, open-front walkers, quadru- muscles can cause an abnormal gait. conservative treatments – physical therapy, pedal canes (lightweight metal canes with four oral medications and intrathecalbaclofen – feet), and gait poles. Electric wheelchairs let In addition, because the body makes natural have failed to reduce spasticity or chronic more severely impaired adults and children adjustments to compensate for muscle pain. In the procedure, a surgeon locates and move about successfully. imbalances, these adjustments could appear to selectively severs overactivated nerves at the be the problem, instead of a compensation. In The computer is probably the most dramatic base of the spinal column. the past, doctors relied on clinical examination, example of a communication device that can observation of the gait and the measurement of Because it reduces the amount of stimulation make a big difference in the lives of people motion and spasticity to determine the muscles that reaches muscles via the nerves, SDR is with cerebral palsy. Equipped with a computer involved. Now, doctors have a diagnostic most commonly used to relax muscles and and voice synthesizer, a child or adult with technique known as gait analysis. decrease chronic pain in one or both of the cerebral palsy can communicate successfully lower or upper limbs. It is also sometimes with others. For example, a child who is Gait analysis uses cameras that record how used to correct an overactive bladder. Potential unable to speak or write but can make head an individual walks, force plates that detect side effects include sensory loss, numbness or movements may be able to control a computer when and where feet touch the ground, a uncomfortable sensations in limb areas once using a special light pointer that attaches to a special recording technique that detects muscle supplied by the severed nerve. headband. activity (known as electromyography), and a computer program that gathers and analyzes Even though the use of microsurgery the data to identify the problem muscles. Using techniques has refined the practice of SDR gait analysis, doctors can precisely locate surgery, there is still controversy about how which muscles would benefit from surgery selective SDR actually is. Some doctors have concerns because it is invasive and irreversible
Page 46 www.ILmassageCE.com A person with severe cerebral palsy may be unable to speak clearly. The massage therapist How common is fibromyalgia? and the client need to devise an unspoken code that allows them to communicate. Ideas include Scientists estimate that fibromyalgia affects blinking the eyes once for “yes” and closing them for no; or using hand signals, such one 5 million Americans age 18 or older. For finger for “yes” and two for “no.” Other signals could be agreed upon to indicate discomfort unknown reasons, between 80 and 90 percent or other conditions. of those diagnosed with fibromyalgia are women; however, men and children also can Massage and cerebral palsy cerebral palsy and ensure they find the be affected. Most people are diagnosed during People with cerebral palsy, including children, massage relaxing and enjoyable. middle age, although the symptoms often can derive many benefits from massage that become present earlier in life. is handled correctly. A 2004 study of children Massage for these people is geared to People with certain rheumatic diseases, with cerebral palsy in early intervention palliative care, making light gliding strokes such as rheumatoid arthritis, systemic lupus programs conducted by the Easter Seal Society and gentle kneading most effective in creating erythematosus (commonly called lupus) or and the United Cerebral Palsy Foundation a relaxing experience for the client. Passive ankylosingspondylitis (spinal arthritis) may be found symptoms in children decreased stretching and joint mobilizations should be more likely to have fibromyalgia, too. following massage therapy [Hernandez-Reif omitted or used only with caution because et al.]. the bone integrity of patients whose mobility Several studies indicate that women who is impaired often is also compromised. A have a family member with fibromyalgia are The researchers said after 12 weeks of twice- massage for a person with CP should never more likely to have fibromyalgia themselves, weekly massage therapy sessions (added to hurt. but the exact reason for this – whether it is their standard care, which included physical heredity, shared environmental factors, or both therapy), very young children with CP showed Part II: Fibromyalgia – is unknown. One current study supported reduced spasticity and less overall arm About fibromyalgia by the National Institute of Arthritis and hypertonic (rigid) muscle tone. They noted Fibromyalgia syndrome is a common and Musculoskeletal and Skin Diseases (NIAMS) the reduction in spasticity was very important chronic disorder characterized by widespread is trying to determine whether variations in because spastic tone disorder – a major factor pain, diffuse tenderness, and a number of other certain genes cause some people to be more for many with CP – leads to increased muscle symptoms. The word “fibromyalgia” comes sensitive to stimulithat lead to pain syndromes. tone or rigidity, decreased range of motion from the Latin term for fibrous tissue fibro( ) and formation of contractures and limited and the Greek ones for muscle (myo) and pain What causes fibromyalgia? movement. In addition, children who received (algia). The causes of fibromyalgia are unknown, massage therapy in the study had improved Although fibromyalgia is often considered an but there are probably a number of factors range of motion scores for hip extension. arthritis-related condition, it is not truly a form involved. Many people associate the development of fibromyalgia with a physically The volunteer licensed massage therapists in of arthritis (a disease of the joints) because it or emotionally stressful or traumatic event, the study followed a strict protocol, addressing does not cause inflammation or damage to the such as an automobile accident. Some connect the head, face and scalp; shoulders, arms and joints, muscles, or other tissues. Like arthritis, it to repetitive injuries. Others link it to an hands; chest, hips, legs and feet; and back however, fibromyalgia can cause significant illness. For others, fibromyalgia seems to occur of each child. Techniques included stroking, pain and fatigue, and it can interfere with a spontaneously. light circular massage, kneading, flexing wrist person’s ability to carry on daily activities. and fingers, rolling and stroking arms; small Also like arthritis, fibromyalgia is considered Many researchers are examining other causes, fingers circles and other fingertip techniques; a rheumatic condition, a medical condition including problems with how the central moving the child’s knee toward his chest that impairs the joints and/or soft tissues and nervous system (the brain and spinal cord) without forcing joints to work the hips; and causes chronic pain. processes pain. circle strokes on the back. In addition to pain and fatigue, people who Some scientists speculate that a person’s Considerations have fibromyalgia may experience a variety of genes may regulate the way his or her body other symptoms including: processes painful stimuli. According to this Massage therapists should assess a client’s condition to determine the severity of his or Cognitive and memory problems theory, people with fibromyalgia may have a (sometimes referred to as “fibro fog”). gene or genes that cause them to react strongly her condition and modify massage treatments Sleep disturbances. to stimuli that most people would not perceive appropriately, regardless of age. Comfort for Morning stiffness. as painful. There have already been several the client is important; cushions or alternate Headaches. genes identified that occur more commonly positions, such as seated or on the side, should Irritable bowel syndrome. in fibromyalgia patients, and researchers are be considered. Massage also can be performed in a wheelchair. Painful menstrual periods. currently looking at other possibilities. Numbness or tingling of the extremities. A therapist must remember that the condition Restless legs syndrome. is caused by problems in the brain; the Temperature sensitivity. contractures and tightening of connective Sensitivity to loud noises or bright lights. tissue around muscles are symptoms of that problem. To reach the goal of improving Fibromyalgia is a syndrome rather than a muscle tone, a therapist must look beyond disease. A syndrome is a collection of signs, a client’s limbs. Many bodyworkers find symptoms and medical problems that tend to craniosacral work, with gentle rocking, slow occur together but are not related to a specific, range-of-motion exercises and manipulation of identifiable cause. A disease, on the other hand, arms and legs, works best. But therapists may has a specific cause or causes and recognizable have to experiment with different approaches signs and symptoms. to find the right moves to help clients with www.ILmassageCE.com Page 47 Back side of the body: The occiput, Following are some of the most commonly suboccupital muscle insertions; used categories of drugs for fibromyalgia. trapezius, midpoint of the upper border; Analgesics supraspinatus, above the medial border Analgesics are painkillers. They range of the scapular spine; gluteal, upper outer from over-the-counter acetaminophen quadrants of buttocks; and great trochanter, (Tylenol) to prescription medicines, such posterior to the trochanteric prominence. as tramadol (Ultram), and even stronger Front side of the body: Low cervical, narcotic preparations. For a subset of anterior aspect of the intertransverse spaces people with fibromyalgia, narcotic at C5-C7; second rib, second costochondral medications are prescribed for severe junctions; lateral epicondyle, 2 cm distal to muscle pain. However, there is no solid the epicondyles; and knee, medial fat pad evidence showing that for most people proximal to the joint line. narcotics actually work to treat the chronic pain of fibromyalgia, and most doctors Risk factors hesitate to prescribe them for long-term Causes and risk factors are unknown, but use because of the potential that the person some things have been loosely associated with taking them will become physically or disease onset, according to the Centers for psychologically dependent on them. Figure 1: Tender points on the body Disease Control. These include: Nonsteroidal anti-inflammatory drugs used to diagnose fibromyalgia Stressful or traumatic events, such as car (NSAIDs) accidents, post-traumatic stress disorder As their name implies, nonsteroidal How is fibromyalgia diagnosed? (PTSD). anti-inflammatory drugs, including Research shows that people with fibromyalgia Repetitive injuries. aspirin, ibuprofen (Advil, Motrin) and typically see many doctors before receiving Illness, such as viral infections. naproxen sodium (Anaprox, Aleve), are the diagnosis. One reason for this may be Certain diseases, such as rheumatoid used to treat inflammation. Although that pain and fatigue, the main symptoms of arthritis and chronic fatigue syndrome. inflammation is not a symptom of fibromyalgia, overlap with those of many Genetic predisposition. other conditions. Therefore, doctors often