[Fundamentals] Chpt 6 - Full

Indications and Contraindications

• Indication - A condition for which an approach would be beneficial.
• Contraindication - A condition for which an approach would be harmful. there are 3 types of contraindications.

• General - No massage techniques may be performed.
• Regional - Particular areas must be avoided.
• Application with Caution - A condition that requires the massage therapist to adapt the massage techniques so the client's safety is maintained.

• [Example of Indication and Contraindications] A diabetic patient has blood sugar over 200, it would be an indication to give them insulin to lower their blood sugar, However if their blood sugar is 70, it would be a contraindication to give them insulin to lower it.   

Indications for Massage

• Objective - Results that can be seen.
• Subjective - Results that are assumed from effective based on experience.

• The Effects of massage are both physical(Objective) and mental(Subjective).
• [Example of Objective and Subjective] If a patient says they think they have a fever and you can see they are sweating and flushed, that is Objective. If a patient says they have a headache, you can not see any signs, therefor it is Subjective.

• Anatomic benefits can be measured Objectively.
• Biochemic benefits can be measured Objectively and Subjectively.
• Physiologic benefits can be measured Subjectively.

Approaches to care

When considering approaches to care there are several ways of going about it, how do you decide which and why? Firstly, lets address the 3 approaches you can take, these are; Therapeutic change, Condition management, and Palliative care. 

• Therapeutic change

• This change process requires client energy and resource expenditure. Resources required; Support systems, Motivation, Information, Finances.
• Practitioner needs include knowledge and skills, careful assessment protocol, and professional support.
• Therapeutic change might be unrealistic at a particular time or under set of circumstances, Condition management or Palliative care can be offered instead. 

• Example of Therapeutic change - because athletes are looking to improve their physical qualities to compete massage could improve their flexibility allowing them to push off more efficiently and run faster.

• Condition management

• Support for clients unable to undergo therapeutic change process for various reasons; Chronic health condition. Life circumstances that create chronic stress, A situation for which change is not viable, Need to postpone time frame for change.
• Accounts for the largest client base for therapeutic massage.
• Benefits: Manages existing physical compensation patterns, Can slow the progression of chronic conditions, Can prevent a situation from becoming worse, Offers emotional support for stress symptoms.

• Example of Condition management - Construction worker with repetitive pain in hands, show the client how to manage the symptoms.

• Palliative care

• Uses of palliative care include; Meeting pleasure needs, coping with chronic pain, making the transition from life to death.
• Can reduce pain, but not necessarily suffering. (suffering can be mental and spiritual.)

• Examples of Palliative care - Day spa customers: Massage services are not part of a cohesive treatment plan, usually do it as a one-time experience, not possible to provide any true therapeutic change or condition management benefits because there is no time for proper assessment.

Pathology, Health, and Therapeutic Massage.

• Pathology - is the study of disease. To practice safely, massage practitioners need a basic understanding of pathologic processes:

• Referring appropriately, recognizing contraindicating symptoms, recognize general types of disorders, specific signs and symptoms, and the development of disease processes, and understanding possible interactions between massage and medications.

• Health - optimal functioning with freedom from disease or abnormal processes. Factors that can influence health are:

• Inherited(Genetics) and constitutional traits, Lifestyle(diet, exercise, rest, stress level.),Beliefs and attitudes, self-esteem, loving relationships. Authentic personality and freedom from self-hindering patterns.

• Dysfunction - the in-between state of "not-healthy" and "not-sick".

• Effective approaches to dysfunction include mind/body medicine, stress management, and prevention methods. Active pathologic processes often require more aggressive treatment.

• Peak performance - maximum conditioning or functioning to a particular action. (physical or mental, energy consuming or stressful)

• During Peak performance your body does not hold back energy expenditure. Injury, Depletion and Illness can result if you do not give the body enough time to recover. 

• Disease - occurs when homeostasis cannot be returned to normal easily.

• In "Acute" cases of disease homeostasis can be returned to normal quickly, however in "Chronic" cases the body's homeostasis may never be restored and compensation is developed because of it. (Compensation is the process of counterbalancing a defect in body structure or function. (You limp on your left leg because your right leg has been injured.)) Further details in "Development of Pathologic Conditions"

• Functioning limits - The body has anatomic and physiologic functioning limits, the heart can only beat so fast, the endocrine can only secrete a maximum amount of hormones. 

• The body can only perform at an extent, when this is reached the body signals this by pain, fatigue or strain. However when the extraordinary events can push the body's functioning limits. Normally the body will never allow us to push past our limits, showing you signs of fatigue or pain before we can reach those limits, but in rare circumstances events may happen that will make the body push far beyond those limits and allow us to be super human for a short duration. (Mother lifting a van to save her child.)
• On the other hand " Dysfunction" results when the reserve runs low because restorative mechanisms are unable to function effectively, or when the body begins to "limit" function in an attempt to maintain higher energy reserves.
• Many massage professionals will serve people at the beginning of dysfunctional patterns; ie when the client does not feel their best, but are not sick. After dysfunction has set in, an intervention should be applied at the point where ROM limits were first observed.

