CE INSTITUTE LLC BLOG

Arthritis includes more than 100 diseases and conditions that affect joints, the tissues that surround the joint, and other connective tissue. Symptoms vary depending on the specific form of the disease, but typically include pain and stiffness in and around one or more joints.  Some rheumatic conditions can also involve the immune system and various internal organs of the body.[i]

Arthritis affects more than 1 of 4 U.S. adults (that’s about 54.4 million people). It is a leading cause of work disability in the United States and one of the most common chronic conditions in the nation. Arthritis is a common cause of chronic pain. 

There is a lot of conflicting information and little scientific research or published studies about arthritis indications and contraindications for massage therapy or bodywork.

Arthritis sufferers usually have a good deal of joint irritation and inflammation. As such, it is usually contraindicated to massage (or provide heat around) an “inflamed” area.  However, some arthritis sufferers state that their pain is greatly relieved by heat, and there has been research over the years that shows heat was helpful with chronic medical conditions such as arthritis in SOME cases.

Some arthritic sufferers may find that a gentle massage therapy session could provide pain relief. Others could say this same work irritated their inflammation. It’s up to the bodyworker and client to evaluate and decide what services can safely be provided to that arthritic client. 

The client usually knows what irritates and soothes them. It’s important to ask questions and listen to their answers because each individual usually knows their own body best. If there are ever any questions about safely providing service, it is best to seek physician approval and/or direction.

Osteoarthritis (OA)

Osteoarthritis affects over 30 million Americans and is the most common form of arthritis in the US. It is caused by the damage or breakdown of joint cartilage between bones.  It is sometimes called degenerative joint disease or “wear and tear” arthritis. These changes usually develop slowly and get worse over time. It most frequently occurs in the hands, hips, and knees.

Osteoarthritis can cause severe joint pain, swelling, and stiffness. In some cases, it also causes reduced function and disability; some people are no longer able to perform their daily tasks and, in some cases, are not able to work. Severe cases may require joint replacement surgery, particularly for knees or hips.[ii]

Heberden’s Nodes

Heberden's nodes are often seen in osteoarthritis. They are hard bony swellings and growths that develop on distal interphalangeal joints. Precaution – do not press or apply pressure to swollen joints!

Bouchard’s Nodes

Bouchard's nodes are often seen in osteoarthritis.  They are hard bony swellings and growths that develop on proximal interphalangeal joints. Precaution – do not press or apply pressure to swollen joints!

Rheumatoid Arthritis (RA)

Rheumatoid Arthritis, is an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) in the affected parts of the body.

RA mainly attacks the joints, usually many joints at once. These attacks are also commonly called “flare-ups”.  In some cases, it may be contraindicated to work on a client while they are experiencing a “flare-up”. That’s because the client could have extreme irritation which might become worse by any type of pressure or touch. Unfortunately one of the only ways to know if their medical condition would be worsened by massage is through experimentation - and it would be unwise to experiment on clients. Also, just because a client has had massage in the past without irritation, does not mean they will have the exact same result with every massage session.  Unfortunately we do not know why different responses can happen with what seems like similar massage sessions; and as such, practitioners should avoid doing anything where it feels like an experiment with a client where they could be worse off than before they started their massage or bodywork session. Just think of the old adage when performing massage or bodywork: do no harm!

It is up to the bodyworker and client to decide if they should proceed with service during a “flare-up”. It is always best to seek approval and/or direction for services from a medical physician regarding medical conditions if you and/or the client are unsure about which service(s) are safe and/or beneficial.

Rheumatoid arthritis commonly affects joints in the knees, hands and wrists. In a rheumatoid arthritic joint, the lining of the joint becomes inflamed, causing damage to joint tissue. This tissue damage can cause long-lasting or chronic pain, a lack of balance, and deformity within the joints themselves.

