Professionalism
Confidentiality is the principle that the client's information is private and belongs to the client.
Client information is never discussed with anyone other than client without written permission.
Release must be signed by client if any professionals wish to exchange information about client.
Client files must represent accurate information and only with relation to the service offered.
Clients must understand that files may be ordered released by the court, since massage therapists
have no professional exemptions.
Clients also need to know that confidentiality will be breached because of laws that require
professionals to report alleged abuses & all threats of deadly harm by the client to self or others.
Clients must not be acknowledged in public unless they acknowledge the professional first.
Professional Boundaries
Needs sustain life, while wants lead to a sense of satisfaction. Needs and wants often become
confused in the client’s mind. When needs are met for someone by another, it is easy for that
person to feel bonded. The more dysfunctional a client is, the more important it is to keep
boundaries in the professional relationship. Massage professionals should have a clear
understanding of personal motives, and carefully maintain professional boundaries. People who
have been emotionally, physically, or sexually abused may not have had a chance to define or
recognize personal boundaries, so setting limits during a massage session may be a safe way to
begin this process. Anything that prevents us from being able to touch a person in a respectful,
nonjudgmental way must be examined so that we can decide whom we may best serve.
The right of refusal is a client’s right to refuse or stop treatment at any time.
Professionals also have the right of refusal if a just and reasonable cause exists. You may refuse
to work with anyone, as long as you explain the reasons why - this is called disclosure.
A massage professional has the right to refuse to treat any area of the body and terminate the
professional relationship if s/he feels the client is sexualizing the relationship or if the
professional feels adversely influenced in any way by the client. Clear professional boundaries
support an effective therapeutic process for both the client and the professional.
Massage Therapy and Intimacy
In a therapeutic relationship, the professionals knowledge and skills are focused on assisting the
client in achieving therapeutic outcomes. Intimate means inmost, essential, most private or
personal, closely associated, very familiar. Massage therapy may become intimate. It is unethical
for the client or the practitioner to interact on a sexual level. Sexual response is part of the
relaxation response from parasympathetic autonomic nervous system. It is the practitioner's
responsibility to monitor the client, and diffuse sexual energy. If a professional relationship
cannot be maintained, therapy should be stopped, and the client referred to another professional.
A parent or legal guardian must be present when massaging a child under the age of 18. Never
work behind a locked door.
Ethical dilemmas
Years of experience validate that when we encounter difficult circumstances in a professional
situations, it is seldom a problem with a technical skill and almost always an ethical dilemma.
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
summarized by Slenn, Crone and Schwartz
page 1
Ethical dilemmas can be challenging to resolve, especially for young professionals who can have
emotional regard for a situation. As professionals we are expected to engage in a careful
decision-making process. Each decision is unique. A few rules are absolutes: a professional does
not breach sexual boundaries with a client; clients are to be referred when the skills required are
out of the scope of practice or training of the professional; all care must focus on giving help and
avoiding harm; and clients are to be given complete information about the treatment. A decision
making model proves successful in that many ethical dilemmas are uncertain or inconsistent
situations and require this methodical approach to problem solving. Decision-making requires a
person to consider the facts, possibilities and consequences of cause and effect.
Communication Skills
It is best to use direct honest communication, focusing on the situation rather than the person and
delivered in a gentle, respectful way. The professional’s thought process at the moment of
professional touch may influence the intent of that touch; it is important to monitor your thoughts
and feelings while professionally communicating through touch so the client does not
misinterpret the unspoken intent of the therapist.
Body language delivers the strongest message, heightened when a lack of continuity exists
between what is heard, seen and felt. Tone of voice is considered to be more important than the
actual words spoken since words can have mixed meanings, depending on an individual’s
definition. You should communicate in the style (visual or auditory) utilized by the client.
Reflective listening involves restating what was said, to indicate that you have received and
understood the message clearly. Active listening may clarify a feeling or emotion attached with
the message but does not add to or change the message. I-messages are useful in avoiding
conflict as they concentrate on feelings and concerns and do not blame, criticize and provoke, as
you-messages would do.
