What Will It Look Like When We Go Back To Work?

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Editor’s Note: This is an opinion piece about what it might look like to go back to practice. If you have your own thoughts, ideas, concerns, or questions, please share them in the comments section of this blog. We are working to gather information from our community and experts in and outside the massage and bodywork profession to help our members move forward.

Be sure to read the special COVID-19 digital-only issue of Massage & Bodywork magazine.

By Ruth Werner

Hello my friends.

I hope you’re on hiatus, and I hope you and your family are healthy. I hope you’ve been safe at home, enjoying your loved ones, doing your taxes, getting your inboxes down to zero, and reassessing your work situation as you contemplate what comes next—all while doing your bit to flatten the curve. Your local health-care workers thank you for your efforts. (And as the mother of two adult children who are on the front lines of the pandemic, I thank you too.)

I’ve been doing a lot of thinking and talking and reading about what we might expect in the near future for our profession. I have had many rich and revelatory conversations with massage therapists and educators who are trying to make the best of this situation, and I am grateful to them all. And I thank ABMP and Massage & Bodywork magazine for this opportunity to share some ideas with you. And before we go any further: a disclaimer. This is all my opinion. It’s based on resources that I trust, which are listed at the end. But I’ve been wrong before, and I may have some of this wrong too. If I do, I will be the first to broadcast it, I promise.

While I know there are still some massage therapists who are seeing clients even now (April 1, and this isn’t a prank), I believe most have shut down their practices—either through ethical and risk-related reasons, or because of governmental mandates. Let’s remember: your government doesn’t understand your work. Some states have made exemptions for “essential services” and included versions of massage therapy, or chiropractic with massage under that umbrella. Some states have shut down massage clinics but support therapists making home visits. Some have contradictory language that leaves massage therapists utterly in the dark about whether they are allowed to be in practice. My point is this: your state’s laws notwithstanding, right now it is not safe to see clients. It’s not safe for you, and it’s not safe for them. So even if technically you are allowed to practice, I hope you aren’t doing it.

Also, this won’t last forever. And it’s not too early to think about what things have to be in place for us to think about reentering the marketplace.

What Needs to be True For Us to Work Safely?

Another disclaimer: I am not an epidemiologist. My expertise in this area comes from many years of the study of the interface between massage therapy and various pathologies, and my willingness to read a lot of complicated material, and then force smart people to explain it to me. What I share here is a compilation of information and ideas I have drawn from many different resources and conversations, all through my own filter of understanding our profession and its unique position in the health-care field.

Experts and epidemiologists who are working on the challenge of reopening businesses are thinking about infection rates and public safety. Some experts suggest that when 70 percent of the population has been exposed to the SARS-Co-2 virus, most people will be safe: this is called “herd immunity.” But because of the high mortality rate of COVID-19, achieving 70 percent exposure is likely to result in close to a million deaths in the United States. For this reason, waiting for herd immunity to occur naturally is unacceptable. Instead, we must achieve that 70 percent rate of exposure through the use of a safe and effective vaccine—which, as you know, involves a type of controlled exposure to the virus.

Eventually, most of our population will have been exposed to the virus in one way or another. For the best chances of survival and recovery, we want that spread to happen as slowly as possible. As of now, a typical person with SARS-Co-2 virus will pass the infection to about three other people. Those people pass it along to three others, and then three more for each person, and so forth. Numbers of new COVID-19 infections will begin to drop only when that pass-along rate is less than one. We can achieve that goal in a few ways: by strict physical distancing; with a vaccine; and by limiting who goes out in public according to their infection status. But we can’t know about infection status without appropriate testing, and lots of it.

Staging Your Practice

When business restrictions related to COVID-19 are lifted, massage therapists will have to make some important decisions about their work. Without extensive testing and/or an effective vaccine, they will not know their immune status. This would make working with potentially vulnerable clients both unsafe and unethical. Our elected officials may not make this judgment, however, and they may prematurely invite massage practices back into business.

