Learning Objectives. Pretest. Pretest

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1 Blood Clot Risk & Massage Therapy A Webinar with Tracy Walton, MS, LMT Part 2 of the Common Cardiovascular Conditions Webinar Series 1 Background Tracy Walton Author Educator Researcher Massage Therapist Specialist in massage therapy and cancer care 2 Last webinar: Blood clot symptoms & signs This webinar: Blood clot risk 3 1

2 Learning Objectives Which populations are at higher risk of DVT Why pressure on lower extremities might be contraindicated because of a silent clot Two simple DVT Risk Principles for a safer practice How to get help from a client s physician 4 Pretest 1. Which of the following DVT risk factors is thought to be the strongest? a. Ulcerative colitis and Crohn s disease b. Major surgery in last 12 weeks c. Varicose veins d. Age Pretest 2. Which of the following best describes DVT Risk Principle 1? a. With elevated DVT risk, limit pressure to level 3 on the symptomatic area b. With elevated DVT risk, limit pressure to level 2 on at-risk areas c. Limit joint movement on symptomatic lower extremities d. Avoid all contact with someone with high DVT risk 6 2

3 Pretest 3. Which of the following is a physician s responsibility described in DVT Risk Principle 2? a. Assess client s DVT risk from the medical record b. Speak directly to massage therapist s concern about massage and DVT c. Approve direct pressure and joint movement in the at-risk area d. All of the above are physician responsibilities in DVT Risk Principle 2 7 Pretest 4. How can a massage therapist promote a productive exchange with a client s physician about the client s DVT risk? a. Correspond in writing b. Use the massage therapy pressure scale c. Involve the physician s nurse d. All of the above may promote productive communication 8 Pretest 5. Why might a massage therapist choose a more cautious response to DVT risk in a vacation setting than in private practice? a. A vacation setting may offer less continuity of client care, and little or no session documentation b. Clients are more likely to report DVT risk factors in a vacation setting c. Clients with cancer or heart disease are more likely to seek massage on vacation than at home d. A therapist is more likely to see one-time clients in private practice than in a vacation setting 9 3

4 Pretest 6. Which of the following best describes pressure level 2 on the massage therapy pressure scale? a. Light lotioning b. Heavy lotioning c. Medium pressure d. Deep pressure 10 What is DVT? Deep = in a deep vein (not superficial) Venous = in a vein (not an artery) Thrombosis = condition of having a clot (thrombus) 11 Other Terms Embolus Moving body (clot, gas bubble, fat), traveling through the blood 12 4

5 Pulmonary embolism (PE) Movement of a dislodged clot to an artery or arteriole of the lungs MTs careful not to dislodge a clot 13 Where Does DVT Occur? Lower extremities Upper extremities Pelvic veins Mesenteric veins Most common; Focus of webinar 14 What Do We Do? Several Scenarios Diagnosed DVT DVT symptoms or signs, but no diagnosis Pulmonary embolism In treatment for DVT Elevated DVT Risk With signs/symptoms Without signs/symptoms 15 5

6 Signs and Symptoms of DVT (in Extremity) Pain Tenderness Swelling Warmth Redness Dilation of superficial veins Palpable cord Cyanosis in nailbeds, skin Fever of unknown origin (low-grade) Clinically silent (asymptomatic) DVT is asymptomatic 50% of the time In 2/3 of PE patients, no DVT symptoms 16 How do We Use Information about DVT Risk? Pressure level 3 Massage pressure >level 2 on lower extremities could disturb deep veins Joint movement may also disturb deep veins Awareness of risk factors Consider them in asymptomatic clients Consider them in symptomatic clients Awareness of DVT Risk Principles 1 & 2 17 What Increases DVT Risk? 3 General Conditions Venous stasis (slowing blood flow) Hypercoagulability (increased clotting tendency) Injury to endothelium (inner walls of veins) 18 6