The following is suggested for resolving ethical dilemmas:
1. Examine the facts, possibilities, logical causes and effects, and your feelings about the
situation, speaking with a peer about the situation in a peer review or support context.
2. Plan a time to talk about the situation with the other person or people involved.
3. Begin the conversation by identifying the problem as you see it.
4. Use the standard I-message format to provide information and professional disclosure
about your inability to work with or be comfortable with the situation.
Dealing with Suspected Unethical or Illegal Behavior of Fellow Professionals
When concern develops about the conduct of a colleague, an approach that combines selfreflection, peer support, supervision, and effective communication skills is the best way to deal
with these situations. Carefully reflect on the personal motivation causing the concern.
Intervention should be based on concern for the person and client. Discuss the situation with a
colleague in a peer support situation and explore the motives. If others share your concern, speak
directly to the colleague. Bringing the concern to their attention can help resolve the problem. It
is unprofessional to ignore unethical behavior - a willingness to get involved supports
professional integrity.
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
summarized by Slenn, Crone and Schwartz
page 2
HYGIENE, SANITATION & SAFETY
HYGIENE OF THE MASSAGE PROFESSIONAL
Clients notice the way we look and act, as well as our energy and vitality levels. It is important to
take care of ourselves not only to function at our best, but also to set an example for our clients.
Prevent breath odor by brushing & flossing teeth; avoid eating foods that cause breath odors;
avoid chewing gum
Bathe or shower at the start of each day using soap to clean key areas were odors are: armpits,
genitals (especially of odors during menstruation) and feet
Keep hair clean and make sure your hair doesn't touch the client
Avoid wearing perfume, after shave or perfume in hair products; avoid heavy makeup
Nails should not extend past the fingertips; keep area under nail clean; hangnails, breaks and
cracks in the skin must be clean and kept covered
Nail polish, hand jewelry , necklaces and bracelets must not be worn giving a massage
Clothing should be loose and made of cotton/cotton blend and must breath and absorb; scrubs
work well as clothing; sleeves should be above elbows, but not sleeveless
T -shirts and shorts are inappropriate unless shorts are knee length or longer
If professional perspires heavily, change clothing between sessions
Clothing should be laundered in a disinfectant, usually bleach
Comfortable shoes should be worn; wearing socks or going barefoot is unprofessional
Male practitioners must keep facial hair shaved or nearly trimmed
SMOKING
The smell of smoke can cause reactions in sensitive individuals, so any smoke odors from the
professionals are reason for concern.
The massage professional should never smoke in the therapy room, even when clients are not in
it - the smell can linger in carpets, draperies and other furniture.
If the practitioner must smoke during business hours it should be done outside, away from any
access doors or windows.
The practitioner must wash hands carefully after smoking before touching a client.
If client is bothered by smoke odors refer them to practitioners that do not smoke.
ALCOHOL & DRUGS
Because they affect thinking, feeling, behavior and functioning the practitioner must never be
under the influence when working.
Any prescription or over the counter medication that affects mental and physical abilities and is
taken by practitioner can put the client at risk.
Practitioner should wait at least 12 hours after drinking last before working with a client.
Clients should be referred or rescheduled if professional's ability is affected.
SANITATION
Sanitation is primarily important to prevent the spread of contagious disease.
Viruses invade cells and insert their own genetic code into the host cell’s genetic code.
Bacteria cause disease by secreting toxic substances that damage tissue, become parasites inside
cells, and/or form colonies in the body that disrupt normal function.
Fungi such as yeasts and molds can live on the skin or mucous membranes.
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
and the Center for Disease Control web site, summarized by McCauley and Schwartz page 3
Protozoa infest human fluids and cause disease by parasitizing or destroying cells.
Pathogenic animals called metazoa are mostly worms that feed off human tissue.
Most pathogens cause skin diseases and spread through direct contact .
DISEASE PREVENTION AND CONTROL
Pathogens spread by environmental contact in food, water, soil and surfaces; by
opportunistic invasion through disruption of normal skin and mucous membranes; and by
person-to-person contact with the person carrying a disease such as common cold.
Aseptic techniques such as sterilization, disinfection and isolation, kill and disable pathogens on
surfaces before they can be transmitted; protective apparel, such as mask, gown and gloves, are
sometimes used.
