A small bottle of hand sanitizer and a face mask sit on a counter, to illlustrate safety and sanitation in massage, with flowers blurred in the background.

Practicing massage therapy now, with enhanced sanitation, laundry and client-interaction procedures layered on top of universal precautions, looks very different than it did three months ago.

New safety and sanitation protocols related to both businesses in general and health care practices have been recommended by various entities, including the Centers for Disease Control & Prevention, World Health Organization and Federation of State Massage Therapy Boards (FSMTB).

Author and massage therapist Anne Williams, who has a long track record of creating educational products in the massage field — and who helped create the FSMTB’s “Massage and Bodywork Guidelines for Practice with COVID-19 Considerations” — has updated the digital textbook she wrote with fellow massage professional and husband, Eric Brown, “Preventing Disease Transmission in a Massage Practice,” to include in-depth information on coronavirus(COVID-19).

Massage therapists may access the entire textbook free of charge, a contribution from Williams and Brown to help educate and support massage therapists who are reopening now.

What follows is a transcript of a conversation between Williams and MASSAGE Magazine’s editor in chief, Karen Menehan,  on best practices related to re-opening and operating a massage practice safely. Watch a video of the interview here.

Karen Menehan: Hi, this is Karen Menehan, editor of MASSAGE Magazine. I’m here with Anne Williams, co-author with Eric Brown of the digital textbook, “Preventing Disease Transmission in a Massage Practice,” which was very recently updated with information on COVID-19.

The book takes a deep dive into how infectious diseases are transmitted, as well as the sanitation and hygiene protocols that any massage therapist should consider implementing before returning to practice. Anne Williams is a licensed massage therapist of 23 years. She has worked as a massage educator and was also director of education for ABMP for several years.

Today, she’s focused on instructional design for adult learners through her company, Massage Mastery Online. Welcome, Anne.

Anne Williams: Thank you so much for having me. I’m excited to be here.

KM:  Yeah, thank you. Can you start by telling our audience why increasing knowledge about disease, particularly COVID-19, is so important right now before they reopen and see clients?

AW: Yeah. I’ve really spent the last almost three months now researching COVID-19 to be able to keep our digital textbook updated and to really understand as much as I can about this really scary coronavirus. And the thing about this virus is that it’s highly contagious and we don’t know everything that we need to know yet about how it’s transmitted. And when you don’t really know how something’s transmitted, you’re not always as efficient or effective in preventing the disease.

We have to take every single precaution because we’re still a little uncertain about exactly what it is that’s going to create the right circumstances for people to pass this from person to person.

And I think one of the things that’s crazy about this disease is 35% of people who test positive for COVID-19 are asymptomatic carriers. They have absolutely no symptoms. They have no indicators that they’re sick, but yet they can transmit this disease to their friends, to their families, to their clients.

I think that’s something that we have to factor in. We literally have to assume that we ourselves are infectious at all times, and that every client who walks through our door has a potential infection. And that just is the way that we stay really vigilant and really safe. And maybe some of us will look back in time and say, “”Oh wow, I really overdid it.” But if you’re alive and if all your family members are alive, I would say that that’s a great price to pay for being maybe a little overly cautious.

KM: And so when you say overly cautious, what would that look like in a massage practice right now? Or is being overly cautious, really just being safe at this point?

AW: Being overly cautious is exactly where you should be to be safe. We’re all hearing the stories, like the hairstylist who exposed 91 people in a week at her hair salon. We don’t want to be that therapist, and we certainly don’t want that to be the story of massage therapy for the general public.

We want clients to be able to relax fully in our session rooms, and that means they have to believe that we’ve got things dialed in. That we know what we’re doing. That we’re knowledgeable. That we’re practicing every precaution to keep them safe.

And I know that if I walk through the door of a clinic and it was looked at all dusty or dirty, I would turn around and walk back out. And if I walked in and my therapist wasn’t wearing a mask, I would turn around and walk back out. Part of it is creating a safe environment, and that’s mental and emotional safety as well as just physical safety.

KM: Could we just look beyond the universal precautions? Can you just summarize some of the things that are included in the book regarding the protocols and procedures massage therapists should be implementing around sanitation and safety?

