Massage Contraindications & Precautions Every Therapist Should Know

Massage therapy in general is a very safe, effective and enjoyable therapeutic modality. But there are times when it is not safe for a person to receive massage. Massage and other forms of bodywork should be avoided when certain risk factors are present, or when the potential risk from massage outweighs the benefit. It is up to massage therapists to know the contraindications to massage, how to appropriately modify treatments, when to seek medical clearance, when to withhold massage completely, and how to communicate all of this with their clients.

What is a massage contraindication? A massage contraindication is a pre-existing condition that may respond negatively to therapeutic massage techniques. People with contraindications to massage therapy should avoid massage or bodywork until the condition has resolved. In some cases, massage may still be provided IF the treatment is modified to compensate for the condition, or if treatment is avoided at the affected area of the body.

For massage therapy students preparing for the Massage and Bodywork Licensing Exam (MBLEx), you can expect to see several questions about contraindications and precautions on the massage exam. On the MBLEx Content Outline provided by the FSMTB, contraindications are listed in the third content area, along with areas of caution, pathology and special populations, together accounting for 14% of the massage exam.

For currently practicing massage therapists, as well as other clinicians who may provide therapeutic massage as part of their treatments, such as physical therapists and PTAs, having a thorough working understanding of the contraindications for massage is critical in order to reduce the risk of injury to our clients and patients. This article includes examples of different types of contraindications, as well as a list of common massage contraindications and precautions.

This article goes into detail about these contraindications and precautions for massage therapy. It presents key definitions and concepts that are important for massage students starting their clinicals or preparing to take the massage licensing exam. The information here can also serve as a helpful reminder of massage contraindications for practicing therapists. The end of this article lists some answers to frequently asked questions about contraindications and massage safety precautions.

Massage contraindications, precautions and indications for the MBLEx

A massage contraindication is any condition or factor that makes a specific treatment inadvisable due to an increased risk of injury. Massage therapists are responsible for knowing the contraindications and expected effects of the treatments that they offer. This includes understanding the risks associated with deep tissue massage, Swedish massage, hot stone massage, sports massage, or any other bodywork treatment that you offer. Therapists must also consider each client’s individual factors, the severity of their condition, and other individual risk factors that will affect the client’s tolerance of massage and the treatment plan. A massage contraindication may be site specific, pathology related, or associated with special populations.

A massage precaution is a condition that may not prohibit the client from receiving massage, but requires the therapist to make some special accommodations. Massage precautions are sometimes called relative contraindications, because the decision about how to modify the treatment, or to withhold or postpone the massage depends on various client factors such as severity and potential risk.

A massage indication is a massage term that means ‘a condition in which it is reasonable to expect improvement directly related to massage therapy’. In other words, an indication for massage is a reason to get a massage. If massage therapy is indicated, then it is not only safe for the client, but it is expected to produce a noticeable improvement. Common indications for massage include: mental or emotional stress, increased muscle tension, muscle aches and pains, posture deviations due to muscle imbalance, and other soft tissue restrictions that affect movement and function.

Massage therapists must assess for contraindications and precautions during the initial client assessment. The client data on the health history form is the primary source of information that lets the therapist know about any contraindications or precautions that the client may have. It is important for the therapist to discuss the completed form with the client during the verbal assessment. Massage therapists must also use clinical reasoning skills to determine if it is safe to proceed with the massage, if modifications need to be made, if medical clearance is needed, or if massage therapy should be withheld at this time. Therapists should also inquire about recent injuries or illnesses and at the beginning of each followup client session, to rule out the onset of a new contraindication. Since a new contraindication can occur at any time, each visit should begin with asking about any new injuries or changes in health status.

The therapist’s level of skill, knowledge and experience is also a factor. A massage can be beneficial for a client with a certain condition if the treatment is modified appropriately. But a massage done incorrectly (e.g. too intense) may worsen the same condition. This comes down to training and experience. Massage therapists seeking to work with more vulnerable, at-risk clients can take continuing education courses to be able to safely and competently work with a specific population or condition. Contraindications and precautions are important to study and review periodically, not only for the MBLEx but also to keep clients safe during daily practice. Learn more about content on the MBLEx in our massage exam prep course.

