Foundations

110 Section 4 Making initial contact with the client
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observed rather than make assumptions as to the cli-

Box 11.2 Recording the consultation ent’s condition or allude to a diagnosis. For example,
‘the client appears to have suffered a stroke’ would be
l Name best reported as follows:
l Date of consultation l the client’s speech is slurred
l Current medication l the client has motor and sensory impairment on the
l Reasons for treatment right-hand side.
l Presenting signs and symptoms
l Contraindications and precautions Time

l Need for referral
When a therapist works in a busy practice it may be
l Overall health
difficult to recall accurate details of clients and any pre-
l Treatment plan vious treatments. To assist with recall, the client record
l Consent may be used. Once a treatment has been performed
l Treatment findings the therapist should document all details in the client
l Evaluation of treatment record immediately after the consultation or as soon as
possible after the treatment has ceased. For accuracy
of record keeping it is recommended that the record-
Guidelines for good record ing of the client’s needs and clinical presentation takes
keeping place during the interview, and that the treatment plan
It is vital that the massage therapist maintain accurate, be recorded prior to the application of any treatment.
thorough and detailed client records. As no professional Once the treatment has concluded, and the client is
body, insurance agency or government department cur- returning to a state of dress, the treatment procedures
rently stipulate guidelines as to how to correctly format and the evaluation should be recorded. All entries
or document massage therapy records, the following should be prefaced with the date, time and signature of
recommendations are suggested to assist the thera- the therapist.
pist to maintain accurate, thorough and detailed client
records. Legibility
All contents of the client record must be legible. Records
Accurate, concise and comprehensive that are unable to be read or understood by others may
records lead to incorrect interpretation that may result in mis-
A massage therapist must ensure that the information takes being made. If decisions are affected by illegible
recorded on the client record is accurate and compre- writing it is essential that the massage therapist checks
hensive, yet brief. Everything that is medically relevant with the source before continuing the treatment.
should be concisely included. The accuracy of the record
is imperative. For example, there is a marked difference Medical terminology
between stating the ‘client has low back pain’ and ‘cli- The massage therapist should have a thorough under-
ent complains of low back pain’. The first statement is standing of appropriate medical terminology. Using
definitive whereas the second statement describes the medical terminology incorrectly may prove to be
view of the client who may instead have buttock or pel- ambiguous or confusing to another health practitioner.
vic pain but refers to it as low back pain. The therapist
should be sure to include the client’s informed consent Abbreviations and symbols
or refusal of any part of the treatment. Abbreviations and symbols are often used as a short-
The documentation must be able to withstand inde- hand form of documenting information that is used to
pendent scrutiny. This is important as the record or part save time and space. Abbreviations and symbols are
of the record may be passed onto other health care pro- commonly used throughout the health professions and
fessionals or be subpoenaed in cases of legal action. As reflect a common scientific language. It is important
such, the therapist should keep in mind that the writ- that the therapist adopt the use of such abbreviations as
ten comments contained in the client’s record, includ- the use of any uncommon abbreviations may confuse
ing those referring to the type of care given, the client’s other health practitioners accessing client records. To
condition, their observed demeanour or perceived state enable the massage therapist and any other health pro-
of mind, may be used at a later time as evidence in an fessional with approved access to client files to inter-
action for negligence, malpractice or the like. The thera- pret all records it is recommended a key to abbreviated
pist must ensure the record is an honest and thorough terms be available and located within proximity to the
account of all interactions with the client. file; for example, on the front of a filing cabinet that
stores records. Common abbreviations that are particu-
Objectivity larly useful to the massage profession can be found in
copyright law.
All language used within a written report should be Appendix 2.

objective and definitive. The massage therapist should A summary of guidelines for good record keeping
ensure all words used in the report describe what was appears in Box 11.3.
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11 The health assessment process 111
record keeping were based on recommendations made

Box 11.3 Guidelines for good record keeping through common law cases. The information provided
below represents privacy and health record Acts and
l Record client’s name. Check spelling is correct. Codes developed in Australia and New Zealand over
Date of birth can be a further identifier. the last decade.
l Write accurately, concisely and comprehensively.
l Write objectively. Australia

l Record during the consultation or immediately
The Privacy Act 1988 was amended in 2000 to cover
after treatment. comprehensive privacy law for private organisations
l Begin each new entry with the date, time and
including health service providers in Australia. This
your signature. Act provides privacy protection for clients as well
l Write legibly.
as providing scope for health professionals to share
l Use appropriate medical terminology. information. The amendment to the Act provides 10
l Use only commonly accepted abbreviations, National Privacy Principles (NPP), which establish the
symbols and terms. minimum standard for the private health care sector
l Use ink. (see Figure 11.1)
l Cross through a mistake with a single line, and At present Victoria and New South Wales (NSW)
initial the change. are the only states to have a comprehensive data protec-
l Never erase or use white-out. tion regime. The Victorian state government passed the
l If blank spaces exist, draw a line through them Health Records Act in 2001 and the NSW state govern-
so that other information cannot be added by ment passed the Health Records and Information Pri-
others who may have access to the file. vacy Act in 2002. Like the Commonwealth’s Privacy
(Source: adapted from Forrester & Griffiths 2010; Act 2000, the Victorian Health Records Act 2001 and
Van Leuven 2000; Staunton & Chiarella 2003) the NSW Health Records and Information Privacy Act
2002 establishes standards for the handling of health
information. This Act describes Health Privacy Prin-
ciples (HPP) similar to those of the Commonwealth’s
Errors
Privacy Act. In the Victorian Health Records Act, Prin-
ciple 4 of the HPP discusses data security and data
As client reports are legal documents they must be writ- retention. It states that a health professional must keep
ten in ink. If a therapist makes an error on the record a client information for a period of no less than seven
correction should be made by simply placing a single years following the last occasion on which a health ser-
line through the incorrect information. The use of cor- vice was provided to the client, or if the client was a
rection fluid or total obliteration of the incorrect entry minor (under 18 years of age) at the time of the last
may suggest to a third party that the massage therapist consultation, then all records must be kept until the
may have something they wish to conceal. Writing over child reaches 25 years of age. Similarly, this is also dis-
or altering the mistaken words may cause confusion and cussed in Part 4, Division 2 of the NSW Health Records
misunderstanding and should be avoided. and Information Privacy Act 2002 under Retention of
Health Information.
Recording using ASTER The Australian Capital Territory passed the Health
It is unfortunate that at times a therapist may consider Records (Access & Privacy) Act in 1997. It is based on
the recording of information to be a cumbersome and the NPP and is intended to allow patients access to their
time-consuming task. To assist in making this necessary own medical records in the public and private sectors.
task easier the massage therapist would be wise to adopt The Northern Territory Government is currently
a recording system such as the ASTER approach. Such developing privacy legislation for use in the public
an approach also ensures the therapist maintains accu- sector.
rate, thorough, consistent and detailed client records. The other states have issued instructions requiring
Three ASTER charts are illustrated in Appendix 5. broad compliance by government agencies with the
As each ASTER chart has limited space for informa- NPP but appear to be moving towards separate privacy
tion to be documented the therapist should adopt the legislation covering public or private sector bodies. In
abbreviation system previously described and located in regard to retention of client records it is advisable that
Appendix 3. An example of a documented case using all massage therapists follow similar requirements to
the abbreviations described is provided in Appendix 6. those for Victoria and NSW.
Government legislation New Zealand

and record keeping The New Zealand Privacy Act 1993 applies to the han-
copyright law.
All client records are subject to certain legal require- dling of all personal information collected or held by
ments. These legal requirements were formed either government agencies and most businesses including
through government legislation or common law. Many health professionals. The legislation identifies ‘personal
of the recommendations under guidelines for good information’ as information about an identifiable living
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1. COLLECTION
This section sets out the health professional’s requirements for collecting information. Only necessary personal
information can be collected by lawful and fair means. Before collecting the individual’s personal information
the health professional must explain the purpose for collecting information and any law that requires specific
information to be collected, as well as gaining client consent before collecting the information.
2. USE AND DISCLOSURE

This section prohibits the use or disclosure of personal information about an individual for any purpose other
than the primary reason for collecting the data, unless: the client has consented to it; the information is not of a
sensitive nature; the information is health information and is necessary for research relevant to public health or
safety; to prevent serious and imminent threat to the client’s life, health or safety or to public health and safety;
or if it is required or authorised by or under law.
3. DATA QUALITY
The health professional must take reasonable steps to ensure the personal information collected, used or
disclosed is accurate, complete and up to date.
4. DATA SECURITY
The health professional must ensure reasonable steps are taken to protect the client’s personal information from
misuse and loss, or from unauthorised access, modification or disclosure.
5. OPENNESS
This section requires the health professional to be open about what client records are held, why and how they
are kept, how they are collected and how they are used. This section also requires the health professional to
develop a policy document on how client information is managed. This document must be made available to all
who ask.
6. ACCESS AND CORRECTION

This section gives the client the right to access their personal records and a right to have the information corrected
that is incomplete or out of date.
7. IDENTIFIERS
This section limits the use of identifiers (a number assigned by an organisation to identify the client, such as a
Medicare number or private health insurance number) by a health professional to the purposes for which they
were issued. That is, these identifiers cannot be used as client identification codes.
8. ANONYMITY
Where lawful and practicable, the client has the option of not identifying themselves when presenting at the
clinic.
9. TRANSBORDER DATA FLOWS

This section sets out the terms for transferring client information out of Australia.
10. SENSITIVE INFORMATION

The health professional may collect sensitive information from the client only when the client has consented or
is required to by law.
(National Privacy Principles adapted from the Privacy Amendment (Private Sector) Act 2000.
Online. Available: http://www.privacy.gov.au/publications/npps01.html)
Figure 11.1 The National Privacy Principles
person, irrespective of whether it is on a computer or 2000. The Act allows the Privacy Commissioner to
a paper file. establish Codes of Practice that apply the IPP to spe-
copyright law.
The legislation is based on 12 Information Privacy cific activities and industries or to allow exemptions. In
Principles (IPP), which are similar to the Australian 1994 the commissioner established the Health Informa-
NPP in the Privacy Amendment (Private Sector) Act tion Privacy Code which covers the Health Information
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11 The health assessment process 113
rivacy Rules. For further information regarding

P 2 Erica is a 19 year-old girl who is undergoing
New Zealand’s Health Information Privacy Code 1994 psychiatric treatment for anorexia nervosa. She has
and its most recent updates go to: never had a massage before and has been referred
http://www.privacy.org.nz/health-information- to you by her psychiatrist. She is currently on anti-
privacy-code/ depressant medication and feels nervous about
receiving a massage.
CONCLUSION (a) How might massage benefit Erica?
The ASTER system of charting can form the backbone (b) What concerns might she have that you need to
of consistent, professional and comprehensive consul- be aware of?
tations. Good record keeping benefits both the client (c) What modifications would you make to provide
and the therapist and accurate and up-to-date records a safe and effective massage?
help a therapist to recall quickly all relevant details of (d) Complete an ASTER form using correct
an individual client, assisting them to deliver the most abbreviations to record a theoretical massage
appropriate treatment and to be alert to health changes treatment you have performed on Erica.
over time. For any massage therapist in professional
practice, keeping accurate and up-to-date client records Further reading
is an essential part of every practice. Forrester K, Griffiths D 2010 Essentials of Law for
Health Professionals. (3rd edn). Elsevier, Sydney
Questions and activities Fryer G 2001 Abbreviations for use in osteopathic case
1 Your client, Nancy, is suffering from neck pain notes. Journal of Osteopathic Medicine, 4(1):21–4
and stiffness. The right side is mostly affected Sloane SB 1997 Medical Abbreviations and Eponyms
and is accompanied with restriction in movement. (2nd edn). Mosby, St Louis
Headaches occur frequently for Nancy and she Thompson DL 2002 Hands Heal: Communication,
attributes this to stress and tension that builds up Documentation, and Insurance Billing for Manual
throughout her working day in front of a computer. Therapists (2nd edn). Lippincott Williams & Wilkins,
She enjoys regular massage to ease the build up Baltimore
of tension in her neck and to reduce her levels of
stress.On her health history form Nancy has noted References
that she has Type I diabetes and takes insulin Forrester K, Griffiths D 2010 Essentials of Law for Health
injections to regulate her blood sugar levels. Nancy Professionals. (3rd edn). Elsevier, Sydney
takes Panadol™ (paracetamol) for her headaches Privacy Amendment (Private Sector) Act 2000. Online.
when needed and uses a hot pack to ease the tension Available: http://www.privacy.gov.au/publications/
at the end of a working day. npps01.html (accessed 9 August 2009)
(a) Nancy is coming to you for massage for relief of Rattray FS, Ludwig LM 2000 Clinical Massage Therapy:
Understanding, Assessing and Treating Over 70
tension in her neck and back. You are seeing her
Conditions. Talus Inc, Toronto
for the first time and wish to assess her needs
Staunton P, Chiarella B 2003 Nursing and the Law (5th
thoroughly in this first meeting. What questions edn). Churchill Livingstone, Sydney
would you ask Nancy to gain information about —— 2008 Nursing and the Law (6th edn). Churchill
her presenting complaint? Livingstone, Sydney
(b) You are not familiar with the condition of Thompson DL 2002 Hands Heal: Communication,
diabetes and unsure about the impact massage Documentation, and Insurance Billing for Manual
will have. What questions will you ask Nancy Therapists (2nd edn). Lippincott Williams & Wilkins,
to gain enough insight to perform a safe and Baltimore
effective massage? Tuchtan CC, Tuchtan VM 2000 Theory in Practice: Modern
(c) Are there contraindications or precautions to Soft Tissue Techniques. Self- published, Melbourne
this massage? If so, list them. Van Leuven K 2000 Clinical Companion: Fundamentals
(d) You have gathered all the appropriate information of Nursing. Prentice-Hall Health, New Jersey
from your client. What treatment plan would
you recommend for a one-hour massage?
(e) How would you record all this information on
an ASTER form?
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12
precautions and safe
practice for massage
Jan Douglass chapter
LEARNING OUTCOMES
l Develop an understanding of the principles required for the safe application of massage
therapies
l Assess each client to determine whether they can be safely treated within the scope of
practice of the therapist
l Recognise and locate anatomical structures which may be endangered under pressure
l Identify conditions which may be absolutely contraindicated or outside the scope of practice
of massage therapy
l Safely treat relatively contraindicated conditions
l Identify situations in which referral to other health care professionals is necessary
INTRODUCTION together an understanding of the physiological effects of

Bodies are by nature complex and the unique combina- massage, knowledge of the current health status of the
tion of health, fitness, lifestyle, genetics and injury that individual client and an awareness of any potential dan-
presents in each client is potentially limitless. Although gers when designing the treatment plan.
therapeutic massage does not generally employ particu-
larly invasive techniques, there is always a risk that a PRINCIPLES
client will experience an adverse reaction to the mas- Safe and effective treatment is achieved when the
sage or that the therapist may inadvertently cause injury principles of natural medicine as described in Chap-
with an inappropriate application of technique. Under- ter 1 are observed. In particular, the therapist should
standing how to perform an effective massage without consider the ‘whole person’ and aim ‘to do no harm’.
causing any harm to the client is fundamental to main- Through research, ongoing assessment and monitor-
taining a successful massage practice. ing of the client and the ability to be flexible and cre-
Any treatment benefit also carries the potential for ative when responding to client feedback the therapist
harm. This harm may occur where excess pressure will be well prepared in achieving this outcome (see
could damage vulnerable structures or disrupt normal Figure 12.1).
function, or through physiological changes occurring
locally or systemically. The massage therapist needs
enough understanding of these processes to avoid treat-
Research
ments which may produce undesirable side effects or be
dangerous to individual clients.
The current health status of the client including any Assessment Monitoring
diagnosed, undiagnosed or past medical conditions, sur-
gical history and any recent or past injuries must also Client
be considered. It is the responsibility of the massage
therapist to be familiar with the pathophysiology of any
medically diagnosed condition of the client and to take
this into account during assessment and treatment. Action
By connecting the physiological effects of treat-
ment with the presenting history of the client the thera-
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pist is able to inform the client which symptoms can Figure 12.1 A client-based model showing the interac-
or cannot be alleviated and any potential side effects of tion between research, assessment and monitoring
the treatment. This chapter demonstrates how to draw which determine the actions of the therapist
115
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Research Action
Good training will teach the effects of individual Responding quickly and appropriately to any adverse
modalities on body structures and systems and clinical effect of the massage will help to maintain client con-
experience develops this knowledge further. Taking a fidence in the therapist and avert unnecessary negative
thorough history of each client, updating this at every outcomes. This may be as simple as reducing the pres-
session and noting any responses to previous treatment sure or adapting the technique in some way. In rare
will guide the therapist in choosing appropriate treat- cases the massage cannot be performed at all. In any
ment modalities and pressures. uncertain circumstance it is better to err on the side of
caution and ensure the safety of the client than to con-
Assessment tinue with a potentially harmful treatment.
Clients are assessed on a session-by-session basis for
their suitability to receive specific techniques keep- INDICATIONS AND SCOPE
ing in mind that the health and fitness of an individual OF PRACTICE
can fluctuate from day to day. This includes a visual Massage has a long history and has appeared in many
check of any skin conditions that may be present and forms (see Chapter 2). Today popularity of massage and
careful palpation to determine the correct pressure other natural therapies means that a diverse range of
for damaged tissue or to identify areas of numbness. modalities are studied and practiced, and yet the ulti-
Any feedback about reactions experienced after pre- mate aims of relaxation and the general health benefits
vious treatments should be recorded and taken into of massage remain relatively unchanged. To safely con-
consideration. tinue this age-old tradition without fear of harm to the
client the modern massage therapist must first under-
Monitoring stand the limitations of the therapies they perform.
Massage therapists must continually monitor each cli- Each bodywork modality approaches healing in a
ent during and after the massage and note or act upon different way and each carries a range of indications
any adverse effects that may be experienced as a result for which the techniques are known to be suitable and
of the treatment. Keeping a check on the level of com- beneficial. The therapist must make sure they are aware
fort of the client during and after the treatment enables of the physiological effects of each modality they offer.
the therapist to anticipate any potential problems. For Table 12.1 shows the usual physiological effects of the
example, a person with hypotension, anaemia or bal- massage strokes used commonly in Swedish massage.
ance problems should be assisted to come into an At the initial consultation and all subsequent
upright position after the completion of the massage, appointments the massage therapist ascertains the cur-
given water and checked for clear responsiveness before rent health status of the client and clearly defines the rea-
the therapist leaves the room. son for seeking treatment. This combination of clinical
Table 12.1 Common physiological effects of massage
Technique Effect
Stroking Stimulation of superficial blood and lymph flow
l effleurage Stretching and shearing forces in skin and superficial fascia
l friction Reduction of sympathetic neural activity:
l promotes relaxation
l may reduce the perception of pain
l may reduce anxiety and improve sleep
l may increase digestive function
l may increase immune activity
Relieves muscular soreness
Compression Releases fascial restriction
l pétrissage Relieves muscular tension
l kneading Increases local blood flow to skin and skeletal muscles
l squeezing May increase systemic blood pressure when performed over large vessels:
l rolling l increases local blood pressure
l compresses superficial blood and lymph vessels
Percussion May increase local blood flow to skeletal muscles

l hacking Neural stimulation or sedation:
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l cupping l promotes relaxation

l vibration Loosens mucous from respiratory membranes
l tapôtement
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12 Precautions and safe practice for massage 117
presentation and stated outcome together give direction p ressures away from more fragile structures. Reflex
to the overall design of the treatment plan. The therapist movements, such as the blink reflex, defend vital organs
then brings into the equation a knowledge of the effects when any threat is detected. However, there are some
of each technique considered for use in order to design a areas of the body which are exposed to the therapist dur-
treatment plan that both addresses the request for treating the massage that are less well protected, especially
ment and keeps the client safe. since the client is often relaxed during a massage and
Finally, the therapist needs to know when to refer is not likely to use enough postural guarding to prevent
a client for immediate medical attention or specialised injury. Vulnerable structures which may be damaged or
therapies which are outside their own scope of practice. whose functioning may be affected by excess pressure
Massage clients often ask for medical and nutritional are termed ‘endangerment sites’.
advice and unless the therapist has an appropriate quali- Consideration must be given to bony projections,
fication these questions should be referred to an appro- blood vessels, lymph vessels and nodes, nerves and
priate health professional. Psychological issues which organs which may be located superficially or without
require professional counselling should not be addressed adequate protection from pressure. (See Figure 12.2.)
by the massage therapist unless the therapist is also a The therapist needs to be conscious of the degree of
trained counsellor. Table 12.2 provides some examples pressure exerted by different means — elbows, palms,
of conditions which require specialist training. knuckles and so forth — and by the force and direc-
tion in which they are delivered. For example, localised
thumb pressure delivered at 90 degrees with force can
Case example be useful in releasing trigger points but acutely damag-
ing to more fragile tissues.
A new patient presents to a clinic with a history of In addition to considering pressure from techniques
low back pain and requests a spinal manipulation. delivered during the treatment, the therapist should also
This is outside the scope of massage therapy and be mindful of compression occurring as a result of posi-
the therapist must explain the reason this cannot be tioning the client on the treatment table. The effect may
performed and offer suitable alternative techniques to be immediate and easily resolved; for example, an arm
address the problem.
draped over the table exerting static pressure on the bra-
chial nerves or blood vessels between the table edge and
the humerus can cause paraesthesia (altered sensation)
ENDANGERMENT SITES
in the hand or fingers. This may be mildly unpleasant
Most of the vulnerable organs of the body are well but usually resolves quickly once the arm is shifted to a
protected from mechanical or traumatic injury. The more supportive position. Alternatively, the effect may
heavy skeleton and tough muscles absorb and distribute be more subtle and longer lasting such as can occur with
incorrect positioning of a pregnant woman. During the
latter half of the pregnancy it is unwise for the mother to
Table 12.2 Examples of conditions requiring lie flat and supine as the womb can move up under the
specialised training rib cage applying pressure to the inferior vena cava (the
large vein returning blood from the lower body to the
Condition Therapies heart). This can result in reduced blood flow to the foe-
Joint replacement l Physiotherapy
tus with possible long-term consequences for the baby.
l Remedial therapy
l Manual lymph drainage (MLD) Effects of compression
Lymphoedema l Combined decongestive
Almost all massage techniques create compression
Lipoedema therapy (CDT) within the tissues; even superficial effleurage distorts
Venous oedema l Physiotherapy
and places shearing forces on the collagen fibres in the
superficial fascia. Elbows, knuckles, thumbs, flat hands
and fingers are all appropriate tools for delivering com-
Dermatological l Aromatherapy
pression. The massage therapist must be aware of the
problems l Beauty therapy different effects of each technique in the tissue to which
Stroke l Remedial therapy it is applied as well as potential changes in blood flow,
rehabilitation l Physiotherapy any change in neural activity, digestive function or res-
l Occupational therapy piration. Table 12.3 outlines how the therapist can work
Chronic regional l MLD
safely with compressive techniques and actions the
pain syndrome l Physiotherapy therapist can take to reduce risks to the client.
Frozen shoulder l Remedial therapy
Nerve impingement
l Physiotherapy
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Nerves are most vulnerable to impingement when they

