Introduction Chapter 10 Adaptive Massage

Chapter 10 Introduction

Adaptive Massage • Standard massage routines are designed
for the average client’s needs
__________________________________________________________________________________________
• Some clients will have physical, emotional,
Susan G. Salvo and health-related challenges requiring
adaptation of the massage or positioning

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Introduction Introduction

• Most important: view all clients as people • When adapting massage for clients with
• Special needs are an important, but special needs, the strokes themselves
might not change
secondary, consideration
• Regard all injuries and conditions with • More likely changes are pressure, speed,
duration, or frequency of massage;
gentleness, kindness, and acceptance positioning; and safety precautions

• Best source of information is the clients
themselves

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Communication of Amputations
Special Needs
• Obtain consent during interview to
• Clients may indicate their need for massage the stump
adaptive measures when their
appointment is scheduled • Asking for details about surgical procedure
(e.g., whether muscle was wrapped
• If possible, research condition ahead around stump) helps locate trigger points
of time
• Ask client whether stump is sensitive or
• Ask client questions during interview numb

• Boundaries (professionalism, 5 Copyright © 2008 by Saunders, an imprint of Elsevier Inc. 6
confidentiality) should remain consistent All rights reserved.
for all clients

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Amputations: Amputations:
Phantom Limb Sensation Prosthetic Appliances

• Definition: feeling pain and other • Some clients may want to remove
sensations in the amputated limb prosthetics; others may not

• Also known as phantom limb pain • Look out for chafing or friction wounds at
site of prosthetic—avoid inflamed areas,
• Cause is complex—involves both broken skin, or open wounds during
peripheral and central nervous systems massage

• Calming effects of massage generally help
clients with phantom limb pain

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Central Venous Catheter Central Venous Catheter

• Also called a central line • Use of catheter makes prone position
• Flexible tube inserted into a large vein and difficult or impossible—use side-lying
position, bolsters, pillows, etc.
left in place for an extended period
• Used for dialysis, blood withdrawal, • Avoid tension or excessive movement
near catheter
chemotherapy, or medications
• Do not allow massage lubricant to come in
contact with catheter dressing or sutures

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ICDs Pacemaker Users

• ICD: implantable cardioverter defibrillator • Pacemaker is an electrical device to help
• Used to treat abnormal heart rates client regulate heartbeat
• Delivers electrical shock to restore normal
• Usually inserted near the pectoralis major
heart rate and rhythm muscle
• Massage considerations:

– Massage contraindicated once device
discharges

– Other modifications listed under pacemaker

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Pacemaker Users Stent

• Massage considerations: • Small, expandable, lattice-shaped metal
tube or hollow perforated tube
– Main concern is whether incision has healed;
if so, apply gentle effleurage • Creates an increase in vessel duct
diameter
– Avoid vigorous massage on pectoral region
– Pacemaker wires (leads) may run over • If located superficially, local massage is
contraindicated
clavicle and down into chest cavity; avoid
moving client’s arm over head when • If in deep vessel or duct, use only light
mobilizing shoulder joint because this may pressure over or near site
disturb connections

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Breast Implants 15 Massaging Women 16
or Large Breasts with Large Breasts

• Main issue—comfort while • It can be difficult to
lying prone access chest
muscles of large-
• Offer rolled towel or pillow chested women in
for support under, above, the supine position
or between breasts
• Ask client to use back of her hand
• Many clients prefer support to retract breast tissue medially
from both above and below
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• Adjust face rest if needed All rights reserved.

