Massage Therapy What is a Contraindication / Modification?

When a symptom, incident, or circumstance creates a scenario where treatment becomes inadvisable, it is considered to be a contraindication (CI). Generally CIs are conditions that deliver an explanation as to why Registered Massage Therapy treatment is withheld to prevent harm to the patient. A CI in massage therapy simply means that massage treatment is not applicable, given the circumstance. They can be grouped into several categories, including Absolute General, Absolute Local, Relative, and General. It’s important to note that sometimes these groupings can vary in name, however, they all typically follow the same idea.

When the initial treatment plan has to be adjusted to allow a safe and effective treatment due to contraindications, it is considered to be a treatment modification. They can alter various aspects of the treatment, such as the chosen technique, pressure/direction of the technique, patient position, hydrotherapy duration, temperature, location, treatment duration, and the area(s) treated. 

Absolute General Contraindications

This is considered a total massage contraindication, meaning massage therapy is not recommended to any part of the body, at all. The purpose of this is to prevent an exacerbation of symptoms of their condition and to protect the patient from experiencing that. Although a medical doctor may clear massage therapy, refusal of a massage treatment from the therapist may also serve as a precautionary step. In the event of a contagious disease or infection, then this type of CI can also exist to protect the safety of the massage therapist and their following patients.

Some cases which are considered to be Absolute General Contraindications include:

• Acute conditions which require medical attention or first aid such as Appendicitis, Anaphylaxis, Diabetic Coma, Cerebrovascular Accident, Insulin Shock, Pneumothorax, Atelectasis, Myocardial Infarction (Heart Attack), Severe Asthma Attack Acute Seizure, Status Asthmaticus, or Syncope (Fainting).
• Acute Pneumonia
• Advanced Kidney/Respiratory/Liver Failure (possible to modify treatment with medical consent)
• Diabetes, with complications (Gangrene, very unstable/high blood pressure, or advanced kidney/heart disease)
• Eclampsia
• Hemophilia
• Hemorrhage 
• Intoxication (drugs & alcohol)
• Meningitis
• Myocardial Infarction or Post-Cerebrovascular Accident due to condition not stabilizing
• Right after major surgery
• Severe Atherosclerosis
• Severe, undiagnosed headache in individuals aged over 50 years old
• Severe, unexplained internal pain (must see an MD immediately)
• Shock 
• Severe, unstable Hypertension
• Significantly high fever
• Pitting Edema
• Chronic active Hepatitis
• Non-terminal, highly Metastatic Cancers
• Systemic infectious or contagious conditions
• Contagious, airborne, or infectious diseases such as Flu, Cold, Sore Throat due to Strep Throat, Shingles, etc)
• Vascular complications
• Advanced organ failure
• Infective & Non-Infective Endocarditis/Pericarditis
• Lung abscess or lung tumor
• Sepsis (blood infection) or Bacteremia (bloodstream infections)
• Infectious Skin Conditions (Cellulitis, Generalized Exfoliative Dermatitis, Acute Psoriatic Arthritis, Impetigo, Staphylococcal Infections such as Scalded Skin Syndrome and Toxic Shock Syndrome, Folliculitis, Carbuncles, Erysipelas, Scarlet Fever, Necrotizing Fasciitis – flesh-eating disease)

Absolute Local Contraindications

When a condition or symptom is grouped into the Absolute Local category, then it means that massage therapy is not recommended to the affected local area, but it can be done to the surrounding tissue with additional care. Local conditions can consist of the acute stage to prevent further inflammation or an exacerbation of symptoms. Extra caution to the neighboring soft tissue and musculature also ensures the area is not agitated further. Depending on the severity of the condition/symptom, the therapist may need to modify the treatment as far as to avoid the affected limb completely, as well as to avoid putting the patient in positions that could poorly support and compress the affected area.

Some cases which are considered to be Absolute Local Contraindications include:

• Areas of Acute Inflammation
• Acute flare-up of Inflammatory Arthritides such as Rheumatoid Arthritis, Systemic Lupus, Reiter’s Syndrome, Erythematosus, or Ankylosing Spondylitis
• Acute Neuritis 
• Acute Trigeminal Neuralgia 
• Life-threatening Aneurysms
• Deep Vein Thrombosis, Thrombophlebitis, or Arteritis 
• Phlebitis
• Ectopic pregnancy
• Esophageal Varicosities
• Frostbite 
• Local contagious conditions 
• Local irritable skin condition
• Unstable malignancy
• Open Wound/Sore/Decubitus ulcer
• Pain syndromes (reflex sympathetic dystrophy or causalgia)
• Radiation therapy site up to several weeks post-radiation therapy (with medical consent)
• Recent burn
• Sepsis
• Undiagnosed Lump/Cyst/Mole
• Thromboangiitis Obliterans (Buerger’s Disease)
• Severe Varicose Veins
• Varicosities (up to 24 hours post-treatment with saline injection)
• Venomous Bites or Stings

Relative Contraindications

Relative Contraindications are conditions or symptoms that require the treatment plan to be modified, to execute safe and effective therapy. When a patient comes in with a condition or is presenting with symptoms that are considered to be a relative contraindication, then it just means that the Registered Massage Therapist (RMT) will need to use the patient’s current assessment and health history to formulate a plan with the intent to prevent any negative reactions. Modifications to the treatment can include the pressure/direction of the technique, avoiding the use of specific massage techniques, shortening the treatment duration, modifying the patient positioning on the massage table, using additional pillows/towels, avoiding the injured area, etc. If an RMT is not fully decisive on a modified treatment plan, then they should contact the patient’s medical doctor to discuss their condition, with the patient’s consent. 

