Key Points

• A client with a complex health challenge can benefit from a conversation between their massage therapist and their health-care team.

• Conversation is not the same as permission; MTs do not need a doctor’s permission to massage a client whose health is challenged.

• Ultimately, it is up to the massage therapist and their client to decide the safest and most effective course of bodywork.

As a pathology educator and podcaster, I field a lot of massage therapists’ questions about working with clients with complex diseases or conditions. I do what I can to answer them, although I’m not always able to respond in a timely manner. But I also see massage therapists reaching out to their peers in public social media settings with similar questions. And I want to offer the opinion that social media might not be the best place to get advice about tricky pathology situations in practice. Here are some lightly edited examples of why:

Post: I have a client who is recovering from a heart attack and wants to receive massage. Any ideas on what I should do?

Comment: Get a doctor’s note.

Post: My client is recovering from a bad infection, and they had to use IV antibiotics. Now they want massage. I’m a little nervous about this. Your thoughts?

Comment: Check with the doc!

Post: My client had breast cancer and now has lymphedema in her right arm. She wants massage but

I haven’t been trained in manual lymphatic drainage. Can I work on her?

Comment: ABSOLUTELY NO MASSAGE without a doc’s permission. 

Post: My client has occasional numbness in his right foot following his knee surgery. He is training for a bike race and wants to receive massage. I’m not sure what to do for him.

Comment: Has he been cleared for massage by his doc?

Are we sensing a theme? Most massage therapists who don’t work in medical or clinical settings don’t expect to see clients with complex health situations very often. But this happens all the time: Someone coinfected with HIV and hepatitis C may visit a practitioner who specializes in helping clients with high-risk pregnancies. A person with diagnosed blood clots in her legs may show up at a student clinic because her doctor said massage would “help her circulation.” A patient with amyotrophic lateral sclerosis may want to receive massage from the therapist at her hairdresser’s shop. A person disabled by a major stroke may love the hand, arm, and shoulder massages she gets at her nail salon. Each of these scenarios comes from real-life communications I have had with massage therapists or clients, and each one presents some significant challenges for practitioners who want to work both safely and effectively. For a lot of people, that means checking with the doctor first.

I appreciate this impulse. It’s a good instinct: It means massage therapists are aware that some situations are more complicated than others, and it would be smart to get a medical authority to give us a green light to move forward.

But that authority is probably underinformed about the risks and benefits of massage therapy, and that green light may not provide all the input we need. We might want someone in charge to give us permission to work. But what we need is more information to work safely. Those are two different things.

Why Do We Want a Doctor’s Note?

The concept of the doctor’s note is one I have struggled with since I went to massage school about a million years ago. My instruction, when we had questions about our clients’ safety, was to “call their doctor.” As if that would work. Even in the early ’80s, this wasn’t practical advice—I couldn’t call my own doctor and get someone on the line, much less trying to call someone else’s. And, assuming such a thing were even possible, then what? What is the purpose of calling the doctor? Why do we want a doctor’s approval for our work?

I identify three main reasons massage therapists want to get a doctor’s note, which have varying levels of usefulness:

• Doctors know more about anatomy, physiology, and pathology than massage therapists.

• A doctor’s note will ensure massage therapy is safe.

• A doctor’s permission or prescription will protect the massage therapist from legal action if the client is injured.

Reason 1: Doctors Know More about Anatomy, Physiology, and Pathology than Massage Therapists

Most massage therapists in the US get a solid introduction to important concepts in anatomy and physiology, and at least some information about how pathologies alter function. But this education often doesn’t feel like an adequate base on which to make decisions about massage therapy in the context of complicated health challenges. So naturally, we want to go to the experts on this topic—and that means our clients’ health-care providers. This is a completely reasonable strategy, and to the extent that getting information about the details of a client’s health situation might help massage therapists make better choices, this is a great reason to have a conversation with a doctor or other health-care provider. Note: Having a conversation is not the same as asking permission.

Reason 2: A Doctor’s Note Will Ensure Massage Therapy is Safe

Doctors should (and mostly do) give reliable advice for their patients in the context of many activities of daily living—whether it’s safe for them to drive, or what kinds of exercise they should do or avoid, for instance. But it is not a doctor’s job to decide whether your massage is safe. 

