THE MANUAL THERAPISTS DILEMMA-DO WE CAUSE HARM?
As I researched for this article I found without surprise, larger issues were at play. Once on the side of regulation for our industry, now I have concern as to the efficacy of this road. What began as a simple article on contraindications turns out to be a journey in understanding the nature of our work and the decisions we are face every day regarding our practice. Steven Goldstein BSHSc MST MusculoSkeletal Therapy, ACNM Australian College of Natural Medicine, Chair National Education Subcommittee, AAMT Australian Association Massage Therapists.
One of the most basic considerations for manual therapist is to understand how and when to proceed with caution or not to treat at all. Our ‘duty of care’ requires that we recognize when a condition or situation presents itself that would make it unsafe for the client to receive our touch. Furthermore our care requires us to ‘do no harm’. And if indeed we proceed with a treatment and did not heed or understand the indications contrary to massage, we open ourselves up to malpractice and personal liability.
Contraindications provide a basic framework for understanding when, and under what circumstances, a particular therapeutic intervention is appropriate for treating the patient/client with minimal risk of injury. Therefore, contraindications serve as a guideline to help us determine if we should institute certain precautions in treatment, withhold treatment altogether, or recommend alternative treatments that would be more appropriate (Batavia 2003).(1)
Therapists understand that by modifying their depth of pressure, selecting techniques that are appropriate to the tissue type and the situation create efficacy in our treatment. We know a thorough case history is necessary, and to implement a treatment plan we must consider the clients medical history to ascertain if treatment is appropriate. Fundamentally we are always asking when can we and when can we not provide treatment. With serious medical conditions, we realize that we are obligated to modify our treatment by the site or area we touch, the position we need to place the client in to achieve desired results or the time frame we can work as in the stages of inflammatory response. And of course we have to know when not to treat a serious medical condition.
Traditionally contraindications have been categorized as total, local or site specific and/or medical. We were taught to pay attention to systemic or skin conditions that exhibited infectious or contagious symptoms, local traumas and injuries that showed the effects of partial tear, avulsions, lesions, fractures, breaks or punctures of soft-tissue structures, to name a few. Most traumas we understand are commonsense wise, and depending on the conventional wisdom of the time, many conditions are considered totally contraindicated.
I, for example, taught in 1986 could never treat acute injuries, or that cancer and pregnancy, erring on the side of safety, were totally contraindicated. By today standards this is not the case.
Problems with the Laundry List Approach:
One thing that can be stated with some certainty regarding contraindications is: ‘a blanket approach with absolutes will work but then we probably wouldn’t treat any of the relative contraindicated conditions’. An excellent resource for understanding how sources differ regarding contraindications is M. Batavia’s article (2003) Contraindications for therapeutic massage: do sources agree?, published in the Journal of Bodywork and Movement Therapies, 8(1), 48-57.
Batavia goes on to say: “Contraindications cited in these sources were classified as relative contraindications, absolute contraindications, precautions, or contraindications and precautions. A relative contraindication is a situation where massage should not be done in certain circumstances, but could be done in other circumstances. It also refers to what type of massage is being performed. For example, one type of massage might be contraindicated for a particular condition, but another type of massage might not be. An absolute contraindication is one where massage should not be done under any circumstances. A precaution is a situation where massage can be performed, but with particular precautions related to the pathology.”(2)
What is interesting about this article is Batavia found when purveying all the various physical therapy, manual therapy and massage texts he found a majority of the sources failed to cite specific references to support the position of the described contraindications and another 76% failed to offer alternative treatment strategies for those conditions that were considered precautions or contraindications. And half the sources he consulted failed to identify that more than 90% of the conditions have a precaution or contraindication associated with them. (3)
So how are we to reconcile this immense discrepancy and how do we as massage educators help students and practitioners navigate this difficult terrain?
Batavia goes on to say:, “While contraindications are a valuable guideline, to often they are misused and misunderstood in our educational programs. Many, if not most, massage therapy training programs are lacking in subject matter directly related to evaluating pain and injury conditions. In that situation contraindications are commonly used as a basic “laundry list” of situations or conditions to avoid when using massage.
The detriment to this approach is that frequently it is not spelled out there is a difference between relative and absolute contraindications. Without that distinction most of these conditions get lumped into absolute contraindications in an effort to err on the side of safety and precaution. While this does help the practitioner keep from providing treatment in a situation where it is not appropriate, it also dramatically limits the effectiveness of clinical work.”(4)
Batavia cites an example that an absolute contraindication is treatment for an inflamed area, when in actually it is a relative contraindication. He believes more clinical research is needed to validate contraindications listed in various sources, and we need to educate the educators, “we need better educational preparation of the faculty and instructors that are teaching from these materials as well. To some degree an absence of listed contraindications can be balanced by adequate knowledge of anatomy and physiology coupled with developed clinical reasoning skills.