EXAM REVIEW
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ADAPTIVE MASSAGE
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INTRODUCTION
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Standard massage routines are designed for the average client’s needs
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Some clients will have physical, emotional, and health-related challenges requiring
adaptation of the massage or positioning
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Many clients who have special needs may be touch-deprived, and massage can go a long
way to provide safe touch and meet psychosocial and physiological needs.
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Most important: view all clients as people
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Special needs are an important, but secondary, consideration
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Regard all injuries and conditions with gentleness, kindness, and acceptance
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When adapting massage for clients with special needs, the strokes themselves might not
change
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More likely changes are pressure, speed, duration, or frequency of massage; positioning;
and safety precautions
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Best source of information is the clients themselves
COMMUNICATION OF
SPECIAL NEEDS
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Clients may indicate their need for adaptive measures when their appointment is
scheduled
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If possible, research condition ahead of time
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Ask client questions during interview
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Boundaries (professionalism, confidentiality) should remain consistent for all clients
AMPUTATIONS
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Obtain consent during interview to massage the stump
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Asking for details about surgical procedure (e.g., whether muscle was wrapped
around stump) helps locate trigger points
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Ask client whether stump is sensitive or numb
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Many practitioners of energy work such as polarity and Reiki treat the energy field of
the missing limb as if it were still present.
AMPUTATIONS:
PHANTOM LIMB SENSATION
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Definition: feeling pain and other sensations in the amputated limb
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Also known as phantom limb pain
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Cause is complex—involves both peripheral and central nervous systems
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Calming effects of massage generally help clients with phantom limb pain
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Approximately 70% of people with amputations experience phantom limb sensation.
The cause is not completely understood; possible explanations include a neuroma
(tumor) at the severed nerve ends, abnormal input from nerves in the amputated
area, or signals from the CNS out to the limb.
AMPUTATIONS:
PROSTHETIC APPLIANCES
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Some clients may want to remove prosthetics; others may not
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Look out for chafing or friction wounds at site of prosthetic—avoid inflamed areas,
broken skin, or open wounds during massage
CENTRAL VENOUS
CATHETER
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Also called a central line
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A central line is usually inserted into the right subclavian vein of the upper chest.
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Flexible tube inserted into a large vein and left in place for an extended period
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Used for dialysis, blood withdrawal, chemotherapy, or medications
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Use of catheter makes prone position difficult or impossible—use side-lying position,
bolsters, pillows, etc.
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Avoid tension or excessive movement near catheter
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Do not allow massage lubricant to come in contact with catheter dressing or sutures
ICD’S
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ICD: implantable cardioverter defibrillator
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Used to treat abnormal heart rates
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Delivers electrical shock to restore normal heart rate and rhythm
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Massage considerations:
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Massage contraindicated once device discharges
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Other modifications listed under pacemaker
PACEMAKER USERS
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Pacemaker is an electrical device to help client regulate heartbeat
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Usually inserted near the pectoralis major muscle
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Massage considerations:
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Main concern is whether incision has healed; if so, apply gentle effleurage
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Avoid vigorous massage on pectoral region
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Pacemaker wires (leads) may run over clavicle and down into chest cavity;
avoid moving client’s arm over head when mobilizing shoulder joint because
this may disturb connections
While the client is prone, offer a soft pillow to place under the chest for added
comfort.
STENT
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Small, expandable, lattice-shaped metal tube or hollow perforated tube
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Creates an increase in vessel duct diameter
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If located superficially, local massage is contraindicated
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If in deep vessel or duct, use only light pressure over or near site
BREAST IMPLANTS
OR LARGE BREASTS
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Main issue—comfort while lying prone
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Offer rolled towel or pillow for support under, above, or
between breasts
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Many clients prefer support from both above and below
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Adjust face rest if needed
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If available, use a face rest that can be adjusted above the
level of the table along with the cylindrical pillows.
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Some table manufacturers carry tables fitted with recesses
for the breasts. These tables come with cushions which
can be placed in the recesses when they are not needed.
MASSAGING WOMEN
WITH LARGE BREASTS
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It can be difficult to access chest
muscles of large-chested women in
the supine position
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Ask client to use back of hand to retract
breast tissue medially
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The client’s hand serves not only to hold
back the breast tissue but also to provide
a boundary between herself and the
therapist.
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Self-massage of the breast is often
recommended for sub-glandular implants.
