Holistic | Disability

10 Issue 95 January 2011 InternatIonal therapIst www.fht.org.uk

Last year, the FHT received a letter from Ron Cottrell, a member of public with

cerebral palsy. Mr Cottrell had contacted the FHT as the leading professional association for therapists, to express his extreme dismay and frustration at being refused massage therapy on a number of occasions. He explained that ‘this treatment provides fantastic pain relief for me and gives me a quality of life I never seemed to have had before’.

Fortunately, Mr Cottrell regularly sees two very good therapists, but his letter raised a number of questions. Why had therapists been reluctant to treat him? What are the issues and possible challenges involved in treating clients with a disability, and how many of our members are regularly treating and improving the quality of life of people with long-term mobility problems?

To establish some answers, we conducted an online survey, to which more than 300 members responded – 90 per cent had treated a client with a physical disability and 48 per cent on a regular basis. It is thanks to a handful of these members that we were able to publish much of the information in this article. Please visit our website to view or download their personal accounts (see page 51 for more details).

A note regarding terminologyPlease note that for the purposes of this article, the terms ‘disabled person(s)’, ‘physical disability’, and ‘disability’ are used for literary purposes, and refer to any client who has a long-term disability or impairment to their mobility.

There is a broad spectrum of conditions, circumstances and factors that can impact on a client’s mobility. Some of the most frequently cited by members in our survey were Parkinson’s disease, multiple sclerosis (MS), motor neurone disease (MND), cerebral palsy, arthritis, stroke, spinal injuries or deformities, amputation, and ageing.

We look at some of the issues when treating clients who have long-term mobility problems and at the benefits that therapies can bring

A touch of equality

In each, the extent of mobility and severity of symptoms can vary considerably over time, from client to client, but also in the individual. Some may be able to walk unaided, while others may need walking aids, or be wheelchair- or bed-bound.

Catherine Wood, MFHT, a complementary therapy coordinator at Dove House Hospice, Hull, offers therapies to patients and their carers as part of a multi-disciplinary team. She says: ‘When a patient becomes disabled physically by their illness, upper and lower limb or lung function may be impaired, affecting their ability to perform the normal activities of daily living that well people take for granted, such as climbing stairs, and getting dressed. Fatigue, pain, nausea, gastrointestinal disturbances, breathlessness and anxiety can, in themselves, also disable a person’s physical activity and affect quality of life.

‘Patients disabled by neurological conditions, such as Parkinson’s, MS and MND may experience muscle spasms, pain and rigidity, gradually causing the loss of ability to independently move limbs. Speech may become impaired making verbal communication difficult, swallowing and the enjoyment of tasting and eating food may be lost, and in the case of MND, eventually breathing unaided becomes difficult.’

Many of these symptoms and problems may also affect clients whose physical

Reminder about CRB checksthe Vetting and Barring scheme aims to protect children and vulnerable adults. While the scheme is being reviewed by the government (see page 41), please note that therapists working in some establishments, including a school, hospital or care home, may be required to have a Criminal records Bureau (CrB) check. self-employed members can obtain a CrB check/enhanced disclosure via the Fht Vetting and Barring scheme. Contact DDC ltd on 0845 644 3298, quoting your membership number.

Disability | Holistic

InternatIonal therapIst www.fht.org.uk www.fht.org.uk InternatIonal therapIst Issue 95 January 2011 11

every client is unique, and one of the virtues of being a qualified and skilled practitioner is being able to adapt treatments to meet the client’s needs.

some therapists may be daunted by the thought of treating someone with a physical disability. arguably, there is an issue of competency if the therapist is newly qualified or inexperienced, but other reservations may be because of a lack of understanding about the client’s condition or a fear of doing harm and possible litigation.

therapists need to be aware that refusing to treat someone because they are disabled could be regarded as discrimination. the equality and human rights Commission advised the Fht that ‘the law states that you can’t treat a person less favourably because they are disabled, and refusal to provide them with a therapy could amount to “less favourable” treatment. a therapist who is concerned about treating a disabled person could speak to them to find out what type of treatment they are and are not comfortable with, speak to their doctor (with permission), or speak to a professional association for more guidance.’

