The best part of college was the first two terms of school.
We had two classes a week where we would work on each other and practice draping, how to landmark certain areas of the body and learn new massage techniques. It was a new massage treatment twice a week.
All you would hear in our class were students saying “I love school” as they received their massages from classmates.
The other thing you would hear, was me snoring!
Every time I got on the table I would fall asleep. Teachers regularly came up to me saying “you have to stay awake to give your therapist feedback!”, my response: “I’m sleeping, I’d say they’re doing a good job!”
When we got into the student clinic, we would wear it like a badge of honour when a supervisor asked how the treatment went and we could say: “well, they fell asleep, so pretty good”.
But is that really the best thing? I know it’s great for the patient and it’s an obvious sign they’re relaxed, but what about for the therapist? Is it in our best interest? Is there an issue as far as our safety?
Sleep Disorders & Parasomnias
There are 81 major sleep disorders which are then put into eight major categories.
Some of them you’ve probably heard of, maybe even experienced and more than likely have a few patients who deal with sleep disorders like insomnia, sleepwalking, and sleep apnea.
Within those eight classifications, the fifth one is called “parasomnias”.
Parasomnias are undesirable physical or experiential events that happen during entry to sleep, within sleep, or during arousal from sleep. Those events can be sleep-related movement, behavior, emotions, perceptions, dreaming, and autonomic nervous system functioning and are typically associated with arousal from non-REM sleep. There are several parasomnias that are associated with REM sleep, but since it takes 90 minutes to actually get into REM sleep, those ones probably aren’t much of a concern for us.
Confusional arousal is one of those disorders associated with non-REM sleep and involves the person being mentally confused or having confused behavior after waking up. These are most common with kids but are common with 6% of 15-24-year-olds and present in 1% of the population over the age of 65.
Sleep-related dissociative disorders happen during the transition from wakefulness to sleep or after waking up during the first or second stage of sleep (the first five or ten minutes) and involves a disruption of integrative features of consciousness, memory, identity, or perception of the environment.
One study showed these sleep disorders to be more prevalent among the general population than was previously thought and also showed it is not uncommon for a person to have more than one parasomnia. However, there is no real treatment for these type of sleep disorders as they are considered benign and quite often are due to a lack of good sleep. An example given was a sleep-deprived doctor being woken up from a deep sleep, may have confusional arousals and can possibly make errors in judgment.
Most of these things disorders during the first 1/3 of the night when people are going to sleep, but can also be quite common during daytime naps. So, when we look at the example just given, think about your practice and how many shift workers you treat? How many police officers, firefighters, nurses, city workers, or any other night shift workers do you have that come in?
People could have parasomnias and not know it, especially those who are sleep deprived before they even come and see you.
When we look at patient safety, it’s important to know about these kinds of things as someone could wake up during or after a treatment and be very confused about where they are, what they are doing, and even what just occurred while they were on the table.
Paralysis And Lucid Dreaming
Have you ever had a moment where you woke up from sleep and couldn’t move? Or you felt like there was an intruder in the room, pressure on your chest, or the feeling of an out of body experience?
Well, that is sleep paralysis, and part of sleep paralysis is the hallucinations that occur while in this state. It can happen when you are falling asleep, or when you are waking up from sleep, and is divided into three classifications:
- Intruder Hallucinations (hearing voices, sensing something evil is in the room)
- Incubus Hallucinations (chest pressure, difficulty breathing, perception of pain)
- Unusual Body Experiences (flying/floating sensation, out of body experiences, emotional bliss)
In one of the oldest known accounts of sleep paralysis, a woman described the events as the devil laying on her chest, as well as being choked by a great dog. Another study done with Mexican adolescents found that 27.6% of the subjects had experienced the phenomenon of “a dead body climbed on top of me”, which was determined to be a form of sleep paralysis. Some descriptions of this kind of hallucinations even go to the extent of people being fearful of being killed or raped in their bed. These “incubus” hallucinations are more likely to occur when entering a sleep cycle.
Interestingly one study looked at the relationship between sleep paralysis and lucid dreaming. When we are lucid dreaming (which happens more during REM), we actually have the ability to control the dream or wake up from it, because we are aware that we are in a dream state. In the study, lucid dreaming had more of a connection with the third class of sleep paralysis (unusual body experiences) and actually had a positive effect and showed a positive association with imagery. However, the study also pointed out that sleep paralysis has more to do with poor sleep, and increased stress and anxiety.
How many patients do you have that come to you because getting a massage helps them with sleep, stress, and anxiety? Probably quite a few of them, and as it turns out, sleep paralysis is pretty common. One systematic review estimated 7.6% of general population, 28.3% of students, and 31.9% of those who deal with things like depression and anxiety, also deal with sleep paralysis.
Imagine if one of your patients had this happen on your table when entering a sleep cycle. Through no fault of their own (and none to you as well) they could have this type of a hallucination and possibly feel you were involved or part of the hallucination. The important thing is to make sure you protect yourself. Make sure you keep a journal or notebook around to document if something seems strange after the treatment. Keep detailed notes on what occurred in the treatment as a protection for you and your practice…just in case.
Consent For Massage Therapy
Before any treatment starts, part of the interview process with a patient is getting consent for treatment, especially if you need to work in sensitive areas like the gluts or adductors.
Just recently in Ontario, it was made mandatory to have this documented before each treatment whether you have a previous therapeutic relationship with a patient or it was the first time. Many saw this as a hindrance in practice and felt it would just be annoying for a patient to have to do this every time!
While I can see that side of the argument, why not look at it on the other side and think about what it does for the practitioner rather than the patient (don’t get me wrong, it should be done as a protection for the patient as well).
Studies have shown how the sleeping brain can still interact with its environment. One study showed that not only can movement be triggered by nociceptive stimulus during sleep, but also behavioral responses can occur. Again, think about what could happen if your patient falls asleep on the table and you have to work on the sacrotuberous ligament (or any sensitive area). If for whatever reason they normally wouldn’t allow someone or typically did not want to be touched in this area (even though they initially gave you consent), when that nociceptive stimulus is applied, the patient could have a behavioral or movement response without actually realizing it.
Remember that consent happens throughout the treatment and it can be taken away at any point even if it was given at the beginning. This could be an instance where a patient is actually revoking or is confused about consent because of an altered state of consciousness, and a behavioral response could be induced even though you technically did nothing wrong. This is where you want to have things documented appropriately to make sure your safety and your practice is always protected.
While I know many of the things talked about in this post might be a rare occurrence, it is possible to have these things happen. I agree that patient safety is of the utmost importance, I also believe therapist safety is just as important. This isn’t to say you should never allow a patient to sleep during a treatment, many of them love the fact that they can get a quick nap in and feel much more relaxed. What I am saying is we all need to be aware of some of the above-mentioned issues to make sure we are kept safe as well. If you’re ever unsure of someone’s reaction during a treatment, or after, make sure you document it so you always have a record to refer to…just in case the worst scenario happens and a patient reports you.