Chapter 19: Massage for Special Populations
Prenatal Massage
LO 1: Explain the benefits of prenatal massage.
LO 2: Demonstrate proper positioning when massaging a pregnant woman during each trimester.
LO 3: Explain the contraindications for prenatal massage.
LO 4: Describe maternal concerns by trimester that are considerations for prenatal massage.
LO 5: Practice a basic infant massage routine on a life-sized doll.
LO 6: Describe the benefits of infant massage.
LO 7: Explain special considerations for providing massage to children.
LO 8: Differentiate considerations for working with older clients who are frail vs. active.
LO 9: Explain accommodations for providing massage to people with various disabilities.
LO 10: Explain major considerations when providing massage to people with cancer.
LO 11: Explain accommodations for providing massage to people in hospice or end-of-life care.
Why Study Massage for Special Populations?
Massage benefits span ages and abilities; growing opportunities to work with expectant mothers, infants, and diverse populations.
Understanding diversity enhances career opportunities and aligns massage with conditions needing adaptation.
Special-population massage requires tailoring to unique physiologic needs, positioning, and technique adaptations.
Introduction to Massage for Special Populations
Massage is beneficial for nearly everyone; some populations require special handling due to physiologic needs.
Target groups include: pregnant women, infants, children, older adults, people with disabilities, critically ill patients, and those with cancer or in hospice/end-of-life care.
Education and continuing education are encouraged for those who want to specialize.
Explain Prenatal Massage
Pregnancy involves physical changes (enlarging abdomen, breasts, weight gain) and hormonal changes (softening ligaments) affecting comfort and emotional state.
Benefits for mother and fetus: relaxation, improved sleep, reduced pain, potentially improved maternal and fetal outcomes.
Prenatal massage is performed like regular massage with trimester-specific considerations.
Considerations for Prenatal Massage
Setup: step stool for easier mounting/dismounting; bolsters/pillows for comfort; accessible bathroom and robe; fetus may press on the bladder.
Massage duration: generally shorter; many women past 30 weeks may be uncomfortable lying flat for more than ~45–50 minutes.
Positioning options across trimesters:
Early pregnancy: prone or supine positions:
Around 22 weeks onward: use semi-reclining supine (45°–70°) with head/torso supported; pillows/wedge under knees to relieve lower back strain; avoid vena cava compression.
Side-lying: most comfortable throughout pregnancy; pillows under head, abdomen, upper knee, between legs; hug a pillow for fetal-pose comfort.
Prone: possible early in pregnancy if anterior superior iliac spines allow abdomen clearance; use specially designed cushions/tables; opinions vary among instructors.
Body areas needing attention: neck, upper back, lower back, hips, legs, feet; emphasis on back/neck due to posture changes and shallow breathing.
Abdominal massage: only light gliding in second/third trimester; deep massage on abdomen is contraindicated during pregnancy; obtain explicit permission for any abdominal work.
Safety: avoid deep abdominal techniques; monitor for discomfort; edema considerations and potential contraindications.
Maternal Concerns by Trimester
First Trimester (Weeks 1–13): hormonal changes may cause breast tenderness, nausea, mood swings, fatigue, heightened sensitivity to smells; higher miscarriage risk, so massage often postponed unless medically approved.
High-risk factors include: age under 20 or over 35, prior pregnancy complications, multiple gestation, maternal illnesses, Rh incompatibility, history of DVT, or uterine abnormalities.
First-trimester massage guidelines: avoid abdominal stimulation and reflex points promoting uterine contractions; avoid uterus/ovary reflexes on feet/legs; schedule when nausea is minimal; focus on relaxation and stress relief (upper back, rib cage, shoulders, lower back, legs).
Second Trimester (Weeks 14–26): fetus grows; relaxin hormone softens ligaments, necessitating caution with ROM to avoid overstretching. Abdominal changes and pelvic pressure require positioning adjustments.
Supine position limited after ~week 20 due to potential vena cava/abdominal vessel compression; use semi-reclining or side-lying positions.
