Massage therapists and bodywork practitioners are responsible for ensuring the medical safety of all those who seek our services. As we navigate our way into the mainstream, be it in a salon, spa, medical office, clinic, hospital, research setting or private practice, we must make decisions that reflect a broad spectrum of knowledge regarding the indications, precautions and contraindications for our work.

Typically, our training includes hundreds of hours of instruction in anatomy, physiology, pathology and assessment that is meant to give us the skills needed to make decisions about when to, and when not to, massage.

Still, my personal observations and recent encounters compel me to discuss the imprecise and risky matter of how to proceed when there is doubt about the medical safety of administering massage and bodywork.

My Experience
Being the director of a massage therapy school clinic that traffics approximately 70 clients per week means, among other things, that I preview each client's medical history, and decide if they are appropriate candidates to receive massage from students in varying stages of training. My career history of 15 years in nursing, 12 years practicing massage therapy and 11 years teaching anatomy, physiology and pathologies, offers me a relatively deep well to draw from when I must answer the question we all ultimately face with each and every client: "Is this client medically appropriate for massage therapy?"

Regardless of the experience and knowledge I have to rely on, situations arise where no answer is clear, and I am challenged to my medical, ethical and legal limits. This case scenario highlights a process and procedure that can be helpful when assessing a client with questionable medical conditions. (Names have been changed for purposes of confidentiality.)

A Case Of Thrombophlebitis
Mary Smith, age 35, with no previous massage experience, seeks massage for stress management. Her medical history includes chronic ulcerative colitis, fibromyalgia and a two-week history of thrombophlebitis in her left leg. The cause of her thrombophlebitis is unknown. She is on steroid medication for her colitis, and reports that she is not taking anticoagulant medication for her thrombophlebitis because it occurs in a superficial vein.

I explained to this client that thrombophlebitis is contraindicated for massage, and I recommend that she wait until this condition is resolved. I read her the information from Ruth Werner's text A Massage Therapist's Guide to Pathology that clearly states, "Massage is strictly systemically contraindicated for thrombophlebitis."

Mary, not satisfied with my decision or explanation, contacted her physician, a specialist in vascular conditions. Ultimately, I had a telephone conversation with her physician who insisted that my concerns and precautions were unfounded, and that Mary's thrombophlebitis would benefit from massage. He further suggested that my resources and opinion about massage for this condition were outdated and inaccurate.

Confused by the physician's perspective, and feeling somewhat intimidated by his confrontation, I said that I would investigate the matter further. I began my research. Every written resource available to me supported the opinion that massage therapy is contraindicated for thrombophlebitis. My network of corroboration included two chiropractors, a surgeon, two osteopathic physicians and many veteran massage therapists and instructors. None of them agreed with the physician's viewpoint on thrombophlebitis and massage therapy.

Next, I contacted my massage malpractice insurance company to inquire into who is liable if a client is injured by massage when it is prescribed or recommended by a physician. I was informed that if a massage therapist performs massage and the client is medically injured as a result, the legal system would determine liability based on several factors. They would survey a group of massage therapists to learn what the majority of massage therapists would decide in the same situation. A physician's order or recommendation to massage would be taken into consideration, but it did not absolve a massage therapist from medical, legal or moral liability in the face of doubt.

In other words, regardless of who recommends massage, or who advises a massage therapist about what is safe, the therapist is responsible and liable for his or her decision to massage a client.

Essentially, then, I had to make my own best decision about the medical safety of massage in Mary's case. I decided, based on the results of my research, that her current condition of thrombophlebitis was contraindicated for massage therapy. Next, I faced a serious test: Could I respectfully and confidently stand my ground with Mary's physician?

The outcome was that I explained to the physician that while I respected his perspective, I was concerned with Mary's safety, and that I was unwilling to give her an appointment for a massage while she had thrombophlebitis. I informed him that based on information available to most conscientious massage therapists, he may meet similar resistance to massaging a client with thrombophlebitis, and I requested that he send me any written information that confirms his perspective, since I was open to learning more about new thinking on this subject. We agreed to disagree, and Mary did not receive massage therapy in the student clinic.

Mary and I had a lengthy conversation about my disagreement with her physician. She was able to hear that my lack of comfort with her absolute medical safety was in her best interest, and she agreed to wait to seek massage therapy when her thrombophlebitis was resolved.

Conclusion
The client with a medical history is like a unique research project that bids us to investigate, differentiate, perceive and ultimately decide what we believe is safe for the client, and what we are willing to be liable for. Medical advisement and permission can assist us to form our best medical, ethical and legal judgment, but there is no one ultimate authority to provide us with absolute answers when the medical safety of massage is questionable. No doctor, medical professional or bodywork guru can be the final judge, and no textbooks contain all the answers. Each of them may offer us valuable information and guidance, but in the end, we are responsible and liable for the decisions we make and the effects they have on our clients.

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Dianne Polseno, former chair of the National Ethics Subcommittee, is a practicing massage therapist, practical nurse, academic director and teacher at the Bancroft School of Massage Therapy. She is the author and publisher of Comprehensive Review Manual For Massage Therapists. She can be reached at: 1 Raymond St., North Smithfield, RI 20896-8215, or at: dipol@aol.com.

Bibliography
Werner, Ruth. A Massage Therapist's Guide to Pathology. Baltimore: Lippincott, Williams & Wilkins, 1998.