7 What Increases DVT Risk? Specific Risk Factors Family hx of DVT or PE Inherited blood clotting disorders (Factor V Leiden, others) Central venous catheters Pregnancy, childbirth (last 6-8 wks) Obesity Oral contraceptives Estrogen replacement Some hormone therapies Disseminated intravascular coagulation (DIC) Nephrotic syndrome Ulcerative colitis, Crohn s disease Lupus Sepsis Cigarette smoking High altitude (>14,000 ft) IV drug use Red = High; Orange = Medium; Green = May be low. NOTE: This is a partial list. Sources disagree on ranking of risk factors. The above impressions are based on literature search. MTs are advised to research risk factors and consult client s physician in each case. 19 What Increases DVT Risk? Specific Risk Factors Major surgery, last 12 wks Trauma (esp. burns, multiple, SCI, fx of lower extremity) Immobility/bed rest (72+ hrs) Paralysis History of DVT, phlebitis Age (40+? 60+? 65+? 75+) Prolonged sitting (4+ hrs), last 4 wks Active cancer especially adv ca primary ca of lung, pancreas, GI Cancer treatment (last 6 mos) Congestive heart failure Heart attack Atrial fibrillation Stroke Atherosclerosis Varicose veins Red = High; Orange = Medium; Green = May be low. NOTE: This is a partial list. Sources disagree on ranking of risk factors. The above impressions are based on literature search. MTs are advised to research risk factors and consult client s physician in each case. 20 Themes? Cardiovascular conditions Cancer and treatment Hormones Medically complex conditions Inactivity Age 21 7

8 Cardiovascular Conditions often Run In Packs Principle If one cardiovascular condition is present, be alert for others. 22 What Increases DVT Risk? Specific Risk Factors Major surgery, last 12 wks Trauma (esp. burns, multiple, SCI, fx of lower extremity) Immobility/bed rest (72+ hrs) Paralysis History of DVT, phlebitis Age (40+? 60+? 65+? 75+) Prolonged sitting (4+ hrs), last 4 wks Active cancer especially adv ca primary ca of lung, pancreas, GI Cancer treatment (last 6 mos) Congestive heart failure Heart attack Atrial fibrillation Stroke Atherosclerosis Varicose veins Red = High; Orange = Medium; Green = May be low. NOTE: This is a partial list. Sources disagree on ranking of risk factors. The above impressions are based on literature search. MTs are advised to research risk factors and consult client s physician in each case. 23 Concern Increases Medium and high risk factor Multiple risk factors Medical complexity 24 8

9 The Massage Pressure Scale Classifies massage pressures: Layperson terms Tissues displaced Common uses Therapist body use (From Walton, T. Medical Conditions and Massage Therapy: A Decision Tree Approach. Philadelphia: Lippincott Williams & Wilkins, 2011.) 25 Massage Guidelines for Symptoms DVT Signs & Symptoms (no dx) Pain Tenderness Swelling Warmth Redness Superficial veins dilated Palpable cord Cyanosis in nailbeds, skin Fever of unknown origin Massage Therapy Guidelines Avoid pressure > level 1 on lower extremities Avoid joint movement on lower extremities Urgent medical referral Liability precaution: Avoid contact with lower extremities Urgent medical referral No session Immediate medical referral 26 Massage Guidelines for Elevated Risk and Symptoms High level of concern DVT Risk and Symptoms Avoid contact w/lower extremities Urgent/immediate med referral 27 9

10 Massage Guidelines for Elevated DVT Risk DVT Risk No symptoms Use DVT Risk Principle 1 Use DVT Risk Principle 2 28 DVT Risk Principle 1 If there is an elevated risk of thrombosis, use cautious pressure (level 1 or 2 maximum) on areas of risk and avoid joint movement in these areas. 29 DVT Risk Principle 2 Follow DVT Risk Principle 1 until client s MD: 1. Assesses client s DVT risk 2. Understands concern about disturbance by direct pressure/joint mvt 3. Speaks directly to your concerns about massage & DVT 4. Approves direct pressure/joint mvt in area 30 10

11 Story #1 68 year old client Breast cancer history (Completed tx 2 yr ago) Taking tamoxifen Hypertension Wanted medium pr on legs HOW MANY Risk Factors? 3 31 Story #1 68 year old client Breast cancer history (Completed tx 2 yr ago) Taking tamoxifen Hypertension Wanted medium pr on legs HOW MANY Risk Factors? 3 32 Story #1 68 year old client Breast cancer history (Completed tx 2 yr ago) Taking tamoxifen Hypertension Wanted medium pr on legs HOW MANY Risk Factors?

12 Story #1 68 year old client Breast cancer history (Completed tx 2 yr ago) Taking tamoxifen Hypertension Wanted medium pr on legs? HOW MANY Risk Factors? 3 34 Story #1 68 year old client Breast cancer history (Completed tx 2 yr ago) Taking tamoxifen Hypertension Wanted medium pr on legs HOW MANY Risk Factors? 3 35 Story #1 68 year old client Breast cancer history (Completed tx 2 yr ago) Taking tamoxifen Hypertension Wanted medium pr on legs It s fine to massage! HOW MANY Risk Factors?