Comments from our survey respondents

indicated that a number of members who felt particularly confident and comfortable working with disabled persons:l had worked with disabled persons in a previous

career, such as nursing, social work, teaching, or palliative care;

l had received specialist training, either through the charity or organisation they worked for, or private CpD courses;

l were part of a wider, multi-disciplinary team caring for the client, enabling them to seek relevant guidance and support, for example, from physiotherapists, Gps, care specialists; or

l had a disability of their own, or cared for a relative or friend with a disability.

however, a number of members who responded to the survey indicated they had little or no such experience the first time they worked with a disabled person.

For many, meeting and talking to the client, thoroughly researching the client’s condition and how it affects that individual, and seeking guidance from the client’s carer and/or Gp gave them the confidence and knowledge they needed.

disability has another root cause. In addition, clients may also experience/have:l muscle atrophy;l an impaired immune system;l depression and anxiety (particularly if

there are fears for the future, or the client has difficulty breathing);

l seizures; andl heightened or reduced sensitivity to pain

and pressure.

Client assessment and consent to treatAs with all clients, a full, in-depth assessment must be carried out before the initial treatment, and a shorter assessment before every subsequent treatment. This will provide the therapist with information on the client’s current physical and emotional status, and indicate how to proceed.

It will also highlight whether the therapist needs to seek guidance, knowledge, or GP consent, and make him/her aware of any potential situation that may arise during treatment, such as a seizure, muscle spasms, involuntary movement of the limbs or head, breathlessness, or vomiting. It is vital that the therapist knows what do in such situations, for the safety of both the patient and themselves.

Janet Lindop, MFHT, a complementary and sports massage therapist who has worked in NHS and healthcare settings, usually dedicates the first appointment to the consultation when working with a disabled person. She says they often focus on their disability and fail to mention other problems, simply because they have ‘learned to live with them’. Janet conducts a more ‘investigative’ consultation, enabling her

to accurately assess effective treatment. ‘Your initial contact with a client is visual,

so I look for any difficulty of movement and diminished strength, such as opening the door, moving across the room, sitting down, or, if a stick or wheelchair is used, how they manage their aids,’ explains Janet.

‘A relative or carer may need to attend the consultation, as the patient can be apprehensive and forget to mention things, or have trouble hearing or answering your questions. I always ensure acknowledgment and eye contact with a client, even when someone else is answering on their behalf.

‘Completing the standard consultation may not bring to light all information, so I conclude with a friendly chat to relax and encourage them to talk about their life. Quite often you find a hidden nugget of information that you’re glad you discovered.’

As always, it is important to explain what a treatment will involve, and its potential benefits, effects and limitations. Only when a client understands the treatment can they provide informed consent. Where written consent cannot be obtained due to their disability or because they lack competency, implied consent must be documented or obtained from a member of their care team.

Communication issuesMost therapists will establish at least once during the course of a treatment if the massage pressure is right for the client and if they are comfortable. This is particularly important when treating clients with a physical disability, and even more so if they have difficulty communicating, are visually impaired or hard of hearing. The therapist may need to interpret non-verbal cues that

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12 Issue 95 January 2011 InternatIonal therapIst www.fht.org.uk

indicate whether the client is comfortable and happy to continue treatment, bearing in mind that consent should be ongoing.

Sally Styles, MFHT, gives complementary therapies to children with cerebral palsy at Craig-y-parc school, Cardiff. She says: ‘I started with reflexology because that’s what the students were used to receiving, then slowly introduced massage and aromatherapy. I got to know each student’s method of communication. How to interpret a ‘yes’ or ‘no’ response was most important because I needed to be sure that students wanted therapy and that it wasn’t being forced onto them because they had been assessed to have it. Some students have yes/no cards with symbols on, some have vocal indicators, some use facial expressions and some I work with intuitively.’

Similarly, Ysobel Albone, MFHT, who treats clients at a care home for people with neurological problems, says that when treating a client with Huntington’s disease, ‘I can tell by her sighs what she is and is not enjoying. This varies every week, so I had to learn to read her sighs and groans quickly’.

Some therapists also stress the importance of gently talking the client through what they are going to do next in the treatment, particularly if this is outside the client’s vision, for example, behind them. Eyes can convey a lot of information, so maintaining eye contact where possible can also help therapists and their clients.

