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A Guide for Massage Therapists

A n n e W i l l i a m s, LMT, CHT, BFA

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2nd edition
Copyright © 2015 Anne E. Williams
Copyright © 2007 Anne E. Williams
351 West Camden Street
Baltimore, MD 21201-2436 USA

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any material contained herein. This publication contains information relating to general principles of medical care which
should not be construed as specific instructions for individual patients. Manufacturers’ product information and package
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Writing and producing Spa Bodywork: A Guide for Massage Oregon). Chris Froelich and the team at Somerset School of
Therapists has involved the contributions of many people, Massage Therapy (New Jersey), Ray Siderius and Jill Stanard
some of whom are unknown. I am thankful to all of them and the team at Oregon School of Massage Therapy
and would like to acknowledge those who stand out here. (Oregon), and Lisa Hensel at Seattle School of Reflexology
for the Reflexology Foot Spa Workshops.
I am grateful to have had the opportunity to work with the
team at Lippincott Williams & Wilkins, and I am thankful I want to say a grateful “Thank you” to Keith Shawe whose
for their tireless enthusiasm and hard work. I would partic- considerate feedback on the first edition and unwavering
ularly like to thank Linda Francis for her great organization, support helped me develop my confidence and skill as a
understanding, and support. I also want to acknowledge writer.
Pete Darcy who approved the proposal for the first edition
of Spa Bodywork and suggested me for the Massage Mastery I extend my sincere appreciation to my family and friends
project. Pete, I’ll always appreciate your creativity, vision, for understanding when I couldn’t be at events because of
and insight. Many thanks also to Spa Bodywork’s first project the book and for their unwavering support and encourage-
manager, David Payne, who was always sensible and practi- ment during the time that I was writing. “Thank you” to
cal (while remaining flexible) and to Susan Schlosstein who Mom and Dad; Jill Shawe; Cindy, Larry, Jason, and Sarah
inspired me with her support and interest. Rantanen; Pam, Kurt, Joe, Gloria, and Natalie Mayer; Rick,
Sharon, Jeff, and Gayle Selden; Anthony Knoll; Derek
During its development, Spa Bodywork has been reviewed by Peace; Deanna Scalf; Edana Biddle; Gretchen Pelsma; and
a number of professionals in the massage industry, each of Kim Virant. Thank you to my amazing and inspiring fitness
whom have given thoughtful and helpful input, so I would trainer, Burt Henry.
like to thank them for their time and contribution.
I am especially grateful to my rock climbing and adven-
Thanks to the photographer Mel Curtis and his team, ture family who keep life in Colorado so fun. “Thank
Connie and Doug, for their visual contribution to the first you” Abram Herman, Jon Barr, Jessica Barr, Ronie Warner,
edition of the book and to Rick Giase for the additional Arthur Nisnevich, Michael Pastko, Tyler Knowles, Adele
photos needed for the second edition of the book. Thank Schopf, Chris Devenney, Ryan Jaret, David Weinstein,
you also to June Pendleton of Universal Companies and Christy Sims, Tiffany and Zack Shocklee, Aleya Littleton,
Professor Jim Simon of Rutgers University for help with and Brian Halterman.
some of the images. Thank you to the team at Savi Day Spa
for allowing us to use their facility for the location shots, I would also like to thank the amazing massage and spa pro-
especially Kelly Wilson and Mary Wilson. Thank you to fessionals, spa instructors, aromatherapists, administrative
the models that gave up their weekends and did their best staff, workshop participants, and individuals who I have had
with body mechanics on the slippery floor! The models the privilege of working with and learning from, especially
were Debbie Bates, Destiny Harrison, Catharine Jakeman, Alicia Chapman, Alla Kammers, Amanda Flynn, Amy Klein,
Sunny Kim, Melody Lickert, Faithann McVeigh, Natalie Amy Stark, Andrea McClelland, Andrea Niemeyar, Andrew
Mayer-Yeager, Erin Murphy, Earl Nabritt, Jason Priest, Keith Biel, Angie Parris-Raney, Angie Patrick, Angie Schneider,
Shawe, Jenni Shires, Jill Wells, and Tiffany Williams. In the Anita Harper, Ben Benjamin, Bill Fee, Bill Langford, Carey
second edition, thank you to Ronie Werner, Aleya Littleton, Rosen, Carrie Ebling, CG Funk, Cherie Sohnen-Moe, Cher-
and Brian Halterman. yl Young, Chris Damalas, Christy Cael, Cindy Babb, Cliff
Korn, Clint Chandler, Cynthia Ribeiro, Darren Buford,
The material for this book was originally developed for four David Christian, Debra Persinger, Deby Giske, Dennis
different spa programs, and so I am deeply grateful to the and Gina Simpson, Diana Thompson, Elan Schacter, Erin
individuals who believed in spa/aromatherapy training for Murphy, Faithann McVeigh, Felicia Brown, Gemini Sanford,
massage therapists and were willing to invest in the equip- Geraldine Thompson, Gini Ohlson, Ingrid Martin, Jack Elias,
ment and training necessary to launch these programs. Jacki Borde, Jade Shutes, James Sutherlin, Jan Schwartz, Jeff
These individuals include Feliz Rodriguez for the original Mahadeen, Jenni Shires, Jenny Good, Jesse Cormier, Jill Sta-
program at Ashmead College and Meredyth Given, Kim nard, Jim O’Hara, Jolie Griffin, Judy Scheller, Julie Carico,
Lothian, Lorine Hill, Siri McElliott, and Eric Rasmussen for Kate Bromley, Kate Zulaski, Katharine Appleyard, Kathy
the second program at Ashmead College (Washington and Thielen, Katie Armitage, Kim Precord, Kitty Lawrence, Lara

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iv Acknowledgments

Bracciante, Laura Allen, Leslie Young, Lincoln Heartsong, Thank you to everyone at Associated Bodywork & Massage
Margie Miller, Marla Gold, Marsha Elston, Marti Mornings, Professionals, with a special thank you to our leaders, Les
Mary Ann Foster, Mary Bryan, Meghan Lawrence, Melanie Sweeney and Bob Benson, and to our education team Cindy
Hayden, Melody Lickert, Pat Archer, Patty Glen, Rick Gar- Williams, Kathy Laskye, Taffie Lewis, Katie Mills, Kristen
bowski, Rick Rosen, Roger Patrizio, Roz Burnet, Ruth Wer- Coverly, and Brian Halterman.
ner, Scott Dartnall, Shannon Alyea, Shelly Johnson, Su Bibik,
Susan Salvo, Terri Zelepuza, Til Luchau, Tom Lochhaas, Ve- Last but not least, “thank you” to my amazing partner, Eric
ronica McHugh, Vickie Branch, Vicky Karr, Victoria Rober- Brown, for being an inventive thinker and collaborator and
son, and Whitney Lowe. an endless source of wisdom, support, and inspiration.

I would like to dedicate the second edition of Spa Bodywork:

A Guide for Massage Therapists with love to my dear friend, Erin Murphy, who
is an inspiration to massage and spa students, fellow teachers,
administrators, and professional therapists who have the
privilege of working with her and knowing her.

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Spa Bodywork: A Guide for Massage Therapists is primarily a Organization and Structure
textbook for the massage student enrolled in a spa pro-
gram. It is also a guide for the practicing massage therapist Spa Bodywork is practical and comprehensive in its approach.
who wishes to add spa treatments to a private practice or For example, spa instructors will find that the materials
work in the spa profession. To some extent, the text can be are presented in a format that can be easily referenced and
used by estheticians to improve their product knowledge that is flexible enough to allow them to use as little or as
and develop new skills for full-body skin care. much of the information as they choose. Students can be
As the title implies, Spa Bodywork aims to illuminate directed to the treatment considerations and procedure
the powerful links between massage and spa treatments. section, whereas advanced therapists will find the detailed
Many of the spa products often used just for beauty have background on spa products useful. The topics have been
the same physiological effects as massage or act in synergy divided into three main areas.
with massage techniques. Seaweed, for example, stimulates
Part 1: Spa Foundations
local circulation and metabolism and supports the natural
detoxification process of the body. Many useful minerals in Part 1: Spa Foundations provides a framework for massage
seaweed can be absorbed through the skin. Seaweed treat- therapists venturing into the world of spa. The first chap-
ments can have a pronounced effect on the thyroid, so they ter gives a history of the spa industry and defines the types
must be used carefully. This requires a good knowledge of of spas that are common in the United States. Chapter 2
the products and application methods being used. Simi- describes the equipment needed to deliver spa treatments
larly, therapeutic mud such as Dead Sea mud and Moor and the different types of spa products therapists encounter
mud have proven anti-inflammatory properties, so they are in spa body treatments. In Chapter 3, client and therapist
used in Europe to treat arthritis and other musculoskeletal safety issues such as ethics, scope of practice, sanitation and
disorders. Such products can be used to support relaxation hygiene, cautions, contraindications, and safety protocols
and stress reduction or as part of a treatment plan for injury are discussed. Although skin care is out of the scope of prac-
rehabilitation. tice for massage therapists in most states, every therapist
Spa Bodywork breaks each spa treatment down into an working in a spa should have a basic understanding of the
easy-to-understand sequence of steps that have been carefully skin. This information is provided in Chapter 3 along with
designed to provide an efficient routine for the practitioner a clear discussion of scope of practice restrictions related to
and a satisfying experience for the client. It gives instructions spa work for massage therapists.
for standard methods of delivery as well as for some creative Chapter 4 (Your Spa Massage) is a new topic added to the
options that make sense when the service is provided by a second edition to support new therapists as they venture
massage therapist. In these cases, the service is designed to into spa work. It looks at the subtle elements of massage
incorporate a natural healing substance such as mud, seaweed, application that help create a vivid and lasting positive
shea butter, or essential oils into the massage. Clients do not impression for clients. It also explores the creative use of en-
have to give up their massages to enjoy spa treatments. hancers to elevate the massage experience toward an artistic
The basic concepts and application methods covered expression of touch that exceeds client expectations.
earlier in the book lay the foundation for more advanced Chapter 5 teaches core techniques that are essential to
techniques that are described in later chapters. All aspects the effective application and removal of spa products. These
of a treatment are addressed including indications and con- techniques include modest spa draping, positioning the cli-
traindications for the treatment, equipment needs, product ent for product application, and removal techniques for the
choices, promotion, combining one service with another, dry room and wet room. In Chapter 6 (Water Therapies),
and client management during the treatment. the basic principles of hydrotherapy are discussed together
Although wet room treatments (i.e., treatments that de- with the proper use of wet room equipment such as Vichy
pend on expensive hydrotherapy equipment such as Vichy showers, Swiss showers, and hydrotherapy tubs.
showers) are discussed in Chapter 5 and 6, the emphasis It is important to have a solid understanding of aroma-
is on the delivery of spa treatments in a dry room setting therapy when working in a spa environment. Chapter 7
(no shower). This makes the book usable in a wide range of introduces aromatherapy, provides an overview of the
surroundings because it shows how spa services that are usu- physiological and psychological effects of essential oils,
ally thought to be too difficult to deliver in a dry room (e.g., describes basic methods of application, and presents
seaweed and mud) can be used in both the day spa and small some simple ways to add essential oils to any treatment.
private practice without the need for expensive equipment. Smell-scapes refer to the aroma landscape that a therapist

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vi Preface

creates to enhance a spa treatment. This concept is defined, come alive through these massage methods, natural spa
and readers are given practical advice about creating a vari- products, and unique treatments. The first section of this
ety of unique smell-scapes. New to the second edition is an chapter explores ayurvedic bodywork and spa applications
extended discussion on methods for blending essential oils including Indian head massage, abhyanga, udvartana, and
creatively and safely. shirodhara. The second section of this chapter looks closely
at the natural plant products from Indonesia, which infuse
Part 2: Spa Treatments their medical and spa practices with luxury and opulence.
In Part 2: Spa Treatments, the lessons learned in Part 1 For students who are rapidly advancing in their spa skills,
become a stepping-stone for more advanced techniques. ayurvedic and Indonesian treatments will offer some new
Common treatments delivered routinely at most spas are challenges that keep learning fun and interesting.
described in step-by-step detail in Chapter 8 (Exfoliation
Treatments) and Chapter 9 (Body Wraps). In Chapter 10 Part 3: Your Spa Career
(Spa Foot Treatments), reflexology, satisfying massage tech- Part 3: Your Spa Career helps massage therapists bring all of
niques, and various products such as clay and seaweed are their new skills together into well-designed spa treatments,
combined for pain-relieving and revitalizing foot services. a spa program, a signature spa service, and a satisfying
The sample treatments described at the back of the book spa career. In Chapter 15 (Your Spa Program and Menu of
for each chapter demonstrate how basic treatments can be Services), therapists explore their personal life missions and
combined with different treatment concepts and promo- visions and weave these into a spa philosophy to inform
tional descriptions to create many ready to use treatments their ideas about meaningful spa programs. Individual
or inspire therapists to create their own services. treatment design and in-depth session planning help read-
Fangotherapy, the use of clay, mud, and peat for healing ers turn standard spa applications into multidimensional
purposes, is discussed in Chapter 11. This chapter looks at and dynamic pieces of performance art in Chapter 16 (Treat-
the traditional use of fango in Europe as well as its evolu- ment Design and Your Signature Spa Treatment). Chapter
tion in the United States. Popular relaxation treatments are 17 (You in the Spa Profession) looks at career opportunities
described, as are the use of fango for acute, subacute, and and choices to help students plan their first career steps af-
chronic muscular conditions. ter graduation. An expanded section on starting a private
In Chapter 12 (Thalassotherapy), the therapeutic ben- practice or spa that includes spa bodywork treatments is
efits of seaweed are explored in relationship to a number new in this second edition.
of popular services. In each of these chapters, traditional
approaches are described along with variations in tech-
niques and creative departures that suit the special skills Chapter Organization
of a massage therapist and allow application in a dry room
Each chapter in the book begins with an outline and a
list of key terms with definitions. The treatment chapters
Stone massage (Chapter 13) is a popular massage sys-
have the same internal structure so that information can
tem at spas and clinics across the country. It requires focus
be found quickly. Each of these chapters has the following
and commitment to the treatment, attention to detail, and
excellent massage skills. The routine taught in this chap-
ter walks the reader through the basic elements of a stone • Introduction: At the beginning of each chapter, the
massage before teaching more advanced techniques that topic is introduced and the framework for the treat-
require practice. The goal is to move beyond effleurage with ment is set up. If the treatment has a unique history, as
stones to a more satisfying form of bodywork that includes is the case with thalassotherapy, this is briefly described.
a variety of techniques, including deep tissue and range of Product details are also described in this section when
motion work. New in the second edition is an increased appropriate. For example, a number of different types of
focus on working with stones safely. Associated Bodywork & fango are used in spa treatments, and each has a differ-
Massage Professionals (ABMP), the largest massage therapy ent set of therapeutic benefits. When developing a spa
association in the United States, reports that burns from service, the therapist needs to have enough information
hot stone massage are the highest liability claim area expe- to be able to choose the fango most likely to achieve the
rienced by massage therapists. The revised Stone Massage desired therapeutic goal.
chapter in Spa Bodywork is based on best practices for safe • General Treatment Considerations: This section dis-
stone massage as required by ABMP for stone massage cusses the indications, contraindications, and any other
liability insurance coverage. special considerations for the delivery of each service.
Ayurvedic-inspired spa treatments and Indonesian- For example, in a body wrap, claustrophobia is always
inspired spa treatments are based in countries that have a concern. Even clients who have no previous history
rich histories and complex cultures and described in of claustrophobia may become panic-stricken when
Chapter 14. The environment, the people, the traditional wrapped. This section gives practical advice about how
medical systems, and the myths from India and Indonesia to avoid or deal with such situations.

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Preface vii

• Treatment Overviews: Treatment overviews allow ther- Online Resources

apists to get a speedy snapshot of the indications, con-
On the inside front cover of this book, you will find infor-
traindications, supplies, and treatment steps involved in
mation and a scratch-off code for accessing the many online
each service. These overviews benefit the therapist who
resources developed to enhance your learning and practice
likes a concise list and wants to find information quickly
and also provide a framework for understanding treat-
Students and all readers may access a series of engaging
ment details in the procedure sections.
video clips created especially for Spa Bodywork, as well as an
• Treatment Procedures: Each treatment procedure de-
online quiz to test their knowledge and understanding.
scribes how to prepare for the treatment and position
Instructors will find an array of resources designed to
the client at the beginning of the service. The treatment
help them present the materials in this text effectively.
is broken down into easy-to-follow steps accompanied by
Instructor resources include a test generator, PowerPoint
photos that illustrate how to position the client and how
slides, and a Teaching Resource document developed for
to apply the products. When appropriate, variations in
each chapter. This resource contains learning objectives,
treatment delivery methods are discussed, taking into ac-
lecture outlines, instructor demonstration checklist, and
count the available equipment, positioning of the client,
student activities.
timing limitations, and the implications of combining a
treatment with enhancers or other treatments. Although
wet room options are described when appropriate, all of
the treatment steps are based on dry room delivery.
• Sanitation Boxes: Sanitation boxes appear in the pro-
cedure section to remind the therapist about cleanliness
In the last 10 years, complementary therapies such as mas-
and hygiene. Methods for cleaning specific equipment
sage, traditional Chinese medicine, acupuncture, aroma-
used in the treatments are described.
therapy, meditation, yoga, and hydrotherapy have gained a
• Broaden Your Understanding Boxes: Some chapters
wider acceptance with the general public. At the same time,
contain a box that helps to give the therapist an under-
stress in the workplace has increased, resulting in a higher in-
standing of the broader application of spa therapies.
cidence of diseases such as repetitive musculoskeletal injury,
Some of these boxes focus on the use of a unique prod-
heart disease, high blood pressure, and panic attacks. There
uct in other countries (i.e., the use of fango in Europe),
has never been a better time for therapists to promote the
whereas others focus on treatments or techniques used
use of spa therapies, and the continuing expansion of the spa
by estheticians (e.g., What is a facial?).
industry is evidence for the strong demand that exists. From
• Spa Fusion Sections: At the end of each chapter, a “Spa
spa’s origins in ancient cultures and from its established
Fusion” section provides useful information, a study tip,
use in Europe, it is plain that spa assimilates many forms of
review questions to test knowledge and comprehension,
therapy into a comprehensive system that leads to wellness.
and a chapter summary.
The spa experience can be life changing. Far from being just
a luxury, spa therapy represents the bold first step toward a
Appendices better form of health care. Its future is in the hands of those
Appendix A provides sample treatments that can be used, dedicated therapists and visionary spa owners who have the
as they are, to guide treatment design in the therapist’s ability to provide a space where clients can experience bal-
private practice, clinic, or spa. The sample treatments also ance and celebrate life while receiving exceptional care.
show how a basic treatment procedure is delivered within I hope that this book inspires massage therapists to in-
the context of an overall treatment concept. Promotional clude spa therapies in their practices or to find a job in the
descriptions and ready-to-use recipes provide a valuable spa industry that is challenging and rewarding. I believe
resource for planning how to add spa services to an existing that the use of the products and treatments described in
massage practice. By using the main treatment as a starting these chapters will support better health and wellness. I am
point and adding other therapeutic elements to it, the ther- grateful for the opportunity to share spa with all of the tal-
apist can learn to develop highly original spa services. ented therapists and students who populate this wonderful
A master list of essential oils with botanical names is provided profession, and I invite therapists to share their spa experi-
in Appendix B, and Appendix C provides a list of sources for spa ences, best practices, and suggestions. These can be sent by
products and equipment to help therapists find the necessary email to
materials for the delivery of treatments. Appendix D provides
ready-to-copy forms for the spa business, and Appendix E gives Anne Williams
answers to the chapter review questions. Boulder, Colorado

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Williams_2E_FM_printer_file.indd viii 10/24/13 3:43 AM
Table of Contents

Acknowledgements iii 3 Client and Therapist Safety 32

Preface v Spa Ethics 33
Commitment to Personal and Professional
Boundaries 33
PART ONE Spa Foundations 1 Scope of Practice 35
1 Spa from Past to Present 2 Spa Sanitation and Hygiene 37
Diseases 37
A Brief History of Spas 3 How Diseases Are Transmitted 39
European Spas in the 18th and 19th Centuries 3 Preventing the Transmission of Disease 40
The Modern European Spa 4 Sanitation of the Facility, Equipment, and Supplies 43
Spa in the United States 5 Universal Precautions 46
Basic Spa Categories 6 Creating a Safe Environment 48
Destination Spas 6 Safety of the Facility 48
Resort Spas 6 Safety of the Client 48
Amenity Spas 7 Safety of the Therapist 49
Medical Spas 7
Cautions and Contraindications 50
Day Spas 8
Spa-Specific Considerations 56
Hot Spring Spas 8
Common Conditions That Require Caution 56
Mobile Spas 8
Critical Thinking and Contraindications 61
The Spa Client 9
Documentation of Sessions in a Spa 62
Spas for Women 9
Spas for Men 9 4 Your Spa Massage 68
Spas for Families 10
Programs for Teens 10 Overview of a Wellness Massage Session 69
Before the Massage 69
Spa into the Future 10
The Massage 72
2 Spa Equipment and Products 13 After the Massage 73
Opening and Closing the Massage 73
Dry Room Equipment 14
Resting and Holding Strokes 74
Massage Tables 15
Breathwork 74
Basic Linens 17
Aromatherapy Inhalations 78
Hot Towel Heating Units 17
Use of an Auditory Cue 78
Product Warmers 18
Paraffin Warmers 18 Massage Enhancers 78
Body Wrap Materials 18 Warm Packs 79
Body-Warming Equipment 18 Steamy Aromatic Towels 79
Spa Clothing 19 A Simple Hand or Foot Treatment 80
Other Dry Room Supplies 19 Paraffin Dip 81
Easy Aromatherapy Enhancements 81
Wet Room Equipment 19
Tubs 19 Putting Your Spa Massage Together 82
Showers 20 Sequencing 82
Specialized Environments 22 Routines 84
Purchasing and Maintaining Equipment 23 Subtle Factors That Influence the Massage 85
Spa Products 23 5 Foundation Skills for Spa Treatment
Cleansers 23 Delivery 96
Toners and Astringents 23
Exfoliation Products 23 Spa Draping 97
Treatment Products 24 Posterior Leg 97
Moisturizers 24 Anterior Leg 97
Important Product Terms 24 Breast Drape 97
Product Exploration 25 Anterior Pelvic Drape 97
Your Spa Environment 25 Turban Drape 97
What the Client Sees—Décor 25 Gluteal Drape 97
What the Client Hears 28 Simple Hair Drape 97
What the Client Smells 28 Side-Lying Drape 97
What the Client Tastes 29
What the Client Feels 29
Accessibility and Functionality 29
Planning Spa Treatment Rooms 29

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x Table of Contents

Positioning the Client When Applying Aromatherapy Massage 149

Spa Products 100 Aromatherapy Baths 150
The Side-Lying Position 101 Aromatherapy Wraps 150
The Sit-Up Method 101 Aroma Mists and Aura Mists 151
The Flip-Over Method 101 Support Lotions 151
Basic Application Techniques 101
Application by Hand 101
Application with One Hand Gloved 101
PART TWO Spa Treatments 154
Application by Brush 101
Application with Gauze or Fabric 101 8 Exfoliation Treatments 155
Application by Mist 101 Types of Exfoliation Treatments 156
Application of Product with a Sugar Shaker 101
General Treatment Considerations 156
Dry Room Removal Techniques 103 Scope of Practice 156
Steamy Rosemary Towels 104 Skin Conditions 156
Herbal-Infused Towels 104 Overexfoliation 156
Hot Towel Removal—Legs 104
Dry Skin Brushing 156
Hot Towel Removal—Feet 104
Dry Skin Brushing Techniques 157
Hot Towel Removal—Back 104
The Enhanced Dry Skin Brushing Procedure 158
Hot Towel Removal—Arms 105
Hot Towel Removal—Abdominal Area and The Salt or Sugar Glow 160
Upper Chest 105 The Salt or Sugar Glow Procedure 162
Other Dry Room Removal Techniques 105 The Full-Body Polish 165
Moving a Client from Plastic to a Preset The Full-Body Polish Procedure 165
Massage Sheet 105 The Body or Loofah Scrub 167
Wet Room Removal Techniques 105 The Buff and Bronze 167
The Handheld Shower 105 The Buff and Bronze Procedure 168
The Standard Shower 105 Home Care and Retail 171
The Swiss Shower 106
The Vichy Shower 107 9 Body Wraps 173
General Treatment Considerations 174
6 Water Therapies 110 Contraindications 175
General Uses for Hydrotherapy 111 Healing Crisis 175
Introduction to Hydrotherapy 111 Allergies or Sensitive Skin 175
Therapeutic Characteristics of Water 112 Modesty 175
Hydrotherapy Benefits and Effects 113 When the Wrap Goes Wrong 175
Benefits of Using Hydrotherapy in a Massage and Claustrophobia 175
Spa Practice 113 Wrapping Materials 176
Effects of Hydrotherapy Applications 113 The Hot Sheet Wrap 176
Hydrotherapy Applications 117 Hot Sheet Wrap Types 176
General Treatment Considerations 117 The Hot Sheet Wrap Procedure 177
Hydrotherapy Applications 120 The Cocoon 181
Cocoon Types 182
7 Introduction to Aromatherapy for Spa 129 The Cocoon Procedure 186
Aromatherapy—An Art and Science 130 Tension Wraps 189
Techniques for Tension Wrapping 189
Essential Oils 131
Safety Considerations 134 10 Spa Foot Treatments 194
Pathways In and Out of the Body 137
The Physiological and Psychological Effects of General Treatment Considerations 195
Contraindications 195
Essential Oils 137 Reflexology Certification 195
Physiological Effects 137
Possible Reactions to Reflexology 195
Psychological Effects 142
Therapist and Client Comfort during Reflexology 195
Blending Essential Oils 143 Elements of a Spa Foot Treatment 196
Carrier Products 143
A Quick Foot Assessment 196
Essential Oil Concentrations 145
Soaking and Cleansing the Feet 197
Synergy 145
Exfoliation 197
Top, Middle, and Base Note Blending 146
Foot Massage 199
Approach to Blending 146
Reflexology 203
Application Methods 148 Treatment Products 208
Inhalations 149 Finishing Products 211
Aromatic Exfoliations and Body Shampoos 149

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Table of Contents xi

A Sample Foot Treatment Procedure 211 Seaweed Odor 237

Session Start 211 Cellulite and Cellulite Products 238
Step 1: Soak and Cleanse 211 The Slimming Seaweed Cocoon Procedure 238
Step 2: Exfoliation 211 Session Start 238
Step 3: Move the Client to the Treatment Table 211 Step 1: Exfoliation of the Posterior Body 238
Step 4: Foot Massage 212 Step 2: Application of a Cellulite Cream to Target Areas
Step 5: Reflexology 212 of the Posterior Body 239
Step 6: Application of a Treatment Product 212 Step 3: Exfoliation and Cellulite Cream Application on
Step 7: Process 212 the Anterior Body 239
Step 8: Removal of the Treatment Product 212 Step 4: Application of Seaweed 239
Session End 213 Step 5: Cocoon 239
Step 6: Process—Massage the Face and/or Feet 240
11 Fangotherapy 215 Step 7: Unwrap 240
Fangotherapy in Europe 216 Step 8: Application of Firming Products 241
Fangotherapy in the United States 217 Session End 241
Types of Products Used in Fangotherapy 217 The Seaweed Breast Treatment 241
Clay 217 Other Seaweed Treatments 242
Mud 219
Peat 220 13 Stone Massage 247
General Treatment Considerations 220 General Treatment Considerations 249
Contraindicated Individuals 220 Contraindications 249
Broken or Inflamed Skin 220 Stone Temperatures 249
Fango Temperature 221 Therapist Safety 249
Mixing and Storing Fango Products 221 Draping and Insulation for Placement Stones 249
Preventing Dry Out 221 Essential Oils 249
The Full-Body Fango Cocoon 221 Equipment and Setup 250
The Fango Back Treatment Procedure 222 Stones 250
Session Start 222 Heating Units 250
Step 1: Steam the Back with Hot, Moist Towels 223 Equipment Organization 251
Step 2: Cleanse the Back 223 Core Techniques 251
Step 3: Exfoliate the Back 224 Introduction of the Stones to the Client’s Body 251
Step 4: Massage the Back 224 Stone Flipping 251
Step 5: Application of Warm Fango 224 Stone Transitions 252
Step 6: Process—Massage the Legs and Feet 224 Bad Stone Body Mechanics 252
Step 7: Remove the Fango 224 Heating Unit Speed versus Body Speed 252
Step 8: Application of a Finishing Product 224 Remove Enough Stones 252
Session End 224 Draping 252
The Fango Scalp and Neck Treatment Stones on the Face 252
Procedure 225 Basic Strokes 253
Session Start 227 Long Strokes with the Stone Flat 254
Step 1: Steam the Head and Face 227 Stone Pétrissage 254
Step 2: Massage the Neck 227 Wringing with Stones 255
Step 3: Massage the Scalp 227 Stone Stripping 255
Step 4: Application of Warm Fango to the Head 227 Rotation of a Stone with Compression 255
Step 5: Process—Massage the Feet and Hands 227 Stone Vibration 255
Step 6: Remove the Fango from the Hair 227 Deep Tissue with the Edge of a Stone 255
Step 7: Face Massage 227 Deep Tissue with the Flat of the Stone 255
Session End 228 Friction with Stones 255
Stone Tapotement 255
Fango Applications for Musculoskeletal Injury and
Vascular Flush with Stones 255
Disorder 228
Stone Strokes for Specific Areas 255
Acute Conditions 228
Posterior Leg: Gastrocnemius and Soleus Pin and
Subacute Conditions 230
Stretch 255
Chronic Conditions 230
Posterior Leg: Hamstring Pin and Stretch 255
12 Thalassotherapy 232 Posterior Leg: Double-Arm Deep Tissue Stroke 259
The Back: Stoning the Lamina Groove 259
A Brief History of Thalassotherapy 233 The Back: Latissimus Pin and Stretch 259
The Therapeutic Benefits of Seaweed for the Anterior Leg 259
Body 233 Anterior Leg: Quadriceps Pin and Stretch 259
General Treatment Considerations 235 Anterior Leg: Tensor Fasciae Latae and Iliotibial Tract
Contraindications 235 Stretch with Stones 259
Sensitive Skin 236 Arm: The Triceps 259
Product Form and Application Considerations 236 Arm: Flexor or Extensor Pin and Stretch 259

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xii Table of Contents

Hands 259 16 Your Spa Program and Menu of Services 334

The Neck: Prone 259
The Neck: Supine 259 Benefits and Drawbacks of Spa Body Treatments 335
A Basic Full-Body Stone Massage Procedure 260 Your Spa Philosophy 336
Session Start 260 Your Life Mission 336
Step 1: Posterior Placement 260 Creating Your Spa Program 340
Step 2: Massage the Posterior Legs 261 Choosing Spa Treatments for Your Program 340
Step 3: Massage the Back 261 Balance Your Spa Program 343
Step 4: Transition to the Supine Position 262 Review Other Spa Programs 343
Step 5: Anterior Placement 262 Design Individual Treatments 346
Step 6: Massage the Anterior Legs 262 Write Detailed Treatment Guides 348
Step 7: Foot Massage 262 Refine Your Treatments 348
Step 8: Abdominal Massage (Optional) 262 Your Spa Menu 348
Step 9: Arm and Hand Massage 262 Design 348
Step 10: Neck Massage 263 Writing Style 348
Step 11: Face Massage 263 Essential Contents 351
Session End 263
17 You in the Spa Profession 353
14 Culturally Based Spa Treatments 265
Your Career Plan 354
Ayurvedic-Inspired Spa Treatments 266 Self-assessment for Career Planning 354
Core Concepts in Ayurveda 266 Explore Your Options 354
General Treatment Considerations 273 Have a Plan—It Can Change 360
Indian Head Massage 281 Activities for Further Exploration 360
Abhyanga 286 Plan to Thrive 360
Udvartana 293 Write Your Career Plan 361
Shirodhara 295 Work as an Employee 363
Indonesian-Inspired Spa Treatments 297 Identify and Research Potential Spa Employers 363
Indonesian Spa Products 297 Write a Resume 363
Treatment Considerations 298 Write a Cover Letter 364
Indonesian-Inspired Massage 299 Interviewing 364
Indonesian-Inspired Exfoliation and Body Wrap Negotiating the Employment Package 367
Treatments 308 Meeting and Exceeding the Employers
Balinese Boreh–Inspired Treatment 310 Expectations 368
Javanese Lulur Ritual 310 Starting a Private Practice 369
Your Business Plan 369
PART THREE Your Spa Career 316
15 Treatment Design and Your Signature
Spa Treatment 317 Appendix A. Sample Spa Treatments 386
Individual Treatment Design 318 Appendix B. Essential Oils and Their Botanical
The Therapeutic Goal 319 Names 407
Finding Inspiration through a Treatment
Concept 319
Appendix C. Resources 409
Treatment Texture 320 Appendix D. Ready-to-Copy Forms 411
Enhancing Treatments 324 Appendix E. Answers to Chapter Review
Transitions 324
Product Planning 325 Questions 420
Client Management 325
Retail Sales as Part of the Treatment 326 Glossary 421
Treatment Planning Forms 326
Considerations When Pricing Services 330
References 426
The Signature Spa Treatment 330 Index 431

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Spa from Past to

Chapter Outline K e y Te r m s
A Brief History of Spas Ayurveda: The 5,000-year-old medical system of India. Ayurveda influ-
European Spas in the 18th and 19th Centuries ences are often used in spa treatments.
The Modern European Spa Esthetician: This word is a variant of the word aesthetician, which is
Spa in the United States derived from aesthetic, a branch of philosophy dealing with the nature
Basic Spa Categories of beauty. Estheticians are beauty specialists with around 300 to 750
Destination Spas
hours of training. Their scope of practice includes skin care, hair re-
Resort Spas
Amenity Spas moval, and makeup application.
Medical Spas Exfoliation: A procedure that removes dead skin cells from the surface of
Day Spas the skin, stimulates lymph circulation, and increases muscle tone when
Hot Spring Spas used with manual friction.
Mobile Spas Hamam: An Islamic bath characterized by a vaulted ceiling and a raised,
The Spa Client heated marble platform called a hararat, which is used for massage or
Spas for Women exfoliation.
Spas for Men Hydrotherapy: The use of water in one of its three forms (liquid, solid, or
Spas for Families vapor) at specific temperatures for therapeutic purposes.
Programs for Teens
The Kur system: A German medical system that includes spa treatments
Spa into the Future
as part of a wider system for health and wellness. Kur treatments are
SPA FUSION medically prescribed and paid for by the national health care system.
INTEGRATION OF SKILLS Luxury spa: A spa with exceptional accommodation, a full range of treat-
STUDY TIP: Group Discussion ments, the latest advances in spa technology, a full array of wet room
SPA INSPIRATION: My Spa Experience equipment, and well-trained staff.
CHAPTER WRAP-UP Radon: A naturally occurring atmospheric gas that is radioactive and is
released as uranium in rock and soil as it breaks down. It is used in
trace amounts in Europe for the treatment of arthritis and asthma.
Spa: A commercial establishment that provides health and wellness treat-
Spa therapy: A general term for a wide range of spa treatment methods
or techniques used by various professionals in different settings to sup-
port health and wellness.
Spa treatment: A general term for a treatment that uses water, specialized
products, and various techniques to bring about relaxation, address a
specific pathology, and/or support overall health and wellness.
Terme: From the Greek therme meaning heat, and thermai meaning of or
related to hot springs.
Thermal mud: Thermal mud comes from the areas around hot springs. It
can be applied at the site while still hot from the spring water, or it can
be extracted and heated for later application elsewhere.

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Chapter 1 Spa from Past to Present 3

through to allow disks of natural light to shine down on the

The spa profession is dynamic, changeable, and difficult bathers were more modest than their Roman counterparts.
Bathers would stop first at the camekan, a small court of
to define or categorize. It employs a variety of professionals
changing cubicles surrounding a fountain, before entering
that may include physicians, chiropractors, ayurvedic the hararat (hot marble baths). Bathers would receive a vig-
orous massage or kese (exfoliation with a rough cloth) on
doctors, massage therapists, estheticians, life coaches,
a raised marble platform above the wood or coal furnaces
counselors, dietitians, yoga instructors, spiritual leaders, that are used to heat the hararat.
Although the use of the public hamam is on the decline,
cosmetologists, dermatologists, cosmetic surgeons,
travelers to Istanbul can still experience a Turkish bath
naturopathic doctors, hypnotherapists, fitness trainers, complete with an exfoliating scrub and a brief invigorat-
ing massage. Historical hamams such as the Galatasaray
and others. A wide range of therapies may be offered in an
Hamam in Beyoglu give visitors a glimpse of the lasting
array of different settings under the heading of “spa”. This splendor of the Ottoman Empire.
Perhaps the most famous ancient spas were those of
chapter aims to briefly describe the historical roots of the
the Roman Empire, where public baths were a part of the
spa profession and its evolution in the United States and to culture that served an important social function as well as
providing a means of hygiene. The central role of spas in
define broad categories of spas and the types of individuals
Roman culture led to a well-developed use of hydrotherapy
that frequent them. It also looks at the future of spas and (healing with water), and garrisons were often built around
hot springs so that the soldiers could heal their battle
the potential role that spa plays in a broader system of
wounds. By 43 AD, the Roman public viewed the baths as
health care. a way to relax and maintain health, and by the early fifth
century AD, there were 900 baths in Rome alone. Although
not everyone could afford a massage, all classes used the
A Brief History of Spas baths. Apart from the bath itself, there would usually be an
area that served as a community center, a restaurant, fitness
It is hard to pin down the origin of spa therapy. Mineral center, bar, and a performance center where a juggler, a
springs and thermal muds were probably used long before musician, or even a philosopher might entertain.
the first civilizations developed. In Finland, for example,
nomadic people heated holes in the ground with hot rocks
European Spas in the 18th and 19th Centuries
and covered them with a tarpaulin to have a warm place
for bathing.1 These saunas were also holy places where In the 18th and 19th centuries, Europeans would take
births and deaths took place. In much the same way, North the waters for common ailments such as rheumatism and
American Indian tribes used a separate hut or a covered respiratory disorders. Often, spas were built in secluded
sweat lodge built partly into the ground. Large stones were mountain towns, providing visitors with spectacular views;
heated in a fire and taken inside the hut, where they were fresh, clean air; and exercise on nature walks. A trend in
sprinkled with water. Many early civilizations had a version spas at the time was to employ medical professionals who
of the spa bath, which combined some form of social in- carefully monitored each visitor’s treatment. Eventually,
teraction with cleanliness. Russian steam baths, which can spas expanded to include restaurants, casinos, theaters,
still be found in Europe, combine hot air and steam piped racetracks, and other forms of entertainment. One such
from a boiler. The atmosphere is humid, and the aim is to mineral spring town is Spa in Belgium (Fig. 1–1). The rich,
get the body to perspire continuously for a period after the royal, and famous have been visiting the mineral springs
bath has finished. of Spa since the 16th century. The writer Victor Hugo was
Traditionally, Arabs would bathe only in cold water an advocate of Spa’s curative waters and visited it often.
and would never use a tub because this would subject the The town, situated in a wooded valley surrounded by un-
bather to his or her own filth.2 Cleanliness is intertwined dulating hills and mineral-rich springs and rivers, is still a
with Islamic spirituality. The hamam (bath) became popu- favored destination for those seeking rest and relaxation.
lar around 600 AD after Muhammad recommended sweat Some speculate that the word spa can be traced to the
baths. They gained religious significance after this and be- name of the town, but it is more likely that it comes from
gan to be built close to mosques. When the Arabs conquered the Latin words espa (fountain) and sparsa (from spargere
Syria, they quickly adopted Roman and Greek forms of or “to bubble up”). “Health through or by water” is sanus
bathing with hot water and steam, and cold water bathing per aquam (SPA) and solus per aqua (SPA) is Latin for “by
fell out of fashion. The hamam became central to the com- water alone.”
munity, serving as both a place of spiritual retreat and for The use of water has long been central to spa therapy
socializing with friends. The beautiful vaulted ceilings cut because bathing in mineral-rich waters has some positive

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4 Spa Bodywork: A Guide for Massage Therapists

administering last rites to the gravely ill, he used water

and herbs to cure them. Kneipp’s healing system, which
combined physical exercise, simple food, hydrotherapy
and herbs, forms the basis of modern naturopathy. He is
well known for the wet nightshirt treatment in which the
remedy was to wear a shirt that had been dipped into wa-
ter with salt or hay flower.

The Modern European Spa

The modern spas of Europe are still based on the hydrother-
apy principles developed by Priessnitz and Kneipp. Visitors
to the Bad Hofgastein Spa in Austria stay at a comfortable
hotel with an indoor thermal pool fed by the mountains
waters, a whirlpool, sauna, Turkish bath, fango (mud) treat-
ments, massage, radon baths, and a bar with a fireplace.
Arthritic patients at the Spa are given the “Gastein cure.”
This treatment consists of visits to the radon caves of the
Radhausberg Mountain and seems to be effective for arthri-
tis, sinusitis, and chronic asthma sufferers (Fig. 1–2). Radon
is a naturally occurring radioactive gas released by rock, soil,
and water from the breakdown of uranium. It is absorbed
by the body in very small doses through inhalation and
through the skin in the 70% to 80% humidity that is found
deep in the mountain caves. The use of environments with
trace amounts of radon is not unique in Europe. In fact,

FIGURE 1–1 Spa, Belgium. The copper tubs used at Termes de Spa in
Belgium date back to the 1800s.

effects on the body. The medical benefits of “taking the

waters” were advanced in Europe by two natural healers
who developed their ideas in the early 1800s. The first was
the Austrian Vincent Priessnitz (1799–1852) who promoted
“the cold water cure.” The “cure” consisted of drinking large
amounts of cold water, bathing in cold water, following
a simple diet, and participating in physical activity in the
open air. Priessnitz was able to use the cold water cure to
care for a personal injury that doctors of the time thought
untreatable. In 1826, Priessnitz opened a water cure estab-
lishment at Gräfenberg in the mountains of Silesia, where
his ideas were adopted by many prominent physicians.3
The second natural healer was Father Sebastian Kneipp
(1824–1897), a German priest who cured himself of pul-
monary tuberculosis by bathing in the icy Danube and
“shocking” his body into health. In one of his many books,
My Water-Cure (1894), Kneipp writes, “Being a priest, the
salvation of immortal souls is the first object for which
I wish to live and die. During the last 30 or 40 years,
however, the care for mortal bodies has absorbed a con- FIGURE 1–2 Bad Hofgastein Radon Cave at Bad Hofgastein Spa
siderable portion of my time and strength.”4 Instead of in Austria.

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Chapter 1 Spa from Past to Present 5

some research appears to support the use of radon inhala- and drugless healing that were among the forerunners of
tion and radon baths for asthma, hypertension, osteoarthri- alternative medicine as we know it today. Dr. John Harvey
tis, and diabetes.5–8 Kellogg pioneered many of the practices that have been
Visitors to the little spa town of Le Mont-Dore in Auvergne, proven in modern medicine at the Battle Creek Sanitarium
France, can take the radon-rich air in the form of a nasal irriga- (the San) in Michigan. Kellogg recommended a good veg-
tion with a tube inserted up one nostril. They breathe in a gas etarian diet, regular exercise, correct posture, fresh air, and
drawn from a nearby natural hot spring. Although this gas is proper rest. He persuaded women to discard their corsets
mostly carbon dioxide, it also contains a radon concentration and ignore fashion to improve their breathing. Kellogg
that is well above average. The radon is supposed to activate also practiced some questionable medicine, including elec-
the blood, combat allergies, improve digestion, and stimulate tropathy and radium cures. Many regarded him as a quack,
the immune system.9 even though he was one of the nation’s leading surgeons.
The Italian towns of Abano, Montegrotto, Galzignano, Kellogg’s program was offered in a luxurious, restful, and
and Battaglia, which lie in a broad, green plain northeast elegant setting that was often attended by the rich and
of the Euganean Hills in the Veneto of Italy, are famous for famous.11
their ancient thermal baths. The spa at Montegrotto dates In 1934, Elizabeth Arden turned her Maine summer
from the 76th century BC, and the remains of Roman spas home into a beauty and health spa called the Maine Chance.
in the area can still be seen. Abano Terme (terme means She targeted two groups of women; those that were middle
thermal bath) is considered to be one of the oldest spa aged trying to recapture youth and plain women looking
centers in the world. According to legend, the Abano waters for a means to achieve “beauty in a jar.”12 With cosmetics
were warmed when Phaeton, the offspring of the sun, as her primary product, Arden pioneered the integration of
fell and landed in the mineral springs. It is likely that the diet, exercise, sports, yoga, facials, massage, beauty train-
inactive volcano there feeds the 130 hot springs in the area ing, and pampering into a focused spa program. She used
that still flow at a constant temperature of 188°F (86°C). science and technology to develop her concept of beauty
Guests enjoy thermal treatments under the supervision of and to turn that concept into a $20-million industry.
medical staff, and the Euganean Hills mud found in the Today, Arden’s signature, Red Door Salons are recognized
area is used for arthritis and fibrosis neuritis as well as for worldwide.
gout and metabolic problems. Spas in the early 1960s developed the stigma of “fat
It is common in Italy, as in many European spas, for the farms” for wealthy women who wanted to lose weight and
guest to stay up to 3 weeks and receive daily treatments. In detoxify (sometimes from drug and alcohol addictions).13
Germany, for example, spa therapies are regarded as medi- The fat farm stigma may have slowed the growth of the spa
cal treatments and as a general preventive against poor industry for some time, but the concept of an integrated
health. Over 9 million Germans enjoy the benefits of “the program of fitness, diet, and healthy lifestyle training bal-
Kur system” each year. In the Kur (cure) system, a person anced with pampering treatments and beauty became es-
spends 2 to 4 weeks in a climate chosen for his or her condi- tablished. This comprehensive approach differentiates the
tion. Patients receive a wide range of treatments, including American spa from its European counterpart, where the
massage; mud, herbal, and seaweed applications; inhalation focus is usually on treating a recognized medical condition.
therapy; and the use of mineral and thermal water. Part In the 1970s, hair salons seeking to expand their busi-
of the treatment is enjoying leisure time in a beautiful, nesses started to offer à la carte spa treatments as well as
efficiently run natural setting. Long-term studies show that regular salon services. This transformation of the salon into
the number of sick days taken by German workers who re- the day spa was the idea of Noelle De Caprio.14 She regu-
ceived a Kur treatment drop by an average of 60%.10 Medi- larly attended spas in Europe and wanted to offer her cli-
cal drug consumption and other health care costs also de- ents a mini-spa experience in the convenience of her salon.
crease. The long-term effects of the Kur system include a She also recognized that Americans rarely had the time or
drop in the number of early retirements and an increase in the money to travel for 3 or 4 weeks to experience spa treat-
productivity throughout the patient’s working life. ments in Europe. Making these services available locally,
in easy-to-manage, half-day or full-day packages, added to
their popularity. Other salon owners quickly followed De
Spa in the United States
Caprio’s lead. By 2010, there were an estimated 19,900 spas
After the Industrial Revolution, spa treatments were seen as in the United States, and 7 out of every 10 of these estab-
less scientifically viable than fast-acting, medically measur- lishments is a day spa.15
able drugs. As a result, the European concept of spa did not Over the last 10 years, complementary therapies such
cross the Atlantic intact. Even though hydrotherapy cures as massage, traditional Chinese medicine, acupuncture,
quickly gained popularity in mid-1800s America, spa and aromatherapy, meditation, yoga, and hydrotherapy have
complementary therapies developed in different directions. gained acceptance with the public, especially for illnesses
In the early 1900s, water-cure centers became rallying and injuries that are not so effectively treated using conven-
points for new medical ideas including meat-free diets tional medical approaches.16 At the same time, Americans

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6 Spa Bodywork: A Guide for Massage Therapists

now have greater access to information about health care

options. This has led to the birth of integrative approaches
in which alternative and conventional medicine are prac-
ticed side by side in many spas to improve health and fight
disease.17 Another factor in the growth of the spa industry is
the general increase in the level of stress being experienced
by the American public and a decrease in the amount of lei-
sure time.18 Spas offer guests a way to decrease stress while
improving their health at the same time.
According to a survey conducted by the International
Spa Association (ISPA), 150 million visits were made to U.S.
spas in 2010, producing $12.8 billion in revenue. Over a
decade, the amount of spa revenue has grown from $5 bil-
lion in 1999 to $12.8 billion in 2010. Shopping malls, cruise
ships, and fitness clubs are adding spas, and they have even FIGURE 1–3 New Age Health Spa, New York.
become a feature or focus of large hotels and resorts. Once,
spa was only for the wealthy and privileged, but today, there
is a spa experience available for every budget. American spa
owners are a vibrant and creative bunch and draw inspira- wish to detoxify, a juice fast replaces regular meals. Body
tion from a range of healing modalities, spiritual systems, treatments include a full range of services such as a shirod-
and cultural influences to create a unique experience for hara spiritual treatment, aromatherapy body wrap, and a
their guests. maple sugar body scrub. As the name suggests, this type of
spa targets a client who is looking for a spiritual as well as
physical experience.19

Basic Spa Categories Resort Spas

Because of the diversity that currently exists within the A resort spa offers different recreational opportunities
industry, spas are difficult to place into clear categories. such as hiking, rock climbing, water sports, shopping,
For example, spas might be grouped on the length of tennis, golf, and horseback riding as well as spa services.
the client’s stay or on the focus of the spa program. A Often, it is the beautiful natural landscape around a re-
destination spa might be a weight loss spa, or it might be sort that is the primary reason for the visit, and the spa
a spiritual retreat. A resort spa might be an adventure spa itself is just one of many activities offered to the resort or
focusing on healthy athletes or a family spa with programs hotel guest. Some resort spas are a cross between the des-
for both adults and children. Spas might be luxury spas tination and hotel spa where health programs are on offer,
with expensive treatments and high-tech equipment or and guests can choose from low-fat spa cuisine or more
budget spas with moderately priced services and a relaxed traditional fare. The Watermark Hotel and Spa in San An-
décor. The following list of spa types will help you begin tonio, Texas, is a resort spa that sits right on San Anto-
to understand the general differences between basic spa nio’s famous River Walk (Fig. 1–4). Guests can explore the
categories. 2.5 miles of trails that follow the San Antonio River, shop
in boutiques, or make an excursion to the Alamo. The spa,

Destination Spas
Guests visit a destination spa for a weekend, a 4-day pro-
gram or longer to make significant lifestyle changes or to re-
lax completely. Spa programs focus on fitness, healthy diet,
detoxification, and lifestyle education. Some destination
spas offer classes and services geared toward spiritual as
well as physical renewal. Many destination spas offer a full
menu of beauty services in addition to the spa program. A
good example is the New Age Health Spa (Fig. 1–3). This is a
destination spa with a philosophy of mindful living, a calm
mind, and a strong body. They offer guests a program that
is spiritual while promoting fitness, good nutrition, and en-
joyment of the outdoors. A typical day includes a morning
meditation, a 3-mile hike, and yoga classes. For those who FIGURE 1–4 The Watermark Hotel and Spa in San Antonio, Texas.