fibromyalgia, NSAIDs also relieve pain. have to rule out other potential causes of How is fibromyalgia treated? The drugs work by inhibiting substances these symptoms before making a diagnosis Fibromyalgia can be difficult to treat. Not all in the body called prostaglandins, which of fibromyalgia. Another reason is that there doctors are familiar with fibromyalgia and its play a role in pain and inflammation. are currently no diagnostic laboratory tests for treatment, so it is important to find a doctor These medications, some of which are fibromyalgia; standard laboratory tests fail to who is. Many family physicians, general available without a prescription, may help reveal a physiologic reason for pain. Because internists or rheumatologists (doctors who ease the muscle aches of fibromyalgia. there is no generally accepted, objective test specialize in arthritis and other conditions They may also relieve menstrual cramps for fibromyalgia, some doctors unfortunately that affect the joints or soft tissues) can treat and the headaches often associated with may conclude a patient’s pain is not real, or fibromyalgia. fibromyalgia. Antidepressants they may tell the patient there is little they can Fibromyalgia treatment often requires a team Perhaps the most useful medications do. approach, with a doctor, physical therapist, for fibromyalgia are several in the possibly other health professionals, and most A doctor familiar with fibromyalgia, how- antidepressant class. These drugs work importantly, the patient, all playing an active ever, can make a diagnosis based on crite- equally well in fibromyalgia patients role. It can be hard to assemble this team, ria established by the American College of with and without depression, because and it may be a struggle to find the right Rheumatology (ACR): a history of widespread antidepressants elevate the levels of certain professionals to treat the patient. However, pain lasting more than three months, and the chemicals in the brain (including serotonin the combined expertise of these various presence of diffuse tenderness. Pain is consid- and norepinephrine) that are associated professionals can help people improve their ered to be widespread when it affects all four not only with depression, but also with quality of life. quadrants of the body, meaning it must be felt pain and fatigue. Increasing the levels of on both the left and right sides of the body as A good place to find members of such these chemicals can reduce pain in people well as above and below the waist. ACR also a treatment team is a clinic. There are who have fibromyalgia. Doctors prescribe has designated 18 sites on the body as possible pain clinics that specialize in pain and several types of antidepressants for people tender points. To meet the strict criteria for a rheumatology clinics that specialize in arthritis with fibromyalgia, described below. fibromyalgia diagnosis, a person must have 11 and other rheumatic diseases, including Tricyclic antidepressants. When or more tender points, but often patients with fibromyalgia. taken at bedtime in dosages lower fibromyalgia will not always be this tender, Only three medications, duloxetine than those used to treat depression, especially men. People who have fibromyalgia (Cymbalta1), milnacipran (Savella), and tricyclic antidepressants can help certainly may feel pain at other sites, too, but pregabalin (Lyrica) are approved by the U.S. promote restorative sleep in people those 18 standard possible sites on the body Food and Drug Administration (FDA) for with fibromyalgia. They also can are the criteria used for classification. the treatment of fibromyalgia. Cymbalta was relax painful muscles and heighten Figure 1 shows the location of the nine originally developed for and is still used to the effects of the body’s natural pain- paired tender points that make up the 1990 treat depression. Savella is similar to a drug killing substances called endorphins. American College of Rheumatology criteria used to treat depression, but is FDA approved Tricyclic antidepressants have been for fibromyalgia. The anatomical locations only for fibromyalgia. Lyrica is a medication around for almost half a century. Some of tender points associated with fibromyalgia developed to treat neuropathic pain (chronic examples of tricyclic medications include: pain caused by damage to the nervous system). used to treat fibromyalgia include
Page 48 www.ILmassageCE.com amitriptyline hydrochloride (Elavil, to other therapies because of the potential Other ways to improve quality of life Endep), cyclobenzaprine (Cycloflex, for addiction. Benzodiazepines include Besides taking prescription medicine, there Flexeril, and Flexiban), doxepin clonazepam (Klonopin) and diazepam are many things people can do to minimize the (Adapin, Sinequan) and nortriptyline (Valium). impact of fibromyalgia on their lives. These (Aventyl, Pamelor). Both amitriptyline Other medications include: and cyclobenzaprine have been In addition to the previously described Getting enough sleep. Getting enough proven useful for the treatment of general categories of drugs, doctors sleep and the right kind of sleep can help fibromyalgia. may recommend or prescribe others, ease the pain and fatigue of fibromyalgia. Selective serotonin reuptake depending on a person’s specific symptoms Even so, many people with fibromyalgia inhibitors. If a tricyclic antidepressant or fibromyalgia-related conditions. For have problems such as pain, restless legs fails to bring relief, doctors example, for people with irritable bowel syndrome or brainwave irregularities that sometimes prescribe a newer type syndrome (IBS), doctors may suggest interfere with restful sleep. It is important of antidepressant called a selective fiber supplements or laxatives to relieve to discuss any sleep problems with the serotonin reuptake inhibitor (SSRI). constipation or medications such as doctor, who can prescribe or recommend As with tricyclics, doctors usually diphenoxylate/atropine (Lotomil) or treatment for them. prescribe these for people with loperamide (Imodium) for diarrhea. A Exercising. Although pain and fatigue fibromyalgia in lower dosages than prescription medication called alosetron may make exercise and daily activities are used to treat depression. By (Lotronex) is approved for the treatment difficult, it is crucial to be as physically promoting the release of serotonin, of severe IBS with diarrhea that does not active as possible. Research has repeatedly these drugs may reduce fatigue and respond to other treatment. Another drug, shown that regular exercise is one of the some other symptoms associated with lubiprostone (Amitiza), is approved for the most effective treatments for fibromyalgia. fibromyalgia. The group of SSRIs treatment of IBS with constipation. People who have too much pain or fatigue includes fluoxetine (Prozac), paroxetine to do vigorous exercise should begin with Antispasmodic medications may be useful (Paxil) and sertraline (Zoloft). Newer walking or other gentle exercise and build for relieving intestinal spasms and reducing SSRIs such as citalopram (Celexa) or their endurance and intensity slowly. abdominal pain. Other symptom-specific escitalopram (Lexapro) do not seem Making changes at work. Most people medications include sleep medications, to work as well for pain as the older with fibromyalgia continue to work, but muscle relaxants, and headache remedies. SSRIs. they may have to make big changes to SSRIs may be prescribed along People with fibromyalgia also may benefit do so. For example, some people cut with a tricyclic antidepressant. from a combination of physical and down the number of hours they work, Studies have shown that a occupational therapy, from learning pain switch to a less demanding job, or adapt combination therapy of the management and coping techniques, and a current job. The employer of a person tricyclicamitriptyline and the from properly balancing rest and activity. who face obstacles at work, such as an SSRI fluoxetine resulted in uncomfortable desk chair that leaves his greater improvements in the Complementary and alternative therapies or her back aching or who has difficulty study participants’ fibromyalgia Many people with fibromyalgia also lifting heavy boxes or files, may make symptoms than either drug alone. report varying degrees of success with adaptations that will enable the person to Mixed reuptake inhibitors. Some complementary and alternative therapies, keep the job. And sometimes it is just a newer antidepressants raise levels of including massage, movement therapies case of asking for the accommodation. An both serotonin and norepinephrine (such as Pilates and the Feldenkrais method), occupational therapist can help a person and are therefore called mixed chiropractic treatments, acupuncture and design a more comfortable workstation or reuptake inhibitors. Examples of various herbs and dietary supplements for find more efficient and less painful ways these medications include venlafaxine different fibromyalgia symptoms. to lift. (Effexor), duloxetine (Cymbalta) and Although some of these supplements are being People who are unable to work at (Savella). In general, these drugs work studied for fibromyalgia, there is little, if any, all because of a medical condition better for pain than SSRIs, probably scientific proof yet that they help. FDA does may qualify for disability benefits because they also raise norepinephrine, not regulate the sale of dietary supplements, so through their employer or the federal which may play an even greater role in information about side effects, proper dosage government. Social Security Disability pain transmission than serotonin. and the amount of a preparation’s active Insurance (SSDI) and Supplemental Benzodiazepines ingredient may not be well known. People who Security Insurance (SSI) are the largest Benzodiazepines can sometimes help are using or would like to try a complementary federal programs providing financial people with fibromyalgia by relaxing tense, or alternative therapy should first speak with assistance to people with disabilities. painful muscles and stabilizing the erratic their doctors, who may know more about the Although the medical requirements brain waves that can interfere with deep therapy’s effectiveness as well as whether for eligibility are the same under the sleep. Benzodiazepines also can relieve it is safe to try in combination with current two programs, the way they are funded the symptoms of restless legs syndrome, a medications. is different. SSDI is paid by Social neurological disorder that is more common Will fibromyalgia get better with time? Security taxes, and those who qualify among people with fibromyalgia. The for assistance receive benefits based Fibromyalgia is a chronic condition, meaning disorder is characterized by unpleasant on how much they have paid into it lasts a long time – possibly a lifetime. sensations in the legs and an uncontrollable the system. SSI is funded by general However, it may be comforting to know that urge to move the legs, particularly when at tax revenues, and those who qualify fibromyalgia is not a progressive disease. It rest, in an effort to relieve these feelings. receive payments based on financial is never fatal, and it will not cause damage to Doctors usually prescribe benzodiazepines need. For information