Written by Sam Mishra, The Medical Massage Lady
Sam Mishra (The Medical Massage Lady), is a multi-award winning massage therapist, aromatherapist, accredited course tutor, oncology and lymphatic practitioner, trauma practitioner, breathwork facilitator, reiki and intuitive energy healer, transformational and spiritual coach and hypnotherapist.
Massage therapy is generally a very safe option, but occasionally, a strong, deep-tissue massage can aggravate certain medical issues rather than help them. I personally give a very firm massage, and while this achieves results, there have been occasions where I have eased off because the client’s condition called for a more gentle approach. There have been reported cases, however, where trauma to the soft tissue has occurred, resulting in issues such as pulmonary embolism.
Some bruising is to be expected due to controlled microtrauma with instrument-assisted soft tissue mobilization. This is explained to the client and is all part of how that particular modality works. However, severe bruising, hematomas, and rhabdomyolysis (excess protein being released into the bloodstream due to a crush injury to the muscle, which can cause renal failure) are often a result of poor technique during a straightforward deep-tissue massage. Unfortunately, one of my clients experienced a large hematoma at the hands of another local therapist, and it could have so easily been avoided.
Pain perception has many contributing factors: physical, psychological, and emotional. In chronic pain cases in particular, it often involve dysfunction of the nervous system, making it understandable how clients can have setbacks following a poorly executed massage. Certainly, the ability of a deep-tissue massage to overwhelm the nervous system is one of the reasons I refuse to offer it to anyone dealing with unresolved trauma, whose nervous system is already dysregulated. Sadly, this is something that I know too many other therapists wouldn’t even question.
Reports of hospitalization and even surgery for substantial swelling and leg numbness as a result of poor technique and neuropathy due to a crushed nerve, although rare, emphasize the need for more in-depth physiology training for massage therapists.
Upon entering the world of massage therapy in 1997, remembering the reasons why you shouldn’t massage someone seemed to be the most important consideration. However, providing a safe service isn’t simply about knowing the contraindications; it’s also about being able to navigate them effectively. Two-thirds of clients now seek massage for a wide range of medical issues and sports injuries, yet a large proportion of massage therapists do not possess the medical knowledge necessary to manage these cases. This is why so many therapists post on social media groups expressing unease and demonstrating incompetence when it comes to assessing contraindications or accommodating medical conditions. The significant gap in Level 3 training on the safe management of medical issues is responsible for this. Newly qualified therapists are often left with a basic template of contraindications, which holds little value because they lack the knowledge to apply it or act upon the responses appropriately.
I firmly believe that massage therapists should take accountability for their practice, operating within their scope of expertise. Just as I would have done as a nurse, therapists should acknowledge their obligation to undertake further training and research for professional development when they encounter challenges in managing medical disorders. While mentoring student nurses in post-operative care skills or running active birth workshops, as I did during my midwifery years, may not be necessary for massage therapists, consistently keeping up to date with research in both practical techniques and medically focused theory has helped me maintain a high level of competence in my practice.
Learning practical techniques and covering some basic anatomy and physiology is all well and good, but what I’ve witnessed from other therapists and from clients who come to me after poor experiences elsewhere clearly demonstrates that Level 3 training lacks the material needed to work competently with medical conditions. Observing a client’s health being seriously jeopardized by a supposedly experienced therapist and trainer who had very limited comprehension of physiology and no understanding of common conditions, even those covered in Level 3 training, is inexcusable. When training providers become overconfident and ignorant yet continue to teach inexperienced therapists using the same limited knowledge base they learned years ago, the cycle simply perpetuates itself.
I am also quite concerned about the number of therapists on social media groups saying they have a client with a particular medical issue and asking how they should treat them. The answer is simple: they shouldn’t be treating the client if they don’t understand anything about the condition they are addressing.
Client demographics in the massage industry have significantly changed compared to when I first qualified in 1997, as have the reasons clients seek this type of therapy. So why haven’t the fundamentals being taught reflected this change? More and more, we are seeing clients wanting to combine conventional and complementary treatments. Massage is no longer just the pampering session it used to be; it has become a supplemental medical treatment for long-term conditions. Possibly, the recognition of massage as a pain-relieving therapy in palliative care settings and its consequent acknowledgment by the medical community due to qualitative research demonstrating its efficacy—have contributed to this change. As a result, conditions once taught to be contraindicated may no longer be so.
In today's world, massage therapists must have a solid understanding of common medical conditions and how they affect the body’s systems. This includes knowledge of a condition’s etiology, symptoms, side effects of medications, and contraindications to create safe treatment plans for their clients. To achieve the best outcomes, therapists must also be confident in their ability to manage medical conditions, understand the risks, and know when to decline treatment or refer the client to another specialist. We must not become complacent and risk seriously damaging someone’s health for the sake of maintaining a fully booked diary or earning more money.
