Ruminations on Contra Indications
The Manual Therapists Dilemma-Do We Cause Harm?
As I researched for this article I found without surprise, larger issues were at play. Once on the side of regulation for our industry, now I have concern as to the efficacy of this road. What began as a simple article on contraindications turns out to be a journey in understanding the nature of our work and the decisions we are face every day regarding our practice. Steven Goldstein BSHSc MST MusculoSkeletal Therapy, ACNM Australian College of Natural Medicine, Chair National Education Subcommittee, AAMT Australian Association Massage Therapists.
One of the most basic considerations for manual therapist is to understand how and when to proceed with caution or not to treat at all. Our ‘duty of care’ requires that we recognize when a condition or situation presents itself that would make it unsafe for the client to receive our touch. Furthermore our care requires us to ‘do no harm’. And if indeed we proceed with a treatment and did not heed or understand the indications contrary to massage, we open ourselves up to malpractice and personal liability.
Contraindications provide a basic framework for understanding when, and under what circumstances, a particular therapeutic intervention is appropriate for treating the patient/client with minimal risk of injury. Therefore, contraindications serve as a guideline to help us determine if we should institute certain precautions in treatment, withhold treatment altogether, or recommend alternative treatments that would be more appropriate (Batavia 2003).(1)
Therapists understand that by modifying their depth of pressure, selecting techniques that are appropriate to the tissue type and the situation create efficacy in our treatment. We know a thorough case history is necessary, and to implement a treatment plan we must consider the clients medical history to ascertain if treatment is appropriate. Fundamentally we are always asking when can we and when can we not provide treatment. With serious medical conditions, we realize that we are obligated to modify our treatment by the site or area we touch, the position we need to place the client in to achieve desired results or the time frame we can work as in the stages of inflammatory response. And of course we have to know when not to treat a serious medical condition.
Traditionally contraindications have been categorized as total, local or site specific and/or medical. We were taught to pay attention to systemic or skin conditions that exhibited infectious or contagious symptoms, local traumas and injuries that showed the effects of partial tear, avulsions, lesions, fractures, breaks or punctures of soft-tissue structures, to name a few. Most traumas we understand are commonsense wise, and depending on the conventional wisdom of the time, many conditions are considered totally contraindicated.
I, for example, taught in 1986 could never treat acute injuries, or that cancer and pregnancy, erring on the side of safety, were totally contraindicated. By today standards this is not the case.
Problems with the Laundry List Approach:
One thing that can be stated with some certainty regarding contraindications is: ‘a blanket approach with absolutes will work but then we probably wouldn’t treat any of the relative contraindicated conditions’. An excellent resource for understanding how sources differ regarding contraindications is M. Batavia’s article (2003) Contraindications for therapeutic massage: do sources agree?, published in the Journal of Bodywork and Movement Therapies, 8(1), 48-57,
Batavia goes on to say: “Contraindications cited in these sources were classified as relative contraindications, absolute contraindications, precautions, or contraindications and precautions. A relative contraindication is a situation where massage should not be done in certain circumstances, but could be done in other circumstances. It also refers to what type of massage is being performed. For example, one type of massage might be contraindicated for a particular condition, but another type of massage might not be. An absolute contraindication is one where massage should not be done under any circumstances. A precaution is a situation where massage can be performed, but with particular precautions related to the pathology.”(2)
What is interesting about this article is Batavia found when purveying all the various physical therapy, manual therapy and massage texts he found a majority of the sources failed to cite specific references to support the position of the described contraindications and another 76% failed to offer alternative treatment strategies for those conditions that were considered precautions or contraindications. And half the sources he consulted failed to identify that more than 90% of the conditions have a precaution or contraindication associated with them. (3)
So how are we to reconcile this immense discrepancy and how do we as massage educators help students and practitioners navigate this difficult terrain?
Batavia goes on to say:, “While contraindications are a valuable guideline, to often they are misused and misunderstood in our educational programs. Many, if not most, massage therapy training programs are lacking in subject matter directly related to evaluating pain and injury conditions. In that situation contraindications are commonly used as a basic “laundry list” of situations or conditions to avoid when using massage.
