About 15 percent of the current U.S. population is 65 years or older, and as the baby boomers continue to age, the size of this group will continue to grow. Combine this population with those who are chronically ill or have suffered a serious injury, and it’s easy to see how now and in the future you may have clients who are deemed medically fragile.
Although the benefits of massage therapy are likely similar for medically fragile clients, there are a wide array of things that will be different when working with these clients. Read on to learn more about what you can expect—and what’s expected of you—when working with medically fragile clients.
What Is Meant by Medically Fragile?
A medically fragile client can be loosely defined as someone with serious and complex medical conditions and a frail constitution. These clients will likely fall into one of three categories: chronic or terminal illness, suffering from severe injury or advanced age. Some other common terms that are used to describe the medically fragile are medically frail, medically complex or technology-dependent.
Because medically fragile spans such a large range of conditions and client demographics, massage therapists are going to need to be prepared to evaluate how the definition of medically fragile may vary across clients. Julie Goodwin, a massage therapist and educator, considers a wide array of variables when thinking of how a medically fragile status may apply to her clients. “To me, assignment of a medically fragile or medically frail status evolves from an interview, observation, assessments of medical treatment and medication side effects, physical and social risk, and a review of medical records or treatment transcripts,” says Goodwin. “This often represents multiple health conditions from which recovery or rehabilitation is unlikely, medical treatments and medications that create side effects that interfere with daily functioning, and impairments to mobility and cognition.”
Remember, there is really no “typical” medically fragile client, so you’re going to need to be able to adapt quickly and be flexible.
When Massage Is Beneficial
Even though the session for these clients will be different, the benefits they receive are similar to the benefits massage provides to all other clients. “All the reasons why a non-fragile person would want a massage would be applicable here, too,” says Susan Salvo, a massage therapist and author who specializes in the medically fragile. Goodwin echoes this sentiment. “In my practice, pain relief, relaxation and increased range of joint motion are typical reasons for seeking massage therapy,” she explains. “Most of my clients I have deemed medically fragile are elderly (over 65).”
While massage therapy is effective for many of the same reasons as it is with more typical clients, there are still some reasons medically fragile clients seek out massage therapy that are more common than others. The most common therapeutic reasons include pain and stress management, decreased swelling, improved range-of-motion, relief from nausea, fatigue, insomnia, and a feeling of calmness and improved mood. Massage can also be beneficial for clients who suffer from psychosocial issues such as isolation, hopelessness, depression and anxiety. “Massage can bring comfort to these clients and their caregivers,” says Salvo, “which can be especially important when spoken language is difficult or impossible.”
What You Need to Know
Space. When working with medically fragile clients, the location of the massage therapy session is going to depend in large part on the client, and can range from your practice location to the client’s home to a medical facility or nursing home. For each of these settings, massage therapy sessions will need to be adapted. For example, Salvo recommends scheduling all appointments at your practice during daylight hours.
Here, too, you need to think of how you can make the space easy for the client to negotiate, like making sure there is enough space between furniture and walls to accommodate wheelchairs and walkers. “Modifications in my location include lowering the table to ease access and assisting the client around the treatment space,” says Goodwin. “Working with the client only in a semi-reclining supine position, avoiding repositioning and working with the client clothed are other modifications I often make.” You should also consider using linens in contrasting colors for those clients who might be visually impaired.
Alternatively, if you see medically fragile clients on an outcall basis— either in their home or at a hospital or long-term care facility—different accommodations need to be made. Evening hours, for example, are sometimes better in these settings because there will likely be fewer disruptions. Space is limited in these settings, too, so don’t bring a portable table or massage chair. Instead, assume you’ll massage the client where they are, whether that’s in bed, in a wheelchair or while seated in a recliner. “If the client is in bed, the bed is often placed against a wall, limiting access to all sides of the body,” adds Ann Catlin, owner and director of the Center for Compassionate Touch.
Working with the care coordinator or nurses is a must. Ask for specific instructions, Salvo encourages, and when you go to the client’s room, obtain their permission before entering. Many times, these clients may have people in their room, too, whether medical staff or visiting family, so don’t be afraid to introduce yourself and explain why you’re there. A curtain pulled around your client often indicates a health care professional is performing care that requires privacy, says Salvo, so you should wait outside the room or in the hallway until they’re finished.
Other things Salvo suggests considering include:
Safety. Some medically fragile clients are going to be unsteady on their feet or experience dizziness, and so falling will be a big safety concern. You need to make sure you don’t allow a client to move without assistance from a member of their health care team, whether that’s from a chair or their bed. Also, if you need to step away from a client, make sure the bed rails are raised before doing so.