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Chapter 1 Spa from Past to Present 7

which occupies the entire second floor of the hotel, of-

fers various beauty services, massage, and hydrotherapy
à la carte.20

Amenity Spas
At one time, amenity spas, which are usually found in ho-
tels, offered basic services only and were really an after-
thought even in large hotels. A massage room, a simple
fitness center containing little more than a treadmill, and
a basic salon were usually all that was offered to guests.
Many hotels now view spa services as an important con-
tributor to the bottom line, so they have started to offer
full-service facilities.21 Keeping pace with this trend, small-
er hotels, bed-and-breakfasts establishments, and even
some time-shares have moved toward offering in-room
massage or mobile spa services if they do not have room
for a full-service spa.

Medical Spas
In many ways, the medical spa is a direct counterpart of a
European spa at which guests receive health care services
in a relaxing and beautiful natural setting. Some hospitals
are adding spas to ease the discomfort of the terminally ill
and to help with pain management. Three different types of
medical spas (sometimes called medi-spas or medspas) are
listed by SpaFinder. 22
The first type is the esthetics-oriented medical spa, which
includes services such as Botox or collagen injections, chem-
ical skin peels, laser hair removal, laser skin treatments,
liposuction, plastic surgery, and sclerotherapy (spider vein
elimination). In this type of spa, medical cosmetic and clini-
cal esthetics procedures are offered together with revital-
izing treatments (such as massage) to support the recov-
ery process. A good example is the Juva MediSpa, which is
linked to the Juva Health and Wellness Center.23 Skin health
and beauty are addressed with anti-aging and skin damage
treatments, Botox injections, liposuction, and breast aug-
mentation. The body–mind connection and its effect on
health are treated using hypnotherapy, psychotherapy, fit- FIGURE 1–5 Juva MediSpa, New York.
ness training, and nutritional consultations (Fig. 1–5).
The second type of medical spa is the complementary
or alternative medicine spa, where the program designed
for each guest is based on one of the alternative medicine The third type of medical spa is the preventive health
systems such as ayurveda or Chinese traditional medicine. care spa in which medical staff carry out a number of tests
Naturopathic medicine, nutrition therapy, Western herbal (blood tests, bone density screening, etc.) before design-
medicine, and acupuncture all fall into this category. The ing the treatment program. Sometimes, the spa specializes
Maharishi Vedic Health Center in Lancaster, Massachusetts, in general areas such as weight loss, pain management,
uses authentic ayurveda treatments for disease prevention or prenatal or postnatal care. They may also offer specific
and chronic disorders.24 Traditional diagnostic procedures programs for particular conditions such as diabetes, high
such as Vedic pulse diagnosis are used in designing the blood pressure, or chronic insomnia. The Canyon Ranch
treatment and spa regime. Guests can also take part in yoga Health Resort in Tucson, Arizona, combines the well-
classes, healthy cooking instruction, and evening lectures known luxury and pampering of the famous Canyon Ranch
on Maharishi Vedic medicine. Spas with a health and healing center (Fig. 1–6).

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8 Spa Bodywork: A Guide for Massage Therapists

FIGURE 1–6 Canyon Ranch Spa Executive Health Program.

The Executive Wellness Program is a 4-day health program

that includes a complete physical examination as well as life-
style assessment. The general approach of Canyon Ranch is
to encourage guests to make a long-term commitment to
healthy living so as to decrease the occurrence of disease.25

Day Spas
Day spas are mini-retreats with services delivered à la carte
or in half-day to full-day packages. The Day Spa Associa-
tion defines a day spa as a spa that offers a full range of
treatments including massage, body treatments, hydro-
therapy treatments, esthetic services, weight management,
yoga, or meditation, with hair care, manicures, and pedi-
cures. Many business owners are using the term day spa
loosely to indicate an establishment that focuses on beauty
and/or wellness. An example of a creative day spa concept
is Embodywork, a day spa in Decatur, Georgia, that offers
daily retreats based on the principle that “a good life begins
with being good to ourselves” (Fig. 1–7).
Clients can choose a half-day or full-day retreat that
begins with a conversation about health, diet, relationships,
and exercise goals. Conscious breathing exercises progress
to a full-body massage and full-body polish. After lunch,
the client can choose between a facial, reflexology, hand and FIGURE 1–7 Embodywork, a creative day spa concept in Decatur,
foot treatment, or body wrap for their final service.26 Georgia.

Hot Spring Spas

Mobile Spas
Hot springs spas use the natural thermal waters from hot
springs in their spa regime or treatments. The Ojo Caliente Mobile spas bring day services directly to clients at their
Spa surrounds the Ojo Caliente hot springs in New Mexico home, office, hotel room, or at a party. The treatments
(Fig. 1–8). This spring was sacred to the ancestors of the are designed to be set up and delivered on-site and are
Tewa tribes that still live in the region.27 The mineral pools popular as a feature at bachelorette parties, prom parties,
are open to the public for an entry fee, or spa guests can and corporate retreats. Treatments include seated mas-
opt for a private pool and spa treatments that include sage, manicures, pedicures, reflexology, facials, and diet
facials, massage, and body wraps. consultations.

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Chapter 1 Spa from Past to Present 9

Although massage remains the most accepted treat-

ment at spas, facials, manicures, and pedicures are pop-
ular. Clients report that they want to focus on health,
fitness, anti-aging, increased energy, and stress reduction.31
Many clients visit spas simply to revitalize themselves and
give themselves a break from work stresses. Cultural ele-
ments that include ayurvedic medicine, Native American
wisdom, and Asian influences are used to inspire treat-
ments and create links to the environment and the global
In general terms, spas attract clients by adopting a phi-
losophy and creating a menu of services that appeal to a
specific group of clients. The facility, its visual appearance,
the equipment available, and the price of its services will
also play a role in attracting these target clients to the spa.
Clients are as diverse and difficult to define as the spas they
attend, so it is helpful to look at the different ways that spas
design their programs to attract a particular type of client.

Spas for Women

FIGURE 1–8 Ojo Caliente Hot Spring. Spas for women can take many forms. A spa for women
might offer expensive high-tech skin care or detoxification,
vegetarian cuisine, and yoga. Anything and everything is pos-
sible. A spa might cater to brides, to mothers and babies, to
The Spa Client athletes, or to grandmothers. For example, the target client
of the Body Shop Spa in Utah, close to Zion National Park,
In Roman times, the local spa was a focal point of the com- is a female on a budget (services are moderately priced), be-
munity and enjoyed by all social classes. This is still the tween the ages of 18 and 65 years, who wants to lose weight
case in some parts of Europe where spas are a part of the and enjoy the outdoors. The program at the spa is based
mainstream health care system. Although the American spa on a seven-point philosophy that addresses nutrition, en-
industry encourages the idea that spa is for everyone and durance, strength, flexibility, self-awareness, education, and
should be a regular part of a healthy lifestyle, there is still a relaxation. Manicures, pedicures, and massage are available,
bias in the social status of individuals that attend spas. but rock climbing lessons and hiking replace other normal
In the 1960s and the 1970s, the average American spa spa services.32
client was most likely to be wealthy, female, and over- The Olympus Health Spa in Washington is a women-
weight. Her goals for visiting the spa probably included only spa because clothing throughout the spa is optional.
weight loss, exercise, and pampering in the form of beauty Body scrubs and massage are offered in a Roman bath set-
treatments. She expected the best possible service and was ting while other guests lounge nearby in the hot pools or
a discriminating customer.28 The ISPA Spa-Goer Survey for converse in the sauna. It is a communal experience that
2003 showed that the primary spa client was still female caters to groups of women enjoying each other’s company
but has a middle to upper middle class income ($72,200 an- while they relax and renew. This spa has built its business by
nual household income).29 This client is most likely to be selling the “just for women” experience.33
Caucasian (87%), with African Americans, and those of
Asian descent making up only 9% of the spa-going popula-
Spas for Men
tion. In 2010, the ISPA reports that spas are branching out,
and spa owners are targeting various income backgrounds Research carried out using SpaFinder shows that nearly
and age groups. The industry study reveals that 80% of spas 29% of men book their own appointments, and the number
have introduced special packages targeted at diverse client of men attending spas has tripled since 1987. The Interna-
groups, including men, couples, teens, families, athletes, tional Spa and Fitness Association suggests that spas can
and seniors. Over 6 in 10 spas introduced discounts and target men by linking spa treatments to health and fitness,
incentives to attract first-time clients, although franchises by offering discount treatments for men, and by using spa
with membership rates took off in 2010.30 The number of treatments as interesting giveaways at business meetings
men attending spas is growing rapidly, and men currently and conventions. The Nickel Spa in New York City, which
comprise 29% of the market. Products and services for has cobalt and silver décor, was designed specifically for
teenagers are also on the rise. men. It has a menu of massage and facials that meet the

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10 Spa Bodywork: A Guide for Massage Therapists

special needs of men including a Love Handle Wrap, a full- Spa into the Future
body wax called the Bodybuilder’s Special, and 15 different
skin care lines.34 By its very nature, spa is indefinable, ever changing,
diverse, and evolving. Therapists and clients alike are
Spas for Families embracing spa treatments as a means of promoting health
and wellness. This seems likely to continue as the pub-
Spas that target families offer services that fit every mem- lic understanding of spa treatments develops. The rate
ber’s needs. There may be a full spa offering services for men of growth in the industry is expected to become steadier
and women as well as programs geared toward teens. Child as the dramatic boom of recent years slows down. It is
care facilities for the younger members of the family might likely that spa will continue to drive a movement toward
be offered with programs designed to get everyone together a more integrated form of medicine. Currently, one-third
such as horseback riding or hiking. The Pointe Hilton in of all Americans are in favor of complementary medicine
Phoenix, Arizona, is a good example of this because they becoming more widely available within the conventional
offer a full-service spa, coyote camp for the kids, a family medical system. This is the trend in Europe, where 60%
pool, and a golf course.35 of the public in Belgium and 74% of the public in the
United Kingdom use alternative forms of medicine for
wellness. Spas provide a place where conventional medi-
Programs for Teens
cine and exceptional client care have become integrated.
Some day spas focus on the needs of teenagers with treat- Taking care of oneself by being willing to receive care
ments that address oily skin, acne, and sports injury. Spa and pampering is an important aspect of healing in a spa
prom parties are a clever way to introduce young women and environment. Although spa is still often considered as
men to the benefits of spa treatments. Teens enjoy the chance just a luxury, it is likely that spa services will come to be
of preparing for the big event surrounded by a group of viewed as necessary for thriving in a fast-paced contem-
friends getting manicures, pedicures, facials, and body wraps. porary lifestyle.

STUDY TIP: Group Discussion you support the health of your mind? What about
your spirit?
We all learn most effectively when we are actively
involved with information. One way to get involved is to 3. Explore each of the following words as part of a
form a study group and hold group discussions about meaningful spa experience. What does each word
reading assignments and class lectures. Get together mean to you? How might it be expressed in the
two to four other students and explore the elements activities a client participates in at a spa?
shown in the image developed by the ISPA Education a. Nourishment
Committee (Fig. 1–9) through the questions provided b. Movement
below. Have one person keep notes on ideas that came c. Touch
up during your discussion. Photocopy these notes so d. Aesthetics
that everyone in the group has a copy. Instructors can e. Environment
also use these questions for in-class discussions. f. Cultural expression
g. Social contribution
1. Four words are used on the outside of the image h. Waters
(revitalize, rejoice, relax, reflect). Describe what each
of these words means to you and how these words SPA INSPIRATION: My Spa Experience
are mirrored in different activities you undertake in
your life. Create your own collage of words and images that
express the type of spa experience you would like to
2. The words body, mind, and spirit are shown in the offer clients or receive yourself. Share your collage
next level of the image. Describe one way you with your classmates and explain why the visual ele-
support the health of your body each day. How do ments and words you use express your ideas of spa.

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Chapter 1 Spa from Past to Present 11
















FIGURE 1–9 ISPA 10 Elements Image.

CHAPTER WRAP-UP Spas provide a space where clients can experience each
element represented in the image and reflect on its
The ISPA Education Committee developed the presence or absence in their lives. Movement, touch, an
10 Elements of the Spa Experience image shown in appreciation of beauty, our connection to the environ-
Figure 1–9 that we discussed previously.36 Their goal ment, cultural expression, social contribution, the heal-
was “to help define the elusive and ever changing ing quality of water, and nourishment both of the body
nature of the spa experience” and to “create a foun- and the soul are the essential concepts on which spa
dation, a common language, and career path for the is founded. The spa experience can be life changing.
emerging spa professional.” Many concepts, important Far from being just a luxury, spa therapy represents
to the practice of spa, emerge from the ISPA’s dialog the bold first step toward a better form of health care.
around the 10 Elements image. The most impor- Its future is in the hands of those dedicated therapists
tant perhaps is the idea of integration. Everything is and visionary spa owners who have the ability to pro-
connected. Feeling beautiful, feeling joyous, feeling vide a space where clients can experience balance and
healthy, and feeling energetic are signs of a balanced celebrate life while receiving exceptional care.
life. A balanced life requires both reflection and action. (continued on page 12)

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12 Spa Bodywork: A Guide for Massage Therapists

REVIEW QUESTIONS 5. The word spa originated from:
Multiple Choice a. A mineral spring town in Belgium named Spa
b. The Latin words for fountain (espa)
1. Many early civilizations had a version of a: c. The Latin words for by water alone (solus per aqua)
a. Spa shower d. No one is really sure although more than likely
b. Exfoliation treatment it is from a Latin source.
c. Meditation center
Fill in the Blank
d. Spa bath
6. In Germany, there is widespread acceptance
2. Roman baths may have originally been built to of spa therapies as a viable form of treatment
treat soldier’s battle injuries. By 43 AD, they were for individuals who have not responded to
used by: conventional medicine. This system is called the
a. Field soldiers only ___________ system.
b. Emperors only
c. All classes of the Roman Empire 7. An Austrian healer named Vincent Priessnitz was
d. Men only an advocate of the ________ cure.

3. The Turkish bath is called a: 8. Naturopathic medicine is rooted in the

a. Sweat lodge healing methods of a German priest named
b. Garrison ______________.
c. Hamam
d. Camekan 9. At Bad Hofgastein, patients with arthritis,
sinusitis, and chronic asthma take part in the
4. In the 18th and 19th centuries, Europeans would “Gastein cure.” This cure consists of visits to
go to spa towns to heal common ailments such as caves where __________ is absorbed and inhaled
rheumatism and respiratory disorders. This practice in small amounts.
was known as:
a. “Take the mud” 10. The ISPA Spa-Goer Survey for 2003 indicates that
b. “Take the waters” the primary spa client will be of middle to upper
c. “Take the cure” middle class income and _______________.
d. “Take the air”

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Spa Equipment and

Chapter Outline K e y Te r m s
Dry Room Equipment Antioxidants: Antioxidants are substances that prevent damage to cells
Massage Tables and DNA by free radicals.
Basic Linens Astringents: Astringents are skin toner for oily skin. They contain alcohol
Hot Towel Heating Units to dissolve excess oil during facial treatments to ensure the skin is clean
Product Warmers before a treatment product is applied to the face.
Paraffin Warmers
Botanicals: Botanicals are plant extracts used in spa products to achieve a
Body Wrap Materials
Body-Warming Equipment specific therapeutic goal.
Spa Clothing Cleansers: Cleansers are skin care products used to remove impurities
Other Dry Room Supplies from both the skin’s surface and the pores during routine face cleaning
Wet Room Equipment or during a facial or spa body treatment.
Tubs Dry room: A treatment room in which there is no shower or hydrotherapy
Showers equipment.
Specialized Environments Exfoliation products: Skin care products used to remove trapped debris
Purchasing and Maintaining Equipment while sloughing off dead skin cells, smoothing the skin’s surface,
Spa Products stimulating circulation in the local region of the skin, and relaxing or
invigorating the body.
Toners and Astringents
Exfoliation Products Fragrance: An ingredient in spa products used to enhance the smell of
Treatment Products a product. Fragrances added to spa produces will be either natural or
Moisturizers synthetic (human-made).
Important Product Terms Hot towel cabinet (cabbi): A piece of spa equipment used to heat up
Product Exploration towels for spa treatments.
Your Spa Environment Hydrotherapy tub: A specialized tub with multiple air and water jets used
What the Client Sees—Décor to deliver professional therapeutic hydrotherapy immersion treatments.
What the Client Hears Moisturizers: Skin care products formulated to soften the epidermis and
What the Client Smells increase the skins hydration (water content) by reducing evaporation.
What the Client Tastes
Paraffin warmer: Paraffin warmers (sometimes called “dips”) hold paraf-
What the Client Feels
Accessibility and Functionality fin wax that is used to cover the hands and feet of the client.
Planning Spa Treatment Rooms Sauna: Saunas are rooms constructed of cedarwood used to promote
perspiration through dry heat.
SPA FUSION Steam room: A steam room is an enclosure that can be filled with steam
INTEGRATION OF SKILLS from a steam generator so that people can bath in the vapor to induce
STUDY TIP: Up to the Test! sweating or to aid respiratory conditions.
SPA INSPIRATION: There Is No Substitute for Swiss shower: A specialized shower stall with multiple shower heads that
Direct Experience! surround the client with jets of water directed at specific areas of the body.
CHAPTER WRAP-UP Toners: Skin care products used to complete the cleansing process and
help to restore the skin’s acid mantle.
Treatment products: Products such as seaweed or mud that are used
during a spa treatment to elicit a particular therapeutic benefit.
Vichy shower: A specialized shower with a horizontal rod with holes or
water heads that rain water down onto the client from above a wet table.
Wet room: A special treatment room that is tiled, has drains in the floor,
and houses equipment such as Vichy showers or hydrotherapy tubs.


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14 Spa Bodywork: A Guide for Massage Therapists

equipment, wet room equipment, spa product categories,

There is no doubt that the luxurious surroundings of and methods for creating a relaxing spa environment. The
an upscale spa enhance the mood and character of the
detailed procedures for using each piece of equipment
spa experience. But with attention to detail and with an
and additional equipment and supplies, which are needed
eye toward functional ambiance, spa treatments can be
for specific spa bodywork treatments, are discussed in
delivered satisfactorily in a small spa, massage clinic, or
greater detail in other appropriate chapters. Sanitation of
private practice without inordinate expense.
equipment is discussed in Chapter 4.
The term spa equipment refers to all items and tools a
therapist might use in his or her spa bodywork practice.
The equipment must be well made, safe, attractive, and Dry Room Equipment
comfortable for the client and not cause undue stress to
The term dry room refers to a treatment room in which
the therapist’s body. Each piece of equipment represents there is no shower or hydrotherapy equipment. Instead, hot
towels are used to remove spa products from the client’s
an investment in your business and in your clients. When
body, or clients take showers in a different area. Essential
you purchase your own equipment, do so carefully after dry room equipment includes massage tables, linens, hot
towel heating units, product warmers, paraffin warmers,
researching brands, understanding available options, and
body wrap materials, body-warming equipment, and other
comparing products. This chapter describes dry room treatment room supplies (Fig. 2–1).



FIGURE 2–1 Examples of dry room equipment. (A) Hot towel cabinet (cabbi). (B) Product warmer. (C) Treatment bar. (D) Paraffin warmer. (E) Body
wrap materials including a wool blanket, thermal space blanket, wet wrap sheet, and plastic body wrap sheet. (F) Free-standing heat lamp. (G) Fomentek
water bottle. (H) Electric (thermal) booties and mitts.

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Chapter 2 Spa Equipment and Products 15

Massage Tables massage sometimes prefer plush padding because the table
feels more comfortable and “nurturing.”
Portable massage tables are a popular choice for massage
therapists who do outcall work or work from their homes Covers
because these tables are designed to fold up for easy trans-
port to different locations. If you intend to offer spa treat- Most massage table manufacturers today use different
ments as part of your private massage practice, you may types of vinyl, with different degrees of softness, to cover
want to consider investing in a stationary, hydraulic lift, the table surface. Because a sheet covers the table surface,
or electric lift table with additional features such as sit-up the softness of the table cover usually does not make a dif-
options, side extenders, arm shelves, and plush padding. ference to the client. Most important, the cover should be
Stationary tables are constructed with solid frames that durable and easy to clean. Oil, creams, and spa treatment
often include built-in storage space for items such as tow- products can break down the top layer of the vinyl, so the
els, lotions, oils, and cleaning products. Some newer mod- table must be cleaned to ensure that it lasts. Wipe the table
els include features such as hot towel cabinets, foot soaking down with a suitable cleaning product between clients and
tubs, and sit-up options. Most tables have some type of lift use diluted bleach solutions only if the table comes into
to raise or lower the table. With a manual lift, the therapist contact with body fluids. Some therapists use antibacterial
simply turns a handle to raise and lower the table height. wipes to give the table a quick cleaning and prevent drying
Hydraulic lifts use a system of pumps and motors to power out of the vinyl top.
the mechanical motion. Electric lift tables use motors to
change the table height. The height of both hydraulic and Accessories
electric tables can be adjusted during the treatment, using A variety of massage table accessories are available from
a foot pedal, to facilitate different massage or spa tech- table manufacturers to increase the client’s comfort and
niques or make it easy for the client to get on or off the help you work efficiently without undue stress on your
table. Because they have heavier bases and height-adjusting body (Fig. 2–3):
equipment, stationary tables are usually much more expen-
sive than portable tables (Fig. 2–2). • Arm shelf: An arm shelf can be attached to the front of
the table to provide a place for clients in the prone position
Table Padding to rest their arms. This is useful because it gives you easy
The padding on massage tables varies from a single-layer to access to the sides of the client’s body. In the supine posi-
multiple-layer systems. Multiple-layer systems are typically tion, side extenders can be placed on each side of the table
more comfortable because the deeper foam layers are firm, to widen the table and provide more space for the arms.
giving support, whereas the upper foam layer is softer and • Side extenders: Side extenders provide a resting place
conforms to the client’s body. Padding comes in 1-inch to for the arms in both the prone and supine positions.
4-inch thicknesses. Firm table paddings (1.5 to 2.5 inches) • Sit-up feature: Some massage tables allow the thera-
are sometimes preferred by therapists who offer deeper pist to place the client in a sitting position. This is a nice
techniques because the client doesn’t sink away from the feature if you plan to work with pregnant clients, if you
stroke. Therapists who offer spa bodywork or relaxation offer reflexology, or if you are also an esthetician and
offer facials. A cushion is often needed to support the
client’s lower back because the steep angle of the upper
portion of the table tends to create a gap.
• Bolsters: Bolsters are used to support the client’s body
for complete relaxation while on the table. These pillows
and cushions come in a variety of shapes and sizes and
are usually placed under the knees and neck when the
client is supine and under the ankles when the client is
• Massage stool: Massage stools usually have wheels
so that they can be rolled around the massage table.
Sitting down at appropriate points during the massage
or spa treatment helps rest your feet. Most stools can
be adjusted to different heights, and some are available
with back supports. Some therapists instead sit on a
Swiss exercise ball during sessions, which can encourage
good body mechanics.
• Step stool: A stepping stool is useful for clients for get-
FIGURE 2–2 Stationary table. A stationary table is a good choice for
spa environments because the frame often includes built-in storage space ting on and off the table. A long, flat exercise step also
for items such as towels, lotions, oils, and cleaning products. works well because it is wide enough to prevent missteps.

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16 Spa Bodywork: A Guide for Massage Therapists


FIGURE 2–3 Massage table accessories. (A) Arm shelf. (B) Side extenders. (C) Bolsters. (D) Massage stool.
(E) Step stool.

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Chapter 2 Spa Equipment and Products 17

Basic Linens Blankets

The centerpiece of a well-designed and comfortable spa Have washable cotton blankets on hand to keep the client
room is the massage table well made up with linens. For warm. Clients often experience a drop in peripheral body
therapists on a budget, plain sheets and a large bath towel temperature as their blood pressure lowers during the mas-
can be used. Multi-tonal colors in slightly varying shades sage or beginning of a spa treatment. This is normal, but a
give an impression of texture and depth. Take care to match chilled client cannot relax completely. Heavy blankets feel
the linens to the décor of the room. An upscale spa might nurturing and comforting for many clients and give the
opt for Egyptian cotton and a matching coverlet with a mul- client the sensation of being snug and secure. Some clients
titude of different throw pillows. Massage and spa suppliers find that heavy blankets feel suffocating and restrictive.
provide everything from the basics to very expensive linens. Have a few options on hand to accommodate each client’s
needs. The blanket is always placed over the top massage
Massage Sheets sheet. If a blanket comes into contact with the client’s body
Purchase massage sheets from a massage or spa supplier or (which is likely), it should be laundered before it is used
department store (twin size). Cotton, flannel, and cotton with another client.
blends all work well and feel soft and comfortable. Make
Linen Storage
sure that the material is thick enough to provide sufficient
coverage, avoiding thin see-through sheets that are inappro- Linen is washed in hot water with detergent, dried with
priate for draping. Make sure that sheets are small enough heat, and stored in a closed container. You want to have
not to touch the ground during the session, an unsanitary enough linen on hand to get through 2 days of business
condition. White, cream, earth-toned, and pastel colors are without doing laundry if possible. The amount of linen you
easy to bleach, but darker colors tend to show oil stains. need varies based on the type of massage and spa work you
Massage and spa suppliers sell laundry products that help do. For example, if you provide dry room spa treatments,
to get oil out of massage sheets, but over time, oil usually you are likely to go through 16 hand towels and 2 bath
build up in the fabric and can smell or look dirty. Plan to towels per client. A good start for a new spa bodywork prac-
replace massage sheets regularly to prevent this situation. tice might be 10 sets of sheets, 10 face cradle covers, 15 bath
Disposable sheets are available from spa suppliers, but sheets, 15 bath towels, 100 hand towels, and 2 cotton blan-
these are not as cost-effective as washable linen and impact kets. Dirty linen is stored in a closed, ventilated container,
the environment with unnecessary waste. preferably outside the treatment room, until it is laundered.

Face Cradle and Bolster Covers

Hot Towel Heating Units
A pillowcase can be used to cover the face cradle, provide
draping material (breast drape, anterior pelvic drape, etc.), or Hot towels are required throughout spa body treatments,
cover bolsters. Fitted face cradle covers available from mas- even when a shower is available. You have a number of
sage suppliers are better than a pillowcase because they fit options in the way you heat and maintain your towels.
the face rest snugly and do not fall off. Fitted bolster covers These options include the following:
that enclose the entire bolster prevent cross-contamination • Hot towel cabinet (cabbi): Hot towel cabinets (often
between clients; often, a bolster is not covered but placed called a cabbi) range in size from small 6-towel units to
under the bottom massage sheet. Face cradle and bolster much larger 72-towel units. They look like small refrig-
covers that come in contact with the client’s skin must be erators and are placed somewhere convenient close to
laundered and changed for each client. the treatment table.
• Hydrocollator: Hydrocollators are most often used to
heat hydrocollator packs but also heat towels and hot
Bath towels and larger bath sheets are often used over sheets for body wraps. They keep water at a constant
the top massage sheet to provide warmth and additional 165°F and, in busy spas, are useful as a source of hot
draping material. Choose lightweight ones that will not water for filling foot soaking containers.
be bulky during draping. They are also easy to launder. • Hot stone heaters: For massage practices and spas that
Bath towels are often used to wrap hydrocollator packs or are on a budget, a hot stone heating unit filled with water
other hot packs to prevent burning the client. Hand towels is a cheap and efficient alternative to the more expensive
are sometimes used as draping material to protect the cli- cabbi. A hot stone heater can hold up to 20 towels and is
ent’s hair from oil or to make a roll to support the neck. also a useful heater for hot sheet wraps, spa products, and
Hot, moist hand towels are used to remove spa products the stones used in a hot stone massage. Remove the tow-
from the client’s skin or to provide a warming body steam els from the heating unit and wring out the excess water
(placed over the face, wrapped around the feet, etc.) during before putting them into an insulated soda cooler to keep
the session. Any towel that comes into direct contact with them hot until use. If only a few towels are needed for the
the client’s skin or hair must be laundered between clients. treatment, a crock pot serves the same purpose.

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18 Spa Bodywork: A Guide for Massage Therapists

• Soda cooler: When you remove product with hot towels, perspiration. The type of material used for the wrap will
the towels must be close at hand to keep the process depend on the amount of trapped body heat needed for
quick and efficient. Walking back and forth to a hot the wrap to be effective and the type of treatment product
towel cabbi disrupts the flow of the treatment and is being used during the session. These body wrap materials
time-consuming. Instead, transfer the towels from any are commonly used:
of the previously mentioned heating units to a small
• Heavy wool blanket: A heavy wool blanket is ideal for
soda cooler (9 to 12 quarts) and place this near to the
trapping enough heat to make the client perspire in
treatment table for convenience. Make sure to close the
detoxification wraps. The blanket must be large enough
lid of the soda cooler to maintain the heat inside each
to wrap up and around a large person (80 to 90 inches
time you open it to remove a towel.
works well). Washable wool is essential because the blan-
ket will need to be washed between clients.
Product Warmers • Thermal “space” blanket: The thermal blanket is a
heavy emergency blanket. It is plastic on the outside and
There are some situations where a spa product is meant to has foil on the inside to prevent loss of body heat.
be applied cold, but in most cases, spa product is warmed • Wrap sheets: Hot (or cold) wet wrap sheets (for wet
before it is applied to the body. There are many different wraps such as herbal, coffee or milk, and honey) are
types of spa product warmers. Some are effectively double made of 100% cotton, heavy muslin, or a combination
boilers with two pots so that the spa product can warm of linen and either cotton or fleece. Flannel is never used
inside a small pot placed inside a second larger water-filled with hot wet sheet wraps because it is difficult to wring
heating pot or an electrically heated outer pot. Lotion out completely, so it may burn the client.
warmers heat spa products to around 122°F with a ther- • Body wrap plastic and Mylar: Plastic and Mylar sheet-
mostat to control the temperature. A hot stone heating unit ing (Mylar is like a light tinfoil) are used with messy prod-
can hold towels on one side and a metal or Pyrex container ucts such as seaweed or mud. If the body was wrapped in
full of spa product on the other. To avoid contamination, a fabric, the fabric rather than the skin would absorb the
cover the container with a lid while it is in the heating unit. product. Plastic and Mylar come on large rolls that are
Metal warmers will contaminate seaweed and mud, so usu- cut to about 6 feet per client. Mylar tends to keep the
ally, these products are heated in a Pyrex glass container in a body warmer but is a bit more expensive.
water bath and then placed in a plastic container before the
treatment (glass may break, so it is dangerous). Never use a
microwave oven to heat spa products because microwaves Body-Warming Equipment
are likely to affect many of the product’s therapeutic prop-
erties. Lastly, many products will break down, change con- In a spa body treatment, the client might be draped with
sistency, or lose their therapeutic benefits if left in a warmer only a hand towel across the breasts and a hand towel
for too long. across the genitals. If external heating is not provided, the
Treatment bars are an expensive but handy way to heat client might get cold during the treatment. Here are some
several products at the same time. These bars are usually built of the ways you might ensure the client’s warmth and com-
into the treatment room and have a number of inlaid pans fort during a session:
on a large heater, rather like the food heaters used in buffets • Heat lamps: Heat lamps can be hung above the treat-
at restaurants. The heater pans can hold such varied items ment table and placed on a dimmer switch to allow for
as towels, hot stones, products, hot soapy water for hand more or less heat. Free-standing units with flexible necks
washing, hot wrap sheets, and product application brushes. are available, but these have large heavy bases that take
up a good deal of space in the treatment room.
Paraffin Warmers • Electric table warmers: Electric table warmers can be
used to heat up the sheets before the client gets onto the
Paraffin warmers (sometimes called “dips”) hold paraffin treatment table. For body wrap treatments, the client
wax that is used to cover the hands and feet of the client. will often be lying on a piece of plastic sheeting that
Paraffin has been used to treat arthritis or sore joints but is sits on top of a thermal blanket and wool wrap blan-
most often applied to enhance other spa services. It is best to ket. Electric table warmers cannot warm the client suf-
use a high-quality professional unit on a rolling stand rather ficiently through all of these layers and are not used in
than an ordinary home care unit, which usually heats up this situation.
more slowly and does not have good temperature control. • Table pads: Wool and fleece table pads provide extra
softness and warmth on the massage table. Many con-
tain electrical heating devices with adjustable heat con-
Body Wrap Materials
trols to keep the client warm during the session. Some
In many spa body treatments, the client is wrapped to therapists believe that electrical devices disrupt the
allow the treatment product to absorb or to encourage client’s electromagnetic energy field, however, and use

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Chapter 2 Spa Equipment and Products 19

such pads only to warm the table; they turn off the pad book. Access to the Internet is also a plus because it
once the client arrives. Wool is a desirable material be- allows you to quickly look up information on emerging
cause it breathes and allows the body to regulate its own drugs, pathologies, and recommendations for session
temperature a little better. The drawback of wool pads is protocols.
that they require dry cleaning and may cause some cli- • Clock: A visible clock helps you stay on schedule and
ents to experience allergic reactions. Synthetic fiber and adjust your treatment plan as the session progresses.
cotton pads are also available. Spa treatments and treatment elements requiring spe-
• Fomentek: A Fomentek is a large water bottle designed cific application times (body wraps, mud or seaweed
to sit flat on the treatment table. Put the bottle under a applications, etc.) are easily tracked using a digital timer.
pillowcase and place it directly beneath the plastic layer • Storage area: A cabinet with hinged or sliding doors is
or the wet sheet. This provides warmth and comfort dur- best to keep extra supplies such as table cleaners, extra
ing a body wrap. hand gel sanitizer, boxes of tissue, and clean linens out
• Microwavable packs: Corn, rice, or flax packs heated in of sight. Soiled linens should be stored in a closed, ven-
a microwave are a good way to apply external heat to a tilated container, preferably outside the treatment room
client during a spa treatment. Do not use a hydrocolla- in a separate laundry area.
tor pack because the client may get burned if he or she • Wastebasket: Wastebaskets in massage treatment rooms
lies down on top of the pack. Instead, hydrocollator should have a lid opened and closed with a foot pedal to
packs can be placed under the feet to increase core body prevent hand contamination. Dispose of paper towels
temperature. used for cleaning the massage table and hard surfaces,
• Booties and mitts: Electric or microwavable booties used vinyl gloves, used tissues, and other items in the
and mitts are good for keeping spa products warm on wastebasket. The wastebasket should be cleaned and san-
the feet or hands. They can be used at any time to keep itized at the end of each day.
the client warm, but if used for too long, the client’s • Music system: Music often significantly impacts the
limbs may start to feel heavy and swollen. Because ther- client’s ability to relax and enjoy the session. The music
mal booties and mitts cause increased vasodilatation in system might be as simple as a CD player or MP3/
the distal limb, it is important to use flushing strokes iPod system. Ensure the sound has a clean quality and
toward the heart after removing them. that the system is in good working order (no skipping
CDs, etc.).
• Supplies for cleanliness and safety: Approved clean-
Spa Clothing
ing products (discussed in Chapter 3), paper towels,
Clients receiving a spa body treatment may feel uncom- extra tissue boxes, gel hand sanitizer, alcohol, finger cots
fortable with the degree of skin exposed during the ses- (vinyl finger covers to protect against the transmission of
sion. Although the breasts and genitals are never exposed, pathogens if your cuticles are rough or if your skin is bro-
the client might only be draped over these areas. Dispos- ken), vinyl gloves, and a first aid kit should be stored in
able undergarments preserve client modesty and make spa the treatment room for ease of access. Also, have a large,
product application easier because they are made of a thin, battery-operated flashlight in case of a power failure.
permeable fabric that allow spa product to reach the skin.
Small-, medium-, and large-sized women’s briefs, thongs,
and bras and men’s briefs or boxers should be made avail-
able to clients. For wet room treatments, dark blue or black
Wet Room Equipment
disposable undergarments are much better than white ones,
The term wet room refers to a treatment room that con-
which become transparent when wet. A fluffy terry robe,
tains specialized hydrotherapy equipment such as profes-
washable spa slippers, terry hair protectors, and terry body
sional grade tubs, showers, and wet tables. Often, wet rooms
wraps allow clients to move about in the spa or to move
will be tiled and have drains in the floor for easy cleaning.
from one treatment room to another in comfort.
The unique pieces of equipment that might be found in wet
room environments can be broken into three categories:
Other Dry Room Supplies tubs, showers, and specialized environments.
Dry rooms used for massage and spa treatments need cer-
tain basic items to be functional and efficient. These items Tubs
might include the following:
Therapeutic baths (sometimes called balneotherapy) use a
• Reference library: During the course of your profes- variety of tubs in different sizes with different features to
sional practice, you will need to look up a condition, provide clients with a relaxing and beneficial experience
medication, or other information. Key reference books (Fig. 2–4). Essential oils (aromatherapy bath), herbs (herbal
that should be available include an up-to-date medical bath), seaweed, seawater or algae (thalassotherapy or algo-
dictionary, drug reference, and a pathology reference therapy), and mud or clay (fangotherapy) are common

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20 Spa Bodywork: A Guide for Massage Therapists

FIGURE 2–4 Tubs. (A) A full-body immersion could be offered in a whirlpool, professional hydrotherapy tub,
or soaking tub. It may contain additives such as seaweed, fango, or herbs. (B) Professional hydrotherapy tub with
underwater massage.

additives that increase the therapeutic benefit of the water improve circulation and lymph flow. Modern hydrother-
treatment. Tub features will vary based on the manufacture. apy tubs come with a self-cleaning function that makes
Read the instruction manual that comes with each piece sanitizing the jets of the tub easier. The therapist puts a
of equipment carefully for proper operation and sanita- concentrated disinfectant (formulated by the manufac-
tion. The types of tubs commonly used at spas include the ture of the tub) in a special holder and then pushes a
following: button.
• Foot soaking tubs: Foot soaking tubs range from inex-
pensive basins filled with warm water and additives to Showers
deluxe pedicure stations with whirlpool features. Pedi-
Therapeutic showers are used to remove a product from the
cure stations consist of a comfortable reclining chair
client, to facilitate a desired physiological effect, to warm
with an attached foot soaking basin plumbed for water
the body in preparation for another treatment, or to cool the
and drainage. They often have a whirlpool feature with
body at the end of a treatment (Fig. 2–5). Shower features
jets that agitate the water, which feels pleasant to the
will vary based on the manufacture. Read the instruction
feet, and a handheld spray used to remove spa product
manual that comes with each piece of equipment carefully
or rinse the feet. Although they are most often used dur-
for proper operation and sanitation. In a spa wet room, five
ing the delivery of pedicures, which is out of the massage
main types of showers are used:
scope of practice and provided by nail technicians, they
work well for therapists offering reflexology-based foot • Handheld shower and wet table: A handheld shower is
spa treatments as discussed in Chapter 10. used in combination with a wet table for the easy removal
• Soaking tub: Soaking tubs at spas are like standard of product. Some handheld showers can deliver a pulsat-
bathtubs but much more luxurious. They tend to be high ing water massage and may also have an attachable body
sided, roomy, and design savvy. Soaking tubs might be brush for exfoliation. A wet table has a special surface to
used to warm the body before a treatment or soothe the channel water into a receptacle under the table or a drain
body and remove product at the conclusion of a session. in the wet room floor. The table is often constructed of
• Whirlpool tub: Whirlpool tubs have jets that agitate heavy plastic or acrylic for easy clean up and sanitation.
the water and “bounce” it against the client’s body. This A soft waterproof insert makes the table comfortable for
manipulates the soft tissue and causes effects similar to the client.
some massage strokes. Whirlpool tubs might be used • Standard shower: A standard home shower is less expen-
as a standalone treatment or as the beginning or end- sive than a Swiss or a Vichy shower but does not allow
ing to a combined session where multiple treatments are the same range of control. The pressure of the water, the
strung together. degree of pulsation, and the temperature of the water can-
• Hydrotherapy tub: The main type of tub used in a spa not be controlled by the therapist as they can with more
setting is a hydrotherapy tub. These tubs are designed for specialized equipment. The client is moved between the
professional use with multiple air and water jets. Profes- massage table and the shower as needed during the treat-
sional hydrotherapy tubs have an underwater massage ment to remove product, or the client uses the shower to
hose that uses air pressure aimed at specific body areas to freshen up at the end of a session.

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Chapter 2 Spa Equipment and Products 21


FIGURE 2–5 Showers. (A) This image shows a handheld shower used in combination with a wet table. (B) A stan-
dard shower is less expensive than specialized showers but does not allow the same range of therapeutic control. It is
used primarily for removing spa treatment products or cleaning up at the end of a session. (C) A Swiss shower sur-
rounds the client with jets of water directed at specific areas of the body. (D) A Vichy shower is a horizontal rod with
holes or water heads that rain water down onto the client from above the wet table. (E) A Scotch hose directs a strong
stream of water at the client to increase vital energy and for other therapeutic purposes.

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22 Spa Bodywork: A Guide for Massage Therapists

• Swiss shower: A Swiss shower surrounds the client with Specialized Environments
jets of water directed at specific areas of the body. Usu-
Specialized environments are used at spas to produce a
ally, the shower stall has pipes in all four corners with 8
specific therapeutic effect by forcing the body to maintain
to 16 water heads coming off each pipe. The water heads
homeostasis in response to calculated environmental influ-
are adjusted according to the client’s height and the
ences (Fig. 2–6). The types of therapeutic rooms or adapta-
treatment goals of the session. A control panel outside
tions often found at spas include the following:
the shower stall allows a therapist to control contrasting
warm and cool jets of water. • Steam room: A steam room is a room or enclosure that
• Vichy shower: A Vichy shower is a horizontal rod with can be filled with steam from a steam generator so that
holes or water heads that rain water down onto the client people can bath in the vapor to induce sweating or to
from above the wet table. Vichy showers are used to rinse aid respiratory conditions. There are many special con-
spa products off the client, but they can also be used as siderations when building a steam room because it is a
a treatment in themselves. A control panel allows the moist environment where all building materials must
therapist to alternate between hot and cool water, which be waterproof or resistant to corrosion and decay. Seats
increases the therapeutic benefits of some products and inside the steam room are built with a slop to allow con-
uses the mechanical effects of water on soft tissue. Vichy densation to run off of their surfaces. A floor drain and
showers have an adjustable face guard that is meant to nonskid floor ensures a clean and safe environment.
keep water off the client’s face. • Steam showers: Steam enclosures are specialized show-
• Scotch hose: A Scotch hose is an apparatus that directs ers that produce the same effects as a steam room but in
a strong stream of water at the client for therapeutic pur- a shower-like environment. They often have steam heads
poses. Clients stand at the end of the wet room holding that fill the enclosure with steam vapor and a shower fix-
on to handles that are attached to the wall while a thera- ture that can be used alternately with steam.
pist directs the pressurized stream in a specific sequence • Steam cabinet: Steam cabinets are like small steam
over the client’s body. “pods.” The client sits down on a plastic bench, and the

FIGURE 2–6 Specialized environments. C

(A) Steam shower. (B) Steam canopy. (C) Sauna.

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Chapter 2 Spa Equipment and Products 23

cabinet is closed around him or her, leaving the head It’s important to know some basics as you start to explore
exposed. Steam cabinets are often used to warm and the differences in spa products and methods for working
moisten product while it is absorbing into the skin. with them effectively. You will also want to review the safety
• Steam canopy: A steam canopy fits over the top of a wet recommendations related to the skin and spa products dis-
table or massage table and can be used in place of a blan- cussed in Chapter 3 (Client and Therapist Safety).
ket for body wraps. Like a steam cabinet, the head of the Spa products fall into basic categories including cleans-
client resides outside the warm and steamy interior envi- ers, toners or astringents, exfoliation products, treatment
ronment, which may be used to promote detoxification products (sometimes called masks), and moisturizers.
or to encourage product absorption.
• Sauna: A sauna is a room that is constructed of either
cedarwood or hemlock because these woods can with- Cleansers
stand moisture and resist fungi. Saunas are used to pro- Cleansers rid the skin of dead cells, excess sebum, dirt, and
mote perspiration through dry heat and to help the body other impurities. An effective cleanser removes impurities
to naturally detoxify. Saunas contain a kiuas. This is an ap- from both the skin’s surface and the pores. Soaps are alka-
paratus that heats rocks that are used to heat the air inside line and will strip the skin of its acid mantle upsetting the
the sauna. Water is poured on the rocks to briefly elevate proper pH of the skin and leaving it dry. Soaps also leave
the humidity in the air and the temperature in the sauna. a dulling film on the surface of the skin. It is important
to find a gentle body cleanser that rinses off completely.
A cleanser will often be used at the beginning of a treatment
Purchasing and Maintaining Equipment to purify the skin before a second product, such as a treat-
The right equipment is an absolute necessity to the spa ment mask, is applied. A cleanser applied with warm water
therapist. Keep these items in mind when you source, assess, provides enough lubrication for Swedish massage strokes
compare, and decide on equipment purchases: to be used. This relaxes muscles, stimulates circulation, and
adds a textural experience for the client. The use of water
• Durability: Many therapists purchase economical home
with the massage strokes stimulates and energizes the body.
care equipment such as paraffin warmers or hot stone
warmers with an eye to cutting costs. This type of equip-
ment is meant for infrequent home use and can’t hold Toners and Astringents
up to continuous use in a busy spa or massage clinic.
Toners complete the cleansing process and help to restore
Purchase professional equipment that will last your
the skin’s acid mantle. They are usually glycerine based and
business for at least 5 years.
do not contain alcohol, so they are suitable for dry skin
• Manufacturer’s time in business: Assess any equip-
types. Astringents are a stronger form of toner designed
ment manufacturers for the amount of time they have
for oily skin. Astringents usually contain alcohol to dis-
been in business. Some equipment comes with warran-
solve excess oil. Toners leave the skin feeling fresh and cool.
ties that can protect your investment should the item
Alcohol is very drying for the skin, but a gentle toner applied
malfunction or break down. You want to know that the
with massage strokes feels invigorating and refreshing. As
manufacturer is going to be in business should you need
we progress through chapters, you may notice that a skin
replacement parts or equipment.
toner is often used as a treatment step in the procedures
• Consumer reports: Before purchasing equipment, read the
section. This is a good skin care practice but also acts as a
consumer reports on the item to find out about the experi-
safety measure. Toners return the skin to a balanced pH,
ences of people who have worked specifically with the piece
which decreases the chances of the client developing skin
of equipment you are contemplating for your business.
sensitivity to strong treatment products such as seaweed.
• Return on investment: Spa equipment is often luxu-
rious and opulent. It’s easy to get enticed to purchase
something that is beautiful but won’t provide an appro- Exfoliation Products
priate return on investment. Think about how many
specific treatments you will have to deliver in order to Exfoliation products are used to remove trapped debris
pay off the equipment when you contemplate what you while sloughing off dead skin cells, smoothing the skin’s
really need for your business. surface, stimulating circulation in the local region, and re-
laxing or invigorating the body. The salt glow is a classic
exfoliation treatment that first developed as a “friction”
technique in traditional hydrotherapy. At the time, its pri-
Spa Products mary focus was to increase the vital energy of the body and
not to smooth the skin. These treatments were applied to
If you add spa treatments to your menu of services in your patients in weakened conditions who had various, often un-
private practice or if you work as an employee at a spa, you diagnosed, chronic medical conditions. Now, it is a popular
will be surrounded by a multitude of different spa products. and refreshing body treatment offered at most spas.

