One of the most important components of sound bodywork practice is an understanding of pathology. Without it, a therapist's mechanical skills are just that -- purely mechanical. But simply knowing pathology basics or having references at hand is still not enough. In each situation, the therapist will need to assess the application of these guidelines according to how the client is presenting at that particular moment.

Massage instructor Ruth Werner, author of A Massage Therapist's Guide to Pathology, says, "I think it's safe to say that pathology is under-addressed in many massage schools. I've taught hundreds of therapists in my workshops and not many of them felt they got adequate training on this topic in massage school." In her guide, Werner notes three areas in which the practitioner should be knowledgeable in order to properly apply their skills: "how the human body works when it is healthy, how the body works in the context of disease or dysfunction, and how a particular bodywork modality may influence those processes, either for good or for ill."1

Werner's own experience with massage training was part of her motivation to write the book. "I went to massage school in Seattle almost 20 years ago," she says. "It was a different profession then. The people who got massage were healthy people with a little money to burn on a self-indulgent treat, or people who weren't looking for legitimate massage. When we did our section on contraindications in school I completely bombed it -- I couldn't make any kind of connection between disease states and bodywork choices."

As an instructor at Brian Utting School of Massage in Seattle, Wash., Werner developed what she refers to as a "bee-in-my-bonnet" attitude about the lack of pathology information therapists were receiving. "I worked with the owner and director of the school, Brian Utting, and the person who came every year to help teach contraindications, Sue Carlson, to restructure the way the material was offered to make a little more sense. But I was still convinced that we didn't have enough tools to make informed choices."

When a family transition necessitated a move for Werner away from Seattle, Utting gave her a going-away present -- a computer and a job. "He said, 'You keep saying we don't have enough information about contraindications. Now you'll have time to put it together for us.' So I took about a year, and I used maybe half a dozen textbooks and I compiled some ideas about the list of conditions we'd been working with." On completion of the project, Werner considered broadening application of her work. She approached Utting, requesting his permission to market the information outside of the school. "He'd paid me for my time and commissioned the project, so it was important that he be behind this effort. He said, 'Sure, give it your best shot.' And I did." At the 1998 American Massage Therapy Association national convention in Washington, D.C. -- within five years of starting her initial draft for Utting's school -- Werner was opening a box containing the first copies of her published work.

A second edition followed in 2002. "I can't possibly cover all the pathologies every massage therapist might ever need to know," Werner says. "With every edition of the book I try to include more topics that are pertinent -- I base these decisions mostly on feedback I get from other pathology teachers and participants in my workshops. This is a constantly changing subject."

Werner is currently working on a third edition, scheduled for release in January 2005. "I'm adding about 20 new articles, and all the artwork and design features will be updated and made more user-friendly." Never one to stand still, Werner has yet another project in the works -- a reference guide for quick decision-making.
"It will cover more conditions than A Massage Therapist's Guide to Pathology, but with less of the description of the pathophysiology of the disease process."

As a teaching physician interested in preventive medicine, Dr. Kalyani Premkumar, author of Pathology A to Z -- A Handbook for Massage Therapists, shares Werner's concern for therapists' lack of pathology background and was equally inspired to do something about it. "It was apparent to me," she says, "that it was not possible for students to obtain the information they need about different pathologies in the short period of training they had. They needed a book that provided information on different pathologies and organized in a way that they can easily find any pathology searching by systems or just looking up diseases arranged alphabetically. They needed a book that also had illustrations and photos of diseases that they may come across."

To fulfill that need, she decided to put together a book that would serve both in training and in practice. Each condition is described by cause, signs and symptoms, and risk factors, and includes recommendations and cautions for therapists. In the appendix, Premkumar also covers side effects of commonly used drugs and presents strategies for infection prevention. In this way, she sees her reference book as a tool for safeguarding therapists and their clients, especially in cases of contagious disease. An additional valuable resource is the listing of organizations and support groups for various diseases that can be of use for both client and therapist.

Premkumar describes her book as comprehensive and easy to use. Diseases are listed alphabetically, but therapists can also utilize the word and system-wise indexes for page reference. "I wanted to produce a book that was handy, that practitioners can pull out from their shelves and quickly read about the pathology even while the client is in the office." Even with a solid pathology background, a therapist may come across a disorder they are not familiar with or perhaps have forgotten.

