Foundations

50 Section 2 The professional therapist
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a lubricant used and the therapist should have reason-

ably foreseen that an allergic reaction could occur, then Box 5.8 Providing information for informed
consent
the therapist may be considered liable in negligence for
that omission.
l Discuss the massage procedure.
Consent l Discuss the proposed benefits.
l Discuss the common side effects or risks.
Valid consent
l Discuss that confidentiality is assured.
A valid consent for a client involves the massage thera- l Discuss who will provide the massage, their
pist spending time to explain the treatment and request- expertise and qualifications.
ing consent to perform that treatment, thus consenting l Discuss the time involved.
to a therapeutic relationship (Salvo 2007). Consent to l Discuss the costs involved.
massage therapy should be obtained from the client
l Discuss other options available for treatment
before the therapist commences massage. Valid consent if necessary.
consists of three elements:
l Answer all questions asked by the client.
1 consent is given freely and voluntarily
l Draw diagrams and give written information
2 consent given is informed where appropriate.
3 the client giving consent has the legal capacity to
(adapted from Staunton & Chiarella 2008)
give such consent.
The validity of consent, will only be satisfied if the
three elements of consent can be established. Informed
consent is supported by the ethical principle of auton-
omy and the legal principle that people have the right to established that any undue persuasion or influence was
determine what shall be done to their bodies (Hawley brought to bear on a client to obtain consent, that con-
1997; Staunton & Chiarella 2008). sent will be invalid (Staunton & Chiarella 2008).
Consent can be given in three ways:
1 implied Informed consent
2 verbally Informed consent requires that the client have sufficient
3 in writing. information to determine if they want to receive a par-
Implied consent occurs where a client undresses and ticular massage or therapy (see Box 5.8). The massage
lies on the massage table as instructed in readiness for a therapist needs to explain: the massage procedure; how
massage to begin, but no words of consent are spoken. long it will last; what is expected of the client; other
The client’s compliance with the request would prob- options available; the proposed benefits; the common
ably imply consent to begin massage. Verbal consent side effects or risks of treatment; who will provide the
occurs when the client is on the massage table in readi- massage; that confidentiality is assured; and the costs
ness for the massage to begin and the therapist asks if for the massage, including any ongoing costs. Time
it is okay to begin, to which the client verbally agrees. should be provided for the client to ask questions (Fritz
Consent provided in writing, as occurs when a client 2004; Staunton & Chiarella 2008).
signs a consent form prior to treatment, serves as docu-
mentary evidence of what the client has verbally given Legal capacity to give consent
consent for. Legally, any person 18 years and over can give and with-
There is no legal requirement that consent forms hold consent to massage therapy. The client must also
must exist, but a written consent form is documentary have the cognitive capacity to understand the nature
evidence that consent was given should a controversy and consequences of the proposed therapy. Generally
arise over that point (Staunton & Chiarella 2008). One though, a child over the age of 16 years is usually con-
should not assume that the signing of a consent form sidered capable of giving valid consent. It is possible
means consent cannot be a matter of controversy, as a but problematic to obtain consent from a child under
client may not have read the consent form nor under- 16 years, as age cut-off points vary between states and
stood its terms. This may nullify the protection this territories in Australia. In New Zealand a child is a per-
document provides. Note that consent for one thera- son under 16 years of age, or less than 20 years of age
pist to do a massage does not assume that another ther- in cases of diminished capacity to provide consent to
apist may perform the massage (Forrester & Griffiths undergo treatment (Geer 2000). Accordingly, caution
2005). The three elements of consent are now detailed suggests the need to obtain consent from the parent or
below. guardian of a child under 16 years (Staunton & Chi-
arella 2008; Weir 2007).
Free and voluntary consent An adult with an intellectual disability who is able
This is consent given by a client without any undue
copyright law.
to comprehend the nature and consequences of the mas-

pressure from the massage therapist or other staff. The sage therapy is legally able to give consent. Where the
therapist must respect the autonomy of the client in individual is unable to comprehend the nature and con-
regard to their choice of massage therapy. If it can be sequences of massage therapy, consent will need to be
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5 Scope of practice, ethics and law in massage therapy practice 51
obtained from the parent or legal guardian on behalf of therapist with regard to consent for massage,
that person. It is necessary for a client to give a valid taking into consideration any state or territory
consent (that includes all the principles discussed) to legislation.
treatment otherwise a civil action in assault may arise
(Staunton & Chiarella 2008). It is advisable for any Recommended reading
health professional to consult with the relevant legisla- Breen K, Plueckhahn V, Cordner S 1997 Ethics, Law and
tion in their state or territory. Medical Practice. Allen & Unwin, Sydney
Remember litigation concerning informed consent Dimond B 1998 The Legal Aspects of Complementary
should never occur because failure to obtain consent Therapy Practice: A Guide for Health Care
before an examination and massage is professional Professionals. Churchill Livingstone, London
negligence and constitutes substandard care. Clearly Forrester K, Griffiths D 2010 Essentials of Law for Health
gaining a valid consent is essential before the therapist Professionals (3rd edn). Elsevier, Sydney
commences massage. Stone J 2002 An Ethical Framework for Complementary
and Alternative Therapists. Routledge, London
CONCLUSION Weir M 2007 Complementary Medicine: Ethics and Law
As part of their routine practice a massage therapist (3rd edn). Prometheus, Brisbane
makes countless decisions regarding client care every
day. Such decisions are informed by the therapist’s References
knowledge and understanding of the various legal Anderson K, Anderson L, Glanze W (eds), 1998 Mosby’s
requirements and ethical principles that affect the way Medical, Nursing and Allied Health Dictionary (5th
in which they practice. With an understanding of their edn). Mosby, St Louis
legal and ethical responsibilities, a therapist may adhere Australasian Legal Information Institute. Online.
to simple procedures and safeguards to avoid common Available: www.austlii.edu.au (accessed 21 Oct 2009)
legal and ethical pitfalls. Australian Association of Massage Therapists (AAMT).
Online. Available: www.aamt.com.au (accessed 21 Oct
An understanding of a therapist’s scope of practice,
2009)
ethics and law will assist in guiding the therapist through
Australian Capital Territory Legislation Register —
the legal aspects of a massage practice. Therapists Occupational Health and Safety Laws. Online.
should be aware of their scope of practice, including Available: www.legislation.act.gov.au/a/1989-18/
professional regulation for massage therapists, limits of default.asp (accessed 21 Oct 2009)
practice and referral of clients to other members of the Australian Traditional Medicine Society Ltd (ATMS). Online.
health care team. Consideration of the ethical principles Available: www.atms.com.au (accessed 21 Oct 2009)
will also assist in guiding a therapist throughout their Breen K, Plueckhahn V, Cordner S 1997 Ethics, Law and
professional life. Medical Practice. Allen & Unwin, Sydney
Ongoing professional education, competent skills Chisholm R, Nettheim G 1992 Understanding Law (4th
and sound procedures should prevent any client from edn). Butterworths, Sydney
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to proper lawful requirements is essential to prevent a Available: www.comlaw.gov.au/ComLaw/Legislation/
potential negligence action. All health care profession- ActCompilation1 (accessed 21 Oct 2009)
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regulations, and be sure to obtain consent before any Relations. Online. Available: www.deewr.gov.au
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essential to obtain legal advice so as to provide lawful Dimond B 1998 The Legal Aspects of Complementary
and ethically principled health care. Therapy Practice: A Guide for Health Care
Professionals. Churchill Livingstone, London
Questions and activities Forrester K, Griffiths D 2001 Essentials of Law for Health
Professionals. Harcourt, Sydney
1 Describe the scope of practice of a massage therapist, —— 2005 Essentials of Law for Health Professionals
taking into consideration specific state and territory (2nd edn). Elsevier, Sydney
legislation and professional association guidelines. Fritz S 2004 Mosby’s Fundamentals of Therapeutic
2 Define non-maleficence and describe how it relates Massage (3rd edn). Mosby, St Louis
to duty of care as a massage therapist. Geer B 2000 Legal implications in nursing practice. In:
3 Describe how a negligence action might arise from Crisp J, Taylor C (eds), Potter & Perry’s Fundamentals
a massage practice. of Nursing. New Zealand Supplement. Mosby, Sydney,
4 Discuss how the ethical principle of ‘autonomy’ Chapter 21
relates to a therapist’s personal decisions in regard Geldard D 1993 Basic Personal Counselling (2nd edn).
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your personal values and beliefs and how they will Hawley G (ed), Ethics Workbook for Nurses. Social
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5 A person who is 15 years old makes an appointment Lee W 1999 An Introduction to Multicultural Counselling.
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Nursing, 9(1):44 thelaw.tas.gov.au/index.w3p (accessed 21 Oct 2009)
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Available: www.nla.gov.au/oz/law.html (accessed An Introduction to Critical Thinking for Nurses.
21 Oct 2009) MacLennan & Petty, Sydney
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2009) edn). Prometheus, Brisbane
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Staunton P, Chiarella M 2008 Nursing and the Law (6th
edn). Churchill Livingstone, Sydney
copyright law.
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6
defining boundaries in the
client–practitioner relationship
David Stelfox and Sonya Bailey chapter
LEARNING OUTCOMES
l Identify physical and emotional boundaries that relate to massage practice
l Establish and maintain professional boundaries with clients
l Deal effectively and respectfully with people of differing cultures
l Describe the importance of professionalism in providing a safe environment
l Demonstrate sensitivity and respect for a client’s physical and emotional boundaries
INTRODUCTION
Box 6.1 Defining boundaries
Society is regulated not just by laws but also by a gen-
eral adherence to more voluntary codes or standards
In general terms, a boundary may be defined as a
of behaviour. People draw from their culture, their life
line, or a set of parameters, which indicates the limits
experiences and their upbringing to determine what of an area or territory. Boundaries can be personal or
they think is acceptable behaviour — and beyond the professional.
boundary of that lies behaviour that they personally find Personal boundaries are self-created limits
puzzling, distressing or offensive. for the purpose of establishing and maintaining a
Although there may be general societal norms healthy sense of separateness from others. These
regarding ‘being polite’, due to the personal nature of boundaries offer protection, recognition and a sound
the boundaries people set, there is plenty of scope for sense of self.
misinterpretation of anyone else’s actions. For example, Professional boundaries are limits established for
while one person on a train might think it polite to mind the purpose of promoting and maintaining integrity in
their own business, the passenger in the seat next to professional relationships. A professional therapeutic
them might feel rudely ignored if attempts at conversa- relationship is where there is a balance between
tion are not reciprocated. safety, care, and compassion (existing in a boundary)
In fact people are often not aware that a boundary and risk-taking (stretching boundary limits)
exists until it has been challenged or trespassed. An (Salvo 2003).
interaction may occur after which emotions flare and the
mood changes. Sometimes a person’s reaction can be as
entirely comfortable with. In this regard, Northouse and
subtle as coughing to clear their throats in response to
Northouse write (1998: 144):
a somewhat personal question. Alternatively, the person
may perceive the question as a more serious violation Due to the types of interventions and activities carried
and respond by becoming defensive, confused or even out in health care settings, clinicians often need to en-
aggressive. Box 6.1 defines boundaries. ter the patient’s intimate distance zone … Some peo-
An awareness of the boundaries of others is vital ple will accept and appreciate clinicians’ willingness
for all health care therapists. It is particularly relevant to provide needed care within these close distances.
in massage therapy, which necessitates the therapist However, those situations in which the clinician enters
entering into the client’s ‘personal space’ or transgress- the intimate distance zone by accident or with little
attentiveness to the patient may produce discomfort.
copyright law.
ing what is normally perceived as ‘intimate distance’.

In order to administer massage therapy, the therapist Massage may bring to the surface very personal
must make physical contact with the body of the cli- emotions and feelings for either the client or the thera-
ent, something the client may not be used to, or even pist, which are outside the client–therapist relationship.
53
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Box 6.2 Activity 1 Box 6.3 Activity 2
Consider the different types of relationships you Take a separate piece of paper and quickly write
have with people: friends, acquaintances, work down the personality traits and mannerisms you
associates, family. How does your interaction like in people, and those that you don’t like. Try to
with them differ? Observe the type and style of avoid rational thought or political correctness; write
conversation — is it feeling-based or thought-based? down whatever occurs to you spontaneously. Your
Does your body language alter depending on the responses to this exercise can serve to illustrate
type of relationship you have with a person? Check how personal perceptions and prejudices (i.e.
the distance between you and the person you are subjective experiences) can determine your personal
interacting with: public distance is usually defined boundaries, and therefore the parameters of your
as 3.6 to 7.6 metres (lecture, public presentation); client–therapist relationships.
social distance is usually 1.2 to 3.6 metres (casual
or workplace settings); personal distance is defined
as 0.45 to 0.75 metres (conversations with close
friends); 0.45 metres or less defines what is known Understanding his or her own personal boundaries
as intimate distance (reserved for very close friends, may help the therapist to define the parameters of their
partners, lovers, children). client–therapist relationship so that they can confidently
give a massage to a stranger without feeling threatened,
uncomfortable or unsafe. It may also assist in develop-
ing appreciation and empathy for the client’s boundar-
Given the characteristically unconscious or unarticu- ies, allowing the therapist to be sensitive to the client’s
lated nature of boundaries and their fickle, often unpre- vulnerabilities, fears and insecurities. By observing their
dictable and fluctuating state, it is easy to see how responses to other people, the therapist’s own boundar-
confusion and misunderstanding can occur. ies may become clearer. If someone speaks to a thera-
As a health professional, it is up to the massage pist in a harsh tone, how do they respond? Responses
therapist to create clear, healthy boundaries with their may vary from aggression, assertiveness, fear or confu-
clients. In fact it is their professional duty. Well-located sion. The therapist may even remain neutral; that is, not
boundaries provide a safe, supportive and sustainable experience any emotional response. How the therapist
environment for therapist and client alike. Because of responds will be dependent on a number of variables —
the fluid and individualistic nature of the participants’ such as the therapist’s physical and personal wellbeing,
boundaries, the therapeutic relationship is dynamic. As mood and time of day — as well as the parameters of
such it requires constant reassessment and attentiveness the therapist’s own personal boundaries.
on the part of the therapist (Taylor & Ziegler 1999).
Self-disclosure
PERSONAL AND PROFESSIONAL In order to gain as much information as possible about
BOUNDARIES a client before formulating an understanding of their
Boundaries can be divided into two broad catego- condition of health and determining a treatment plan, it
ries, professional and personal. Professional bound- is important to encourage them to openly and honestly
aries are promoted instead of dictated by the relevant disclose details of their current situation pertaining to
professional associations, which dictate guidelines for their health. Self-disclosure may be defined as the act of
scope of practice, code of conduct, ethical responsi- verbally or non-verbally communicating to others some
bilities and standards of practice. Personal boundaries degree of personal information.
relate more to the experience of living, a person’s iden- This can be an issue from both the client’s perspec-
tity and perception of the world and themselves. They tive and the therapist’s perspective. As a therapist, it is
are determined by beliefs, prejudices, personal experi- important to be objective in choosing the questions to
ences, family upbringing, culture and customs. ask a client. It is a good idea for the therapist to always
Personal boundaries tend to be subjective in nature. ask her or himself ‘is this question of therapeutic sig-
For the purpose of this chapter the term subjective nificance or am I just being curious?’ In this regard it is
refers to an individual’s personal, emotional experi- important to be familiar with the Privacy Act 1988 and
ences — ‘belonging to the individual consciousness The Privacy Amendment (Private Sector) Act 2000 and
or perception’. Objective on the other hand is ‘dealing the conditions contained therein (available for down-
with outward things or exhibiting facts uncoloured by load at www.comlaw.gov.au). One way of assisting the
feelings or opinions’ (Australian Concise Oxford Dic- client to feel at ease with a line of questioning is to pro-
tionary 1995). For example, an objective assessment of vide them with an explanation of how the information
a client may refer to their age, sex and medical history, sought may contribute to a better treatment outcome. It
whereas a subjective assessment may include feelings is important to assure the client that the questioning is
copyright law.
about whether the therapist enjoys the company of the relevant to the consultation.
client or not or if the client gestures remind them of The client will possibly feel obliged to answer
someone they know. regardless of whether or not they are comfortable with
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6 Defining boundaries in the client–practitioner relationship 55
the degree of disclosure. Some clients may ask personal employer or employee, discussion of work-related
questions of the therapist and even place the therapist in issues should be avoided during therapy sessions.How-
a difficult position ethically. It is best for the therapist ever, where a relationship develops subsequent to the
to stay honest with the client if this occurs and tell them commencement of therapy, it is often best to terminate
that they are not comfortable with the direction of the the client–practitioner relationship.
conversation. By doing this in a positive and friendly Stepping into the role of therapist with a friend,
manner the therapist will allow the client to do the same partner, parent, co-worker or sibling can be a challeng-
if they are not comfortable with any aspect of the thera- ing transition. The main issue arising in dual relation-
pist’s case-taking practices. ships revolves around shifts in which one player holds
the greater power or knowledge according to their role
Right to refuse at the time. When a power differential exists (i.e. one
Both the client and the therapist have the right to refuse person holds more power or knowledge than the other),
the treatment (i.e. receiving and giving). If the therapist there are two considerations: firstly, how will the person
finds that they are unable to express positive regard for a in power use the power advantage that they have at this
prospective client because of their personal boundaries time; and, secondly, how will the person in a situation
or because they do not feel that the client can respect of less power respond to the situation?
their professional boundaries, then they have the right When dealing with dual role situations the therapist
to refuse service. However, the therapist should be able must always remember that the power advantage they
to justify their decision to the client. If the therapist hold in that role must never be abused regardless of
explains to the client their right, as a client, to refuse any whether the client is a stranger, friend, family member,
or all aspects of the treatment at any time, then the cli- employer or acquaintance. One of the therapist’s pri-
ent’s sense of empowerment and safety can be enhanced mary roles is to support and nurture the client. Intimate
and the client–therapist relationship can flourish (Fritz sexual relationships between therapist and client must
2004). be avoided. Most professional codes of ethics prohibit
such relationships and, should one develop between
Dual roles the therapist and the client, it is wise to terminate the
professional relationship. A time apart once the profes-
Dual roles can occur where the therapist has more than sional relationship has been terminated is recommended
one type of relationship with their client. In each rela- to reduce the influence of the client–therapist relation-
tionship there is likely to be a different set of expecta- ship on the personal relationship.
tions and responses. The most common dual roles or Particularly in dual role situations it is important to
relationships that can occur in practice involve: establish clear professional boundaries such as the dura-
l family
tion of the consultation, the fee for service (see Box 6.5)
l social
and the treatment plan. Such clear professional bound-
l friendship aries will assist in avoiding any misunderstandings or
l dating unclear expectations regarding the service.
l sexual
l employee or employer Physical boundaries

l client/therapist. In a professional environment the physical space
A dual role may develop in two distinct ways. between people is generally arm’s length. In fact this
Firstly, a relationship may have existed prior to com- would generally hold true of any non-intimate relation-
mencement of therapy. For example, the client may ship, as people need a certain amount of physical space
already be a friend, family member, or employer/ between themselves and the next person. In elevators
employee. Secondly, the relationship may develop after people are not able to get this physical space so they
the commencement of therapy. In the first situation it tend to compensate by avoiding eye contact and focus-
is essential to establish ground rules before commence- ing their attention on the door. Although this response
ment of therapy. In the case of the client being a friend
or family member, an agreement that there should be
no mention of social matters during a treatment session
Box 6.5 Pricing in dual role situations
is appropriate. Where the client is a work colleague,
When considering discount pricing policies or
Box 6.4 Activity 3 ‘mates rates’ it is important to take into account the
following:
What topics of conversation would you not be l Does this pricing structure support your value
comfortable to talk to a client about? The answer and skill-base as a professional therapist?
to this question may help you empathise with your l What is an equitable exchange for your time and
copyright law.
client. If you are not comfortable, consider whether energy?

