At Wits End Wellness Centre Inc.

Ruminations on Contraindications

One of the most basic considerations for manual therapist is to understand how and when to proceed with caution or not to treat at all. Our ‘duty of care’ requires that we recognize when a condition or situation presents itself that would make it unsafe for [a] client to receive our touch. Furthermore our care requires us to ‘do no harm’. And if indeed we proceed with a treatment, and did not heed or understand the indications contrary to massage, we open ourselves up to malpractice and personal liability.

Contraindications provide a basic framework for understanding when, and under what circumstances, a particular therapeutic intervention is appropriate for treating the patient/client with minimal risk of injury. Therefore, contraindications serve as a guideline to help us determine if we should institute certain precautions in treatment, withhold treatment altogether, or recommend alternative treatments that would be more appropriate (Batavia 2003).(1)

Traditionally contraindications have been categorized as total, local, or site specific and/or medical. We are taught to pay attention to systemic or skin conditions that exhibited infectious or contagious symptoms, local traumas and injuries that showed the effects of partial tear, avulsions, lesions, fractures, breaks or punctures of soft-tissue structures - to name a few. Most traumas, we understand, are common sense wise and depending on the conventional wisdom of the time, many conditions are considered totally contraindicated.

Absolute contraindications clearly are those when the application of technique compromises the safety of the client or the practitioner. Fiona Rattray (2000) in Clinical Massage Therapy states “…contraindications may be absolute; in other words, massage is an inappropriate method of treating a particular condition that affects the whole body or a part of the body.”(2)

Massage literature has an extensive laundry list of Absolutes. There exists a problem, however, that some of the Absolutes can be relative. Some are myths, such as massage therapy will systemically metastasize all cancer. Others make good sense, such as inappropriate deep friction applied to healing fractures or compromised soft-tissue.

Rattray looks at Absolutes for general conditions and Absolutes for local conditions (see below). Clearly we would have little controversy with Rattray’s lists.

Absolute Contraindications for General Conditions (3)
Acute conditions requiring first aid or medical attention, such as:
• Anaphylaxis shock
• Appendicitis
• Cerebrovascular accident CVA Stroke
• Diabetic coma or insulin shock
• Myocardial infarction
• Pneumothorax
• Severe asthmatic attack
• Acute seizure
• Syncope (fainting)
• Acute pneumonia
• Advanced kidney, liver or advance respiratory failure
• Diabetes with complications such as gangrene
• Pregnancy with pre-eclampsia or eclampsia toxaemia
• Hemophilia
• Hemorrhage
• Post CVA or heart attack where condition has not stabilized
• Severe artherosclerosis
• Severe undiagnosed headaches in those over 50 years of age
• Severe unstable hypertension
• Shock ( although there is controversy here)
• Significant fever (38.5° C or 101.5° F)
• Systemic, contagious or infectious condition

Absolute Contraindications to Local Conditions (4)
Massage therapy is not appropriate locally for the following conditions:
• Acute flare-up of inflammatory arthritidis, such as rheumatoid arthritis, systemic lupus erythematosus or ankylosing spondyliti
• Acute neuritis
• Acute trigeminal neuralgia
• Aneurisms deemed life-threatening
• Abdominal aorta (depending upon location)
• Deep vein thrombosis, thrombophlebitis or arteritis
• Ectopic pregnancy
• Esophageal varicosities
• Frostbite
• Local contagious condition
• Local irritable skin condition
• Malignancy if judged unstable
• Open wounds, sores or decubitis ulcers
• Pain syndromes such as causalgia or reflex
sympathetic dystrophy
• Radiation therapy
• Recent burn
• Sepsis
• Undiagnosed lump
• Varicosities (up to 24 post-treatment with saline injection)

Relative Contraindications: Modifications to Treatment
With many systemic conditions such as asthma or multiple sclerosis, we may not massage during the acute or flare-up stage
but can apply treatment between flares or stages.

Batavia terms ‘relative contraindications’ as those that Rattray would view as the situation where you modify your treatment plan. Rattray calls these ‘treatment modifications.’ (5) p147

Modifications to treatment are necessary, whether a client has a condition that is contraindicated or not. The massage therapist is always adjusting and modifying treatment based on the previous results and feedback from the client. Assessment and palpatory literacy also determine, with case history, the appropriateness of treatment . . . Orthopaedic physical assessment may or may not be appropriate.

With pregnancy, we modify for fundamental reasons, hormonal changes that release relaxin to relax pelvic ligaments, positional changes to accommodate supine hypotension and fetus growth. 

With cardiovascular concerns such as thrombus or emboli, we might dislodge a clot and/or facilitate a life threatening situation. 

Other modifications might be with hydrotherapy, where the application of heat to an already inflamed area will painfully
congest the site further.

With Fibromyalgia, deep work is generally contraindicated due to pain amplification and sensitivity, yet deeper work can be applied as the pain sensitization changes.

. . . The challenge . . . is to place [a] contraindication in context with the health history obtained from the client, decide on the severity of the condition and differential diagnosis, decide which modifications to treatment through the varying of technique, position, duration, depth, speed, and autonomic nervous system response.

Clear decision-making will aid [a massage therapist] in stepping outside of fear to help make an informed decision regarding the treatment and welfare of [our] clients, though the maxim "when in doubt, do not treat", is always appropriate.

1. Batavia, M. (2003). Contraindications for therapeutic massage: do sources agree? Journal of Bodywork and Movement
Therapies, 8(1), 48-57.1
2. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus
Inc, 148
3. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus
Inc, 148
4. ibid
5. ibid

Article written by Steven Goldstein BSHSc (MST MusculoSkeletal Therapy, ACNM Australian College of Natural Medicine, Chair National Education Subcommittee, Australian Association Massage Therapists).   Article taken from NHPC (formerly AMTWP) Connections magazine, Winter 2008 issue found here.

Used with permission. Thank you, Steven!