COVID-19 and Massage:
What are the Concerns?
Massachusetts state government allowed close contact personal services to resume business in June, and many massage therapists have by now reopened their doors, with abundant precautions in place. You may be wondering: what is the concern about massage and COVID-19? The risks fall into two main categories: personal risk, and risk of contributing to spread. Consideration of these factors is an individual choice for both the massage therapist and the client.
Personal Risk
People come in all varieties, with differing motivators and levels of risk tolerance. The pandemic has made that vividly clear. Those willing to play the risk game might decide they are safe based solely on demographics. Others might want to consider the known side effects of a bad case of COVID-19. Bottom line, are you feeling lucky? And is your massage therapist, who interacts with possibly many more people than you do, feeling lucky?
Demographics
If you are white, young, female, healthy, not pregnant, and a non-smoker, chances are you might escape a COVID-19 infection relatively unscathed. The risks go up dramatically with each decade of increase in age, and with certain additional health conditions. The Centers for Disease Control has created and occasionally updates a list of conditions that are associated with increased risk of severe illness with COVID-19.
Physical Impacts of Infection
Now that the pandemic has been with us for nearly a year, we know a lot more about COVID-19 than we first did. We still don’t know everything, though. As Dr. Robin Schoenthaler, a local doctor who writes and teaches about the virus, said recently, “We’re building the plane as we fly it.”
With respect to massage considerations, the effect of the virus can be grouped into three main categories:
Circulatory impact
One important thing that researchers have learned relevant to massage is that COVID-19 is much more than a respiratory virus, and can have dramatic, damaging effects on the circulatory system. In some cases, it also seems to have lasting effects on the heart, skeletal muscles, and autonomic nervous system.
Viruses cannot reproduce by themselves. To survive and thrive, a virus targets a portion of a human or animal cell, invades it, and hijacks the cell’s own mechanisms to replicate itself. COVID-19 makes its initial invasion into the body through ACE-2 (angiotensin-converting enzyme 2) receptors on cells in the nose and throat. ACE-2 receptors are also abundant in endothelial cells, which line blood vessels. Because these receptors play in an important role in modulating the cardiovascular system, including factors like blood pressure and clotting, a COVID-19 infection can cause havoc: heart attacks, strokes, and micro-clotting throughout blood vessels and organs that are rich in endothelial cells.
In April, a study published in the journal Lancet[1] found damage to endothelial cells in the lung, heart, kidney, liver and intestines of people with COVID-19. Because circulatory massage impacts all organs that filter and pump blood, this is a concern.
Fortunately, multi-organ damage is mostly confined to people with severe illness, and they will obviously not be seeking massage. Some damage appears to last beyond the initial acute stage, however. Reports of myocarditis in well-known athletes like Red Sox pitcher Eduardo Rodriguez have raised awareness that COVID-19 can cause heart damage of unknown duration.
The pool of data so far is sparse, but one research study in Germany found that a cohort of 100 patients who were considered recovered from COVID-19 after three weeks had cardiac involvement (78%) or myocardial inflammation (60%), independent of pre-existing conditions, severity of illness, or time since diagnosis.[2]
An additional study, which did cardiac magnetic resonance imaging (MRI) on 26 Ohio State athletes who had survived mild or moderate COVID-19, showed four with possible myocarditis and eight more with other evidence of prior injury or scar tissue.[3]
The study involved relatively few participants and included neither a baseline of the athletes’ hearts before they came down with COVID-19 nor a control study. But concern about these findings, and the larger German study, caused colleges to consider postponing their fall seasons, and resulted in guidance for continued monitoring of athletes who are COVID-19 survivors.[4]
If you have had the virus and are seeking massage, it is important to disclose information about your symptoms and experiences to the massage therapist so that they can work with you safely. A careful massage therapist will ask questions about your activity level, energy, and medications to determine how to work with you safely given any potential heart and circulatory conditions.
Musculoskeletal Impact
As with many viruses, a common symptom of COVID-19 is muscle pain. In a relatively rare condition known as rhabdomyolysis, the muscles can actually start to disintegrate and release toxic waste products into the circulatory system. This has a severe impact on the kidneys and in extreme cases can cause kidney failure.