Concepts related to massage contraindications and side effects

Side effects are secondary effects of a treatment or intervention. They are often undesirable or even harmful, but not always. Massage is not a risk-free treatment. The side effects associated with massage are generally mild and short-lived (less than a day or two), especially for a gentle relaxation massage. Even deep tissue massage rarely produces any significant or harmful side effects when the client is screened properly and the therapist is knowledgable and skilled. Massage therapy for a healthy person could result the following harmless side effects:

• An emotional release
• Feeling sleepy afterwards
• Mild bruising
• Feeling a little sore the next day
• Skin feeling smoother and less dry

An adverse reaction is an undesirable bodily response to the treatment. If massage is contraindicated for a client for a particular reason, then there is the expectation that there could be an adverse reaction because of the contraindicating condition.

An adverse event is basically a harmful side effect or other unwanted effect that results from the massage session. It is more severe and longer lasting than the typical side effects of massage. Adverse events from massage therapy are rare, but can occur due to accident, negligence or lack of training. Adverse events should be documented on an incident report. Examples of an adverse event caused by massage or bodywork session can include:

• Dislocation of joint during assisted stretching or joint mobilization
• Fracturing of a rib due to excessive pressure or not modifying the treatment for clients with osteoporosis
• Fracturing the xiphoid process (of the sternum) or styloid process (of the temporal bone)
• Burn from hot stone or hot pack, or even ice pack if used directly on the skin
• Client fall when attempting to get up from the massage table (e.g slipping, orthostatic hypotension)
• Dislodging of a blood clot that causes a stroke or pulmonary embolism
• A dangerous drop in blood pressure due to stimulation of the carotid sinus (a baroreceptor at the base of the internal carotid artery)

Another concept related to massage contraindications is the red flags and yellow flags. These are signs or symptoms that the therapist should become aware of during an initial client assessment (and during followup sessions) when discussing the client’s current condition, past medical history, and recent changes. A massage therapist will understand the client’s current condition better after conducting a physical assessment. Therapists should stay alert for client reports of pain that wakes them up at night, night sweats, changes in bowel or bladder habits, or progressively worsening symptoms.

• Red flag is a warning that it may not be safe to proceed with the massage. There may be a serious pathology present that requires the client to see their physician or another specialist first.
• Yellow flag is an indicator that is is probably ok to proceed with massage, but to be cautious and monitor the client for any adverse reactions.

If you are ever uncertain about whether or not it is safe to proceed working with a client, ask them to get their doctor’s advice about their symptoms and get approval for massage. Just remember the adage: “When in doubt, refer out”.

Confusion about massage safety and contraindications

Many conditions came to be considered as contraindications for massage due to expert opinion, not through any specific research. Therapists may have differing opinions on whether or not it is safe to provide massage in these cases, or if a physician referral is warranted. However, some contraindications have very little debate about them. For example, a client with a DVT or hematoma should definitely not receive massage at or near the affected site. The mechanical effect of massage presents an obvious risk of dislodging a clot and forming an embolism. *Note: It is important for massage therapists to clarify any abbreviations that the client uses on their client intake paperwork, to avoid overlooking a contraindication for massage.

There are other conditions where some experts claim massage is indicated, and other experts claim that massage is contraindicated. Massage for a client with hypertension (high blood pressure) comes to mind as one example of this.

For some health conditions, massage has been considered a contraindication for a long time, even when there is no evidence that it can increase risk of harm to a client. For example, massage and bodywork is often contraindicated for a pregnant client during the first trimester of pregnancy. The reasoning is that this trimester is most associated with miscarriages, and there are concerns about certain types of massage and bodywork techniques having the potential to cause a miscarriage. While each of the trimesters require special precautions to prevent injury to the woman and the fetus, the notion that massage causes miscarriages is a myth. Another myth is that massage is totally contraindicated for anyone with cancer. While there are circumstances where massage is contraindicated for a cancer patient, like when they are receiving certain medical treatments, massage can provide many therapeutic benefits for clients with cancer.