your question may result in the same response for l Is the discount sustainable with respect to your
your client. ability to make a living?
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may be quite unconscious, its purpose is to reduce the limits within the professional relationship. For example,
intimacy of the experience. sexual intimacy is not an option, yet the degree of con-
A massage therapist will be asking their clients to nection the therapist has with the client is reflective of
undress, and the therapist will be touching their skin, the boundaries of both client and therapist.
palpating their muscles and providing a certain degree So what happens when that contract cannot be
of nurturing and soothing that is generally only provided agreed upon? Much of how people interact or respond
or exchanged by intimates (Taylor & Ziegler 1999). In with other people can occur on an unconscious level. For
order for this not to be a boundary violation for either example, the therapist may remind their client of their
the therapist or the client, certain protocols can be put in daughter and relate with them on that level. The thera-
place to help draw the experience into the professional pist may become a party to this contract without real-
realm. Such protocols include: ising it and take on the role of daughter unknowingly.
l creating a treatment plan with the client so that the What is occurring here is that the client is projecting
purpose and sequence of events are well mapped a personal relationship onto the therapist (transference)
before treatment begins and the therapist is responding to that projection (coun-
l providing the client with every opportunity to speak ter-transference). The therapist needs an objective basis
up if there is something they are not comfortable upon which to relate to the client to avoid responding
with; this includes a decision to terminate the treat- to the transference of the client. That objectivity may
ment come in the form of reassessing the goals of the session;
l providing the client with very clear instructions the therapist checking in with his or her self and ask-
about what clothing they need to remove and what ing the question ‘is this conversation or behaviour in the
they may leave on, as confusion about the degree best interest of the client for the purpose of achieving
of undress can be very disconcerting for the client the desired therapeutic outcome?’ In this way the thera-
— where a client is having a massage for the first pist can step outside of the immediate relationship and
time, information about the need for disrobing may redirect it to a healthier arena (Salvo 2003).
be provided at the time the appointment is made
l leaving the room when the client undresses and
Sexual boundaries
instructing them to cover themselves with draping A boundary issue that arises frequently for the practis-
that has been provided ing massage therapist as well as their clients is the issue
l draping body parts that are not being massaged (see of sexuality. Massage may be a very intimate and per-
Chapter 15) sonal experience so it is not surprising that it may evoke
l avoiding massaging or touching erogenous zones
sexual feelings or responses. This becomes a problem
(these are parts of the body that are particularly sen- if either party feels unsafe, uncomfortable or violated
sitive to sexual stimulation and include the genitals, in some way. Confusion can also arise when massage
anus and breasts). therapists advertise their services as some people still
associate massage with the sex industry. The term mas-
Intimacy sage therapist is used throughout this book in prefer-
ence to the term ‘masseur’ since it conveys the fact that
The word intimate comes from the Latin intimus, the practitioner is indeed a therapist, and it is less likely
meaning inmost (Australian Concise Oxford Diction- to convey connotations of a sexual nature. All graduates
ary 1995). What that actually means to an individual of massage training courses are encouraged to use this
appears to range between a sense of closeness and unity term when referring to their profession and when adver-
with all things, including inanimate objects and plants, tising and promoting the services they offer.
to hosting an intimate dinner for a select few, or to hav- Confusion relating to sexual boundaries may arise
ing sexual relations with someone. Intimacy appears to in massage therapy for three main reasons. The first rea-
move across planes from spiritual to social to sexual but son is that massage may be, for some, a very intimate
what is consistent is the element of connection with an and physical experience; two attributes that are usually
‘other’. present in sexual relations. For the client this may be
mistaken for or translated as a sexual experience. This
Emotional boundaries connection tends to be more evident in today’s culture,
Emotional boundaries are fluid and can change with where there are limited outlets for touch and intimacy
each client and from session to session with the same outside of sexual relations (Jordan 2000).
client. The degree of intimacy is usually an unspoken
contract between two people. There are some obvious
Box 6.7 Activity 5
Box 6.6 Activity 4
A client is having problems in their relationship with
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Consider the forms or ways that intimacy manifests their teenage son and asks for your advice.
in your life. What role are they projecting onto you?
Who do you feel close to and why? How do you respond?
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The second reason relates to the associations includes the reawakening of sexual desire. It is the pro-
attached to the word ‘massage’. Massage has some- cess of massage as opposed to the massage therapist that
times been used as a cover for the illegal sex industry may kindle this reawakening (Polseno 2000). See Box
and although it has diminished considerably since the 6.8 for suggestions for promoting clear sexual boundar-
legalisation of prostitution, the association is some- ies and Box 6.9 for a seven-step intervention model.
times still apparent. This confusion is constantly being
reduced by such factors as increased public awareness CULTURAL CONSIDERATIONS
and education about therapeutic massage, state legisla- Massage therapy is practised in many forms through-
tion regarding use of the term ‘massage’ in advertising, out the world, each with its own style, customs and
greater acceptance and referrals by the medical profes- techniques. Australia as a multi-cultural nation offers
sion, and increased scientific validation of the benefits the massage therapist the potential to work with clients
of massage (Howard 1999). from a variety of cultural backgrounds, with each bring-
The third reason is the parasympathetic nervous sys- ing an experience and expectation of massage that may
tem’s response to massage. As Polseno (2000) explains, differ from the therapists. It is important to be aware of
this response occurs when mind and body are qui- cultural differences and to adapt the treatment accord-
etened and all of a person’s fears, pressures, stresses ingly.
and ‘shoulds’ are put to one side; a more fundamental Probably the most obvious issue relating to the cul-
or essential nature emerges and the experience of mas- tural background of a client in a massage setting would
sage may in fact awaken sexual feeling. The peripheral be concern about body boundaries. People of some eth-
nervous system can be categorised into sympathetic and nic groups and associated religious beliefs (e.g. Islam,
parasympathetic. The sympathetic nervous system is Hindu) may have different perceptions of their physical
often referred to as the ‘flight/fight’ response, which is body. To some the body may be considered sacred. To
a high-stress state that suppresses non-essential func- others it may be held as very private, something that
tions of the body — one of those functions being sex cannot be revealed readily to others. In addition, beliefs
drive. The parasympathetic system ‘re-normalises’ the about the shape and size of the body can differ signifi-
body and returns homeostasis, or balance. Massage cantly from one culture to another.
encourages the relaxation response and sometimes that Disrobing for a massage, then, may be cause for
concern to both female and male clients. It may seem
Box 6.8 Suggestions for promoting clear sexual
logical that unless a person feels comfortable with dis-
boundaries robing then they are unlikely to make an appointment
for a massage in the first place, though this is not nec-
essarily the case. Massage is an acceptable and most
l Assume a professional phone manner. Provide a
desirable approach to the treatment of many health con-
clear description of the service you provide as a
massage therapist.
ditions in some cultures. Furthermore, a client may be
of the belief that the massage can be delivered without
l Dress professionally. Consider the image you
wish to project to your client with respect to
the need for removal of clothing.
dress. People from countries where civil unrest and politi-
l Ensure your workplace is professional in its
cal violence have occurred (for example, Central and
appearance and function.
South American countries) may have been victims of
l Clearly explain the procedure you wish to
brutality and torture. They may still carry the physical
implement in delivering the treatment, including
and emotional scars of these experiences with them.
which parts of the body you intend to massage. Such clients should be dealt with sensitively. While it
Gain the client’s consent before proceeding. is natural for the therapist to express strong concern at
l Give clear instructions to the client about what
the sight of disfigurements such as scarring and mal-
clothing, if any, needs to be removed prior to formations due to fractures, it must be realised that the
treatment. client is usually self-conscious of them, and too much
l Drape the client appropriately. Only undrape that
specific part of the body you are currently
working on. Box 6.9 Seven-step intervention model
l Make your touch deliberate and purposeful.
l Some parts of the body are more sexually 1 Stop the session using assertive behaviour.
charged than others, so if one part elicits a 2 Describe the behaviour you are concerned about.
sexual response, attend to another part of the 3 Ask the client to clarify their behaviour.
body. 4 Restate your intent and professional boundaries.
l By explaining the parasympathetic response to 5 Evaluate the client’s response.
male clients it may prevent embarrassment, or 6 Continue or discontinue the session as
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concerns they have about becoming aroused appropriate.

during a massage. 7 Document the situation.
(Association of Massage Therapists Australia 2001) (Benjamin 2005)
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a ttention may lead to further distress. The massage consideration so that the treatment plan is adjusted
therapist should also be aware that body mutilations or accordingly and the need for possible referral to another
alterations, such as scarification, body piercing or tat- health care therapist is determined. The massage thera-
tooing, are culturally sanctioned in many ethnic groups. pist should look for indications that the client may be
In such cases the therapist need not show concern and, experiencing pain or discomfort. Such indicators may
in fact, should be careful not to express shock or sur- be flinching, abrupt tensing, body armouring (tensing
prise in the client’s presence. up in certain areas), change of breathing rhythm, facial
A complexity of emotions and troubled thoughts contortions or perspiration.
may exist below the surface and massage therapy can People of some Middle-Eastern cultures, for exam-
beneficially unlock and release these. However, the ple, may not respond well to the suggestion of exercise
massage therapist must work with sensitivity, develop- or stretching as part of their treatment. If a therapist
ing the client’s faith and trust so that they feel comfort- wishes to propose such a strategy, careful and thorough
able to release the physical and emotional tension that explanation of the benefits of exercise to the client’s
the body has held within it. It is possible that in some health condition may help. Such an issue should never
cases this may result in the need for referral to a quali- be pushed too vehemently though.
fied counsellor, psychotherapist or psychologist. Com-
petence in counselling is generally outside the scope of Clients of a different cultural or
practice of a massage therapist so the benefit of referral ethnic background
for counselling needs to be considered. The possibility The text that follows provides guidelines for dealing
of providing massage therapy in conjunction with coun- with clients from a different cultural or ethnic back-
selling from a suitably qualified counsellor, psycholo- ground.
gist or psychotherapist, offers much benefit to the client.
Disrobing and draping are dealt with in Chapter 15
and the guidelines provided there apply for every cli- Establish the possible influence of the
ent. A key consideration is the gaining of informed con- client’s ethnicity and culture on the
sent from the client before beginning any massage or proposed treatment
physical assessment. This must include the provision There are many cultural factors that contribute to an
of information to the client about the need to disrobe, individual’s perception of their health and how they feel
clarification where necessary of what is required, and their health condition may be best treated. People from
non-pressured consent from the client (see Chapter 5). different cultures explain the causes of ill-health differ-
Where language is a problem for a client of a different ently (e.g. to some it is the intrusion of an evil spirit or
cultural background it may be necessary to have some- the result of living outside of the laws of their society or
one present who is able to translate. nature). Different ethnic groups have faith in different
Menstruation may have certain cultural beliefs asso- types of treatments and may turn to therapists of quite
ciated with it and a woman may not feel comfortable different health care approaches when confronted with
receiving a massage treatment at such time. (Regardless illness.
of cultural beliefs, any female may feel uncomfortable This may seem strange and even inappropriate to
with the prospect of massage during menstruation.) It some people in Western society. For example, West-
should also be realised that the sex of the client, and ern biomedicine (its pharmaceutical drugs and surgical
the therapist, may prove an issue for consideration. procedures) is perceived by many cultures (e.g. South
People of many ethnic groups (e.g. people of Islamic Asian, Chinese, South American) as too strong. The
faith, orthodox Jews, and even people of Anglo-Saxon Chinese and Vietnamese believe that it is too ‘hot’ or
culture) have preferences for a therapist of the same ‘yang’. When ill, these people often turn to massage
sex as themselves. This should be acknowledged and or other traditional healing approaches as an alterna-
respected. tive to the Western biomedical approach. While this
Different areas of the body can have cultural beliefs may seem fine, it is always important for the therapist
associated with them. As such some individuals may to evaluate the appropriateness of massage to the treat-
not feel comfortable having those parts massaged or ment of the client’s problem. For example, in Trinidad
even touched. For example, in some cultures a person’s and other islands of the West Indies, conditions such as
soul is believed to be attached to their head and touch- cancer, mental illness and even oedema of the legs are
ing, massaging or manipulating it may cause the soul seen as the result of an evil spirit that has entered the
to escape, eventually resulting in death or in the person body. Massage therapy is viewed as a legitimate means
going mad (Waxler-Morrison et al 1990). Once again, if of expelling or exorcising this spirit and thereby restor-
informed consent is gained for the intended areas of the ing health.
body to be worked on then no issue should arise. As a guiding principle, always gather as much infor-
In some cultures, high value is placed on stoicism, mation as possible about the client, their ethnic back-
especially by males (e.g. South-East Asian ethnic ground, their beliefs about health, illness and treatment,
copyright law.
groups), and the client may not complain about pain and their expectations of the treatment. Most of this
— either pre-existing pain or pain that is experienced information can be gained during the early ‘ice-break-
during a massage treatment. This should be taken into ing stage’ of the consultation. The therapist should be
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aware that it may be appropriate to recommend that the

client seek the services of another health care provider Box 6.10 Questions for determining the influence
of culture on treatment of clients
whom the therapist considers may be better suited to
treating their condition.
l Place of birth — city or rural?
Encourage the client to ask questions l Length of time in Australia and did you have any
and express themself freely during the family living here before immigrating (this may
determine the degree of familiarity the client has
case-taking and massage treatment
of their new cultural setting)?
People of some cultures (e.g. Chinese, Nepalese, Japa- l Occupation in country of origin?
nese and South-East Asian) seldom ask questions of a l Occupation in Australia?
health therapist because they consider it impolite. Clear
l Describe the nature of your health problem?
and open communication is the best means of avoiding
l What do you think may have caused it?
dissatisfaction and achieving positive results. Encour-
l How has it affected you (at home, at work)?
age the client to provide input and feedback at all stages
l What results do you hope the treatment will
of the massage session.
achieve?
Accommodate the client’s perspective
of their illness when determining the
best treatment approach a considerable influence and contribute to major differ-
ences within ethnic groups. Massage therapists should
As mentioned previously, some cultures have entirely not make any assumptions. Just because someone from
different perceptions of health, illness and health care. a particular ethnic group dresses in Western clothes and
These perceptions should be acknowledged, respected speaks perfect English doesn’t mean that they don’t live
and accommodated. For example, people from some according to strict traditional practices and beliefs. Con-
regions in the north of India have a cultural belief versely, a woman dressed in traditional ethnic clothing
(ãrdha-angani = ‘half-body’) where the left half of a may be quite casual or non-observant of the traditional
married woman’s body belongs to her husband and his cultural practices of her homeland.
family (Waxler-Morrison et al 1990). This has obvious Clear communication, awareness of special consid-
implications where massage or physical examination of erations associated with particular ethnic groups and a
this half of the body is considered necessary. Another willingness to respect and accommodate cultural dif-
consideration is that any marital problems may be seen ferences in clients are probably the keys to effectively
to manifest as muscular tension, pain or paralysis to the dealing with clients of different cultural backgrounds
left side of the body. to the therapist. Box 6.10 lists possible questions to ask
a client for determining whether cultural background
Refer where appropriate to other health may influence the client’s treatment plan.
therapists
People from many ethnic groups (e.g. from rural India,
Vietnam, Sri Lanka, Nepal) and older people from CONCLUSION
countries such as Greece, Turkey, Italy and Cyprus turn Boundaries are an implicit and inevitable facet of all
to traditional healing practices for both simple and seri- individuals. They may be attributable to someone’s
ous health problems. These may include home reme- cultural background or simply the result of someone’s
dies, folk medicine, massage or other forms of tactile upbringing and life experiences. The quality of the ther-
therapy. Throughout South-East Asia tiger balm and apeutic relationship is greatly dependent upon the skill
other similar ointments and oils, which tend to be asso- and sensitivity with which boundaries are acknowl-
ciated with the treatment of muscular aches and pains, edged and handled.
are used internally and topically to treat a wide range Sound therapist protocols in the massage setting not
of health conditions (cure-alls), including quite serious only help to define the professional relationship, they
ones. A professional massage therapist must be aware of also remove impediments to therapeutic outcomes.
these perceptions and know when it may be necessary Client and therapist safety requirements must also be
to encourage a client to visit a more appropriate health met and treatment expectations must be mutual. These
care provider who can best treat their health problem. various objectives can be created and maintained by the
careful monitoring and maintaining of workable bound-
Avoid ethnic stereotyping aries between therapist and client.
Usually there will be shared experiences, values and Some basic tools that can be put in place for avoid-
beliefs among people of a given ethnic group. However, ing most misunderstandings are:
there may also be significant intra-ethnic diversity. In l solid communication skills
Indonesia, for example, there are people of Muslim, l a high level of professionalism
copyright law.
Hindu, Christian and Buddhist faiths, so their religious l awareness and adherence to the professional code
beliefs can be different. In addition, social class, level of ethics
of education and area of origin (urban or rural) can have l sensitivity to the client’s boundaries
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l the therapist’s awareness of their own subjective McIntosh N 2005 The Educated Heart. Lippincott,
boundaries. Williams &Wilkins, Philadelphia
Although a client’s boundaries may be radically dif- Northouse LL, Northouse PG 1998 Health Communication:
ferent from a massage therapist’s, and therefore lead Strategies for Health Professionals. Appleton &
to vastly different behaviours and expectations, those Lange, Stamford
boundaries are not necessarily right or wrong, good or Paiva C 2004 Keeping the Professional Promise. MT
bad. The important thing is to recognise and respect the Publishing, Hamilton Ontario
boundaries, for with consciousness and consideration Salvo S 2003 Massage Therapy: Principles and Practice
they can be positively navigated to enhance relations. (2nd edn). WB Saunders, Philadelphia
Yardley-Nohr T 2006 Ethics for Massage Therapists
With recognition and respect of such boundaries comes
Lippincott, Williams & Wilkins, Philadelphia
the solid foundation for a sound and healthy working
relationship between the massage therapist and client.
References
Questions and activities Association of Massage Therapists Australia (AMTA)
2001 The issue of sexuality and massage. AMTA
1 Professional and personal boundaries may Journal 2001, 12(2): 6–9
become blurred when treating friends or family. Australian Concise Oxford Dictionary 1995. Oxford
Differentiate between personal and professional University Press, Melbourne
boundaries, and describe some strategies you may Benjamin P 2005 Tappan’s handbook of healing massage
adopt to ensure these boundaries are maintained, techniques (4th ed). Prentice Hall, New Jersey, p 95
even when providing treatment to friends or family. Fritz S 2004 Mosby’s Fundamentals of Therapeutic
2 For a professional massage therapist it is important Massage. Mosby, St Louis
to respect a client’s physical boundaries. When in Howard H 1999 Sexual harassment survey. AMTA Journal,
clinical practice, what strategies could you adopt to 10(5): 17
avoid violations of a client’s physical boundaries? Jordan D 2000 Sexual vs compassionate touch. Massage
3 When in practice, you sense that a client may be Therapy Journal, Summer
making unwanted advances towards you. Describe Northouse LL, Northouse PG 1998 Health Communication:
how you would establish and maintain clear sexual Strategies for Health Professionals (3rd edn).Appleton &
Lange, Stamford, Connecticut
boundaries with this client.
Polseno D 2000 Desexualising the massage experience.
Massage Therapy Journal, (39): 136–43
Recommended reading Salvo S 2003 Massage Therapy: Principles and Practice.
Banjamin B, Sohnen-Moe, C 2003 The Ethics of Touch. WB Saunders, Philadelphia
SMA Inc, Tucson Taylor K, Ziegler K 1999 Self-examination in healing
Benjamin P 2005 Tappan’s handbook of healing massage relationships. Massage Therapy Journal, Summer,
techniques (4th edn). Prentice Hall, New Jersey 38(2): 65–74
Fritz S 2004 Mosby’s Fundamentals of Therapeutic Waxler-Morrison N, Anderson J, Richardson E (eds)
Massage (3rd edn). Mosby, St Louis 1990 Cross-Cultural Caring: A Handbook for Health
Helman CG 2007 Culture, Health and Illness (5th ed). Professionals. UBC Press, Vancouver
Oxford University Press, Melbourne
copyright law.
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the evidence for massage therapy

Sandra Grace chapter 7
LEARNING OUTCOMES
l Describe the concept of evidence-based practice
l Discuss types of evidence and their application to massage therapy
l Outline the challenges for conducting trials in massage therapy
l Outline the current scientific evidence for massage therapy
l Describe how to locate and assess evidence
INTRODUCTION The Cochrane Collaboration, an international organisa-

The past 20 years has seen increasing use of massage tion dedicated to preparing, maintaining and promoting
therapy by the Australian public (MacLennan et al the accessibility of systematic reviews[1] of the effects
2006). This trend has been accompanied by a growing of health care interventions, established its first cen-
demand for massage therapy practitioners to interact and tre in the UK in 1992. By 2003 there were 9280 con-
communicate with medical practitioners, physiothera- tributors from 87 different countries (Green 2004). The
pists, chiropractors, osteopaths and other therapists. Cochrane Complementary Medicine Field was regis-
Massage therapists are called upon to discuss treatment tered in 1996. It has over 7000 randomised controlled
options with clients, write referrals, and to complete trials (RCTs)[2] and 250 systematic reviews (University
treatment plans for insurance clients. An understanding of Maryland Centre for Integrative Medicine 2007).
of the concepts that underpin evidence-based practice is The methodologies used to determine the quality of
essential for effective communication with other health evidence, and the term ‘evidence-based medicine’ are
care professionals and those clients who want to under- attributed to a group at McMasters University in Can-
stand how their treatments work. It is also important so ada in the early 1990s (Sackett et al 2000). The terms
that therapists are able to know how to access and eval- ‘evidence-based practice’ or ‘evidence-informed prac-
uate research-based evidence, and empirical evidence, tice’ have been described as:
for the purpose of incorporating what is relevant and l the conscientious, explicit and judicious use of cur-
appropriate into the treatment plan of the client. rent best evidence in making decisions about the
care of individual patients (Sackett et al 1996)
THE EVIDENCE-BASED MEDICINE l patient care based on evidence derived from the
MOVEMENT best available studies (National Health and Medical
Evidence-based medicine is an approach to health care Research Council [NHMRC] 2009)
that involves looking for the best available evidence l the integration of best research evidence with clini-
to inform decisions about diagnosis and treatments. cal expertise and patient values (Sackett et al 2000).
Although some references to the evidence for medi- Evidence-based practice acknowledges the complex-
cal practice date from hundreds of years ago, it was ities associated with applying scientific evidence in prac-
not until the 1970s that the evidence-based medicine tice. Decisions about health care are informed by three
movement came to prominence (Doherty 2005). In factors: available evidence, practitioners’ clinical judg-
1972 Archie Cochrane, a Scottish epidemiologist, in his ments and clients’ preferences. Practitioners use their
book Effectiveness and Efficiency: Random Reflections
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clinical experience to judge whether research findings

on Health Services called for a critical summary of all are applicable in particular instances. Could, for exam-
available evidence of treatment effectiveness so that cli- ple, Quinn’s findings (2002) on the effects of massage
ents could be assured of receiving the best possible care. on clients who had two or three tension-type headaches
61
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a week be useful for a client suffering daily migraines? I feel a great debt of gratitude to you for fixing my
Clients discuss treatment options with their practitioners troublesome sciatica and I did not expect you to be
and choose whether or not to take up research-based rec- able to do it in one go! … Nor did I expect the side
ommendations in their treatment plans. Evidence-based benefits from your relaxation therapy and general
practice, by definition, incorporates three important con- back pain relief. Your wide knowledge and down to
siderations. These are listed in Box 7.1. earth experience make you a true Angel of Healing.
Massage therapy, Acuscen Scenar treatments,
What constitutes evidence? Gold Coast
When massage therapists are asked how they know that Several months ago I started to feel a sharp pain in my
massage is an effective therapy they often report posi- right shoulder blade. Not long after, I started to suffer
tive feedback from their clients, or improvements they from dull headaches on the right side of my head and
observe in their clients, such as reductions in muscle neck. I could not attribute this to any one incident …
spasm or increased ranges of motion. However, there has Along with my medical investigations I started having
long been debate over whether these are valid and reli- fortnightly massages … The relief was instant. The
able forms of evidence for the effectiveness of massage limited movement in my neck and the headaches start-
therapy. Most health care professionals rely heavily on ed to disappear so quickly. Within three visits I was
biomedical or scientific evidence; that is, evidence that back to 100%. I can’t believe I suffered for months
results from human trials in a controlled environment. before taking action.
Tip-to-toe massage, Sydney
Two main types of evidence for
Massage practitioners often hear stories like these
massage therapy which make strong claims for the clinical evidence of
massage therapy. With the emphasis that is now being
1. Clinical evidence placed on client-centred care, it is likely that clients’
Many of the techniques performed in massage therapy opinions about the benefits they receive from massage
have been passed down from practitioner to practitioner, therapy will become increasingly important. There is
often with variations and embellishments. For example, also increasing recognition in the literature of the expe-
the ‘nerve massage’, which consists of massage strokes riential knowledge that practitioners gain through their
and pressure points to the cranium, spine and along the clinical experience (Higgs et al 2001).
path of the sciatic nerves, is said to date back to Sister
Kenny (an Australian nurse who developed a controversial
2. Biomedical/research-based evidence
technique for treating polio patients in the 1930s). Many
visceral massage techniques, such as colon massage, At this point in time research-based evidence to sup-
have also been passed down in this way. Such massage port claims about the physiological and therapeutic
techniques persist today because the practitioners who effects of massage therapy is limited. However, this
use them believe in their effectiveness. Almost all mas- does not mean that there is evidence that massage
sage techniques are based on traditional use and it is only therapy is harmful or ineffective. It simply means that
recently that there has been a call to investigate the claims there is insufficient evidence to say either way (see
made about these techniques using scientific methods. Box 7.2).
For a long time clients have reported clinical ben- Opposition to massage therapy and other comple-
efits from massage therapy. The following are examples mentary medicines often focuses on their lack of scien-
of the hundreds of testimonials used as part of many tific evidence (Dwyer 2004; Phelps 2001). However, at
massage therapy clinics’ advertising: this stage many Western medicine diagnostic tests and
treatments also lack a scientific evidence basis. In one
At first I was sceptical as to what a 10 minute mas-
American study only 21% of 126 diagnostic and thera-
sage may be able to achieve. However my doubts have
peutic technologies assessed by the National Institute
vanished. I look forward to your visits, as do the long
of Health were found to be firmly based in research-
queue of my colleagues.
generated scientific evidence (National Health Service
Corporate Massage — Sydney
Research and Development Centre for Evidence-Based
Medicine 1999). Other authors suggest that 20–50% of
Box 7.1 Elements of evidence-based practice
Evidence-based practice refers to a model of