It is not yet clear what causes the muscles to be impacted by COVID-19. It could be that the virus attacks actual muscle cells due to the presence of ACE-2 receptors in the muscles. Or, the muscle pain and damage could be a downstream effect of an overreaction by the body’s immune system to the virus.[5]
If you have had the virus and are seeking massage, it is important to disclose this information to the massage therapist so that they can work with you safely. A careful massage therapist will ask you about your energy and activity level and whether you are still experiencing weakness or pain in your muscles, and will adjust the treatment accordingly. Even if you are used to getting deep massage, it may be that your muscles need more time to heal and return to normalcy, so the massage therapist should adjust the intensity and duration of their work.
Long Term Symptoms
Some people, even young people who may have had just a mild case of COVID-19, are developing persistent symptoms (sometimes referred to as “long haul” COVID). Researchers are still learning about the people who are susceptible to this condition, but theories are that it is related to an inflammatory process, or possibly an overactive immune response in the central nervous system. Several studies[6],[7] have reported lingering symptoms like fatigue, fever, joint pain, heart arrhythmia, headaches, and breathing problems. One advisory[8] estimates that up to 10 percent of people who have had COVID-19 may experience long term symptoms.
If you are young and healthy but tend to have an over-reactive immune system, the risk of becoming a long hauler is worth considering. If you are a COVID-19 survivor experiencing lingering symptoms, it is important to disclose this to a massage therapist, so that the therapist does not work too intensely and cause an adverse reaction.
Your Bubble: is it “safe”?
Okay, so you’ve decided that you’re in a safe demographic, you are aware of the potential effects of getting sick with COVID-19, and you still really want that massage. You work from home, you don’t go out and party or even eat out at restaurants, and you are in what you consider a small, safe “bubble” – the group of people you spend time with on a regular basis without a mask on. You know a massage therapist whom you feel you can trust. She’s not fond of eating out, she works out at home instead of in a gym, she home schools her kids, goes to church online, has her groceries delivered, and she is assiduous with cleaning and use of personal protective equipment in her massage office.
Even so, just keep in mind that your bubble does not consist of only the people you spend time with unmasked. A bubble also includes all of the people they spend time with unmasked, and all of the people those people spend time with unmasked. The same is true for your massage therapist.
The diagram on this page, copied from Facebook, illustrates the reality of most bubbles, and explains why exponential spread can happen as a result of small gatherings or unsafe mask use:
If you decide to get a massage, interview your massage therapist carefully about his or her connections, habits, and other clientele. And know that even so, you may or may not learn everything. Who wants to admit that one time when they let down their guard and partied with friends? Who wants to “out” their relative who hates to wear a mask and takes it off at every chance?
There is an unfortunate stigma of dirtiness and blame associated with pandemics, even though, by its nature, a pandemic disease is extremely contagious and hard to avoid contracting. That stigma can cause people to conceal information that might help you determine whether they feel “safe” to you. And putting your trust in a bubble of unknown size and quality can lead to spread.
Which brings us to the second major factor to consider regarding massage. With appropriate protections and care, the chance of contracting COVID-19 from getting or giving massage is small but not zero. So how important is it to you whether getting a massage might contribute to spread?
Risk of Spread
Several factors would ideally go into calculating the risk of spread:
Infection Rate in the Community
The state’s COVID-19 dashboard and color-coded system of identifying communities at risk could be used as a rough estimate of how safe it might be to venture into the community for activities like massage. The current system gives cities and towns a color code of grey (lowest risk), green, yellow, or red based on two factors adjusted for population size: the average rate of new cases per day in the past two weeks, and the percent of all tests that had a positive result in the past two weeks.
Of course, the accuracy of these numbers is affected by how many people seek and are able to get testing: something that is not sufficiently looked for is much harder to quantify. But it is reasonable to conclude that a community color coded grey or green would be safer than a community coded red.
Keep in mind that the safety of a public activity in one community may be influenced by the level of infection in surrounding communities. For example, does a massage therapist in your town see only people who live in your town, or also people who work in town but go home to other, less safe communities?