But as I mentioned your government doesn’t understand your work. It is vital that people who are unfamiliar with massage do not make the final decisions about our safety—for us or for our clients. That’s our job. No one is going to tell us how to do it, and we need to take it seriously.

It’s impossible to predict what it will look like for massage therapists to get a green light on going back into practice—and whether that green light should actually mean “go.” I have heard some colleagues discuss a phase-in opening process, and I think this is an excellent idea.

The first phase of reopening could happen when new infection rates are falling, and viral testing is fast, accurate, and accessible. At this point, I recommend that massage therapists open their practices only if they know for sure that they are virus-free, and all the people in their life are virus-free. Further, I suggest they only work with clients who are also known to be virus-free. Any other choice would continue to put people at unnecessary risk.

Would using masks and gloves during massage cut down on the risk of communicability? Possibly. Would it reduce that risk enough to make it safe to practice? My opinion (and it’s just my opinion!) is no. I would be happy to be proved wrong. But the safest, lowest-risk option is to know that both parties in the massage therapy session are uninfected.

Later, when a large portion of the population has been exposed or vaccinated, then I predict that massage therapy practices will be able to operate more freely. Even then, I still recommend that massage therapists work only if they are immune, either through a history of exposure, or by vaccine. I predict that when we reach this time, we will be busier than ever, and well-appreciated by other health-care providers who can recommend self-care, pain relief, and stress reduction through our work. (I know I can’t wait to get on a table—I have never needed a massage more.)

I have one more important point about opening up again. Even with a phase-in reentry, massage therapists must be prepared to close again if necessary. Many experts predict a second wave of infections a few months after our initial numbers recede. This may require that we go back into isolation for some period of time, although we should be better able to deal with another outbreak by then. If we plan ahead for this, we will be more able to anticipate all the factors that go into this decision.

When We Reopen

What kinds of changes do we need to make when the time is right to reopen our doors? I have a few suggestions:

  • Reevaluate hygienic practices and scheduling practices. Use recommended disinfectants and schedule the time necessary for them to be effective. Swab more than the face cradle: get all the surfaces your client touched. Sorry, but the days of 10-minute turnovers are probably over. In this vein, it may be time to reconsider your choices for personal protective equipment—not necessarily hospital gowns, gloves, and masks, but uniforms and linens. Do you have blankets or other covers that you use multiple times between laundering? Time to reconsider that practice. I have advocated for massage therapists to change their shirt or apron with every client for years; maybe it’s time to plan on that adjustment too.
  • Air quality. Do you work in a small room with little ventilation? Has a client ever coughed or sneezed in there? Consider whether an air filter would be helpful. Although the COVID-19 virus is not efficiently spread as an airborne pathogen, clients who cough or sneeze may expel particles small enough to float. An air filter needs to be fine enough to catch those particles to be effective.
  • Waiting room. Does your office have a waiting room where people may be seated close to one another? It may be time to redesign this, or to manipulate schedules to minimize populating a waiting room that needs to be thoroughly cleaned and disinfected regularly.
  • Vaccine policy. And lastly, I predict that you are going to need to make a decision about a vaccine. We expect to have a vaccine for COVID-19 within 18–24 months. As professionals who work intimately with others, I suggest that it will be important for massage therapists to get the vaccine. But the other half of that question is whether you will be willing to work with clients who are neither immune nor vaccinated. These clients may leave viral traces for other clients who are neither immune nor vaccinated, and the cycle could begin again.

This is a very touchy topic, with a lot of ramifications, and I won’t go deeply down this rabbit hole here. But it’s something you will need to decide, and you will need a carefully considered rationale for your policy.

What Comes Next?

When it comes to how to reopen a practice and what new standards we should adopt, many massage therapists will probably look to health-care policy providers. We have an opportunity in this moment to work for closer relationships with organizations like the Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA). These bodies set infection control standards for many health-care providers. It would help hundreds of thousands of massage therapists if we had specific, practical, and evidence-informed guidance on this topic for us as well, and I encourage our membership organizations to represent our profession well in this arena.