That is such an important sentence, I will repeat it: It is not a doctor’s job to decide whether your massage is safe.

This is partly because the term massage can mean anything from manual lymphatic drainage to Rolfing, with all modalities in between—and the safe practice parameters along that spectrum vary. It’s also because doctors are not formally educated about massage therapy, so it is impossible to predict whether their assumptions about your work are accurate. 

But do you know who is educated about massage therapy? Massage therapists. And, like it or not, the responsibility to determine whether massage is safe lies solely with the practitioner. We may want more information about a client’s situation to make the best choices, but getting more information is not the same as asking someone else to tell us whether our work is safe.

Reason 3: A Doctor’s Permission or Prescription Will Protect the Massage Therapist from Legal Action if a Client Is Injured

This is a common misconception. If a massage therapist injures a client by working outside their scope of practice and not delivering an appropriate standard of care (see Standard of Care, Scope of Practice, page 57), it doesn’t matter if they have a prescription from a medical doctor for massage—the client’s injury is the massage therapist’s ethical and legal responsibility. 

On the other hand, a practitioner who seeks appropriate consultation with the client’s health-care team demonstrates due diligence in working safely, effectively, and within scope of practice, and that may provide some legal shelter. But once again, consultation is not the same as permission.

Ultimately, only two people have to agree for a massage to take place: a client and a practitioner who works within an appropriate scope of practice and provides an appropriate standard of care. The primary-care doctor doesn’t have to “clear it,” nor the surgeon, nor the physical therapist, nor anyone else. This is true, even when the client has a complicated health history that requires further exploration for the best clinical decision-making. That said, if a doctor strongly suggests against massage therapy, that opens the door to gathering more information—on both sides of the conversation.

How Do We Know Our Work is Safe?

I hope every massage therapist wants to do work that is both safe and effective. Truthfully, the safest option in any situation is not to do massage at all; in that way, no one will ever be injured by massage therapy. But that isn’t effective, is it? 

We evaluate the safety of our work through the knowledge we attain during our education. This is why we learn anatomy, physiology, and pathology. We also learn how various types of massage therapy influence function, because that must inform some of our clinical decisions: The effects of myofascial release are not the same as those of craniosacral therapy, for instance, and we use these modalities for different outcomes.

But what happens when a client has a complicated health situation? How do we establish safe and effective work for this person? We can find information about potential risks and benefits of massage from four main sources: the client, the therapist’s education, the therapist’s peers and community, and the client’s health-care team.

Often, a person who lives with a condition is an expert on that topic, and they are the best resource for the information we need to make clinical decisions. A client with a colostomy bag or an amputation or who uses a wheelchair will have ideas about how to receive massage comfortably, for instance; no further consultation is required.

Massage therapists may also use their own resources for information—textbooks and internet searches, their community, and connections on social media. This can yield some good ideas, but as we have seen, a tendency among massage therapists is to defer to a medical authority (“Get a doctor’s note!”) to make difficult decisions.

When a client’s situation is particularly puzzling, or the potential for adverse events are substantial, it becomes necessary—with the client’s permission—to consult with their health-care team. 

What Does Consulting with Health-Care Providers Look Like?

The goals of communications with the client’s other providers are twofold: to get information about potential risks related to massage therapy, and to be sure that the client’s and therapist’s goals for massage are in alignment with the health-care team’s goals for treatment. Notice that these goals do not include asking permission to provide massage, or getting clearance, or in any way making other providers responsible for the decisions the massage therapist makes.

That said, having a record of these communications demonstrates the massage therapist’s commitment to the best possible outcomes for the client. Building good relationships with other health-care providers is in the best interest of our clients, of course, but also of the practitioner, and ultimately the profession as a whole.   

What might this communication look like? When we reach out to other providers for information to help make clinical decisions, we need to do a few things. We need to:

• Establish that the client has given permission for their information to be shared

• Describe the client’s situation (disease or condition, and medications and side effects) and their goals for bodywork 

• Cite or describe relevant massage therapy benefits that serve those goals (with links to appropriate research, if necessary)

• Provide a clear and concise description of the work, including parameters for pressure, duration, and frequency of sessions, and possibly what won’t be included

• Make a clear statement of a question or concern regarding specific risks for adverse effects of massage therapy and being in alignment with the health-care professional’s treatment goals

• Invite a response

• Offer to provide updates or progress reports

This seems like a lot to include in a short letter, so I, with the help of Allissa Haines of Massage Business Blueprint, have created a sample template for an email that can be customized for your use (see Sample Communication to Doctor on page 59, downloadable for ABMP members at abmp.com/members/business-management/client-forms/physician-forms). This can be forwarded to the physician by the client to ensure privacy and security.