about the SSDI the joints, muscles or internal organs. In many only for people who have not responded people, the condition does improve over time. www.ILmassageCE.com Page 49 and SSI programs, contact the Social researchers are focusing on ways the body Improving symptoms. A better Security Administration. processes pain to better understand why understanding of fibromyalgia and the Eating well. Although some people people with fibromyalgia have increased mechanisms involved in chronic pain with fibromyalgia report feeling better pain sensitivity. These studies include: are enabling researchers to find effective when they eat or avoid certain foods, no An investigation into the relationship treatments for it. Some of the most specific diet has been proven to influence between variations in a gene called promising lines of research in this area fibromyalgia. Of course, it is important to ADRA1A and risk factors for chronic include the following: have a healthy, balanced diet. Not only will pain conditions. Increasing exercise. Although proper nutrition give people more energy The establishment of a tissue bank fibromyalgia is often associated with and make them generally feel better, it of brain and spinal cord tissue to fatigue that makes exercise difficult, will also help them avoid other health study fibromyalgia and to determine regular exercise has been shown to be problems. the extent to which chronic pain in one of the most beneficial treatments fibromyalgia patients is associated with for the condition. A new study is Tips for good sleep for your client – or the activation of cells in the nervous trying to determine whether increasing yourself system and the production of chemical lifestyle physical activity (that is, Keep regular sleep habits. Try to get to messengers, called cytokines, that adding more exercise such as walking bed at the same time and get up at the same promote inflammation. up stairs instead of taking the elevator) time every day – even on weekends and The use of imaging methods to throughout the day produces similar vacations. evaluate the status of central nervous benefits to exercise for fibromyalgia, Avoid caffeine and alcohol in the late system responses in patients diagnosed improving symptoms such as pain, afternoon and evening. If consumed with fibromyalgia compared with those fatigue and tenderness. The study too close to bedtime, the caffeine in diagnosed with another chronic pain is also examining the potential coffee, soft drinks, chocolate and some disorder and pain-free controls. mechanisms by which lifestyle physical medications can keep you from sleeping or An investigation to understand how activity might influence symptoms. sleeping soundly. Even though it can make the activation of immune cells from Other research is examining the you feel sleepy, drinking alcohol around peripheral and central nervous system effectiveness of a 16-week program of bedtime also can disturb sleep. sources trigger a cascade of events a simplified form of tai chi on pain and Time your exercise. Regular daytime leading to the activation of nerve cells, other measures such as sleep quality, exercise can improve nighttime sleep. But chronic pain, and the dysregulation of fatigue, anxiety and depression. avoid exercising within three hours of the effects of analgesic drugs against Research is also examining ways bedtime, which actually can be stimulating, pain. to help people maintain helpful keeping you awake. An intensive evaluation of twins in exercise programs. Because many Avoid daytime naps. Sleeping in the which one of the pair has chronic people with fibromyalgia associate afternoon can interfere with nighttime widespread pain and the other does increased exercise with increased sleep. If you feel you cannot get by without not, along with twins in which neither pain, doctors and therapists often a nap, set an alarm for one hour. When it of the pair has chronic pain, to help have a difficult time getting goes off, get up and start moving. researchers assess physiological patients to stick with their exercise Reserve your bed for sleeping. Watching similarities and differences in those program. The new research is the late news, reading a suspense novel with and without chronic pain and examining patients’ fears that cause or working on your laptop in bed can whether those differences are caused them to avoid exercise as well as stimulate you, making it hard to sleep. by genetics or environment. behavioral therapies to reduce fears Keep your bedroom dark, quiet and A study examining the use of cognitive and help them maintain exercise. cool. behavioral therapy in pain patients, Improving sleep. Researchers Avoid liquids and spicy meals before which researchers hope will advance supported by NIAMS are investigating bed. Heartburn and late-night trips to the their knowledge of the role of ways to improve sleep for people bathroom are not conducive to good sleep. psychological factors in chronic pain with fibromyalgia whose sleep Wind down before bed. Avoid working as well as a new treatment option for problems persist despite treatment right up to bedtime. Do relaxing activities, fibromyalgia. with medications. One team has such as listening to soft music or taking The Patient-Reported Outcomes observed that fibromyalgia patients a warm bath, that get you ready to sleep. Measurement Information System with persistent sleep problems share (A warm bath also may soothe aching (PROMIS) initiative. The PROMIS characteristics with people who have muscles.) initiative is researching and developing sleep-disordered breathing, a group What are researchers learning about new ways to measure patient-reported of disorders, the most common of fibromyalgia? outcomes (PROs), such as pain, fatigue, which is the obstructive sleep apnea, A number of government studies have been physical functioning, emotional distress characterized by pauses in breathing approved to learn more about fibromyalgia. and social role participation that have a during sleep. These researchers are Following are descriptions of some of the major impact on quality of life across a studying whether continuous positive promising research now being conducted: variety of chronic diseases. The goal of airway pressure (CPAP, a therapy Understanding pain. Research suggests this initiative is to improve the reporting administered by a machine that that fibromyalgia is caused by a problem and quantification of changes in patient- increases air pressure in the throat in how the body processes pain, or more reported outcomes. NIAMS supports an to hold it open during sleep) might precisely, a hypersensitivity to stimuli that effort to develop PROMIS specifically for improve the symptoms of fibromyalgia. normally are not painful. Therefore, several use in patients with fibromyalgia. Other groups of researchers are National Institutes of Health-supported examining the link between sleep
Page 50 www.ILmassageCE.com disturbance and chronic pain in Characteristics Fibromyalgia syndrome Myofascial pain syndrome fibromyalgia and are studying whether behavioral therapy Tender points with pressure Trigger points and referred pain for insomnia might improve Primary symptom application; intense, diffuse patterns with pressure application; fibromyalgia symptoms. pain muscle twitch Gender 85 percent women Equally men and women Massage considerations Some estimates are as high as 14 Ruth Werner, president of the Massage Prevalence Up to 3 percent of population Therapy Foundation, a massage therapist, percent of the population author of the influential textbook for therapists Life-long problem; can be Can be a chronic or a short-term Prognosis “A Massage Therapist’s guide to Pathology” managed but not cured problem and others, says: “The most important message People are believed to have active trigger Hypothyroidism, hyperuricemia and about massage for fibromyalgia is that patients points, which are tight and painful. Latent hypoglycemia also have been implicated. have good days and bad days. Their tolerance trigger points are not painful unless they are for depth, speed and pressure in massage can Risk factors irritated, and do not refer pain. However, vary greatly day to day; the therapist must Factors that may increase the risk of latent trigger points may be linked to range-of- always stay within individual pain tolerance.” developing active trigger points include: motion problems and muscle weakness. They Muscle injury. Muscle stress and The body of research on massage therapy also can quickly turn into active trigger points repetitive stress may increase the risk of and fibromyalgia is not large. However, a with very little stimulus. number of studies support that relaxation developing trigger points. Work practices Patients with myofascial pain typically report control massage can improve sleep patterns that include repetitive motion, in particular, regionalized aching and poorly localized and decrease pain, fatigue, anxiety, depression may increase the risk for people. pain in muscles and joints. They may report and even cortisol levels in adults with Inactivity. People who have been unable numbness or other sensory issues. They may fibromyalgia. to use their muscles because of other not be aware that there is weakness in the illnesses may develop trigger points. Experts generally encourage gentle massage, affected muscles. Stress and anxiety. People who experience with slow progression only when appropriate How common is myofascial pain stress and anxiety frequently may be more to a specific client. Trigger point massage syndrome? likely to develop trigger points. Some may help with tender points, but aggressive, No one really knows how prevalent the theorists say stressed people may be more deep pressure should not be used. Lymph disorder is. But myofascial pain is very likely to clench their muscles, a kind of drainage therapy can also be helpful to a client common; nearly everyone will develop repetitive strain that may contribute to – but only with very light movements. Other a trigger point at some time. Some have developments of trigger points. modalities are indicated, but only with caution estimated 14 percent of the population Age: Chronic myofascial pain occurs and within the client’s tolerance. Any use of has trigger points producing pain. Other mainly in men and women between 30 ice or ice massage is contraindicated. researchers say that up to 23 million and 60 years old. Researchers are unsure Part III: Myofascial Pain Syndrome Americans have chronic musculoskeletal pain why younger and older people appear less About myofascial pain syndrome involving trigger points. susceptible to the disorder. A disorder that shares many qualities of What causes myofascial pain syndrome? Signs and symptoms fibromyalgia is myofascial pain syndrome The cause myofascial pain is also unknown, The key symptom of myofascial pain is the (MPS). It is a painful disorder that can affect but researchers have identified several factors presence of the trigger points that respond to any skeletal muscles and produce acute or that appear to contribute to it. Abnormal touch and create a twitch response leading to chronic musculoskeletal pain. The pain centers stresses such as sudden stress on shortened pain. The trigger points are bands or nodules around sensitive points in the muscle called