Asymptomatic spread
In March, the World Health Organization reported that up to 80 percent of all COVID cases may be asymptomatic. In contrast, based on a survey of more than a dozen different studies, the Centre for Evidenced-Based Medicine at the University of Oxford estimates that the true figure ranges between 5 and 80 percent.[9]
Five to 80 percent is a huge range. Why don’t we know more precisely? Because testing has not been abundant and frequent enough to determine who is actually walking around with the virus. At the time of data collection, someone may be “pre-symptomatic” and have not yet come down with symptoms, or they may remain truly asymptomatic throughout the period of contagion. For that same reason, it has been difficult to determine how much asymptomatic carriers contribute to spread.
The basic advice “If you feel sick, stay home” ideally prevents clients with the most obvious, virulent cases from walking through the massage room door. Unfortunately, standard precautions like measuring a client’s temperature and oxygen saturation and asking screening questions will not help detect asymptomatic cases. And, as with many viruses, there is a period in which an infected person is contagious but not yet symptomatic.
Testing considerations
How much can you trust testing, anyway? Currently, the primary method of testing in most locations is the nasal swab, or RT-PCR test (reverse transcriptase polymerase chain reaction). A negative result might reflect one or more conditions:
The study received some criticism of its survey sample, and by its nature it does not account for cases that never develop symptoms. At a minimum, it does indicate that testing is a useful tool for measuring spread in the community, but it is not a bullet proof way to measure whether a person is or will become contagious. And, a test represents only a snapshot in time, not a permanent “get out of jail free” card for an individual whose result is negative.
Masks and other protection
Massachusetts requires masks to be worn by both the massage therapist and client “except where an individual is unable to wear a face covering due to a medical condition or disability.” Because the primary method of transmission for COVID is now thought to be aerosols (fine particles that are thought to be able to linger in the air for up to 3 hours), masks are very good protection, but not 100 percent safe--especially if the client decides to pull down their mask and take a breather while lying prone in the face cradle (and who could blame them? Wearing a face mask in a face cradle can feel pretty suffocating).
Even with masks properly worn, the environment in which massage happens is not considered low risk, due to the amount of time spent in close contact – far closer than the recommended six feet apart, and far longer than the recommended 10 to 15 minutes maximum for close interactions.
Current regulations require the therapist to wear a smock or gown and eyeglasses or eye protection, and change between each client, in addition to the usual protocols for washing hands and linens. Any massage therapist who does not do this, and who does not disinfect exposed surfaces between each client, could potentially expose their next client to infection from the previous client.
Room ventilation
If you have ever entered a massage room that feels stuffy and smells like the cologne of the client before you, you know what good ventilation is not. In a respiratory pandemic, ventilation of the massage office is paramount for the safety of client and therapist. An organization called SmartAir has an informative blog that references recommended ventilation rates without making the reader pay for the standards guide developed by ASHRAC (the American Society of Heating, Refrigeration and Air Conditioning Engineers).
The ASHRAC standard states that as a rule of thumb, a typical room in a home with two people in it should exchange all of its air with fresh outdoor air at a rate of between .7 and 2 air changes per hour. For offices, the recommendation increases 2 to 3 changes per hour, and for health care environments where virus is known to be present, the recommendation increases to 6 to 12 changes per hour.
If you are considering getting a massage, it is worth inquiring whether the office has windows, and does the therapist open them for fresh air exchange? What kind of filters are in use if the office has an HVAC system? How many people does the therapist see in a day, and how much time elapses between each session? This can all contribute to the quality and safety of the air in an office environment.
According to SmartAir, an office with two open windows can achieve the bare minimum recommendation of .35 air changes per hour. In New England winters, or in urban areas where outdoor air is polluted, opening windows alone is not feasible protection. For increased safety, a fan or HEPA air filter would seem a wise investment to help clean the air in a massage room.
A Final Note
If you have made it all the way to the end of this discussion, thank you! You probably care more than the average person about the considerations involved with massage and COVID-19. In the midst of a respiratory pandemic, spending an hour in a small room in close contact with a person outside your household carries greater than zero risk. It requires careful precautions, clear, complete communication, and responsible behavior on the part of both client and therapist. A vaccine is on the way, but that does not give any of us cause to let down our guard anytime soon.