AW: Sure thing. The truth is, Karen, they are lengthy. There are big changes in store if you want to open your practice safely. That’s really hard for people to hear because being a massage therapist is hard work already. But what I would tell you is the first thing you need to change is your screening processes. No walk-in clients. This is a time where 24 hours before that client arrives at your clinic, you want to call them and make sure that they don’t have any symptoms of any illness.

And I say that, that broad scope of illness, because COVID-19 is crazy. It presents with this crazy array of symptoms, with respiratory symptoms, with digestive symptoms, with skin symptoms. Any change in someone’s health picture, I would view as suspicious at this time and err on the side of caution.

KM: Can I just ask though, you mentioned how 35%, I think was the figure you gave, of people can be asymptomatic, would you suggest that the therapist in that intake interview also ask prospective clients what their social distancing practices have been or if they’ve perhaps been exposed to COVID? [Editor’s note: Experts have raised that figure to 45% or more since this interview took place.]

AW: Absolutely. I think we have to screen really carefully. And so part of that screening looks like: Have you had symptoms that are like a cold or like a flu or other symptoms in the last 14 days? Have you been around people who have had symptoms? Has a healthcare professional told you to self-isolate for the last 14 days? Have you recently been tested for COVID-19? What was the result?

I think one of the things I cover in the book, and specifically in some training videos that we just actually posted today, are some of these step-by-step things with really specific language that therapists can adopt and use for their own practices because this whole policy piece is what’s really tricky. There are a lot of policy changes we need to make. Now I’m jumping ahead, so actually I’ll stop myself and kind of come back to this original question.

We’re screening 24 hours ahead of time and we’re screening right at the door, and we need to change our client arrival procedures. Clients need to stay in their cars until we text them or call them to come to the door. We need to greet them at the door. Not hug them, not kiss them, not shake their hands like we’ll want to do because we’re warm and lovely people, but keeping six feet of distance between us.

We’re going to need to take their temperature with a thermal-scan, no-touch temperature reader and make sure that they don’t have a fever. We’re going to check that they have a proper face mask. And if they don’t have a proper face mask, we should provide them with a disposable face mask that they can wear during the session. We’re going to ask them to sanitize their hands with an alcohol-based hand sanitizer.

If they’re wearing gloves, the outside surface of those gloves is contaminated. They need to remove those. And if they really don’t want to give them up, take them back to their car. Otherwise, toss them in a no-touch trash can. You can’t decontaminate with alcohol, or even with soap and water, the surface of a medical glove, so they need to remove those.

And people sometimes think, “Well, I’ll just wash my hands with gloves on and that’s good enough.” But that doesn’t work on that type of surface. You don’t actually decontaminate them. You have to be careful about that.

KM: With so many entities, including the FSMTB and the CDC and the government and local agencies, giving information about sanitizing procedures, is there any one source massage therapists can go to, to really understand what they need to do?

AW: I actually helped with the FSMTB document in terms of content structure, and then taking a lot of the work of the task force and putting it into a format. And I’m in alignment with 99.9% of that document.

What I’ve done with the textbook, and then I tried to reflect back to the task force committee, was really look at the World Health Organization and the CDC, take their practices in terms of what they’re recommending to nurses or to other health care providers like physical therapists, and really apply that in a massage setting. How does that really function in our setting, with our needs?

And there are actually some things that sort of heightened our need for precaution. We’re in enclosed, private spaces with a client for an hour. And one of the things we don’t really know about COVID-19 right now is how much viral load does it take to produce an infection. But being in enclosed spaces, we know that’s problematic. We know we need to be running HEPA filters, opening windows, ventilating the space. In some ways, to practice without a mask in those settings would just be crazy. It would be crazy and it would be negligent for the client, and for our own lives and to protect our families.

KM: Yeah. Understood. One of the things you touched on the book is the concept of informed consent.

AW: Yes.

KM: Could you expand on that a little bit?

