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.
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.
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 firstname.lastname@example.org.
This article also appeared in the special COVID-19 issue of Massage & Bodywork.
- Coronavirus, Explained. Vox. n.d. Accessed April 2, 2020. www.vox.com/coronavirus-covid19.
- Editorial Board. “Opinion: Got Coronavirus Antibodies?” Wall Street Journal. April 1, 2020. www.wsj.com/articles/got-coronavirus-antibodies-11585782003.
- Florida, Richard and Steven Pedigo. “How Our Cities Can Reopen after the COVID-19 Pandemic.” Brookings. March 24, 2020. www.brookings.edu/blog/the-avenue/2020/03/24/how-our-cities-can-reopen-a....
- Meyerowitz-Katz, Gideon. “Here’s Why Herd Immunity Won’t Save Us from the COVID-19 Pandemic.” ScienceAlert. March 30, 2020. www.sciencealert.com/why-herd-immunity-will-not-save-us-from-the-covid-1....
- US Department of Labor. “OSHA Worker Rights and Protections: Occupational Safety and Health Administration.” n.d. Retrieved April 2, 2020. www.osha.gov/workers/index.html?fbclid=IwAR1cw6pY9EOVblU5VdaZ3Lia48J_hf8....