Picture this: A person infected with SARS-CoV-2 is making blood clots. Gazillions of them. All over their body. Some are tiny, blocking the capillary supply to the skin and organs. Others are big enough to cause heart attacks, strokes, and pulmonary embolism.
At the same time, the person has signs of bleeding in other parts of their body. Bruises form with little or no trigger. Their gums bleed with regular toothbrushing. Petechiae may develop in the skin: small, reddish, or purplish spots that are the result of microvascular bleeding under the skin. Somehow, their blood is simultaneously too thick and too thin.
What in the world is going on here? And what should massage therapists know about this situation?
To set up a conversation about blood-clotting problems related to COVID-19, we will do a cursory review of our wonderful capacity for hemostasis: maintaining our blood clotting functions within boundaries for health and safety.

Hemostasis: Balanced Blood Clots

Under normal circumstances, our blood flows through our thousands of miles of blood vessels, delivering oxygen and nutrients, removing carbon dioxide and wastes. The O2–CO2 exchanges happen at the alveoli in the lungs and at the capillary level in the tissues. It is meant to be a closed system, meaning that red blood cells are kept within the circulatory vessels. If they manage to escape, then something is wrong.
Among our blood components, we have cell fragments called platelets or thrombocytes. These tiny, smooth corpuscles move through our circulatory system, scanning for possible breaches and rough spots. If something in the system is disrupted, then the platelets activate: they become spiky, they secrete a lot of chemicals that act on other platelets and clotting factors in the blood, a fibrin net is woven, and a plug—that is, a clot—is formed. The factors that prompt this process are identified as the Virchow triad, named for a 19th-century German pathologist who made some early observations about blood clotting (Image 1).
Blood clotting is not a bad thing; this mechanism serves an important life-preserving function, and we would be in a lot of trouble if it didn’t work. But it must be balanced by clot-melting mechanisms, or we get into a different kind of trouble. Most of our clot-melting chemicals are produced by the liver; when they do their work, the fibrin nets are dismantled, clots are degraded, and blood flow is restored.
When all goes well, we form and melt clots all the time, in appropriate responses to tissue damage or other factors. But when we form more clots than we can melt, we are at risk for complications like thrombi (clots that form onsite and can become big enough to block blood flow) or emboli (fragments of thrombi or debris that travel through vessels to other locations). Many things can upset our hemostatic processes. Heart disease, trauma, pregnancy, autoimmune disease, inflammation, and some types of cancer can all cause pro-clotting imbalances in these mechanisms. But the focus of this article is the hemostatic derangement that occurs in the presence of systemic infection with SARS-CoV-2, the virus that causes COVID-19.
I am deeply grateful to Dawn, a generous massage therapist and COVID-19 survivor, who experienced a version of this process, and shared her story (see Dawn’s Timeline).

Dawn’s Timeline

Dawn, a massage therapist from Texas, was kind enough to chat with me about her experience. Here is her timeline of interactions with COVID-19 and its complications:
• December 2019: Dawn takes care of her brother who is in the hospital with an undiagnosed infection. He needs a ventilator, dialysis, and other interventions. Weeks later his health-care team agrees that he had all the signs and symptoms of COVID-19 before it was officially recognized in that part of the country.
• March 19, 2020: Dawn wakes with a feeling of heaviness in her chest. She has had bronchitis in the past, and she assumes this is another bout. She is bedridden for three days, and then symptoms subside.
• March 25, 2020: Dawn has no fever, cough, congestion, or trouble breathing, but she has debilitating fatigue and needs two naps a day just to function. She has a sudden onset of extreme muscle soreness in her upper body, and spends much of the next few weeks with pain-relieving lotion on her trunk and arms. During a bath, she notices bright pink spots all over her legs. These get progressively larger over the next several days.
• April 16, 2020: Many of the pink spots have converged into large wheals. They are intensely itchy, like “ants biting.” Her legs are bilaterally swollen at the end of every day. In a consultation with a “tele-doc,” she is counseled to cut down on her activity (she had been walking four miles every day), to raise her legs whenever she rests, and to take a baby aspirin daily. (Although her doctor doesn’t ask about this, she is also experiencing severe and prolonged bleeding in her mouth when she brushes her teeth.)
• April 24, 2020: After mild exercise, large bruises form over the wheals on Dawn’s legs. She has tingling sensations in her upper lip that persist for a few days.
• April 25, 2020: Dawn is tested for COVID-19. Her nasopharyngeal swab is negative, but her serum antibodies are positive. This indicates that she has had the infection in the past, but the viral population in her upper respiratory tract is low.
• April 30, 2020: Dawn’s rash is 95 percent gone, and she is almost at normal activity levels.
• May 12, 2020: Dawn’s rash on her legs flares up again, and she now has dark purple spots on her toes: COVID-toe.