muscles; mechanical factors, such as having that are taut, hypertonic bands of fibers within trigger points, which may be felt as taut bands one leg longer than the other; or skeletal a mass of muscle that is less tight. Palpitating of muscle. It may be local or referred pain, asymmetry are thought to be a common the tissue can produce a muscle flicker, or and include tightness, tenderness, stiffness causative factor. Poor posture, stress, overuse twitch response. and limited movement, twitching and muscle or repetitive use of muscles, poor techniques weakness. Other unique symptoms include: for work activities or a static position for a Referred pain. In addition to the area of Many of the trigger points correspond to long period also can put excessive strain on the affected muscle, there is pain from the acupuncture points used to treat pain, and muscles, leading to chronic pain. trigger point elsewhere on the body. many types of pain, including headaches, jaw The science of trigger points is evolving. Regional pain: Trigger points usually pain, neck pain, low back pain, pelvic pain and While they were traditionally thought of as flare up in specific regions, often around arm and leg pain, have been linked to trigger microscopic injuries to individual muscle the neck and shoulders. Jaw muscles often points. fibers that created a pain cycle, researchers develop trigger points, causing pain all While they sometimes appear similar – and a now think they might be a neuromuscular over the face and head. person may suffer with both – the differences reaction with a microscopic contraction that Pain patterns. The areas of skeletal between fibromyalgia and myofascial pain are inhibits circulation, creating the taut band and muscles that are likely to develop trigger significant. They include: releasing chemicals that increase sensitivity points have been mapped, as have the and pain. patterns of referred pain. Others theories suggest that anemia and Reduced range of motion and feelings of deficiencies in calcium, potassium, iron and muscle weakness are common, as well as vitamins may play roles; chronic infections tingling and stiffness. Sleep problems also may and sleep deprivation also are suspected. be present. www.ILmassageCE.com Page 51 How is myofascial pain syndrome Prognosis National Institutes of Health (NIH) in 1997 diagnosed? Myofascial pain syndrome is a chronic stated that acupuncture is being “widely” There are no specific tests or criteria for pain disorder that is not fatal. But without practiced – by thousands of physicians, diagnosing MPS. Nearly everyone has trigger treatment, it can significantly reduce the dentists, acupuncturists and other practitioners points, often latent and not actively causing quality of life for sufferers. The pain, however, – for relief or prevention of pain and for pain, and that, too, complicates diagnosis. can be minimized with treatment. various other health conditions. According to However, physicians looking for the source Treatments the 2007 National Health Interview Survey, which included a comprehensive survey of of pain normally know to look for the trigger Dealing with trigger points is the ultimate goal complementary and alternative medicine points, the biggest clue to diagnosing the of myofascial pain treatments. Desensitizing by Americans, an estimated 3.1 million syndrome. them to alleviate pain can be addressed a U.S. adults and 150,000 children had used A physician will perform a thorough history number of ways. These include trigger-point acupuncture in the previous year. Between the and examination, including a review of injections, physical therapy, acupuncture, local 2002 and 2007 NHIS, acupuncture use among symptoms. The doctor will examine areas of anesthetics or numbing solutions, vapo-coolant adults increased by three-tenths of 1 percent pain, including range of motion and strength spray and local moist heat applications; and (approximately 1 million people). testing. The physician may feel for trigger massage with manual pressure to help stretch points by applying gentle finger pressure affected muscles. Medications to the painful area to find tense areas, and Trigger point injections Numbing medications or corticosteroid monitor a patient’s reaction. He or she may medications may be used during needling. During a trigger point injection, the doctor apply pressure on or around the trigger points Other medications treat the signs and inserts a needle with an anesthetic into and looking for the telltale twitch. symptoms of myofascial pain syndrome, around a trigger point, a procedure called including: Lab tests may be ordered to look for medical “needling.” Dry needling is sometimes Nonsteroidal anti-inflammatory drugs causes of muscle pain, such as vitamin D performed with no injected medications. These (NSAIDs). These drugs, sold over- deficiency or hypothyroidism. can relieve the pain around the trigger point. the-counter, include ibuprofen (Advil, Complications Steroids Motrin and others) and naproxen (Aleve). If they are not already present, myofascial Steroids may be used in areas where Prescription NSAIDs also may be pain syndrome can lead to other issues over inflammation is confirmed or suspected. dispensed. time. These include: Botulinum toxin (Botox) may be used to block Depression medications: A class of Muscle weakness: While trigger points acetylcholine release at the neruomuscular medications for depression, tricyclic don’t actually hurt muscles, the pain junction. antidepressants, may be used for pain. and a patient’s tendency to avoid using Topical anesthetics Amitriptyline (Elavil) often is used for this the affected muscle can lead to muscle At least one study found that a topical pain. weakness over time. Other unaffected anesthetic patch helped reduce myofascial pain muscles also can be stressed when the Massage considerations without the discomfort of an injection. The muscle affected by myofascial pain does Therapists should discuss the areas of pain study found those who received the patch had not function properly. with a client and massage those and adjacent fewer subjective symptoms and increased pain Sleep issues: Patients enduring myofascial areas. Therapeutic massage can help loosen thresholds. pain syndrome often find it difficult to get tight muscles and relieve any cramping are comfortable or sleep. Simple moving while Physical therapy spasms. Long hand strokes along the muscle or sleeping can activate a trigger point. A physical therapist will design a plan based specific pressure on specific areas may release Fibromyalgia: The two syndromes on a patient’s symptoms. These may include: tension. Moist heat may be used to soften often co-exist in people. Some experts Stretching: Gentle stretching exercises fascia before bodywork begins. Deep gliding, believe people with fibromyalgia are more with the affected muscle may help ease kneading and deep-friction movements are all sensitive to pain signals. Whether that pain. Numbing solutions may also be used indicated with client tolerance. Slow, gradual sensitivity connects the two syndromes is during the exercise. pressure may work best. an area still to be explored. Identifying pain factors: If poor posture, Massage also can help clean up the debris for example, causes muscle stress in a Can myofascial pain be prevented? that results when muscle cells can’t exchange person’s back, a physical therapist can nutrients for metabolic waste. There are no specific regimens to prevent provide exercises to correct the posture. Avoid oscillating movements such as myofascial pain. However, the general rules Workplace issues, such as muscle overuse percussion and vibration because these for maintaining a healthy body may at a and ergonomics, also may addressed. movements may cause localized contractions. minimum reduce the severity of MPS: Massage also may be a key part of the PT Therapists must be mindful of a patient’s pain Focus on and improve posture. plan. (See below). Maintain a healthy weight; reduce if and tolerance levels at all times. overweight. Acupuncture Part IV: Chronic Fatigue Syndrome Based on traditional Chinese medicine, during Exercise regularly. About chronic fatigue syndrome: The Eat a healthy, well-balanced diet. an acupuncture session, a practitioner places mystery disease Learn stress-management techniques. thin needles at specific points in the body. Chronic fatigue syndrome, or CFS, is Learn about issues such as repetitive This process is believed to adjust and alter the a devastating and complex disorder motion problems and the proper body’s energy flow into healthier patterns, and characterized by overwhelming fatigue that precautions to take, at work and during is used to treat a wide variety of illnesses and is not improved by bed rest and that may exercise and sports. health conditions, including myofascial pain. be worsened by physical or mental activity. A report from a Consensus Development People with CFS most often function at a Conference on Acupuncture held at the
Page 52 www.ILmassageCE.com significantly lower level of activity than they Other commonly observed symptoms in Infectious agents were capable of before the onset of illness. CFS Due in part to its similarity to acute or In addition to these key defining Abdominal pain. chronic infections, CFS was initially thought characteristics, patients report various Alcohol intolerance. to be caused by a virus (i.e., Epstein-Barr, nonspecific symptoms, including weakness, Bloating. mononucleosis). However, a CDC four-city muscle pain, impaired memory and/or mental Chest pain. surveillance study found no association concentration, insomnia and post-exertional Chronic cough. between CFS and infection by a wide variety fatigue lasting more than 24 hours. In some Diarrhea. of human pathogens, including Epstein-Barr cases, CFS can persist for years. Dizziness. virus, human retroviruses, human herpesvirus Dry eyes or mouth. 