Contraindications/Cautions for Structural Integration: A discussion

Contraindications/Cautions for
Structural Integration: A discussion
Shonnie Carson and Carrie Gaynor
Shonnie Carson RN, BS, ANP, CAR, BCSI is a Certified Advanced Rolfer™ in Phoenix and has been practicing since 1981. She currently serves as Vice Chair of the Certification Board for Structural IntegrationSM. Shonnie is an Adult Nurse Practitioner and had a 34- year career as an R.N., largely in hospital medical/surgical and rehabilitation areas including three years as Director of Nursing for a 120-bed hospital.
Carrie Gaynor, BSN, RN, KMI, BCSI is a Board Certified Structural IntegratorCM. She has been practicing since 2003. In 2006 she joined the faculty of KMI, teaching both Anatomy Trains® and KMI courses. She earned her nursing education at the University of Rochester and is a member of Sigma Theta Tau International Honor Society of Nursing®. Carrie serves as a member of the Certification Board for Structural IntegrationSM and the Board of Directors of the International Association of Structural Integrators®, reflecting a deep commitment to enhancing knowledge resources and networks.

In May 2008, the ninth edition of “Contraindications and Cautions for Deep Bodywork” by Schleip, Luchau and Schewe was published.1
We are responding to their invitation to contribute to this growing discussion. Further, there is evidence suggesting that Structural Integration (SI) practitioners would benefit from a tool or form in which to gather pertinent health history on clients. We are offering a sample health history form more tailored to the needs of Structural Integrators. It is in this context that the sample health history is intended to alert the practitioner to contraindications for SI, indications to modify techniques, the need for medical permission or collaborative relationship. It is our hope that this form will enable the practitioner to individualize session work and maximize the outcome for their clients.
Our intention is to offer our viewpoints as two Structural Integrators with considerable medical education and experience. Our hope and purpose is not to replace the information in that article, but to stimulate further discussion and to offer a wider range of opinion to the Structural Integration community.
It is important to acknowledge that there is great variation in styles of work within the SI community and therefore difficult to give absolute guidelines without some explanations or qualifications. If you are very new in your SI practice it may be appropriate to contact a moremature practitioner for consultation or
mentoring.
The style of your work is a factor in determining how and if SI work can be done given pre-existing health conditions. Common language found in the literature suggests that the term “deep body work” is synonymous with aggressive or painful work. We disagree and take this opportunity to lend clarity.
We will use the term “forceful touch” as a term identifying touch whose speed, depth, or pressure is such that the client is unable to remain relaxed and open to receiving work.
Hallmarks of this style of work are: the client’s response is breath holding, contracting, tensing or withdrawal from touch, and expressing that the work is painful. Often the client willdisengage or dissociate from the practitioner or the experience.
The term “appropriate touch” is a term identifying touch that is evidenced by the client being able to have normal breathing patterns and able to be relaxed and open and participating with the practitioner in the work.
The tissue engagement hallmarks are: the practitioner is aware of appropriate layers of tissue and is able to “listen and follow” tissue patterns and changes, rather than making a willful imposition of the practitioner’s idea of how the tissue “should” change.
IASI Yearbook 2011 Page 83 If your work tends to be in the category of “forceful touch” then some conditions will not be appropriate for your work that would be appropriate for a practitioner with less intrusive “appropriate touch.”
Liz Stewart, GSI faculty member, offers courses such as “Surfing the Superficial Fascia” through the IASI CE program and GSI (www.rolfguild.org). This is a wonderful resourcefor those practitioners wanting to learn how to touch with a refined and precise contact of tissue layers. 2
We want to be clear that we are not discussing this information in the context of“treating” any of these conditions with SI, but rather discussing if and how it is appropriate to do SI work in the presence of any of these conditions.
Our approach will be to discuss general categories and highlight specific diagnosis examples. Please note that we are not going to necessarily define diagnoses, as that information is readily available from many sources. We will leave it to the individual practitioner to obtain that information.
Gaining medical clearance Because very few physicians understand what SI consists of, we suggest that when physician clearance is recommended, if the client is cleared for massage work, that should be appropriate clearance. This is of course, a wonderful opportunity for physician education.
Physicians are much more receptive to documented research rather than anecdotal information. IASI has developed a marketing brochure for SI, which you may want to include for their information.
Circulatory conditions
-Atherosclerosis and Arteriosclerosis–a significant percentage of the population is living with these changes in the circulatory system. This diagnosis by itself is not a contraindication but should alert the practitioner to obtain a complete and detailed history that may reveal some of the following that would warrant caution.