Happily, in the early stages of treating a client who has difficulty communicating, most of our survey respondents received support and guidance from relatives, carers, and staff who were familiar with the client(s) and what they were trying to articulate.

Communicating effectively may hinder the ‘flow’ of a treatment, but it is a very important aspect of safety. Some clients may also value the friendly interaction they have with their therapist as much as the treatment. Elizabeth Holmes, MFHT, is a complementary therapist who works with clients aged 63 to 94. ‘While my clients are having treatment, they do like to chat,’ Elizabeth explains. ‘For those who are hard of hearing, I find myself almost shouting and leaning forward, and I sometimes have to break the flow of movement so I can face them for them to understand.’

Adapting treatmentsThis article cannot give specifics on adapting treatments for disabled persons as there are so many variables. However, there were some common themes in the responses we received to our online survey:Client knows bestCarers, relatives and members of a multi-disciplinary team can offer invaluable advice when it comes to adapting treatments. However, remember that the client is the best person to understand the nature of their disability and limitations to treatment.

Type of treatmentThe treatments most frequently used by our survey respondents were remedial and Swedish massage (combined, 70 per cent) reflexology (54 per cent), aromatherapy (40 per cent), Indian head massage (35 per cent) and reiki (33 per cent). However, treatment selection will depend on the therapist’s qualifications; what is most appropriate for the client and their preference that day; and what parts of the body can be accessed and treated without causing discomfort.

Non-touch, or very gentle therapies, may be particularly useful for clients with more severe disabilities, or if the area that requires specific attention is inaccessible. Hilary Campbell-Martin, MFHT, who works as a senior therapist at a substance misuse charity in Northern Ireland and also treats clients who have lost limbs, finds that the Bowen technique and Emmett technique are safe, gentle, and effective for those with mobility problems. ‘If a client is unable to lie on a treatment couch, I can work with them standing, sitting or in their wheelchair if necessary. Clients can be treated lying in a hospital or hospice bed without disturbing wiring or tubing from medical equipment. Clothing does not have to be removed, which can be reassuring for clients who may feel sensitive about their bodies, about missing or differently-abled limbs, or for those who wear colostomy bags.’Positioning the clientWhile some clients may be able to get on to a treatment couch, either on their own or with assistance from another person or hoist, others may need to be treated in a standard chair, wheelchair or bed.

Clients and their carers will know their limitations, so it is important to establish these and to provide assistance if needed, for example, removing shoes or moving a leg. Bolsters or towels can provide support.

For clients who are prone to seizures, it may be wise to carry out treatment on the floor, or ask a carer to stand on the opposite side of the couch or bed.

While client comfort is paramount, it is equally important that therapists do not injure themselves. David Godfrey, FFHT, who provides complementary therapies at the Disability Foundation at the Royal National Orthopaedic Hospital, Middlesex, says: ‘I have learned over the years how not to let sitting or lying on the floor affect me physically. I frequently shift my position to make myself comfortable and when the treatment is finished, I do some stretching exercises before the next client arrives’.Proceed with cautionWhen treating a client with a disability for the first time, it may be advisable to keep the treatment very short and gentle, to see how they respond. Janet Lindop suggests that in particular, therapists need to consider ‘the specific physiological complications with abnormal anatomy when giving treatment. Use cautious palpation and visual assessment, and if in doubt, seek advice from the client’s GP’.

Some medications and orthodox treatments can create contraindications. As always, open dialogue with other health professionals helps to ensure relevant information is communicated to the wider team, which protects client safety.

If there is any concern during treatment,

sally styles, MFht, complementary therapist at Craig-y-parc school

Nothing is text book at Craig-y-parc – from learning

how to communicate differently to not being able to locate a bony structure

because it’s not where it said it would be in the book

Sally Styles giving reflexology to youngsters at Craig-y-parc school

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therapists are strongly advised to stop. Regardless of whether permission has been obtained, it is the therapist who is responsible for the client’s well-being and safety during treatment.Timing and length of treatmentSome spas, clinics or salons may expect therapists to work to a strict appointment system, with very little time between clients. However, when working with someone who has a disability, this can be an issue. Catherine Wood explains: ‘Extra time may be needed for assistance with positioning, dressing and communication. Issues of timing treatment around the positive and negative effects of medication, shortening treatment time to suit levels of tiredness and

tolerance, and adapting pressure and touch to take into account muscle tone, touch tolerance and skin fragility are all issues for consideration. Common sense and thinking on your feet are essential.’