MASSAGING WOMEN
WITH LARGE BREASTS
LAB
instructor demo on a student and then the do
partner trades for half an hour each
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BREAK
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COLOSTOMY OR ILEOSTOMY
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Colostomy—incision in the colon to provide an opening between the bowel and the abdominal
wall
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Patients with lower colostomies can regulate their bowels; patients with upper colostomies
and ileostomies cannot.
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Ileostomy—similar to colostomy; incision is in the small intestine
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Stoma—section of colon wall attached to the abdominal wall
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A bag is attached to the opening to collect fecal material
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The fecal matter exits the body through the stoma and enters the bag.
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Not all colostomies are permanent; some are a temporary measure to allow the colon or rectum to
heal after surgery.
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Recommend that client not eat for two hours before massage—decreases bowel motility
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Suggest that client empty bag before massage begins
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Use side-lying position to accommodate opening and bag
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Do not apply lubricant on or near bag opening—interferes with adhesive
CHRONIC ILLNESS
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Definition: A condition of the body for which no cure is known
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Massage therapy can reduce suffering and increase comfort
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Obtain medical clearance; apply massage more gently, more frequently, and for
shorter periods than with other clients
TERMINAL ILLNESS
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Definition: A condition in which the client is expected to die within a time frame,
usually 6 months
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Goal of the massage therapy session is to improve quality of life
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Obtain medical clearance; apply massage more gently, more frequently, and for
shorter periods than with other clients
END-OF-LIFE MASSAGE
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Massage can reduce suffering and increase comfort
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Use gentle pressure; treatments should be more frequent but shorter
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If visiting client in hospice or at home, client may prefer to be massaged in her bed
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In hospital, check with medical staff for any helpful information
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Work around catheters, equipment, etc.
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When making choice to work with a terminally ill patient, commit to keep patient as client
until his or her death
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Use focused, gentle, calm touch.
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Know that you will probably become attached to the client, cry when death comes, mourn
the loss, grieve with his family, and grow from this experience.
CANCER
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Once viewed as terminal illness—focus was length of time patient had to live
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With new technologies and medications, now often viewed as chronic condition—allows
greater focus on quality of life
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Characterized by uncontrollable growth of abnormal cells that form a neoplasm or tumor
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A tumor is either a benign tumor or cancerous
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A cancerous tumor will often metastasize, or spread its cells to other parts of the body
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Note that another word for neoplasm is tumor.
S The suffix –oma means tumor.
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A harmless tumor is a benign tumor; a benign tumor does not metastasize, but it could
become dangerous if it puts pressure on vital areas in the body.
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A cancerous tumor is known as a malignant tumor.
TYPES OF CANCER
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Cancers are named for the type of tissue from which they are derived
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Carcinoma: arises from epithelial tissue
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Melanoma: grow from melanocytes
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Sarcoma: develops from muscle cells or connective tissue
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Leukemia: rapid growth of abnormal white blood cells
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Lymphoma: arises from lymphatic tissue
CANCER AND MASSAGE
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Massage is one option to help cancer patients live more active, pain-free lives
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American Cancer Society advocates massage to help and comfort patients, not to
treat the cancer itself
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As safe as activities of daily living, hot bath, or mild exercise
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Some of the benefits of massage for cancer patients include promoting relaxation,
improving sleep, reducing pain, increasing blood flow, boosting immune functions,
reducing lymphedema, decreasing nausea, improving skin during radiation therapy,
and reducing fatigue.
CANCER TREATMENTS
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Surgery—removes cancerous tissue and nearby lymph nodes
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Massage to promote lymph flow
Radiation therapy—uses radiation to eradicate cancer cells
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Massage gently, avoid lubricant on treatment area, use cool towels on areas that burn
or itch
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Common side effects from radiation include skin that appears sunburned, hair loss,
reduced white blood cells (WBCs) and platelets, blood vessel fragility, fatigue, loss of
appetite, and weight loss.
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Chemotherapy—drugs used to slow or stop growth of cancer cells
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Client may be extremely fatigued; assist client on and off massage table if needed
The side effects of chemotherapy are similar to those of radiation therapy. They include
nausea, vomiting, diarrhea or constipation, reduced WBCs and platelets, blood vessel
fragility, fatigue, weight loss or gain, fever, and hair loss.