Scar management l Remedial therapy lie close to a bone with minimal surrounding tissue or
l MLD
padding. This occurs at most of the cranial and some spi-
l Physiotherapy
nal nerve exits as well as in the limbs, particularly at the
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Eyes
Cranial foramina for nerve exits
• Supraorbital
• Mental
• Trigeminal
Stylus of mastoid
process
Carotid artery
Brachial plexus Vertebral artery
Tracheal cartilage
Jugular vein Cervical nerve
Submandibular
Cervical lymph exits
lymph nodes
nodes Suboccipital
lymph nodes
Spinous
Xiphoid process
processes of
Liver
thoracic and
Axillary lymph
cervical vertebrae
nodes
Brachial
vessels and
Median nerve nerves Medial and
Antecubital lateral
lymph nodes epicondyles
Radial nerve
Ulnar nerve
Kidneys
12th (floating) rib
Sciatic nerve exits
Femoral artery
Femoral vein
Femoral nerve
Inguinal lymph
nodes
Popliteal lymph
nodes
Peroneal and
tibial nerves
Popliteal blood
vessels
Dorsalis pedis artery

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Figure 12.2 Endangerment sites — structures vulnerable to pressure where care must be taken when using
compressive or percussion techniques
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Table 12.3 Working safely with compressive techniques
Research l Know the location of the endangerment sites

l Superficial
structures may be palpable under gentle pressure
l Check pulses at the carotid, radial and dorsalis pedis artery
Assessment l Visuallylocate and assess the extent of any bruising, rash or irritation, recent surgical scar or
traumatic injury within the treatment area
l Test areas of neurological deficit to determine appropriate pressure
Monitoring l Always involve the client in setting the boundaries for tolerance of pain during treatment
l askfor feedback during treatment, especially during high-pressure techniques
l Check that arms and ankles extended over the edges of the table are positioned to avoid
pressure on nerves or blood and lymph vessels
l Make sure the angle of the neck does not extend posteriorly to any great extent as this can
impinge the vertebral artery and cause dizziness, mental confusion or even the cold clammy
signs associated with shock
Action l If the client indicates that the massage pressure is too great or if vulnerable sites are
identified prior to treatment it may be advisable to adapt the techniques used to avoid injury
l If symptoms of inappropriate compression do occur:
l reduce pressure by employing flatter techniques, flat hand, flat fingers or forearm and/or
reduce the force exerted during treatment
l reposition the client
l cease treatment if necessary
l Choose side-lying or bent-knee positions, place bolsters under hips or rib cage to reduce
lumbar pressure when lying supine or prone or reduce pressure on the breasts when lying
prone
l Do not allow pregnant women to lie flat after the 5th or 6th month
anterior elbows and posterior knees. Evidence of excess in the body. These changes may be subtle, such as
nerve compression would be described as tingling, changes in colour and complexion, or more dramatic,
numbness, burning, shooting or stabbing pains in the such as the acute pain experienced when inflamed tissue
area distal to the impingement site; for example, excess is damaged further. Some general categories of patho-
pressure on the ulnar nerve at the medial epicondyle will biological issues will be presented later in this chapter.
produce altered sensation in the fourth and fifth fingers.
CONTRAINDICATIONS
Blood or lymph vessel The Mosby Medical Encyclopaedia (1996) defines
impingement a contraindication as ‘a factor that prohibits a certain
Throbbing, aching, tingling and changes in skin colour treatment for a specific patient due to some condition
or temperature may all occur as a result of excess com- of the patient’.
pression of a blood vessel. Arterial compression is espe- The health status of an individual can change over
cially dangerous as this is often not detected early and time, be it minutes or seasons, as a result of environ-
the limb may be cool and pale before any other symp- mental influences such as stress or pollens or as a part
tom is reported. Venous compression generally leads to of biological and biorhythmic cycles lasting months or
blue or red discolouration and is often accompanied by a single day. Updating information and carefully moni-
tightness, tingling, pain or throbbing. toring clients on a session-by-session basis is critical to
Signs of compression of lymph vessels will have a ensuring the therapist is always fully aware of the state
slower onset. There may be a tight feeling in the extrem- of the client and can select and apply appropriate, safe
ities which may or may not be accompanied by visual therapies at every visit.
swelling. Lymph nodes are metabolically active sites of
immune reactions and isolation chambers for harmful Absolute contraindications
microorganisms or toxins. Excess pressure may disrupt The term ‘absolute contraindications’ applies to situ-
these functions or spread unprocessed lymph into the ations or conditions in which the massage cannot be
systemic circulation. safely performed. Some conditions such as deep vein
thrombosis may be temporary and once a medical
Physiological changes clearance is given massage therapy can commence or
resume. Others such as congestive heart failure may
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Changes in the function of tissues or systems can also

occur as a result of pressure. These changes may be be untreatable and therefore massage will be contrain-
local or systemic and any potential harm depends on dicated permanently. Table 12.4 provides examples of
the underlying condition or disease processes present absolute contraindications to massage.
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Table 12.4 Some examples of absolute contraindications
Untreated arterial or venous Blood clots which form in arteries or veins may cause local inflammation,
thrombus changes in blood flow patterns and oedema and require immediate medical
attention. Massage generally influences blood flow and there is a potential for
clots to be dislodged and become an embolus with negative consequences
for the client. Massage must not be performed until medical treatment is
undertaken. A medical clearance should be sought
Congestive cardiac failure Failure of the heart to adequately clear the blood returning from the venous
(cardiac oedema) system causes an increased pressure in the veins resulting in peripheral
oedema. Massage may inappropriately promote blood flow through the heart
causing a pulmonary oedema which is a medical emergency
Toxaemia/pre-eclampsia During the later stages of pregnancy excessively high blood pressure and
proteinuria can develop. This is a medical emergency and may require
hospitalisation. Signs of pre-eclampsia include sudden onset of swelling,
headaches and blurred vision
Systemic infection Clients suffering systemic infections will generally feel much worse if
l influenza massage is performed and the increase in circulation may make the infection
l cellulitis worse. Medical clearance that the infection is resolved or under control
l meningitis should be obtained before massage is performed
Undiagnosed oedema Oedemas of an unknown origin should be medically assessed as they may
indicate serious pathology. Once the diagnosis is known the massage may
be performed with caution
Untreated aortic aneurysm The wall of the aorta is thin and forms a ballooning of the vessel which
may be ruptured with increased arterial pressure of external compression.
Thrombus may also form at the site of the aneurysm. Surgical repair may be
undertaken and once medical clearance is given massage may be performed
with caution
Alcohol and recreational drug The effects of intoxication may be accelerated if massage is performed soon
use after consumption. There may also be altered sensation and inability to give
adequate feedback about pressure or comfort
Relative contraindications Table 12.5 The 20 leading specific causes of burden

It may seem obvious that severe, undiagnosed or of disease and injury in Australia, 2003
untreated medical conditions are outside the scope of 1 Coronary heart disease
practice of massage therapies, but increasingly clients 2 Anxiety and depression
with complex medical histories seek massage as an 3 Type 2 diabetes
adjunct to their conventional treatment or as a way to 4 Stroke
improve their quality of life. The value of massage as a 5 Dementia
stress management technique is well recognised. 6 Lung cancer
While it is a good idea in such situations to get med- 7 Chronic obstructive pulmonary disease (COPD)
ical clearance before performing the massage treatment, 8 Adult-onset hearing loss
particularly in palliative settings, it may also be true that 9 Colorectal cancer
the doctor may not be fully aware of the biophysical 10 Asthma
effects of all massage modalities and may take an overly 11 Breast cancer
simplistic view in which ‘massage can’t hurt’, which is 12 Suicide and self-inflicted injuries
not always true. On a very general level it is important 13 Road traffic accidents
to know the most prevalent conditions and diseases in 14 Prostate cancer
Australian populations and the safety or otherwise of 15 Osteoarthritis
massage in these conditions (see Table 12.5). 16 Alcohol dependence and harmful use
A relative contraindication is a condition, diagno- 17 Personality disorders
sis, medication or other characteristic of the client that 18 Back pain
requires the therapist to take some kind of precaution. 19 Schizophrenia
20 Lower respiratory tract infections
This doesn’t mean treatment cannot be done and in most
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cases treatment will still be performed. It does usually (Source: adapted from Australian Institute of Health and Welfare (AIHW)
2003 Australia’s Health (no 11). AIHW, Canberra, p. 41. Online. Available:
involve finding out more information about a particular http://www.aihw.gov.au/publications/index.cfm/title/10585 [accessed
disease state and avoiding certain body parts or specific 2 Sept 2009])
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techniques. For example, vibration techniques on the e specially if techniques such as aromatherapy are within
sternum are often contraindicated for asthma sufferers. the scope of practice and appropriate to the condition.
The therapist may respond to a relative contraindica- Care must be taken when assessing local infec-
tion by shortening the length of the session, monitoring tions for treatment keeping in mind that infection can
any reactions during and after the massage or careful be spread through the blood and lymph and techniques
positioning of the client on the table before the treatment which increase circulation may be contraindicated in
commences. Tables 12.6 and 12.7 provide examples of the affected area.
relative contraindications and the precautions a massage Ensure the client has sought appropriate first aid
therapist should take to make the massage treatment safe. or medical care and if an adverse reaction occurs refer
them back to their primary health care provider.
PATHO-BIOLOGICAL
CONSIDERATIONS
Any attempt to list every potential condition and the Case study 1
impact of every technique would be overly lengthy and
it is not possible to neither describe every scenario in An older client who is also a keen gardener arrives
which the massage therapist might find themselves nor for a treatment with a deep scratch on the forearm.
prescribe an action for every occasion. The following The skin around the scratch is red and swollen and
presentations should be identified as they apply to spe- there is a small amount of pus in the wound. The
cific conditions and the effects of massage considered client seems unconcerned and has not covered the
when planning the treatment. wound. The therapist decides not to massage that
arm and explains the reason for this to the client.
Infection During the massage the therapist notices that the
reddened area around the wound site seems to be
Whilst severe systemic infection is absolutely con- enlarging. At this point the massage is stopped and
traindicated for any form of massage a localised or the client referred for medical attention.
minor infection may not prevent treatment altogether,
Table 12.6 Working safely with relative contraindications
Research l Take a full history:

l Is
the condition to be treated within the therapists’ scope of practice?
l Are there other health issues or injuries?
l What symptoms are being experienced right now?
l What signs or symptoms or adverse reaction might be anticipated?
l Be clear about what symptoms you can realistically expect to alleviate
Assessment l Take into account:

l skincondition
l age
l level of fitness
l general health
l usual daily activities
l Ask questions at every session to elicit any change in health status:
l always record current health status in the notes for that session
l discuss any change in health status to determine what changes to the treatment plan may be
necessary before commencing the treatment
Monitoring l Monitor for any change in level of comfort of the client
l Look for any adverse reaction during and after the treatment
Action l Respond to client feedback by adapting the massage as necessary
l Ifa serious adverse reaction is experienced the treatment may need to cease altogether and either:
l refer the client for medical attention, or
l refer for specialist therapy
Precautions l Do not stroke toward inflamed or oedematous tissue

l No stroking over, broken or irritated skin
l Gentle pressure only if skin is fragile
l Avoid working close to recent wounds
l Do not compress varicose veins
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l Reduce pressure over spider veins

l Do not compress inflamed tissue
l No percussion over abdomen, kidneys, joints, varicose veins
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Table 12.7 Examples of relative contraindications
Condition Consideration Response

Hypertension l Cardiovascular l No deep abdominal techniques
disease (CVD) l Monitor for signs of any adverse reaction
Diabetes l CVD l Takea thorough history of current symptoms and disease progression
l Neuropathies l Startwith short treatment times
l Oedema l Monitor for hypoglaecemic reactions during and after treatment
l Tissue integrity
Treated malignancy l Oedema l Know what secondary pathologies have developed or may develop
l Pain l Assess for the presence or risk of lymphoedema and refer for
l Tissue integrity specialist treatment
Chronic obstructive l CVD l May have problems lying flat
pulmonary disease l Inflammation l Monitor for signs of respiratory distress or infection
(COPD) l Infection
Asthma l Inflammation l May have problems lying flat, or prone

l Allergic response l Many modalities leave out sternal manipulations
l Monitor for any exacerbations of symptoms for 24 hours following
treatment
Traumatic injuries l Acute injury l Takea thorough history of the injury and any rehabilitation already
l Chronic injury completed
l Inflammation l Work within the pain tolerance of the client
l Oedema l No massage over broken bones, skin, bruises or damaged tissue
l Pain
Arthritis l Chronic injury l Stay distal to any acutely inflamed joints

l Autoimmune l Work within the pain tolerance of the client
reaction l Monitor for any adverse reaction for at least 24 hours following
l Inflammation treatment
l Pain
l Oedema
Disc herniation l Acute injury l Takecare in positioning the client on the table
l Chronic injury l Nodeep work in acutely inflamed cases where muscle tension
l Inflammation may be protecting the damaged disc
l Pain l Work within the pain tolerance of the client
l Monitor chronic conditions for a return of acute inflammation
Inflammatory bowel l Inflammation l Take care with deep pressures over the abdomen
disease l Pain l Commence any course of treatment in a remitted state
l Autoimmune l No treatment with acute flare up
Recent fracture l Acute injury l Work distal to the injury (no proximal treatment until healing is well
l Inflammation progressed)
l Oedema l Avoid movements or positions which may place stress on the
l Tissue Integrity fracture site
l Pain
Post-polio l Muscle weakness l Reduce pressures generally

syndrome l Fatigue l Start with short treatment times to monitor client response
l Pain
Varicose veins l CVD l Massage proximally and not over distended vessels
l Inflammation l No pressure techniques distally to affected veins
l Pain
Recent surgery l Tissue integrity l Beginwith distal treatment

l Acute injury l Nomassage over new surgical wounds
l Oedema l Medical clearance may be advisable in complex cases
l Inflammation
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l Pain
Allergies l Inflammation l Ensure the treatment room is free of any known allergen and
l Oedema generally avoid flower pollens, perfumes and pet dander
l Track for changes over the 24 hour period immediately following
treatment to ensure no reactions have occurred
(Continued)
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Table 12.7 Examples of relative contraindications—cont’d
Condition Consideration Response

Pregnancy l Cardiovascular l Massage in each trimester of pregnancy will require different levels
changes of awareness and adaptations by the therapist. Refer to Chapter
l Oedema 19 for details.
l Use side-lying positions or upper body elevation during the 3rd
trimester
Multiple sclerosis l Autoimmune l Start with shortened treatment times and gentle pressures
reaction l Monitor for adverse reactions for a few days after treatment
l Neural disorder
l Inflammation
l Pain
Skin integrity of an unknown origin. For most diagnosed oedemas it

Healthy skin is a tough material capable of resisting is safe to work proximal to the oedema with effleurage
tearing and stretching forces in many directions. Skin movements in the direction of lymph and venous blood
that is broken, bruised, inflamed, dry cracked or old flow.
will have reduced resistance and will therefore be more
easily damaged.
Prior to treatment visually assess the areas of skin to
be included in the treatment and monitor throughout the Case study 3
session for signs of inflammation, persistent erythema
(reddening), pain or bruising. Avoid massage over A new mother arrives for her first appointment with
damaged skin and never massage over open wounds a swollen ankle but with no history of injury. During
or recent surgical sites. It may also be appropriate to the pregnancy both legs swelled to some extent.
change the medium used; for example, a finer oil such One ankle resolved quickly after the birth but not the
as apricot kernel or sesame will have less drag on the other. In this situation massage cannot be performed
and the woman should be referred for medical
skin and may be more suitable than almond or olive oils
assessment.
when massaging fragile skin.
Case study 2 Inflammation

The body responds quickly to injury or invasion and
The family of an elderly resident in a nursing inflammation is an important part of this early response.
home requests a regular massage treatment It is designed to stabilise damaged tissue and set up the
for their relative who is suffering from joint pain best environment for the immune system to perform
and immobility. During the initial assessment the
its role in protecting the body from invasion. Inflam-
massage therapist notices that the skin of the client
mation also initiates many of the processes required
is very thin and has many small bruises, cracks
for wound healing. There are vital temporary changes
and tears. The therapist decides to use very light
oils and creams and no deep tissue techniques are
in tissue structure which it is important not to disrupt
performed. Throughout the session the therapist and compressive massage should not generally be pre-
observes the response of the skin to the treatment formed directly over acutely inflamed tissue.
and checks that the pressure is comfortable for the Test inflamed tissue with gentle pressure to gauge
client. sensitivity before commencing the treatment. Depend-
ing on the extent of the inflammation or the severity
of the injury the area may be too sensitive to massage
firmly but effleurage may be well tolerated. Monitor for
Swelling signs of increased redness or heat during the treatment
Swelling can be caused by a variety of conditions and and stop the massage or stay distal to the inflamed area
knowing the cause of the swelling is important in select- if this occurs.
ing appropriate treatments. Often this can be determined Inflammation which occurs as a result of the mas-
from the history, such as when a sports person presents
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sage may indicate an underlying condition which

with a swollen ankle after sustaining an injury during requires medical investigation such as infection, or is an
training. However, it is not always possible to determine indicator that the pressure exerted during the massage
the cause and massage is contraindicated for oedemas exceeds the ability of the tissue to resist damage.
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Cardiovascular disease
Case study 4
The effects of compression on blood vessels or lym-
phatic structures that are already damaged and the
A regular client is a little late for his appointment
and trips on the curb running across the road
effects on blood pressure and flow systemically must
to the clinic. The ankle is immediately sore and
be considered in anticipating any possible adverse reac-
already beginning to swell. The therapist offers a tions for clients with known cardiovascular disease.
cool compress and a foot stool to elevate the leg Take a thorough history, and make sure you have enough
during the interview. The client usually has massage specific information about the diagnosed condition even
for neck tension and tight hamstrings and, on this if it is not related to the reason for seeking the massage.
occasion, the usual treatment is performed with Avoid using pressure over damaged vessels such
the exception of the distal leg on the affected side. as varicose veins. Deep abdominal techniques may
Effleurage techniques are used proximal to the injury increase systemic blood pressure and should be avoided
and in the pain-free range. for clients with uncontrolled hypertension or aortic
aneurysm.
If the client experiences exacerbated symptoms of
their disease, such as palpitations, cool and clammy
Pain
skin, or exhibits any other adverse symptoms during the
Whilst some deep tissue techniques do involve rela- treatment, the massage should be stopped and the client
tively painful procedures these should never be so referred for medical attention.
acutely painful that the person has to brace themselves
against the pain. A good guide for appropriate pain can
be to ask the client to relax and breathe deeply — if this Case study 6
is not easily achievable then the pressure is too great
and should be reduced. Massage should never cause A regular client with a history of cardiovascular
extensive bruising. Bruising is an indication of cross- disease and stable medicated hypertension
ing the boundary between a therapeutic effect and tissue experiences dizziness and nausea during a relaxation
damage; in this case small vessel rupture. treatment. This is an unusual response for this client
Continue to ask for feedback from the client when and the therapist ceases the treatment and refers the
treating painful areas. It is better to work within a client back to their primary health care professional.
framework of acceptable pain, guided by the tolerance
of the client, and to aim to resolve deep and stubborn
tension over a course of treatment rather than trying to Neural disorders
push problem tissues further than their structural integ- There are numerous conditions, disabilities and disorders
rity can tolerate. Use the visual analogue scale (refer to that involve changes in neural function and each must
Chapter 17) to gain specific feedback from the client be individually researched in order to treat these clients
about depth of pressure throughout the treatment. safely. Alterations in sensory neural function may render
the client unable to fully determine pressure or give a
reliable pain response. This is typical of the peripheral
neuropathies experienced by diabetics.
Case study 5
A woman in her 70s presents for a massage with a Case study 7

gift voucher from her daughter who has requested
a relaxation massage for her mother. During the A client with motor neurone disease requests a
interview the woman mentions that she has some massage to help with the adverse effect of the lack
lower back pain and is soon to see a neurosurgeon of skeletal muscle activity. Although the massage
to be assessed for surgical intervention. therapist asks for feedback about pressure and pain
During the treatment the therapist notices that during the treatment the client continually states
there is some tightness in the gluteal muscles that the pressure is fine. The next day, however, the
and suspects that this is contributing to the back client experiences the feeling of being ‘run over by
pain. Deep tissue massage is performed in this a truck’ with whole body soreness and discomfort.
area. It is painful to the client but as the client is In this case the therapist has failed to take into
not experienced in receiving massage therapy the consideration the altered sensation of the client and
client assumes this is usual. After the treatment the has delivered a massage which was too vigorous.
client has difficulty walking and the following day
significant bruises appear on the buttocks.
In this case the therapist has overstepped Autoimmune conditions
the boundaries of pain, and has not adequately
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considered the age of the client or monitored In autoimmune conditions there may be periods of
her during the treatment. Not surprisingly neither exacerbation and remission and therefore the level of
the mother nor the daughter speak highly of this inflammation and pain should be monitored at each
therapist or recommend her to others. appointment. It can be a good idea to start with short
treatment times and less invasive techniques and
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onitor for a good response before applying full ther-

m this depends largely on the extent of the original injury.
apy. Elicit feedback about the effects of the massage for Inflammation which persists over many months or years
the few days following the treatment and cease treat- can create fibrotic induration in the tissues. Old scars
ment if massage initiates any persistent exacerbation of can also become dense and fibrous. Whilst this fibre
symptoms. may require more vigorous treatment excess pain and
acute tissue damage should be avoided.
In the same way that rehabilitation exercises are
Case study 8 progressed in stages, the massage treatment should also
progress from more proximal uninjured areas moving
During the initial interview a new client discloses to lighter techniques over the injury site with increasing
that she has Crohn’s Disease. She has requested pressures over a course of several treatments.
massage for low back pain. The therapist ascertains Work within pain limitations and watch for any
that the symptoms of the Crohn’s Disease are not return to acute stages of inflammation or infection.
particularly bad at present and plans a treatment
which does not involve any deep abdominal
massage and decides to shorten the first massage. Case study 10
After explaining the reason for this the client is happy
to have a shorter treatment and agrees to phone A new client presents with ongoing symptoms
the therapist the next day to report on any adverse from a fractured elbow that occurred several years
reactions to the massage. ago. Mobility had never completely returned and
After three treatments of increasing duration whilst there is no visible swelling the area is warm
without a flare up of any digestive symptoms the to the touch. The therapist decides not to perform
therapist and client agree to include abdominal compressive techniques below the affected elbow
massage in the treatment. However after this session and uses only gentle effleurage strokes in the
adverse symptoms are experienced and it is agreed inflamed area, checking several times that the
that abdominal massage will not be included in future pressure is not painful. At the next appointment the
treatments therapist asks for feedback about the elbow after the
last treatment and the client reports that there was no
Acute injury exacerbation of any symptoms. Over the course of
several treatments the therapist works more deeply
Fractures, surgical wounds, abrasions and traumatic into the elbow, finding thickening of the connective
injuries will be accompanied initially by acute inflam- tissue which responds well to friction techniques.
mation and oedema and there may be a risk of infection.
It is best to wait a few days for this to reduce before treat-
ment begins. Tissues which are weakened by damage Palliative care
may take a few weeks to repair fully. It is recommended Research shows gentle massage therapies have a greater
to begin with proximal treatments and use less compres- effect in providing temporary pain relief than touch
sive techniques on tissue that is undergoing healing. alone. It is important to know the history of any diseases
and obtain a clear understanding of the symptoms that
the client is experiencing. The aim of the treatment in
Case study 9 the palliative care setting is often focussed on pain relief
or stress reduction.
A regular client has recently had a hip replacement
and returns for their regular massage treatment
10 days after the surgery. The therapist has not Case study 11
previously treated anyone so soon after a hip
replacement and undertakes some research about The family of a person with terminal cancer ask you
this condition before the client arrives for their to provide some massage therapy in the hospice
appointment. The therapist checks that the client to help keep their relative more comfortable. When
is comfortably positioned on the massage table the therapist assesses the client’s oedema in the
and re-checks for comfort a few times during the extremities it is also noted that the client is obviously
treatment. No techniques are performed over the in great pain whenever gross movements are
surgical site and no deep techniques are performed required. The therapist decides to massage only
on the affected leg. During subsequent massages the face, hands and feet with very gentle effleurage.
the affected area is gradually included (as pain and Feedback is sought a few times about the pressure
comfort allow) and within a few weeks the client is and towards the end of the session the client relaxes
receiving their usual massage. and begins to doze off.
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Chronic injury CONCLUSION