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24 Spa Bodywork: A Guide for Massage Therapists

New therapists and clients practicing skin care at home Moisturizers can be classified depending on their oil, water,
often overexfoliate the skin by working too vigorously or by and wax content. In general, from heavier to lighter, you
using exfoliation products too often. Overexfoliation on a will find:
regular basis can lead to an increase in epidermal thickness
• Balms or butters: These types of products are often
resulting in a “leathery” skin appearance. The skin should
water free and contain mixtures of oil and beeswax that
not be exfoliated more than once a week except by estheti-
are very heavy and protective. They might be used in
cians for a specific treatment goal.
cold weather seasons to lock moisture into the skin and
guard against lower temperatures and the elements such
Treatment Products as wind, which can chap the skin.
• Creams: Creams are combinations of oil and water but
Treatment products, sometimes referred to as “masks” are
tend to have more oil than lotions.
usually applied with a specific purpose or treatment goal in
• Lotions: A lotion tends to have a lower emollient content
mind. One treatment product might be applied to the body,
than a cream and may be water based or aloe vera based.
or a series of treatment products might be applied in a par-
It feels lighter on the skin because it is less occlusive.
ticular order. There are many different treatment products
options you might try depending on the session goals and
the type of consistency you want in the product (the feel of Important Product Terms
the product on the skin). Learning to read a product label is an important skill for
Treatment products tend to have benefits for the skin anyone applying spa products to clients. A product label
and may also have benefits for muscle, stress reduction, or will indicate the type of seaweed or botanical product which
enhanced body energy. An example is Parafango, which is a has been added, if dyes or fragrances have been added, if the
mixture of mud and paraffin. Massage therapists might apply product has ingredients that might be potential allergens
Parafango to relax hypertonic muscles, soothe arthritis pain, for a particular client, or that the product has undesirable
and promote greater range of motion. An esthetician would fillers or chemicals. Milady’s Skin Care and Cosmetic Ingredient
find it useful in improving the appearance of cellulite. A full- Dictionary by Natalia Michalun is an excellent guide to
body seaweed mask is an effective treatment for fibromyalgia, product ingredients.1 The following terms are used widely,
stress reduction, and low energy. The mineral elements in so they require a basic explanation.
many seaweed products are absorbed through the skin and
support the general health of the entire body by stimulating pH
metabolism and the natural detoxification processes of the The pH of a product refers to its level of acidity or alkalinity;
body (see the safety information on seaweed before using it pH is measured on a scale of 1 to 14, from acid to alkaline.
on yourself or with clients). An esthetician will apply a mask A pH of 7, which is in the middle of the scale, is considered
to the facial or body skin to tighten sagging skin, absorb to be neutral. If the product’s pH is lower than 7, it is acidic.
excess oil, hydrate and moisturize the skin, soothe irritated If its pH is higher than 7, it is alkaline. The skin is naturally
skin, and beautify the skin. slightly acidic with a pH between 4 and 6 depending on the
skin type. In general, the less acidic the skin (the higher the
Moisturizers pH number) is naturally, the more prone it is to irritation
and sensitivity. The more acidic the skin (the lower the pH
Moisturizers are usually applied at the end of a session to
number) is naturally, the less prone it is to sensitivity.
replace any natural skin oils and moisture lost during the
other steps of the treatment. Moisturizers are most often Antioxidants
formulated to soften the epidermis and increase the skin
Antioxidants are substances that prevent damage to cells
hydration (water content) by reducing evaporation. They
and DNA by free radicals. Free radicals are compounds pro-
might also be formulated to tighten the skin so that it
duced by chemical reactions in the cell that involve oxida-
appears firmer or to deliver therapeutic components such
tion. Normal metabolic reactions and external factors such
as retinol (vitamin A), which reduce the appearance of fine
as UV radiation, exposure to chemicals such as pesticides,
lines, wrinkles, and skin discoloration. Moisturizing com-
air pollution, drugs, and cigarette smoking can produce
ponents can be broken into three areas:
free radicals. Free radicals interfere with a cell’s biochem-
• Occlusives: These are components in moisturizers that istry and play a role in some diseases associated with age
work by forming a thin film on the surface of the skin to including heart disease and cancer. They attack fats, car-
reduce moisture loss from evaporation. bohydrates, proteins, and enzymes including the collagen
• Humectants: This type of component attracts water in the dermis. This results in decreased skin elasticity and
from the air in order to hydrate skin. pliability. Common antioxidants include vitamins E and
• Emollients: These components restore oils to skin that C, carotenoids (lycopene, lutein, beta-carotene), selenium,
is deficient in factors such as amino-lipids to make the green tea, and honey. These ingredients are often found in
skin softer, pliable, and more resilient. anti-aging cosmetics or after-sun products.

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Chapter 2 Spa Equipment and Products 25

Botanicals to remove from the client’s body and may require a foam-
ing cleanser to lift it off the client’s skin. Some products
Botanicals are plant extracts used in spa products to
may dry out quickly and need a plastic cover to keep them
achieve a specific therapeutic goal. The botanical extracts
moist. It is not a good idea to find these things out during
added to a preparation are often chosen because they are
a session. Ordering and trying out new spa products is the
anti-inflammatory, soothing, or antiseptic, although they
best way to discover new treatments and new ways of using
may have a wide range of other actions depending on the
products. Only by practicing regularly with products will
extract. The concentration of the botanical extract and
the treatment steps and transitions between the steps be-
other components in the preparation will determine the
come easier. For example, there is an exfoliation product on
overall therapeutic value of the preparation. Sometimes, an
the market that goes on wet and dries as it is rubbed in. It is
extract is added to a preparation for marketing purposes in
brushed away with a dry towel. It requires only one towel for
very low concentrations, so it will add very little if anything
removal on the entire body (eight towels would normally be
to the therapeutic properties of the product. Sometimes,
required). This is faster and easier than a “wet” exfoliation
the preparation only contains an isolated chemical compo-
requiring hot towel removal, and it feels just as satisfying as
nent of the original botanical extract.
dry skin brushing (discussed in Chapter 8).
Fragrances enhance the smell of a product, and even prod-
ucts such as seaweed and mud are often fragranced. The
Your Spa Environment
fragrance used will be either natural or synthetic. Natural
The client’s perception of the massage business is created
fragrances are usually based on natural essential oils or bo-
or altered through his or her five senses because this is how
tanical extracts. Synthetic fragrances are usually composed
we interpret our environment. We create a special spa envi-
of a small number of artificially synthesized compounds,
ronment by paying attention to what the client sees, hears,
which on their own may cause skin irritation or unwanted
smells, tastes, and feels during the session. If you own your
side effects such as headaches or a slightly sore throat. The
spa business, you have control of many of the issues we are
popularity of aromatherapy has led to the increased use of
about to discuss. If you work as an employee, you will have
essential oils in expensive skin care lines. Although this is
less opportunity to determine how the environment of the
a positive move, it is difficult to determine the quality and
business is set up. Still, by considering client perception and
purity of the essential oils that are being used.
comfort issues, you can make good choices in the develop-
Natural Ingredients ment of your own business space or make good recommen-
dations to your employer if it is necessary.
The term natural is not regulated in the cosmetic industry.2
A company can legally put just about anything in their
product and call it “natural” if they want to. A product line What the Client Sees—Décor
claiming to be all natural will usually still contain some syn-
Every business has its own unique focus and personality.
thetic ingredients, dyes, or preservatives. In aromatherapy,
A therapist who practices relaxation massage, soothing spa
it is well known that an essential oil may smell differently
body treatments, and stress reduction is likely to operate in
from batch to batch. The smell of the oil is naturally vari-
a different environment from the therapist who practices
able due to the climatic conditions during the year in which
clinical massage and spa body treatments with a rehabili-
it was grown, the time of day at which it was harvested, the
tative or health care focus. The first may choose soothing
skill of the distiller, and the means by which it was stored
color combinations and images of natural beauty for the
and shipped. All of these circumstances will affect the final
walls, whereas the second might choose a neutral color
chemical composition of the oil and therefore its therapeu-
palate, medical charts, and anatomical models. To choose
tic properties and its smell. If the oil smells the same from
your own appropriate décor, consider the techniques you
batch to batch, the consumer would be right to wonder if
will use and the types of clients you desire. Color, window
the oil has been adulterated with isolated components or
treatments, flooring, lighting, wall decorations, and extra
synthetic additives to achieve a reliable fragrance. Many
touches are all elements of decoration.
products claiming to be all natural have a consistent fra-
grance, which is not possible without the addition of other Color
chemicals to standardize the scent.
There are many ways to think about color, and choose the
colors that are right for your business. Therapists can learn
Product Exploration
from color psychology and color symbolism in making
It is important to know the products that you are using their decisions.
and to “play” with the products before you apply them to Color psychology is a field of study that evaluates the
a client. Individual seaweeds will have different mixing and effect of color on human behavior and emotion. Color sym-
spreading properties. Some types of mud will be difficult bolism explores the cultural significance of color and what

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26 Spa Bodywork: A Guide for Massage Therapists

• Stimulating
• Increased mental attention
• Increased anxiety ratings
• People argue more in
yellow rooms
Blue: • Babies cry more in Orange:
yellow rooms
• Decreased irritation levels • Creative stimulant
in stressful conditions • Increases enthusiasm
• Decreased anxiety ratings • Used in color therapy for
• Decreased blood pressure respiratory conditions
• Slowed breathing patterns • Increased metabolism
• Increase of physical

Purple: Red:
• Increased blood
• Appetite suppressant pressure
• Decreased anxiety • Adrenal stimulant
• Mentally balancing • Increased anxiety
• Creative stimulant • Increased performance
Green: on tasks

• Decreased tension and

• Decreased anxiety ratings
• Decreased blood pressure
• Decreased performance
on tasks
• Balancing

FIGURE 2–7 Color psychology is a field of study that evaluates the effect of color on human behavior and
emotion. This diagram shows some of the effects of color based on research.

colors mean to different groups of people. Color psychol- in Western society, blue is associated with excelling (blue
ogy is appropriate for situations in which the business has ribbon), loyalty (true blue), and noble descent (blue blood).
no cultural overtones. For example, a therapist who delivers It is also associated with intelligence (bluestocking) and
relaxation treatments might use a green palate because stud- morality (blue laws).
ies have demonstrated that green colors decrease tension and
Window Treatments
stress, slow breathing patterns, and, in some cases, decrease
blood pressure.3,4 A clinical massage therapist or a spa focused Window treatments are an important design feature in
on physical fitness might note the results of a study showing any room and provide privacy, light control, and style. In a
weight lifters can lift more weight in rooms with a blue palate; spa environment, privacy is very important. Window treat-
blues seem to promote strength and physical gains.5 A thera- ments should not be so sheer that people outside can look
pist working with pregnant mothers, parents, and infants in and see the body treatment session. Window treatments
would not choose a yellow palate because research shows that also control light entering the room. Natural light stream-
babies cry more frequently in yellow rooms (Fig. 2–7).6 ing through sparkling windows might be desirable during
Color symbolism works well when a business has cultural the client consultation or assessment. When the spa treat-
overtones or a specific client group (Fig. 2–8). For example, ment starts, softer, dimmer light is more relaxing. You can
a business focused on Eastern bodywork might choose col- choose between semi-sheer fabrics that diffuse the light and
ors with cultural significance in Asian countries. The color rich opaque fabrics that shut it out completely.
red might play a decisive role because in Asia, red is the col- Windows are often the main focal point in the treatment
or of good luck and a wedding color. It has positive, joyful room. Interesting and well-planned window treatments
overtones. A business set in a busy urban area and wanting add style and eye-catching appeal. They also absorb sounds
to attract businessmen might choose a blue palate because, from outside and from the room itself, helping create a

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Chapter 2 Spa Equipment and Products 27

• Warmth
• Stimulating conversation
• A warning
• Cowardliness
(in Western cultures)
• Courage (in Japan)
• The season of spring
Green: • Support to soldiers who White:
are in battle
• Nature and the beauty • Sourness (the flavor) • Heaven
of nature • Gods
• Movement forward • Angels
• Youth • Truce and peace
• Naiveté • Things that are rare
• Jealousy • Purity
• Envy Black: • Cleanliness
• Victory (in Greece)
• Sophistication
• Elegance
• Expertise
• Darkness
• Loss of consciousness
• Things that are
Blue: underground or illegal Red:
• Travel • Punishment
• Loyalty • Energy
• Feelings of sadness • Aggression
• Unexpected opportunities • Passionate love
• Social prominence • Beauty (in Russia)
• Achievement • Luck and happiness
• A noble character (in Asian cultures)
• Intelligence
Purple: • Battle (in Roman times)
• Protection from harm
• Morality • Royalty
• Authority
• High-ranking official
• Exaggeration
• Ornamentation
• Meditative states

FIGURE 2–8 Color symbolism explores the cultural significance of color and what colors mean to different
groups of people. This diagram shows some of the cultural associations of color.

quieter overall environment while conserving energy by used to help clients feel connected to the earth and nature.
insulating the glass. Clinical or rehabilitative businesses benefit from medical
charts and images that allow clients to see and understand
Lighting the structures involved in their soft tissue condition. Busi-
In the treatment room, dimmer switches work well. Lights can nesses specializing in Eastern bodywork or Eastern-inspired
be made bright for cleaning or sanitizing equipment, put at a spa treatments are likely to hang Asian images or objects on
medium setting for the health intake consultation, and turned the walls to evoke a sense of that culture and create continu-
down for the spa treatment. Several pools of soft, diffused ity in the client’s experience. Wall decorations can be func-
light or diffuse natural light are more relaxing than one bright tional as well as beautiful. For example, fabric wall hangings
light in a corner or the room being too dark. Avoid the use of dampen noise, whereas a stylish mirror gives the client a place
candles because open flames are a safety hazard, and they can to freshen up at the end of the session and allows the therapist
pollute the air, especially when they are used in small rooms. to check his or her body mechanics during the session.

Wall Decorations Extra Touches

Wall decorations can promote the image of the business, Decorative items on shelves, side tables, and windowsills help
make a soothing impression on the client, and dampen sound. create interest and define the room’s style. A relaxation business
In relaxation-oriented spas, images of natural beauty are often using an all-natural theme might display shells, nonblooming

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28 Spa Bodywork: A Guide for Massage Therapists

plants (to avoid allergies), or interesting stones. A clinical or morning until after the last session of the day. The use of a
rehabilitative business might feature anatomical models of sea salt scrub on your hands can help to exfoliate skin that
the body. Rattan baskets, bamboo, and Japanese river stones holds the aroma of cigarette smoke. Although this might
might adorn an Eastern bodywork business. Items can be func- seem harsh, clients who do not smoke often find the linger-
tional as well as decorative. For example, in a business focusing ing smell of cigarette smoke intolerable.
on ayurvedic bodywork, one therapist has different types of In a therapeutic setting, the good smells from natural es-
Indian, Nepalese, and Bhutanese bells and chimes on display. sential oils used in aromatherapy can promote relaxation
They are beautiful to look at but also sound lovely when she and a pleasant mood. This is important because stress is at
rings one to signal the beginning and end of the session. the core of many modern diseases, and studies suggest that
decreasing stress improves one’s health and immunity.11,12
Smells can evoke intense emotional reactions and can even
What the Client Hears be used to change behavioral patterns. Credible evidence
The auditory environment is also important because it sets shows agreeable aromas can improve our mood and sense
the tone for the session and may mask outside noise. Con- of well-being.13 This is not surprising because olfactory re-
sider the treatment room flooring. A tile or wood floor may ceptors are directly connected to the limbic system, the old-
cause echoes that are annoying or distracting. The wrong est and most emotional part of the human brain.
sort of music may also be disturbing and irritating to the In a study of how scent impacts social relationships,
client. Most therapists have probably heard spa or massage people in photographs were given a higher “attractiveness
CDs that are downright alarming. One CD on the market rating” when the test subjects were exposed to a pleasant
features wolves howling incessantly in every song—it is dif- fragrance. In a test of shampoos, a product initially ranked
ficult for a client who feels like prey to relax! last in performance was ranked first in a second test after its
The right music can evoke strong feelings and beneficial aroma was adjusted.14
physiological changes in the client. Research shows that Therapists can use gentle, soft aromas to enhance the
music decreases anxiety, decreases systolic blood pressure, client’s perception of the business and to provide an emo-
and decreases heart rate even when the person is actively tionally satisfying experience. For example, diffusing citrus
stressed.7 Music also exerts complex influences on the essential oils throughout an area can purify the air, repel
central nervous system and can, in a short period of time, insects, enhance mood, and make the area smell clean and
change brain waves associated with an alert state to brain fresh. A commercial nebulizing diffuser works well to elimi-
waves associated with a relaxed state.8 In a single session of nate microbes and promote a clean, healthy living or work-
music therapy delivered to hospice patients with chronic ing space (Fig. 2–9). Avoid the use of strong scents and even
pain conditions, music decreased the participants’ over-
all levels of pain and increased their physical comfort.9
Research also shows that the positive physiological benefits
of music are increased when patients can choose their own
music.10 It is a good idea to have a variety of musical styles
available and to ask clients about their musical preferences
during the client consultation. Clients can also be encour-
aged to bring their own appropriate music for the session.

What the Client Smells

Good ventilation and fresh air are important in the spa
treatment space. In the warm, closed environment of the
treatment room, aromas from a previous client (e.g., heavy
perfume, cigarette smoke) can persist into the next session
if the room is not well ventilated. Open the windows be-
tween clients if possible or point a fan at the ceiling to circu-
late the air. Leafy, nonblooming foliage plants make good
natural air purifiers. Because many clients have allergies to
blossoms, flowers, despite their beauty, should not be used
in the treatment room.
Therapists must also consider their own smells and how
they may impact a client. Avoid strong-smelling deodor-
ants, perfumes, and aftershave products. Brush your teeth
FIGURE 2–9 Nebulizing diffuser. A commercial nebulizing diffuser
after meals and rinse your mouth with mouthwash between works well to promote a clean, healthy living, or working space without
clients. Smokers should not smoke after showering in the overscenting the air.

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Chapter 2 Spa Equipment and Products 29

too much of a soft scent. Don’t use scented carpet sprays, under warm water, holding a warm pack, or rubbing them
laundry detergent, or fabric softeners because these have briskly before the session.
synthetic ingredients and may irritate clients.
When using aromas, use products with natural rather Accessibility and Functionality
than synthetic fragrances. Synthetic fragrances are artificial
and do not come from aromatic plants, fruits, or flowers. When designing your spa space, think about each area of
Clients often develop adverse reactions to synthetic fra- the business and analyze its accessibility and functionality.
grances (headaches, sore throat, sneezing, coughing, and Consider the entrance and reception area, dressing area,
emotional irritation) and may come to dislike all aromas as and the bathroom.
a result. Aromatherapy and the use of pure, natural essen-
Entrance and Reception
tial oils are discussed in detail in Chapter 7, Introduction to
Aromatherapy for Spa. When choosing a business location, consider its accessibil-
ity. Are doorways, hallways, and bathroom entrances wide
enough to accommodate a wheelchair? Is there enough space
What the Client Tastes around furniture to accommodate someone in a cast and on
In most cultures, food and drink have celebratory asso- crutches? Does a long flight of stairs make the business pro-
ciations. Children commemorate their birthday with ice hibitive for elderly clients? Is parking convenient and user-
cream parties, cake is eaten at weddings, and special friends friendly or will clients be spending the first 10 minutes of
are invited over for a meal. Incorporating small food items their sessions looking for a space and feeling stressed?
in the session is a pleasant and smart practice. Clients can The reception area must be friendly, neat, and function-
sometimes get up from a session and feel shaky and dizzy al. Clients generally fill out paperwork in this area while
from low blood sugar. A small snack provides an opportu- waiting for their session. They might also pay for the ses-
nity for the client to wake up and come back to the “real sion and book additional sessions in this area. Magazines, a
world” before venturing back out into the busy world. It retail area, tea or water, and comfortable chairs and attrac-
doesn’t have to be elaborate and can be as simple as a cup tive furnishing help ensure the client’s comfort.
of green tea served from a Chinese tea set after an Asian-in- The Undressing and Dressing Space
spired service or a complementary chocolate on Valentine’s
Day. Similarly, a treatment developed for athletes might Carefully plan the space where clients remove their clothing
serve a sports drink as part of the session. In the summer, before the session and get dressed afterward. A screened-off
clients might enjoy leaving their treatment with a colorful area provides a sense of privacy and decreases the client’s
Popsicle to remind them that spa is fun. Granola bars and a anxiety that the therapist might walk into the room unex-
bowl of fresh fruit might be offered to clients. Fresh, filtered pectedly. Place a chair and hooks behind the screen where
water should be provided before, during, and after the ses- clients can hang their clothing. A small container for per-
sion. Food and drink should be simple and manageable but sonal items such as keys and jewelry helps ensure clients do
focus on the intention of the offering: to welcome; to nour- not misplace or forget them. A box of tissue, disposable wet
ish on a spiritual level; and to show care, thoughtfulness, wipes, and mirror are useful as well.
and appreciation.
The Bathroom
In the bathroom, provide only liquid soap. Have on hand
What the Client Feels
amenities that make it easy for clients to tidy up after
Once on the treatment table, the client should be envel- the session. Gentle face cleanser, makeup remover, and
oped in warm, soft textures whenever possible. Bolsters moisturizer allow women to remove their makeup before
support the joints in a relaxed position. Blankets, warm a session or fix it up afterward. Disposable combs, bobby
packs, Fomentek water bottles, and heat lamps help keep pins, spray gel, and hair bands come in handy, especially
clients warm throughout the session. Lotion warmers heat after a neck massage using oil. Contact lenses solution,
massage oil or spa products so that it does not feel cold spray antiperspirant (solids or gels used by more than
when applied. Never use a microwave oven to heat products one person are unsanitary), and mouthwash are also
because microwaves may affect the product’s therapeutic appreciated.
properties. Because many products break down when heat-
ed, it is recommended to use 1-oz bottles with flip or pump
Planning Spa Treatment Rooms
lids. These small bottles are filled with fresh product at the
beginning of each day so that the larger container is not If you are planning your own spa business, you need to
exposed to heat and can remain in the refrigerator. think about how each treatment room can be organized
Some therapists have chronically cold hands, which can and equipped to allow for the delivery of multiple treat-
feel shocking to the client at the beginning of the session. ments. In Chapter 15 (Treatment Design and Your Signa-
Warm your hands as much as possible by holding them ture Spa Treatment), you will learn about how to organize

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30 Spa Bodywork: A Guide for Massage Therapists

and develop a meaningful menu of services to entice clients treatment it is unlikely to generate revenue on a daily basis
to your business and build their loyalty. If you develop a and becomes a wasted space. Plan your menu and your
highly specialized treatment, you may need a highly spe- treatment rooms with enough flexibility so that each room
cialized treatment room to enable its delivery. The problem is generating income for your business every hour you
is that a treatment room designed solely for a specialized are open.

STUDY TIP: Up to the Test! Absolutes in an answer choice often signal that it’s the
wrong choice. Finally, when your tests are returned
To do well on any written test, you must not only to you corrected, look it over carefully and determine
know the information but also have a good test-taking the sources of the test’s information, which helps you
plan. A good plan helps prevent test anxiety and leads know what to study next time. For example, if you
to better test scores. Try the PASS method to do your missed two lectures but know the textbook material
best on the next test: well, you still might have difficulty on a test if the
P ⴝ Prepare: Prepare for the test by breaking the test instructor asks questions primarily from lecture con-
topics into different study sessions. Don’t try to learn tent. You now know that attending every lecture is a
a whole chapter the night before the test. For example, must if you want a good grade in this particular class.
for a test on a chapter with three key subject headings,
you might plan four study sessions. Study one subject SPA INSPIRATION: There Is No Substitute for
in each of the first three study sessions and then study Direct Experience!
all the topics together in the final study session. Write
Isadora Duncan, the famous American dancer,
yourself a test from the chapter. By combing the chapter
remarked, “What one has not experienced, one will
for test questions, you predict what the instructor might
never understand in print.” Spa equipment is best
ask and have a good chapter review in the process.
understood through direct experience. Have some fun
A ⴝ Arrive early: Before leaving for school, eat a light by contacting local spas in your area. Let them know
meal but avoid sugar, which can adversely affect your that you are a student in a spa program and would
thinking. Drink lots of water because people think like to visit the spa as part of your learning process.
better when they are hydrated. Get plenty of sleep the Ask a therapist to show you around and describe the
night before the test so you are well rested. Arrive early different types of products and equipment he or she
and read through your notes one last time. Then put uses in their facility. This way, you will have an excel-
the notes aside and focus on your breathing while you lent point of reference when you start to think about
clear your mind. purchasing your own equipment and create your own
spa environment.
S ⴝ See success: Don’t fall into negative thinking (e.g.,
“I don’t know this chapter well enough and I’m sure
to fail!”). Give yourself positive energy (e.g., “I studied.
I’m ready. I’ll do great!”). See yourself succeeding and The quality of the equipment that you use, the quality
answering every question with ease. Visualizing success of lubricants and spa products that you use for mas-
helps your mind relax and focus on the test content. sage and spa treatments, and the time and care you
S ⴝ Strategize: Proven test-taking strategies can help put into planning your spa space convey your level of
you score high. First, read the directions carefully. professionalism to your clients. Although it may seem
Many students assume they understand the direc- early to start thinking about equipment needs and
tions and then make wrong choices based on false décor for your business, it’s not too early to explore
assumptions. Next, answer everything you know first. options. Try out different massage tables and different
This warms up your brain and gives you confidence. lubricants. Purchase sample sizes of spa products such
If you’re stuck, underline key words and define them as mud, salts, and seaweed. Start to explore interior
in the margins of the test or on scrap paper. Thinking design and think about color choices and window
about key terms often unlocks the answer to a test treatments and visit a spa show in your area for dem-
question. Look for absolutes such as always and never. onstrations of specialized equipment. Starting now

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Chapter 2 Spa Equipment and Products 31

helps ensure you to be prepared to enter the massage 5. A shower with a horizontal rod with holes or water
and spa profession with a clear and informed plan. heads that rain water down onto the client from
This also helps you keep your spa career vision alive, above the wet table is called:
an important motivator when the massage and/or spa a. A Swiss shower
program gets challenging! b. A Kneipp shower
c. A Vichy shower
REVIEW QUESTIONS d. A Dutch shower
Multiple Choice True or False
1. Dry room equipment is:
a. Equipment that has a self-drying feature 6. There are some situations where
b. Equipment used in a room where water a spa product is meant to be applied warm, but,
treatments are delivered in most cases, spa product is cooled before it is
c. Equipment used in a room where water applied to the body.
treatments are not delivered
d. Equipment that is meant to get wet 7. The main type of tub used in a
spa setting is a common bathtub designed for
2. A Fomentek is: professional use with color therapy to cause the
a. A shower with seven water heads water to change colors during the session.
b. A large water bottle designed to sit flat on the
treatment table 8. Steam cabinets are like small steam
c. A type of wrap blanket that is highly insolated “pods.” The client sits down on a plastic bench,
d. A heat lamp hung over the top of the massage table and the cabinet is closed around him or her,
leaving the head exposed.
3. A wet table:
a. Has a plush, comfortable velvet-like cover that 9. A sauna is a room that can be filled
resists water with steam from a steam generator so that people
b. Has a cold hard surface to channel water can bath in the vapor to induce sweating or to aid
c. Has a special surface to channel water covered respiratory conditions.
by a plastic mat for comfort
d. Has a special surface that has a self-drying finish
for use between clients 10. Exfoliation products are used to
remove trapped debris while sloughing off dead
4. A shower that surrounds the client with jets of water skin cells, smoothing the skin’s surface, and
directed at specific areas of the body from shower invigorating the body.
heads in the four corners of the stall is called:
a. A Swiss shower
b. A Kneipp shower
c. A Vichy shower
d. A Dutch shower

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Client and
Therapist Safety

Chapter Outline K e y Te r m s
Spa Ethics Antiseptics: A type of cleaning agent that is generally appropriate for use
Commitment to Personal and Professional in a spa setting so long as no blood or body fluid is present.
Boundaries Code of ethics: A document or creed that states a professional group’s
Scope of Practice ethical principles and the values by which the group abides.
Spa Sanitation and Hygiene Direct contact: The transfer of a pathogen from an infected person to
an uninfected person through touch, sexual contact such as kissing or
How Diseases Are Transmitted
Preventing the Transmission of Disease intercourse, or expelling body fluid droplets onto a person by sneezing,
Sanitation of the Facility, Equipment, and Supplies coughing, or touching mucous membranes and then touching an
Universal Precautions uninfected person without having washed the hands.
Creating a Safe Environment Disinfectants: A type of cleaning product that should not be used on the
Safety of the Facility skin and that is stronger than an antiseptic. Disinfectants kill or are
Safety of the Client effective against most bacteria and viruses.
Safety of the Therapist Estheticians: People licensed to practice professional skin care.
Cautions and Contraindications Indirect contact: The transfer of a pathogen from an infected person to
Spa-Specific Considerations an uninfected person via an inanimate object (known as a fomite) such
Common Conditions That Require Caution
as a countertop, doorknob, toy, or magazine.
Critical Thinking and Contraindications
Documentation of Sessions in a Spa Lice: Parasitic animals that can be spread via direct and indirect contact
that suck the blood of their hosts and cause itching.
SPA FUSION Mites: Parasitic animals, similar to lice, that can be spread via direct and
INTEGRATION OF SKILLS indirect contact that suck the blood of their hosts and cause itching.
STUDY TIP: Graphic Organizers Pathogen: A producer of disease.
SPA INSPIRATION: Your Spa Journal Power differential (power advantage): The authority a massage
CHAPTER WRAP-UP therapist is granted by a client based on the client’s perception of the
massage therapist as a knowledgeable and skilled health care provider.
Scope of practice: A term used by regulating boards of health care pro-
fessions to describe the techniques, activities, and methods that are
permitted to a therapist under the law.
Sterilization: The elimination of all microorganisms on and in an object
through heat, chemical substances, or irradiation.
Universal precautions: A protocol used in health care settings that
reduces the risk that health care workers will be exposed to bloodborne
diseases transmitted through broken skin, mucous membranes, or
contact with blood and body fluid.
Vector transmission: The transmission of a pathogen via vectors (insects
or animals capable of transmitting diseases, including mosquitoes,
flies, fleas, ticks, mites, rats, dogs, and cats).
Vehicle transmission: The transmission of a pathogen by a “vehicle”
such as air, food, and liquid.


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Chapter 3 Client and Therapist Safety 33

relationship involves learning how to assert and maintain

This chapter aims to introduce new spa therapists to your own boundaries while respecting the boundaries of
clients. One area where this is particularly important is in
areas that will need attention and careful planning before
issues related to sex (see number 8 of the ABMP Code of
spa treatments are offered as an employee or in a private Ethics in Table 3–1).
There are various levels of sexual misconduct, ranging
practice. The first area we will explore is ethics and how
from lack of attention to sexual innuendo, to sexual impro-
massage ethics are applied to spa-related situations. Next, priety, to sexual abuse of clients. You must always control
the atmosphere of the spa business. Allowing clients to
is a closer look at sanitation, hygiene, and safety as it relates
act inappropriately is as serious as acting inappropriately
to spa equipment and spa environments. Reviewing the yourself.
details of contraindications and understanding how spa Lack of Attention to Sexual Innuendo
treatments might adversely affect a client’s condition is It is not uncommon for people to compliment each other
and express their affection by positively commenting on
also important. We will discuss common conditions and
another person’s appearance. In a spa setting, this can
spa-specific contraindications that will help you know lead to mistrust. If you tell a client, “you look really good
in those jeans,” it plants a seed of doubt and mistrust in
when to postpone a treatment or suggest a different service
a client’s mind about your intentions, regardless of how
to ensure the client’s health. long you have known each other or how innocent the com-
ment. Because of the intimate nature of spa work, refrain
from making any body comments that indicate approval
or disapproval of a client’s body and physical features such
Spa Ethics as the eyes, mouth, or hair. Do not carry magazines, pic-
tures, or written material of a sexual nature to the work
Ethics is a major branch of philosophy exploring values,
environment. Do not allow the client to make sexual jokes
morals, right and wrong, good and evil, and responsibility.
and discourage clients from commenting on your personal
Also called moral philosophy, ethics is a system of princi-
appearance by downplaying those types of compliments
ples governing the appropriate conduct for an individual
with a brief “thank you” and then a return to the business
or group. It is concerned with values and the standards by
at hand.
which human actions can be judged right or wrong. Ethics
are different from laws, which are rules of conduct that are Sexual Impropriety
recognized by a community as binding or enforceable by
Sexual impropriety is more serious than a general lack
authority. Some behaviors may be legal but nonetheless are
of attention to sexual innuendo and could lead to sexual
not ethical. For example, it is not illegal for a therapist to
harassment charges. Behaviors that could be labeled as
date a client, but the massage community actively discour-
sexual impropriety include the following:
ages this as unethical because dating a client may cause the
client harm. • Any behavior that is immodest or encourages immod-
A code of ethics states a professional group’s ethical esty in clients; for example, a therapist who stands in the
principles. It suggests values by which the group abides. treatment room while the client undresses in front of
Table 3–1 shows the code of ethics for members of Asso- him or her or allows a client to place himself or herself
ciated Bodywork and Massage Professionals (ABMP), the on top of the drape exposing the genitals or breasts
largest massage therapist membership organization in the • Draping loosely or deliberately looking at a client’s body
United States. Review this code of ethics as a reminder of while adjusting a drape; not using draping practices or
ethical principles that guide your work as a massage thera- pressuring a client to take off his or her underclothing
pist. In a spa setting, certain ethical standards are placed in when he or she leaves it on; and not providing disposable
greater focus than in other work environments. Let’s review spa underclothing, which allows a client to receive a full-
those areas now. body spa treatment without a loss of modesty
• Using nicknames for clients, especially those that have a
sexual connotation, or allowing the client to use sexual
Commitment to Personal and Professional
nicknames for you such as “Romeo,” “Handsome,”
“Baby,” “Honey,” or “Sexy”
Boundaries are conscious and subconscious imaginary lines • Telling a client jokes or listening while a client tells jokes
that mark the limits of an individual’s personal space or ter- of a sexual nature
ritory. Boundaries create a separation or a border between • Discussing one’s own sexuality within hearing of a client
a person and other people and between a person and the (it’s a bad idea with coworkers as well because it could
environment. Part of establishing a healthy therapeutic lead to a sexual harassment claim)

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34 Spa Bodywork: A Guide for Massage Therapists

TABLE 3–1 Associated Bodywork & Massage Professionals Code of Ethics

1. Commitment to High-Quality Care
I will serve the best interests of my clients at all times and provide the highest quality of bodywork and service possible. I recognize that the obli-
gation for building and maintaining an effective, healthy, and safe therapeutic relationship with my clients is my responsibility.
2. Commitment to Do No Harm
I will conduct a thorough health history intake process for each client and evaluate the health history to rule out contraindications or determine
appropriate session adaptations. If I see signs of, or suspect, an undiagnosed condition that massage may be inappropriate for, I will refer that
client to a physician or other qualified health-care professional and delay the massage session until approval from the physician has been granted.
I understand the importance of ethical touch and therapeutic intent and will conduct sessions with the sole objective of benefitting the client.
3. Commitment to Honest Representation of Qualifications
I will not work outside the commonly accepted scope of practice for massage therapists and bodywork professionals. I will adhere to my state’s
scope of practice guidelines (when applicable). I will only provide treatments and techniques for which I am fully trained and hold credible
credentials. I will carefully evaluate the needs of each client and refer the client to another provider if the client requires work beyond my capa-
bilities, or beyond the capacity of massage and bodywork. I will not use the trademarks and symbols associated with a particular system or
group without authentic affiliation. I will acknowledge the limitations of massage and bodywork by refraining from exaggerating the benefits of
massage therapy and related services throughout my marketing.
4. Commitment to Uphold the Inherent Worth of All Individuals
I will demonstrate compassion, respect, and tolerance for others. I will seek to decrease discrimination, misunderstandings, and prejudice. I
understand there are situations when it is appropriate to decline service to a client because it is in the best interests of a client’s health, or for my
personal safety, but I will not refuse service to any client based on disability, ethnicity, gender, marital status, physical build, or sexual orienta-
tion; religious, national, or political affiliation; social or economic status.
5. Commitment to Respect Client Dignity and Basic Rights
I will demonstrate my respect for the dignity and rights of all individuals by providing a clean, comfortable, and safe environment for sessions,
using appropriate and skilled draping procedures, giving clients recourse in the event of dissatisfaction with treatment, and upholding the integ-
rity of the therapeutic relationship.
6. Commitment to Informed Consent
I will recognize a client’s right to determine what happens to his or her body. I understand that a client may suffer emotional and physical harm if
a therapist fails to listen to the client and imposes his or her own beliefs on a situation. I will fully inform my clients of choices relating to their
care, and disclose policies and limitations that may affect their care. I will not provide massage without obtaining a client’s informed consent
(or that of the guardian or advocate for the client) to the session plan.
7. Commitment to Confidentiality
I will keep client communication and information confidential and will not share client information without the client’s written consent, within the
limits of the law. I will ensure every effort is made to respect a client’s right to privacy and provide an environment where personal health-related
details cannot be overheard or seen by others.
8. Commitment to Personal and Professional Boundaries
I will refrain from and prevent behaviors that may be considered sexual in my massage practice and uphold the highest professional standards
in order to desexualize massage. I will not date a client, engage in sexual intercourse with a client, or allow any level of sexual impropriety
(behavior or language) from clients or myself. I understand that sexual impropriety may lead to sexual harassment charges, the loss of my
massage credentials, lawsuits for personal damages, criminal charges, fines, attorney’s fees, court costs, and jail time.
9. Commitment to Honesty in Business
I will know and follow good business practices with regard to record keeping, regulation compliance, and tax law. I will set fair fees and practice honesty
throughout my marketing materials. I will not accept gifts, compensation, or other benefits intended to influence a decision related to a client. If I use the
Associated Bodywork & Massage Professionals logo, I promise to do so appropriately to establish my credibility and market my practice.
10. Commitment to Professionalism
I will maintain clear and honest communication with clients and colleagues. I will not use recreational drugs or alcohol before or during massage
sessions. I will project a professional image with respect to my behavior and personal appearance in keeping with the highest standards of the
massage profession. I will not actively seek to take someone else’s clients, disrespect a client or colleague, or willingly malign another therapist
or other allied professional. I will actively strive to positively promote the massage and bodywork profession by committing to self-development
and continually building my professional skills.

Used with permission from Associated Body & Massage Professionals.

Members commit to follow ABMP Code of Ethics to protect clients, themselves, and the massage profession.

• Gender-based comments or harassment, which includes undraped bodies, no matter how “artistic” they are, in
verbal, nonverbal, or physical intimidation or hostility the reception area)
based on sex or sex-stereotyping such as comments • Requests to date or acceptance of an offer to date
about another therapists sexual orientation or criticism • E-mailing or phoning clients or sending them notes or
of a sexual orientation cards that are not specifically and exclusively related to
• Displaying or distributing sexually explicit drawings, the spa session; for example, it is acceptable to call a
pictures, and written materials (i.e., showing pictures of client the day after a session and ask how the muscles

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Chapter 3 Client and Therapist Safety 35

are feeling. It is not acceptable to call a client for a con- FOR YOUR INFORMATION 3–1
versation about personal details of events the client men-
tioned in the session. The Power Differential
In a spa setting, a power differential is defined as the authority
Sexual Abuse a massage therapist is granted by a client, based on the cli-
In a therapeutic relationship, the therapist develops a ent’s perception of the massage therapist as a knowledgeable
and skilled health care provider. Take a moment to contem-
power advantage over the client because the therapist is
plate your relationship with these people: parent, boss, best
the caregiver (For Your Information 3–1). For this reason,
friend, physician, teacher, counselor, spiritual leader, or spouse.
any sexual misconduct, whether or not the client consents, Each of these relationships involves differing levels of trust,
is considered sexual abuse. The therapist is responsible closeness, loyalty, respect, and responsibility. It is likely that you
and liable for sexual abuse, even if the client initiates it. perceive some of these people as having more authority than
Never engage in any sexual activity with a client, whether you in some situations. For example, if you go to your spiritual
in or out of the treatment room. This includes behavior leader to discuss a personal concern, you grant him or her the
that could reasonably be interpreted as sexual, including power of an advanced understanding of spiritual concepts. It
touching with the hands, body, mouth, or genitals the is easy to assume that history teachers are more knowledge-
client’s genitals, breasts, mouth, or anus; allowing the cli- able about history than other people or that dentists know
ent to touch you; or allowing or encouraging the client to more about teeth than other people. When clients make an
appointment with a massage therapist, a power differential is
touch himself or herself or masturbate during the session
at play in the relationship because the client assumes and re-
in your presence, or directly after the session, in the treat-
spects the therapist’s understanding of soft tissue structures and
ment room. If the therapist masturbates or touches himself manual techniques that reduce tension and pain. Furthermore,
or herself in a sexual manner in the presence of the client, during the session, the client shares details of his or her personal
it is sexual abuse. health history and is situated at a level below the therapist, in a
Sexual impropriety may lead to sexual harassment vulnerable reclining position, while unclothed under a drape.
charges and the loss of massage credentials. Sexual abuse The therapist by virtue of his or her knowledge and skill in the
could lead to loss of massage credentials, lawsuits for per- area of massage is granted control of the situation, so he or
sonal damages, criminal charges, fines, attorney’s fees, court she has a power advantage over the client.
costs, and jail time. Ethical massage therapists remain aware of the power dif-
ferential and seek to minimize it as much as possible to ensure
the mental, emotional, and physical safety of clients. When
Scope of Practice the power differential is minimized, clients are better able to

In number 3 of ABMP’s Code of Ethics, therapists make a • Take an active role in the decision-making process to
commitment to honest representation of qualifications by determine reasonable treatment goals.
agreeing to work within a defined scope of practice. The • Alert a therapist to an uncomfortable technique or voice
term scope of practice is used by regulating boards of health concerns.
• Give honest feedback on the quality of treatment or the
care professions to describe the techniques, activities, and
effectiveness of sessions.
methods that are permitted to a therapist under the law.
• Maintain their boundaries, personal power, and responsi-
Although most states define the scope of practice for mas- bility for health.
sage in similar terms, small variations require the therapist • Actively practice self-care activities and other types of
to carefully inspect and understand the scope of practice in therapy to augment the results achieved from massage or
the state where he or she practices massage. Ohio’s scope of spa sessions.
practice for massage therapy provides a good example and
You can actively minimize the power differential by listening
states, “Massage therapy is the treatment of disorders of the
carefully to clients and responding compassionately to their
human body by the manipulation of soft tissue through needs while representing the benefits of massage, spa treat-
the systematic external application of massage techniques ments, and your personal skill level realistically. You can give
including touch, stroking, friction, vibration, percus- clients choices about the types of techniques that might be
sion, kneading, stretching, compression, and joint move- used in the session and product options. If you remain atten-
ments within the normal physiologic range of motion; and tive, you will notice when a client tenses because of discomfort
adjunctive thereto, the external application of water, heat, and urge the client to speak up if a technique causes pain.
cold, topical preparations, and mechanical devices.” Finally, you can encourage clients to seek out other therapists
Florida’s definitions show an example of a variation that might help them meet treatment goals and discuss self-
that is uncommon. It states that “massage means the ma- care options that speed or enhance treatment outcomes.
In all cases, whether the client actively gives all of the
nipulation of the soft tissues of the human body with the
power to the therapist or not, the therapist is always respon-
hand, foot, arm, or elbow, whether or not such manipula-
sible for what happens in a session and must constantly
tion is aided by hydrotherapy, including colonic irrigation, strive to understand and minimize the power differential.
or thermal therapy; any electrical or mechanical device;
or the application to the human body of a chemical or

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36 Spa Bodywork: A Guide for Massage Therapists

herbal preparation.” Colonic irrigation, also called colon that he or she must apply the aromatherapy balm four
hydrotherapy, or colonics, involves the low-pressure injec- times a day for 2 weeks is prescribing.
tion of water into the colon for cleansing purposes using a Clients sometimes ignore messages from their bodies
mechanical device. It is believed to flush toxic buildup out that indicate something is wrong. When a massage therapist
of the colon, leading to better overall health. This type of listens, is empathetic, and suggests that a medical opinion
treatment is usually not included in the massage scope of be sought, it provides a space for the client to acknowledge
practice. his or her concerns and seek help.
Restrictions to Scope of Practice Adjusting Bones Is Out of Scope
A chiropractor is a medical professional who adjusts bones
Usually, the definitions will list some of the restrictions to improve structural alignment and free nerve tissue, lead-
to the practice of massage. Arizona definitions state that ing to better overall function. Sometimes, a client’s bones
“practice of massage therapy means the application of mas- will shift naturally during the application of a massage
sage therapy to any person for a fee or other consideration. stroke. This is normal and should not cause alarm. A thera-
Practice of massage therapy does not include the diagno- pist is working outside his or her scope of practice if he or
sis of illness or disease, medical procedures, naturopathic she tries to get a bone to move. It is not uncommon for mas-
manipulative medicine, osteopathic manipulative medi- sage therapists to developed highly refined palpation skills.
cine, chiropractic adjustive procedures, homeopathic neu- Sometimes, therapists can feel that a bone is not aligned
romuscular integration, electrical stimulation, ultrasound, normally. If a therapist attempts to shift the bone by using
prescription of medicines or the use of modalities for which a thrusting movement or even holds in his or her mind the
a license to practice medicine, chiropractic, nursing, occu- intent to move the bone with a massage stroke, he or she
pational therapy, athletic training, physical therapy, acu- is working out of his or her scope of practice. Instead, the
puncture or podiatry is required by law.” therapist should refer the client to a chiropractor.
You may notice that three primary restrictions to scope
of practice come up repeatedly in massage law. Massage Counseling Is Out of Scope
therapists cannot diagnose a patient’s condition, prescribe Another area where massage therapists may venture out of
a medication or treatment, or adjust a client’s bones. Let’s their scope of practice is counseling. People seek out coun-
look at each of these areas in more depth. seling from a mental health care provider to gain insight
into personal or psychological problems. It is not uncom-
Diagnosing Is Out of Scope mon for clients to share personal issues with their massage
Some therapists fall into diagnoses accidentally and do not therapists during sessions. This is not a scope of practice
realize the serious ramifications of their actions. The term violation so long as the therapist listens compassionately
diagnose means to identify an illness or disorder through but does not give advice or professional input. At other
an interview, physical examination, and medical tests. For times, listening is not enough, and the client expresses a
example, a client may describe to the therapist a set of symp- need for guidance or becomes emotional. The massage
toms that the therapist recognizes as a particular soft tis- therapist must be very careful not to counsel the client or
sue condition such as carpal tunnel syndrome. A therapist try to talk the client through the situation. If listening is
who says, “Oh, your condition is carpal tunnel syndrome not enough, the massage therapist should refer the client to
and you need to take 1,200 mg of ibuprofen a day, wear a a professional mental health care provider. In all cases, the
wrist splint, and receive treatment massage” has crossed the massage therapist must know and understand the scope of
line and is diagnosing. Anytime the therapist labels a set practice and its restrictions in the state where he or she pro-
of symptoms as a defined medical condition, he or she is vides massage services.
diagnosing. Instead, the therapist should acknowledge the
Skin Care Is Out of Scope
seriousness of the client’s symptoms and suggest the client
The spa industry has grown so rapidly that this has created
visit a physician for a diagnosis.
some confusion about the scope of practice for therapists
Prescribing Is Out of Scope delivering spa services. Much of this has centered on mas-
The term prescribe means to direct a patient to follow a par- sage therapists and estheticians (people licensed to prac-
ticular course of treatment, specifically to use a particular tice skin care). In many states, the board of cosmetology has
drug at set times, and in specified dosages. When the thera- raised concerns that massage therapists are encroaching on
pist in the example stated earlier advised the client to take the scope of practice of estheticians when they provide such
1,200 mg of ibuprofen a day and wear a wrist splint, he was services as a seaweed wrap or body polish. On the other
prescribing. Therapists sometimes accidentally prescribe hand, in some states, massage therapists are concerned that
things such as herbal remedies or aromatherapy cures. estheticians are using massage techniques that manipulate
To say to a client, “You should drink six glasses of pepper- soft tissue while applying products, so they are encroaching
mint tea a day for your stomach condition,” is prescribing. on the scope of practice for massage therapists.
To suggest a client take supplements offered in the spa gift The basis of such concerns is that many of the products
shop to improve health is prescribing. To explain to a client used in the spa industry affect the physiological health

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Chapter 3 Client and Therapist Safety 37

of the muscle tissue and body as well as the health and of the properties of products such as mud and seaweed for
appearance of the skin. A seaweed wrap could be used for the skin. Massage therapists who want the broadest pos-
relaxation or as an active treatment to support a client with sible understanding of a treatment will also want to under-
fibromyalgia, sore muscles, or low energy (general mas- stand its implications for the skin, even though they will
sage scope of practice). A seaweed wrap can also be used probably not market these effects to their clients.
to soften, hydrate, and beautify the skin (general esthetics Therapists should check to see if there are any treat-
scope of practice). Body polishes stimulate local circulation ments or practices that are not allowed by the regulatory
to superficial soft tissue structures, tone muscle tissue, and body in the state where they are practicing. Both ABMP and
increase the vital energy of the body as in a classic friction the American Massage Therapy Association (AMTA) cover
rub (general massage scope of practice). They are also an spa treatments delivered by massage therapists with some
exfoliation treatment that deep cleans, softens, smooths, various restrictions. Call your professional association to
and beautifies the skin (general esthetics scope of practice). check that your liability insurance policy covers the treat-
This issue is further complicated because laws and regu- ments you are offering.
lations vary widely from state to state. A treatment that is Therapists who are trained both as massage therapists
within the scope of practice for massage therapists in some and as estheticians are growing in numbers. These thera-
states may be banned for massage therapists in another pists can market and deliver spa treatments for both the
state. For example, massage therapists cannot cleanse, ex- body and skin at the same time.
foliate, mask, or tone the facial tissue in most states. They
can apply creams or lotions (including essential oils) to the
face to perform a massage. In many states, massage thera- Spa Sanitation and Hygiene
pists cannot use the word facial even when describing a fa-
cial massage (they must say “face massage”). In a few states, Spa therapists are required by health standards and pro-
however, massage therapists can provide facials using cer- fessional ethics to provide a clean environment for clients
tain types of product only. Usually (but not always), mas- that ensures they don’t pick up any diseases while they are
sage therapists can use an exfoliation product such as salt at a spa or massage clinic. Therapists must understand
on the body (except the face) to increase local circulation how infectious diseases are spread and then adopt stan-
and relax muscle. Products such as seaweed and mud can dard sanitation procedures to prevent the spread of these
be used to promote changes in soft tissue or for relaxation diseases. Sanitation protocols include therapist hygiene; the
or revitalization. sanitation of the treatment room, equipment, and product
In many states, estheticians cannot apply products containers; and general cleanness of the facility. The state
with any stroke other than effleurage. They can use vari- board of massage, the state board of cosmetology, the state
ous strokes on the face, arms to the elbows, feet to the department of health, and the Centers for Disease Con-
knees, and on the décolleté (upper chest) for beautifica- trol and Prevention (CDC) are useful sources of additional
tion purposes only. They cannot manipulate soft tissue, so information for people working in spas or massage clinics.
they should avoid strokes that lift, knead, or broaden the
muscles. Again, in certain states, the previous statement is
not true, and estheticians even receive training in full-body
massage. A disease is defined as an infectious or noninfectious
This textbook is written on the premise that spa body abnormal condition that results in medically significant
treatments are a shared practice. It assumes that massage symptoms and often has a known cause. Diseases may
therapists will focus on the benefits of a treatment for the cause changes in the appearance, structure, or function of
body, and estheticians will focus on the benefits of the cells, tissues, organs, or systems in the human body. The
treatment for the skin. The treatment steps for the massage signs and symptoms of diseases may result from the disease
therapist may be the same steps that an esthetician uses, process itself or the immune system’s attempt to defeat an
but the goals of the treatment (therapist’s intention) will infectious agent. Such signs and symptoms include but are
be different. This may also be expressed in the promotional not limited to fever, nausea, elevated white blood cell count,
descriptions used to sell the treatments to the public. The fatigue, and cardiovascular and metabolic changes.
massage therapist markets the benefits of the treatment for The terms acute, subacute, and chronic are often used to
the body, whereas the esthetician markets the benefits of note a disease’s severity or stage. When a disease is in an
the treatment for the skin. acute stage, the symptoms are severe, and in some cases, the
Throughout the treatment chapters, esthetically oriented situation is more dangerous. The acute stage usually lasts a
information is included in “Broaden Your Understanding” short time before the symptoms decrease, and the body en-
boxes. This information has been separated from the main ters a subacute stage. A chronic disease, persists for a long
body of the text to avoid confusing new spa therapists who time or regularly recurs.
are still unclear about their scope of practice. Estheticians Types of diseases include autoimmune, cancerous, de-
who are using the book as a reference will want to be aware ficiency, genetic, metabolic, and infectious diseases. You

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38 Spa Bodywork: A Guide for Massage Therapists

probably learned something about each of these disease sexually transmitted diseases chlamydia and lymphogranu-
types in your massage training so our focus here is a review loma venereum; and some respiratory diseases.
to prevent the spread of infectious diseases in a spa environ-
ment. Viruses
Viruses are smaller than bacteria and cannot self-replicate
Infectious Diseases or self-reproduce outside a living host cell (plant, animal,
or human). To grow and spread, they effectively take over
Infectious diseases, also known as communicable diseases, the host cell, causing the cell nucleus to replicate both its
are caused by an infectious agent referred to as a pathogen. own genetic material and that of the virus. The cell is usu-
The term pathogen comes from the Greek pathos meaning ally eventually destroyed when it ruptures, and the new viral
“suffering or disease” and gen meaning “producer.” There- particles formed are released into the extracellular fluid to
fore, a pathogen is a producer of disease. The term refers infect more cells. Viruses mutate quickly, making them dif-
to infectious organisms such as bacteria, viruses, fungi, ficult to treat effectively. Some viruses lie dormant in cells
and protozoa. Parasitic animals can also be passed from until a stimulus or a decline in the host’s defenses activates
person to person or from animals to people and cause them. Some persistent viruses, such as HIV which causes
disease. AIDS, can enter or exit a cell without killing it.
Bacteria Viruses are present in infected body fluids such as
Bacteria are one-celled living organisms found in every blood, saliva, or droplets from the nose, mouth, or geni-
environment on earth, including inside and outside the talia. They are transmitted person to person or animal to
human body. They divide and multiply independently of a person. Although most viruses cannot live long without a
host and can thrive in almost any environment including host, some, such as the herpes simplex virus, can linger on
on nonliving surfaces such as plastic. Most bacteria are not surfaces for several hours and infect a person via indirect
harmful, and many bacteria are necessary for good health. contact. This is one reason why the proper sanitation of lin-
The immune system relies on probiotic bacteria (sometimes ens and equipment in a spa environment is so important
referred to as the intestinal flora), which live in the intesti- (discussed below).
nal track. Probiotic bacteria aid normal food digestion and
provide immune support against certain viruses, yeasts, Fungi
parasites, and pathogenic bacteria. Fungi, which include molds and yeasts, comprise a large
Pathogenic bacteria such as Escherichia coli (E. coli) and group of simple plantlike organisms that are larger and
Salmonella enteritidis (Salmonella) may enter the body through more complex than bacteria. Warm, moist environments
improperly handled food or unwashed hands (especially promote the reproduction of fungi through simple cell
after toilet use) and cause food poisoning or acute diarrhea. division and the production of large numbers of spores.
Staphylococcus aureus is the species of bacteria that causes A common fungus, Candida albicans, is present in the
“staph” infections. It commonly lives harmlessly on the mouth, mucous membranes, vagina, and rectum. It can also
skin and hair and around the nose. It can potentially be travel through the bloodstream and affect the throat, intes-
passed to massage clients by therapists who touched their tines, and heart valves. Candida becomes dangerous when
own hair or nose and then touched a client without first some change in the body environment allows it to grow out
decontaminating their hands. If staph gets into a cut and of control. When it grows out of control in the mouth, it is
rapidly reproduces, it may cause serious infection and blood called thrush. When it grows out of control in the vagina,
poisoning. Streptococcus pneumoniae, known informally as it’s often called a yeast infection or vaginitis. In individuals
pneumococcus, causes pneumonia when it is inhaled into with low resistance due to other diseases such as leukemia
the lungs and cannot be cleared. Its relative, Streptococcus or AIDS, Candida can enter the bloodstream and cause a se-
pyogenes, causes “strep throat” among many other diseases. rious infection in vital organs.
Pathogenic bacteria normally live on the skin and hair, in A group of related fungi cause skin infections character-
the nose, throat, and lungs or in the intestines without ized by red, scaly patches known commonly as ringworm,
causing a problem. They infect the body only when its de- but despite the name, it is not caused by a worm (Fig. 3–1).
fenses are low or when the pathogenic bacterium suddenly Ringworm might be found on the skin (tinea corporis),
comes into contact with vulnerable tissue.1 scalp (tinea capitis), around the groin (tinea cruris, some-
Rickettsiae and chlamydiae are smaller than bacteria but times called jock itch), or feet (tinea pedis, most often
still classified as bacteria. These pathogens are parasites called athlete’s foot). Ringworm is highly contagious and
that must live inside a cell at the expense of their hosts. In is transmitted via skin-to-skin contact or contact with con-
most instances, these organisms are transmitted through taminated items such as unwashed sheets, flooring, and
the bites of insects such as lice, ticks, and fleas. Rickett- combs. Therapists who practice spa treatments or massage
siae are responsible for a number of serious diseases such barefoot can pass an undetected fungal infection to clients
as typhus and Rocky Mountain spotted fever. Chlamydiae or pick up a fungal infection when clients walk barefoot in
cause trachoma, an eye infection that causes blindness; the the same area.

