discussed in more detail below). If the client has recently seen their physician, it is relevant to ask why. If the client talks about a disease or condition in which you are unfamiliar, the pathology should be looked up prior to beginning the massage to be sure there are no contraindications. If the client is having restrictions in movement or range-of-motion difficulties due to hypertensive muscles or joint problems, the discovery of past injuries may be illuminating and may influence the degree to which a client’s limbs may be safely moved without causing harm. Assessing pain Before any other question of pain is asked, the particular quality of a client’s pain is important to know. There is acute pain and there is chronic pain. In layman’s terms, this is the equivalent of short, sharp, emergency type pain and dull, achy, long- term pain, respectively. For the therapist, a client experiencing acute pain may still be in the initial stages of an illness or injury, perhaps ruling out massage altogether if not just locally. It is best to avoid areas of acute pain with a client even if it is determined that a massage may proceed, particularly in regards to some regularly used techniques such as petrissage (kneading) and tapotement (percussions) which may cause muscle guarding which may lead to further pain. The quality of a client’s pain is the ‘Q’ part of the acronym OPPQRST which is used to gain more detail about the client’s discomfort. Beginning with ‘ O ,’ the other letters stand for Onset , as in, when did the client’s pain begin? If acute pain began within the last 72 hours, this is further indication that an illness or injury may be too recent for the therapist to treat. ‘ P ’ stands for Provocative , in effect asking if there anything the client does that makes the pain worse. ‘ P ’ stands for Palliative , which asks the client if there is anything that makes the pain lessen or go away altogether. ‘ Q ’ for Quality was discussed earlier. ‘ R ’ is for Radiation and seeks to answer whether the client’s pain radiates or travels to other areas of their body. For example, acute or chronic pain that radiates from the lateral side of the neck to the medial border of the scapula on the same side may indicate trigger points in the Levator Scapula muscle. In another instance, pain accompanied by a burning or tingling sensation which radiates from the inferior (lower) gluteal region down the outer thigh to the knee may indicate an injury or hypertension in the Piriformis muscle which is innervating the sciatic nerve below it. Naturally, we also want to know the Site of the pain, indicated by the ‘ S .’ ‘ T ’ is for the Timing of the pain or how often the pain is present. The less often the client experiences pain may indicate a client is in the recovery phase of an illness or injury and that a massage is more likely to proceed safely. In addition to these questions, whether the pain is keeping the client awake at night could potentially indicate a lack of sleep for the client and that a relaxation massage may actually be the best course of treatment for a particular session. Medications Along with allergy information, clients often forget to include any over-the-counter or prescription drugs they are taking. However, this information is highly relevant to discovering contraindications. For example, over the counter drugs like aspirin may not only reduce a client’s sensitivity to pain, but is also a blood thinner; this is something to consider during a massage. According to Brent A. Bauer, MD, the director of Complementary and Integrative Medicine Program at Mayo Clinic, there are considerations therapists should take note of when the client is taking medicines that thin the blood. Bauer says, “One common medication that may require treatment alterations is anticoagulant medications [blood thinners] like Warfarin because they may make your clients more prone to bruising and internal bleeding.”(AMTA) Prescribed pain killers like narcotics such as Codeine, Hydrocodone and Oxycodone are high in strength and will likely cause a client to misjudge a therapist’s depth of pressure.
A massage therapist should also have a working knowledge of pathologies, particularly of the integumentary system (the skin), and observe any skin condition the client is aware of prior to the massage to be sure they are not coming into contact with infectious diseases. Note, however, that clients are often unaware of skin condition on their posterior body, which means that an on-the-spot assessment may have to be conducted while performing the massage. This could lead to severe soreness for the client days after the massage has been given. These same medications often induce nausea in clients which may mean the therapist avoids using rocking or vibration techniques. Anti-inflammatory drugs (NSAIDS) such as Naproxen or ibuprofen will mean the avoidance of techniques that cause inflammation like cross-fiber friction, or vasodilation which will occur during the use of hot compresses or hot stones. Other possible side-effects of pain relieving medication may include dizziness and low blood pressure, meaning that a more upbeat or faster paced massage is indicated. Corticosteroids taken by a client may come in the form of Cortisone or Prednisone and are most often used to treat inflammation. The side-effects of Corticosteroids include swelling of the limbs, thinning of the skin and high blood pressure. Lymphatic massage, light effleurage or tapotement may be ruled in for the massage for each of these respective side-effects. In addition, although they can be taken orally, Corticosteroids are sometimes injected at the site of an injury. For the therapist, this means that again, techniques that typically cause inflammation are contraindicated and the injection site should be avoided altogether so that the absorption of the medication is not interfered with. This same consideration applies to clients who are diabetic. If they are injecting insulin, the site of the injection should be avoided for six hours so as not to increase the absorption rate. Clients with cardiovascular diseases are sometimes prescribed lipid lower drugs, diuretics or anticoagulants. These three drug types sometimes cause gastrointestinal stress in which case the therapist should avoid massaging the abdomen or putting the client in a semi- reclining position (for massage tables that have this feature). Conversely, a client with a respiratory problem who is on a bronchodilator (an inhaler) would benefit from the semi- reclining position while the prone position is avoided. Female clients taking estrogen as part of hormone therapy are often prescribed estrogen, which can have the effect of making a woman’s breasts tender. If this is the case, place a pillow under the chest if the prone position cannot be avoided if the client suffers this condition. Also note that estrogen, when prescribed, can have additional effects such as rashes, hot flashes, leg pain, phlebitis (inflammation of the veins) or a blood clot in the lower limbs. If these conditions are present or suspected, the session should be postponed until a physician clears the client for massage. Lastly, there are occasions when a therapist encounters a client on medications for anxiety or depression. Antidepressants, for example, can make a client either tired and lethargic or restless. The therapist must adjust their massage strokes accordingly to either end the session with energetic techniques like tapotement or use long, slow, gliding effleurage respectively. In cases where a client is taking an anti-anxiety drug, the client usually has a diminished sense of touch upon their body, in which case the therapist should use caution if attempting firm or deep pressure. There is no shortage of medicines a client may be taking, so it is worthwhile to double-check with the client and make note of them. Once the interview has concluded and the therapist has gathered all the necessary information, the therapist should incorporate their critical thinking skills to determine which
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