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The Decision Tree

When faced with the question, "what is it about 'X' that contraindicates massage?" you need to sort the information and make good clinical decisions. This thinking process is shown in a visual decision tree, which sorts complicated medical problems into smaller, more manageable ones. In the decision tree in Figure 1, the elements of the clinical problem are spelled out and sorted into easy-to-use boxes. You can see information about "X"-or the client's condition-on the left side of the tree. Possible adjustments in massage are shown on the right side. In this generic tree, arrows show how any of the medical information might lead to any of the massage responses. In a decision tree for a condition such as neuropathy (Figure 2), there are many more arrows, linking specific health information on the left with specific massage changes on the right. The decision tree is not a new concept in health care. In fact, more elaborate "clinical algorithms" exist in medicine. In this case I've adjusted the format for use with massage contraindications.

Room for Medical Information

The disease or condition "X" does not look the same in every client. One client with lymphoma may show only a painless lump. In another, lymphoma can cause breathing difficulty or gastrointestinal bleeding. Still another may be profoundly affected by fatigue, intense itching and reduced blood counts.

Since the massage should be geared to what is actually going on with the client instead of a condition name, a single, flat contraindication for "X" may not apply to all three clients. My own work in the field of cancer and massage therapy bears this out. At one time I had two clients with pancreatic cancer coming in on the same day every week, with two vastly different clinical pictures. There was no single, simple contraindication for "X" that would serve those two clients. Instead, I made many massage adjustments and substitutions for one of them, and just a few for the other.

The Left Side of the Tree

On the left side of the tree, the condition "X" is sorted into smaller bits of relevant information. There are four boxes on the left side, containing typical features of a condition. These are essentials, complications and medical treatment. Medical treatment is followed by the effects of the treatment on the body.

Some essentials are listed in the essentials box. Here, characteristics of the condition, signs and symptoms, and relevant medical findings are noted. Information to go in this box could include the basics of what it is-an infection, a tumor, trauma to a tissue, or an impairment in organ function. Signs and symptoms could include a rash or fever. Findings could include a mass found in the lung on the last MRI or even a fracture. In this box are "things that make condition 'X,' condition 'X.'"

In the middle box are complications: significant effects on organ or tissue function that occur once the disease has been around long enough to complicate things. Items in this box might include liver function impairment, heart disease, breathing difficulties or infection. A common cold in the essentials box may lead to bronchitis or pneumonia in the complication box. A hepatitis C infection may lead to cirrhosis and portal hypertension. An open fracture may lead to infection in the bone. Cancer of the pancreas may spread to the bones over time, and so on. In the complications box are things that have worsened the client's condition. In fact, sometimes there may be some overlap between the essentials and the complications, as complications give you the symptoms and signs that are considered essential to the disease. The perfect box doesn't exist for all medical information; however, it's important to put it somewhere to make sure it's handled in the session.

The two boxes at the bottom left hold medical treatment and the effects of treatment. These are important facets of a client's experience, as sometimes medical treatment itself changes the body in ways that require massage adjustments. The medical treatment box holds everything from splinting to chemotherapy, and includes surgery, antibiotics, inhalers and hormone therapy. Some of these are associated with unintended negative events such as side effects, adverse reactions or complications. For example, a side effect of chemotherapy is nausea. One complication of surgery is infection. Some hormone therapies result in hot flashes or joint pain. A severe rash may occur as an adverse reaction to a drug.

With the left side of the tree filled out for a given condition, you've begun to answer the question, "What is it about 'X' that contraindicates massage?" Now you can turn to the question, "What is it about massage that's contraindicated?"

The Right Side of the Tree

If the left side of the decision tree is the information side, the right side of the tree is the action side (Figure 1). It holds actions you take as a massage therapist. I suggest that several elements of massage therapy go in the right-hand box. These elements are the "ingredients" of massage therapy. When divided into its elements, it's much easier to discuss whether something is contraindicated, neutral or even indicated. These elements are contact, lubricant, pressure, joint movement, friction, site, position, draping, speed, rhythm, length of session, scheduling of session and intention.

In addition, there are two other actions you might take in response to the client's medical picture: 1) a medical consult (seeking more information from a client's physician or nurse); or 2) a medical referral, sending a client to a physician for more help than you can provide.

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