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Massaging Women Colostomy or Ileostomy
with Large Breasts
• Colostomy—incision in the colon to
• Alternative—massage with client in side- provide an opening between the bowel
lying position and the abdominal wall

• Ileostomy—similar to colostomy; incision is
in the small intestine

• Stoma—section of colon wall attached to
the abdominal wall

• A bag is attached to the opening to collect
fecal material

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Colostomy or Ileostomy Chronic Illness

• Recommend that client not eat for two • Definition: A condition of the body for
hours before massage—decreases bowel which no cure is known
motility
• Massage therapy can reduce suffering and
• Suggest that client empty bag before increase comfort
massage begins
• Obtain medical clearance; apply massage
• Use side-lying position to accommodate more gently, more frequently, and for
opening and bag shorter periods than with other clients

• Do not apply lubricant on or near bag
opening—interferes with adhesive

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Terminal Illness End-of-Life Massage

• Definition: A condition in which the client is • Massage can reduce suffering and
expected to die within a time frame, increase comfort
usually 6 months
• Use gentle pressure; treatments should be
• Goal of the massage therapy session is to more frequent but shorter
improve quality of life
• If visiting client in hospice or at home,
• Obtain medical clearance; apply massage client may prefer to be massaged in her
more gently, more frequently, and for bed
shorter periods than with other clients

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End-of-Life Massage Cancer

• In hospital, check with medical staff for • Once viewed as terminal illness—focus
any helpful information was length of time patient had to live

• Work around catheters, equipment, etc. • With new technologies and medications,
• When making choice to work with a now often viewed as chronic condition—
allows greater focus on quality of life
terminally ill patient, commit to keep
patient as client until his or her death

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Cancer Types of Cancer

• Characterized by uncontrollable growth of • Cancers are named for the type of tissue
abnormal cells that form a neoplasm or from which they are derived
tumor
– Carcinoma: arises from epithelial tissue
• A tumor is either a benign tumor or
cancerous – Melanoma: grow from melanocytes

• A cancerous tumor will often metastasize, – Sarcoma: develops from muscle cells or
or spread its cells to other parts of the connective tissue
body
– Leukemia: rapid growth of abnormal white
blood cells

– Lymphoma: arises from lymphatic tissue

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Cancer and Massage Cancer Treatments

• Massage is one option to help cancer • Surgery—removes cancerous tissue and
patients live more active, pain-free lives nearby lymph nodes

• American Cancer Society advocates – Massage to promote lymph flow
massage to help and comfort patients, not
to treat the cancer itself • Radiation therapy—uses radiation to
eradicate cancer cells
• As safe as activities of daily living, hot
bath, or mild exercise – Massage gently, avoid lubricant on treatment
area, use cool towels on areas that burn or
itch

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Cancer Treatments Cancer Guidelines for Therapist

• Chemotherapy—drugs used to slow or • Obtain medical consent first
stop growth of cancer cells • Be attentive about pressure, client position

– Client may be extremely fatigued; assist client and comfort, and areas to avoid
on and off massage table if needed
– Use gentle pressure or modalities that use
very little pressure

• Inquire about client health at the start of
every session

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Cancer Guidelines for Therapist Clients Infected with HIV
or Living with AIDS
• Use a side-lying position if client cannot
lie prone • HIV—Human Immunodeficiency Virus

• Be cautious of pressure, traction, and – Virus that causes AIDS
ROM activities if cancer has spread – Virus affect T-lymphocytes or T-cells
to bone
• AIDS—Acquired Immune Deficiency
• Avoid IV lines, catheters, surgical wounds, Syndrome
radiation burns, known tumor sites
• Patients who have AIDS

– Are infected with HIV

– Have three or more opportunistic infections,
and/or T-cell count below 200

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Clients Infected with HIV Clients Infected with HIV
or Living with AIDS or Living with AIDS

• Three elements required for transmission • Massage considerations:
of HIV:
– Inquire about areas to be avoided (e.g., sites
– Virus must be in proper environment to of blood work)
survive (body fluid)
– Assess general vitality and other conditions
– Virus must be in sufficient quantity to survive (e.g., bedridden client might have reduced
(found in blood, semen, vaginal secretions, bone density) that might limit Swedish
breast milk) gymnastics or ROM

– Virus must have a port of entry

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Clients Infected with HIV Clients Infected with HIV
or Living with AIDS or Living with AIDS

• If body fluids spill, wash linens separately • No known cases of HIV transfer from client
in detergent and bleach; wipe down table to massage therapist while performing
with bleach solution massage have been reported