The detriment to this approach is that frequently it is not spelled out there is a difference between relative and absolute contraindications. Without that distinction most of these conditions get lumped into absolute contraindications in an effort to err on the side of safety and precaution. While this does help the practitioner keep from providing treatment in a situation where it is not appropriate, it also dramatically limits the effectiveness of clinical work.”(4)
Batavia cites an example that an absolute contraindication is treatment for an inflamed area, when in actually it is a relative contraindication. He believes more clinical research is needed to validate contraindications listed in various sources, and we need to educate the educators, “we need better educational preparation of the faculty and instructors that are teaching from these materials as well. To some degree an absence of listed contraindications can be balanced by adequate knowledge of anatomy and physiology coupled with developed clinical reasoning skills.”(5)
So what are considered Absolute Contra indications?
Absolute contraindications clearly are those when the application of technique compromises the safety of the client or the practitioner.
Fiona Rattray (2000) in Clinical Massage Therapy states: ‘….contraindications may be absolute; in other words, massage is an inappropriate method of treating a particular condition that affects the whole body or a part of the body.”(6)
Massage literature has an extensive laundry list of Absolutes, the problem as Batavia has stated is that some of the Absolutes can be relative. Some are myths, such as massage therapy will systemically metastasize all cancer, other make good sense, such as inappropriate deep friction applied to healing fractures or compromised soft-tissue.
Can Massage Spread Cancer?
No, it cannot. Massage of a solid tumor site should be avoided, but there is more to a person than a tumor site. An old myth warned that massage could, by raising general circulation, promote metastasis since tumor cells travel through blood and lymph channels. We now recognize that movement and exercise raise circulation much more than a brief massage can, and that routine increases in circulation occur many times daily in response to metabolic demands of our tissues. In fact, physical activity usually is encouraged in people with cancer; there is no reason to discourage massage or some form of skilled touch. Massage is practiced widely at the Dana-Farber Cancer Institute, Memorial Sloan-Kettering, and growing numbers of hospitals around the country. Metastasis is not a concern; instead, patients and researchers report countless benefits.
- Tracey Walton, Nationally Certified Massage Educator from Florida, USA (7)
Rattray looks at absolutes for general conditions and absolutes for local conditions.
- Absolute Contraindications for General Conditions (8)
- Acute conditions requiring first aid or medical attention, such as:
- Anaphylaxis shock
- Cerebrovascular accident CVA Stroke
- Diabetic coma or insulin shock
- Myocardial infarction
Severe asthmatic attack
Advanced kidney, liver or advance respiratory failure
Diabetes with complications such as gangrene
Pregnancy with pre-eclampsia or eclampsia toxaemia
Post CVA or heart attack where condition has not stabilized
Severe undiagnosed headaches in those over 50 years of age
Severe unstable hypertension
Shock ( although there is controversy here)
Significant fever (38.5° C or 101.5° F)
Systemic, contagious or infectious condition
Clearly we would have little controversy with Rattray’s list. Or this is from the CATCM – Canadian Association of Therapists in Complementary Medicine regarding Absolute Contraindications.(9)
Haemophiliacs people, possess not or few blood platelet which allow the coagulation of the blood during wound. Since massage can, occasionally, cause of micro muscular wounds (during kneadings for example) it is counter-indicated to make a massage. Even the lymphatic drainage which is however a light massage, which favors the movement of the lymph, can provoke haemorrhages.
The phlebitis is an inflammation of a vein (usually at the level of the legs). Massage can dislodge a bloody clot lodged in the affected vein, which could then lodge itself elsewhere in the organism (lung, brains). In the event of phlebitis, no massage, even of the non affected zones must be made. If the therapist suspects a phlebitis, he should redirect its client to the hospital immediately.
Fever indicates that organism fights an infection. It is important to let the body do his work. Massage can provoke an increase of the body temperature, what should not be advised because body temperature is already too high. Moreover, massage could favor the movement of the infection in another zone of the body.
Little objection would be made with these lists, and when looking at the listed conditions, I would probably not treat most of them. I also do not contest the rationale that working on a client with a fever can cause harm, but where is the evidence to that effect? When is it appropriate to treat a person with a low grade fever? Or is it?
