Every now and then, Massage & Bodywork readers clamor for a basic hygienic practices refresher article. In this column, we will look at the actions of an entirely fictional massage therapist who is in a hurry and makes a few unfortunate errors in how she sets up her office for the day.
Meet Myrtle
Myrtle the massage therapist was—as usual—running late on a Monday morning. Fortunately, on Friday she had started to launder her favorite colorful flannel sheets and face cradle covers. She is conscientious about energy use, so she washed them all in cold water, but she used extra non-chlorine bleach so they’d be really clean. The wet laundry sat in her washing machine for a couple of days, but she luckily remembered to put it all in the dryer early in the morning. Everything was mostly dry by the time she tossed it all into the back of her car and drove to her office. She hoped her first client wouldn’t notice that her uniform shirt was still a little damp.
Grabbing her armful of unfolded laundry, Myrtle hustled into her session room. Her table was marked with oily handprints—not the kind of impression she wanted to make. Dropping her sheets on the floor, she grabbed a translucent bottle of 10 percent bleach solution off her open shelf. She realized the bottle had been there for several months, so she took a careful whiff of the contents. It was still potent enough to make her eyes water, so she spritzed her table and quickly wiped it off with a paper towel.
She adjusted one fitted sheet, then realized that with six clients on the books for her seven-hour shift, her time to dress her table between appointments would be extremely limited. So she used an old trick: she layered the rest of the fitted sheets on top of the first, so she could simply peel them off one by one. She quickly folded the extra, slightly damp flat sheets and stacked them on her open shelves where she kept towels, bolsters, books, and other equipment.
As Myrtle fitted her face cradle into the top of the table, she realized it was a little sticky. From the top drawer of her desk, she grabbed an alcohol-soaked towelette: a leftover from her last trip to the barbecue restaurant. She quickly wiped down the face cradle before stacking six covers on it. Then she used the moist towelette to wipe her doorknob, the light switch plate, her bottle of lubricant (which was getting a little grimy), and lastly, her own hands. Surveying the room, Myrtle nervously bit the loose skin off her hangnails, and decided she was ready to greet her first client.
How many mistakes did Myrtle make? (Answer: plenty.) Let’s take a look.
Principles of Hygiene
Universal Precautions are a set of protocols that were introduced in 1987 (after HIV/AIDS and hepatitis B had become major public health issues) to create some uniformity in how medical professionals could limit contact with body fluids in the working environment. Standard precautions were added to include guidelines on how to avoid all potentially harmful body fluids, including amniotic fluid, blood, blood-tinged saliva, breast milk, cerebrospinal fluid, pericardial fluid, pleural fluid, semen, synovial fluid, vaginal secretions, and vomit (emesis). Obviously massage therapists are unlikely to be exposed to cerebrospinal, pericardial, or pleural fluid in the course of an average day, but some of these others are not outside the range of possibilities, especially blood, blood-tinged saliva, breast milk from lactating women, and vomit. It is important to note that sweat and tears—perhaps the fluids that massage therapists are exposed to most often—are not described as infectious fluids.
The methods that infectious agents use to jump the gap from one host to another have been exhaustively studied. The process essentially boils down to three issues: a reservoir or source of the infectious agent, a mode of transport, and a susceptible new host. Possible reservoirs can include other humans or animals, or inanimate habitats like contaminated computer keyboards, food that harbors potentially dangerous bacteria, or cash that may be handled by hundreds of people. The susceptibility of a new host depends on a number of variables, from species, to inborn immunity, to variable resistance. Finally, the mode of transport can be direct (like blood-to-blood exchange), indirect through the air with respiratory secretions, or by way of an intermediate object like a doorknob or a light switch. These disease-relaying objects are sometimes called fomites.
Massage therapists carry a responsibility to create an environment in which the potential for a pathogen to pass from one person to another is as close to zero as possible. Most massage equipment cannot be sterilized, but much of it can be effectively cleaned or disinfected (for the technical definitions of those terms, see Definition of Terms, page 37). The benefits of good hygienic practice go beyond conveying a sense of professionalism. Massage therapists work with skin-to-skin contact, and the risk of picking up an inadvertent infection, or of spreading one to another client, is a career-shortening (and possibly life-shortening) occupational hazard.
While many pathogens don’t last long outside a human host, a few can be sturdy in a warm, moist setting. Hepatitis B, herpes simplex, and tuberculosis are examples of pathogens that have been seen to last for hours, weeks, or longer if the circumstances are conducive. For instance, warm, humid environments that are not frequently cleaned provide multiple potential sites for the transfer of infectious material.
If Myrtle had the following information, she could improve her hygienic practices, and reduce the risk for harm to herself and her clients.