Rheumatoid arthritis can also affect the lungs, heart, and eyes.  RA usually attacks many joints at once. [iii]

Fibromyalgia

Fibromyalgia is a frequently debilitating and painful condition that can have "tender points" on the body. Tender points are specific places on the neck, shoulders, back, hips, arms, and legs. These points can elicit extreme pain when pressure is applied to them.

The American College of Rheumatology approved new revised diagnostic criteria in 2010 for fibromyalgia that eliminated the 1990 tender point testing criteria.

The new 2010 diagnostic criteria uses the Widespread Pain Index, and symptom severity scale in place of tender point testing under the 1990 criteria.[iv] 

The 2010 “Widespread Pain Index” (WPI) is shown here in the colorful picture of the body (top).  The 1990 “Tender Point” criteria body chart is shown here with the red dots on the body (to the right).

As a bodyworker it is important to know where the “tender spots” are when working with fibromyalgia clients.  It is questionable whether pressure should be applied to these tender point spots as this can be very painful for a fibromyalgia client. Always avoid working on any areas of lost sensation or numbness.

Fibromyalgia can also cause disability, a lower quality of life and widespread pain all over the body beyond the “tender points”.  People with fibromyalgia may be more sensitive to pain than people without fibromyalgia. This is called “abnormal pain perception processing”. Fibromyalgia affects about 4 million US adults, about 2% of the adult population. The cause of fibromyalgia is not known, but it can be effectively treated and managed.^vii 

People with fibromyalgia can also be GREAT candidates for Massage Therapy!

The CDC reports US adults with fibromyalgia may have complications such as:

• More hospitalizations. People with fibromyalgia are twice as likely to be hospitalized as someone without fibromyalgia.
• Lower quality of life, especially for women. A woman with fibromyalgia has 40% less physical function & 67% less mental health than a healthy woman.
• Higher rates of major depression. Adults with fibromyalgia are more than 3 times more likely to have major depression than adults without. (Screening and treatment for depression is extremely important.)
• Higher death rates from suicide and injuries. Death rates from suicide and injuries are higher among fibromyalgia patients, but overall mortality among adults with fibromyalgia is similar to the general population.
• Higher rates of other rheumatic conditions. Fibromyalgia often co-occurs with other types of arthritis such as osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis.[v]

Gout

Gout is a form of arthritis generally caused by a build-up of uric acid in the joint. It regularly starts in the big toe joint and other joints that are furthest from the heart where our body’s temperature is coolest, where the uric acid can “crystalize”.  

Gout is considered one of the most painful kinds of arthritis.  Symptoms include:

• Pain/tenderness
• Tightening of the skin
• Swelling
• Redness or discoloration
• Warm to the touch

Gout is generally caused by consuming purine rich foods, such as alcohol, anchovies, dried beans, gravies, liver and peas.

Most people who have gout are house-bound and are unable to stand or walk without extreme pain.  It is ill-advised to press on the affected area, and it is recommended to seek approval and/or direction for bodywork from a medical physician regarding medical conditions.  This may include rescheduling any services that involve the affected area (i.e., foot reflexology for someone who has gout in their big toe).  Massage and bodywork services should never elicit extreme pain.

To learn more, please register for training at https://ceinstitute.com/

#massage #massagetherapy #massageprecautions #massagecontraindications

[i] Centers for Disease Control & Prevention.  Arthritis. (2018, February 21). Retrieved May 03, 2018, from https://www.cdc.gov/arthritis/basics/index.html

[ii] US Health & Human Services. “Arthritis.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 3 Apr. 2018, www.cdc.gov/arthritis/basics/osteoarthritis.htm.

[iii] US Health & Human Services. “Arthritis.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 3 Apr. 2018, www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html.

[iv] Wolfe, F; et al. (May 2010). "The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity" (PDF). Arthritis Care Res. 62 (5): 600–610. doi:10.1002/acr.20140. PMID 20461783

[v] National Center for Chronic Disease Prevention and Health Promotion | Division of Population Health. “Arthritis.” Centers for Disease Control and Prevention,  3 Apr. 2018, www.cdc.gov/arthritis/basics/fibromyalgia.htm.

