Always and Never: Massage Safety Essentials

Some Essential Principles to Avoid Harm

When giving massage:

Never apply direct pressure onto the spine. You may, however, work on the muscles that run down both sides of the spine, these are known as the erector spinae muscles. (Note that during massages the hands of the giver will often run over the spine but care is taken to ensure that pressure is never applied onto the spine itself.)

Never apply direct pressure onto the back of the knee.

Never perform a stretch in a hard, fast or jerky manner, or on someone with joint hypermobility syndrome.

Never perform a Thai massage on someone who has a back problem (e.g. a slipped disk).

Never ingest a massage oil or essential oil.

Never try and learn new techniques from the Video Tutorial Notes section of this book.

Always check if the receiver is allergic to any ingredient in your oil or cream.

Always find out if the receiver has a medical contraindication or a condition that limits the massage.

Always check for contraindications and take the list of medical contraindications seriously.

Always, if in doubt about anything, seek medical advice before massage.

Always, before any massage, ensure the receiver signs a consent form, specifically confirming that they do not have any of the listed medical contraindications.

Always stop massaging and seek medical advice if any kind of problem develops.

Always perform stretches slowly and carefully and ask for feedback to avoid injury because everyone is different.

Always be cautious when using your body weight during any technique, especially during Thai massage or when massaging an elderly or infirm person, or someone with fibromyalgia.

Always be cautious when using your elbows and forearms. As a beginner, your elbows and forearms will not be very sensitive and you may cause bruising.

Always wipe up oil or cream spillages as soon as they arise to prevent yourself or someone else from slipping and falling.

Always ensure your table is at a comfortable height for you. If you are using a bed, come close to the receiver to avoid straining your back.

Always allow sufficient time for the body to recover between deep treatments (e.g. sports/deep tissue massage — 2-3 days).

Health and Safety For Massage: Medical Contraindications

Important Warnings

Medical Contraindications Medical contraindications are health conditions, symptoms or situations that mean you cannot safely massage someone at all, or must carefully restrict a massage treatment in certain ways, for example, avoiding certain areas, or avoiding certain techniques - such as deep pressure techniques, percussive techniques, or stretches.

Attached , is a document listing the medical contraindications for massage, which you can download and print out. It is strongly advised that you print out this document which features the following lists of contraindications, or keep the document to hand electronically, so that you can refer to these lists as and when you need to, because it will take time and be quite difficult to memorize and remember these with 100% accuracy - which is is the degree of accuracy that you need.

'Massage Professional' has been designed to be suitable for non-professionals and the following lists and warnings reflect this.

Certified practitioners may have the training to work in some of these circumstances with medical permission. These warnings should be taken seriously; in certain cases, irresponsible practice can be fatal.

Remember that while massage is skill of healing, to help someone, you need to ensure that, loyal to the Hippocratic Oath sworn by ancient and modern doctors, you must: 'first, do not harm'.

Beyond helping to ensure you do not accidentally harm someone, paying close attention to contraindications is in your own best interests as well. This helps to protect you, the massage giver or therapist, from:
1) Potential litigation
2) Moral distress and doubt as to whether your treatment could have contributed to a client's deterioration or relapse
3) Spreading infections.

Total Contraindications:

If a potential client or massage receiver has any of the following 'total contraindications', it means you must not perform any massage techniques on them.

Some therapists might have undergone supervised training to be able to give adapted treatments to clients who have some of these conditions, but as an online course we cannot safely or responsibly provide this. As such, if you are already a professional massage therapist, you may find our lists of total contraindications are longer than what you expect - this is very much deliberate.

Ignoring contraindications can be dangerous or even fatal.

Total contraindications may be considered 'medical permission conditions' in some cases, but it is extremely important that the client's doctor is specifically consulted prior to treatment. The doctor must be informed exactly what the treatment would involve (e.g. will there be stretches? will there only be soft pressure? which body parts will be massaged) and the doctor must be informed that you have received only general training in massage and not specialist training. Permission for a treatment, complete with any necessary restrictions (e.g. avoid the legs; don't do any stretches, etc) should be given in writing, and keep a record of this medical advice.