Now in its second edition, Pathology A to Z has been updated and expanded with references provided for each pathology addressed. For the convenience of those with computers, the reference book is also available on an interactive CD. "By having the ability to quickly find information about the disease and its treatment," Premkumar says, "the therapist will be able to make decisions on how they should approach the client, despite variations in the clinical
scenario." (see "Contraindication Conundrum" sidebar)


Disease and Reasoning
Taber's Cyclopedic Medical Dictionary defines pathology as, "The study of the nature and cause of disease, which involves changes in structure and function," or "a condition produced by disease." The term itself comes from the Greek words pathos, meaning disease or suffering, and logos, meaning reason. When disease is present, any variety of structural and/or chemical alteration of normal body processes can take place. The study of how the disease alters this normal function is called pathophysiology.2

Werner writes in her book, "Our first job, before we ever touch a client, is to determine whether that person is capable of adjusting to the changes massage precipitates."3 In their work, therapists need to develop a "sense of intention," she says. "We should know why we are doing what we are doing every minute that we are working on a client."4

Werner's words underscore the importance of understanding pathology and pathophysiology. The therapist is not writing on a blank slate, as it were. With each known effect of massage or bodywork, there is also the underlying physiological base to which it is applied -- one that may or may not respond in a positive manner. For the purposes of her text, Werner separates therapies into two general categories, noting this is, of course, an oversimplification and that "every bodywork and every modality has to use both of those ways of being with a person." Mechanical therapies are described as enacting change while the more reflexive/energy-based approaches are inviting change.5

"One way to think about health," Werner says, "is as the ability to adapt to changing environments -- external and internal. Massage challenges the internal status quo when we push blood and lymph, alter what neurotransmitters or hormones might be prevalent, maybe change the dilation of certain blood vessels. When a person struggles with health because of chronic or acute conditions, massage can add extra stress to that process, so we want to do it carefully and intentionally. Sometimes this is appropriate, like when we friction old, gummy scar tissue, or help to stretch out contracted muscle and fascia." But if the client's health is so fragile that they can't keep up with the changes initiated by bodywork, it can be overwhelming. Although benefits can be derived in such cases as cancer patients undergoing active medical treatment or touch-deprived elderly with complex pathologies, Werner cautions that the therapist must proceed with deliberation.

Those bodyworkers who are trained in multiple modalities have options outside of Swedish massage to offer clients whose health is challenged, Werner says. In the absence of contagious conditions (where close physical contact contraindicates any kind of bodywork), the therapist may choose a more reflexive or energetic approach. While overtreatment with energy work may leave one feeling fatigued or off-center for a few days, being overtreated with mechanical work can have more serious consequences, such as dislodging a blood clot. "So, of course we save the work that has the strongest mechanical impact for clients whose vitality can keep up with it," she says. "Fortunately, that's the vast majority of people who seek massage."

In the presence of disease, the therapist is affecting change in a body that has already undergone alteration from the norm. Likewise, the varied effects of different modalities must be taken into consideration. There is no one hard and fast rule that covers all. As Werner points out, "Each practitioner of each bodywork modality must research how that modality influences processes during health and disease, and must apply that information in a conservative, knowledgeable way to achieve the best possible results with his or her clients."6

What do therapists need as a basic working knowledge? In her courses, Werner includes contagious and non-contagious skin conditions, cardiovascular diseases, common musculoskeletal conditions, public health issues, and cancer. "More to the point," she adds, "I would love to see therapists develop the critical thinking skills it takes to be able to gather information about how a disease changes physiological function, and to be able to ask some intelligent questions of the client and/or the client's healthcare team to draw some good conclusions about how to structure a bodywork session for maximum benefit with minimum risk. In my book I share a lot of facts, but I do it in a way that is easily reproducible. I hope that someone who needs information on some topic that's not in the book could go to another more technical resource and still be able to pick out the key pieces to make a good decision."

How does a therapist determine if her knowledge base of pathology will enable her to safely and appropriately meet the needs of her current clientele? According to Werner, it depends on the clientele. "If a brand-new therapist is working in a setting where he or she is seeing a lot of clients with complicated health issues," she says, "that person will -- I'd like to hope, anyway -- find out fairly quickly that more information is necessary."


Contraindications
Premkumar says any attempt to develop a general list of contraindications for therapists to follow would likely be incomplete. "One can come up with a list based on the diseases prevalent in a particular location," she says, "but the list would vary from region to region. Given the ease with which people move from one region to another, it is going to be very difficult for therapists if they rely on a list of diseases for which massage is indicated or contraindicated. Also, therapists would then become 'technicians' if such a list was available. The curriculum of massage therapy schools needs to be changed in such a way that their students are able to come up with indications and contraindications based on an individual client and the disease or diseases they present."

Although time restraints within a training program will limit the amount of material that can be covered, our experts suggest some basics that are essential in practice. "Certainly skin, musculoskeletal, and nervous disorders should be focused upon," Premkumar says. "I have tried to cover all the pathologies relating to these systems and most disorders of other systems." But, she notes, therapists continue to inquire about pathologies not listed in her book, as well as how to approach clients presenting with variations on the information provided.