Absolute Contraindications to Local Conditions (10)
Let us proceed to look at Rattray list of absolute for local conditions. Again, with most, no objections to her advisory, but there are grey areas. What about very gentle touch modalities such as Reiki, Therapeutic Touch or the technique I utilise, Two Pointing?
Massage therapy is not appropriate locally for the following conditions:
- Acute flare-up of inflammatory arthritidis, such as rheumatoid arthritis, systemic lupus erythematosus or ankylosing spondylitis.
- Acute neuritis, acute trigeminal neuralgia.
- Aneurisms deemed life-threatening- abdominal aorta depending upon location.
- Deep vein thrombosis, thrombophlebitis or arteritis.
- Ectopic pregnancy
- Esophageal varicosities
- Local contagious condition
- Local irritable skin condition
- Malignancy if judged unstable
- Open wounds, sores or decubitis ulcers
- Pain syndromes such as causalgia or reflex sympathetic dystrophy.
- Radiation therapy
- Recent burn
- Undiagnosed lump
- Varicosities (up to 24 post-treatment with saline injection)
Let us select reflex sympathetic dystrophy for an example
Ruth Werner in A Massage Therapist Guide to Pathology, comments on reflex sympathetic dystrophy: (p242)
“Most RSDS patients have little or no tolerance for touch of any kind, at least where the pain syndrome began. Physical therapy is often recommended to keep affected joints moveable and functioning; massage may help to relieve some of the pain associated with this therapy. Massage within tolerance in other parts of the body may be welcome and supportive.”(11)
So are we to look at Fiona Rattray list and conclude we have an absolute contraindication for RSDS or we look to Ruth Werner’s version. This is the grey area massage therapists find when needing to determine a course of treatment for an individual with as serious a condition as RSDS. Physical therapy is recommended, but massage therapy is not? Remedial therapists in Australia are often trained extensively in Range of Motion assessment, testing and application, does this then imply that massage application is out, but those that practice massage and have skill in ROM can apply physical therapy principles? Relative or Absolute?
Contraindications: Debatable Arguments: “Massage Therapists Do Not Harm People”
Albert Schatz (2 February 1920 – 17 January 2005)
Toward the end of his life this dedicated scientist published a website dedicated to healing and the law pertaining to massage therapy. He had until his death in 2005, practiced his version of massage for over 20 years. As a 23-year-old graduate student in 1943, Dr. Schatz discovered the antibiotic Streptomycin which was the first effective means of treating tuberculosis. This disease, also known as consumption and The Great White Plague, has killed more than a billion people during the last two centuries.
Dr. Schatz initiated the research which led to the discovery of Nystatin, an antibiotic which controls fungus and yeast infections. He has also done research with other infectious diseases, cancer, multiple sclerosis, atherosclerosis, the proteolysis-chelation theory of dental caries, fluoridation, the role of chelation in the formation and fertility of soils, and the use of garbage and soil to teach science, spiritual healing, and subtle energy.(12)
Schatz in his guest editorial article in Massage Magazine March/April 1998, spoke of why would massage therapists be regulated as an industry when there has been no evidence that massage causes harm.
Massage Law Newsletter, Vol. 5 No.1 1998
Schatz states, “The term contraindications refers to conditions which predispose people to harm by massage. Contraindications in and of themselves do not invariably cause harm. They are conditions for which massage may be potentially harmful.
This means that people with contraindications may or may not be harmed by massage. Moreover, if only one individual with a contra-indication is harmed by massage, that in and of itself does not necessarily mean that the contraindication was directly responsible for the harm. To establish a direct cause-effect relationship requires a significant number of cases of harm.(13)
Schatz in 1998, was in a spirited debate with Elizabeth Leach, Executive Director Ontario Massage Therapists Association, Toronto, Canada.
The core of Leach’s argument was this; “That massage therapy performed by massage therapists is quite safe. Massage therapy performed by unregulated individuals is not.’ (14) Massage Magazine September/October 1998, (75):8
Schatz response to Leach was, “Your Letter did not address the main point of my Guest Editorial because you did not present any well-documented evidence that massage therapists – unregulated or regulated – have actually harmed people. Instead, you focused on potential harm.