Injuries that do not heal well may become chronic. This Massage usually has beneficial effects in the health and
is usually defined as inflammation, pain or restricted functioning of all body systems but the potential for
mobility that persists for more than 3 months, although harm must always be considered. The ability to select
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appropriate treatment methods and monitor adverse References

outcomes is vital to conducting a safe practice. A good Andrade C-K, Clifford P 2001 Outcome Based Massage.
massage therapist will routinely connect the positive Lippincott Williams & Wilkins, Maryland
effects of massage with any potential physiological Australian Institute of Health and Welfare (AIHW) 2003
dangers, adapting and adjusting the course of treatment Australia’s Health (no 11). AIHW, Canberra, p 41.
to achieve the best possible benefits without the risk of Online. Available: http://www.aihw.gov.au/publications/
inadvertently harming the client. index.cfm/title/10585 (accessed 2 Sept 2009)
The keys to safe treatment are to be as aware as Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD
possible of the limitations of any technique within the 2007 The burden of disease and injury in Australia
scope of practice, have a thorough knowledge of the 2003. Australian Institute of Health and Welfare
history and medical status of the client, to assess and (AIHW), cat no PHE 82, AIHW, Canberra
monitor on an ongoing basis any reactions to treatment, De Domenico G, Wood EC 1997 Beard’s Massage (4th
and to apply the fundamental safety principles in every edn). WB Saunders, Philadelphia
massage treatment. Kutner JS, Smith MC, Corbin L, Hemphill L, Benton K,
The safety of the client and the reputation of the ther- Mellis BK, Beaty B, Felton S, Yamashita TE, Bryant LL,
apist are both well served by the overriding principle — Fairclough DL 2008 Massage therapy versus simple
touch to improve pain and mood in patients with
when in doubt, don’t.
advanced cancer: a randomised trail. Annals of Internal
Medicine, 149:369–79
Questions and activities Mosby Medical Encyclopaedia 1996 Online. Available:
1 Locate the endangerment sites on yourself and http://medical-dictionary.thefreedictionary.com/
another student or family member. contraindication (accessed 2 Sept 2009)
2 Research each of the conditions listed in Table 12.2 Salvo S 1999 Massage Therapy Principles and Practice.
and list techniques that would be inappropriate and WB Saunders, Philadelphia
appropriate for each.
3 Purchase a medical dictionary for your clinic and
browse through it regularly.
Recommended reading
Premkumar K 2010 Pathology A to Z — a Handbook for
Massage Therapists (3rd edn). Lippincot Williams &
Wilkins, Philadelphia
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13
pharmacological considerations
for massage therapy practice
Michael Nott chapter
LEARNING OUTCOMES
l Describe potential interactions between massage and therapeutic drugs
l Be aware of specific interactions for commonly used drugs
l Discuss management procedures for adverse effects of drugs in massage therapy
INTRODUCTION
no increase in blood levels of endorphins were found
A massage therapist will see clients from different after massage (Day et al 1987), whereas in another
walks of life, representing a broad cross section of the study small increases in blood levels (which might of
community. Many of these clients will be taking pre- course indicate larger increases at neuronal sites of
scribed medications as directed by their primary care action) were recorded (Kaada & Torsteinbo 1989). A
physician, others may be taking proprietary medicines continuing problem, even in the face of evidence for
they have purchased ‘over the counter’ at pharmacies elevated endorphin levels in massage and other physi-
and from supermarkets. Others may be taking herbal cal therapies, is that of causality: are the beneficial
or other preparations provided by their complementary effects of massage mediated by the concomitant rise
medicine practitioner or purchased from a health food in endorphin levels (Bender et al 2007)? The levels of
store, or social drugs obtained legally or illegally. This other neurotransmitters and hormones, such as cortisol,
chapter aims to address concerns that may arise when noradrenaline, oxytocin (only in women), insulin, dopa-
clients who are taking medicines or other drugs present mine, serotonin and neuropeptide Y, similarly change
for massage treatment. In addition to understanding any during and after massage (see Holst et al 2005 and note
underlying medical conditions that clients may present that some conclusions from their work are extrapolated
with, the massage therapist should also develop a knowl- from animal studies). There is enough evidence to pro-
edge of common medications that clients may be taking pose that some of the benefits of massage, such as pain
and the resultant considerations for the application of relief and relaxation, are mediated by such chemical
massage treatment. By taking a preliminary medication signals. Consequently, if massage does release endor-
record of the client as part of the ASTER process (see phins, or other neurotransmitters or hormones, then it
Chapter 11) and considering the consequences for mas- is possible that any drugs the patient is taking might
sage, the therapist will be well equipped to prepare a enhance or reduce the beneficial effects of massage by
treatment approach that is optimal for the client. interacting with these body chemicals. It could also be
possible that the application of massage may affect the
INTERACTIONS BETWEEN MASSAGE way in which a drug acts in the body.
THERAPY AND DRUG THERAPY A practical scenario facing the practitioner could
It is widely proposed that massage therapy causes the be a patient suffering back pain and taking codeine
release of endorphins in the brain and that these natu- (an opioid which relieves pain by acting on the same
rally occurring opiates contribute to such beneficial nerve receptors as the body’s endorphins). The prac-
effects as relaxation and pain reduction. But there is titioner would be aware that the endorphins that are
conflicting evidence to support the contention that mas- released during light massage might be less effective
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sage releases endorphins. Generally, as is often the than expected because they are competing for the same
case in other complementary therapies, there are but receptors as the codeine.
few well-controlled trials on the physiological effects At this stage it is wise to consider the known
(including endorphin release) of massage. In one study effects of drugs and of massage and to be careful of an
127
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interaction. Thus, if the client is taking an opioid then for burns, such rules will equally apply for the applica-
the quality of the massage itself might be affected. If the tion of hot and cold therapy.
client is taking drugs with sedative properties (which
include the opioids) the practitioner would warn the cli- CARDIOVASCULAR CONDITIONS
ent that the massage may make them drowsy and pos- Ischemic heart disease
sibly too relaxed and inattentive to drive home safely Typically prescribed drugs for symptoms of angina are
after the consultation. nitrates, β-adrenoceptor antagonists, and calcium chan-
nel blockers.
THE IMPORTANCE OF A CLIENT’S
Drug treatment of angina pectoris aims to address
MEDICATION HISTORY
the imbalance between blood supply to the heart muscle
A client’s medication record should constitute part of (the coronary vessels being constricted or blocked) and
the formal pre-massage history taking (see Chapter 11). the amount of work the heart has to do. Such drugs act
Such a record will give clues to symptoms the client to reduce force and rate of contractions of the heart or
may be experiencing. The client may be taking pre- dilate peripheral blood vessels so that the heart has less
scribed drugs, or those purchased over the counter in a work to do (for a review see Michel 2006).
pharmacy or supermarket. Herbal remedies and nutri- The nitrates are the mainstay of treatment (glyc-
tional supplements should also be considered. In some eryl trinitrate being the most common, but isosorbide
cases adverse effects of drugs may impact on the quality nitrates are also used). Nitrates act by dilating periph-
and safety of the massage. It is therefore incumbent on eral arterial and venous blood vessels. β-adrenoceptor
the practitioner to be aware of any such reactions, and to antagonists (also called β-blockers; e.g. metoprolol,
be ready to advise and take action when needed. atenolol and many others ending with ‘olol’) reduce
It is unlikely that the client will volunteer informa- sympathetic drive to the heart, thus lowering rate and
tion about their use of illegal drugs, such as amphet- force of contraction. They also dilate the peripheral
amines, cocaine and opioids. These drugs of course blood vessels. The calcium channel blockers (like vera-
exert behavioural effects and may mask pain (e.g. pamil, diltiazem, amlodipine, felodipine and nifedipine)
the opioids) and it is common practice in professions similarly affect peripheral blood vessels and, in addi-
employing massage and manipulation to refuse treat- tion, dilate the coronary vessels and directly reduce
ment if such illegal drug use is suspected. heart contractility.
In this chapter commonly used drugs (see Table All drugs used to treat angina are prone to cause pos-
13.1) are described according to the diseases for which tural hypotension (Michel 2006). Thus clients are likely
they are used. These diseases are generally chosen on to feel dizzy or faint upon changing from the recumbent
the basis of frequency in the population, but with a bias to standing position. Practitioners should caution clients
towards those that would be likely to bring a client to to slowly and carefully return to a standing posture at
massage. Emphasis is given to drugs used in diseases a slow rate and with care after the massage. It is also
that, though not frequent in the population, present par- advised that the therapist remain close by during this
ticular challenges for the massage therapist. For each period in case the client is unsteady, and provide stan-
drug, adverse effects that have a bearing on the comfort dard first aid if the client faints.
and safety of the massage treatment are emphasised,
even though they may not be the most serious adverse Heart failure
effects overall. Advice is also provided on how to man- Typically prescribed drugs for heart failure are digoxin,
age any potential problems if they arise (see Table 13.1). angiotensin converting enzyme (ACE) inhibitors, anti-
arrhythmic drugs, cardiac stimulants, diuretics and anti-
PAIN MEDICATION AND MASSAGE hypertensive drugs.
Many of the conditions listed below involve pain and Heart failure is a condition where the heart becomes
inflammation, and clients may be prescribed non- incapable of pumping sufficient blood to satisfy body
steroidal anti-inflammatory drugs (NSAIDs) such as tissue demands. Heart failure may be due to hyperten-
Celebrextm (celocoxib) for rheumatoid arthritis or have sion causing the heart to enlarge and become less effi-
obtained less potent drugs such as paracetamol from a cient. In some cases it may be due to poor perfusion
pharmacy or supermarket. Other patients may be pre- or death of heart muscle itself, both due to coronary
scribed an opioid such as morphine or obtained codeine ischaemia, or alternatively there may be an arrhythmia
from a pharmacy. Opioids and NSAIDs both raise the which underlies the problem.
pain threshold. That is, clients taking these drugs may Until recently, digoxin was the drug of first choice in
experience pain only when higher levels of a painful treating heart failure. Digoxin directly increases cardiac
(nociceptive) stimulus are applied. The therapist should contractility and slows heart rate if there is excessive
be aware that massage can become injurious to tissues activity coming from the pacemaker region of the atria.
at levels below the threshold of pain. The implication Digoxin is still used if heart failure is associated with
for massage is that these clients should be provided
copyright law.
atrial tachycardia, however current treatment focuses on

with a less intense massage than normal. In particular, reducing the oedema associated with the disease. The
the therapist should not wait for the client to signal the main drugs used for this are the ACE inhibitors such as
experience of pain. In addition, to decrease the potential captopril and enalapril (Rocco & Fang 2006).
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Table 13.1 Drug types, their common and generic trade names, diseases for which they are used, adverse effects and precautions for the massage therapist
Copyright © 2010. Churchill Livingstone Australia. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses
Common conditions or symp- Possible side

Drug type Generic name (trade name) toms for which they are used ffects
e Precautions for massage
Angiotensin Captopril (Capoten™) Heart failure; Mild postural Advise to stand up slowly; be prepared
converting enzyme hypertension hypotension; for fainting
(ACE) inhibitors giddiness; potential
to faint
Angiotensin II Iosartan (Cozaar™)
receptor antagonist
Anticontractile drug Dantrolene (Dantrium™) Spacticity; Drowsiness; No special precautions except to
multiple sclerosis muscle weakness ensure client is fully alert if intending
to drive. Therapist could choose to
shorten treatment time to avoid over-
fatiguing the client with MS, and apply
13 Pharmacological considerations for massage therapy practice

some stimulating, but gentle, massage
techniques to increase levels of alertness
Antiseizure drugs Phenobarbitone (Prominal Mysoline™) Epilepsy Sedation; Advise to stand up slowly; be prepared
Phenytoin (Dilantin™) hypotension for fainting
sodium valproate (Epilim™, Valpro™)
Antihistamines 1st generation: Hay fever; nausea; vomiting; Dry hot skin; Use hydrating oils and apply a gentle
Diphenhydramine (Benadryl™, skin disorders sedation massage; precaution with fatigue/
Benacine™, Dramamine™ etc) drowsiness after massage; ensure client
Promethazine (Pothiazone™, is fully alert before driving. Therapist
Phenergan™, Avomine™ etc) could choose to use some stimulating,
but gentle, massage techniques in the
2nd generation:
massage to increase levels of alertness
Loratidine (Claratyne™)
Fexofenadine (Telfast™) Terfenadine
(Teldane™)
Anti-inflammatory Aspirin (Aspro™, Bex™, Dispirin™ etc) Dysmenorrhea; Reduced pain Modify depth and intensity of massage
permitted under U.S. or applicable copyright law.
analgesics, aspirin plus (Codral™, Aspalgin™) endometriosis; fibromyalgia; response and monitor closely any application of
Non-steroidal coedine, celecoxib (Codiphen™, headache; osteoarthritis; fever; hot and cold therapy as pain perception
anti-inflammatory Celebrex™ etc) inflammation may be blunted
drugs (NSAIDS) Ibuprofen (Brufen™, Raphen™)
Indomethacin (Indocin™, Arthrexin™)
Paracetamol (Panadol™, Tylenol™)
paracetamol plus codeine (Codral™,
Panadeine™, Codalgin™ etc)
Antimanic drug Lithium (Lithicarb) Manic depression; psychoses; Acne; tremor Skin infection control;
schizoaffective illness reassure patient; soothing, repetitive
massage strokes may be helpful
129
(Continued)
Account: s8715057
130
Table 13.1 Drug types, their common and generic trade names, diseases for which they are used, adverse effects and precautions for the massage therapist—cont’d
Section 4 Making initial contact with the client

Common conditions or symp- Possible side
Drug type Generic name (trade names) toms for which they are used effects Precautions for massage
β-adrenoceptor Atenolol (Tenoromin, Noten™, Anselol™) Angina; anxiety; migraine; Mild postural Advise to stand up slowly and support
antagonists Fenoterol (Berotec™) hypertension hypotension; client; be prepared for fainting
Metoprolol (Betaloc™, Lopressor™, giddiness; potential
Minax™) to faint
β-adrenoceptor Salbutamol (Ventolin™) Asthma; chronic obstructive Muscle tremor; Reassure patient; no other action
agonists Orciprenaline (Alupent™) pulmonary disease (COPD) tachycardia
Terbutaline (Bricanyl™)
Salmeterol (Seretide™)
Benzodiazepines Alprazolam (Xanax™, Kalma™, Anxiety; anorexia nervosa; Sedation; confusion Clients may feel drowsy or fatigued
Ralozam™) bulimia nervosa; epilepsy; after the treatment and therapist should
Bromazepam (Lexotan™) multiple sclerosis ensure client is fully alert before driving
Clonazepam (Rivotril™) home.
Diazepam (Valium™, Ducene™ etc) Therapist could choose to use some
Lorazepam (Ativan™) stimulating, but gentle, massage
Oxazepam (Serepax™, Murelax™, techniques in the massage to increase
Alepam™) levels of alertness
Calcium channel Amlodipine (Norvasc™) Angina; hypertension Mild postural Advise to stand up slowly and support
blockers Diltiazem (Cardizem™, Coras™, Dilzem™) hypotension; client; be prepared for fainting
Felodipine (Plendil™, Agon™) giddiness; potential
Nifedipine (Adalat™, Oros™, Nifecard™) to faint
Verapamil (Isoptin™, Cordilox™,
Veracaps™, Anpec™)
Corticosteroids Inhaled: Beclomethasone (QVAR); Asthma nil No action
fluticasone with salmeterol (Seretide™)
Oral: Predisolone (Panafcort™) Systemic inflammation; Wasting of muscle Take particular care to control intensity
rheumatoid arthritis; tissue or protein; reduced of massage; use hydrating oils; take
organ transplant rejection bone strength; skin precautions for infected skin
wasting and possible
fungal infection
Topical: Betamethasone (Betnovate™) Skin inflammation, eczema, Thinning of skin; Control intensity of massage; use
psoriasis possible fungal hydrating oils; take precautions for
infection of skin infected skin
Account: s8715057
GABA agonists Baclofen (Lioresal™, Clofen™) Multiple sclerosis; Sedation Clients may feel drowsy or fatigued
spasticity after the treatment and therapist should
ensure client is fully alert before driving

home. Therapist could choose to
shorten treatment time to avoid over-
fatiguing client with MS, and apply
some stimulating, but gentle, massage
techniques to increase levels of alertness
Insulin Various formulations (various names) Type I diabetes Hypoglaecemic Oral glucose or sucrose (jelly beans, one
episode: faintness, or two candy bars or two bananas); in
clammy skin, tremor emergency call ambulance
Timing of massage appointments
with insulin intake is important when
scheduling diabetic clients. Massage over
the site of recent injection is to be avoided
13 Pharmacological considerations for massage therapy practice