6, enteroviruses, rubella, Candida albicans, and Some experts have suggested that chronic Earaches. more recently, bornaviruses and Mycoplasma. fatigue syndrome and fibromyalgia syndrome Irregular heartbeat. Taken together, the CDC says these studies are two names for the same condition, with Jaw pain. suggest that among identified human CFS the early form of fibromyalgia. However, Morning stiffness. pathogens, there appears to be no one pathogen one key difference seems to be that persons Nausea. that causes CFS. with chronic fatigue experience more fatigue Night sweats. and persons with fibromyalgia experience However, in mid-2010, the medical-scientific Psychological problems (depression, community was abuzz with a new report that more pain. irritability, anxiety, panic attacks). supported a 2009 study in which scientists No specific diagnostic tests are available for Shortness of breath. identified a murine leukemia virus (MLV)- CFS. Moreover, since many illnesses have Skin sensations, such as tingling. related virus called XMRV in blood samples incapacitating fatigue as a symptom, care must Weight loss. from patients with documented CFS. be taken to exclude other known and often These symptoms do not contribute to the The findings were discounted when other treatable conditions before a diagnosis of CFS diagnosis of CFS. researchers subsequently were unable to find is made. MLF-related virus gene sequences in CFS How common is CFS – diagnostic Because of the limited knowledge about this patients. challenges mysterious condition, a patient must satisfy Diagnosing chronic fatigue syndrome (CFS) So, in 2010, a U.S. Food and Drug two criteria to be diagnosed with chronic can be complicated by a number of factors: Administration researcher decided to test fatigue syndrome: 1. There’s no diagnostic laboratory test or frozen samples of blood taken from well- 1. Have severe chronic fatigue for at least six biomarker for CFS. documented CFS patients about 20 years ago. months or longer that is not relieved by 2. Fatigue and other symptoms of CFS are In collaboration with the National Institutes rest and not due to medical or psychiatric common to many illnesses. of Health, the new team searched for MLF- conditions associated with fatigue as 3. CFS is an invisible illness and many related viruses in both patients and healthy excluded by clinical diagnosis. patients don’t look sick. donors. In August 2010, the team reported 2. Concurrently have four or more of the 4. The illness has a pattern of remission and the researchers had found MLF-like virus following symptoms: relapse. gene sequences in 32 of 37 (86.5 percent) of Self-reported impairment in short- 5. Symptoms vary from person to person in the CFS patients, compared with 3 of 44 (6.8 term memory or concentration severe type, number and severity. percent) of healthy donors. enough to cause substantial reduction Dr. Harvey J. Alter at the NIH’s Clinical in previous levels of occupational, These factors have contributed to an Center emphasized that the new findings educational, social, or personal alarmingly low diagnosis rate. Of the 4 million do not prove causality for the virus, but do activities. Americans who are estimated to have CFS, provide more support for the earlier study. His Sore throat that’s frequent or recurring. less than 20 percent have been diagnosed. Tender cervical or axillary lymph team is continuing to test the theory. The issue Causes of CFS nodes. has attracted much attention because of its The cause or causes of CFS remain unknown, Muscle pain. potentially far-reaching implications. Alter’s despite a vigorous search and debate. While Multi-joint pain without swelling or group is currently screening blood donors for a single cause for CFS may yet be identified, redness. evidence of transmission to recipients. If these another possibility is that CFS represents a Headaches of a new type, pattern or viruses do cause CFS, protecting the nation’s common endpoint of disease resulting from severity. blood supply will be a top priority. multiple sudden causes. Some of the possible Unrefreshing sleep. However, the possibility remains that CFS may causes of CFS might be due to infectious Post-exertional malaise (extreme, have multiple causes leading to a common agents, immunological dysfunction, stress prolonged exhaustion and sickness endpoint, in which case some viruses or other activating the hypothalamic-pituitary adrenal following physical or mental activity) infectious agents might have a contributing (HPA) axis, neurally mediated hypotension, lasting more than 24 hours. role for a subset of CFS cases. Recently and/or nutritional deficiency. published research suggests that infection The fatigue and impaired memory or As such, it should not be assumed that any with Epstein-Barr virus, Ross River virus and concentration must have impaired normal daily of the possible causes listed below has been Coxiellaburnetti will lead to a post-infective activities, along with other symptoms that formally excluded, or that these largely condition that meets the criteria for CFS must have persisted or recurred during six or unrelated possible causes are contradictory. in approximately 12 percent of cases. The more consecutive months of illness and must Conditions that have been proposed to severity of the acute illness was the only factor not have predated the fatigue. trigger the development of CFS include virus found to predict which individuals would have infection or other traumatic conditions, stress, persistent symptoms characteristic of CFS at and toxins. the six-month and one-year period following infection. www.ILmassageCE.com Page 53 Immunology Recent studies revealed that CFS patients Nutritional deficiency It has been proposed that CFS may be caused often produce lower levels of cortisol than There is no published scientific evidence that by an immunologic dysfunction, for example do healthy controls. Similar hormonal CFS is caused by a nutritional deficiency. inappropriate production of cytokines, such abnormalities have been observed by While evidence is currently lacking for as interleukin-1, or altered capacity of certain others in CFS patients and in persons with nutritional defects in CFS patients, it should immune functions. As of today, one thing related disorders like fibromyalgia. Cortisol also be added that a balanced diet can be is certain: there are no immune disorders suppresses inflammation and cellular immune favorable to better health in general and would in CFS patients on the scale traditionally activation, and reduced levels might relax be expected to have beneficial effects in any associated with disease. Some investigators constraints on inflammatory processes chronic illness. have observed anti-self antibodies and immune and immune cell activation. As with the Risk factors complexes in many CFS patients, both of immunologic data, the altered cortisol levels Women are diagnosed with chronic fatigue which are hallmarks of autoimmune disease. noted in CFS cases fall within the accepted syndrome at least four times as often as However, no associated tissue damage typical range of normal, and only the average between men. of autoimmune disease has been described in cases and controls allows the distinction to be The condition is most common in people in patients with CFS. The opportunistic infections made. Therefore, cortisol levels (under normal their 40s and 50s, but it can affect people or increased risk for cancer observed in conditions) cannot be used as a diagnostic of all ages. persons with immunodeficiency diseases or marker for an individual with CFS. in immunosuppressed individuals is also not A placebo-controlled trial in which 70 CFS Complications observed in CFS. Several investigators have patients were randomized to receive either just Many of the possible complications with CFS reported lower numbers of natural killer cells are related to lifestyle. They include: enough hydrocortisone each day to restore or decreased natural killer cell activity among their cortisol levels to normal or placebo Depression because of a lack of diagnosis CFS patients compared with healthy controls, pills for 12 weeks concluded that low levels as well as symptoms. but others have found no differences between Side effects from medication. of cortisol itself are not directly responsible patients and controls. for symptoms of CFS, and that hormonal Adverse effects from lack of activity. Social isolation. T-cell activation markers have also been replacement is not an effective treatment. reported to have differential expression However, additional research into other Missing work or losing a job. in groups of CFS patients compared with aspects of neuroendocrine correlates of CFS Symptoms of CFS controls, but again, not all investigators have is necessary to fully define this important, and Chronic fatigue syndrome can be consistently observed these differences. largely unexplored, field. misdiagnosed or overlooked because its One intriguing hypothesis is that various Neurally mediated hypotension symptoms are common to other many triggering events, such as stress or a viral Other studies have been conducted to disorders. Fatigue, for instance, is found infection, may lead to the chronic production determine whether disturbances in the in hundreds of illnesses. The nature of the of cytokines and then to CFS. Administration autonomic regulation of blood pressure and symptoms, however, can help distinguish CFS of some cytokines in therapeutic doses is pulse (neurally mediated hypotension, or from other illnesses. known to cause fatigue, but no characteristic NMH) were common in CFS patients. The Primary symptom pattern of chronic cytokine secretion has ever investigators were alerted to this possibility As the name chronic fatigue syndrome been identified in CFS patients. when they noticed an overlap between their suggests, this illness is accompanied by Finally, several studies have shown that CFS patients with CFS and those who had neurally fatigue. However, it’s not the kind of fatigue patients are more likely to have a history of mediated hypotension. NMH can be induced we experience after a particularly busy day or allergies than are healthy controls. Allergy by using tilt table testing, which involves week, after a sleepless night or after a single could be one predisposing factor for CFS, laying the patient horizontally on a table and stressful event. It’s a severe, incapacitating but it cannot be the only one, because not all then tilting the table upright to 70 degrees for fatigue that results in a dramatic decline CFS patients have it. Many patients do report 45 minutes while monitoring blood pressure in both activity level and stamina. The intolerances for certain substances that may be and heart rate. Persons with NMH will develop illness results in a substantial reduction in found in foods or over-the-counter medications lower blood pressure under these conditions, occupational (work-related), personal, social or and products such as alcohol or the artificial as well as other characteristic symptoms, such educational activities. sweetener aspartame. as lightheadedness, visual dimming or a slow response to verbal stimuli. Many CFS patients Other symptoms Hypothalamic-pituitary adrenal (HPA) experience lightheadedness or worsened Many CFS patients may experience other axis fatigue when they stand for prolonged periods symptoms, including: Multiple laboratory studies have suggested or when in warm places, such as in a hot Irritable bowel. that the central nervous system may have an shower. These conditions are also known to Depression or psychological problems important role in CFS. Physical or emotional trigger NMH. (irritability, mood swings, anxiety, panic stress, which is commonly reported as a pre- attacks). Neurally mediated hypotension and postural onset condition in CFS patients, alters the Chills and night sweats. tachycardia syndromes share some of the activity of the hypothalamic-pituitary-adrenal Visual disturbances (blurring, sensitivity to symptoms of CFS. They should be considered axis, or HPA axis, leading to altered release light, eye pain). if symptoms are common with changes in of corticotrophin-releasing hormone (CRH), Allergies or sensitivities to foods, odors, position, after eating, unusual amounts of cortisol and other hormones. CRH influences chemicals, medications or noise. or inadequate fluid intake, or increases in the immune system and many other body Brain fog (feeling like you’re in a mental activity. Current evidence does not support systems. It may also affect several aspects of fog). these conditions as being universally present in behavior. Difficulty maintaining upright position, patients with CFS. dizziness, balance problems or fainting.