In massage, disinfection is most often used, rather than sterilization or isolation.
The most effective deterrent to the spread of disease is proper hand washing:
Wash hands and forearms in hot, running water.
Use either soap or an antiseptic hand cleaner.
Create a lather with soap.
Interlace your fingers during washing.
The blunt wooden edge of an orange stick can be used under the fingernails.
Rinse well, keeping the fingers pointed down.
Dry your hands and forearms with a clean towel.
Use the towel to turn off the water, open doors, etc.
UNIVERSAL PRECAUTIONS
Developed initially to prevent the spread of blood-borne diseases such as HIV and HBV,
universal precautions prevent the spread of both bacteria and viral infections.
Guidelines include recommendations for use of gloves, masks and protective eye wear when in
contact with blood and body secretion and includes clean up procedures.
Massage practitioners need to stay current and follow (CDC) Centers for Disease Control and
Prevention recommendations, standards and guidelines.
Gloves are not necessary unless skin of practitioner or client has rash, cut, abrasion infection or
any condition that transmits fluids. Use of a mask may be indicated to prevent the therapist from
transmitting diseases to clients with impaired immunity (AIDS, cancer treatments,
immunosuppressive drugs, etc.)
With training and under medical supervision practitioner may work on clients having contagious
conditions - using universal precautions is essential though.
Disposable gloves available in case there is contact with blood, vomit, urine or feces.
A 10% bleach solution should be used to clean up spills of body fluids; only use solutions
stronger than 10% if excessive amounts of blood or other substances present.
If an open wound is exposed to a contaminated substance it should be flushed immediately with
large amounts of hydrogen peroxide or a 10% bleach solution.
Bathrooms should always be cleaned as if they were contaminated. Bleach is the preferred
cleaning agent.
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
and the Center for Disease Control web site, summarized by McCauley and Schwartz page 4
APPROVED CLEANING SOLUTIONS
High-level sanitation: products labeled "sterilant/disinfectant glutaraldehyde air
dry" - massage professionals do not need to practice high level sanitation techniques under
normal conditions.
Medium level sanitation: Bleach solution: 1 part bleach to 9 parts water, made up fresh daily
(10% solution) or a hospital disinfectant labeled "tuberculocidal."
Low-level sanitation: hot, soapy water or a hospital disinfectant effective against viruses and
bacteria. Hands are to be washed in hot, soapy water or with surgical soap.
Low-level (for hand washing) and medium-level (for body fluid spills) procedures are adequate
for most therapeutic massage situations.
THE MASSAGE ENVIRONMENT
Massage room must be at least 75 degrees, have ventilation to remove odors, lighting must be
able to produce five foot candles of light at floor level during cleaning.
Must have a sanitary toilet facility with adequate supply of hot and cold water, and fly-tight
containers for garbage and refuse.
All lubricants used must be stored in a container that prevents contamination, and bulk lubricant
should not come in contact with the massage professional.
All soiled linens must be put into a covered receptacle immediately; used linens must be stored
in a closed bag or container, and cleaned with detergent and a 10% bleach solution in a washing
machine with hot water of at least 140 degrees.
Do not shake linens; dust with a damp cloth; clean from cleanest area to dirtiest; clean away
from your body and uniform; any object that falls on the floor should not be used.
