Ep 412 - Factor Five:"I Have a Client Who . . ."Pathology Conversations with Ruth Werner

0:00:01.8 Ruth Werner: Hello. I Have a Client Who listeners, Ruth Werner here, and I'm so excited to let you know that my library of online self-paced continuing education courses has just expanded. I now have a two hour ethics course called A Doctor's Note is Not Good Enough... And What is Better? This NCBTMB approved course goes into why a doctor's permission or approval or even a prescription doesn't provide the legal or safety protection you might think it does. Then we look at how to start useful conversations with healthcare providers that will actually get us to safe and effective massage for our clients with complex conditions. Visit my website at ruthwerner.com for more information and to register for A Doctor's Note is Not Good Enough... And What is Better?  

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0:02:53.7 RW: Hi, and welcome to "I Have A Client Who... " Pathology Conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Warner, author of A Massage Therapist Guide To Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer, even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice. And sometimes as we have all learned, that is harder than it looks. Being aware of blood clots, legitimate concerns about blood clots, well honed knowledge about blood clots. These are all part of our profession's requirements for safe practice, right? And over the years that I have been doing I Have A Client Who, I have gotten, I'm sure a dozen stories about clients with blood clots in one context or another. 

0:04:03.9 RW: And today we're going to add one more. This is a look at a condition called Factor V Leiden. And here's our story. Hi, Ruth says our contributor. I have several clients all in the same family who have Factor V and they tell me that they have asked their doctor and they have been cleared for a massage. Okay, this is Ruth and possibly you know my thoughts on doctor's clearance and we will of course get back to that later. Our contributor then says, I typically do medium pressure and sometimes ACE MediCupping with a machine and we've never had any issues that I'm aware of. One of the family members has a complicated history with breast cancer. She's had a few lymph nodes removed and has a double mastectomy. During her surgery, she threw off a tremendous number of clots according to her doctor, and this was due to the Factor V. 

0:05:00.7 RW: They also reconstructed her breasts, but the right one failed. So she has a good amount of scar tissue and she responds very well to any type of therapy and she loves scar work, but frankly, I'm a little uneasy about creating an inflammatory response in her body. If I work deeply using deep tissue or cupping, is that enough to create blood clots in her particular situation? Thank you for any insight. Again, she says she has been cleared for massage by her doctor. Okay, let's go ahead and talk about that first thing. Maybe this doctor is really knowledgeable about massage therapy and they have a clear idea of what medium pressure and ACE MediCupping with a machine means. But frankly, we can't depend on that. So once again, I will fall back on the value of a productive consultation with the healthcare team rather than relying on clearance if we're not sure we're all on the same page about things like pressure, intensity, frequency, duration, risks of pulmonary embolism and other variables that might impact our client's massage therapy experiences. 

0:06:16.2 RW: But that's too easy for me to fall down that rabbit hole. So instead, I'm going to exercise some self-discipline and we will turn our attention to Factor V and see why this massage therapist is concerned. You are probably aware that the process of blood clotting is fabulously complex and it involves cascades of chemical reactions that are important for blood clotting specialists to know about but not so much for massage therapists. However, for the purposes of this discussion, I need for you to know that normal Factor V is a healthy substance and it plays an important role in initiating blood clotting and its activity in forming clots is then turned off by another chemical called activated protein C. The condition called Factor V Leiden, L-E-I-D-E-N, or Factor V thrombophilia, that's thrombo for clot, philia for loving is what we're talking about, right? Factor V Leiden. 

0:07:25.6 RW: People who have it produce a form of Factor V that does not respond to the activated protein C and the result is they form lots more clots than other people, and of course we know this can be dangerous. Factor V Leiden is a genetic disorder, and that explains why this massage therapist has several clients all in one family who have it. It makes people more prone to forming clots especially in their legs. And this is of course a setup for pulmonary embolism. More rarely, Factor V Leiden is associated with strokes. My educated guess is that this has to do with a patent foramen ovale. That's a common defect in the structure of the atrial septum that lets debris cross from the right side of the heart to the left side where clots then might be pumped to the brain or anywhere else in the body. 

0:08:23.5 RW: Factor V Leiden is not an X-linked disorder. Males and females can have it. About 5%, that's one in 20 of the Caucasian population has at least one positive gene, but it is rarer among other ethnic groups. The majority of people with the Factor V anomaly never have any problems and may never know. But people who have it, who have any indwelling medical devices like catheters or IVs or central lines, they need to be aware of the risk of a problem. Anyone who's pregnant or who supplements estrogen maybe for birth control or hormone replacement therapy is also at much higher risk for clotting complications than other people. Factor V Leiden is a silent condition until an abnormal clot forms, but it can be tested in regular lab testing. If a person inherits the faulty gene from one parent, this is called the heterozygous type, then they have about a 10% higher chance of having a problematic clot at some point in their life than someone who doesn't have Factor V Leiden. 

0:09:35.5 RW: But if they inherit faulty genes from both parents, this is called the homozygous type, then the risk is much higher. 60% of this population will probably have at least one serious clot-related event in their life. If a person has this condition, it can be harder to carry a baby to term. The risk of miscarriage is higher. This group also has a higher than average risk for chronic venous insufficiency. That's a complication of severe varicose veins and they're more vulnerable to potentially dangerous venous ulcers. Other contributors to blood clot risk for people with Factor V Leiden are the same as the contributors to blood clot risk for anyone but magnified. And this includes, as we mentioned, supplementing estrogen in any form, being immobile, being obese, having injuries or surgeries or illnesses. In addition, people with Factor V Leiden who have any blood type other than O turn out to have a higher risk of a problem. Interestingly, the risks associated with Factor V Leiden only applies to clots in veins. There does not seem to be a strong statistical correlation between having Factor V Leiden and the chance of having a heart attack or a stroke unless these events happen in younger patients. And then we would look to see if they have a blood clotting disorder. 