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Chapter 3 Client and Therapist Safety 39

FIGURE 3–1 A group of related fungi cause skin infections character- FIGURE 3–2 Head lice (Pediculus humanus capitis), body lice (Pediculus
ized by red, scaly patches known commonly as ringworm, but despite humanus), and pubic lice (Pthirus pubis–often called crabs) suck the blood
the name, it is not caused by a worm. Ringworm might be found on of the host and cause itching.
the skin (tinea corporis), scalp (tinea capitis), around the groin (tinea
cruris, sometimes called jock itch), or feet (tinea pedis, most often called
athlete’s foot). clothing but could be passed from clothing to massage
sheets. Pubic lice are nicknamed “crabs” because of their
crab-like appearance. They are usually spread through sex-
ual contact but might also be spread to clothing or linens.
Protozoa (from the Greek protos meaning “first” and zoon
Although they tend to inhabit the groin area, they can live
meaning “animal”) is a single-celled organism regarded as
in any course body hair (armpits, eyebrows).
the simplest form of animal life. They grow in moist envi-
ronments such as fresh water, marine environments, de- Mites
caying organic matter, wet grass, and mud. Protozoa cause Mites (Sarcoptes scabiei) like warm, moist areas of the body,
diseases such as amoebic dysentery, which is usually con- especially skinfolds. They burrow under the skin and live off
tracted through contaminated water or food; African sleep- the blood of the host (Fig. 3–3). Mite infestations are often
ing sickness, which is spread by the tsetse fly; and malaria, referred to as scabies. The excrement of the mite is highly
which is transmitted by the anopheles mosquito. irritating and leads to itchy, red allergic reactions. Like lice,
mite infestations are highly contagious and spread through
Parasitic Animals
person-to-person contact or from clothing and linens.
The parasitic animals of most concern to massage thera-
If a lice or mite infestation occurs at your massage clinic
pists are mites and lice because they are spread very easily
(e.g., a client calls to say she just found out that she has
through direct contact or contact with infected sheets and
lice), cancel all appointments until the facility can be deep
clothing. Lice and mites do not carry infectious bacteria,
cleaned. Wash in hot water and detergent any linens or
viruses, or fungi to the host. Instead, their wastes cause in-
cloth materials that may have come into contact with the
tense itching that leads the host to scratch the skin, leaving
infected person and then dry them with heat. Vacuum car-
it open to more serious infection.
peted floors carefully and change bath mats and towels in
Lice the bathroom. Mop hard floors and wipe down all hard sur-
Head lice (Pediculus humanus capitis), body lice (Pediculus faces. Lice and mites live only about 38 hours off the host,
humanus), and pubic lice (Pthirus pubis—often called crabs) but care should be taken that they are not spread to an un-
suck the blood of the host and cause itching (Fig. 3–2). suspecting client.
Head lice often spread among grade school children and
must be treated with repeated applications of special
How Diseases Are Transmitted
shampoos. A fine-tooth comb is passed through the hair to
remove eggs. Body lice live in the seams of clothing rather An infectious pathogen must breach the body’s defenses
than directly on the host. This type of lice is usually seen in to cause a disease. Some pathogens, called opportunistic
homeless people who do not have regular access to launder- pathogens, cause disease only if the host’s immune sys-
ing facilities. Body lice are transmitted through unwashed tem is depressed. Others, called virulent pathogens, readily

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40 Spa Bodywork: A Guide for Massage Therapists

fomite where an uninfected person touches it obtaining the

pathogen via indirect contact.

Vehicle Transmission
Air, food, and liquid that are routinely taken into the body
provide a mode of transport for pathogens. This type of
pathogen transmission is called vehicle transmission.
Pathogens can travel in the air in droplets (usually mucous
droplets such as are released by a sneeze), aerosols (very
small droplets that may have evaporated from droplets on a
surface), or dust particles. This is why people often get sick
after flying on a plane; because cabin air is recycled, patho-
gens have repeated opportunities to infect passengers.
A number of pathogens are found in food. If these patho-
gens are not killed during food processing, they are trans-
mitted directly to the gastrointestinal tract. Bacteria in the
intestinal flora of animals may be safe for those animals but
unsafe for humans. For example, Salmonella is part of nor-
mal chicken intestinal flora but can cause serious illness in
humans if it is not destroyed during food preparation. The
food preparer may also be infected and transfer pathogens
to otherwise uncontaminated food.
FIGURE 3–3 Mites (Sarcoptes scabiei) like warm, moist areas of the body, In the United States, drinking water is generally safe,
especially skinfolds. They burrow under the skin and live off the blood of
the host.
but if the water supply is contaminated with human or ani-
mal fecal matter (e.g., sewage), it may cause serious illness.
Homes and businesses with a private well should have the
cause disease when they gain entrance to the body. Patho- water tested annually to ensure its safety. Pathogenic organ-
gens are transmitted by direct contact, indirect contact, isms as well as harmful chemicals such as lead and radioac-
vehicle transmission, or vector transmission. tive isotopes such as radon can enter well water and cause
health problems.
Direct Contact
Vector Transmission
The sweat and sebum in skin provide some natural protec-
tion against the transfer of pathogens via direct contact of Vectors are insects or animals capable of transmitting dis-
the skin. But if the skin is damaged by cuts, scrapes, wounds, eases, including mosquitoes, flies, fleas, ticks, mites, rats,
burns, or even dryness that leaves the skin with microscopic dogs, and cats. Vectors are mobile and can easily spread a
breaks, the chances of infection increase. disease to previously uninfected areas. The vector usually
Pathogens often reside around areas with mucous mem- breaks the skin through a bite or sting but may also cause
branes such as the nose, lips, eyes, gastrointestinal tract, disease through its feces. A pathogen might be located on
genitourinary tract, genital area, and anus. Lymph tissue the outside surface of a vector and spread through physical
such as the tonsils, mucus, and cilia provides some protec- contact with food or a surface when it lands (e.g., flies).
tion for the mouth and respiratory system. Other mucous
membranes provide less protection. Preventing the Transmission of Disease
An infected person can transfer a pathogen to an unin-
fected person through touch, sexual contact such as kiss- It is impossible to know if a client who walks in through the
ing or intercourse, or expelling body fluid droplets onto a door of your business is infected with a pathogen. Similarly,
person by sneezing, coughing, or touching mucous mem- you may be infected and not know it. Because pathogens
branes and then touching an uninfected person without that cause serious illness are all around us, sanitation and
having washed the hands. hygiene practices are required at all times to prevent the
spread of disease. These practices include therapist hygiene;
Indirect Contact sanitation of equipment, supplies, and the building; and
An infected individual can transfer a pathogen to an inani- the use of universal precautions.
mate object (known as a fomite) such as a countertop, door-
knob, toy, or magazine. A person might touch his or her Therapist Hygiene
nose or mouth and then touch the fomite, sneeze or cough As health care providers, spa therapists must adhere to
on a fomite, or fail to wash his or her hands after using the the highest standards of personal hygiene. This includes
toilet and then touch a fomite. The pathogen lingers on the cleanliness of the body and hair; wearing clean, appropriate

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Chapter 3 Client and Therapist Safety 41

clothing; removing jewelry; proper hand washing; and after removing gloves. Decontaminate your hands with an
attending to issues such as smoking and illness. alcohol rub before moving from a potentially contaminated
body area (such as the feet) to a clean body area (such as the
Cleanliness of Body and Hair
face) during a spa treatment or massage. Do the same when
Shower daily and wash your hair on work days. Avoid the
moving from contact with an unsanitized inanimate object
use of scented antiperspirants, perfumes, colognes, after-
(e.g., a product container) to the client. As well, wash and
shaves, and body care products because these may cause
decontaminate your hands before and after eating or using
sensitivity or allergies in some clients. As described ear-
the restroom.2 The CDC provides specific recommenda-
lier, the hair can act as a reservoir for pathogens such as
tions for hand washing and the use of alcohol-based hand
Staphylococcus aureus and must be tied back so that it does
sanitizers for health care workers, as described in For Your
not touch the client during the delivery of a spa treatment
Information 3–2 and Figure 3–4.
or massage. Men should shave before each work shift or
keep facial hair neatly trimmed. If you touch your own hair Therapists Who Are Smokers
during a session, including facial hair, you must sanitize The smell of cigarette smoke lingers in hair, on clothing, on
your hands before touching the client. skin, on the breath, on carpets, and on fabrics such as win-
For better hygiene and client comfort, keep your nails dow treatments and linens. Smokers often become oblivi-
short, natural, and filed to a smooth edge. Long nails, nail ous to the smoke odor and do not realize its impact on
polish, and artificial nails are breeding grounds for patho- nonsmoking individuals. Many nonsmokers intensely dis-
gens and may scratch a client; they are best avoided. Brush like the smell of cigarette smoke. Some are so sensitive that
and floss your teeth before the shift and directly after eat- they cannot tolerate the lingering smell of smoke anywhere
ing food during breaks in the day. Because therapists and around them. Even clients who can tolerate the smoke odor
clients come into close contact during spa treatments, it is often associate it with an environment that is unclean, so
a good idea to rinse your mouth with mouthwash before they may subconsciously feel uncomfortable.
each new client. Smoking should never be allowed in the treatment room,
Therapists who perspire heavily while giving spa treat- reception area, bathrooms, hallways, office area, or laundry
ments can wear sweatbands on the forehead and wrist to area of a spa business. Therapists who smoke must strive
prevent droplets of perspiration from falling onto the to balance their personal needs with the client’s needs. In
client. A clean towel can be used to absorb perspiration the best case, a therapist would smoke before showering,
throughout the session if necessary. washing the hair, dressing, and brushing the teeth. After
Clean and Appropriate Clothing showering and dressing, the therapist would not smoke
Launder your work uniform or clothing at the end of each again until after all of that day’s spa sessions. A therapist
working day. Short sleeves are better for spa work because who is unable to finish the day’s spa sessions before having
long sleeves, which may touch the client’s skin and be- a cigarette must make every effort to minimize the impact
come contaminated, may then contaminate the next client. on clients. Use a mechanic’s jumpsuit to cover and protect
Although many therapists like to work barefoot, this is not clothing. Cover your hair with a plastic shower cap and
advised. Your feet may harbor an undetected fungal infec- put hand lotion on your hands before handling cigarettes
tion, which can be spread to an unknowing client getting (which rinses away when the hands are washed and keeps
on and off massage table or wet table. For clients with sup- smoke odor from seeping into skin). Smoke outside at a
pressed immunity, this may cause serious complications. good distance away from the spa business. After smoking,
Remove jewelry including rings, wristwatches, bracelets, wash any areas of skin that might come into contact with
and necklaces. These items contain small crevices and sharp smoke. You might include the use of a salt scrub on your
edges that can harbor bacteria or potentially scratch a cli- hands to help eliminate the smell of smoke. Your face, neck,
ent. Small earrings that will not touch the client are fine. arms, and hands should all be washed. Brush your teeth
and rinse with mouthwash.
Proper Hand Washing
Proper sanitation of the hands is probably the single most Therapists Who Are Sick or Have Allergies
important part of the sanitation protocol for therapists (For A therapist who is sick or may have a contagious infection
Your Exploration 3–2). You need to clean your nails care- must protect clients by canceling all spa appointments. The
fully and use foaming liquid soap to thoroughly wash your common cold is caused by a large number of different vi-
hands up to your elbows. An alcohol-based hand rub is rec- ruses and is easily transmitted through the air or by direct
ommended for decontaminating the hands before the ses- contact. In general, the viruses that cause colds incubate in
sion, before or after certain treatment steps, and at the end the body for 12 hours to 5 days and then become contagious
of a session. Non–alcohol-based hand rubs have not been 23 hours before the onset of symptoms. The person remains
adequately evaluated by the CDC and are therefore not rec- contagious for about 5 days after the onset of symptoms.3
ommended. In those instances where you use gloves (see the Therapists with allergies with symptoms similar to those
upcoming section for details), wash your hands and decon- of a cold are not likely to be contagious but may need to
taminate them before putting gloves on and immediately take extra precautions to prevent spreading pathogens.

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42 Spa Bodywork: A Guide for Massage Therapists


Proper Hand Washing and Hand Decontamination

1. Clean your nails before your hands using an orange stick or

a personal nailbrush that has not been used by anybody
else. Wash your hands with a non–antimicrobial soap or an
antimicrobial soap (liquid soap with a pump dispenser is the
most sanitary—avoid bar soap) for 30 seconds using fiction and
lather to lift contaminants off the skin’s surface.

2. Clean the area between your fingers and from your forearms
up to your elbows. Rinse your arms and hands thoroughly with
running water and dry them with a disposable towel.

3. Use the same towel to turn off the water tap and to open any
doors on the way to the treatment room.

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Chapter 3 Client and Therapist Safety 43


Proper Hand Washing and Hand Decontamination (continued)

4. Use an alcohol-based hand sanitizer at these times: (A) Directly

after washing your hands and directly before touching the cli-
ent. (B) Directly after washing your hands and directly before
donning gloves and directly after removing gloves. (C) Directly
after moving from a potentially contaminated body area (e.g.,
feet) and directly before working on a clean body area (e.g.,
face). (D) Directly after touching an unsanitized inanimate
object (e.g., product container) and directly before touching
the client. (E) If you accidentally touch your hair or a mucous
membrane (eyes, nose) or cough or sneeze during the session.
Do not retouch the client until your hands have been decon-
taminated with the hand sanitizer. (F) Directly after removing
soiled linens from the table and directly before handling fresh

For example, if your eyes are itchy and watering, you must system. Wear heavy cleaning gloves, a face mask, and eye
decontaminate your hands if you rub your eyes in the mid- protection when handling cleaning products and increase
dle of a session. If sneezing is a problem, wear a face mask the ventilation in rooms where you are cleaning by open-
as an extra precaution. Inform clients that you suffer from ing windows or running ceiling fans. Many cleaning prod-
allergies to prevent the impression that you are sick. If you ucts also cause damage to the environment. In recent years,
are uncertain whether your symptoms are those of a cold or interest has increased in using natural, environmentally
allergy, take your temperature. Allergies usually do not el- friendly products for cleaning. Finding suitable products
evate body temperature, whereas even a low-grade cold will. is often difficult because of the unique challenges of sani-
tation in health care environments. Some U.S. and Cana-
dian health care workers have formed an association called
Sanitation of the Facility, Equipment, Health Care Without Harm: The Campaign for Environ-
and Supplies mentally Responsible Healthcare. This group offers a kit
A clean facility has a lower risk of pathogen transmission. to help health care providers “go green.” The kit can be
To provide a clean environment, pay attention to the proper ordered through their website at
use of cleaning products, sanitation of the treatment room /goingGreen. At the very least, avoid heavily scented clean-
and equipment, care of linens, proper product handling, ing products and look up cleaning product dangers at the
and general housekeeping activities. Occupational Safety and Health Administration (OSHA)
website at
Cleaning Products Antiseptics
A variety of cleaning products can be used in the spa busi- Antiseptics are safe for use on the skin and create an un-
ness. Use dusting aids and wood polishes on wood surfaces favorable environment for pathogen reproduction. Anti-
and glass cleaners on windows and mirrors. Antiseptics septics are weaker than disinfectants and do not kill some
and disinfectants are the most important types of cleaners types of pathogens but are generally appropriate for use in
used in a health care setting because they reduce the trans- a spa setting so long as no blood or body fluid is present.
mission of disease. These types of cleaners are described in Hand soap, iodine, hydrogen peroxide, and rubbing alcohol
detail below. are commonly used antiseptics. Rubbing alcohol is often
Note that cleaning products often contain ingredients used to spray clean countertops, doorknobs, and spa equip-
that cause irritation to eyes, the skin, and the respiratory ment in between clients.

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44 Spa Bodywork: A Guide for Massage Therapists

FIGURE 3–4 Proper use of gloves. (A) Directly before putting on gloves, wash your hands as described in the
section on “Therapist Hygiene,” and decontaminate your hands with an alcohol-based hand sanitizer. The gloves
should fit snugly and not roll down your hands while giving massage. When it is time to remove the gloves, peel
the first glove from the wrist to the fingers so that it is turned inside out. Any contaminants are now on the inside
of the glove away from you. (B) Place the fingers of your ungloved hand inside the second glove and peel it back
so that it is inside out. Make an effort not to touch the outside of the gloves with your ungloved hand. Dispose
of the gloves in a closed trash container and immediately wash and decontaminate your hands with alcohol after
removing the gloves.

Disinfectants including Staphylococcus, Streptococcus, hepatitis, HIV,

Disinfectants are stronger than antiseptics and should herpes, and tinea (the fungus that causes ringworm).
not be used on the skin. They kill or are effective against • Phenols (also called cresols): Phenols are used on hard
most bacteria and viruses. Disinfectants are also called ger- surfaces and are effective against tuberculosis, bacteria,
micides and bactericides. Commonly used disinfectants fungus, herpes, and the flu virus. Phenols are irritating
include bleach solutions, phenols, and quaternary ammo- for skin and the respiratory system.
nium compounds (quats). Disinfectants are used for deep • Quaternary ammonium compounds (quats): Quats
cleaning at the end of the day, if an infectious agent may be are formulated to kill pathogens on a variety of hard sur-
present (e.g., if a client denied having a cold but sneezed and faces and are effective against pseudomonas, Staphylococ-
coughed throughout the session) or if blood or body fluids cus and Salmonella, certain bacteria, HIV, and the hepati-
are present. tis B and C viruses.
• Bleach solutions: Bleach mixed with water in a 10% con- Sterilization is the elimination of all microorganisms
centration is used to clean hard surfaces such as counter- on and in an object through heat, chemical substances,
tops, equipment, and floors and to clean linens exposed or irradiation. Sterilization is rarely used in massage en-
to body fluids. It is noted to be effective on pathogens vironments but might be used in a spa environment. It is

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Chapter 3 Client and Therapist Safety 45

commonly used in hospitals where moist heat (hot water or Modern hydrotherapy tubs usually have a self-cleaning
steam) or dry heat is used to sterilize medical instruments. function that makes sanitizing the jets of the tub easier:
Sterilization with an autoclave (a device in which high tem-
• Put a concentrated disinfectant (formulated by the man-
perature and pressure is used to sterilize instruments) may
ufacturer of the tub) into the special holder and then
be used in some spa environments where estheticians use
push the button.
sharp implements to pierce the superficial layers of the skin
• At the end of the cleaning cycle, dry the tub and put out
when performing deep cleaning facials that include extrac-
fresh bath mats and towels for the next client.
tions of whiteheads and blackheads.
• Between clients, wipe down the area around the tub, includ-
Sanitation of the Treatment Room and Equipment ing the floor and any handrails, with an antiseptic, and deep
clean the area with a disinfectant at the end of the day.
Sanitizing the treatment room and equipment involves a
cleaning step that removes visible dirt and a sanitation step Small, one-person steam cabinets should be completely
that removes most pathogenic organisms from inanimate wiped with an antiseptic between clients. For larger steam
objects with an antiseptic. Follow these guidelines: rooms or steam showers, sanitize the floor and seat between
clients, although the walls can be left until the end of the
• Wipe down countertops, equipment, treatment chairs day. Disinfect this equipment at the end of each workday.
and tables, the floor, and any other hard surface such
as doorknobs, handles, and cabinets with an antiseptic Proper Care of Linens
such as alcohol between clients.
• If possible, open windows and doors to ventilate the Clean linens are stored in a closed cabinet until they are
room and circulate air. brought out for use. Decontaminate your hands after
• At the end of the day, deep clean the treatment room, touching soiled linens and before placing fresh linens on the
equipment, and hard surfaces with a disinfectant. table. Linens may include massage sheets, face cradle covers,
• Usually, a sick client is sent home without receiving a spa bolster and pillow covers, uniforms, smocks, hair wraps, robes,
treatment. If you suspect that a client was on the verge washable slippers, blankets, draping material, and washable
of a cold or the flu, deep clean the treatment room with floor mats. Any item that comes into contact with the client’s
a disinfectant before proceeding with the next session. skin or hair during the session must be stored in a closed, ven-
• Regularly dust window blinds, shelves, decorative items, tilated container and washed before use with another client.
picture frames, and lamp fixtures. Keep electronic equip- Soiled linens should not be stored in the treatment room but
ment and CDs neatly organized and free from dust. should be moved to the laundry or work area. At the end of
• Wash all reusable equipment such as metal or plastic bowls, the day, wash linens in hot water with regular detergent, dry
spatulas, application brushes used in spa treatments, and them with heat, and return them to the closed cabinet. Handle
soda coolers (used to hold hot towels) in hot, soapy water linens soiled with body fluids with special caution as discussed
and sanitize them with alcohol between clients. in the upcoming section on “Universal Precautions.”

Specialized equipment such as foot soaking basins, Proper Product Handling

hydrotherapy tubs, showers, and massage tools such as hot
Keep lubricants and special treatment products refrigerated
stones used in stone massage must be cleaned and sanitized
between uses to prevent the breakdown of their natural oils or
with a disinfectant between clients. Foot soaking basins
therapeutic properties. Transfer lubricants used for massage
are of special concern especially if they have jets that might
from larger, bulk containers to smaller bottles so that they
harbor bacteria:
can be heated without damaging the unused product, which
• Wash them with hot, soapy water and spray them with a would break down if heated, cooled, and reheated. Some
disinfectant. products are dispensed directly into your hand using a pump
• Allow the disinfectant to remain for 10 minutes and top or flip lid. Take care to decontaminate the pump con-
then wipe the basin dry. tainer with an antiseptic both before and after each session.
• If the basin has jets, flush a bleach solution through the Remove spa products from their original closed contain-
jets to eliminate pathogens. ers with a sanitized spoon or spatula and placed them in pre-
sanitized holders for later use during the treatment. Cover
Follow these guidelines for cleaning a shower:
the spa product with plastic wrap to avoid contamination
• Clean, disinfect, and dry the shower after use by each client. before use. All products would become contaminated if you
• Disinfect the shower curtain or door and the floor out- used your hands to remove the product or dip into the origi-
side the shower. nal container during the treatment. Discard any unused spa
• Change all towels and the mat outside the shower for product rather than return it to the original container. Dur-
each client. ing a body treatment, proper waste disposal procedures are
• Use only liquid soaps or shower gels. Bars of soap that important. Some items used in the treatment are used only
have been used by more than one person are unsanitary once (e.g., gauze, sponges, and plastic body wrap). Dispose
and should not be left in the shower or sink. of these items in a closed trash can immediately after use.

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46 Spa Bodywork: A Guide for Massage Therapists

Housekeeping Activities membranes, or contact with blood and body fluid. To un-
The general cleanliness of the facility must be assessed and derstand universal precautions, it is helpful to understand
maintained on a daily basis. The reception area, retail area, HIV/AIDS and hepatitis, to know when to use gloves, and
office area, hallways, and bathrooms all need attention. to know the proper methods for cleaning up body fluids
and items exposed to body fluids.
• Vacuum or sweep and mop floors daily.
• Wipe items such as coffee tables, beverage dispensers, HIV/AIDS
toys in the reception area, doorknobs, handrails, and the HIV causes AIDS. HIV is transmitted through body fluids
reception countertops daily with an antiseptic. including semen, vaginal secretions, and blood and can be
• Deep clean bathrooms and empty trash bins at the end transmitted during pregnancy from a mother to her fetus
of each work day. or after birth through breast milk. HIV can also be spread
• Clean window ledges, retail shelving, picture frames, and by drug users sharing a needle, by accidental needle pricks,
light fixtures weekly. and from infected blood used in a blood transfusion (rare
• Fish tanks and water fountains are not advised because in developed countries). There is no evidence that HIV is
they may harbor pathogens and are difficult to keep transmitted through saliva, sweat, tears, urine, or feces
clean. unless the fluid contains blood. There is no evidence that
Think also about the safe use of food items in the busi- HIV is spread through casual contact such as sharing tow-
ness. Home-baked products are not advised, but individu- els, food utensils, telephones, or swimming pools. HIV is
ally wrapped items such as chocolates, granola bars, sports not believed to spread by biting insects such as mosquitoes
bars, and popsicles can be used. It’s a good idea to provide or fleas.3
filtered water from commercial dispensers. These water HIV is a retrovirus that can live in the infected indi-
containers come presealed to prevent contamination. Use vidual for a long time before causing symptoms. The Na-
disposable cups for all beverages including tea, juice, or tional Institute for Allergies and Infectious Diseases reports
water. Table 3–2 provides a checklist of tasks to ensure you that people infected with HIV develop a flulike illness 1 to
maintain a clean, sanitary, and safe facility. 2 months after their initial exposure to HIV. The symptoms
are often mistaken for another viral infection and clear up
within a week or two. Severe symptoms may not appear
Universal Precautions
for 10 years or longer. (Children born with HIV develop
The purpose of universal precautions is to ensure that symptoms around the age of 2 years.) During this period,
health care workers protect themselves from blood- HIV is slowly multiplying and killing immune system cells.
borne diseases transmitted through broken skin, mucous Gradually, infected people experience periodic symptoms

TABLE 3–2 Tasks to Ensure a Clean, Sanitary, and Safe Facility


❏ Open doors and windows to ventilate ❏ Wash all bowls, implements, applica- ❏ Clean windows, window frames, and window
room. tion brushes, trays, and other equip- ledges.
❏ Remove soiled linen from table, face ment with hot, soapy water and wipe ❏ Deep clean the reception area and wipe down
cradle, bolsters, etc. with a disinfectant before storing them chairs, the beverage service, magazines, and
❏ Wipe massage table, face cradle, and in closed containers. decorative side tables.
bolster with disinfectant. ❏ Wash cloth products such as massage ❏ Wipe down shelving used to hold retail items
❏ Cover table, face cradle, and bolsters sheets, blankets, robes, slippers, hand and dust retail items.
with fresh linens. towels, bath towels, and shower mats ❏ Dust light fixtures, picture frames, the music
❏ Disinfect countertops, door handles, in hot water with detergent and dry system, shelving, and decorative items in the
and any objects clients regularly touch. using heat before storing in a closed treatment room.
❏ Disinfect the lubricant container or container. ❏ Organize CDs, storage cabinets, and
bottles used to hold spa product. ❏ Deep clean and disinfect bathrooms. supplies.
❏ If tools (hot stones, massage tools, ❏ Clean floors, clean and disinfect ❏ Check smoke detectors to ensure they are in
etc.) were used during the session, items in the reception area, clean any good working order.
wipe them with a disinfectant. beverage service items, clean common ❏ Check and replace light bulbs both inside
❏ If a shower or wet room has been areas, and disinfect items such as and outside the facility.
used, it must be disinfected and dried. handrails and doorknobs. ❏ Water and dust plants.
❏ If a hydrotherapy tub or foot basin with ❏ Empty and disinfect trash bins.
jets has been used, the jets must be
flushed with bleach or the manufac-
turer's recommended cleaner and dried.
❏ Change bath mats and towels if
shower or tub has been used.

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Chapter 3 Client and Therapist Safety 47

such as swollen glands, decreased energy, weight loss, fevers When to Use Universal Precautions
and night sweats, persistent yeast infections, short-term Spa therapists rarely make contact with clients’ body fluids in
memory loss, persistent pelvic inflammatory disease, fre- practice, but in some situations, a therapist may be exposed
quent and severe herpes outbreaks, and shingles. to a body fluid and therefore be at risk for infection. A scab
An HIV infection is called AIDS when the HIV-infected may rub off during the application of a product, a blemish
person has fewer than 200 CD3⫹T cells (the immune sys- may erupt under the pressure of a massage stroke, menstrual
tem’s primary infection fighting blood cells). Uninfected blood may leak onto the treatment table, or a client may
adults usually have 1,000 or more CD3⫹T cells. The im- experience nausea during treatment and vomit in the treat-
mune system, gradually destroyed by HIV, loses its ability ment room. Universal precautions are an approach to infec-
to fight off common pathogens that usually do not cause tion control in which all blood and body fluids are treated
illness in healthy individuals. In people with AIDS, these as if infected with HIV, hepatitis, or another bloodborne
opportunistic infections can be severe and often are fatal. pathogen. Universal precautions are guidelines for dealing
People with AIDS are also prone to developing various can- with broken skin and mucous membranes, blood and other
cers, especially those caused by viruses and cancers of the body fluids, and the cleanup of body fluids. Important com-
immune system (lymphomas). ponents of universal precautions include the following:
Massage and many spa treatments are safe for HIV-
positive clients who do not have symptoms. In the advanced • Correctly using gloves
stages of AIDS, many forms of bodywork or spa treatments • Properly cleaning linen soiled with blood or body fluids
may still be safe, but the most effective techniques depend • Properly cleaning surfaces contaminated with blood or
on the individual client’s level of health. It is unlikely that body fluids
a therapist would contract HIV from a client during the Use of Gloves
delivery of a spa treatment or massage, but the use of uni- Vinyl gloves are worn to protect both the client and thera-
versal precautions is required. This is especially important pist from the transmission of disease. Wear gloves at these
because an HIV-positive client must be protected from an times:
undetected infection the therapist may have.
• Any time the potential exists to come into direct contact
Hepatitis with blood or body fluid
Several different viruses cause different forms of hepatitis, • If the client has broken skin such as a scratch, open cut,
termed hepatitis A through G. These are diseases character- or blemish
ized by inflammation of the liver. Hepatitis A, B, and C are • If you have broken skin on your hands or forearms, such
the most common forms. as a scratch, hangnail, or blemish
• If you are likely to come into contact with mucous mem-
• Hepatitis A virus (HAV): HAV is transmitted through
branes; this is rare in a spa environment, but in some
contaminated food and water or by contact with fe-
states, intraoral massage is sometime used with condi-
ces. It usually resolves in a few weeks without medical
tions such as temporomandibular joint disorder
• When you are cleaning linens or hard surfaces soiled
• Hepatitis B virus (HBV): HBV is spread through many
with blood or body fluids
of the same routes as HIV but is a hundred times more
• If the client is HIV-positive or has a condition that causes
contagious than HIV. Many people who contract hepati-
weakened immunity
tis B recover fully and have no long-term complications.
• If you are HIV-positive or a hepatitis carrier
Some individuals develop chronic hepatitis B and be-
come carriers of the disease. These people may develop Wear gloves also any time you are concerned about the
varicose veins on the stomach and esophagus, cirrhosis potential for infection or the client requests it.
of the liver, and liver cancer.4 Latex gloves break down when exposed to oil-based
• Hepatitis C: Hepatitis C is transmitted primarily lubricants such as those used in massage. Latex may also
through contact with infected blood (often by drug us- cause a mild to very serious allergic reaction or skin sensi-
ers sharing needles). Hepatitis C spreads less commonly tivity. For this reason, vinyl gloves are recommended. Vinyl
through sexual contact and childbirth, but these are pos- gloves do not break down when exposed to oil-based lubri-
sible routes. Of people who contract hepatitis C, 75% to cants or spa products and seldom cause allergic reactions
95% develop chronic long-term infections and have an or skin sensitivity.
increased risk for cirrhosis and liver cancer.5
Proper Cleanup of Soiled Linen
Spa treatments and massage are contraindicated for in- Linens soiled with blood or body fluids should be handled
dividuals with acute hepatitis. Clients with chronic hepati- with gloves and stored in a leakproof bag until they can be
tis can benefit from many spa treatments, but techniques laundered. Wash these linens separately with laundry de-
should be chosen based on the individual’s level of health. tergent and chlorine bleach. Dry them with heat and store
Universal precautions are required. them as normal in a closed cabinet.

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48 Spa Bodywork: A Guide for Massage Therapists

Proper Cleanup of Blood or Body Fluids on • Fire plan: Check with state authorities to ensure that
Hard Surfaces proper fire and safety codes are followed. At least one
Add one part bleach to nine parts water (10% bleach solu- fire extinguisher and smoke detector should be in clear
tion) to clean hard surfaces contaminated with blood or view; more are likely needed. Check the fire extinguisher
body fluid. Wear gloves and use disposable cleaning materi- and all smoke and heat detectors monthly to ensure they
als such as paper towels to wipe up the spill. Dispose of the are in good working order. A fire escape route should be
cleaning materials in a closed trash container. clearly indicated in every room. The use of candles, in-
Because new information about communicable diseases is cense, and open flames is not advised.
issued often, keep up-to-date about the most recent standards • Emergency numbers: Keep a list of emergency phone
and guidelines issued by the CDC ( numbers by the business phone. This includes the local
fire station, poison control center, police department,
ambulance, and local hospital or emergency medical
facility. Keep your liability insurance coverage up-to-date
Creating a Safe Environment and display a copy on the premises.
Injury or harm is unlikely to happen in a safe environment.
In such an environment, conditions that may cause injury Safety of the Client
have been eliminated. Procedures are adopted to increase
To ensure the safety of the client, stay up-to-date with your
security and plans made to efficiently handle any accidents
training in CPR and first aid. A first aid kit should be kept
that may occur. The safety plan should include guidelines
in each treatment room along with hydrocortisone cream,
for ensuring the safety of both clients and therapists. If you
which can be used to decrease any skin reactions to spa
decide to open your own practice, you have greater control
products. Never give a spa treatment without first taking
over safety issues than if you work as an employee. As an em-
a thorough health history. If you have any concern that a
ployee, maintain your awareness of safety issues and alert
spa treatment is contraindicated for a particular client, err
your supervisor should you feel that the environment is not
on the side of caution and contact the client’s physician or
conducive to your safety and/or the safety of your clients.
postpone treatment. Because all therapists will need to look
up a health condition, medication, or other information at
Safety of the Facility some point during their professional career, have available
key reference books including an up-to-date medical dic-
The facility must be accessible to a wide array of clients, tionary, drug reference, and pathology reference book.
including those who are unsteady on their feet and those Some clients need help getting on and off the treat-
using wheelchairs. Assess the parking area, common areas, ment table. Provide a wide step stool and offer assistance
equipment, and fire plan: to elderly clients, pregnant clients, and clients with physical
• Parking area: Begin an assessment of the facility in the challenges. Do not leave alone a client who is unstable and
parking area. Is the pavement smooth and even, or are may fall. Instead, assist the client to the treatment room
cracks or an uneven surface present that may cause a cli- and help with undressing if appropriate. After the session,
ent to fall? Is lighting adequate and the pathway to the wipe the client’s feet with a paper towel to remove excess
front door unobstructed? If clients must climb stairs or lubricant from the foot massage, which could cause a client
use a wheelchair ramp, are these areas well lit and hand- to slip while getting off the treatment table, especially in
rails provided? wet rooms with tiled floors.
• Common areas: All common areas such as the reception
area, hallways, and bathrooms should have good light- Alcohol, Drugs, and Prescription Medications
ing and nonslip flooring and be free of area rugs (which It is a serious breach of professional ethics for the therapist
may cause a client to trip) and barriers. Bathrooms to work while under the influence of an illegal drug or alco-
should include a lavatory at wheelchair height and hand- hol. This would place clients at risk of emotional harm or
rails. Doorways should be wide enough to accommodate physical injury. These substances also interfere with logical
people with physical disabilities, and lever-style door reasoning and decision making, which might lead to mak-
handles used. ing a poor treatment choice for a client. Alcohol and drugs
• Equipment: Regularly check equipment to ensure that also influence the therapist’s behavior and feelings and
it is in good working condition. Check bolts, hinges, and may result in inappropriate communication or emotional
knobs for tightness before each spa session. Any exposed outbursts. Therapists who are suffering from a hangover
electrical cords should be heavy-duty and taped down should cancel any spa appointments or refer their clients to
around the edges of the room, behind furnishings and another therapist.
equipment when possible. Do not run extension cords Sometimes, a therapist must take prescription medica-
across a doorway or in any area where therapists or tions for a condition or disorder. Each situation is unique,
clients must walk. as is the therapist’s response to the medication. Be aware

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Chapter 3 Client and Therapist Safety 49

that medications may alter your perception, change your to discuss the situation, document this conversation and
behavior, or affect your physical abilities. Talk with the pre- keep it with the accident file. If a client is involved, a signed
scribing physician about possible side effects in relation to release is required before sending client information to an
your spa duties and responsibilities. Always act in the best outside entity (e.g., insurance company, equipment manu-
interests of the client. If the medication interferes with your facturer). This protects the client’s privacy.
physical or mental ability to provide a safe and beneficial
spa treatment, you may need to explore different medica-
tion options or take a break from your career until the situ- Safety of the Therapist
ation improves. While at work, you may be required to lift heavy objects
Spa treatments may also be contraindicated for clients such as laundry, bulk spa products, or housekeeping sup-
taking a prescription or over-the-counter medication that plies. Always use good body mechanics to prevent back in-
distorts their perceptions of hot, cold, pain, or pressure, or jury. You will also come into contact with strong cleaning
you may have to adapt the treatment to each client’s needs. products and should wear heavy gloves, a face mask, and
Do not provide a spa treatment to a client under the in- protective eyewear to prevent contact with your eyes, respi-
fluence of an illegal drug or alcohol because it would place ratory system, or skin.
both of you in an unsafe situation. Spas that serve alcohol When you take good care of yourself, you are less likely
as part of a treatment should rethink this policy because it to suffer an injury or illness while working as a spa thera-
places them at liability risk in the event the client has a slip pist. Proper nutrition, adequate sleep, exercise, stress reduc-
and fall accident at the spa facility or an accident while driv- tion activities, and good body mechanics all support your
ing home from the spa. health and longevity in the profession.

Accident Report Client Screening

Any time that anyone at a business—including employees, In some areas, illegitimate massage at illegitimate spas is
the owner, clients, and visitors—is injured in an accident, still used as a cover for prostitution. Although most clients
causes injury to another, or causes property damage, an understand that professional massage is for wellness and
accident report should be written and filed. This report good health, some people seek massage for sexual grati-
should provide detailed and accurate information about fication. Regardless of whether your practice is based in
the accident, the people involved, injuries or property dam- your home or office or as a “call-out” service, careful client
age, and how the situation was resolved. This information screening helps ensure your safety.
must be accurate and detailed because it may be used by an The screening process begins when the client calls to
insurance company to process a claim or may be evidence in book an appointment or inquire about fees and services.
a lawsuit. The accident report should include the following: Ask clients for their name, address, home phone number,
work phone number, occupation, and how they heard
• The address and location in the premises where the
about the spa business. Record all of this information in
accident occurred
a client’s new file. Ask what type of spa treatment or mas-
• The date and time
sage they are looking for (e.g., relaxation, sports, hot stone
• The name of the person filing the report and his or her
massage, an herbal body wrap). Ask if this is the first spa
job title
treatment or massage and/or if they have received spa treat-
• The name, address, e-mail, and phone number of all
ments or massage regularly. With clients who have had spa
individuals involved and those of any witnesses
treatments or massage before, ask them to describe the re-
• A detailed account of what happened
sults they experienced and their current expectations for a
• Written witness accounts of what happened when
spa treatment or massage. If the answers do not seem le-
gitimate, be courteous but continue to question and edu-
• A description of injuries or property damage
cate the client. For example, you might say, “I would like
• How the matter was resolved (e.g., the individual was
to inform you about our spa policy.” This information can
sent to the emergency room, the individual refused med-
include the policies for a no-show client, the draping policy,
ical treatment and went home)
and the policy on drugs and alcohol. A client who confuses
If more information later becomes available, it should massage with sexual favors may say something such as, “Do
be documented and kept in the same file as the accident you provide erotic massage or spa treatments?” “What will
report. For example, if a client was injured by falling off you wear during the spa treatment?” “What do you look
a wet table and a physician diagnosed an ankle sprain the like?” “Can I massage myself during the session?” or “Will
next day, record this in the file. If the accident was caused by you help me if I get excited?” Remain courteous but end the
equipment failure (e.g., the wet table suddenly buckled due conversation and refuse the appointment.
to a faulty brace), file a report with the manufacturer im- All therapists should be careful about booking new cli-
mediately. File a copy of this letter along with any response ents during times when they are alone in the office. Avoid
from the manufacturer. If the manufacturer telephones this situation whenever possible. If you cannot avoid such

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50 Spa Bodywork: A Guide for Massage Therapists

a situation, make arrangements with someone available to an injury that requires medical attention, or symptoms
assist by telephone. Tell this person the time of the appoint- that are intense and unexplained (e.g., intense headache
ment and that you will call again after the intake interview. pain). For example, a client with chickenpox or pink eye
If anything feels strange during the intake interview, cancel should not receive a spa treatment because the client
the session and politely ask the client to leave. When the cli- is extremely contagious, and these conditions could be
ent leaves, call your backup person to say that you are safe. passed to the therapist or to other clients. Similarly, mas-
The backup person should be instructed to call you if you sage should not be provided to relieve headache pain in
have not called by the time specified, and if you do not pick a client with a recent concussion. Not only would mas-
up the phone, they should call emergency services. sage overstimulate this client, but the client also needs to
see a physician to rule out serious complications. Note in
Incident Report Table 3–3 that many conditions are contraindicated in
An incident report is written whenever an unusual event an acute stage, when the body is inflamed and the condi-
occurs that creates an unsafe environment or distress for tion flares up, but are not contraindicated in a subacute
a client, therapist, or business owner. For example, a thera- or chronic stage. Usually, if massage is contraindicated,
pist might file an incident report if a client makes sexual spa treatments will also be contraindicated; sometimes,
advances during a spa session and the therapist had to end the opposite is true. Sunburn is a good example. Mas-
the session. The report should go directly to the business sage is contraindicated, but a soothing aloe vera and
owner, who should then inform the client that he or she German chamomile essential oil wrap are not.
is no longer welcome at the spa. Another example is a cli- • Local contraindication: A condition may affect only
ent who is unhappy with the spa session and demands a one area of the body. Spa treatments can be applied to
refund. The therapist should document why the client was the rest of the body, but the local area is avoided. If a cli-
unhappy and actions taken to solve the problem. An inci- ent recently had a mole removed, you would not massage
dent report should include the following: or apply seaweed over the area of reforming skin. If a cli-
ent has a swollen knee, you would not apply warm mud
• The date, time, and place the incident occurred
to the area distal to the swelling and the swollen area,
• The name of the person filing the report and his or her
but the area proximal to the swelling and the rest of the
body can be treated.
• The name, address, e-mail, and phone number of all
• Advanced understanding: Some therapists receive ex-
involved individuals and any witnesses
tra training and specialize in working with clients with
• A detailed account of what happened
specific conditions. Because of their experience, often
• Written witness accounts of what happened when
through participation on a health care team, they develop
an advanced understanding of the condition and know
• How the matter was resolved (e.g., the client was told
the limits of spa treatments and massage. These thera-
that he or she is no longer welcome at the clinic, the cli-
pists can often work safely with a condition that would
ent was given a refund and referral to another therapist)
be contraindicated for a less experienced therapist. Nov-
ice therapists may avoid certain conditions early in their
practices and then work with the same condition later as
their knowledge increases with professional experience.
Cautions and Contraindications Regardless of your level of experience, it is important to
obtain a physician’s release with complex conditions or
A contraindication is any condition that makes the ap-
clients who are taking multiple medications.
plication of spa treatments unadvised or potentially dan-
• Physician’s release: Before providing spa treatments to
gerous to the health of the client. Table 3–3 provides an
clients with certain conditions, it is prudent to obtain a
overview of conditions that may contraindicate spa treat-
physician’s release. The release indicates that the physi-
ments or require greater caution from the therapist. Follow-
cian believes that the spa treatment will not harm the cli-
ing are the different types of contraindications and other
ent and may prove beneficial to the client’s health. Some
physicians do not understand spa treatments, their phys-
• Absolute contraindication: If the client has a condition iological effects, or the increased burden they might place
that is an absolute contraindication, the client should on a client’s system. If possible, explain to the physician
not receive a spa treatment or a massage. Examples in- or the physician’s staff the types of methods you plan to
clude a significant fever (100°F or higher), vomiting, a use in the client’s session and the ways these methods
cold (unless the symptoms have been present for 5 days might affect the client’s body systems. This may help the
or longer; usually, people are contagious from 24 hours physician make the best possible recommendations.
before they notice symptoms to 5 days after the first • Use caution: In many cases, spa treatments are not con-
symptom), an acute systemic condition (when the condi- traindicated, but the session must be adapted to fit the
tion affects the entire body and not just one local region), (text continues on page 56)

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Chapter 3 Client and Therapist Safety 51

TABLE 3–3 Contraindications Chart












Abortion, recent UC AU UC UC UC UC UC C UC C UC UC ▲ UC ▲
Acne vulgaris C UC SC SC SC SC SC SC SC UC UC UC SC SC ▲ X
Acromegaly X UC UC UC UC UC UC UC UC UC C b
Addison’s disease X UC UC UC UC UC UC UC UC UC C UC UC ▲ UC UC
AIDS (client condition X UC UC UC UC UC UC UC UC UC UC UC UC ▲ UC UC
Allergies: shellfish, ▲ ▲ C ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
iodine, seafood
Alzheimer’s disease X UC UC UC UC UC UC UC UC UC C C C UC UC UC
Amenorrhea ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Angina pectoris X UC C UC UC UC UC UC C C C UC C UC UC UC
Anorexia nervosa X UC UC C ▲ ▲ ▲ UC C UC C ▲ C ▲ UC ▲
Anxiety disorder X ▲ UC ▲ ▲ ▲ ▲ ▲ ▲ ▲ C C C UC UC ▲
Arteriosclerosis X UC C b
Asthma ▲ UC ▲ ▲ ▲ ▲ ▲ ▲ ▲ C ▲ UC ▲ ▲ ▲
Atherosclerosis X UC C b
Athlete’s foot C SC ▲ SC SC SC SC SC SC ▲ ▲ ▲ ▲ SC SC
Bed sore or pressure X SC AU SC SC SC SC SC SC SC C UC UC ▲ SC SC
Bipolar disorder X UC UC UC UC UC UC UC UC UC C C C UC UC UC
Bronchitis ▲ UC ▲ ▲ ▲ ▲ ▲ ▲ ▲ UC ▲ UC ▲ ▲ ▲
Bruise SC SC ▲ ▲ ▲ ▲ SC SC SC SC ▲ ▲ ▲ SC SC
Cardiac arrest, X UC C UC UC UC UC UC C C C UC C UC UC UC
history of
Cerebral palsy X
Chickenpox X
Cholecystitis Xb
Chronic fatigue ▲ UC ▲ ▲ ▲ ▲ ▲ UC UC C ▲ UC ▲ UC ▲
Cirrhosis of the liver X
For a description of the conditions, please refer to a pathology textbook.
Except under medical supervision or with advanced training or specialized understanding.
▲, indicated/safe; AU, advanced understanding required; C, contraindicated; SC, site contraindicated; UC, use caution.
(continued on page 52)

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52 Spa Bodywork: A Guide for Massage Therapists

TABLE 3–3 Contraindications Chart (continued)












Common cold (2 to UC UC UC UC UC UC UC UC UC UC ▲ UC ▲ UC UC
3 days after acute)
Congestive heart Xb
Conjunctivitis X
Constipation ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ UC ▲ ▲ ▲ ▲ ▲
Contact dermatitis SC UC SC SC SC SC SC SC SC C C UC SC SC SC
Contusion or X
concussion, recent
Coronary artery X UC Cb UC UC UC UC UC C C C UC C ▲ UC UC
Crohn’s disease X UC UC UC UC UC UC UC UC UC C UC UC ▲ UC UC
Cushing’s disease X UC UC UC UC UC UC UC C UC C UC UC UC UC UC
Cystic fibrosis X UC AU UC UC UC UC UC UC UC UC UC UC ▲ UC UC
Cystitis (chronic; ▲ UC ▲ ▲ ▲ ▲ ▲ UC ▲ C ▲ ▲ ▲ ▲ ▲
acute C)
Depression X ▲ UC ▲ ▲ ▲ ▲ ▲ UC ▲ UC UC UC UC ▲ ▲
Diabetes insipidus X UC Cb Cb UC UC UC UC UC UC C UC UC UC UC
Diabetes mellitus X UC C C UC UC UC UC C C C UC C ▲ UC UC
Diarrhea Xb
Diverticulitis X UC UC UC UC UC UC UC UC UC C UC UC ▲ UC UC
Diverticulosis X UC UC UC UC UC UC UC UC UC C UC UC ▲ UC UC
Dysmenorrhea ▲ UC ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Embolism X UC Cb UC UC UC UC UC C C C UC C ▲ UC UC
Emphysema ▲ UC UC UC UC UC ▲ UC UC C ▲ UC ▲ UC ▲
Endocarditis X
Endometriosis ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Fever X
Fibrocystic breast ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Fibroids ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Fibromyalgia ▲ AU ▲ ▲ ▲ ▲ ▲ UC ▲ UC ▲ UC ▲ UC ▲
Flaccid muscles ▲ AU ▲ ▲ ▲ ▲ ▲ UC ▲ UC ▲ ▲ ▲ ▲ UC
Gastritis (chronic; UC UC UC UC UC UC UC UC UC C UC UC ▲ UC UC
acute C)
For a description of the conditions, please refer to a pathology textbook.
Except under medical supervision or with advanced training or specialized understanding.
▲, indicated/safe; AU, advanced understanding required; C, contraindicated; SC, site contraindicated; UC, use caution.