Premkumar makes use of the current literature as well as her own medical background and experience as the base for her recommendations. But she notes the literature applicable to massage is woefully lacking. "There is an urgent need for massage-related research, especially of the kind that addresses strokes and techniques, duration of massage, and frequency of treatment that is effective for a particular disorder."

Even with the information that is out there, Werner says it is unrealistic for any therapist to be aware of every possible contraindication. "But," she says, "we should be able to conduct some basic research to be able to draw some pretty safe conclusions." In her classes, Werner emphasizes conditions that massage therapists either need to be most cautious about or are most likely to see. "I spend a lot of effort on skin conditions -- contagious things like herpes, ringworm, and parasites so that people can lose some of their fear about these issues -- and the more common non-contagious issues like psoriasis, eczema, and of course skin cancer. I really hammer skin cancer, since we get to see more of our clients' skins than they do. I've lost count of how many times I've had people tell me they spotted something that needed some attention before their client did.

"Then I put a lot of energy into cardiovascular diseases -- the invisible conditions like atherosclerosis and heart failure that will probably kill almost half of us. People are terrified of head lice, but you don't die from head lice. Over a million people in the United States will have a heart attack this year, though."

Another focus for Werner is musculoskeletal conditions, noting that for those seeking healing of these conditions through massage, the response is good. "I like to dive deeply into the constantly changing understanding of fibromyalgia -- although I predict that eventually this won't be listed as a musculoskeletal disease -- in comparison to myofascial pain syndrome, with overlap to other stress-related diseases like irritable bowel syndrome and chronic fatigue."

In terms of public health issues, Werner says therapists not only need to be aware of contagious diseases such as TB and HIV/AIDS, but also issues of diet and exercise like Type 2 diabetes and metabolic syndrome, a newly recognized phenomenon involving five physical markers. When occurring together, these signs (high blood pressure, high triglycerides, low high-density lipoprotein, high blood sugar with insulin resistance, and a large waist) exponentially raise the risk for cardiovascular disease and/or diabetes. "We, who need to be in the loop about common conditions that affect systemic health, should be aware of this if for no other reason than to be able to give good advice to our clients."

During her own training, Werner says the words "cancer" and "massage" were never used in the same sentence. "Now massage school clinics are accepting clients recovering from cancer surgery, and some who are still undergoing chemotherapy or radiation treatment. And while I think it's great that more people who are ill seek out massage as a coping strategy, I am concerned that students and practicing therapists are being called upon to make decisions they don't have the equipment to make."

Although these are the major points Werner emphasizes in her teaching, she adds, "It doesn't discount the hundreds of other conditions that may be absolutely key to any given person's education. Regional issues like lyme disease or West Nile Virus are important depending on timing and geography, and for many people diseases that are related to inherited predisposition, autoimmunity, or central nervous system damage form the bases for their practices."


Information at Hand
As our experts have pointed out, applying your skills properly takes more than mechanical knowledge. "Clients' safety," Premkumar says, "should be paramount on any therapist's mind, and I think clients are safe as long as a therapist, no matter how experienced, has the understanding that there may be something missing in his or her knowledge base, gives utmost importance to continuing education, and keeps up with the latest developments."

In her strategies for safe practice, Premkumar highlights the steps therapists can take to further self-education and ensure well-being for themselves and their clients: "Be well informed about infectious diseases so that you can recognize them in your client and avoid further harm to the client, yourself, or others visiting the clinic, keep reference books, a medical dictionary, and other resource materials in the clinic for easy and ready reference about rare disorders, read the health sections of newspapers to be aware of local endemics and epidemics, join local, national, and international massage organizations, and subscribe to journals to be current with progress made in the field and other health-related issues."7

Considering the power of massage and the possibility that clients can get hurt, Werner says, "It is our responsibility to minimize that risk, which is impossible to do without enough information. I taught a workshop last year in which most of the participants were working in a spa setting with high volume and fast turnover. These therapists were not encouraged or even supported in obtaining a thorough health history for their clients. Then they spent a weekend with me talking about contagious skin conditions and cardiovascular disease, and realized how dangerous their situation really is. Even therapists working in less time-conscious settings need to be able to get key information, and we don't have to keep it all in our heads. Life is, after all, an open book test."

Shirley Vanderbilt is a staff writer for Massage & Bodywork magazine.
References
1 Werner, R. A Massage Therapist's Guide to Pathology. Philadelphia: Lippincott, Williams and Wilkins, 2002: vii.
2 Thomas, C., editor, Taber's Cyclopedic Medical Dictionary, Edition 18. Philadelphia: Davis, 1997: 1421.
3 Werner, ix.
4 Ibid., viii.
5 Ibid., vii.
6 Ibid., viii.
7 Premkumar, K. Pathology A to Z -- A Handbook for Massage Therapists. Calgary, Canada: VanPub, 2000: 365-6.