PREMISE AND FIRE SAFETY
Infants & young children should not be left unattended; women in the last trimester of a
pregnancy should not be left in the massage room alone and may need help off the massage
table; elderly persons may be less steady on their feet and should not be left in massage room
alone; any client whose mobility is impaired, including those with visual impairments, may need
assistance getting on & off massage table
To prevent falls provide good lighting; do not use throw rugs (they may slip or tangle the feet);
avoid slippery tile floors; keep floors and walkways uncluttered; keep electrical & phone cords
out of traffic areas; regularly check all massage equipment to be sure it is sturdy; make sure that
all outside entrances are free of clutter & hazards
If an accident occurs, all information must be written down about the accident, the following
provided to the insurance company: where & when the accident occurred; detailed information
about accident; names & addresses of the person or people involved; names of any witnesses;
names of manufacturers, if equipment is involved
To prevent fires provide a nonsmoking environment (if you have to have smoking area, make
sure there are ashtrays and they are emptied regularly); regularly check all electrical cords &
equipment; never use candles, incense or any open flames; make sure the massage area is
equipped with a smoke detector and fire extinguisher and check them regularly
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
and the Center for Disease Control web site, summarized by McCauley and Schwartz page 5
PATHOLOGIC CONDITIONS AND INDICATIONS FOR MASSAGE
Inflammation (heat, redness, swelling, and pain); local - limited area vs. systemic - all over
body (inflammatory diseases); benefits from massage: stimulation releases body’s own
inflammatory agents; certain types of inflammation trigger body to complete the healing process;
massage may facilitate the dilution and removal of irritant by increasing lymph flow.
Inflammation triggers tissue repair involving regeneration (new functional cells) and replacement
(different cells that form scar tissue - fibrosis); massage can slow scar tissue formation and make
it more pliable.
Therapeutic inflammation: slight localized inflammation can jump start the healing process; deep
cross-fiber friction and connective tissue stretching are commonly used; these are
contraindicated if healing process is suppressed, in sleep disturbance, compromised immune
system, high stress load, or conditions with impaired repair and restorative ability such as
fibromyalgia; anti-inflammatory medication
Pain is the main reason people seek health care; receptors are nociceptors, which adapt little;
prostaglandins released from injured tissue makes nociceptors more sensitive; aspirin and other
anti-inflammatory drugs inhibit the action of prostaglandins; excess stimulation of sensory
organs causes pain. Pain classification: acute, chronic, intractable (massage can distract),
phantom
Pain locations: localized, projected (proximal nerve compression), radiating (diffused around),
referred (body area and visceral organ involved receive innervation from same spinal segment –
dermatome).
Origins of Pain: somatic superficial (skin); somatic deep (muscle, joints, tendons, and fascia);
visceral
Pain sensations: pricking or bright; burning (stimulates cardiac and respiratory activity); aching
(from visceral organs, often referred pain, may be sign of life threatening organ disorder); deep
pain (poorly localized, nauseating, accompanied by sweating and changes in blood pressure,
initiates reflex spasm of muscle - steadily contracting muscle becomes more ischemic and
ischemia stimulates pain receptors, the pain initiates more muscle spasm creating pain-spasmpain-cycle; muscle pain (caused by inadequate blood supply, pain persists till blood flow
resumes).
Massage may reduce the need for pain medication thus reducing the side effects of medications;
intervention for acute pain is less invasive and focused to support current healing process, but
chronic pain is managed with either symptom relief or a more aggressive rehabilitation approach.
Impingement Syndromes: compression – pressure on a nerve by a bony structure; entrapment –
pressure on a nerve from a soft tissue
Impingement of cervical plexus (headache, neck pain, trouble breathing); brachial plexus
(shoulder, chest, arm, wrist, and hand pain, thoracic outlet syndrome, and whiplash [sic]); lumbar
plexus (low back discomfort, lower abdomen, genitals, thigh, and medial lower leg pain); sacral
plexus (gluteal, leg, genital, and foot pain); have some idea of potential muscles involved with
each plexus impingement
Massage can stretch and soften connective tissue that may impinge the nerve as well as
normalize muscle tension patterns and this will reduce pressure on the nerve.
Psychologic Dysfunction: mind and body have direct effect on each other; major mental health
dysfunctions: trauma (physical injury caused by violent or disruptive action or toxic substance,
or psychic caused by severe emotional shock); post-traumatic stress disorder (flashbacks, state
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
summarized by DiCarlo, Esposito and Schwartz page 6
dependant memory, somatization, anxiety, irritability, sleep disturbance, grief, fear, worry,
anger, avoidance behavior); pain and fatigue syndromes (chronic non productive factors that
influence daily life, such as fibromyalgia, chronic fatigue, Epstein-Barr Virus, sympathetic reflex
dystrophy, arthritis, neuropathy); anxiety and depression disorders (mood swings,
hyperventilation, sleep disturbance, memory disturbance, anger, fatigue, change in appetite and
activity); stress related illness (increased stress load, cardiovascular problems, hypertension,
heartburn, ulcer, bowel syndrome, respiratory illness)
Massage, with its compassionate touch and pain management, can sooth either hyper- or
hypoactivity of the autonomic nervous system and provide normalized breathing and a sense of
inner balance, supporting the actions of qualified mental health professionals – the rest is not our
role.
