Ep 110 – Obesity Pressures: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

Close up of an obese back

An obese client wants help with low-back pain, but she can’t take deep pressure. What to do? Ruth might get a little strident in this discussion of weight, health, judgmental language, and hands-on options.


Healwell Community: www.healwell.org/community

Werner, Ruth. “Demystifying Obesity: Looking Beyond the Scale.” Massage & Bodywork magazine, July/August 2018, page 40. www.massageandbodyworkdigital.com/i/992435-july-august-2018/42.

Author Images: 
Ruth Werner, author of A Massage Therapist's Guide to Pathology
Ruth Werner's logo
Author Bio: 

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP's partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner’s books are available at www.booksofdiscovery.com. And more information about her is available at www.ruthwerner.com


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Full Transcript: 

0:00:00.0 Speaker 1: Ruth Werner's best-selling book, A Massage Therapist's Guide to Pathology is a highly regarded comprehensive resource that sets the standard for pathology Education. Written for massage therapy students and practitioners, this ground-breaking resource serves up a comprehensive review of the pathophysiology, signs, symptoms, and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com.

0:00:32.4 Speaker 2: Anatomy Trains is happy to announce our return to the Dissection Lab in person, January 10th to the 14th, 2022 at the Laboratories of Anatomical Enlightenment in Boulder, Colorado. We are thrilled to be back in the lab with Anatomy Trains' author Tom Myers, and master dissector Todd Garcia. Join students from around the world and from all types of manual movement and fitness professions to explore the real human form, not the images you get from books. This is an exclusive invitation, email info@anatomytrains.com, if you'd like to join us in the lab.


0:01:17.2 Ruth Werner: 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 am Ruth Werner, author of A Massage Therapist's 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.

0:02:02.3 RW: Today's story comes from a massage therapist from Ohio who shared this post in a massage therapy Facebook group. Frankly, I have to say it was very brave of them to share this, because it made them a possible target for a lot of negative commentary. Fortunately, most of what I saw in response to this post was positive and helpful, probably led by the tone of the massage therapist whose only purpose in sharing was to be helpful for the client, and their story goes like this. I need some suggestions. I had a new client today, she's extremely obese. The problem is she has so much adipose tissue, I need to apply pressure to even be able to get to her muscles and she can't take any pressure, she says it hurts too bad. She wants to start coming regularly. I don't know how to help her if I can't get to her muscles. This was followed by information that the client was unwilling to go to a doctor because she was tired of being told that she just has to lose weight to feel better.

0:03:05.2 RW: I followed this thread for a little bit, and then I got distracted 'cause I had some other work I had to do, and I did not go back to see where this all landed, but what I did do was reach out to the commenter to see if they would be willing for me to share this story in our podcast, and I asked for a little more information. The contributor generously said yes, and told me this about the client. She's 23 and she's in good health. No health issues at all. She came to me because her legs go numb and tingle, sometimes just one side, sometimes both at the same time, especially when sitting. She wants her low back pain and the numbness and tingling in her legs to be fixed. She's a hair stylist, so she has a lot of tension in her shoulders also. She has a very good self-esteem and is very comfortable with her body, she just doesn't like the doctors telling her she should just lose weight. Okay, so there's lots to say about this situation, we could delve into possible sources for low back pain or for numbness and tingling in a person's legs, but it seems to me the tougher question here is about how to deliver safe, effective body work for a person who's large.

0:04:16.8 RW: And before we go any further, I need to talk a little bit about language. In our society, we have some standards about appearance that are not always fair or realistic, and the words we use to describe people who don't fit into standards for body size can sometimes feel pejorative or judgemental, even when they're meant to be simply descriptive. And so, people like me who try not to hurt anybody's feelings, we sort of dance around words like overweight and fat and heavy, but these terms have so many problems attached to them. I take a particular exception to the term overweight, especially as a person who has always viewed herself as overweight, because it's a comparative term. Overweight compared to what? Am I not allowed to take up this much space for some reason? The standard guide that we use in healthcare settings, the body mass index or BMI is supposed to identify the point at which a person's height, weight ratio, puts them at risk for disease, that's its intended purpose.