Athlete’s foot (also known as tinea pedis) is an infection of the skin and feet that can be caused by a variety of different fungi. Although athlete’s foot can affect any portion of the foot, the infection is most often between the toes. Athlete’s foot is typically characterized by skin fissures or scales that can be red and itchy.

Athlete’s foot is spread through contact with infected skin scales or contact with fungi in damp areas (for example, showers, locker rooms, whirlpools, etc.) Athlete’s foot can be a chronic infection that can recur frequently.

Appropriate hygiene techniques may help to prevent or control Athlete’s foot.[i]

WebMD reports: “Athlete's foot is mildly contagious. It can be spread through direct contact with the infection and by skin particles left on towels, shoes, or floors.”[ii]

Bodyworkers should avoid working directly on or around athlete’s foot. 

They should also make sure that all areas touched by this infection (i.e. the floors, linens, etc.) are disinfected. 

It is always best to seek approval and/or direction for services from a medical physician regarding medical conditions.

To learn more, please register for training at https://ceinstitute.com/

#massage #massagetherapy #massageprecautions #massagecontraindications

[i] National Center for Emerging and Zoonotic Infectious Diseases. “Water, Sanitation & Environmentally-Related Hygiene.” Centers for Disease Control and Prevention,  6 Feb. 2017, www.cdc.gov/healthywater/hygiene/disease/athletes_foot.html.

[ii] Debra, Debra MD. “Understanding Athlete's Foot -- the Basics.” WebMD, WebMD, reviewed on: 9 Mar. 2017, www.webmd.com/skin-problems-and-treatments/understanding-athletes-foot-basics.

Having high blood glucose for many years can damage blood vessels that bring oxygen to some nerve endings. Damaged nerves may stop, slow, or send messages at the wrong times, especially during a massage appointment. Numbness, pain, and weakness in the hands, arms, feet, and legs may develop over time with diabetic neuropathy. Problems may also occur in various organs too. Diabetic neuropathy is the medical term for damage to the nervous system from diabetes. The most common type is peripheral neuropathy, which affects the arms and legs or upper/lower extremities.

Sometimes nerve damage can deform or misshape feet, causing pressure that can turn into blisters, sores, or ulcers. Poor circulation can make these injuries slow to heal. Sometimes this can lead to amputation of a toe, foot, or leg or any area that cannot heal, usually from a cut of the dermis which can lead to infection. This is one of the reasons why it is so important for massage therapists to maintain good fingernail hygiene.

 It is ill-advised to work on any bodily surface area that the client cannot feel.  Diabetic clients can experience numbness, especially in the distal extremities, due to the common nerve damage that can occur with this life-long disease. Furthermore, a diabetic’s capacity to heal from skin nicks or cuts is poor.  The smallest unhealed cut on a diabetic could result in infection, necrosis (tissue death), amputation, sepsis and/or death.  It is important to use special caution when working with diabetics, and as always, seek approval and/or direction for services from a medical physician regarding medical conditions.

To learn more, please register for training at https://ceinstitute.com/

#massage #massagetherapy #massageprecautions #massagecontraindications

Eczema is a term for several different types of skin swelling. Eczema is often called dermatitis. Most types of eczema cause dry, itchy skin and rashes on the face, inside the elbows and behind the knees, and on the hands and feet. Scratching the skin can cause it to turn red, and to swell and itch even more.

Eczema is not contagious. The cause for it is not known. It is likely caused by both genetic and environmental factors. Eczema may get better or worse over time, but it is often a long-lasting disease. People who have it may also develop hay fever and asthma.

The most common type of eczema is atopic dermatitis. It is most common in babies and children, but adults can have it too. As children who have atopic dermatitis grow older, this problem may get better or go away, but sometimes the skin may stay dry and get irritated easily.[i]

It is ill-advised to apply pressure over any area of the skin that is broken, has blisters or deep cracks.  An individual is prone to an infection with ruptured skin.  There are medical creams available to help an eczema break-out; however, this should be prescribed by a doctor.

