by Robert Schleip, Til Luchau and John Schewe. 8th edition, April 2018

Atherosclerosis - a build-up of plaque in artery walls. Care needs to be taken so that any thrombi are not dislodged (See under ‘Embolism and Thrombi’)

Arteriosclerosis - hardening of the arteries. Care is needed because there is usually some atherosclerosis and high blood pressure associated with this. No deep bodywork in advanced stages. Get medical clearance for your work if the client takes medication for circulatory problems.

Autoimmune diseases
The immune system produces antibodies against the body's own tissues.  Pressure on inflamed tissues can be aggravating.
a) Lupus - attacks the connective tissue mainly in the skin, kidneys, joints and heart. Pressure contraindicated during acute flares.

b) Rheumatoid arthritis (RA) - immune system attacks the joints, and its associated muscles, tendons, ligaments and blood vessels; pressure contraindicated during inflammatory stage. (Note: In “osteoarthritis” deep bodywork tends to be more helpful than in RA).
c) Scleroderma (“hardened skin”) - a build-up of collagen fibers around organs (problems with absorption when around the small intestines) and in the dermis of the skin; increasing stiffness at joints along with muscle weakness. Pressure contraindicated during inflammatory phase.
d) Ankylosing spondylitis - inflammation of tissues around the spine causing the connective tissues of the sacrum and spine to solidify. Don’t use pressure on areas of pain and inflammation in acute episodes.

Bipolar Disorder (manic –depressive): during manic phase Rolfing is traditionally contraindicated, since it could in principle increase the amplitude of the extreme mood-swings.

Cerebral Palsy: Result of Cerebral Palsy & Rolfing® study: in mild + moderate cases Rolfing® helpful; serious cases might get worse. Most recent science info: connective tissue restrictions more important factor in CP patients than was thought before (e.g. tissue shortness in the triceps surae often limits their walking ability in terms of very limited dorsiflexion mobility of the feet).

Cancer: Contrary to frequent advice given in the last century, current guidelines no longer consider massage as generally contraindicated in cancer conditions. One major exception is osteomyelitis, for which deep massage is still contraindicated. For most other cancer pathologies there is no evidence that massage causes or contributes to a metastatic spreading of the cancer.

For breast cancer some guidelines still warn against direct pressure on the tumour location while others suggest that the potential minor risk (of spreading malignant cells into lymph nodes) is being overweighed by major beneficial effects on the immune system and on softening the connective tissue stroma around the tumour, both of which tend to inhibit the growth and also the potential metabolic spreading of the tumour. For safety reasons we recommend either following the first suggestion or getting permission by the patient’s physician before applying deep tissue work directly to a breast tumour location.

Cancer treatments, such as surgery, radiation, or chemotherapy, can have their own cautions and contraindications to deep bodywork.

If you are working with cancer patients, we recommend preparing yourself with the following guidelines:  

Connective tissue disease: E.g. osteomyelitis, lupus, scleroderma: no deep work.

Diabetes: Be careful about tissue condition (tissue can be more fragile) and avoid pressure in areas of less sensation or paresthesia. Don't do deep work on area of recent insulin injection: could accelerate insulin uptake.

Embolism or Thrombus: a) Venous emboli - usually land in the lungs causing pulmonary embolism. b) Arterial emboli - can lodge themselves in the coronary arteries (heart attack); the brain (stroke), the kidneys, or the legs (phlebitis).

Deep bodywork is contraindicated because of the risk of dislodging a thrombus. If the client takes blood thinners as a medical precaution against clotting, ask for a medical clearance for any kind of deep tissue work affecting the circulatory system.

Epileptics: avoid hyperventilation or high levels of sympathetic arousal (eg., from painful work).

Headaches: Some types of headaches get worse with any kind of massage around the head/neck/shoulder area. This is more common for migraines, and in the early stages (though other clients will direct you to apply pressure in these areas).  If the client has previous experience with receiving massage as a remedial treatment, they can often tell whether it is helpful or not to work on their upper end. Tension headaches (which are usually more bilateral) tend to respond more positively.

Heart conditions: OK, if not restricted from exercise (if fingernails get purple or blue, stay off).

Hemangioma: These are congenital benign tumors, made up of newly formed blood vessels. Different types, usually on the skin, yet sometimes also in brain and viscera. Particularly in cases of known visceral type (e.g. hepatic hemangioma), no deep work in this area should be applied because of the danger of internal bleeding.

Herpes (and other potentially infectious skin conditions, including warts): Don't touch infected areas without gloves; avoid sliding; don’t cause pain.

High blood pressure (extreme):  Don't work in way that makes clients hold breath, or use positions that put head lower then the body.  Deep work on uncontrolled high blood pressure patients should be with medical supervision (deep bodywork often RAISES blood pressure)

Impaired elimination systems: Use caution with colostomies, candida, kidney, and liver issues. Use less pressure; shorter interventions; more time between sessions.

Implanted stents: The medical literature contains one documented case in which deep abdominal bodywork lead to dislocation of a ureteral stent (a stent is a device that has been implanted to keep a blocked or narrow passageway open). Therefore, it is best to inquire if clients have medical appliances or implants such as stents, so this knowledge can be taken into account when working in the respective areas.

Intervertebral disc issues: With non-acute cases, avoid shearing motions, longitudinal compression, and extreme twisting or bending. Work slowly and cautiously to avoid decompensating a stable system.

