Update: Relating COVID 4-phase approach to manual practice

Last week, Governor Inslee announced a 4-phase approach to re-opening our state in the face of COVID-19 risks. These phases represent a graduated way of balancing relative risk of exposure/transmission with genuine benefits of being back at work (financial, services provided, mental well being, etc.). I like this graduated approach; that seems realistic given the likelihood that opening up will increase cases. As folks have mentioned, I expect that we’ll be moving back and forth, hopefully only between phases 2-3, for a while. This is a plan we have to live into and alter as we see the consequences.

And this got me thinking: how could I articulate 4 levels of safety parameters with regard to my clientele? When is it appropriate to work with people who have a range of needs? Here’s my current best thinking about it.

What follows is a guideline based upon my own skill set with considerations. I am NOT saying that this is what the Governor’s phases indicate, nor that this is what the Board of Health/Massage Board is advocating. This is not an interpretation of public health policy. It is a guideline I’m creating for myself using the principles of the public health guidelines. If it helps you think about your own practice, I’m grateful.

I’m assuming that IF I’m practicing, I’m doing so with the appropriate level of PPE, sanitization, health screening, etc. (My following posts will consider these in light of new guidelines.) As I learn more, it’ll likely change, as any good map does.

Phase 0-1: Most restricted — Emergent services only
This is the most conservative approach to seeing people. (To keep the numbering in sync with the governor’s plan, I’m using a zero to indicate the level of shut down we’ve already been exercising.) Because most of what we do is NOT emergent care, most of us are not seeing people at this time.

The exceptions I can imagine or have made include:
• alleviating impairment of basic functions: chewing/swallowing, digestion, and elimination/toileting; breathing for base line (not optimal levels)
• alleviating severe CNS/neural impingement and/or severe pain
• alleviating specific positional/movement problems that, if left untreated, would have long term, significant detriment for the patient

Examples in my practice:
• a baby with feeding difficulties significant enough to be diagnosed with failure to thrive
• a patient with severe vertigo who was unable to get to the bathroom without hurting herself
• a patient, post-concussion, whose symptoms worsened to include double-vision and severe vertigo

• Mostly I’ve made these exceptions per request from a referring MD/ND (their condition has been screened at that level as well)
• The work takes only as long as it takes. When I feel improvements to the specific problem have been made, I call the session. (So far, this has been between 20-30 minutes.) This minimizes our mutual exposure and leaves their body enough energy to recuperate.

Phase 2: Near-most restricted — Moderate to Severe, and A Good Fit
Opening up as on a particular date could mean that we’re flooded with a lot of requests for appointments right away. So we’ll have to prioritize, at least enough to take care of our own bodies going back to work after such a long stasis (wow — my hands/arms/attention have lost their stamina!). I’m interested in working with people who need my specific skills.

• opening up to people with moderate as well as severe symptoms: CNS/ANS dysfunction, acute/subacute musculoskeletal injuries, digestive/eliminative problems, post-op rehab, etc.
• these are people for whom home care/self care is not an option; they may have resumed other care as well (PT, DC, etc.)
• therapeutic interventions (“clinical massage”)
• sessions are shorter (limiting exposure as well as practitioner self-care)
• people whose needs are a good fit for my particular skills (cranial, visceral, structural — what are your best skills, who are your best clients?)

Example from my practice
• client who has severe scoliosis and chiari malformation; working from home has aggravated her symptoms significantly. Her DC hasn’t reopened; she managed with home care for about 5 weeks, then starting getting neural signs from the CNS impingement
• established client with chronic sciatica who ‘over gardened’ during SAH and now can’t walk, sleep, etc.

• These people may need longer sessions and/or have multiple goals. Prioritizing their needs is important as you begin a new phase of treatment.
• Remind clients that these sessions won’t be like their usual sessions; at least, they will have lost the momentum they had before the shut down.
• These folks may be coming in with a lot of residual tension! Take care of your hands/body!
• Working mostly with established clients and/or known referrals; we want a high level of trust with regard to client self-reporting.
• When we get to this phase, I’m considering getting tested for antibodies. In particular, I’m considering focusing on reaching out to front line workers to offer discounted sessions.

Phase 3: Modest restriction — Mild to Moderate Symptoms and/or General ANS Relief
Unless your work or work place is specialized, here are the folks that, IMO, make up a large portion of our clientele. They are relatively healthy people who seek out massage therapy to improve their daily lives. Massage as an intervention here is on a par with yoga, stretching, meditation and general fitness. (This is when gyms will be allowed to open at 1/2 capacity.)

Our work makes a tangible difference with: movement and range, posture, modest aches/pains, better sleep, decreased stress or general anxiety, etc. While not “essential” or perhaps even “critical,” touch at this level is still a health care activity. It is both therapeutic and preventative. Our clients will have missed us greatly! And, there will be a whole new layer of people significantly in need of touch and stress relief.

One concern I have for this time is that we might over-relax our hygiene/PPE habits. This time, in my imagination, will feel the most like normal, while not being fully open. Hopefully by this time, we will have access to any diagnostic testing and many of us will have had antibody testing. (I am undecided about requiring antibody testing of my clients.)

It’s also likely that there will be heaps of emotional/psychological processing going on. As a society and as individuals, we’ll be at the beginning of seeing the long term effects of this pandemic. By all estimates, this will be a difficult process. This phase will include looking back at where we’ve been with COVID, while at the same time still living with it as an active public health concern. We will start to ask ourselves ‘where are we now?’

As providers who spend a lot of time with clients, who share the intimacy of touch with our clients, it’s likely that we will be having those conversations with people as they ‘return’ to their bodies through touch. Clarifying our scope of practice–we’re not counselors– will be important. As will our own self care during this time. How can you hold your own heart? How do you want to be present with others?

Phase 4: Open practice — ‘Not so new’ normal; Post-traumatic growth
There will be a time when all the new measures of hygiene and safety feel integrated into our practices–we will become accustomed to it. That’s the way humans are as a species: we’re adaptable. Many of us have integrated wearing gloves into our work while doing intraoral work. Some of us have been in the profession long enough to remember when draping was optional. While we won’t always need to be on high alert, we will become more familiar with what high alert means on a practical level. If we can learn from this process, adapt and gain skills that support our health and the health of our clients, we will be stronger for it.

This is called post-traumatic growth. It’s different than resilience. Resilience is when we are able to undergo a challenge and respond to it without overwhelm. On the other side, we move forward much the same as we were before. Post-traumatic growth is when we are changed by what happens to us, sometimes significantly. Adaptations become habitual; new skills are learned; our sense of self is changed. There is no going back. While we do grieve what we lost, we can also honor what we have learned and how we have continued on. Both resilience and post-traumatic growth are capacities we can develop.

COVID-19 is too huge a phenomenon, too widespread, too devastating, to not call for growth. My deep prayer is that inside such a global re-orientation of human attention and activity, we’ll be able to have a different conversation together on the other side. A conversation that is more inclusive, more sustainable and more healthy in all respects.