To learn more, please register for training at https://ceinstitute.com/

#massage #massagetherapy #massageprecautions #massagecontraindications

[i] NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases. “Eczema | Dermatitis | Atopic Dermatitis.” MedlinePlus, U.S. National Library of Medicine, 23 Apr. 2018, medlineplus.gov/eczema.html.

Elderly clients usually require many special considerations including:

• Communication issues/brain disease
• Loss of sensation/nervous tissue atrophy
• Drier skin including brittle fingernails and toenails
• Frailty i.e. thinning skin, osteoporosis, etc.
• Lost range of motion, muscular contractures, poor movement/coordination
• Difficulty dressing/undressing, difficulty sitting/standing, getting on/off table 

One of the most important considerations for geriatric clients is to keep your work entrance and work area clear and clutter free.  According to American Family Physician Magazine[i], accidental falls account for 70% of deaths in persons 75+ years old.

It is advised for bodyworkers who service elderly and geriatric clients to seek out specific classes and training in geriatric care.  The care of geriatric clients could be an entire book on its own.  A solid investment in geriatric training could be a good investment to properly work with this vulnerable population. 

To learn more, please register for training at https://ceinstitute.com/

#massage #massagetherapy #massageprecautions #massagecontraindications

[i] Fuller, George F. “Falls in the Elderly.” American Family Physician, 1 Apr. 2000, www.aafp.org/afp/2000/0401/p2159.html.

A fever is a temporary increase in your body temperature, often due to an illness. Having a fever is a sign that something out of the ordinary is going on in your body.  For an adult, a fever may be uncomfortable, but usually isn't a cause for concern unless it reaches 103 F or higher.

Fever occurs when an area in your brain called the hypothalamus — also known as your body's "thermostat" — shifts the set point of your normal body temperature upward. When this happens, you may feel chilled and add layers of clothing or wrap up in a blanket, or you may shiver to generate more body heat, eventually resulting in an elevated body temperature.

Normal body temperature varies throughout the day — it's lower in the morning and higher in the late afternoon and evening. Although most people consider 98.6 F normal, your body temperature can vary by a degree or more — from about 97 F to 99 F — and still be considered normal.

Fever or elevated body temperature might be caused by:

• A virus
• A bacterial infection
• Heat exhaustion
• Certain inflammatory conditions (i.e. rheumatoid arthritis)
• A malignant tumor
• Some medications (i.e. antibiotics, seizure or blood pressures medications)
• Some immunizations
• Sometimes the cause of a fever can't be identified[i]

A fever can be a sign of a more serious medical illness, which could include infectious or contagious disease.  It is usually best to refer a feverish client to a physician for medical diagnosis or care. Do not work on a client who has a fever until serious illness including contagious disease has been ruled out as a potential cause.

To learn more, please register for training at https://ceinstitute.com/

#massage #massagetherapy #massageprecautions #massagecontraindications

[i] Mayo Clinic Staff. “Fever.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 21 July 2017, www.mayoclinic.org/diseases-conditions/fever/symptoms-causes/syc-20352759.

Hemophilia is a rare inherited bleeding disorder in which the blood does not clot properly. This can lead to spontaneous bleeding as well as bleeding following injuries or surgery.  Hemophilia is caused by a mutation, or change, in one of the genes that provides instructions for making the clotting factor proteins needed to form a blood clot. This change or mutation can prevent the clotting protein from working properly or could be missing altogether.

Hemophilia can result in: 

• Bleeding within joints that can lead to chronic joint disease and pain
• Bleeding in the head and sometimes in the brain which can cause long term problems, such as seizures and paralysis
• Death can occur if the bleeding cannot be stopped [i]

Bodyworkers/massage therapists should obtain physician approval and direction for massage or bodywork with a hemophiliac.  A simple bump or bruise could be a life-threatening situation for them. 

