CONTRAINDICATIONS AND CAUTIONS FOR DEEP BODYWORK
in collaboration withTil Luchau and John Schewe
9th edition, May 2008
Atherosclerosis - a build-up of plaque in artery walls. Care needs to be taken so that any thrombi are not dislodged (See under ‘Embolism and Thrombi’)
Arteriosclerosis - hardening of the arteries. Care is needed because there is usually some atherosclerosis and high blood pressure associated with this. No bodywork in advanced stages. Get medical clearance for your work if the client takes medication for circulatory problems.
The immune system produces antibodies against the body's own tissues. Don’t work on acutely inflamed tissues.
a) Lupus - attacks the connective tissue mainly in the skin, kidneys, joints and heart. Contraindicated during acute flares.
b) Rheumatoid arthritis - immune system attacks the joints, and its associated muscles, tendons, ligaments and blood vessels;
contraindicated during inflammatory stage. (Note: With “osteoarthritis” deep bodywork tends to be more successful).
c) Scleroderma (“hardened skin”) - a buildup of collagen fibers around organs (problems with absorption when around the small intestines) and
in the dermis of the skin; increasing stiffness at joints along with muscle weakness. Contraindicated during inflammatory phase.
d) Ankylosing spondylitis - inflammation of tissues around the spine causing the connective tissues of the sacrum and spine to solidify. Don’t work on areas of pain and inflammation in acute episodes.
Bipolar Disorder (manic –depressive): during manic phase, deep bodywork could be contraindicated, since it could then increase the amplitude of the extreme mood-swings.
Borderline (as psychological diagnosis, originally understood as diagnosis for clients on the border between neurosis and full psychosis): Be careful. There have been (very) few reports about deep work triggering a psychotic episode. Full psychosis is in most cases a contraindication, and of course should be performed with supervision by a psychiatrist.
Cerebral Palsy: Result of Cerebral Palsy & Rolfing® study: in mild and moderate cases Rolfing® helpful; serious cases might get worse. Most recent science info: connective tissue restrictions more important factor in CP patients than was thought before (e.g. tissue shortness in the triceps surae often limits walking ability in terms of very limited dorsiflexion mobility of the feet).
Cancer: Connective tissue can often act as a barrier to the spread of cancer by encapsulating the cancerous cells. The problem is that deep work could theoretically cause the cancerous cells to metastasize (move through circulatory or lymphatic system to other places in the body). Usually okay if the person has a clean bill of health for 5 years. Pay special attention to lumps in abdomen, or lymph nodes in groin or armpit. (Lumps in abdomen could be hard feces. Let client monitor it: if no change after 3 days, perhaps have it examined). After mastectomy: check with doctor whether massage in the area (incl. the arm) is indicated. Sometimes it is not advisable to increase the lymphatic flow in that area.
Connective tissue disease: E.g. osteomyelitis, lupus, scleroderma: no deep work.
Diabetes: Be careful about tissue condition and loss of sensation. Don't do deep work on area of recent insulin injection: could accelerate Insulin uptake.
Embolism or Thrombus: a) Venous emboli - usually land in the lungs causing pulmonary embolism. b) Arterial emboli - can lodge themselves in the coronary arteries (heart attack); the brain (stroke), the kidneys, or the legs (phlebitis). Deep bodywork is usually contraindicated because of the risk of dislodging a thrombus. If the client takes blood thinners as a medical precaution against clotting, ask for a medical clearance for any kind of deep tissue work affecting the circulatory system.This precaution is even more strongly advocated in clients who have had a pulmonary embolus, or have had a Greenfield filter installed (a filter in the vena cava to prevent blood clots from reaching the lungs).
Epileptics: avoid hyperventilation
Headaches: Some types of headaches get worse with any kind of massage around the head/neck/shoulder area. This is quite common for migraines in the acute stage, probably due to infection and/or CNS over-stimulation. If the client has previous experience with receiving massage as a remedial treatment, they can often tell whether it is helpful or not to work on their upper body. Tension headaches (which are usually more bilateral) tend to respond more positively.
Heart conditions: OK. if not restricted from exercise (if fingernails get purple or blue, stay off)
Hemangioma:These are congenital benign tumors, made up of newly formed blood vessels. Different types, usually on the skin, yet sometimes also in brain and viscera. Specially in cases of known visceral type (e.g. hepatic hemangioma) no deep work in this area because of the severe danger of internal bleeding.
Herpes (and other potentially infectious skin conditions, including warts): Don't touch infected areas.
High blood pressure (extreme): Don't work in way that makes clients hold breath. Deep work on uncontrolled high blood pressure patients should be with medical supervision (deep bodywork often RAISES blood pressure).
Impaired elimination systems: Use caution with colostomies, Candida, kidney, and liver issues; careful. More spacing between sessions
Intervertebral disc problems: With non-acute cases, avoid shearing motions and extreme bending. Don't decompensate a stable system.
With acute cases: although bodywork can help creating space for the retreat of the tissue and to resolve some of the secondary compensations, be very careful and don’t work on the affected segment alone since local muscle spasms may have developed there as an important protection for the slipped disk. Releasing this muscular bracing too soon may put the client in danger. .
I.U.D.: Be careful with any deep abdominal work in female clients which use an intra-uterine device for birth control. It is possible that an I.U.D may become displaced, possibly leading to complications.