The following are total contraindications:

After recent operations (increased risk of blood clot; wait 12 months or seek medical advice)
Ankylosing spondylitis
Bell’s palsy
Bone diseases (e.g. osteomalacia, rickets, Paget's disease)
Brain haemorrhage or tumor / tumour
Cardiovascular conditions (much depends on the condition and other factors; consider a total contraindication or an important medical permission contraindication - high blood pressure, for example, should be under control before any treatment, and massages must be restricted - this is discussed in detail later in this section)
Cervical spondylosis
Head lice
Hematoma / haematoma
Hepatitis (acute stage, then seek written medical permission)
Diarrhea / diarrhoea
Fever
Fungal infections (if large area of the body is affected)
Hemophilia / haemophilia
Infectious diseases (e.g. common cold, flu, meningitis)
Intoxication (alcohol or recreational drugs - can distort sensory awareness)
Impetigo (if not medically treated yet or sores still weeping)
Kidney infections, stones or failure
Meningitis
Migraine (during an episode)
Osteoporosis
Paget's disease
Pregnancy
Scabies
Vomiting
Whiplash

Medical Permission Conditions:

These are potentially dangerous conditions. You need medical permission to give massages to these receivers, and to follow the doctor's specific written advice very carefully.

Consider these contraindications the same as total contraindications unless:

1) The client's doctor has provided written permission for the client to have the treatment.
2) The named doctor knows what qualifications and experience you have, e.g. whether you have completed online courses only.

If the doctor gives specific instructions and you do not fully understand them, do not massage until these instructions have been 100% clarified and understood. If in doubt, do not massage.

The following are medical permission conditions:

Arthritis (e.g. osteoarthritis, rheumatoid arthritis)
Cancer (instructions vary according to type of cancer and treatment received that may prohibit or restrict treatments, seek specific medical advice from the client's doctor, ensuring the doctor knows you are not trained in oncology massage - despite lack of clear evidence that massage techniques can spread metastatic cancer, the whole affected body part should be considered a local contraindication, so avoid e.g. limb, torso, head - as relevant)
Cardiovascular conditions (depends on the condition and other factors; can be a Total Contraindication)
Cirrhosis of liver (if advanced)
Edema / oedema
Emphysema / COPD
Epilepsy
Diabetes (see further information provided)
Gastric ulcers
Headaches (when severe and unexplained you must not perform any massage - medical attention is needed)
Inflamed nerve
Lower back pain / lumbago (refer to osteopath or doctor)
Medical condition already being treated
Multiple sclerosis (contraindicated during acute episodes / attacks / relapses; seek doctor's advice for massage during remission)
Muscular disorders (e.g. muscular dystrophy, myasthenia gravis)
Neck - any condition
Nervous system dysfunction (e.g. muscular sclerosis, Parkinson’s disease, motor neurone disease)
Neurological conditions (e.g. dementia, severe autism, severe learning difficulties)
Parkinson's disease
Postural deformities
Respiratory infections (except chronic sinusitis)
Rheumatism
Skin diseases
Slipped disk / disc (see below)
Spastic conditions
Stroke (must not be recent, must be fully recovered, otherwise dangerous)
Swelling in a particular area (localized)
Transient ischemic attack / Transient ischaemic attack (ITA)
Tuberculosis
Undiagnosed pain, lumps or bumps
Unlisted medical conditions
When taking prescribed medication

Local Contraindications:

Local contraindications are conditions that restrict massage treatments.

Do not apply any massage techniques, include pressure or stretches, to areas of the body affected by:

Acne (depending on severity and degree of inflammation)
After a heavy meal (avoid the abdomen)
Arthritis
Athlete's foot
Bedsores
Blisters
Boils and carbuncles
Bursitis (acute, seek medical advice if unsure)
Cold sores
Cramps (acute, severe; massage can help long-term spasms)
Endometriosis (avoid the abdomen)
Fibrosis
Fractures (wait until fully healed, recovery time will vary - seek medical advice)
Fungal infections (if only a small area of the body is affected, otherwise consider a total contraindication)
Gall stones (avoid the abdomen when painful)
Goitre (avoid the neck)
Gout (avoid acute flare-ups)
Hernia (avoid the abdomen)
Hormonal implants
Impetigo (must be after treatment, in recovery stage)
Injuries (acute or undiagnosed)
Menstruation (abdomen, lower back, thighs can be sensitive — apply with softer touch)
Pelvis inflammatory infection (avoid the abdomen)
Prolapsed uterus / vagina (avoid the abdomen)
Recent abrasions, bruises, cuts, swelling, areas of inflammation
Scar tissue (recovery times will vary and can be long — seek medical advice)
Shin splints (acute or severe; severe cases need medical attention, but mild cases may benefit from gentle massage)
Shingles (usually ribs, sometimes face)
Sprains
Strains ('pulled muscle')
Sunburn
Tendonitis (acute stage)
Trigeminal neuralgia (when acute, avoid the face)
Varicose veins (avoid area around these, as well as area directly below these - as a beginner or if in doubt, leave more distance, not less)
Warts
Further Essential Warnings For Massage