Box 7.2 Absence of evidence
practice that considers:
l practitioners’ expertise
There is a very important difference between not
l clients’ preferences and values and
enough evidence to say whether treatment is
l the best available evidence
effective and sufficient evidence to say there is no
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when determining the most suitable treatment effect or a harmful effect.

approach for each client. Absence of evidence does not mean evidence of
(Sackett et al 2000) absence (of effect).
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7 The evidence for massage therapy 63
mainstream medical care and almost all surgery have relatively specific and where the number of additional
not been evaluated by randomised controlled trials variables likely to affect the outcome is few and can
(Ezzo et al 2001; Pelletier 2005). be expected to be balanced out by the randomisation
The Australian Acute Musculoskeletal Pain Guide- procedure. The RCT is therefore an excellent tool for
lines Group (2004) published guidelines for practitio- most types of medical research which involve a sin-
ners for the management of musculoskeletal pain of gle organ, biochemical response or drug effect, and in
less than 3 months duration. A summary of their advice disablement terms it is particularly valuable for stud-
for the management of acute low back pain is shown in ies of impairment.
Table 7.1. Although massage therapy is located in the (Andrews 1991: 5)
‘No studies done’ category, the group pointed out that Even if it is accepted that RCTs are the least biased
this should not be interpreted as ineffective treatment. method to test for efficacy, because there are so many
variables to consider when developing massage therapy
Evidence grading research design, different studies sometimes produce
Opinions differ about the strength and type of evidence different results (see, for example, Callaghan 1993 on
required to support diagnostic procedures and therapies. conflicting evidence for the effects of massage on sports
Evidence grading is based on the idea that types of evi- performance). Systematic reviews and meta-analyses
dence vary in their ability to predict the effectiveness which combine multiple RCTs and statistically pool the
of health practices (Australian Acute Musculoskeletal data may provide more compelling biomedical science
Pain Guidelines Group 2004; Sackett et al 2000). RCTs evidence. Systematic reviews are regarded as the stron-
are ranked highly in evidence grading systems. gest form of evidence in Western science. Evidence
The purpose of the RCT is to provide mathemati- grading is based on perceived strengths and weaknesses
cal evidence either in support or against one form of of different study types and findings. Higher grades of
treatment compared to none or another form of treat- evidence are considered more likely to reliably predict
ment. It is an excellent tool in research where marked outcomes than lower grades. Table 7.2 provides an
changes are expected, where the factors involved are example of a typical evidence grading system.
Recommendations for treatment are also graded
according to the strength of supporting evidence. For
example, the Oxford Centre for Evidence-Based Medi-
Table 7.1 Extract from ‘Information Sheet February cine (Phillips et al 2001) lists the following grades of
2004, Acute Low Back Pain’ recommendation:
Evidence Treatment A Consistent level 1 studies
Evidence of l Staying active B Consistent level 2 or 3 studies or extrapolations
effectiveness l Having written information to from level 1 studies
discuss with your practitioner
l Heat wrap therapy (not routinely C Level 4 studies or extrapolations from level 2 or
available in Australia) 3 studies
Mixed results l Muscle relaxants D Level 5 evidence or troublingly inconsistent or
(some studies l Non-steroidal anti-inflammatory inconclusive studies of any level.
show pain relief drugs (NSAIDs)
and others do l Spinal manipulation Evidence for the effectiveness of
not) massage therapy
Inconclusive l Acupuncture The majority of claims regarding massage therapy’s
l Back exercises physiological efficacy have not been verified by recent
l Back schools clinical research. Much of the efficacy of massage
l Bed rest therapy is based on expert opinion (level 5) and D rec-
l Cognitive behavioural therapy ommendations, and this lack of high quality scientific
l Injection therapy evidence has been the basis of much criticism of the
l Topical treatments acceptance and use of massage therapy by mainstream
No studies done l Analgesic medication medical practitioners (Sampson & Atwood 2005).
(It is important to l Electromyographic biofeedback A number of factors have contributed to the pau-
note that these l Lumbar supports city of scientific research in massage therapy. First,
findings do not l Massage at this point in time, there are few massage therapists
mean that these l Multi-disciplinary rehabilitation with research skills, or researchers with the interest or
measures will in the workplace funding to conduct massage research. Massage therapy
not help you; l Traction training focuses on developing knowledge and skills for
they indicate that l Transcutaneous Electrical
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massage practice; there has been little focus on encour-

more research is Nerve Stimulation (TENS) aging future researchers. Second, the methods of bio-
needed.) medical science research, such as RCTs, are not readily
(Source: Australian Acute Musculoskeletal Pain Guidelines Group 2004) applicable to massage therapy.
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Table 7.2 A typical evidence-grading system
Level Intervention
1 Systematic review Systematic location, appraisal and synthesis of evidence from scientific studies
2 A randomised Subjects are allocated to a treatment/intervention group or a control group using
controlled trial a randomisation procedure, such as tossing a coin or a random number table,
and the outcomes of each group are compared
3a A pseudo-randomised Subjects are allocated to a treatment/intervention group or a control group
controlled trial using a pseudo-randomisation procedure, such as days of the week, and the
outcomes of each group are compared
3b A comparative study Example, a non-randomised controlled trial: subjects are allocated to a
with concurrent treatment/intervention group or a control group using a non-randomisation
controls procedure and the outcomes of each group are compared
Example, cohort study: outcomes for groups of people observed to be exposed
to a treatment/intervention are compared to outcomes for groups of people not
exposed
Example, case-control study: people with the outcome, disease or condition
(case) and an appropriate group of people without the outcome, disease or
condition (controls) are selected and information about their previous exposure/
non-exposure to the intervention is compared
3c A comparative study Example, historical control study: outcomes for a prospectively collected group
without concurrent of people exposed to the intervention are compared with a previous group of
controls people either treated at the same institution but without the intervention or
treated with a control intervention
4 Case series Measures of an outcome are taken before and after the intervention is
introduced to a series of people and then compared
5 Expert opinion Expert opinion with no critical appraisal
(Source: derived from National Health and Medical Research Council Stage 2 consultation: Guidelines for developers 2009)
Trials that have been conducted have often been There is a risk, however, that in meeting the require-
criticised for poor methodology, including: ments for scientific research the study may become too
l Sample size is too small to permit mathematical far removed from the realities of practice to produce
calculation of probabilities supporting or refuting useful results. Standardised massage protocols, for
the hypothesis. example, do not correlate to real life treatments where
l Lack of control or comparison group. Menard routines are adapted to suit individual needs. RCTs may
(1994) argued that there is no such thing as placebo be more suited to researching specific medicinal herbs
touch and innovative study designs are called for. In and nutrients for particular medical conditions, and less
one study a sham reflexology technique was used well suited to studying real-life and complex applica-
where pressure was applied either too lightly or too tions of massage therapy.
heavily to be considered effective and on inappro-
priate points for the condition being treated (Oleson Potential avenues for research
& Flocco 1993). Despite the complexities of finding or developing suit-
l Lack of random assignment to a group. able methodologies for massage therapy research, it is
l Inadequate outcome measures: tools used to mea- possible to design research studies for massage therapy
sure outcomes (such as range of motion) may lack that generate evidence capable of informing clini-
validity and reliability or be inadequate (e.g. tools cal practice. Several alternative ways of assessing the
for measuring palpatory changes, feelings of well- effectiveness of complementary medicine, including
being). massage therapy, have been canvassed and these are
l Lack of clinical relevance (Vickers 1999). For discussed below.
example, one of the few systematic reviews show-
ing evidence of benefit for massage therapy is Clinical auditing
antenatal perineal massage for reducing perineal Systematic clinical auditing was proposed by Melchart
trauma. However, this massage is not practiced in
copyright law.
et al (1997). In clinical auditing, client files are used as

Australia. a source of data for analysis. For example, a review of
l Lack of standardisation of the massage protocol files of all clients in a clinic who have presented with
used in the study. neck pain could provide information about the type and
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duration of treatment and responses to it. Systematic Systematic reviews

clinical auditing that uses large samples of clients can The scope of massage therapy with its diversity of
also be used to determine future research questions for practices presents specific challenges for conducting
RCTs. reviews. In addition, massage therapy trials are some-
times difficult to locate as they are often published in
Pragmatic research non-standard or non-listed journals. Nevertheless, the
Another approach is pragmatic research which may number of systematic reviews of massage therapy is
be applied to real-life situations. Complete treatment increasing. Overall, systematic reviews have found that
programs can be considered without identifying the there is little good quality evidence for the effects of
underlying mechanism of action for each interven- massage (see Table 7.3).
tion, provided that there is a clear, clinically relevant
outcome (Long 2002; Nahin & Straus 2001). A particu-
lar advantage of this approach is that it recognises that FINDING AND EVALUATING THE
massage treatment programs are frequently multifocal, EVIDENCE
collaborative (with the client) and integrated into the From the outset of a career in massage therapy it is
client’s lifestyle. important to keep up to date with the latest research.
If therapists never undertake any further study, never
Outcome measures attend conferences or read journals and texts after their
Outcome measures (standardised questionnaires) first massage therapy qualification then they may not
are proving to be particularly useful in pragmatic know when new developments emerge in the field. The
research designs. The Oswestry Disability Question- massage therapy professional associations recognise
naire and the Vernon Mior Neck Disability Question- the importance of continuing professional education
naire are examples of outcome measures that have and have made ongoing participation in educational
research and clinical applications. Subjects complete activities compulsory for all members. Ways of keep-
the questionnaire before and after the intervention and ing abreast of new developments and/or latest research
the results are compared. (Responses to each question include:
are scored 0–5, with 0 for the first response, 5 for the l conferences and workshops: conducted by profes-
last response and intermediate responses scored 1, 2, sional associations and private organisations
and so on). l conference proceedings: often made available after
Outcome measures are now frequently used in the conference (usually free to members of associa-
massage therapy research. They are simple to admin- tions or for a small cost to non-members)
ister and their standardised scoring systems allow l journals; for example, Journal of Bodywork and
comparisons of clients’ responses over time. It is the Movement Therapies, International Journal of
reported validity of these outcome measures in differ- Therapeutic Massage and Bodywork, Journal of
ent client populations that is having a big effect on the Alternative and Complementary Medicine, Jour-
scientific evidence base for complementary medicine nal of Complementary Therapies in Medicine,
(Hurst & Bolton 2004; Miettinene et al 2004; Yeo- Australian Journal of Physiotherapy, Medical
mans 2000). Journal of Australia, British Medical Journal,
the Lancet. Note that using search engines like
THE SCIENTIFIC EVIDENCE FOR THE google or yahoo will often take you to the jour-
EFFICACY OF MASSAGE THERAPY nal home page but access to the full text article
Massage therapy is grossly under-researched, particu- may require payment. Access is usually free from
larly defined types of massage for defined conditions your training institution’s library or your local
(Ernst 2002). Lack of funding and research expertise library
are cited as the main barriers to research. Some clinical l books
trials have shown that massage therapy is effective in l websites of research centres; for example, National
the following areas (Peters et al 2002): Centre for Complementary and Alternative Medi-
l reducing anxiety and improving the perceived qual- cine (USA), National Institute of Complementary
ity of life for patients with cancer Medicine, (Australia)
l reducing anxiety and depression in women who had l websites of professional associations (e.g. Asso-
been sexually abused ciation of Massage Therapists, Association of
l improving function and self-image and reducing Remedial Masseurs, Australian Association of
anxiety and depression in adults with multiple scle- Massage Therapists, Australian Natural Thera-
rosis pists’ Association, Australian Traditional Medicine
l improving lymphatic drainage and tissue oxygen- Society)
ation l Cochrane Reviews (www.cochrane.org/reviews/)
copyright law.
l improving respiratory function in asthmatics l internet searches (databases such as AMED,
l reducing pain and stiffness in chronic inflammatory PubMed, Medline, PEDro, google scholar)
conditions such as rheumatoid arthritis. l peer group discussions.
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Table 7.3 Systematic reviews of the effectiveness of massage therapy
Author(s) Title Author(s)’ conclusion Evidence

Beckmann & Antenatal perineal Antenatal perineal massage reduces the likelihood of Evidence of
Garrett 2006 massage for perineal trauma (mainly episiotomies) and the reporting of benefit
reducing perineal ongoing perineal pain and is generally well accepted by
trauma women. Women should be made aware of the likely benefit
of perineal massage and provided with information on how
to massage
Brosseau Deep transverse DTFM combined with other physiotherapy modalities did Inconclusive
et al 2002 friction massage not show consistent benefit over the control of pain, or
(DTFM) for treating improvement of grip strength and functional status for
tendonitis patients with iliotibial band friction syndrome or for patients
with extensor carpi radialis tendonitis. These conclusions are
limited by the small sample size of the included RCTs. No
conclusions can be drawn concerning the use or non-use of
DTFM for the treatment of iliotibial band friction syndrome.
Future trials, utilising specific iliotibial band friction syndrome
methods and adequate sample sizes are needed, before
conclusions can be drawn regarding the specific effect of
DTFM on tendinitis
Cooke & Aromatherapy: a These studies suggest that aromatherapy massage has Inconclusive
Ernst 2000 systematic review a mild, transient anxiolytic effect. Based on a critical
assessment of the six studies relating to relaxation, the
effects of aromatherapy are probably not strong enough
for it to be considered for the treatment of anxiety. The
hypothesis that it is effective for any other indication is not
supported by the findings of rigorous clinical trials
Eason et al Preventing perineal Factors shown to increase perineal integrity include avoiding Inconclusive
2000 trauma during episiotomy, spontaneous or vacuum-assisted rather than
childbirth: a forceps birth, and in nulliparas, perineal massage during
systematic review the weeks before childbirth. Second-stage position has
little effect. Further information on techniques to protect the
perineum during spontaneous delivery is sorely needed
Ellis et al Iliotibial band There seems limited evidence to suggest that the Inconclusive
2007 friction syndrome: conservative treatments that have been studied offer any
a systematic significant benefit in the management of iliotibial band
review friction syndrome. Future research will need to re-examine
those conservative therapies, which have already been
examined, along with others, and will need to be of sufficient
quality to enable accurate clinical judgements to be made
regarding their use
Fernandez- Are manual The most urgent need for further research is to establish the Inconclusive
de-Las- therapies effective efficacy beyond placebo of the different manual therapies
Penas et al in reducing pain currently applied in patients with tension-type headache
2006 from tension-type
headache? A
systematic review
Furlan et al Massage for low- Massage might be beneficial for patients with subacute Inconclusive
2008 back pain and chronic non-specific low-back pain, especially when
combined with exercises and education. The evidence
suggests that acupuncture massage is more effective than
classic massage, but this needs confirmation. More studies
are needed to confirm these conclusions and to assess
the impact of massage on return-to-work, and to measure
longer-term effects to determine cost-effectiveness of
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massage as an intervention for low-back pain
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Table 7.3 Systematic reviews of the effectiveness of massage therapy—cont’d

Green et al A systematic This systematic review and critical appraisal found Inconclusive
1999 review of insufficient evidence to support craniosacral therapy.
craniosacral Research methods that could conclusively evaluate
therapy: biological effectiveness have not been applied to date
plausibility,
assessment
reliability
and clinical
effectiveness
Hansen et al Massage and Massage and touch interventions have been proposed Inconclusive
2006 touch for dementia as an alternative or supplement to pharmacological and
other treatments to counteract anxiety, agitated behaviour,
depression, and if possible to slow down cognitive decline
in people with dementia. This review provides an overview
of existing research on the use of massage for people
with dementia. Eighteen studies of the effects of massage
interventions were located, but only two small studies were
of a sufficient methodological rigour to count as evidence to
answer the question of effect. The small amount of evidence
currently available is in favour of massage and touch
interventions, but is too limited in scope to allow for general
conclusions
Haraldsson Massage for No recommendations for practice can be made at this time Inconclusive
et al 2006 mechanical neck because the effectiveness of massage for neck pain remains
disorders uncertain. Pilot studies are needed to characterise massage
treatment (frequency, duration, number of sessions, and
massage technique) and establish the optimal treatment to
be used in subsequent larger trials that examine the effect of
massage as either a stand-alone treatment or part of a multi-
modal intervention. For multi-modal interventions, factorial
designs are needed to determine the relative contribution of
massage. Future reports of trials should improve reporting of
the concealment of allocation, blinding of outcome assessor,
adverse events and massage characteristics. Standards of
reporting for massage interventions, similar to CONSORT,
are needed. Both short- and long-term follow-up are needed
Marine et al Preventing Limited evidence is available for the effectiveness of Inconclusive
2006 occupational stress interventions to reduce stress levels in health care workers.
in health care Larger and better quality trials are needed
workers
Moyer et al A meta-analysis of Single applications of massage therapy reduced state Evidence of
2004 massage therapy anxiety, blood pressure, and heart rate but not negative benefit
research mood, immediate assessment of pain, and cortisol level.
Multiple applications reduced delayed assessment of
pain. Reductions of trait anxiety and depression were
massage therapy’s largest effects, with a course of
treatment providing benefits similar in magnitude to those of
psychotherapy. No moderators were statistically significant,
though continued testing is needed. The limitations of a
medical model of massage therapy are discussed, and it is
proposed that new massage therapy theories and research
use a psychotherapy perspective
O’Mathúna Therapeutic touch There is no evidence that therapeutic touch promotes Inconclusive
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& Ashford for healing acute healing of acute wounds

2003 wounds
(Continued)
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Table 7.3 Systematic reviews of the effectiveness of massage therapy—cont’d

Preston et al Physical therapies All three trials have their limitations and have yet to be Inconclusive
2004 for reducing replicated, so their results must be viewed with caution.
and controlling There is a clear need for well-designed, randomised trials of
lymphoedema of the whole range of physical therapies if the best approach to
the limbs managing lymphoedema is to be determined
Robinson Therapeutic Given the high prevalence of anxiety disorders and the Inconclusive
et al 2007 touch for anxiety current paucity of evidence on therapeutic touch in this
disorders population, there is a need for well conducted randomised
controlled trials to examine the effectiveness of therapeutic
touch for anxiety disorders
Simkin & Nonpharmacologic The five methods included continuous labour support, Inconclusive
O’Hara 2002 relief of pain during baths, touch and massage, maternal movement and
labour: systematic positioning, and intradermal water blocks for back pain
reviews of five relief. An extensive search of electronic databases and
methods other sources identified studies for consideration. Critical
evaluation of controlled studies of these five methods
suggests that all five may be effective in reducing labour
pain and improving other obstetric outcomes, and they are
safe when used appropriately. Additional well-designed
studies are warranted to further clarify their effect and to
evaluate their cost effectiveness
Thorgrimsen Aromatherapy for Aromatherapy showed benefit for people with dementia in Inconclusive
et al 2003 dementia the only trial that contributed data to this review, but there
were several methodological difficulties with this study.
More well designed large-scale RCTs are needed before
conclusions can be drawn on the effectiveness of aroma
therapy. Additionally, several issues need to be addressed,
such as whether different aroma therapy interventions are
comparable and the possibility that outcomes may vary for
different types of dementia
Underdown Massage The only evidence of a significant impact of massage on Inconclusive
et al 2006 intervention for growth was obtained from a group of studies regarded to be
promoting mental at high risk of bias. There was, however, some evidence of
and physical health benefits on mother–infant interaction, sleeping and crying,
in infants aged and on hormones influencing stress levels. In the absence
under six months of evidence of harm, these findings may be sufficient
to support the use of infant massage in the community,
particularly in contexts where infant stimulation is poor.
Further research is needed, however, before it will be
possible to recommend universal provision
Vickers et al Massage for Evidence that massage for pre-term infants is of benefit Inconclusive
2004 promoting growth for developmental outcomes is weak and does not warrant
and development wider use of pre-term infant massage. Where massage
of pre-term and/ is currently provided by nurses, consideration should be
or low birth-weight given as to whether this is a cost-effective use of time.
infants Future research should assess the effects of massage
interventions on clinical outcome measures, such as medical
complications or length of stay, and on process-of-care
outcomes, such as care-giver or parental satisfaction
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Assessing the evidence supported by scientific evidence and will be discarded.