– Anticoagulants–if presently taking or recent history, there may be an increased tendency to bleed or bruise. Forceful tissue work is not appropriate. Care should be taken with intranasal work. Variables in the reason for taking these medications such as a chronic or acute condition, how long the client has been on the medication, etc. effect whether SI work is appropriate. If uncertain, obtain a clearance from the physician.
– Embolism/Thrombus (clots)–particularly in the lower extremities. If this is only on history and is not acute and not being currently treated, then SI work would not necessarily be contraindicated. Caution should be used with forceful work on the lower extremities particularly in the presence of moderate to severe varicosity.
If the client is currently being treated for embolism or thrombus and there is swelling/discoloration/redness in tissue you should not work on or around the area. If the client is on anticoagulants for recent embolism you should not do tissue work without clearance from the physician. If you are uncertain we suggest obtaining clearance for bodywork from the treating physician.
– Varicosities–direct or forceful work on the veins is contraindicated especially in the lower extremities.
– Phlebitis is an inflammation of the lining of a vein or artery. The danger with phlebitis is the potential for embolus or clots. Work on or around the acute area is contraindicated during the acute stage. See comment on embolism and anticoagulants.
– Aneurysms–if known and unresolved, a physician’s release should be obtained. Direct work in or around the area of the aneurysm is contraindicated.
– Edema (swelling) in the tissues, especially the lower extremities–this indicates not only impaired circulation which can lead to emboli, but also can be symptomatic of cardiac, pulmonary or kidney conditions which may or may not be diagnosed. We encourage you to learn to recognize the different degrees of edema such as 1+ up to 4+. Forceful work is contraindicated in the presence of more than minimal (1+) edema because there is a danger of dislodging clots or tissue damage. If the condition is chronic and the client is not under medical care you should encourage the client to obtain a medical exam.
IASI Yearbook 2011 Page 84
Cardiac (heart) conditions
History of MI (myocardial infarction or “heart attack”) is not a contraindication.However, if the client has unstable angina or is experiencing frequent episodes of chest pain with or without using nitrates frequently to control chest pain (angina) physician clearance is recommended.
If the client has a history of cardiac surgical procedures such as heart catheterization, stents, or open heart surgery it will generally be appropriate to do SI work under the following conditions:
– Incisions are healed (generally that is six weeks post operatively).
Note: there can be complications with sternum healing after open heart surgery (Coronary Bypass Grafting (CABG) surgery, heart or valve surgery). This often involves intricate measures to repair the sternum including omental flap procedures. Is this is suspected or reported please obtain permission or guidance from appropriate sources including the physician.
– No indication of edema, embolism/thrombus or recent initiation of anticoagulants. If any of these are present-review comments on the appropriate issue.
– No exercise restrictions. The best possible scenario is that the client has completed a structured cardiac rehabilitation program.
– If the client has assistive devices such as Greenfield filters, pacemakers, defibrillators, etc. obtaining clearance from the physician is recommended.
Note: literature review reports 20-25% of  cardiac events patients experience depression. According to Kathleen King, “emotional distress and functional disabilities decrease over time and appear tobe stable by 6 months after the event”. 3
Working with these clients offers an opportunity to use your skills to be alert to possible depression and to be aware of the potential need for appropriate referral for mental health support or other collaborative practice opportunity.

High blood pressure (hypertension) If treated and under control, hypertension is not contraindicated.
Forceful work that results in the client holding breath is not recommended as that can raise blood pressure.
If the client has extreme high blood pressure that is not amenable to control by medication that is a contraindication and work should not be done without physician clearance.
Autoimmune diseases
Included in this category (but not limited to) are Lupus, Rheumatoid Arthritis, Ankylosing Spondylitis, and Scleroderma.
As a general statement, it is usually best not to work on acutely inflamed areas. However, many chronic conditions can have positive response to SI work that is not forceful. Many of these conditions are accompanied by restriction in the movement of the connective tissue, and SI work can often help these clients maintain more mobility.
Psychiatric disorders
There are many sources in the SI community for the practitioner wishing to develop a better understanding of how to deal with emotional content that may arise during sessions. An excellent reference would be Waking the Tiger by Peter Levine 4 and his doctoral thesis “Accumulated Stress, Reserve Capacity, and Disease.” 5
We suggest that you have a resource list of mental health care providers you are comfortable referring to and that can be helpful when emotional content deserves the attention of a professional provider. Be cautious with clients in psychotherapy. Their therapist should know they are receiving bodywork.
Clients with Bipolar Disorder, or borderline disturbances (on the border between neurosis and full psychosis) warrant caution. Depending on the severity, SI work can trigger destabilizing episodes. If you are uncertain, then the client should obtain the supervision of a psychologist, psychiatrist, or counselor, and you should have clearance from the physician.
Psychosis (all forms) is a contraindication.