13 Did These Steps Occur? Has the physician: x x x 1. Assessed client s DVT risk 2. Understood concern about disturbance by direct pressure/joint mvt 3. Spoken directly to MT s concerns about massage & DVT 4. Approved direct pressure/joint mvt in area 37 No, No, No, And no. Continue with DVT Risk Principle 1 38 Story #1 Eventually talked more with client s physician Dr. approved pressure on lower extremities Advanced pressure to level 3 there Continued for years Then back to DVT Risk Principle 1 as client aged, health (CV events) 39 13

14 Story #2 38 year old client Pancreatic cancer (Advanced, in treatment) Abdominal surgery (1 wk ago) Wanted medium pr on legs HOW MANY Risk Factors? 3 40 Story #2 38 year old client Pancreatic cancer (Advanced, in treatment) Abdominal surgery (1 wk ago) Wanted medium pr on legs HOW MANY Risk Factors? 3 41 Did These Steps Occur? Has the physician: 1. Assessed client s DVT risk 2. Understood concern about disturbance by direct pressure/joint mvt 3. Spoken directly to MT s concerns about massage & DVT 4. Approved direct pressure/joint mvt in area 42 14

15 Yes, Yes, Yes, And yes. Discontinue DVT Risk Principle 1 Advance pressure to Level 3 on lower extremities 43 What to do to Enhance MD Communication? No time for conversation Try in writing Use pressure scale Get client involved Involve nurse Concerns dismissed Use pressure scale Press the point Involve nurse 44 Practicing DVT Risk Principle 1 Indefinitely Client taking blood thinners due to DVT history When DVT risk level not going to improve When DVT risk level expected to heighten 45 15

16 Lean More Conservatively Massage settings favoring single-time or occasional clients 46 The Massage Setting/ Continuity of Care Principle In massage settings Favoring single-time rather than repeat clients Lacking continuity of care Using little or no documentation therapists should take a cautious approach to medical conditions 47 Ask Questions Any past or current health care providers stated concern about your blood clot risk? Are any of the following things true for you? [List risk factors] Any CV conditions? Any BP or heart medications? Any of the following? [List DVT Signs/Symptoms] Activity level, day to day, week to week? What is your age? 48 16

17 What To Say to Client? In yr health history, things that can blood clot risk in the legs In MT, don t disturb at-risk areas until MD can advise (Even when there are no symptoms) Today, avoid significant pressure/movement of legs Focus on upper body, bottoms of feet Cautious approach, but best If you want more pressure, let s get MD input 49 Add, for a 1-Time Client It s a 1-time session while you are here I need to work gently on your legs If you were scheduled for a course of massage, we could bring your doctor into conversation Today, focus on things that can help you feel better, not worse. Upper body focus, plus bottoms of feet. How s that sound? 50 Review DVT Approaches Approaches to DVT symptoms and risk What do they have in common? How to use? 51 17

18 Massage Guidelines for Symptoms DVT Signs & Symptoms (no dx) Pain Tenderness Swelling Warmth Redness Superficial veins dilated Palpable cord Cyanosis in nailbeds, skin Fever of unknown origin Massage Therapy Guidelines Avoid pressure > level 1 on lower extremities Avoid joint movement on lower extremities Urgent medical referral Liability precaution: Avoid contact with lower extremities Urgent medical referral No session Immediate medical referral 52 Massage Guidelines for Elevated DVT Risk DVT Risk No symptoms Use DVT Risk Principle 1 Use DVT Risk Principle 2 53 Massage Guidelines for Elevated Risk and Symptoms High level of concern DVT Risk and Symptoms Avoid contact w/lower extremities Urgent/immediate med referral 54 18

19 Common Features of these DVT Approaches 1. Conservative, cautious 2. Can be difficult to assess when to use 3. BUT, easy to implement 4. Often easy to convince client 5. Involve physician 55 Our Thinking Process DVT = too much information? No clear recommendations Conservative options Conscious thinking process Map and compass, not a GPS 56 Reflections on DVT and MT Role MTs apply pressure on lower extremities Can t diagnose Not highly educated Low risk tolerance High stakes 57 19

