Risky Business: From Daily Practice to COVID-19

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Risky Business: From Daily Practice to COVID-19

By Cal Cates

As massage therapists, we never want to come from a place of fear, but a little healthy fear can really help us when it comes to considering risk. MTs are thinking a lot about risk these days. Risk of working or not, and, of course, the risks within a range of client presentations.

What is “risk” within this context? And what do we mean by “risk assessment?” A risk is a situation in which there is exposure to harm or danger. Risk is also when I (or someone else) create or expose someone to danger or harm. Risk assessment is really about asking ourselves, “What are the risks of massage therapy for this client? How do I limit and even remove those risks?”

The ability to bring real and current information into our decision-making is what being a good practitioner is all about.

Health Intake

The key to risk assessment is knowing what to do with the information people share (and don’t share) in response to the questions we ask them. Most of us have our clients fill out a health intake form once. Maybe we have them complete a new one every 12 months or so, but each time we work with them during the intervening time, we’re typically doing a completely verbal and visual intake and, thereby, risk assessment.

When a new health concern emerges, the profession trains a laser focus on the most important new intake questions. We all get excited and add these questions to our forms and conversations, but many of us don’t know what to do with the answers. We don’t know why we’re asking these questions or what we’ll do with less-than-ideal answers. What if, instead, we add COVID-19 and what we think we understand about it to the list of possible variables in our minds when we consider the answers to standard intake questions, as we’ve done with so many other conditions over the years? This is not to say that we shouldn’t add COVID-specific questions, but sometimes when we focus so specifically on one thing, we miss the bigger picture.

What Are Your ADLs?

One big-picture question that has gotten a lot of press recently is “What are your ADLs?” or “activities of daily living.” You’ve actually been asking this question as long as you’ve been a massage therapist. You may not have been phrasing it this way, but this is possibly one of the most important questions to consider in risk assessment. “Talk to me about how you use your body.”

This is how I ask my client about their ADLs. I don’t want to know what they “do,” per se. I really want them to think about their days in terms of “using” their bodies. “I spend a lot of time sitting, staring at a computer.” “I have a 2-year-old child and they want to be picked up all of the time right now.” “I work from my couch with my computer on my coffee table.” This is all useful information that we don’t even realize we’re using to decide the overall intent of any massage we’ll provide.

If I’m working with a person who was recently hospitalized, had surgery, is living with a disease, or who I know to be under the direct and regular care of a health-care provider (HCP), I want to know, “Has your [insert HCP title here] suggested you limit any aspect of your activity?” If they respond in the affirmative, then I need to know more. What kind of limitations? Why? Are the limitations helping with the concern? How long has it been recommended you adhere to these limitations?

Thinking is Essential

Then I have to think. I have to use these answers to decide how they apply to my massage work and how my work will likely affect this client. If they’ve been asked to limit weight-bearing exercise, I will need to adjust my pressure. If they’re told to “exercise as you’re able,” and they tell you that they’re not “able” to do much more than go up the stairs or that they become short of breath when they walk up the three steps to their front door, that gives you some insight into how you may need to adapt your session to lessen any risk of additional fatigue.

There is a lot that goes into considering risk. The bottom line is that you need to do your absolute best to limit or remove potential risks. Anyone who finds themselves on your table could have any number of potentially “risky” conditions or diseases. They could have had one recently or could be recovering. When it comes to COVID, we’re all talking about coagulopathy, muscle and joint pain, headaches, and other hard-to-assess complaints that could have a wide range of possible causes. Because we have COVID “on the brain,” we are likely to assume either (because it feels too scary to consider otherwise) that it’s “unlikely” that their complaints are COVID-related or (because we tend toward serious caution) that it’s “very likely” that their complaints are COVID-related.

When I feel like the truth of this is all too much, I go back to Tracy Walton’s most exceptional book, Medical Conditions and Massage Therapy: A Decision Tree Approach. I love and cherish this book, not nearly as much for its ability to guide me through specific conditions as for its indispensable “Principles of Contraindication” section. When assessing risk and the safest possible action with a client, there are a few of Walton’s principles that really help me to be able to lay my head on my pillow at night knowing that I did the right thing. The safest thing.

The “Waiting for a Diagnosis Principle” is gold in the current climate, but really any time a client comes in with a new complaint. The gist is that if you’re working with a person who has been tested for some condition (ANY condition), their HCP had reason to believe that they have that condition. As such, you should treat them as though they have whatever the condition is until proven otherwise. To bring it back to COVID-19, it’s not crazy to assume that everyone you’ll massage in the foreseeable future is waiting for a COVID-19 diagnosis. As such, the least risky thing to do is to assume that their new headache, joint aches, and/or fatigue are related to a forthcoming COVID-19 diagnosis.