Nervous system disorders
These disorders are not contraindications for SI work. If there are specific client issues that the practitioner is unsure of, then obtaining physician clearance is prudent.
IASI Yearbook 2011 Page 85
Most of these disorders, including (but not limited to) cerebral palsy, MS, various dystonias, Parkinson’s, and paralysis states, are accompanied by shortening/restriction in the musculature and connective tissue. SI work can often help these clients maintain more mobility. If you are unsure, you should obtain clearance
from the treating physician.
Epilepsy/seizures
There are many variables to consider with these clients. If there is only a history, particularly related to a specific incident, and no recent occurrence or treatment, this is not contraindicated.
If there has been recent seizure activity and / or the client is taking medication for seizures, obtaining physician clearance is prudent. Also, the client should be informed that SI work may alter the need for medication. It is not uncommon that medication dosage may be reduced.
Practitioners should be aware that triggers for seizures vary widely and may include hyperventilation and certain types of lighting or visual stimuli.
Cancer
There is wide variation in cancers, and to make a blanket statement is difficult. There is some theoretical concern that tissue work may result in “breaking tissue encapsulization” or in cancer cells moving to another part of the body. However, we are unaware of any research supporting this conclusion. Cancer spreads toother locations long before it is detectable (called micro metastasis) and when a cancer is evident it is highly likely it was there for some time.
The massage community has moved away from the belief that cancer is an automatic contraindication. In articles in Massage Today both Tracy Walton4 and William Handley5 have offered viewpoints that massage is NOT contraindicated with a cancer diagnosis. Their view is that massage (tissue work) is beneficial and that the contraindications are based on limited understanding of how cancer is spread and the effect of uneven or lacking research.
If the purpose of SI is to create a more functional structure with a higher level of health, then it is appropriate to assume that SI can contribute to the client’s system becoming more capable of effectively responding to challenges.
Many cancer treatment centers support the use of different forms of bodywork to enhance the recovery of clients. There is no documentation (that we are aware of) to support removing SI from this category.
Caution should be used if the client is in current treatment and the cancer diagnosis is acute. If the client is in that stage, then physician clearance should be obtained.
When treatment has been completed and tissue is healed from treatments, then SI work can be very appropriate.
The five-year clean bill of health common cautionary against SI work is not supported by any documentation or research. If the treatments or surgery have resulted in muscular/tissue restrictions, often these can be improved very effectively with SI. Specifically, work with women post mastectomy can usually dramatically improve not only neck, shoulder, and arm function, but also improve rib cage and respiratory movement. It is Shonnie Carson’s experience, after years of working post-treatment with clients with various cancer diagnoses, that all have had beneficial responses to SI work.
It is always prudent that if a practitioner observes any lumps, masses, or unusual things present, the client should be encouraged to seek medical attention.
Scar Tissue
Surgery, radiation, and traumatic injuries, and their resultant scarring, interrupt fascial continuities and alter the transmission of force through movement planes. This can bedramatically reduced by appropriate tissue work.
Sensitive appropriate and specific SI work can reduce pain and improve mobility, adding an important aspect to the healing process that islikely to be emotional as well as physical.
Your history should include the date of occurrence/intervention, and complications such as deficiencies in muscle strength, ROM, lymph circulation, and neural hypersensitivities.
The scar should be healed–usually about six weeks after surgery or injury. Note cautions in the Cardiac surgery section.
In his 2009 presentation to the Fascial Research Congress, “Fasciae in Recovery from Cancer Surgery,” Willem Fourie, PT states that soft tissue therapy should be part of therapy following surgery, and the role of the manual therapist in healing includes the restoration of tissue glide and flexibility between fascial planes
IASI Yearbook 2011 Page 86
SAMPLE CLIENT HISTORY FORM FOR STRUCTURAL INTEGRATION
Client Name: __________________________________________________________
Phone: H___________________ C_____________________ W________________
Mailing Address: _____________________________________________________
E-Mail: ____________________________________________________________
Referred by: ___________________________________________________________
What is your main reason/ goal for Structural Integration work?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
While Structural Integration is not a medical treatment, it is relevant to know about one’s
physical and psychological history for most informed and individualized session work.
Please complete the following questions.
Please indicate any areas below which you are aware of pain or numbness.
Use a P for pain and an N for numbness.
__neck __shoulders __elbows __hands __wrists __hips
__lower back __upper back __knees __ankles __feet __other (please note below)
Physical and Psychological History
Date of Birth _______/ _______/________ Current height : ______ weight: _______
Current Medications and indications:
Prescription meds
____________________________________________________________________________
____________________________________________________________________________
Over the counter items – please include pain meds, vitamins, herbs, etc.
