Update: Getting back to Work — screening clients

Once we have confirmed that people’s need is critical enough to come in for a massage (earlier post), and we’ve created a clean-as-possible clinical environment (next posts), we can further check their health to make sure it’s safe to continue.

We are checking that the client is healthy on the day of the session — healthy enough to receive massage. We are not screening for particular diseases. This may seem like two sides of the same coin. But it is critical that we, and they, understand the difference. The goal is to confirm that people are presenting with both a lack of common symptoms and signs of body function within normal range.

Symptoms are assessed through intake questions. This requires trust in the client’s honesty: fever, cough (dry or productive), shortness of breath/difficulty breathing, and sudden loss of taste/smell. These are the most common early symptoms that people have. Even though a small number of cases remain asymptomatic throughout the course of the disease, most people DO have symptoms — even mild ones. So invite them to be thorough; better to over report than under report or minimize what they feel. Add to this: known exposure to COVID-19 or to people with COVID-19 (travel, work, family, etc.).

Signs we can check easily with simple, low-cost equipment: temperature, blood oxygen level coupled with heart rate, and breath rate. Each of these vary, within homeostatic range, at time of day, activity level and from person to person. Ask your clients to arrive 5 minutes early to allow heart and breath rate to normalize after the activity of arriving at your door.

We can encourage our clients to get to know what their baselines are. Home monitoring is easy or they can get this information from their HCP’s office/health portal. These signs are part of a standard health check up, so the data should be in their charts.

Here’s what we’re looking for:

• temperature: “fever” is defined as anything over 100.4° F  Using an ear, forehead or infrared thermometer. Clearly, devices that touch them need to be disinfected between clients.

• blood oxygen level: normal range is 95-100% (perceivable “difficulty breathing” generally happens with levels of 88-92%).  Using a fingertip device, easily available for home use. Also disinfect before each use.

• pulse rate: 60-100 beats per minutes (over 100 is high). Count the beats in a 12 second period, then multiply by 5; or count the beats in a 6 second time and multiple by 10.

• breath rate: 12-20 breaths per minute (over 22 is high). Similarly, count the breaths over 15 seconds then multiply by 4; count breaths over 20 seconds then multiply by 3.

We include pulse and breath rate because they are the initial compensations that the body makes when lung volume is compromised. If the alveoli are not able to continue with O2/CO2 exchange in a healthy way, we adapt by either breathing more or pushing more blood through the lungs. The client may or may not perceive these changes — but they are changes that happen as COVID-19 attacks the lungs, even before the body’s immune response kicks in (creating fever, coughing, fatigue, etc.).

Keep in mind that many conditions can create these signs. If the client has chronic, well-managed conditions that can create these signs — and they know where their baselines are — we adjust our screening to rapid or severe changes in those levels. Also keep in mind, the more risk factors or vulnerabilities the client has (age, high risk diseases such as hypertension, lung compromise, cardiac compromise, etc.), the more conservative your appraisal should be. Always err on the side of caution.

Again, we are not screening to see if they have a particular condition (COVID or otherwise). We are checking to see if their cardio-vascular physiology is within healthy parameters. It is not our responsibility, nor in our scope, to diagnose disease. 

How the findings guide our decisions:

Any symptoms or uncertainty on your part about the client’s self-reporting is reason enough to postpone. An out-of-normal-range sign in these areas is cause enough to postpone the massage. At the least. Multiple signs and symptoms require us to urge them to contact their HCP for active disease screening (COVID-19, pneumonia, bronchitis, etc.).

If the client reports no known recent exposure or symptoms, and the above vital signs are within healthy parameters, we can conclude that they have a high probability of health. We can welcome them into our practice, while still protecting against the possibility of contagion by using all the PPE and disinfecting protocols outlined for our profession.

So far in my practice, the few clients I’ve seen have been more than willing to be screened and are thankful for extra measures and conscientiousness that these measures show.

Thanks to Bonnie Wong, DO and Robbin Blake for helping me clarify my thoughts.