Scope of Practice
Scope of Practice
I recently had a female client in her 50’s who complained of lower back pain (uh-oh), sore shoulders and a stiff neck with limited Range of Motion. The sore lower back situation was chronic, and had lately been accompanied by painful sciatica in her right leg. She purchased a 50-minute massage (not enough time) and asked for it to be ‘deep’. She works in sales, at a computer all day, and was in Jackson Hole on a ski vacation – she had been skiing every day and the slopes were icy and hard-packed.
Warning signs go up all over the place for me when I have a client like this. I am likely to see her once and never again. My customer-service ethic on the one hand kicks-in (yes – I can cure all that ails you and give you the deep tissue massage that you have asked for) but then so does my training in Scope of Practice and just plain awareness that there is, in fact, very little I can do for her beyond general relaxation – with a fairly light Swedish massage. Unfortunately, I didn’t listen to my more sensible self – but listened to the ‘business’ self that says give the customer what she is asking for. After 50 minutes of addressing neck, shoulder, hip, glutes, hamstrings, hip rotators and other areas I associate with lower back pain, she came out into our reception area, went pale in the face, and had to sit down. She complained that her back was even more sore now – though not in a criticizing sort of way as the massage had felt good to her at the time. During the massage, my work on her right piriformis had shown it to be extremely sensitive to touch, whereas that on her left side was OK. This seemed most likely connected to her sciatica on that side – the tight piriformis perhaps pinching or compressing the nerve. I mentioned this subjectively to her.
I feel that I should not have given her the massage that she asked for – but instead let her relax both muscularly and mentally with a nice, peaceful Swedish massage. This is what should have been dictated by the limits of my own Scope of Practice – and I would have felt much better to see her walking comfortable, rather than stiffly, out of the spa.
A friend called me today to say that she was experiencing weakness in both of her hands, and that upon waking up in the morning her hands were numb as though she had been sleeping on them in a bad way (which she thinks she was not). I told her right away that I am not a doctor and may not diagnose things (especially over the phone) – and then mentioned that these symptoms could be indicative of nerve damage in her lower C-spine – I know because I have had a triple-fusion neck surgery for exactly that in recent years. “Have you had a doctor’s opinion on this?” I asked her.
“Well,” she said, “I’ve been to the chiropractor – and he ‘adjusted’ me.” If there’s one thing that makes me squirm – it’s hearing stories of chiropractors who go in and start ‘adjusting’ people who’s symptoms speak to potential spinal problems – when, clearly, NOTHING should be done without a proper diagnosis by a qualified MD with the aid of an MRI scan and or X-rays. I told her my thoughts on this and that, in my humble opinion, this chiropractor was working outside of his Scope of Practice and that she should seek a proper diagnosis.
“Once you have that diagnosis – whatever it is – I want you to ask your doctor if massage is indicated in order to help with either the cause or the symptoms. Then I can consult with your doctor about a massage prescription and we can move ahead.” It could be that muscles in the thoracic outlet or C-spine area are in spasm and causing her discomfort. In that case, I do sincerely think I can help her without risk to my practice or her health – and a competent doctor’s order is a much more comforting umbrella under which to work to help soothe her pain. Anything else is speculation, and clearly beyond our Scope of Work.
Hamish and Rochelle.