Contraindications are guidelines, unique to each client, situation, and body region. Some are
regional (specific area of body), while others are general (those that require physician’s
evaluation to rule out serious underlying conditions; mental health conditions also fit here) –
when in doubt, refer.
Massage should be avoided in all infectious diseases, suggested by fever, nausea, lethargy, until
physician evaluates)
Tumors and Cancer: benign tumor (remains localized and usually slow growing); malignant
(cancer) spreads via metastasis, cells migrate by lymphatic or blood vessels.
Massage, under medical supervision and not overtaxing the system, can support the immune
system when battling cancer.
Medications are prescribed to inhibit, stimulate, or replace a chemical in the body; effects of
massage can be synergistic or antagonistic to the medication – either can cause problems.
Massage can be used to manage undesirable side effects of medicines, especially sympathetic
effects.
Be aware of anti-inflammatories, muscle relaxants, anticoagulants, analgesics and other
medications that alter sensations - contact physician if unsure.
Endangerment sites have unprotected nerve and blood vessels close to the skin, or fragile bony
projections that can easily break, or vulnerable organs like the kidney. Be familiar with them for
safety.
Referrals between you and doctors and other health care providers; if you refer a client to a
doctor some sort of written permission is needed to continue to see the client; keep information
with client’s records; indications for referral include unexplainable pain, fatigue, inflammation,
rashes, edema, mood alterations, infection, bruising, nausea, vomiting, diarrhea, fever, chill,
changes in appetite, sleep, & elimination (bladder or bowel), sores, changes in appearance of
warts & moles, indigestion, persistent hoarseness or cough, bleeding, lumps; underlined are
warning signs of cancer
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
summarized by DiCarlo, Esposito and Schwartz page 7
Indications and Contraindications To Massage: The Ontario Model
Absolute Contraindications
General:
1) Acute pneumonia
2) Advanced kidney failure (medical consent)
3) Advanced respiratory failure (medical
consent)
4) Diabetes with complications
5) Eclampsia-toxemia in pregnancy
6) Hemophilia
7) Hemorrhage
8) Liver failure (medical consent)
9) Unstable CVA (stroke)
10) Unstable MI (heart attack)
11) Severe atherosclerosis
12) Unstable hypertension
13) Shock (all types)
14) Elevated fever (above 101 F)
15) Acute conditions (first aid/medical
attention)
Anaphylaxis (allergic reaction)
Appendicitis
CVA (stroke)
Diabetic coma/insulin shock
Epileptic seizure
MI (heart attack)
Pneumothorax/atelectasis (collapsed
lung)
Severe asthma attack
Syncope (fainting)
1)
2)
3)
4)
5)
16)
Highly metastatic cancers not
judged to be terminal
17)
Systemic contagious/infectious
conditions
Local (Regional) - may be general in
some cases:
1) Acute inflammatory/arthritic conditions
(medical consent)
2) Acute neuritis
3) Aneurysms deemed life-threatening
(e.g. abdominal aorta)
4) Ectopic pregnancy (tubal)
5) Esophageal varices (bleeding)
6) Frostbite
7) Local contagious condition
8) Local irritable skin condition
9) Unstable malignancy
10) Open wound/sore
11) Phlebitis/thrombophlebitis
12) Recent burn
13) Sepsis (infection in bloodstream)
14) Temporal arteritis
15) 24-48 hours after anti-inflammatory
treatment (target tissue and vicinity)
16) Undiagnosed lump
Other Important Considerations:
Therapists are expected to consult with healthcare professionals as needed.
Emotional/psychiatric conditions affect massage, decisions are according to case with
medications a factor.
Clients may be allergic to oils/creams, cleansers/disinfectants used on sheets and tables.
The presence of surgical pins, staples, and or artificial joints may alter treatment.