Nitrates Glyceril trinitrate (Anginine™, Deponit™, Angina Severe postural Assist client to stand slowly and be
Nitrodisc™ etc) hypotension with prepared for fainting
Isosorbide (Isordil™, Isolgen™, Sorbidin™) potential to faint
Oral hypoglycaemic Chlorpropamide (DiabeneseTM) Type II diabetes Hypoglaecemic Oral glucose or sucrose (jelly beans, one
drugs episode: faintness, or two candy bars or two bananas); in
clammy skin, tremor emergency call ambulance
Timing of massage appointments
with insulin intake is important when
scheduling diabetic clients
Selective serotonin Fluoxetine (Prozac™) Depression Dizziness; Reassure client; soothing, repetitive
reuptake inhibitors anorexia nervosa; bulimia nervousness; tremor massage strokes may be helpful
(SSRI) nervosa; chronic fatigue
syndrome
Serotonin Sumatriptan (Imigran™) Migraine None affecting Light massage may help relive symptoms
antagonists massage
Stimulant anorectics Diethylproprion (Tenuate™) Obesity Anxiety; restlessness Reassure client; soothing, repetitive
massage strokes may be helpful
Thiazide diuretics Acetazolamide (Diamox™) Hypertension, oedema Postural hypotension; Assist client to stand up slowly; be
giddiness, potential prepared for fainting
to faint
Tricyclic Amitriptyline (Tryptanol™, Endepo™, Depression; persistent Dry hot skin; sedation Hydrating massage oils; gentle massage;
antidepressants Tryptine™) headache; neuropathic pain Clients may feel drowsy or fatigued after
Imipramine (Tofranil™, Imipran™, the treatment and therapist should ensure
Melipramine™) client is fully alert before driving home
Trimipramine (Surmotonil™) Therapist could choose to use some
stimulating, but gentle, massage
131
techniques in the massage to increase
levels of alertness
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In this complex and life-threatening condition anti- may be aimed at the anxiety itself, in which case spe-
arrhythmic drugs, cardiac stimulants, diuretics and cific anti-anxiety drugs such as a benzodiazepine may
anti-hypertensive drugs are also used depending on the be prescribed, or at symptoms, such as heart palpita-
underlying pathology. tions, in which case a β-adrenoceptor antagonist may
Clients suffering from heart failure and presenting be prescribed. The benzodiazepines are the most com-
for massage will commonly experience dizziness and monly used anti-anxiety drugs, and of these alprazolam,
feelings of faintness due to the underlying poor cardiac bromazepam, diazepam, lorazepam, and oxazepam
output. As such, the massage therapist should advise the are commonly chosen because of their relatively long
client to get up from the table slowly after the massage duration of action (Baldessarini 2006). As the benzo-
and be prepared just in case the patient faints. The drugs diazepines cause sedation the massage therapist should
used to treat heart failure may themselves cause central caution the client about driving home after the massage
effects leading to sedation, confusion and tremors, but if they are feeling sleepy post-treatment.
these are not as significant as the underlying circulatory These days drugs that were previously reserved
problems (Rocco & Fang 2006). The massage therapist for the treatment of depression are being prescribed
can reassure the client if these effects occur and advise for anxiety, as the diagnostic lines between anxiety
the client not to drive home after the massage if they are and depression become blurred. Clients suffering from
feeling sleepy or confused. anxiety therefore might be receiving a selective sero-
tonin reuptake inhibitor (SSRI) or a reversible inhibitor
Hypertension of monoamine oxidase (RIMA) such as moclobemide
Typically prescribed drugs for hypertension are thiazide that typically do not cause sedation. Rarely, such cli-
diuretics, β-adrenoceptor antagonists, calcium channel ents may be taking a tricyclic antidepressant (TCA) that
blockers, angiotensin converting enzyme (ACE) inhibi- could make them sleepy. For more information on these
tors and angiotensin II receptor antagonists. drugs see the section on depression below.
Many different drug types are used to treat hyper-
tension or high blood pressure. If the condition is mild a Depression (minor) and affective
single drug may be prescribed. For more severe hyper- disorders (major depression)
tension a combination of drugs, each at a relatively low Typically prescribed drugs for affective disorders are
dose, is chosen. The intention is to act at a number of selective serotonin reuptake inhibitors (SSRIs), revers-
points of blood pressure control and thus minimise the ible inhibitors of monoamine oxidase (RIMA), tricyclic
side effects profile of any one drug. antidepressants, and lithium.
Clients presenting with hypertension are likely A herbal remedy for affective disorders is St John’s
to be taking one or more of the following: a thiazide wort.
diuretic (e.g. acetazolamide), a β-adrenoceptor antag- At any time it is estimated that around 20% of the
onist (e.g. alprenolol, metoprolol and many others population is suffering from depression (McLennan
all ending in ‘olol’), a calcium channel blocker (e.g. 1997). For some clients, depression may be associated
amlodipine, felodipine or nifedipine), an ACE inhibi- with chronic pain, or a neurotic or personality disorder.
tor (captopril and many others, all ending in ‘pril’) If a client reports that they are receiving treatment for
or an angiotensin II receptor antagonist (e.g. losartan depression then they may be experiencing a short-term
and others, all ending in ‘artan’). For a review of cur- personal response to a set back in life and relationships.
rent treatment practice see Chapter 25 of Bryant and They may be having counselling with or without a short
Knights (2006). period of drug therapy.
To a greater or lesser extent all anti-hypertensive At the extreme the client may be experiencing major
drugs may cause postural hypotension, so that clients depression (monopolar affective disorder) or, much less
feel dizzy or faint upon changing from the recumbent to commonly, manic depression (bipolar affective disor-
standing position. Practitioners should caution clients, der). The affective disorders are so-named because of
and remain aware and prepared to act during the vulner- characteristic marked mood (affect) changes. Psycho-
able period after the massage when the client, whose sis (with agitation, hallucinations, delusions) is another
blood pressure control is adjusted to the recumbent characteristic. There are also atypical affective disor-
position, is about to stand up. ders, and severe depression, associated with neurotic
and personality disorders. In all cases, clients may be
PSYCHIATRIC/MENTAL HEALTH undergoing prolonged and intense medication with
CONDITIONS antidepressants, along with other treatments.
The drugs of first choice for affective disorders are
Anxiety the SSRIs such as fluoxetine, sertraline, fluvoxamine,
Typically prescribed drugs for anxiety are benzodiaz- paroxetine and citalopram, along with moclobemide
epines, and β-adrenoceptor antagonists. which is a RIMA, and the newer compounds nefazo-
copyright law.
Clients suffering from anxiety may be receiving done, and venlafaxine. Due to their more marked side
drug therapy in addition to other support such as coun- effects, the tricyclic antidepressants such as imipra-
selling, particularly if the anxiety is acute or prolonged. mine, amitriptyline, trimipramine and clomipramine
Anxiety may also accompany depression. Drug therapy are generally reserved for more refractory cases, as
Account: s8715057
13 Pharmacological considerations for massage therapy practice 133
is mianserin. The irreversible monoamine oxidase cortex that are responsible for attention and short-term
inhibitors (MAOIs), such as phenylzine and tranyl- memory (Hoffman 2006). Thus the child becomes more
cypromine, because of their serious side effects and focused and attentive, and less troubled (and trouble-
life-threatening food interactions, are drugs of last some). Drug therapy is given for extended periods. Tak-
resort. Extracts of St John’s wort also have been ing into account the low doses involved, it is unlikely
shown to be effective in treating depression though that clients will have adverse effects that impact on
less so than the tricyclic antidepressants. Lithium is massage.
used for treating the mania of bipolar affective dis- High doses of psychostimulants, such as those taken
order. For a review of the use of antidepressants in illicitly, may cause excitement, palpitations and tremor
Australia and New Zealand see Chapter 19 of Bryant and, over time, psychosis and chorea (jerky and explo-
and Knights (2006). sive fidgety movements around the body).
None of these drug treatments alone would pre-
clude massage therapy. The tricyclic antidepressants Schizophrenia
are noted for their atropine-like activity (Leonard & Typically prescribed drugs for schizophrenia are pheno-
Richelson 2000) which tends to dry the skin and raise thiazines and other antipsychotic drug groups.
its temperature. In this regard the therapist may choose Antipsychotic drugs are used to treat schizophrenia,
to use, as a lubricant for massage, oil that is hydrating and the mainstays are the phenothiazines such as chlor-
and nourishing to the skin, such as sweet almond oil promazine (Baldessarini & Tarazi 2006). A variety of
and, in consultation with the client, reduce the intensity other drugs are used in order to gain control with the
of the massage. Among other effects of the tricyclics minimum of side effects, however given that the disease
is sedation and the practitioner should caution the cli- is so serious, major side effects are tolerated in the quest
ent about driving home afterwards if they are feeling for control.
sleepy. Schizophrenia is increasingly treated on outpatient
principles and clients who are controlled by drugs
Anorexia nervosa and bulimia will, no doubt, present for massage. They are likely to
nervosa exhibit a range of drug side effects with implications
Typically prescribed drugs for anorexia nervosa and for massage, including sedation, hypotension, drying
bulimia nervosa are selective serotonin reuptake inhibi- and heating of the skin, and when drug dosage is high,
tors (SSRIs), and benzodiazepines. extrapyramidal effects such as limb stiffness, twitch-
Psychoneurotic eating disorders such as anorexia ing, muscle tremor and spasms (Baldessarini & Tarazi
nervosa and bulimia nervosa are commonly associated 2006).
with anxiety and depression. Such conditions are treated The massage therapist should counsel the client
by antidepressants such as fluoxetine (a SSRI; see ear- about tiredness after the massage, adjust the massage
lier section on depression) or an anti-anxiety drug like to account for the hot and dry skin, account for tense
benzodiazepines (e.g. diazepam). Fluoxetine does not muscles which are under excessive neuronal drive, and
dry the skin as do other antidepressant drugs such as the be prepared for postural hypotension when the client
tricyclic antidepressants (see earlier section on depres- gets up from the table.
sion) and its use should not affect massage. A common
outcome of treatment with benzodiazepines is tiredness RESPIRATORY CONDITIONS
so the massage therapist should caution the client about Asthma
driving home after the massage. Typically prescribed drugs for asthma are β-adrenoceptor
agonists such as salbutamol, anti-inflammatory steroids
Attention deficit hyperactivity such as beclamethasone, anticholinergic drugs such as
disorder (ADHD) ipratropiumand, and mast cell stabilizers such as cro-
Typically prescribed drugs for ADHD are psycho-stim- moglycate.
ulants such as methylphenidate . Asthma is treated with drugs such as mast cell stabi-
About 1% of children are diagnosed as suffering lisers (cromoglycate and nedocromil) to prevent the ini-
from ADHD, with the incidence in boys being 10 times tial response to allergens. The inflammatory response of
greater than in girls. Attention deficit hyperactivity dis- asthma is treated with anti-inflammatory steroids such
order usually becomes apparent between the ages of as beclomethasone. The mainstay of treatment are the
3 to 7 years (Findling & Dogin 1998) but the condition β-adrenoceptor agonists such as salbutamol, terbuta-
may persist into adulthood. Massage is commonly used line, fenoterol and orciprenaline that relax the smooth
for the treatment of ADHD, generally in children who muscle of the bronchioles.
are on drug therapy. To minimise systemic side effects, anti-asthma
Drug treatment relies on paradoxical effects of the drugs are preferably administered by inhalation, rather
psychostimulants dexamphetamine and methylpheni- than orally. Even so, the β-adrenoceptor agonists still
copyright law.
date, which logically, by stimulating the child, should commonly cause skeletal muscle tremor (Securs 2002).
make matters worse. However evidence suggests that, Clients should be reassured that this would not cause
at low doses, amphetamines and methylphenidate a problem in massage and be encouraged never to miss
selectively stimulate the frontal areas of the cerebral a dose of their medication.
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ENDOCRINE AND METABOLIC Dysmenorrhoea

CONDITIONS Typically prescribed drugs for dysmenorrhoea are anti-
Diabetes inflammatory analgesics.
Type I diabetes mellitus (known also Women suffering from dysmenorrhoea may be tak-
as juvenile onset; insulin dependent ing anti-inflammatory analgesics such as aspirin or
paracetamol to relieve pain. These drugs, called non-
diabetes mellitus; IDDM)
steroidal anti-inflammatory drugs (NSAIDs) inhibit the
Typically prescribed drugs are insulins (human and production of prostaglandins which normally sensitise
bovine). nerve fibres to painful stimuli. Thus the pain perception
Clients experiencing type I diabetes mellitus war- of clients taking these drugs will be reduced. Of par-
rant particular attention due to the condition itself. ticular importance in massage is that musculoskeletal
They will have injected insulin sometime that day pain sensitivity is lessened and the intensity of mas-
before presenting for the massage. Hypoglycaemia, sage should be reduced accordingly. These drugs also
due to inadequate food intake before the massage, have an anti-platelet action and accordingly increase
or due to the increase in muscle activity during the the tendency to bleed (bruise). This is another reason
massage (Davis 2006), is the most likely complica- for being gentle with clients taking anti-inflammatory
tion and must be dealt with immediately. Symptoms analgesics.
will be recognised by the client and therapist as feel-
ings of faintness, clammy skin and tremor. The thera- Endometriosis
pist should make sure the client is seen on time so as
not to interfere with the balance of their insulin/food Typically prescribed drugs for endometriosis are anti-
schedule, and should make sure the client has a glu- inflammatory analgesics.
cose source (such as marshmallows or jelly beans) at Precautions and likely drug and massage implica-
hand before the massage begins. (The therapist could tions are as for dysmenorrhoea (see above).
also have a glucose source handy in the clinic just
in case.) Massage around the site of injection could Premenstrual syndrome
increase blood flow to the area and potentially increase Typically prescribed drugs for premenstrual syndrome
the absorption of insulin. As a precaution this would are non-steroidal anti-inflammatory analgesics.
be best avoided. The pain of premenstrual syndrome may be treated
with prescription or over-the-counter anti-inflamma-
Type II diabetes mellitus (known also tory analgesics (such as those containing aspirin or
as maturity or adult onset; non-insulin paracetamol). The massage therapist should restrain the
dependent diabetes mellitus; NIDDM) intensity of the massage as pain perception in the client
may be reduced with these medications.
Typically prescribed drugs are oral hypoglycaemic
drugs, and insulins.
ALLERGIC CONDITIONS
A major predictor for type II diabetes is obesity and
as Australians become heavier the disease becomes more Hay fever
prevalent. The incidence has doubled sine the 1980s and Typically prescribed drugs for hay fever are antihista-
now 7% of adults have the disease. Depending on the mines, nasal vasoconstrictors and nasal anticholinergics.
severity of the disease, type II diabetes mellitus may be Hay fever (allergic rhinitis) is particularly common
controlled by diet and exercise; by oral hypoglycaemic in Australasia and approximately 20% of the popula-
drugs; by injections of insulin or a combination of these tion experiences it (Australian Institute of Health and
strategies (Davis 2006). Welfare 2001). Hay fever follows an immune response
Clients generally warrant the same attention as to allergens whereupon autacoids, such as histamine,
those with type I diabetes mellitus although clients serotonin and prostaglandin, are released from mast
receiving insulin should be considered most prone to cells to cause inflammation, nasal congestion and
hypoglycaemic episodes. Clients receiving oral hypo- hypersecretion.
glycaemic drugs (alone) would be less likely to experi- Clients with hay fever may have been prescribed
ence a hypoglycaemic attack (or ‘hypo’), and the least an orally administered antihistamine or obtained an
likely would be those whose diabetes is controlled by over-the-counter preparation. Antihistamines block
diet and exercise. the action of a number of the autacoids released by the
The therapist should be alert to symptoms of hypo- immune response (not just histamine) and are thus very
glycaemia in the client: feelings of faintness, clammy effective. The older drugs, such as diphenhydramine
skin and tremor. It is advisable for the massage therapist and promethazine, are sedative and may be useful at
to schedule the client in advance and see them promptly night, but in the daytime they make people sleepy and
to avoid interfering with the balance of their drug/ they pose a risk for drivers and users of machinery.
food regimen. As in cases of type I diabetes, a glucose
copyright law.
Newer antihistamines such as loratidine, terfenadine

source should be kept at hand and the therapist should and fexofenadine are less sedating.
be ready with first aid procedures, including a 000 call Some antihistamines have marked atropine-like
in emergencies. activity and cause the skin to become dry and feel hot.
Account: s8715057
The therapist may choose to use a lubricant that is People suffering from neuropathic pain, because
hydrating and nourishing to the skin, such as sweet it is often intractable, tend to try different treatment
almond oil, and reduce the intensity of the massage. modalities, including massage. The practitioner will
In addition, if the client is taking a sedating-type no doubt be using gentle techniques with these cli-
antihistamine it would be wise to caution them about ents. There is no particular issue with drugs used
potential additive effects of a sedative drug and a relax- except that the antidepressants may dry the skin and
ing massage if they are considering driving from the the antiepileptics have sedative properties so that the
appointment. usual post-massage precaution about driving a car is
Hay fever may also be treated by spraying drugs into advised.
the nose. Drugs administered this way are vasoconstric-
tors such as xylometazoline, corticosteroids, mast cell Epilepsy
stabilisers, and nasal anticholinergics such as ipratro- Typically prescribed drugs for epilepsy are phenobar-
pium, which dry up secretions. Generally, drugs admin- bitone (one of the long-acting barbiturates), carbam-
istered by nasal spray act locally and will not produce azepine, clonazepam (a long-acting benzodiazepine),
sufficient systemic concentrations to cause concern phenytoin, gabapentin and sodium valproate.
with massage. Epilepsy presents a range of potential problems to
For more information on allergic rhinitis and its the massage therapist, the main one being a seizure epi-
treatment see Chapter 32 of Bryant and Knights (2006). sode during treatment. In this instance the therapist’s
appropriate response is to apply first aid.
NERVOUS SYSTEM CONDITIONS Carbamazepine (as well as other anticonvulsants)
is also used for treating trigeminal neuralgia, a severe
Multiple sclerosis and acute pain in the face and neck associated with the
Typically prescribed drugs for multiple sclerosis are trigeminal nerve. Some sufferers seek massage as an
benzodiazepines, GABA agonist and dantrolene. adjunct therapy.
Drugs used to reduce the symptoms of multiple Anti-seizure drugs generally cause sedation, in addi-
sclerosis are centrally acting antispastic drugs such as tion to other specific side effects.
the benzodiazepine diazepam, and the GABA agonist For specific adverse effects of particular anti-seizure
baclofen (GABA being a central nervous system trans- drugs see MIMS Annual (2008).
mitter which acts to reduce neuronal activity to skel-
etal muscle), and drugs such as dantrolene, which act MUSCULOSKELETAL CONDITIONS
directly on the muscles to reduce contractility. The
centrally acting drugs are likely to cause sedation and Osteoarthritis
practitioners should warn patients about the danger Typically prescribed drugs for osteoarthritis are anti-
of tiredness if driving home after massage. The anti- inflammatory steroids, and non-steroidal anti-inflam-
contractile drug dantrolene lowers muscle tone, without matory analgesics.
causing sedation (Kita & Goodkin 2000) and should not Drugs used in treating osteoarthritis typically are
affect massage. anti-inflammatory steroids such as prednisolone, and
non-steroidal anti-inflammatory analgesics such as
Neuropathic pain aspirin, indomethacin and ibuprofen (see Chapter 55 in
Typically prescribed drugs for neuropathic pain are tri- Bryant & Knights, 2006, for treatment regimens). As
cyclic antidepressants and antiepileptics. with analgesics, generally the threshold for pain in the
Pain usually results from inflammation in non- client may be elevated and the practitioner must restrain
neuronal tissue that produces chemicals that stimulate the limits of the massage to avoid tissue damage. Pro-
pain fibres. Neuropathic pain, however, originates in longed systemic administration of steroids leads to bone
the nerves themselves. It is often intense, persistent and weakness due to net protein and calcium loss and weak-
debilitating. There is a strong psychological component ening of muscle, skin and connective tissue and fungal
to the ensuing suffering and for that reason antidepres- infections of the skin. Appropriate lightness of touch is
sants are used. But it seems that the antidepressants, advised and use of gloves may be necessary if there
such as imipramine, not only enhance the mood of the is skin infection.
person suffering neuropathic pain but also reduce the
transmission of pain itself. Some antiepileptics, such as Paget’s disease (osteitis
gabapentin and carbamazepine, are used and likewise deformans)
appear to interfere with pain pathways. Non-steroidal Typically prescribed drugs for Paget’s disease are non-
anti-inflammatory drugs (NSAIDs) are not much use steroidal anti-inflammatory analgesics, calcitonin, and
and this is not surprising since inflammation is not the phosphonates.
cause of the pain. Neuropathic pain is associated with Drugs used for treatment of Paget’s disease are the
non-steroidal anti-inflammatory analgesics, such as
copyright law.
diabetic neuropathy, shingles (following chickenpox),

trigeminal neuralgia, spinal cord injury and post- aspirin, indomethacin and ibuprofen, and drugs to help
surgical trauma (especially after amputations), cancer re-mineralise bone, such as calcitonin and phosphonates
and multiple sclerosis. (Marcus 2002). As with analgesics, generally the
Account: s8715057
threshold for pain in the client may be elevated and the SKIN CONDITIONS
practitioner should restrain the intensity of the massage Inflammatory skin conditions
to avoid tissue damage. A gentle massage would be
Topical corticosteroids are used to treat persistent
indicated anyway, as the bones of sufferers of Paget’s
inflammatory skin conditions such as eczema and pso-
disease are very prone to fracture.
riasis. These underlying conditions may present issues
to be dealt with in massage and the drugs themselves
Rheumatoid arthritis
cause important adverse effects (Schimmer & Parker
Typically prescribed drugs for rheumatoid arthritis are 2006). Topical corticosteroids tend to thin and weaken
anti-inflammatory steroids, non-steroidal anti-inflam- the skin so that it becomes easy to tear and bruise.
matory analgesics, gold salts, penicillamine, and sulfa For this reason the intensity of massage in susceptible
salazine. areas should be restrained. Topical corticosteroids also
Drugs used in rheumatoid arthritis are the anti- encourage fungal infections. If the skin is infected then
inflammatory steroids such as prednisolone, and non- gloves should be worn and the infected areas should be
steroidal anti-inflammatory analgesics such as aspirin, avoided.
indomethacin and ibuprofen. As with analgesics gener-
ally, the threshold for pain in the client may be elevated OTHER CONDITIONS
and the practitioner should restrain the intensity of the
massage to avoid tissue damage. Headache
These days rheumatoid arthritis is often treated Typically prescribed drugs for occasional headaches
at source by drugs that apparently interfere with are anti-inflammatory analgesics.
the underlying autoimmune response. These include Normal headache is usually self-treated with a com-
gold salts, penicillamine and sulfasalazine. It is mon over-the-counter non-steroidal anti-inflammatory
unlikely that their effects would interfere with massage drugs (NSAIDs) such as aspirin or paracetamol. If the
treatment. client is taking these drugs the therapist should be care-
For details of drugs used to treat rheumatoid arthritis ful about the intensity of the massage because the cli-
see Chapter 55 of Bryant and Knights (2006). ent’s tolerance for pain is increased (so that injury could
occur without the warning signs of pain) and they have
Fibromyalgia an increased tendency to bleed (bruise).
Typically prescribed drugs for fibromyalgia are anti- Typically prescribed drugs for persistent headaches
inflammatory analgesics, anti-anxiety drugs, and tri- are tricyclic antidepressant, and benzodiazepines.
cyclic antidepressants or selective serotonin reuptake Persistent headaches, depending on the history
inhibitors (SSRIs). of the client, may require prescriptions for a tricyclic
Fibromyalgia is a name given to a group of symp- antidepressant such as amitriptyline, or a long acting
toms marked by generalised pain (can be felt in many benzodiazepine anti-anxiety drug such as diazepam or
different parts of the body) and muscle stiffness. Sleep lorazepam. All these drugs cause sedation and the thera-
problems and attendant daytime tiredness are also com- pist may advise against the client driving a car immedi-
mon in fibromyalgia. ately after the consultation.
Clients experiencing fibromyalgia characteristi- Typically prescribed drugs for migraines are
cally complain of tenderness and pain in skeletal mus- β-adrenoceptor antagonists (β-blockers), antihista-
cles. This chronic condition may induce anxiety and mines, and serotonin antagonists.
depression. Typical medications include non-steroidal Clients experiencing a migraine headache with
anti-inflammatory drugs (NSAIDs; such as aspirin, nausea and vomiting are unlikely to present for mas-
paracetamol and indomethacin). Long-acting benzodi- sage. The migraine condition and its associated drug
azepines, such as diazepam and lorazepam, are favoured treatment are as complex as it is common. Prophylaxis
as anti-anxiety drugs. Occasionally an antidepressant may involve treatment with a β-adrenoceptor antagonist
such as fluoxetine, or amitriptyline (which has a seda- (β-blocker), or an antihistamine, or a serotonin antago-
tive and atropine-like effect), is required (see section on nist such as sumatriptan.
depression). For a review of current treatment strategies for
Pain perception of clients taking NSAIDs is reduced. migraine and other headaches in Australia see Chapter
Of particular importance in massage is that musculosk- 21 of Bryant and Knights (2006).
eletal pain sensitivity is lessened and the intensity of
massage should be reduced accordingly. These drugs Obesity
also have an anti-platelet action and therefore increase Typically prescribed drugs for obesity are stimulant-
the tendency to bleed. This is another reason for being anorectics, sibutramine, and antidepressants.
gentle with clients taking anti-inflammatory analgesics. Drugs used as adjuncts to the treatment of obesity
Clients who are taking anti-anxiety and antidepres- typically are the stimulant anorectics such as diethyl-
propion and phenyldimetrazine (Westfall & Westfall
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sant drugs should be reminded of their sedative effect