Standards of research vary widely and it can be difficult Techniques that produce the best results for clients will
to determine which research findings are worthy of our be retained. Some techniques may be shown to be effec
attention. Asking the following questions may be useful tive by mechanisms different from those we currently
in determining the credibility and relevance of emerg- understand. Menard (1994) noted that the body sys-
ing evidence for massage therapy. tems which show the most physiological responsiveness
1 Who are the authors? Research carried out by repu- to massage therapy (integumentary, cardiovascular,
table universities, government bodies and non-profit autonomic nervous, and neuro-immune systems) are
organisations may be more credible than research also those that are highly responsive to psychological
sponsored by businesses with vested interests. interventions such as guided imagery, hypnosis, and
2 Where is the research published? The quality biofeedback. Future research may demonstrate a more
of publications varies a lot. Journals that are peer strongly psychological basis for the effectiveness of
reviewed, that is, that only publish research find- massage therapy than has been demonstrated to date.
ings after they have been scrutinised by a group of It is also possible that increasing value will be given to
experts in the field and accepted as credible, are clients’ perceptions of their treatment outcomes. In any
likely to report high quality evidence. case, massage practitioners will need to keep up to date
with current research and assess its relevance for their
3 How recent is the study? Research findings can
own practices as they strive to provide the best available
rapidly be superseded by subsequent research espe-
care for their clients.
cially in fields where there is a lot of research activity
(e.g. climate science). In such cases articles that are Questions and activities
more than even a few months old may be out of date.
In massage therapy where the number of research 1 Describe what is meant by ‘evidence-based
studies published each year is limited, research find- practice’. What is its relevance to massage therapy
ings may remain current for periods of 5 to 10 years. practice?
4 What is the quality of the research methodol- 2 Discuss how research-based evidence can be
ogy? It is beyond the scope of this chapter to exam- applied to massage practice.
ine some of the sophisticated strategies that are 3 Collect five testimonials from your clients in
used to assess the quality of research. However, it clinic. Discuss the ranking of this type of evidence
is useful to consider such study design features as in a typical evidence grading system. Discuss the
whether a protocol was specified and whether it was potential bias inherent in this type of evidence.
realistic or well-explained, the number of partici- 4 What are some of the limitations that researchers
pants in the trial (sample size), whether there was face when designing a randomised controlled trial
a control group, and whether the participants were into the effectiveness of massage therapy?
randomised to the control and treatment groups. 5 Practice using the Oswestry Disability Questionn
5 What references are cited in the article? Refer- aire (Fairbanks, Couper, Davies, O’Brien 2001,
ences indicate the extent to which the research has www.workcover.vic.gov.au) as an assessment tool
used the current literature in setting its context and in class and then in clinic. Discuss its strengths and
in developing its argument. References should be as weaknesses. Locate other outcomes measures that
current as possible. may be useful in practice.
6 Are the findings relevant to your clinical prac- 6 Locate an article about massage therapy research
tice? Are your clients sufficiently like those in the that has been published in the last 5 years on a
study to extrapolate the findings to your workplace? topic of particular interest to you (e.g. research
Could the findings be appropriate to clients dissimi- on massage for treating headaches or knee pain).
lar to those in the study (e.g. could the treatment or Discuss ways of locating research evidence with
technique utilised in the study be applied to clients members of your group.
with different conditions to those in the study)? 7 Locate a recent research article in a massage
therapy journal. Evaluate the quality of the
CONCLUSION evidence (e.g. authors, quality of publication, study
design features such as sample size, randomisation,
To date, most evidence for the effectiveness of massage
control, references, and usefulness).
therapy is based on the experiential knowledge of prac-
titioners and feedback from clients. There is an increas-
ing number of scientific studies into the effectiveness Endnotes
of massage therapy as research skills and funding 1 Systematic reviews appraise high quality research
increase, and as innovative study designs are explored (often randomised controlled trials) relevant to a
to overcome the challenges of applying scientific meth- particular area and often use statistical techniques
ods to the complex area of massage therapy. It is likely to combine the studies.
copyright law.
that some scientific research will validate claims about 2 Randomised controlled trials (RCTs) are studies
massage therapy’s effectiveness. It may be that some where participants are allocated to treatment groups
techniques that were thought to be effective are not or control groups using a randomisation procedure.
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SECTION 3
the massage setting
Lisa Casanelia chapter 8
LEARNING OUTCOMES
l Create an atmosphere and environment that is conducive to relaxation massage therapy
l Differentiate between the varying types of massage environments
l Describe the various forms of massage equipment and their specialised use
l Identify the benefits, necessary precautions and hygienic application of the different types of
oils and lubricants used for massage

INTRODUCTION THE MASSAGE SETTING

As the public image of massage therapy has evolved over When providing a service, the massage therapist has a
recent years more and more people are turning to mas- professional responsibility to provide a clean and safe
sage as a form of preventative health care. This broad- environment for the client and the therapist should also
ened awareness has created greater scope for the massage maintain a high standard of personal hygiene (see Chap-
therapist to provide their services in many diverse set- ter 10). When in practice it is essential for the massage
tings. For example, the massage therapist may establish therapist to work within the boundaries of ethical practice
a practice in their home, in a clinic with a combination of at all times (see Chapter 5) and maintain adequate pro-
different health practitioners, in a spa, in a corporate envi- fessional indemnity insurance, in addition to maintaining
ronment, at sporting clubs or events, in shopping centres, proper records (see Chapter 11). The massage therapist
at markets or at exhibitions. They may also choose to should also display their qualifications and professional
provide treatments at nursing homes, hospitals, in private association memberships. As a professional health care
homes or hotels so as to allow the broader community to provider the massage therapist has the responsibility
enjoy the benefits of massage therapy. to keep their skills current and to refer clients to other
Irrespective of locality, it is important for the ther- health practitioners where necessary (see Chapter 5).
apist to provide a setting for the massage that will When providing a massage treatment the therapist
enhance the benefits of relaxation when providing a should always allow adequate time for each client, and
massage treatment. Factors that a therapist would take leave time to prepare for the next client to ensure cli-
into consideration include the temperature of the room, ents are not kept waiting. As with any business, a client
privacy of the client, standard of hygiene, professional- reassured by the subtle indicators of a professionally
ism and ethical practice, use of suitable lighting, aromas conducted business will gain the most from the service.
and the addition of music. Such factors are important in The care taken by the therapist to ensure the massage
enhancing the sensory ambience of the massage. The room is kept clean and inviting will provide important
type of environment the therapist chooses to work from cues for the client about the assiduousness the therapist
will dictate how much control the therapist has over the has for their work and bestow vital first impressions on
massage setting. The nature of the massage setting, and the client.
the resources and equipment required by the massage When preparing a massage room for treatment, there
therapist, such as massage table and linen, are deter- are four factors that must be considered. These factors
mined by whether the therapist is mobile, home-based, may be referred to as the tranquillity, aroma, ambi-
in a clinic, or providing seated massage in a work envi- ence and comfort of the treatment room. The features
ronment. This chapter describes how to prepare a set- of these important considerations are described below.
copyright law.
ting suitable for delivering a massage and addresses When combined, these factors make for an ideal mas-
some of the varying types of massage environments that sage setting that is sure to induce feelings in any client
a therapist may work from. of wellness, comfort, security and relaxation.
73
Account: s8715057
74 Section 3 Preparing for massage practice
Tranquillity are colours that are warm and inviting but may be too
The massage therapist should create a peaceful, quiet stimulating to be used in the massage setting, which
space for massage that is free from external distur- aims to enhance relaxation (Gimbel 1994). A massage
bances, distractions and interruptions. The external therapist may enhance a room further with the use of
sound of telephones, traffic din, television, radio or appropriate pictures on the walls and effective light-
machinery can be most disruptive to the relaxation pro- ing. Where possible, overhead lights should be oper-
cess and can startle clients from a relaxed state. Even a ated by a dimmer switch, or alternatively the room lit
ticking clock might distract some people. Certain cli- with a soft bulb. The addition of a strategically placed
ents may find music intrusive in the massage setting lamp to provide lighting that is soft enough to create a
and others will find it enhances their ability to relax. mood of relaxation, but bright enough for the therapist
Where possible, a therapist should allow the client the to observe the client’s skin for any abnormalities, may
preference with regard to the type of music played. also prove useful in enhancing the massage setting. In
Conversation should be kept to a minimum and relevant terms of ambience, a tidy and uncluttered room that is
to the massage setting. A therapist who uses the mas- pleasing to the eye will convey the impression of an
sage time to tell clients about their personal life and organised and caring professional therapist who takes
talk incessantly through a massage can be annoying pride in their work, thereby instilling confidence in
and, more importantly, professionally inappropriate. the client about the therapist’s abilities.
Likewise, a therapist who loses contact during the mas-
sage to answer the telephone, the door or to attend to Comfort
something other than the massage will be disrupting the Client comfort is of utmost importance to the massage
relaxation process by breaking the flow and continuity therapist. The massage room should be warm, the tow-
of the massage treatment. Disruptions to the massage as els soft and the massage table comfortable. Massage is
well as unexpected and obtrusive noises can interfere all about touch, and the application of the various mas-
with the client’s ability to relax during a massage. As sage techniques will serve to stimulate different tactile
such the therapist should attempt to minimise all such skin receptors, creating a wide range of sensations and
annoyances to optimise the tranquillity of the massage responses for the client. Comfort on the massage table
environment. is very important in encouraging the body to relax. In
order to increase the clients’ level of comfort the thera-
Aroma pist should make use of bolsters and pillows and posi-
tion them to suit the individual size, shape and needs of
The massage therapist should give consideration to the
the client.
smell of a massage room. A fresh, pleasant-smelling
The linen used for the massage should be soft and
environment that is welcoming and not overpowering
clean and, where possible, warmed to really encourage
will enhance the ambience. Massage rooms can tend to
the body to relax into the massage. A client who is cold
become stuffy with the warmth of the room and all the
on the massage table will tense their muscles, making it
varying odours clients bring with them. The use of a fan
difficult to achieve a restful effect during the massage.
to gently stimulate circulation of air can help disperse
As such, the massage room should be at a temperature
stale smells and minimise any disagreeable odours. The
that is comfortable for the client. A temperature in the
subtle use of essential oils in a vaporiser, or essential
massage room between 22 and 25 degrees Celsius is
oil mist sprays, can assist in enhancing the mood and
ideal — during the treatment the client will ‘let go’
freshness of a massage room. Plants or flowers can also
and their body temperature will decrease. In addition
be used to cleanse the air and enhance the energy in a
to this, the therapist can use blankets, hot packs, elec-
room. As some clients may be sensitive or even aller-
tric blankets and heated towel racks (that warm the
gic to certain aromas or flowers, the therapist should
towels) to keep the client sufficiently warm throughout
always check for individual sensitivities prior to treat-
the massage. Creating a comfortable environment is
ment. When used appropriately, however, a client may
vital during the massage, as a client who is comfort-
find the use of subtle aromas a welcome addition to the
able during the treatment will benefit most from the
massage treatment.
massage.
Factors such as the tranquillity, aroma, ambience
Ambience and comfort of the treatment room are important for
Visually the massage room should be pleasing to the a successful massage treatment. A massage room that
eye; uncluttered, clean and enhanced by subtle light- beckons the client into its tranquil space and encour-
ing. The paintwork should look fresh and be free of ages a sense of relaxation simply from entering the
greasy hand marks. As certain colours are believed room is a blessing for a therapist, as well as the client.
to enhance relaxation, the therapist may make use of A client should begin to relax simply by breathing in
such colours on the walls or on accessories to create the beautiful surroundings and easing themselves into
the right effect. Shades of blue, violet and turquoise the soft warm towels that drape the massage table. It is
copyright law.
are colours that promote feelings of calm and relax- to the therapist’s advantage to create such a welcoming
ation and as such would be well suited to a massage massage setting; one that will only serve to enhance the
treatment room. Red and orange on the other hand treatment provided. The client always remembers the
Account: s8715057
8 The massage setting 75
overall experience, even if they may not recall specific Mobile massage practice
details such as what the practitioner or receptionist said The mobile massage practice is where the therapist vis-
to them. its the client in his or her own home or hotel. The thera-
The therapist should take as much care in their own pist transports the massage table and accessories to the
presentation as they would with the presentation of the clients’ premises and sets the equipment up in the space
massage room. The dress of the practitioner should be provided. In such a practice, the therapist will have less
conservative, neat and clean and portray a professional
image to the client. A massage therapist’s attire should
be comfortable and allow freedom of movement. The
practice of massage may be inclined to attract the wrong Box 8.1 Putting the massage into practice
kind of clientele at times and the attire of the practitio-
ner should not lend itself to any doubt about the services
l Prepare the massage room.
that are being provided.
l Greet the client and introduce yourself.
Box 8.1 provides a summary of a typical massage
l Take the client’s case history.
consultation sequence, from preparing the massage
l Explain the massage procedures.
room to writing the treatment record.
l Receive consent for the proposed treatment.
l Explain to the client how you wish them to

DIFFERENT MASSAGE
ENVIRONMENTS prepare for the massage (disrobing, draping,
position on massage table, etc).
Massage therapists can invent their own image and l Leave the room while the client prepares.
style, be self-employed or work as an employee, have
l Wash your hands and forearms.
one practice or several, and work in one field or many.
l Knock before re-entering the room.
As such, they have a variety of wonderful opportunities
l Adjust the client draping and pillows to ensure
and these options are diversifying as massage increases
client comfort and warmth.
in popularity. An understanding of the advantages and
l Commence massage as discussed and
disadvantages associated with the various options for
consented to.
practice may help the therapist in deciding the option
l Check with the client during the massage
that best suits them.
regarding depth of pressure, client comfort and
warmth.
Home-based massage practice
l If treatment changes or time is running short,
The home-based massage practice, as the name implies, renegotiate treatment plan and gain consent for
is a massage practice established in the therapist’s home. any changes made before proceeding.
How the therapist decides to set this up will largely be l At the end of the massage, allow time for the client
dependent on the available space in their home. Ide- to rest a few moments to refocus, and assist
ally in this situation the clinic room will be separated your client off the massage table if necessary.
from the rest of the house, with its own bathroom and l Leave the room while your client gets dressed
separate entrance. A therapist setting up a professional again.
practice could not expect clients to feel comfortable l Wash your hands and forearms.
entering their private home for massage treatment if it l Knock before entering the massage room, ask
involved walking through living spaces, meeting the how the client feels and offer a drink of water.
family members, using the bathroom, which may be l Make suggestions about how to enhance the
an ensuite to a bedroom, or having the massage in a feelings of relaxation and explain what to expect
room that doubles as a spare bedroom or is cluttered after a massage, recommend any self-care or
with things that are unrelated to massage. Such an envi- exercises to do at home and educate the client
ronment would appear unprofessional to the client and where appropriate about the correct use of
perhaps a little too intimate and personal for their level posture, exercise and the benefits of regular
of comfort. massage.
When appropriately established, a home-based l Collect payment for the massage, provide a
practice can be a lovely healing space for massage, receipt and check if the client wishes to
separated from shopping centres and associated noises schedule another appointment.
and activities, offering a special space; a space that the l Ensure the client has all their belongings and see
therapist has more control over in terms of windows and them to the door.
fresh air, lighting, paintwork and room fittings. Practi- l Write up ongoing client treatment record.
tioners considering establishing a home-based practice l Prepare the room for the next client, change
should check their local council’s regulations relating linen, clean equipment and refresh the room.
to matters such as parking requirements, signage and l The therapist should have enough time to refresh
copyright law.
health regulations, before proceeding. Box 8.2 provides themselves, have a snack, drink some water, and
a list of advantages and disadvantages of a home-based stretch in preparation for their next client.
practice. l Repeat the cycle.
Account: s8715057
Box 8.2 Advantages and disadvantages Box 8.3 Advantages and disadvantages of a
of a home-based practice mobile massage practice
Advantages of a home-based practice include: Advantages of a mobile massage practice include:

l convenience of location for the therapist l overheads are low (petrol costs and vehicle
l cost effectiveness for the therapist maintenance might not be as expensive as

l therapist can combine home-duties in between leasing commercial premises)
clients l the fees charged for mobile massage services
l greater control over external and internal are usually higher

environment l the work environments vary throughout the day,
l access to washing machine and clothes dryer which may add interest to the therapist’s work
for laundering linen l the client may feel more at ease in their own
l flexible working hours home

l the practice is part of the home, thus some l the client has greater opportunity to be relaxed
home expenses may be tax deductible. before and after massage.

Disadvantages of a home-based practice include: Disadvantages of a mobile massage practice include:
l clients may feel more vulnerable entering a l the therapist may feel vulnerable entering an
therapist’s private home environment they are unfamiliar with

l clients may expect the therapist to be on call at l the therapist has little control over the massage
hours beyond their specified clinic hours setting

l therapists may feel isolated in their massage l the therapist is restricted by the amount of
practice. equipment they can physically carry

l the distance of travel between clients may be
time consuming.
control over the surroundings and should encourage the
client to set aside a quiet space that is free from the dis-
tractions of telephone, family, visitors, television and Box 8.4 Advantages and disadvantages of a
other sources of interruption. It is possible to ask the clinic-based practice
client to provide articles such as pillows, linen, music,
hot packs or other accessories that will reduce the bur- Advantages of a clinic-based practice include:
den of what the practitioner must carry with them to l greater exposure to the general public
appointments. Box 8.3 provides a list of advantages and l professional image
disadvantages of mobile massage practice. l shared knowledge with other practitioners and
less isolation in a multidisciplinary clinic
Clinic-based practice l shared expenses, advertising and reception
A clinic-based practice generally refers to a prac- duties with other practitioners

tice that is set up commercially. This could include a l the clinic can provide more varied equipment for
therapist working in a: beauty salon; medical practice; clients

physiotherapy, chiropractic or osteopathic practice; per- l client database can be shared between
sonal training studio; natural therapies practice; or may practitioners

involve the therapist working on their own or with a l a diversity of practitioners, their experience and
combination of different therapists. The therapist could range of knowledge and skills, may draw a wide
be self-employed or an employee, or perhaps even an range of clients.
associate with other practitioners. The clinic-based Disadvantages of a clinic-based practice include:
therapist would be in a setting where they have greater l higher overheads
visibility to the general public and as such may acquire l parking may be restricted.
more business from passers by than any other practice

set up. The clinic may have a more professional set up
of facilities, have a receptionist and may have the ability injury places a significant financial burden on compa-
to offer clients a variety of different services, attract- nies annually; a burden that is not necessary considering
ing a range of clientele into the clinic. Box 8.4 provides workplace stress and injuries are largely preventable.
a list of advantages and disadvantages of clinic-based Evidence suggests that massage may positively impact
practice. upon workplace stress and aid employee productivity
and wellbeing (Rich 2002). As more and more employ-
Work-site massage practice ers are turning to massage in the workplace to assist
employee health and morale, the good news is that
copyright law.
With today’s fast-paced workplaces, many employers

are becoming increasingly aware of the benefits to their almost any type of workplace setting has the possibility
business of injury and stress reduction strategies for for massage to be utilised regardless of the type, size or
their staff. Having employees off work due to stress or location of the business.
Account: s8715057
have a duty of care to provide a safe environment for

Box 8.5 Advantages and disadvantages of their clients. A massage table that is old and rackety and
work-site massage
groans and rattles under the weight of the client will not
bestow a sense of comfort, security or safety, and will
Advantages of work-site massage include: no doubt interfere with the client’s ability to relax and
l the closed environment of a workplace means
enjoy the massage. The quality of the therapist’s equip-
that word of your services will move fast ment will impart important impressions regarding their
l the massage is easily accessible to anyone in
professional standards and the quality of care provided
the office to the client.
l the massage is not disruptive to the client’s
The massage table is the most important piece of
working day as they can stay in the office equipment. Not only necessary for client comfort, the
l the massage through the clothing and in a
massage table also determines the ease with which the
seated position may mean it is less intimidating therapist can provide the massage treatment. For most
for some people who would be reluctant to have therapists the massage table will be the most expensive
massage normally
piece of equipment they will purchase. As such, invest-
l if the practitioner also has a massage practice
ment in a massage table requires thought and thorough
then this will become a good source of research on the part of the therapist.
advertising and attract new clientele
Massage tables can be stationary, portable, electric
l overheads will be low (petrol costs and car
or in the form of a chair. The type of table the thera-
maintenance).
pist chooses to buy will be dependent on how they wish
Disadvantages of work-site massage include:
to set up their clinical practice. The portable massage
l the environment may be disruptive and the
table will of course be the most versatile option, allow-
massage may be interrupted by work priorities
ing the therapist to easily store, carry and transport their
l the therapist is limited by brief massage time
practice to different locations. The therapist can choose
l the therapist is limited by what they can
from a wide range of massage tables at varying degrees
physically carry to the job of quality and price. A therapist may be tempted to
l the seated massage techniques are usually more
purchase the least expensive massage table and end up
taxing on the therapist’s hands with a table that is uncomfortable, unstable and prone to
l travelling to the office site may be time
breaking. The following features of a massage table are
consuming. explained to aid the therapist in the purchase of a table
that best suits their needs.
The work-site massage is ideally suited to provide

massage to employees in their work environment. Like Massage table features
the mobile massage therapist, the therapist will usu- Height
ally travel with their equipment to the work site. In The height of the massage table is critical for assist-
some situations the business may provide space and ing the therapist to maintain good body positioning and
equipment for the massage practitioner. The massage thereby place minimal strain on their body. Most mas-
itself can be on a massage table or, more commonly sage tables permit adjustment of the height of the table,
in the work environment, it will be a seated, clothed and this is a most important feature for the therapist.
massage. The seated massage is more suited to the Table height it seems is a matter of personal preference
workplace setting as it poses fewer interruptions to and a general rule commonly used to determine height
the work environment. The seated massage may be is to have the massage table reach the therapist’s
applied at the client’s desk or in a separate space with knuckles when the hands are curled loosely into a fist
a specialised seated massage chair. The duration of the hanging by the therapist’s side. A table that is too high
seated massage is generally 10 to 20 minutes and the will mean the therapist will resort to using upper body
techniques are performed through the client’s clothing. muscle strength as a result of being unable to use their
Regular massage using a massage table will require a body weight over the top of the massage strokes. As
private room and more time for the massage appoint- the therapist develops their skills and develops greater
ments, which may not be possible in some work envi- body awareness they will be able to determine a table
ronments. Box 8.5 provides a list of advantages and height that best suits their needs. The size of the cli-
disadvantages of work-site massage based on a seated, ent on the massage table, the type of techniques and
clothed massage of short duration in the work environ- modalities being employed and the body areas being
ment. worked will all generate a need to vary the height of
the massage table. The electric massage table offers
MASSAGE EQUIPMENT the massage therapist the perfect solution for adjusting
table height throughout a massage treatment. A stan-
copyright law.
There are a few pieces of equipment needed by a thera-

pist to perform massage. The massage therapist must dard portable or fixed massage table will range from
feel confident about the quality and effectiveness of 64 cm to 80 cm in height, with increments of 5 cm on a
their equipment and should choose carefully as they height adjustable table.
Account: s8715057
Width Armrests can be helpful for clients who are larger,