The therapist should be aware of public health issues and other info provided by the Health
Department.
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
summarized by DiCarlo, Esposito and Schwartz page 8
Conditions Requiring Awareness
(possibility of adverse effects/consider
medical consent)
General:
1) Condition of spasticity/rigidity
2) Asthma
3) Cancer
4) Chronic congestive heart failure
5) Chronic kidney disease
6) Drug therapy: anti-inflammatory, muscle
relaxants, anticoagulants, analgesics, or
any that alter sensation, muscle tone,
reflex actions, cardiovascular function,
kidney/liver function, or personality
7) Coma (may be absolute CI)
8) Diagnosed atherosclerosis
9) Drug withdrawal
10) Emphysema
11) Epilepsy
12) Hypertension
13) Immunosuppressed client
14) Inflammatory arthritis cases
15) Major or abdominal surgery
16) Moderately severe or juvenile onset
diabetes mellitus
17) MS (multiple sclerosis)
18) Osteoporosis/osteomalacia (weakened
bones)
19) Pregnancy/labor
20) Post MI (heart attack)
21) Post CVA (stroke)
22) Recent head injury
Local (Regional):
1) Acute disc herniation
2) Aneurysm
3) Acute inflammatory condition
4) Anti-inflammatory treatment site
5) Chronic superficial thrombosis
6) Buerger’s disease (obstruction of
small/medium-sized arteries/veins by
inflammation triggered by smoking)
7) Chronic arthritic conditions
8) Chronic abdominal/digestive disease
9) Chronic diarrhea
10) Contusion
11) Endometriosis (disease in which
patches of endometrial tissue, normally
found in uterine lining grows outside
lining)
12) Flaccid paralysis/paresis
13) Fracture (while casted & immediately
after removal)
14) Hernia
15) Joint instability/hypermobility
16) Pyelonephritis (kidney
infection)/stones
17) Mastitis (breast infection)
18) Minor surgery
19) PID (pelvic inflammatory disease)
20) Pitting edema
21) Portal hypertension (abnormally high
blood pressure in the hepatic portal
vein)
22) Prolonged constipation
23) Recent abortion/birth
24) Trigeminal neuralgia (tic douloureux)
Indications and Contraindications to Massage per Body System: The Oregon Model
NOTE legend for the following disorders: bold indicates no massage, underlined
indicates possibility or certainty of being contagious, asterisk (*) means avoid region,
“@” means refer to physician for diagnosis, “!” means may treat if working with
physician direction
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
summarized by DiCarlo, Esposito and Schwartz page 9
Integumentary System:
 Bacterial Conditions
Acne*, Furuncle* (boil), Carbuncle* (mass of boils), Cellulitis*, Folliculitis*, Impetigo*,
Syphilis
 Viral Conditions
Bell’s Palsy*@, Herpes simplex*, Herpes Zoster* (shingles), Warts
 Fungal Conditions
Ringworm*, Athlete’s foot*, Fungal infections of the nails*
 Allergic Reactions
Atopic Dermatitis*@ (eczema), Contact Dermatitis*, Urticaria* (hives)
 Benign Conditions
Mole*@ if changes, Psoriasis*, Scleroderma (autoimmune disease)
 Malignant Conditions
Skin Cancer (squamous cell, basal cell carcinoma, melanoma, Karposi’s sarcoma)
Skeletal/Muscular System/Articulations:
 Specific Disease Processes
Atonicity*@ (flaccidity), Contracture, Convulsion@, Fibrillation@ if continuous,
Hypertonicity@ if recur with no explanation, Spasms, Tic@
 Soft Tissue Injuries
Dislocation@, Sprains*, Strains*, Subluxation (partial dislocation where articular cartilages
touch)
 Infectious Processes
Osteomyelitis@
 Inflammatory Processes
Ankylosing Spondylitis!, Bursitis*, Fibromyalgia@!, Gouty arthritis*, Lupus erythematosus!,
Osgood-Schlatter Disease*, Rheumatoid Arthritis!, Tendinitis* (inflammation of tendon),
Tenosynovitis* (inflammation of tendon and sheath)
 Compression Processes
Carpal Tunnel Syndrome*@ (inflammation in tendon sheath creates pressure on median nerve)
 Degenerative Processes
Muscular dystrophy! (atrophy of skeletal muscle without nerve involvement), Osteoarthritis*
(degenerative joint disease of the articular cartilage), Osteoporosis
 Abnormal Spinal Curve
Kyphosis, Lordosis, Scoliosis
 Disordered Muscular Processes
Low Back Pain@, Spasmodic Torticollis@, Temporomandibular Joint Dysfunction!