Yes. This means you have to be unpopular and defer treatment until they have confirmed they do not have COVID-19 by receiving a test and furnishing you with the results of that test. Of course, risk assessment is about honesty. At this point, accepting test results means you are willing to accept that you are mostly sure the client doesn’t have COVID-19. Testing is becoming more accurate, but no test for any disease is 100 percent accurate. As a colleague and friend of mine recently suggested, “A negative COVID test doesn’t feel so different to me from being mostly sure there aren’t brown recluse spiders hiding in my massage linens.” It’s a risk. We can only limit it so much.

Risk, like ethics, is something very personal, but honesty is key when deciding your true threshold for risk and when communicating that risk to your clients.

Risk and DVT

When we’re talking about deep vein thrombosis (DVT) risk, we have to remember that people can have DVT without having any signs or symptoms. DVTs are more common than you may think (even before COVID-19) and as many as 50 percent are “silent,” found only on autopsy after a person has died from related complications.1 While a majority of DVTs happen in the lower extremities and it is more common for them to be unilateral (happening on only one side), they can happen in a variety of places in the body and can be bilateral, so we really have our work cut out for us in terms of risk assessment with DVT. We always have.

If you suspect a DVT, massage should not happen until it’s ruled out or treated. End of story.

Experts will tell you that massage therapy doesn’t affect circulation and, in some ways, they’re right. Massage therapy disturbs local, superficial blood flow. It doesn’t oxygenate muscle tissue or “increase” the speed of circulation in a systemic way. However, unskillful, invasive, deep massage may compress tissues directly over a clot in a way that disturbs and possibly dislodges the clot. Another step we forget to discuss is that changes in orthostatic pressure, like the ones that happen when a client lies down on your table at the beginning of a session and then stands up again at the end, can be enough to change blood flow and inspire a clot to break off with grave consequences.

The simple act of lying down and getting back up again can be the straw that breaks the blood clot camel’s back. This doesn’t mean it’s your fault if a client lies on your table and throws a clot, but if you had sent them to their HCP instead of working with them, that was one less time they exposed themselves to that risk and it put them one step closer to safe diagnosis and treatment.

And here’s where you get to hate me. DVTs happen all of the time. You are working now and have worked for years with people who had undetectable and undiagnosed blood clots. Every day that we provide massage we are accepting the risk of silent clots. No amount of interviewing or ADL questions can really poke that info to the surface. It’s a risk we’ll never fully remove. And yet, we have to remain diligent and do everything we can do to notice what is noticeable and to respond appropriately.

If you “discover” or even have solid reason to suspect a client has an undiagnosed blood clot, the way to create the lowest risk situation is to defer the session and instruct them to go directly from your office to their HCP to have it ruled out. Providing a massage while “avoiding the area” is a risky plan of action. You cannot provide any kind of massage to this person and know that you mitigated risk to the best of your ability until they have seen their HCP.

When Ruth Werner tells you we “can’t feel confident” that massage won’t lead to embolization in a client with symptomatic or asymptomatic coagulopathy, that means that it could. The same is true for any client at risk of DVT. And what that really means is that you need to ask yourself, “How will I feel if this person has a pulmonary embolism after (or during) this massage or if they ‘throw a clot’?” Some things are always a risk. Any client, even in pre-COVID days, could harbor undetected blood clots.

If you’re after 100 percent safety, massage therapy is not the career for you. If you can live with some ambiguity and the responsibility that comes with it, you’re golden.

In the greater scope of things, skillful massage is remarkably safe—especially compared to other pain-relieving interventions. And that “skilled” qualifier comes with knowing how to identify the most obvious risks we can find. But it also comes with the caveat that we could miss something. Don’t let this fact prevent you from doing what can be done to lessen risk.


1. S. Waheed, P. Kudaravalli, and D. Hotwagner, Deep Vein Thrombosis (DVT), (Treasure Island: StatPearls Publishing , 2020).

author bio

Cal Cates is an educator, writer, and speaker on topics ranging from massage therapy in the hospital setting to end-of-life care and massage therapy policy and regulation. A founding director of the Society for Oncology Massage from 2007–2014 and current executive director and founder of Healwell, Cates works within and beyond the massage therapy community to elevate the level of practice and integration of massage overall and in health care specifically.



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