Indications and Cautions

Chapter 9


Indications and Cautions




Objectives


After completing this chapter, the student will be able to perform the following:


1 List the general indications for massage.


2 Describe illness and injury and how they predispose a client to contraindication or caution for massage application.


3 Evaluate various medications for indications/cautions for massage.


4 Identify and avoid endangerment sites.



Key Terms






























Massage can be very beneficial for athletes and those involved in physical performance activity such as dance, if the professional performing the massage understands the multidimensional aspects of the client’s experience. If not, massage can impair optimal function of the performance. Because of the intense physical activity involved in sports, an athlete may be prone to injury. The massage therapist often works with clients from many different sport or fitness activities. Physical rehabilitation programs are also varied. The author of this text owns just about every sport for dummies and idiot’s guide to various sport performance books. I often use these types of books to help me understand various sport activities and to determine indications and benefits of massage. Unit I discusses the basic movement functions an athlete uses to accomplish a sport-specific task. Massage is beneficial, is used to allow the body to complete these movements, and can manage compensation patterns that result from repetitive movement.


Because therapeutic massage has widespread effects on the physiologic functions of the body, it is the massage professional’s responsibility, when applying massage techniques, to have knowledge of pathology, contraindications, and endangerment sites. It is difficult to obtain a consensus on such information, however, because not all sources agree.



Indications for Massage



Objective




Normal physiologic mechanisms inhibit the tendency to function at the body’s anatomic and physiologic limits. We usually do not run as fast as we can, work as long as we can, or exert all of our energy to complete a task. Instead the body signals fatigue, pain, or strain before the anatomic or physiologic limits are reached, and we back off. This very important protective mechanism allows us to live within a healthy range of energy expenditure while maintaining functioning energy reserves in case of emergency or extraordinary demand. This is not necessarily the case for athletes, who often strive to exceed normal physical and mental functioning.


Dysfunction occurs when energy reserves run low because restorative mechanisms are not able to function effectively, or when the body begins to limit function in an attempt to maintain higher energy reserves.


If a person plays tennis and overstretches the shoulder reaching for the serve, the body senses danger of harm to the joint. Neurologic sensors may reset muscle patterns, limiting range of motion slightly to prevent this from happening again. Physiologically, protective space has been created even though range of motion has been sacrificed. If this continues, eventually the limited range of motion interferes with the ability to play tennis. Dysfunction occurs. If perpetuated and compensated for over time, pathology usually develops. The person could end up with a frozen shoulder or tendonitis.


Massage intervention just after the first event, coupled with a more conservative playing style or improved playing form, might reverse the process, and dysfunction would not develop. Intervention applied at the point at which range-of-motion limits are first observed would likely still be effective in reversing the dysfunctional process. Interventions introduced after pathology has begun are more complex, sometimes aggressive, and occasionally too late to support repair and restoration of function. Also, it may take longer before benefits are noticed.


Massage can support the restorative process to help athletes maintain peak performance for extended periods. The benefits of massage are most effectively focused on assisting people to stay within the healthy range of physical functioning and supporting those who wish to achieve fitness.


Illness occurs when a body process breaks down. A person whose immune system did not effectively fight off a cold virus becomes ill with a cold. A person with diabetes is ill. Chronic fatigue syndrome, ulcers, cancer, and multiple sclerosis are all examples of illness.


Injury occurs when tissue is damaged. Cuts, bruises, burns, contusions, fractured bones, sprains, and strains are examples of injuries.


Illness tends to indicate general cautions and contraindications, whereas injury more often indicates regional cautions and contraindications.


Therapeutic massage is indicated for both illness and injury. Massage techniques for illness involve very general application of massage to support the body’s healing responses (e.g., stress management, pain control, restorative sleep). This approach to massage, sometimes called general constitutional application, is more reflexive in nature and is used to reduce the stress load so that the body can heal. (See Unit Three for specific massage interventions for illness and sport injury.)


Massage for injury incorporates aspects of general constitutional massage because healing is necessary for tissue repair. The more mechanical application of lymphatic drainage is used to control edema. Gliding methods are used to approximate (bring close together) the ends of some types of injured tissue, as in minor muscle tears and sprains. Hyperstimulation analgesia and counterirritation reduce acute pain. Methods to increase circulation to the area support tissue formation. Connective tissue applications are used to manage scar tissue formation. Inflammation is a factor in both illness and injury because healing in both cases involves appropriate activation of the inflammatory response system.


Healing an injury is taxing on the body and strains the restorative mechanism. If an injured person is not in a state of health to begin with, it is common for the stress of the injury to compromise the immune system, and the person then becomes susceptible to illness.


Because many diseases and injuries have similar symptoms, it is difficult to determine the specific underlying causes of pathology. The massage professional must refer clients to qualified, licensed health care providers for a specific diagnosis.


In general, massage is indicated for



The following areas of effect are especially beneficial for the population targeted in this textbook.



Inflammation


Therapeutic massage seems to be beneficial in cases of prolonged inflammation. Possible theories regarding this include the following:



The processes of inflammation trigger tissue repair. Tissue repair is the replacement of dead cells with living cells. In the type of tissue repair called regeneration, the new cells are similar to those they replace. In another type of tissue repair called replacement, the new cells are formed from connective tissue and are different from those they replace, resulting in a scar. Often fibrous connective tissue replaces damaged tissue. Most tissue repairs are a combination of regeneration and replacement. A goal of the healing process is to promote regeneration and keep replacement to a minimum. Massage has been shown to slow the formation of scar tissue and to keep scar tissue pliable when it does form (Table 9-1).