• Development of Pathologic conditions - 

• Illness occurs when a body process breaks down, it also tends to indicate cautions and general contraindications.
• Injury occurs when tissue is damaged.
• Types of massage for injury can help edema, pain, circulation, approximation, and scar tissue formation.
• Healing taxes the body's reserves, our goal as the practitioner is to help the body supply healing so that it may heal faster, we do this by relieving stress, a relaxing the body. If a body is high on stress and cannot relax your body will heal a lot more slowly than it would without stress.

• If we cannot help the client with injury massage or illness massage we need to refer them to a professional that can help them.

• Signs - objective abnormalities than can be seen or measured by someone other than the patient.
• Symptoms - Subjective abnormalities felt only by the patient.
• Syndromes - Groups of Signs and Symptoms usually from a common cause.
• Acute Diseases - developed signs and symptoms quickly but only last for a short duration.
• Chronic Diseases - Opposite of acute, signs and symptoms may developed slowly and last a long duration, possibly until death.
• Communicable Diseases - can be transmitted from one person to another.
• Homeostasis - relevant constancy of the body's internal environment. 
• Compensation - a process of counterbalancing a defect in structure or function.
• Risk Factors - predisposing conditions that make a disease or injury more likely to happen; Genetic or inherited traits, Age-related or biologic factors, Lifestyle, Environment, Preexisting or primary conditions, Stress.
• General Adaptation Syndrome(GAS) - three stage response to harmful stimuli; Alarm("Fight or Flight"), Resistance reaction, Exhaustion. (Prolonged or excessive "Fight or Flight" response can disrupt normal functioning throughout the body.
• Generalized Stress Conditions -  The hypothalamus acts on the interior pituitary gland to cause the release of adrenocorticotropic hormone (ACTH) this stimulates the adrenal cortex to secrete glucocorticoid. while this is happening the sympathetic division of the autonomic nervous system(ANS) i stimulated by the adrenal medulla, resulting in the release of epinephrines and norepinephrines to assist with the body in responding to the stressful stimulus.

 Pathologic Conditions and Indications for Massage.

• Inflammatory Response - Processes that minimize tissue injury to promote healing

• Active, important part of the healing process, the primary signs are; Heat, Redness, Swelling, and Pain. Occurs in response to injury and may also accompany  specific immune system reactions. Sometimes the inflammatory response can be more intense or prolonged than desired, and can be suppressed by antihistamines or antiinflammatories.
•  Heat and Redness - Histamine, Prostaglandins, and kinens are associated with inflammation. Dilated blood vessels increase blood volume and bring WBCs.
• Swelling and Pain - Edema results in increased permeability of vessel walls. Increased pressure triggers pain receptors. Inflammatory exudate is the fluid that accumulates.
• Extent of Inflammation - Local(on your hand or arm.) Systemic(Allergic reaction-full body response) Chronic Inflammatory Disease(Hepatitis, RA).
• [How Massage can benefit prolonged Inflammation; it activates the body's natural antiinflammatory agents, triggers completion of process, involves lymphatic flow to dilute and remove irritant.]

• Indications for Inflammatory Response

• Tissue Repair - Combination of two processes; Regeneration with similar cells, and Replacement with fibous connective tissue(Scar Tissue).
• Healing Process Goals -  Promote regeneration, minimize replacement. Slow the formation of scar tissue. Keep scar tissue that does not form pliable.
•  Therapeutic Inflammation creates a controlled, localized area of inflammation to jump-start the healing processes. The types of therapeutic inflammation include: Deep friction, Connective tissue stretching, Moxibustion(burning the skin), and Acupuncture.
• Contraindications - Suppressed Healing mechanisms, Conditions of impaired repair and restorative functions (unless carefully monitored), Use of antiinflammatory medications.

Pain

• Pain is a very important mechanism to understand, it's a complex, private, and abstract experience. Managing pain can be a major challenge, it can affect us in many different ways; Physiologic, Psychologic and Social Aspects. The Practitioner needs to recognize that the clients pain is what they say it is, and exists when the client says it does.
•  There are four processes involved in pain sensations; 

• Pain transduction - Noxious stimuli lead to electrical activity in pain receptors.
• Pain transmission -  Pain impulses travel through PNS(Parasympathetic Nervous Systom) and CNS(Central Nervous System).
• Pain modulation - neural activity can influence pain transmission at the spinal cord, also involves activity in primary afferent pain receptors.
•  Pain perception - subjective experience.

• Fast Pain - Local and specific, Sensation on the surface, Prickling, Sharp, Electrical.
• Slow pain -  More Diffuse(spread out), Felt in deeper tissues, Burning, throbbing, aching, usually associated with tissue damage.
• Utility of pain sensations - Cue us to protect ourselves from further hurt, Initiate a search for medical assistance, Help pinpoint underlying cause.
•  Nociceptors(Ends of dendrites) - 

•  These are found in almost every body tissue, respond to any type of stimuli, and adapt slightly, or not at all.