The fact that many therapists are not registered with a governing authority is another problem. Clients who feel their health may have been jeopardized by a therapist's ignorance will not receive any assistance if they file a complaint. Lack of registration can stem from many reasons, but it may be that the therapist does not have enough expertise to meet the criteria for some professional bodies or lacks the experience to explain how clients’ medical conditions affect muscle tension.
Another issue I strive to address when training therapists is the tendency to only treat the symptoms, which means the client will not experience much change. By understanding the etiology, therapists can address the root cause because they will have the information needed to adjust techniques, and potentially the duration, placement, or entire modality. A common problem here is that when a client has lived with a medical condition for an extended period or had an injury many years ago, they often don’t think it is relevant and may not mention it on the consultation form. For example, if someone has had depression for 20 years, their baseline changes compared to the non-depressed version of themselves. This altered baseline becomes their new normal, so they may no longer consider themselves depressed, even though they may still be. Many therapists lack the tools to inquire about such information if they have only completed basic training.
A perfect example is a woman who contacted me to schedule a massage and noted that she was taking warfarin, an anticoagulant. This information is only useful if the therapist knows what warfarin is, its side effects, and the questions necessary to determine if the client is contraindicated. When I reviewed her consultation form, I saw that she had been diagnosed with osteoporosis and antiphospholipid syndrome. In the four years prior, she had fractured her pelvis three times and her ribs simply from sitting. An experienced therapist would immediately know this client was contraindicated. But suppose she did not have osteoporosis; the therapist would still need to know to ask when her warfarin levels were last checked. Patients on warfarin routinely visit clinics to monitor their INR (International Normalized Ratio) levels and ensure stability. If the INR is not stable, the client would be contraindicated due to the increased risk of bleeding and heavy bruising, which are not conducive to a therapeutic session.
This client was also at risk of blood clots due to antiphospholipid syndrome, which, had she not been contraindicated, would require adjustments to massage techniques and potentially limit the areas worked on. In her case, osteoporosis was clearly severe and would likely have resulted in a fracture. The significant bruising caused by warfarin, covering her legs in dark purple discoloration, would have made even a light Swedish massage impossible. However, if her warfarin levels were stabilized and there was no skin discoloration, an adjusted massage could have been possible following consultation with her general practitioner.
As it stood, if I had not possessed the experience and knowledge I do, proceeding with even a light massage could have caused severe bruising, broken bones, or a blood clot or bleed, potentially leading to a stroke. It is concerning that some therapists might proceed regardless even with a deep tissue massage. I know of another local therapist who had been practicing for many years and was training others but gave a client a deep tissue massage, despite being informed that the client’s medication was for osteoporosis. This is one of the absolute contraindications taught to trainee massage therapists.
Perhaps some people might think I am exaggerating when I say that massaging this client could have resulted in a stroke, but there are, in fact, many neurology reports where neck manipulation or incorrect positioning of the neck has led to blood vessel injury, causing a brain stroke or paralytic brain attack. In 1992, The Lancet referred to "salon stroke syndrome," where a beauty treatment resulted in a life-threatening stroke.
There was also a case in 2015 where a woman had a stroke following a massage at a spa, which resulted in swallowing issues and the loss of use of one hand. In this particular case, the client reported sudden pain in her neck during the massage, but the therapist attributed it to tension. What had actually happened was that the carotid artery, a major artery in the neck, had split, and a blood clot had traveled to the woman’s brain.
This is why I conduct such an in-depth consultation, something my clients often comment on, and why I refuse to receive a massage from anyone who is not experienced or knowledgeable. If someone doesn’t ask the right questions, I’m out the door.
Many insurance companies have four levels of risk that determine the level of cover required, and I am covered to the highest level because I offer deep colon massage, which can carry the risk of bowel perforation and bleeding. I know that the majority of clients seeking an abdominal massage for constipation won’t think to ask the therapist for details about their registration and insurance. It is worrying that so many therapists would proceed without properly inquiring about the client’s bowel function, diet, or associated medical conditions, potentially working on a client who may not be a suitable candidate for abdominal massage.
Even if you are not familiar with a particular medication, asking about it can provide equally valuable information. It may reveal a problem the client has not previously disclosed or highlight potential adverse effects that could arise during treatment. If they don’t already have one, I often advise therapists to get a BNF (British National Formulary), which enables them to research drugs and educate themselves on potential applications and negative effects.
Overall, I’ve found that self-employed therapists are more likely to excel at consultations since they have more time and aren’t constrained by strict schedules or business policies. However, for those who may be restricted by time constraints due to company policies, simply enquiring about the frequency of visits to the doctor could highlight something not listed among contraindications and clarify the client’s reasons for seeking therapy with you. In the absence of an official diagnosis, when a client is still under investigation by their medical team, it is important to proceed with therapy cautiously, taking any potential diagnoses into consideration.
This approach may also uncover factors that influence how you work. For example, recurrent stomach aches could be caused by stress, which massage can help relieve, or they could indicate an unidentified ulcer, which would require an alternative course of action.