Laundry
1. Standard laundering has good antimicrobial effect with water temperatures between 71°F –77°F (21.6°C–25°C), if the detergent is used according to the manufacturer’s directions. This is adequate for most situations.
2. Chlorine bleach will wear out fabrics, and, of course, it is not appropriate for colors. However, nonchlorine bleach is only a color booster: it does NOT have antimicrobial action.
3. If chlorine bleach is added to the wash, it becomes most active at temperatures above 135°F (62.7°C). Most home hot water heaters heat water to 120°F–140°F (48.4°C–60°C), so bleach in a home washing machine may not reach its full antimicrobial potential.
4. The recommended amount of bleach is a ratio of 50 to 150 parts per million (ppm); 150 ppm of bleach in a standard top-loading washing machine with a 40-gallon tub is 8 ounces of bleach per load. In a front-loading washing machine with a 24-gallon tub, it is 4.8 ounces.
5. Bleached laundry must be thoroughly rinsed (professional laundry services do this at least twice) to minimize irritation to users.
6. Laundry must not be left damp: mildew can begin growing within 24 hours.
7. All laundry should be dried on high heat (160°F, 71.1°C). Ironing adds extra antimicrobial action, but this is probably not a practical suggestion for most massage therapists.
8. Clean laundry must be packaged to keep it clean until its next use. It should be wrapped in plastic, or stored in a clean, closed container (and never dumped on the floor).
Session Room
1. For cleaning high-touch surfaces like massage tables and face cradles, the Centers for Disease Control and Prevention (CDC) recommends a freshly mixed 10 percent bleach solution; this is inexpensive and easily available. Bleach-infused wipes can be useful in this application, but it is important to read the labels for best results: some of them require at least 10 minutes of uninterrupted exposure to be effective.
2. Bleach solutions lose their potency quickly. It is important to store them in opaque (not translucent) containers, or away from the light, and to replace them about once a month.
3. Alcohol and alcohol-soaked towelettes are specifically not recommended for cleaning surfaces, because alcohol evaporates quickly; it works best with prolonged contact against targeted pathogens.
4. Stacking sheets and face cradle covers is simply a bad idea. Clients sweat, they drool, they may use strong-smelling soap or scents, and sometimes they have open and uncovered sores or cuts that may ooze and contaminate the sheets below. Think about being the sixth or seventh client of the day—what company might you have on the sheet you’re lying on?
5. Myrtle was smart to realize that the doorknob and light switch plate in her office should be regularly cleaned, but the alcohol wipe wasn’t a good choice—again, because alcohol evaporates before it can be effective, and because she used it previously on the face cradle. Further, the most contaminated surface in a massage room may not be the most obvious. Computer keyboards are veritable breeding grounds for pathogens, and it can be difficult to clean them thoroughly.
Personal Hygiene
1. Myrtle needs to take better care of her cuticles. Tiny lesions are potential microbial portals of entry, even if no visible scab or cut is open on the skin. Bacteria that are harmless on a client’s skin may not be harmless if they are able to enter a massage therapist’s system through a hangnail, paper cut, or other minor lesion.
2. Hand washing has been extensively studied. Washing hands in warm running water with plain soap for 10–30 seconds is still considered the best hand-washing option. Alcohol-based gels are more effective than wipes, because they keep alcohol close to the skin for a longer period of time if they are used as directed: that means rubbing the recommended amount over the hands, between the fingers, into the cuticles and so on, and continuing to rub until the skin is dry—not wiping hands on a towel or clothing.
3. Myrtle uses a uniform shirt, but she might consider investing in several of them so she can change with each new client. This prevents one client whose arm or leg might brush against her uniform from encountering the same surface as the previous client.
What’s practical?
The hygienic practice guidelines provided here are drawn from recommendations by the CDC and other resources for health-care professionals in hospital, dental, and home-care settings. Individual states may also have specific guidelines for massage therapists. These recommendations may be more strict or stringent than many people find practical, but our job as professionals is to be more careful than is absolutely necessary. The goal of this article is to promote the creation of a setting in which the surfaces that one client touches are cleaned or replaced before the next client comes in. This means sheets are removed and replaced, and bolster covers, face cradle covers, uniforms, and other fabrics are also refreshed. Non-fabric surfaces like the table, doorknob, and switch plates are also cleaned regularly. If a therapist uses thermal packs, stones, or other massage tools, these must also be disinfected between clients.
Taking care of our equipment, our working environment, and ourselves takes time, energy, and investment in good cleaners. But it can give us the good health and longevity to more effectively take care of our clients. Now go wash your hands!
Ruth Werner is a writer and educator approved by the NCBTMB as a provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2012), now in its fifth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.