The array of devices that modern medicine can use to improve physical function is amazing to behold. There are now more than 1,700 different types of medical implants and devices, and that list continues to grow. While many are specifically for laboratory or surgical use, this discussion focuses on devices that are temporarily or permanently attached to the body—especially those that require caution during a massage.

Implanted medical devices are not a new phenomenon. All carry some risk related to surgical mishaps, infection, or allergic reactions. In addition, an implant may require some accommodation in a client’s daily activity, which may influence the choices a massage therapist makes. The following is by no means a comprehensive list, but it covers some of the most common implants likely to influence massage therapy sessions.

Prosthetic Joints
Replacement knees, hips, and shoulders are extremely common medical implants. They carry some cautions for massage therapy, mainly related to postsurgical complications and limited range of motion. The column “Baby Boomers and Joint Replacement Surgery,” Massage & Bodywork, November/December 2010 (www.massageandbodyworkdigital.com/i/70065/97), examines this topic thoroughly.

Cardiovascular Implants
Most implants that manage blood-flow issues or other cardiovascular problems pose few risks for a client who wants to receive massage. The therapist needs to know these implants are present, however, along with the involved underlying conditions. Several types of implants have to be adjusted or replaced on a regular basis, so information about the client’s current status is valuable as well.

Arterial Stents
Stents are small tubes inserted inside damaged arteries. They are usually used in branches of the aorta, coronary, or carotid arteries, but they can also be used in brain vessels. The presence of a stent may mean that the patient uses anti-clotting medications, which carry cautions for massage.  

Pacemakers
A pacemaker is a small device that controls the heartbeat when the body’s natural system to fulfill that function has been damaged. A pulse generator is housed just under the skin of the chest, and leads are implanted in the heart.
Pacemakers that have been in place for more than a few months pose no specific cautions for massage, as long as the client is comfortable on the table. Practitioners who use magnets as part of therapy may need to gather more information about safety, however.

Defibrillators
A defibrillator is another device that controls the heartbeat, but unlike a pacemaker, it is designed to intervene only when needed. If the person goes into arrhythmia—tachycardia (rapid heartbeat) or fibrillation—the machine can deliver mild or extreme electric shocks to reset a healthy heart rhythm. People who have implanted defibrillators typically have tissue damage from a history of heart attacks, cardiomyopathy, or some rare inherited disorders.
A person with an implanted defibrillator needs to keep cellphones a minimum of 6 inches away from the device, and avoid using headphones because of the magnets. Massage therapists who use magnets in their therapy should likewise avoid this with these patients.

Vena Cava Filters
A vena cava filter is a small wire device shaped like an octopus. It is inserted via a leg vein into the vena cava in order to trap clots that may ascend from the lower extremities. Trapped clots can then be melted with natural or supplemented chemicals before they do any damage.

The presence of a vena cava filter is not a contraindication for massage, but does suggest that the client has a history of developing threatening clots from the legs or pelvis; this obviously has implications for massage therapy choices. Further, clot-management medication likewise calls for caution with pressure during massage.

Diabetic Implants
Clients who have diabetes may manage their condition with a couple of different devices.

Insulin Pumps
Insulin pumps are computerized devices carried close to the body that deliver insulin via a catheter inserted through the skin into the fatty tissue below. Insulin is delivered both as a slow, continuous drip and in larger doses after a meal. Insulin pumps carry a risk of the catheter becoming dislodged.

Peritoneal Dialysis
A peritoneal dialysis system involves a permanent tube in the abdomen through which fluids can be transferred. This uses the peritoneal lining as a substitute for failing kidneys. Diabetes is a common reason to use peritoneal dialysis, but people with kidney damage from other causes may also have this implant.

Pain Management Implants
People who live with chronic, severe pain may use a variety of devices. This is a field with lots of new technology, so the equipment used in this context changes often. Here are a few to be aware of:

TENS/PENS Units
Transcutaneous electrical nerve stimulation (TENS) and percutaneous electrical nerve stimulation (PENS) units deliver low-level electrical stimulation through electrodes on the skin surface. They are noninvasive and economical, but sometimes ineffective for very severe pain.

Intrathecal Pumps
Intrathecal analgesia therapy delivery systems use an implanted reservoir of medication and a catheter to deliver a drug directly to the spinal canal. This allows the patient to use much less of the medication, since it doesn’t go through the digestive system before reaching the spinal cord. The reservoir is refilled every few months.
Patients with intrathecal pumps may have some activity limitations, especially on bending and twisting, but if the pump is stable and functional, it shouldn’t affect their ability to receive most types of massage.

