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The Importance of Pathology for Massage Therapists

by Su Fox(more info)

listed in massage, originally published in issue 215 - July 2014

Pathology: (Greek: pathos, meaning ‘experience or suffering’, and  -logia, meaning ‘an account of’);

  1. The branch of medicine concerned with the cause, nature and origin of disease, including the changes occurring as a result of disease;
  2. The manifestations of disease, including changes in the tissues;
  3. Any variant or deviant condition from the normal.

An anxious friend rang me recently to say that her uncle, an elderly man with multiple sclerosis, had been told by his hospital not to come in for routine assessments because he'd just been diagnosed with C diff and she wanted to know if it was safe to go and visit him. I had never heard of C diff so began an internet search as we were speaking. On the NHS website I quickly discover the full name, Clostridium difficile, and that it's a bacteria found in the gut. In healthy children and adults it's controlled by the other intestinal bacteria, but if the normal bacterial balance is upset, for example when someone has been on a course of antibiotics, C diff infection occurs.

While relaying this information to my friend I wonder simultaneously about C diff infection and massage. Would it be safe? Would it be advisable? Some infections would not prevent someone having a massage - a mild cold or a fungal skin infection such as athlete's foot - but the sensible practitioner would take precautions around contact and enquire about comfort. So then I look up spread of the disease and discover that it's highly infectious, and that the route of infection is via spores found in the faeces, that can be passed from hands onto surfaces and objects where they can survive a long time. Touching a contaminated surface and then touching your mouth or nose brings the bacteria right into the body. Right, I'm thinking, in the acute stage, after diagnosis and before the infection is responding to treatment, massage would be a total contraindication, because of the high risk of infection, to myself and to others using the same environment.

Who is at risk, I wonder? NHS direct shows me that it's people who've been on antibiotics, the elderly and people with ongoing medical conditions. My friend's uncle is in his 70s, has multiple sclerosis and had been misdiagnosed with a gastric infection and given a course of antibiotics by his doctor. It was only when his symptoms worsened that further tests revealed the true cause. So what are the symptoms? Diarrhoea, high temperature and painful abdominal cramps. At this point, I realize that someone with an acute C diff infection would be too unwell to want a massage anyway.

However, if I was presented with someone recovering from a C diff infection, what do I now know that would let me make a sensible decision about how to proceed? Assuming the symptoms had subsided and the client was responding well to their medical treatment, my first thought would be about hygiene precautions. If I was working in an institution, a hospital or care home, say, I’d ask the staff what precautions were in place and observe these. I would make sure I removed any jewellery that might come into contact, wear short sleeves and wash my hands and forearm up to the elbow thoroughly before and after contact with an antibacterial gel. In any other situation I would put all table linens straight into a hot wash after the treatment and wipe down surfaces that the client had come into contact with, such as the door handles, chair and toilet seat, if he used it, with a cleaner containing some bleach. I would take care not to touch my face. I am a healthy adult, and hopefully my intestinal bacteria are working fine, but if I'd recently taken antibiotics, I would probably refer the client to another practitioner, for my own protection.

Last of all, I would consider what kind of treatment might be beneficial. Anything that might boost rather than stress an overworked immune system would be indicated, so I’m thinking slow, soothing techniques, nothing too deep, maybe no rocking if there’s still any trace of nausea. And since this is infection that affects the intestines, I would avoid abdominal massage.

Pathology is the branch of medicine that studies disease, the causes, how the disease effects cells and tissues, and the symptoms. If it is an infectious disease, pathology also looks at how it is spread. In a way, we are all everyday pathologists. When you wake up in the morning with a queasy stomach and wanting to throw up, your first thought will probably be “What did I eat last night?”, closely followed by wondering whether the other people who shared your evening meal are also on their way to the bathroom. Next your mind will start checking if colleagues at work have been off sick with stomach problems, while your hand goes to your forehead to see if you have a temperature. You’re trying to establish possible causes for your symptoms - was it the prawn cocktail? was the meat too rare? On the other hand, lots of people at work have been 'coming down' with stomach upsets, plus you have a temperature, so perhaps it’s a bug?  Depending on the results of your mental investigation, and the way in which your symptoms are developing, you may decide to stay in bed and rest, take some Nux Vomica, take some Imodium, go on line to NHS direct or call the surgery to make an appointment. You’ve made a differential diagnosis and decided on the next course of the treatment.

Pocketbook of Pathology

I believe that this kind of thinking is an essential aspect of taking a case history and that a basic knowledge of pathology is essential for making safe and responsible decisions about treatment. Many people who ask for a massage or bodywork are not suffering from a highly infectious medically diagnosed disease, as in the example above, but that doesn’t mean that pathology is irrelevant. Let’s take a very common presenting problem. The client says “I want a massage because my calves are sore and aching”. Before you allow your twitching hands loose on her gastrocnemius, you need to do a bit of detective work. Look at your client. Is she young, elderly, thin, overweight, pregnant? What shoes is she wearing? Even before you’ve begun the case history, there are important clues right before your eyes, which can be logged while you take her history.

