Ep 424 Cancer, Clots, and COVID ”A Complicated Client: Have a Client Who . . .Pathology Conversations with Ruth Werner

0:00:00.0 Speaker 1: Are you looking for a company that empowers your growth and development? Look no further than the Elements Massage brand, where all massage therapists have the opportunity to thrive, through the Elements Massage Career Advancement Program. In the Elements Massage Career Advancement Program, Elements Massage Studios recognize, reward, and uplift their massage therapists, rewarding continuous learning, commitment, and growth. The elements Massage Career Advancement Program includes Professional, Elite, and Master levels, where massage therapists will enjoy higher commission rates, access to continuing education and development opportunities, and unique career growth opportunities to propel them toward a successful future. Evaluate your career and apply to an Elements Massage Studio today. Visit elementsmassage.com/careers and take the first step towards a fulfilling journey. That's elementsmassage.com/careers.

0:01:05.5 S1: Unlock exclusive 20% discounts on all earthlite products, from portable tables and chairs to professional sheets and oils. Simply visit earthlite.com, create an account and enter your ABMP member ID during registration. Enjoy free ground shipping on orders over $75 and stationary or electric lift tables at a $395 flat rate, a significant savings on everything you need to enhance your practice. We are proud to assist you as the world's number one brand in massage, earthlite.com.

0:01:47.1 S1: Anatomy Trains is thrilled to invite you to our four-day in-person fascial dissection intensive, April, 16th through 19th 2024 with Master Dissector, Todd Garcia and Anatomy Trains author Tom Myers, at Todd's brand new Laboratories of Anatomical Enlightenment in Westminster, Colorado. Discount offered for upfront payment in full and payment plans are available for this life-changing educational experience. Don't miss it. Learn more and sign up at anatomytrains.com.

[music]

0:02:34.7 Ruth Werner: Hi, and welcome to, I have a Client Who, Pathology Conversations With Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about, and teaching about where massage therapy intersects with diseases and conditions that might limit our clients' health. We almost always have something good to offer, even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice. And sometimes as we have all learned, that is harder than it looks. Today's episode comes with a lovely alliterative title, I just couldn't resist it. Cancer Clots and COVID, A Complicated Client. And it started with a letter in Facebook Messenger, which by the way is a perfectly fine way to get in touch with me. And the letter goes like this.

0:03:42.2 RW: Hi, Ruth. Please let me know if it isn't okay to contact you in this forum for this type of question, but I have a complicated multi-layered case. My client is a five foot nine inch lunch lady with a smoker's voice who restores old 1960s land yachts with her husband, Oldsmobiles and Chevys. She's a very colorful lady. She's also a colon cancer survivor. Three years out from surgery who had complications after her colectomy, a perforated bowel and sepsis. She had a colostomy procedure to bypass the colon while it healed and that was removed a year and a half ago. Now she has significant scar tissue in her abdominal region as you can imagine, especially where the colostomy bypass was. She was referred to me due to pain from scarring in her abdominal region as well as back and neck due to flexion in the abdominal region to alleviate her pain.

0:04:42.3 RW: She was responding well to visceral myofascial treatment. Her scars are softening, her pain is going down and she just got COVID for the first time two weeks ago. She was fully vaccinated, but she is not recovering quickly. She still smokes probably one or two cigarettes a day. I'm concerned about blood clotting risk with her history and working in her abdominal region. She has no history of clotting, but she has several risk factors. I have a call in with her doctor to discuss this. I'm waiting to hear from her doctor, but I'm curious as to your thoughts moving forward with the COVID diagnosis and how long I might wanna consider waiting until I resume her treatment. Well, I replied this, I said I will put some thought into this, but my short answer is she can probably receive massage that doesn't challenge her ability to adapt so she doesn't get sore.

0:05:40.0 RW: She has no lung symptoms like shortness of breath or increased fatigue. It's a great idea to discuss clotting concerns with her doctor given her circumstances. But those terrifying blood clotting events that we all heard about were mostly with unvaxxed people at the beginning of the pandemic. It's still a concern, but much less than it used to be. And the contributor wrote back this. They said that's the way I was thinking and leaning. Her docs have not been very helpful. They obviously have little experience with a knowledgeable LMT, so I wanted to run it by someone who can help me think through the layered pathologies and risk. Happy to contribute with a podcast.

0:06:21.2 RW: Okay. So thank you contributor. Really appreciate this story. Would love to get to know this client. She sounds like a really great person and indeed this is a very complex situation. Just to review, our client is 64 years old. She smokes a little, three years ago she had surgery for colon cancer that involved a colectomy, a colon perforation, sepsis, and a temporary colostomy. For those who aren't a hundred percent sure about all this vocabulary, a colectomy is surgery to remove a part of the colon. A colon perforation means that the wall of her colon was accidentally opened so that fecal matter could leak into her peritoneum. This is a very dangerous setup for peritonitis. And sepsis suggests that indeed she had an infection that got into her bloodstream that may have led to body-wide and life-threatening inflammation. I've done at least one other. I have a client who episode on sepsis and an article on sepsis and post sepsis syndrome, so I'll be sure to put links to those in our show notes. And then on top of all that complicated history she got COVID.