With acute/painful cases: although skilled bodywork can help create space for the retreat of the tissue and to resolve some of the secondary compensations, be very careful and don’t use direct pressure on the affected segment alone, since local muscle spasms may have developed there as protection for the irritated nerves. Releasing this muscular bracing too quickly may aggravate the client’s symptoms. Work slowly and cautiously, and have client monitor and report their post-session responses so that you can adjust your pace, pressure, and duration accordingly.

IUD (intrauterine device):  Be careful with any deep abdominal work in female clients who use an intra-uterine device for birth control. It is possible that the IUD may become displaced, possibly leading to complications.

Menstruation (if strong): If the client tends to have very strong menstruation symptoms with high amount of blood loss, any kind of deep tissue work or even massage in the area of pelvis, abdomen and thighs - if done around the days of the client's period - can sometimes increase circulation and therefore the severity of the menstruation. Conclusion: either give the client the option to cancel a session for that reason if the date collides with a strong period at the same time; or give only a very gentle movement awareness session, which does not tend to overly increase circulation in the pelvic region.

Nose work, special conditions: For any intranasal work be especially careful with regular cocaine users, nasal polyps, and nose surgery including cosmetic surgery.

Pain medication: Use caution regarding reduced sensation and greater possibility of tissue or nerve damage. (Same with paresthesia)

Pregnancy:  Rule of thumb: no deep work. Thought to be a greater risk of triggering a miscarriage by deep work during first 3 months (especially through work around the pelvis, abdomen, adductors adductors). Later in pregnancy this is thought to be less likely, though deep work is sometimes use to hasten delayed labor.

Psychosis: Be careful. There have been (very) few reports about deep work triggering a psychotic episode.

Varicose veins: Don't use pressure, sliding, or shearing forces on veins. Keep in mind that varicosities can be deep and not visible as well.

Whiplash: If recent, unstable, or inflamed, deep bodywork can aggravate.

 No deep work with:

  • Abscess teeth (no mouth work)
  • Aneurysm
  • Bone fractures or acute soft tissue injuries: wait for full healing (6 weeks - 3 months)
  • Clients on Cortisone (wait 2-3 months)
  • Feverish clients
  • Hemophiliacs
  • Hodgkin's disease (cancer of lymph system)
  • Infectious conditions (with some exceptions, like HIV: get medical supervision)
  • Leukemia
  • Osteoporosis (usually post-menopausal women)
  • Phlebitis: same risk as for ‘embolism or thrombus’
  • Recent scar tissue (including regular or plastic surgeries): no deep work on this area until scarring process is complete (usually at least 6 weeks)

In General

Cautions -- Unless you are legally licensed to do so:
1. Don't prescribe, not even vitamin C.
2. Never label or name any condition, don't diagnose (yet you can refer to a previous diagnosis of a medical doctor).
3. Be careful with people who are in psychotherapy or are seeing a doctor. (Their psychotherapist or physician should know they are getting bodywork).

Ask about medical history (including medications) before work begins. If ever in doubt, get medical supervision.

Closing Remarks:

Previous editions of this paper contained some suggestions on HOW to best work with some of the above and other medical conditions. Later several other practitioners added their personal suggestions on this aspect. Soon it became apparent that there are almost as many different treatment suggestions to each of those conditions as there are different adjunct therapies represented within our community (visceral manipulation, psycho-emotional, craniosacral, chiropractic, nutritional, etc.). Therefore, this article is now limited only to conditions where caution with deep pressure is warranted.

This compilation should be considered a list of cautions and contraindications to hands-on work involving direct pressure; though not necessarily to hands-on work, per se. Practitioner adaptability (as well as knowledge and sensitivity) are key: If the pressure, duration, and frequency of application are adjusted accordingly, touch therapy of some kind (often lighter, shorter, or less frequent) can be helpful to those experiencing most every condition listed.

All of the above is the private opinion of the authors based on their knowledge and clinical experience as Certified Advanced Rolfers®. It is published here in order to stimulate further discussion and development. It will be updated and improved from time to time; i.e. this paper is a continuous work in process. For any additions and suggestions please contact the authors.

No legal liability on the information of this article is intended or accepted by the authors. If you are not a licensed medical practitioner you are legally obliged to consult an M.D. for any medical diagnosis.

In describing contraindications for deep tissue work it is NOT assumed that Structural Integration or any other modality is a medically oriented healing modality. Whether it is depends on other factors like the qualification and intention of the practitioner and the working contract or agreement with the client. Deep tissue practices like Structural Integration or Myofascial Release are very often used not as a medical healing modality but as a holistic method for increasing the sense of aliveness and embodiment (i.e. "being more at home in your body"). Even in those non-medical treatment situations it is possible to list medical contraindications, as this can be done for jogging, walking, dancing or other non-medical activities.

Book Recommendation:

Ruth Werner & Ben E. Benjamin; A Massage Therapist's Guide to Pathology, Williams & Wilkins 1998, US $37.
(Discusses more than a 100 common medical conditions and what a bodywork practitioner should know when dealing with them. Includes clear guidelines if or how massage is indicated or contraindicated. Extremely useful and worth the price!).

Review Articles:

Grant KE; Massage safety: injuries reported in Medline relating to the practice of therapeutic massage—1965–2003. J Bodyw Movem Ther (2003) 7, 207-212.

Batavia, M: Contraindications for therapeutic massage: do sources agree?

J Bodyw Movem Ther (2004) 8, 48–57.

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