There are many myths and unknown’s about what is or isn’t a contraindication. In my opinion, it is best to err on the side of caution and keep client safety as the primary objective (“First, do no harm…”). If massage is safe for the client but you do not know how well they will tolerate it, it may be best to provide a gentle or short first treatment, just to see how the client’s body responded to it. *Be sure to educate the client ahead of time on any potential side effects such as muscle soreness.

Not sure if you should provide massage for a client? Try asking yourself these questions:

1. Does this client have any pre-existing conditions?
2. Could massage exacerbate the condition itself or any related symptoms?
3. Could massage create new problems for this client, or add to their stress because of this condition?
4. Does the planned massage treatment pose any risks to the client’s general health?
5. Could my license or reputation as a professional be at risk if I massage this client?
6. Is there any alternative treatment that I can skillfully provide that would help this client reach their therapeutic goals without any risk of harm?

Types of massage contraindications and precautions

There is a long list of potential massage contraindications and precautions. Grouping or categorizing these contraindications can help massage therapy students and new therapists understand the big-picture concepts of contraindications. This is especially useful when preparing for the massage exam. Grouping contraindications can also help with the clinical reasoning that therapists must use to decide what to do when they discover that a client has a contraindication for massage. Note: You will likely see different massage reference sources using slightly different labels when describing contraindications. This is kind of like asking different people to describe a stop sign. One person may describe it as a “red sign with white letters”. Another person may describe it as “a flat metal sign found at intersections”. And a third person may describe it as “an octagonal sign that is attached to a post”. Each of these descriptions is correct. The important point though is that they know what to do when they see the stop sign. Here is a helpful way to group massage contraindications:

Systemic contraindications to massage

Systemic contraindications are conditions that affect the entire body. A systemic absolute contraindication, sometimes called a total contraindication, precludes massage entirely. Examples of these conditions include severe, acute, or infectious conditions, where massage is likely to cause more harm than benefit. Systemic relative massage contraindications affect the entire body, but are generally less severe or acute. Many chronic conditions are considered systemic relative contraindications. For example, osteoporosis, rheumatoid arthritis, multiple sclerosis, and anxiety. People with these conditions can often receive massage and bodywork safely with appropriate treatment modifications. Here is a list of systemic conditions that either prohibit massage entirely or require modified treatments, depending on the stage and severity.

• Acute conditions, or the acute stage of chronic conditions.
  • After surgery. This includes orthopedic procedures, general surgery, etc. Clients may have pain, discomfort, difficulty sleeping, stiffness or other symptoms after their procedure. And they may want to get a massage to help reduce these symptoms, especially if they are used to receiving massage. It is best to get clearance from the surgeon before providing (or resuming) massage with these clients. There may be specific modifications or restrictions that you will need to use to accommodate the client’s current condition. The client may also be on antibiotics or blood thinners after a major surgery too. Do not rely on the client knowing or remembering any special precautions that you need to take. Get this information directly from the patient’s physician.
  • Recent traumatic injury
    • Concussion (until medically cleared)
    • Rhabdomyolysis
    • Joint dislocation or subluxation; unstable joint (may be systemic or local contraindication)
  • Systemic infection. These overlap with systemic contagious conditions.
    • Sepsis
    • Bacteremia
    • Meningitis
    • Systemic skin infections:
      • Staph infections
    • Osteomyelitis. Can begin locally but spread throughout the body.
    • Cancer that has metastasized
    • Lymphatic infections
    • Viral or bacterial infections
      • Respiratory infections
        • Pneumonia
        • Influenzas
        • Cold. Rhinovirus, coronavirus, etc.
      • Sinus infection
    • If any signs or symptoms of an infection are present
      • Fever. Generally, an elevated body temperature of over 100 or 101 degrees (F) is when massage becomes contraindicated.
    • Kidney infection
    • Urinary tract infection (UTI)
  • During acute event
    • Shock
    • Stroke
    • Heart attack
    • Aneurysm
    • Drug withdrawals
    • Severe or unexplained pain, including severe headache or internal pain
    • Acute appendicitis
• Pregnancy is a precaution that affects the entire body (see section further down this article)
• Clients with compromised immune function
• Contagious (infectious) conditions. These are just a few examples of common contagious conditions that are systemic contraindications for massage. These conditions are contraindications to protect the therapist and other clients, and also to avoid spreading the condition to other areas of the client’s body. Any contagious disease that can be spread through contact, droplet or airborne is a systemic & absolute contraindication.
  • Parasitic infections
    • Scabies
    • Head lice
  • Fungal infections
    • Tinea infections
      • Athlete’s foot (tinea pedis)
      • Jock itch (tinea cruris)
      • Ringworm (tinea corporis)
  • Bacterial infections
    • Tuberculosis (active)
    • Strep or staph infections; MRSA
    • Impetigo
    • Pink eye (bacterial)
  • Viral infections
    • Pink eye (viral)
    • Varicella zoster (chicken pox, shingles…)
• During acute flareup of chronic diseases
  • Rheumatoid arthritis (RA)
  • Shingles
  • Psoriatic arthritis
• Current medical treatments
  • Cancer treatments such as chemotherapy or radiation
• Other systemic conditions:
  • Uncontrolled hypertension (HTN)
  • Diarrhea
  • Organ failure
  • Acute hepatitis, or if jaundice is present
  • Nausea & vomiting
  • Intoxicated clients. Any client under the influence of alcohol, recreational or prescription drugs
  • Severe atherosclerosis or arteriosclerosis