Neurologic Conditions:
 Specific Disease Process
Dyskinesia@!, Dystonia@!, Insomnia@, Peripheral neuropathy@, Tinnitis@, Vertigo@
 Vascular Processes
CVA@! (stroke), Headache@ if persistent & severe, Head Injury@ if severe
symptoms(contusion/laceration, subdural/epidural injury), TIA@! (transient ischemic attack)
 Infectious Processes
Conjunctivitis*, Parkinson’s Disease!, Poliomyelitis!, Postpolio Syndrome@!
 Neuromuscular Processes
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
summarized by DiCarlo, Esposito and Schwartz page 10
Multiple Sclerosis!, Spinal Cord Injury!, Trigeminal Neuralgia*
 Miscellaneous Disorders
Seizure Disorders!, Sleep Apnea, Thoracic Outlet Syndrome@!
Endocrine System:
 Specific Disease Processes
Diabetes Mellitus!, Hyperglycemia!, Hypoglycemia@, Hyperthyroidism!, Hypothyroidism!,
Neuropathy!
Cardiovascular System:
 Physiologic Processes
Anemia@!, Aneurysm@, Angina Pectoris! (chest pain), Arteriosclerosis/atherosclerosis!,
Congestive heart failure!, DVT* (deep vein thrombosis, blood clot), Hemophilia! (blood
clotting disorder), MI@! during rehabilitation (myocardial infarction, heart attack),
Mononucleosis@, Phlebitis*, Raynaud’s Syndrome@ and avoid triggering,
Syncope@(fainting), Varicose Veins*
Lymphatic and Immune Systems:
 Specific Disease Processes
Allergy@, Autoimmune Disease@!, Chronic Fatigue Syndrome@, HIV! and avoid fluid
contact, Lymphedema@!
Respiratory System:
 Specific Infectious Disease Processes
Asthma!, Tuberculosis, Upper Respiratory Infections@ if symptoms severe or persistent
Gastrointestinal System:
 Specific Disease Processes
Constipation@ if symptoms severe or persistent, Diarrhea@ if persistent or dehydration,
Flatulence@ if painful (intestinal gas), Halitosis@(bad breath)
 Inflammatory Processes
Appendicitis@, Cholelithiasis/Cholecystitis@ (gall stones), Cirrhosis@!, Colitis@ and !if
chronic, Crohn’s Disease@ and ! if chronic, Diverticulosis@ if symptoms persist, Duodenal
Ulcer@, Hepatitis@!, Gastritis@, Hernia*, Pancreatitis@ and ! if chronic, Stress Ulcer@,
Ulcer@
Metabolic System:
 Specific Disease Processes
Cystic Fibrosis!, Malnutrition@, Obesity
Genitourinary System:
 Specific Disease Processes
Breast Cancer@ if changes noted, Dysmenorrhea@, PID@ (pelvic inflammatory disease),
PMS@ if symptoms severe (premenstrual syndrome), Testicular Cancer@, Toxic Shock
Syndrome@, UTI@ (urinary tract infection/bladder)
 Sexually Transmitted Disease
Genital Herpes@, Gonorrhea@, HIV! and avoid fluid contact, Syphilis@
Psychiatric Disorders:
 Specific Disease Processes
Anxiety/Depression@! (emotionally erratic, unstable behavior)
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
summarized by DiCarlo, Esposito and Schwartz page 11
Hydrotherapy
As a liquid, water can be pressurized in showers and whirlpools. As steam, it can relax & cleanse, aid in
respiration, & sterilize tools. As ice, it can be used as an anesthetic & to minimize edema – good therapy for
sprains, strains, contusions, hematomas and fractures. Water can be used internally by drinking or by forcing
streams of water into orifices, as in an enema, douche, bidet, or nose or ear bath. It can be used externally
by full/partial baths, showers, compresses, packs, hot water bottles; frozen ice bandages, and steam.
