ABSTRACT Contraindication lists give guidance to manual therapy practitioners regarding how to handle the symptoms and conditions that they may encounter with their clients. This July 2023 issue of Structure, Function, Integration focuses on autoimmune disorders and the considerations that structural integration (SI) practitioners, in particular, need to consider when working with people with any of these conditions. Topics discussed include whether we have to refer these clients elsewhere every time, whether SI can help people with autoimmune conditions, and what specific cautions are warranted. Rolfers often have clients with complex medical histories, including autoimmune diagnoses, and they may still benefit from this work.
Autoimmune disorders1 are a complex category of diseases that are on contraindication lists for manual therapists to apply caution. This includes people with lupus, rheumatoid arthritis, scleroderma, and ankylosing spondylitis, to name a few. As is frequently pointed out in comparative studies, contraindications to deep myofascial work or manual therapy, in general, are not agreed upon by practitioners, researchers, instructors, and state governments, as well as other regulating bodies (Batavia 2004). To the careful structural integration (SI) colleague, this brings up complicated considerations:
Can I work with this client?
Should I refuse to do any touch work when considering their medical history?
Would a ‘Ten Series’ be possible? Or should I only work with light touch?
Do I need a doctor’s note to proceed?
Among the instructors of the Dr. Ida Rolf Institute® (DIRI), many of us recommend asking clients for medical recommendations from their physicians for everything on the list: Contraindications and Cautions for Deep Bodywork (2018) by Robert Schleip, PhD, Til Luchau, [founder of Advanced-Trainings.com], and John Schewe, Rolfing® SI instructor. Or we recommend considering refusing to work with clients with any of the diagnoses listed there.
In my opinion, there are four problems with a strict usage of that type of “do no harm” interpretation:
1. We punish honesty and full disclosure. We might even encourage omissions when we gain a reputation for providing excellent work but being overly cautious.
2. Referring out and refusal of services may be experienced as harmful. Do no harm means doing our best to avoid causing more suffering due to our therapeutic decisions, including the harm done when a client’s hope for relief is shattered once again when referred elsewhere.
3. There is not enough evidence. Evidence of potential harm done by manual therapy is limited. Contraindication lists for manual therapy are written by experienced practitioners who make general suggestions. We know the obvious, local contraindications: Stay away from undiagnosed rashes, raised moles, warts, and skin tags. Don’t touch anything oozing, scabbing, red and swollen, broken, torn or otherwise infected, inflamed, and highly sensitive.
4. Medical specialists increasingly refer people with autoimmune disorders to manual therapists. Ironically, there is a trend for general-, orthopedic-, internal-, and functional-medicine physicians to send their complex cases to SI practitioners. Endocrinologists, rheumatologists, and plastic surgeons do directly recommend or even prescribe manual therapy in cases of autoimmune disorders.
For this July 2023 Caution Column, we will be considering specific autoimmune disease patterns and give some practical advice, which can be summarized as:
Work with the client, ask for feedback, and observe reactions and responses – verbal and nonverbal. Proceed slowly and cautiously in any case, with any possible underlying pathology, and with any seemingly healthy person. There are very few conditions that truly make slow bodywork dangerous to the client. The person is not an autoimmune disorder.
Do We Have to Refer Out?
There are many types of autoimmune disorders, including:
Graves’ disease,
Hashimoto’s disease,
multiple sclerosis,
rheumatoid arthritis,
systemic lupus erythematosus,
and celiac disease, to name a few.
What considerations are necessary to determine whether a person with an autoimmune disorder should avoid deep Rolfing SI manipulations or when it may be cautiously possible?
Autoimmune disorders are often detailed on contraindication lists for deep manual therapy techniques, but as Schleip, Luchau, and Schewe (2018) point out at the end of their list for SI and myofascial mobilization practitioners:
“This compilation should be considered a list of cautions and contraindications to hands-on work involving direct pressure; though not necessarily to hands-on work, per se. Practitioner adaptability (as well as knowledge and sensitivity) are key: If the pressure, duration, and frequency of application are adjusted accordingly, touch therapy of some kind (often lighter, shorter, or less frequent) can be helpful to those experiencing most every condition listed.”
So the answer to our first question is, according to these Certified Advanced Rolfers deeply involved with research for decades – it is indeed “cautiously possible” to work with individuals with autoimmune disorders.2 Many clients with autoimmune conditions that include chronic pain can benefit very much from SI work and often describe it as the only thing that works.
Can We Help?
What are the possible benefits of SI for a person with an autoimmune disorder?
Pain relief, calming the autonomic nervous system, reduced inflammation in general, reduced anxiety and depression, improved sleep, and the benefits caused by that, especially regarding tissue repair and lower cortisol levels, which improve metabolic activity. In our practices, we often notice that clients start paying more attention to nutrition and exercise, which are very important in the long-term management of autoimmune conditions. The way that most SI practitioners integrate movement education into their practice is also highly beneficial for long-term results since clients learn to limit pressure and torque on joints and build tonic function through their whole system.
There are hardly any autoimmune conditions that do not have pain in the person’s soft tissues and joints. Our work improves the hydration, lymphatic drainage, and distribution of synovial fluid, as well as often leading to neurological changes that lift pain thresholds in general.
I’d go so far as to say that, in particular, clients with autoimmune conditions should receive SI work!
What Should We Actually Do Differently?