Page 54 www.ILmassageCE.com All of these symptoms may co-occur in Self-diagnosis A decrease in stamina that interferes with CFS, or they may indicate that a person has Chronic fatigue syndrome can resemble many daily living activities. another treatable disorder. Only a health care other illnesses, including mononucleosis, Memory and concentration problems professional can diagnose CFS. Lyme disease, lupus, multiple sclerosis, that seriously affect work or school What’s the clinical course of CFS? fibromyalgia, primary sleep disorders, severe performance. obesity and major depressive disorders. Loss of independence, livelihood and The severity of CFS varies from patient to Medications can also cause side effects that economic security. patient, with some people able to maintain mimic the symptoms of CFS. Alterations in relationships with family and fairly active lives. For most symptomatic friends. patients, however, CFS significantly limits Because CFS can resemble many other Worries about raising children. work, school and family activities. disorders, it’s important not to self-diagnose CFS. It’s not uncommon for people to Concerns about the potential impact of While symptoms vary from person to person in mistakenly assume they have chronic fatigue decreased sexual activity on intimate number, type and severity, all CFS patients are syndrome when they have another illness that relationships. functionally impaired to some degree. CDC needs to be treated. studies show that CFS can be as disabling as Feelings of anger, guilt, anxiety, isolation multiple sclerosis, lupus, rheumatoid arthritis, It’s also important not to delay seeking a and abandonment are common in CFS heart disease, end-stage renal disease, chronic diagnosis and medical care. CDC research patients. While it’s normal to have such obstructive pulmonary disease (COPD) and suggests that early diagnosis and treatment feelings, unresolved emotions and stress similar chronic conditions. of CFS can increase the likelihood of can make symptoms worse, interfere with improvement. pharmacological therapies and make recovery CFS often follows a cyclical course, harder. alternating between periods of illness and Treatment for CFS relative well-being. Some patients experience Managing chronic fatigue syndrome can Treatment options partial or complete remission of symptoms be as complex as the illness itself. There is There are many different types of treatment during the course of the illness, but symptoms no cure, no prescription drugs have been and management tools available for chronic often reoccur. This pattern of remission and developed specifically for CFS, and symptoms fatigue syndrome. These include: relapse makes CFS especially hard for patients vary considerably over time. These factors Professional counseling. to manage. Patients who are in remission may complicate the treatment process and require Cognitive behavioral therapy (CBT). be tempted to overdo activities when they’re patients and health care professionals to Graded exercise therapy (GET). feeling better, which can actually cause a constantly monitor and frequently revise Symptomatic treatment. relapse. treatment strategies. Alternative therapies. Support groups. The percentage of CFS patients who recover One key to managing CFS is working Pharmacologic therapy. is unknown, but there is some evidence to with health care professionals to create an Sleep hygiene. indicate that the sooner a person is treated, the individualized treatment program. This Pain therapy better the chance of improvement. This means program should be based on a combination Orthostatic instability treatment. early diagnosis and treatment of therapies, for example traditional and Antidepressants. Testing for CFS alternative, which address symptoms, activity management and coping techniques. Professional counseling Because there is no blood test, brain scan Consulting a trained professional will help or other lab test to diagnose CFS, it’s a Identification of a CFS patient’s greatest most patients build effective coping skills. A diagnosis of exclusion. If a patient meets the problem is most important because the illness supportive counselor can help develop coping diagnostic criteria outlined above, a health care affects people differently. Relief of symptoms skills to lessen the anxiety, depression, grief, professional will first take a detailed patient is the primary treatment goal. Expecting a CFS anger and guilt that often accompany chronic history, including a review of medications patient to feel “normal” (for example, a return illness. A therapist, using problem-solving that could be causing the fatigue. A thorough to usual activities) should not be the immediate techniques and standard psychotherapy and physical and mental status examination goal because trying to reach that goal may counseling methods, can help work through will also be performed. Next, a battery of aggravate the illness. CFS is a complicated these issues. In some cases, a therapist may laboratory screening tests will be ordered illness and therefore may require input from a recommend a combination of medication and to help identify or rule out other possible variety of medical professionals. Primary care psychotherapy. causes of symptoms. The physician may also providers can develop effective treatment plans order additional tests to follow up on results based on their experience in treating other Sometimes chronic illnesses like CFS of the initial screening tests. A diagnosis of illnesses. affect the entire family, not just the patient. Consulting a behavioral health professional insufficient fatigue could be made if a patient Coping with CFS may be helpful to address changes in family has been fatigued for six months or more but Living with chronic fatigue syndrome can dynamics related to living with CFS. does not meet the symptom criteria for CFS. be difficult. Like other debilitating chronic It can be difficult for a person to talk to a illnesses, CFS can have a devastating impact Cognitive behavioral therapy (CBT) physician or other health care professional on daily life, requiring patients to make Cognitive therapy seeks to help the patient about the possibility that they may have significant lifestyle changes and adapt to a overcome difficulties by identifying and chronic fatigue syndrome. A variety of health series of new limitations. changing dysfunctional thinking, behavior and emotional responses. This involves care professionals, including physicians, Common difficulties nurse practitioners and physician assistants, helping patients develop skills for modifying Common difficulties for CFS patients include can diagnose CFS and help develop an beliefs, identifying distorted thinking, relating problems coping with: individualized treatment plan for a person. to others in different ways, and changing The changing and unpredictable symptoms. behaviors. www.ILmassageCE.com Page 55 Cognitive behavioral therapy, or CBT, is often and these endpoints should be reached before useful, current information, and they can prescribed to help chronically ill patients the patient becomes tired. Each patient will provide a sense of community with people who cope with illness and develop behaviors and have to determine her individual limits by trial understand what you’re going through. Some strategies that help improve symptoms. It and error; limits on time or repetition assist patients do not have the energy to physically has been successful in helping patients with in this goal. At this stage in the understanding join a support group but can benefit by cardiovascular disease, diabetes and cancer, of the illness, prevention of tiredness and participating via teleconference (recent study and recent studies indicate that CBT can be reactivation of the prevention of activation reported at the IACFS/ME conference). useful in treating some CFS patients. CBT can of the syndrome and an increase in overall Support groups are not appropriate for help patients understand their limitations, pace fitness are appropriate goals. GET may be everyone, and some CFS patients may find themselves appropriately, and avoid push-and- summarized by the adage that no exercise is that a support group actually adds to their crash cycles. bad, some is good, but too much is not helpful. stress rather than relieving it. Most support Clinicians may want to refer some CFS Symptomatic treatment groups are free, collect voluntary donations, or patients to behavioral health professionals to People with CFS display different patterns charge modest membership dues to cover basic help them problem-solve and develop specific of primary symptoms. Symptom severity expenses (such as refreshments at meetings or techniques for conducting activities of daily can also vary considerably. Clinicians and photocopying costs). living that have become difficult. Referral to a patients should communicate with one another A useful support group should include: neuropsychologist, neurologist or psychiatrist about which symptoms are most disruptive Both newcomers and patients who have for evaluation and testing may be necessary or disabling and tailor the management plan had CFS for longer periods of time to to determine whether other underlying accordingly. Treatment can be directed toward provide a balance of perspectives for the conditions may be involved. It should be noted the most problematic symptoms as prioritized group. that training to improve cognition is a highly by the