Some cases which are considered to be Relative Contraindications include:

• Acute Disc Herniation
• Aneurysm
• Acute Inflammatory Conditions and Injuries
• Chronic Congestive Heart Failure
• Any anti-inflammatory injection site (up to 21 days post-injection)
• Any chronic/long-standing Thrombosis
• Bell’s Palsy (eye infection possibility)
• Buerger’s Disease
• Bursitis
• Chronic Arthritic Conditions
• Chronic Abdominal/Digestive Disease
• Chronic inflammation (Sinusitis, Chronic Bronchitis)
• Contusion
• Diarrhea
• Endometriosis
• Flaccid Paralysis or Paresis
• Irritable Bowel Syndrome (IBS) flare-up
• Inflammatory Bowel Disease (IBD)
• Fracture (during cast & post cast removal) 
• Frozen shoulder
• Hematoma
• Hernia
• Indwelling Medication Catheter (thorax)
• Infections, including Parasites 
• Hypermobility (joint instability due to increased ROM)
• Hypomobility (joint limitation due to decreased ROM) due to pins, screws plates, wires, or surgical shortening of ligaments
• Lymphedema
• Kidney Stones/Infection
• Mastitis
• Cancer
• Migraine
• Spasticity Conditions (Cerebral Palsy, Hemiplegia, Multiple Sclerosis, Spinal Cord Injury)
• Rigidity Conditions (Parkinson’s)
• Minor surgery
• Ostomy site
• Pelvic Inflammatory Disease (PID)
• Pitting edema
• Portal Hypertension
• Prolonged Constipation
• Raynaud’s Disease & Phenomenon
• Recent abortion
• Recent vaginal birth
• Diabetes
• Drug Withdrawal
• Epilepsy
• Fibromyalgia
• Spasmodic Torticollis
• Stress fracture site
• Temporomandibular Joint (TMJ) Dysfunction
• Tracheotomy site
• Trigeminal Neuralgia between attacks
• Varicosities 
• Inflammatory Arthritides (Rheumatoid Arthritis (RA), Systemic Lupus Erythematosus (SLE), Rheumatoid Arthritis (RA), Systemic Lupus Erythematosus (SLE), Rheumatoid Arthritis Gout, Pseudo-Gout, Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Gonorrhea, Tuberculosis, and Osteomyelitis)
• Joint Dislocation
• Osteomalacia/Osteoporosis
• Compromised immune system
• Pregnancy
• Recent head injury
• Severe asthma and emphysema
• Seizure Disorders
• Uncontrolled high blood pressure

General Contraindications

General Contraindications refer to conditions in which the Registered Massage Therapist (RMT) does not require a significant amount of treatment modifications – if any at all – but will still need to be aware of any potential adverse effects that could be caused by receiving massage therapy treatment. This will be dependent on the patient’s current symptoms which they are presenting during the pre-treatment assessment, as well as the patient’s general health history information that may assist the therapist in ensuring a safe and effective session. Additionally, the therapist may need to consult with the patient’s medical doctor for consultation or may require them to provide written consent.

Some cases which are considered to be General Contraindications include:

• Conditions of Spasticity (Cerebral Palsy, Hemiplegia, Multiple Sclerosis, Spinal Cord Injury), or Rigidity (Parkinson’s)
• Asthma
• Cancer
• Immunocompromised patients
• Coma
• Debilitation
• Abdominal surgery or major surgery
• Diagnosed Atherosclerosis
• Drug withdrawal
• Chronic Kidney Disease
• Emphysema
• Fibromyalgia
• Hypertension / Hypotension
• Inflammatory arthritides
• Medications: anti-inflammatories, muscle relaxants, stimulants, anticoagulants, analgesics, medications that can alter sensations, muscle tone, cardiovascular function, standard reflex reactions, liver or kidney function, or emotions
• Moderate Diabetes Mellitus
• Osteoporosis or Osteomalacia
• Pregnancy and labor
• Post-Cerebrovascular Accident or Myocardial Infarction
• Congestive Heart Failure (CHF)
• Recent head injury
• Seizure Disorders
• Allergies (oil/lotion, detergents, other, etc)

Modifications

To cater to contraindications, there are several things a Registered Massage Therapist (RMT) may choose to do to modify a treatment. Some of these can be as simple as adjusting pillowing techniques to adequately support an injured area or avoiding movements to certain limbs if there is a local inflammatory response. Others can include avoiding painful positions, motions, and soft tissues. Understanding what compensating tissues are affected, how to read non-verbal cues from the patient, avoiding painful areas, avoiding open cuts/wounds/sores, and allowing room for patient feedback on the modified treatment can be helpful to the therapist. In rare and, sometimes, severe situations, allergies and allergy attacks can be life-threatening if the therapist is not aware. 

The RMT will make many attempts to ensure a safe and effective Massage Therapy treatment. The extensive health history form which patients are required to complete includes safety barriers, including information the patient can provide for the therapist before their initial appointment. Some of them include the reason for RMT treatment, allergen information, pre-existing and current medical conditions, medications, and consent. 

Christina Sharma, RMT

(Massage Therapy Vancouver)