Understanding Indications and Contraindications

By Ruth Werner
[Pathology Perspectives]

I recently had an interesting phone conversation with a friend who is a massage therapy school administrator. She wanted some guidance for a new pathology educator. We had a spirited discussion (which is to say, a friendly disagreement) about whether some condition, I don’t remember which, contraindicates massage therapy. I maintained that with appropriate accommodations it would be possible to design a session that could be helpful and safe, even in a situation where the client was frail and their constitutional health was compromised.
After a brief silence, my friend asked, “Well if that’s true, then what is a contraindication anyway? And how are we supposed to teach it?”
That conversation blossomed into this article, which is dedicated to massage therapy pathology educators everywhere, but which is intended for use by every well-meaning massage therapist who sees clients with health challenges—and I’m willing to bet that’s the majority.

A Little Vocabulary

The terms indication and contraindication are sometimes used a bit carelessly in massage therapy education. To be precise, an “indication” is a situation in which a particular intervention is expected to have a positive effect on the outcome of the disease or condition, and a “contraindication” is the opposite: a situation in which an intervention should be avoided because of risks to the client. We can say some situations indicate or contraindicate massage, but in reality, I believe it is more accurate to say that massage therapy addresses the person, rather than the disease. So rather than saying massage is indicated or contraindicated, it is generally better instead to weigh relative risks and benefits of massage therapy in a particular situation, in order to design a session that maximizes benefits while avoiding risks.
And here’s where it gets tricky. Massage therapy is a huge term! It can encompass virtually any kind of systematically applied, educated, and outcome-oriented touch. So, it is possible to imagine bringing something useful into almost any nonemergency pathologic situation.

Analyzing the Variables

When we have a client who is not in perfect health, how do we determine how to serve their best interests?
Some of the variables that impact our decisions include client goals, stage of the condition, communicability, medications and side effects, and client resiliency.

Client Goals

It’s not by accident that this is at the top of the list—and yet it is amazing how many session plans I read in which what the client wants is not mentioned. A person’s reasons for visiting a massage therapist may have nothing to do with their chronic health challenges. Someone who lives with knee arthritis may also have slept funny and have a kink in his neck that he’d like to work out. In this situation, his knee is beside the point and should not be the main focus of the session.

Stage of the Condition, Inflammatory State

In situations where a person pursues massage therapy to help with a chronic problem, we need to evaluate how the condition affects their health and function, and whether this informs our decisions about bodywork. Examples include things like autoimmune diseases: a client may want massage therapy to help with the pain related to rheumatoid arthritis, but if they are in flare-up when they come to see us, our work needs to be gentler than if they are in remission.
Some of these decisions may also be guided by location. A person with one inflamed ankle that needs gentle touch may welcome work that is more challenging on the other side.


In some situations, we may be able to offer some benefits to a client, but the associated hazard to the therapist is not acceptable. Someone with the flu who is coughing and sneezing and achy might enjoy some gentle massage therapy that helps to clear sinuses and improve sleep. But if the client is still contagious, then the risk to the therapist outweighs the benefit to the client. Indeed, acute, contagious, systemic infections are the only situations where I cannot see a way for massage therapy to provide benefits without risks.  

Medications and Side Effects

Medications add an additional set of variables. For a client who uses Lopressor to manage high blood pressure, or insulin for diabetes, or Humira to manage psoriasis, we need to know what the drug is for, what side effects it might have, and how these issues impact the client’s quality of life and goals for massage therapy. Some medications affect the integrity of the skin (topical corticosteroid creams, for instance), and that must change the way we work. Other medications sometimes cause dizziness and lethargy, so clients may need stimulating strokes to finish a session. It is important to ask clients how their medications affect them in order to predict how to adjust massage therapy to that situation.

Client Resilience and Activities of Daily Living

I saved this for last because it’s a good bookend to client goals. All of our clients, but especially those who struggle with health, have good days and bad days: days when they feel ready for anything, and others when they feel pretty puny. One of our jobs is to meet people at their current level of energy, and to keep the challenges that our work imposes within their capacity for adaptation. This sensitivity can help keep our work safe, even if we don’t know all the details of the other points in this list.


I have used phrases like “make appropriate accommodations for client needs” for decades, but I have come to the conclusion that this is an inadequate piece of advice, and it might be useful to offer a list of specific accommodations that massage therapists can make as part of session planning for clients who live with health challenges.
I have divided these accommodations into four categories: technique, environment, equipment, and special services. I would love for readers to look at this list and identify what I’ve missed—then let me know, so I can improve the way I communicate about this important topic.

1. Accommodations of Technique

This heading refers to any special skills or modalities that might be more suitable than others for a given situation. And within those modalities we can also adjust for:
Areas of the body to focus on, to avoid, or to treat with special care. An example would be an area where sensation is impaired. We don’t have to avoid it altogether, but it is not appropriate to try to change the quality of the tissues in an area where a person cannot give accurate feedback about pressure or comfort. Another example is the feet of clients with diabetes. Because this disease can cause nerve damage and delay healing, sores here might be both painless and potentially dangerous, and we are in a position to recognize that risk.
Pressure. I hope this is self-evident: we adjust our pressure according to the resilience and feedback of our client. This may change dramatically from one session to another, and not always in the same direction.
Sometimes clients ask for or expect a depth of pressure that is not necessarily in their best interest. In these situations, we must communicate that we respond to what we feel in their tissues—where they begin to resist is where we must begin to back off. There are some special skills for conducting those difficult conversations, but that is a topic for another time.
Frequency and duration of sessions. Most massage therapists work in 50–90-minute sessions. This is a convenient amount of time, and it works well for lots of situations. But in some cases, an hour is too long or too short; or once a week is too often or too seldom. It is completely appropriate to alter the frequency and duration of sessions to accommodate for what will help our clients accomplish their goals with massage therapy.