Accessibility. You aren’t going to want to move furniture from a client’s room, but you can try to make as clear a path as possible around the bed or chair to facilitate your work. If you need blankets or pillows or linens, however, ask someone to help you locate these items instead of looking for them yourself or bringing your own.
Emergency. Be sure you ask about the facility’s emergency protocol in advance so you can take proper measures. If an emergency occurs, Salvo recommends raising the bedrails to keep the client secure and then stepping out into the hallway to call for help instead of pushing the call button. Many times, you’ll get a quicker response this way.
Intake. Intake is always important, but especially so with medically fragile clients. The length of intake will differ based on the client, but make sure to have extra time allotted as most times you’ll need to talk with these clients longer. “Intake is extensive, and likely to comprise most of the client’s initial visit,” says Goodwin. “I prepare the client ahead of time by letting them (or the person making the appointment, who is often a family member) know what information to bring, including a list of health conditions, a list of all prescribed and over-the-counter medications, and the names of primary and specialist health care providers, to name a few.”
Remember, however, that when working in a hospital or other care facility, you won’t always have access to a client’s medical records. “It’s important to note that a massage therapist will only have access to the medical record if they have a formal relationship with the organization, either as an employee or a contracted service provider,” Catlin cautions.
Also, be sure the room is well lit and relatively quiet. Turn down the volume on the TV or radio, for example, or ask the nursing staff to hold calls while you’re conducting your intake. Salvo also suggests being systematic in your intake, asking how the client is feeling before moving on to more in-depth questions.
The Massage Session
Flexibility. As with most special populations, massage therapists need to be flexible when working with medically fragile clients. “Therapists are challenged to remain flexible and adaptive,” Catlin explains. “You’ll need to let go of preconceived ideas about how a session will unfold or how the client will respond.”
Positioning. Of all the differences you might notice when working with a medically fragile client, the massage therapy session itself may be where you see the biggest contrast, starting with how the client is positioned. “They’re rarely going to get disrobed,” says Salvo. “Depending on how medically fragile or how mobile they are, you’ll have to be willing to massage through clothing or just with what they have on, which might be a hospital gown or leisure clothing.” Before beginning, remind the client that they should let you know if anything hurts or causes discomfort so you can make the proper modifications.
When considering positioning, the client should be in a supine, semi-reclining, side-lying or seated position. If you’re working in a long-term care facility or hospital, many times the nursing staff will prefer to position these clients if they can’t manage on their own, so be aware of that before starting the massage. Prone positions, too, are not appropriate if there are any medical devices on the anterior surface of the chest or abdomen, like drain tubes or IV lines.
Catlin suggests thinking of ways you can work with the current location and position of the client to help with positioning. “For example, use the hospital bed controls to adjust the position, or use pillows to support the arms or raise the feet off the mattress,” she says.
Timing and Technique. Although the time you spend actually massaging these clients may be shorter than usual—typically from 15 to 45 minutes, according to Catlin—the length of the session when you include intake will still be an hour or more. Remember, too, that these clients are often going to need more time for activities such as using the restroom, drinking water or getting comfortable, and they may like to share personal stories, so you need to be patient.
“Technique modifications include shortening session duration to avoid overtiring the client, limiting or eliminating techniques that may stimulate systemic circulation, and decreasing pressure and increasing lubrication,” says Goodwin. “Also, choose a lubricant unlikely to trigger an allergic reaction, and take extra steps to preclude transmission of infectious pathogens.”
Salvo echoes this caution, advising massage therapists to use only unscented products or products that have a scent that is familiar to the client. Additionally, a different container should be used for each client whenever possible, or single-use lotion packs or the client’s own lotion could be used, with permission from the client, of course. Be sure to sanitize exterior surfaces both before and after use.
Whatever technique you use, making sure the level of pressure is appropriate is a must and requires you to continually check in with the client to ensure they are comfortable.
After the Massage Therapy Session
When the massage session is over, be sure to replace a client’s eyeglasses if you’ve removed them, as well as their socks or slippers. You might also ask the client if they need anything, Salvo suggests. After placing used linens in the hamper and sanitizing your hands, make sure to complete your session or SOAP notes. “Be sure to let the patient care coordinator know if you found unreported issues, such as swelling, redness or bruising,” Salvo adds.
Clients who are considered medically fragile often want—and need—the very real benefits offered by massage therapy, but you might have to modify your approach to accommodate the unique needs of the medically fragile client. Learning ahead of time what you’ll need to know when working with this population is a great place to start.