0:05:22.8 RW: But it is an incredibly imprecise white person-centric and inaccurate way to describe whether someone's height, weight ratio is healthy. And terms like fat or obese are often used specifically as insults, which gives us very limited descriptors for people who are larger than our culture suggests they should be. And this of course opens yet another can of worms about biases related to body size, disordered eating, the appearance of self-control, the way our culture fetishes food and a million other things. But while it all contributes to societal attitudes about size, anti-fat bias is not the topic of our conversation today. However, if this is a topic that interests you, I will refer you to the Healwell online community, where the topics of unconscious bias and attitudes about body sizes have been beautifully explored.

0:06:21.8 RW: We also need to re-examine our biases about the relationships between weight and health. There are some statistical correlations between people who are fat and some health risks, like diabetes, arthritis, high blood pressure, heart disease, and certain kinds of cancers. However, statistical correlation is not the same as causation, and I know a lot of people who are technically overweight by the BMI standard, whose blood pressure, blood glucose and athletic abilities are far better than other people I know, who are fit by the BMA standard for good health. And I know lots of thin people who have had severe enough arthritis to undergo knee and hip replacements. Thin people with heart disease, thin people with colon cancer. The list goes on and on. So it's not appropriate to assume that a person's weight is an inevitable contributor to any health problems they might live with, and that's a lot of setup to talk about obesity as a health issue rather than as a judgment issue.

0:07:24.4 RW: And the link between being fat and caloric intake is so, so, so much more complicated than it looks like, and I'm not going to get into that here, except to say three things, one, obesity as a health-challenging condition in this context that sometimes it's called adiposity-based chronic disease, is described by the World Obesity Federation as a chronic relapsing progressive disease process that is notorious and difficult to treat. Nothing in that description talks about obesity being a failure of willpower or a sign of weak character. It is caused by a multitude of factors, including caloric intake and exercise, but many others as well. Two, the amount of money this country spends on weight control and treatments for obesity is over $200 billion per year, and that does not include what individuals spend on diet plans and diet pills and other types of interventions to help them try and deal with this.

0:08:30.0 RW: And three, it is well established that restrictive dieting is a major contributing factor to obesity. So, I'm not offering solutions to this problem, I'm in fact, suggesting that what we call a problem might not really be that big of a problem. Fat people can be fit and healthy with great blood pressure and great blood glucose and wonderful stamina and strength. And some fat people are at risk for other health challenges, and all fat people are people, and they deserve our unconditional positive regard. I have seen massage therapists say in public that they add a fat surcharge to their services, or that they don't wanna work with fat people at all. And to them, I say, thanks for the warning, I will be happy to take my business elsewhere. I wrote an article on obesity in general and appropriate massage accommodations for it in Massage & Bodywork Magazine, and I will be sure to put a link to that in the show notes.

0:09:34.1 RW: Our contributor for this episode, who identifies as overweight themselves, wants to be helpful for this client who struggles with low back pain and has some nerve signs in her legs, numbness and tingling when she sits down, and this client does not respond well to deep pressure. That's not surprising, it's probably more often the case that people with really thick superficial fascia are more pressure sensitive than others. The advice I saw offered on that Facebook thread was generally good. Work with the tissue, not against it, focus on nerve supply and the skin and superficial fascia to induce a reduction in pain. And I will add something else, this client said she wants to come regularly, that means that somehow this massage therapist has created a space for her where she feels safe and welcome and celebrated and allowed to take up the space she takes up, and that is a gift.

0:10:32.2 RW: This client might not be able to receive the same kind of massage we see represented in technique videos with thin and fit people as opposed to fat and fit people, at least not at the beginning of this therapeutic relationship. But what she can receive is skilled, compassionate touch, gauged to reduce her pain and increase her quality of life in a setting that celebrates her for taking great care of herself. So, my advice to this massage therapist is, don't worry about accessing muscles right now, just help her feel good. If her low back pain and leg nerve signs get worse, it might be necessary to refer her out to a doctor, but see if you can't find a primary care provider who is more focused on helping a person than on just getting rid of the fat. That's my two cents, and I'm standing by it.

0:11:28.1 RW: Hey everybody, thanks for listening to I Have A Client Who, pathology conversations with Ruth Werner. Remember, you can send me your I Have A Client Who stories to, ihaveaclientwho@abmp.com. That's ihaveaclientwho, 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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