• If therapist comes in contact with body • Clients with HIV are unusually susceptible
fluids, wash area of contact with hand to infection—maintain sanitation and
soap for two minutes cleanliness (as with all clients)

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Geriatric Clients Geriatric Clients

• Definition: Someone who is 70 years of • Assess client during premassage
age or older interview; ensure she can hear and
understand you
• Many changes occur as we age: examples
include decreased reflexes, sight, and • Make sure client feels comfortable and
hearing; decreased muscle and bone safe
strength; atherosclerosis
• Guard against chilling during massage by
• Condition varies widely from person to using blanket and/or heater
person

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Geriatric Clients Massaging Geriatric Clients

• When visiting client at home, knock before • Avoid deep work unless ordered by
entering room physician

• Put objects back in their places • Massage for short periods to avoid tiring
• Be patient client
• Client may be lonely or depressed—be
• Reduce treatment time and pressure to
attentive and sensitive to emotional needs minimize bruising

• Assist client to sitting or standing
position—blood pressure may drop

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Pediatric Clients Pediatric Clients

• Defined as clients 3−18 years old • Consider requesting that parent remain in
• May be accompanied by anxious room when massaging young client,
especially near sensitive areas
parents—child often has injury or illness
• Explain procedures to both child and • Massage sessions for young children are
often only 30 to 45 minutes
parent; obtain informed consent from
parent or guardian (by law) • Spend extra time establishing rapport

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Large Clients Large Clients

• Clients usually have history of verbal • Massage considerations:
abuse and blame about weight—therapist
should be aware of this and avoid – Palpitate to discern
badgering the client difference between
adipose and muscle
• Adipose (fat) tissue contains many blood tissue
vessels and is susceptible to bruising—
avoid deep work of fatty tissue – Lower table height or
stand on platform
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All rights reserved. – Massage on floor if
necessary

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Hearing Impaired Clients Hearing Impaired Clients

• Allow extra time for premassage interview • Find out early whether client reads lips
• Make eye contact whenever possible— • Face client, maintain eye contact, speak

sign of attention clearly and distinctly
• Use gentle tapping and gestures as • Keep view of your face unobstructed
• Use facial and hand gestures to help
needed
• When repeating a sentence the client did convey meaning

not understand, rephrase the information

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Hearing Impaired Clients Speech Difficulties

• If client has an interpreter, speak to client, • Ask client to repeat anything you do not
not interpreter understand

• Do not assume a hearing aid completely • Ask whether any accommodations can be
corrects hearing loss made on his behalf

• Consider use of flash cards with printed • If client speaks a language you do not
questions and answers to aid in understand, ask whether he can bring
communicating with hearing impaired someone to interpret
clients

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Visually Impaired Clients Visually Impaired Clients

• During premassage interview, allow extra • Announce presence before entering room;
time to give and receive information speak in normal tone of voice

• Ask client to explain her impairment and • Address client by name and state your
what assistance (if any) is needed name

• Keep massage facilities free of barriers • To assist client, stand in front or to left of
and clutter client

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Visually Impaired Clients Contact Lens Users

• Describe surroundings to client (e.g., “The • Many clients remove lenses before
massage table is at two o’clock.”) massage—have contact lens solution
available
• Be sure client knows you are there before
beginning touch; maintain contact during • If user keeps contacts in, show him how to
massage as much as possible adjust face rest cover to avoid eye
compression

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Contact Lens Users Spinal Abnormalities

• While client is supine, avoid massage near • Kyphosis—humpback condition
or over eyes • Lordosis—swayback condition
• Scoliosis—lateral spine distortion
• Moving face cushion to side of frame
reduces eye compression of contact users

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Kyphosis Lordosis

• Clients may be uncomfortable lying in the • Common in clients who are overweight or
prone position have flaccid abdominal muscles

• Place a cushion under the clavicles; • Place pillow under anterior superior iliac
adjust face rest to level above table spine (ASIS) when client is in prone
position

• Use bolster under ankles; use pillows to
correct externally rotated femurs

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Scoliosis Clients in Wheelchairs

• Abnormal curve is in thoracic position; ribs • If massage studio is not in an accessible
and hips are in distorted positions building, perform the massage off-site

