Pelvic Floor Treatment - Interstitial cystitis S.C.

[Body.worker]

I've been working with this new female client who first complained of "sciatica" pain. After the initial treatment she experienced positive results and has now become a regular client (once a week).
She was surprised that massage actually brought her such relief and even told me she didn't think it'd do anything for her.

Oh how I love when this happens!

She has a very hypertonic Psoas (R>L), so I educated her about the impact of this on her pelvic alignment and treated it accordingly. Again, she mentioned she felt the most relief after the session.

Today she volunteered the information that she suffers from Interstitial cystitis (detail she didn't mention on my intake interview) {See links for IC: http://en.wikipedia.org/wiki/Interstitial_cystitis http://www.icawareness.org/dailyfacts.html }, and also asked me if I could do "bladder massage". She has been reading about it.
I said to her that I was not familiar with her condition and that I definitely would inform myself on the subject and present options to her.

After reading online about Interstitial cystitis, it makes a lot of sense that she suffers from it as her pelvis is bound by the hypertonic soft-tissue around it. (Whatever the root cause may be).
I had no idea what she meant by "bladder massage" at the moment, but now it's clear she was talking about pelvic floor treatment (even if she didn't know it).

I'm totally OK with giving this a try (Do no harm above everything else), and she's obviously comfortable with me working around sensitive areas.

My question is: Would I be stepping in a gray area here? How do I make sure I'm not risking my good standing with the state licensing office by breaking local laws?

I have read them and I'm not sure if it's appropriate or not. Very vague laws and obviously a lack of input/feedback from therapists.

Here is the Massage Practice Act for the state of South Carolina:

http://www.llr.state.sc.us/pol/massagetherapy/index.asp?file=interpretations_of_the_massage_p.htm

Is this out of my scope of practice???

What do you think?

[WaltFritz]

Was it your impression that your client was seeking internal treatment? Many times IC is done internally, though much can be done externally as well. Most MT's are not able to do internal work due to licensing limitations. That being said, working the lower abdominal region, just above the pubic bone, can be very helpful for a wide variety of issues, IC included. I am an MFR therapist, so these would be my techniques of choice and work quite well.

Any questions?

[Body.worker]

Yes I was referring to internal treatment. My question wasn't focused on the how-to of treatment, but on interpretation of the laws, and how it affects treatment.

I didn't graduate in the state of SC, I graduated in UT, and the school required us to study local laws and regulations, and it was also part of the test to qualify for a license. I remember it was an actual booklet with several pages, and in it it defined the scope of practice for Massage Therapy, and differentiate it from other professions such as Physical Therapists and Occupational Therapists.

When I got licensed in SC, there was no test nor any reference to local laws, so I looked them up (see link above), and as I said, it is vague.

Most MT's are not able to do internal work due to licensing limitations.

This is my point. As of right now, I can't seem to identify my licensing limitations.

I'm going to quote from the S.C. Department of Labor, Licensing and Regulation's website: (WARNING:this might be too long for some of you).

This is a statement of the Advisory Panel for Massage/Body Work as to what ethical practice is and should not be construed to control billing issues, insurance issues or employment contracts.

PURPOSE

The purpose of the interpretations is to help safeguard public health, safety and welfare by clarifying the use of certain terms that are used in the practice act and to provide guidelines for licensees that are consistent with accepted standards and practice in the profession.

INTERPRETATIONS OF SECTION 40-30-30

B. A person who is licensed to practice massage/bodywork therapy shall not diagnose illness or disease, perform medical procedures, chiropractic adjustments, utilize electro-therapeutic devices as defined in Section 40-30-30, prescribe medicines, or engage in practices for which a license to practice medicine, chiropractic, nursing, physical therapy, occupational therapy, acupuncture or podiatry is required by law, unless the person is duly licensed in that profession.

4. “Massage/bodywork therapy” means the application of a system of structured touch of the superficial tissues of the human body with the hand, foot, arm, or elbow with or without aid by hydrotherapy, thermal therapy, massage devices, human hands, or the application of herbal preparations for therapeutic, relaxation, or educational purposes.

It is further defined by pressure, friction, stroking, rocking, kneading, percussion, or passive active stretching within the normal anatomical range of movement. Complimentary methods including the external application of water, thermal therapy, hydrotherapy, lubricants, and other topical preparations, including but not limited to herbal remedies, body wraps and salt scrubs.

5. “Sexual Activity” means any direct or indirect physical contact or verbal communication by any person or between persons which is intended to erotically stimulate either person, or which is likely to cause such stimulation. Such activity includes but is not limited to sexual intercourse, fellatio, cunnilingus, masturbation and *Royal* intercourse. As used herein, masturbation means the manipulation of any body with the intent to cause sexual arousal. Sexual activity can involve the use of any device or object and is not dependent on whether penetration, orgasm or ejaculation has occurred. This includes the application of any oil, lotion or substance to any body with the intent to stimulate or cause sexual arousal.

