By Ruth Werner
June 1, 2020
Someday—maybe soon (whatever that means, in this time-distorted world)—we are all going to have to figure out the dos and don’ts of working with people who have had COVID-19. Because this is such a new phenomenon with lots of variations we are just beginning to figure out, the safety of massage therapy in this context is an open question. Massage therapists are going to have to put critical thinking skills to use, so we can make safe and effective clinical decisions.
A wide variety of complications can accompany or follow infection for some COVID-19 patients. Blood clotting is one important issue, of course. COVID-related coagulopathy is the topic of my pathology column in the July/August 2020 issue of Massage & Bodywork. But blood clotting may not be all that COVID-19 survivors will face. Some patients develop renal failure, arrhythmia, seizures, chronic headaches, fatigue, muscle damage, and any number of other complications that might influence choices about massage therapy. These complications may be transient, or they may mark the beginning of a new long-term health challenge for COVID-19 survivors.
How do we process this to bring our best to the massage therapy session? We use the same process that we use for all our clients with all their possible pathologies: we gather relevant information, weigh the variables, identify risks and benefits of bodywork, and then design a session to maximize benefits while minimizing risks.
In general, the most important information we can gather is what kind of activity level this client can tolerate, and how will we keep the challenge of bodywork within that limitation? (Note: this is true for every client and always has been, but it’s even more important for people who have had a bout with SARS-CoV-2.)
Note: my goals here are twofold:
- I want to prompt massage therapists to be more conservative than is absolutely necessary, especially in the context of an entirely unstudied population of potential clients: COVID-19 survivors.
- I want to support massage therapists to be critical thinkers, to cope with a level of uncertainty (which preceded COVID whether we knew it or not), and to process multiple pieces of information to make safe and effective clinical decisions.
What new data do we need to make these decisions? I have compiled some questions, with rationales and decision points, that I hope will be especially helpful for our clients who are confirmed survivors or probable survivors (e.g., had all the symptoms but no positive test) of SARS-CoV-2. Of course, this list will continue to evolve as we learn more about how to serve this special group of clients.
Questions to Ask
- What does your medical doctor say about your risk of communicability?
(Rationale: If the client has been cleared to return to work or to end self-isolation, then the risk of communicability should be over. If not, we need to delay, for their benefit and ours.)
- What does your medical doctor advise about getting physical activity?
(Rationale: If the client is advised to return to normal activity levels as soon as possible, then massage is more likely to be safe. However, if the client is advised to be careful about exercise—as might be seen with a cardiac or pulmonary rehabilitation program—then the intensity of massage therapy must also be scaled back.)
- What do you do in terms of physical activity?
(Rationale: We need a clear sense of what kinds of physical challenges people put their bodies through on a daily basis. This might range from someone who is essentially sedentary but takes a hot shower each morning, to someone who walks a few times a week, to someone who is training for an event with newly scarred lungs or potentially inflamed blood vessels. Within these questions we must dig out the most specific information we can find: “walking for 20 minutes” might mean a leisurely stroll on a smooth sidewalk, or it might mean a quick jaunt up a hill that raises the heart rate. That makes a difference in a client’s ability to adapt to environmental challenges. Further, many COVID-19 survivors have widely varying and unpredictable levels of fatigue and energy. We must not risk overwhelming someone’s physical capacity with overenthusiastic massage.)
- Do you have any new (that is, since your infection) skin marks, lesions, or rashes, especially on the toes, but anywhere on the body?
(Rationale: If yes, delay the session until these have cleared OR use very light work everywhere, and especially in the area of any discoloration—this may be a sign of microvascular clotting/ bleeding, especially if the lesions don’t blanch with finger pressure.)
- Do you have any new (that is, since your infection) experience of severe deep muscle or joint pain—unrelated to recent physical activity?
(Rationale: If yes, do very light pressure work, and refer them to their primary care provider. This symptom might prompt people to seek massage, but it can be an indicator of acute inflammation, muscle damage, or poor tissue perfusion.)
- Do you have any new (that is, since your infection) discomfort with exertion?
(Rationale: We are looking most specifically for chest pain, shortness of breath, dizziness, headache, or cramping in a new pattern. If the answer is yes, refer them to their primary care provider, who should know about this, because it may be a sign of cardiovascular or respiratory distress.)
- Are you taking any drugs to manage blood clotting?
(Rationale: If yes, delay massage until this is finished, OR use very light work because of blood clotting and bruising risk.)
- What other long-term consequences of your infection affect your life?
(Rationale: This could include relapsing symptoms, kidney dysfunction, gut pain, headaches, heart problems, debilitating fatigue, seizures, PTSD related to the trauma of surviving a life-threatening infection, or things we haven’t even thought of yet. Decisions about bodywork must be made with these complications in mind, so you might want to have a decent pathology reference at hand.)
Again, this list of questions must continue to evolve as we learn more about short-term and long-term challenges that people who have lived through COVID-19 may face. This is just a starting place, and I hope it is helpful.
Ruth Werner is a former massage therapist, a columnist for Massage & Bodywork, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (available at booksofdiscovery.com), now in its seventh edition, which is used in massage schools worldwide. Werner is available at ruthwerner.com or email@example.com.