The M Technique for the Hand
When working with medically fragile clients, Susan Salvo recommends
a technique developed by Jane Buckle called the “M” Technique. This
technique uses a patterned sequence of three repetitions and light pressure
that remains unchanged, allowing the client’s body to become used
to the new stimuli and eventually relax. Following is the “M” Technique
sequence for the hand:
1. Alternate hand stroking to elbow
2. Lateral movements palm down
3. Joint circling
4. Scissor hold/pressure point/stroke
5. Turn hand over
6. Little finger links
7. Lateral movements, palm up
8. Handshake
9. One-hand stroking to elbow
Figure 1: PA wrist The most common problem I’ve seen is that the PA projection is performed with the hand extended flat on the cassette, which elevates the wrist slightly, causing the carpals to appear jammed together. If the clinician instructs the patient to place their hand in a gentle fist position, this will help place the carpal bones of the wrist closer to the cassette. (Figure 2)
Figure 2: PA wrist with hand in gentle fist Technical factors that are important to keep in mind include the following: 10 x 12 inch (24 x 30 cm) crosswise for two or more images on one cassette; for a digital screen, use lead masking to get more than one image one the cassette; for a detail screen, use the tabletop technique; 50-60 kVp range, mAs 4-5; and minimum SID of 100 cm.
Figure 3: PA wrist When evaluating the PA view of the wrist (Figure 3), the joint spaces of the wrist have a width of 2 mm or less. Only the radiocarpal joint is slightly wider. The carpometacarpal joints are slightly narrower than the midcarpal joints. The capitolunate joint is considered the baseline joint width to which other joint spaces can be compared. Make sure to look at all of them: the radiocarpal, the proximal intercarpal, the midcarpal, the distal intercarpal and the carpometacarpal joint spaces.
Figure 4: The carpal arcs The carpal joint spaces should be symmetrical. The cortical margins of the bones should be parallel. One excellent way of looking at the positioning of the carpals is by using three carpal arcs. (Figure 4) The first arc is a smooth curve outlining the proximal convexity of the scaphoid, lunate and triquetrum. The second arc traces the distal concave surfaces of the same bones, and the third arc follows the main proximal curvatures of the capitate and the hamate.
Figure 5: The carpal bones: scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate An arc is disrupted if it cannot be traced smoothly. A break in one of the arcs indicates a fracture or the disruption of a ligament leading to a subluxation or dislocation.
Figure 6: Lateral wrist positioning Can you remember the names of all the carpal bones? You’ve got the scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate. (Figure 5)
Figure 7: Lateral view of the wrist The lateral radiograph of the wrist is obtained with the arm adducted with the ulnar side of the forearm on the cassette. The elbow is flexed to 90 degrees, adjusting the hand and wrist to make certain they are in a true lateral position. The same technical factors can be used for the lateral projection as for the PA projection. (Figure 6) If an X-ray table is not available, any sturdy table will do. This is a non-bucky technique.
Figure 8: Position of the pisiform for the true lateral wrist projection When evaluating the lateral view of the wrist (Figure 7), it is important to first determine if a true lateral view has been performed. A true lateral view is defined by the relationship between the pisiform, capitate and scaphoid bones. On a standard lateral view, the palmar cortex of the pisiform bone should overlie the central third of the interval between the palmar cortices of the distal scaphoid pole and the capitate head. (Figure 8)
Figure 9: Axis of the scaphoid The axis of the lunate runs through the midpoints of the convex proximal and concave distal joint surfaces, and can best be drawn by finding the perpendicular to a line joining the distal palmar and dorsal borders of the bone. (Figure 10) The capitate axis joins the midportion of the proximal convexity of the third metacarpal and that of the proximal surface of the capitate. (Figure 11)
Figure 10: Axis of the lunate Since we are discussing the lateral view of the wrist, we can’t ignore the most commonly luxating/dislocating bone in the body, which is the lunate. Scapholunate instability can be assessed in the lateral view by measuring the scapholunate angle (30-60 degrees is normal – Figure 10) and the capitolunate angle (<30 degrees is normal – Figure 11). If the lunate is angulated dorsally, it is termed a DISI type of instability, which stands for dorsal intercalated segmental instability. Most agree that anything over 80 degrees for the scapholunate angle indicates instability. As far as VISI, volar intercalated segmental instability, or palmar flexion instability, when the lunate is tilted palmarly too much, most agree that VISI cases are most likely a normal variant, especially if the wrist is very lax.
Figure 11: Axis of the capitate The Oblique View
Figure 12: Oblique wrist Other Considerations
Figure 13: Oblique wrist demonstrating the trapezio-trapoidal joint Functional views can also be performed if there is a question of ligamentous injury. Radial and ulnar deviation projections place stress on the intercarpal ligaments, which is used most often to evaluate the scaphoid bone. The clenched-fist PA wrist view can be also used to demonstrate a widening of the scapholunate distance.