We’ve found during our training courses that one of the bottomless conversations is about massage contraindications. It’s a conversation that if not handled well can literally go on forever and even put fear in new people to this type of work, the question is, should it?
The varying lists of Massage Contraindications can feel like a tricky subject for many massage therapists. Should we massage or should we send them away? Is it really possible to actually seriously harm someone through massage? Many people simply assume that their massage therapist is trustworthy, educated and knowledgeable about their condition and that they are adhering to the principles of the Hippocratic oath – first do no harm. Many massage therapists find themselves faced with the dilemma of treating pain conditions but often without the backing of a long degree level training as enjoyed by physiotherapists, chiropractors and osteopaths. As a massage therapist we want to help – but when is it safe or not safe to treat?
So lets have a look at the prickly issue of contraindications.
Can we keep it simple?
Wouldn’t it be great if there was a simple answer to a simple question? Certainties can make us feel safe. And how simple to be given lists of conditions and guidelines for how safe or not it may be to treat with massage, right? All you have to do as a massage therapist is learn the list of contraindications, educate yourself, and then you can be sure those who request your service are protected by never giving massage for any condition that might be contraindicated. Professional associations and insurance companies feel safe because you adhere to the safe list. Surely all that paperwork protects us all. Doesn’t it?
If only, but unfortunately not.
According to Mitchell Batavia who wrote an article for the Journal of Bodywork and Movement Therapies, many of the so called current contraindications we learn as massage therapists come from sources with greatly differing lists. He states “The present study found the number of CI guidelines listed by different sources varied widely. One physical therapy source listed 3 CIs whereas another listed as many as 86” and “The number of CIs and precautions vary markedly among therapeutic massage sources”.
What about those of us who are skilled in many different modalities that all come under the heading of massage? For example, trigger point therapy, myofascial release, stretching or meridian based systems such as Hawaiian Lomi Lomi, Thai massage or Japanese Amma. These modalities have very different or in some cases no taught contraindications. The long list of contraindications developed for Swedish massage is often generalized to these massage techniques also – but with no rationale as these techniques work on very different physiological principles than Swedish massage.
By coming into contact with students from many different qualifying courses. Our experience suggests that students are taught widely varying lists of contraindications and although there is sometimes similarities, there’s no really reliable consistency between them other than what might be obvious, for example recent operations.
The same study also showed that there was no clinical evidence supporting many of the recommendations leading the author to conclude “many contraindications for massage lack a scientific basis”. Batavia found that most of the contraindications cited had no reliable evidence or research to back them up but were based on “opinion, theory or common sense more than actual data”.
It appears that many taught contraindications have not moved with the times and more recent research. For example, we have seen taught contraindications that suggest pregnant women should not be massaged, or even cancer patients. Pregnancy massage has likely been used since the beginning of time. Both pregnancy massage and oncology massage are widely used all over the world today.
Lists of contraindications also routinely neglect to mention psychological conditions and how they affect pain in the body. We have also not seen advice around the relative safety of massaging someone with a background of known severe trauma, sexual or physical abuse or a diagnosis of severe mental health problems such as schizophrenia. In our experience massage therapists are routinely likely to encounter such issues, yet are left without any relevant support of how to “first do no harm” with such people and situations. We do touch on this subject in our Heartworks Lomi Lomi Advanced Level 2 as we believe it to be essential. We also highly recommend additional learning of some skills on how to deal with this kind of situation, for example a counselling course or a modality like EFT (Emotional Freedom Technique aka Tapping). We also drive home to all our students that they would be wise to refer people on to a trained/experienced health care practitioner if at any point they feel out of their depth.
It’s interesting because contraindication lists often abdicate responsibility to a medical practitioner for deciding whether a patient should receive massage or not. Although we feel it is important to be open to and willing to establish good communication with medical professionals, we doubt whether busy GPs have the time or interest to keep up with the latest research around manual therapy and what may or may not be useful for the patient. With all due respect, this is simply not their area of expertise. It is up to us to become experts and have mature discussions with both our customers and other health care professionals about what is best for the patient based on the latest informed evidence.