and possible additive sedation caused by the massage, 2006). The centrally acting neurotransmitter uptake
and given appropriate advice about driving after the inhibitor sibutramine is now being used (Sanders-Bush
massage. & Mayer 2006). Adverse effects of both groups of
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drugs include anxiety and agitation but, apart from the c lient. If the skin is infected then the practitioner should
need to reassure the client, no problems with massage wear gloves, and infected areas should be avoided (see
are likely. Chapter 10).
Antidepressants such as fluoxetine (ProzacTM) are
also prescribed occasionally. Reported effects of dizzi- Drug dependence and abuse
ness, nervousness and tremor may be noted by the cli-
Drugs typically abused in society are alcohol, opiates,
ent but again present no major concern for the client or
stimulants, cannabis and hallucinogens.
therapist.
Clients may present for massage while they are tak-
ing drugs (but not being treated for drug dependence),
Chronic fatigue syndrome (CFS)
or as part of a drug rehabilitation program. Much will
Typically prescribed drugs are selective serotonin reup- depend on whether the client has volunteered the infor-
take inhibitor (SSRI) antidepressants. mation about drug taking in the pre-massage history
Clients suffering from CFS may be prescribed a taking. The experienced practitioner should be aware of
SSRI antidepressant such as fluoxetine (see section on cues and take precautions accordingly.
depression). Alcohol and opiates such as heroin (and methadone
which is used in rehabilitation) are central nervous sys-
Menopause tem depressants, which cause sedation. If the therapist
Typically prescribed drugs for menopause are oestrogen suspects, or knows, that the client is under the influence
and progestogen hormone replacement therapy (HRT). of alcohol or illicit drugs a standard procedure is to refuse
The predominant treatment for the unpleasant treatment. If the client is receiving opioid replacement
symptoms of menopause, and the longer-term issue therapy (for heroin dependence) by means of metha-
of osteoporosis, is HRT involving serial courses of an done, LAAM (levo acetyl methadol) or buprenorphine,
oestrogen and a progestogen (Belchetz 1994). As osteo- their pain threshold is likely to be elevated and the ther-
porosis, and associated weakening of bone, is an issue apist will be accordingly careful in giving the massage.
for safety in massage it is reasonable (but not demon- After the treatment the client should be cautioned about
strated by data) that older post-menopausal women on the possibility of sedative effects of massage adding to
HRT would be less prone to inadvertent fracture during the effects of the drug, particularly if they are intending
massage. However, with warnings on adverse effects of to drive a car afterwards.
HRT, particularly regarding HRT being a risk factor for The rationale for the use of methadone, LAAM and
dementia, at least in older women (Woodward 2007), buprenorphine in the treatment of opioid dependence
long-term HRT therapy remains controversial. is that they are relatively safe substitutes for heroin.
HRT is unlikely to cause adverse effects of conse- Like heroin, they are opioid agonists but because they
quence for massage. Rather, HRT will reduce hot flush are given orally in a controlled environment (e.g. a
and skin sensitivity associated with menopause, which pharmacy) the psychological reinforcement associ-
might otherwise make massage intolerable. ated with illicit drug use paraphernalia and settings is
avoided and there is no risk of infection. Moreover,
these drugs, unlike heroin, are slowly inactivated by
Immuno-suppressant therapy the body so that the repeated need for a ‘quick fix’ is
Typically prescribed drugs for immunosuppressant attenuated.
therapy are corticosteroids and specific immuno-sup- Naltrexone is also used but, being an antagonist,
pressants. acts in a different way by blocking the effect of heroin.
High doses of corticosteroids such as cortisone or The rationale for the use of naltrexone is that if the drug
prednisolone are used (along with other medications) dependent person reverts to heroin it will have little or
to suppress the immune response in autoimmune disor- no effect.
ders, and in clients who have undergone an organ trans- Stimulants such as amphetamine and cocaine can
plant. Such therapy is usually long term and inevitably cause psychotic episodes as can methylenedioxy meth-
leads to adverse effects, some of which may impact on amphetamine (MDMA; ‘Ecstasy’). It is possible that
massage. massage could precipitate such an episode, thus endan-
Corticosteroids cause protein breakdown so that gering the client and practitioner. As with illegal use of
muscles become thinner and weaker, and skin develops opioids, it is standard practice to refuse a consultation
striae and a tendency to bruise. Corticosteroids cause in such cases.
negative calcium balance in bone, resulting in fragile Cannabis (particularly after chronic use) and hallu-
bones and osteoporosis. Fungal infection of the skin and cinogens such as LSD or psilocybin (from magic mush-
nails may also occur. For a review of immunosuppres- rooms) may cause psychoses. The practitioner will be
sant therapy see Schimmer and Parker (2006). aware that massage can induce emotional states and
The client should first seek advice from their pri- should be prepared to refuse a consultation if drug use
mary care practitioner before having a massage and is suspected, even if the client appears calm. Drug coun-
copyright law.
the massage therapist should contact the primary care selling may be proposed if the occasion arises.
practitioner if there are any doubts. Massage may then For further information on adverse effects of drugs
proceed gently and with constant feedback from the of dependence and abuse see O’Brien (2006).
Account: s8715057
DRUGS THAT CAUSE MUSCLE PAIN The danger with mild to moderate muscle pain is
This chapter has concentrated on the interaction between not so much the pain itself, but that the person pre-
commonly used drugs and the massage process. Until scribed the drug will stop taking it and miss out on
recently there has been little attention given to drugs the significant protective action against heart disease.
which actually cause muscle and joint pain although The practitioner would council against this action if
it has been long known that cocaine causes myalgia in the opportunity arose and refer the client back to the
some people and the muscle relaxant suxamethonium, prescriber. It is possible that a smaller dose could be
which is used to paralyse muscles in general anaesthesia, given or that the preparation is changed to more recent
causes postoperative muscle pain in some people. Two and less lipid soluble statin which may not penetrate
drug groups have become very commonly prescribed skeletal muscle cells to the same extent as earlier
in the past three decades: the angiotensin converting versions.
enzyme (ACE) inhibitors which became available in the The incidence of muscle pain seems to be much
late 1970s and the statins which became available in the higher during and after exercise, and one study shows
1980s. Both of these, particularly the latter, can cause that only 20% of athletes can tolerate the statins pre-
muscle pain. Table 13.2 lists drugs which are known to scribed for familial high cholesterol (Sinzinger &
cause muscle pain. O’Grady 2004); they either change to another drug strat-
egy for reducing cholesterol or give up on drug therapy
Statins entirely. For the general population this may also be a
concern when we consider that many people start to
Statins are typically prescribed drugs for reducing cho-
exercise in earnest when they learn they have high cho-
lesterol. The per capita incidence of muscle pain and
lesterol. It is ironic that the very drug prescribed to help
damage by statins is low (though variable depending on
the condition interferes with a new zeal for exercise. A
the report you read) but because the use of statins is so
counterpoint to be made is that, in clinical trial results,
prevalent (over 20% of men and women over the age of
the incidence of muscle pain in placebo-treated patients
50 are prescribed statins) it is likely that some clients
is almost as high as (but still significantly less than) in
presenting for massage because of muscle soreness are
patients receiving statins.
in fact experiencing an adverse effect of these drugs. In
very rare cases the drugs, particularly the ones which
were first introduced, cause muscle breakdown, a rise of ACE inhibitors
muscle protein levels in the blood and eventual kidney ACE inhibitors are typically prescribed drugs for reduc-
failure. The exact mechanism of the adverse effect on ing blood pressure. The most common adverse condi-
muscle is still uncertain but may be due to intracellular tion caused by ACE inhibitors is cough. Muscle pain is
depletion of essential metabolites, or destabilisation of a far less common adverse effect, however, given that
cell membranes, resulting in increased cytotoxicity. many people are given ACE inhibitors for the treatment
Table 13.2 Drugs that cause muscle pain
Therapeutic Incidence of Predisposing

Drug class Example use muscle pain factors Mechanism
ACE inhibitors Enalapril Reduce Uncommon Unknown Possibly increased
blood potassium levels;
pressure possible increased
levels of bradykinin
(a pain-producing
peptide)
Depolarising Suxamethonium Relax Common but Unknown but there Intense muscle
neuromuscular muscles in transient is a rare genetic contractions
blockers anaesthesia condition leading preceding relaxation
to exaggerated during anaesthesia;
response possibly increased
potassium levels
Statins Atorvastatin Reduce Mild pain Genetic (due to Intracellular
cholesterol common; absorption and depletion of essential
serious pain metabolic changes); metabolites or
and damage environmental (e.g. destabilisation of
copyright law.
uncommon exercise increases cell membranes,

chances) resulting in increased
cytotoxicity
Account: s8715057
of moderate to severe hypertension, it is possible that a Quinine

client or two will experience muscle soreness as a result Quinine, introduced from Central America into Western
of these drugs. Advice to the massage client would be use as a tonic, and then an antimalarial, has a protec-
for them to check with their doctor to get an opinion on tive effect on muscle. It reduces the frequency of tetanic
the possibility that the drug (and not something else) is contractions so that peak muscle tension during titanic
causing the problem. There are many other drugs which contractions is reduced. For this reason quinine is used
can be used to treat hypertension (see section on hyper- to reduce muscle cramps, and some clients may present
tension) and which do not cause muscle pain. for massage while taking this drug. There is no special
response demanded of the therapist.
Suxamethonium
Suxamethonium is used in general anaesthesia in order Dantrolene
to relax the pharyngeal/laryngeal skeletal muscle and Dantrolene is a drug used to reduce muscle tension
allow easy insertion of the anaesthetic gas tubes into and spasms in conditions such as spasticity. It acts to
the trachea. Its value is that it is very short acting. Suxa- reduce the calcium released within the muscle during
methonium is classed as a depolarising neuromuscular contraction. Hence the intensity of the contraction is
blocking drug because it blocks neuromuscular trans- reduced. There is no special response demanded of the
mission by causing a sustained depolarisation of the therapist.
muscle cell membrane in the region of the motor nerve
terminal. Anaesthetists observe repetitive muscle con- Botulinum toxin
tractions throughout the body for a few seconds after IV
Botulinum toxin (Botox™) is well known for its use
administration of the drug before the muscles become
in cosmetic enhancement procedures. It acts by pre-
flaccid (relaxed). The muscle pain that patients expe-
venting the release of the chemical transmitter acetyl-
rience postoperatively is probably due to the original
choline from nerve terminals and thereby blocks nerve
intense contractions caused by suxamethonium. Another
muscle transmission. It is also used to block transmis-
possibility is that potassium, released from cells that are
sion in painful spasm situations such as in cerebral
repetitively stimulated, in turn activates sensory (pain)
palsy (CP) but requires a repeat of the injections every
nerve terminals in muscle. In most cases a patient’s
3–6 months. Massage is an effective symptomatic (but
soreness will have passed before the patient leaves hos-
not curative) intervention for the treatment of CP either
pital but, after a short one-day procedure, it is possible
alone or in conjunction with Botox. With the muscles
that a client might present for massage for soreness
being more relaxed after Botox treatment, massage is
occasioned by suxamethonium. A gentle massage and
less likely to be painful and may therefore, safely, be
reassurance that the condition is short term is all that
more intense.
would be required. If the suxamethonium had been used
Whereas dantrolene is taken orally and is absorbed
as an adjunct to invasive surgery, or intense limb manip-
into the blood stream so that it tends to weaken muscles
ulation, then the massage therapist would of course
right throughout the body, Botox is injected into the
avoid contact around the site of the procedure.
spasm site and is thereby localised.
DRUGS THAT REDUCE MUSCLE CONCLUSION

SPASM Many massage clients will be taking prescribed or other
Benzodiazepines medications. Such medications may have an impact on
Benzodiazepines act to enhance the effects of the inhib- the safety and therapeutic outcome of massage therapy.
itory neurotransmitter GABA (gamma amino butyric The therapist should take a preliminary medication
acid) in the brain. GABA is the most common neu- record of the client, be equipped to advise clients, be
rotransmitter in the brain and it is not surprising that ready to modify the massage accordingly and to take
drugs which enhance its effect have multiple effects action to prevent adverse outcomes. Knowledge of typi-
and uses. Thus benzodiazepines are used as sedatives, cal effects of currently used drugs, and the ability to
anaesthetics, anti-anxiety agents and anti-epileptics. source information on newer drugs, is the necessary
Because they dampen neuronal activity, they are also precondition for appropriate actions.
used as centrally (i.e. brain) acting muscle relaxants.
They act by reducing the frequency of nerve impulses Questions and activities
in descending motor nerve pathways to skeletal mus- During pre-massage history taking your clients may
cles. They are used for acute and chronic muscle spasm report they are taking various medications. For each of
conditions. Clients from time to time will come for a the clients listed below, record:
massage to relieve muscle tightness and associated 1 further information (if any) you would seek from
pain. Since these drugs are sedatives, clients should be the client
warned of the risk of driving home after the massage 2 advice or warnings (if any) you would give to the
copyright law.
which itself is likely to make the client sleepy. More client

information on benzodiazepines is found in the section 3 actions you should be prepared to take during the
on anxiety. consultation.
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Client 1 — Reports he is taking pain killers for Friedman PA 2006 Agents affecting mineral ion
arthritis. homeostasis and bone turnover. In: Brunton LL et al
Client 2 — Says she is being treated with blood (eds), Goodman and Gilman’s The Pharmacological
thinners for clotting problems. Basis of Therapeutics (11th edn). McGraw-Hill, New
Client 3 — Says he is being treated by the doctor York, Chapter 61
Harrison DG, Bates JN 1993 The vasodilators. New ideas
for high blood pressure.
about old drugs. Circulation, 87:1461–7
Client 4 — Reports she is being treated with Hoffman BB 2006 Therapy of hypertension. In:
Tofranil™ for depression. Brunton LL et al (eds), Goodman and Gilman’s The
Client 5 — Seems agitated and wants the massage Pharmacological Basis of Therapeutics (11th edn).
to calm herself down but does not recall taking McGraw Hill, New York, Chapter 32
any prescribed medications. Holst S, Lund I, Petersson M, Uvnäs-Moberg K 2005
Client 6 — Says she takes a drug for cholesterol and Massage-like stroking influences plasma levels
wants a massage because she has sore legs. of gastrointestinal hormones, including insulin,
and increases weight gain in male rats. Autonomic
Further reading Neurosciences, 120:73–9
Kaada B, Torsteinbo O 1989 Increase of plasma β-
Bryant B, Knights K 2006 Pharmacology for Health
endorphins in connective tissue massage. General
Professionals (2nd edn). Mosby, Sydney
Pharmacology, 20:487–9
Brunton LL et al 2006 Goodman and Gilman’s The
Kita M, Goodkin DE 2000 Drugs used to treat spasticity.
Pharmacological Basis of Therapeutics (11th edn).
Drugs, 59:487–95
McGraw Hill, New York
Leonard BE, Richelson E 2000 Synaptic effects of
Katzung B et al 2007 Basic and Clinical Pharmacology
antidepressants. In: Buckley PF, Waddington JL
(10th edn). Mosby, London
(eds), Schizophrenia and Mood Disorder: The New
MIMS Annual 2008 MIMS Australia & CMPMedica
Drug Therapies in Clinical Practice. Butterworth–
Australia Pty Ltd, St Leonards
Heinemann, Boston
Upfal J 2006 The Australian Drug Guide (7th edn,
McLennan W 1997 Mental Health and Wellbeing; Profile
revised). Black Inc, Melbourne
of Adults. Australian Bureau of Statistics, Canberra
Marcus R 2002 Perspective article. An expanded
References overview of postmenstrual osteoporosis. Journal of
Australian Institute of Health and Welfare 2001 Chronic Musculoskeletal and Neuronal Interactions, 2(3):195–7,
Diseases and Associated Risk Factors. AIHW, Online. Available http://www.ismni.org/jmni/pdf/Marcus.
Canberra pdf, (accessed 4 August 2009)
Baldessarini RJ 2006 Drug therapy of depression Michel T 2006 Treatment of myocardial ischemia. In:
and anxiety disorders. In: Brunton LL et al (eds), Brunton LL et al (eds), Goodman and Gilman’s The
Goodman and Gilman’s The Pharmacological Basis Pharmacological Basis of Therapeutics (11th edn).
of Therapeutics (11th edn). McGraw-Hill, New York, McGraw Hill, New York, Chapter 31
Chapter 17 MIMS Annual 2008 MIMS Australia & CMPMedica
Baldessarini RJ, Tarazi FI 2006 Pharmacotherapy of Australia Pty Ltd, St Leonards
psychosis and mania. In: Brunton LL et al (eds), O’Brien CP 2006 Drug addiction and drug abuse. In:
Goodman and Gilman’s The Pharmacological Basis Brunton LL et al (eds), Goodman and Gilman’s The
of Therapeutics (11th edn). McGraw-Hill, New York, Pharmacological Basis of Therapeutics (11th edn).
Chapter 18 McGraw Hill, New York, Chapter 23
Belshetz PE 1994 Hormone treatment of postmenopausal Pferrerkorn JA 2009 ‘Muscle-sparing’ statins: preclinical
women. New England Journal of Medicine, 330:1062– profiles and future clinical use. Current Opinion in
71 Investigational Drugs, 10:245–52
Bender T, Nagy G, Barna I, Tefner I, Kádas E, Géher P Phillips PS, Haas RH, Bannykh S, Hathaway S, Gray N L,
2007 The effect of physical therapy on beta-endorphin Kimura BJ, England JD F 2002 Statin-associated
levels. Euopean Journal of Applied Physiology, myopathy with normal creatine kinase levels. Annals
100:371–82 of Internal Medicine, 137:581–5
Bryant B, Knights K 2006 Pharmacology for Health Rocco TP, Fang JC 2006 Pharmacotherapy of congestive
Professionals (2nd edn). Mosby, Sydney heart failure. In: Brunton LL et al (eds), Goodman and
Davis SN 2006 Insulin, oral hypoglycemic agents, and Gilman’s The Pharmacological Basis of Therapeutics
the pharmacology of the endocrine pancreas. In: (11th edn). McGraw-Hill, New York, Chapter 33
Brunton LL et al (eds), Goodman and Gilman’s The Sanders-Bush E, Mayer SE 2006 5-Hydroxytryptamine
Pharmacological Basis of Therapeutics (11th edn). (serotonin): receptor agonists and antagonists. In:
McGraw-Hill, New York, Chapter 60 Brunton LL et al (eds), Goodman and Gilman’s The
Day JA, Mason RR, Chesrown SE 1987 Effect of massage Pharmacological Basis of Therapeutics (11th edn).
on serum level of beta-endorphin and beta-lipotropin in McGraw-Hill, New York, Chapter 11
healthy adults. Physical Therapy, 67:926–30 Schimmer BP, Parker KL 2006 Adrenocorticotropic
copyright law.
Findling RL, Dogin JW 1998 Psychopharmacology of hormone; adrenocortical steroids and their synthetic
ADHD: children and adolescents. Journal of Clinical analogs; inhibitors of the synthesis and actions of
Psychiatry, 59 (suppl 7):42–9 adrenocortical hormones. In: Brunton LL et al (eds),
Account: s8715057
Goodman and Gilman’s The Pharmacological Basis Woodward M 2007 Dementia Risk Reduction: the
of Therapeutics (11th edn). McGraw-Hill, New York, Evidence. Alzheimer’s Australia, Paper 13. Online.
Chapter 59 Available: http://www.alzheimers.org.au/upload/Risk
Securs MB 2002 Adverse effects of β-agonists. Journal of ReductionSept07.pdf (accessed 4 August 2009)
Allergy and Clinical Immunology, 110:S322–8 The Million Women Study 2009. Online. Available: http://
Serruys PW, Brower RW, Katen HJ, Bom AH, Hugenholtz www.millionwomenstudy.org/publications/ (accessed
PG 1981 Regional wall motion from radiopaque 3 Aug 2009)
markers after intravenous and intracoronary injections Westfall TC, Westfall DP 2006 Adrenergic agonists and
of nifedipine. Circulation, 63:584–91 antagonists. In: Brunton LL et al (eds), Goodman and
Sinzinger H, O’Grady J 2004 Professional athletes Gilman’s The Pharmacological Basis of Therapeutics
suffering from familial hypercholesterolaemia rarely (11th edn). McGraw-Hill, New York, Chapter 10
tolerate statin treatment because of muscular problems.
British Journal of Pharmacology, 57:525–8
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copyright law.
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SECTION 5
body mechanics for
14
the practice of massage1
Lauriann Greene
and Richard W Goggins chapter
LEARNING OUTCOMES
l List the five primary steps to injury prevention
l Describe the three main aspects of body mechanics
l Describe or demonstrate neutral posture while standing and sitting
l Describe at least two important pieces of advice to follow to avoid hand and wrist injury
INTRODUCTION p reventing MSDs. Since multiple factors are involved

