Permission for patient to receive massage therapy

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Permission for patient to
receive massage therapy
“Massage for what ails you”
19 W. Main St #206
Westborough, MA 01581
508-241-2110 N/508.479.7665 C
DATE:
PATIENT:
I, _______________________________ (Physician’s Name), have reviewed the
attached information entitled “Information for the Physician – Effects of Massage
Therapy.” In particular, I understand that therapeutic massage may increase
circulation of blood or lymph, and that the massage therapist will be applying
kneading and stroking at various pressures.
I have reviewed this patient’s record and have (check one below)
____ found no conditions or treatments that would contraindicate or caution hands on massage therapy
____ found that massage therapy should be adjusted or modified in the following
ways: (attach suggested location restrictions, pressure restrictions, list particular
medical conditions or treatments that restrict massage)
____ found that massage therapy is inadvisable for the following reasons: (attach
listing of any contraindicating medical conditions or treatments that apply)
__________________________
Signature of Physician
__________________________
Print primary care practitioners name
----------------------------------------Date
Information for the Physician: Effects of Massage Therapy
A patient currently in your care is considering massage therapy in this office. A concern was raised during the
patient’s medical history discussion that needed further clarification. The sheet is intended to provi de you with
the information needed in order to decide whether therapeutic massage is indicated, permissible or
contraindicated for your patient. It accompanies the attached clearance form, which needs to be filled out and
signed if you decide to permit your patient to receive therapeutic massage sessions here.
1. Massage therapy practiced here involves kneading and stroking movies at varying pressures on the
tissues. It is thought ot increase local circulation.
a. Several controlled investigations suggest that this style of massage may increase blood and
lymph flow via direct compression with the hands and secondary effects of the skeletal muscle
relaxation.
2. This type of kneading and stroking may be therapeutic in some situations.
a. Manually increasing lymph flow away from edematous tissue may be helpful when the edema is
due to a nonacute injury. The usefulness of increased blood flow to skeletal muscle prior to
athletic events is widely recognized. In addition, release of muscle spasm increase range of
motion, and prevents injury. Finally, massage can lower levels of stress hormones and decrease
pain and discomfort. Other physiological effects of massage are demonstrated but not
mentioned here.
3. Circulatory massage may be contraindicated in some medical conditions.
a. Circulatory massage should not be performed directly on sites of local inflammation, malignancy,
or where it may aggravate pain. It should not be performed on areas where thrombosis is
present or suspected. Pressure should not be applied when clotting time is compromised.
Other medical conditions such as hepatitis, renal failure, or congestive heart failure may
preclude vigorous circulatory massage because it may hasten clearance of blood or lymph from
various fluid compartments. Circulatory massage as practiced here is not applied to areas
swollen by infection. General circulatory massage is too vigorous for clients with fever or who
are undergoing aggressive medical treatments.
4. Alternatives to circulatory massage exist so that treatment can be adjusted to most medical situations.
a. Touch can be lightened, areas avoided and other modifications made so that the overall effect is
less circulatory and less powerful.
The exact physiological effects of massage on the body are being studied and knowledge is advancing
rapidly. In order to practice safely while recognizing the validity of the research done to this date, we
decide these issues in the conservative. I encourage you to participate in this decision and appreciate your
time and consideration. Please call if you have any questions. Please sign and complete the attached
clearance form and mention any exclusions to treatment.
Thank you for your help.
Nina Capobianco, LMT
Chris Kanz, LMT
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