Local contraindications for massage

The presence of local massage contraindications means that massage should be avoided at the affected area. These are site specific contraindications. The site where massage is contraindicated could be small. For example, the client could have a wart or other lesion on one finger that should be avoided. Or a local contraindication could apply to an entire region, such as avoiding the entire left upper extremity due to an acute injury. Depending on the condition and severity, it could be an absolute local contraindication, or a relative local contraindication. I’ll differentiate the absolute and relative meanings more in the next sections.

• Blood clots (if the client currently has blood clots). A history of blood clots is not a contraindication.
  • Deep vein thrombosis (DVT). Often affects the lower extremities, but can occur in any vein. A DVT is an absolute contraindication if it is unstable, has not been treated yet, or has signs and symptoms (e.g., pain, swelling, tenderness, discoloration). If there is any concern, withhold treatment until cleared by the client’s physician.
  • Thrombophlebitis. This is a blood clot in a vein that causes inflammation of the vein.
  • Varicose veins. Very light and superficial work only.
• Localized infections
  • Cellulitis. This could also be a systemic contraindication depending on the size of the affected area and the overall health of the individual. Cellulitis can easily spread to other parts of the body and can be life threatening. So, a client who is elderly or in poor health should wait until the condition has resolved before receiving massage.
• Local skin conditions
  • Sunburn
  • Folliculitis
  • Boils
  • Warts
  • Open lesions or areas of broken skin
    • Ulcers, blisters, cuts (lacerations), avulsions, abrasions, etc.
  • Hypersensitive areas. Light work may be ok, and actually beneficial as a desensitization technique.
• Undiagnosed lumps or masses.
• Acute flareups of localized conditions.
  • Eczema
  • Psoriasis
  • Edema
• Any current medical treatment site or implanted device
  • Fistula site (for dialysis)
  • Pacemaker
  • Implanted insulin pump
  • Recent injection site (e.g. insulin, vaccination)
• Local acute injuries
  • Muscle strain
  • Tendon or ligament sprain
  • Areas of local inflammation, redness & warmth (signs of trauma or infection)
  • Burn
  • Bruise (contusion)
  • Hematoma
  • Unhealed or unstable fracture (non-union)
  • Compartment syndrome
  • Bell’s palsy
  • Recent minor surgery (e.g. stitches to close small cut)
• Areas with pitting edema

A local contraindication is different from an area of caution. The areas of caution are the same for everyone. These are areas of the body that are naturally vulnerable to injury, particularly from deep massage techniques. Massage areas of caution are also called endangerment sites. Delicate tissues and structures that are vulnerable and located at these sites may include: nerves, arteries, veins, lymph nodes or vessels, or fragile bones. Examples of areas of caution are the axilla (arm pit), femoral triangle (groin), antecubital fossa (anterior elbow), anterior cervical area, xiphoid process, and popliteal region (behind the knee). Massage students preparing for the MBLEx can learn more about these topics using our practice tests.