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Chapter 3 Client and Therapist Safety 53

TABLE 3–3 Contraindications Chart (continued)












Gastroenteritis X
Gastroesophageal UC UC UC UC UC UC UC UC UC C UC UC ▲ UC UC
reflux disease
Goiter UC UC C ▲ ▲ ▲ ▲ UC ▲ UC ▲ ▲ ▲ UC UC
Graves’ disease X UC UC C UC UC UC UC UC UC UC UC UC ▲ UC UC
Hemophilia X C C UC UC UC UC UC C C C UC C ▲ UC UC
Hemorrhage X
Hepatitis (chronic; X UC Cb UC UC UC UC UC UC UC C UC UC ▲ UC UC
acute C)
Herniated disk X SC AU SC SC SC SC SC SC SC C UC UC ▲ SC ▲
Herpes simplex SC SC SC SC SC SC SC SC SC SC SC SC UC SC ▲
Hypercholesterolemia X UC Cb UC UC UC UC UC UC UC C UC C ▲ UC UC
Hypertension X UC Cb UC UC UC UC UC C UC C UC C ▲ UC UC
Hyperthyroidism X UC UC C UC UC UC UC UC C C UC UC ▲ UC UC
Hypotension X UC Cb UC UC UC UC UC C UC C UC C C UC UC
Hypothyroidism X UC UC C UC UC UC UC UC UC C UC UC ▲ UC UC
Ichthyosis vulgaris UC UC UC UC UC UC UC UC ▲ C ▲ ▲ UC UC UC X
Impetigo X
Inflammation, acute C AU AU AU AU AU SC SC SC C C AU UC C SC
Inflammation, ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Inflammation, sub- C AU AU AU AU AU UC SC AU C UC UC UC SC UC
Influenza X
Insomnia ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Intestinal obstruction X
Irritable bowel UC UC UC UC UC UC UC UC UC UC UC UC ▲ UC ▲
Jaundice X
Kidney stones X ▲ UC ▲ ▲ ▲ ▲ ▲ ▲ ▲ UC ▲ UC ▲ ▲ ▲
(acute C)
Lice X
For a description of the conditions, please refer to a pathology textbook.
Except under medical supervision or with advanced training or specialized understanding.
▲, indicated/safe; AU, advanced understanding required; C, contraindicated; SC, site contraindicated; UC, use caution.
(continued on page 54)

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54 Spa Bodywork: A Guide for Massage Therapists

TABLE 3–3 Contraindications Chart (continued)












Lou Gehrig’s disease Xb
Lupus (in remission) X UC C UC UC UC UC UC C C C UC C ▲ UC UC
Lymphangitis X
Lymphedema Xb
Meningitis X
Menopause ▲ UC ▲ ▲ ▲ ▲ ▲ UC UC UC ▲ ▲ ▲ ▲ ▲
Mononucleosis X
Multiple sclerosis Xb
Muscular dystrophy X UC UC UC UC UC UC UC UC UC C UC UC ▲ UC UC
Myocardial infarction X UC C UC UC UC UC UC C C C UC C UC UC UC
(history of)
Myocarditis X
Neuropathy X SC C SC SC SC SC SC C C C UC UC ▲ SC SC
Obesity ▲ AU UC ▲ ▲ ▲ UC UC UC C ▲ UC ▲ UC ▲
Osteoarthritis X UC UC ▲ ▲ ▲ ▲ ▲ UC ▲ UC UC UC ▲ UC UC
Ovarian cysts ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Pancreatitis (chronic; X UC UC UC UC UC UC UC UC UC C UC UC ▲ UC ▲
acute C)
Paralysis Xb
Parkinson’s disease X UC UC UC UC UC UC UC UC UC C C C UC UC UC
Pelvic inflammatory X
Pericarditis X
Peripheral vascular X SC C SC SC SC SC SC C C C UC C ▲ SC SC
disease, mild
Peritonitis Xb
Phlebitis X SC C SC SC SC SC SC C C C UC C ▲ SC SC
Pleurisy, nonbacterial X UC C b
Polycystic kidney X ▲ UC ▲ ▲ ▲ ▲ ▲ UC ▲ C ▲ ▲ ▲ ▲ ▲
Preeclampsia X
Pregnancy, high risk X UC C C C C C UC C C C UC C C C UC
For a description of the conditions, please refer to a pathology textbook.
Except under medical supervision or with advanced training or specialized understanding.
▲, indicated/safe; AU, advanced understanding required; C, contraindicated; SC, site contraindicated; UC, use caution.

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Chapter 3 Client and Therapist Safety 55

TABLE 3–3 Contraindications Chart (continued)












Premenstrual ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Prostatitis ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ UC ▲ ▲ ▲ ▲ ▲
Pseudo sciatica X UC UC UC ▲ ▲ ▲ ▲ UC ▲ UC ▲ ▲ ▲ UC ▲
Pulmonary edema X
Pyelonephritis X
Raynaud’s syndrome UC Cb UC UC UC UC UC UC UC C UC C ▲ UC UC
Rheumatoid arthritis X UC AU UC UC UC UC UC C SC C UC UC ▲ UC UC
Ringworm X
Scabies X
Scars, old UC ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Scleroderma X UC AU UC ▲ ▲ ▲ UC UC ▲ C UC UC UC UC ▲
Sebaceous cyst UC UC UC UC UC UC SC SC UC UC ▲ ▲ ▲ UC ▲ X
Sickle cell disease X UC C UC UC UC UC UC C C C UC C ▲ UC UC
Sinusitis (no fever ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲
Site infection or SC SC UC SC SC SC SC SC SC ▲ ▲ ▲ ▲ SC SC
Skin tabs UC ▲ ▲ ▲ ▲ ▲ UC UC ▲ ▲ ▲ ▲ ▲ UC ▲ X
Substance abuse, X ▲ UC ▲ ▲ ▲ ▲ ▲ ▲ ▲ UC UC UC ▲ ▲ ▲
recovery from
Sunburn C AU C C C C C C C C C ▲ SC C SC
Thromboangiitis X SC C SC SC SC SC SC C C C UC C ▲ SC SC
Thrombophlebitis X SC C SC SC SC SC SC C C C UC C ▲ SC SC
Tonsillitis X
Tuberculosis (no X ▲ UC ▲ ▲ ▲ ▲ ▲ ▲ ▲ UC ▲ ▲ ▲ ▲ ▲
longer infective)
Ulcers ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ UC ▲ ▲ ▲ ▲ ▲
Urethritis X
Varicose veins SC UC UC UC UC UC UC SC UC UC UC UC ▲ UC UC

For a description of the conditions, please refer to a pathology textbook.
Except under medical supervision or with advanced training or specialized understanding.
▲, indicated/safe; AU, advanced understanding required; C, contraindicated; SC, site contraindicated; UC, use caution.

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56 Spa Bodywork: A Guide for Massage Therapists

client’s overall vitality and stamina. Obviously, a client Common Conditions That Require Caution
who is young and in good physical condition can receive
a more vigorous spa treatment than an elderly client who Although the range of conditions you might see as a pro-
is thin and frail. Sometimes, the spa treatment is short- fessional spa therapist is vast, hypertension, integumentary
ened or certain methods are avoided. Sometimes, the way issues, diabetes, and allergic reactions to spa products are
in which the client is positioned on the table is changed more common, so they require special attention.
to accommodate a particular condition. You may be able
to work with the client as you normally would but with
increased vigilance. Watch for any change in the client’s Blood pressure refers to the force of blood pushing against
condition or for side effects or adverse effects that may blood vessel walls as it circulates throughout the body.
develop. A sudden increase in pain, moderate to intense A sphygmomanometer is an instrument that measures this
discomfort, agitation, nausea, headache, or excessive diz- pressure at two different moments. The systolic pressure is
ziness is a sign that the client is not responding to spa the peak pressure in the arteries, which occurs near the be-
treatments normally. If any of these symptoms occurs ginning of the cardiac cycle during ventricular contraction.
during a treatment, stop the session, offer the client wa- The diastolic pressure is the lowest pressure of the resting
ter, and allow the client to relax. Monitor the client at phase of the cardiac cycle during ventricular relaxation.
all times and do not allow the client to leave until the A blood pressure cuff measures the pressure in the arter-
symptoms have disappeared. If symptoms persist after ies in millimeters of mercury, which is why the abbreviation
the session has ended, you should consult a physician. mm Hg is used in blood pressure descriptions.
If the symptoms increase rapidly after the session has High blood pressure, called hypertension, is a blood
ended, the client could be in danger, and you should call pressure consistently elevated above 140 mm Hg systolic
emergency services. and 90 mm Hg diastolic. Usually in chart notes, physicians
or nurses would write this blood pressure as 140/90 mm
Hg. The top number refers to the systolic pressure and the
Spa-Specific Considerations bottom number the diastolic number.
Essential hypertension is hypertension that is not due
The spa product chosen for a particular treatment, the
to some other pathology. Secondary hypertension is high
surface area of the body that it is to cover, and the over-
blood pressure that is a symptom of a separate pathology
all condition of the client all need careful consideration.
such as a hormonal disorder. Malignant hypertension is
A spot treatment may be safe when a full-body applica-
a dangerous condition in which the diastolic pressure in-
tion is contraindicated. If the product, or some of its in-
creases rapidly over the course of weeks or months and
gredients, can penetrate the skin and enter the circulation
requires immediate medical attention. Most hypertension
(e.g., essential oils), it must be used with more caution.
cases are essential hypertension and are caused by smok-
In such a situation, a full-body application would allow
ing, being overweight, a sedentary lifestyle, a salty diet, high
substantially more of the product to penetrate than a spot
alcohol consumption, stress, age, and genetic factors as
evidenced in a family history of hypertension. Pregnancy,
Seaweed applications can affect thyroid medications, so
kidney disease, and adrenal and thyroid gland disorders are
they should be avoided in cases of hypothyroidism or hyper-
some of the causes of secondary hypertension.
thyroidism (except when used under the direction of a phy-
Hypertension is a serious condition that causes damage
sician). Peppermint, eucalyptus, and rosemary essential oils
to the heart and blood vessels. Left untreated, it can lead
will counteract the effects of many homeopathic remedies,
to atherosclerosis, aneurysms, stroke, heart failure, heart
so they should not be applied to a client who is using such
attack, kidney failure, and vision problems. Blood pressure
remedies to treat a condition. If the client is taking a pre-
parameters are the following:
scription or over-the-counter medication that distorts his
or her perception of hot, cold, pain, or pressure, postpone • Normal: less than 120/80 mm Hg
the treatment. For the same reason, clients under the in- • Prehypertension: 120/80 to 139/89 mm Hg
fluence of drugs or alcohol should not receive a treatment. • Stage 1 hypertension: 140/90 to 159/99 mm Hg
Also, offering wine, champagne, or other alcoholic drinks • Stage 2 hypertension: 160/100 mm Hg and above
as part of the treatment or spa package endangers the client
and may affect the legal liability of the clinic or spa. Some clients with hypertension take prescription medica-
Clients who are pregnant, in a weakened condition, have tions to control their blood pressure and reduce their risks
neurological conditions, have heart conditions, or have un- of adverse effects related to the interplay of spa treatments
controlled high or low blood pressure should not receive and hypertension. Still, some spa treatments should not
hydrotherapy treatments except when under the care of a be delivered without first consulting the client’s physician.
physician. Similarly, such clients need a doctor’s release for For example, any deep abdominal massage is contraindi-
full-body spa treatments including mud, herbal hot sheet cated for clients with elevated blood pressure or who are
wraps, and seaweed wraps. taking blood pressure medications, but gentle, superficial

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Chapter 3 Client and Therapist Safety 57

abdominal massage for relaxation is usually fine. Also avoid body wraps, fangotherapy, and thalassotherapy for more
very vigorous or very stimulating massage or spa techniques detailed information.
that trigger the sympathetic nervous system. This includes The Skin
intense hydrotherapy treatments such as contrast showers The skin is the largest organ of the body and has many im-
or baths (discussed in Chapter 6, Water Therapies), cold portant functions (Fig. 3–5). Color and texture changes,
treatments, or exposure to heat in a sauna or steam room. such as paleness, redness, bumpiness, or yellowing, reflect
Saunas raise the temperature of the client’s skin to above the overall health of the body and may indicate internal dis-
103°F. This change in skin temperature stimulates sweat- ease. Rashes and skin eruptions illustrate poor nutritional
ing, the elimination of wastes through the skin, a faster habits, stress, allergies, and sensitivities.
heart rate, and lower blood pressure. The outer layer of the skin is called the epidermis. It
For healthy adults, the reduction of blood pressure is a contains no blood vessels but has many nerve endings. The
temporary reaction to the body’s rise in skin temperature. epidermis has multiple sublayers called strata. The bottom
When a healthy person exits the sauna, blood pressure re- layer of the epidermis is the stratum basale layer, which pro-
turns to normal. People with high blood pressure also expe- duces a constant supply of new cells. Keratinocytes make
rience this temporary lowering of blood pressure, but after up 80% to 90% of the epidermis and produce keratin. As the
leaving the sauna, their blood pressure can behave abnor- Keratinocytes mature, they lose water and flatten out. They
mally, sometimes rising dramatically. are shed when they reach the outermost layer of the epider-
mis called the stratum corneum.
Integumentary Conditions The stratum corneum provides the barrier function of
A basic understanding of the skin is vital to every thera- the skin, protecting the body from microbial invasion and
pist working in a spa to ensure client safety. Massage lubri- injury. It also protects the body from water loss. In fact, this
cants and body treatment products affect the skin, so they layer is 1,000 times more impermeable to water than most
must be chosen with care. For example, although a product other membranes of living organisms.
might be indicated for a client’s muscular condition, it may A healthy stratum corneum is compact with an orderly
be contraindicated for the client’s skin condition. Massage arrangement of cells in what is often referred to as the
therapists therefore need a good knowledge of skin types “brick and mortar” of the skin. The bricks are dead cells
and skin problems so that they know when to direct the filled with keratin. The mortar is the lipids between the
client to an esthetician or dermatologist for professional cells that “cement” them together. When the corneum
skin care. layer is damaged, the cells are thin and arranged in an un-
The essential oils used in aromatherapy are often mis- even pattern. Damage allows preparations applied to the
used in skin care because the word oil is misleading. Essen- skin to penetrate more readily. This is way dry or scaly
tial oils do not directly address dry skin conditions by add- skin may give a burning sensation when products are
ing oil or moisture to the skin. In fact, most essential oils applied to it.
are quite drying for the skin and can cause irritation if used On the stratum corneum, sebum, perspiration, and
inappropriately on a particular skin type. Essential oils are other water-soluble acids produce a pH of 4.4 to 5.6. This
useful as antiseptics and for helping the body to relax. is the skin’s acid mantel that acts as a defense mechanism
Stress plays a role in many skin disorders, so massage against invading microbes (Fig. 3–6). Research indicates
therapists and estheticians can work together for the ben- that the low pH in the stratum corneum also plays a role in
efit of the client. A full-body massage using spa products corneocyte maturation (the maturation of the keratin-filled
that are appropriate for the client’s skin condition can sig- cells that make up the stratum corneum).
nificantly reduce stress and have a significant impact on The inner layer of the skin, the dermis, is thicker than the
skin health. Improvements in the condition of the skin take epidermis and is composed of connective tissue that con-
a while and require patience. At least a month is required tains collagen and elastin. Collagen makes up a large part of
before a significant improvement can be seen in most con- the dermis (70%) and gives the skin structural support for
ditions. Often, skin conditions require many months to re- cells and blood vessels. It forms a network of microscopic
solve. When estheticians and massage therapists recognize interwoven fibers that allows for stretching and contraction
the potential synergy of the work that they do, they can pro- of the skin. It also aids in the healing of wounds. Moisture
vide integrative and supportive treatment plans for clients. is important for keeping the collagen network supple.
Table 3–4 provides an overview of skin types and condi- The follicles, sweat glands, sebaceous glands, most of the
tions which the massage therapist should be aware of. Some sensory receptors, and nerve endings are all found in the
essential oils appropriate for each condition are included reticular layer of the dermis. The sebaceous glands secrete
in the table. This information will be useful for massage sebum, an oily, waxy substance composed of various kinds
therapists making blends for a safe full-body massage and of lipids that lubricate the skin. Normally, it flows through
for estheticians using essential oils in skin care treatments. the oil ducts, leading to hair follicles. When sebum becomes
In addition, recommendations are given on products that hardened, the follicle becomes blocked. This is what causes
should be avoided. Go to the chapters on aromatherapy, blackheads (comedones). Excessive flow of oil from the oil

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58 Spa Bodywork: A Guide for Massage Therapists

TABLE 3–4 Important Skin Types and Conditions


Normal The skin is clear, with an even tone Full-body massage blends with essential oils of lavender, neroli, Roman or German
and texture, and good color and is chamomile, geranium, jasmine, frankincense, or rose. Citrus oils can also be
blemish free. used in moderation. Seaweed, clay, mud, and peat can be used at full strength.
Oily Characterized by the overproduc- Full-body massage blends with essential oils of bergamot, tea tree, lemon,
tion of sebum. Enlarged pores grapefruit, lavender, geranium, German chamomile, or cedarwood in a jojoba
(follicles) may be filled with visible base. If inflammatory acne is present, products should be diluted or the client
grease and debris. Blemishes may should be referred to an esthetician before the treatment progresses. Seaweed
be present on the face or back. mixed with aloe vera and clay is appropriate. Mud and peat should be avoided.
Oil dry Sebaceous output has slowed and Full-body massage blends with essential oils of lavender, German chamomile,
the skin is not receiving enough geranium, rose, carrot seed oil, frankincense, myrrh, and Roman chamomile in
natural oil. The skin appears dry shea butter or a heavy carrier oil such as sweet almond. Keep products covered
and dehydrated. and moist while on the skin and do not allow clay, peat, or seaweed to dry out.
Refer the client to an esthetician for a professional skin care evaluation.
Water dry Skin that is “water dry” has sufficient Full-body massage blends with essential oils of carrot seed, seaweed essential
oil but lacks moisture. The skin is oil, frankincense, myrrh, German chamomile, Roman chamomile, yarrow,
thin in texture, with small capillaries helichrysum, rose, or geranium. Avoid citrus oils in high concentrations. Avoid
showing in certain areas. This type the use of clay and direct the client to mud, peat, seaweed, shea butter, or
of skin is prone to fine lines, early honey applications instead. Refer the client to an esthetician for a professional
wrinkles, and a flaky appearance. skin care evaluation.
Sensitive The texture of the skin tends to be Full-body massage blends with essential oils of helichrysum, carrot seed,
fine with redness, heat, broken lavender, rose, frankincense, geranium in sweet almond oil, or expeller-
capillaries, and itching patches. pressed sunflower oil (12 drops maximum of essential oil in 2 oz of oil). Avoid
Sensitive skin reacts to strong products with dyes and synthetic fragrances. Avoid hot treatments such as
chemicals, cleaning products, sheet wraps or Parafango. Dilute seaweeds to half strength with aloe vera gel
dyes, and fragrances. or wheat germ oil. It is a good idea to keep hydrocortisone cream on hand in
case of skin irritation.
Acne on the back Blackheads, whiteheads, pimples, If the condition is mild, then the massage therapist can proceed with massage
redness, and irritation may be or a body treatment. Full-body massage blends that benefit oily skin and acne
present. If the condition is inflamed include tea tree, lavender, German chamomile, Roman chamomile, yarrow,
and hot, do not apply product to grapefruit, bergamot, and lemon mixed in jojoba or hemp oil. Avoid the use
the area. of peat, paraffin, Parafango, and mud and direct the client toward clay or
seaweed instead.
Psoriasis Skin cells divide much faster than A wide range of essential oils is indicated because psoriasis is considered by
normal, resulting in round, red- many to be a stress-related disorder. Nurturing oils that are unlikely to cause
dish patches with silvery scales. irritation include neroli, ylang ylang, rose, lavender, cypress, helichrysum,
Psoriasis usually affects the yarrow, and frankincense. A combination of these oils can be mixed in hemp
elbows, knees, lower back, ears, seed oil, apricot kernel oil, or expeller-pressed sunflower oil. Although mild
and scalp. cases of psoriasis do not seem to be irritated by spa products, mud and peat
should be avoided. Direct the client to clay, Parafango, paraffin, honey, shea
butter, or diluted seaweed instead. Refer the client to a dermatologist.
Eczema and dermatitis These terms are used to describe If the condition is mild, the massage therapist can proceed with full-body
many chronic and inflammatory massage or the application of a product to the body. Essential oils of German
disorders of the skin. Scaling and chamomile, Roman chamomile, yarrow, frankincense, helichrysum, lavender,
papule formation as well as red and myrrh can be used in shea butter, sweet almond oil, hemp oil, or borage
oozing vesicles may accompany oil. Seaweed may cause irritation, so it should be diluted. Mud and peat
burning and itching sensations. should be avoided, but clay or Parafango can be used. Avoid products with
synthetic fragrances or dyes. Refer the client to a dermatologist.

glands may produce seborrhea and problem skin. Emo- skin into the bloodstream where they may affect the body
tional stress increases the flow of sebum. on a physiological level. There are many factors that con-
The skin was thought to be impervious to most chemicals tribute to the passage of these ingredients through the skin.
until, in the 1960s, dimethyl sulfoxide (DMSO) was shown Lipophilic (literally “lipid-loving” or “fat-loving”) ingredi-
to transport other substances through the skin barrier and ents penetrate better than hydrophilic (“water-loving”) in-
into the bloodstream. It is important to understand that gredients. Essential oils pass rapidly through the skin due to
some of the ingredients of spa products do pass through the their lipophilic nature. The polysaccharides (mucilaginous,

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Chapter 3 Client and Therapist Safety 59

Stratum corneum
Stratum lucidum
Stratum granulosum Epidermis
Stratum spinosum
Epidermal ridge
Stratum germinativum
Capillary loop

Nerve ending

Epidermis lifted to reveal

papillae of the dermis

Dermal papillae
Sweat pore
Papillary layer of dermis
Nerve endings
Sebaceous gland
Reticular layer of dermis
Arrector pili
muscle of hair
Hypodermis (subcutaneous tissue)
Blood vessels

Hair root
Sweat glands
Nerve to hair follicle
Adipose tissue
FIGURE 3–5 The skin is the largest organ of the body and has many important functions. Color and texture
changes, such as paleness, redness, bumpiness, or yellowing, reflect the overall health of the body and may
indicate internal disease. Rashes and skin eruptions illustrate poor nutritional habits, stress, allergies, and

slimy substances) in seaweed also pass readily through the other seed oils),7 oleic acid (found in almond, cod liver oil,
skin. It is not surprising that small-sized molecules pene- and others),8 menthol (found in some essential oils such as
trate faster than larger molecules or that a viscous formula- peppermint),9,10 and squalene (found in olives, wheat germ
tion will pass through more slowly than more fluid prepa- oil, and shark liver oil).11
rations. Dead cells and lipid accumulation in the stratum Any areas of broken skin such as open wounds, scratches,
corneum as well as sebum pH and skin thickness affect the blemishes, or scabs are local contraindications. Contagious
rate at which a substance passes through the skin.6 Some skin conditions such as cellulitis, impetigo, mites (scabies),
natural components increase skin penetration. These in- and lice are absolute contraindications, and spa treatments
clude linoleic acid (found in evening primrose oil and some or massage should not be provided. Hives is a reaction to

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Less More
Acidic Skin Neutral Alkaline
sensitive sensitive

FIGURE 3–6 pH Graph. On the stratum corneum, sebum, perspiration, and other water-soluble acids produce
a pH of 4.4 to 5.6. This is the skin’s acid mantel that acts as a defense mechanism against invading microbes.

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60 Spa Bodywork: A Guide for Massage Therapists

stress or an allergy that makes the skin hot, swollen, and Allergies
itchy. It is a local contraindication if it is confined to one It is possible for clients to have allergies to spa products,
small region but an absolute contraindication if wide- so therapists must understand something about allergies
spread. and how they occur. A primary function of the immune
With a skin condition that is contagious but confined system is to differentiate “self” from “nonself” substances.
to one small area such as boils, fungal infections including The immune system destroys or subdues anything identi-
ringworm, herpes simplex, and warts, the area is locally con- fied as nonself as fast as possible. Allergies are an immune
traindicated, but spa treatments or massage can be applied system response and are not caused by an infectious agent.
to other areas of the body. Separate used linens that were ex- Even substances that pose no threat to the body such as
posed to contagious skin conditions, especially herpes, and pollen, pet dander, a component in a lubricant, or other
use bleach and hot water in the wash cycle. Sanitize your allergens (substances that causes an allergic reaction) are
hands, wear vinyl gloves, and clean all massage equipment perceived by the immune system as a threat. Common al-
and the treatment room with extra care after the session. lergies such as hay fever induce mast cells (cells that play a
Avoid massaging directly over areas of acne (a bacterial role in wound healing and protection against pathogens) to
infection of the sebaceous glands), using heavy creams in release histamine and other chemicals that change vascular
these areas, or applying natural products such as mud that permeability. This inflammatory response leads to symp-
may contain bacteria that could enter the body through toms such as watery eyes, itching skin, swelling, a runny
broken skin. Any of these activities might spread the infec- nose, or vomiting and diarrhea (with food allergies). In
tion to other areas of the client’s skin or cause increased severe allergic reactions, known as anaphylaxis, mast cells
blemishing by blocking pores. release large amounts of histamine that lead to edema and
Dermatitis is a nonspecific term describing many types sudden low blood pressure. Symptoms can include hives,
of skin inflammation. Often, dermatitis is caused by con- redness, shortness of breath, coughing, sneezing, decreased
tact with an irritating substance or allergen. Eczema is heart rate, fainting, and shock. The rapid onset of localized
caused by hypersensitivity reactions of the skin. Psoriasis swelling is called angioedema. Swelling that occurs in the
is a noncontagious skin disorder in which epithelial skin tongue, larynx, or pharynx might block airflow, creating a
cells replicate rapidly in patches and turn itchy and scaly. life-threatening condition. Peanuts (and other nuts), fish
If the skin of a client with any of these conditions is very and shellfish, latex, bee stings, and some foods such as milk
inflamed, is open due to scratching, or is weepy or crusty and eggs can cause severe reactions of this sort. Clients with
with delicate scabs, treat the areas as a local contraindica- known allergies to nuts should not receive massage with a
tion and avoid the application of spa products. lubricant containing ingredients from that nut (e.g., peanut
If the skin is in relatively good condition, not overly oil, almond oil). Clients with a known allergy to shellfish
inflamed, intact, and not crusty, it may respond well to or seafood should not receive seaweed treatments or con-
massage with a natural anti-inflammatory lubricant such tact products with seaweed in them. People who know they
as hemp seed oil and skin-soothing essential oils such as are at risk for anaphylactic reactions usually keep medica-
German chamomile and helichrysum oil (see Chapter 7 on tion with them, such as Benadryl or injectable epinephrine
aromatherapy). Do not use mud, seaweed, or products with (EpiPen).
synthetic fragrances, dyes, mineral oil, lanolin, coconut oil,
grapeseed oil, or cocoa butter on clients with dermatitis, ec-
zema, or psoriasis. Diabetes
Precancerous skin conditions such as actinic lesions and Diabetes is a group of related conditions that result in el-
skin cancers such as basal cell carcinoma and squamous evated levels of blood sugar (hyperglycemia). About 98% of
cell carcinoma are local contraindications. Malignant mela- all diabetes cases are either type 1 (rare and more serious)
noma spreads rapidly and is treated aggressively, often with or type 2 diabetes (approximately 20.8 million cases in the
chemotherapy and radiation. Any spa treatments for clients United States). Gestational diabetes affects about 4% of all
with malignant melanoma should take place only under pregnant women and accounts for around 135,000 cases
the guidance of the client’s physician. each year.12
Skin injuries such as burns (including moderate to se- In type 1 diabetes, the body does not produce insulin,
vere sunburn), ulcers, or open wounds are local contraindi- the hormone needed to convert sugar (glucose) into en-
cations. Widespread burns and ulcerations may be an abso- ergy. It may have genetic roots, as it runs in families, or be
lute contraindication, depending on their severity. The scar caused by exposure to certain drugs, chemicals, or infec-
tissue that forms over burns, ulcers, or wounds responds tions. It is caused by an autoimmune response in which
well to massage, seaweed treatments, and mud treatments killer T cells damage parts of the beta cells in the pancreas
in the subacute and chronic stages. These natural products where insulin is created, causing a lifelong deficiency.
and massage can improve the appearance and mobility of People with type 1 diabetes must take injections of insu-
this type of scar tissue. Keloid scar tissue and raised moles lin and monitor their blood sugar levels carefully to avoid
are local contraindications. very high levels, which can cause ketoacidosis, or very low

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Chapter 3 Client and Therapist Safety 61

blood sugar, which can cause insulin shock. Ketoacidosis is diabetes. If possible, discuss with the physician the types
a condition in which the body metabolizes fats for fuel be- of methods you would like to use in the session and their
cause the lack of insulin does not allow glucose to be used effects on the body to obtain the best possible recommen-
for energy in cells. The acidic waste of rapid fat metabolism dations to ensure the client’s safety.
changes the pH balance of the blood and can led to shock,
coma, and death.
In type 2 diabetes, the body does not produce enough Critical Thinking and Contraindications
insulin, or target cells have fewer receptor sites for insu-
Therapists discover contraindications or situations that
lin than needed. Although the exact cause of type 2 dia-
require caution from the client’s completed health intake
betes is unknown, it is linked to high-carbohydrate diets
form and the intake interview, from observations of the cli-
and is often treated with diet, exercise, and medications.
ent, and from palpation findings or reactions the client has
Some people with type 2 diabetes have to supplement this
to the spa treatment.
regime with self-administered insulin. Although people
Often, the client has a condition diagnosed by a physi-
with type 2 diabetes do not experience ketoacidosis, they
cian and understands how that condition affects the body.
may develop a blood pH imbalance related to high blood
As long as the condition is not completely contraindicated,
sugar, called hyperosmolality, that can lead to shock,
the client and therapist can discuss session goals and plan
coma, and death.
adaptive measures to ensure comfort during the session. In
Insulin shock, very low blood sugar, can occur in both
some cases, a client’s condition may be serious or complex
type 1 and 2 diabetes but can be treated effectively simply by
enough to cause concern, in which case the therapist should
ingesting juice, milk, candy, or sugar-containing soft drinks
contact the client’s physician and obtain a release. Clients
right away to increase blood sugar levels. Over time, dia-
who do not have a diagnosed condition but who com-
betes can lead to serious complications, including cardio-
plain of symptoms such as fatigue, muscle weakness, un-
vascular disease, stroke, hypertension, aneurysm, edema,
explained pain or stiffness, persistent headache, or feelings
ulcers, gangrene, amputations, kidney disease, impaired vi-
of lethargy should see their physician and obtain a release
sion, blindness, and neuropathy.
before receiving a spa treatment. Undiagnosed symptoms
The types of spa techniques that can be used with clients
may indicate a serious condition that might be exacerbated
who have diabetes depend on the state of the individual’s
by spa treatments. Following is the basic process by which
health. Clients with poorly treated diabetes may have seri-
therapists rule out contraindications:
ous edema, ulcerations on their extremities, impaired cir-
culation, and/or severe neuropathy. Very light massage or 1. Administer a health intake form and review the form
energetic techniques might be the only treatments that carefully.
are appropriate for such clients. Hydrotherapy treatments 2. Conduct a health intake interview and ask the client to
using extremes of hot and cold temperatures, hot stone describe symptoms, general health, goals for the spa ses-
massage, or the application of aggressive treatment prod- sion, and side effects from medications. Ensure that the
ucts such as seaweed are contraindicated. On the other client has listed all medications and conditions on the
hand, a client who monitors blood sugar carefully, eats a health intake form.
healthy diet, gets exercise, and experiences few complica- 3. Look up unfamiliar diagnosed conditions in a pathol-
tions may benefit from a variety of spa treatments. ogy reference. A Massage Therapists Guide to Pathology by
Keep in mind the fact that spa treatments often stimu- Ruth Werner is highly recommended.
late the body, which uses up available glucose and insulin 4. Determine if the client’s condition has flared up (moved
faster, which can lead to an imbalance, usually low blood suddenly from a chronic stage to an acute stage with
sugar.13 It’s important to talk this over with the client who intense symptoms). A condition that has flared up is
may need to plan mealtimes and insulin injections to bet- more likely to be contraindicated. If the symptom level
ter accommodate the spa session. Clients can also monitor is normal for the client and the condition has not flared
their blood sugar immediately before the spa treatment and up, spa treatment is more likely to be safe for the client.
make necessary adjustments by eating a small snack or in- 5. Look up medications in a drug reference. Note the side
jecting insulin if needed. Keep some form of sugar in your effects of the medication and check these against the
office (juice, candy, regular soft drinks) in case a client be- client’s experience. If the client describes symptoms
comes hypoglycemic. If a diabetic client becomes confused, that are listed as adverse effects of a medication, the
irritable, weak, or shaky or has clammy skin, stop the ses- situation needs further discussion. A call to the client’s
sion and give the client some sugar. If the client does not physician is advised.
respond quickly to the sugar, call emergency services imme- 6. Conditions vary from client to client, depending on
diately. It is not in the massage therapy scope of practice to other variables in the client’s life. After researching the
test a client’s blood glucose level or inject insulin. condition and medication and questioning the client
Spa therapists should obtain a physician’s release when about any side effects experienced from medications,
working with a client with advanced or poorly treated assess the client visually. Get an overall impression of

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62 Spa Bodywork: A Guide for Massage Therapists

the client’s physical health, level of vitality, and stam- As mentioned previously, Table 3–3 provides an over-
ina. Don’t underestimate your intuition. Even if the view of conditions for quick reference, but do not rely
reference books say massage or spa treatment is okay, completely on such a list. Each client and each situation is
but if your gut tells you “no,” listen to your gut. different, and therapists need to learn to reason clinically
7. Determine if the client is contraindicated, needs a so that they can make appropriate decisions for each cli-
physician’s release, has any area that should not receive ent. Novice therapists may shy away from conditions that
treatment, should be referred to a more experienced an experienced therapist can work with safely. If you have
therapist, or should be referred to another health care any doubt about the suitability of a spa treatment for a
provider. If you decide that a spa treatment is not client, be cautious and postpone the treatment until you
contraindicated and that you do not need a physician’s have obtained a physician’s release or can discuss the situ-
release but adaptive measures are required, discuss your ation with your supervisor. Contraindications for specific
thoughts with the client. What does the client hope to spa treatments are described in greater detail in upcoming
achieve from the session? What type of spa treatment chapters.
does the client want? How does the client feel right
now? How does the client hope to feel at the conclusion
of the spa session? Depending on the client’s condition,
you may eliminate the use of some techniques or adjust Documentation of Sessions in a Spa
the temperature of some aspects of the treatment to
reduce the load on the client’s body. You may decide The client intake process is just as important for a spa treat-
to avoid the use of hydrotherapy (e.g., a hot pack) and ment as it is for massage, and before being treated, all cli-
shorten the session’s length (e.g., offer a 30-minute ses- ents need an evaluation of their physical condition. Refer
sion instead of 60 or 90 minutes). to your massage therapy textbook to provide details of the
8. A client may list a few symptoms but not have a diag- health intake process in the event you need a reminder. To
nosed condition or be taking medications. Question set a relaxing tone, you might provide a cup of herbal tea
the client carefully. Perhaps a client tells you about and soak the client’s feet in a decorative tub while he or she
weekly headaches believed to be from neck and shoul- fills out the health intake form (Fig. 3–7). The type of in-
der tension. The client may have periods of nausea and formation included on the health form will depend on the
refer to them as “nervous stomach.” The nausea may scope of the spa, the services offered at the spa, or the needs
occur when the client must give a presentation at work. of the therapist for that particular session. A nutritionist
The client also reports being unable to sleep for the may ask some questions about the client’s diet, whereas an
last week and feeling moody and irritable. The client esthetician will focus on the condition of the skin and a
believes these symptoms are related to work stress and massage therapist will ask about muscular conditions. Spas
not related to any serious condition. You palpate the can plan to have one intake form or several different forms
shoulders through the client’s clothing and confirm the that suit individual therapists or services.
neck and shoulders are very tense, and the headaches When the client has completed the form, introduce
could be the result of this tension. You have to decide if yourself, describe the benefits of the treatment the client
it is safe to provide a spa treatment or massage. Prob- is about to receive, and review the form verbally with the
ably it is. Although these symptoms could be related client. Ask the client follow-up questions about health
to a more serious condition, the client has given you conditions and medications to rule out contraindications.
a logical explanation, and your shoulder and neck Also ask clients about their expectations of the session
palpation supports the client’s perception about the so that you can tailor methods and experiences to their
headaches. Your visual assessment tells you the client is particular needs.
in moderate physical health and has good skin coloring, After the session, take a few moments to process the re-
and your impression of the client’s overall vitality and sults with the client. Ask the client about methods he or
stamina is good. You decide to proceed with the session she found particularly enjoyable or effective. This is a good
but remain vigilant and check in regularly to determine time to recommend other beneficial services or home care
that the client has not had an increase of symptoms or products for the client. Document what occurred during
pain related to the session. the session, the client’s results, and next steps if appropriate
on a form such as the spa treatment record (Fig. 3–8). In the
A different client might tell you about waking up with event of a liability claim, you will need this basic informa-
pain in all the joints, with a pounding headache, and feel- tion to protect yourself and your business.
ing incredible fatigue. The client can give no explanation All therapists should plan some time at the beginning
for these symptoms. Because these symptoms came on very and end of every treatment, even for retuning clients, to
suddenly with no logical explanation, you refer such clients discuss the client’s current condition, determine the results
to their physician for a release and postpone the session. obtained from treatment, and document what happened
Remember, when in doubt, refer out. during the session.

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Chapter 3 Client and Therapist Safety 63


Patient's Name Date

Address State Zip

Phone Occupation

Emergency Contact Phone

Primary Health Care Provider

Name Phone
Address State Zip

Current Health Information

Please list all conditions currently monitored by a health care provider.

Please list all the medications you took today (include pain relievers and herbal remedies).

Please list the medications you took in the past 3 months.

Please list and briefly explain (including dates and the treatment received) the following:




Tobacco Use: Current Past Never Comments

Alcohol Use: Current Past Never Comments
Drug use: Current Past Never Comments

Are you currently menstruating? Yes No

Have you received a spa treatment before? Yes No

If yes, what types of spa treatment have you received?

FIGURE 3–7 Spa health form. The type of information included on the health form will depend on the scope
of the spa, the services offered at the spa, or the needs of the therapist for that particular session. A nutritionist
may ask some questions about the client’s diet, whereas an esthetician will focus on the condition of the skin and
a massage therapist will ask about muscular conditions. Spas can plan to have one intake form or several different
forms that suit individual therapists or services. (continued)

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64 Spa Bodywork: A Guide for Massage Therapists

Current and Previous Conditions

Please check all current and previous conditions and give a brief explanation, if appropriate, in the comments section
at the end of this form.

Current Past Current Past

Headache Lymphedema
Pain High blood pressure
Sleep disorders Low blood pressure
Fatigue Poor circulation
Infections Swollen ankles
Fever Varicose veins
Sinus condition Asthma
Skin conditions Bowel dysfunction
Athlete's foot Bladder dysfunction
Warts Abdominal pain
Skin sensitivities Thyroid dysfunction
Sunburn Diabetes
Burns Pregnancy
Bruises Fibrotic cysts
Aversions to scent Pacemaker
Aversion to oils Phlebitis
Allergies Raynaud's syndrome
Sensitivity to detergents
Aversion to cold Other Conditions:
Rheumatoid arthritis
Spinal problems
Disc problems
Tendonitis, bursitis Comments:
Dizziness, ringing in the ears
Mental confusion
Numbness, tingling
Sciatica, shooting pain
Therapist's Name:
Anxiety, panic attacks
Heart disease Signature:

Blood clots Date:


FIGURE 3–7 (continued)

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Chapter 3 Client and Therapist Safety 65


Patient's Name Date

Date: Therapist: Comments: Retail items purchased:

Treatment received:

Date: Therapist: Comments: Retail items purchased:

Treatment received:

Date: Therapist: Comments: Retail items purchased:

Treatment received:

Date: Therapist: Comments: Retail items purchased:

Treatment received:

Date: Therapist: Comments: Retail items purchased:

Treatment received:

Date: Therapist: Comments: Retail items purchased:

Treatment received:

FIGURE 3–8 Spa treatment record. Document what occurred during the session, the client’s results, and next
steps if appropriate on a form such as the spa treatment record.

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66 Spa Bodywork: A Guide for Massage Therapists


Direct Contact Transmission
• The transfer of a • The transfer of a
pathogen via direct pathogen via an
contact with the skin insect or animal

Indirect Contact Vehicle

• The transfer of a Transmission
pathogen to an • The transfer of a
inanimate object pathogen via air,
and then to dust, food, or
another person water

Example of a graphic organizer.

STUDY TIP: Graphic Organizers join as a professional. Requiring a health intake form
and checking it carefully to ensure spa treatments are
Graphic organizers are visual representations of not contraindicated for your client is just as impor-
concepts, ideas, and other information. They can help tant to your integrity and professionalism. Make sure
you organize and clarify information to improve your to keep the proper reference books on hand and to
comprehension and recall. They are especially useful research any unknown medications or client condi-
for visual and kinesthetic learners. Visual learners ben- tions before providing spa services. Document your
efit from the structure of graphic organizers, whereas sessions to ensure you have good records to follow on
the process of creating a graphic organizer motivates treatments and to protect yourself in the event of a li-
kinesthetic learners. ability claim. You are also required by health standards
to provide a clean, hygienic, and safe environment for
SPA INSPIRATION: Your Spa Journal your clients. Good sanitation skills require practice.
Journaling can be a powerful practice during your It’s easy to forget small things in the course of a busy
spa training program. It allows you to keep track of day, but such forgetfulness may cause a client to get
the changes you are making on a mental, emotional, sick. For example, a new therapist might forget to san-
physical, and spiritual level. You will face challenges itize her hands before moving from foot massage to
during your schooling—everyone does—and when another area of the body. This client is now potentially
you capture these in a journal you begin to see the exposed to a fungus that can take hold and grow on
pattern of your strength. This is exciting! Ask your- another area of the skin. A new therapist might forget
self simple questions to begin the process of journal- to disinfect the oil bottle between clients. The second
ing such as, “What did I learn in my class today that client is then exposed to pathogens from the first
was particularly interesting? How will this change because the therapist touches the skin, touches the
the way I approach my spa work?” or “What are bottle, and then touches the new client’s skin. Good
some of my challenges right now? How can I better sanitation practices also require you to pay attention
organize my life to get the most out of my training to your every gesture. Did you touch your hair or
program?” scratch your nose as you transitioned from one body
area to another? If you did, you should decontami-
CHAPTER WRAP-UP nate your hands before you touch the client again. Be
vigilant and practice thinking about sanitation as part
As a professional spa therapist, you want to practice of your spa treatment application. If you accidentally
exceptional ethics at all times to maintain your per- skip a sanitation step, stop and practice incorporat-
sonal integrity and the integrity of the massage and ing the step. In this way, you will be ready when you
spa professions. This means learning and following a are a professional to provide your clients with the best
code of ethics as established by the organizations you possible care.

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Chapter 3 Client and Therapist Safety 67

REVIEW QUESTIONS 6. A protocol used in health care settings that
reduces the risk that health care workers will be
Multiple Choice exposed to bloodborne diseases is called:
1. A creed that states a professional group’s a. Universal precautions
principles and the values by which the group abides b. General precautions
is called: c. Code of precautions
a. A code of values d. Health workers precautions code
b. A code of principles
c. A code of professionalism 7. Showing artistic pictures of undraped bodies in
d. A code of ethics the massage or spa reception area is a form of:
a. Sexual assault
2. The transfer of a pathogen from an infected b. Sexual impropriety
person to an uninfected person through touch c. Ethical conduct
is called: d. Professional conduct
a. Direct contact
b. Indirect contact 8. When regulations state that massage therapists
c. Vector transmission cannot diagnose a patient’s condition, prescribe a
d. Vehicle transmission medication or treatment, or adjust a client’s bones
they are referring to:
3. A type of cleaning product that should not be used a. Code of ethics restrictions
on the skin is: b. Sanitation and hygiene restrictions
a. An antiseptic c. Sexual impropriety restrictions
b. Alcohol d. Scope of practice restrictions
c. A disinfectant
d. Hydrogen peroxide 9. Offering wine, champagne, or other alcoholic
drinks as part of a spa treatment:
4. The authority a massage therapist is granted by a a. Is fine if the client is of legal drinking age
client because the massage therapist is a health care b. Is fine so long as the client does not consume
provider is called: more than two drinks
a. The health care authority c. May lead to criminal charges against the
b. The power differential therapist
c. The authority difference d. Endangers the client and may lead to liability
d. The health care differential claims

5. A term used by regulating boards of health care 10. A skin condition that is contagious but confined
professions to describe the techniques, activities, to one small area such as boils, fungal infections
and methods that are permitted to a therapist including ringworm, herpes simplex, and warts is:
under the law. a. A local contraindication
a. Health care authority b. An absolute contraindication
b. Power differential c. Not a concern
c. Code of ethics d. Can receive treatment so long as the therapist
d. Scope of practice wears gloves

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Your Spa Massage

Chapter Outline K e y Te r m s
Overview of a Wellness Massage Session Aroma mist: A combination of distilled water and essential oils placed in
Before the Massage a misting bottle. It is misted over the client at the end of a session to fill
The Massage the treatment room with a refreshing scent.
After the Massage Aromatherapy inhalation: One drop of an essential oil or 1 drop of a
Opening and Closing the Massage blend of different oils is briefly rubbed together in the hands before the
Resting and Holding Strokes
hands are passed over the client’s nose in an arc so that the oil can be
Aromatherapy Inhalations enjoyed on a deep inward breath.
Use of an Auditory Cue Auditory cue: A cue, such as the ringing of a chime, used to signal the
Massage Enhancers beginning and ending of the massage session.
Warm Packs Diaphragmatic breathing: A breathing exercise that promotes deep,
Steamy Aromatic Towels relaxed breathing patterns.
A Simple Hand or Foot Treatment Massage enhancers: Additional session elements or small complemen-
Paraffin Dip tary treatments that increase the client’s enjoyment of the session.
Easy Aromatherapy Enhancements Paraffin: Paraffin is a waxy substance obtained from the distillates of
Putting Your Spa Massage Together wood, coal, petroleum, or shale oil. It is used to coat the skin and trap
heat and moisture at the skin’s surface.
Subtle Factors That Influence the Massage Pursed-lip breathing: A breathing technique that promotes deep, relaxed
breathing patterns.
SPA FUSION Routines: Routines are a series of strokes that are planned in advance,
INTEGRATION OF SKILLS delivered to body areas in a preset order, and practiced until they flow
STUDY TIP: Party! That’s Right. Party! smoothly together.
SPA INSPIRATION: Spa Massage Olympics Sequencing: Sequencing refers both to the sequence of strokes (the order
IT’S TRUE! Diaphragmatic Breathing Exercises in which strokes are applied to a given body area) and to the overall
Support Different Client Groups sequence of the massage (the order in which body areas are massaged).