•  Pain transmission to cerebral cortex

• Neospinothalamic tract - carries type A(fast pain) nociceptors to the thalamus.
•  Paleospinothalamic tract - carries type C(slow, chronic pain) nociceptors to the brainstem.

• Influences on perception of pain

• Emotional interpretation -  Hypothalamus and limbic structures.
• Rational interpretation - Frontal cortex 
• CNS Mechanisms
• Neurotransmitters and neuromodulators(substance P, acetylcholine, norepinephrine, epinephrine, dopamine, serotonin)
•  Endorphines

• The pain threshold is the point at which a stimulus is perceived as painful. This Varies somewhat among individuals. Perceptual dominance, some pain overshadows other pain; can be activated by massage that “hurts good”.
• Pain tolerance is the duration or intensity of pain endured before relief is sought. This varies widely among individuals  

• Origins of pain

• Somatic - from stimulation of skin, skeletal muscle, joints, tendons, and fascia.
• Visceral - from stimulation of internal organs  

• The Cortex accurately locates origin of most somatic and some visceral pain.

• Acute pain - A disease, symptom, or a temporary treatment aspect.

• Warning signal that arouses sympathetic nervous system. Temporary, sudden onset, localized. Client is often able to describe it. Arouses sympathetic ANS.

• Chronic pain - persists or recurs for indefinite periods, usually longer than 6 months.

• Major health problem for many, Obscure onset(Hidden, or concealed), Character and quality can change. Anxiety, sleep disturbances, depression common,  Multidisciplinary approach to treatment.

• Intractable pain - Is persistent with treatment or without demonstrable disease.

• Intractable pain poses the greatest challenge to health care providers. Massage provides temporary relief through distraction.

• Phantom pain - Can occur after an amputation.

• Pain or other sensations seem to originate from amputated extremity, Brain misinterprets stimuli from proximal portions of sensory nerves.

• Referred pain - felt far from its origin.

• Visceral pain and deep somatic pain can refer, A diagnosis must be obtained from a physician.

• Sources of information for assessment:

• Subjective information from the client, Direct observation of verbal and nonverbal information, Gender and, cultural differences in expression

• Sympathetic responses to acute pain:

• Decreased ROM, Muscle guarding, Trigger points, Areas of increased or decreased sensitivity

 Impingement Syndrome

• Two types of nerve impingement:

• Compression - pressure on a nerve by a bony structure.
• Entrapment - pressure on a nerve by soft tissue. 

• Impingement classified by the plexus affected.  

• The Cervical plexus - includes the phrenic nerve and the ventral branches of four upper cervical nerves.

• Symptoms - headaches, neck pain, breathing difficulties, and pain sensations in neck, ear, and shoulder (transmitted by cutaneous branches of nerves.)
• Origins of pressure - include suboccipital and the sternocleidomastoid muscles, and shortened connective tissues at cranial base.

• The Brachial plexus - situated in the neck and axilla.

• Symptoms - pain in the shoulder, chest, arm, wrist, and hand, and thoracic outlet syndrome.
• Origins of pressure - include scalenes, pectoralis minor, subclavius, and arm muscles.

• Lumbar plexus

• Symptoms - pain in lower back, belt area, lower abdomen, genitals, thigh, and medial lower leg.
• Origins of pressure - can include quadratus lumborum, psoas, and lumbar dorsal fascia.

•  The Sacral plexus - sciatic nerve and serves the pelvic structure, buttocks, and lower limb.

• Symptoms - gluteal, genital, leg, and foot pain
• Origin of sciatic pressure - include piriformis muscle and ligaments of the sacroiliac joint  

• Massage can reduce pressure on nerves:

• Soften and stretch connective tissue, normalize muscle tension patterns, restore normal resting length to shortened muscles.

Psychological Dysfunctions

• Science has validated the mind/body link in terms of health and disease. Many risk factors for the development physical(body) pathologic conditions are mentally(mind) influenced.
• Major types of mental health dysfunctions - Trauma, Posttraumatic stress disorder, Pain and fatigue syndromes, Anxiety and depressive disorders, Stress-related illness.

• Massage can physically influence mental state through compassionate touch. Soothing ANS Hyper and Hypo Activity, Managing pain, normalizing breathing patterns, providing support for returning the body to normal homeostasis.
• 
  

Tumors and Cancer

• Tumors - benign (usually localized and slow-growing) or malignant (can metastasize).

• Detection of Cancer - Point out abnormalities or changes, suggest medical evaluation.
• Cancer not always a contraindication - Massage can support immune function as part of comprehensive treatment program, it's important not to overtax the body's systems.

 Medications

• Massage and medications can interact synergistically or antagonistically to; 
  stimulate a body process, 
  inhibit a body process, or 
  replace a body function.