swedish ch.11

Special populations

Groups of individuals who are disadvantaged, vulnerable, and/or at risk for harm

Causative/contributory risk factors

• physical/cognitive limitations

• life stage

• Unique life circumstances that restrict an individual’s rights/privileges

Special Populations

•One or more chronic illnesses

•Disabled

•Have impairments

•Require more-than-usual healthcare services and/or specialized healthcare services

Disability

Impairment or condition that makes it more difficult for someone to participate in one or more major life activities

➢Ex: seeing, speaking, hearing, eating, sleeping, walking, learning, reading, working

Quality of Life (QL)

Perception people have regarding their position in life in context of their culture and value systems

➢Degree to which person is able to participate in and enjoy life events

•Massage can improve QL

➢Feelings of comfort and improved mood

➢Reduced stress and pain, improved function

➢Social connection through compassionate/safe touch

Pregnancy Massage

•Modifications of massage techniques and body positions to meet the needs of women as they undergo changes during pregnancy and postpartum period

•Lower back pain is most common reason for pregnancy massage  

➢Hip, shoulder, and neck pain and improved mental health are other common reasons

•Massage benefits can extend to co-parent

➢Invite them to sessions and teach them effleurage\petrissage done at home

➢Convey same precautions licensed practitioners follow such as avoiding skin lesions

Pregnancy Massage and
Spa Hydrotherapy

•Clients can sit in hot baths or hot/dry saunas for ≤20 min irrespective of pregnancy stage

➢Bath temp limit: 104°F (40°C)

➢Sauna temp limit: 158°F (70°C) 15% humidity

•Temperatures or time frames exceeding these guidelines may result in damage to the unborn

Pregnancy Massage, Essential Oils, and Topical Cannabidiol Products

Essential oil use is safe

➢No reports of abnormal/aborted fetuses from their use by inhalation/topical application

•Topical CBD not recommended

➢Guidance from FDA as there is no evidence suggesting its safety during this developmentally important time

High-Risk Pregnancy

•Pregnancy more likely to have complications

➢Ex: disease and maternal/fetal death

•Risk factors include

➢Maternal age (<15 and >35 years)

➢Multiple babies

➢Preexisting condition (hypertension, HIV infection)

➢Pregnancy-related conditions (preeclampsia, placenta previa)

Massage and
High-Risk Pregnancy

•Maternal age and multiple babies

➢No special massage modifications

•Ones that require massage modifications are found in sections discussing 2nd and 3rd trimesters

Massage During First Trimester

•First trimester: first 14 weeks

•Modifications for

➢Miscarriage signs and symptoms

➢Deep vein thrombosis

➢Morning sickness

➢Breast changes

Miscarriage

Noninduced embryonic/fetal death or passage of conception products before week 20

•Signs/symptoms include

➢Abdominopelvic pain and cramping

➢Vaginal bleeding or spotting

➢Discharge of tissue

Massage and Miscarriage

Postpone massage during S/S of miscarriage

•Refer them to OBGYN/HCP

➢True for all trimesters

•Time after miscarriage can be emotionally/physically taxing

➢Relaxing/nurturing massage indicated

Massage Safety in First Trimester

•Massage/foot reflexology is safe

➢Cannot cause miscarriage or premature labor

•Denying massage services to these clients may be unlawful, discriminatory, and unethical

➢Violates person's autonomy or decisional authority

Deep Vein Thrombosis (DVT)