CANCER GUIDELINES FOR THERAPIST
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Obtain medical consent first
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Be attentive about pressure, client position and comfort, and areas to avoid
S Use gentle pressure or modalities that use very little pressure
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Inquire about client health at the start of every session
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Use a side-lying position if client cannot
lie prone
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Be cautious of pressure, traction, and ROM activities if cancer has spread
to bone
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Avoid IV lines, catheters, surgical wounds, radiation burns, known tumor sites
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To massage a patient with cancer, clearance must be obtained from the health care
provider. As with other patients, the massage therapist needs to accept the client’s
appearance unconditionally. It would be helpful for the therapist to educate himself or
herself regarding the type of cancer the client has. Upon learning of the cancer, the
therapist should modify the massage to the type of cancer the patient has, as well as the
kind of treatment the patient is undergoing. In addition, the massage therapist should
document client symptoms, areas of the body worked, techniques used, and outcomes of
techniques used.
CLIENTS INFECTED WITH HIV
OR LIVING WITH AIDS
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HIV—Human Immunodeficiency Virus
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Virus that causes AIDS
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Virus affect T-lymphocytes or T-cells
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AIDS—Acquired Immune Deficiency Syndrome
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Patients who have AIDS
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Are infected with HIV
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Have three or more opportunistic infections, and/or T-cell count below 200
Three elements required for transmission of HIV:
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Virus must be in proper environment to survive (body fluid)
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Virus must be in sufficient quantity to survive (found in blood, semen, vaginal secretions, breast
milk)
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Virus must have a port of entry
Tears, sweat, and saliva do not appear to contain enough of the virus to cause infection because no
known cases of transmission by the body fluids have been reported. It has been speculated that it
would take 6 to 10 gallons of saliva to have enough concentration for the virus to be transmitted. It’s
safe to say that, for most of us, this is physically impossible.
CLIENTS INFECTED WITH HIV
OR LIVING WITH AIDS
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Massage considerations:
S Inquire about areas to be avoided (e.g., sites of blood work)
S Assess general vitality and other conditions (e.g., bedridden client might have reduced
bone density) that might limit Swedish gymnastics or ROM
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Deep massage is contraindicated for patients with Kaposi’s sarcoma. Even light massage
may be painful around lesions.
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If body fluids spill, wash linens separately in detergent and bleach; wipe down table with
bleach solution
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If therapist comes in contact with body fluids, wash area of contact with hand soap for two
minutes
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To wash linens, use detergent and one-quarter cup of chlorine bleach; machine dry. To wash
table and equipment, use 1 part bleach to 10 parts water.
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No known cases of HIV transfer from client to massage therapist while performing massage
have been reported
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Clients with HIV are unusually susceptible to infection—maintain sanitation and cleanliness
(as with all clients)
GERIATRIC CLIENTS
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Definition: Someone who is 70 years of age or older
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Many changes occur as we age: examples include decreased reflexes, sight, and hearing;
decreased muscle and bone strength; atherosclerosis
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Condition varies widely from person to person
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Geriatric clients represent the fastest growing populations in the massage industry.
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Some geriatric clients will have a number of the other conditions discussed in this chapter, such
as kyphosis, hearing and vision impairment, and wheelchair use.
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Assess client during pre-massage interview; ensure she can hear and understand you
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Make sure client feels comfortable and safe
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Guard against chilling during massage by using blanket and/or heater
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The most comfortable position for elderly clients are supine and side-lying.
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Because elderly people tire easily, a 30-minute session may be best.
GERIATRIC CLIENTS
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When visiting client at home, knock before entering room
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Put objects back in their places
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Be patient
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Client may be lonely or depressed—be attentive and sensitive to emotional needs
MASSAGING GERIATRIC
CLIENTS
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Avoid deep work unless ordered by physician
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Massage for short periods to avoid tiring client
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Reduce treatment time and pressure to minimize bruising
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Assist client to sitting or standing position—blood pressure may drop
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The clinical term for a drop in blood pressure when standing is orthostatic
hypotension.
PEDIATRIC CLIENTS
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Defined as clients 3−18 years old
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May be accompanied by anxious parents—child often has injury or illness
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Explain procedures to both child and parent; obtain informed consent from parent or
guardian (by law)
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Consider requesting that parent remain in room when massaging young client, especially
near sensitive areas
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Massage sessions for young children are often only 30 to 45 minutes
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Spend extra time establishing rapport
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In some states, it is required that a parent supervise the massage of a pediatric client.