Menstruation (if strong): If the client tends to have very strong menstruation symptoms with high amount of blood loss, any kind of deep tissue work or even massage in the area of pelvis, abdomen and thighs - if done around the days of the client's period - can sometimes increase circulation and therefore the severity of the menstruation. Conclusion: either give the client the option to cancel a session for that reason if the date collides with a strong period at the same time; or give only a very gentle movement awareness session which does not tend to increase circulation in the pelvic region.
Nose work, special conditions: For any intranasal work be especially careful with regular cocaine users, nasal polyps, and nose surgery including cosmetic surgery.
Pain medication: Use caution regarding reduced sensation and greater possibility of tissue or nerve damage. (Same with paresthesia)
Pregnancy: Rule of thumb: no deep work. Be aware: danger of triggering a miscarriage by strong myofascial work is greatest during first 3 months (specially through work around the pelvis, abdomen, adductors, medial legs, or feet). Later in pregnancy this gets less likely. If you work with somebody who is pregnant, you may want to have them sign a form that they are aware of the increased risks and still want to get deep work from you, etc.
Varicose veins: Don't work veins.
Whiplash: If inflamed, it might get worse.
No deep work with:
* Abscess teeth (mouth work)
* Bone fractures or acute soft tissue injuries: wait for full healing (6 weeks - 3 months)
* Clients on Cortisone (wait 2-3 months)
* Feverish clients
* Hodgkin's disease (cancer of lymph system)
* Inflammatory conditions (includes such things as tendonitis and bursitis; contraindicated during acute stages; work peripheral to site possible when inflammation has subsided)
* Infectious conditions (with some exceptions, like HIV: get medical supervision)
* Osteoporosis (usually post-menopausal women)
* Phlebitis: same risk as for ‘embolism or thrombus’
* Recent scar tissue (including regular or plastic surgeries): no work on this area until scarring process is complete (usually at least 6 weeks)
Unless you are legally licensed to practice healing:
1. Don’t prescribe, not even vitamin C.
2. Never label or name any condition, don't diagnose (yet you can refer to a previous diagnosis of a medical doctor)
3. Be careful with people who are in psychotherapy or are seeing a doctor. (Their psychotherapist or physician should know they are getting bodywork).
Ask about medical history (including medications) before work begins. If ever in doubt, get medical supervision.
Best book: Ruth Werner & Ben E. Benjamin; A Massage Therapist's Guide to Pathology, Williams & Wilkins 1998, US $37. (Discusses more than a 100 common medical conditions and what a bodywork practitioner should know when dealing with them. Includes clear guidelines if or how massage is indicated or contraindicated. Extremely useful and worth the price!). Click here for the ‘Quick Reference Chart’ of this book.
Best journal paper: Keith Eric Grant; Massage safety: injuries reported in Medline relating to the practice of therapeutic massage—1965–2003. Journal of Bodywork and Movement Therapies 7(4).207-212; 2003. To quote from the conclusions of this excellent paper:
"1. Practitioners should inquire if clients are being treated with anticoagulants, to avoid using pressure or friction likely to lead to excessive bruising or hematomas.
2. Practitioners should inquire if clients have medical appliances or implants such as stents, to avoid the risk of displacement or damage.
3. Work done over a contusion or hematoma should be limited to lymphatic drainage, to avoid further tissue damage.
4. Caution should be used not to impinge superficial nerves against underlying bone with excessive pressure or friction.
5. Care should be taken with the vertebral artery as it runs through the transverse foramina of C5/C6 to C2, and particularly with the posteriolateral loop of the artery superior to C2. Although massage therapists do not use high velocity-low amplitude techniques, sudden or extreme cervical hyperextension with rotation that could lead to vertebral artery compression should be avoided. Immediate attention should be paid to symptoms of sudden headache, dizziness, vertigo, slurred speech, or loss of consciousness. Excessively deep or repetitive friction over the posteriolateral loop should be avoided.
6. Training programs should insure that training in anatomical knowledge and technique is interspersed with practical experience sufficient to develop good kinesthetic/palpatory skills, awareness of client response, and clinical humility."
Previous editions of this paper contained some suggestions on HOW to best work with some of the above and other medical conditions. Later several other practitioners added their personal suggestions on this aspect. Soon it became apparent that there are almost as many different treatment suggestions to each of those conditions as there are different adjunct therapies represented within our community (craniosacral, herbology, visceral manipulation, psycho-emotional, atlas-chiropractic, etc.). Therefore this article is now limited only to where and how NOT to work.
All of the above is the private opinion of the authors based on their knowledge and clinical experience as advanced Rolfing® practitioners. It is published here in order to stimulate further discussion and development. It will be updated and improved from time to time; i.e. this paper is a continuous work in process. For any additions and suggestions please contact the authors.
No legal liability on the information of this article is intended or accepted by the authors. If you are not a licensed medical practitioner you are legally obliged to consult an M.D. for any medical diagnosis.
In describing contraindications for deep tissue work it is NOT assumed that Structural Integration or any other modality is a medically oriented healing modality. Whether it is depends on other factors like the qualification and intention of the practitioner and the working contract or agreement with the client. Deep tissue practices like Structural Integration or Myofascial Release are very often used not as a medical healing modality but as a holistic method for increasing the sense of aliveness and embodiment (i.e. "being more at home in your body"). Even in those non-medical treatment situations it is possible to list medical contraindications, as this can be done for jogging, walking, dancing or other non-medical activities.<