____________________________________________________________________________
____________________________________________________________________________
Allergies:
Medications__________________________________________________________________
Latex or other (ie. Seasonal / hay fever)____________________________________________
IASI Yearbook 2011 Page 87
Reproductive History (circle what applies):
If female are you menstruating, pregnant, or post-menopausal? _________________________
Number of pregnancies ______________ Number of live births __________________
Contraception method _______________ Age(s) of Children_____________________
Hot flashes Pain/discomfort with intercourse
Pain/discomfort with menstruation or ovulation
Please indicate age or year and description for any of the following:
Surgical History / Hospitalizations (including cosmetic)
____________________________________________________________________________
____________________________________________________________________________
Injuries (auto accidents/falls/etc.) _______________________________________________
____________________________________________________________________________
Fractures/Sprains requiring splinting or with swelling _____________________________
____________________________________________________________________________
Cancer:
location/type_________________________________________________________________
treatment/date________________________________________________________________
Additional Health History (circle all that apply)
Respiratory:
Repeated or frequent bronchitis or pneumonia Asthma
Unexplained shortness of breath or difficulty breathing Tuberculosis
Cardiac:
Pulse irregularities / heart murmurs Phlebitis or embolism/thrombus (clots)
High blood pressure Episodes of chest/jaw/arm pain
High cholesterol Episodes of fatigue/midback pain/indigestion
Anticoagulation therapy (blood thinners) Arteriosclerosis/atherosclerosis
Digestive:
Food intolerance (indicate type)____________________________________________
Eating Practices_________________________________________________________
Hiatal hernia Diabetes: Type I or Type II
Ulcers Hypoglycemia
Frequent indigestion/acid reflux Braces (teeth)
Constipation /diarrhea Dental / jaw problems
Colitis TMJ
Bulimia / anorexia Grinding / clenching teeth
IASI Yearbook 2011 Page 88
Skeletal:
Osteoporosis/osteopenia Spine / disc problems
Arthritis: osteo / rheumatoid /other Joint problems
Nervous System:
Headaches Weakness /inability to move a part of the body
Epilepsy / seizures Psychiatric history / treatment
Dizziness / loss of balance ADD /ADHD
Numbness /loss of sensation Learning /communication disabilities
Urinary:
Infections /stones Incontinence / leaking
Difficulty urinating Prostate problems
Miscellaneous:
Eye problems / glaucoma / detached retina / cataracts
Glasses / contact lenses / lasik surgery
Hearing / Ear problems
Movement or exercise practices and frequency
____________________________________________________________________________
____________________________________________________________________________
Hobbies/Sports_______________________________________________________
Treatments you have sought out to help you with the reason you are here:
____________________________________________________________________________
PCP: ___________________________ Chiropractor: ______________________________
Massage: ________________________ Acupuncture: ______________________________
Other: ___________________________________________________________________________
Do you give your permission to contact these practitioners if necessary Y / N
Is there any other additional information I need to know about you as a client?
____________________________________________________________________________
____________________________________________________________________________
This form is accurate to the best of my knowledge.
Client signature ____________________________________________________________________
Print name ________________________________________________________________________
Date______________________
IASI Yearbook 2011 Page 89
where possible. Additionally, Fourie provides an excellent and concise presentation on fascial physiology and the effects of fibrosis on the layers of tissue and the secondary resultant impaired mobility. 8
Sharon Hancoff, CAR has developed techniques for working with scar tissue that are unlike any other techniques being taught.9
Sharon teaches workshops on these techniques and the techniques are easy, gentle, and extremely effective in not only normalizing the appearance of scars, but also decreasing impaired mobility.
Diabetes and hypoglycemia
Working with diabetic or hypoglycemic clients is not contraindicated. Practitioners should be aware of the following cautions:
Many diabetics, particularly those with poorly controlled diabetes have decreased ability for tissue repair (healing), often have impaired circulation and may have decreased sensation, particularly in the extremities.
A condition called peripheral diabetic neuritis is not uncommon. The symptoms are frequent and/or persistent burning or pain in the lower extremities. So forceful tissue work in extremities is not recommended or should only be done with caution.
Tissue work on insulin injections sites that are older than six hours should not increase insulin uptake and is not contraindicated.
Clients with hypoglycemia (low blood sugar) should be encouraged to eat some protein before sessions and watch for signs of fatigue,or clammy skin, as these may be early signs of low blood sugar.
Infectious/inflammatory conditions
Any acute infectious or inflammatory condition is a contraindication for SI work, in the affected area, during the acute stage.
Work with acute feverish clients is contraindicated.

Conditions such as tendonitis and bursitioften respond very well to work after theacute stage.
Osteomyelitis is an infection of bone and often makes the bone very fragile so forceful work in the affected area is contraindicated.
If the client has a systemic (generalized) in