My more detailed report (in the Massage Law Newsletter. 5(2):1-12, 1998) expands my Guest Editorial. This report includes some of my research on harm over a period of several years. The title of the report is: Research shows that massage does not cause harm. Where adequate research was done, no harm was found and no state regulation was enacted. There”””””””””””””””””””””””””””””””’’s no need for state regulation to protect the public from harm, or for any other reason.(15)
Are we overly concerned about contraindications? What has evidenced based research shown to substantiate the ‘laundry lists’? Is it more that we desire the government and public perception that we are a legitimate health care provider, and that we conform to standards and practices that are in line with our ethical principles? Clearly we should have concern about contraindications, just as we have with sites of caution. However all conditions need to some degree be researched by the practitioner. The amount of training, your time in practice, the experience you have working with specific conditions all need to be considered when regarding whether or not to treat a condition listed as contra-indicated.
Relative Contraindications: Modifications to Treatment?
With many systemic conditions such as asthma or multiple sclerosis, we may not massage during the acute or flare-up stage but can apply treatment between flares or stages.
Batavia terms ‘relative contraindications’ as those that Rattray would view as the situation where you modify your treatment plan. Rattray calls these ‘treatment modifications.’ (16) p147
Modifications to treatment are necessary, whether a client has a condition that is contraindicated or not, the manual therapist is always adjusting and modifying treatment based on the previous results and feedback from the client. Assessment and palpatory literacy also determine with case history, the appropriateness of treatment.
Would you not assess if you found systemic contra-indications? Is assessment also contra-indicated? Again it would depend on what the assessment entailed. Orthopaedic physical assessment may or may not be appropriate. With pregnancy we modify for fundamental reasons, hormonal changes that release relaxin to relax pelvic ligaments, positional changes to accommodate supine hypotension and fetus growth.
With cardiovascular concerns such as thrombus or emboli, we might dislodge a clot and/or facilitate a life threatening situation. Other modifications might be with hydrotherapy, where the application of heat to an already inflamed area will painfully congest the site further.
With Fibromyalgia, deep work is generally contraindicated due to pain amplification and sensitivity, yet deeper work can be applied as the pain sensitization changes.
Batavia makes a cogent statement: “Guidelines around contraindications should be consistent in the literature that supports a profession. Variation in these guidelines can lead to inconsistent treatment and a great deal of confusion in both academic and clinical settings. In addition it is important that there be adequate evidence to support the use of various contraindications as well. This is one area where the massage therapy profession is at a disadvantage because despite an increasing number of textbooks devoted to massage, there is still a lack of supporting evidence used for making many of these decisions about contraindications.”
As I consulted many of the standard texts in massage education, most were using a ‘laundry list’ format. The challenge as you review contraindications is to place the contraindication in context with the health history obtained from the client, decide on the severity of the condition and differential diagnosis, decide which modifications to treatment through the varying of technique, position, duration, depth, speed, autonomic nervous system response.
We are taught when in doubt, do not treat, this maxim is still appropriate. On the other hand, clear decision-making will aid you in stepping outside of fear to help make an informed decision regarding the treatment and welfare of your client.
1. Batavia, M. (2003). Contraindications for therapeutic massage: do sources agree? Journal of Bodywork and Movement Therapies, 8(1), 48-57.1
2. ibid Batavia
3. ibid Batavia
4. ibid Batavia
5. ibid Batavia
6. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148
7. Cancer & Massage FAQ’s http://www.tracywalton.com/index.html
8. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148
9. Jocelyn Vincent ACDMD, CATCM – Canadian Association of Therapists in Complementary Medicine, http://www.asscdm.com/index.htm
10. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148
11. Ruth Werner, 2005 3rd Ed., A Massage Therapist Guide to Pathology, comments on reflex sympathetic dystrophy: (242)
13. Albert Schatz, Guest Editorial, Massage Magazine March/April 1998, (72):7
14. Leach, E. Letters to the Editor, Massage Magazine September/October 1998, (75):8
15. Albert Schatz, An Open Letter to Elizabeth Leach, Massage Law Newsletter, Vol. 5 No.1 1998 http://www.healingandlaw.com/Massage_Law_Newsletter/massage_law_newsletter.html
16. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148