Edema common in legs/feet; gentle/swimming-like lymph or light gliding massage may help; avoid deep leg massage if DVT risk or signs present.
Monitor varicose veins; use light massage around affected areas; avoid deep techniques on abdomen.
Third Trimester (Weeks 27–40+ and Birth): uterus enlarges; increased musculoskeletal strain; possible diaphragm pressure, heartburn, constipation, hemorrhoids, urinary frequency, edema, and diastasis recti risk (separation of linea alba).
Supine and prone positions should be avoided due to fetus safety and intrauterine pressure concerns; focus on relaxation and pain relief for weight-bearing joints, back, hips, neck, shoulders.
Edema, varicose veins, and decreased tissue tolerance require light, cautious techniques around the lower extremities and abdomen.
Massage during labor: can provide relief between contractions with firm sacral pressure and targeted pelvic-area work.
Massage following birth: can begin after physician approval; 6–8 weeks postpartum for relaxation and recovery, neck/shoulder pain relief, and support for infant care demands.
Contraindications for Prenatal Massage
Obtain physician permission especially for high-risk pregnancies or when complications exist.
Acute conditions to monitor include:
Morning sickness, nausea, vaginal discharge or bleeding, diarrhea, abdominal pain, decreased fetal movement.
Pre-eclampsia/pregnancy-induced hypertension: contraindicated until physician clearance.
Varicose veins and Deep Vein Thrombosis (DVT): light massage only around affected areas; avoid deep leg massage and monitor for signs of DVT; refer to physician if suspected.
Preeclampsia signs include systemic edema, sudden weight gain, headaches, dizziness, and potential seizures.
Clinical Observations and Safety Points
ABM: Abdominal massage is generally restricted to light gliding movements in later trimesters; ensure consent for abdominal work.
If edema is systemic or widespread, consult with the client’s physician prior to massage.
Breast and chest area considerations for side-lying and semi-reclining positions.
DVT warning: avoid deep massage of the legs; watch for redness, tenderness, swelling; refer if signs present.
Use of cushions, wedges, and specialized tables designed for safe side-lying/prone support.
Postpartum and Labor Considerations
Labor: lower back and sacrum can benefit from sustained, gentle pressure during contractions.
Postpartum: focus on relaxation, recovery from infant care strain, and gradual ROM restoration with gentle modalities.
Explain Varicose Veins, DVT, and Pelvic Edema (Prenatal)
Varicose veins: common due to progesterone and relaxin; light gliding around affected areas only; avoid deep techniques to reduce clot risk.
DVT: pregnancy increases risk; avoid deep massage of calves/thighs; refer if signs are present; use light lymph drainage around affected areas if advised by a physician.
Edema: mild edema may be massaged superficially; generalized edema may require physician input.
Labor, Birth, and Aftercare
Labor massage can help with pain and anxiety; sacral pressure may reduce back pain during contractions.
Postpartum massage helps with relaxation, neck/shoulder/back relief, and reintegration after infant care, often integrated with healthy exercise and diet.
Infant Massage
History: long tradition across cultures; Fredrick Leboyer and Vimala Schneider McClure popularized infant massage in the modern era; CIMI formation and Loving Hands concepts.
Purpose: to foster bonding, communication, and health benefits through loving touch.
Who Should Perform: ideally the parent or primary caregiver; caregivers are taught to massage using a life-sized doll for modeling; therapists train caregivers rather than massaging infants directly.
Teaching Methods: life-sized doll demonstrations; two routines taught: simple routine for premature/newborns and a more active routine for well babies (6–8 weeks and older).
Massage Routines Overview:
Simplified Routine (preterm and newborn): 15 minutes, gentle ROM, head-to-toe progressions, gliding with gradual leg/arm ROM; helps infant become accustomed to touch.
Well-Baby Active Massage Routine (6 weeks and older): 20 minutes; combines Swedish strokes (gliding, kneading, friction, percussion), Asian strokes to address fetal tuck, reflexology on feet, and a playful airplane-runway stroke to end. Proximal-to-distal progressions on arms/legs; include ROM and nurturing contact; parental involvement is key.