Range of motion or aggressive bodywork techniques should not be used.  Anything that would cause pressure on the skin (thus underlying blood vessels) could create potential damage.  It is always best to seek approval and/or direction for services from a medical physician regarding medical conditions where a client could easily bleed from any type of pressure.  

To learn more, please register for training at https://ceinstitute.com/

#massage #massagetherapy #massageprecautions #massagecontraindications

[i] National Center on Birth Defects and Developmental Disabilities. “Hemophilia.” Centers for Disease Control and Prevention, 2 Mar. 2017, www.cdc.gov/ncbddd/hemophilia/facts.html.

Mayo Clinic reports that there are more than 3 million Herpes Simplex I United States cases per year.  Herpes simplex is a common viral infection that is contagious. If you’ve ever had a cold sore or fever blister, you picked up the herpes simplex virus. Most cold sores are caused by herpes simplex virus type 1 (HSV-1). 

Other names for cold sores caused by HSV-1 are:

• Cold sore
• Oral herpes
• Mouth herpes
• Herpes simplex labialis[i]

This virus can be spread by skin-to-skin contact with an adult who carries the virus. An adult does not have to have sores to spread the virus.

The herpes simplex virus is spread from person to person through close contact. You can get a herpes simplex virus from touching a herpes sore. Most people, however, get herpes simplex from an infected person who does not have sores. Doctors call this “asymptomatic viral shedding.”

Once a person becomes infected with a herpes virus, the virus never leaves the body. After the first outbreak, the virus moves from the skin cells to nerve cells. The virus stays in the nerve cells forever, but it usually just stays there. In this stage, the virus is said to be dormant, or asleep. However, it can become active again.[ii]

Some people have no symptoms from the infection, while others develop painful and unsightly cold sores. Cold sores usually occur outside the mouth, on or around the lips. When they are inside the mouth, they are usually on the gums or the roof of the mouth. They are not the same as canker sores, which are not contagious.[iii] 

Do not touch on or around a cold sore.

Herpes Whitlow (aka Herpetic Whitlow)[iv]

Herpes whitlow is a viral infection of the hand and is contagious with person to person contact[v]. As such, it is a massage contraindication. Herpes whitlow results from exposure to type 1 or type 2 herpes simplex virus (also contagious) into broken skin. The infection may occur as a complication of primary oral or genital herpes lesions.

Health care workers specifically exposed to oral secretions are the most susceptible (e.g., dental hygienists, respiratory therapists). They can be affected if they are not using universal precautions.

Signs and symptoms of herpetic whitlow include the abrupt onset of edema, erythema, and significant localized tenderness of the infected finger. Often, the pain is out of proportion to the physical findings. Fever, lymphadenitis, and epitrochlear and axillary lymphadenopathy may be present. Small, clear vesicles are present initially. These may eventually coalesce and mimic a bacterial infection.

Herpes whitlow usually is self-contained and resolves in two to three weeks. Pharmaceutical treatment within the first 48 hours of symptom onset may lessen the severity of infection. This infection recurs in 30 to 50 percent of cases, but the initial infection is typically the most severe.

Herpes Zoster aka Shingles

Almost 1 out of every 3 people in the United States will develop shingles, also known as herpes zoster, in their lifetime. There are an estimated 1 million cases of shingles each year in this country. Anyone who has recovered from chickenpox may develop shingles; even children can get shingles.

Shingles is caused by the varicella zoster virus (VZV), the same virus that causes chickenpox. After a person recovers from chickenpox, the virus stays dormant (inactive) in the body. Scientists aren’t sure why the virus can reactivate years later, causing shingles.  The risk of shingles increases as you get older.[vi]

Shingles cannot be passed from one person to another. However, the virus that causes shingles, the varicella zoster virus, can spread from a person with active shingles to cause chickenpox in someone who had never had chickenpox or received chickenpox vaccine. 