Absolute contraindications to massage therapy

Absolute contraindications, sometimes called total contraindications, mean that massage therapy and bodywork are completely prohibited at this time, and should not be done under any circumstances for the entire body (systemic absolute) or at a specified area (local absolute). Any life-threatening condition is considered an absolute contraindication. Many of the systemic conditions listed above are also considered absolute precautions during the acute or infectious stages.

Relative contraindications to massage (AKA, massage precautions)

A relative contraindication is sometimes called a massage precaution. A massage precaution is a condition in which it may be ok to proceed with massage IF the additional safety measures are taken. For example, the massage treatment or technique will likely need to be modified in some way, or extra care should be taken to monitor the client’s reaction to certain treatments. Relative contraindications should be assessed on a case-by case basis.

Treatment modifications or adaptive measures refers to changes that a massage therapist can make to a treatment plan or the applied techniques in order to compensate for a client’s relative contraindication. Examples of ways that a therapist can modify the massage treatment include:

• Avoiding an area of the body
• Shorten the duration of the massage session
• Use light pressure only and avoid deep work
• Modify the client’s position with additional supports, or have the client in a sitting position
• Avoiding certain techniques (e.g. deep tissue, friction, stretching, fast techniques)
• Apply massage strokes in a specific direction only
• Using or avoiding certain products (lubricants, essential oils, scrubs)
• Avoiding certain modalities (e.g. heat, cold)
• Schedule the session according to the client’s medication administration
• Modify the session based on the client’s condition at that time

A massage precaution is a condition in which it is ok to proceed with massage IF the treatment or technique is modified appropriately.

***Diseases, pathologies and other medical conditions that are relative contraindications for massage can range in severity, from requiring minimal precautions to becoming absolute contraindications in severe or acute cases. Clients with medical conditions that are currently affecting their daily activities should get their physician’s approval for massage before beginning therapy. Their doctor may have specific recommendations on how to modify the session to reduce the risk of causing harm. Here are some examples of conditions that are often relative contraindications:

• Bleeding & clotting disorders
  • Hemophilia. Severe hemophilia is a systemic & absolute contraindication to massage. Mild to moderate cases may be ok with physician clearance and gentle, modified treatments.
  • Thrombocytopenia. Light massage only.
• Specific organ disease or failure
  • Cardiovascular system
    • Heart (severe vases are absolute contraindications)
      • Heart failure, CHFE, endocarditis or pericarditis
    • Blood vessels
      • Hypertension (uncontrolled HTN is systemic / absolute contraindication)Hypotension & orthostatic hypotensionVaricose veins.
  • Respiratory system
    • Lungs (severe cases are absolute contraindications)
      • Respiratory failure
      • Emphysema
        • Chronic Obstructive Pulmonary Disorder (COPD)
  • Nervous system. *If sensation is impaired, then heat and cold therapies and deep massage is contraindicated. The concern is that the client may not be able to sense if the pressure is too intense or if the temperature is too much.
    • Central nervous system
      • Dementia
      • Epilepsy / seizure disorder
      • Multiple sclerosis
      • Vertigo
      • Stroke / CVA. For late effects of stroke such as muscle rigidity. Get physician clearance first due to increased risk of another stroke.
      • Parkinson’s disease
    • Peripheral nerves
      • Neuritis. This is a group of inflammatory conditions of the peripheral nerves
      • Neuralgia
      • Raynaud’s disease
      • Neuropathy
        • Diabetic neuropathy
        • Peripheral neuropathy
  • Digestive system
    • GI tract
      • Inflammatory bowel disease (IBD)
      • Ulcerative colitis
      • Crohn’s disease
      • Irritable bowel syndrome (IBS)
      • Celiac disease
    • Liver failure
  • Urinary system
    • Kidney disease or failure (advanced kidney failure is an absolute/systemic contraindication)
    • Kidney stones
  • Integumentary system
    • Dermatitis
• Pain disorders may require lighter work
  • Fibromyalgia
  • Myofascial pain
• Inflammatory conditions
  • Systemis lupus erythematosus (SLE)
  • Gout
  • Ankylosing spondylitis
  • Psoriatic arthritis
• Musculoskeletal conditions
  • Scoliosis may require treatment or position modifications in severe cases
  • Whiplash (damage to neck muscles and other cervical structures)
  • Joint replacements (e.g. hip, knee, shoulder, etc). After acute stage.
  • Osteoporosis. This condition can range from mild cases (osteopenia) to severe osteoporosis. Avoid deep work on clients at risk for fracture. Osteomalacia (softening of the bones due to vitamin D deficiency) also weakens bones making them susceptible to fractures.
  • Osteoarthritis can be a relative/local contraindication during acute flareup.
• Other relative contraindications or precautions for massage. Determined on a case-by-case basis. Will often need the client’s physician to give medical clearance in order to safely and responsibly provide massage or bodywork services.
  • Cancer. Massage is generally safe for people who have cancer. However, massage may be contraindicated for people with certain types of cancer that can be worsened by massage. Massage may also be contraindicated while a person is receiving cancer treatment.
  • Autoimmune conditions. These conditions can be complex and affect many systems of the body. Certain types of massage or bodywork may or may not be appropriate depending on the type of autoimmune disease, the severity, and other treatments/medications that the patient may be receiving. Paralysis. Allergie
  • Lyme disease
  • HIV / AIDS
  • Diabetes or hypoglycemia. The client may need a snack or juice before massage, or keep juice available. Client may have other complications or precautions if currently on dialysis or has diabetic ulcers, neuropathy, etc.
  • Leukemia
  • Edema & lymphedema
  • Advanced age (not due to age itself, but age-related changes such as thinner skin, slower healing time, and decreased tissue resilience). Geriatrics have an increased likelihood of having one or more massage contraindications or precautions.