Spinal Cord Stimulation
Spinal cord stimulation involves implanting a pulse generator under the skin of the abdomen and running leads into the spinal canal. Electrical pulses are administered directly to the spinal cord to replace pain signals with a tingling sensation. Spinal cord stimulation is a relatively new intervention with a significant list of possible complications, but it shows promise as a drug-free method of treating severe pain. Patients with this device must not undergo MRI testing because of the implanted metal parts.

Oncology Implants
Massage clients who are undergoing cancer treatment may have a variety of equipment to manage, but these are probably the most common:

Radioactive Seeds
Some types of cancer are treated by injecting small radioactive pellets, called seeds, on or near tumor sites. Patients are usually counseled to avoid close contact with others while the seeds are in place, at least for several weeks. After they have been removed or lost their potency, this caution is lifted.

Portacaths & PICC Lines
Portacaths (also called ports) and peripherally inserted central catheter (PICC) lines are devices that provide easy long-term access via an implanted tube to the circulatory system for the administration of medicine. PICC lines use veins in the arms, while portacaths typically access the subclavian vein. These devices carry a list of serious possible complications, including blood clots, infection, and occlusions. At their best, patients with these devices can enjoy normal activities, including exercise and massage, but the access area may need special accommodation with position and pressure.

Ostomies
If colorectal cancer or some type of inflammatory bowel disease has led to the removal of a substantial part of the small or large intestine, a patient may have an ostomy: a surgically created opening to the digestive tract that allows liquid fecal material to accumulate in a changeable bag.

It is important to reiterate that the list above is very much abbreviated. Massage therapy clients may also have implanted mesh to repair hernias and other wounds; shunts that drain excessive cerebrospinal fluid into the abdomen; drains for chronic infections; and any number of other devices. Most of them come with few restrictions, but the massage therapist who works with these clients must be diligent about getting enough information to help keep clients safe and comfortable.

Advice from the experts
To help create a practical application for all this information, I consulted with several therapists who work with medically frail people. I asked, “What are the most important things massage therapists should know about working with implants or attached devices?” Here are some of their responses:

“Other people on the client’s team are also great sources of information. Occupational and physical therapist guidelines can provide a safe parameter for massage, so consult with them if your client gives you permission.”
Xerlan Deery, Pennsylvania educator and massage therapist

“It comes down to three variables: pressure, site, and position. Many implants aren’t fully ‘locked in’ by scar tissue for a few months after surgery. During this time, massage must be carefully gauged so as not to disrupt new scar tissue that is knitting the device into the body. Positioning and site-specific cautions also remain in play. Your client can guide you into what positions feel comfortable and what areas he or she wants you to avoid, but pressure on and around the device site must always be adjusted to respect the delicate connections that these devices require.”
Gayle MacDonald, author of Medicine Hands: Massage for People with Cancer (Findhorn Press, 3rd ed., 2014) and Massage for the Hospital Patient and the Medically Frail Patient (Lippincott Williams & Wilkins, 2004).

“Did you accidentally step on your client’s oxygen tube? Don’t panic: they’re very sturdy. But don’t linger there. Treat any appliances as sort of extra appendages. Remember where things are when your client turns over so you can anticipate bolstering and draping issues.”
Tracy Walton, author of Medical Conditions and Massage Therapy: A Decision Tree Approach (Lippincott Williams & Wilkins, 2011).

I’ve learned over the years that clients can give you lots of good information. If you’re dealing with a new and unexpected situation, it is a simple thing to say, “I’ve never had a client with a ____ before. How can I make you comfortable?”

Options and Opportunities
Massage in hospital and rehabilitation settings continues to be a big growth area for the profession, but this requires a special skill set, along with compassion, scientific knowledge, and the ability to create a serene space in the middle of what can be a hectic, frantic venue. That is a remarkable ability, and we can celebrate those among us who have created this professional pathway.

Author’s note: I give great thanks to the people who so generously shared their insight and experience for this article. I am eternally grateful to be able to share their wisdom with a wider audience.

Ruth Werner is a former massage therapist, a writer, and a continuing education provider approved by the
NCTMB as a provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2013), now in its fifth edition, which is used in massage schools worldwide. Werner is available at
www.ruthwerner.com or wernerworkshops@ruthwerner.com.

To read this article in our digital issue, click here.