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Chapter 4 Your Spa Massage 69

generally viewed as a healthy activity to promote a balanced,

Massage in a spa setting is just like massage in any functional life and is regularly promoted at spas, wellness
centers, private practices, and massage clinics. We are about
other setting; it is usually customized to fit the needs
to examine the sequence of events that occur in a wellness
of the individual client and can take many forms. All massage. Note that the sequence of events in a health care
massage (also called treatment or rehabilitative massage) is
types of massage, including Swedish, lomilomi, Thai,
likely to be different. Usually, a health care massage requires
sports, craniosacral, orthopedic, Shiatsu, myofascial more in-depth assessment of the client such as a posture
and range of motion assessment and more detailed treat-
work, ayurvedic marma point therapy, stone massage,
ment planning.
neuromuscular therapy, and many others, are offered in spas
around the country. Sometimes, the whole massage routine Before the Massage
will be based on one style (e.g., lomilomi), and sometimes, When a client arrives for his or her first massage appoint-
a combination of techniques from many styles (e.g., Thai, ment at the spa, make every effort to make the person
feel welcome. Orient the client to the new environment
marma point massage) will be integrated with Swedish and recognize that a new client is making numerous
massage strokes. The spa may train everyone to deliver the boundary adjustments to participate in the massage ses-
sion and is likely to feel some nervousness or discomfort
same massage, or they may allow each therapist to do his as a result.
or her own massage routine. The goal is to develop your
The Greeting
massage skills so that you can fluidly adapt to the style of As the client walks through the door, you or the reception-
massage requested by employers or meet the needs of your ist should be on hand with a warm greeting. Step out from
behind the reception desk to shake the client’s hand and
clientele in a private massage or spa business. This chapter smile while making eye contact. Hand the client a clip-
provides an overview of a wellness massage session before board with the required paperwork (usually, a health his-
tory form and documents relating to informed consent)
looking closely at the subtle factors that can influence a and explain each document. Show the client to a seat in the
client’s enjoyment of a session. Finally, we put everything reception area and perhaps offer a cup of herbal tea. The cli-
ent fills out the paperwork and hands it in to you. In many
together into a beautiful, flowing, and luxurious session. spas, this process might take place in a quiet room, apart
from the reception area, and be accompanied by a relaxing
foot soak.
Overview of a Wellness Massage
The Tour
With paperwork in hand, you escort the client into the
Massage theory and techniques are sometimes taught in treatment area. Point out where the bathroom is located
isolation, especially in the early portions of a massage train- and any amenities such as the steam room or sauna the
ing program. Students focus on one skill at a time and then client might use on his or her next visit. Let the client
put them all together into an organized whole. Alternately, know if a shower is available before or after the massage.
you may have completed your massage training program Show the client into the treatment room and explain
so that you can focus on specialization in spa therapies. where to undress and hang clothing. It’s a good idea to
In either case, it is helpful to preview the big picture to bet- remind clients to remove jewelry before the session because
ter understand where and how different skills are used dur- lubricants can cause jewelry to look tarnished and delicate
ing a wellness massage session—the type of massage session pieces may be damaged during massage strokes. Use a small
often offered at spas. dish to hold personal items so that jewelry is not lost or
Let’s review the difference between wellness massage and forgotten.
health care massage. The public seeks wellness massage
to decrease stress, promote relaxation, support the body’s The Interview
natural restorative mechanisms, and have an enjoyable ex- The client interview does not need to be a complex process,
perience that leaves the body feeling refreshed and revital- but each of the items we preview here should be discussed
ized. Wellness massage is also used to reduce temporary to ensure the safety of both client and therapist. The over-
pain from overexertion caused by activities such as weekend view here is to describe where and how an interview occurs
athletics or by unusual work stress. This type of massage is in the progression of a wellness massage, so in-depth details

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70 Spa Bodywork: A Guide for Massage Therapists

are not included. Refer to your massage program training that the client has signed an informed consent form.
materials or instructor for more information about any An example is provided in Figure 4–1.
processes you feel uncertain about. Offer the client a seat 2. Rule out contraindications: Review the client’s
and sit down facing the client. The initial intake interview completed health history form. In some cases, you may
should accomplish a number of tasks but take no longer need more information from the client about a par-
than 10 minutes: ticular condition to rule out contraindications. When
you feel you understand the client’s medical picture
1. Policies and procedures: Briefly review the spa’s and that massage is not contraindicated, treatment
policies and procedures and information relating to planning begins. A sample of a health history form
informed consent, including the scope of practice and a discussion of contraindications is provided in
for massage and the limitations of massage. Ensure Chapter 3.

FIGURE 4–1 Example of an informed consent statement and form. An informed consent statement and form
is a document that fully informs clients about choices related to their care. It discloses policies and limitations
of services that might affect their care. All of the national massage organizations require massage therapists to
provide informed consent documentation to their clients as part of their codes of ethics. (continued)

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Chapter 4 Your Spa Massage 71

FIGURE 4–1 (continued)

3. Client expectations: Ask the client to share about massage is likely to expect this massage to be exactly
expectations for the session. It’s sometimes help- the same as the first. In this case, the client may wonder
ful to ask, “What results do you want to achieve?” or what’s going on when you use a different style or tech-
“When you leave here today after your session, what niques. In each of these circumstances, you can set the
do you want your body to feel like?” In a relaxation client up for a good experience by explaining that there
session, it is common for clients to want to feel more are many different types of massage and then describ-
relaxed or to have less tension in a particular area. ing some of the techniques you plan to use and their
First-time clients may not know what to expect and may effects.
be anxious. They may have seen a picture of massage Although concerns about the therapist’s gender
or read about the benefits of massage in a magazine. have diminished because people become more educated
Perhaps, a friend described a positive massage expe- about massage, some clients want to choose the gender
rience. A client who has received only one previous of their therapist and may be surprised if this was not

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72 Spa Bodywork: A Guide for Massage Therapists

discussed during the booking phone call. In our culture, something like this: “Undress to your level of comfort.
many men and women tend to feel more comfortable Some clients choose to remove all of their clothing and
with a female therapist. Many women may feel less self- this is fine, and others prefer to leave on some of their
conscious about how their bodies look to other women. underclothing, which is also fine. You will always be draped
Some women have concerns about the potential sexual during the session, and I will only undrape the area where
misconduct of a man based on some past experience, I am working. This is to keep you warm but also to pre-
whereas others may worry that their male partners will serve modesty.” This is also a good time to check if the cli-
feel uneasy that they have received massage from a man. ent needs to use the restroom before undressing. Unless the
Some men feel anxious about receiving an enjoyable client needs assistance getting on the massage table, leave
experience from a man’s touch. Cultural and religious the room while the client undresses. Because some clients
beliefs can also influence clients. Although these stig- feel nervous that the therapist may walk back in while they
mas can frustrate male therapists, this situation con- are partially undressed, it helps to say that you will knock
tinues to improve because people embrace massage as a and wait to hear they are ready before you enter.
regular health care practice. All clients have the right to
determine what happens to their body. If the client asks Prepare Yourself for the Massage
for a therapist of a specific gender, this request must be Usually, clients need no more than 5 minutes to undress
honored. Sometimes, a client’s expectations of massage and situate themselves on the massage table. Use this time
are not reasonable, however. In this case, outline for the to warm up your hands and to ground and center your
client what is realistic and what is beyond the scope of energy for the session. Use the restroom if you need to and
massage. wash your hands carefully directly before returning to the
4. Determine treatment goals: With the client’s input, treatment room.
determine specific treatment goals for the session.
This can be fairly simple, as in the following example,
or fairly complex. In a wellness massage, treatment The Massage
goals are based on the client’s expectations and often
Knock and wait for the client’s response. Enter the treat-
help you focus on areas that need the most attention
ment room and greet the client again. If the client is in the
during the session. For example, the goals for a session
prone position and cannot see what you are doing, explain
might be to decrease bilateral neck tension, decrease
your actions or movements (e.g., “I’m just going to start the
upper back tension, and decrease foot soreness. You
music and turn on this space heater so you don’t get cold.”).
then know that you will be massaging this client’s
A client who doesn’t know what you are doing may become
back, neck, and feet. Will the client want other areas
nervous when hearing you moving about the room.
5. Plan the massage: Sometimes, clients only want 1. Bolster: Decontaminate your hands and use bolsters to
selected areas to be massaged, or they may want a support the client’s position on the table.
full-body massage with extra focus in certain areas. 2. Check in: Ask the client about the room temperature
Clarify the plan before the session starts. You might and turn on a heater or add a blanket over the drape if
say something like, “I’m going to start on your back to the client is cold. Warm packs might be placed on the
focus on your upper back tension and your shoulders. client at this time (discussed later in this chapter).
These tense areas are probably contributing to your 3. Open the massage: There are a number of ways to
neck pain. Would you like me to work on the back open a massage. You might choose to use a breathing
of your legs? Yes? Okay, then I will massage your legs exercise such as those described later in this chap-
before I turn you over and focus on your neck. Would ter. You might apply a resting and holding stroke or
you like me to massage your arms and the front of perhaps add a creative flourish such as ringing a small
your legs? Great. How about your abdominal muscles? chime to mark the start of the session.
No? Okay, I will finish with a good 20 minutes on your 4. Follow the treatment plan: Once the massage starts,
sore feet.” This is a good time also to ask clients about follow the plan you discussed with the client. If you
their music preferences and preferences for lubricants. discover an area of particular tension that needs mas-
When all these things have been decided, the session sage but was not part of the original treatment plan,
can begin. talk with the client about this. It’s as easy as saying
something like, “Carole, I’ve found an area on your low
Transition to Massage back where the tissue is very bound up. I would like to
Before you leave the treatment room, show the client the spend some extra time working on this area. We didn’t
massage table and explain the position you would like the discuss this earlier, but would you mind if I cut some
client to take on the table after undressing. Because clients time off the massage of your legs to work longer on
may feel very nervous about how much clothing they need your low back?” Carole will answer yes or no or may ask
to remove, it’s important to reassure them. You might say a question. This negotiation helps minimize the power

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Chapter 4 Your Spa Massage 73

differential and encourages clients to make decisions Ask if the client would like to book another session.
about their own body, as discussed in Chapter 3 in the Some therapists choose to collect the fee and schedule
section on ethics. Make sure to address each area where additional sessions before the massage. This way, the
the client wants work. client can be on the way as soon as the session ends.
Sometimes, new massage therapists frustrate clients Both methods are fine.
by not getting to important areas in a timely manner. 4. Book a session: Book the session and give the client an
In one case, the client reported to the spa manager that appointment card with the date and time.
she specifically requested 30 minutes of work on her 5. Say goodbye: You might remind clients to pay atten-
back and 30 minutes on her neck. She told the thera- tion to how their body feels as a result of the massage.
pist she didn’t want any other areas massaged. The Phrase this in “goodbye language” to avoid opening a
therapist massaged the client’s legs, feet, and arms, and new conversation that would be better in the privacy of
spent only 15 minutes on her back and 5 minutes on the treatment room. Say something like, “Remember
her neck. The manager questioned the new therapist to keep track of how your body feels so we can discuss
and found that she felt uncomfortable with neck mas- it when I see you at your next session.” Shake the cli-
sage and was avoiding it. In school, she had learned a ent’s hand warmly as you walk toward the door. This
full-body massage routine, and that was what she was behavior helps the client transition out of the massage
most comfortable doing. Ethically, this therapist should session and back into the real world. It also helps to
have explained her limitations up front and referred maintain the boundaries of the therapeutic relation-
the client to another therapist until she had the skills ship, end the session on a friendly note, and keep you
needed to meet the client’s needs. on schedule with future clients.
5. Close the massage: The massage can be closed in a 6. Chart notes: Complete the chart notes and documenta-
number of ways, as discussed later in this chapter. Many tion for the session and file the client’s record neatly.
therapists match their massage opening to their mas- 7. Change the room: Cleaned, disinfect, and sanitize the
sage closing. For example, if they opened with a breath- treatment room as needed to prepare it and the massage
ing exercise, they close with a breathing exercise. table for the next session, as discussed in Chapter 3.
8. Self-care: You might now perform any regular self-care
activities such as stretching or eating a snack before the
After the Massage next client arrives for a session.
Your actions following the massage help ensure the client Massage sessions involve interpersonal skills such as pro-
has had a good experience: fessional communication, ethics, and boundary setting and
practical skills such as draping, bolstering, along with the
1. Transition out of the massage: After closing the
actual massage techniques. The theory that underlies all of
massage, remove the bolsters and ask the client to get
these skills is of primary importance. Without an under-
dressed. Provide disposable wet wipes and a dry hand
standing of the physiological effects of massage techniques,
towel for the client to clean up or explain that amenities
you wouldn’t know which methods to use to address a
such as saunas, whirlpool baths, or showers are avail-
client’s neck tension. Without an understanding of the
able. Sometimes, therapists give clients suggestions for
structures of the neck, you wouldn’t know where to apply
activities they can use at home to improve the condition
techniques. Each skill is important, and together these dif-
of their muscle tissue, such as stretches or self-massage.
ferent types of skills create an accomplished massage pro-
If you intend to give home care, ask the client to dress
fessional. As you review this outline of a wellness session,
and remain in the treatment room. This way, you
think about areas where you would like to improve your
can demonstrate the stretches or massage techniques
efficiency and smoothness. For example, if you find that
privately. If not giving home care, ask the client to meet
you always feel uncomfortable greeting clients and explain-
you at the reception desk after dressing.
ing the paperwork included in the health intake, practice
2. Sale of retail product: In many spas, the sale of retail
these skills with a friend or supervisor. Practice what you
product is required of all of the staff working at the spa.
will say and do out loud, as if it is really happening, until
If you intend to sell retail products, know each product
you gain the desired fluidity.
line well and think carefully about products that would
truly benefit your client. Ask clients if they would like to
hear about some of the products in the retail area that
might be of benefit. If the client says, “yes,” then outline Opening and Closing the Massage
one of two key products and show the client these prod-
ucts before processing the client’s fee for the session. Consider the following examples of how two different mas-
3. Collect the fee: Back in the reception area, collect the sage therapists open and close their sessions.
fee for the massage and offer the client water. Clients Steve pays attention to how he opens and closes his
appreciate bottled water they can take with them. massages. He likes to use resting and holding strokes

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74 Spa Bodywork: A Guide for Massage Therapists

and breathwork (described below). To open the massage, The closing of the massage should leave a client feeling
he places his hands on the client with clear intent and complete, peaceful, and balanced. You want the client to
allows the client to accept and become use to his touch. know the massage is ending before it actually ends and to
He asks the client to take three deep breaths and release start to return to normal waking consciousness smoothly
all body tension with each exhalation. Steve’s touch is without being jarred awake. Avoid abrupt closings that
assured and firm. The client feels a therapist who is ener- leave a client feeling rushed or disturbed.
getically balanced and focused and who has a plan. The Therapists use a variety of techniques to formally open
client relaxes before Steve even undrapes a body area, and close the massage, including resting and holding strokes,
confident that Steve knows what he is doing. The open- breathwork, aromatherapy inhalations, and auditory cues.
ing is a simple moment, and yet it can affect clients’ trust
level and willingness to allow their body to let go and Resting and Holding Strokes
relax. At the end of the session, Steve finishes the mas-
sage, redrapes the client, and places his hands in the same In a resting or holding stroke, the hands are placed, with-
position as when he opened the massage; although this out lubricant, on the client with the intent to greet the cli-
time, the client is supine. Steve asks the client to breathe ent and allow the client time to become accustomed to the
deeply for three breaths and to slowly wake up with each unfamiliar touch. You might match your inhalations and
exhalation. The exhalation of each breath brings the exhalations to those of the client during a resting stroke to
client gently back to the real world and leaves the client feel in sync with the client’s rhythms. Tension in the client’s
feeling peaceful. body, the client’s temperature and breathing patterns, and
Jay doesn’t worry much about how he starts and finishes the quality of the tissue under your hands all convey an im-
his massages. When he enters the treatment room, he fuss- pression, which may affect how you proceed with the ses-
es with the drape, leaves the client to look around for the sion (Fig. 4–2).
massage lubricant, and then struggles to place the bolster
under the client’s knees. The client’s body tenses to ward Breathwork
off the irritating sensations of all this disjointed activity.
Jay undrapes the client’s leg and starts massaging but soon Breathwork in massage is an important skill. A breathing
leaves to adjust the volume of the music. When he returns exercise such as the diaphragmatic breathing technique
to the client, he reminds the client to relax, but the client described in For Your Information 4–1, the pursed-lip
remains watchful for the first 20 minutes of the session.
Once Jay settles into the massage, he has good massage
techniques, and the client eventually relaxes deeply when
Jay works on the posterior legs and back. The client is calm-
ly drifting when Jay abruptly replaces the drape and says,
“Okay, time’s up, and I’ll meet you up front in the reception
area when you’re dressed.” He pulls out the bolster and
leaves the room. The client gets up quickly from the mas-
sage table and gets dressed. The client has less muscle ten-
sion but feels oddly irritated.
The opening and closing of the massage are important
moments because they “frame” the entire massage experi-
ence. The opening of a massage is a formal moment that
recognizes the importance of what is coming. Massage is
an opportunity for the body to change in a positive way,
to release long-held tension, to rest, to recover, and to have
a healthy experience of touch. In many ways, a massage
starts the minute a therapist enters the treatment room
and approaches the client. Even if the client is in a prone
position and cannot see the therapist, root hair receptors in
the skin will recognize changes in air movement and heat.
This may trigger instinctive survival responses that cause
the client naturally to be tense during the initial contact.
It is better to look at the client, offer a verbal greeting,
and approach slowly with therapeutic intent. Don’t look
around for bolsters or massage lubricant. Have everything
FIGURE 4–2 In a resting or holding stroke, the hands are placed,
ready before the client enters the treatment room so that without lubricant, on the client with the intent to greet the client and
your entrance into the room can be calm and relaxed. allow the client time to become accustomed to the unfamiliar touch.

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Chapter 4 Your Spa Massage 75


Diaphragmatic Breathing
Diaphragmatic breathing is used with the client in a supine position both to assess the client’s breathing pattern and to educate
the client about proper breathing. It works well to use this technique at the beginning of a session. Communication skills are key
because you will “coach” the client into a functional breathing pattern. Focus on ensuring that the client’s breaths are slow,
rhythmic, and relaxed. Keep the exercise short enough that the client does not become concerned about losing time from the

1. Place your hand on the client’s abdominal area and ask the client
to lift your hand with each inhalation up to three times.

2. Place one hand on each side of the ribs and ask the client to move
your hands outward with the breath up to three times.

(continued on page 76)

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76 Spa Bodywork: A Guide for Massage Therapists


Diaphragmatic Breathing (continued)

3. Place the fingers of one hand on the lower section of the ster-
num and ask the client to lift your hand with each breath up to
three times.

4. Have the client put the breaths together by cueing your hands. Ask
the client to inhale first, filling up the abdominal area, then laterally
expanding the ribs, and then allowing the chest to rise. Touch each
area in order as the client inhales and pace the client on a full, even
breath. As the client exhales, it can be effective to gently massage
any areas of the upper neck that look tense, such as the shoulders,
which may tend to pull forward or up during breathing. Repeat the
cueing and coordinated breathing up to three times.

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Chapter 4 Your Spa Massage 77


Pursed-Lip Breathing

Pursed-lip breathing tones and strengthens the diaphragm and

helps to reeducate the client’s kinesthetic sense of breath. When
the client exhales with lips “pursed” (imagine the lips closing around
a straw), this creates resistance for the diaphragm. The diaphragm
contracts on the inhalation and relaxes on the exhalation. Pursed-
lip breathing keeps the diaphragm working at the same time that
it is relaxing. Use this technique at the opening or closing of the
massage session with the client in a supine position or sitting up in
a chair. As with diaphragmatic breathing, communication skills
are important as you coach the client through pursed-lip breath-
ing. Place your hand on your client’s abdominal area and instruct
the client to raise your hand with each inhalation by breathing in
through the nose on a slow 2- to 4-second count. Demonstrate
the pursed-lip position of the mouth for the client and instruct the
client to exhale through the lips on a slow 4- to 8-second count. The
client should exhale through the lips as slowly as possible. Practice
the technique a few times. Clients who are interested in improving
their breathing and toning the diaphragm can practice pursed-lip
breathing 20 to 40 times, twice a day at home.

breathing technique described in For Your Information 4–2, session, as desired by the client, and can help clients develop
or simply asking the clients to take three deep breaths greater breath awareness and help change poor breathing
can help clients drop into their body, center themselves patterns. These exercises set the client up to breathe more
energetically, and consciously release unnecessary muscle evenly and deeply throughout the session, enhancing relax-
tension. Breathwork helps you tune into the client’s breath- ation and ensuring proper amounts of carbon dioxide and
ing rhythms and thereby pace the massage to the client. oxygen in the blood.
Many people breathe with a disturbed pattern that can
disrupt the delicate balance of carbon dioxide and oxygen Breathwork throughout the Massage
in the blood. Proper breathing during a session revitalizes Breathwork is important throughout the massage and can
the body by ensuring the correct levels of oxygen and car- be used in a variety of circumstances. Sometimes, you may
bon dioxide in the body. The use of breathwork in a session notice that a client is taking a breath, holding it without
helps clients become more aware of their breathing patterns conscious awareness, and then letting it out suddenly.
and can lead to better breathing on a regular basis. Still, spa Some clients regularly hold their breath without realizing
therapists must walk a careful line here. Too much focus it. You might say, “As I massage, try to focus on the even
on a breathing pattern can disrupt the client’s relaxation inward and outward movement of your breath. Try to make
experience and may cause resentment. Some clients resist each breath full and complete. This will help regulate your
breathwork because they just want to “get on with the mas- breathing pattern and help relax your muscles.” Clients
sage.” Breathing exercises used in wellness massage should then become aware of their breathing. Clients typically
be brief and to the point. focus on breathing for a short time and then forget about
The diaphragmatic breathing technique and the pursed- it, but they are likely to breathe more regularly throughout
lip breathing technique are brief enough to be used in every the remainder of the session.

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78 Spa Bodywork: A Guide for Massage Therapists

You can also match your own breathing to the client’s to oil or 1 drop of a blend of different oils is briefly rubbed
help pace the massage to the client’s natural body rhythms. together in the hands before being passed over the cli-
Alternatively, focus on your own breathing to add intention ent’s nose in an arc so that the oil can be enjoyed on a
to a stroke or to ensure that your movements flow in har- deep inward breath. The therapist then proceeds with the
mony with breathing. In this case, you are likely to exhale massage. Choose soothing oils such as a drop of laven-
as strokes move away from your body and inhale as strokes der, mandarin, or cardamom at the onset of the massage
come back. Your breathing pattern can also cue a client to to support the relaxation process. Stimulating oils such
breathe more regularly. For example, if you take an audible as peppermint, rosemary, or eucalyptus help the client
inward breath at the start of the stroke, you may find that “wake up” at the end of the session as part of closing the
the client joins in. As you exhale during the application of massage.
the stroke, the client might again follow along.
Clients can be encouraged to release bound muscle
tissue with their breathing. As a muscle is lengthened, Use of an Auditory Cue
as you move from the origin of a muscle to its insertion An auditory cue, such as the ringing of a chime, can be
during a stroke, or as you move from distal body areas to used to signal the beginning and ending of the massage
proximal body areas, encourage the client to take a full session. This opening might be paired with resting and
breath and then exhale as the stroke is performed. Your holding strokes, an aromatherapy inhalation (described
directions to the client should be simple: “Please take a earlier in this chapter), or a breathing exercise. This form
full breath, and now, release it.” If an area is particularly of massage opening and closing creates a sense of ritual
painful or tense, the client can use breathing to release the and lends the session a more spiritual formality. Over
area or decrease the pain. For example, if you are applying time, an auditory cue may become linked in the client’s
a stroke on the back and, as you approach the rhomboid mind with relaxation, causing an instantaneous relax-
muscles, the client tenses and you feel increased muscle ation response.
tension, you can say to the client, “I’m going to drop into
this bound tissue. Take a full breath and feel as if you
are using your breath to lift up my forearm. Good. Take
another deep breath and feel the tension dissipate as you Massage Enhancers
release the breath. Good!”
In certain stretching techniques, such as active isolated Therapists who would like to work in an established
stretching and post-isometric relaxation, the use of breath spa should make sure that their Swedish massage is
is fundamental to the technique. Potentially painful meth- flowing and elegant. Work to engage the tissue so
ods such as trigger point therapy require a client to breathe that the strokes have depth and intent. Practice drap-
through the technique to better tolerate the discomfort. ing efficiently and incorporating a variety of strokes so
that the massage feels complete. When developing a spa
massage, try to make the service as luxurious as pos-
Aromatherapy Inhalations
sible by adding several small but exceptional massage
Aromatherapy inhalations are used either at the begin- enhancers. These enhancers might include the use of
ning or end of the massage (Fig. 4–3). One drop of an steamy aromatic towels, aroma mists, a simple hand and

FIGURE 4–3 Aromatherapy inhalations. Aroma inhalations are used either at the beginning or end
of the massage. One drop of an oil or 1 drop of a blend of different oils is briefly rubbed together in the
hands before being passed over the client’s nose in an arc so that the oil can be enjoyed on a deep inward

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Chapter 4 Your Spa Massage 79

TABLE 4–1 Spa Massage and Enhancers—Sample Outline

1. Client supine, semireclined, and bolstered 1. Client prone and bolstered
2. Place a warm pack on the belly. 2. Place a warm pack on the back and on the bottom of the feet.
3. Place a drop of lemon oil in the hands and pass the hands in an arc over 3. Place 1 drop of lavender oil on a tissue and tuck it into the
the client’s nose for one or two breaths. bottom of the face cradle so that the client can smell a light
4. Place an aromatic hot towel over each foot and steam the feet. Remove 4. Massage the posterior legs and gluteals. Undrape the back and
the towel and proceed with the foot massage. place a steamy rosemary towel on the back.
5. Massage the anterior legs. 5. Massage the back. At the end of the back massage, apply a body
wash gel with warm water and work it into lather. Remove the
lather with a hot towel. Redrape the back.
6. Massage the arms and hands. Apply an exfoliation product to the hands 6. Remove the warm pack that is sitting on the feet. Turn the client
and then remove it with a hot towel. Paraffin dip the hands and wrap into a supine position. Place a warm pack under the neck and an
them in cellophane and a warm towel. eye pillow over the eyes. Rebolster the client.
7. Remove the pillows from under the client’s head and proceed with a neck 7. Massage the feet. At the end of the foot massage, apply exfolia-
and face massage. Place a steamy aromatic towel on the face at the end tion cream to the feet and scrub the feet. Remove the exfoliation
of the massage. product with hot towels.
8. Remove the paraffin from the hands, remove the warm packs, and turn 8. Massage the anterior legs and abdominals.
the client into the prone position.
9. Rebolster the client and massage the posterior legs and gluteals. 9. Massage the arms and hands.
10. Massage the back. Apply a foaming exfoliation product to the back and 10. Massage the neck and face. Place a steamy, aromatic towel
work it into lather. Remove with steamy aromatic towels. over the face to end the massage. Remove the towel and use an
aroma mist spritzed high over the client.
11. Spritz an aroma mist over the client and throughout the treatment room to 11. Allow the client to relax on the treatment table for an extra ten
complete the massage. When the client gets off the table, they will smell minutes before they get up.
the fresh scent.

foot treatment, paraffin dips, the use of warm packs, an Warm Packs
eye pillow, and a firming face massage. The spa massage
outline presented in Table 4–1 is meant to provide some Chapter 6 (Water Therapies) describes the use of hot
structure for those developing a relaxation spa massage. and cold packs to facilitate a change in muscle tissue
The outline helps the therapist to see how the mas- and to achieve a physiological effect on the body. In a
sage is enhanced with little extras to make it special. relaxation massage, the goal is to support client relax-
Step-by-step directions for some useful enhancers are ation and help clients rest, breath, and reflect on their
described below. inner thoughts and to feel revitalized at the end of the
session. Warm packs of rice, corn, or flax seed keep the
client warm but do not generate enough heat to produce
perspiration (Fig. 4–4). They are used to make the client
feel pampered and cozy and are placed on the back and
on the feet. In the supine position, a warm pack can be
placed on the belly, around the feet, and, if the shape is
appropriate, under the neck. Eye pillows filled with fra-
grant herbs can be warmed or cooled and placed over the
eyes to block out excess light. A Fomentek water bottle
might be placed under the bottom massage sheet to pro-
vide warmth, or the table can be heated with an electric
table warmer.

Steamy Aromatic Towels

Steamy aromatic towels make a pleasing enhancer when
FIGURE 4–4 Warm packs. Warm packs of rice, corn, or flax seed keep
the client warm and feel soothing and nurturing. Use them to enhance used during a full-body relaxation massage (Fig. 4–5).
your relaxation massages. For example, a steamy aromatic towel can be applied to

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80 Spa Bodywork: A Guide for Massage Therapists

skin irritation because essential oils are volatile sub-

stances and begin to evaporate rapidly the minute that
they are placed on the hot towels in the cooler. They will
mostly burn off before the first towel is used, leaving
only some of the scent behind. Skin irritation is there-
fore minimized.

Herbal-Infused Towels
Muslin bags filled with fragrant herbs can also be used to
scent towels. A muslin bag of herbs is added to the water
that the towels are heated in. A nice combination is euca-
lyptus leaf, rosemary, clove buds, and juniper berry. A half
a cup of herbs to around 16 quarts of water provides a nice
concentration, although more or less herbs can be used
FIGURE 4–5 Steamy aromatic towels. Steamy aromatic towels make
a pleasing enhancer when used during a full-body relaxation massage.
according to taste. Towels heated in herbal solutions will
They might be applied to the back, face, or feet as part of your massage be lightly stained.

A Simple Hand or Foot Treatment

the back directly before the back massage. This warms
During a relaxation massage, a simple hand or foot
the tissue and feels especially satisfying. Another way of
treatment can be added to make the massage special
using a hot towel on the back is to apply a bit of body
(Fig. 4–6). These enhancers take up very little massage
wash gel or foaming exfoliation cream with warm water
time and are a memorable part of the experience for
at the end of the back massage. Lather it with the hands
the client. For a simple foot treatment, prepare the
and then remove the lather with a hot towel. This takes
massage table by placing a bath towel at the end of the
only 1 minute out of the massage but becomes a mem-
table where the client’s feet will sit. Place two hot, moist
orable moment for the client. Another benefit is that
hand towels in a soda cooler. Just before or just after
they don’t feel oily at the end of the session. A steamy,
the foot massage, simply apply a little exfoliation cream
aromatic towel can be used in the same way on the feet
(a cream that has rough textured ingredients that polish
before the foot massage, on the face before the face mas-
sage, or on the face at the end of the service as a closing

Preparing Steamy Towels

To prepare the towels, pull off all the tags, then fold the
towels in half (the long way), and roll them up like a sau-
sage. It is important that all the tags are removed because
they could scratch the client. Place the towels in a hydrocol-
lator, hot towel cabinet, or stone massage heating unit for
20 minutes at 165°F. With thermal gloves, remove a towel
from the water, wring it out, and place it in a soda cooler.
Close the lid of the cooler and remove the next towel. Keep
the lid of the cooler shut as much as possible so that the
towels stay hot throughout the treatment. Towels can be
enhanced by soaking them in herbal infusions or adding
essential oils just before use.

Steamy Rosemary Towels

Add 3 to 5 drops of rosemary essential oil to the soda
cooler full of hot towels. As each towel is removed, it
will fill the treatment room with a refreshing scent.
Most single oils such as eucalyptus, common sage
(Salvia officinalis), Spanish sage (Salvia lavandulifolia), FIGURE 4–6 A simple hand or foot treatment. During a relaxation
thyme and lemon oil smell good, but floral scents such massage, a simple hand or foot treatment can be added to the session to
enhance the massage experience. Apply an exfoliation cream to the hand
as ylang ylang and jasmine are not as pleasant in steam. or foot directly before or after the massage and then remove the cream
The essential oil on the towel is not likely to cause any with hot, steamy hand towels.

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Chapter 4 Your Spa Massage 81

the skin) to each foot. Scrub the feet with the exfolia-
tion cream and then place a hot towel over each foot.
After the feet have steamed in the towels (about 30 sec-
onds), use the towels to remove the exfoliation prod-
uct. A simple hand treatment is conducted in the same
way. An exfoliation cream is massaged into the hand
and up to the elbow. A hot, moist towel is placed over
each hand, and the product is removed directly before
or after the hand massage.

Paraffin Dip
Paraffin is a waxy substance obtained from the distillates
of wood, coal, petroleum, or shale oil. It is used to coat
the skin and trap heat and moisture at the skin’s surface
FIGURE 4–8 Aroma mist. An aroma mist is usually made from
(Fig. 4–7). This increases local circulation, which improves distilled water with some added essential oils, but a hydrosol (flower
joint mobility and increases absorption of spa products water) can also be used. The mist is spritzed high over the client while
whenever they have been applied before using the paraffin. he or she is in a supine position to fill the treatment room with a
refreshing scent.
It is an effective treatment for chronic arthritis, tight mus-
cles, and painful joints. It also leaves the skin soft, and it
feels warm and sumptuous.
To apply paraffin to the hands or feet, wipe or mist the Easy Aromatherapy Enhancements
area with alcohol so that it is properly sanitized. Dip the
hand or foot into the paraffin and allow the paraffin to Aromatherapy is the use of essential oils for healing and
harden slightly before dipping the area again. Dipping the wellness. It is discussed in depth in Chapter 7. Small aroma-
area up to five times should be sufficient. Wrap the paraffin- therapy enhancements stand out as moments of particular
covered hand or foot in cellophane wrap or a plastic bag, radiance in a good relaxation massage. Essential oil mas-
before placing it into a heated mitt or a warm towel. To re- sage blends create an olfactory reaction that may facilitate
move the paraffin, simply peel off the cellophane wrap deeper relaxation in the client. It is a good idea to provide a
together with the wax in one piece. The hands can be dipped selection of from three to five blends so that the clients can
while the client is on the table in the prone or semi-reclined choose which one they like best. Aroma mists are another
position. The feet can be dipped while the client is on the way to bring the pleasure of good smells into the massage.
table in the supine position. Paraffin can also be applied An aroma mist is usually made from distilled water with
with a brush or on gauze strips, which wrapped around the some added essential oils, but a hydrosol (flower water) can
body area. also be used. The mist is spritzed high over the client while
he or she is in a supine position to fill the treatment room
with a refreshing scent (Fig. 4–8). The scents used in the
treatment can be varied to keep the client’s olfactory “pal-
ate” stimulated.
Earlier, we discussed aroma inhalations, which might be
used either at the beginning or end of the massage. As was
mentioned previously, 1 drop of an oil or 1 drop of a blend
of different oils is briefly rubbed together in the hands
before being passed over the client’s nose in an arc so that
the oil can be enjoyed on a deep inward breath. Relaxing
or calming oils are used at the beginning of the massage,
whereas refreshing, stimulating oils are used at the end of
the session.
Table 4–2 provides some nice aromatherapy blends
that are generally popular with clients. These blends
can be mixed into a plain massage cream or in expeller-
pressed vegetable oil for the massage, or they can be mixed
FIGURE 4–7 Paraffin application. Paraffin is used to coat the skin and with water for an aroma mist. The table also includes a
trap heat and moisture at the skin’s surface. Wipe or mist the hands or list of single oils that work well for aroma inhalations.
feet with alcohol so that it is properly sanitized. Dip the hand or foot into
the paraffin and allow the paraffin to harden slightly before dipping the Aromatherapy and blending techniques are discussed in
area again. Chapter 7.

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82 Spa Bodywork: A Guide for Massage Therapists

TABLE 4–2 Easy Aromatherapy

The following blends can be added to 1 fl oz of The following blends can be added to 1 oz of The following blends can be mixed up and used
an expeller-pressed oil (i.e., hazelnut, sweet distilled water. undiluted (1 drop) in the hands for an aroma
almond, sunflower) or plain massage cream. inhalation.
The numbers refer to drops.
Relax Factor Radiance Inspiration
Frankincense 4 Atlas cedarwood 5 Rose 1
Mandarin 8 Neroli 2 Mandarin 10
Ylang ylang 2 Lavender 4 Clove 1
Cypress 2 Grapefruit 6
Refreshing Revitalize Verve
Rosemary 3 Grapefruit 8 Rosemary 2
Clary sage 2 Eucalyptus 1 Geranium 1
Lemon 7 Cypress 2
Geranium 1 Sweet orange 6
Citrus Star Summer Sparkle
Grapefruit 11 Mandarin 6 Peppermint 1
Jasmine 1 Lemon 7 Grapefruit 8
Geranium 1
Muscle Ease Rain Siesta
Sweet birch 3 Juniper berry 4 Lime 7
Juniper berry 2 Thyme 2 Jasmine 1
Lavender 6 Lavender 6
Lemon 6 Cypress 3
Detox Mental Boost Quietude
Sweet fennel 5 Rosemary 2 Neroli 2
Juniper berry 4 Basil 4 Clary sage 5
Grapefruit 10 Lemon 7 Sandalwood 10
Body Boost Sweet Dreams Wake Up
Peppermint 1 Neroli 2 Peppermint 2
Tea tree 2 Lavender 7 Rosemary 2
Lavender 6 Mandarin 10 Basil 1
Lemon 6

strokes with other strokes, such as myofascial work, neuro-

Putting Your Spa Massage Together muscular therapies, compression strokes, Asian bodywork
methods, or with resting/holding strokes used to open and
The techniques used in Swedish massage form the foun- close massage sessions. An overview of Swedish techniques
dation of most therapists’ massage routine, even those and considerations is provided in Tables 4–3 and 4–4 for
practicing specific different forms or systems of massage. review. Think about the individual strokes, how they tie
Swedish massage is sometimes called relaxation massage, together, their effects on the body, and how you palpate
but Swedish techniques have many benefits in addition and adapt the techniques during a massage. The next step
to relaxation. In fact, Swedish massage techniques can is then to understand how to sequence the massage and use
be delivered with light, moderate, or deep pressure for a the subtleties of massage skills.
variety of treatment outcomes. Swedish massage still uses
the six traditional stroke techniques given French names
by Dr. Johann Mezger in the 1800s. These techniques are
effleurage, pétrissage, friction, tapotement, vibration, Sequencing refers both to the sequence of strokes (the order
and joint movements (also called Swedish gymnastics or in which strokes are applied to a given body area) and to the
range of motion techniques). Each of these techniques is overall sequence of the massage (the order in which body
performed with the depth and vigor most appropriate for areas are massaged). In Swedish massage, the strokes often
the individual client. Therapists often integrate Swedish follow a defined progression from effleurage to pétrissage,

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Chapter 4 Your Spa Massage 83

TABLE 4–3 Overview of Swedish Massage Techniques

Effleurage A long, gliding stroke Desquamation of dead skin cells, Should not be used distal to an area of in- Superficial; moderate;
usually applied increases circulation and lymph flammation or injury; avoid application or deep, shingling
toward the heart flow, triggers parasympathetic over open skin lesions, skin diseases, technique
nervous system response, sup- or bruises. Avoid prolonged application
ports venous return, causes on the limbs of clients with cardiovas-
relaxation cular disorders, high blood pressure, or
circulatory conditions.
Pétrissage A rhythmic stroke Stimulates sebaceous secretion, Avoid use with atrophied muscles that Skin rolling, fulling pé-
that lifts the muscle increases circulation and lymph lack moderate tone. Do not use over trissage, and wringing
off the bone and flow, activates Golgi tendon open skin lesions, skin diseases, pétrissage
compresses it organs (GTOs) to relax muscles, bruises, acute injuries, inflammation, or
between the fingers decreases adhesions moderate to severe varicose veins.
Friction A heat-producing Superficial friction is stimulating Do not apply friction over open skin Superficial friction,
chafing or rubbing and warming and increases lesions, skin diseases, bruises, acute circular friction, linear
stroke blood and lymph flow. Deep injuries, inflammation, or moderate to friction, and cross-fiber
friction separates muscle fibers severe varicose veins. friction
and breaks up adhesions and
scar tissue.
Vibration A pulsating tremor- Primarily stimulating and then Do not apply vibration over open skin Fine vibration; coarse
like or oscillating relaxing; sustained vibration is lesions, skin diseases, bruises, acute vibration including
stroke numbing and analgesic and injuries, inflammation, or moderate to jostling, shaking, and
decreases muscle guarding; fast severe varicose veins. rocking
vibrations can cause muscle
contractions and stimulate
Tapotement A rapid and rhythmic Short applications are stimulating; Do not apply tapotement over the kidneys, Light, moderate, hack-
percussion stroke longer applications are relaxing. over bony areas, especially directly over ing, cupping, beating,
with which the Very light tapotement causes va- the spine, or over bruises or varicose slapping, pincement,
hands are used in soconstriction of capillaries in the veins. and tapping
various formations local area. Moderate tapotement
to drum on the causes increased circulation,
client useful for loosening of mucus.
Joint movements Movements such as Stimulate the production of syno- General contraindications include acute Active, passive, and
flexion, extension, vial fluid to nourish and protect injuries to bones, joints, muscles, or restricted
abduction, and the joint structure; increase range nerves. Techniques that traction the
adduction per- of motion joint are contraindicated for sprains,
formed as part of rheumatoid arthritis, and hypermobile
the massage joints. See specific contraindications in
Table 13–1.

to friction, to vibration, to tapotement, with joint move- might be used directly after effleurage, pétrissage, and mod-
ment added as appropriate. Each stroke addresses the tis- erate friction with vibration and tapotement coming after.
sue in a different way, and the sequence of strokes takes Another factor determining the sequencing of techniques is
into account the physiological changes that have occurred the quality of the client’s tissue and how quickly it changes.
in soft tissue during the preceding stroke. In a traditional Some clients need a prolonged warmup, whereas others are
Swedish massage, the therapist might simply deliver ready for deep work early in the session. Sometimes, areas of
each type of stroke to the body area in a predefined order taut muscle tissue require work with very specific techniques
before moving on to the next body area. Alternatively, the to reset muscle length and promote better muscular balance.
order of the strokes might be changed to meet the client’s As you contemplate how you want to sequence your
particular needs. massage, remember that there are advantages to starting
Often, a therapist will combine different massage systems the massage with the client supine and other advantages to
in a session, which may change the sequencing of the strokes. starting prone. When the massage starts in a supine posi-
For example, if myofascial release techniques are being com- tion, clients can open their eyes and look at the therapist.
bined with Swedish massage and deep tissue work, myo- This is important if the client is new to massage and does
fascial techniques would probably be applied first because not know the therapist. Being able to visually check with the
they are used on dry skin without lubrication. Deeper work client during the first half of the massage helps the client

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84 Spa Bodywork: A Guide for Massage Therapists

TABLE 4–4 Overview of Swedish Massage Considerations

• Desquamation of dead The effects of the massage Palpations skills increase with • Intention: client centered
skin cells technique on the body more experience. Develop • Contact: quality of touch
• Increased sebaceous vary, depending on how palpation skills by being • Use of lubricant: Use lubricant in
secretion to condition skin the stroke is applied. Pay aware of what you see and moderation. Remove excess lubri-
• Increased blood and attention to the following: feel during the massage cant if not absorbed into the skin.
lymph circulation • Technique: gliding versus session. • Pacing and leading: Match the
(increased tissue warmth) lifting • Visual: How does the client client’s pace and then lead a client
• Improved nutrient and • Depth: light versus deep look (skin color, expression, to more relaxing rhythms.
waste exchange in local • Speed: fast versus slow posture, etc.)? • Depth: Engage the tissue unless a
tissue • Direction: toward the • Move: How does the client superficial massage is requested.
• Improved venous return heart versus away from move (stiffly, lightly, force- • Rhythm: Use regular patterns or
• Decreased muscle the heart fully, smoothly, etc.)? strokes and a regular tempo.
spasm, tension, and • Duration: brief applica- • Touch: How does the tissue • Flow and continuity: Techniques
soreness tion versus prolonged feel (crackly, taut, fluid, hot, should flow in an uninterrupted
• Decreased adhesions in application cool, clammy, etc.)? action so the client experiences the
myofascia • Sound: How does the client constant and steady pressure of
• Decreased pain sound when he or she com- your hands.
• Increased range of municates (relaxed, sleepy, • Stroke length: Work the length
motion and joint health anxious, fretful, etc.)? of the muscle or the length of the
• Increased relaxation body area.
• Decreased symptoms
relating to stress
• Improved muscle tone

gain confidence and relax. Clients often experience conges- Always be clear about what will happen during the massage
tion when they are placed face down in a face cradle. One of by saying things like, “In a full-body massage, I massage the
the advantages to starting the massage in the prone position legs, feet, arms, back, neck, gluteal muscles (the muscles of
is that the client’s sinuses have time to decongest during the the buttocks), abdominal muscles (the muscles of the belly),
second half of the massage when they are turned into the and the face. Would you prefer I avoid any of these areas?”
supine position. This sequencing allows the client to leave Although the client’s wishes always prevail (unless they are
the session feeling more alert and with less facial puffiness. asking for techniques that are contraindicated, illegal, or out
Specific treatment goals may also determine the sequenc- of the massage scope of practice), the therapist can educate
ing of a session. For example, if the client has lower back clients about the benefits of massage for certain areas. For
pain, the therapist might choose to release the hamstrings example, clients often feel uncomfortable with the idea of
and adductors of the legs before working the back and then having their gluteals or abdominal muscles massaged. When
turn the client supine to finish with psoas work and low a therapist takes the time to explain the importance of releas-
back stretches. In health care–oriented massages, some ing tension in these muscles, the client may feel safe enough
regions of the body might not be massaged, allowing more to give it a try. The three examples of massage sequences in
time for problem areas and their associated structures. Table 4–5 demonstrate how diverse sequencing can be.
Most important to sequencing the massage is the infor-
mation the client provides during the intake interview. This
process involves designing the session to meet the client’s
needs. It is a little like a negotiation. The client might say, Routines are a series of strokes that are planned in advance,
“I want a lot of work on my back and legs.” The therapist delivered to body areas in a preset order, and practiced until
might say, “Do you only want me to work on these areas, they flow smoothly together. Some spas and massage clinics
or would you like a full-body massage with extra focus on develop set routines that are delivered by all of the busi-
these areas?” The client might then say, “I want you to work ness’s therapists. These standardized wellness sessions often
on my back, legs, feet, and neck with most of the work on include enhancing extras such as the use of warm packs,
my back.” The therapist can also suggest areas the client aromatherapy, and foot soaks to increase the sense of lux-
needs to have massaged based on assessment findings. The ury and relaxation experienced by the client as we discussed
therapist and client now have an agreed plan for the session. previously. The drawback to standardized wellness sessions
The term full-body massage often means something differ- is that clients may not get the specific work they need for
ent to the client than to the therapist. Clients sometimes say their particular areas of muscular tension. The advantage
they want a full-body massage and then express dismay when is that clients know beforehand what the massage will be
their abdominals or gluteals are undraped and massaged. like and can count on receiving the same massage when they

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Chapter 4 Your Spa Massage 85

TABLE 4–5 Examples of Different Massage Sequencing

1. Begin with client prone. 1. Begin with client supine. 1. Begin with client prone.
2. Place warm pack on the lower back. 2. Place warm pack on abdominals. 2. Place warm packs on hamstrings.
3. Open massage with holding strokes. 3. Open massage with diaphragmatic 3.Open the massage with holding strokes.
4. Massage posterior legs. breathing exercise. 4. Myofascial release to back.
5. Remove warm pack and place on feet. 4. Massage neck and face. 5. Swedish massage back.
6. Massage back. 5. Massage arms. 6. Deep tissue massage back.
7. Remove warm pack. 6. Massage anterior legs and feet. 7. Remove warm packs from hamstrings and
8. Turn client supine. 7. Remove warm pack from abdominals. place on back.
9. Transition to anterior massage with 8. Turn client prone. 8. Myofascial release to posterior legs.
diaphragmatic breathing exercise. 9. Transition to posterior massage with 9. Swedish massage posterior legs.
10. Massage anterior legs. holding strokes. 10. Remove warm packs.
11. Massage feet. 10. Massage back. 11. Turn client supine.
12. Massage abdominals. 11. Massage posterior legs. 12. Myofascial release anterior legs.
13. Place fresh warm pack on abdominals. 12. Close massage with three deep breaths. 13. Swedish massage anterior legs.
14. Massage arms and hands. 14. Massage abdominals.
15. Massage shoulders and neck. 15. Psoas release work.
16. Massage face. 16. Passive hamstring stretches.
17. Close massage with holding strokes. 17. Passive lower back stretches.
18. Massage neck and upper arms.
19. Close massage with holding strokes.

return for another session. When massage is used purely for techniques in a flowing, integrated professional massage.
relaxation, the predictable quality of a set routine can actu- After mastering these core skills, you can consider how subtle
ally add to the client’s sense of safety and ability to unwind. factors such as intention, depth, stroke length, and rhythm
The danger for the therapist is that a set routine makes it profoundly influence the client’s massage experience.
easy to stop paying close attention to the individual client.
Routines for specific body areas are very useful in relax- Therapist’s Intention
ation settings. For example, some therapists develop a very It is always important to ground and center yourself before
effective foot routine that helps them to build a loyal cli- a session. This helps to calm your energy and focus your
entele who especially like foot massage. In many spas, the mind so that you are fully present during the session. Some
face is massaged while the body is cocooned in a body wrap. therapists forget this principle and talk loudly; bang into
If a therapist has taken the time to develop a face massage things; fuss with supplies, the drape, or the music; and
routine that incorporates a variety of strokes, it is likely to cause such static in a room that the client cannot com-
enhance the client’s experience. For Your Information 4–3 pletely relax. Before entering the treatment room, take a
demonstrates a nice face routine. A foot routine is provided moment to center and ground your energy. Pay attention
in Chapter 10 (Spa Foot Treatments). to your tone of voice and volume. Talk softly but not so
The use of routines is not advised for health care–oriented softly that the client has difficulty understanding your ver-
massage or massage sessions in which the client and thera- bal directions. Everything should be ready for the session
pist have agreed on specific treatment goals. In these cases, before the client undresses and moves into position beneath
the therapist must adapt the massage to the client’s specific the drape. If the music level is set and music is playing; if the
needs and to moment-by-moment changes that occur in the lubricant is warm and within reach; and if extra blankets,
client’s soft tissue structures. The term routine should not bolsters, and draping material are readily available; you are
be confused with a “treatment protocol” in which a series likely to feel more centered and grounded.
of techniques are used in a particular order. For example, When working with a therapeutic intention, maintain
in trigger point work, the protocol is to warm the area with appropriate professional boundaries and work in such a
friction strokes or skin rolling before the trigger point is way that the client will not experience emotional, physical,
located and treated. Joint movement and flushing strokes mental, or spiritual damage from the session. Therapeutic
are applied after the trigger point has been treated to help intention also includes the idea that you are focused only
reset the muscle’s normal resting length. on the session. You are “present,” “in the moment,” and
paying attention to the client’s facial expressions, sounds,
soft tissue, and communication. When you walk through
Subtle Factors That Influence the Massage
the door of the treatment room, everything but the client
If you are a novice massage therapist who is still a student should go away. Set aside all thoughts about bills, relation-
or entering your first massage-related job, you will want to ship problems, to-do lists, and plans with friends so that
master each individual technique before trying to combine you focus only on the client.