Thrombus/blood clot within deep vein

➢Pulmonary embolism is acute complication

•Pregnant clients 5-6Xs higher risk for DVT

➢Risk remains until 10 wks postpartum

•S/S are

➢Unilateral leg swelling

➢Heat

➢Redness or noticeable discoloration

➢Pain and tenderness

Massage and DVT

DVT diagnosis: avoid affected lower extremity

•No diagnosis: look for DVT S/S

➢If present, avoid affected lower extremity

➢Refer client to HCP

•True for all trimesters and will continue until week 10 postpartum

Morning Sickness

Nausea with/without vomiting

➢Effects approximately 75% of pregnant clients

➢Can occur any time of day/night

Hyperemesis Gravidarum

severe and uncontrollable nausea and vomiting

➢Some cases require hospitalization

Massage and Morning Sickness/Hyperemesis Gravidarum

•Massage indicated

➢May reduce symptom severity

•Semireclining position while supine helps reduce nausea

•Avoid techniques causing client to rock/shake

➢Excessive motion may worsen nausea

•Have disposable emesis bag available

Breast Changes

Breasts enlarge, become heavier, and tender

➢Changes begin by week 8

•Breasts may leak colostrum (early breast milk) during 3rd trimester

Massage and Breast Changes

•Position client for comfort while prone if tenderness present

➢Use pillows under, above, between breasts, depending on comfort

➢May need to adjust face rest frame above table

•Can use side-lying position

•Work around bra if client wears one during massage

Massage During Second Trimester

Second trimester: weeks 15-28

•Modifications for

➢Supine hypotensive syndrome

➢Preterm labor

➢Preeclampsia

➢Gestational diabetes

➢Placenta previa

Supine Hypotensive Syndrome

Drop in blood pressure from compression of pregnant uterus against blood vessels

➢Decreased venous return reduces cardiac output, which may decrease placental blood flow and lead to fetal distress/death

•S/S are dizziness, light-headedness, SOB, pallor, nausea, and agitation

Massage and
Supine Hypotensive Syndrome

Use left lateral tilt or side-lying position beginning week 22

➢Earlier if client is “showing”

➢Also used in 3rd trimester

Left Lateral Tilt

Place small cushion beneath right hip while client is supine in semireclining position

•This moves uterus off blood vessels

Side-Lying Position

Client on left side

•Use pillows beneath head, arm, and leg

➢Upper/lower extremities same height

➢Spine in neutral position; not rotated

•Remove pillows before asking client to get up and get dressed

Pregnancy Tables and Accessories

Tables with pregnancy recesses and specially designed bolstering systems available

•These allow pregnant clients in 2nd or 3rdtrimester to lie prone safely

Seated Position

Pregnant clients in 2nd and 3rd trimester can receive seated massage

•Clothed or unclothed with proper drape

Preterm Labor

Regular uterine contractions and changes in cervical size (dilation) or length (effacement) ≥20 or ≤37 weeks

➢Can cause preterm (premature) birth

➢Health risks for baby is greatest before week 34

Massage and Preterm Labor

Massage postponed during preterm labor

•Massage administered during pregnancy may reduce preterm labor risk

➢Teach co-parent/caregiver to massage mother at home

•If preterm birth, teach infant massage to promote parent-child attachment behaviors

Preeclampsia

Persistent high blood pressure and protein in urine

➢Develops ≥20 wks and resolves after childbirth

•Untreated can lead to serious/fatal complications

•More common in first pregnancies, many prior pregnancies, young/advanced maternal age, higher order multiples

Complication of Preeclampsia

Eclampsia: preeclampsia plus seizures

•HELLP syndrome: severe preeclampsia

➢Hemolysis: destruction of red blood cells

➢Elevated Liver enzymes

➢Low Platelet count

•S/S include hypertension (>140/90), sudden weight gain, generalized edema called anasarca, severe headaches, visual disturbances, protein in urine

Massage and Preeclampsia

Massage postponed

•Screen clients for preeclampsia starting at week 20 by looking for widespread edema, severe headaches, visual disturbances

➢If present: postpone massage and refer client to HCP

➢This restriction true for 3rd trimester

Gestational Diabetes Mellitus

Diabetes in pregnant females who did not already have diabetes

•More common in obesity, advanced maternal age, family history, non-Whites

•Can lead to excessive fetal growth, preeclampsia, maternal hypoglycemia, preterm birth, infant respiratory distress syndrome