Testing

For massage therapy (and other businesses) to be safe again, we need to know who has the virus now, and who has had it in the past—and we need this information quickly and accurately. This involves at least two different types of tests, possibly at multiple times.

Who has it now?

The test we currently rely on involves a nasal swab that is inserted way-the-heck to the back of the sinuses to get a mucus sample, which is then examined for signs of the COVID-19 genetic material. There are a couple of problems with this system. One is that it takes several days to get results, so a person who has been tested may be infectious but not yet be instructed to self-isolate. The other is that this test has a high rate of false negatives. That is, the person is pronounced COVID-free, even though they may not be. This has repercussions for their own health of course, but also for the well-being of everyone they contact. Having an accurate test that provides answers in hours (or even minutes) about a person’s infectious status is a critical step in the transition back to normalcy.

Who has already had it?

The other test we need, a serum antibody test, looks for signs of past infection. Antibodies appear in the blood serum about five days after exposure, so it may be necessary to do this test twice. An antibody test shows a history of exposure, but it doesn’t indicate current status—this is why the swab test is still necessary.

Many people may already have been exposed to the virus and either had no symptoms, or assumed they had the flu. We need to know who they are! If a person is positive for the antibody, but negative for the nasal swab, this means they have some level of immunity, and it is safer for them to be in public than for others. Antibody tests are being used for people with confirmed infections now, and should be available to the general public soon.

All this presupposes that exposure to the virus renders effective immunity, which is still an open question. We see in human and animal models with infections involving a similar coronavirus that exposure provides immunity for at least a few years. We also see that this virus has been slow to mutate. Those facts together suggest (but don’t promise) that a history of exposure may offer some protection from new infections—protection that will probably last until a vaccine can be made available.

The availability of fast, accurate swab tests and serum antibody tests are a high priority in making decisions about going back to work. People need to use them so we can collect important data. Until we have a clear idea of our own and our clients’ infection status, it is not realistic to think about reopening a massage practice. The availability and accuracy of widespread testing is the factor that will determine the timeline—not a politician’s announcement.

If We Do This Right

If we make this transition well, and if we work to build relationships with other health-care providers and policy-making bodies, then the profession of massage therapy could emerge from COVID-19 sad to have lost loved ones, but stronger than ever. We could use this “pause button” on our profession to look at our own practice habits—and to make the appropriate updates. We could do this in such a way that a majority of massage therapists would be willing and able to update as well. And in the process, we could create a standard of practice that would encompass necessary business versatility, therapist safety, and excellent, evidence-informed client care.

COVID-19 is a dangerous, horrible, often deadly disease. In every single way, it would be better if we didn’t have this challenge. But since we do, let’s step up and use this opportunity. I am standing by to be helpful.

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
www.booksofdiscovery.com), now in its seventh edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com.

 

This article also appeared in the special COVID-19 issue of Massage & Bodywork.

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Comments

You make it sound like we actually have control over these factors.

Testing is still scarce. We don't even have the resources to test everyone currently showing covid symptoms, let alone the luxury of testing everyone's antibodies for immunity (we have our current inept governments, federal AND local, to thank for all that). So frequent testing, even testing AT ALL, is not a feasible option. Suggesting we wait for a vaccine, when you yourself stated it's at least a year and a half away in accessibility, is also unhelpful. I suppose between these two factors alone that means we should all close up shop until Thanksgiving next year, or risk being shamed as unethical therapists.

Nobody here wants anyone else getting sick - but posting suggestions that pragmatically don't make sense is unnecessary, and certainly not helpful. In the future, I would prefer a massage therapist who is actually presently practicing to write these op-eds, as reading them from people who no longer rely on hands-on work to earn their living anymore is beyond frustrating.

The author is *the* massage therapy industry's expert on pathology. Ruth Werner has been writing textbooks about pathology and massage since before I enrolled in massage school 16 years ago. I've looked to my old path textbook for guidance time and time again throughout my career, not only because Ruth is an expert in her field, but because her advice skews toward common sense. It may not be a convenient truth, but when few absolutes are known about a pathogen, we are ethically bound to choose policies that carry the least amount of risk to our clients, our loved ones and lastly, to ourselves. It's your choice if you want to take this as "shaming", but if you do I'd ask you if it's a defensive response to engaging in something that you know in your heart isn't the most altruistic course of action. 