Colic/Gas/Constipation Routine: abdominal-focused techniques (I Love You tracing across colon, descending/transverse/ascending patterns), knee-to-abdomen passive ROM, and facial strokes; routine can be repeated several times daily.
Infant Massage Demonstration and Safety:
Use an infant-sized doll for teaching; ask for caregiver consent before initiating massage on infant.
Environment: quiet, warm room (around 75°F / 23.9°C); ensure infant comfort and safety; risk of chilling is high in newborns.
Signs of engagement/disengagement: eye contact, cooing, smiling, alertness indicate willingness; fussing, crying, looking away indicate disengagement.
Lubricant selection: one oil only (sweet almond, grape seed, or olive oil); edible, food-grade oil preferred since infants may ingest oil; test for allergies on inner wrist for 15 minutes.
Contraindications: if infant shows signs of illness, consult physician; massage intensity and pace should be adjusted to avoid overstimulation.
Infant Massage Safety and Communication:
Parent-led care is emphasized; skin-to-skin or skinship benefits are highlighted.
Ensure the infant’s cues guide the session; not all babies will tolerate a full massage.
Massage rooms should be calm and warm to prevent chilling; hold and comfort the infant if needed during transitions.
Provide Massage Services for Children
Children generally enjoy touch, but attention spans are shorter; adjust massage length to the child’s age and temperament.
Growth changes in children are rapid; bone density is lower, increasing fracture risk; immune system is developing, so illnesses can be more prevalent.
Contraindications for children mirror adult guidelines, with extra attention to fever (fever is a contraindication).
Extra considerations:
Parent or guardian must be present during the session.
Be vigilant for signs of abuse (bite marks, scratches, bruises); report suspected abuse as required by law.
Consider body-image concerns during puberty; sometimes massage through clothing may be appropriate.
Know the Benefits of Working with Clients Over Fifty-Five
The 55+ population is rapidly expanding; often includes both active and frail individuals.
Physiologic aging affects multiple systems: musculoskeletal tone, bone density, cardiopulmonary function, neurological and sensory systems.
Benefits of massage for older clients include:
Improved mobility and flexibility; relief from muscle hypertonicity, cramping, spasms.
Reduced anxiety, pain, and blood pressure; improved digestion/elimination.
Enhanced one-on-one connection and nurturing touch; increased independence in activities of daily living.
The Active Older Client (robust): generally fewer limitations; but still consider table height, breath pattern, and safety when transitioning; limit prone-down time to 15–20 minutes if needed; side-lying may be preferred.
The Frail Older Client: may have multiple health conditions requiring cautious, shorter sessions; ROM should be gentle; stationary touch and light pressure may be preferable; may be treated in home or seated positions; coordination with the client’s physician is important.
Communication and assessment are crucial; obtain thorough health history; update medications and health status regularly; consider using mobility aids; ensure wheelchair-accessible facilities.
Perform Massage for Clients with Disabilities
Disability vs. impairment: an impairment is a physical/functional abnormality; a disability restricts daily activities.
Accommodations must be tailored to each disability to ensure safety and comfort.
General approach: ask if assistance is needed; do not assume; adapt environment and technique to fit mobility, sensory, or cognitive needs.
Auditory Impairment:
Speak slowly, face the client, avoid loud voices; provide writing tools or devices if helpful.
If a sign-language interpreter is present, speak directly to the client and allow translation time; avoid guiding attention away from the client.
Visual Impairment:
Guide client safely, use descriptive cues for movement and room layout; if client uses a guide dog or cane, accommodate appropriately.
Offer assistance with intake forms and ensuring the client can navigate the space.
Visual Impairment and Safety: maintain verbal updates about room changes, position changes, and foot/hand placements.
Limited Mobility:
Ensure wheelchair access and clear pathways; adjust table height; consider at-home or chair-based sessions when needed.
Use extra bolsters for comfort; assist as requested and maintain client autonomy.
Paralysis:
Transfer assistance may be required; avoid deep techniques on paralyzed areas due to loss of sensation; use gentle lymphatic/ROM to maintain flexibility where safe.