What caution is warranted for SI practitioners to consider when working with clients who present with an autoimmune disorder?
I like to ask about flare-ups, which are temporary states with higher levels of inflammation, fatigue, and brain fog. It leads to the person having particularly sensitive areas.
During a flare-up, I let the client decide whether they want to rest or still come in for a session, but depending on the intensity of fatigue and sensitivity, I might only do very calming superficial work: craniosacral therapy, manual lymphatic drainage, or just holding an area with gamma touch (Hack et al. 2023). These can be useful in reducing inflammation and swelling. It will calm the nervous system, and relieve pain, but it is not an SI session. If I’m in the middle of a Ten Series with them, I often tell the client that we’ll do a different session to help them recover from the flare-up, and that we’ll continue in the series after they have the resources necessary to integrate change.
In Practice
I have built a reputation for working well with chronic pain patients and clients with health conditions that are unclear and/or rare. The majority of my clients have ongoing health problems, genetic disorders, functional dysfunctions like autoimmune diseases, and/or complications after viral infections.
Conditions that gradually worsen and go along with a lot of pain are tough on the practitioner. But in my practice, I’ve seen that as long as I manage my own emotions and let the client lead, I can actually help a lot. My suffering from insecurity and helplessness is nothing compared to how my client feels every day.
Many of our practices are aimed at increasing function and alignment, improving mobility, and sometimes directly leading to measurable increases in desired performance, as in athletes. When a practitioner is used to clear, immediate, long-lasting results, it can be demoralizing and often draining to work with clients who don’t get better.
In those cases, I have learned to ask clearly how my treatments feel useful, and what are the actual goals for treatment. Even a couple of hours of more ease in a person’s body can be worth the expense and the energy invested in coming to our practice or receiving a house call. It’s really up to the client, but first it is up to us to ask.
The good news is that most autoimmune conditions in our practice don’t present that way any longer. I believe that the vague term ‘autoimmune conditions’ on lists of contraindications come from the times when only the most debilitating symptoms led to a diagnosis. As with other conditions explored in this column: Don’t make any assumptions based on a diagnosis!
You may find yourself working with a fit, athletic, well-embodied person and find out about an autoimmune condition during casual conversation. Just continue what you’ve been doing, and make sure your client knows to inform you when symptoms show up.
Endnotes
1. Comprehensive list with links to specific information and an overview of the general pathophysiology currently thought to cause autoimmune diseases can be found at http://www.mountsinai.org/health-library/diseases-conditions/autoimmune-disorders.
2. Evans et al. (2002) reported in their randomized controlled trial the long-term effects of manual therapy and exercise on patients with chronic neck pain, including those with underlying autoimmune conditions such as rheumatoid arthritis. The study found that a combination of spinal manipulation and exercise was more effective than either treatment alone in reducing pain and improving function. The authors suggest that manual therapy may be a useful adjunct to conventional treatments for chronic neck pain in patients with autoimmune conditions.
Further, Elliot, and Burkett (2013) did a randomized controlled trial evaluating the effects of massage therapy on carpal tunnel syndrome-related symptoms in patients with rheumatoid arthritis and other autoimmune conditions. The study found that massage therapy significantly reduced pain and improved function compared to a control group that received no intervention. The authors suggest that massage therapy may be a useful adjunct to conventional treatments for carpal tunnel syndrome in patients with autoimmune conditions.
Lu Mueller-Kaul has been a Rolfing SI Instructor with the Dr. Ida Rolf Institute® since 2019 and coauthor of The Rolfing® Skillful Touch Handbook (2022) with Bethany Ward and Neal Anderson. She mostly teaches Phase I courses, bringing physiology, therapeutic relationships, and Skillful Touch together so students learn an adaptable spectrum of touch skills while staying aware of the space they hold for each client. Mueller-Kaul began her journey as a licensed naturopathic physician in Germany in the 1990s. Along the way, she practiced acupuncture, chiropractic adjustments, and traditional Chinese medicine before coming to the United States to study Rolfing SI. She would love to read your thoughts and feedback, and she’s happy to offer a free phone call, just schedule via the contact form on www.QforLu.com or email Lu@QforLu.com.
References
Anderson, Neal, Bethany Ward, and Lu Mueller-Kaul. 2022. The Rolfing® Skillful Touch Handbook. Boulder, Colorado: Dr. Ida Rolf Institute
Batavia, Mitchell. 2004. Contraindications for therapeutic massage: Do sources agree? Journal of Bodywork and Movement Therapies 8(1):48-57.
Elliot, Rex, and Brendan Burkett. 2012. Massage therapy as an effective treatment for carpal tunnel syndrome. Journal of Bodywork and Movement Therapies 17(3):332-338.
Evans, Roni, Gert Bronfort, Brian Nelson, and Charles H. Goldsmith. 2002. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine (Phila Pa 1976) 27(21):2383-2389.
Hack, Lina Amy, Neal Anderson, Bethany Ward, and Lu Mueller-Kaul. 2023. Publishing The Rolfing Skillful Touch Handbook: An interview with the authors. Structure,
Function, Integration 51(1):62-69.
Schleip, Robert, Til Luchau, and John Schewe. 2018. Contraindications and cautions for deep bodywork. Available from https://advancedtrainings.com/contraindications/.
Keywords
autoimmune diseases; autoimmune conditions; contraindication; manual therapy; inflammation. ■
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