If you have had COVID-19, please disclose that to your massage therapist so he or she can interview you about symptoms and impacts and work with you safely.
Regardless of whether you have had COVID-19, think you’ve had it but couldn’t get tested, or have not yet encountered it, please wear a mask and wear it well. Cancel your appointment if you’re feeling sick. And remember that the massage therapist who sees you is taking a gamble that you, and every other person he or she works with, is a safe bet.
____________________________
[1] Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R et al. Endothelial cell infection and endotheliitis in COVID-19. The Lancet. 2020;395(10234):1417-1418. doi:10.1016/S0140-6736(20)30937-5
[2] Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(11):1265–1273. doi:10.1001/jamacardio.2020.3557.
[3] Rajpal S, Tong MS, Borchers J, et al. Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection. JAMA Cardiol. Published online September 11, 2020. doi:10.1001/jamacardio.2020.4916.
[4] Kim JH, Levine BD, Phelan D, et al. Coronavirus Disease 2019 and the Athletic Heart: Emerging Perspectives on Pathology, Risks, and Return to Play. JAMA Cardiol. Published online October 26, 2020. doi:10.1001/jamacardio.2020.5890.
[5] Paliwal, VK, Garg, R.K., Gupta, A et al. Neuromuscular presentations in patients with COVID-19. Neurol Sci 2020;41:3039–3056. doi:10.1007/s10072-020-04708-8.
[6] Davido B, Seang S, Tubiana R, deTruchis P. Post-COVID-19 chronic symptoms: a postinfectious entity? Clin Microbiol Infect. 2020;26(11):1448-1449. doi:10.1016/j.cmi.2020.07.028
[7] Carfì A, Bernabei R, Landi F. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020;324(6):603–605. doi:10.1001/jama.2020.12603.
[8] Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of Post-acute COVID-19 in primary care. BMJ 2020;370:m3026. doi:10.1136/bmj.m3026.
[9] Heneghan C, Brassey J, Jefferson T. COVID-19: What proportion are asymptomatic? The Centre for Evidence-Based Medicine. April 6, 2020. Accessed December 11, 2020. http://www.cebm.net/covid-19/covid-19-what-proportion-are-asymptomatic
[10] Kucirka LM, Lauer SA, Laeyendecker O, Boon D, Lessler J. Variation in False-Negative Rate of Reverse Transcriptase Polymerase Chain Reaction-Based SARS-Cov-2 Test by Time Since Exposure. Annals of Internal Medicine. 2020. doi:10.7326/M20-1495.
Personal Risk
People come in all varieties, with differing motivators and levels of risk tolerance. The pandemic has made that vividly clear. Those willing to play the risk game might decide they are safe based solely on demographics. Others might want to consider the known side effects of a bad case of COVID-19. Bottom line, are you feeling lucky? And is your massage therapist, who interacts with possibly many more people than you do, feeling lucky?
Demographics
If you are white, young, female, healthy, not pregnant, and a non-smoker, chances are you might escape a COVID-19 infection relatively unscathed. The risks go up dramatically with each decade of increase in age, and with certain additional health conditions. The Centers for Disease Control has created and occasionally updates a list of conditions that are associated with increased risk of severe illness with COVID-19.
Physical Impacts of Infection
Now that the pandemic has been with us for nearly a year, we know a lot more about COVID-19 than we first did. We still don’t know everything, though. As Dr. Robin Schoenthaler, a local doctor who writes and teaches about the virus, said recently, “We’re building the plane as we fly it.”
With respect to massage considerations, the effect of the virus can be grouped into three main categories:
- Circulatory impact
- Musculoskeletal impact
- Long term symptoms
Circulatory impact
One important thing that researchers have learned relevant to massage is that COVID-19 is much more than a respiratory virus, and can have dramatic, damaging effects on the circulatory system. In some cases, it also seems to have lasting effects on the heart, skeletal muscles, and autonomic nervous system.
Viruses cannot reproduce by themselves. To survive and thrive, a virus targets a portion of a human or animal cell, invades it, and hijacks the cell’s own mechanisms to replicate itself. COVID-19 makes its initial invasion into the body through ACE-2 (angiotensin-converting enzyme 2) receptors on cells in the nose and throat. ACE-2 receptors are also abundant in endothelial cells, which line blood vessels. Because these receptors play in an important role in modulating the cardiovascular system, including factors like blood pressure and clotting, a COVID-19 infection can cause havoc: heart attacks, strokes, and micro-clotting throughout blood vessels and organs that are rich in endothelial cells.