A blanket contraindication list stating “don’t touch A” rarely reflects clinical reality. Both massage therapists and customers are unique. Customer X with a cancer diagnosis may be perfectly safe to massage whereas because of various medical complications, customer Y is not.
Examples of commonly taught contraindications that may need a makeover
Cancer: Over 20 years ago the general consensus was that massage therapists should never massage someone with cancer. This advice is clearly outdated and there is a great deal of excellent work being done with massage and cancer. Do an internet search on this yourself and you will see. Yes, you should definitely educate yourself about when too and when not too. Yes, definitely liaise with the patient and the medical team, but yes – you can treat if you have the competence and confidence.
Osteoporosis: Much of the advice around osteoporosis is woefully inadequate assuming the people may fracture into a million pieces if you so much as touch them. Of course we need to exercise care with pressure when working with people with known osteoporosis but this will vary from each man and woman, and the degree of progression of the condition. Many massage recommendations often verge way too far on the side of ultra caution recommending that stretches for example should not be used. This advice flies in the face of research that has found stretching to be helpful for osteoporosis. Educating yourself about the condition and your customers own susceptibility to fracture makes more sense than blanket recommendations of not treating. Many people with osteoporosis are leading normal, energetic, exercise filled lives and subjecting them to a feather light massage or refusing to touch them can deny them a valuable service.
Herniated disc: Massage therapists are often advised not to touch people with a herniated disc in the acute stage. Again there is no evidence basis for this – an appropriately informed and educated massage therapist can provide much needed pain relief in the early stages of herniated disc. Positioning, good communication and your own education about the condition are key factors but there seems no viable reason to not treat.
Pregnancy: It is still commonly taught that massage should be avoided in the first trimester although pregnancy massage experts agree there is no basis for this. The recommendation has sprung from the heightened risk of miscarriage in the first 3 months and the fear that the massage therapist will be “blamed”. Again, educating yourself and a pregnant woman about the reality can be helpful to help them make an informed choice about whether massage is for them rather than turning pregnant women away because of a myth. Remember as we said before, pregnant women have been receiving massage ever since pregnant women have existed!
Scars: Massage therapists are often advised to avoid scars for months or in some cases years after they have healed. Yet even the medical profession are recommending patients self massage scars to improve appearance and reduce the possibility of adhesions that cause even more problems. Recent research has shown fascial work to be key in improving the appearance and functionality of scars and waiting too long before receiving appropriate manual therapy work can lead to even more problems. Do an internet search and read for yourself.
So where too from here?
If we can’t always rely on our lists of contraindications given in the classroom how on earth do we keep people safe and ensure we are “doing no harm”?
This is where our motto is “If in doubt, don’t”. This means that if you don’t feel confident or competent to massage someone for example who has a serious health issue, then don’t. Then begin your own research assignment, educate yourself. Grow your knowledge base to grow your confidence and competence.
As Tracy Walton advocates with her eminently sensible “Decision Tree” approach to working with complex client conditions, the informed massage therapist should ask themselves two simple questions:
1. What is it about the medical condition that contraindicates massage?
2. What is it about massage that is contraindicated?
If both of these questions are explored and answered, a safe treatment plan can be created. In many cases, several factors such as pressure, technique, positioning, or avoiding local areas can be modified to allow you to treat safely even if someone is on the dreaded contraindication list!
So don’t throw away your contraindication list. But make sure you know why the conditions on it are contra-indicated. If they are only contra indicated for Swedish massage or have no basis in current research then you can make informed decisions accordingly. Read, attend courses, surf the internet and talk to other informed and experienced health care providers. This will keep you and your people MUCH safer than the list!
1. Contraindications for therapeutic massage: do sources agree? – Mitchell Batavia Journal of Bodywork and Movement Therapies
Volume 8, Issue 1 , Pages 48-57, January 2004
You can access the snippets of this article here: https://www.sciencedirect.com/science/article/abs/pii/S1360859203000846
2. Medical Conditions in Massage Therapy: A Decision Tree Approach (LWW Massage Therapy and Bodywork Educational Series) [Paperback]
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