Hypertension (high blood pressure)

Massage therapists are often taught that high blood pressure is a total contraindication for massage because the blood vessels may be more delicate from the chronic state of trauma caused by high blood pressure. As such, the application of pressure could potentially harm these fragile blood vessels. However, recent studies have shown that gentle massage often seems to help normalize high blood pressure by boosting the circulation around the body. According to this evidence, gentle massage could be beneficial.

So, what should a therapist do if a client has high blood pressure? Massage or not massage? Approximately one in three adults in the USA have high blood pressure, so this is a very important consideration.

It should be okay to massage clients who have high blood pressure on the condition that their blood pressure is under control and being managed appropriately by their doctor. To reduce risk of harming the client, as well as potential lawsuits, you should get medical permission - ask the client to obtain this over a brief telephone conversation, before they actually meet with you.

Additionally, for these clients, stick to gentle massage disciplines, such as Swedish or Hawaiian, avoiding deeper, more stimulating treatments, such as hot stone, deep tissue or Thai.

If the client has another type of cardiovascular condition, once again, instruct them to consult with their doctor before any treatments. A small amount of hassle or delay is much better than hurting someone.

Joint hypermobility syndrome

Do not apply stretches on people who have joint hypermobility syndrome as you may cause harm without them realizing.

Asthma

It is safest to avoid using any scented or perfumed oils with asthma sufferers. Warn them exactly what is in the oil(s) you are going to use and ensure they are okay with it.

Lying flat can make breathing more difficult for some people with asthma. They may breathe easiest when their upper body is supported, or when they are in the side position, so you can discuss these possibilities with them.

Cancer

Instructions vary according to type of cancer and treatment received that may prohibit or restrict treatments, seek specific medical advice from the client's doctor, ensuring the doctor knows you are not trained in oncology massage. Despite lack of clear evidence that massage techniques can spread metastatic cancer, the whole affected body part should be considered a local contraindication, so avoid e.g. limb, torso, head - as relevant.

Diabetes

Diabetics often have fragile blood vessels, as well as areas of thin skin, and other skin conditions.

As such, to ensure you do not hurt someone with diabetes, it is definitely essential to get a doctor's written permission for the receiver, ensuring they know your own particular skill level.

To give someone with diabetes a massage, to avoid causing damage, their muscle tissue must be healthy and their circulation must be good. Only these areas can be massaged - all areas with tissue damage, vascular damage and thinning skin should be avoided.

Skin Disorders that are fine to massage

These are not contraindications, you can massage them without worrying:

1) Vitiligo 2) Skin tags - but be cautious not to break with with vigorous movements 3) Liver spots / age spots.

Acquired Immune Deficiency Syndrome (AIDS)

Only use gentle strokes if the person is feeling unwell.

For your own protection:

1) Avoid open cuts or weeping skin on the receiver 2) Cover-up any cuts on your own skin, and wash any towels used.

Colitis, Crohn's disease, diverticulitis, ulcers of the stomach or duodenum

For these conditions, only perform very gentle massage on the abdomen.

Allergies

Ensure the receiver isn't allergic to any oil you plan to use before the treatment starts, or anaphylactic shock and death can result.

Spinal curvature:

If the receiver has abnormal spinal curvature, massage, cautiously applied, can help relieve muscle tension and enhance mobility. However, ensure the receiver is comfortable, using pillows/cushions to provide support where they might need it.

Hiatus hernia, indigestion and heart burn

The massage receiver may not be comfortable lying down. Some people may wish to be massage sitting upright while others may prefer to have their upper body or head raised with cushions or pillows.