In April, a study published in the journal Lancet[1] found damage to endothelial cells in the lung, heart, kidney, liver and intestines of people with COVID-19. Because circulatory massage impacts all organs that filter and pump blood, this is a concern.
Fortunately, multi-organ damage is mostly confined to people with severe illness, and they will obviously not be seeking massage. Some damage appears to last beyond the initial acute stage, however. Reports of myocarditis in well-known athletes like Red Sox pitcher Eduardo Rodriguez have raised awareness that COVID-19 can cause heart damage of unknown duration.
The pool of data so far is sparse, but one research study in Germany found that a cohort of 100 patients who were considered recovered from COVID-19 after three weeks had cardiac involvement (78%) or myocardial inflammation (60%), independent of pre-existing conditions, severity of illness, or time since diagnosis.[2]
An additional study, which did cardiac magnetic resonance imaging (MRI) on 26 Ohio State athletes who had survived mild or moderate COVID-19, showed four with possible myocarditis and eight more with other evidence of prior injury or scar tissue.[3]
The study involved relatively few participants and included neither a baseline of the athletes’ hearts before they came down with COVID-19 nor a control study. But concern about these findings, and the larger German study, caused colleges to consider postponing their fall seasons, and resulted in guidance for continued monitoring of athletes who are COVID-19 survivors.[4]
If you have had the virus and are seeking massage, it is important to disclose information about your symptoms and experiences to the massage therapist so that they can work with you safely. A careful massage therapist will ask questions about your activity level, energy, and medications to determine how to work with you safely given any potential heart and circulatory conditions.
Musculoskeletal Impact
As with many viruses, a common symptom of COVID-19 is muscle pain. In a relatively rare condition known as rhabdomyolysis, the muscles can actually start to disintegrate and release toxic waste products into the circulatory system. This has a severe impact on the kidneys and in extreme cases can cause kidney failure.
It is not yet clear what causes the muscles to be impacted by COVID-19. It could be that the virus attacks actual muscle cells due to the presence of ACE-2 receptors in the muscles. Or, the muscle pain and damage could be a downstream effect of an overreaction by the body’s immune system to the virus.[5]
If you have had the virus and are seeking massage, it is important to disclose this information to the massage therapist so that they can work with you safely. A careful massage therapist will ask you about your energy and activity level and whether you are still experiencing weakness or pain in your muscles, and will adjust the treatment accordingly. Even if you are used to getting deep massage, it may be that your muscles need more time to heal and return to normalcy, so the massage therapist should adjust the intensity and duration of their work.
Long Term Symptoms
Some people, even young people who may have had just a mild case of COVID-19, are developing persistent symptoms (sometimes referred to as “long haul” COVID). Researchers are still learning about the people who are susceptible to this condition, but theories are that it is related to an inflammatory process, or possibly an overactive immune response in the central nervous system. Several studies[6],[7] have reported lingering symptoms like fatigue, fever, joint pain, heart arrhythmia, headaches, and breathing problems. One advisory[8] estimates that up to 10 percent of people who have had COVID-19 may experience long term symptoms.
If you are young and healthy but tend to have an over-reactive immune system, the risk of becoming a long hauler is worth considering. If you are a COVID-19 survivor experiencing lingering symptoms, it is important to disclose this to a massage therapist, so that the therapist does not work too intensely and cause an adverse reaction.
Your Bubble: is it “safe”?
Okay, so you’ve decided that you’re in a safe demographic, you are aware of the potential effects of getting sick with COVID-19, and you still really want that massage. You work from home, you don’t go out and party or even eat out at restaurants, and you are in what you consider a small, safe “bubble” – the group of people you spend time with on a regular basis without a mask on. You know a massage therapist whom you feel you can trust. She’s not fond of eating out, she works out at home instead of in a gym, she home schools her kids, goes to church online, has her groceries delivered, and she is assiduous with cleaning and use of personal protective equipment in her massage office.