The virus is spread through direct contact with fluid from the rash blisters caused by shingles.  Shingles is less contagious than chickenpox and the risk of a person with shingles spreading the virus is low if the rash is covered.

A person with active shingles can spread the virus when the rash is in the blister phase. A person is not infectious before the blisters appear. Once the rash has developed crusts, the person is no longer infectious.

People who have shingles are advised to:

• Cover the rash and avoid touching or scratching it.
• Wash hands often to prevent the spread of varicella zoster virus.
• Avoid contact with “vulnerable” people until the rash has developed crusts.[vii]

For bodyworkers, someone who has never had chickenpox should avoid contact with shingles (close contact could lead to virus transmission).  It is ill-advised to work on or over the blister-like sores (shingles) – even when virus transmission is not a concern.  While all blister patterns are different, herpes zoster regularly breaks out on one side of the body and may form a pattern that looks like a line.  Allow blisters to heal and skin become fully intact prior to working over the affected area and as always, it’s best to seek approval and/or direction for services from a medical physician regarding medical conditions.

To learn more, please register for training at https://ceinstitute.com/

#massage #massagetherapy #massageprecautions #massagecontraindications

[i] American Academy of Dermatology. “Herpes Simplex.” Herpes Simplex | American Academy of Dermatology, Retrieved online: 1 May 2018, www.aad.org/public/diseases/contagious-skin-diseases/herpes-simplex#overview.

[ii] American Academy of Dermatology. “Herpes Simplex.” Herpes Simplex | American Academy of Dermatology, 1 May 2018, www.aad.org/public/diseases/contagious-skin-diseases/herpes-simplex#causes.

[iii] National Institutes of Health. “Cold Sores.” MedlinePlus, U.S. National Library of Medicine, 23 Apr. 2018, medlineplus.gov/coldsores.html.

[iv] Clark, Dwayne C. “Common Acute Hand Infections.” American Family Physician, 1 Dec. 2003, www.aafp.org/afp/2003/1201/p2167.html.

[v] Higuera, Valencia, “What you Need to Know About Herpetic Whitlow”  Healthline, 21 June 2017, https://www.healthline.com/health/herpetic-whitlow

[vi] National Center for Immunization and Respiratory Diseases. “Shingles (Herpes Zoster).” Centers for Disease Control and Prevention,  19 Jan. 2018, www.cdc.gov/shingles/about/overview.html.

[vii] National Center for Immunization and Respiratory Diseases. “Shingles (Herpes Zoster).” Centers for Disease Control and Prevention,  19 Jan. 2018, www.cdc.gov/shingles/about/transmission.html.

Hepatitis is an inflammation of the liver, the largest organ inside the body.  The liver helps the body to digest food, store energy, and remove poisons. Hepatitis is not contagious through casual human contact such as massage, especially when proper professional sanitation practices are used, such as:

• do not work on broken skin and wash hands before/after client service
• wear gloves or use other protective measures when a practitioner has a skin cut
• do not touch one’s own mouth, nose, eyes or other mucous membranes after working with clients until the practitioner has washed their own hands

Viruses cause most cases of hepatitis. The hepatitis type is named for the virus that causes it (i.e., hepatitis A, hepatitis B or hepatitis C). Drug or alcohol use can also cause hepatitis. In other cases, the body mistakenly attacks healthy cells in the liver which causes the inflammation and disease.

Clients with hepatitis may vomit or have nausea. Discontinue service if a client begins to vomit (with hepatitis or for any condition).  Vomiting can be a sign of serious medical distress.  The client must ascertain why they vomited so it can be determined if medical care is required.

Normally clients infected with hepatitis would not be contraindicated for massage or bodywork, however, when a client has any type of acute infection, it’s important for them to seek proper medical care outside of massage.  Massage might help a client feel better, but that does not mean a client should avoid or discontinue conventional medical care for their disease.

To learn more, please register for training at https://ceinstitute.com/

#massage #massagetherapy #massageprecautions #massagecontraindications