patient, but only after underlying People with whom the CFS patient feels specialized therapy and requires input of conditions applicable to those symptoms have comfortable. trained behavioral health clinicians. been investigated and excluded. Leaders who empathize, gently draw CBT is frequently prescribed as part of the Primary symptoms may include sleep out shy members and keep others from therapeutic process; it helps patients learn to problems, muscle and joint pain, cognitive dominating, and who distill discussion into manage activity levels, stress and symptoms. dysfunction, fatigue, headaches and sore useful information. CBT can help chronic fatigue patients better throat. Gastrointestinal complaints, orthostatic A history indicating the group is stable and adapt to the impact of their condition and instability (relating to standing upright), meeting the needs of its members. improve their level of function and quality of depression and allergies are also seen in many Some support groups may put their own life. patients. Aggressive symptom management interests before those of the individual patient. for these and other disruptive symptoms is Graded exercise therapy (GET) Groups that engage in any of the following indicated. Graded exercise therapy (GET) is physical activities should be avoided: activity that starts very slowly and gradually Memory and concentration complaints are two Promise sure cures and quick solutions. increases over time. Some people with CFS of the more distressing symptoms reported by Conduct meetings that are mainly “gripe” avoid all activity because personal experience people with CFS. Relaxation and meditation sessions. has demonstrated a link between exertion and training and memory aids, such as organizers, Urge patients to stop prescribed treatment symptom severity. An even greater number schedulers and written resource manuals, can and recommend a single solution to their of people engage in an endless “push-crash” be helpful in addressing cognitive problems. problem. cycle in which they do too much, crash, rest, Stimulating the mind with puzzles, word Insist that patients reveal private or start to feel a little better and do too much games, card games and other activities may sensitive information. once again, perpetuating the cycle. Exercise, also be beneficial for some patients. Demand allegiance to a cult-like, however, is a normal and required bodily Health care professionals should use caution in charismatic leader. function; studies have shown that even healthy prescribing stimulants for cognitive problems. Charge high fees. people who do not exercise do not feel well. Mild stimulants may be helpful for some Require patients to purchase products. When beginning an exercise program, it is patients, but stronger stimulants can lead to the Pharmacologic therapy important to avoid the push-pull cycle and “push-crash” cycle (do too much, crash, rest, instead balance physical activity. Pharmacologic therapy is directed toward the start to feel a little better, do too much once relief of specific symptoms experienced by the A GET program that includes active stretching again, and so on) and cause relapse. individual patient. There are many over-the- followed by range-of-motion contractions Alternative therapies counter (OTC) and prescription drug therapies and extensions is usually an effective start. Deep breathing and muscle relaxation that can be used to treat sleep difficulties, Five minutes per day is a typical starting techniques, massage and healing touch, and cognitive problems, pain and other symptoms point for an individual who has been totally movement therapies like stretching, yoga and of CFS. inactive. When beginning a GET program, tai chi can be beneficial for some CFS patients it is important to avoid extremes and Many CFS patients are sensitive to in reducing anxiety and promoting a sense of instead balance physical activity and rest. medications, particularly sedating medications. well-being. Research has shown that gradual, guided Therapeutic benefits can often be achieved physical activity can help persons with CFS. Patients should discuss all potential alternative at lower than normal dosages, so health Appropriate rest is an important element of therapies with health care professionals. care professionals should try prescribing a fraction of the usual recommended dose to GET and patients must learn to stop activity Support groups before illness and fatigue are worsened. start and gradually increase as necessary and Many people with CFS find it therapeutic to as tolerated. All medications can cause side The end point of each GET session should be meet with other people who have this illness. effects, which may lead to new symptoms or preset by the clock or number of repetitions, Support groups can provide patients with worsen existing symptoms, so it is important to
Page 56 www.ILmassageCE.com routinely monitor all prescription drugs, OTC Control noise, light and temperature. therapeutic results and managing possible therapies and supplements. Avoid caffeine, alcohol and tobacco. complications. Some drugs act on multiple body systems Light exercise and stretching earlier in the Treatments for orthostatic problems include and symptoms. For instance, tricyclic day, at least four hours before bedtime, volume expansion for CFS patients who do antidepressants may not only improve mood, may also improve sleep. not have heart or blood vessel disease. If but may help with sleep and pain. Prescribing When sleep hygiene is not successful, the use symptoms do not improve with increased fluid such drugs allows the use of fewer medications of pharmaceutical drugs may be indicated. and salt intake, prescription medications and to address multiple symptoms with minimal Initial medications to consider are simple support stockings can be prescribed. side effects. antihistamines or over-the-counter sleep Antidepressants Nutritional and herbal supplements products. If this is not beneficial, health care Research shows that CFS is not a form of Nutritional supplements and vitamins professionals are encouraged to start with a psychiatric illness or depression. However, are frequently used by people with CFS prescription sleep medicine in the smallest many people with chronic illnesses, including for symptom relief. There have been few possible dose and briefest period possible. those with CFS, may suffer from secondary clinical trials on nutritional supplements and Unrefreshing sleep can be present even depression as the patient makes the multiple vitamins; these products are unregulated, and though medications may help patients adjustments to having a devastating, chronic information on potency and side effects is achieve required hours of sleep. A sleep illness. frequently unknown. However, many CFS specialist should evaluate patients whose sleep As many as half of CFS patients develop patients report symptom relief with use. remains non-restorative following standard depression sometime during the course of the Therefore, health care professional and patients interventions. illness. When it’s present, depression needs to need to talk about supplement use and OTC Primary sleep disorders such as sleep apnea be treated. Although treating depression can products to determine safety, effectiveness and (brief pause in breathing during sleep) and reduce anxiety and stress, it is not a cure for possible negative interactions with prescribed narcolepsy (uncontrollable sleeping) exclude CFS. medications and therapies. the diagnosis of CFS, and most people with Professionals are advised to use caution in CFS patients should be advised to avoid herbal such disorders respond to therapy. It is very prescribing antidepressants. Antidepressant remedies like: important for health care professionals to get a drugs of various classes have other effects that Comfrey. careful sleep history. may act on other CFS symptoms and/or cause Germander. Pain therapy side effects. Licorice root. CFS pain occurs both in muscles, myalgia, There are brief psychiatric screening tools Ephedra. (sometimes described as “deep pain”) and available that can be given and scored in Chaparral. joints (arthralgias). Patients may also complain the primary care setting, such as the Beck Yohimbe. of headaches (typically pressure-like) and Depression Inventory. Results of these Kava. allodynia, which is generalized hyperalgesia or screening tools that point to a possible Bitter orange. soreness of the skin to touch. underlying depression or other psychological Any other supplements that are potentially Most pain therapy begins with simple disorder require a referral to a mental health dangerous. analgesics (pain-relievers) like acetaminophen, professional. Nutritional supplements can’t take the place of aspirin or non-steroid anti-inflammatory For other problems good diet and nutrition, so a well-balanced diet drugs (NSAIDS). Additional therapy can be Medications such as aspirin, is encouraged. Some people with CFS report managed by a pain specialist. Counseling for acetaminophen (Tylenol and others) and sensitivities to various foods or chemicals, pain management techniques is advisable for nonsteroidal anti-inflammatory drugs including refined sugar, caffeine, alcohol and patients with this kind of constant pain. (NSAIDs) such as ibuprofen (Advil, tobacco. Pain management should include Motrin and others) may be prescribed for Sleep hygiene nonpharmacological treatments and alternative pain. The majority of