I, for one, think it is fantastic that ABMP has gone out and solicited highly relevant content from a renowned subject matter expert (Pathology and Disease, that seems applicable) who happens to also understand our field (former LMT) and is actually a board certified educator and researcher.  She is familiar with creating balanced, science-based content and making it teachable AND understandable to average laypeople.  We could find many who might rely on unqualified, uneducated, irrelevant individuals to help them (along with whatever aspirational nonsense is in their own brain) to create their response to the new realities of a post-COVID 19 world, but we can probably leave that to the US Executive branch.  I think it's fantastic how quickly ABMP put out this issue and that Ruth Werner's column, in particular, gives much food for thought on how to move forward in my profession. With caution, with grace, and with a newfound level of professionalism, I look forward to returning to work...eventually.  

Stephanie F., thank you for expressing heartfelt frustration in your comment. I really appreciate it! When I read what you wrote, I felt less alone. When I read Ruth Werner's careful, excellent piece, I thought -- sarcastically -- ok no problem, I and my clients can wait 24 months!!

It's not that Werner is wrong. She describes various measures that would allow greater guarantees of safety to client and practitioner. The problem is that these measures don't seem likely to arrive on a timeline that will allow many practitioners to survive.

Many of ABMP's excellent columnists and contributors have teaching and publishing empires which seem to provide, or at least anchor, their livelihoods. More power to these folks! Their work elevates our profession. But, like Stephanie, I would like to see ABMP step forward right now with more voices from -- and more advice to -- we practitioners who actually, completely, totally depend on our practices for a living.

 

 

 

 

this is scary times i have been closed since March 15th . Reading your letter i am not sure when i will reopen lots to do before i get there.. . i own my own business and am self reliant.

Although I don’t agree with 100% of the things you said, I think this article is SO well written and addresses just about every topic I’ve been mulling over in my head when it comes to massage therapy during these crazy times. Part of what has been so frustrating is exactly what you talked about: many state regulatory procedures aren’t equipped to effectively govern our industry simply because they don’t understand our industry. This has given me a lot to think about and I greatly appreciate that you took time to write this 

While not a hardcore anti vaxxer myself I believe there is reason for concern over adjuvants.

Aside from that however, we know that these viruses mutate every year and vaccines won't protect you from mutated strains. It may become an annual thing like the flu shot.

For those who for whatever reason refuse vaccinations, does that make our career over?

Thank you so much for the article. You have been the voice of reason in our profession. There are tough bits of advice and will make it difficult for some businesses to adjust, ie spas. In my opinion it may be years before we can truly say it is safe and that we know who has been infected and is now immuned.

I appreciate your thoughtful article! Especially your list of specific considerations around reopening and adoption of new protocols. It's very pragmatic. It's empowering to step outside of the "if/when" mindset and move towards a "how" approach.

Ruth, thank you so much for this article. It is well written and I agree. I have been thinking much the same way. I was just really starting to think about what it will look like if and when I reopen. It helps to make a plan, even if the plan needs adjusting as we go. The only thing I don’t think you mentioned was insurance. I was wondering if we need to contact our insurance companies to make sure we will be covered when we reopen our practices. It is a bit frustrating that we still can’t get good quality tests. I am hopeful that the antibody test will help me determine whether to work on someone. I was wondering if I will request a statement or note from their doctor, or a valid test certificate or what? For an antibody test. When I first suspended my practice, I was thinking I would not work on people for two weeks after they had been traveling, once I reopened. Things have changed since then, for sure. Might be a good policy to add just in general, because who knows what else is lurking out there? Might be hard on folks who are traveling on vacation, but I don’t take new people anymore anyway. But some of my clients travel a lot, so not sure how that will go over. But mostly I want to keep clients safe and if someone has not been immunized or has not any antibodies, I think they won’t get a massage from me. The antivaxers aren’t going to like it, but that’s life.