If a client discloses that they take the blood pressure medication doxazosin, for example, you may want to follow up with additional questions to determine whether their blood pressure is well-regulated or if they have experienced any side effects, such as vertigo or dizziness, which are common with doxazosin. If this is the case, the therapist would need to ensure that the client sits up slowly after treatment.
Additionally, because massage improves circulation, high blood pressure has historically been on the contraindication list. However, studies have shown that massage helps individuals with hypertension because it affects the nervous system, causing blood vessels to dilate and lowering intra-arterial pressure. An inquiry into a client’s history of stroke or other cardiovascular diseases can identify increased risks, which would then indicate that the hypertension becomes an absolute contraindication. Examples include peripheral artery disease or atherosclerosis, where plaque could potentially break away and travel through the bloodstream. Having the knowledge to assess and determine which areas can be treated, as well as adjusting techniques for those areas, is critical. It is easy to see how a case of simple backache could potentially become high-risk, particularly if the therapist is not asking the relevant questions to safeguard their client.
We become therapists to help clients feel better, but when every client has their own individual story and unique set of needs, how can we truly help them if we offer the same massage we gave to every other client with completely different needs over the past month? We can only achieve this by possessing the knowledge, practical ability, and clinical and ethical discernment required to fully understand a client’s medical history. If any of these factors are missing, we are not offering individualized therapy. My clients truly value the unique perspective I provide because of the deeper comprehension I have of their situations, drawing from my medical experience. Even my midwifery knowledge makes an appearance in my sports massages.
Conclusion: Injury as a result of massage is rare, but it does happen, and more often than not, it occurs with clients who have a medical condition of some kind and see therapists who aren’t registered, aren’t adequately trained, and are more concerned with taking the client’s money than taking accountability for their health and safety. The ability and humility of a therapist to identify more risky therapeutic settings is a key indicator of their competence. The most important aspect of a therapist’s job is managing high-risk situations that might arise once or twice in their career.
So many times, I’ve heard clients say, "No pain, no gain," which can sometimes be true with massage, such as with deep tissue massage when working against resistance in the tissue or when clients find instrument-assisted soft tissue mobilization a little painful. However, there are some overconfident therapists who may even criticize conventional health care, and they tend to ignore side effects and misinterpret serious symptoms. Unfortunately, inexperienced, overconfident therapists may actually distract clients from more appropriate health care by overlooking significant warning signs and passing them off as a tight muscle or an accumulation of toxins, attempting to make it sound like they know what they’re talking about.
I always tell clients: never be afraid to ask a therapist for their registration details or qualifications, because reputable therapists will have no problem answering your request. When you find an experienced therapist who truly understands your condition, can answer your questions, offers self-help measures, and is willing to refuse certain treatments if it’s in your best interest, hold on to them. After all, you wouldn’t want to go to a hospital and be treated by unqualified nurses or doctors, would you?
If you are a therapist wanting to ask the important questions and deliver safe and effective therapy, you can complete training with me, focusing on risk factors, etiology, symptoms, and more, by clicking here.
Read more from Sam Mishra
Sam Mishra, The Medical Massage Lady
Sam Mishra (The Medical Massage Lady), is a multi-award winning massage therapist, aromatherapist, accredited course tutor, oncology and lymphatic practitioner, trauma practitioner, breathwork facilitator, reiki and intuitive energy healer, transformational and spiritual coach and hypnotherapist. Her medical background as a nurse and a midwife, combined with her own experiences of childhood disability and abuse, have resulted in a diverse and specialised service, but she is mostly known for her trauma work. She is motivated by the adversity she has faced, using it as a driving force in her charity work and in offering the vulnerable a means of support. Her aim is to educate about medical conditions using easily understood language, to avoid inappropriate treatments being carried out and for health promotion purposes in the general public. She is also becoming known for challenging the stigmas in our society and pushing through the boundaries that have been set by such stigmas within the massage industry.
References:
Chih-Ya Chang, Yung-Tsan Wu, Liang-Cheng Chen, Rai-Chi Chan, Shin-Tsu Chang, Shang-Lin Chiang, (2015) Massage-Induced Brachial Plexus Injury. Physical Therapy, Volume 95, Issue 1, January, Pages 109–116
Giese, S, Hentz, VR. (1998) Posterior interosseous syndrome resulting from deep tissue massage. Plastic Reconstructive Surgery 102:1778-1779
Mikhail, A, Reidy, JF, Taylor, PR, Scoble, JE. (1997) Renal artery embolization after back massage in a patient with aortic occlusion. Nephrology Dialysis Transplantation 12:797-798
Trotter, J. F. (1999) Hepatic Hematoma after Deep Tissue Massage. New England Journal of Medicine; December Vol. 341 No.26
Vanderhooft, J. E. (2023) High Radial Nerve Palsy Resulting From Massage. AIM Clinical Cases. December.
https://www.themedicalmassagelady.co.uk/blog/why-medical-information-is-so-important.html