Massage and
Gestational Diabetes Mellitus

Massage postponed until condition is well managed (HCP determined)

•Put blood glucose meter it accessible place

•Insulin: avoid vigorous massage over sites of recent injection for 24 hrs

➢Local massage may increase absorption, decrease blood glucose, and cause hypoglycemia

Placenta Previa

Placenta partially/totally covering cervix

•Most common sign is painless vaginal bleeding that is bright red

Massage and Placenta Previa

Massage postponed until condition resolves or child is born, and mother fully recovers

Massage During the Third Trimester

Third trimester: weeks 29 to birth

•Modifications for

➢Relaxin

➢Gastroesophageal reflux disease/heartburn

➢Lower back pain and uterine ligament pain

➢Edema in the legs, ankles, and feet

➢Varicose veins

➢Stretch marks

Relaxin

Hormone that activates collagenase, causing collagen to breakdown and reduce its strength

➢Relaxes pelvic ligaments to assist childbirth

➢Has a slight effect on all joints

Massage and Relaxin

Modify joint mobilizations and traction

➢Ex: support beneath joint with one hand while mobilizing with other hand

➢Ex: avoid manual traction of lower extremities

•May cause separation and pain over sacroiliac and pubic symphysis joints

•Restriction for 4-6 mo postpartum

Gastroesophageal Reflux
Disease and Heartburn

Periodic regurgitation of gastric contents into esophagus

•Main symptom is heartburn

➢Burning sensation behind sternum

➢Worsens when lying down

➢Usually occurs 30-60 min after meals or at night

Massage and GERD/Heartburn

Schedule appt 3 hrs after meals

•Semireclining position while supine reduces heartburn symptoms

Lower Back Pain

From postural changes

➢Leaning back to compensate for increased abdominal girth

➢Can cause anterior pelvic tilt and strain to lumbar spine and pelvic joints

•Also from relaxin mentioned previously

Massage and
Lower Back Pain

•Massage indicated

•Spend time on lower back, lumbosacral, and gluteal areas

•If lower back pain is severe or does not subside after massage, refer to HCP

➢Pain may be kidney infection or preterm labor

Uterine Ligament Pain

Sudden sharp/jabbing pain from overstretched uterine ligaments

➢Sudden movements can cause ligaments to tighten quickly and then relax after few sec

•Uterine ligaments most often involved

➢Round ligament

➢Broad ligament  

Round Ligament

From anterolateral uterus, passes through groin, labia majora, terminates at mons pubis

➢Between layers of broad ligament discussed next

•Pain referred to groin, abdomen, and/or anterior thigh

 

Broad Ligament

•Double-layer section of peritoneum that extends from uterus, surrounds ovaries and fallopian tubes, and connects to walls/floor of pelvis

•Pain referred to lumbar and/or glute regions

 

Massage and Lower
Back/Uterine Ligament Pain

Lower back pain: massage can help

•Uterine ligament pain: this is usually experienced while repositioning or getting on/off the table

➢If it occurs, suggest they lie back slowly and remain there until pain subsides

➢Then to move again, but more slowly

Edema in Legs, Ankles, and Feet

Occurs from

➢Increased fluid volume (up to 50%)

➢Enlarged uterus compressing vessels

➢Pregnancy hormones

•More severe at end of day and during summer months

Massage and Edema in
Legs, Ankles, and Feet

Place affected areas on cushions

➢This raises them above level of heart

•Use light pressure effleurage applied centripetally and skin stretching

➢Massage proximal first, then distally (massage thigh, then leg, then ankle, and foot last)

➢Recommended pressure is 5 grams

Mild swelling of legs, ankles, and feet normal and not contraindicated

•However

➢Widespread swelling requires referral as it could indicate preeclampsia

➢Unilateral leg swelling, especially with heat, redness, pain, and tenderness, requires referral as it could indicate DVT

Varicose Veins

Enlarged veins caused by incompetent valves

•S/S are fatigue or achiness in legs

➢Later, veins appear bluish-purple in skin, are bulbous and tortuous, and feel hard

