Ep 50 – Ultrasound Ears: “I Have a Client Who …” Pathology Conversations with Ruth Werner

00:00 Speaker 1: Ruth Werner's best-selling book, A Massage Therapist's Guide to Pathology is a highly regarded comprehensive resource that sets the standard for pathology education. Written for massage therapy students and practitioners, this groundbreaking resource serves up a comprehensive review of the pathophysiology signs, symptoms, and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com. Oakworks is a proud supporter of ABMP and the massage therapy profession, and is happy to extend a special offer to ABMP podcast listeners. For a limited time, all ABMP podcast listeners receive 25% off Oakworks items with the code ABMP Summit 25. Go to massagetables.com and use the code ABMP Summit 25 at check out to receive 25% off your Oakworks purchase.

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01:11 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 client's 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 submission comes from a massage therapist in Florida who gives us an amazing story. When I shared it with a friend who has some expertise and very strong opinions on this topic, she was similarly gobsmacked. It's a corker, and it has shown me what I want for my own super power. And it goes like this.

02:20 RW: "I have a client who was in his mid to late 70s. He had anterior hip and groin pain that limited his ability to walk, like he couldn't walk to his mailbox. I worked with him for several sessions focusing on his glutes, hip flexors, quads, hamstrings, iliacus, and adductors. He didn't improve. In fact, he had more pain and could walk even less. There was nothing present in the tissues that I felt that could be leading to that level of discomfort from a short walk. I advised him to go to his primary care physician, but he declined and he stopped coming to see me." Okay, so far so good. The massage therapist didn't know what was going on for this fellow, but it was clear enough that whatever she was doing wasn't a solution, so especially since he's getting worse instead of better, she did the right thing and referred him out, other than that, no particular red flags, right? Here's the rest.

03:17 RW: "A few weeks later, I followed up with him via email and he gave me a run-down on what had happened. He said one day he'd noticed that his whole leg seemed swollen and painful, so he got in to see his doctor. His doc looked at his leg, and said, 'Oh, I don't like that at all. You're going to the ER now.' And in the hospital, an ultrasound revealed a large clot in his groin. He stayed in the hospital until he was stabilized with Coumadin, and later, he had vascular surgery to remove a 16-inch long clot. He resumed treatment with me several months later. Leg pain was no longer an issue, but he had some serious butt pain." So what was going on here? Was a DVT, the deep vain thrombosis, the cause of the clients anterior hip and groin pain that led him to seek out massage? We may never know. Clearly whatever was going on for him was not musculoskeletal or we would have seen some improvement with the combination of skilled body work and time, but instead he got worse. It's possible that he had some kind of injury or lesion that then led to the formation of a large blood clot in the area later. It's hard to imagine what that might be, but the human body is capable of all kinds of astonishing things, as we see in this podcast every week.

04:43 RW: But here's the scary bit. If he had been harboring a blood clot in his groin during his massage sessions, it is totally possible that this massage therapist could have precipitated an embolism. Evidently, this didn't happen because it wasn't until a few weeks later that he ended up in the ER. I looked up the statistics today. About 370,000 cases of DVT are diagnosed each year in this country, and about 100,000 people die of pulmonary embolism each year. That's a good reason to exercise an abundance of caution when this is a possibility. We could speculate about this client all day and not really get anywhere. Instead, I'd like to shift our attention to some uncomfortable truths.

05:35 RW: Uncomfortable truth number one: DVT can be hidden and unpredictable. Many people have an assumption that DVT always begins in the lower leg and it always involves some combination of swelling, pain, discoloration, and edema. That is often true, but it is not always true. DVT frequently begins in the thigh or the pelvis, where it is really hard to detect early. And the bigger the vessel is that's obstructed, the longer it takes for symptoms to develop. So being able to recognize those more typical signs is important, but it does not cover every situation. Uncomfortable truth number two: Suspected DVT puts massage therapists in extremely difficult situations. An earlier episode of "I Have A Client Who," that was number 42, which published on October 23rd, 2020, if you wanna go back and listen, provided two stories. Subtle signs in the legs of two different clients that met some of the DVT criteria. The massage therapist encouraged both of those clients to go to their doctor. One was willing and happy to do it, the other was pretty upset about it, but he went too. And they both came up negative for DVT.

