The subject of contraindications is a tricky one for most massage therapists. When should we treat? When should we leave well alone? Is it possible to actually seriously harm someone through massage? Likewise for consumers it is important to know that your massage therapist is trustworthy, educated and knowledgeable about your condition and is certainly operating under the principles of the Hippocratic oath – first do no harm. This is increasingly important as many massage therapists in the UK 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. We desperately want to help – but when is it safe or not safe to treat?
So lets have a look at the thorny issue of contraindications – to treat or not to treat that is the question!
Most of us want a simple answer to a simple question in this world and certainties make us feel safe. This is the thinking behind giving practitioners lists of conditions with guidelines for how safe or not it may be to treat with massage. Simple, right? Massage therapists learn the list of contraindications, educate themselves, and make sure clients are protected by never giving massage for any condition that might be contraindicated. Professional associations and insurance companies feel safe because we have a list. You know – paperwork protects us. Doesn’t it?
The matter is way more complex than this and here’s why:
- Many of the contraindications we learn as massage therapists were developed for Swedish massage only. 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 Thai massage or Amma. These modalities have very different or in some case 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.
- As a teacher of advanced techniques I come into contact with students from many different qualifying courses. Personal experience suggests that students are taught widely varying lists of contraindications and there is no reliable consistency between them.
- Even more disturbingly a study by Mitchell Batavia in the Journal of Bodywork and Movement Therapies (1) showed that “Sources markedly varied regarding what conditions were considered contraindicated for massage”. One physical therapy source listed 3 contraindications for therapeutic massage whereas another listed as many as 86
- The same study also showed that there was no clinical evidence supporting many of the recommendationsleading 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”
- Many taught contraindications have not moved with the times and the research. For example, I have seen taught contraindications that suggest scars should not be massaged for up to 2 years! Even surgeons recognize the importance of massage in producing “functional scars” and self -massage is routinely recommended to improve appearance of scars post surgery. Similarly I have seen recommendations not to massage tendonitis “in the inflammatory stage. Although tendinitis is still a very common diagnosis, research increasingly documents that what is thought to be tendinitis is usually tendinosis. Tendonosis is breakdown of collagen fibres and no inflammation is involved. The fundamental assumption about why tendonitis should not be massaged in the early stages is incorrect yet this information is still being routinely taught
- Lists of contraindications also routinely neglect any recommendations around psychological conditions. I have NEVER seen any 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 my 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 clients.
- Contraindication lists often abdicate responsibility to a medical practitioner for deciding whether a patient should receive massage or not. Although it is vitally important to establish good communication with medical professionals I 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. This is simply not their area of expertise as confirmed by several GPs who are my clients! It is up to us to become experts and have mature discussions with medical professionals about what is best for the patient based on the latest informed evidence.
- The blanket contraindication list “don’t touch X” rarely reflects clinical reality. Both massage therapists and clients are unique. Client X with a cancer diagnosis may be perfectly safe to massage whereas because of various medical complications, Client Y is not.
Examples of commonly taught contraindications that may need a makeover
Cancer: 20 years ago we were all taught that we should never massage someone with cancer. This advice is totally outdated and there is a great deal of excellent work being done with massage and cancer. Yes you should educate yourself about the whys and wherefores. Yes you should liaise with the medical team. But yes – you can treat.
Osteoporosis: Much of the advice around osteoporosis is woefully inadequate assuming the client may fracture into a million pieces if you so much as look at them. Of course we need to exercise care with pressure when working with clients with known osteoporosis but this will vary from client to client 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 clients own susceptibility to fracture makes more sense than blanket recommendations of not treating. Many clients with osteoporosis are leading normal, energetic, exercise filled lives and subjecting them to a feather light massage or refusing to touch can deny them a valuable service.
Herniated disc: Massage therapists are often advised not to touch clients 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, client 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 your client about the reality can be helpful to help the client make an informed choice about whether massage is for them rather than turning pregnant women away because of a myth.
Scars: As mentioned above, 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.
Towards a more logical approach – critical thinking and developing expertise
So if we can’t always rely on our lists of contraindications given in the classroom how on earth do we keep our clients safe and ensure we are “doing no harm”
The answer lies in our own education as massage therapists. Most massage therapists (particularly in the UK where the qualifying levels are low) are ill informed about different pathologies. Keeping up with the current research and really understanding the physiological basis of client presenting conditions can help us make informed decisions about treatment – which techniques may be safe to use and which may be locally contra-indicated. Swedish massage is only one tool in the tool box and there are usually many other massage techniques that can be appropriately used. For example, Swedish massage is often contraindicated for clients with cardiovascular problems as it aims to boost circulation. However there is no reason meridian or certain fascia based techniques shouldn’t be used.
As Tracey Walton advocates with her eminently sensible “Decision Tree” approach (2) 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?
Both of these questions must be explored and answering them will enable you to draw up a safe treatment plan for your client. 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 contra indication list!
So don’t throw away your contraindication list. But make sure you understand 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. Go on courses, surf the web and talk to other informed medical providers. This will keep you and your client MUCH safer than the list!
To watch the JING TV! episode about contraindications please CLICK HERE
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
2. Medical Conditions in Massage Therapy: A Decision Tree Approach (LWW Massage Therapy and Bodywork Educational Series) [Paperback]
About Rachel Fairweather and the Jing Institute
Rachel Fairweather is co-founder and director of The Jing Institute of Advanced Massage Training – an organisation dedicated to excellence in all aspects of postgraduate massage training. We are dedicated to helping massage therapists have the lifestyle and business you deserve. Based in Brighton, we offer courses around the country including London and Edinburgh. Our courses include longer qualifications in advanced massage including our revolutionary BTEC Level 6 (degree level) in Advanced Clinical and Sports massage and 1-2 day CPD courses in Marketing, Hot Stone Fusion, trigger point, myofascial release, stretching, pregnancy, on site, living anatomy and many others.
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