Even so, just keep in mind that your bubble does not consist of only the people you spend time with unmasked. A bubble also includes all of the people they spend time with unmasked, and all of the people those people spend time with unmasked. The same is true for your massage therapist.
The diagram on this page, copied from Facebook, illustrates the reality of most bubbles, and explains why exponential spread can happen as a result of small gatherings or unsafe mask use:
If you decide to get a massage, interview your massage therapist carefully about his or her connections, habits, and other clientele. And know that even so, you may or may not learn everything. Who wants to admit that one time when they let down their guard and partied with friends? Who wants to “out” their relative who hates to wear a mask and takes it off at every chance?
There is an unfortunate stigma of dirtiness and blame associated with pandemics, even though, by its nature, a pandemic disease is extremely contagious and hard to avoid contracting. That stigma can cause people to conceal information that might help you determine whether they feel “safe” to you. And putting your trust in a bubble of unknown size and quality can lead to spread.
Which brings us to the second major factor to consider regarding massage. With appropriate protections and care, the chance of contracting COVID-19 from getting or giving massage is small but not zero. So how important is it to you whether getting a massage might contribute to spread?
Risk of Spread
Several factors would ideally go into calculating the risk of spread:
- Rate of infection in the community
- Role of asymptomatic spread
- Availability and accuracy of testing
- Personal protection (masks)
- Room ventilation
Infection Rate in the Community
The state’s COVID-19 dashboard and color-coded system of identifying communities at risk could be used as a rough estimate of how safe it might be to venture into the community for activities like massage. The current system gives cities and towns a color code of grey (lowest risk), green, yellow, or red based on two factors adjusted for population size: the average rate of new cases per day in the past two weeks, and the percent of all tests that had a positive result in the past two weeks.
Of course, the accuracy of these numbers is affected by how many people seek and are able to get testing: something that is not sufficiently looked for is much harder to quantify. But it is reasonable to conclude that a community color coded grey or green would be safer than a community coded red.
Keep in mind that the safety of a public activity in one community may be influenced by the level of infection in surrounding communities. For example, does a massage therapist in your town see only people who live in your town, or also people who work in town but go home to other, less safe communities?
Asymptomatic spread
In March, the World Health Organization reported that up to 80 percent of all COVID cases may be asymptomatic. In contrast, based on a survey of more than a dozen different studies, the Centre for Evidenced-Based Medicine at the University of Oxford estimates that the true figure ranges between 5 and 80 percent.[9]
Five to 80 percent is a huge range. Why don’t we know more precisely? Because testing has not been abundant and frequent enough to determine who is actually walking around with the virus. At the time of data collection, someone may be “pre-symptomatic” and have not yet come down with symptoms, or they may remain truly asymptomatic throughout the period of contagion. For that same reason, it has been difficult to determine how much asymptomatic carriers contribute to spread.
The basic advice “If you feel sick, stay home” ideally prevents clients with the most obvious, virulent cases from walking through the massage room door. Unfortunately, standard precautions like measuring a client’s temperature and oxygen saturation and asking screening questions will not help detect asymptomatic cases. And, as with many viruses, there is a period in which an infected person is contagious but not yet symptomatic.
Testing considerations
How much can you trust testing, anyway? Currently, the primary method of testing in most locations is the nasal swab, or RT-PCR test (reverse transcriptase polymerase chain reaction). A negative result might reflect one or more conditions:
- You did not have COVID-19 at the moment the test was given. A negative test result does not protect you from getting COVID-19 in the next hour, the next day, or the next week if you are exposed to it.
- The person who administered the test did not swab your tissues sufficiently to get a good sample.
- You were harboring the virus, but not in enough volume to be detected by the test.
- The test was faulty.
The study received some criticism of its survey sample, and by its nature it does not account for cases that never develop symptoms. At a minimum, it does indicate that testing is a useful tool for measuring spread in the community, but it is not a bullet proof way to measure whether a person is or will become contagious. And, a test represents only a snapshot in time, not a permanent “get out of jail free” card for an individual whose result is negative.