Massage Therapy Best Practice: keeping your clients safe

There are some precautions that massage therapists should take with all clients, regardless of their current medical conditions or medical history. These are part of professional massage standards. This is similar to the concept of best practice, which refers to the procedure, or way that something is done which has been shown by research and experience to produce optimal results. To keep clients safe, it is best practice for massage therapists to:

• Have a thorough understanding of any health conditions that your client has, and how massage can affect this person or affect any underlying pathology.
• Document each client’s relevant health history and current condition, and keep this record on hand so that you can easily review it before the session. This is especially important if you work with the client infrequently. Most practice management apps and software for massage have a place to make important client notes (e.g. allergies) that can be reviewed before each session.
• Be aware of any client allergies, particularly contact allergies to massage oils, essential oils, lotions or other products that you may use in your practice.
• Monitor for client comfort frequently. Be alert for nonverbal cues as well.
• Practice good sanitation procedures to minimize the risk of cross contamination.
• Have each client update their health history information at least once per year, or more frequently if they have had a change in health status.
• Ensure that each client understands that he/she should inform you of any discomfort during the massage or bodywork session.
• Be aware that other body areas may be sore or have additional needs due to being overworked from compensating for the injured or affected area.
• Keep your massage area, equipment and supplies sanitized. Also practice good hygiene.

Medications as contraindications for massage

Some medications increase the massage client’s risk of injury. The pathology section of the MBLEx also covers content about classes of medications that the massage therapist should be familiar with. Some of the most common medications that have the potential to affect the client’s response to massage include:

• Pain medications
• Cardiovascular medication (blood pressure meds)
• Blood thinners such as Warfarin (Coumadin)
• Antibiotics
• Cortisone

Massage contraindications and precautions during pregnancy

As mentioned above, the first trimester of pregnancy is often considered a contraindication of massage. This time of the fetus development has the highest occurrence of miscarriages. There is no scientific evidence concluding that massage can cause a miscarriage through direct work on the abdominal area or reflexively through stimulation of certain acupressure points. Even if massage practitioners aren’t convinced that massage or bodywork can cause a miscarriage, many of them will still avoid offering their services to clients in the 1st trimester simply for liability reasons. No one wants to be accused of contributing to a spontaneous abortion. Here are a few precautions that massage therapists should follow when working with a pregnant client.