➢These worsen after sitting/standing for prolonged periods

Massage and Varicose Veins

Avoid affected area for 10 wks postpartum

➢Due to increased risk of blood clots within veins

Stretch Marks

Indentations from overstretched skin

•More common on abdomen, breasts, hips, buttocks, thighs

•Begin as painless pink, red, purple, reddish brown, or dark brown marks

➢Later fade to silver

•Texture different than normal skin

Massage and Stretch Marks

Light pressure over stretch marks

➢3 on 10-pt pressure scale

•Massage will not reduce/minimize stretch marks

➢They are not buildup of collagen

Childbirth

process of delivering baby, placenta, membranes, and umbilical cord to outside world

•Lochia: vaginal discharge after childbirth

Vaginal Childbirth

Childbirth products delivered out of mother’s vagina

•Most people are discharged and go home 24 to 48 hrs after uncomplicated vaginal delivery

Massage and Vaginal Childbirths

Client must be medically stable

➢Vital signs within normal limits

➢Client conscious and comfortable

➢Prognosis good to excellent

•Position client for comfort

➢Ex: breast support while prone

•Work around undergarments if needed

➢May use menstrual products because of lochia

Cesarean Childbirth (C-section)

Surgical removal of baby, placenta, membranes, and umbilical cord though incision in abdominal wall

•Most people discharged and go home 3 days after uncomplicated C-section childbirth

Massage and C-section Childbirths

Client must be medically stable

•Communicate with patient care coordinator

➢Follow their directives

•Position client for comfort

➢Side-lying position may be needed to avoid pressure on recent incisions and drain tubes

•Work around undergarments if needed

➢May use menstrual products because of lochia

More on Massage and C-sections

Avoid vigorous massage on lower extremities for 12 wks after surgery

➢Thighs and legs

➢Because of increased blood clot risk

Massage and C-section Incision

Avoid area near incision until

➢Sutures or staples are removed

➢Area is dry, not moist or open

➢Into remodeling (maturation) phase

•May take up to 8 wks after surgery

•Area around incisions should not be manipulated in ways that stress it while healing

Scar Massage after C-section

Scar massage can begin once incision is healed

•Use skin rolling near and over scar

•Massage tissues in several directions

➢Circular, vertical, horizontal

•Begin with light pressure, then deeper

➢Adjust it according to client’s pain tolerance

•Discontinue and refer client to HCP if scar is redder, warmer, or more painful on subsequent sessions

Clients Who Are Breastfeeding

Breastfeeding (nursing): feeding child with milk from lactating breasts

•Fluid may leak from breasts between feedings

Massage and Breastfeeding

Offer water before/after massage

➢Fluid needs increase during this time

•Work around bra if worn during massage

•Position client for comfort

➢Side-lying position if breasts are sore/tender

•Breastmilk does not require special handling precautions such as disinfection

Infant Massage

Modifications of massage techniques and body positions to meet needs of a child and child’s family

➢Newborn to age 3

•Taught to parents and caregivers

•Promotes parent–child interaction

•Use doll to demonstrate while parent does them on the child

Massaging the Baby

Massage can begin:

➢45 min after bottle feeding

➢Immediately after breastfeeding

•Use food-grade oils

•Sessions are short (10-15 min)

•Parents enjoy time with child

➢Use techniques the child enjoys

Child and Adolescent Massage

3 yrs old through adolescence

•Child and parents/legal guardian must approve procedures

➢Use terms the child understands

•Parent/legal guardian signs consent

➢Age 18 for therapeutic/medical procedures (clinical)

➢Age 16 for nontherapeutic/wellness procedures (spa services, self-care)

Child and Adolescent Massage: Practice Setting

To build rapport with young child

➢Interact while they play with toys

➢Children can bring blanket, toy, or stuffed animal, which remains with them entire time