Water can be a sedative (warm bath), increase elimination from skin (steam bath), be an antispasmodic (hot
compresses), reduce fever (cold sponge bath), treat minor burns (cold water immersion), be an anesthetic
(ice), control blood flow and swelling after injuries (ice bag), restore and increase muscle strength and
resistance to disease (whirlpool, contrast baths)
The effects of water are primarily reflexive effecting the autonomic nervous system – cold stimulates
sympathetic, warm stimulates parasympathetic. The change of heat energy in tissues can be classified as a
mechanical effect. Short cold applications vasoconstrict blood vessels, but have a secondary effect of
increased circulation to re-warm tissues. Long cold applications depress and decrease circulation. Short hot
application vasodilate vessels and depress and deplete tone. Long hot applications cause a combined
depressant and stimulant reaction. In theory, stimulation of skin receptors via hydrotherapy can reflexively
alter activity in corresponding organs. Also, direct pressures by water can have mechanical effects on the
nerves and blood vessels in the skin.
Effects of heat: increased circulation, metabolism, inflammation, respiration, perspiration; decreased pain,
muscle spasm, tissue stiffness, WBC production
Effects of cold: increased stimulation, muscle tone, tissue stiffness, WBC and RBC production; decreased
inflammation, pain, respiration, digestive process, circulation (at first, followed by increased circulation)
Effects of ice: increased stiffness; decreased circulation, metabolism, inflammation, pain, muscle spasm;
apply ice periodically, not continuously, e.g. ice bag compression for 20 min., twice/day; contraindications:
vasospastic disease, cold hypersensitivity, cardiac disorder, compromised local circulation; precautions: no
frozen gel packs/ice directly on skin, no ice longer than 30 min. at a time, no pain-causing exercises after
cold, no cryotherapy for paralyzed, or coronary artery disease, or certain rheumatoid conditions.
Rules of Hydrotherapy – Ontario Model
Check thoroughly for possible contraindications - circulatory and kidney problems, skin conditions.
Procedures given for time, temperature, etc. are guidelines, not absolutes - adapt method to individual.
Have the client go to the bathroom before treatment.
Stay with client during treatment, or have some way for client to contact you, such as by using a bell.
Explain the complete treatment beforehand so client knows what to expect and what is expected.
Room is draft-free, clean, quiet; equipment sanitary, in good working condition; clean towels & sheets.
Keep the client from becoming chilled during or after the treatment.
When using cold temperatures, the water should be as cold as possible and within the tolerance of the client.
A 10 degree difference is the minimum needed to create stimulation and change in circulation.
Warm temperatures as warm as necessary and within the client's tolerance. Too hot can be debilitating.
More is not better. It is not more effective to use greater extremes in temperature or greater lengths of time aim is to achieve a positive change, and too much can overtax, damage, or set back the condition.
Ask questions about comfort level & thirst during treatment; talking to a minimum; allow client to relax.
Check respiration & pulse before, during & after, especially w/long hot treatments; should stay fairly even.
Watch for discomfort and/or negative reactions to the treatment.
Stop the treatment if a negative reaction occurs.
Generally, short cold treatments are followed by active exercise. Prolonged cold and hot treatments are
followed by bed rest and then exercise.
Apply cold compresses to the head with hot treatments and prolonged cold treatment.
Never give a cold treatment to a cold body. Always warm the body first (e.g. a warm foot bath).
Temperatures over 110 degrees should not be used; below 56 degrees is painful.
The R.I.C.E. First Aid application of hydrotherapy is appropriate for most soft tissue injuries, especially
sprains and strains. Always refer serious injuries to a medical doctor . R.I.C.E. Stands for:
R - Rest I - Ice C - Compression E - Elevation
Adopted from “Mosby’s Fundamentals of Therapeutic Massage” by Sandy Fritz,
summarized by Carroll and Schwartz page 12