2. Accommodations of Environment

This heading addresses what we can do to make our workspace friendlier for our clients who may have certain limitations or challenges.
Temperature. This can refer to the temperature of the room (some medications cause flushing, so a cooler room is a nice option) or to how we use our equipment—which we’ll look at in the next section. Remember, stones, packs, and other devices can be hot or cold—and our clients may have situations that call for one over the other. That table warmer that is delicious for most clients might be terribly uncomfortable for the client with multiple sclerosis who doesn’t tolerate hot temperatures well.
Other ambient features: sound, odors, light. Music or ambient sound can have a profound impact on a person’s ability to relax in the massage therapy room. Some people are extremely sensitive to odors, and others may derive benefit from skillfully used aromatherapy. Even the levels of light can be an issue: if our clients are photosensitive, then strong lighting can be problematic; if they are vision-impaired, then dark rooms become hazardous.
Privacy. It is normal to expect that a massage session is conducted in complete privacy, but that might not suit some clients. Some situations may even be best addressed with work in quasi-public areas, like in a seated massage space where familiar people are close by for a client who lives with a condition that makes it uncomfortable to be separated from others. This might describe a person with posttraumatic stress syndrome or some kinds of anxiety disorders, or someone with Alzheimer’s disease or other types of dementia who is easily disoriented.
Level of undress. “Undress to your level of comfort” is a direction I’ve heard from a lot of massage therapists, and this is a good thing. Some people will be happy to “take it all off” and others will want a layer (or more) between you and them in addition to the top sheet. We need to be willing to meet them wherever they fall on that spectrum. This level of comfort may also vary from one appointment to another, and clients have no obligation to be consistent in determining what their comfort level is from one day to the next.
Timing. Most clients won’t have major health issues related to what time of day they receive massage, but some do. The easiest example to point to here is someone who uses insulin to manage their diabetes. It is generally a good idea to schedule a session in the middle of their eating cycle rather than when they’re already hungry (low blood sugar that could be exacerbated by massage), or when they’ve just taken a dose of insulin with a meal (massage might impact insulin uptake).

3. Accommodations with Equipment

This heading covers how we use tools to help create the best and safest experience for our clients with health challenges.
Bolsters and other support. This is an obvious one that doesn’t just apply to people with health challenges: all our clients have a better experience if proper bolstering allows them to relax fully. But for people with bone or joint problems, osteoporosis, surgical implants, or other factors that might limit their comfort on the table, good support—with cushions, bolsters, rolled-up towels, or other devices—is essential for safe and effective massage therapy.
Furniture. Not all massage has to happen on a table. Some situations call for a massage chair, a recliner, a wheelchair or hospital bed, or working on a pad on the floor. An example of this might be someone who has recently had surgery and isn’t ready to lie flat on a table—a good massage chair might provide a more relaxing experience. Another thing to consider is table height. Some clients with limited mobility might need a stepstool or a lower table to get safely on or off. (If I were still in practice, I would invest in a hydraulic table that allowed me to adjust height for every client without having to reset all the legs every time.)
Oils, lotions, creams. This is hard to overemphasize: not all oils, lotions, and creams are appropriate for all clients, or even all massage therapists. We may have our favorite oil or lotion, but it is imperative to keep something hypoallergenic on hand—not just for those with sensitive skin, but also for those prone to respiratory allergies who can have a delayed reaction to some types of oils.
Tools. We made passing reference to massage tools in the section on temperature, but some devices may be especially useful, or important to avoid, for clients with various challenges. Clients who have limits to pressure or intensity of massage need for us to be especially sensitive: these are people for whom we must avoid using tools that might interfere with our ability to sense subtle changes in the tissues. In short, don’t use your thumb protector for clients with heightened pain sensation.
Hot and cold applications also fall under this heading, again with cautions for temperature tolerance. What other massage tools might need to be altered or avoided for clients who live with health challenges?

4. Accommodations with Service

Lots of massage therapists offer special add-on services, from hot towels on the feet to facial moisturizers. These can be wonderful additions to your practice, but there are some services that are specifically geared toward clients with pathologic challenges.
Help getting on or off the table. Some clients will benefit from your presence as they get on and off the table. This may create some challenges for draping; it’s up to you and them to work out what works best. But if your client is not steady on their feet, they need you with them during those transition moments.
Similarly, it is worth taking a fresh look at what it takes to get from your parking lot into your office. Are there areas that get icy? Do you have some steps that might be tricky for a person who uses a cane or a walker to negotiate? Some clients may need assistance getting safely into and out of your office.
Time to transition back to full speed. A number of people can benefit from some recovery time after a massage: those who use blood pressure drugs or other medication that makes them a little logy, those with some numbness or lack of good sensation in the feet, and others. This can be an important accommodation for people who might experience some dizziness when they sit up after a massage therapy session. However, this is something a lot of massage therapists may not be able to control. If we work in a spa or franchise that is built on a specific turnover time, then we can’t always encourage a client to linger for a few minutes before getting dressed. One workaround is to attend to them while they sit up, and encourage them to stay in the waiting area for a few minutes before going back out into their normal pace.
In short, we cannot rubber-stamp decisions about massage therapy in the context of pathologies. Each practitioner, each client, and each appointment produces a different set of variables that must inform choices about bodywork, practically on a minute-to-minute basis. One of the most important jobs we do is to keep all those variables and accommodations in our consciousness all the time. Only in this way can we be sure we are bringing our very best to the table.
Do you have other accommodations that you find useful in your work with clients who live with pathologies? I would love to hear about them.

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (available at BooksofDiscovery.com), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.