The first line of questioning tries to ascertain the possible cause. Does the client know why her legs are sore? If she ran a marathon the previous weekend, you’re heading down one path, and your knowledge of muscle physiology suggests overuse and lactic acid build up, but reminds you to ask about severity of pain, and whether bruising or inflammation are also present. If she tells you she’s got varicose veins, your knowledge of pathology says damage to the valves, pooling of blood in the veins, local contraindication. The next step down this path is to ask her to stand up so you can locate the damaged veins clearly before you begin the treatment.

Another obvious cause, if she’s pregnant, would be to enquire about swollen ankles and sensations of heaviness. Perhaps she’s suffering from oedema, tissue swelling resulting from inadequate lymphatic drainage, a common problem in late pregnancy. If this is the right path, your pathology detector tells you to avoid heavy massage on the calves and instead use light drainage or techniques to improve lymphatic flow, and to put supports under her legs for comfort.

If the causation is still a mystery, carry on with the case history. Questions about occupation and lifestyle may reveal clues. She’s a sales person in a flagship shoe store. Does this mean standing around all day, in heels? You’re back to the overuse / lactic acid path, with Achilles tendon complications. Ask her to rotate her ankles. Is there full range of movement or restricted dorsiflexion? If her Achilles is tight, some remedial exercises might be indicated as well as regular massage.

If your client says she returned from visiting her son in Australia last week, alarm bells should start ringing. When did she notice the soreness in her calves? Do they also feel swollen, hot and sore to touch? If she isn’t sure, ask to look. Symptoms of inflammation soon after a long haul flight suggest the possibility of a deep vein thrombosis and you know this is a total contraindication, at least until your client has been to her doctor and had her symptoms checked. (Remember, it is not your role to tell the client she has a DVT and at this stage it’s a supposition not a fact. Her medical practitioner has the responsibility of diagnosis and the skills to do this.)

Still no reason behind the aching calves? Of course, there might not be one, but it’s worth looking at the client’s medication. If she is taking statins for high blood pressure, for example, muscular aches are one of the side effects and it might be wise to treat this as a local contraindication and avoid massaging the legs, until she has checked with her doctor. Knowing how common medications affect physiology can help with good treatment decisions. Is she elderly, with a history of mini strokes, and is she taking an anti-coagulant drug, to thin the blood? People often forget the exact names of prescriptions drugs, but can usually say what they are for. Drugs that thin the blood, for example, predispose a person to bruise easily. Ask to look at her calves, to ascertain whether her symptoms are due to bruising. Perhaps she banged her legs against something and has simply forgotten. But if this is the cause of the soreness, massage is locally contraindicated.

I hope this illustrates how it cannot be taken for granted that what seems like an ordinary problem, and one that could easily be remedied by massage, may not, in fact, be that simple, and without the necessary detective work, the problem could be exacerbated rather than eased, and in the case of potential DVT, with very serious consequences.


  1. Krystal Liggett said..

    This article makes you realize how important it is to take a history and ask questions! Something as simple as soreness in the calves really could be something we shouldn’t mess with m, if the correct questions are asked and answered correctly! It’s also a bit terrifying that something that simple could lead to a contraindication!

  2. Cherry said..

    Contact Madiba Herbal Center through email ( or WhatsApp +16183561110 they have 100% herbal cure for Multiple sclerosis (MS)) suffers, i was once diagnosis x

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About Su Fox

Su Fox BSc PGCE UKCP Reg MTI Reg CSTA Reg has worked as a complementary therapist and psychotherapist since 1988. For over twenty years she taught massage and related skills in day care centres for the elderly, people with learning difficulties, and mental health issues as well as professional massage qualifications at Hackney Community College. She was director and chair of The Massage Training Institute between  1991 – 2000 and during that time co-authored, with Darien Pritchard, Anatomy, Physiology and Pathology for Massage and authored The Massage Therapist's Pocketbook of Pathology, which has just been revised and reissued as The Massage Therapist’s Pocketbook of Pathology  published by Lotus Publishing.

During this time she was also running a successful private practice in psychotherapy at The Burma Road Practice in North London, focusing particularly on trauma work. She is a trained EMDR practitioner. Su has always believed that the talking therapies need to address the body, and that alternative therapies often failed to consider mental and emotional health, and this led her to write Relating to Clients. The Therapeutic Relationship for Complementary Therapists, published in 2009. In 1993 she added craniosacral therapy to her qualifications and has been a regular contributor to Fulcrum, the journal for the Craniosacral Therapy Association, including a series entitled ‘In The Supervisor’s Chair’. She currently serves on the supervision committee for the Association.

Her current interests are spirituality and its contribution to well being, and the psychology of the ageing process and end of life issues. Su can be contacted via

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