6. “Therapeutic, relaxation and educational purposes” means purposes intended to positively affect the health and well being of a client and does not include sexual activity.

B. Standards of Conduct

1. Draping of Clients: Licensees shall provide a clean drape for each client for the purpose of maintaining professional standards, and to ensure the clients safety, comfort, and privacy. The areas that must be draped are the gluteal and genital areas for male and female clients, and the breast area for female clients. The drape may be adjusted in order to perform therapeutic treatment to the gluteal and breast tissue.

2. Breast Massage: For the protection of the client and the massage therapist, massage of the breasts must be performed in a professional and ethical manner and with prior written consent from the client or physician referral on file. When medical reasons are involved and contraindications may be an issue, a physician’s referral is necessary.

C. Scope of Practice

Animal Massage (including Equine Massage) is under the jurisdiction of the Board of Veterinary Medicine and not within the scope of practice of massage/bodywork therapy as defined in this chapter although animal massage can be preformed by anyone who has obtained authorization from the animals veterinarian.

Still clueless.

[Body.worker]

Perhaps this topic may need to be moved under another category. Mods, that is OK with me.

[shivashiva]

While your legal scope of practice must ultimately determine whether you can practice internal work in your location or not, your first question should be "Was I trained in this technique?" You don't mention at all whether this is the case or not and I must point out that nothing is within your scope of practice that you weren't AT LEAST trained in and preferably have significant experience with, whether or not it's "legal" for you to do so.

The way you approach this thread troubles me for future newbies who may read it and interpret "as long as the law states that it's within my scope of practice, I can practice it." while that is not really the case at all. No one should practice any techniques (on the public, for money, under the umbrella of "massage therapist") that they haven't be trained in and/or have significant experience with.

Which brings me to the fact that if you do have training in internal techniques, surely your trainers would have instructed you as to how to go about seeking the legal requirements in any state where you wished to practice, especially since this is not common practice for massage therapists.

[JLWmassage]

http://www.clearpassage.com/

I would check out this clinic. I have a female client that travels to Clear Passages for internal work. And she says there for about a week when she goes

[jdcan]

Maybe you could check with your professional organization (ABMP, etc.)to make sure it's legal in your state.

While I agree that you have to be careful to work within your knowledge limits so as to "do no harm", it's interesting to see that the lay person's book, The Trigger Point Therapy Workbook, encourages people and their gentle, patient partners to work on internal pelvic trigger points.

[JasonE]

There are multiple external approaches to helping clients with pelvic floor issues. Walt Fritz has already suggested one method. Here are others that I have used for pelvic floor issues:

Myofascial Release of the abdomen, glutes, and inner thighs
Positional Release of the psoas, iliacus, glutes, and hip rotators
Dermoneuromodulation for the cluneal, iliohypogastric, pudendal, and femoral nerves
Active Isolated Stretching for the glutes, psoas, iliacus, hip rotators (especially obturator internus and externus), quads, adductors, hamstrings, and abductors
Trigger Point therapy along the borders of the sacrum and coccyx, focusing on the glutes and hip rotators, and around the ischial tuberosity - particularly the medial aspect (with client foreknowledge and consent) - Beware of where you are! - it may also be possible to access a portion of levator ani, depending on the client's anatomy.

I have never done internal work of any kind, and will not attempt to do so until I have more training in it. With so many other options available, there is little need and I am in no rush.

Before you attempt pelvic internal work, consider referring this person to a Physical Therapist or similar licensed health professional. Though this seems to fall into a "gray area" of massage licensing, it doesn't seem worth the risk of potentially losing your license to practice. Some other health care professions (such as PTs) are definitely able to do internal work as appropriate.

In your shoes, I would try all available external methods first. If the client needed more assistance and internal work was indicated, I would refer her elsewhere.

[Body.worker]

All responses heard and acknowledged.

Going to go into more depth on this one, but it will have to be tomorrow.

[JasonE]

Yesterday I saw a new client. She was referred to me by her chiropractor (another one of my regular clients).

This new client is pregnant and has a long history of back problems. Though her first pregnancy was uneventful, she recently had a severe flareup of back pain with limited mobility. In addition to that, she still experiences post-partum incontinence. She has been doing pilates to strengthen her core muscles, but it hasn't provided any lasting relief.

Among other things, this pregnant client needs pelvic floor work, and I discussed that with her while we went through her medical history and why she was referred to me. We did the entire session with her clothed, focusing on orthopedic tests, positional release, active isolated stretching, and dermoneuromodulation. By the end, she felt much better and was moving around without discomfort. She rebooked immediately and inquired about doing longer sessions on a regular basis. She understands that I can't guarantee anything, but she trusts me now and will be more open to whatever will help her most in the future.

When she returns, I hope to learn whether the work we did has had any impact upon her incontinence issues.