The width of the massage table is also an important with longer limbs, or for those who find it more comfort-
factor, especially when considering client comfort. A able with their arms supported in front of them when lying
large adult should fit comfortably on the massage table prone. Armrests are generally attached to the face cradle.
and have enough room for their arms to be supported Bolsters are great tools for the therapist and can be
by the table. For the therapist’s benefit, a narrow table acquired in different shapes and sizes for the purpose of
allows for greater reach and less strain on their body. supporting the client in various positions.
A compromise between these two is a contoured table Carry cases are an essential tool for the therapist who
allowing for support of the client and easy access by plans to provide mobile massage services. The case pro-
the therapist. The width of standard massage tables will vides protection for the table, keeping it clean as well as
vary, ranging between 610 mm and 700 mm with the protecting the vinyl from nicks and added wear. It also
most popular width being 680 mm. permits the table to be transported with greater ease by
use of a shoulder strap or wheels.
Length The wedge is a big wedge-shaped piece of foam
covered in vinyl that is suitable for supporting a client
A standard massage table should be approximately
in a seated or semi-reclined position, and is ideal for the
1850 mm in length. This can be further extended by
pregnant client.
approximately 335 mm with the addition of a face cradle,
The face recess plug fills the face hole recess to sup-
making it long enough to accommodate taller clients.
port the client when they are lying face up.
Footstools are ideal for aiding clients onto and off
Table frame
the massage table.
The frame of the massage table provides the table with Stools on wheels and ‘fit balls’ are ideal for main-
stability and strength; the frame is commonly made taining good posture when accessing awkward parts of
from steel, aluminium or wood. Steel-frame tables the client’s body, such as the head and neck, the feet or
provide good strength and durability but will tend to when the client is in a side-lying position.
be heavier. Aluminium-framed tables are lighter, but
generally do not have the same durability or strength
Caring for the massage table
of steel tables. While wooden-frame tables tend to add
weight to a massage table, they are strong and can be Considerations of hygiene dictate the need to clean the
aesthetically pleasing. They are usually more expensive massage table surface after coming into contact with
than the metal-frame tables. The addition of cables and a client. Strong disinfecting solutions tend to have an
struts to the frame provides greater support. A table can eroding effect on the vinyl and, as a result, manufactur-
be tested for stability, movement, comfort and squeaks ers of massage tables tend to suggest the use of mild
by having someone lie on it while the therapist applies detergents with warm water to clean the surface. Oils
downward force and rocking movements to the person’s and perspiration coming in contact with the vinyl can
body. also harden and erode the vinyl over time. If strong dis-
infecting solutions are used on the massage table for
Padding and vinyl cleaning, they should be followed with a wipe with a
damp cloth or warm soapy water to reduce the drying-
The comfort of the massage table is dependent on the
out effect on the vinyl.
quality and density of the foam and the quality of the
To preserve a table, the less contact the vinyl has
vinyl. The softness of the vinyl will add to the table’s
with these eroding factors the greater its longevity. A
level of comfort and the durability of the vinyl will
simple solution to reduce wear on a table is to keep the
extend its life. Double-density foam is fairly standard
vinyl protected with fitted covers that can be removed
for a massage table. However, the difference in the qual-
and replaced after each client. Regular maintenance
ity of the foam used will dictate its level of comfort and
checks, such as tightening any screws or nuts, repairing
its lifespan. Cheaper foams will lose their cushioning
any tears to the vinyl, and applying lubricant to squeaky
effect much faster than higher-quality foams, regardless
joints can also extend the life of a massage table.
of the density.
The massage chair
Weight
The massage chair is designed for therapists who wish
The weight of portable massage tables will vary from
to provide massage in workplace environments, mar-
approximately 12 kg to 18 kg.
kets, exhibitions or really anywhere inventive they wish
to set up their service. The chair is easily transported.
Massage table accessories
It either folds up or divides into two easy pieces and
The face cradle can be added to a standard massage weighs 10–12 kg. Such chairs are designed for the cli-
table and it can be fixed or adjustable. The cushioning is ent to be comfortably supported as well as relaxed in the
copyright law.
generally much softer and more supportive than the face seated position. Some chairs can be fully adjustable to
hole that is part of a standard massage table. In terms of suit each client’s individual needs and others will have
client comfort this is a most important accessory. more basic fixed attachments.
Account: s8715057
The desktop massager is another option, where a

chest pad and face cradle are combined in an attachment
that sits on a desk.
Figures 8.1a to 8.1e show a portable massage table,
contoured massage table, electric massage table and
massage chair.
Figure 8.1a Portable massage table
Figure 8.1d Massage chair
Figure 8.1b Contoured massage table with face cradle

and arm rest attachments
copyright law.
Figure 8.1c Electric massage table Figure 8.1e Adjustable desktop positioned
(photographs courtesy of Athlegen)
Account: s8715057
Almond oil Safflower oil

Properties: Contains vitamins A, B1, B2 and B6 Properties: There are two types of safflower oil; a
and a small amount of vitamin E with mono and monounsaturated oil with oleic acid and a poly-
polyunsaturated fatty acids. It keeps reasonably unsaturated fat with linoleic acid. The
well. polyunsaturated oil will go rancid fairly quickly.
Uses: Protects and nourishes the skin and is good Uses: Beneficial on painful inflamed joints, sprains
for dry skin and eczema. and bruises.
Cost: $$ Cost: $
Apricot kernel oil Sunflower oil
Properties: Apricot kernel oil is very similar in Properties: Contains vitamins A, B, D and E and is
make-up to sweet almond oil. high in unsaturated fatty acids, light in texture and
Uses: Good for dry skin, especially the face. has a non-greasy feel.
Cost: $$$$ Uses: Beneficial to bruises, skin diseases and leg
ulcers.
Avocado oil
Cost: $
Properties: Contains vitamins A, B, D and E. The
unrefined oil is dark in colour and may have a Sesame oil
cloudy appearance. Slightly pungent smell. Properties: Is rich in vitamins and minerals and its
Uses: Good cosmetic qualities for dry and high content of vitamin E gives it excellent stability.
wrinkled skin. Uses: Beneficial for dry skin, eczema and
Cost: $$$ psoriasis.
Cost: $$
Grapeseed oil
Properties: Contains a high percentage of linoleic
acid and some vitamin E, and is usually a refined
oil processed by solvent extraction. Key:
Uses: Is popular with therapists for its light non- $ = inexpensive
greasy properties. $$= average
Cost: $ $$$ = above average
$$$$ = expensive
Olive oil
Properties: The best grade to use is extra virgin. It
is primarily a monounsaturated oil and has a
slightly pungent smell.
Uses: Beneficial for dehydrated, itchy or inflamed
skin. (Goldberg, 2001; Wildwood, 1996;
Cost: $$ Battaglia, 1995; Price, 1993)
Figure 8.2 Vegetable oils commonly used in massage therapy
Lubricants
Most vegetable oils are suitable for the application
For the application of Swedish massage techniques a of massage. Figure 8.2 highlights some of the more
lubricant is required to reduce drag and assist in the commonly used oils, their uses in massage, and a com-
gliding strokes. There are many options for the therapist parative cost guide.
in choosing a type of lubricant, each providing a differ- Vegetable oils will have a tendency to become ran-
ent texture, viscosity, odour and absorption rate. cid over a period of time when exposed to air, heat or
light. The stability of a vegetable oil will depend on its
Vegetable oils fatty acid content. Oils high in saturated fatty acids are
Vegetable oils can be extracted from nuts, seeds or fruit more stable than those high in unsaturated fatty acids.
by cold pressing or by heat extraction. Heat extraction The vitamin E content of an oil will also increase stabil-
follows a complicated refining process that uses very ity, therefore those oils containing both saturated fatty
high temperatures to extract the oil. Refining can have acids and vitamin E will have a longer shelf life (Price
a destructive effect on the vitamin and enzyme content 1993).
of the oil as well as removing the natural flavour and To increase the shelf life of vegetable oils follow
these steps:
copyright law.
aromas of the oil. Refining does, however, give an oil

greater stability and a longer shelf life. Cold-pressed l store in amber glass
unrefined oils are more desirable to use in massage l keep stored in a dark cool place away from direct
because of their nutritive qualities (Price 1993). sunlight
Account: s8715057
l keep the lid tightly on the oil bottle when not in

use Box 8.6 The essential pieces of equipment for
l add vitamin E oil to extend shelf life (5% vitamin E massage
to 95% vegetable oil)
l purchase in small quantities rather than stockpiling l Massage table or massage chair.
larger amounts. l A collection of pillows and bolsters of assorted
sizes.
Water-soluble vegetable oils l A variety of linen and a blanket to drape the
client and keep them warm.
The water-soluble oils have been developed especially
l A suitable music collection and a means for
for massage therapists to ease the laundering of oil from
playing the music.
their linens and clothing. An emulsifier has been added
l Oils and lubricants appropriate for massage.
to the oil to make it easily disperse in water.
l Client consent forms and treatment forms for
record keeping and a secure place to store them.
Mineral oils
l Cleaning and disinfectant supplies.
Mineral oils are saturated hydrocarbons extracted from
l Tissues.
petroleum. Being a foreign substance to the human body
l A chair for the client to sit on.
that does not nourish or penetrate the skin, mineral oil
smothers the skin leading to blocking of the pores. Pro-
longed use may lead to dry skin conditions as a result of
the mineral oil removing the skin’s natural oils (sebum).
Mineral oils are not recommended in skin care, despite lubricant in use. The lubricant should be applied to the
the fact they are very common in many cosmetics and therapist’s hands first rather than directly to the client.
creams (Mehran 2000). Some massage therapists choose The therapist warms the lubricant in their hands by gen-
to use mineral oil for massage because it is odourless, tly rubbing them together, and applies it sparingly to
cheap, non-staining and does not go rancid. the area to be massaged. The lubricant is reapplied until
the area is covered sufficiently — allowing for an easy
Talcum powder glide over the surface with minimal friction but not so
Talcum powder may be used as a lubricant for massage. much that the therapist’s hand is slipping off the sur-
It provides a surface that is less slippery than oil and face. Experience will determine an appropriate amount
would be more commonly used in sports or remedial of lubricant to use as well as determining when it is
massage, where deeper more specific techniques are necessary to reapply. Box 8.6 summarises the essential
applied and less glide is necessary. Corn flour is some- equipment for a massage therapist.
times used as a dry lubricant and is suitable for use in
manual lymph drainage massage. CONCLUSION
There are many factors that must come together to make
Lotions and creams a massage therapist successful in their practice. The
Various lotions and creams may be used as an alterna- technical skills of massage are only a small part of the
tive to oils. They will generally be less greasy in texture whole package that clients will seek when looking for a
and provide a less slippery surface than oil, requiring therapist. The massage setting and all of the factors that
more frequent application. Some lotions and creams comprise it, such as tranquillity, aroma, ambience and
specially formulated for massage have a similar feel to comfort contribute significantly to the client’s experi-
oil and allow for easy glide. ence of massage. Because massage requires touch, the
Lotions and creams may be preferred by the thera- therapist must instil a sense of security and trust in the
pist because they are less staining to linen and cloth- service they provide by ensuring that all of these factors
ing and will have a longer shelf life than vegetable oils. are in place. It takes some effort to learn the skills of
They may be preferred by the client because they are massage to be a good therapist, but it requires a great
less greasy on the skin, can be scent-free, and possi- deal of thought and care to become an outstanding
bly available as a hypoallergenic lotion, which in some therapist. To be successful in practice, a massage thera-
cases may be an important consideration. pist must set themselves apart — creating a successful
business by paying attention to all the small details that
Dispensing the lubricant contribute to an enjoyable massage treatment.
Dispensing the lubricants must be done in a contami-
Questions and activities
nation-proof way. This means using containers with a
squeeze top or a pump top for easy and safe application. 1 State five strategies to increase the shelf life of
Thick creams that cannot be squeezed from a bottle will vegetable oils.
2 Write a proposal for a corporate client that describes
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require disposable spatulas to retrieve them from the

container. the benefits of work-site massage.
The right amount of oil used with each client will 3 Based on the factors that contribute to an ideal
depend on the dryness of the skin and the type of massage environment (tranquillity, aroma, ambience
Account: s8715057
and comfort), describe in detail the features of your Mehran D 2000 Nature in Cosmetics and Skin Care:
ideal massage room. A Compendium of Ingredients Used in Cosmetic and
4 State the equipment required by a mobile massage Skin Care Chemistry (translated). Allured Publishing
therapist and describe how best they could pack Corporation, Illinois
and carry such equipment to create a setting in Price S 1993 Shirley Price’s Aromatherapy Workbook.
someone’s home that would be suitable for massage. Understanding Essential Oils from Plant to Bottle.
Thorsons/HarperCollins, London
5 Describe the features of a comfortable massage
Rich G 2002 Massage Therapy: The Evidence for Practice.
table set-up. Mosby, St Louis
Wildwood C 1996 The Bloomsbury Encyclopaedia of
References Aromatherapy. Bloomsbury Publishing, London
Battaglia S 1995 The Complete Guide to Aromatherapy.
Watson Ferguson & Co, Brisbane
Gimbel T 1994 Healing with Colour. Simon & Schuster,
Sydney
Goldberg L 2001 Massage and Aromatherapy: A Practical
Approach (2nd edn). Nelson Thornes Ltd, Cheltenham
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9
self-care for the
massage therapist
Lisa Casanelia chapter
LEARNING OUTCOMES
l Develop strength and flexibility in preparation for massage
l Perform self-massage techniques
l Develop a self-care program to minimise the strain of performing massage regularly
l Cultivate awareness of individual strengths and weaknesses
INTRODUCTION Appropriate equipment, including a massage table that

The human hand is a unique part of the body. Mechani- is adjusted to the correct height, and effective tech-
cal massage devices and other such apparatus can never nique, posture and use of body weight when providing
replace the ability of the hand to mould to the contours a massage, are important preventive factors to overuse
of the human body or sensitively interpret the soft tis- injuries. To avoid developing injuries when in practice
sues of the body. The quality of the human touch and the the massage therapist can cultivate an awareness of
contact it provides is far superior in therapeutic value how the hands and body move whilst performing mas-
to any machines or tools designed to replicate massage. They may then adopt a daily exercises regime that
sage. As such the hands are appropriately designed to encourages mobility and flexibility whilst strengthen-
perform intricate patterns of touch and movement that ing the hands, forearms and body. Without such regular
allow massage techniques to be varied in their applica- exercise a therapist may find that their wrists, fingers
tion. This ability combined with the dense distribution or hands start to ache after months or years of practice.
of tactile skin receptors through the fingertips make for Exercise strengthens the hands so they can cope with
a powerful combination of interpretation and applica- the demands of massage, minimising the possibility of
tion ability through touch. repetitive injury. This chapter will introduce a self-care
The massage therapist is indeed fortunate to have regimen for therapists to maintain their strength, endur-
the ability to apply unique strokes and assess the cli- ance and flexibility.
ent’s condition through the use of their hands. Those
who have received a massage from a skilled therapist A DAILY REGIME
would be well aware of the types of strokes and touch The massage therapist should perform specific exercises
that can be applied to the body with the hands. The designed to stretch and strengthen the thumbs, fingers,
ability to provide such touch is the primary tool of the wrists and forearms on a daily basis. Such exercises will
massage therapist and a therapist working in a busy assist the therapist to perform in their clinical practice.
practice would perform their skill many times over in The old adage ‘you should practice what you preach’
the course of a day. As in any profession, the tools of the holds true for the massage therapist. As advocates of
trade, the therapist’s hands, must be protected and cared regular massage the therapist should also partake in
for so as to prolong the working life of the therapist. regular massage; the use of self-massage will benefit
As massage is a manual therapy that is repetitive the health of the therapist and assist in increasing the
in nature it is not uncommon for massage therapists to longevity of their massage career. It is very easy for
develop overuse injuries. The thumbs, fingers, wrists the massage therapist to incorporate exercise and self-
massage into their practice regime. What follows are
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and shoulders are common injury sites arising from

improper use and positioning of the therapist while per- simple recommendations for self-care of the hands and
forming massage. Prevention of injury, fatigue and mus- body that serve as a guide for the therapist in developing
cle strain can be achieved in a number of practical ways. a daily self-care regime to suit their practice.
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Flexibility and mobility exercises joint). Repeat this movement several times, then do the
Muscles by nature display qualities of contractility and same for each of the fingers and the thumb.
elasticity; allowing them to contract and shorten when The entire sequence should be repeated on the oppo-
stimulated and relax when not stimulated. It is impor- site hand.
tant for the health of muscles that their mobility is main-
tained, as a muscle that is shortened for a prolonged Flexibility of the forearm flexors
period may become hypertonic and loose its flexibility. Stand in front of a desk and place the palms and fingers
This is not ideal as a muscle in its shortened position flat on the desktop with the fingers facing back toward
is a muscle that has a decreased range of movement the body. Move the body away from the desk until a
and a compromised ability to provide maximum effort stretch is felt in the front of the forearms and wrists. If
or strength. Whilst performing a massage a therapist is this stretch feels too strong it can be modified by allow-
continually contracting and relaxing their musculature. ing the fingers to curl over the edge of the desk to lessen
After performing repeated massages it is not uncom- the intensity of the stretch (see Figure 9.1).
mon for a therapist’s muscles to feel fatigued.
Day in and day out the massage therapist works Flexibility of the forearm extensors
and replicates the same movements and uses the same
In a similar manner to the above exercise, place the back
muscles. A therapist who does not stretch their muscles
of the hands flat on the desktop with the fingers facing
under such conditions, so as to elongate them back to
back toward the body. Move the body away from the
their normal resting length, may end up with a posture
desk until a stretch is felt in the back of the forearms and
that is contracted and hunched, and hands and fore-
wrists (see Figure 9.2).
arms that feel weary and ache. Mobility and flexibility
are very important for the massage therapist to allow
for proper functioning and health of the muscles and Finger flexibility
for correct alignment and posture. As such, a therapist Resting on a table, spread the thumb and index finger
should incorporate a daily stretching routine into their out and away from each other. Repeat the process with
massage practice as part of their self-care. index finger and middle finger and so on to stretch each
A stretching program for the massage therapist must finger in turn (see Figure 9.3).
target specific muscles of the body. The mobility and
flexibility exercises under the following subheadings Flexibility of pectoralis major
focus on muscle groups that are commonly overworked Stand close to a wall or a corner with one arm out to the
during massage and have the potential to become con- side at shoulder height and with the elbow bent and the
tracted from overuse. hand facing forward. Rest the forearm on the wall and
When a therapist performs these exercises the lunge the body forward, away from the arm. A stretch
following recommendations apply: should be felt across the top of the chest and into the
l The feeling in the muscle should be a gentle stretch front of the shoulder (see Figure 9.4).
rather than an intense or painful feeling.
l Breathing should be relaxed throughout the exercise.
l The stretch should be held for a period of approxi-

mately 8 to 10 slow breaths.
l The exercise should be performed equally on both
sides of the body.
l The exercise should be performed at the beginning
and end of a working day and, where possible, in
between clients.
Hand mobility exercises

Use the right hand to work on the left hand, which will
remain relaxed and passive throughout. Begin by gently
folding and unfolding each of the fingers in turn (3–5
repetitions per finger); start with the little finger, finish
with the thumb. Gently hold the end of the little finger
and take it through a large easy circle (circumduction)
several times clockwise, then anticlockwise; this
movement is not a stretch but rather a light and easy
movement. Repeat on each of the other fingers includ-
ing the thumb.
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Gently hold the knuckle (metacarpophalangeal

joint) of the little finger and move it back and forth
(extension followed by flexion of the carpal metacarpal Figure 9.1 Flexibility of the forearm flexors
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9 Self-care for the massage therapist 85
Figure 9.2 Flexibility of the forearm extensors Figure 9.4 Flexibility of pectoralis major
Figure 9.3 Finger flexibility Figure 9.5 Flexibility of latissimus dorsi
Flexibility of latissimus dorsi Flexibility of upper trapezius

Rest the back flat against the wall with the knees bent as Sit on a chair with an upright posture and stabilise the
if sitting in a chair. Bring the arms together in front of trunk and shoulder girdle by holding onto the side of the
the chest, with the elbows bent and touching each other. chair with one hand. The other hand guides the head in
The palms should also be touching and facing toward gentle side-bending where the ear is moving toward the
the body. Take a deep breath in and on the exhale lift the shoulder (see Figure 9.6).
arms up as a unit over the head and towards the wall.
The hands should touch the wall above the head and Flexibility of rhomboids
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slide up the wall as high as they can go. At the maxi- Sitting in a chair, cross the arms in front of the chest and
mum stretch, hold and breathe deeply several times grasp the sides of the chair, drop the head forward and
before releasing the position (see Figure 9.5). open up the shoulder blades by moving them away from
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r eaching down toward the shoulder blade. The other

hand reaches across toward the elbow and increases the
stretch by grasping the elbow and pulling it backward.
Hold this stretch as you breathe deeply several times
(see Figure 9.9).
Flexibility of thoracic spine

Lying on the floor use a bolster (or a towel rolled up to
create a bolster) and place it across the spine and just
below the shoulder blades. Lay over the bolster and
allow the thoracic spine to extend and the chest to open
up. Lay there for several minutes, breathing deeply (see
Figure 9.10).
Figure 9.6 Flexibility of upper trapezius
the spine. Hold this stretch and breathe deeply several

times (see Figure 9.7).
Flexibility of anterior shoulder

Kneel down next to a massage table facing away from
it, clasp the hands together behind the back and lift them
as a unit to rest on the massage table, and keep the chest
open and body upright. To maximise the stretch lower
the body so the buttocks are lowered toward the heels.
Hold this stretch for a minute, rest and repeat several
times (see Figure 9.8).
Figure 9.8 Flexibility of anterior shoulder
Flexibility of triceps brachii
Bring one arm up straight beside the head with the
fingertips stretched up and the palm facing backward.
Bend the arm at the elbow until the fingertips are
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Figure 9.7 Flexibility of rhomboids does not match de-

scription of stretch in text Figure 9.9 Flexibility of triceps brachii
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Figure 9.10 Flexibility of thoracic spine
Back loosening exercise

Lie supine on a carpeted floor or folded blanket and
bend both knees so the feet are flat on the floor about
hip width apart. With the knees apart and arms resting Figure 9.11b Back loosening exercise
on the floor away from the body, slowly move both legs,
tipping them over to the right as far as is comfortable.
Slowly bring the legs back to the middle and then over
to the other side. Repeat this movement several times,
paying attention to the back and hips, consciously
softening and relaxing these areas as they move (see
Figure 9.11a). Stretch the legs out in front of the body
and rest for 30 seconds.
Bend the knees again and continue the movement as
before, only this time, gently roll the head in the same
direction as the legs. Repeat this movement slowly and
gently from side to side several times, paying attention
to relaxing the back, hips and neck (see Figure 9.11b).
Rest as before.
Figure 9.11c Back loosening exercise
Bend the knees and resume the movement as before,

this time rolling the head in the opposite direction to the
legs. Repeat this several times, paying attention to areas
in the body holding tension and consciously let it go
(see Figure 9.11c). Rest as before.
Bend the knees up and resume the original move-
ment (i.e. only the legs tipping side to side). Notice if
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it feels easier and if the rest of the body automatically

participates. Rest as before. Observe while resting if the
body feels more comfortable and notice if the back, hips
Figure 9.11a Back loosening exercise and legs feel more relaxed.
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Resistance exercises Strengthening the fingers

For the therapist to perform a 1-hour massage with Using a peg or a butterfly clip (used to fasten papers) place
ease they require a minimum degree of strength. To the end between the thumb and index finger and squeeze
perform 8 massages in 1 day, over 5 working days the two fingers together to open the peg or clip. Repeat
a week, the therapist requires a much greater degree this several times and move on to the second digit and
of muscle strength and endurance. The development thumb. Continue this through the fingers, noticing the dif-
of such strength and endurance of the musculature ference in strength between each finger (see Figure 9.15).
is imperative so that the therapist does not fatigue
during their working day. Fatigue will increase the
chance of injury.
The following resistance exercises are designed to
build strength, improve function, increase muscular
endurance and increase power in muscles that are com-
monly used whilst performing massage.
When a therapist performs these exercises the fol-
lowing recommendations apply:
l Start out with a minimal resistance and progress to
a heavier load over time as the exercise becomes
easier.
l Aim to perform up to 10 repetitions of the exercise
and repeat three sets of these repetitions on each
side of the body.
l Perform strengthening exercises every other day.
Figure 9.13 Strengthening forearm flexors