0:07:35.3 RW: Her massage therapist is quite rightly concerned about blood clot risk, and is unsure when it will be safe to get back to work to help this person have less pain related to her abdominal scarring. As it happens, I am writing this episode during the week that marks the four-year anniversary of the national shutdown for COVID-19. This has been stirring up all kinds of feelings and memories for me, and I imagine for you too. One of the things that I watched in those early days with great concern were the stories about young people dying of clot-related complications, strokes, and heart attacks in numbers like we'd never seen before. I remember hearing an interview with a brain surgeon, who described watching the blood form new clots literally while he was trying to remove others. Solving the mystery of COVID-related blood clotting continues to be a challenge, and experts have about a bazillion theories ranging from exaggerated inflammation, and of course that was definitely another big factor in those early pre-vaccine days to an upset in clotting factors to damaged endothelium because endothelial cells have that receptor that SARS-CoV-2 virus really, really likes.

0:08:54.7 RW: Let's be clear, the threat of COVID-related mortality is not over. Every week in this country, we lose between 1,000 and 1,500 people to this infection. And people at high risk for COVID complications deserve our care and courtesy, in terms of wearing masks in crowded places and taking other precautions. With that said, I sat about gathering information for this episode with the assumption that in our post-vaccine world and different varieties of the COVID virus now active that life-threatening clots among COVID patients would no longer be considered a huge risk, at least not like in 2020. And I was not entirely correct, I did find substantial data on elevated risks for deep vein thrombosis and venous thromboembolism and on the risks for cardiovascular events. That is to say heart attack and stroke for people with both severe and mild cases of COVID. And also, and I've been tracking this since the early days as well, there is still a school of thought that suggests that tiny micro clotting in the capillaries could be a factor in long-term organ damage and fatigue that we see with long COVID.

0:10:19.1 RW: So in my head at least, I categorize COVID-related clotting into two different things. On the one hand, we see big clots that cause big damage, pulmonary embolism when they arise in veins and heart attack, stroke, or other kinds of infarctions when they arise in arteries. On the other hand, we see little tiny clots, microscopic ones that get trapped in capillaries, depriving local tissues of oxygen and nutrients. These are less life-threatening and they melt with our own anti-clotting chemicals, but they may be responsible for some of the many, many symptoms that are reported with long COVID. How does this apply to our client in today's story? Well, remember, she wants to receive massage to reduce her pain and increase her mobility, and this means abdominal massage. The focus of the work is on her abdominal scar tissue. So maybe this isn't really a big issue.

0:11:20.3 RW: I mean, after all, she has no clotting history and to date, no signs or symptoms that this is a threat. Although her recovery from COVID seems to be going slowly, but as our contributor points out, she does have some risk factors. She smokes. She's 64, she has a history of sepsis, which indicates a very active inflammatory process and she's probably sedentary at least right now because she's been sick. I think these are very legitimate concerns, especially since we still see more blood clotting problems with people who have recently had COVID compared to those who have not recently had COVID. I love, love, love that this massage therapist wants to consult with the doctor about blood clotting risk, and when it might be safe to get back to work. As we know, consulting with a doctor is different from getting permission, but our clients' healthcare practitioners may not always understand how important it is that we get a chance to discuss our concerns with them.

0:12:26.5 RW: And so sometimes we are left without that option. What do we do? Well, let's run this through a risks, benefits, accommodations analysis, and see where we land. What are our risks? Well, maybe this client is developing big clots that could be fragmented and dislodged. Again, on the venous side, that's gonna end up in the lungs. On the arterial side, clot fragments could go almost anywhere, but the coronary and carotid arteries are special risks for heart attack and stroke respectively. Or maybe this is someone who's dealing with tiny little micro clots and that might be part of why she seems to be healing slowly. These micro clots get trapped in capillaries. They don't pose the same kind of risks as big clots. I do not have hard data on the role of massage therapy for this kind of situation, but typically exercise and movement are recommended in this kind of setting.

0:13:24.7 RW: So, I'm inclined to suggest that gentle non-intrusive massage could also be beneficial. All right. Let's look at some possible benefits. This client was deriving good results from our contributor's work, which they described as visceral myofascial treatment. Continued work with this strategy could help her have less pain, more mobility in her abdomen, less stooping in her neck and shoulders. All of these are part of our client's goals. So, when we think about accommodations, let me ask you, can you see a way to get to those benefits while avoiding those risks? I think you probably can with some specific cautions. Consulting with a doctor about blood clot risk is a great way to get started, but if that's not possible, then when the client feels ready, I suggest starting extremely conservatively with short sessions, gentle pressure. Maybe the client could also be taught some stretches or movement patterns that she can perform on her own within her tolerance, and any follow-up questioning has to include specific information about bruising, new pain, and very, especially any kind of breathing difficulty or excessive fatigue.

0:14:44.4 RW: I'm willing to bet that if we fall back on this old standby of slow progress that is in tune with a client's resilience, this massage therapist will stay safe and help her to progress. Maybe not as quickly as before, but hopefully she doesn't have to lose ground while she is in recovery. And then as she gets better and she can tolerate more, maybe her massage therapist can increase time or pressure or in other ways bring her very best skills to the table. Thank you so much contributor for sharing your delightful client with us. I'm sure all of our listeners join me in wishing her and you very well as you continue to work together.

[music]

0:15:39.9 RW: Hello. I have a Client Who listeners, Ruth Werner here, and I'm so excited to let you know that my library of online self-paced continuing education courses has just expanded. I now have a two-hour ethics course called A Doctor's Note is Not good enough and what is better? This NCBTMB approved course goes into why a doctor's permission or approval or even a prescription doesn't provide the legal or safety protection you might think it does. Then we look at how to start useful conversations with healthcare providers, that will actually get us to safe and effective massage for our clients with complex conditions. Visit my website at ruthwerner.com for more information and to register for a Doctor's Note is Not Good Enough, and what is better?