CFS patients experience some therapies. Stretching and movement therapies, Antihistamines and decongestants may form of sleep dysfunction. Common sleep gentle massage, heat, toning exercises, relieve allergy-like symptoms. complaints include difficulty falling asleep, hydrotherapy (water therapy for healing) and Medications may be available to treat hypersomnia (extreme sleepiness), frequent relaxation techniques can be helpful for CFS symptoms such as dizziness, skin awakening, intense and vivid dreaming, care. Acupuncture, when administered by a tenderness and anxiety. qualified practitioner who is knowledgeable restless legs and nocturnal myoclonus (night- Alternative therapies time muscular spasm). Most CFS patients about CFS, may be effective for pain Studies suggest that acupuncture may decrease experience non-restorative sleep as compared management in some patients. fatigue, pain, anxiety and other symptoms of to their pre-illness experience. Orthostatic instability treatment CFS. Other complementary therapies include: Health professionals can help people with Some patients with CFS may also exhibit Deep-breathing and muscle-relaxation CFS adopt good sleep habits. Patients should symptoms of orthostatic instability (relating techniques. be advised to practice standard sleep hygiene to standing upright), in particular frequent Meditation techniques: dizziness and light-headedness. Depending Massage and healing touch. Establish a regular bedtime routine. on severity and clinical judgment, these Movement therapies such as stretching, Avoid napping during the day. patients should be referred for evaluation yoga and tai chi. Incorporate an extended wind-down by a cardiologist or neurologist. Specific period. treatment for orthostatic instability should Massage considerations Use the bed only for sleep and sex. only be started following confirmed diagnosis Gentle massage can help a client with CFS as Schedule regular sleep and wake times. and by clinicians experienced in evaluating it soothes the nervous system, relieves muscle and joint pain and can improve sleep. Massage www.ILmassageCE.com Page 57 also will stimulate the parasympathetic NOTES response, cleanse tissue and stimulate Pathology of chronic circulation for a client who cannot handle conditions for massage exercise. therapists Because a person’s symptoms can vary from Final Examination Questions day to day, the therapist must ask the client Choose the best answer for questions at each session about current symptoms and 21 through 25 and then mark your answers adjust the massage accordingly. If the client on the answer sheet found on page 59 or is feeling overly fatigued, the treatment proceed to www.ILmassageCE.com to time should be reduced; lighter-than-normal complete your final examination.. pressure is appropriate. Therapists should always be ready to assist 21. Massage for people with cerebral palsy clients who feel dizzy or light-headed after can always include: treatment. a. Deep tissue massage with maximum Bibliography pressure. Introduction “A Massage Therapist’s Guide to Pathology,” Fourth edition. By Ruth Werner. 2009, b. Passive stretching. Lippincott Williams & Wilkins, a Wolters Kluwer business. The 2007 National health Interview Survey, Centers for Disease Control. c. Joint mobilizations. Massage Therapy: An Introduction. National Center for Complementary and Alternative Medicine – National Institutes of Health d. Light gliding strokes and gentle Part I: Cerebral Palsy Boyle CA, Decoufle P, Yeargin-Allsopp M. Prevalence and health impact of kneading. developmental disabilities in US children. Pediatrics. 1994;93:399-403. Murphy CC, Yeargin-Allsopp M, Decoufle P, Drews CD. Prevalence of cerebral palsy among ten-year-old children in metropolitan Atlanta, 1985 through 1987. Journal of Pediatrics 1993;123:S13-20. 22. A person with myofascial pain syndrome Batshaw ML. Children with disabilities (4th edition). Baltimore MD: Paul H. Brookes Publishing Co.;1997. experiences pain that centers around Postnatal Causes of Developmental Disabilities in Children Aged 3-10 Years – Atlanta, sensitive points called: Georgia, 1991. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. 1996;45:130-134. Geralis E (Editor). Children with cerebral palsy: a parents’ guide. Rockville, MD: a. Tender areas. Woodbine House; 1991. Economic costs associated with mental retardation, cerebral palsy, hearing loss, and b. Trigger points. vision impairment – United States, Centers for Disease Control and Prevention.2003. MMWR 2004;53:57-9. c. Pressure points. Honeycutt AA, Grosse SD, Dunlap LJ, Schendel DE, Chen H, Brann E, al Homsi G. Economic costs of mental retardation, cerebral palsy, hearing loss, and vision d. Key points. impairment. In: Altman BM, Barnartt SN, Hendershot GE, Larson SA, editors. “Using survey data to study disability: results from the National Health Interview Survey on Disability: Research in social science and disability, volume 3. Amsterdam: Elsevier; 2003. p. 207-28. 23. Which of the following is not a therapeutic “Cerebral palsy symptoms in children decreased following massage therapy.” Early Child Development and Care, Vol. 175, No. 5, July 2005. technique or massage that can help loosen “Cerebral Palsy: Hope Through Research,” National Institute of Neurological Disorders and Stroke, tight muscles and relieve cramps for people National Institutes of Health. Publication date December 2009. NIH Publication No. 10-159 with myofascial pain syndrome? “Working with Clients Who Have Cerebral Palsy” By Ruth Werner, LMP, NCTMB. Massage Today, August 2002, Vol. 2, Issue 8. Accessed online Nov. 13 at massagetoday.com. a. Long hand strokes. “Mosby’s Pathology for Massage Therapists, Second Edition.” Susan G. Salvo. 2004 and 2009 Mosby, Inc., an affiliate of Elsevier Inc. b. Moist heat. “A Massage Therapist’s Guide to Pathology,” Fourth edition. By Ruth Werner. 2009, c. Deep kneading movements. Lippincott Williams & Wilkins, a Wolters Kluwer business. Part II: Fibromyalgia d. Oscillating movements. Fibromyalgia. Centers for disease Control and Prevention. Accessed online Nov. 15, 2010 at http://www.cdc.gov.arhritis/basics/fribromyalgia.htm. “Mosby’s Pathology for Massage Therapists, Second Edition.” Susan G. Salvo. 2004 and 2009 Mosby, Inc., an affiliate of Elsevier Inc. 24. A key difference between chronic fatigue “A Massage Therapist’s Guide to Pathology,” Fourth edition. By Ruth Werner. 2009, Lippincott Williams & Wilkins, a Wolters Kluwer business. syndrome and fibromyalgia syndrome is Fibromyalgia and CAM: National Center for Complementary and Alternative Medicine. What is Fibromyalgia? National Institutes of Arthritis and Musculoskeletal and Skin that people who suffer with fibromyalgia: Diseases – National Institutes of Health. Acupuncture. National Center for Complementary and Alternative Medicine. Fibromyalgia: Fast Facts, Questions and Answers, Summaries of Research.National a. Tend to get less sleep. Institutes of Arthritis and Musculoskeletal and Skin Diseases – National Institutes of Health b. Experience more fatigue. Fibromyalgia: MedLine Plus. U.S. National Library of Medicine: http://www.nlm.nih. gov.medlineplus/fibromyalgia.html. Accessed online Nov. 15, 2010. c. Have severe abdominal swelling. Part III: Myofascial Pain Syndrome Treatment of myofascial pain syndrome. Hong CZ. http://www.ncbi.nlm.nih.gov/ d. Experience more pain. pubmed/16945250 Myofascial Pain Syndrome. Mayo Clinic staff. http://www.mayoclinic.com/health/ myofascial -pain-syndrome. Accessed online Nov. 15, 2010. Cleveland Clinic: Chronic Myofascial Pain. http://my.clevelandclinic.org/disorders/ 25. Which of the following is not a factor chronic_myofascial_pain/hic_chronic_myofascial_pain_cmp.aspx. Accessed online Nov. 15, 2010. in diagnosing chronic fatigue syndrome eMedicine: Myofascial Pain. Updated April 7, 2010. Emedicine.medscape.com/ (CFS)? articles/313007. Accessed online Nov. 15, 2010. “Mosby’s Pathology for Massage Therapists, Second Edition.” Susan G. Salvo. 2004 and 2009 Mosby, Inc., an affiliate of Elsevier Inc. a. The illness has a pattern of remission “A Massage Therapist’s Guide to Pathology,” Fourth edition. By Ruth Werner. 2009, Lippincott Williams & Wilkins, a Wolters Kluwer business. and relapse. Part IV: Chronic Fatigue Syndrome Chronic Fatigue Syndrome. Centers for Disease Control. www.cdc.gov./cfs. b. There’s no diagnostic laboratory test Chronic fatigue syndrome. MedlinePlus, U.S. National Library of Medicine. www.nlm. nih.gov/medlineplus/ency/article/001244. Accessed online Nov. 16, 2010. or biomarker. Chronic fatigue syndrome. Cleveland Clinic. http://my.clevelandclinic.org/disorders/ chronic_fatigue_syndrome/rheumatology_overview.aspx. Accessed online Nov. 16, c. The patient has a pale, chalky 2010. Chronic fatigue syndrome. Mayo Clinic staff. www.mayoclinic.com/health/chronic- appearance. fatigue-syndrome/DS00395. Accessed online Nov. 16, 2010. “Viruses found in chronic Fatigue Patients.” Aug. 30, 2010. National Research d. Symptoms vary from person to Matters, National Institutes of Health. www.nih.gov.researchmatters/august 2010/08302010chronicfatigue.htm. Accessed online Nov. 16, 2010. person. “Mosby’s Pathology for Massage Therapists, Second Edition.” Susan G. Salvo. 2004 and 2009 Mosby, Inc., an affiliate of Elsevier Inc. “A Massage Therapist’s Guide to Pathology,” Fourth edition. By Ruth Werner. 2009, Lippincott Williams & Wilkins, a Wolters Kluwer business. MIL02PCE12
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