Strengthening the forearm flexors
and extensors
Hold a weight in one hand with the palm facing down,
the elbow bent and the wrist in a neutral position
(neither flexed nor extended). Bend the wrist upward
and then release it back to the starting position; repeat
10 times (see Figure 9.12). Repeat this exercise with the
palm facing up (see Figure 9.13).
Strengthening the hand

A variety of objects can be squeezed in the palm of
the hand to increase strength and avoid overusing any
one set of muscles. Such objects include a tennis ball,
squash ball or stress ball. Squeeze the object with
moderate strength, with the wrist in a neutral position
(neither flexed nor extended). Repeat 10–20 times on
each hand (see Figure 9.14).
Figure 9.14 Strengthening the hand
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Figure 9.12 Strengthening forearm extensors Figure 9.15 Strengthening the fingers
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Figure 9.17 Strengthening rhomboids
Figure 9.16 Strengthening serratus anterior
Strengthening serratus anterior

Lie supine on the floor with the knees bent and a folded
towel placed between the floor and shoulder blades.
Place weights in either hand and extend the arms up
in front of the chest with the palms facing each other.
Keeping the arms straight, stretch one arm up higher,
extending it out from the shoulder, and then drop it back
so that the shoulder blade compresses back into the
towel. Repeat this on the same side 10 times and then
repeat on the other side. Repeat the cycle three times
(see Figure 9.16).
Strengthening rhomboids
Lean down over a low bench and support the body with
one knee and arm resting on the bench. The free hand
holds a weight and the arm hangs down by the side. Figure 9.18a Strengthening rotator cuff
Bend the elbow as you bring the hand with the weight
back toward the chest. The action comes from the
scapula being squeezed toward the midline. Repeat SELF-MASSAGE
10 times on each side and repeat the cycle three times All massage therapists would be aware of the benefits
(see Figure 9.17). of massage. Massage therapy may assist in relieving
tension in tight and contracted muscles and as such is
Strengthening rotator cuff of benefit to the therapist. Possessing the skills of mas-
Sit on the edge of a chair, holding a weight in either hand in sage application the therapist is limited only by their
front of your chest. The elbows are bent and together and imagination when it comes to self-massage and it is
the palms are facing each other (see Figure 9.18a). From recommended that the therapist employ a variety of
this position, bring the arms out to the sides keeping the techniques to apply self-massage to their body.
elbows bent and parallel to the ground (see Figure 9.18b). There is a wide range of massage tools on the mar-
From here, lift your arms up straight over your head with ket that can assist the therapist in applying self-massage
the palms facing forward (see Figure 9.18c). Finally bring to areas of the body that may be difficult to access.
the arms back to the starting position by first turning the A simple and inexpensive self-massage tool that is
palms to face each other, then bring the elbows together readily available in many households is a tennis ball or
copyright law.
as they are lowered. Repeat this cycle seven times and golf ball. The therapist can use these to assist in mas-
then reverse the order for the last three cycles. Rest in saging muscles that are not easy to access by placing
between repeating this sequence twice more. the ball against a wall or on the floor and using their
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Receiving a regular massage from a colleague or

other fully qualified massage therapist is also an effec-
tive way of preventing overuse injuries. Trading mas-
sages with another massage practitioner provides the
opportunity for both therapists to benefit from each
other’s skills.
CONTRAST ARM BATHS

To reduce fatigue and aid recovery after a day of mas-
sage a therapist may find relief through the use of hydro-
therapy treatments. A simple hydrotherapy method
to use is a contrast arm bath. Using a double sink or
two small tubs about sink size, fill one with hot water
(as hot as can be tolerated) and the other with cold water
(ice may be added to make it extra cold). Beginning
with the hot water, place the forearms and hands into
the water and leave for approximately 2 minutes, fol-
low directly into the cold water and leave for approxi-
mately 30 seconds. Repeat the cycle from hot to cold
three times, beginning with hot and ending with cold.
At the end of the sequence shake the excess water from
Figure 9.18b Strengthening rotator cuff the arms and hands and allow to air dry. The arms and
hands should be tingling and feeling very much alive.
Figure 9.19a Self-massage to forearm flexors
Figure 9.18c Strengthening rotator cuff
body weight to lean into the ball and roll it around on

the muscles.
The forearm flexors and extensors are muscles
that are frequently overused during massage and self-
massage can be applied to these muscles by using the
forearm of the opposite arm to stroke along their length
(see Figures 9.19a and 9.19b). Self-massage tech-
niques should be incorporated into the therapist’s daily
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warm-up and warm-down routines and used in between

massage treatments where possible to maintain the
health of the muscles and minimise the risk of injury. Figure 9.19b Self-massage to forearm extensors
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GENERAL HEALTH an adequate treatment when skilled at techniques.

As a health care provider the massage therapist has the They can provide an excellent, enjoyable and effec-
responsibility to educate clients about how to look after tive massage treatment when they adopt correct body
themselves and maintain optimal health and wellness. mechanics, strengthen their weaknesses and take care
It is also important that, as a practitioner, the massage of their tools of the trade — their hands. Massage thera-
therapist also adopts a lifestyle that promotes health and pists who preserve the strength, flexibility and health of
wellness so as to provide a role model for their clients. their hands and body will go a long way towards ensur-
For instance, a therapist will generally recommend that a ing a healthy and rewarding career.
client receive regular massage as a form of preventative
health. So too must the therapist receive regular mas- Questions and activities
sage. A therapist that looks after their health, receives Design a weekly health and fitness plan specifically for
regular massage, follows an exercise program and has the practicing massage therapist that takes into consid-
a healthy diet and lifestyle will portray a positive role eration strength and flexibility of the relevant muscle
model to the client and serve as a worthy advocate for groups, providing a rationale for each activity.
the massage profession.
The suggestions in Box 9.1 may assist the massage References
therapist in looking after their health whilst in clinical
Greene L 1995 Save Your Hands! Injury Prevention for
practice.
Massage Therapists. Gilded Age Press, Colorado
Greene L, Goggins R 2008 Save Your Hands! The
CONCLUSION Complete Guide to Injury Prevention and Ergonomics
Students about to embark on careers as massage thera- for Manual Therapists (2nd edn). Gilded Age Press,
pists must recognise the physical nature of the pro- Florida
fession. As manual practitioners, therapists perform Kisner C, Colby L 2007 Therapeutic Exercise, Foundations
repetitive movements, many whilst leaning over a mas- and Techniques (5th edn). FA Davis Company,
sage table; movements that are both physically demand- Philadelphia
ing and draining on the body. The strength, flexibility
and health of therapists are key factors in the ability
of practitioners to execute massage techniques effi-
ciently and effectively. Massage therapists can provide
Box 9.1 Suggestions for massage therapists to

maintain their health
l Receive regular massage.

l Maintain the health and integrity of the skin of
the hands and forearms.
l Maintain the health and integrity of the nails.
l Vary the part of the arm and hand used in

performing massage to decrease the risk of
overuse injuries.
l Adopt a healthy diet and lifestyle.
l Maintain flexibility and mobility through regular

exercise.
l Maintain the strength and endurance of muscles
required to perform massage.
l Cultivate awareness of movement and posture
by practising movement therapies such as
yoga, tai qi, pilates, qi gong, Feldenkrais or
martial arts, or by consulting with an Alexander
technique teacher, who can provide advice
about how to use the body more efficiently when
delivering massage therapy.
l Become aware of the makeup of the hand and
take note of any individual weaknesses that may
exist.
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l Use correct hand technique and correct body

mechanics.
l Recognise and respond to any injuries promptly.
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10
infection control in massage
therapy practice
Ellie Feeney and Heather Morrison chapter
LEARNING OUTCOMES
l Define infection and explain the causes of infection
l Describe the routes of transmission and methods of entry of infectious agents into the human
body
l Identify possible infection risks in the practice of massage therapy
l Define Standard and Additional Precautions, the work practices required to ensure infection
control in the practice setting
l Describe the application of Standard and Additional Precautions in the practice of massage
therapy

INTRODUCTION as ‘a disease caused by the invasion of the body by

Massage therapists have both a moral and legal duty of pathogenic microorganisms’ (Harris et al 2006). These
care to protect their clients, their employees and them- microorganisms such as bacteria and viruses reproduce
selves from harm. Harm can come from many sources, and multiply inside the human body until there are suf-
however this chapter will focus on how harm can be ficient numbers to cause disease symptoms. The micro-
caused by infectious diseases, and then most impor- organisms may either be naturally occurring in or on the
tantly, what massage therapists need to do to carry out body or arrive there as a result of attack and invasion
their duty of care in relation to this. from an external source.
Infectious diseases by definition are communicable; The characteristic features of infection differ
that is, they can be passed on, or transmitted, from per- depending on the type of organism and the location
son to person. of the infection within the body, and may be due to
Massage therapy is a relatively safe health care the action of the microorganisms themselves or to the
modality. There are very few reports of disease trans- action of the body’s immune system that is seeking to
mission as a result of massage treatments (Vickers & destroy them.
Zollman 1999). However, massage by its very nature
involves direct contact between humans and so there is Some history of infectious disease
always the possibility that transmission of infection from Infectious diseases and epidemics, throughout history,
client to therapist or therapist to client can occur. Not all have been considered with fear and superstition, a con-
clients encountered will have an infectious disease but dition which still exists in some parts of the world or
everyone has the potential to carry or spread infection. in relation to some infectious diseases today. In earlier
This chapter aims to outline the causes of infections times, it was thought that infections were the result of
and their modes of transmission as well as the work bad airs or ‘miasmas’, or were brought to an area by
practices that need to be employed within the massage travellers. Treatment for infectious diseases included
setting to ensure a safe work environment for both mas- the use of potions and pain killers, and what we con-
sage therapist and client. sider today as barbaric practices such as blood-letting
and harsh laxatives.
WHAT IS INFECTION?
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Famous examples of epidemics occurred from the

Before the practice of infection control can be imple- twelfth to fifteenth centuries when it was estimated
mented it is necessary to understand what infection that tens of millions of people died in Europe in suc-
is and where it comes from. Infection can be defined cessive epidemics of the bubonic plague, a bacterial
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infection. But as late as 1917–1918, the Spanish ‘flu’ Pathogens are derived from four main groups of
pandemic killed 21 million people, more than three microorganisms — viruses, bacteria, fungi and para-
times the number of deaths that occurred during World sites. Each of these major pathogenic groups will be
War 1 (Lee & Bishop 2002). discussed in turn.
There is certainly truth to the ease with which infec-
tion can be spread by ‘travellers’ and the speed with Viruses
which we can travel great distances today means that Viruses are amongst the smallest of the microorganisms
worldwide epidemics — pandemics — are a continuing and most are incapable of surviving for long periods of
threat. time outside of a host cell. They survive by infecting
In the seventeenth century the microscope allowed a host’s normal cells and inserting their own genetic
the presence of microorganisms to be observed, how- material into them. A host is any organism — plant, ani-
ever it took another 200 years until the late 19th cen- mal or human — in or on which the virus can live. The
tury before the relationship between these microbes genetic material of the virus takes over the metabolic
and disease was proposed — known today as the germ machinery of the host cell and forces it to manufacture
theory of disease. ‘Even after microorganisms came to viral proteins. These viral proteins are assembled into
be recognised as agents of disease, many years of pains- new viruses and are then released from the host cell.
taking research were required to relate specific diseases One infected cell is capable of producing hundreds of
with the agents that caused them’ (Black 2008). new viruses and these newly released viruses are then
Important infection control strategies such as pas- free to infect neighbouring cells. When a certain per-
teurisation of milk, use of disinfectants, and hygiene centage of cells are infected, signs and symptoms of the
practices such as hand washing were gradually imple- disease become apparent.
mented in the late 1800s, but in the early 20th century
more than 60% of all deaths in the world could still be
Bacteria
attributed to infectious diseases (Lee & Bishop 2002).
In Western countries, due to advances in understanding Bacteria are single-celled organisms, the majority of
of the causes and transmission of infectious diseases, which can survive in the environment on their own.
better sanitation, disinfection and hygiene practices, Bacteria replicate quickly by dividing and multiplying
and thanks to the development of many antimicrobial to produce a bacterial colony. The colony requires spe-
agents to treat a range of infections and vaccinations cific temperatures and nutrients for replication and dies
to prevent many, this figure is now less than 5%. In quickly if these requirements are not met. The human
developing countries, however, millions of people still body by its nature is warm, moist and nutritious and
die each year from infectious diseases which could be provides an ideal environment for bacterial growth.
prevented or treated (Lee & Bishop 2002). When pathogenic bacteria enter the human body
they need to multiply to relatively large numbers before
disease symptoms occur. The signs and symptoms of
INFECTIOUS MICROORGANISMS
bacterial infections are usually as a result of the secre-
The environment in which people live is teeming with tion of toxic substances from the bacteria, damage to
an immense variety of microorganisms and modern the host cells from the formation of the bacterial colony
technologies are revealing their amazing diversity. or the consequences of the body’s immune response to
These minute organisms are found in all aspects of the bacterial invasion.
the environment, from soil and water to the food people
eat and the air they breathe. Many of these tiny crea- Fungi
tures are even found on and in the human body, some
actually assisting in vital functions such as digestion. Fungi are a very diverse group of organisms that range
These diverse groups of microorganisms that exist in from small single-celled organisms such as yeasts to
balance or ‘harmony’ with the physiology of the human large plant-like structures such as mushrooms. The
body are referred to as ‘normal flora’. It is essential that majority of fungi are harmless to humans, however the
this balance between normal flora and the body is main- few that are capable of causing infections fall into two
tained for good health. Changes in the physiological main groups — yeasts and moulds. Although both yeasts
condition of the body can alter the balance of microbes, and moulds can cause infections, this occurs more com-
commonly allowing the overgrowth of one species to monly if there are other predisposing factors in the host,
the detriment of others and resulting in infection and such as immunosuppression from a pre-existing illness
disease. or drug therapy. Such infections are classified as oppor-
The abnormal overgrowth of normal flora can be tunistic as they take advantage of the weakened immune
one way in which infectious disease manifests. Another system to become established.
way is by microorganisms which are not normally a part
of the body, successfully invading it, or by organisms Parasites
which are ‘normal flora’ in one part of the body, mov-
copyright law.
A parasite is an organism that derives its nutrients

ing to another part in which they do not normally exist. from a host. Technically all pathogens are parasitic by
These microbes are referred to as pathogens, which by nature as they derive their nutrients from the body after
definition are disease-causing organisms. infecting it. It is convention, however, that parasitic
Account: s8715057
10 Infection control in massage therapy practice 95
microorganisms refer to a diverse group of microbes Transmission of organisms via contact

called protozoa, such as giardia and cryptosporidium. Contact transmission itself can be divided into three
Generally, protozoa enter the body through con- subgroups — direct, indirect and droplet. Direct trans-
taminated food or water or from direct contact with the mission of microorganisms means contact with the
protozoa in the environment. Parasites then infect the source of infection such as an infected person or animal.
body in various ways, creating infestations that cause Indirect transmission means there is an intermediate
tissue damage. between the source of infection and the newly infected
person. These intermediates can be inanimate objects
Other infectious organisms such as massage tables, computers, workbenches, writ-
Parasites are not always microorganisms. Parasites can ing implements and money, in fact just about anything
include large multicellular organisms called helminths that is found in a workplace or clinic. Droplet trans-
(worms and flukes) that live inside the body. Tape- mission occurs when someone sneezes or coughs on
worms can grow inside human intestines to an amazing another person within about 1 metre of their presence.
length of several metres (Boon et al 2006). Arthropods This person is not in physical contact with the person
are another example of parasites that can be seen with who sneezes, only their secretions.
the naked eye and include lice and scabies. These are Contact transmission is of major importance in mas-
ecto-parasites; that is, they live on the outside of the sage therapy as an integral part of a massage treatment
body and derive nutrients from the body by biting and involves touching the skin of clients as well as objects
sucking blood. with which they have come into direct contact.
Transmission of organisms via vehicles

WHERE ARE INFECTIOUS AGENTS Certain elements of our environment can facilitate the
FOUND? transfer of microbes to new human hosts. These ele-
As mentioned previously, microbes can be found almost ments are air, water and food.
anywhere — in air, water, soil, food, and on animals, Breathing in air that contains pathogenic microor-
people and even the surfaces of inanimate objects. ganisms is an efficient way for a microbe to establish an
Remember that the majority of these microbes are infection in the body, especially in the respiratory tract.
completely harmless to humans and form a natural part Both viruses and bacteria can be airborne and travel on
of our ecosystem. However, some are pathogenic to air currents. Water is also a vehicle for bacteria, viruses
humans and are responsible for a large variety of infec- and common parasitic protozoa to enter the body, espe-
tious diseases. cially via the digestive system. Contaminated food can
also act as a vehicle for transmitting infection into the
Transmission and entry body.
of infectious agents To apply knowledge of these transmission mecha-
nisms, it is essential that any food or water offered to
Although many pathogens have a great potential for
clients follows acceptable storage and food handling
harm to humans they can only do so if they can be trans-
guidelines.
mitted and enter the human body. It is important then,
for infection control, to understand the ways in which Transmission of organisms via vectors
microbes can be transmitted. Mechanisms of transmis-
sion of microorganisms may be categorised under three As already discussed, it is not necessary to come into
main headings — contact, vehicle and vector. direct contact with the source of infection to enable
transmission of infectious diseases. In addition to indi-
rect contact and vehicle transmission it is also possible
for infectious agents to be transmitted via vectors. Vec-
tors such as insects are carriers of disease and transmit
Box 10.1 Mechanisms by which microorganisms infectious agents such as bacteria, parasites and viruses
can be transmitted from infected sources to humans.
There are two ways that vectors can transmit infec-
Through contact tion. The first is mechanically, by carrying a pathogen
l direct — touching from its source to a host. A clear illustration of this is the
l indirect — via inanimate objects common housefly or blowfly that first visits decompos-
l droplet — sneezing/coughing ing rubbish and then lands on a person, or an inanimate
Via the use of vehicles object with which a person may then come in contact,
l air — breathing in depositing pathogenic microorganisms in the process.
l water — ingesting/bathing The second mechanism is biological, where an insect
l food — spoilage/ingestion already infected with a pathogenic organism bites and
copyright law.
Via the use of vectors transmits that infection to the host. Vectors such as these
l mechanical — carried on the outside of an insect are mosquitoes and ticks transmitting organisms which
l biological — carried by an infected insect cause, for example, Ross River fever, malaria and Lyme
disease.
Account: s8715057
Although mechanical vector transmission of infec- IDENTIFYING AND RESPONDING TO

tion would be more likely to occur than biological trans- INFECTION RISKS IN THE MASSAGE
mission in the majority of Australian massage clinics, it CLINIC ENVIRONMENT
is still necessary for a massage therapist to ensure that So far, this chapter has discussed the types of organisms
pests, vermin and insects cannot gain access to the treat- that cause infection, their sources, their modes of trans-
ment room. The therapist must take measures to ensure mission, and their portals of entry into and exit from a
that any such infestations that may arise are dealt with host.
appropriately. It is important for the massage therapist to relate this
knowledge to the massage clinic setting and to develop
HOW DO INFECTIOUS AGENTS ENTER and apply sound policies and procedures designed to
AND EXIT THE BODY? prevent the spread of infection in their workplace.
For a microbe to be pathogenic it must not just travel In the massage clinic environment, the most likely
to the body but also gain entry into the body and then sources of pathogenic microorganisms will include the
multiply into sufficient numbers to cause disease. The clients themselves and the practitioners and employees,
human body is designed in such a way as to prevent or as well as inanimate objects (called fomites) such as
minimise this potential invasion. door handles, light switches, linen, equipment, massage
A major physical barrier to infection is healthy, tables and other work surfaces.
intact human skin. Skin is a thick impenetrable multi- There is no way of identifying all of the potential
layered barrier against microorganisms and it is difficult disease-causing organisms that a massage therapist
for any microbe to cross this barrier unless the barrier may be exposed to within the clinical setting. These
has been breached or damaged in some way, such as by will vary, depending on the location of the clinic and
cuts, burns or insect bites. The areas of the body where the clients who frequent it. For example, if the client
there is no skin covering are more likely points, or por- base includes a large number of children, the range of
tals, of entry for pathogens. These areas include the: infectious diseases a therapist will be exposed to will be
l respiratory system: nose and mouth different than if the clinic’s clients are predominantly
l digestive system: mouth and anus elderly. Despite the differences in client demographics
l genitourinary system: vagina and urethra
some commonalities will exist, based on the disease
l other body structures such as mucous membranes,
prevalence within the community. Table 10.1 identifies
conjunctiva of the eyes, and ears. some of the more common infectious diseases that may
Different types of infectious agents use different be encountered within a clinic environment and their
portals of entry; for example, an airborne virus or bacte- corresponding modes of transmission.
ria is more likely to enter the respiratory tract than cross When a susceptible person (host) has been exposed
the skin barrier. Knowing how infectious agents enter to an infectious agent, there is a period of time between
the body can aid us in developing and utilising appro- this exposure and the onset of signs and symptoms
priate preventative measures. Knowing the exit routes of the infection. This is called the incubation period,
is of equal importance for infection control as microbes and the person will most likely be contagious during
that exit the body also act as sources of infection. this period and so can pass on the infection to oth-
During an infection the immune system, together ers without knowing they are developing the infection
with other processes of the body, acts to eradicate or themselves.
remove the invading pathogen. As a result, the infec- In many infections, the characteristic symptoms
tious agent is shed from the body in sputum and mucosal appear and the disease runs its course quickly, with
secretions, saliva, vomitus, semen and vaginal secre- the person recovering. However, this is not always the
tions, urine, faeces and blood. It is very likely that the case. In some situations, the disease progresses quickly
massage therapist at some point in their practice experi- but then becomes persistent, in others the disease pro-
ence will have to handle situations in which exposure gresses slowly and persists for long periods of time.
to these bodily fluids occurs, either through accident, In this persistent state there may be few or no obvious
through injury or circumstances particular to individual symptoms, however the person can continue to shed the
clients. Application of effective infection control strate- pathogenic microorganisms during this time.
gies will minimise the risks for both therapist and clients
Implementing infection control in
in the aftermath of being presented with these hazards.
the massage clinic environment
Infection control guidelines have been developed by
the Australian Government Department of Health and
Box 10.2 Important portals of entry of Ageing for all health care settings including massage
microorganisms for massage therapists clinics. These guidelines include work practices which
are integral to preventing the spread of infection and are
called Standard and Additional Precautions.
copyright law.
l Damaged or broken skin

l Respiratorytract: nose and mouth These work practices have been adopted by the
l Mucosal membranes: eyes and ears health departments of all Australian states and terri-
tories. Their implementation in the health care setting
Account: s8715057
Table 10.1 Examples of some common diseases in a clinical setting and their mechanisms of transmission
Organism Type of organism Transmitted by Disease