Where Does This Land Us?

Consulting with a health-care provider can feel like a lot of work, and to avoid all the fuss, it is tempting to assume that everything will be OK if we just do super-light massage and hope for the best. But is that choice in the best interest of the client? I suggest no. 

Establishing communication with a client’s health-care provider can feel intimidating. We have to go through extra steps to ensure privacy and security. We must represent ourselves professionally and carefully. We need to be thorough but succinct. It’s a skill that takes practice, but I hope the samples we’ve shared here will give you a model for how you can develop your communications about your clients who have complex health situations.

When we represent ourselves well to our clients’ other providers, we build professional bridges that benefit us. As a doctor, wouldn’t you be interested in referring more patients to a massage therapist who demonstrates such commitment to their clients’ well-being? And these communications benefit the profession, which is well represented by your clear dedication to excellence. Most of all, they benefit our clients, who depend on us to have their best interests at heart.

What happens if, after gathering as much information as you can, you still don’t feel confident about your plans? This is where the word prudent in the description of standard of care is important. Prudence dictates that if you’re not sure that your plan of action is safe, you either need to change your strategy, or you must choose not to work at all—which can be the right decision, if the client’s or your well-being would otherwise be compromised.

But truly, between your own experience, your education, and your many sources of reliable information (which include your clients’ health-care providers), you almost always have the tools you need to make safe and effective clinical decisions. 

It’s not a doctor’s job to decide whether your work is safe. But a doctor or other health-care provider can have an informative conversation with you about some of the variables that must feed into your clinical decisions. This kind of consultation is not the same as getting permission—it is so much better. 

Resources

Çakici, N. et al. “Systematic Review of Treatments for Diabetic Peripheral Neuropathy.” Diabetic Medicine: A Journal of the British Diabetic Association 33, no. 11 (2016): 1466–76. https://doi.org/10.1111/dme.13083.

Ezzo, J. et al. “Is Massage Useful in the Management of Diabetes? A Systematic Review.” Diabetes Spectrum 14, no. 4 (2001): 218–24. https://doi.org/10.2337/diaspect.14.4.218.

Lyu, Wei-Bo et al. “Effect of Self-Acupoint Massage on Blood Glucose Level and Quality of Life in Older Adults With Type 2 Diabetes Mellitus: A Randomized Controlled Trial.” Journal of Gerontological Nursing 45, no. 8 (2019): 43–8. https://doi.org/10.3928/00989134-20190709-05.

Standard of Care, Scope of Practice

Standard of Care

The legal definition for the term standard of care is a diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance. Obviously massage therapists don’t diagnose, but as clinicians we are also obliged to deliver an acceptable standard of care. The expectation is that a practitioner will make clinical decisions that an average, prudent provider in a given community would practice. 

For instance, if a massage therapist chooses to do intrusive work deep in the pelvis knowing the client had been diagnosed with an ovarian cyst, that would not be delivering an appropriate standard of care. By contrast, if a person with appropriate credentials performs lymph drainage technique for a client with a sprained ankle, that is an appropriate standard of care.  

Scope of Practice

The term scope of practice is an important concept, and it is essential that massage therapists be familiar with what it means. Fortunately, it’s not difficult.

For virtually every helping profession, scope of practice means two things: competency and permission. Massage therapists who work within their scope of practice provide skills they are competent to offer, and they limit those interventions to what is permitted by both the client/patient and by local laws and regulations.  

Competency

Every jurisdiction that regulates massage therapy imposes some baseline of professional skills and knowledge to maintain public safety. This is usually achieved through completion of an approved massage therapy school or apprenticeship program. Some locations have no regulation of the practice of massage, however. In these areas, anyone can call themselves a massage therapist, even with no education in the field at all, so a baseline level of competence cannot necessarily be assumed.