Coordinate with physician for contraindications and safe transfer practices; consider in-bed massage if appropriate.
Prosthetics/Amputees:
Assess need to remove prosthesis; check for phantom pain; massage at the stump site only with physician clearance.
Monitor for soreness around prosthetic attachment; work contralateral limb for reflex relief where applicable.
Perform Massage for the Critically Ill
Purpose: provide gentle, caring touch to comfort and relax patients who are critically ill.
Benefits: reduces discomfort, improves mobility, eases emotional distress, reduces isolation and fear, fosters a positive attitude.
Considerations and Precautions:
Always align with the patient’s needs; when in doubt, ask the client and consult with physicians/caregivers.
Critically ill conditions change rapidly; continually assess visually and verbally; adjust as needed.
Techniques: focus on soothing touch; stationary touch, light circular friction, compression, and lymphatic work; avoid aggressive movements; ROM should be minimal and cautious.
Sessions may be abbreviated; sometimes holding a hand or simple presence is appropriate when the patient cannot tolerate a full massage.
Client feedback may be limited due to illness or medication; adapt based on cues and physician guidance.
Massage for Cancer Patients
Cancer is not a single disease; guidelines depend on cancer type, stage, site, treatment, and patient stamina.
Historically viewed as contraindicated; current evidence suggests massage cannot spread cancer and can be beneficial when properly adapted.
Key Considerations:
Obtain thorough intake: cancer type, stage, treatment history, medications, current symptoms, lymph node involvement, infections, fatigue, neuropathy, and organ involvement.
Coordinate with physician or oncologist; use oncology massage guidelines (e.g., Society for Oncology Massage).
Develop an individualized treatment plan; inform the client of expected effects and obtain informed consent.
Adjust massage type, depth, duration, and frequency to the patient’s current condition and treatment side effects.
Evaluate site restrictions, tissue stability, and immune status; be mindful of fatigue, nausea, and overall stamina.
Timing with Treatments:
Best to massage before chemotherapy to reduce anxiety and improve tolerance of treatment; massage can be resumed after side effects subside.
Post-radiation and post-surgery considerations vary; consult physicians for area-specific restrictions.
Treatments and Side Effects of Cancer Therapies:
Surgery: avoid incision sites, recent edema or clots, and post-surgical risk of thrombosis; avoid lower extremity massage until cleared.
Chemotherapy: side effects include nausea, vomiting, mouth sores, weight loss, hair loss, fatigue, anemia, low platelets, neuropathy.
Radiation: skin changes (rash, burns), tissue fragility, edema risk; avoid irradiated areas; avoid deep pressure near treated region; lymphedema risk if lymph nodes were irradiated.
Hematopoietic stem cell/bone marrow transplant: immune suppression; risk of infection; full-body massage not advised during acute periods.
General precautions: avoid infection risk, monitor blood counts, adjust pressure and duration to fatigue levels, consider energy-based modalities (Reiki, therapeutic touch) when appropriate.
Massage Benefits for Cancer Patients (Highlights):
Pain relief, reduced nausea, improved digestion/elimination, reduced stress, relaxation, better sleep, reduced anxiety, mood support, alleviation of muscle tension, improved quality of life, and enhanced overall well-being.
Massage Corner Highlights (Cancer):
Discuss metastasis concerns, four common metastasis routes (direct invasion, body cavities, bloodstream, lymphatic system), and the importance of not near tumors or regions at risk of metastasis unless cleared by physicians.
Metastasis stages: (1) cells break away, (2) circulation through blood/lymph, (3) implantation at secondary sites.
Prognosis: metastasis patterns differ by cancer type; be vigilant for new pain or signs of metastasis during massage.
Additional Notes:
Cancer is a broad field; professionals should seek oncology massage training and resources (e.g., S4OM). Objectives include safe practice, case-by-case assessment, and ongoing physician communication.
Family and friends of cancer patients can benefit from learning simple massage techniques to support their loved one.