The work massage therapists do is physically demand- in causing work-related injuries, a successful prevention
ing. Massage practitioners: strategy must be holistic and multifaceted, combin-
l use repetitive movements combined with hand force
ing many of these tactics to address all of the potential
l hold pressure or stay in one position for a long time,
causes.
causing static loading to their tissues There are five primary steps to injury prevention:
l work in awkward postures that stress vulnerable
1 maintaining awareness of the risk of injury in your
parts of their bodies. work
These work-related risk factors, combined with 2 understanding how risk factors cause injury
other personal physical and emotional risk factors, 3 reducing risk factors through ergonomics
result in a high rate of symptoms and musculoskeletal 4 developing good body mechanics and work
disorders (MSDs) (Greene & Goggins 2006; Albert et al practices
2007). Therapists report MSDs most often in the parts 5 taking care of your general physical and emotional
of their bodies that are most vulnerable to musculosk- health, including physical conditioning.
eletal injury — the thumbs, wrists, shoulders, neck and
lower back. ERGONOMICS: A FIRST STEP
Injury is preventable, however. There is a great deal TOWARD GOOD BODY MECHANICS
you can do to prevent injuries from occurring in the first Because a massage therapist’s work is so physically
place, and to minimise their effects if they do occur. demanding, workplace risk factors play a primary
Developing good body mechanics is an important part role in causing MSDs among these practitioners. The
of a holistic approach to injury prevention. science of ergonomics provides proven and remark-
ably effective ways of addressing these risk factors to
A holistic approach to injury prevent injury by making the work environment fit the
prevention worker better.
Proven methods exist to lower the incidence of work- Good body mechanics and good ergonomics go
related injury. Many of them involve making simple but hand in hand. You won’t be able to use good body
important changes to your activities, both at work and mechanics in a workspace that is poorly designed and
elsewhere; others will take more thought and practice to doesn’t fit your body. If your table is not at the right
apply. But taking the necessary steps to prevent injury height and width for your body and your techniques,
is much easier and less disruptive to your career than for example, your posture will suffer no matter how
dealing with an injury once it has occurred. much you try to focus on working in the proper posi-
copyright law.
Decades of research have shown that reliance on tions. On the other hand, if you don’t use good body
just one tactic, such as improving your body mechanics mechanics when working at your table, you won’t be
or doing strengthening exercises, is rarely effective in getting the full injury prevention benefit of having an
143
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144 Section 5 Providing the massage treatment
adjustable table and setting it to the proper height. The The goal is to have ‘good’ body mechanics, not ‘per-
best results occur when you use ergonomics principles fect’ body mechanics. In the real work world, no one
and body mechanics principles simultaneously in your uses perfect form at every moment. The idea is to use
work. your body in a natural and efficient way, maximising
In addition to helping you avoid awkward postures, your strength and avoiding overuse of the most vulner-
good body mechanics often help you reduce your over- able parts of your body.
all level of effort. By using your body more efficiently,
you will use muscles that are best suited for the work Breathing
and avoid fatigue and stress to your tissues. Deep, regular breathing is an essential component of
good body mechanics. Poor, shallow breathing is often
Good ergonomics supports good the result of physical tension caused by emotional
body mechanics stress, and can be the first indication that you are not
Following these principles of ergonomics will help you using good body mechanics. Shallow breathing and
to use good body mechanics at all times: breath holding have a number of negative effects:
l Take the time to adjust the height of your treatment l your muscles receive less oxygen, something that
table based on the size of your client and the tech- they need to work efficiently
niques you will be using. A power-adjustable table l accumulated tension contributes to static loading in
allows you to make these adjustments quickly, even the tissues

in the middle of a session. l emotional tension interferes with overall body
l Make sure you have adequate space around your awareness.

table, so you can open up your stance and use As you work, focus on maintaining a deep, regular
your lower body to generate power and movement. breath pattern. If you catch yourself breathing shallowly
A good guideline is to leave at least 1 metre (3 feet) or holding your breath, ask yourself if you are emotion-
of open space around all sides of the table. ally stressed or physically tense or tired. If you are emo-
l Wear comfortable, supportive shoes with good trac- tionally stressed, try to figure out why and use coping
tion, and make sure that flooring surfaces provide techniques to let go of the stress. If physical tension is
good traction. This will also help you to use your the problem, examine your body mechanics and see if
lower body more effectively. your posture or technique might be the cause. In either
l Avoid over-scheduling, limiting the number of mas- case, consciously taking a deep breath from the dia-
sages you do in a day or week to what your body phragm and blowing it out slowly will almost instantly
can comfortably handle. Also avoid scheduling too counteract both emotional and physical tension.
many demanding massage sessions, such as deep
tissue work, back-to-back. It’s important to avoid Posture
becoming fatigued, since fatigue can hamper your The position that places the least amount of stress on
coordination and affect your body mechanics. the body is called ‘neutral posture’. In neutral posture:
l Set clear boundaries with your clients and with l your joints are aligned and under minimal stress
yourself. Be prepared to politely say ‘no’ to clients l your muscles move in their mid-range of motion,
who request techniques or treatments that would where they work most efficiently and generate
place you at risk for injury. greater force with less effort
l your nerves, ligaments and blood vessels are not
DEFINING GOOD BODY MECHANICS compromised.
Good body mechanics is the use of positions, postures By aligning your joints, your skeleton will bear
and movement patterns that allow you to distribute most of your body weight and take the stress off your
stress evenly throughout your body. Practicing good muscles and tendons. In manual treatment, the arms are
body mechanics allows you to use the strength and often used in a weight-bearing capacity; for example,
momentum of the entire body to create motion, rather when you lean in with your upper body weight to apply
than using smaller parts of your body that are more pressure. By keeping your wrists and elbows straight,
easily injured. As a result, your movements are more you will transfer the load up through the skeletal system
flowing, even, relaxed and controlled. to the larger muscles of your chest and shoulders.
Body mechanics concentrates on three aspects of Reasons to use these larger muscles include:
your work: l they are stronger and better suited to applying force
1 your breathing than smaller muscles

2 your posture, or the way you align the different l you can apply the same amount of force with less
parts of your body effort

3 your movements, including your techniques and l they will be less likely to fatigue and become injured
how you position your body in relation to your than smaller muscles.
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client’s body. When you begin to work, it is important to start in

These three components work together, supporting a neutral posture. It will form the basis of your body
and building on each other. mechanics, and you should return to it as often as
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14 Body mechanics for the practice of massage 145
p ossible during your sessions to give yourself much- below your elbow level. This will allow you to use your
needed moments of rest and recovery. If you get in the body weight to apply pressure, without bending and
habit of working in this way, your body will eventu- stressing your lower back. A ‘thicker’ client or a client
ally develop a memory for your neutral posture and will in side-lying position will require a lower table height.
instinctively want to return to it. For deep tissue work, passive stretching, and other tech-
niques requiring more force, use an even lower table
Standing neutral posture setting so you can use more of your body weight to
To familiarise yourself with standing neutral posture apply pressure.
and experience what it feels like, stand in front of a
mirror with your feet roughly at shoulder width, with Seated neutral posture
your knees straight but not locked. Make sure your Except for the position of your legs, seated neutral pos-
major joints are aligned: ture is basically the same as standing neutral posture.
l ears over shoulders Additional elements to look for include:
l Feet flat on the floor for stability.
l shoulders over hips
l Knees bent at 90 degrees, or lower legs extended a
l hips over knees
l knees over ankles.

bit in front of you
l Hips slightly higher than your knees
Look for these main elements of standing neutral
posture: l Greater than a 90-degree angle between the tops of
l three curves in your spine — inward in your lumbar

your thighs and your torso.
region, outward in your thoracic region, and inward You may want to sit higher than you would at a com-
in your cervical spine puter or at the dinner table so you can use more of the
l head level, forehead and chin perpendicular to the
muscles in your torso and hips and be ready to ‘pop
floor up’ quickly to do a technique that is better done while
l shoulders relaxed, clavicle bones parallel to the
standing.
floor For delicate work, such as treatment to the head and
neck area, place the table at or just below seated elbow
l scapulae down and flat against your ribs
level. It may also help to have your elbows supported or
l upper arms hanging down at your sides
resting on the table as you do these small motions.
l elbows slightly bent
Standing and seated neutral postures should feel
l wrists straight comfortable. If you find these postures difficult to attain
l hands close to the neutral ‘handshake’ position. or maintain, it may be that your body has made adap-
To maintain a neutral posture while standing, adjust tations over the years that have tightened or weakened
your table height according to the size of your client your muscles. To restore neutral posture, you will need
and the techniques you do. For work requiring moderate to stretch tight muscles and strengthen weak ones.
downward pressure but long strokes, such as relaxation Exercises designed to improve posture and receiving
massage, adjust your table so that the client is 5–8 cm massage can be very helpful.
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Figure 14.1 Standing neutral posture for most massage

work. Stand behind the stroke to generate more force. Figure 14.2 Seated neutral posture for precision work
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Working in near-neutral postures your way up. In general, keep your feet approximately
The concept of good body mechanics is to move shoulder width apart.
through a range of near-neutral postures in order to
minimise stress on your body. Good body mechanics Working at the head or foot of the table
are dynamic, with postures that are always changing. When you work at the head or foot of your table, your
As you start your day, arrange your table, your seating, feet should be directly under your shoulders, or place
and other elements of your workplace to enable you to one foot a bit forward and one behind. Face the client
begin your work in a neutral posture. squarely and avoid any twisting motions, so you keep
your hips and shoulders in line with the table.
Positioning your client
Client comfort is a priority, but so is your comfort as a Working at either side of the table
practitioner. It is nearly always possible to find a posi- When you are working at either side of the table, place
tion that is comfortable for the client, and also allows your outside foot ahead of you and the foot closest to
you to maintain near-neutral postures as you work. the table behind you. This position will turn your hips in
Position your clients close enough to you that you do towards the table while allowing you to shift your weight
not have to hold your arms far out in front of you or back and forth during longer strokes or movements.
lean forward to reach them. If you are standing at the Be sure to maintain the natural curves of your spine
side of the table, work only on the side of the client that and avoid ‘rounding’ your back, particularly in the lum-
is closest to you. To avoid reaching across the client to bar spine. If you do not have a power-adjustable table
work on their far side, walk around to the other side of and you need to work at a lower angle to the client,
the table. widen your stance and bend your knees a bit to get
If you are applying a particular technique, use the lower rather than bending at the back. Stand behind
hand that is closest to the area you are treating to avoid your strokes, with your feet well back of where your
reaching. There is nothing wrong with asking clients to hands are on your client, and use your legs and hips
move over to the side of the table closest to you. to create movement. Focus on keeping your hips under
You can also position the client’s legs or arms for your torso rather than letting your pelvis tilt back or
easier access. Abducting a client’s leg or arm so it forward.
angles towards the side of the table will allow you to
work on that body part without having to twist, bend Movement of the torso
or reach. Pay particular attention to the way you move your lower
A good rule of thumb is to work only on the parts back, neck and shoulder girdle. Many muscles run
of your client’s body that you can access directly, both between the neck and shoulder, so movement in one of
visually and manually. For example, with your client these areas will affect the other. The thoracic spine is
lying supine, you would work on the front of the quadri- relatively inflexible, so the way you move your shoul-
ceps, but then move the client into a side-lying position ders will directly affect your lower back and hips, and
to work on the iliotibial band. vice versa.
You have the option of placing your clients either
prone, supine, side-lying or seated. You will find that Movement of the lower back
certain techniques are more effective and easier to per-
form in one position than in another. Experiment by To protect your lower back, avoid bending forward
placing your clients in all four positions, and identify more than 20 degrees or twisting at the waist, particu-
which of your techniques works best in each position. larly while you are lifting or applying any amount of
Learn to work with the position, not against it. force. Move your feet to reposition your body so you
are squarely in front of the part of your client you want
to work on to avoid twisting. If you have to bend for-
Movement ward, you can minimise strain on your lower back by
Now that you are aware of your breathing and posture, maintaining a neutral spine and supporting the weight
and your client is optimally positioned, it is time to start of your upper body with your arms.
moving. You will want to keep moving as you work to
increase circulation and use your larger muscles to gen- Movement of the neck
erate force. As you move, use your breathing to coun- Try to maintain the inward curve in your neck and keep
teract any tension that may develop so your movements your head in a neutral position — balanced squarely
remain fluid and relaxed. over your cervical spine rather than thrust forward,
tipped downward, tilted or twisted to the side. Maintain
Starting with a solid base of support a small amount of movement in the neck to prevent ten-
To be able to use the force and momentum of your entire sion from building up in the neck muscles.
Your vision plays an essential role in the way you
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body, you need a stable base of support. With your

lower body stable, but flexible, the rest of your body can position your head and neck. If you focus your vision
move fluidly, including your knees, hips and shoulder on the client lying on a table, you will tilt your head
girdle. To generate force, start at the ground and work forward and stress the neck muscles. Visual assessment
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and periodic monitoring of the client is important, but it straight. Avoid flexion and extension, as well as ulnar or
is not necessary to stare down at them during the entire radial deviation. Taking your wrists out of neutral as you
treatment session. When you do need to look down, apply pressure with your hands places more stress on
gaze downward with your eyes, tipping your head down their tendons, and increases the pressure within the car-
as little as possible. pal tunnels in your wrists, all of which can lead to injury.
There is a small range (10–15 degrees) of wrist
Movement of the shoulders bending that is acceptable and will not add undue stress
Many people, including massage therapists, stand with to the joints. A good visual indication that you are bend-
their shoulders internally rotated, their chests caved in, ing your wrists too much is wrinkles or folds in the skin
and their heads jutted forward. Working with your shoul- on the side you are bending toward. You can help keep
ders rounded forward or elevated is one of the more awk- your wrists straight by supporting one hand with the
ward and potentially damaging positions you can get into. other as you apply pressure.
Protect your shoulders by keeping them down and
back as much of the time as possible. When tension
or fatigue set in, you may find yourself elevating your
shoulders and winging out your elbows to the sides. Ask
yourself periodically ‘where are my shoulders?’ and
consciously bring them back down if necessary. Take a
deep breath to counteract tension that could be causing
you to raise your shoulders. Bring your elbows in close
to your sides and slide your shoulder blades down your
back. Squeeze your shoulder blades together a little to
stabilise them. Keep your sternum forward and lifted, to
avoid caving in at the chest.
Movement of the upper extremities

Although you may use your hands and arms to deliver
treatment, they should be the last part of a chain of
movement, rather than the initiators of the movement. Figure 14.3 Supporting the wrist helps to keep it
Whenever possible, avoid moving your upper extremity straight
independently from the rest of your body. Your power
should come from your core muscles, chest, back, hips
You should also keep your thumbs as straight as pos-
and legs, not just from your arms. The only exception to
sible when using them, but even then limit how much you
this rule will be small, precise techniques done with light
use them and how much pressure you apply with them.
pressure, which require using only the small muscles of
Your forearms and elbows are good alternatives to over-
your hands and arms. If you start by using light pressure
using your fingers, thumbs or hands in massage work.
and progress to using deeper pressure, consciously take
the time to transition to using larger muscles. If you are
seated, you may need to move to a standing position to
allow you to engage the rest of your body.
Using your hands, fingers, and particularly your
thumbs by themselves should be kept to a minimum in
your work. Moving these small, vulnerable structures
independently places them at too great a risk of injury.
Restrict your use of these delicate structures to the work
you do with little to no pressure. Keep your hands soft
and relaxed to avoid static loading of the intrinsic mus-
cles of the hands.
As you lean in with body weight, keep your elbows
fairly straight, but not locked, so you can use the mus-
cles in your upper arms to protect your elbow joints.
Avoid fully pronating or supinating your forearms,
particularly when you apply pressure, since these posi-
tions stress the attachments of the flexor and extensor
muscles at the epicondyles of the elbow. These mus-
cles have only so much stretch to them, and if they are
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pulled taut by forearm rotation, they will be more easily

strained by finger movements or wrist bending.
The most important single piece of advice to follow Figure 14.4 Keeping the thumb straight reduces the
to avoid hand and wrist injuries is to keep your wrists chance for injury
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to avoid static loading or repetitively doing the same

techniques in the same position.
Frequently changing your position helps dispel mus-
cular tension, increases circulation, and provides gen-
eral physical conditioning. The impact of your work is
more evenly distributed to your body as a whole, rather
than fatiguing just your upper extremities. Make it a
goal to move frequently and fluidly around the table,
repositioning yourself and your client as needed. The
best strategy for your long-term health is to develop
multiple ways to treat any given part of the body or
pathology.
Balancing large movements and small

movements
When you work on adhesions, trigger points, or spe-
cific injury sites, you may feel that you have to do a
lot of small, repetitive movements on a small area of
a client’s body. Continual, intensive treatment of small
Figure 14.5 Using the forearm as an alternative to the
areas during a lengthy session is not a good idea for
fingers and thumbs your musculoskeletal health, nor is it an effective treat-
ment strategy for most clients. Try to balance periods
of intense treatment with lighter treatment. Limit the
time you spend treating small areas with fine, intensive
movements to a small percentage of the total treatment
time for that client.
Maintaining awareness of your body

mechanics
Even with the best of intentions, it can be difficult to
practice good body mechanics consistently during your
workday. As your awareness slips, you can find yourself
pushing your body past its limits or developing bad
habits over time. Pay close attention to the way your
body is responding to the work you are doing. A happy
medium exists where your own needs and self-aware-
ness are balanced with your concentration on your cli-
ent’s needs.
Self-awareness helps you stay in tune with your
body and respond promptly to symptoms. As you work,
remain attentive to the signals your body is sending
you. Fatigue, tension, discomfort, pain, and shallow or
held breath are indications that your body mechanics
are less than ideal, that the techniques you are using are
putting too much stress on your body, or simply that
Figure 14.6 Using the elbow as an alternative to
the hands
you are emotionally stressed or overworked. The faster
you can identify the cause of the problem and correct
it, the better you will be able to protect yourself from
injury.
Varying your movements

Questions and activities
Even if you are using good body mechanics, you can
still overuse a part of your body. If you overuse your 1 What ergonomic principles will you put into
hands, fingers and thumbs, you can still injure yourself. practice to aid the use of good body mechanics?
2 What relationship does breathing have to body
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For this reason, varying the parts of your upper extremi-

ties to deliver treatment is essential in preventing upper mechanics?
extremity MSDs. The same holds true for your neck, 3 Describe what ‘neutral posture’ refers to and how
back and lower extremities; you need to keep moving this posture can be of benefit to you in practice.
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Endnote References
1 This chapter has been adapted from Save Your Albert WJ et al 2007 A survey of musculoskeletal injuries
Hands! The Complete Guide to Injury Prevention and amongst Canadian massage therapists. Journal of
Ergonomics for Manual Therapists (2nd edn) 2008, Bodywork and Movement Therapy, 1–8
with the permission of Body of Work Books, an imprint Green L, Goggins R 2006 Musculoskeletal symptoms and
of Gilded Age Press injuries among experienced massage and bodywork
professionals. Massage & Bodywork, Dec–Jan:48–58
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positioning and draping the client

Lisa Casanelia chapter 15
LEARNING OUTCOMES
l Demonstrate accepted practice and procedure for draping, pillowing and positioning
of clients
l Adapt draping and positioning of clients for massage according to individual needs
INTRODUCTION DRAPING MATERIALS

When a client is receiving a massage for the first time The therapist can choose to use a variety of draping
he/she may feel apprehension regarding disrobing materials, such as towels, sheets and blankets, dispos-
and what areas of the body may be exposed. A com- able linens, fitted linens that fit snugly onto the massage
plete explanation of what clothes should be removed table, or any combination of all of these things. What-
and how only the agreed areas to be massaged will ever the therapist chooses, they must ensure that drap-
be uncovered at any given time will ensure the client ing materials are freshly laundered, stored in a clean
feels safe, secure and adequately covered throughout and dry environment and only used for single use. To
the massage. To ensure this happens the professional launder massage linens some therapists choose to use
therapist must have the ability to drape (or cover) a linen service that supplies and launders their linens.
the client, and move the client from one position to In a busy practice this may be a practical idea as laun-
another during the course of the massage treatment, dering linens every day can be time consuming for the
in a manner that appears easy and natural to the
client, and does not disrupt the flow of the massage. Box 15.1 Draping guidelines
The purpose of this chapter is to describe simple
methods of draping and positioning the client so as l Only the area being massaged should be
to promote the effects of the massage and maximise ndraped.
u
treatment benefits for the client, in an environment l Only the areas the client has consented to
that is safe and secure. massage should be undraped.
l Ensure feet are adequately draped, as the
THE IMPORTANCE OF DRAPING extremities are likely to feel the cold.
A full body relaxation massage requires the therapist l Instil trust in the client with efficient, confident
to skilfully manage movement from one body area to and secure draping practices.
another and the draping and undraping of each part of l Create a firm and secure boundary — a ‘draping
the body without disrupting the flow of the massage. line’.
When used effectively, draping will appear effortless l Do not place your hands beyond the draping line.
to the client and create a natural flow in the massage l Use freshly laundered draping materials.
sequence. The procedure of draping is important for the l If choosing to work with towels ensure they are
maintenance of privacy and warmth of the client during large enough to make the client feel adequately
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the massage treatment. covered, or use more than one towel.