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Adolescent boys easily develop erections during massage—use bunched-up draping
around groin to conceal this. Stop massage briefly if client is aroused; leave room “to get
a drink of water.”
LARGE CLIENTS
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Clients usually have history of verbal abuse and
blame about weight—therapist should be aware
of this and avoid badgering the client
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Adipose (fat) tissue contains many blood vessels
and is susceptible to bruising—avoid deep work
of fatty tissue
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Clients who are large or who have generous
amounts of fragile subcutaneous tissue require
special consideration.
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Massage considerations:
S Palptate to discern difference between
adipose and muscle tissue
S Lower table height or stand on platform
S Massage on floor if necessary
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Make sure you have a comfortable floor mat
available if the client prefers being massaged on
the floor.
HEARING IMPAIRED CLIENTS
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Allow extra time for pre-massage interview
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Make eye contact whenever possible—sign of attention
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Use gentle tapping and gestures as needed
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When repeating a sentence the client did not understand, rephrase the information
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Find out early whether client reads lips
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Face client, maintain eye contact, speak clearly and distinctly
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Keep view of your face unobstructed
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Use facial and hand gestures to help convey meaning
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If client has an interpreter, speak to client, not interpreter
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Do not assume a hearing aid completely corrects hearing loss
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Consider use of flash cards with printed questions and answers to aid in communicating with hearing
impaired clients
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Be aware of the location of your hands when working near hearing aids
SPEECH DIFFICULTIES
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Ask client to repeat anything you do not understand
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Ask whether any accommodations can be made on his behalf
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If client speaks a language you do not understand, ask whether he can bring
someone to interpret
VISUALLY IMPAIRED CLIENTS
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During pre-massage interview, allow extra time to give and receive information
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Ask client to explain her impairment and what assistance (if any) is needed
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Keep massage facilities free of barriers and clutter
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Announce presence before entering room; speak in normal tone of voice
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Address client by name and state your name
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To assist client, stand in front or to left of client
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When you are helping a client move from one area to another, some clients will touch your
right elbow or shoulder and follow you.
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Describe surroundings to client (e.g., “The massage table is at two o’ clock.”)
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Be sure client knows you are there before beginning touch; maintain contact during
massage as much as possible
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Do not feed, pet, or interact with a client’s service dog without permission.
CONTACT LENS USERS
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Many clients remove lenses before massage—have contact lens solution available
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If user keeps contacts in, show him how to adjust face rest cover to avoid eye
compression
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Moving face cushion to side of frame reduces eye compression of contact users
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Massage near or over eyes is discouraged for all clients, not just contact lens users.
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While client is supine, avoid massage near or over eyes
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Be sure to place the face rest cushion in its original position after the massage. In
fact, it is a good idea to remove the face cushion and reshape every week or so
because the sides of the cushion will spread with repeated client use.
SPINAL ABNORMALITIES
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Kyphosis—humpback condition
S Clients may be uncomfortable lying in the prone position
S Place a cushion under the clavicles; adjust face rest to level above table
S Kyphosis can occur at any age and has a number of causes. In adults, the most
common causes include osteoporosis and arthritis.
S When the rounding of the back becomes extremely pronounced, it is called
hyperkyphosis, or Dowager’s hump.
Lordosis—swayback condition
S Common in clients who are overweight or have flaccid abdominal muscles
S Place pillow under anterior superior iliac spine (ASIS) when client is in prone position
S Use bolster under ankles; use pillows to correct externally rotated femurs
Scoliosis—lateral spine distortion
S Abnormal curve is in thoracic position; ribs and hips are in distorted positions
S Offer client pillows and allow her to position them until she feels supported and
comfortable
S Scoliosis occurs most often (60–80%) in females. It usually develops during early
adolescence and the cause is generally unknown.
S In severe cases, the thoracic vertebrae may be rotated, which would strain the client’s
back muscles.