Hospice and End-of-Life Care
Hospice overview: compassionate care for terminally ill individuals, focused on comfort, quality of life, and family support rather than cure.
End-of-Life Care: care plans emphasize pain relief, emotional support, and spiritual considerations; goal is to maximize comfort and dignity.
Massage in hospice/end-of-life scenarios:
Massage is gentle, noninvasive, and focused on reducing pain and anxiety; avoid deep or painful techniques.
Sessions are often short (15–20 minutes) and can involve hands, feet, or light full-body touch; energy work (Reiki, therapeutic touch) may be incorporated.
Family involvement is common; caregivers and loved ones may desire participation with appropriate guidance.
Practitioners should respect patient autonomy and family wishes; communication with care teams is essential.
Ethical and Spiritual Considerations:
Your personal beliefs should be set aside to honor the patient’s beliefs and end-of-life wishes.
Recognize the patient’s transition as a personal journey; provide grounding and shielding as needed.
Ethical, Philosophical, and Practical Implications
Safety first: obtain informed consent, respect contraindications, and coordinate with healthcare providers.
Individualized care: adapt to the patient’s health status, stage of illness, treatment plan, and personal preferences.
Communication: clear intake forms, ongoing consent, and regular updates with caregivers and clinicians.
Professional boundaries: respect patient dignity, family dynamics, and cultural/spiritual values; consider emotional and psychological aspects of touch.
Documentation: record health status changes, treatment adaptations, and any observed responses to massage.
When in doubt, err on the side of caution and provide smaller, gentler interventions rather than aggressive techniques.
Quick Reference: Core Concepts, Formulas, and Key Points
Pregnancy trimesters: three phases of ~13 weeks each, totaling ~39 weeks (often approximated as 40 weeks).
Positioning essentials: semi-reclining/supine with support (to prevent vena cava compression); side-lying is highly recommended; avoid prolonged full-prone/supine in later trimesters.
Abdominal massage: generally contraindicated in first trimester; light gliding movements in second/third trimesters; obtain consent before any abdominal work.
Contraindications in prenatal massage include signs of preeclampsia, vaginal bleeding, persistent vaginal discharge, severe morning sickness, and significant edema or DVT symptoms; refer to physician as needed.
Infant massage routines require caregiver involvement; use life-sized dolls for instruction; well-baby routine lasts about 20 minutes; simplified routine ~15 minutes for preterm/newborns; colic/gas routine targets abdominal function.
Safety with disabilities: adapt environments, transfer methods, and communication; always verify if assistance is needed; consider mobility aids and ensure facilities are accessible.
Cancer considerations: treat on case-by-case basis; obtain physician recommendation; tailor to cancer type, site, treatment, and patient stamina; avoid tumor sites and areas with active metastasis; be mindful of immune status and infection risk.
Hospice/end-of-life massage: comfort-focused, minimal depth, possible energy work; coordinate with family and care team; respect patient’s wishes and timing.
Questions for Review (from the chapter's end-of-chapter prompts)
How does massage benefit a woman during a normal, healthy pregnancy?
Which considerations should be made when positioning a woman in the second and third trimesters?
Which type of massage is applied to the abdomen during the first trimester?
What are common contraindications for prenatal massage?
Who is best suited to perform infant massage?
List at least four benefits of infant massage.
Which considerations should be observed when massaging minors?
What accommodations should be made for someone who is hearing impaired or visually impaired/blind?
When massaging a person with paralysis, which considerations should be observed?
How does massage benefit a person who is critically ill?
Why has massage been considered contraindicated for people with cancer, and how has this view changed?
What are some benefits of massage for people with cancer?
How can a practitioner reduce the chances of promoting metastasis when massaging a person with cancer?
What are the stages of cancer?
What are the common treatments for cancer?
What are important considerations when determining whether to massage a person with cancer?
When a person is receiving chemotherapy or radiation, when is a good time for massage and why?
Which modifications can be made to massage for a client who fatigues easily?
What considerations apply to hospice or end-of-life care massage?
What accommodations are needed when massaging children, older adults, or people with disabilities?