Influenza virus A Virus Respiratory droplets Influenza
Influenza virus B Airborne
Influenza virus C
Rhinovirus Virus Respiratory droplets Common cold
Parainfluenza virus Airborne
Staphylococcus aureus Bacteria Direct contact Can infect most parts of
Indirect contact the body, including skin
(clothes, linen etc.) Present in folliculitis, acne
Streptococcus pyogenes Bacteria Direct contact Tonsillitis
Airborne Scarlet fever
Cellulitis
Tinea pedis Fungus Direct contact Cutaneous fungal
Indirect contact infection
(foot baths) (athlete’s foot)
Tinea corporis Fungus Direct skin-to-skin contact Cutaneous fungal
infection
(ringworm)
Sarcoptes scabiei (scabies) Parasite Direct contact Secondary bacterial
Indirect contact infection from scratching
Pediculus capitis Parasite Direct contact Secondary bacterial
(head lice) Indirect contact infection from scratching
as the use of personal protective equipment appropri-

Box 10.3 Potential sources of microbes in the ate for the infection, or even isolating the client, are
massage clinic recommended when dealing with such clients, how-
ever it is usually contraindicated for a massage thera-
l Massage tables pist to treat a client who is acutely ill with one of these
l Oilbottles or containers infections.
l Foot baths Within Standard Precautions, depending on the
l Heat packs and eye covers treatment procedure to be undertaken, aseptic tech-
l Linen niques may be required. ‘Asepsis’ is the term used to
l Furniture and furnishings describe the absence of infectious agents that may pro-
l Bathroom facilities
duce disease, however aseptic techniques can be divided
into sterile and clean techniques. True asepsis cannot be
achieved in the massage clinic as it involves sterilisa-
tion equipment that will not normally be accessible to
is designed to provide appropriate protection from a massage therapist, and nor is it required. Instead, pro-
infection for patients or clients, as well as for health cedures of clean techniques are adopted to minimise as
care workers and others entering health care settings. much as possible the transmission of microorganisms.
Standard Precautions are a set of work practices Clean techniques then refers to the work practices
that, when used, achieve a basic level of infection con- that include a high standard of personal hygiene and
trol. They apply to the care and treatment of all patients/ hand washing, the use of barriers to reduce the trans-
clients regardless of their perceived or confirmed infec- mission of infectious agents, the use of environmental
tious status and cover the handling of blood, other controls to reduce transmission and the appropriate
body fluids, non-intact skin and mucous membranes. cleaning of instruments and equipment between clients.
Remember, some people may be infectious without The application of these procedures in the massage set-
even knowing it. ting will be discussed in the next section.
Certain types of infectious agents are difficult to Massage therapists who work in hospitals or other
control with Standard Precautions alone. These are health care institutions will be required to comply with
copyright law.
those passed on by airborne or droplet transmission of the infection control policies and procedures of those
respiratory secretions and include pulmonary tubercu- organisations. Some of these procedures may include
losis, chicken pox, measles, rubella, pertussis (whoop- more stringent sterilisation and disinfection protocols
ing cough) and influenza. Additional Precautions such for certain work equipment.
Account: s8715057
Application of infection control

practices
Personal hygiene and hand washing
Personal hygiene is paramount to infection control. As
a massage therapist, direct person-to-person contact is a
part of every treatment regime. It is therefore essential
that every aspect of personal hygiene be attended to at
the highest possible standard.
Personal cleanliness should be maintained at all
times. Therapists should ensure their hair is clean. The
therapist’s hair should be tied back if it is long enough
to contact the client in any way during the application
of massage techniques. This prevents intrusion in the
therapy technique as well as decreasing transmission of
microbes.
Figure 10.1a Thoroughly wet hands
Hand and nail care is of particular importance as
hands represent the contact between client and thera-
pist. The massage therapist should ensure that there is
no broken skin on their hands or on the skin of the cli-
ent. Any broken skin should be covered appropriately
with a non-absorbent covering or the therapist should
wear protective equipment such as gloves during the
treatment (see next section). The therapist’s nails need
special attention and all fingernails should be cut short
and be free from all traces of dirt or foreign matter.
Acrylic nails should not be worn, and damaged nail pol-
ish should be removed, as these provide many crevices
in which microorganisms can remain during routine
hand washing.
Jewellery on the hands and wrists is also a poten-
tial source of infection and may injure the client, so it
should be removed when massaging and hand washing.
The therapist may opt for more personal protection
through vaccination against common transmissible dis- Figure 10.1b Build up a vigorous lather
eases. This is, however, a very personal choice and all
aspects of this option should be considered, such as rel-
evance of the vaccine, cost, potential of infection and
possible side effects.
One of the most vital protocols that should be
adopted is the correct hand washing routine. Appro-
priate hand washing is the single most effective simple
hygiene method to reduce the transmission of patho-
genic microorganisms from therapist to client. The
wearing of gloves is not a substitute for effective hand
washing. Hands must be washed before and after sig-
nificant client contact of any type, after engaging in any
activities likely to cause contamination, and after the
removal of gloves.
The hand washing routine

The procedure for correct hand washing is shown in Figure 10.1c Remove lather under running water
Figures 10.1a–d. Effective hand washing begins by
removing all jewellery and thoroughly wetting the be taken at this point not to touch the tap handles with
hands with water. A mild pH neutral liquid detergent clean hands. If elbow or foot controls are not avail-
is then applied and a vigorous lather is built up across able then a paper towel should be used to turn the tap
copyright law.
all aspects of the hands, incorporating the palms, back off. Hand washing should continue for a minimum of
of hands, wrists, between the fingers and thumbs, under 10–15 seconds. Hands can then be patted dry with a
the fingernails and up the forearms to the elbows. The clean paper towel or hand towel (Australian Govern-
lather is then washed off in running water. Care must ment Department of Health and Ageing 2004). If hands
Account: s8715057
If the therapist has damaged or broken skin on their

hands or if the client has damaged or broken skin, there
should be no direct skin contact between client and ther-
apist; that is, gloves should be used. Alternatively, there
may be a spill of blood or bodily fluid (such as urine or
faeces from incontinent clients) that needs to be cleaned
and in these situations gloves are also essential. There is
also a particular procedure for the correct removal of the
gloves after clean up or contact with the potential haz-
ard. After contact with the bodily fluid or infected mate-
rial the gloves themselves become sources of infection
and must be handled appropriately. It is necessary that
the therapist does not touch the outer surface of the con-
taminated gloves in order to remove them. Instead the
therapist needs to follow the procedure outlined below.
Figure 10.1d Dry hands with clean towel 1 Grasp the outside of the cuff of one glove below the
wrist.
2 Pull the glove down over the hand, turning the glove
become contaminated with blood or other body fluids inside out as you do so, and continue to hold that
(not sweat), then a 1 minute hand wash should be car- glove in your remaining gloved hand.
ried out as above.
It is important for therapists to monitor the condi- 3 Insert the ungloved fingers inside the cuff of the
tion of their hands following hand washing, and note if other glove.
they are becoming dry or cracked or showing evidence 4 Pull the glove downwards and off the hand and over
of any rashes. Ensuring hands are well moisturised fol- the first glove, turning the second glove inside out
lowing routine hand washing should reduce the inci- in the process.
dence of these reactions occurring. 5 Drop the inverted gloves directly into a lined bin for
disposal.
Alternatives to hand washing 6 Wash your hands. (Remember — wearing gloves is
Waterless hand cleaning using an alcohol based liquid not a substitute for hand washing.)
or gel with emollients is, in most situations, an appro- This procedure is illustrated in Figures 10.2a–d. If
priate substitute for hand washing with soap and water. this procedure is followed correctly there will be no
It is important to use sufficient product (approximately contact with the contaminated surface of the gloves.
5 ml) and spread it over all surfaces of both hands, con- Gloves that have been contaminated then need to be dis-
tinually rubbing it in until dry. When using such a sub- posed of appropriately (see section on waste disposal).
stance, hand washing with soap and water should not
immediately follow its application, as this may promote
an irritant skin reaction.
If hands are visibly soiled, hand washing with a pH
neutral liquid soap and water should still be carried out.
Personal protective equipment

There is a range of personal protective equipment that
may be of use to the massage therapist, such as gloves,
face masks, eye protection and appropriate footwear.
Each of these items is designed to protect the therapist
from infectious agents. The majority of personal protec-
tive equipment may be more useful in clean-up proce-
dures than during client treatment.
Examination gloves
Gloves should be used when there is a risk of exposure
to blood or body fluids. They must be of high standard
and meet Australian guidelines for patient examination.
Latex gloves are the most commonly used gloves for
personal protection, however some people may have or
copyright law.
may develop an allergic reaction to latex. Alternatives

such as those made from vinyl or nitrile should be read-
ily available in the clinic in case a therapist or a client
has such an allergy. Figure 10.2a Grasp outside of cuff below the wrist
Account: s8715057
Figure 10.2b Turn glove inside out down the hand Figure 10.2d Drop inverted gloves into a lined bin
should not be touched by hand while being worn and

needs to cover both the nose and mouth to be effective.
A face mask should be removed as soon as practicable
after becoming moist or visibly soiled and this is done
by touching the ties or loops only. A mask must be dis-
carded as soon as practicable after use and if a single-
use mask is employed the therapist must ensure that it is
indeed used only once.
Clothing
The clothing worn during treatment of clients can also
be considered protective equipment for both the thera-
pist and client. To be protective the clothes must be kept
clean and laundered regularly. If contamination with
bodily fluids occurs, clothes must be changed as soon
as practicable and the soiled clothes bagged for laun-
dering.
Footwear should also be considered. Covered foot-
wear offers the best protection from sharp and heavy
objects, as well as spills and body fluids. As massage
therapy clients are often barefooted themselves as they
prepare for treatment, also consider the possibility of
their leaving fungal organisms on your floor surfaces.
Figure 10.2c Ungloved fingers into cuff of remaining
glove
Shoes should also be cleaned regularly to prevent spread
of infectious agents.
Eye protection
Face masks The final piece of protective equipment that may be of
During the clean up of an infectious hazard or in any benefit to the massage therapist is eye protection. This
other circumstance where there is the potential for is likely to be of most benefit in the cleaning of spills
splashing or spraying of blood or other body fluids or and liquid hazards where there is a potential for splash-
where there is the potential for airborne infection, face ing of blood or body fluids or cleaning chemicals into
masks may be employed. These act as barriers to infec- the eyes.
tion from airborne microbes and can be used to protect
copyright law.
If each of the pieces of personal protective equip-

the therapist and client. ment is employed appropriately this offers a great level
For a face mask to be effective, it must be fitted of protection to the therapist (and the clients indirectly)
and worn according to manufacturers’ instructions. It from occupational exposure to infectious agents.
Account: s8715057
Routine cleaning of the work Cleaning up blood and body substance

environment spills
Good personal hygiene and the appropriate use of per- The massage clinic should have a protocol in place for
sonal protective equipment, while important practices managing blood and body fluid spills. These protocols
for infection control, are insufficient by themselves in should follow Standard Precautions including the use
managing all infection risks in the clinic setting. of personal protective equipment. The basic principles
The entire work environment needs to be considered of blood and body fluid management are outlined in
to ensure adequate infection control. This includes the Box 10.4. These basic steps should be flexible enough
walls and surfaces of the treatment room, all furnishings, to adapt to different circumstances such as the size of
work equipment, bathroom and toilet facilities, and com- the spill, the differing surfaces that the spill is on, the
munal areas such as waiting areas and staff lunch rooms. nature of the spill (blood, urine, vomit, or faeces), the
Routine cleaning of work areas is important because location of the spill, the likely pathogens involved and
deposits of dust, soil and microbes on surfaces can whether there is a likelihood of contact of the spill area
transmit infection. Regular routine cleaning and main- with bare skin.
tenance are therefore necessary to help ensure a safe The clinic should have a ‘Spills Kit’ stocked and
environment for therapist and clients. available for immediate use in case of such spills occur-
Standard cleaning equipment should be readily ring. The Spills Kit should include leak proof bags,
available for routine cleaning as well as for spills man- absorbent material such as absorbent granules and paper
agement. Standard equipment should include clean- towels, gloves and other personal protective equipment,
ing solutions, water, buckets, cleaning cloths and mop all stored in a reusable container with a fitted lid. Items
heads. The equipment should be stored safely in a place that have been used to clean up body fluid spills should
known to all employees of the clinic. All cleaning items be collected and placed in the leak-proof plastic bag
should be changed routinely and especially after dealing and, once secured, can then be disposed of with normal
with blood or body fluid spills. For all routine and gen- household rubbish.
eral cleaning a neutral detergent and warm water should
be used. It is not necessary to use disinfectants or bleach. Cleaning the work equipment
Regular cleaning of the environment and workplace The cleaning routine for work equipment will vary
enables therapists to comply with Standard and Addi- depending on the equipment in question and also on the
tional Precautions. Each massage clinic should develop exposure of that equipment to potential sources of infec-
written cleaning protocols, including cleaning methods tion. All equipment that comes into contact with the
and frequency of the cleaning routine. Consideration client’s skin, directly or indirectly — such as massage
should be given to the order in which items are cleaned. tables, linen, the outside of oil bottles, foot bowls —
Commonsense dictates this should be from cleanest to should be cleaned between uses. Equipment that has
dirtiest and from top to bottom of the room to prevent been repeatedly used but not necessarily in direct client
the depositing of dirt and microbes on clean items.
Routine surface cleaning Box 10.4 The basic principles of blood and body
fluid management
Work surfaces should be cleaned and dried after each
session and when soiled. l Use personal protective equipment such as
Floors should be cleaned daily, and damp dusting gloves, and if indicated, masks, plastic apron
should be used on surfaces, including window furnishings. and eye protection.
l Spills should be cleared before the area is
Wet areas cleaned, as adding cleaning solutions (detergent)
Toilets, sinks, and washbasins need to be cleaned at to the spill increases the size of the spill to be
least daily. During this process avoid the generation of dealt with.
aerosols (avoid splashing and spraying). l The generation of aerosols (airborne particles in
a fine mist or spray) should be avoided, so avoid
Walls and fittings vigorous scrubbing when potentially infectious
fluid is present.
All walls and fittings including curtains need to be
l Carefully remove as much of the spill as possible
cleaned regularly and when soiled. This applies par-
ticularly for those in high traffic areas such as recep- with absorbent material, such as paper towels or
absorbent granules, and dispose of this material
tion waiting rooms, children’s play areas and treatment
in a leak-proof plastic bag.
rooms.
l Clean the area with warm water and detergent.
l If the surface is likely to come into contact with

Storage of cleaning equipment
bare skin, disinfect the area with a diluted bleach
Cleaning equipment should be cleaned and dried before
copyright law.
solution (at least 1000ppm available chlorine)

storage. Mop heads (if detachable) and cloths should and allow to dry.
be laundered and buckets emptied and dried to prevent l Wash hands thoroughly after clean up.
microbial growth on wet materials.
Account: s8715057
contact should be cleaned at the end of the day, and dense plastic container clearly marked with the bio-
some equipment may require a more thorough cleaning hazard waste symbol. Clients who are diabetic or carry
at the end of the week. At the end of the week or month, medication that needs to be injected may also require
depending on the volume of clients, all work equipment such a container to dispose of needles appropriately.
should be cleaned or disinfected.
Storage and disposal
Laundry General and recyclable waste should be removed from
For a massage therapist one of the major items of work the clinic on a daily basis, and placed in the appro-
equipment that must be handled well is linen. As linen priate closed rubbish bins awaiting collection by the
that is used during massage therapy comes into direct local council where available. Care should be taken to
contact with the skin of the client it must be clean to separate recyclable items from normal household rub-
begin with, and once used (soiled), needs to be handled bish. The staff should also take care with paper items
appropriately. to ensure that any confidential client information is not
When handling soiled linen, first check it for foreign included with household rubbish.
objects then place it in an appropriate container or bag If dealing with broken glass or other sharp (non-
close to where it was used. An appropriate container is clinical waste) objects, ensure these items are wrapped
one that can be easily washed, or else it should have a in several layers of newspaper or placed in a container
removable liner that can be easily laundered. Sort the and adequately sealed to prevent injury from any sharp
linen in the laundry area, not the treatment room. Do not edges protruding from the container.
shake the linen out as this spreads microbes to other sur- All waste storage containers must have a closable
faces. Linen heavily soiled with body substances should lid rather than be an open bin. This reduces the like-
be placed in an impermeable (leak-proof) bag for trans- lihood of attracting vermin and other pests that may
port from the treatment area. spread disease.
When washing linen, use detergent and hot water Clinical waste is to be stored securely until it can
and wash linen as soon as practicable to reduce the time be collected by an approved biohazard waste disposal
available for growth of microbes. After washing, clean company. Clinical waste must not be placed in with gen-
linen should be stored away from soiled linen. If linen is eral waste for collection.
to be used within a day it can be stored on open shelves
within the treatment room. If the linen is not to be used in POLICIES AND PROCEDURAL
the immediate future, it should be stored in a closed cup- REQUIREMENTS
board to avoid its exposure to settling dust and microbes. The effective application of Standard and Additional
Precautions in the clinic environment requires the devel-
Managing waste opment of written policies and procedures relating to
The majority of waste generated by a clinic will fall into the work practices mentioned in this chapter, and adher-
the category of general or recyclable waste and therefore ence by all staff to these policies and procedures. It can
should be treated the same as domestic or household be difficult in a busy clinic environment to ensure all of
waste. In the massage clinic there are rarely exceptions these work practices are being following appropriately,
to this. Some therapists, however, may work in clinic and so it is vitally important that time and resources are
rooms that are shared by practitioners from other health allocated so these practices can be proactively estab-
care modalities such as general medical practitioners lished, implemented and monitored.
or acupuncturists. In this case, the clinic may generate Monitoring activities may include developing a sim-
clinical waste. Clinical waste includes sharps such as ple checklist for each room to ensure that infection con-
syringes and needles, scalpel blades, acupuncture nee- trol procedures pertaining to that room are carried out
dles and dermal hammers (used by acupuncturists) as and signed off. Apart from reassuring the therapists that
well as other biological waste such as human tissue and they are working in a safe environment for themselves,
‘free-flowing’ blood. The key to effective waste man- their employees and their clients, it is also a written
agement is in the organisation and set up of appropriate record that the clinic is adopting safe work practices.
containers so that waste can be handled safely from its Other documentation that is essential for the mas-
generation to its storage and safe disposal. sage clinic is an incident reporting protocol.
Any incidents or accidents are recorded, including
Collection incidents relating to breaches of infection control, and
Use appropriate containers to ensure segregation of clini- policies can then be set in place or improved to prevent
cal waste from household waste at the point of generation. any further occurrences.
General waste should be collected in lined bins, allowing
the liner and rubbish to be removed as one at the end of Further information on infection
the day, rather than removing the rubbish alone. These control
The topics and areas of discussion around infection
copyright law.
bins should be of a size suitable for a day’s waste collec-

tion, rather than a large bin which will take longer to fill. control are vast and cannot be completely covered in
Needles or syringes must be deposited into an this chapter. Therapists seeking further or updated
approved clinical waste sharps container — a yellow information on the epidemiology of infectious diseases
Account: s8715057
in Australia and appropriate infection control measures 2 As a massage therapist, what would you do to
are directed to the Infection Control Guidelines for the ensure your personal hygiene is of a high standard
Prevention of Transmission of Infectious Diseases in the for practice?
Health Care Setting, produced by the Australian Gov- 3 Discuss the factors that would need to be considered
ernment Department of Health and Ageing (2004) and when designing policies and procedures for the
endorsed by the Communicable Diseases Network Aus- control of infection in a clinical setting.
tralia, the National Public Health Partnership and the
Australian Health Ministers’ Advisory Council. These References
guidelines are available online at: Australian Government Department of Health and Ageing
h t t p : / / w w w. h e a l t h . g o v. a u / i n t e r n e t / m a i n / 2004 Infection Control Guidelines for the Prevention
publishing.nsf/Content/icg-guidelines-index.htm of Transmission of Infectious Diseases in the Health
Further information is also available from state and Care Setting. Commonwealth of Australia. Online
territory health departments. Available: http://www.health.gov.au/internet/main/
For therapists residing outside of Australia, while publishing.nsf/Content/icg-guidelines-index.htm
these guidelines follow sound principles of infection (accessed 27 Aug 2009)
control, referral to guidelines specific to country of resi- Black JG 2008 Microbiology: Principles and Explorations
dence is strongly recommended. (7th edn). John Wiley, USA
Boon NA, Colledge NR, Walker BR, Hunter JAA (eds)
CONCLUSION 2006 Davidson’s Principles and Practice of Medicine
This chapter has described the importance of infection (20th edn). Churchill Livingstone, Edinburgh, pp. 370
control practices for massage therapists in the clinic Harris P, Nagy S, Vardaxis N 2006 Mosby’s Dictionary
Of Medicine, Nursing & Health Professions. Elsevier,
environment. Pathogenic microorganisms are biological
Sydney
hazards and therapists need to be aware of the poten- —— 2010 Mosby’s Dictinary of Medicine, Nursing &
tial risks that these organisms pose to themselves and Health Professions (2nd edn). Mosby Elsevier, Sydney
others in their care. Although the risk of infectious dis- Lee G, Bishop P 2002 Microbiology and Infection
ease transmission in a massage clinic may be relatively Control for the Health Professions (2nd edn). Pearson
small in comparison with a major teaching hospital, the Education Australia, Sydney
implementation of Standard Precautions will further Vickers A, Zollman C 1999 Massage therapies. British
reduce that risk, allowing therapists to meet their duty Medical Journal, 319: 1254–7
of care in this area towards their clients, and towards
others who may be affected by their massage practice.
Questions and activities

1 For the professional massage therapist, cleanliness of
the massage environment and equipment is of utmost
importance. Describe the massage process — a
treatment episode — and state all potential sources
of microbes that may place a client or therapist at
risk of infection.
copyright law.
Account: s8715057

copyright law.
Account: s8715057
SECTION 4
the health assessment process
Lisa Casanelia chapter 11
LEARNING OUTCOMES
l Apply the ASTER system to guide consultations
l Record appropriate information without hesitation or omission
l Describe the format and list the benefits of a health history form
l Conduct fruitful client interviews
l Follow the statutory guidelines governing data collection
l Fill in ASTER charts quickly, using an accepted system of abbreviations
INTRODUCTION system of charting is comprised of five sequential