•To build rapport with older children and adolescents

➢Ask about video games, favorite music, food, TV shows, or movies

For younger children, massage room lighting should be bright

➢Dark rooms may promote anxiety, especially if they fear darkness

•Older children may choose to listen to music downloaded on digital devices

➢Earbuds: be sure only one is used so they can respond to questions/comments

Ask parent/guardian to remain in room during massage

➢If they elect not to, massage room door remains open, preferably with parent/guardian in view

Child and Adolescent Massage: Body Positions

Positioning is child-directed

•Child may prefer blanket on floor or chair

•Have plenty of blankets, pillows, comfy chair, floor space and table

Child and Adolescent Massage: Techniques

Children wear loose clothing rather than disrobe

➢Still use drape over clothing

•Use oil-free lotions/crèmes on adolescents

•Consider demonstrating massage to younger children first

➢Use items they brought or parent’s forearm

•Duration depends on age/developmental stage

Aging Adults: Geriatric Massage

Modifications of massage techniques and body positions to meet the needs of older and aging adults

•Old age: life stage determined by

➢Chronologic age

•65 begins the life stage of old age

➢Changes in social roles

➢Changes in functional capacities

•Often increased disease, med use, impairment/disability

Physiologic Effects and Associated Diseases of Aging

Average life expectancy in US is 78 yrs

•Senescence: period from old age to death

•92% have at least 1 chronic disease

•Most common:

➢Heart disease, cancer, stroke, diabetes, Parkinson and Alzheimer diseases

Aging: Musculoskeletal System

Loss of bone density

•Increased susceptibility to fractures

•Osteoporosis and osteoarthritis common

➢May lead to high reduction

➢See Fig. 11.9 and 11.10

•Loss of muscle tone, strength, endurance

➢Called sarcopenia

Aging: Integumentary System

Skin thinner, more fragile, and wrinkles

➢Skin heals more slowly

•Increased pigmentation and bruising

•Decrease in fat can cause cold intolerance

•Hair turns gray

•Fungal infections of feet/toenails common

Aging: Nervous System

Changes in balance and coordination increase risk of falls

•Changes in vision and hearing

➢Affects depth perception and night vision

➢Eye may develop white/gray/bluish ring, cataracts, glaucoma, macular degeneration

➢Hearing loss can cause tinnitus (ringing in ears)

•Glasses and hearing aid use common

Aging: Endocrine System

Ovarian function leads to menopause

➢Contributes to osteoporosis

•Thyroid hormone production decreases

➢Reduces metabolism and increases risk of cold intolerance

•Pancreatic function decreases

➢Increases risk of hypoglycemia and type 2 diabetes

Aging: Reproductive System

Females: menopause occurs as ovarian function ceases

•Males: testosterone produced until late 80’s

➢Increased risk of benign prostatic hyperplasia

Aging: Cardiovascular System

Increased risk of anemia. congestive heart failure, hypertension, coronary and carotid artery disease, and orthostatic hypotension (OH)

➢OH: dizziness/loss of balance occurs upon moving from lying down/sitting to standing

Aging: Lymphatic System/Immunity

Increased risk of dehydration

•Immune response is slower and weaker

➢Increases risk of disease

Aging: Respiratory System

Lung capacity and ribcage mobility decreases

➢Increased risk of secretions pooling in lungs

•Bronchitis, influenza, pneumonia more common

Aging: Gastrointestinal System

Increased risk of GERD and fetal incontinence

➢Peristaltic activity may be reduced

Aging: Urinary System

Increased risk of urinary incontinence, urinary tract infection, kidney failure

Practice Setting

Schedule sessions during daylight hours

•Arrange furniture so clients using walker/cane can pass

➢32 inches recommended by ADA

•Allow ample time to fill out intake forms

•Cover draped or clothed client with blanket

Fried’s Frailty Criteria

Determine robustness or frailty

•Score of 2 or less suggests robustness

•Score of 3 or more suggest frailty

1.Slow walking speed

2.Muscle weakness evidenced by weak handgrip and sarcopenia

3.Self-reported exhaustion

4.Low level of physical activity

5.Underweight or unintentional weight loss

Slow Walking Speed

Note how fast or slow the client walks

•Frail clients walk more slowly

➢Slow walking speed may also indicate Alzheimer disease, Parkinson disease, or poor cardiovascular health