06:56 RW: That massage therapist still did the right thing. This is definitely a better safe than sorry situation. But not every client is going to be ready or willing to take our advice, even when we couch it in language like, "I care about you and I want you to be safe. So before we work together, again, I need you to have this looked at," or more forcefully, "This might be nothing, but it might be something really serious, and to be on the safe side, we're going to end the massage now because I really want you to get this looked at today." I called a friend to discuss this because as a person who specializes in oncology massage therapy, she has even more stringent boundaries about clients who might have DVT than I do, and she shared this mini-story. "I had a client who had pain and swelling and discoloration in one leg from a tennis injury, and he wanted me to dig it out with massage, and I said no, that what he really needed was to see a doctor about it and right away. And he got really mad at me and he left and he did not go to see his doctor, but the next day he had an appointment with his physical therapist. My client told his PT about my overreaction, and the PT looked at his leg and said, 'Yeah, she was right. She probably saved your life. Now, go to the emergency room.' And I only know this because after it all got settled, he came back and told me."

08:24 RW: Having a client get mad us for asking them to seek medical attention is something we sometimes have to deal with, and it is not a reason to avoid the scary conversation. Of course, all of this is further complicated by the fact that an unexpected trip to the ER for an ultrasound can carry a hefty bill in the thousands of dollars, even for people who have health insurance. That shouldn't have to be a limiting factor, but given our healthcare system, it can be. Uncomfortable truth number three: There aren't any rubber stamped answers. As a pathology educator, I feel like I should be able to offer some hard and fast, cut and dried, always true guidance for you on this topic, and here's my guilty secret: I can't. As we know, DVT is often subtle or silent until it's not. It often begins in the lower leg, but not always. It carries a risk of embolization and pulmonary thrombosis, but some clots are chronic and stable and patients are encouraged by their healthcare team to use support hose while they maintain typical activities and take medication.

09:41 RW: In those situations, I would advise not to include rigorous massage therapy among those regular activities, but could we make a case for very relaxing gentle off-the leg body work? Possibly. Where does all this leave us? It leaves us in the very hardest place. We need to make informed, careful decisions based on the information we can gather in the moment and on our own. That is we have to use critical thinking to make clinical decisions. If we do it wrong, the consequences in this situation could be deadly, and that is not hyperbole. If there are any observable signs of DVT, these would include swelling, pain, discoloration, a feeling of fullness, especially if our client has any history of problems with blood clotting, then it is appropriate to recommend, or even insist, that they follow up with a doctor or an emergency room. Whether you need to cut your massage short or not to do this, like everything else, that's your call.

10:46 RW: But for someone like the client in our story today with groin and anterior hip pain and no other signs when he came for massage, that does not look like a DVT red flag, at least not until he got progressively worse. Which leads me to my superhero wish. If I were still in practice and if I could choose a superhero power, I would want ultrasound eyes, or I guess it would probably be ultrasound ears, to be able to clearly identify whether my clients were at risk for blood clots in their leg, thigh, pelvis, or elsewhere. What a great superpower that would be, but I don't see it on the horizon nor do I see ultrasound machines and technicians being available in every massage therapy setting, which means we have to go back to our critical thinking skills. No one's gonna do this for us, so be ready.

11:48 RW: Hey everybody, thanks for listening to "I Have A Client Who," pathology conversations with Ruth Werner. Remember, you can send me your "I have A Client Who" stories to ihaveaclientwho@abmp.com. That's I have a client who, all one word, all lowercase at abmp.com. I can't wait to see what you send me and I'll see you next time.

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