To be successful in clinical practice a massage therapist components, as follows:
needs the ability to perform massage manipulations in a A — Assess client needs
masterful fashion. In addition to this the massage thera- S — Select treatment plan
pist must also have the skills to assess the needs of the T — Treat
client, develop a treatment plan that is designed specifi- E — Evaluate
cally for that client, perform the treatment, evaluate the R — Record
treatment and then accurately and thoroughly record the The purpose of this chapter is to identify and explain
entire consultation process. each of the components of the ASTER charting system.
To assist in the accomplishment of these tasks, it is Each component will be addressed within the context of
common for the massage therapist to adopt a strategy the scope of practice of a relaxation massage therapist.
or use a ‘formula’ to prompt them to complete each of For this reason, discussion of the range of joint move-
these tasks in a thorough and precise manner. There ment, orthopaedic assessment and muscle testing have
are many types of formulas therapists will use and, been excluded from this chapter.
depending on the technical abilities of the therapist to
assess and treat the client, these forms will be varied A — ASSESS CLIENT NEEDS
to suit the therapist’s particular needs. For therapists The first component of ASTER involves the assessment.
performing relaxation massage, the ASTER system of Assessment aims to ascertain the presenting needs of
charting provides the perfect system for recording the the client. The assessment of a client’s needs involves
treatment details. evaluating the client’s own goals for massage therapy
This chapter introduces the concept of ASTER and establishing the client’s previous medical history.
charting as a means to assist the massage therapist in The assessment would also include discussion of the
practice to accomplish each of the objectives of a pro- presenting symptomatology, any aggravating circum-
fessional consultation. stances, any changes in activity due to the complaint,
The ASTER formula provides a guide for the and the onset or initial cause of the symptoms.
consultation process and a documentation chart for The gathering and recording of such information is
the recording of massage treatment details. Through vital for several reasons. Firstly, such information will
copyright law.
learning the ASTER formula the massage student will assist in determining the client’s needs and expectations
effectively learn to conduct a professional relaxation for the massage. A therapist will encounter clients who
massage consultation and be able to employ the for- have differing experiences with massage; one may have
mula as a prompt during consultations. The ASTER received massage treatments in the past with another
105
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106 Section 4 Making initial contact with the client
therapist whilst one may have never received any form needs is a vital part of the assessment process. With
of massage therapy. As such, clients may present with society’s hectic pace many people find themselves con-
very clear expectations of what the experience of receiv- stantly on ‘fast forward’, leaving their mind focused
ing a massage might entail. For example, some clients on their external environments with little time to con-
may prefer and expect a deep treatment, whereas others sider their own physical and emotional needs. Encour-
may be seeking a light touch. If the therapist gains an aging a client to focus on and discuss their needs and
insight of the client’s previous experiences and/or cur- sensations, whilst integrating the body and mind, will
rent expectations the massage can then be appropriately encourage them to be active participants in their own
designed to best meet the client’s needs. healing process.
A therapist also gathers information to evaluate The consultation process will highlight the exact
whether massage is a suitable treatment for the client’s needs and expectations of the client. Such information
presenting condition. Occasionally a client may pres- is best obtained through the completion of a health his-
ent to a massage therapist with a known disease state tory form by the client, or elicited via an interview and
or symptoms that would require the therapist to make accurately recorded in detail on an ASTER chart by the
modifications to the treatment or choose not to treat massage therapist.
(refer to contraindications in Chapter 12).
The massage therapist would gather information
Health history form
from the client through a series of questions to estab-
lish the indications and precautions to the application of An efficient way to assess the client’s needs is to have
massage. Such information allows for the implementa- the client fill in a questionnaire prior to the commence-
tion of a safe and effective treatment plan. To illustrate ment of the consultation. Aside from collecting the cli-
this point let’s consider a client who presents for mas- ent’s personal details, indications and contraindications
sage with chronic fatigue syndrome. This client might for massage therapy, and previous massage experience,
complain of reduced energy levels and muscular aches the health history form also serves as a written consent
and pains. With thorough questioning and allowing the to the massage treatment.
client to describe their symptom picture, the therapist A good health history form will contain the follow-
could determine the most appropriate treatment plan. ing particulars and be updated yearly or whenever there
Prior knowledge of the medical condition would allow is a change in the client’s details, whichever is sooner.
the therapist to deliver an appropriate treatment strat- Personal information
egy, which may involve light soft tissue manipulations l Name
and shorter duration to avoid the possibility of exhaust-
l Contact details
ing the client. Box 11.1 lists valid reasons for the gath-
l Date of birth
ering and recording of client information.
l Emergency contact details
The assessment component of the ASTER chart-
ing system forms a critical first step in the consultation l Occupation
process. During the assessment the client and therapist l Recreational activities
take time to interact and determine the individual needs Massage therapy information
of the client whilst developing a mutual understand-
l Previous massage treatment
ing and respect that will underpin all future treatments.
l Reasons for coming for massage treatment
Affording a client time to focus and reflect on their
l Areas to be included/excluded from massage
Health history
l Previous medical history
Box 11.1 Reasons for gathering and recording
client information l Current medical history
l Current medications
l To determine the client’s needs and expectations l Current medical treatments
for massage. Disclaimer

l To evaluate whether massage is appropriate for
l Consent to massage therapy
the client’s condition.
l Outline of the scope of practice of the massage
l To consider the indications and precautions of
massage therapy, to enable a safe and effective
therapist
l Outline of the confidential nature of the consul-
treatment strategy.
l To prompt the client to explore their physical
tation and related procedures
sensations. l Statement that all information provided is true
l To note changes from previous massage sessions. and correct

l To identify any contraindications that may This form may be given to the client prior to the
commencement of massage on the day of treatment or
copyright law.
preclude massage therapy.

l To reveal where referral to an appropriate health
alternatively may be mailed to the client prior to their
care professional is necessary. first consultation for them to complete ahead of time.
All details recorded on the health history form would
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11 The health assessment process 107
be discussed during the client interview, allowing the l What are your expectations for the massage?
client the opportunity to elaborate on their health his- l Are there particular areas on your body where you
tory, previous massage experience and expectations for experience muscle tension?
treatment. A sample health history form is provided in
Appendix 4. Questions to evaluate indications
and contraindications
Client interview After reviewing the client’s health history form the fol-
Once the client’s health history form has been com- lowing questions may be asked:
pleted, it can be discussed as part of the consultation l You have marked … … on your health history form;
during the client interview. The interview aims to gather can you tell me how this condition affects you?
the necessary information already detailed above, and l How long have you had this condition?
also generate further details provided on the health his- l What treatments, if any, are you receiving for this
tory form (see Appendix 4). The client interview will condition?
only be successful in meeting its aims if a positive and l Who is/are the health professional(s) providing the
trusting relationship is established between the therapist treatment? Do I have permission to contact them?
and the client. Factors that contribute to the develop- l Are you currently taking any medication? If so,
ment of such a rapport between the client and therapist what medications?
include the therapist’s professional presentation, their
intent and their ability to communicate confidently with
the client. Questions to evaluate current
During the information-gathering process the thera- symptoms
pist may gain details from the client by asking simple, Clients often present to the massage clinic with aches
clear and precise questions. In addition, it is essential and pains without having seen an appropriate health
that the therapist possess the ability to be an attentive professional for a diagnosis. Many aches and pains
listener. The style of the client interview should include can be the result of the strains of everyday life, includ-
open-ended and closed questions or a combination of ing stress, postural habits or overuse. Through gaining
both types of questioning. Open-ended questions allow awareness and understanding of the client’s symptoms
the client to respond freely without restriction. For a massage therapist may determine whether massage
example, asking a client if they can describe their pain therapy is in fact the most suitable form of treatment or
enables the client to express their feelings using their if referral is more appropriate for the client. If massage
own terminology, thus avoiding the client being led to is appropriate then a determination should be sought as
a particular response. As this type of questioning pro- to whether the massage should be modified (see Chap-
vides much freedom to the respondent it is essential that ter 12). If the therapist is unsure of what path to take,
the question be precise to prevent long and irrelevant referral to an appropriate health professional should be
responses. made prior to any treatment being performed. It should
Closed questions may be phrased in a similar man- be noted that the formulation of a diagnosis is outside
ner to a multiple-choice question, in that there is usually the scope of practice of a massage therapist (see Chap-
a correct or desired response. For example, a therapist ter 5).
may enquire as to the quality of a client’s pain, ask- The following questions may be asked to enable the
ing ‘is it dull and aching, sharp and localised or throb- therapist to evaluate the client’s current symptoms:
bing and intense?’ Although this type of questioning is l Do you have any pain, discomfort and/or stiffness
to the point, it may be limiting and lead to inaccurate today?

responses as the client may feel they need to choose one l Can you show me where the pain, discomfort and/
of the options despite their situation not ideally match- or stiffness is?
ing any of the response choices offered. Such styles of l Can you describe what the pain is like?
questioning may require follow-up questions to facili- l How and when did the symptoms begin?
tate further discussion to allow the therapist to gain l What kinds of activities or positions make the pain
a better insight into the client’s condition. worse?
As a general rule, carefully structured open-ended l What relieves the pain?
questions should predominate during the client inter-
l Is there any time of the day that the pain eases or is
view whilst closed questions are best kept to a minimum.
worse?
Examples of questions that may assist the therapist to
l How has this problem affected your activities of
determine the appropriate treatment plan are detailed
below. daily living?
l Have you seen a health professional for this prob-
lem? If so, do you mind if I contact them in relation
Questions to evaluate the reasons for to your condition?
copyright law.
massage It is imperative that all relevant information obtained

l What brings you in for a massage today? through questioning during the client interview is accu-
l Have you ever had a professional massage? rately recorded in the assessment area of the ASTER form.
Account: s8715057
108 Section 4 Making initial contact with the client
S — SELECT TREATMENT PLAN in consultation with the client, the massage therapist
Once the client has completed the health history form, should be ready to commence the treatment the client
and this has been discussed during a client interview, consented to during the interview.
the massage therapist together with the client may Whilst performing the massage treatment the ther-
determine the best course of treatment. This would apist should use palpation to assess the tissue for any
involve the development of a treatment plan that the problem areas. Palpation is the primary skill of the
client should consent to. The therapist has a profes- massage therapist and involves the placement of the
sional and ethical responsibility to liaise with the cli- therapist’s hands on the client’s tissues to assess their
ent when devising the treatment plan. Any treatment condition. Palpation skills are cumulative and like any
should always be designed around the client’s needs. skill must be practised and refined (Rattray & Ludwig
The therapist has a duty to explain the benefits and/or 2000). Through practice the therapist’s palpation skills
risks of the suggested treatment plan to the client. On can be refined and improved with every treatment they
occasions, based on the information gathered, the thera- perform. The greater the number of clients the therapist
pist may need to refuse to provide a treatment; this is encounters the greater the variations in tissue quality the
referred to as the right of refusal (see Chapter 6). Such therapist will recognise.
refusal would most likely occur when the therapist dis- Rattray and Ludwig (2000) describe the four ‘Ts’
covers an absolute contraindication to the application of of palpation: temperature, texture, tenderness and tone.
massage treatment. The therapist is obliged to discuss When the therapist palpates the client’s tissues dur-
the reasons for refusal with the client and refer them to ing the massage each of the four Ts provides valuable
an appropriate health professional. information to the therapist. Such information may lead
Once the massage therapist has discussed the ben- the therapist to reconsider the treatment plan and, after
efits and potential risks (such as residual pain follow- discussion with the client, discuss a revised treatment
ing deep treatment) of the proposed treatment plan they plan.
must seek consent from the client prior to commenc- Placing a hand over the forehead of someone to
ing treatment (see Chapter 5). It should be noted that assess their temperature is an assessment tool that has
the client has the right to accept, refuse or amend any been used by the layperson as well as health profession-
proposed treatment plan in consultation with the thera- als for centuries. A massage therapist may adapt this
pist. Such procedures could be carried out verbally. same crude assessment technique during treatment, as
However, health professionals are increasingly seek- an area of tissue that feels excessively hot may indicate
ing a written consent that is signed by the client prior local inflammation, resulting from infection or even
to administration of treatment. Along with the client’s injury.
written permission for massage a consent agreement The term ‘texture’ is used to describe the way in
may also include the following information: which a surface feels beneath the fingertips. Whilst
l the treatment goals
performing soft tissue manipulations the therapist will
l the areas of the body that are to be massaged and in
notice the texture of the body tissues. When massaging
what order over healthy areas of tissue the texture will feel uniform
l the duration of the massage
and uninterrupted. However tissues that are injured or
damaged will possess a distinctive texture, often quite
l the degree of undress that is recommended and the
different to that of healthy tissue. For example, when
draping procedures
feeling acute oedema the texture of the tissue will be
l the positions the client will adopt during the massage
firm. When a therapist massages over a soft tissue adhe-
l the procedure to climb on and off the massage table
sion the texture may feel quite rough and bumpy, almost
l the obligation of the client to inform the therapist like corrugated iron. During the treatment the therapist
of any unusual sensation or discomfort during the should make note of the texture of the regions they are
treatment massaging and note changes in texture over subsequent
l an explanation of the potential muscle soreness or treatments.
negative reactions that can be experienced follow- During the massage the therapist may stroke over
ing the massage treatment the soft tissues such as muscle, tendon or ligaments.
l the role of massage as an ancillary health aid rather Occasionally while compressing these tissues the client
than a primary medical treatment may indicate discomfort, tenderness or even pain. They
l the right of the client to alter any part of the treat- may convey such feelings verbally by saying ‘ouch’ or
ment plan or cease the massage at any time. imply them via their body language, perhaps by tensing
If a written consent agreement is to be used its exis- an area of tissue or making a pained expression. Such
tence and the client’s consent to treatment should be feedback on the tenderness of tissue will assist the ther-
noted in the treatment record documents. apist with their treatment.
Muscle tone is defined as the tension within a mus-
T — TREAT cle at rest (Tuchtan & Tuchtan 2000). When a muscle
copyright law.
Once all relevant information pertaining to the client is overused, misused or guarding an injured area, the
has been gathered through the assessment and client muscle shortens, thus increasing the muscle’s tension.
interview, and the treatment plan has been selected Such an area would be referred to as a hypertonic
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11 The health assessment process 109
(hyper = excess) muscle lesion. The opposite may Gaining verbal feedback from the client plays an
occur when a muscle is under-utilised, such as fol- essential role in evaluating the success of the treat-
lowing 6 weeks in a plaster cast due to a broken ment. For example, a client may notice a change in
limb, during which time the muscle becomes smaller, their muscle tone during the massage, and may report
weaker and flaccid. Such areas would be known as a a reduction in local muscle pain. Once the massage
hypotonic (hypo = insufficient) muscle lesion. More treatment has concluded the client should be encour-
often than not a massage therapist deals with hyper- aged to stand and gently move their joints, to notice
tonic musculature. Such lesions are located predomi- any changes. The client may report increased free-
nantly in postural muscles, including the paraspinal dom of movement, reduced stiffness or increased
muscles of the back and the superficial muscles of comfort, providing a vital evaluation of the success
the neck, as well as the regions of the low back and of the treatment. All verbal feedback from the client
buttocks. should be noted in the treatment record. If the client
The massage treatment should follow the treatment reports a negative response to the treatment consid-
plan outlined by the therapist and agreed to by the client. eration must be given as to the reason for such feed-
If during the course of the treatment the client identifies back. The massage therapist must explain the reason
an area of pain or discomfort not initially outlined in the for this to the client, reassess the treatment plan for
health history form or discussed in the client interview, future sessions or refer the client to an appropriate
the therapist should first consult the client and gain con- health professional.
sent for any modification to the original treatment plan.
All information pertaining to temperature, texture, ten-
R — RECORD
derness and tone, gathered during a treatment through
the palpation skills of the therapist, should be noted in The final stage of the ASTER process involves record-
the treatment records. Such a treatment record chroni- ing the consultation process. The client record is con-
cles all treatment sessions, and details the client’s infor- sidered to be an accurate account of the client’s related
mation and responses relating to the massage therapy in medical information, and consists of the health history
the ASTER charting system. form, additional information gathered during the client
Recording appropriate detail in the treatment record interview, and information regarding prior assessment,
will enable the therapist to recall the specific areas treatment or referral for the client. This process of ongo-
and muscles that were problematic for the client during record keeping is known as charting.
ing treatment. These details can then be easily recalled Medical records are an essential component of any
when the client returns for follow-up treatments and massage consultation. The information collected and
allow the therapist to have better follow-through with recorded assists the massage therapist to provide ongo-
their client in consecutive treatments and ultimately ing professional client care. The written document is a
more successful treatment results. testament to the assessment, treatment plan, treatment
and evaluation performed. Reasons for keeping a client
E — EVALUATE record include:
l to enable the therapist to track a client’s progress
From the minute the massage therapist makes first con-
l to assist the therapist to recall previous assessment,
tact with the client an evaluation has already begun;
this includes evaluating the suitability of the client treatment and evaluation, enabling the therapist to
while making an initial appointment, assessing the cli- deliver more specific and beneficial treatment
l to allow the therapist to communicate with other
ent’s needs and a continual evaluation throughout the
treatment. Evaluation is ongoing. However, the fourth health care professionals in the same clinic who
component of the ASTER charting process is the formal may be treating the same client
evaluation, which establishes the success of the treat- l to form, with the client’s written permission, a part
ment performed. During the application of the treatment of the medico–legal report
the therapist may detect changes in the texture of tissues l to provide, with the client’s written permission,
via palpation that will serve as a form of evaluation. For a record of treatment for private health insurance
example, when commencing massage of the posterior companies
thigh and leg with a rowing stroke the therapist is able l to provide the therapist with accurate information
to evaluate the state of the tissue, noting the four Ts. of the entire consultation if the therapist is called as
The therapist may detect hypertonicity in the hamstring a witness in any legal proceeding.
muscle group and, when appropriate, continue to per- As a complete document the client record consists
form massage manipulations over the area. In doing so, of the client questionnaire (as discussed earlier), the
such massage may potentially create a change in the tis- ASTER chart and any other documentation collected
sue texture, via a decrease in muscle tone. During any from other health professionals. There are key fea-
massage treatment the therapist should perform evalu- tures that must be documented on the ASTER chart,
ations of the tissue at regular intervals, to assess any and these include: reasons for the treatment; presenting
copyright law.
changes in condition. signs and symptoms; contraindications and precautions;

During a treatment a client will also provide ver- treatment plan; client consent; treatment findings; and
bal feedback as to the effectiveness of the treatment. the evaluation (see Box 11.2).
Account: s8715057

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What are the three elements of valid consent?

What are the three elements of valid consent?

What are the reasons for keeping a client record?

What are the reasons for keeping a client record?

50 Section 2 The professional therapist

a lubricant used and the therapist should have reason-

to comprehend the nature and consequences of the mas-

influence you. Science Press, Sydney, pp. 24–38, Chapter 2

l Establish and maintain professional boundaries with clients

l Deal effectively and respectfully with people of differing cultures

l Describe the importance of professionalism in providing a safe environment

ing what is normally perceived as ‘intimate distance’.

Box 6.2 Activity 1 Box 6.3 Activity 2

l employee or employer Physical boundaries

client. If you are not comfortable, consider whether energy?

concerns they have about becoming aroused appropriate.

aware that it may be appropriate to recommend that the

the evidence for massage therapy

l Discuss types of evidence and their application to massage therapy

l Outline the challenges for conducting trials in massage therapy

l Outline the current scientific evidence for massage therapy

l Describe how to locate and assess evidence

INTRODUCTION The Cochrane Collaboration, an international organisa-

clinical experience to judge whether research findings

Evidence-based practice refers to a model of

when determining the most suitable treatment effect or a harmful effect.

massage practice; there has been little focus on encour-

Table 7.2 A typical evidence-grading system

et al (1997). In clinical auditing, client files are used as

duration of treatment and responses to it. Systematic Systematic reviews

l improving respiratory function in asthmatics l internet searches (databases such as AMED,

Table 7.3 Systematic reviews of the effectiveness of massage therapy

Author(s) Title Author(s)’ conclusion Evidence

massage as an intervention for low-back pain

Table 7.3 Systematic reviews of the effectiveness of massage therapy—cont’d

Author(s) Title Author(s)’ conclusion Evidence

& Ashford for healing acute healing of acute wounds

Table 7.3 Systematic reviews of the effectiveness of massage therapy—cont’d

Author(s) Title Author(s)’ conclusion Evidence

Assessing the evidence supported by scientific evidence and will be discarded.

References Green C, Martin C, Bassett K, et al 1999 A systematic

for low-back pain. Cochrane Database of Systematic

l Differentiate between the varying types of massage environments

INTRODUCTION THE MASSAGE SETTING

l Explain to the client how you wish them to

Advantages of a home-based practice include: Advantages of a mobile massage practice include:

l cost effectiveness for the therapist maintenance might not be as expensive as

l greater control over external and internal are usually higher

l flexible working hours home

home expenses may be tax deductible. before and after massage.

therapist’s private home environment they are unfamiliar with

hours beyond their specified clinic hours setting

practice. equipment they can physically carry

A clinic-based practice generally refers to a prac- ­duties with other practitioners

therapist working in a: beauty salon; medical practice; clients

sonal training studio; natural therapies practice; or may ­practitioners

more business from passers by than any other practice

With today’s fast-paced workplaces, many employers

have a duty of care to provide a safe environment for

The work-site massage is ideally suited to provide

l Establish and maintain professional boundaries with clients

l Deal effectively and respectfully with people of differing cultures

l Describe the importance of professionalism in providing a safe environment

l employee or employer Physical boundaries

l Discuss types of evidence and their application to massage therapy

l Outline the challenges for conducting trials in massage therapy

l Outline the current scientific evidence for massage therapy

l Describe how to locate and assess evidence

l improving respiratory function in asthmatics l internet searches (databases such as AMED,

l Differentiate between the varying types of massage environments

l Explain to the client how you wish them to

l cost effectiveness for the therapist maintenance might not be as expensive as

l greater control over external and internal are usually higher

l flexible working hours home

A clinic-based practice generally refers to a prac- duties with other practitioners

sonal training studio; natural therapies practice; or may practitioners

l keep the lid tightly on the oil bottle when not in

l Perform self-massage techniques

l Develop a self-care program to minimise the strain of performing massage regularly

l Cultivate awareness of individual strengths and weaknesses

l The stretch should be held for a period of approxi-

r eaching down toward the shoulder blade. The other

GENERAL HEALTH an adequate treatment when skilled at techniques.

l Receive regular massage.

l Vary the part of the arm and hand used in

l Maintain flexibility and mobility through regular

l Use correct hand technique and correct body

l Damaged or broken skin

l If the surface is likely to come into contact with