Benefits of treatmentJust as each client and their treatment is unique, so too are the benefits. Some outcomes are easy to identify: a bowel movement following abdominal massage or reflexology in a client with constipation; improved mobility after a set of exercises; reduced pain during and after aromatherapy massage; feeling or mobility returning to an area of the body after regular massage; or aiding expectoration in a client with

respiratory disease by a chest and upper back massage. Any improvement to well-being directly after treatment, no matter how small, could potentially be perceived as a treatment benefit, particularly if repeatable.

Sally Styles points out it can be difficult to measure treatment outcomes as some clients may not be able to provide detailed feedback, and ‘small things in our world can be huge milestones in theirs – a five-year old child who says “mumma” for the first time, or a child with Rett syndrome who is able to lie still for 20 minutes are both big goals.’

Andy Garner, a client of FHT member Judith Thurston, greatly benefited from the ayurvedic principles and treatments she offers. Andy suffered a spinal injury and lost mobility in his legs after an accident. After receiving a full body Abhyanga and Marma massage, he commented: ‘I felt connected to all parts of my body. The feeling of relaxation and contentment lasted long and continued the next day, although I was physically tired and needed to rest. My mind was more positive and I found myself looking forward rather than back. I had new ideas of future projects. On the second day I felt energetic, emotionally responsive and focused. For the rest of the week, I had good energy and mood and spent much time being active and socialising.’

Treatments can also have a ripple effect, benefiting those who care for the client. Ysobel Albone comments that while treating a client with MND at his home, ‘I quickly realised that I was not only making a difference to him but also to his wife, who was his sole carer. She knew that during the two hours I spent with him, she could relax and have some time to herself’.

The therapist’s perspectiveMany members who responded to our survey said it can initially be daunting to work with disabled persons, and also very upsetting when a client dies as a result of a life-limiting condition. Yet, Jenny Anderson, MFHT, who is a therapy assistant practitioner at James Paget University hospital, says ‘it is very rewarding when you see improvements, no matter how small, and you know you are making a difference to their life’.

there seems a wide discrepancy in how much a therapist may learn about treating disabled persons as part of their therapy qualification(s). the level of training; experience of the training provider; content of the core curriculum; and date of training all appear to play a part in how much practical skill or theoretical knowledge has been passed on to the student.

some colleges and training establishments are excellent at ensuring that students gain experience working with a range of clients, including those with special needs or disabilities. however, Janet Black, MFht, a physiotherapy assistant for leonard Cheshire Disability, at st Bridget’s Cheshire home, West sussex, says: ‘I don’t remember there being any provision for treating people with disabilities in my original training. Much of what I have learned has been through experience and researching the particular conditions that I have come across, as well as the help and support I have received from my physiotherapist colleague at st Bridget’s’.

Catherine Wood says: ‘My personal experience of obtaining training in treating patients with a disability has been “while in

practice”, observing other disciplines, such as physiotherapists and nursing staff, and by working as part of a wider multi-disciplinary team. attending local support group events and study days also helped.

‘availability of training events will greatly depend on location, but many hospices have education departments that provide lectures, conferences and study days on specific life-limiting conditions, including those that involve levels of disability.

‘as a hospice complementary therapy coordinator I am always willing for therapists who are interested in working in palliative or supportive care to enquire about observing therapy practice and seeking information.’

sally styles offers nine-week placements at Craig-y-parc school to students completing their complementary therapy degree at university of Wales Institute, Cardiff, and David Godfrey has written and teaches advanced modules for both massage and reflexology for Middlesex school of Complementary Medicine.

the Fht is looking at the possibility of providing CpD training and we will advise members if this becomes available.

Availability of appropriate training

Our thanksWe thank ron Cottrell; the equality and human rights Commission; paul lewis; each member who responded to our online survey; and especially those who provided additional information for this article: Ysobel albone, Jenny anderson, Janet Black, hilary Campbell-Martin, David Godfrey, elizabeth holmes, Janet lindop, Judith thurston, sally styles, and Catherine Wood. l Please visit www.fht.org.uk/kt/equality to view or download their unabridged submissions in a single document, or see page 51 for individual URLs.