When It All Goes Wrong: Hemostatic Derangement

We know that SARS-CoV-2 first targets the lungs in most patients, but we also know it doesn’t always stop there. It turns out this virus can attack any cells with a membrane receptor site called ACE-2. This includes alveolar cells, but also myocardial cells, kidney cells, the intestinal lining, and (here is the link between COVID-19 and clotting disorders) the endothelial layer of blood vessels—in arteries, veins, and capillaries. And these attacks lead to inflammation (endotheliitis) and damage to the inner lining of blood vessels. In some people, this damage triggers an extreme inflammatory reaction called a cytokine storm—this is a topic addressed in Til Luchau’s article “Understanding COVID-19’s Cytokine Storm” in the May/June 2020 edition of Massage & Bodywork (page 80).
A complicated (and very chemistry-heavy) sequence leads from viral invasion to cytokine overreaction, inflammation, platelet activation, and the precipitation of clotting factors in the complement cascade, but the ultimate outcome is that the infected person develops clots—and lots of them. They can line the alveolar capillaries, interfering with oxygen/carbon dioxide exchange. They can develop in the liver, the kidneys, the brain, and many other tissues. These clots can damage red blood cells trying to pass through narrow spaces—a process that stimulates even more clotting. All this clotting activity leads to a type of multiorgan failure, which is a frequent cause of death for people with the infection. As of this writing, when a person with COVID-19 dies, this is the situation found during autopsy somewhere between 30 percent and 40 percent of the time. That number may change as we learn more about this virus.
But COVID-related clotting disorders have other repercussions as well. Readers may be familiar with Tony Award-winning actor Nick Cordero, whose leg was amputated because clots in his arteries were blocking circulation, which led to the threat of gangrene and blood poisoning. Also as part of the pandemic, young people (that is, people under age 50) with the virus are dying of heart attacks (clots in the coronary artery) and strokes (clots in the cerebral arteries) at higher rates than we have seen before—sometimes before other symptoms are evident. Further, the clots may be in unusual places, especially in the brain, and resistant to typical treatments. This appears to be directly related to COVID-related disruptions in blood-clotting mechanisms.
In addition, the hemostatic disruptions seen with COVID-19 may also cause blood clots in tiny blood vessels on the trunk or extremities. Readers may have seen reports of “COVID toes”—this is a consequence of microvascular obstruction with resulting skin damage. This can also take the form of skin bumps, swelling, and redness on the toes, and petechiae on the extremities or trunk, with dark, flat, discolored patches of skin where microvascular bleeding has taken place.  

Disseminated Intravascular Coagulation

A condition called disseminated intravascular coagulation (DIC) is a serious complication that is identified when a specific type of disordered blood clotting accompanies some other major health challenge. It’s a complicated situation involving both excessive levels of clotting in some areas and excessive levels of bleeding in others. This is because in the hypercoagulable areas, platelets and clotting factors are used up—leaving inadequate supplies to deal with tissue injuries elsewhere. This is why DIC is sometimes called consumptive coagulopathy—clotting factors are consumed.
DIC is identified when blood tests show low levels of platelets (this is called thrombocytopenia), delayed clotting times, and high levels of D-dimer, a substance that indicates fibrin breakdown, or the degradation of blood clots.
Is DIC the situation we see with COVID-19 patients? It’s not entirely clear. Some medical professionals are moving forward with that assumption, while others find some differences between classic DIC, another clotting disorder called antiphospholipid syndrome, and what is now called COVID-associated coagulopathy. For our purposes, it doesn’t matter, but understanding this phenomenon will make a difference in treatment options and survival rates for patients.

Massage Therapy Implications

It’s hard to make confident recommendations about massage therapy in the context of a situation that is so complicated and fraught with unknowns. As I processed mountains of information and held conversations with many generous people who helped talk me off the cliff of confusion, I boiled down my remaining questions to a few primary ones, some of which I was able to answer:
1. Can you have COVID-19 and not have coagulopathy? (Yes)
2. Can you have COVID-19-related coagulopathy and not be hospitalized? (Yes)
3. Can you have coagulopathy and not have obvious symptoms? (Yes)
4. Could massage lead to embolization in a client with symptomatic or asymptomatic coagulopathy? (UNKNOWN, but we have to assume YES)
5. At what point is it safe for a person with a history of coagulopathy to receive massage? (UNKNOWN)
Up until this point, our main goal in the context of COVID-19 has been to minimize the risk of catching or spreading the virus in a massage therapy setting. Now, we have an entirely different risk factor, with the possibility of contributing to blood-clotting complications by way of hands-on bodywork.
In the final analysis, we must decide if the risks related to massage therapy for people who might have COVID-related coagulopathy are any greater than the risks we see with other hidden disorders. Is COVID-related coagulopathy different?
This topic is a moving target, and our understanding of blood-clotting problems in the context of COVID-19 evolves quickly. In the short run, I propose that the best choice is to avoid working with people who are at risk for a current COVID-19 infection and to screen for blood-clotting problems in general. That might mean adding three new questions to a COVID-specific intake form:
• Can you exercise to get your heart rate and respiratory rate up without any problem? (This would indicate whether their cardiopulmonary function is unimpaired.)
• Have you had a new onset of muscle aches and pain since the emergence of the virus? (This is a possible early sign of coagulopathy, and a reason to defer treatment until the person has been tested and cleared of coagulopathy risk.)
• Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin? (This indicates the possibility of microvascular clotting, and is reason to defer treatment until the person has been tested and cleared of coagulopathy risk.)
In terms of clinical decision-making, we can start here: Any new signs of skin lesions or discoloration need to be fully resolved before we can be sure that massage is safe. Any signs of pulmonary or cardiovascular strain needs to be resolved. And any client using an anticoagulant to treat complications related to COVID needs to delay massage until they are no longer at risk for blood clotting.
As we learn more about this situation, guidelines will change. This is a snapshot in time, and I dearly hope that in a year we will look back on this and say, “Yes, we’ve learned a lot since then.” But until that time, we must be cautious and conservative, so that we can keep to our promise to “do no harm.”

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