20 Reflections on DVT and MT Role DVT - hard to know what to do Have to do something Can raise questions, awareness Continue to learn about DVT 58 DVT References Sanofi-Aventis; The Coalition to Prevent Deep-Vein Thrombosis. Accessed October Letai A, Kuter DJ. Cancer, coagulation, and anticoagulation. The Oncologist December 1999; 4(6); Accessed October MedicineHealth.com. Deep vein thrombosis causes. Copyright 2010, WebMD, Inc. Available at: Accessed January Glueck CJ, Lang J. Venous and arterial thrombosis (blood clotting): a body user s guide. Copyright 2007, The Health Alliance. Available at: Accessed January Goldhaber SZ, Grasso-Correnti N. Treatment for blood clots. Circulation, 2002;106;e136-e140. Copyright 2002, American Heart Association. Available at: Accessed January Jabr, F. Massive pulmonary embolism after legs massage (letter to the editor). American J of Physical Medicine and Rehabilitation, 2007 Aug 86(8): 691. Mayo Foundation for Medical Education and Research. Deep vein thrombosis: treatments and drugs. Copyright , Mayo Foundation for Medical Education and Research. Available at: Accessed January Mayo Foundation for Medical Education and Research. Pulmonary embolism: treatments and drugs. Copyright , Mayo Foundation for Medical Education and Research. Available at: Accessed January DVT References Perinatology.com. Deep vein thrombosis (DVT)/pulmonary embolism (PE) risk assessment. Copyright , Focus Information Technology. Available at: Accessed April Prandoni, P. Acquired risk factors for venous thromboembolism in medical patients Copyright 2005, The American Society of Hematology. Available at: Accessed January Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. Canadian Medical Association Journal 2006;175(9): Available at: Accessed January Schreiber D. Medscape.com. Deep venous thrombosis and thrombophlebitis. Copyright , Medscape. Available at: Accessed January StopTheClot.org. Copyright , The National Alliance for Thrombosis & Thrombophilia. Available at: Accessed January Urbano, FL. Homans sign in the diagnosis of deep venous thrombosis. Hospital physician March 2001: Copyright 2001, Turner-White Communication, Inc., Wayne, PA. Available at: Accessed January van Stralen KJ, Rosendaal FR, Doggen CJ. Minor Injuries as a Risk Factor for Venous Thrombosis. Arch Intern Med Jan 14;168(1):21-6. Patient.co.uk. Deep Vein Thrombosis. Accessed 10/11. Medicinenet. Deep Vein Thrombosis. Accessed 10/

21 Thank you! Questions? 61 Just released! Medical Conditions and Massage Therapy: A Decision Tree Approach. Philadelphia: LWW, Description and link at Find out more at Collinge, W. Touch, Caring & Cancer: Simple Instruction for Family and Friends View trailers at complete description at 62 Contact Information Tracy Walton at Reach us at info@tracywalton.com 63 21

22 Additional Questions on Facebook Facebook.com/DrBenBenjamin Some questions I cannot answer Some questions I can answer 64 Blood Clots, Blood Pressure, and Heart Disease Common Cardiovascular Conditions and Massage Other Webinars in this Series 1. Blood Clot Symptoms and Massage Therapy 2. Blood Clot Risk and Massage Therapy 3. Hypertension, Hypotension, and Massage Therapy 4. Angina, Heart Attack, and Massage Therapy 5. Congestive Heart Failure and Massage Therapy 6. Cardiovascular Condition Case Studies 65 CONTEST How to enter: Write a review of a Cardiovascular Conditions webinar on Facebook ( You re eligible for one entry per webinar What you can win: Autographed copy of Medical Conditions and Massage Therapy: A Decision Tree Approach A complete set of the Cardiovascular Conditions and Massage webinar series to give to a friend or colleague 66 22

23 Other Webinars Available on Demand Unraveling the Mystery of Low Back Pain Unraveling the Mystery of Cervical Pain Unraveling the Mystery of Shoulder Pain Unraveling the Mystery of Hip & Thigh Pain Unraveling the Mystery of Knee Pain Unraveling the Mystery of Ankle Pain Massage in Cancer Care Upper Body Disorders Anatomy Trains All Webinars Available at 67 SPECIAL OFFER JOIN the Benjamin Institute ing List & Receive a FREE Ebook on the Low Back Go to: And click Join Our Mailing List 68 Education in Paradise Courses in Costa Rica Beautiful Pura Vida retreat center 2 full days off per course Relaxing day trips & active outings African drumming, salsa dancing, yoga To register, call