Masks and other protection
Massachusetts requires masks to be worn by both the massage therapist and client “except where an individual is unable to wear a face covering due to a medical condition or disability.” Because the primary method of transmission for COVID is now thought to be aerosols (fine particles that are thought to be able to linger in the air for up to 3 hours), masks are very good protection, but not 100 percent safe--especially if the client decides to pull down their mask and take a breather while lying prone in the face cradle (and who could blame them? Wearing a face mask in a face cradle can feel pretty suffocating).
Even with masks properly worn, the environment in which massage happens is not considered low risk, due to the amount of time spent in close contact – far closer than the recommended six feet apart, and far longer than the recommended 10 to 15 minutes maximum for close interactions.
Current regulations require the therapist to wear a smock or gown and eyeglasses or eye protection, and change between each client, in addition to the usual protocols for washing hands and linens. Any massage therapist who does not do this, and who does not disinfect exposed surfaces between each client, could potentially expose their next client to infection from the previous client.
Room ventilation
If you have ever entered a massage room that feels stuffy and smells like the cologne of the client before you, you know what good ventilation is not. In a respiratory pandemic, ventilation of the massage office is paramount for the safety of client and therapist. An organization called SmartAir has an informative blog that references recommended ventilation rates without making the reader pay for the standards guide developed by ASHRAC (the American Society of Heating, Refrigeration and Air Conditioning Engineers).
The ASHRAC standard states that as a rule of thumb, a typical room in a home with two people in it should exchange all of its air with fresh outdoor air at a rate of between .7 and 2 air changes per hour. For offices, the recommendation increases 2 to 3 changes per hour, and for health care environments where virus is known to be present, the recommendation increases to 6 to 12 changes per hour.
If you are considering getting a massage, it is worth inquiring whether the office has windows, and does the therapist open them for fresh air exchange? What kind of filters are in use if the office has an HVAC system? How many people does the therapist see in a day, and how much time elapses between each session? This can all contribute to the quality and safety of the air in an office environment.
According to SmartAir, an office with two open windows can achieve the bare minimum recommendation of .35 air changes per hour. In New England winters, or in urban areas where outdoor air is polluted, opening windows alone is not feasible protection. For increased safety, a fan or HEPA air filter would seem a wise investment to help clean the air in a massage room.
A Final Note
If you have made it all the way to the end of this discussion, thank you! You probably care more than the average person about the considerations involved with massage and COVID-19. In the midst of a respiratory pandemic, spending an hour in a small room in close contact with a person outside your household carries greater than zero risk. It requires careful precautions, clear, complete communication, and responsible behavior on the part of both client and therapist. A vaccine is on the way, but that does not give any of us cause to let down our guard anytime soon.
If you have had COVID-19, please disclose that to your massage therapist so he or she can interview you about symptoms and impacts and work with you safely.
Regardless of whether you have had COVID-19, think you’ve had it but couldn’t get tested, or have not yet encountered it, please wear a mask and wear it well. Cancel your appointment if you’re feeling sick. And remember that the massage therapist who sees you is taking a gamble that you, and every other person he or she works with, is a safe bet.
____________________________
[1] Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R et al. Endothelial cell infection and endotheliitis in COVID-19. The Lancet. 2020;395(10234):1417-1418. doi:10.1016/S0140-6736(20)30937-5
[2] Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(11):1265–1273. doi:10.1001/jamacardio.2020.3557.
[3] Rajpal S, Tong MS, Borchers J, et al. Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection. JAMA Cardiol. Published online September 11, 2020. doi:10.1001/jamacardio.2020.4916.
[4] Kim JH, Levine BD, Phelan D, et al. Coronavirus Disease 2019 and the Athletic Heart: Emerging Perspectives on Pathology, Risks, and Return to Play. JAMA Cardiol. Published online October 26, 2020. doi:10.1001/jamacardio.2020.5890.
[5] Paliwal, VK, Garg, R.K., Gupta, A et al. Neuromuscular presentations in patients with COVID-19. Neurol Sci 2020;41:3039–3056. doi:10.1007/s10072-020-04708-8.
[6] Davido B, Seang S, Tubiana R, deTruchis P. Post-COVID-19 chronic symptoms: a postinfectious entity? Clin Microbiol Infect. 2020;26(11):1448-1449. doi:10.1016/j.cmi.2020.07.028
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