•Robust clients walk more quickly and have a steady gait

Muscle Weakness:
Weak Handgrip and Sarcopenia

Ask the client to squeeze your hand

➢Weak handgrip indicates frailty

➢Strong handgrip indicates robustness

•Look/palpate muscles of lower extremities

➢Sarcopenia: reduced muscle mass and muscle tone and loss of strength from age-related inactivity; indicates frailty

Self-Reported Exhaustion

Ask about energy level

➢Frail clients report they are tired, low energy, fatigued, or no pep or get-up-and-go, spending much time at home

➢Robust clients may report participation in activities such as fishing or gardening, or talk about vacations taken recently or planned

Low Level of Physical Activity

Low levels of physical activity: indicate frailty

•Physically active: indicates robustness

Underweight/Unintentional Weight Loss and Using Vitality Assessments

Ask if client has experienced recent weight loss and if intentional

•Robust client: few, if any, age-related massage modifications

•Frail client: varying degrees of modifications

Geriatric Massage: Body Positions

Ask about sleeping positions

➢Reproduce these when possible

•Clients may be uncomfortable lying prone

➢Ex: dental appliances

•Table is barrier-free and devoid of bolsters while they transfer on/off table

➢This reduces fall risks

•Limit number of times client changes positions

Geriatric Massage: Techniques

•Use adequate amount of lubricant to reduce friction

•Avoid spinal mobilization due to decreased bone density

•During foot massage, no lubricant between toes

➢Avoid suspicious areas and tell client and/or caregiver

•When massage is complete, replace eyeglasses, socks, or slippers and anything removed before massage began

Clients with Visual Impairments

Visual impairment: decreased capacity to see, and it cannot be corrected by usual means such as eyeglasses or contact lenses

•Common causes: presbyopia (far-sightedness), diseases such as glaucoma, cataracts, diabetic retinopathy, age-related macular degeneration

Visual Impairments: Practice Setting

Announce your presence

•Describe surroundings using face of a clock

•Service animal?

➢Do not pet, talk to, feed, or distract it

•Use linens of contrasting color

Clients with Hearing Impairments

Hearing impairment: decreased capacity to hear

➢May occur in one or both ears

•Common causes: advanced age, exposure to noise, ear trauma, ear infections

Hearing Impairments: Practice Setting and Techniques

Announce your presence

➢Gain client’s attention before speaking

•Position yourself in relation to impairment

➢One ear may function better

•Use facial expressions/body language to clarify verbal messages

➢Demonstrate as much as possible

•Hearing aids?

➢Avoid moving hands close to ears

Clients with Mobility Impairments

Mobility impairment: decreased capacity to move or use one or more extremities, or lack of strength to walk, grasp or lift objects

•Common causes: congenital disorders (spina bifida, muscular dystrophy), disease (arthritis, obstructive pulmonary disease), inactivity, injury (spinal cord injury, stroke), advanced age

Mobility Impairments:
Practice Setting

Perform massage offsite if office is not wheelchair accessible

•Include rest period before conducting assessments

•Ask client to describe degree of limitation

•Treat mobility device as part of their body

Mobility Impairments: Techniques

Clients can be  massaged in wheelchair

➢Place pillows atop massage table

➢Use desktop device

➢See Fig. 11.21

•Massage shoulders, chest, arms, forearms

➢Avoid aggressive PROM

Mandatory Reporting

Legislative mandate for individuals who have regular contact with vulnerable populations to file report with protection services when abuse or neglect

➢Ex: children, dependent adults, elderly

•Know applicable laws within your state

➢Called the Duty to Protect