It’s important to highlight the term baseline. Massage therapy regulation is usually put in place to preserve public safety, not to support or improve the skills of local massage therapists. Consequently, educational requirements allow the local regulating agency to expect safe practice (competence), but they don’t include advanced skills. Specialty fields go far beyond a baseline level of education. So even if a person has a massage license, they are not competent to practice a specialty skill like oncology massage therapy, manual lymph drainage, or others without advanced education. If they did so, they would be practicing outside their scope.

Permission

The permission for massage therapists to work comes from two sources: their jurisdiction and their client. All massage must begin with the client’s informed consent. If a massage therapist incorporates some technique or intervention for which they did not obtain their client’s consent (for instance, breast massage or using a percussion tool), they are working outside of their scope of practice.

Also, scope of practice is defined and limited by local laws and regulations. These vary from place to place, and it is incumbent on massage therapists to be familiar with their local rules. Some states allow breast massage if the therapist is appropriately educated and obtains informed consent; others permit massage therapists to work intraorally if they have had appropriate training. Recommending stretches or exercises is allowed in some states, but not others. 

But in every instance, the practitioner must be adequately educated to provide the intervention. So even if someone lives in a state that allows massage inside the mouth, if a licensed massage therapist with no specialized education does this, they are working outside their scope of practice. And if a client suffers an injury because of this uninformed work, the therapist is fully at fault.

Safe, effective, ethical practice demands that massage therapists observe both their scope of practice and standards of care in every interaction with every client.

Resources

American Medical Association. “What is Scope of Practice?” www.ama-assn.org/practice-management/scope-practice/what-scope-practice.

LawInsider.com. “Scope of Practice Definition.” www.lawinsider.com/dictionary/scope-of-practice.

LegalDictionary.net. “Standard of Care.” March 20, 2019. www.legaldictionary.net/standard-of-care.

MedicineNet.com. “Medical Definition of Standard of Care.” www.medicinenet.com/standard_of_care/definition.htm.

NursingWorld.org. “Scope of Practice.” www.nursingworld.org/practice-policy/scope-of-practice.

Sample Communication to Doctor 

Dear Dr. Smith,

Your patient Jennifer Lee has given me permission to contact you. I am aware that Ms. Lee has a history of type 2 diabetes and is currently using diet, exercise, and metformin to manage her condition. She tells me she often feels tired, and she has occasional mild neuropathy that causes pain or numbness in both feet.

Ms. Lee would like to receive massage therapy to help with her pain and fatigue. Along with her other treatments, she hopes this might help her delay or avoid needing to use insulin and frequent pain relievers for her neuropathy.

I have worked with clients with peripheral neuropathy and had some success in reducing symptoms. Research on massage therapy and various types of fatigue is positive, and some studies also suggest that massage therapy can help to stabilize blood sugar. I will include some links to relevant research if you’re interested.  

I believe that light-to-medium pressure massage will be appropriate as Ms. Lee and I start our work together (Levels 1–3 on the Massage Therapy Pressure Scale, available here: www.tracywalton.com/wp-content/uploads/2015/04/Walton-Massage-Therapy-Pressure-Scale-for-WEBSITE.pdf). This would be no more physically challenging than her typical work in the garden each day. We plan to work together in 60-minute sessions for six weeks, and then will evaluate our progress.

Because of her diabetes, I plan to schedule her appointments between meals, when her blood glucose is likely to be most stable. And because she has some occasional numbness in her feet, my work in that area will be especially conservative.

I want to be sure I am supporting your treatment goals for Ms. Lee and not missing any important information about her health or risks before we work together. 

Specifically, I am concerned about Ms. Lee’s report of occasional numbness in her feet. My practice is to not do intrusive bodywork where sensation is impaired. I am concerned that her peripheral neuropathy may affect other nerves as well. 

From your perspective, is this a risk? Do you have any other concerns? And are there other ways my work can support your treatment goals for Ms. Lee?

And finally, would you like me to provide you with updates or progress reports?

Please feel free to contact me.

Best wishes, 

F. Lurraj

888-888-888 / fakemassageemail@x.com / fakeMTwebsite.com

Other sample letter templates are available in a free downloadable eBook called Communicating with a Client's Healthcare Team at massagebusinessblueprint.com/hcp. And the video that accompanies this article is an interview with Allissa Haines, who will talk through the logistics of how to get a letter like this into the hands (or onto the screen) of the person who needs to read it.