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0:12:23.9 RW: Factor V Leiden can't be prevented because it's a genetic disorder. It's treated when necessary with anticoagulant drugs, typically Coumadin, but this is far from a complete and easy solution. Many patients and their prescribing physicians struggle to find the right dosage to maximize the benefits of not forming uncontrollable clots with the risks of having uncontrolled bleeding. And for a lot of people, that can be a hard needle to thread. People with this condition are often advised to be careful about those issues they can control. Being physically active is really important for cardiovascular health and also for weight control. But contact sports are discouraged because we don't wanna give this body any reason to make extra blood clots. Smoking, using estrogens, being sedentary, these are all sort of pro-clotting behaviors that can increase a person's risk of having a problem. Right. So now we have all this information about Factor V Leiden and we need to apply it to the client in this story. 

0:13:00.3 RW: Brief recap, one of my clients with Factor V has a complicated history with breast cancer. She's had a few lymph nodes removed and a double mastectomy. During her surgery, she threw off a tremendous number of clots. According to her doctor, this was due to the Factor V. They also reconstructed her breasts, but the right one failed. So she has a good amount of scar tissue and responds well to any type of therapy. And she loves the scar work, but frankly, I'm a little uneasy about creating an inflammatory response. If I work deeply using deep tissue or cupping, is that enough to create blood clots in her particular situation? Thank you for any insight. Again, says our contributor, This client has been cleared for massage by her doctor. I had some follow-up correspondence with this contributor and I found out a few interesting details. This client is pretty young, 56 years old. 

0:14:26.0 RW: She had recently lost a sister to breast cancer and so underwent testing and was surprised to find that she had it too, which was what led her to a double mastectomy and lymph node removal and then a failed breast reconstruction and lots and lots and lots of blood clots, which as we've seen, her doctor ascribes to her Factor V Leiden. She is otherwise recovering well. She's now able to move and exercise as freely as before her surgery. And importantly, she is not taking any blood thinners or other medications. And our contributor wants to know if she should be cautious or aware of any special risks. Wow. I'll tell you that when I have complicated situations like this with a lot of unknowns, my favorite shortcut involves three main questions. First, what does the client wanna achieve with massage? Secondly, what are their normal levels of daily activity and exercise like?  

0:15:30.3 RW: And thirdly, if there are meds, what are those meds for and what are the side effects? And these bits of information can give us a nice quick snapshot of their general health and resilience. So let's apply that to this client. Here's what we know. This client is relatively young. 56 sure seems young to me. And outside of her breast cancer, she's otherwise healthy and active. She's already had median pressure massage and MediCupping, which she likes, and she has a doctor's clearance for massage, which we have already discussed. She is not using any medication and that's an important detail in this case because Coumadin often leads to bruising and that leads to some decisions about massage therapy. It sounds like her goals for massage are mainly to help her deal with scar tissue and the lingering effects of her surgery. I said to our contributor that the doctor's clearance might not mean much unless this doctor has a very thorough understanding of what they do. 

0:16:33.9 RW: And if that's the case, then clearance might add a sense of safety. But if this is more of a typical, yeah, whatever. If you want massage, go ahead kind of situation, then this doctor might not be aware of the intersections between massage therapy and blood clots and the risk of pulmonary embolism. If I were in this massage therapist's position, I would really like to get permission from this client to clarify that point directly with the doctor. The fact that the client is both under medical surveillance and not on blood thinners is a really good sign that her general resilience is strong and her risk of another clotting episode is likely to be low. So when we weigh all these risks and benefits, especially because she has not had recurring clot-related issues since her surgeries, I think that conservative massage with lots of checking back for comfort is going to be fine. 

0:17:31.8 RW: Inflammation, which seems to be what our contributor is worried about, doesn't necessarily lead to excessive clotting unless there's tissue damage. And I think with conservative massage we can avoid that problem. But let's define a couple of terms. By conservative, I mean no work that is likely to cause any bruising or soreness. It sounds like that's not the kind of cupping that happens here. At least that's what I hope. And by checking back, I mean following up to find out about any inadvertent bruising or soreness or shortness of breath or chest pain or signs of pulmonary embolism that require immediate attention. So my advice to this massage therapist is proceed but with caution. See if you can get a conversation with her doctor, probably through her health records portal to make sure you're all on the same page about blood clots and pulmonary embolism risk. And by the way, there are some very specific do's and don'ts about how to hold these communications. 

0:18:36.1 RW: I happen to have a whole online continuing education class on this topic called A Doctor's Note is Not Good Enough... And What is Better? And of course, I'll put a link to that in our show notes. So dearest contributor, support your client as she continues to recover from this very traumatic event, but mostly thank you. Thank you for sharing this story. Thank you for being both curious and cautious because all of your clients benefit from that kind of attitude. Hey everybody, thanks for listening to, "I Have A Client Who... " Pathology Conversations with Ruth Warner. Remember, you can send me your, I Have A Client Who stories to, ihaveaclientwho@abmp.com, that's I have a client who all one word, all lowercase @abmp.com. I can't wait to see what you send me and I'll see you next time. 

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