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86 Spa Bodywork: A Guide for Massage Therapists


Face Massage Routine
Ask clients if they would like their face massaged as part of their relaxation session, especially if the client is wearing makeup.
If the client is wearing makeup, she may want to remove it before the massage to enhance her enjoyment of the session and
protect her skin. Rich emollient face cream or whipped shea butter is recommended for this treatment. Massage oil, massage
cream, or massage gel are not recommended because these products may leave facial skin feeling clogged and bogged
down. Before touching the client’s face, the therapist’s hands should be sanitized with an alcohol-based sanitizer. This will pre-
vent any microbes that were picked up on the body or in the treatment room from being transferred to the delicate facial skin
and will ensure that the therapist’s hands smell clean to the client. The therapist may want to drape the client’s hair to protect
it from face cream using the simple hair draping method described in the next chapter. To view a video demonstration of face
massage, visit thePoint.

Apply an aromatic towel to the face. Remove a steamy

rosemary or herbal-infused towel from a cooler and
drape it on the face by spreading it from under the chin
to the forehead. Allow the towel to sit on the face for
up to 1 minute and then gently press it into the face to
increase the sensation of heat. Remove the towel from
the face and repeat with a second towel if desired.

Apply a rich emollient facial cream starting under the

chin, coming up around the mouth, around the nose,
up the nose to the forehead, and down the sides of the
face to the chin. Repeat this technique six to eight times
to spread the cream evenly over the surface of the skin.

Perform gentle cross strokes between the eyebrows.

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Chapter 4 Your Spa Massage 87


Face Massage Routine (continued)
Transition into s-bows and cover the whole forehead with
s-bow strokes.

Transition to glide down either side of the nose and

activate the pressure points at the top of the nose and
bottom of the nose as the fingers circle. Repeat this
technique three to six times.

Transition into small figure of eights using light finger pres-

sure and glide over the entire face, chin, and forehead
with this technique.

(continued on page 88)

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88 Spa Bodywork: A Guide for Massage Therapists


Face Massage Routine (continued)
Slide a relaxed hand over one eye in a circular motion
and finish the stroke with pats at the side of the eye.
Repeat this four times and transition to the other eye.

Make small circles around both eyes at the same time

and then transition to the chin using small finger circles.

Lightly pétrissage the jaw line and s-bow the chin, then use
a crossed thumb technique at the chin.

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Chapter 4 Your Spa Massage 89


Face Massage Routine (continued)
Use the index finger and the thumb on both hands to ap-
ply a lifting technique around the upper and lower lips.

Bring the thumb and index finger of one hand around

the mouth in five to seven strokes to smooth the tissue at
the sides of the mouth.

Using soft hands and relaxed wrists, apply a gentle slap-

ping tapotement to the underside of the jaw.

(continued on page 90)

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90 Spa Bodywork: A Guide for Massage Therapists


Face Massage Routine (continued)
Bring the gentle slapping tapotement up the jaw line
and cheek area and then transition back to underneath
the jaw.

Transition from the slapping tapotement into a “snap-

ping” tapotement and apply the stroke to the jaw line
and cheek area on both sides of the face.

To learn this stroke, make a pinching movement with

the thumb and index finger but instead of meeting the
fingers, lift them up off the face.

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Chapter 4 Your Spa Massage 91


Face Massage Routine (continued)
Soothe the sides of the face with gentle upward strokes
toward the top of the forehead.

Gently massage the outer edge of the ear and push

the ear forward to stretch it. Massage the area directly
behind the ear and finish the area by laterally flexing the
neck to one side during a long stroke down the neck,
over the shoulder and down the arm. Repeat this stroke
on the opposite side.

The facial sequence can be repeated up to three times

for a longer face massage. To end the face massage,
place 1 drop of peppermint or lemon oil in the hands
and rub them together and cover the nose lightly for
30 seconds. A second steamy, aromatic towel can be
placed over the face, or place a cool towel over the
face to finish the service.

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92 Spa Bodywork: A Guide for Massage Therapists

Contact the client halfway and tune in to the client’s rhythm and
The quality of your touch is important, and you must think state of being. For example, it may be disconcerting for a
about what your hands are communicating to the client. mildly depressed client to walk through the clinic doors and
Warm, soft, dry, open, and confident hands tell the client that encounter the therapist Chirpy Mary Sunshine. Similarly, it
you are relaxed and self-assured and know what to do. Cool, may be off-putting for an upbeat client who is enjoying a
damp, uncertain hands tell the client that you are anxious great day off to encounter the therapist Low Energy Larry.
or doubtful about the session. Cultivate confidence in your Therapists can learn to “pace” the massage by matching
touch. Do not just touch the client but feel the tissue, open the first part of the massage to the client. As the massage
your hands, and sink into the muscle. Once you establish progresses, the therapist can “lead” the client into more
contact, avoid disrupting it. Sometimes, novice therapists relaxing rhythms. To understand “pacing” and “leading”
take their hands off the client repeatedly while transitioning better, consider one aspect of a counseling and life-coaching
between strokes or lift their hands off the body to get more technique from neuro-linguistic programming (NLP). NLP
lubricant. Instead, try to keep at least one hand in contact uses the word pacing to describe techniques that build rap-
with the client at all times. This helps the client to keep track port between the counselor and the client. The idea is that
of your presence and the progression of the massage. people tend to like people that they are liked, so the counselor
makes himself or herself more like the client. The counselor
Use of Lubricant tunes in to the client’s breathing patterns, speech patterns,
In a Swedish massage, most strokes require the use of lubri- body language, and personal rhythm. During the session,
cation to prevent undue friction between your hands and the counselor uses speech and body language patterns simi-
the client’s skin. Use the lubricant in moderation. When the lar to those of the client. When the client is relaxed and when
client is too slippery, your hands cannot sink into the tissue the counselor feels that a rapport has been established, he or
and manipulate it effectively. After undraping a body area, she starts to lead the client. The counselor breathes with a
turn one hand over and set it on the client’s skin with the new pattern, and the client follows (so long as good rapport
palm side up. Pour a small amount of lubricant into your has been established). The counselor slows down (or speeds
palm and warm it by rubbing your other hand across it, up) his or her speech and changes his or her body language,
staying in contact with the client’s skin. Turn both hands and the client follows. All of this is done while the client and
over and apply long strokes over the entire undraped body counselor are talking about other things. The benefit of this
area to spread the lubricant. As the lubricant is absorbed for the client is that these new breathing patterns, body ges-
into the skin, work the strokes deeper into the tissue. If the tures, and/or speech patterns create a “shift” in the client.
skin becomes dry and the strokes start to drag, apply more It is almost as if these new patterns put a person in touch
lubricant (some drag on the tissue is desirable with certain with new internal resources that allow looking at a situation
strokes). Again, do not break contact with the client. Keep from a new vantage point.1 NLP is much more complex than
one hand in contact with the client’s skin while warming this simple description, but this example can help massage
the lubricant in your hands. If you accidentally apply too therapists think about how they pace and lead clients.
much lubricant and it is not absorbed into the skin during The goal is to match the client’s basic energy levels but
effleurage strokes, remove some of the lubricant with a hand not mimic the client or go to extremes of behavior. For a
towel. It’s better to take a moment and remove the lubricant client and therapist both to be bouncing off the walls with
than give a slippery superficial massage of the body area. hyperactive energy does not do the client any good. Instead,
Most clients do not want to feel oily at the end of the mas- be upbeat but remain grounded until the client can be led
sage. It is a good idea to provide disposable “wet wipe” tow- to more relaxing patterns. If a client is downhearted, you
els and a dry hand towel for the client to use at the end of might still remain positive but subdue your personal energy
the massage if you use oil for the lubricant. Creams and levels and speak in a quiet voice to respect the client’s state
lotions cause less slip but also feel cooler on the client’s skin. of being.

Pacing and Leading Depth

All people have an internal pace or personal “rhythm” that Massage therapists sometimes call a superficial massage a
influences how fast they move, how quickly they react, the “fluff and buff.” Although some clients like gentle massage
speed and cadence of their speech, their physical manner- that only skims the surface of the tissue, most clients want
isms, the speed of their thought processes, and even their the therapist to sink into the tissue, take hold of the tissue,
breathing patterns. At the same time, a client is likely to move the body with confidence, and address tension and
arrive in a particular state of mind and body (state of being). any adhered muscle and fascia. This should not mean that
Perhaps he or she encountered bad traffic and is running you are working so deeply and with so much pressure that
late. Perhaps the client just came from a yoga class and the client feels pain. It means that you can feel the quality
is feeling balanced. Maybe the client is feeling depressed of the tissue and understand how to engage it properly.
because of personal issues. Regardless of the cause of the Working with appropriate depth is a product of good pal-
client’s mental, emotional, and physical state, try to meet pation skills and self-confidence.

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Chapter 4 Your Spa Massage 93

To build these skills, pay attention to the way a client’s movement. Strokes are like the river water. They should flow
tissue feels and how it changes in different areas of the body. in one uninterrupted action so that the client experiences the
In a Swedish massage, effleurage starts out light and quickly constant and steady pressure of your hands. A therapist who
gains depth as the body area softens. Circulation increases has not yet developed flow and continuity might pause during
in the local area, and the tissue begins to “melt,” signaling strokes, lift the hands off the client, change techniques at the
that you can drop deeper into the muscle and fascia. Feel for wrong times, and feel disjointed and sporadic.
the “bottom” of the muscle. Think of sinking into a pillow Changing techniques at the wrong times is a common
or other soft structure. Drop down and maintain an even mistake of novice therapists. For example, it is a bad idea
pressure as the stroke travels the length of the body area. to start with effleurage on the calf muscles, shift to tapote-
One way to learn about depth is to practice on clients or fel- ment at the hamstring, then to pétrissage as the stroke
low students and ask for honest feedback. Ask direct ques- approaches the gluteal muscles, and then back to effleurage
tions like, “Is my pressure deep enough or would you prefer as the stroke moves into the gluteals. The nervous system
more pressure?” If the client answers “more pressure,” sink cannot process these rapid technique changes and may
in and feel what it feels like to sink in. Ask again, “Is this deep become hyperalert and irritated. Instead, start effleurage at
enough or should I be deeper?” Keep asking until the client the ankle, sweep all the way up the leg, and come all the way
communicates that the pressure is just right. Feel what “just back down the leg before shifting techniques.
right” feels like and remember that feeling. Remind clients The great ballet choreographer, Balanchine, often choreo-
to speak up if something hurts or feels too forceful. graphed dance sequences in groups of three. He felt that the
Remember to practice massaging a variety of body types first time an audience saw a dance sequence, it captured their
when learning to work with depth. Each body responds to pres- attention but they did not have time to really see the moves.
sure differently, and you must adapt to the tension levels and When the sequence was repeated a second time, Balanchine
density of the individual tissue. The more massages you give as believed that the audience studied the movement and ana-
a student, the faster you develop these skills. If it happens that lyzed the technique. The third time a sequence was danced,
you start out working with too much depth and a client com- the audience could simply enjoy the beauty of the move-
plains about the pressure, try to avoid becoming fearful but ment. Although massage strokes would not be delivered in
simply promise yourself to pay more attention to the quality strict groups of threes, the same philosophy applies. A client
of the tissue. It is okay to work too lightly or too deeply at first. needs time to be surprised by a sensation, analyze what is
No therapist walks out the training room door and has perfect happening, and then settle into enjoyment of the technique.
depth the first time he or she gives a massage. These skills are
developed over time through practice and mindfulness. Stroke Length
A therapist with strong massage skills tends to use long
strokes that tie body areas together. He or she will travel the
Rhythm in massage is a lot like rhythm in dancing. Ther- length of a muscle’s fibers, or the length of a body area, before
apists with good rhythm apply strokes in a regular pat- changing techniques or lifting the hands away from the cli-
tern at a regular pace or tempo. The client relaxes to the ent’s body. When a stroke is cut short, it leaves the client feel-
rhythm, much as a child relaxes when rocked by a parent. ing oddly frustrated. One area where this happens is on the
Imagine how pétrissage strokes would feel if delivered in posterior and anterior leg. Inexperienced therapists often
an uneven pattern. That sensation may well be distracting stop short in the stroke because they are taught to be careful
and disturbing for the client. Sometimes, the rhythm of the of draping and worry that the stroke will become invasive.
massage changes naturally because you change strokes or The stroke should travel all the way up to the gluteals and
techniques. Deep work is most often applied very slowly, around the greater trochanter, or all the way up to the ante-
whereas tapotement is applied more quickly. You might rior superior iliac spine (ASIS) and back again. On the arm,
deliver the first few passes of effleurage at a quicker tempo the stroke should travel up to the shoulder or even up to the
and then slow down to lead a client into relaxation. neck. Understand the muscles and seek to work their entire
To build good rhythm, think about the regularity of length whenever possible. Many therapists undrape one or
strokes and strive to keep them even in both depth and the other side of the client and travel from the foot, up the
speed. Use music to set the pace for the massage and leg to the back, and then return to the foot again. These
“dance” the strokes as a training exercise. Check in with strokes build clients’ kinesthetic awareness of their bodies
your practice clients and get feedback on their perception and how different body areas relate to each other.
of the rhythm of the massage. As with all massage skills, By learning and integrating the techniques and subtle
rhythm is developed over time and with practice. skills discussed in this chapter, you are preparing to give an
excellent relaxation massage that will help to reduce stress
Flow and Continuity in the clients, rejuvenate their energy levels, relieve muscu-
Flow and continuity refer to the progression of massage strokes lar tension, and help the body to find balance. This level of
from one technique to another and from one body area to integrated work is what keeps clients coming to your busi-
another. Think of a river streaming over rocks in one unbroken ness for repeat massages.

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94 Spa Bodywork: A Guide for Massage Therapists

STUDY TIP: Party! That’s Right. Party! medication levels and sedentary habits.2 Another study
showed that diaphragmatic breathing lowered blood
Students in massage and spa training programs some- pressure as long as it was practiced regularly.3 Patients
times feel like their social lives are curtailed by the with anxiety disorders and panic attacks found that
need to study. One way to study and also have some the diaphragmatic breathing exercise helped them
social time is to hold a study party. To be productive, experience less fear, fewer cognitive symptoms, and
the party should have clear learning objectives and fewer catastrophic thoughts during an attack, and the
planned activities. For example, the schedule might be technique sometimes served as an intervention to pre-
planned like this: vent an attack.4 Finally, patients suffering from chron-
1 to 2 p.m.—Aromatherapy review—led by Steve ic low back pain improved significantly with breath
2 to 2:30 p.m.—Essential oil properties flash cards—led therapy (a variety of techniques were taught including
by Ellen pursed-lip breathing and diaphragmatic breathing).
2:30 to 3:00 p.m.—Food! Everyone brings one dish for This study reports that “changes in standard low back
a potluck pain, measures of pain and disability were compa-
3:00 to 4:00 p.m.—Spa Massage Olympics (See expla- rable to those resulting from high-quality, extended
nation below.) physical therapy.” Again, the regular practice of these
4:00 to 10:00 p.m.—Watch a movie and more food! methods was important for continued benefit.5


A beautiful, flowing spa massage requires careful The topics in this chapter illustrate the diverse skills
thought and lots of practice. One way to make this needed by a professional massage therapist to manage
process fun is to hold a Spa Massage Olympics. Ask a client before, during, and after a relaxation massage
your instructor to set a date and arrange for three session. These skills involve four primary areas: com-
judges. Make a set of large cards with the numbers 1 munication skills, organization skills, client manage-
to 10 for each judge. It works well to have judges score ment skills, and exceptional hands-on skills. Getting
participants on areas such as correctness of stroke clients in and out the door involves many steps along
application, draping skills, routines, sequencing, with giving them an exceptional bodywork experi-
use of enhancers, flow and continuity, rhythm, etc. ence in between. An organized therapist, skilled at
Arrange for prizes and generate some enthusiasm! client management, can better plan and implement a
You can learn a lot by practicing for your event and by meaningful opening and closing of the massage that
watching your competition perform. If your instructor add to the client’s experience and help build client
does not have time for this in the class schedule, this is loyalty. Therapists often emphasize learning advanced
a fun activity for a study party. soft tissue skills and fail to fully appreciate skills that
seem less technical, such as positioning and draping
IT’S TRUE! Diaphragmatic Breathing Exercises and sequencing a relaxation massage appropriately.
Support Different Client Groups Although it is desirable to master a range of therapeu-
tic techniques, the foundation skills of draping and
Several research studies on diaphragmatic breathing fluid relaxation massage lead to an uninterrupted cli-
exercises demonstrate that this technique can help ent experience and allow the client to relax completely
a diverse group of clients meet health care goals as and enjoy the session. Underlying all of these skills is
long as the technique is practiced regularly. In one the ability to communicate effectively when explaining
study, asthmatic adults who practiced diaphragmatic paperwork to clients, directing them to the treatment
breathing exercises experienced a significant reduc- room, describing the benefits of a technique, giving
tion in the medication they used to treat asthma and direction during the session, and coaching the client
a lower intensity of their symptoms. This reduction through an activity such as diaphragmatic breathing.
in symptoms led to increased physical activity, which Lack of skills in any of these areas can directly impact
improved their overall health. Unfortunately, most the therapist’s ability to attract and retain clients and
participants decreased their practice of diaphragmatic make a good living from massage.
breathing after the study and relapsed into previous

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Chapter 4 Your Spa Massage 95

REVIEW QUESTIONS 5. When 1 drop of an essential oil is briefly rubbed
together in the therapist’s hands before being
Multiple Choice passed over the client’s nose in an arc so that the
1. A waxy substance obtained from the distillates of oil can be enjoyed on a deep inward breath it is
wood, coal, petroleum, or shale oil that is used to called:
coat the skin and trap heat and moisture at the a. Opening the massage
skin’s surface is called: b. Closing the massage
a. Seaweed c. An auditory cue
b. Fango d. An aromatherapy inhalation
c. Paraffin
True or False
d. Steam
6. ______ Warm packs of rice, corn, or flax seed keep
2. A series of strokes that are planned in advance, the client warm and increase the client’s enjoy-
delivered to body areas in a preset order, and prac- ment of the session.
ticed until they flow smoothly together is called:
a. A sequence 7. ______ The tags on hand towels used to remove
b. Pacing product from the client’s body should be left
c. Leading intact so that you always know how to launder the
d. A routine towels properly.

3. Additional session elements or small complemen- 8. ______ The use of a paraffin dip on a client’s
tary treatments that increase the client’s enjoyment hands for stiff joints is outside the massage
of the session are called: therapy scope of practice.
a. Add-ons
b. Up sells 9. ______ Essential oil massage blends create an
c. Enhancers olfactory reaction that may facilitate deeper relax-
d. Additions ation in the client.
4. This type of massage is used to decrease stress,
support the body’s natural restorative mechanisms, 10. ______ Flow and continuity refer to the progres-
and reduce temporary pain from overexertion sion of massage strokes from one technique to
caused by activities such as weekend athletics or by another and from one body area to another.
unusual work stress:
a. Wellness massage
b. Health care massage
c. Orthopedic massage
d. Hospital massage

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Foundation Skills
for Spa Treatment

Chapter Outline K e y Te r m s
Spa Draping Dry room: A treatment room in which there is no shower or hydrotherapy
Posterior Leg equipment. Instead, hot towels are used to remove the product from
Anterior Leg the client’s body, or the client takes a shower in a different area.
Breast Drape Exfoliation: A process by which dead skin cells are removed to improve
Anterior Pelvic Drape the skin texture and appearance. Other benefits include increased
Turban Drape
circulation and lymph flow, increased immunity, and relaxation.
Gluteal Drape
Simple Hair Drape Flip-over method: A method of positioning the client for product appli-
Side-Lying Drape cation in which the client flips over after a treatment product has been
Positioning the Client When Applying Spa Products applied to the posterior of the body.
The Side-Lying Position Side-lying position: A client positioning method where the client is
The Sit-Up Method positioned on a treatment table on his or her side so that product can
The Flip-Over Method be applied to both the anterior and posterior areas of the body without
Basic Application Techniques changing positions.
Application by Hand Sit-up method: A client positioning method where the client sits up on
Application with One Hand Gloved the treatment table so that product can be applied to his or her back.
Application by Brush
Wet room: A treatment room in which there is specialized hydrotherapy
Application with Gauze or Fabric
Application by Mist equipment such as showers that remove spa products from the client’s
Application of Product with a Sugar Shaker body, hydrotherapy tubs, and Scotch hoses.
Dry Room Removal Techniques
Steamy Rosemary Towels
Herbal-Infused Towels
Hot Towel Removal—Legs
Hot Towel Removal—Feet
Hot Towel Removal—Back
Hot Towel Removal—Arms
Hot Towel Removal—Abdominal Area and Upper Chest
Other Dry Room Removal Techniques
Moving a Client from Plastic to a Preset Massage Sheet
Wet Room Removal Techniques
The Handheld Shower
The Standard Shower
The Swiss Shower
The Vichy Shower

STUDY TIP: Internet Work!


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Chapter 5 Foundation Skills for Spa Treatment Delivery 97

Breast Drape
This chapter focuses on the basic skills needed to deliver Align the top edge of the main drape with the bottom edge
spa body treatments. It begins with a discussion on how to of a hand towel or pillowcase. As the main drape is pulled
drape a client elegantly and efficiently, preserving the client’s down, the hand towel or pillowcase becomes a breast drape
and takes its place.
modesty, while being able to apply spa products without
inconvenience. You may want to explore the many different Anterior Pelvic Drape
ways therapists position the client on the treatment table After the breast drape is in place, continue to pull the main
drape down until the abdominal muscles are uncovered.
to apply a variety of spa products effectively. Dry room
Align the fold of the main drape with the bottom edge of a
and wet room removal techniques are also discussed. After hand towel or pillow case. As the main drape is pulled down,
the hand towel or pillow case will become a pelvic drape. Tuck
mastering these foundation skills, different treatment steps
the bottom section of the pelvic drape between the legs leav-
can be chosen and matched to develop more creative spa ing a safe distance between the tucking hand and the genitals.
Turban Drape
This type of drape protects the client’s hair from spa products
Spa Draping and prevents heat loss during a treatment. Put a bath towel on
the table before the treatment. Bring the bath towel up over the
In a massage session, range of motion techniques require client’s head to cover the forehead or the eyes. Using the hand
a tight drape that is tucked in, wrapped around the limb, as a wedge on each side of the drape, bring the side portions
and, sometimes, held taut by the client. Clients receiving around the neck and tuck them into the top of the body drape.
spa treatments are draped slightly differently than they
would be in a normal massage. Although the client is always Gluteal Drape
draped, the aim is to preserve modesty and warmth with-
Uncover the back and fold the drape down to the gluteal
out being too fussy. Spa draping should be quick, elegant,
cleft. Grasp the folded edge of the main drape and the bot-
and efficient. Disposable undergarments are useful for
tom edge of the hand towel or pillow case. As the main
treatments in which the client is more exposed because of
drape is pulled down to expose the gluteals, the hand towel
extensive spa product application. The draping methods
or pillow case replaces it. Tuck the bottom of the gluteal
shown in Figure 5–1 work well. For a demonstration of spa
drape between the legs, leaving a safe distance between the
draping, visit thePoint.
tucking hand and the genitals. Fold the edges of the gluteal
drape to create clean lines for product application.
Posterior Leg
To undrape the posterior leg, gather the drape at the greater Simple Hair Drape
trochanter and at the ankle. Fold the bottom end of the Hold diagonally opposite ends of a hand towel at the corner
drape at an angle across the opposite leg while holding and allow the rest of the towel to drop into a triangle. Place
the drape at the greater trochanter as a pivot point. With this on the treatment table before the client gets on it and then
the lower hand, grab the fold of the drape and tuck it under bring the edges around the hair and secure the towel with a
the opposite thigh. Fold the top section of the drape across bobby pin or by tucking the end into the fold of the towel.
the back, leaving the gluteals exposed. With practice, this
draping can be accomplished in three moves and provides a
Side-Lying Drape
clean line for the application of spa products from the toes
to the top of the posterior superior iliac spine (PSIS). Because spa products are applied to the clients while they are
in a side-lying position, this drape is different than it would
be for a massage. It is important to ask clients to wear dispos-
Anterior Leg
able undergarments to preserve their modesty. The sheet is
To undrape the anterior leg, gather the drape at the ante- kept over the client until he or she is moved into the side-lying
rior superior iliac spine (ASIS) and at the ankle. Fold the position. Undrape the client’s upper body (females should
bottom section of the drape at an angle across the opposite either wear a disposable bra or hold a towel over their breasts)
leg using the upper hand to hold the drape at the ASIS as a and place a bath towel across the client’s hip. Grasp the folded
pivot point. With the lower hand, grab the fold of the drape edge of the main drape and the bottom edge of the bath towel.
and tuck it under the opposite thigh. Fold the top section As the main drape is pulled down to expose the gluteals, the
of the drape across the belly, leaving the ASIS exposed. bath towel will replace it, and the sheet is removed completely.

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98 Spa Bodywork: A Guide for Massage Therapists

A1 A2

B1 B2

B3 C1

C2 FIGURE 5–1 Draping techniques. (A1 and A2) Posterior leg drape.
(B1–B3) Anterior leg drape. (C1 and C2) Breast drape. (continued)

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Chapter 5 Foundation Skills for Spa Treatment Delivery 99

D1 D2

D3 E1

E2 F1

FIGURE 5–1 (continued) (D1–D3) Anterior pelvic drape. (E1 and E2) F2
Turban drape. (F1 and F2) Gluteals drape.

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100 Spa Bodywork: A Guide for Massage Therapists

The client needs to be in disposable briefs because the bath room setting. In a wet room, spa products are removed with
towel is used as a cover but is not pulled between the legs. a specialized or handheld shower. Shower removal is quicker
and easier for the therapist than removal using hot towels.
Still, hot towel removal feels wonderful if the towels are hot
Positioning the Client When Applying (rather than lukewarm), and the therapist works with pur-
Spa Products pose, flow, and attention to detail.
Many body treatments, regardless of their therapeutic
Rumi (1207–1273 CE), the well-known Sufi poet, said, “There objectives, have the same basic steps:
are a thousand ways to kneel and kiss the earth.” The same
could be said for spa treatments. There are a thousand ways • Exfoliation step to cleanse, remove dead skin cells, and
to deliver the same treatment. A good therapist will explore invigorate the body
a treatment thoroughly and arrange the treatment steps in • Application of the treatment product
different ways until they can be delivered perfectly with maxi- • Time for the treatment product to absorb and work
mum fluidity. Each therapist brings something different to a • Removal of the treatment product
treatment, and in a private practice, therapist can adapt the • Application of a finishing product (usually a moisture
basic steps and enhance the treatment in unique and creative lotion, gel, or cream)
ways. By contrast, most spas want their therapists to deliver Sometimes, it is better to treat the body in segments because
the same treatment in the same way each time. It is important this helps the treatment to flow more smoothly through the
to maintain this sort of consistency for returning clientele. The product transitions. More often, you have to plan how to
techniques described below work well, but each can be done apply several different products without turning the client
in many different ways. Again, exploration is the best way for over too many times. The treatment procedures section in
therapists to find out what works for them. For a demonstra- each chapter discusses positioning for each treatment. It is
tion of product application, visit thePoint site for this text. helpful if you are familiar with three different application
The choices made when delivering a treatment in a dry positions before continuing. These are the side-lying posi-
room setting may well be different to those made for a wet tion, the sit-up method, and the flip-over method (Fig. 5–2).

A B1

B2 C
FIGURE 5–2 Positioning the client for product application. (A) The side-lying position. (B1 and B2) The
sit-up method. (C) The flip-over method.

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Chapter 5 Foundation Skills for Spa Treatment Delivery 101

The Side-Lying Position need to be considered. The following methods work well
and are shown in Figure 5–3.
The client begins the treatment in the supine position for
the exfoliation step. After exfoliation on the anterior body,
turn the client into a side-lying position for the posterior Application by Hand
exfoliation. The client remains in the side-lying position Smooth the product onto the skin using effleurage strokes.
while the treatment product is applied. Once the product Some products are oily enough to massage into the skin
is applied, roll the client onto his or her back again before with a full range of strokes. The use of massage enhances
wrapping them in warm blankets. The client needs to stay the treatment and is more enjoyable for the client. If apply-
alert throughout the treatment and roll from side to side. ing the spa product by hand, you need to decide if you will
As the spa product is being removed, the client again rolls use gloves or wash it off your hands after the application.
from side to side to be toweled off (in a dry room). Gloves are quickest.

The Sit-Up Method Application with One Hand Gloved

The client begins the treatment in a prone position, and the You may want to apply product with one gloved hand. The
posterior body is exfoliated. He or she turns into a supine posi- ungloved hand is used to undrape body areas as needed or
tion for exfoliation of the anterior side of the body. The knees hold the container of product. This technique works well
are bent, and the treatment product is applied to both the an- with the “flip-over” position described previously.
terior and posterior sides of the legs. Flatten the legs against
the plastic body wrap and then wrap the legs in the body wrap. Application by Brush
Ask the client to sit up (remove the bolster first). Apply the
If the client is sunburned or has delicate skin, using a
treatment product to the back and gluteals and ask the cli-
brush works well so long as the product is thin enough to
ent to lie back down again. Finally, the belly, upper chest, and
be applied with a brush. A large brush (purchase natural
arms are treated, and then the client’s upper body is wrapped.
bristle paint brushes) is quicker and more efficient than the
The product is removed using the same method, and the cli-
smaller brushes used for facials. If massage is included as
ent is only turned over once during the entire treatment. For
part of a different treatment step, applying the product with
some clients, sitting up is impossible because of lower back
a brush will provide a different sort of texture and give the
problems or weak abdominal muscles. In this case, choose the
overall treatment greater tactile variety. Using a brush also
safest and easiest application method for the individual client.
keeps your hands clean if you need to drape and undrape
body areas during the application process.
The Flip-Over Method
In the flip-over method, the client starts the treatment in Application with Gauze or Fabric
the prone position for the exfoliation step. Apply the treat- For some spa products, a piece of gauze or light fabric is
ment product before turning the client. Ask the client to dipped into the product and then applied to the body area.
“flip” over (the goal is to make sure that the client makes a This method is used with paraffin, Parafango, herbal infu-
clean flip and does not get spa product all over the place). sions, and mud, although it can be used with many differ-
You hold up a drape and look away to protect the client’s ent products. It allows you to cover body areas rapidly and
modesty. Exfoliate the anterior body and apply the treat- precisely. Paraffin and Parafango drip easily. The use of the
ment product before you wrap the client. gauze prevents the product from getting onto the floor or
This application method can be messy if the client dripping onto the client. If the product is too warm, it may
doesn’t make a clean flip. Sheets or bath towel drapes are burn the client or be very uncomfortable because the heat
difficult to use because they will become covered in prod- feels intense because a large area is being covered at once.
uct. For this reason, the client will probably want to use dis- This is the main drawback of this method of application.
posable undergarments. The treatment product will be on
the client’s back and posterior legs for an extra 10 minutes Application by Mist
while the anterior body is being treated. This may be prob-
lematic with some products (e.g., very strong seaweed). Very thin or watery products can be sprayed onto the body
with an atomizer or mister. Products that are misted onto
the body feel cool even when the product has been heated.

Basic Application Techniques Application of Product with a Sugar Shaker

When choosing an application technique, the thickness of Dry products such as ground herbs, salt, sugar, medicated
the product, the speed at which it needs to be applied, and powder, or flour can be applied to the body through a
the way the product should feel as it goes onto the body sugar shaker. This is a unique sensory experience for the

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102 Spa Bodywork: A Guide for Massage Therapists


D1 D2

FIGURE 5–3 Application methods. (A) By hand. (B) Using a brush. (C) With one hand gloved.
(D1 and D2) Using gauze or fabric. (E) Using a mist. (F) Using a shaker.

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Chapter 5 Foundation Skills for Spa Treatment Delivery 103

client because the product, even when it is dry, feels like off all the tags, then fold the towels in half (the long way),
raindrops. and roll them up like a sausage. It is important that all the
tags are removed because they could scratch the client. Place
the towels in a hydrocollator, hot towel cabinet, or hot stone
heating unit for 20 minutes at 165°F. With thermal gloves,
Dry Room Removal Techniques remove a towel from the water, wring it out, and place it in
the soda cooler. Close the lid of the cooler and remove the
Use hot, moist towels to remove treatment product from the next towel. Keep the lid of the cooler shut as much as pos-
client’s body in a dry room setting (Fig. 5–4). This is a warm sible so that the towels stay hot throughout the treatment.
and satisfying experience when the towels are steamy hot You can enhance your towels by soaking them in herbal infu-
and you use long, elegant strokes. To prepare the towels, pull sions or adding essential oils just before use. Some therapists

A1 A2

B C1

C2 C3
FIGURE 5–4 Hot towel removal. (A1 and A2) Legs. (B) Feet. (C1–C3) Back. (continued)

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104 Spa Bodywork: A Guide for Massage Therapists


FIGURE 5–4 (continued) (D) Arm. (E) Abdominal area. (F) Upper chest. (G) Product removal with sponges and
hot water.

color coordinate their towels for the treatment (e.g., green towels are heated in. A nice combination is eucalyptus leaf,
towels for seaweed treatments, brown towels for mud treat- rosemary, clove buds, and juniper berry. A half a cup of herbs
ments, beige towels for herbal infusions) to camouflage any to around 16 quarts of water provides a nice concentration,
product stains. For a demonstration of hot towel removal of although more or less herbs can be used according to taste.
treatment product, visit thePoint site for this text. Towels heated in herbal solutions will be lightly stained.

Steamy Rosemary Towels Hot Towel Removal—Legs

Add 3 to 5 drops of rosemary essential oil to the soda cooler Remove a towel from the soda cooler and hold it by the edges
full of towels. As each towel is removed, it will fill the treat- (because it is hot). Let it cool slightly and place it on the
ment room with a refreshing scent. Most single essential oils proximal portion of the leg (anterior or posterior). Allow it
such as eucalyptus, common sage (Salvia officinalis), Spanish to sit on the leg and do not touch it again until it cools down
sage (Salvia lavandulifolia), thyme, and lemon oil smell good, (about 30 seconds). Place both hands on the towel and pull
but floral scents such as ylang ylang and jasmine are not as it toward the distal portion of the leg and off the foot. Turn
pleasant in steam. The essential oil on the towel is not likely to the towel over and use the clean side to make another sweep.
cause any skin irritation because essential oils are volatile sub-
stances and begin to evaporate rapidly the minute that they Hot Towel Removal—Feet
are placed on the hot towels in the cooler. They will mostly Place a hot towel around each foot to steam the feet and
burn off before the first towel is used, leaving only some of provide a nice sensation and then remove the product from
the scent behind. Skin irritation is therefore minimized. one foot at a time.

Herbal-Infused Towels Hot Towel Removal—Back

Muslin bags filled with fragrant herbs can also be used to Place the hot towel horizontally on the lower back and allow
scent towels. Add a muslin bag of herbs to the water that the it to cool slightly without touching it. Place both hands on

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Chapter 5 Foundation Skills for Spa Treatment Delivery 105

the towel and pull it toward the client’s head. As the towel Remove the product from the client’s arms, upper chest,
gets to the neck, pull it off to one side, removing the product and abdominal area and ask him or her to hold onto the
from the shoulder without getting it into the client’s hair. breast drape and sit up. Remove the product from the back
Turn the towel over and use the clean side to make a second and the posterior arms. Roll up the plastic sheet so that the
sweep removing the product from the second shoulder. dirty side is rolled in until it sits as close to the gluteals as
possible and ask the client to lie back down (onto the clean
massage sheet). Move down to the lower legs and wipe the
Hot Towel Removal—Arms feet with a hot towel. Ask the client to bend the knees and
Place the hot towel vertically on the proximal portion of the hold the feet up. Roll up the dirty side of the plastic (that
arm and pull the towel toward the hand in one sweep. Lift is underneath the client’s feet). Place the client’s clean feet
the arm by holding onto the client’s hand and use the clean on the massage sheet, which is underneath the plastic (the
side of the towel to wipe down the other side of the arm. knees are still bent). Remove the spa product from both legs
with hot towels and roll the plastic up as high as possible
under the gluteals. Place the clean legs flat on the massage
Hot Towel Removal—Abdominal Area and sheet and cover the client with a sheet or towel for warmth.
Upper Chest The client then lies back down on the massage sheet and
Place the hot towel horizontally on the belly and pull it from slightly lifts his or her hips so that the plastic can be
the left side to the right side. Turn the towel over and use removed. You need to work quickly and efficiently during
the clean side to remove product from right to left. Place a product removal because the client must stay alert during
hot towel across the upper chest and remove the product by this entire process.
pulling the towel from one side to the other.

Other Dry Room Removal Techniques Wet Room Removal Techniques

Sponges and warm water can be used to remove the product In a wet room, a specialized shower is used to remove
in a dry room setting. In this case, place a bucket of warm spa products from the client’s body. Specialized showers
water close to the treatment table on a rolling cart. Dip a include a handheld shower, a standard shower, the Swiss
sea sponge, large cosmetic sponge, or a washcloth into the shower, and the Vichy shower. Always read the manufac-
water and use it to wipe the product off. Dry the client with turer’s instructions for the particular piece of equipment
a hand towel after the product has been removed. The only beforehand. It is important to practice a treatment at least
problem with sponge removal is that it is difficult to keep two to three times when using a specialized shower so that
the linens under the client dry. Some therapists put a thick the temperature and pressure of the shower are safe and
bath towel on top of the linens before the treatment and get comfortable for the client. Wet room removal techniques
the client to lift his or her body so that this can be removed are shown in Figure 5–6. Wet room equipment and consid-
after the sponge bath. At one spa, the floor was tiled with erations are also described in Chapter 6 (Water Therapies).
a drain in the middle of the room. The massage table was
covered by a plastic wrap and large bath towel. A bucket of
warm water was doused over the client to remove product. The Handheld Shower
This was a quick and efficient method of product removal A handheld shower is used in combination with a wet table
that was also invigorating, surprising, and fun. The client for the easy removal of product. Some handheld showers
was handed a thick terry robe and moved to a fresh treat- can deliver a pulsating water massage and may also have
ment room for massage after the removal of spa product. an attachable body brush for exfoliation. A wet table has a
special surface to channel water into a receptacle under the
table or a drain in the wet room floor. The table is often
Moving a Client from Plastic to a Preset
constructed of heavy plastic or acrylic for easy cleanup and
Massage Sheet
sanitation. A soft, waterproof insert makes the table com-
In many different types of body wraps, the client is covered fortable for the client. Sometimes, a bucket of warm water is
in a spa treatment product and then wrapped in plastic. poured over the client to remove the spa product. This type
After the treatment product is removed, a finishing product of removal provides an invigorating experience for the client,
is applied to the client often in a full-body massage. In a but dry the client quickly so that he or she does not get cold.
dry room setting, you have to get the dirty plastic out from
underneath the client without asking the client to get off
The Standard Shower
the treatment table (a clean massage sheet has been preset
under the plastic). To do this, review Figure 5–5 and unwrap A standard shower is less expensive than a Swiss or a Vichy
the plastic leaving the client covered by the breast drape shower but does not allow the same range of control. The
and anterior pelvic drape (or disposable undergarments). pressure of the water, the degree of pulsation, and the

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106 Spa Bodywork: A Guide for Massage Therapists



FIGURE 5–5 Moving a client from plastic to a preset massage sheet.

(A) Unwrap the client. (B) Remove product from the arms, upper chest,
and abdominal area. (C) Remove product from the back and roll up
E the plastic. (D) Remove product from the legs and roll up the plastic.
(E) Remove the plastic from under the client.

temperature of the water cannot be controlled by the thera- The client returns to the massage table for a massage or to
pist. The client is moved between the massage table and the have a finishing lotion or cream applied.
shower as needed during the treatment. For example, if sea-
weed is applied after exfoliating the client with a dry brush,
The Swiss Shower
the client is moved off the massage table after the seaweed
has been allowed to process and taken to the shower so A Swiss shower surrounds the client with jets of water
that it can be washed off. While being moved, the client directed at specific areas of the body. Usually, the shower
stays loosely covered in the plastic wrap until he or she gets stall has pipes in all four corners with 8 to 16 water heads
into the shower and passes it back to the therapist to throw coming off each pipe. Adjust the position of the water heads
away. The therapist then places clean linen sheets on the for the client’s height. A control panel outside the shower
massage table while the client finishes his or her shower. stall allows you to control contrasting warm and cool jets

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Chapter 5 Foundation Skills for Spa Treatment Delivery 107


FIGURE 5–6 Wet room removal. (A) The handheld shower. (B) The Swiss shower. C
(C) The Vichy shower.

of water. A shower can be used for product removal, as an water droplets. Care must be used when moving the client
active treatment in itself, or to provide the heating phase of off the wet table because the area around the table may be
the treatment for products such as a cellulite cream. slippery with water. Although a finishing lotion or cream
can be applied while the client is on the wet table, it is nicer
to move the client to a dry room massage table for this final
The Vichy Shower
step. Wet rooms may feel a little cold and can echo because
A Vichy shower is a horizontal rod with holes or water of the tiled floor.
heads that rain water down onto the client from above the
wet table. Vichy showers are used to rinse spa products off
the client, but they can also be used as a treatment in them- SANITATION
selves. A control panel allows you to alternate between hot The shower stall or wet table, the floor outside
and cool water, which increases the therapeutic benefits of the shower, the shower curtain (if there is one),
some products and uses the mechanical effects of water on and any other surface that touches the client or water
soft tissue. Vichy showers have an adjustable face guard that must be cleaned, disinfected, and dried between clients.
is meant to keep water off the client’s face, although some Towels and floor mats will also need to be changed
water invariably gets through. A soft, lightweight washcloth between clients.
can be used to cover the client’s face and protect it from

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108 Spa Bodywork: A Guide for Massage Therapists


The Internet provides people with fast access to infor- Multiple Choice
mation, which can be very helpful when you want to
1. A method of positioning the client for product
learn more about anything that is unfamiliar. Some
application in which the client turns over after a
of the information on the Internet is from question-
treatment product has been applied to the poste-
able sources, so we spend a lot of time sorting through
rior of the body is called:
advertising, false claims, and other spam. One way
to avoid this sorting process is to use a teaching- a. The sit-up method
and research-oriented search engine such as Google b. The flip-over method
Scholar available at when c. The side-lying method
you’re looking for information. It can also be helpful d. The pronator method
to look for massage and spa technique videos sup-
plied by massage and spa teachers on TeacherTube 2. This type of drape protects the client’s hair from
( if you want to see spa products and prevents heat loss during a
visual examples of techniques being applied to clients. treatment.
Finally, ask other massage professionals for informa-
tion on a. Facial drape
This social networking site created for the massage b. Gluteal drape
profession by Associated Bodywork and Massage c. Breast drape
Professionals lets you connect with massage people d. Turban drape
across the country.
3. When choosing an application technique, you want
CHAPTER WRAP-UP to consider:
As an aspiring spa professional, you should practice a. The thickness of the product
basic spa skills in preparation for the delivery of core b. The color of the product
spa treatments rigorously. These skills include elegant c. How the product will be removed
spa draping, appropriate positioning of the client for d. Face massage techniques
product application, the use of a variety of applica-
tion methods, and the smooth and efficient removal
4. Oily products lubricate the skin enough so that:
of product with hot, moist towels. Enhancers such
as steamy aromatic towels, firming face massage, and a. They can be applied with steamy hot towels
simple foot treatments provide moments of particular b. They can be applied with a full range of massage
radiance in a spa massage as described in Chapter 4 strokes
(Your Spa Massage). New spa therapists should perfect c. They can be sprayed directly onto the body with
their Swedish relaxation massage and offer several a mist bottle
enhancers while maintaining the flow of the massage. d. They can be applied with powders
If a wet room is used to remove product, practice with
the specialized equipment to ensure that the water
5. Paraffin, Parafango, herbal infusions, and mud can
temperature and pressure are safe and comfortable for
be applied with:
the client. Once these skills are mastered, you will be
able to work more creatively with treatment steps to a. Gauze or fabric that has been coated with the
develop unique services. Remember, you are respon- product
sible for checking the laws and regulations in your par- b. A full range of massage strokes
ticular state to ensure that you are delivering services c. Gloved hands and a full range of massage
within your scope of practice. strokes
d. A mist bottle

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Chapter 5 Foundation Skills for Spa Treatment Delivery 109

True or False 9. Products that are misted onto the
body feel cool even when the product has been
6. Clients receiving spa treatments are
draped slightly differently than they would be in a
normal massage.
10. A Vichy or Swiss shower are used in
a dry room setting to remove products from the
7. Shower removal is slower and harder
client’s body.
for the therapist than removal of products using
hot towels.

8. If the client is sunburned or has deli-

cate skin, or if the product is thin, the use of a large
paint brush for product application works well.

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Water Therapies

Chapter Outline K e y Te r m s
General Uses for Hydrotherapy Buoyancy: Buoyancy refers to floating in water because of the water is
Introduction to Hydrotherapy displaced by bodyweight.
Therapeutic Characteristics of Water Compress: A wet cloth soaked in warm, hot, cool, or cold water (sometimes
Hydrotherapy Benefits and Effects with additives dissolved in the water) that is wrung out and applied to
Benefits of Using Hydrotherapy in a Massage and the skin.
Spa Practice
Cryotherapy: The therapeutic application of cold temperatures.
Effects of Hydrotherapy Applications
Hydrotherapy Applications Father Sebastian Kneipp: A Bavarian priest who combined herbal treat-
General Treatment Considerations ments with water cures.
Hydrotherapy Applications Friction treatments: Friction treatments include salt, sugar, dry brushing,
wet brushing or mitt treatments where the mechanical action of the
SPA FUSION rough-textured product, brush, or mitts against the skin causes local
IINTEGRATION OF SKILLS circulation to increase as the friction generates heat in the tissue.
STUDY TIP: Fact Sheets Full immersion bath: A hydrotherapy treatment where the client’s body
SPA INSPIRATION: Self-care with Hydrotherapy is fully immersed in cold, cool, warm, or hot water for a period of time
IT’S TRUE! Hydrotherapy Improves Physical to stimulate or sedate the body.
Performance for People with Osteoarthritis Homeostasis: The body’s ability to maintain a relatively constant internal
environment despite changing external conditions.
Hunting reaction: Alternating cycles of vasoconstriction and vasodilatation
in response to cold.
Hydrostatic pressure: The amount of pressure exerted by a liquid, in this
case water, when the liquid is at rest. In other words, water has weight.
Hydrotherapy: The use of water for health and wellness.
Mechanical effects: The effects on the body caused by water that is pres-
surized in sprays, whirlpools or through jets to manipulate soft tissue.
Paraffin: A waxy substance obtained from the distillates of wood, coal,
petroleum, or shale oil. It is used to coat the skin and trap heat and
moisture at the skin’s surface.
Sauna: A room where hot air (60° to 210°F) is combined with low humidity
to stimulate metabolism, increase core body temperature, and facilitate
Scotch hose: A hydrotherapy application in which a strong stream of water
is directed at the client to increase circulation, stimulate function, tone
muscles, decrease pain, and decrease congestion in a particular body area.
Steam bath: A hot air bath used to facilitate perspiration that helps the
body naturally detoxify.
Thermotherapy: The therapeutic application of heat.
Vasoconstriction: When the lumen of a blood vessel is contracted, reducing
the diameter of vessel and decreasing blood flow to a region of the body.
Vasodilatation: When the lumen of a blood vessel is relaxed, increasing the
diameter of the vessel and increasing the blood flow to a region of the body.
Vincent Priessnitz: An Austrian farmer who became famous for the cold
water cure, which consisted of drinking large amounts of cold water
and applications of cold water by packing, immersions, and douches.