• 1st trimester
  • Avoid oils that can induce uterine contraction
  • Avoid abdominal massage or sacral massage (unless very light)
• 2nd & 3rd trimester
  • Modify client position for comfort using pillows or a support system specifically designed for the pregnant woman. Position to support the back and avoid compressing the aorta and inferior vena cava.
• Other precautions:
  • Light stretching only
  • Do not use hot packs at the anterior or posterior torso during any stage of pregnancy. Do not use any modalities that can raise the body core temperature (e.g. sauna, hot tub).
  • Avoid joint mobilizations due to increased elastin and risk of hypermobility issues during pregnancy and for 6 months postpartum
• Massage is contraindicated if there are any complications:
  • Eclampsia
  • Pre-eclampsia

Other types of contraindications and precautions for massage and bodywork

Modality-specific contraindications

In some instances, it is ok to use some types of massage treatment modalities or techniques but not others. For example, a client with a recent shoulder or back injury or surgery would not be able to safely tolerate the stretches used in a Thai massage routine, but may be able to safely receive a Swedish massage or manual lymphatic drainage (MLD) on the table. Likewise, a client that is already hypermobile at certain joint(s) should not receive joint mobilization at these joints, because it would further increase the joint instability. Another example is a client that bruises easily, has blood clotting disorder, or is on a blood thinning medication should not receive more aggressive techniques such as cupping, guasha, deep tissue massage or trigger point therapy.

Heat and cold contraindications

The use of heat (hot pack, hot stone, etc.) and cold (ice massage, ice pack, etc.), also called cryotherapy, is contraindicated for clients with decreased sensation of hot and cold (e.g. diabetic neuropathy, sensory nerve damage). Also avoid cold modalities for clients with Raynaud’s disease, or those who have had previous adverse reactions to cold. A precaution regarding the use of hot packs is to never allow the client to lie on the hot pack, especially when using it on the client’s back. This causes the client’s body weight to compress the insulation from the hot pack sleeve and towels, and increases the risk of burns.

Frequently asked questions about massage contraindications and precautions

When should a client seek a physician’s clearance, medical release or prescription for massage therapy?

Any client with a contraindication to massage, or health problems that could potentially be worsened by massage should consult with a physician before beginning a massage or exercise program. The older the potential client is and the more comorbidities present, the more important it is that he or she get medical clearance prior to receiving massage therapy. The client’s primary care physician likely has a thorough understanding of the person’s overall health, and can make an educated recommendation and judgement about the safety of massage for their patient. This may also lessen any liability should the client have negative effects from the massage.

Also, if a client has a condition that has not been recently assessed by a physician, then the therapist should discuss any concerns with the client and encourage the client to make an appointment to get the problem examined by an appropriate medical professional. The massage therapist should refer the client out if the condition, problem or massage contraindication:

• Has the potential to harm the client
• Is getting progressively worse
• Is unexplained
• Is affecting the client’s daily life
• Is hindering any of the body’s normal functions

What if the client’s physician recommends a massage treatment which is contraindicated for the client?

Massage therapists who work in a medical setting or take referrals from physicians may receive a client with a prescription for a massage therapy treatment that is actually contraindicated for this client. If this happens, the massage therapist should discuss their concerns with the referring physician, and educate him or her about why this condition is considered a contraindication to massage. Massage therapists are under no obligation to proceed with a treatment that they think may harm a client, even if the physician writes a prescription.

Can a massage therapist refuse to treat a client?

Yes. If a therapist determines that it is not safe or appropriate to work with a client, then the therapist can explain this to the person. It is your massage license on the line, and you have the right to refuse to provide a service that you believe may cause harm to someone.

What is the difference between a massage precaution and an area of caution?

A massage precaution is a relative contraindication for massage for a specific person. This precaution is related to this client’s health or treatment tolerance, and requires a treatment modification or increased monitoring of response to treatment. For example, a certain area may only tolerate light massage. Or the session length may need to be shortened.