• Offer client pillows and allow her to • Sit or kneel when speaking to client—puts
position them until she feels supported you at his eye level
and comfortable
• Inquire about the client’s limitations—do
not make assumptions

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Clients in Wheelchairs Clients in Wheelchairs

• Ask client the • If client prefers to be massaged on table,
reason for his follow his instructions on how best to help
wheelchair use him transfer from chair to table

• Client may choose • Ask client for feedback during massage
to be massaged in • Trigger points may be located in shoulders
wheelchair; use
pillows or desk topper and chest

• Be sure wheelchair brakes are locked 59 Copyright © 2008 by Saunders, an imprint of Elsevier Inc. 60
before beginning massage All rights reserved.

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Substance Abuse Sexual Abuse
and Drug Addiction
• Crosses all boundaries of gender,
• Massage can assist clients with stress orientation, age, and income
during withdrawal
• Most perpetrators are family members,
• Massage can also provide benefits during friends, or acquaintances (e.g., date rape)
recidivism (relapse)
• Client may need time to establish trust
• Most substance abuse clients need with therapist before massage can be
professional counseling; the therapist can performed
provide moral support and acceptance

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Sexual Abuse Sexual Abuse

• Many survivors adopt extreme behaviors, • Therapist must be a good role model for
e.g., compulsive eating, compulsive appropriate sexual boundaries
exercise, drug or alcohol abuse
• If therapist has any concerns about his/her
• Sexual behavior may also be extreme: own boundaries or is attracted to the
survivor may be fearful or promiscuous client, refer client to another therapist

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Sexual Abuse Sexual Abuse

• Avoid triggering memories and behaviors: • State-dependent memory

– Establish calm and nurturing environment – Some aspect of massage (e.g., position or
touch) may cause client’s body to “remember”
– Ask the client if he knows what his triggers are abuse

– Common triggers: perfume scents, touch in a – Repressed memories become conscious
particular area, body positions, certain music
or colors

– Massage itself may act as a trigger—reassure
client that he or she is in control of session

– Allow client to set boundaries: draping, areas

for massage, speed and depth of massage

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Sexual Abuse Emotional Release
During Massage
• Disassociation
• Most often seen as tears or crying; can
– Coping mechanism: person “leaves the body,” include shaking, twitching, or thrashing
does not feel, or believes abuse is happening
to someone else • Clients in counseling are more likely to
experience releases
– Can occur during massage if client recalls
abuse • If client is aware this might occur, explain
steps you will take ahead of time
– Signs: client unresponsive, a distant look in
the eyes, shaking, disorientation, shift in
breathing

– Stop massage if client disassociates; further
touch can be traumatizing

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Emotional Release Emotional Release
During Massage During Massage

• Process for therapist: • Process for therapist (cont’d.):

– Approach release – Do not offer tissues too quickly
with acceptance
– Remind client she is safe; ask if she wants a
– Discontinue massage break or other comfort measure
and make touch
contact in a neutral – Be accepting of the response; do not
area encourage or repress

– Do not leave 69 Copyright © 2008 by Saunders, an imprint of Elsevier Inc. 70
room unless client All rights reserved.
requests it

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Emotional Release Emotional Release
During Massage During Massage

• Process for therapist (cont’d.): • Responding to your client after the
emotional release:
– Get in touch with your own feelings about
others expressing emotions—allow client to – If asked, mirror back what you observed
express feelings without interruption
– Do not analyze; offer your understanding of
– Support and reassure client state-dependent memory

– Continue massage if possible – Provide space for client to be alone (or to
phone counselor) if requested

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Emotional Release Summary
During Massage
• Massage is an adaptable medium of
• Responding to your client after the therapy, with endless variation
emotional release (cont’d.):
• This flexibility enables the therapist to
– When appropriate, refer client to qualified accommodate many special needs
mental health professional
• Client respect and communication are the
– If release is very uncomfortable for therapist most important aspects to adaptive
to deal with, speak to a counselor, fellow massage
therapist, or peer support group

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