Because the inflammatory response is part of the healing process, the deliberate creation of inflammation theoretically can generate or “jump start” healing mechanisms. Certain methods of massage are used to create a controlled, localized area of therapeutic inflammation. Deep frictioning techniques and connective tissue stretching methods are the most common approaches. The evidence is suspect, and currently research does not support the method, but historically friction has been clinically effective if used with caution.


Benefit derived from the use of therapeutic inflammation depends on the body’s ability to generate healing processes. If healing mechanisms are suppressed, methods that create therapeutic inflammation should not be used. For example, therapeutic inflammation is not used in situations in which sleep disturbance, compromised immune function, a high stress load, or systemic or localized inflammation is already present. This method is also contraindicated if any condition that consists of impaired repair and restorative functions is present, unless application is carefully supervised as part of a total treatment program. Training and competing athletes may not have enough adaptive capacity to resolve inflammation, so caution is advised when considering using methods to create inflammation.


Client use of antiinflammatory medications is another factor that must be considered. If a person is taking such medication—steroidal or nonsteroidal—the effectiveness of therapeutic inflammation is negated or reduced, and restoration mechanisms are inhibited. When these medications are used, any methods that create inflammation are to be avoided (Table 9-2).



TABLE 9-2


Disorders Related to Chronic Inflammation*

























































Disorder Mechanism
Allergy Mediators induce autoimmune reactions.
Alzheimer’s disease Chronic inflammation destroys brain cells.
Anemia Mediators attack erythropoietin production.
Aortic valve stenosis Chronic inflammation damages heart valves.
Arthritis Inflammatory mediators destroy joint cartilage and synovial fluid.
Asthma Mediators close the airways.
Cancer Chronic inflammation causes most cancers.
Congestive heart failure Chronic inflammation causes heart muscle wasting.
Fibromyalgia Mediators are elevated in fibromyalgia patients.
Fibrosis Mediators attack traumatized tissue.
Heart attack Chronic inflammation contributes to coronary atherosclerosis.
Kidney failure Mediators restrict circulation and damage nephrons.
Lupus Mediators induce an autoimmune attack.
Pancreatitis Mediators induce pancreatic cell injury.
Psoriasis Mediators induce dermatitis.
Stroke Chronic inflammation promotes thromboembolic events.
Surgical complications Mediators prevent healing.

*Seemingly unrelated disorders often have a common link—inflammation. This is a partial list of common medical problems associated with chronic inflammation.


From Fritz S: Mosby’s fundamentals of therapeutic massage, ed 3, St Louis, 2004, Mosby.



Pain


The massage professional especially needs to understand the mechanisms of pain. Pain receptors are found in almost every tissue of the body and may respond to any type of stimulus. When stimuli for other sensations, such as touch, pressure, heat, and cold, reach a certain intensity, they stimulate the sensation of pain as well. Injured tissue may release prostaglandins, making peripheral nociceptors more sensitive to the normal pain response (hyperalgesia). Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) inhibit the action of prostaglandins and reduce pain.


Excessive stimulation of a sensory organ causes pain. Additional stimuli for pain receptors include excessive distention or dilation of a structure (typically fluid pressure), prolonged muscular contractions, muscle spasms, inadequate blood flow to tissues, and the presence of certain chemical substances. Because of their sensitivity to all stimuli, pain receptors perform a protective function by identifying changes that may endanger the body.


The point at which a stimulus is perceived as painful is called the pain threshold. This varies somewhat from individual to individual. One factor affecting the pain threshold is perceptual dominance, in which the pain felt in one area of the body diminishes or obliterates the pain felt in another area. Not until the most severe pain is diminished does the person perceive or acknowledge the other pain. This mechanism is often activated with massage application that produces a “good hurt” and creates hyperstimulation analgesia and counterirritation.


Pain tolerance refers to the duration or intensity of pain that a person endures before acknowledging the pain and seeking relief. Unlike the pain threshold, pain tolerance is likely to vary from one individual to another. A person’s tolerance to pain is influenced by a variety of factors, including personality type, psychological state at the onset of pain, previous experiences, sociocultural background, and the meaning of the pain for that person (e.g., the ways in which it affects the person’s lifestyle). Factors that decrease pain tolerance include repeated exposure to pain, fatigue, sleep deprivation, and stress. Warmth, cold, distraction, alcohol consumption, hypnosis, and strong religious beliefs or faith all act to increase pain tolerance.


The origins of pain can be divided into two types: somatic and visceral. Somatic pain arises from stimulation of receptors in the skin (superficial somatic pain) or from stimulation of receptors in skeletal muscles, joints, tendons, and fascia (deep somatic pain). Visceral pain results from stimulation of receptors in the viscera (internal organs).


Pain is usually classified as acute, chronic, intractable, phantom, or referred.



Evaluation and Management of Pain


Because pain is a primary indicator in many disease processes, the massage practitioner must have a basic evaluation protocol for pain to refer his or her clients to the appropriate health care provider. The following guidelines for evaluating pain will help in this process.


Pain has many characteristics. Location, for example, can be divided into four categories:


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Jun 22, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Indications and Cautions

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