Before putting draping into practice the therapist l Keep a blanket at hand to ensure the client can
should give careful consideration to the draping guide- be warmed at any time.
lines described in Box 15.1.
151
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Box 15.2 Draping materials
l Fitted sheet, a towel or other suitable covering to

completely cover the massage table.
l Fitted cover, a handtowel or disposable cover to
protect the face cradle.
l Towels or sheets to cover the client.
l Blankets to drape over other linens to keep the

client warm.
l Pillowcases to protect pillows.
l Handtowels to cover bolsters, create towel rolls,

or drape the chest.
l Handtowels for the therapist’s hands, to remove
excess oil and to use as a barrier between client
and therapist. Figure 15.1 Client fully draped in prone position
on the massage table, as it can be confusing for those who

Box 15.3 Laundering massage linens are new to massage. When covering the client the thera-
pist should adopt draping techniques that cover areas
l Cold-pressed vegetable oils are superior to the of the body that are not being massaged. Such draping
heat-extracted oils and will wash out more readily. techniques will define the physical boundaries or param-
l Water-soluble massage oils are designed to
eters of the massage, and ensure the client feels secure,
wash out well from linens. well covered and warm during the massage treatment. To
l The use of epsom salts, lectric soda, eucalyptus
maximise client warmth throughout the massage it may
oil or specialised detergents in the washing be necessary to add extra draping such as a blanket.
process can aid the removal of oils from the linen.
l All linens should be laundered promptly after DRAPING TECHNIQUES
use. Do not let them sit in a linen basket for days Draping that is performed with ease, and a minimum
before washing. of tucking and adjusting, instils in the client a sense
of confidence about the therapist’s level of skill and
professionalism.
therapist. The draping materials required by the mas- The following draping techniques aim to provide the
sage therapist in practice are outlined in Box 15.2. massage therapist with easy-to-use methods of draping
Despite regular laundering, draping materials will the client, whilst maintaining the security and comfort
have a tendency to accumulate massage oil. They may of the client. Although there are many different ways
become heavy with the oil as it builds up over time and to drape, the following methods of draping have been
develop a greasy feel. As a result of this build-up, linens chosen because of their simplicity for both the client
develop an unpleasant odour, and therefore will need to and the therapist.
be replaced regularly. To increase the longevity of lin-
ens, the therapist should observe the guidelines outlined Client fully draped in prone
in Box 15.3. position
Adjust the draping on the client when first entering the
MASSAGE TABLE PREPARATION massage room, as it is often difficult for the client to
Before the client arrives the therapist should take the drape fully when arranging themselves on the massage
time to prepare the massage table with fresh linens. table. Cover the body completely from neck to toes and
The massage table should be completely covered with a if necessary cover this draping again with a blanket for
towel, sheet or fitted sheet so that the client’s skin does extra warmth. Ensure the client is comfortable with bol-
not come into contact with the surface of the massage sters and pillowing and is adequately warm before com-
table. Where the therapist is using a face cradle attach- mencing the massage (Figure 15.1).
ment, fitted covers or disposable covers can be used.
Handtowels or pillowcases can cover the bolsters or pil- Undraping the back
lows required during the massage. Towels can be placed If a blanket covers the draping, fold this back so that it
at the end of the massage table for the client to drape is double folded over the legs.
himself or herself with or, if a sheet is being used, the With the draping that is directly covering the client’s
sheet should be placed over the massage table with the
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back, pick it up at the low back and tuck this section into
edge folded back so the client may climb in between. the waist of the client’s underwear (Figure 15.2.a).
After the consultation, the therapist must give clear Slide the underwear and draping down to the base of
instructions to the client about how to position themselves the sacrum and fold the top part of the draping down to
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15 Positioning and draping the client 153
Figure 15.2a Tuck the drape into the underwear

Figure 15.3a Fold drape over the lower limb toward
the midline
Figure 15.2b Completed undraping of back

Figure 15.3b Lift the leg to pull the edge of the
draping under the thigh
this drape line to create a flap (Figure 15.2b). This flap
can be used to cover the lower part of the back whilst
working the upper part of the back. It can be easily
flipped back and forth over the back without needing to
interrupt the flow of the massage or the need to tuck and
untuck the draping.
To redrape the back, fold the flap back over the cli-
ent’s back and slide it out from the underwear and over
the back.
Undraping the lower limb

The same draping procedures are used for undraping
the lower limb for both the anterior and posterior aspect.
l When a blanket covers the draping, fold one edge
back so that it is double-folded over the leg not
being massaged.
l With the draping that is directly covering the client,
fold it back over the leg so that the edges fall to the Figure 15.3c Posterior lower limb undraped
midline between the legs (Figure 15.3a).
l Lift the leg that is undraped by supporting it around
the inside of the lower leg with the inside arm (fac- l The draping should sit high on the inner thigh and
ing the head of the table).
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be firm for the client to feel its presence. The top

l The other hand reaches under the leg being lifted to part of the draping at the hip can be tucked into the
pull the drape from the midline of the thigh to the side leg of the client’s underwear or anchored under
of the table towards the hip (Figures 15.3b and d). their hip (Figures 15.3c and e).
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Figure 15.3d Lift the lower limb to pull the edge of the Figure 15.4 The arm undraped
draping under the thigh
flexion, external rotation and abduction. The therapist

must also adjust the client’s draping in this new position
by pulling tight on the edge of the drape at the hip to
ensure the drape is tight around the client’s inner thigh
(Figure 15.3f).
To redrape the lower extremity, lift the leg as done
to drape, and slide the draping out from below the leg.
Undraping the arm

When the client is in supine position and completely
draped, fold the draping back at the shoulder on the
diagonal to reveal the arm. Slide the client’s arm out
from beneath the drape, lift their arm and replace the
drapes so that the arm rests on top of the draping (Fig-
Figure 15.3e Anterior lower limb undraped
ure 15.4). To redrape the arm, reverse the undraping
process.
Undraping the abdomen and chest

Standards in professional practice recommend appro-
priate draping of breasts during a massage. To access
the abdomen and maintain the draping of the chest and
breasts a handtowel is used.
l The handtowel is placed over the chest and secured
by the therapist at the top edge with one hand.
l The therapist’s free hand slides the main drape from
under the handtowel and this is then folded back to
expose the abdomen.
l The handtowel can be secured in under the cli-
ent’s arms and folded accordingly to reveal as
much of the abdomen and ribs as possible whilst
maintaining secure, adequate draping of the breast
area.
Figure 15.3f Tighten drape around inner thigh l The main drape can be secured by tucking it into the
client’s underwear at the hips.
Whilst massaging the abdomen the handtowel can
This method of draping for the lower limb is also be extended to cover the top of the shoulders and chest
ideal for the client who prefers not to wear underwear to keep these areas warm (Figure 15.5).
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when receiving a massage as it creates a firm and secure When massaging the top of the chest, the abdomen
draping line around the inner thigh. can be redraped and the top of the towel at the chest
Access to the inner thigh in supine position, will folded back to the level of the underarm. The drap-
require the therapist to manoeuvre the lower limb into ing can be secured by tucking the towel in between
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Figure 15.7a The back undraped in side-lying position
Figure 15.5 The abdomen undraped
Figure 15.7b Undraping the top leg and thigh in

side-lying position
l To undrape the back, the drape can be folded diago-

nally to reveal the back and secured into the waist
Figure 15.6 The abdomen and chest of a male client of the client’s underwear at the low back and also
undraped
tucked in under the client’s upper arm to prevent
exposure of the anterior torso (Figure 15.7a).
To add greater security for a female client provide
the side of the client’s body and their arms. The same a pillow to hold against their chest which they can
procedures can be followed for a male client to ensure also use for added comfort and support.
the chest area is kept warm whilst the abdomen is being l To undrape the top leg, bring the draping material
massaged. However, draping the chest of a male client over the leg from anterior to posterior, support and
is obviously not as much of a sensitive issue as with the lift the leg as the draping is tucked in under the
female client. The therapist may choose to massage the thigh and brought toward the hip to meet the other
abdomen and chest as a unit without the need for drap- corner of the draping (Figure 15.7b).
ing (Figure 15.6). l Holding both edges of the draping, slide the draping
up the leg and thigh to reveal the area to be mas-
Draping of a client in side-lying saged (Figure 15.7c).
position l To undrape the bottom leg and thigh, the top leg
Draping a client in the side-lying position is often more must first be flexed at a 90 degree angle at the knee
difficult than in the prone and supine positions. The use and hip, moved anterior and supported with a pil-
of a sheet to drape the client may be easier as it will low. The draping is folded back over the leg toward
provide a greater surface area to work with. the midline (Figure 15.7d).
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l Manoeuvre the client on their side with pillows l The therapist lifts the limb to tuck the draping in
positioned to provide support and comfort (see under the thigh and brings the edge back to meet the
Figure 15.20). corner of the draping at the hip (Figure 15.7e).
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Figure 15.7c The top leg and thigh undraped in

side-lying position
Figure 15.7e The bottom leg and thigh undraped in

side-lying position
l The top flap of the draping is still covering the low

back and buttocks and can be folded back on the diag-
onal to reveal one side of the buttocks (Figure 15.8b).
l The gluteal cleft remains draped and only one side
is undraped at a time.
l Repeat the undraping procedure on the opposite
side once the massage has been completed and the
buttocks have been redraped.
l The client’s back can be covered with a drape whilst
the therapist is focused with the massage on the but-
tocks.
Option 2: access to buttocks via

the posterior lower limb
With the client in the prone position follow the proce-
Figure 15.7d Undraping the bottom leg and thigh in
side-lying position
dures for undraping the posterior lower limb.
l Fold the drape back over the leg so that the edges
fall to the midline between the legs (see Figure
Undraping the buttocks 15.3a).
Standard draping procedures in this text undrape the l Lift the leg that is undraped by supporting it around
back to include the superior aspect of the gluteal mus- the inside of the lower leg close to the knee with the
cles. More detailed massage to the gluteal muscles inside arm (facing the head of the table).
may be required when a client presents with a specific l The other hand reaches under the leg being lifted to
problem and massage to these muscles would be indi- pull the drape from the midline of the thigh to the
cated as part of the treatment plan. With the client’s side of the table towards the hip (see Figure 15.3b).
consent, the draping to the buttocks can be done in l The draping should sit high on the inner thigh and
several ways. be firm for the client to feel its presence. The top
part of the draping at the hip can be tucked into the
Option 1: access to buttocks via back leg of the client’s underwear and drawn back to
With the client in prone position, commence the proce- reveal the buttocks (Figure 15.9).
dure for undraping the back.
Option 3: access to the buttocks via
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l With the draping that is directly covering the client,

pick it up at the low back and tuck this section into the side-lying position
waist of the client’s underwear. Slide the underwear With the client in side-lying position follow the proce-
and draping down to the gluteal fold (Figure 15.8a). dures for undraping the lower limb.
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Figure 15.8a Slide drape down to gluteal fold
Figure 15.10 Buttocks undraped via side-lying

position
l To undrape the upper leg, bring the draping mate-

rial over the leg from anterior to posterior, support
and lift the leg as the draping is tucked in under the
thigh and brought toward the hip to meet the other
corner of the draping (Figures 15.7b and c).
l Slide the draping up the leg and thigh and toward
the iliac crest to reveal the buttocks (Figure 15.10).
To access the other side the therapist must turn the
Figure 15.8b Fold drape back to reveal one side client over and repeat the draping procedure on the
of buttocks opposite side.
Draping of a client in a seated

position
A seated massage can take many different forms and
how the therapist chooses to provide the massage will
be dependent on the environment and purpose of the
massage. For the massage therapist who performs seated
massage in the workplace or at events such as markets or
exhibitions, the massage is usually provided fully clothed
due to time constraints and the very public nature of the
massage environment; with the massage techniques per-
formed through the client’s clothing. By contrast, when
operating from a private setting, and when time permits,
the massage therapist may require the client to disrobe to
a certain degree in order to perform the massage. In such
instances a large sheet would be the preferred choice of
draping material as it can be easily tucked and tied into
place. To access the client’s back the sheet can be tied
loosely at the back of the client’s neck with the open-
ing at the back of the body. The sheet can be secured
at the waist of the client’s underwear to hold it in place
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and provide access to the whole back (Figure 15.11a).

To access the back of the client’s neck and shoulders the
Figure 15.9 Buttocks undraped via posterior therapist can untie the sheet and wrap it around the cli-
lower limb ent’s chest and torso (Figure 15.11b).
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Figure 15.12 Holding position of the drape; the client

Figure 15.11a Undraped back in seated position
turning toward the therapist
Figure 15.11b Undraped shoulders and neck in Figure 15.13 Holding position of the drape; the client
a seated position turning away from the therapist
TURNING THE CLIENT FROM PRONE hands on the draping in one of the following ways to suit
TO SUPINE the direction the client has chosen to turn. These scenar-
The client has two direction options for turning over on ios also work equally as well for the client who is turn-
the massage table. The therapist should be practiced at ing from supine to prone but where the therapist secures
both options and be prepared for the client to turn either the drapes is the opposite of that described below.
l Option 1 — the client turns toward the therapist.
way. Often clients are too relaxed to take in instructions
clearly and may misunderstand which way the therapist The therapist holds the side of the draping nearest
has asked them to turn. to them and allows for the draping to slide over the
When turning the client, excess draping or blankets client as they turn (Figure 15.12).
l Option 2 — the client turns away from the therapist.
are removed from the client and put aside for the turn-
ing process, and then repositioned when the turning is The therapist holds the edges of the draping furthest
complete. This means that if two towels are being used from them and allows for the draping to slide over
to drape a client remove one when the client is turn- the client as they turn. The edge of the draping can
ing. The towel covering the torso of the client should be slightly raised to allow room for the client to turn
be positioned lengthways along the client to cover as (Figure 15.13).
much of the body as possible and be used as the drap- The therapist anchoring the draping between the
ing towel for turning. The draping should not be lifted massage table and the therapist’s body can further
completely off the client, as they will feel exposed and secure the draping in this second turning option.
perhaps startled from their relaxed state.
Here is one method. The therapist stands at the side HELPING THE CLIENT ON AND OFF
THE MASSAGE TABLE
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of the massage table and holds the draping at the top

edges near the client’s neck. The client is asked to turn The therapist should not be expected to lift a client
onto their back slowly. As they begin to change their onto the massage table for the safety of the therapist
position from prone to supine the therapist adjusts their as well as the client. When a client is unable to move
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themselves onto a massage table, a seated massage may and many other reasons may require the therapist to
be more appropriate. provide minor assistance to the client. A therapist who
At times, situations will arise when the therapist has an electric or hydraulic table will have an advantage
needs to assist the client on and off the massage table. A as they can lower the table closer to the floor, making
client may be elderly and not very agile, have an injury it easier for the client to get on or off the table. A step
such as a fractured leg, or may have dizzy spells. These or footstool can also be of assistance to help the cli-
ent up onto and off a massage table. Where the client
needs assistance onto the massage table, the therapist
Box 15.4 Assisting the client off the massage table should allow the client time alone to disrobe and pro-
vide them with a gown or draping they can wrap around
l Ask the client to roll onto their side, and bend themselves. The therapist can then provide assistance
their knees and hips to 90 degrees of flexion. for the client to get onto the massage table. Getting
l Stand close to the table, facing the table. off the massage table can often be much harder for a
l Allow the client to reach up to hold onto your client. The steps outlined in Box 15.4 provide a guide
shoulders. for assisting the client off the massage table after a
l Place one hand behind the client’s neck on the treatment.
upper back and the other hand behind their
thighs (Figure 15.14a). CLIENT POSITIONING
l Assist the client to a seated position by swinging Part of the whole effect of achieving relaxation dur-
the client’s legs off the massage table whilst ing a massage is ensuring that the client is comfort-
simultaneously lifting their upper body. The able and able to relax their body whilst on the massage
momentum of the legs will aid the movement table. With the addition of bolsters, pillows and towels
into a seated position (Figure 15.14b). the therapist can support the natural contours of the
l Assist the client down off the massage table. client’s body. Additional supports or alternative posi-
tions may be required for some clients. The following
illustrations provide a guide for the therapist setting
up their massage table and adapting their pillowing
or positioning to suit individual needs (see Figures
15.15 to 15.21).
Figure 15.15 shows an illustration of a massage table
with bolster for placement under the front of the ankles.
Figure 15.16 shows prone position with extra sup-
port for the lower back. Place a pillow under the client’s
abdomen between the hips and the chest. A flat pillow
may be preferred to the bolster under the ankles.
Figure 15.17 shows prone position for reducing
breast discomfort in the prone position. Place a hand-
towel rolled into a sausage shape below the client’s
clavicles at the top of the pectorals.
In a supine position a pillow can be placed under
the client’s head for extra support and comfort (Figure
Figure 15.14a Assisting the client off the massage table 15.18). Some clients may prefer to have no pillow and
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Figure 15.14b Assisting the client into a seated position Figure 15.15 Basic prone positioning
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The therapist will need to position the bolster

under the client’s knees when they turn from prone
to supine. To lift the client’s legs in a supported man-
ner, wrap the feet and legs in the draping they are
lying on (Figure 15.19), grasp this draping and lift
the client’s legs as you slide the bolster under the
client’s knees.
The side-lying position is useful for the pregnant cli-
ent, the elderly and any client that may have difficulty
lying prone. Use a pillow or two for the client’s head
and a pillow or two under the knee of the client’s upper
leg whilst the leg the client is lying on is outstretched
and slightly posterior. An alternative position for the
legs is to have them both flexed at the hip and knee to
about 90 degrees with one or two pillows between the
Figure 15.16 Prone position with extra support for knees (Figure 15.20).
lower back The seated position may be appropriate for clients
that have mobility issues, are wheelchair bound, or
have difficulty being comfortable lying down. A regular
chair, stool or wheelchair can be used. The client sits
down close to the massage table and leans forward over
the massage table and rests their upper body and head
onto several pillows (Figure 15.21).
Figure 15.17 Prone position for reducing breast

discomfort
Figure 15.19 Bolster position to support low back
Figure 15.18 Supine position
others may prefer to have several. Observe your client’s

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level of comfort and adjust to suit. The bolster is placed

beneath the client’s knees. For clients with lower back
complaints an added pillow under the knees may make
them more comfortable. Figure 15.20 Pillowing for side-lying position
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techniques create a definite boundary and a defining line

in which the massage will take place. In addition, drap-
ing provides warmth for the client, and in maintaining
privacy helps create a sense of security, allowing the cli-
ent to feel relaxed and comfortable throughout the mas-
sage treatment. By draping confidently and efficiently
the massage professional will allow a greater sense of
trust and security to be felt by the client. Draping that is
performed swiftly and with ease will go a long way to
ensuring the massage treatment is one that is effective,
efficient and professional, and provides a high level of
warmth, security and comfort to the massage client.
Questions and activities

1 You are commencing a clinic, and anticipate
Figure 15.21 Seated position consulting with up to 5 patients per day for 4 days a
week. You plan to do all your own laundering daily,
CONCLUSION and need to purchase draping materials. Detail
exactly what draping materials you would require
Professional standards of practice require the massage for your clinic, stating the quantities of each.
professional to provide adequate draping for a cli-
2 To ensure clients return to receive massage from
ent, whereby the areas of the body that are not being
you, write a statement relating to draping and
massaged or have not been consented to for massage
privacy that can be given to first-time clients that
will remain covered throughout the treatment. Like
explains the process of, and considerations given to,
massage techniques, draping also requires a degree of
draping in your professional massage practice.
skill and sensitivity. Gaining access to parts of a client’s
body throughout the course of a massage means that the
therapist may need to lift limbs and tuck the draping to Further reading
anchor it in place. The draping should be secure without Andrade C, Clifford P 2008 Outcome-Based Massage
the need for the therapist to readjust it throughout the (2nd edn). Lippincott Williams & Wilkins, Baltimore
massage and the area to be massaged should be suffi- De Domenico G 2007 Beard’s Massage (5th edn).
ciently undraped to gain proper access without the need Saunders Elsevier, St Louis
for the hands to go beyond the draping line. Fritz S 2009 Mosby’s Fundamentals of Therapeutic
Massage (4th edn). Mosby, St Louis
Draping may be considered a form of non-verbal
Salvo SG 2007 Massage Therapy: Principles & Practice
communication with a client about the area that is
(3rd edn). W B Saunders, Philadelphia
about to be massaged. When used correctly, draping
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16
the techniques of Swedish
massage
Steven Goldstein and Lisa Casanelia chapter
LEARNING OUTCOMES
l Describe the conceptual context for palpation and palpatory literacy
l Describe the major Swedish massage strokes
l Discuss the application of each of the Swedish massage strokes
l Discuss the precautions of application for each of the Swedish massage strokes
l Describe the effects of each of the Swedish massage stroke
INTRODUCTION p resence as an effective tool. What is meant by inten-

The massage manipulations of Per Henrik Ling, often tion? Simply put, it is the conscious desire with focus
referred to as the father of Swedish massage, have been to apply each stroke in a particular fashion. A skilled
taught and performed for over two centuries. These practitioner can utilise their intention to deliver the
techniques have been and are still being used by mas- best possible outcome for their applied technique.
sage therapists, other manual therapists and health care Intent later becomes an energetic vehicle in which
workers throughout the world. According to Dorland’s the practitioner can participate in the outcome of the
Illustrated Medical Dictionary (2000) a manipulation is application.
applied skilfully as a form of treatment via the hands or Presence involves committing your body, mind,
with the use of mechanical means. Thus a therapist who heart and soul to the task at hand in the moment. When
uses massage manipulations as a form of treatment could performing massage, one should listen with all facul-
be described as having the ability to treat with their hands ties, and attend to the effects of the applied application
in a skilful manner. Such manipulations would include through the use of cognitive, intuitive, visual and audi-
the various ‘strokes’ introduced throughout this chapter. tory senses. It is a way to directly monitor the language
There are five major categories of Swedish massage of the body both quantitatively and qualitatively by the
strokes that are commonly applied and these are known use of the hands and mind.
as: effleurage; pétrissage; tapôtement; friction; and Presence allows us to be fully aware in the moment
vibration. Each category has a specific role to play in with extraordinary relaxed focus on the massage task
contributing to the overall massage sequence. This chap- at hand. Both of these qualities, intention and presence,
ter will define each of the five Swedish massage strokes are the difference in what can take massage practice to
and discuss their application, usage and variations. the next level of excellence.
The importance of intelligent touch cannot be over-
stated. A conceptual basis for intelligent touch through PALPATORY LITERACY
the development of palpatory literacy is also presented Most students and practitioners of massage focus upon
to help facilitate the student and practitioner to deliver the application of technique as the crucial element in the
quality massage applications. Firstly though, the value delivery of massage. The component most often miss-
of therapist intent and presence will be discussed. ing is the touch behind the technique and the ability to
discern the tissues and structures below the practitio-
HAVING INTENTION AND PRESENCE ner’s hands.
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For massage strokes to be fully effective, the prac- The ‘literacy of palpation’ or palpatory literacy is
titioner can increase the efficacy of the application the ability to distinguish various tissue layers, discern
with the knowledge of how to use intention and localised temperature variations, tissue texture and
163
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tonality. Thus, becoming literate in palpation is a means then recall these bits of sensory recognition during our
through which we achieve our ‘end’. next hands-on experience as guideposts to knowing
Palpation serves as a bridge into the body–mind con- what we are touching; comparing this with other sen-
tinuum and between structure and function. It involves sory memories stored in our somatic databases, and
perception, discrimination and analysis (aspects of with what feels ‘normal’. Once we have a firm grip
conscious awareness) as well as precision, sensitiv- on what normal feels like, abnormal becomes more
ity and dexterity (aspects of physical process). This obvious. Also, it becomes easier to detect changes in
brings to awareness the ways which the mind is ex- our clients from session to session, and even during a
pressed in physicality and how physical states are re- session.
flected through the mind. (Foster 2006: 109)
(Burman & Friedland 2006: 161)
The dictionary definition for palpation is obtained THE FIVE SWEDISH MASSAGE
from the Latin word palpare (circa 1852), meaning to TECHNIQUES
examine by touch especially medically (Merriam-Web- The five Swedish massage techniques are a classifi-
ster Dictionary). cation system of the many variations of techniques
To use touch skilfully is to become proficient in used in Western or Swedish massage. Johann Mezger
using palpation as a language that allows our ability to (1838–1909) has been credited for the introduction of
assess. Assessment is the foundation of manual therapy French terms still used to describe four of the five mas-
and, along with the delivery of massage, palpation is sage techniques: effleurage, pétrissage, tapôtement and
at the heart of assessment. It would be unimaginable frictions (Salvo 1999). That said, these five often form
to begin treatment without a sense of assessment, and the basis of massage training that goes on to blend and
assessment cannot occur without discerning palpation. cross-fertilise more complex strokes. The fifth applied
How is one to determine objective or subjective find- technique, vibration, became popular in the late 19th
ings of the soft tissue without assessment of the soft century (Tappan & Benjamin 1998). Over the years
tissue? The problem-solving and the evaluative process many authors have varied the classification system to
in selection of technique will have palpatory literacy at include additional manipulations: shaking, compression
its core. and touch.
Leon Chaitow writes that, according to Viola
Frymann (1963), ‘Palpation cannot be learned by Effleurage
reading or listening; it can only be learned by palpa-
tion’ (Chaitow 2003: 3). Practitioners with the great- Definition
est degree of ‘rigidity,’ in terms of their training, often Effleurage is a gliding manipulation of the superficial
have the hardest time allowing themselves to feel new tissues. It is used as an introduction to touch at the
feelings and sense new sensations. Those with the most beginning of the massage, and can be blended as a tran-
open, eclectic approaches (massage therapists are a sition stroke between the other five massage techniques.
prime example) usually find it easiest to ‘trust’ their Generally at the beginning of a massage, effleurage is
senses and feelings (Chaitow 2003: 15). used to apply the lubricant, spread it over the surface,
According to Karel Lewit (1999), a noted Czecho- warm the surface layer of tissue and reflexively create
slovakian physician, to begin to learn palpatory skill, a smooth relaxing flow and rhythm for the application
one must possess a firm grasp of anatomy and the sup- of the stroke. Local circulation is increased with the
porting soft tissue structures. According to Chaitow: application of effleurage, and the underlying tissues are
Palpation of tissue structures seeks to determine the
warmed in preparation for deeper manipulations.
texture, resilience, warmth, humidity and the possibil-
Effleurage is derived from the French verb effleu-
ity of moving, stretching or compressing these struc-
rer, meaning ‘to brush against, to skim over or to touch
tures. Concentrating on the tissue palpated, and push-
lightly’. Some authors equally refer to this manipula-
ing aside one layer after another, we distinguish skin,
tion as stroking or gliding (Cassar 1999; Loving 1999;
subcutaneous tissue, muscle and bone; we recognise
Tappan & Benjamin 1998), whilst others describe strok-
the transition to the tendon, and finally the insertion.
ing and effleurage as two different manipulations (Rat-
tray & Ludwig 2000; Hollis 1998; De Domenico &
(Chaitow 2003: 5)
Wood 1997; Holey & Cook 1997).
Palpation is touch awareness, and it often requires The major difference between stroking and effleu-
tactile exploration of a variety of tissue layers over time, rage relates to the depth of pressure applied. Stroking
spanning multiple hours palpating a variety of body is usually performed slowly with gentle pressure that
types. As they say ‘practice makes perfect’ and this is firm enough for the client to feel yet light enough
aphorism is most true in palpatory literacy. so that there is minimal deformation of the subcutane-
Sensing the subtle variations in the qualities of various tissue (Andrade & Clifford 2001; De Domenico
& Wood 1997). It is believed that stroking offers little
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ous tissues requires much practice. Distinguishing the