Recommend that massages should take place when the receiver has an empty stomach to help prevent any pain or discomfort.

Stretch marks

Do not apply deep massage techniques to stretch marks.

Inflammatory conditions you may encounter

These might include: ankle tendon injuries, frozen shoulder, deltoid bursitis, housemaid's knee and tennis elbow. Note that all these conditions should be considered local contraindications - do not massage inflamed areas of the body.

Massage of the muscles of the surrounding areas may, however, be beneficial.

Neurological conditions

Massage therapists need to be aware if a prospective massage receiver has any sort of neurological condition that either affects their ability to understand what is happening, or to communicate with the therapist effectively. If trying to treat someone with severe learning difficulties, dementia or autism, they need to ensure that the intended treatment is fully understood. Guidance from a person's carers may be necessary before proceeding with any treatment and non-verbal communication skills and strategies may make the process easier.

Thin skin

You should not perform stretches or percussive movements on areas of thin skin as this can causing tearing. Only very gentle massage movements should be performed.

Osteoporosis

This is an example of a condition which makes a receiver much more fragile, and should be considered a total contraindication unless you have received professional massage qualifications in person - not just online sources.

If you are confident that you are sufficiently skilled and experienced to treat someone with osteoporosis, then this condition should be considered a 'medical permission condition', requiring the client's doctor to put consent and guidance into writing. This consent should acknowledge your skill level and particular qualifications, and if certain areas of the body are to be avoided, it should state this.

Once a doctor's permission has been received, certain areas of the body may need to be considered local contraindications and avoided.

Any massage on someone with osteoporosis, needs to be:

1) Very gentle
2) Avoid all stretches and joint manipulations
3) Avoid all percussive strokes
4) Integrate extra cushions and supports for the receiver, ensuring they are always well-supported and comfortable
5) Take extra care helping clients onto and off tables
6) Integrate extra caution with all techniques, starting slowly and very softly, and continuously asking for feedback.

Elderly Clients

Be aware that elderly clients may have osteoporosis without realizing it yet. Also be aware that osteoporosis is most common in elderly women.

As such, massage with extra caution for elderly receivers; start slowly and softly, only increase your pressure gradually with elderly receivers. Consider avoiding all stretches and joint manipulations - if they insist that it is all right, then apply these with extra caution, slowly and gently, while asking for feedback.

Fibromyalgia

Be cautious when treating people with fibromyalgia, as they can be extremely sensitive to pain. Ensure not to massage them too hard or too frequently.

Fibrositis and Muscular Rheumatism

Any massage needs to be applied carefully so that you do not cause irritation.

Pregnancy

Massaging a pregnant woman requires special training and specific certification in pregnancy massage. As such, you need to consider this a total contraindication for treatment, and refer the receiver to someone who is sufficiently qualified, unless you yourself have the necessary credentials and insurance in your country.

Common prescription medications to watch out for

The following is a list of common prescribed drugs that can cause side effects which can affect a massage treatment.

As such, you may want to watch out for the following - but please note, these are just common examples you might come across – not a complete list:

Antiarrhythmics
Antihypertensives (e.g. sympatholytics, ACE-inhibitors, and vasodilators)
Beta blockers
Calcium channel blockers (CCBs)
Diuretics
Dopaminergics
Muscle relaxants
Narcotic pain relievers.

Myasthenia gravis and muscular dystrophy

Gentle massage can help alleviate muscle spasm and pain.

The client may be experiencing a loss of sensation, so apply pressure gently and carefully; avoid stretches and joint manipulations, or be very slow, gentle and cautious when performing these.

Myalgic encephalitis (ME)

People with ME may be experience heightened sensitivity, so you must be careful when performing any massage techniques.

Potential energy work consideration with menstruation and massage:

Thai massage therapists generally teach students not to massage the abdomen during the first few days of menstruation. This is, however, mainly to prevent the massage giver from absorbing an intense energy from the receiver.

While most Western people probably will not worry about this, some holistic therapists may like to bear this energy-related consideration in mind.

Epilepsy and energy work

After getting permission from an epileptic client's doctor to perform a massage, massage therapists who also do energy work are advised not to do energy work on the receiver's head.