CLIENTS IN WHEELCHAIRS
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If massage studio is not in an accessible
building, perform the massage off-site
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Sit or kneel when speaking to client—puts you at
his eye level
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Inquire about the client’s limitations—do not
make assumptions
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Ask client the reason for his wheelchair use
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Client may choose to be massaged in
wheelchair; use pillows or desk topper
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Be sure wheelchair brakes are locked before
beginning massage
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If client prefers to be massaged on table, follow
his instructions on how best to help him transfer
from chair to table
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Ask client for feedback during massage
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Trigger points may be located in shoulders and
chest
SUBSTANCE ABUSE
AND DRUG ADDICTION
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Massage can assist clients with stress during withdrawal
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Massage can also provide benefits during recidivism (relapse)
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Most substance abuse clients need professional counseling; the therapist can
provide moral support and acceptance
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Avoid deep work during early withdrawal stages; it may intensify the release of
toxins into the system.
SEXUAL ABUSE
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Crosses all boundaries of gender, orientation, age, and income
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Most perpetrators are family members, friends, or acquaintances (e.g., date rape)
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Client may need time to establish trust with therapist before massage can be performed
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Many survivors adopt extreme behaviors, e.g., compulsive eating, compulsive exercise,
drug or alcohol abuse
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Sexual behavior may also be extreme: survivor may be fearful or promiscuous
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Therapist must be a good role model for appropriate sexual boundaries
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If therapist has any concerns about his/her own boundaries or is attracted to the client,
refer client to another therapist
SEXUAL ABUSE
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Avoid triggering memories and behaviors:
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Establish calm and nurturing environment
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Ask the client if he knows what his triggers are
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Common triggers: perfume scents, touch in a particular area, body positions, certain music or colors
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Massage itself may act as a trigger—reassure client that he or she is in control of session
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Allow client to set boundaries: draping, areas for massage, speed and depth of massage
State-dependent memory
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Some aspects of massage (e.g., position or touch) may cause client’s body to “remember”
abuse
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Repressed memories become conscious
Disassociation
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Coping mechanism: person “leaves the body,” does not feel, or believes abuse is happening to
someone else
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Can occur during massage if client recalls abuse
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Signs: client unresponsive, a distant look in the eyes, shaking, disorientation, shift in breathing
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Stop massage if client disassociates; further touch can be traumatizing
EMOTIONAL RELEASE
DURING MASSAGE
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Most often seen as tears or crying; can include shaking,
twitching, or thrashing
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Clients in counseling are more likely to experience
releases
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If client is aware this might occur, explain steps you will
take ahead of time
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If possible, the therapist should discuss with the client
ahead of time what body part to use for touch in the
event of an emotional release.
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Process for therapist:
S Approach release with acceptance
S Discontinue massage and make touch contact in a
neutral area
S Do not leave room unless client requests it
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Remember not to offer the client too many choices at
once.
EMOTIONAL RELEASE
DURING MASSAGE
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Process for therapist (cont’d.):
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Do not offer tissues too quickly
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Remind client she is safe; ask if she wants a break or other comfort measure
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Be accepting of the response; do not encourage or repress
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Get in touch with your own feelings about others expressing emotions—allow client to
express feelings without interruption
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Support and reassure client
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Continue massage if possible
Responding to your client after the emotional release:
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If asked, mirror back what you observed
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Do not analyze; offer your understanding of state-dependent memory
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Provide space for client to be alone (or to phone counselor) if requested
Allow the client space and time to compose herself, if needed, before she leaves the
massage studio. Avoid asking the client to leave in a raw, open, wounded, or disassociated
state.
EMOTIONAL RELEASE
DURING MASSAGE
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Responding to your client after the emotional release (cont’d.):
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When appropriate, refer client to qualified mental health professional
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If release is very uncomfortable for therapist to deal with, speak to a counselor,
fellow therapist, or peer support group
SUMMARY
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Massage is an adaptable medium of therapy, with endless variation
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This flexibility enables the therapist to accommodate many special needs
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Client respect and communication are the most important aspects to adaptive
massage
LUNCH
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CLINICAL MASSAGE
THERAPY
TECHNIQUES
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LAB
Instructor: Guide class through 5 minutes of
diaphragmatic breathing
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LAB
Instructor demos and discusses the rest of the
Clinical Massage Therapy Techniques
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LAB
Students trade with partners GTO, O&I
Technique and Muscle Approximation 30 minutes
each
Follow up with discussion about observations
discovered with techniques used during trades
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BREAK
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LAB
Students trade with partners Cross Fiber Friction,
Direct Fascial Techniques, Indirect Fascial
Techniques and gentle joint mobilizations
Follow up with discussion about observations
discovered with techniques used during trades
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