A massage area of caution is an area of the body that is vulnerable to injury. There are several areas of caution on the body, and these areas are common to every body, not just certain individuals. These areas should be treated gently in order to avoid damaging sensitive tissues such as nerves, blood vessels and lymph nodes.

What if the contraindication is not discovered until during or after the massage?

First of all, don’t panic. This probably happens more than we realize. That’s not an excuse, and certainly doesn’t exempt negligence or incompetence. It’s just reality. Examples of how this could happen include:

• If a therapist doesn’t know something is a contraindication
• Or the therapist may just forget that something is a contraindication
• The client may not reveal something important, or may not understand that massage can make it worse. Clients often do not provide a thorough medical history unless prompted.
• The client may not reveal a medical change, or the therapist may not ask
• A therapist may not see a contraindication that would normally be noticed during a visual assessment if the client remains clothed or wants additional draping during the massage due to modesty. For example, the therapist may not see skin lesions, signs of infection or local acute condition.
• The client may not know that they have a certain condition. For example, a female client may be pregnant and not know it yet. Or the client may have a contagious condition and not know it.

If you do discover after the fact that a client has a precaution or contraindication, remain calm and attempt to assess any potential damage or risk to the client’s safety. Make every effort to prevent this from happening. Ways you can reduce the risk of this include:

• Learn the contraindications and precautions well.
• Have a thorough intake and assessment process.
• Remember that it is ok to look something up online or in your reference books (or bookmark this page).
• Educate your client on risks, contraindications, and the importance of keeping you informed of any health conditions or changes (and have them sign an informed consent form).
• Communicate with your client. Help them to feel comfortable communicating with you.

What are the contraindications and precautions for hot stone massage or hot packs?

The contraindications and precautions for heat modalities such as hot stone massage, hot packs, paraffin wax hand or foot dip, and other thermal treatments include:

• Impaired circulation at the treatment site
• Open wounds
• Edema
• Fragile skin
• Malignancy
• Decreased thermal sensitivity
• Infection at the area being treated
• Avoid in areas of recent bleeding
• Local acute condition or current inflammation
• Skin conditions such as dermatitis, eczema or psoriasis
• Over superficial metal implants (e.g. artificial knee) which absorb heat faster and could cause burn
• Over implanted devices (e.g. pace maker, insulin pump)
• For clients with certain medical conditions: RA, MS, etc.
• Pregnancy. No hot pack over abdomen or low back. Avoid raising body temperature.
• Over areas where topical liniments or analgesics have been applied (e.g. Tiger Balm, Biofreeze, etc.), or where medication patches are present.
• When the client has impaired cognition and cannot communicate effectively

Is there anything that a client should NOT do before or after a massage?

There are plenty of general recommendations on things to do, or not do, before or after receiving a massage. Most of this advice is based on opinions, or what someone heard somewhere, and is not based on any specific research or scientific evidence. I can offer my opinion on a few things to avoid before or after massage.

Before massage:

• Avoid strenuous exercise before deep tissue massage
• Avoid eating a large meal or drinking a lot of fluid for 2 hours prior. Especially if abdominal work will be done, or if the client has has gastroesophageal reflux problems (GERD)
• Avoid taking medication immediately prior to receiving massage

After massage:

• Avoid taking a hot shower immediately after massage. Since massage can decrease blood pressure, and so can a hot shower, this could potentially lead to the person feeling lightheaded and passing out in the shower.

Is a 90-minute massage too long?

For most healthy adults, a 90 minute massage can be comfortably tolerated. In some cases, the additional 30 minutes compared to the standard 60-minute massage can provide more opportunity to let go of physical and mental stress and benefit from a deeper relaxation effect. However, some clients may not tolerate a 90-minute massage due to health conditions.

Am I too old to receive massage therapy?

No. Age is not a contraindication for massage. The changes that happen to the body as we age however will likely require that the massage therapist take precautions to avoid causing injury. Considerations for the geriatric client include things like fragile skin, increased likelihood of comorbidities, difficulty getting onto or off of the massage table, or even difficulty lying flat on the table.

*I am neither a physician nor a lawyer, and nothing in this post is meant to be medical or legal advice. This is presented for informational purposes only.