Hi Wendy, 

Thanks for your comments. The insurance companies will have to be making some tough decisions too. An educated guess is that they will follow along with what the local ordinances allow. In other words, if it is legal to practice massage, then you are probably covered.

A stickier question will be about the infection status of practitioners and clients. If we can establish that people have been exposed (i.e., they have a positive antibody test), then things should be fine. (Of course that relies on accurate, accessible testing AND on the premise that exposure imparts immunity.) But if one or both people in the exchange are not tested in any way, and we know that asymptomatic viral shedding occurs, then it's a much harder decision. I believe state boards are going to have to set some policy on disclosures.

I remember when MTs were worried about working with clients who were HIV+. Because HIV isn't spread through casual contact, it is a non-issue, and to deny service for that reason is illegal discrimination. But CV-19 is a very different pathogen, of course.

I hope our state boards that work with massage legislation will be well informed and work to protect both our practitioners and the massage therapy profession.

The last massage I did was March 3rd, then I shut down my practice.  I shut down my Air BnB February 1 because I get guests from all over the world. Testing does not seem to be readily available where I live in North Carolina. According to my family doctor, they will not test me unless I have a fever OVER 101 degrees, and have most of the symptoms.  Also, the same doctor either does not have the test for antibodies, or knows nothing about that test.  I feel I am in "limbo" about all this.  I do know that I will NOT be accepting anyone new  and any regulars who have just returned from an airplane flight  I am uncertain about working on them.  I am not alarmed, just being sensible. With a vaccine the better part of 1 and 1/2 years away, maybe I need to reinvent myself.  

Ruth, thank you so much for this article. It is well written and I agree. I have been thinking much the same way. I was just really starting to think about what it will look like if and when I reopen. It helps to make a plan, even if the plan needs adjusting as we go. The only thing I don’t think you mentioned was insurance. I was wondering if we need to contact our insurance companies to make sure we will be covered when we reopen our practices. It is a bit frustrating that we still can’t get good quality tests. I am hopeful that the antibody test will help me determine whether to work on someone. I was wondering if I will request a statement or note from their doctor, or a valid test certificate or what? For an antibody test. When I first suspended my practice, I was thinking I would not work on people for two weeks after they had been traveling, once I reopened. Things have changed since then, for sure. Might be a good policy to add just in general, because who knows what else is lurking out there? Might be hard on folks who are traveling on vacation, but I don’t take new people anymore anyway. But some of my clients travel a lot, so not sure how that will go over. But mostly I want to keep clients safe and if someone has not been immunized or has not any antibodies, I think they won’t get a massage from me. The antivaxers aren’t going to like it, but that’s life.

Thank you for these good ideas.  Going to make 10 aprons while we are closed.  I am also going to implement: 1.) removing all memory foam and fleece on the table and face rest, 2.) before client enters the treatment room, take their forehead temperature and sanitize their hands, 3.) diffuse Thieves essential oil into the air and use in carrier oil on their feet.  This may be over the top but I think it will give clients confidence I am also trying to protect them.  When the curve flattens, it doesn't mean it is gone.  Good practices to prepare for summer stragglers or fall virus resurgence.       

As always, I appreciate your perspective Ruth.  Your work has been invaluable in our field, and certainly helped legitimize our practice to the broader world.  

My concerns are as follows, I am a person who has had 3 rounds of MMR, has been exposed to chicken pox over 16 times, and show zero antibodies when titered.  I know several folx in this boat.  I am also extremely allergic to flu vaccines, hospitalized twice the two times I received it.  And again, many of my clientele are like me, allergic to vaccine.  My personal solution is do use homeoprophylaxsis, which is not acknowledged as valid in the United States, but has been shown in numerous studies from Europe, Asia, and Australia to be exceptionally effective as a form of immunization.  I would be interested to know if therapists like myself, are just done.  Will I be required to end a 15 year career, and start over in a new field at the end of middle age?  I hope not.  
We also need to find a way to serve our vulnerable population in this new era.  They, more than most, need therapeutic, non-medical touch.  I'm still pondering what this would look like myself, but would be interested if you have ruminated about it.  Many of my vulnerable clients only get non-medical touch from me.  As we all know, this is not healthy, but all too common.  