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Chapter 6 Water Therapies 111

use hydrotherapy regularly to promote healthy changes in

Hydrotherapy is the use of water for health and wellness soft tissue structures.
and is a historical cornerstone of the spa experience. As we
discussed in Chapter 1 (Spa from Past to Present), the
Introduction to Hydrotherapy
revitalizing effects of water were well known in ancient
The term hydrotherapy originates in two Greek words: hydro,
cultures around the world. Vincent Priessnitz and Father
meaning water, and therapeia, meaning therapy. Stedman’s
Sebastian Kneipp developed methods and procedures that Medical Dictionary for Health Professions and Nursing defines
hydrotherapy as the “external application of water as a
advanced the understanding of hydrotherapy. Although
liquid, solid, or vapor for therapeutic purposes.”1
spa treatments can be offered without wet room equipment The use of water for healing dates back before recorded
history, and many cultures around the globe have tradi-
such as Vichy showers and hydrotherapy tubs, it is helpful to
tions that include hydrotherapy. North American Indian
be well versed in hydrotherapy principles. For the therapist tribes, for example, used a special hut or a covered sweat
lodge built partly into the ground. Large stones were heated
working in a spa offering hydrotherapy treatments, this
in a fire and taken inside the hut where they were sprinkled
understanding is essential to providing safe and effective with water to warm the air, causing the body to perspire as
a means of purification. There is evidence that every major
client care.
U.S. hot spring was used at some point by an Indian tribe.2
Native Americans considered hot springs to be sacred,
neutral ground. Warriors could rest by hot springs to heal
General Uses for Hydrotherapy battle wounds without worry of attack from another tribe.
Early civilizations often had a version of the spa bath,
The effects of hydrotherapy applications are the same even which combined some form of social interaction with
when the focus of sessions is different. In a wellness setting cleanliness. The hamam (bath) became popular in Islamic
such as a spa or massage practice focused on reducing stress countries around 600 AD after Muhammad recommended
and promoting enjoyment of sessions, hydrotherapy is sweat baths for spiritual cleanliness. Later, hamams became
most often used to relax the body with hydrotherapy baths, central to the community both as a place of spiritual retreat
showers, steams, and saunas. and for socializing with friends. Bathers would stop first at
In spas, hydrotherapy is also used as part of the beautifi- the camekan, a small court of changing cubicles surround-
cation process by estheticians. A particular product might ing a fountain, before entering the hararat (hot marble
be applied to the legs to improve the appearance of cellu- baths). Bathers would receive a vigorous massage or kese
lite. Specialized water applications such as a Swiss shower (exfoliation with a rough cloth) on a raised marble platform
or Scotch hose might then be used to activate the product above the wood or coal furnaces used to heat the hararat.3
or stimulate the skin and circulation as part of the session. As mentioned in Chapter 1 (Spa from Past to Present), the
In health care settings, such as those at some integrated baths of the Roman Empire are probably the most famous
or resort spas, hydrotherapy is applied to support changes in history. The central role of public baths in Roman cul-
needed in the body for the management of a particular ture led to a well-developed understanding of hydrotherapy,
pathology or condition and to rehabilitate musculoskeletal and garrisons were often built around hot springs so that
tissue after injury. In a health care setting, a sauna or steam the soldiers could heal their battle wounds. By 43 AD, the
room might be used as part of the client’s treatment plan. Roman public viewed the baths as a way to relax and main-
If a client suffers a sports injury, ice packs are likely to be tain health, and by the early fifth century AD, Rome alone
applied to the area to reduce inflammation. As the client’s had 900 baths.
injury heals, heat applications might be used to soften scar The medical benefits of hydrotherapy were advanced in Eu-
tissue and improve range of motion as the client returns to rope by two natural healers who developed their methods in
full function. the early 1800s. Many of these methods are still used today
In the first section of this chapter, we discuss the thera- as part of hydrotherapy. The first was the Austrian Vincent
peutic characteristics of water that make it useful and ben- Priessnitz (1799–1852), who promoted “the cold water cure.”
eficial for clients. The physiological, psychological, and This “cure” consisted of drinking large amounts of cold wa-
reflexive effects of hydrotherapy are explained in the next ter, bathing in cold water, following a simple diet, and partici-
section of the chapter, before hydrotherapy applications are pating in physical activity in the open air. Priessnitz used the
demonstrated at the end of the chapter. Whether you choose cold water cure to care for a personal injury that doctors of the
to work on providing wellness massage and relaxation spa time thought untreatable. In 1826, Priessnitz opened a water
work or work in a health care–oriented spa providing condi- cure establishment at Gräfenberg in the mountains of Silesia,
tion management or injury rehabilitation, you are likely to where his ideas were adopted by many prominent physicians.4

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112 Spa Bodywork: A Guide for Massage Therapists

The second natural healer was Father Sebastian Kneipp cool heated tissue and reduce inflammation, whereas sau-
(1824–1897), a Bavarian priest who cured himself of pul- nas and steam rooms use water in a vaporized form to pro-
monary tuberculosis by bathing in the icy Danube and mote perspiration and detoxification.
“shocking” his body into health. In one of his many books,
My Water-Cure (1894), Kneipp writes, “Being a priest, the sal- Water Dissolves Other Therapeutic Substances
vation of immortal souls is the first object for which I wish Water is known as the “universal solvent” because it dissolves
to live and die. During the last 30 or 40 years, however, the so many other substances. Many of the known elements
care for mortal bodies has absorbed a considerable por- found on earth are dissolved in seas and lakes. For example,
tion of my time and strength.” Instead of administering people all over the world have noticed that they feel revital-
last rites to the gravely ill, he used water and herbs to cure ized from a day at the beach and swimming in the ocean,
them. Kneipp’s healing system, which combined physical where seaweeds and minerals dissolve in the water, making
exercise, simple food, hydrotherapy, and herbs, forms the it a rich, therapeutic soup. Many different substances can
basis of modern naturopathy. He is well known for the “wet be dissolved from a solid to a liquid form for absorption
nightshirt” treatment that involved wearing a shirt that through the skin. Substances such as clay, minerals, pow-
had been dipped into water with salt or hay flower. He also dered seaweed, ground oatmeal, and a variety of herbs are
introduced classic methods of friction such as salt glows routinely dissolved in water and applied to the body in baths
and body wraps, which are widely used today in spas.5 and body wraps as part of hydrotherapy at spas.
Today, hydrotherapy applications are used successfully
to treat a broad range of conditions and are particularly use- Water Exerts Hydrostatic Pressure
ful for musculoskeletal problems. Modern research proves Hydrostatic pressure is a term that refers to the amount
what people throughout the ages have always known: Water of pressure exerted by a liquid, in this case water, when the
has healing characteristics that change the way we feel men- liquid is at rest. In other words, water has weight. If you
tally, emotionally, and spiritually. have swum underwater, you have probably noticed that the
deeper you go, the more pressure you feel in your ears from
Therapeutic Characteristics of Water the accumulated weight of the water above you. If you stand
neck deep in water, there is greater hydrostatic pressure on
Water is a unique substance that covers more than 70% of the lower part of your body (deeper) than on your upper
the earth’s surface and provides the natural beauty of oceans, body. Hydrostatic pressure pushes blood and fluid from the
rivers, rain, waterfalls, and snow. The human body is 55% lower body into the thorax. This characteristic of water has
to 60% water, and tissues such as lean muscle (75%), blood been used effectively to treat edema in the extremities caused
(95%), and bone (22%) contain significant amounts of water. by many different conditions. Pregnant women who exer-
Water also has a number of characteristics that make it useful cise in water find that hydrostatic pressure reduces lower leg
as a therapeutic application. Water is versatile and changes edema, decreases the occurrence of varicose veins, improves
forms, dissolves other therapeutic substances, exerts hydro- general blood circulation, and stabilizes blood pressure.6
static pressure, causes buoyancy, and absorbs and transfers
hot and cold temperatures (For Your Information 6–1). Water Causes Buoyancy

Water Is Versatile and Changes Forms Buoyancy refers to floating in water. When you enter a
swimming pool, you displace water and there is an upward
Water is a liquid that can easily be changed into ice or vapor. thrust of water that lifts you. This is why you feel weight-
It is therapeutically useful in all of these forms. As a liquid, less when you swim. The water you displaced supports the
water is applied in baths and showers or used to heat spe- weight of your body. Exercising in water reduces the stress
cial packs, called hydrocollator packs, that bring moist heat on joints, tendons, and bone that would occur with the
directly to a specific body area. Ice packs and ice massage impact of the body moving on a hard surface. People who
have arthritis, are elderly, or have recently undergone sur-
gery for a musculoskeletal condition benefit from move-
ment in a buoyant environment.
Therapeutic Characteristics of Water
Water Absorbs Hot and Cold Temperatures
• Water is versatile and changes forms (water, ice, vapor).
• Water dissolves other therapeutic substances (minerals, Water can be heated or cooled to specific temperatures for
plant materials). therapeutic application to the body as described later in the
• Water exerts hydrostatic pressure (weight of water). chapter when we talk about the effects of hot and cold tem-
• Water causes buoyancy (lift of displaced water). peratures on the structures and function of the body. As you
• Water absorbs hot and cold temperatures. can probably imagine, hot applications increase local blood
• Water transfers hot and cold temperatures circulation, warm soft tissue structures, relax tense muscles,
(conduction ⫽ direct contact, convection ⫽ via air). and soften muscle tissue. Cold applications decrease local
blood flow to an area and increase muscle tone.

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Chapter 6 Water Therapies 113

Water Transfers Hot and Cold Temperatures and prolongs the pleasure the client experienced during the
Water effectively transfers hot and cold temperatures to the session. At the same time, dead skin cells desquamated dur-
body in two different ways. When heated or cooled water ing the massage or body wrap and impurities released from
makes contact with your body, it transfers the warmth or the skin are removed, leaving the client feeling clean and
coolness to your body through conduction (the transfer of revitalized.
hot or cold temperatures through direct contact). Water is In both wellness and health care spas, therapists often
more effective at transferring hot or cold temperatures than suggest that clients use hydrotherapy applications at home
is air, which is why moist heat feels hotter than dry heat. for self-care. Use of hot packs on tight shoulder muscles
Convection is the process by which hot or cold tempera- at the end of a workday can help the client maintain the
tures are transferred via air or gas. For example, it feels lengthening effects achieved through a massage session.
colder when the wind is blowing (wind chill) than if the air Regular Epsom salt baths help reduce stress, decrease mus-
is still. Saunas are an example of the transfer of tempera- cle soreness, and improve sleep. Cold packs are applied dur-
tures via air; water poured over hot rocks turns quickly into ing the early stages of inflammation to reduce swelling and
a vapor, which evaporates into the air and warms it. heat in the tissue and speed the healing process. The simple
These general characteristics of water help lay the foun- act of taking a warm bath at night can serve as part of a
dation for better understanding the mechanisms by which stress reduction regimen. These general benefits comple-
hydrotherapy is effective in the upcoming sections of this ment the significant physiological and psychological effects
chapter. of hydrotherapy applications.

Effects of Hydrotherapy Applications

Hydrotherapy Benefits and Effects Understanding hydrotherapy’s effects on the body begins
with the concept of homeostasis. Homeostasis is the relative
Hydrotherapy applications support many of the benefits constancy of the body’s internal environment. The body’s
and effects of massage and can improve the results clients internal environment includes the extracellular fluid that
experience from the massage or spa session. The benefits bathes cells. From this fluid, cells receive oxygen and nutri-
of hydrotherapy include the pleasure and comfort clients ents, and into this fluid, cells excrete wastes from their met-
receive through hydrotherapy applications. abolic activities. The health of each cell and an organism’s
The effects of hydrotherapy usually depend on the tem- survival depends on the ability of the organism to sustain
perature of the application and the delivery method (bath, a relatively constant internal environment. If the internal
pack, shower, etc.). Let’s consider the benefits of hydrotherapy environment is disturbed to the extent that it can’t adjust,
applications in a massage and spa practice and their physi- such as by prolonged exposure to cold and hypothermia,
ological, psychological, reflexive, and mechanical effects. death of cells and potential death of the organism result.
Humans are able to maintain internal environmental
stability because intricate regulatory mechanisms continu-
Benefits of Using Hydrotherapy in a Massage
ally monitor and correct the body’s internal environment
and Spa Practice
by adjusting physiological functions.8 The body’s core tem-
The use of hydrotherapy applications in both wellness and perature is relatively constant, even in the face of widely
health care spas increases clients’ enjoyment of sessions, varying external environmental temperatures, because of
offers soothing comfort, ensures that clients stay warm, and this ability. For example, the body produces heat when the
provides a useful means of empowering clients to manage core becomes too cool and increases heat loss when the core
many conditions through self-care practices. starts to overheat. Hydrotherapy applications are designed
A recent study suggests that feelings of warmth are asso- to change the internal environment of the body by apply-
ciated with a sense of relaxation and well-being. Researchers ing temperatures above, close to, or below that of the body’s
have found that sensations of warmth alter neural circuits normal temperature (97°F). The physiological effects of
controlling cognitive function and mood, influencing hydrotherapy occur as a result of the body’s attempt to
serotonin levels. So, whether you are lying on a warm beach return to a constant internal state. For example, a common
in the Caribbean, sitting in a sauna or hot bath, or even physiological effect of the application of heat is vasodilata-
working up a sweat through exercise, your brain chemistry tion of blood vessels and increased blood flow to the local
changes and your mood is enhanced.7 area, which moves warm blood out toward the periphery,
Many clients begin to feel cold as a spa session pro- cooling the core of the body. A common physiological ef-
gresses. A warm hydrocollator pack on the feet or low back fect of cold is decreased local edema and decreased pain.
can warm the client and increase the client’s enjoyment The edema is reduced through vasoconstriction of blood
of the session. A hydrotherapy tub immersion (bath) with vessels, which drives warm blood back to the core, ensur-
soothing additives such as essential oils or herbs after a ing the core maintains the proper temperature. As a result,
massage or body wrap boosts the benefits of the treatment pain is reduced by a decrease in nerve conduction velocity.

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114 Spa Bodywork: A Guide for Massage Therapists

Three key factors influence the degree to which the body is • The larger the body area treated, the greater the
affected by hydrotherapy applications: physiological effect on the body: Hydrotherapy appli-
cations can be used over the entire body or locally. If the
• The greater the temperature difference between the
body is immersed in a bath, as in the previous examples,
body and the hydrotherapy application, the greater
the effect is more profound than if a cold pack is applied
the physiological effect on the body: If a client is placed
to one local area, say the hamstring. If the cold appli-
in a bath at 97°F (close to normal body temperature),
cation is a full-body immersion, the hunting reaction
neither the therapist nor the client will notice much of
described in For Your Information 6–2 is potentially
a physiological difference (although a mild tonic effects
deadly because heat from the body’s core is used to delay
occurs with neutral applications). If the same client is
tissue loss at the periphery. If the cold is applied just to
placed in a bath at 110°F, the physiological changes
the hamstrings, the hunting reaction acts as a “pump”
in the body will be readily apparent to both. The pulse
to flush out metabolic wastes in tissues and bring fresh
rate increases, the skin flushes, body temperature rises,
oxygen- and nutrient-rich blood to the area.
metabolism picks up, the blood becomes more alkaline,
and white blood cells increase in number. The client may The effects of hydrotherapy applications can be understood
feel nervous or even agitated by the application and will in terms of six primary categories, which overlap and inter-
probably want to get out of the hot water. relate (For Your Information 6–3):
• The length of the hydrotherapy application influences
• Physiological effects
the physiological effect on the body: A client placed in
• Psychological effects
very cold water (32° to 55°F) will have two very differ-
• Reflexive effects
ent reactions based on the length of the treatment. If the
• Mechanical effects
application is brief (less than 1 minute), blood vessels will
• Effects from dissolved substances
constrict to prevent heat loss. A short time later, blood ves-
• Effects from specific temperatures
sels will dilate as the body attempts to warm itself and pre-
vent tissue loss at the periphery. Muscle tone is increased, A combination of different types of effects usually occurs
and there is an initial spike in blood pressure and respira- simultaneously during a hydrotherapy application. For
tory rate. The client is likely to report feeling refreshed and example, different temperatures cause physiological effects,
invigorated. If the application is longer than 1 minute, and dissolved substances, such as herbs, can influence the
the client’s blood vessels constrict as the body attempts psychological impact of an application.
to move blood to the core to keep the core temperature
consistent. After about 20 to 30 minutes of continuous Physiological Effects
cold, vasodilatation occurs, which increases circulation As mentioned earlier, many of the effects of hydrotherapy
(For Your Information 6–2), although not above the base- occur because the body responds to temperatures above or
line when the cold was first applied. The physiological below normal body temperature in an effort to maintain
processes of the body are depressed, and if the client is not homeostasis. Hydrotherapy applications have a strong
removed from the cold water, death could result. effect on blood circulation, causing vasodilatation of blood
vessels in some instances and vasoconstriction of blood ves-
sels in others. Certain applications can shift blood from
FOR YOUR INFORMATION 6–2 one area of the body to another or cause cycles of vasocon-
striction and vasodilatation that flush the local tissue of
The H
Th Hunting
ti R Reaction
ti metabolic wastes by bringing fresh nutrient- and oxygen-
The hunting reaction involves alternating cycles of vaso- rich blood into an area, pushing blood back out, and repeat-
constriction and vasodilatation. When an ice pack is ing the process. In this way, metabolic wastes are removed
applied to an area, the body undergoes a series of distinct
physiological responses. In the first phase, the blood ves-
sels constrict, and blood flow to the area is reduced. This
decreases local edema and causes the skin to appear pale.
In the second phase, the body attempts to warm the area Physiological Effects of Hydrotherapy
through vasodilatation that increases circulation. If the cold
• Homeostasis is the relative constancy of the body’s internal
persists, vasoconstriction resumes, and the cycle repeats
itself with irregular sequences in an apparent “hunting” for
• Hydrotherapy seeks to change the internal environment of
equilibrium of skin temperature. The benefits of the hunting
the body.
reaction are that vasodilatation phases flush the area with
• Physiological effects occur as a result of the body’s attempt
fresh blood, bringing nutrients and oxygen to the tissue.
to maintain homeostasis.
Vasoconstriction phases squeeze the blood out of the tissue,
• When the body is hot, it attempts to cool itself.
removing many metabolic wastes, before another vasodila-
• When the body is cold, it attempts to warm itself.
tation phase again flushes the area with fresh blood.

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Chapter 6 Water Therapies 115

from the area, leaving the tissue healthier. Certain types of Mechanical Effects
applications cause an increase in blood pressure and heart When water is pressurized in a spray, shower, hydrotherapy
rate, whereas others cause it to decrease. jet, or whirlpool, the force of the water on the skin’s surface
The skin is also directly impacted by hydrotherapy and on the muscle tissue below manipulates the tissue for
applications because sensory receptors are responding to all a mechanical effect. The body may respond to the sensa-
the textures and nuances of feeling created by the applica- tion of water striking the tissue defensively at first, causing
tion and sending rapid signals to the brain. Overheating the muscle tone to increase. Gradually, the body relaxes into
body, as in a sauna treatment or hot immersion bath, stim- the sensation of the pressurized water, and muscular ten-
ulates sweat glands, which helps the skin excrete metabolic sion is reduced, circulation is improved, and overall body
wastes from the body. Metabolic wastes that have accumu- function and vital energy are increased.
lated in the adipose layers under the skin can be metabo- The hydrostatic pressure of water can be considered to exert
lized and released during this process, helping the body to a mechanical effect on body tissue. Recall that water exerts
naturally detoxify. more pressure on body areas that are deeper in the water. This
effect can be used to squeeze fluid from the lower extremities
Psychological Effects
to the thorax; for example, exercising in water reduces edema
Although the psychological effects of water and hydrother- in the lower legs. In some types of hydrotherapy applications,
apy applications are not always as clearly defined as physi- fluids are pulled from the upper body to the lower body.
ological effects, you have only to contemplate your feelings A classic example is the use of a hot foot bath to decrease con-
as you visualize a warm tub full of water, the delights of a gestion in the sinuses due to a cold. The hot water pulls fluid
swimming hole on a hot summer day, or the feel of warm down toward the feet and out of the head. In folk medicine,
sea mist on your face to understand water’s psychologi- migraines are treated with a warm foot bath and an ice pack
cal impact. People love water. In fact, maps of the world’s on the back of the neck. The dilation of blood vessels in one
population show that most of humanity lives near water. body area reduces the fluid congestion in another area.
People gather along coastlines, along the course of rivers, Another type of mechanical effect of hydrotherapy appli-
and on islands. Popular vacation spots are often located on cations occurs with classic friction rubs such as salt glows,
bodies of water.9 Water holds an important place in myth wet skin brushing (like dry skin brushing as described in
and legend and is often viewed as a transformative power. Chapter 8 except the skin is dampened with water or vin-
Artemis in Greek mythology ruled the tides as the goddess egar), or cold mitt friction. The mechanical action of the
of the moon. She also personified the unconscious depths rough-textured product, brush, or mitts against the skin
of the human mind, which are associated with water. Ritu- causes local circulation to increase as the friction generates
als of purification often involve water because it is a sub- heat in the tissue.
stance that washes away dirt from the body and, in some
religions, cleanses the soul. Many cultures believe that life Effects from Dissolved Substances
sprang from water and that special waters impart youth
Earlier, you learned that water is called the universal solvent
and renewed beauty. Water can represent an important pas-
because it dissolves many other substances such as minerals
sage through difficulties to renewal of the spirit. All of these
and plants, creating a therapeutic “soup.” For example, the
conscious and subconscious factors can be at play during
Dead Sea is an ancient landlocked sea whose water has been
hydrotherapy sessions and benefit clients through the plea-
slowly evaporating over the centuries, producing a highly
sure they receive through interaction with water.
concentrated natural salt solution. After bathing in the Dead
Reflexive Effects Sea, people often report a feeling of increased energy and well-
being as well as soft skin. The main mineral elements in Dead
Hydrotherapy applications can produce reflexive effects Sea water are chlorine, magnesium, sodium, calcium, potas-
(sometimes called a consensual response) that occur because sium, and bromine.11 Research on the usefulness of bathing
of a nervous system reaction to the treatment. Reflexive in the Dead Sea confirms that it benefits a variety of skin con-
effects happen in an area removed from the point of lo- ditions because it improves the barrier function of the skin.12
cal application, usually between the skin and the viscera, It is also used to reduce inflammation from musculoskeletal
although heat applied to one limb will increase circulation injuries including back injuries,13 improves the function of
in the other limb. The reflex relationship between the skin joints effected by both rheumatoid and osteoarthritis,14,15 and
and the internal organs is due to a segmental connection. decreases the severity of symptoms associated with fibromy-
Both receive sensory innervation from the same segment algia.16 Additives dissolved in water may have physiological or
of the spinal cord. For example, heat applied to the abdo- psychological effects that enhance and support the benefits
men causes the activity of the intestines to decrease. A hot or of the hydrotherapy application. For example,
cold application to the sternum affects the function of the
esophagus. A cold application to the head stimulates mental • Herbs: When herbs are soaked in water, many of their
activity, whereas the application of a cold pack to the sacrum chemical components are transferred to the water along
or feet causes dilation of the uterine blood vessels.10 with their therapeutic properties. Red clover, lavender

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116 Spa Bodywork: A Guide for Massage Therapists

flowers, chamomile flowers, powdered oatmeal, comfrey, TABLE 6–1 Degrees of Hot and Cold in
elderflower, and calendula petals soothe skin irritation and Hydrotherapy
are used to improve many skin conditions. Juniper berries,
ginger root, clove bud, allspice, rosemary, and sage warm DEGREES OF HOT AND COLD
the body and support perspiration for detoxification treat- Neutral to Very Cold Warm to Very Hot
ments. A wide range of herbs and herbal products are used
Neutral 90°–98°F Warm 98°–100°F
in combination with hydrotherapy applications. Visit spa
and massage supplier websites to research your options. Cool 70°–90°F Hot 100°–104°F
• Milk: Milk, powdered milk, buttermilk, and cream can Cold 56°–70°F Very Hot 104°–110°F
be dissolved in water to soften and condition the skin. Very Cold 32°–56°F Too Hot (don’t use) 110°F and abovea
• Minerals: Minerals in salts such as those from the Dead
Sea, regular sea salt, or Bearn salt from the mineral a
Some products such as paraffin (122° to 126°F), Parafango (120° to
springs of the Pyrenees Mountains of Southern France 126°F), therapeutic mud, and peat (115°F) are applied at temperatures
above 110°F. These products transfer the heat slowly to the body area
dissolve in water, allowing the minerals to be absorbed and do not burn the client.
by the skin to improve both the texture of the skin and
overall body function. Epsom salts are inorganic mineral
foot bath, the peripheral blood vessels dilate, and the client
salts that help the body detoxify and increase general
begins to perspire. The blood flow to the area where hydro-
circulation. They are well known for use with sprains,
therapy is applied increases significantly and flushes the tis-
strains, and sore, fatigued muscles. They also relax the
sue. The heart rate, pulse rate, respiratory rate, and overall
body and are useful for insomnia.
rate of metabolism rise, which increases the consumption
• Seaweed: Seaweed contains many bioactive compounds
of oxygen in the tissues. The rise in core body tempera-
that can be absorbed through the skin and used by the
ture creates an artificial fever, which, in turn, stimulates
body to support overall body function. Seaweeds have
the immune system and causes the body’s white blood cell
high concentrations of vitamins A, B1, B2, B5, B12, C, D, E,
count to increase, inhibiting the growth of some bacteria
and K. They also contain polyphenols and carotenoids,
and viruses. The higher blood flow to the area relaxes mus-
which play a role in protecting the body from oxidative
cles, reduces muscular spasm, increases the extensibility of
stress. Brown seaweeds such as Laminaria, Sargassum, Fucus,
collagen, “melts” the superficial fascia, increases the range
and Ascophyllum species stimulate metabolism, raise body
of motion in joints, reduces pain, and is generally relaxing.
temperature, and affect cell membrane transport, facilitat-
ing detoxification. All seaweeds contain some amount of Effects of Cold
iodine, which influences thyroid activity. For this reason, The physiological responses of the body in reaction to cold
do not use seaweed with clients who have iodine, shellfish, result from the body’s attempt to prevent a decrease in body
or seaweed allergies or who take thyroid medications. temperature. Like heat, brief applications stimulate the
• Essential oils: Essential oils do not dissolve in water, as we body, whereas applications of longer duration sedate the
will discuss in the next chapter (Introduction to Aroma- body. The use of external applications of cold for therapeu-
therapy for Spa), but they are commonly added to baths, tic purposes is sometimes referred to as cryotherapy.
saunas, and steam rooms to increase the therapeutic ben-
efits of these applications. Review Chapter 7 for specific
TABLE 6–2 Effects of Heat and Cold
information on essential oils to use in such treatments.
Effects from Specific Temperatures OVERVIEW OF THE EFFECTS OF HEAT AND COLD

Different reflexive and physiological effects depend on the Hot Cold

temperature of the water applied to the body. Table 6–1 pro- ❏ Perspiration ❏ Decreased local blood flow
vides an overview of common water temperatures used in ❏ Increased local blood flow ❏ Decreased tissue metabolism
hydrotherapy, whereas Table 6–2 summarizes the effects of ❏ Tissue will flush ❏ Decreased edema
❏ Increased heart rate ❏ Increased numbing
hot and cold temperatures. Hot, cold, neutral, and contrast-
❏ Increased pulse rate ❏ Decreased pain
ing temperatures are used in hydrotherapy applications. ❏ Increased metabolism ❏ Initial increase in respiratory
Effects of Heat ❏ Increased oxygen consumption rate
in body tissues ❏ Initial increase in heart rate
The physiological responses of the body to heat result from ❏ Increased white blood cell count ❏ Initial increase in blood
the body’s attempt to prevent a rise in body temperature. ❏ Stimulates immune system pressure
Brief applications stimulate the body, whereas applications ❏ Relaxes muscles ❏ Respiratory rate, heart
of longer duration sedate the body. The use of external ❏ Decreased muscle spasm rate, and blood pressure
applications of heat for therapeutic purposes is sometimes ❏ Increased range of motion gradually drop
❏ Decreased pain ❏ Increased muscle tone
referred to as thermotherapy. ❏ Short applications stimulate ❏ Short applications stimulate
When heat is applied to a client with a full immersion ❏ Long applications sedate ❏ Long applications sedate
bath, steam bath, sauna, hot pack, or partial bath such as a

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Chapter 6 Water Therapies 117

Cold penetrates more deeply into the tissues than heat hydrotherapy treatments were explained. This section of this
because vasoconstriction causes a decrease in local circula- chapter discusses how to clean and sanitize hydrotherapy
tion and tissue metabolism. There is also a decrease in leuko- equipment, how to recognize contraindications and adapt
cytic migration through the capillary walls, which aids in the sessions to ensure client safety, and how to apply common
reduction of edema and pain. Initially, there is an increase in hydrotherapy treatments.
respiratory rate, heart rate, blood pressure, and muscle tone.
These gradually drop if the application of cold is prolonged. General Treatment Considerations
The reduction of nerve conduction velocity leads to a numb-
ing effect that significantly reduces pain. If the cold persists, Before you can offer hydrotherapy treatments, you will
vasodilatation and circulation are briefly stimulated. want to understand these general considerations that
Clients often have difficulty with cold applications and ensure your client’s health and safety. Areas that require
pass through distinct stages that might feel uncomfortable. particular attention include the sanitation of hydrotherapy
The first stage is a sensation of cold that progresses to a feel- equipment and protocols that reduce the transmission of
ing of itchiness or tingling. As the cold continues, the tissue germs and disease, safety issues, and cautions and contrain-
feels as if it is aching and burning. Eventually, numbness dications to hydrotherapy services.
replaces the uncomfortable feelings, and the client relaxes Cleanliness and Sanitation Guidelines for
toward the later stages of the treatment. Hydrotherapy Equipment
Effects of Neutral Temperatures In Chapter 3 (Client and Therapist Safety), you learned how to
Neutral applications are administered at or close to normal prevent the transmission of disease by properly cleaning and
body temperature and produce a tonic and balancing effect sanitizing the treatment room and paying attention to your
in most clients. These types of applications are used to soothe own hygiene and hand washing habits. Hydrotherapy equip-
the nervous system and can be an effective treatment for ment often requires rigorous cleaning and sanitation between
insomnia, nervous irritability, anxiety, or depression. Neutral treatments. Showers, tubs, steam rooms, wet tables, and
applications are sometimes used at the beginning or end of soaking basins must be cleaned, sanitized, and dried between
a hot or cold application to help the body ease into or out of clients. Soaking basins without jets are simply washed with
more extreme temperatures. The use of external applications hot, soapy water; dried; sprayed with alcohol; and left to air
for therapeutic purposes at temperatures close to the body’s dry. If the soaking basin has jets, it must be flushed with an
normal temperature is sometimes called neutrotherapy. approved disinfectant. Modern hydrotherapy tubs usually
come with a self-cleaning function that makes sanitizing the
Effects of Contrasting Temperatures tub jets easier. You put a concentrated disinfectant (formu-
Contrasting applications involve applying a heat applica- lated by the manufacturer of the tub) into a special holder
tion and then a cold application to the same body area in an and then push a button. At the end of the cleaning cycle, you
alternating sequence. This creates a vascular flush in which simply dry the tub. Small, one-person steam cabinets should
the tissues are “pumped” free of metabolic waste buildup be completely wiped out with an antiseptic between clients.
due to the alternating vasoconstriction and vasodilatation For larger steam rooms or steam showers, the floor and seats
of the peripheral blood vessels. Often, the treatment uses a should be sanitized between clients, but the walls can be left
pattern of 3 minutes of heat to 1 minute of cold for three until the end of the day. The floor and walls around hydro-
rounds. The treatment always ends with a cold applica- therapy equipment must also be cleaned with an approved
tion to prevent congestion in the local tissue. Sometimes, disinfectant and dried after each use. Pay particular attention
a longer rotation is used with a ratio of 10 to 15 minutes to handrails and door handles (e.g., the handle of the steam
for the hot application followed by 10 to 15 minutes of cabinet). Bath mats, bath towels, robes, washable slippers,
a cold application. Again, the treatment ends with a cold and hand towels are changed between clients.
application. When using packs to apply heat and cold, it Clients should shower before entering hydrotherapy
works well to place a cold pack on the area of injury and a treatment pools to decrease the spread of waterborne infec-
hot pack proximal to the injury site close to the cold pack. tions. The client’s hair should be secured or covered with a
This relaxes the client and makes it easier to tolerate the cap before using hydrotherapy equipment including tubs,
cold pack. Contrasting applications are used with immer- steam rooms, wet tables, or showers. In the event of body
sion baths, partial baths, showers, and packs. fluid “spills” (e.g., the client suddenly gets sick and vom-
its on the wet table), follow the procedures for “Universal
Precautions” outlined in Chapter 3.
Hydrotherapy Applications Safety Guidelines
Specific safety issues must be considered before you offer
Earlier in the chapter, you learned about the history of
hydrotherapy treatments:
hydrotherapy and the characteristics of water that make it
therapeutically beneficial. Next, the changes that occur on • Equipment: Check hydrotherapy equipment regularly
both a physiological and psychological level as a result of to ensure it is working properly. Maintain the equipment

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118 Spa Bodywork: A Guide for Massage Therapists

according to the manufacturer’s recommendations. mounted temperature gauges to monitor the temperature
Don’t allow bare electrical cords in wet rooms or any in saunas and steam rooms. Never rely on how hot or
areas where they might be exposed to water. Identify hot cold an application “feels” to you. Use a thermometer to
equipment with a sign so that clients don’t inadvertently ensure you are working at the correct temperatures.
touch it. For example, the outside of a hydrocollator can • Timers: In some situations, the client should receive a
get very hot, and the heating units for saunas should be particular type of treatment only for a fixed amount of
surrounded with a grate. time. Use timers with alarms to monitor the client’s ses-
• Health history intake: Hydrotherapy applications sion time. If you rely on a clock, you may forget to check
cause profound physiological changes in clients’ bodies. the start time and leave a client in an application for too
Do not provide any hydrotherapy applications until you long, endangering his or her health.
have conducted a thorough health history intake process,
identified cautions, and ruled out contraindications. Cautions and Contraindications
• Preparation: Install handrails around showers, wet When used properly, hydrotherapy is safe for most clients.
tables, and hydrotherapy tubs to ensure clients have Like massage, hydrotherapy treatments can be contrain-
something solid to hold on to when they get into, out of, dicated completely, contraindicated without a physician’s
or onto and off hydrotherapy equipment. Invest in robes release, contraindicated at a particular location on the
and disposable or washable slippers so that clients can client’s body, or require adaptive measures and increased
move about in warmth and comfort. Don’t allow clients therapist vigilance. For example, in many full-body hydro-
to walk around the facility barefoot. Foot funguses can therapy treatments such as immersion in a hot bath, you
be spread in this manner, and the client is more likely to can decrease the cardiovascular load on the client by using
slip on a tile floor and sustain an injury. warm and cool applications rather than hot and cold ones.
• Water spills: Water is often sloshed about during a The closer the temperature of the application to the client’s
hydrotherapy treatment. For example, the area around body temperature, the less intense the response will be.
a wet table usually gets wet and slippery. Before allowing In general, hydrotherapy is contraindicated for individu-
clients to exit hydrotherapy equipment, take a moment als who have serious heart, circulatory, nervous system, or
and dry the floor with a hand towel. systemic conditions. Open wounds and skin rashes are also
• Oils and lotions: Clients who have had a massage or contraindicated when using extremes of hot or cold. The
who arrive at the clinic or spa covered in body lotion, length of time that the client is exposed to the treatment
cream, or body oil should shower before using hydro- depends on the client’s overall state of health and vitality.
therapy tubs, saunas, pools, or steam rooms. The oil or Children, those in a weakened condition, the elderly, and
heavy cream can block perspiration and make it more those with mental challenges may be contraindicated for
difficult for the body to detoxify. Clients are more likely full-body treatments such as saunas, steam rooms, and
to slip when getting into and out of hydrotherapy equip- immersion baths. Children have thinner skin and become
ment when covered in lubricants. Lotions and oils might overheated or chilled more easily than adults. Elderly cli-
interact with a treatment product (such as mud, sea- ents have less subcutaneous adipose tissue and may be
weed, essential oils) and decrease the effectiveness of the burned by topical hot applications or chilled more easily
session, or the client might leave a sticky residue on seats as a result. Blood vessels may not function efficiently, such
and equipment making cleanup more difficult. that repeated cycles of vasodilatation and vasoconstriction
• Prevent chills: Clients who are wet and exit either cold or may place a heavy burden on the circulatory system.
hot treatments may suddenly become chilled. As clients exit If the client seems healthy enough to benefit from such
hydrotherapy tubs, wet tables, steam rooms, and saunas, treatments, or if treatments are conducted under the super-
wrap them in towels or a robe and get them entirely dried vision or direction of a physician, start slowly. Begin with
off as soon as possible. Pay attention to the temperature of 10-minute sessions and progress up to 15-minute sessions.
treatment rooms and the facility so that clients stay warm. Healthy individuals can remain in saunas, steam rooms,
• Cold clients never respond well to cold treatments: and baths for 20 to 30 minutes. Very cold applications
If a client is cold, don’t put him or her into a cold treat- longer than 20 minutes are not recommended for any cli-
ment (e.g., cold plunge) or apply a cold application. ent because of the risk for tissue damage, frostbite, or even
Warm the client before applying cold. hypothermia. A client who is already cold will not benefit
• Dizziness and low blood sugar: Clients sometimes feel from a cold treatment.
a slight dizziness at the conclusion of the session, or low If a client feels light-headed, nauseous, headachy, or dizzy,
blood sugar may cause shakiness. Make sure clients stay stop the treatment and monitor him or her while he or she
hydrated during sessions by offering them water at regu- is relaxing in a quiet environment at a normal temperature
lar intervals. Have packaged food items such as fitness with a glass of water. If the client’s symptoms increase or per-
bars on hand in cases of shakiness. Educate clients not sist, consult a physician. If symptoms increase rapidly, con-
to eat a heavy meal before a hydrotherapy session. tact emergency services because the client might be in danger.
• Temperatures: Use a thermometer to check the water Specific cautions and contraindications for hydrotherapy
temperature in hydrotherapy tubs and permanently applications are outlined in Table 6–3.

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Chapter 6 Water Therapies 119

TABLE 6–3 Cautions and Contraindications for Hydrotherapy

Acute inflammation Warm and hot applications can increase swelling in injured tissue and thus are contraindicated. Cold applications are indicated.
Allergies Check for allergies to any substances you dissolve into the water for the session. Allergies to iodine and shellfish indicate an allergy
to seaweed or products containing seaweed. Clients might also be allergic to herbs or essential oils, although this is rare.
Artificial devices Hot or cold applications should not be applied over pacemakers, defibrillators, medication pumps, implants, or artificial devices.
Hot and cold applications may be indicated for use with hip and knee replacements.
Asthma Avoid the use of cold applications on clients who have asthma. Ensure that clients with asthma do not get chilled or walk from a
hot environment such as a sauna to a very cool or cold environment such as an air-conditioned hallway. Movement from very
warm to cool environments can trigger asthma attacks.
Athletes Athletes tend to have very low body fat and may be easily burned by topical hot applications or chilled by cold applications.
Use caution and monitor athletes carefully during sessions.
Autoimmune Autoimmune conditions can flare up, causing contraindications for hydrotherapy applications, or a hydrotherapy application
conditions might trigger a flare-up. Ask for a physician’s release before providing hydrotherapy.
Cancer Some types of cancer and cancer treatments cause the client to experience a condition that would not indicate hydrotherapy.
In other cases, hydrotherapy may prove beneficial. Discuss the particular treatment with the client’s physician and obtain a
physician’s release before providing hydrotherapy treatments.
Children Children have thinner skin and become overheated or chilled more easily than adults. Avoid the use of extreme temperatures with
children, shorten applications, and monitor children closely. Don’t apply hydrotherapy applications to infants or very young
children except under the guidance of a physician.
Decreased ability Some pathologies and conditions including arteriosclerosis, nerve injuries, diabetes, spinal cord injuries, neuropathy, and mul-
to sense hot tiple sclerosis decrease the client’s ability to determine if something is too hot or too cold. In many situations, the extremities
and cold are site-contraindicated, or you can choose warm and cool as opposed to hot and cold temperatures.
Diabetes Diabetes can lead to cardiovascular diseases and affect the blood vessels in the legs and feet, depending on the way in which
the condition has been managed and its severity. Consult with the client’s physician to determine if hydrotherapy applications
are contraindicated, site-contraindicated, or require adaptations. Obtain a physician’s release before providing hydrotherapy.
Heart disease Clients with heart disease such as coronary artery disease or congestive heart failure are likely to be contraindicated for hot
full-body treatments such as sauna and steam room use or baths. Medications may alter the way the heart functions, contra-
indicating cold applications. Consult with the client’s physician and obtain a physician’s release.
History of stroke Clients with a history of stroke are contraindicated for full-body hydrotherapy such as saunas, baths, and steam rooms. Local, mod-
erate applications such as a warm pack are likely to be safe. Consult with the client’s physician and obtain a physician’s release.
HIV/AIDS The suitability of hydrotherapy applications for clients with HIV/AIDS depends on the condition of the individual. Consult with the
client’s physician and obtain a physician’s release.
Hypersensitivity to Usually, treatments can be modified to temperatures that are warm and cool if the client has a hypersensitivity to hot or cold.
hot or cold Hydrotherapy treatments should not be unpleasant, and you can adjust temperatures to suit the client’s preferences.
Hypertension At the beginning of both hot and cold full-body hydrotherapy applications, there is an initial spike in blood pressure that may
be dangerous for some clients. Additionally, clients are likely to be on medications that affect the way in which they respond
to hydrotherapy. Modify temperatures to warm and cool, consult with the client’s physician, and obtain a physician’s release
before providing hydrotherapy.
Hypotension Hot or cold full-body hydrotherapy applications may cause fainting in clients with hypotension. Modify temperatures to warm and
cool, consult with the client’s physician, and obtain a physician’s release before providing hydrotherapy.
Lymphedema Hot applications are contraindicated. Neutral and cold applications may be indicated, depending on the condition of the individual
client. For example, exercise in pools close to normal body temperature can be helpful. Consult with the client’s physician and
obtain a physician’s release before providing hydrotherapy.
Medications Clients on various prescription medications may respond adversely to hydrotherapy applications. Consult with the client’s physician and
obtain a physician’s release before providing hot or cold full-body hydrotherapy (local applications are usually not contraindicated).
Mental conditions Hot or cold full-body hydrotherapy applications should be provided to clients with mental conditions only under the direction of a
Multiple sclerosis Hot applications can increase symptoms in people living with multiple sclerosis and are therefore contraindicated. Neutral and
cool applications are indicated.
Obesity Because of the load on the cardiovascular system and because of the way in which adipose tissue holds heat and cold, extreme
hot or cold applications are contraindicated. Warm and cool applications are more appropriate. If the client’s condition is weak-
ened, consult with a physician and obtain a physician’s release before providing hydrotherapy.
Osteoarthritis In some cases, cold applications have caused an increase in symptoms in clients with osteoarthritis. Use cool applications or use
short applications of cold and monitor the client’s responses carefully. Warm to hot applications are generally indicated.
Phlebitis Hydrotherapy is contraindicated except under the direction and supervision of a physician.

(continued on page 120)

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120 Spa Bodywork: A Guide for Massage Therapists

TABLE 6–3 Cautions and Contraindications for Hydrotherapy (continued)

Poor kidney Cold applications are contraindicated.

Pregnancy Hot full-body applications including baths, showers, saunas, and steams are contraindicated. Hot local applications to the
abdominal region are contraindicated. Cool or warm applications are usually not contraindicated, but it is best to consult with
the client’s physician and obtain a physician’s release.
Raynaud’s Cold applications are contraindicated.
Rheumatoid Hot and cold full-body applications are contraindicated. Warm local applications are contraindicated. Neutral and cool local
arthritis applications are safe.
Seizure disorders Hot or cold full-body applications are contraindicated.
Skin conditions Burns including sunburn, open wounds, rashes, and skin infections are contraindications for both full-body and local hydrother-
apy applications. Because some skin conditions benefit from hydrotherapy, you should consult with the client’s physician and
obtain a physician’s release if the condition is pronounced or covers a large body area.
The elderly Elderly clients are more likely to have less adipose tissue and prone to burns or chills from hydrotherapy applications. The heart and
circulatory system may not be strong enough to cope with the cardiovascular load caused by full-body applications. If the client
seems healthy enough to benefit from hydrotherapy, consult with the physician and obtain a physician’s release.
Thyroid disorders Regular hot or cold full-body applications are contraindicated for clients with thyroid disorders. Local applications are generally safe.
Varicose veins Varicose veins are site contraindications for hot and cold packs. If the client has severe varicose veins, full-body applications such as
hot or cold baths may be contraindicated. Consult with a physician if you are unsure about the correct way to proceed with the client.

Hydrotherapy Applications
Common methods of application include hot, warm, or cold
packs, local applications such as ice massage and mustard
plasters, therapeutic showers and immersion baths, hot air
baths, friction treatments, and specialized body wraps. In
a wellness setting, hydrotherapy is most often used to relax
the client, revitalize the body, or remove a treatment prod-
uct such as mud or seaweed. In medical spas, certain types
of wellness centers, many European spas, massage clinics,
and private massage practices, hydrotherapy applications
might not only be used for relaxation but also for condition
management or injury rehabilitation.

Hydrotherapy Packs and Compresses

Pack is a general term for any local hydrotherapy treatment
(hot, warm, cool, or cold) that uses a gel pack, hydrocollator
pack, fomentation pack (moist heat), or commercially made
chemical pack. Some packs are electric, some are heated
in the microwave, some are chilled in a freezer, and some
require specialized equipment. Probably the most effective
hot pack is the hydrocollator pack shown in Figure 6–1.
This type of pack has a canvas casing filled with either sili-
con granules or clay particles that can hold moist heat for
up to 30 minutes. These packs are submerged in water kept
at 65°F in a specialized heating unit called a hydrocolla-
tor. Hot and warm packs are most often used to relax tense
muscles, keep the client warm and comfortable, or soften
tissue before massage is performed.
To apply a hot pack, remove the pack from the hydrocol-
lator using tongs or thermal gloves and wrap it in a mini-
FIGURE 6–1 Hot pack. To apply a hot pack, remove the pack from the
mum of four to six layers of thick towels. Place the bundle hydrocollator using tongs or thermal gloves and wrap it in a minimum of
on the area to be treated for up to 20 minutes. Monitor the four to six layers of thick towels.

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Chapter 6 Water Therapies 121

peeled away while the base of the cup is left intact. Hold on
to the base of the cup while applying the ice to the affected
area in a circular motion. Ice massage of an area can last
up to 20 minutes and is used to reduce inflammation dur-
ing the acute inflammatory stage or to cool tissue after us-
ing intensive heat-producing techniques such as friction.
The term plaster refers to herbal pastes (herbs mixed with
either water or oil) that are spread on a particular body area
or onto a piece of cloth that is then applied to a particular
body region. Mustard plasters are warming and useful for
the treatment of osteoarthritis, poor circulation, back stiff-
ness, joint stiffness, and general muscular aches and pains.
To make a mustard plaster, mix 1 tbsp of mustard seed
powder and 4 tbsp of wheat flour with warm water until
you have a paste of medium consistency. Spread the paste
onto a muslin or cotton cloth and place it over the region
being treated. Because a mustard plaster gets hot and can
even blister the skin, monitor it constantly. Cover the plas-
ter with a warm pack to increase the therapeutic benefits of
the application. Mustard plasters can irritate sensitive skin.
Castor oil packs and castor oil applications have been
FIGURE 6–2 Cold packs. Gel-filled commercial packs or homemade ice
used in both European folk medicine and ayurvedic medi-
packs can be used effectively as cold packs cine (the traditional medical system of India) for centuries
to increase blood and lymph circulation, relax tight muscles,
reduce pain, ease joint stiffness, and break down scar tissue.
pack constantly by lifting it every 5 minutes to check the Castor oil is extracted from castor beans and is high in the
skin for extreme redness so that it does not burn the client. fatty acid ricinoleic acid. It is believed to support natural de-
Clients should never lie on top of hydrocollator packs. toxification in the body. Apply castor oil to the affected area
Gel-filled commercial packs or homemade ice packs can in a thick layer and cover it with plastic wrap. Place a hand
be used effectively as cold packs (Fig. 6–2). In fact, large towel and an electric heating pack over the top of the plastic.
bags of frozen peas make an effective cold pack because the The castor oil “pack” can be left in place for 30 to 45 minutes.
small size of the peas feels lighter on an injury site than ice As you learned earlier, paraffin is a waxy substance
in a plastic ziplock bag or large ice cubes. Gel-filled packs obtained from the distillates of wood, coal, petroleum, or
are also useful because they don’t freeze in a solid block and shale oil. It is used to coat the skin and trap heat and mois-
can be shaped to fit a body area. Cold packs are an effective ture at the skin’s surface. This increases circulation and
treatment for acute inflammation or after a massage treat- softens the local tissue, which improves joint mobility and
ment using friction techniques. Apply cold packs on top of decreases pain. A paraffin dip is an effective treatment for
a thin layer of insulation (rather than the thick layer used chronic arthritis, tight muscles, and painful joints. It also
with a hot pack) for up to 20 minutes. leaves the skin soft, and it feels warm and sumptuous. To
Compresses are wet cloths soaked in warm, hot, cool,