subtleties of tissues will enable the therapist to ‘build a direct mechanical effect, as the depth of technique is
personal database of tactile somatic experiences: ‘The too superficial. However, significant reflexive effects
fascia feels like… the muscles feel like…’. We can have been observed with the application of stroking.
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16 The techniques of Swedish massage 165
Effleurage is applied with greater pressure than strok- from one stroke to another and when moving positions
ing, and its effect on the subcutaneous tissue could around the massage table. The rowing stroke is per-
be described as deforming. Effleurage by contrast has formed by placing the palmar surface of the hand on the
a greater mechanical effect and may also produce the tissues. The hands glide toward the top of the trunk or
same reflexive effects as stroking. Effleurage is said to limb, where the hands then separate and perform a return
have a major effect on venous and lymphatic return. gliding stroke down the sides of the trunk or limb (see
The therapist generally applies effleurage with the Figure 16.1). The hands should be broad and flat with
whole palmar surface of the hand placed on the cli- the entire surface area of the hand making contact with
ent’s body. The therapist then uses their body weight the tissue, the fingers should be relaxed and not rigid or
to ‘lean into’ the superficial tissues, pushing the stroke squeezed together and the fingertips should be slightly
forwards. Traditionally, this technique is performed curled down to meet the tissue.
in the direction of venous and lymphatic flow in the
direction of the heart (Kellogg 1895; Palmer 1912; Half rowing stroke (reinforced effleurage)
Beard & Wood 1964; Andrade & Clifford 2001). There Reinforced techniques allow the therapist to penetrate
is a belief amongst some authors that structural dam- the deeper tissues of the body by decreasing the surface
age may occur to the valves within the veins if effleu- area of application from two hands to one and focusing
rage is applied in a centrifugal direction (Tappan & the body weight of the therapist through this one hand.
Benjamin 1998). However, no evidence exists to sub- The half rowing stroke is generally performed after the
stantiate this claim, yet if the treatment goals are to rowing stroke, working deeper into the tissues. The
increase venous and lymphatic flow, then the direction technique is applied by placing one hand over the other
of the technique should be aligned to the direction of to create a reinforced position. The hand closest to the
fluid flow. body is the one making direct contact with the tissue
An excellent example of refined effleurage is the and the hand reinforcing the stroke will be the more lat-
Hawaiian bodywork of Lomi Lomi massage. Full con- eral hand, allowing for the body to be in a good position
toured gliding flowing strokes are done primarily with of alignment. The reinforced hands glide towards the
the forearms and elbows with the hands as a guide. top of the trunk or limb and then return lightly in a more
lateral position along the side of the body, returning to
Description the starting position (see Figure 16.2).
The application of stroking and effleurage can be lik-
ened to the affectionate caress of a loved one or the Forearm effleurage
petting of a favourite animal. The stroke is applied pur- Forearm effleurage is a broad gliding stroke performed
posefully with gliding movements that gently follow with the fleshy part of the therapist’s forearm. The thera-
the contours of the body. It is applied over large areas, pist aligns their shoulder over the forearm to allow proper
and usually moves distal to proximal in the direction use of their body weight in the application of this tech-
of venous (blood returning to the heart) and lymphatic nique. Forearm effleurage can be applied flowing and
flow to enhance their effects. In order to maintain flow swiftly warming the superficial layers of tissue or it can
and continuity, the return stroke travels in the opposite be applied more slowly and directly to specific tissues
direction with lighter stroking pressure to return to the to penetrate into the deeper layers. The forearm can be
starting position. applied in a longitudinal fashion using the length of the
Throughout the stroke, the contoured and sculpted forearm with the hand leading or in a perpendicular fash-
palms, hands, fingers or fingertips mould and form to the ion with the therapist’s hand facing across the body (see
shape of the body region being treated (De Domenico Figure 16.3). The therapist should ensure their hand is
& Wood 1997). The hands are relaxed and the stroke
is performed in a smooth and rhythmic fashion. The
pressure employed is derived from the therapist leaning
their body weight into the stroke.
Techniques
The therapist can vary the way in which effleurage
manipulations are applied by using differing hand tech-
niques. Depending on the region being treated and the
desired effect, the therapist may apply effleurage with
the forearms, palms, contoured hands, fingers or finger-
tips, and even the side or the back of the hand.
Rowing stroke
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The rowing stroke is generally applied as an introduc-

tory stroke and is often repeated throughout the massage
sequence, integrating other strokes together, transitioning Figure 16.1 Rowing stroke
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Figure 16.2 Half rowing stroke Figure 16.4 Fist effleurage
Figure 16.3 Forearm effleurage Figure 16.5 Hand after hand
not squeezed into a tight fist when using forearm effleu- follows through and the massage therapist continues to
rage as this contracts the forearm muscles and hardens alternate hands as they move forward (see Figure 16.5).
the feel of the technique. In addition, the therapist should
be cautious that the point of the elbow doesn’t come into Side pulls
contact with spine or any other bony prominences. Side pulls are performed by reaching both hands across
to the far side of the client’s trunk or limb. One hand
Fist effleurage glides toward the midline of the trunk or limb while the
Loose fist effleurage is a broad strong effleurage tech- other hand begins the same action when the first hand is
nique primarily used on large muscle groups with well- halfway through its stroke (see Figure 16.6).The thera-
developed or very tight muscles. This technique engages pist can use their body weight to assist with the depth
both the deep and superficial tissues and is performed of the technique by leaning back into the technique as
with the ‘flat’ surface of the fist. The dorsal surface of the the hands move across the sides of the body toward the
phalanges (as opposed to the knuckles) makes contact midline. This technique is unusual in the sense that the
with the tissue. The technique is reinforced by the thera- direction of the technique requires the therapist to pull
pist’s other hand, which wraps around the wrist of the back toward them rather than pushing the technique for-
massaging hand to reinforce the wrist and strengthen the ward with their body weight behind them.
stroke (see Figure 16.4). An alternate reinforced position
is with the second hand cupped inside the loose fist; this Nerve strokes (light stroking)
allows for even greater depth of pressure to be applied. Nerve strokes (also known as cat or feather strokes) are
a light stroking technique that is performed slowly with
Hand after hand light pressure, using the fingertips. The fingertips stroke
This rhythmic technique is soothing and warming to down the area of the body being treated in a continuous
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the tissues with short alternating strokes that should alternating pattern (see Figure 16.7). This stroke is gen-
feel like one continuous stroke. One hand glides up the erally added as the final technique in a sequence as it is
trunk or limb for a short distance followed by the other the lightest of the effleurage techniques and is a gentle
hand, the leading hand is lifted off as the other hand and soothing way to complete an area of the body.
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tissues. Each technique has its own unique action and

its own effect.
The most common pétrissage attribute is known
as kneading. This attribute is much like the kneading
of bread dough. One or both hands compress, lift and
twist the muscles and subcutaneous tissues, often in an
alternating fashion. Pétrissage techniques involve the
use of the whole hand, as the entire palmar surface, the
fingers and the thumb, as well as the tips of every digit
are recruited. With practice, the therapist will find it is
easier to grasp the tissue when kneading is performed
slowly (allowing approximately 2–3 seconds for every
pétrissage stroke). As proficiency increases, the thera-
pist can begin to use a more rapid kneading action to
produce a stimulating effect on the nervous system.
Figure 16.6 Side pulls
Chaitow and DeLany (2000) recommend the kneading
technique rhythm be delivered at around 10–15 cycles
per minute for relaxation or around 35 cycles per min-
ute for stimulation.
Pétrissage is said to encourage peripheral blood
flow, and may assist with the resolution of oedema. It
may be useful in situations of abnormal muscle con-
tracture or soft tissue adhesions (Liston 1995). Through
muscular lengthening and relaxation, pétrissage manip-
ulations may assist painful conditions and relieve mus-
cular fatigue (Chaitow & DeLany 2000; Salvo 2003).
Techniques
There are many variations of pétrissage — each having
its unique movement and employing the hands in dif-
fering ways. Despite the altered dynamics, the unique
Figure 16.7 Nerve strokes kneading motion of pétrissage manipulations remains
a constant.
C-scoop kneading
Pétrissage The hands are placed on the surface of the skin with
Definition thumbs and fingers separated, creating a ‘C’ shape.
Pétrissage is a group of techniques that repetitively lift, The hands alternately glide back and forth grasping
roll, grasp, stretch, compress or squeeze the underlying and picking up and squeezing the muscle between the
tissue. fingers and thumbs. This two-handed technique can
Pétrissage is derived from the French verb pétrir be performed on all large surface areas such as calves,
meaning ‘to knead’. The intention when performing thighs, back and abdomen. For smaller surface areas,
pétrissage manipulations is to lift and squeeze (or ‘milk’) such as the arms, a single-hand technique can be per-
or compress the tissue. When performing pétrissage, formed (see Figure 16.8).
the therapist lifts, rolls, stretches, compresses, kneads
or squeezes the underlying tissue or structures between Circular kneading
their hands (Salvo 2003). Some authors equally refer Circular kneading is comprised of circular motions
to this manipulation as kneading (Fritz 2000; Rechtian synchronised with compression. Performed with one or
et al 1998). Pétrissage consists of several techniques; both hands, circular kneading consists of short rhyth-
namely, kneading, squeezing, lifting, compression and mic circular movements of the finger pads, thumbs,
skin rolling (De Domenico & Wood 1997; Cassar 1999; palms or forearms. If both hands are used the technique
Loving 1999). Some texts add shaking (Holey & Cook may be performed either simultaneously or with alter-
1997; Hollis 1998) whilst others exclude compression nating movements. During the technique the pressure
(Rattray & Ludwig 2000; Salvo 2003). increases to peak mid-way, then with pressure reduc-
ing to complete the stroke. This technique can be per-
Description
copyright law.
formed stationary on a large surface area (such as using

There are many pétrissage manipulations and, as previ- the thumbs to knead the calf muscles) or can travel dur-
ously mentioned, they involve lifting, rolling, stretching the movement to cover the entire tissue with small
ing, compressing, squeezing or kneading underlying circles (see Figures 16.9 and 16.10).
Account: s8715057
Figure 16.8 C-scoop kneading Figure 16.11 Squeezing the arms
Figure 16.9 Reinforced circular finger kneading Figure 16.12 Squeezing the trapezius muscle
ngers. This technique is also known as pincer-grasp

fi
compressions (see Figure 16.12).
Wringing
Wringing is performed with the therapist facing the
body from the side of the massage table. Each hand is
placed on either side of the trunk or limb being mas-
saged. The hands simultaneously glide, lift and shear
between the muscles as they pass each other moving
from one side of the body to the other in opposite direc-
tions (see Figures 16.13 and 16.14).
Skin rolling
Skin rolling is a pétrissage technique that is used for
Figure 16.10 Alternating circular thumb kneading
assessment and treatment. It can be used to assess the
mobility of the superficial fascia. Restricted superficial
fascia is noted where the skin is difficult to lift off the
Squeezing underlying tissue. It may be an indication of problems
This is a non-gliding technique that can be applied such as underlying connective tissue or joint dysfunc-
equally well directly to the skin or through clothing or tion (Fritz 2000). As a treatment technique skin rolling
draping covering the skin. One or both hands grasp, lift improves the mobility of the superficial fascia and, indi-
and squeeze the muscle or muscle group. The hands rectly through its attachments to the deeper structures,
then relax and, whilst maintaining skin contact, glide may influence motion at a deeper level (Andrade &
copyright law.
slightly along the limb, where the technique is repeated Clifford 2001). This involves a pincer-like grip that
(see Figure 16.11). For smaller or individual muscles, places the thumb and forefinger (in the shape of a ‘C’)
squeezing may be performed using the thumb and on the skin, then using a rolling action the finger and
Account: s8715057
ancillary or non-Swedish massage technique. Dr James

Mennell (1920; refer Chapter 2) classifies both pétris-
sage and friction manipulations as compression tech-
niques. Because most massage manipulations involve
an element of compressive force and therefore consti-
tute a compression technique, a separate compression
category may be deemed unnecessary.
There are two types of compression used in massage
— broad compression and specific compression. Broad
compression is a non-gliding technique, using a broad
surface such as the palm or fist, applied perpendicular to
the muscle belly (Fritz 2000; Salvo 1999).
Applied manual components of compression would
be ‘pressing’ or ‘pushing’, squeezing’ or ‘pinching’ and
‘twisting and ‘wringing’.
Figure 16.13 Wringing the mid back
Pressing is bearing down, applying pressure to or
putting weight upon. Pushing is moving something
aside, away or ahead by pressure or contact. Squeez-
ing is compressing an object, especially between two
forces, closing or tightly pressing together. Twisting is
using various turning motions on a body. Wringing is
compressing while twisting or squeezing (Burman &
Freidland 2006).
A practitioner might press up against a fluid vessel,
thus occluding it, blocking its flow. Pushing the same
structure would move the flow forward, encouraging a
draining effect. Compression can be used as an assess-
ment tool to examine and determine soft tissue resilience,
hardness, the ability of the tissue to yield, or the strength,
tension, and mobility of various tissues (Burman & Fre-
idland 2006). When applied to myofascia, adjustment in
Figure 16.14 Wringing the thigh
pressure and force is necessary due to the physical and
autonomic properties of myofascial tissue.
The manual application of force through compres-
sion effects change in the physical properties of the
myofascia tissue, with subsequent softening of the tis-
sue and increased mobility (Schleip 2003).
Compression is often used as an introductory stroke
that can assess the level of tension present within the
tissues and occasionally the depth of the tension. It is
also believed that broad compression has effects on
circulation, muscle resting tension, and rib cage mobil-
ity. Gentle broad compressions are used over the lym-
phatic nodes in manual lymph drainage to encourage
lymphatic flow (Casley-Smith 1997). An osteopathic
model of lymphatic drainage also uses gentle compres-
sion over the ribs and in pre-event sports massage, as no
oil is required, and can be performed through clothing.
Figure 16.15 Skin rolling Broad compressions may increase or stimulate muscle
tone and stimulate arousal and therefore will benefit the
athlete preparing for sport (Loving 1999; Fritz 2000).
thumb lift the skin to loosen it from the subcutaneous Broad compressions are often used in conjunction with
tissue (see Figure 16.15). rocking manipulations and therefore have a combined
effect (see ‘rocking vibration’ later in this chapter).
Compression The hands, the flat of the fists or forearm are applied
According to some authors, compression has been over a broad contact region. Perpendicular pressure is
developed into a distinct manipulation (Fritz 2000; slowly applied to the tissue, sustained and then gradu-
copyright law.
Salvo 1999). Fritz (2000) classifies compression as a ally released. For a more stimulating effect the therapist
Swedish massage technique whereas Salvo (1999) and completes the technique more vigorously (see Figures
Rattray and Ludwig (2000) classify compression as an 16.16 to 16.18).
Account: s8715057

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110 Section 4 Making initial contact with the client

observed rather than make assumptions as to the cli-

l Contraindications and precautions Time

All language used within a written report should be Appendix 2.

record keeping were based on recommendations made

l Write objectively. Australia

Government legislation New Zealand

2. USE AND DISCLOSURE

6. ACCESS AND CORRECTION

9. TRANSBORDER DATA FLOWS

10. SENSITIVE INFORMATION

Figure 11.1 The National Privacy Principles

­ rivacy Rules. For further information regarding

l Identify situations in which referral to other health care professionals is necessary

INTRODUCTION together an understanding of the physiological effects of

Table 12.1 Common physiological effects of massage

Percussion May increase local blood flow to skeletal muscles

l cupping l promotes relaxation

Nerves are most vulnerable to impingement when they

Dorsalis pedis artery

Table 12.3 Working safely with compressive techniques

Research l Know the location of the endangerment sites

Changes in the function of tissues or systems can also

Table 12.4 Some examples of absolute contraindications

Relative contraindications Table 12.5 The 20 leading specific causes of burden

Table 12.6 Working safely with relative contraindications

Research l Take a full history:

Assessment l Take into account:

Precautions l Do not stroke toward inflamed or oedematous tissue

l Reduce pressure over spider veins

Table 12.7 Examples of relative contraindications

Condition Consideration Response

Asthma l Inflammation l May have problems lying flat, or prone

Arthritis l Chronic injury l Stay distal to any acutely inflamed joints

Post-polio l Muscle weakness l Reduce pressures generally

Recent surgery l Tissue integrity l Beginwith distal treatment

Table 12.7 Examples of relative contraindications—cont’d

Condition Consideration Response

Skin integrity of an unknown origin. For most diagnosed oedemas it

Case study 2 Inflammation

sage may indicate an underlying condition which

A woman in her 70s presents for a massage with a Case study 7

­ onitor for a good response before applying full ther-

Chronic injury CONCLUSION

appropriate treatment methods and monitor adverse References

l Be aware of specific interactions for commonly used drugs

l Discuss management procedures for adverse effects of drugs in massage therapy

atrial tachycardia, however current treatment focuses on

Common conditions or symp- Possible side

13 Pharmacological considerations for massage therapy practice

Section 4 Making initial contact with the client

ensure client is fully alert before driving

13 Pharmacological considerations for massage therapy practice

ENDOCRINE AND METABOLIC Dysmenorrhoea

Newer antihistamines such as loratidine, terfenadine

diabetic neuropathy, shingles (following ­chickenpox),

sant drugs should be reminded of their sedative effect

Table 13.2 Drugs that cause muscle pain

Therapeutic Incidence of Predisposing

uncommon exercise increases cell membranes,

of moderate to severe hypertension, it is possible that a Quinine

DRUGS THAT REDUCE MUSCLE CONCLUSION

which itself is likely to make the client sleepy. More client

l Describe the three main aspects of body mechanics

l Contraindications and precautions Time

l Write objectively. Australia

rivacy Rules. For further information regarding

l Identify situations in which referral to other health care professionals is necessary

l cupping l promotes relaxation

Research l Know the location of the endangerment sites

Research l Take a full history:

Assessment l Take into account:

Precautions l Do not stroke toward inflamed or oedematous tissue

l Reduce pressure over spider veins

Asthma l Inflammation l May have problems lying flat, or prone

Arthritis l Chronic injury l Stay distal to any acutely inflamed joints

Post-polio l Muscle weakness l Reduce pressures generally

Recent surgery l Tissue integrity l Beginwith distal treatment

onitor for a good response before applying full ther-

l Be aware of specific interactions for commonly used drugs

l Discuss management procedures for adverse effects of drugs in massage therapy

diabetic neuropathy, shingles (following chickenpox),

l Describe the three main aspects of body mechanics

l Describe or demonstrate neutral posture while standing and sitting

INTRODUCTION p reventing MSDs. Since multiple factors are involved

l Make sure you have adequate space around your awareness.

1 your breathing than smaller muscles

client’s body. When you begin to work, it is important to start in

l knees over ankles.

l three curves in your spine — inward in your lumbar

Figure 14.1 Standing neutral posture for most massage

l Fitted sheet, a towel or other suitable covering to

l Blankets to drape over other linens to keep the

l Handtowels to cover bolsters, create towel rolls,

l To undrape the back, the drape can be folded diago-

l The top flap of the draping is still covering the low

l With the draping that is directly covering the client,

l To undrape the upper leg, bring the draping mate-

techniques create a definite boundary and a defining line

l Describe the major Swedish massage strokes

l Discuss the application of each of the Swedish massage strokes

l Describe the effects of each of the Swedish massage stroke

INTRODUCTION p resence as an effective tool. What is meant by inten-

ngers. This technique is also known as pincer-grasp