It will be grand day when we hit 70% exposure, but that day is a long way off.  

Respectfully,
Adrienne

Hi Ruth!
I highly respect your experience and body of work. Thank you so much for your practical viewpoints. In my experience, pathology is not the only voice at the table of the evolution of humanity. Antibody testing or injections for everyone is simply not realistic in my experience. Like a member mentioned above, I also received vaccinations with effects that did not show up in my blood later when entering a hospital internship. I am also reactive to some vaccines that others can tolerate, and know personally of vaccine injured people and children. Luckily the studies of neuropsychoimmunology and biocognition, the experience of holistic immune support, and all the latest research into spontaneous remissions do not look at just one aspect of the dynamics. I am passionate because my neurologist politely asked me to leave his practice and to keep doing whatever I was doing when my 15 years of relapsing remitting MS symptoms were no longer an issue because I had found energywork and cognitive reframing of stressors. Still to this day if bigger stressors come along, and symptoms return, mental reframing changes my inner states and biological responses. I am symptom free again. Fourteen years of chronic pain from numerous spinal injuries slowly became a thing of the past after working with more practitioners, techniques, and body wisdom than I can count. Upper respiratory and lung issues that were getting progressively worse went away when I spontaneously did New Zealand Maori Haka style self treatment. Two things come to mind, one, no one waited for cars to become 100% safe in order to use them daily. And two, the four minute mile was seen as impossible until one man did it, and now many can. Cont...

Humans are greater than a biomarker. I felt extremely impacted when I realized I had to close my practice because not enough was known, and I could not be morally safe. But the way out of this will most likely not be determined by less-than-a-micron pokey lil buggers, but by the inner wisdom and guidance we all have moment to moment to know when each of us are ready to re-engage in the ways that do or do not feel appropriate for us. I closed before I was told to, because I recognized the need, after listening to many different sources of information, as well as considering the people I had just seen last... a client from Seattle and my dad and stepmom that work in the hospital. My family and friends PPE’d on the frontlines could be me had I stuck with other routes of education. They are suiting up. Some MTs are already suiting up it sounds like, within medical/chiro interfaces, which when I just looked is understandable as "therapeutic" is on the essential list.* One day I’ll be very ready to suit up too (life has been about my fourth grader in the meantime, and I initially thought essential meant food and breathing). We each have different feelings about this new way of preparing ourselves and our treatment spaces. I've started making changes to be ready, and part of me feels I was prepared my whole life for this. We are each trillions of cells including viruses, so welcome new comer virus, hope you learn some manners soon. I know it will somehow work out. I’m grateful for the wisdom we all collectively have. This experience of life is symbolic before real, in my experience, and we are learning tremendous new things. And whenever I feel the collective pain of the suffering and loss I remember some ways are even worse. We are here to be challenged, we are here for all the opportunities of experience for greater discernment and compassion... some through a lil pokey teacher. Cont...

* Essential Critical Infrastructure Workers PDF
First section, second item: 
Health care providers and caregivers (e.g., physicians, dentists, psychologists, mid-level practitioners, nurses and assistants, infection control and quality assurance personnel, pharmacists, physical and occupational therapists and assistants, social workers, speech pathologists and diagnostic and therapeutic technicians and technologists).

It may not say "massage" but I'm pretty sure we are "therapeutic," especially if physical and occupational therapists and their assistants and technicians are listed. Maybe dependent on our training? Has any one heard any more specifics on this? I took a six month hospital massage course and internship, almost 800 hrs total, 16 years certified and working, was an EMT, have a Bachelors... does this change anything? Thanks for listening. Been kinda cooped up. Just read the blog about loving to touch, can also be loving to create space for our clients, keeping connection. Will focus myself there and continue self care in the meantime. <3