AW: Yes. An informed consent really has to expand in terms of the way that we understand it. In my sort of background as an educator working really at a national level when I was with ABMP, there are some states that are really whole hog on informed consent and some states that really have no idea what this is. I’m going to backtrack and just try to do my best as an educator to explain this well.

Informed consent is really the legal right of a client to be able to make choices related to their body, and only an informed client can make choices related to their body. Informed consent is also the ethical obligation of a therapist to make sure that a client is fully apprised so that they can make good choices. We need to make them aware of a few things.

And I actually created a policy document that you can share with clients that’s available as part of the book. It just got uploaded this morning, so it’s kind of new. You might not have seen it. But this document talks about the client needs to sign off that they recognize that they’re at higher risks with close contact.

They need to sign off that if they have a higher risk condition, they’ve consulted their doctor or are choosing to go forward with a massage anyway. And they also need to sign off that they understand in the event that the therapist, a client at the clinic, another staff worker test positive for COVID-19 within a two-week period of their session, that the health department may very well contact them for follow up as part of COVID-19 contact tracing.

We are not going to make a client’s full health care records available to the health department, but their name and their contact details will be part of the information that the client needs to release before they ever receive a massage from us. I know it starts to feel really overwhelming and a lot, and that’s one of the reasons for the textbook is it provides an opportunity to constantly add materials as they become relevant for therapists and for schools.

KM: You mean having the textbook be in a digital format so that you can update it as kind of a living document?

AW: Yes.

KM: It does sound a little overwhelming. And based on a lot of communication I’ve seen on social media, there are a lot of massage therapists who are resistant to the idea of implementing practices to this degree. And I’m wondering what you can tell them just about the safety of their own practice, of their own health, and why this is so important?

AW: Yeah. We see this. We see people who believe that COVID-19 is a hoax. And it’s easy to sort of decide to be polarized. “I’m going to take this side.” “I’m going to take this side.” And we definitely see that in our news media, they’re polarizing. And that leaves all of us sort of in this limbo space where we’re not sure what to believe.

As somebody who’s been researching this for two months, almost three now, I can understand why people start to resist and push back. It’s because nobody knows exactly what’s happening, and nobody can tell you, this is a fact and here are 15 research studies to back it up. All they can say is, “We suspect it looks like this. We suspect that this virus behaves like this.” But we know that hundreds of thousands of people are dying. That is a reality. There’s no doubt about that.

I would just say, please enter the conversation. Please, just let’s talk about it. Please share your concerns. Why do you think that this is a hoax? Where does that come from and how does that sort of serve you? Because if you take this home to your mom or your grandma, or your dad or your grandpa, or your child or yourself, then it was really inconvenient to believe that it was a hoax.

And that’s one of the things that I want to talk to therapists about a little bit is, first of all, let’s take a step back. Eighty percent of people who get COVID-19 recover at home without hospitalization. That’s the truth. That’s the statistic that the CDC and the World Health Organization stand behind. There’s 20% of people who are going to end up in the hospital, and around 88% of those will have a high risk, underlying health condition. And the percentage around how many of those will die is still in flux, so I’m not going to state a number, but enough people to make me worried about it.

And here’s the thing, who can afford to be hospitalized in the ICU for eight days? Anybody?

KM: Not me.

AW: Not me. I’m going to lose my house. I’m going to lose everything that I’ve worked for, and so will you, because it’s eight to 14 days in an ICU unit. It’s horrible. It’s a horrible disease when it really takes hold of you.

And we don’t know what the long-term ramifications of catching this disease are. There’s some speculation that people will experience long-term lung damage.

I’m saying speculation because it hasn’t been out there long enough for us to really know. But there’s also some speculation that it comes with a whole host of mental health issues after you recover. Is it worth it? Why not just take every precaution that you possibly can? Err on the side of safety for yourself and your family. And if a year from now, we all go, “Oh, that was a hoax,” you’ll still be alive to hear about it.

KM: And do you feel wholeheartedly that if massage therapists do employ the protocols and procedures outlined in your book or by the CDC or the FSMTB, that they can practice safely and protect themselves from contracting the virus?

AW: I would say that there is still a risk, from everything that I’ve read. And one of the things we’ll have to watch is if we find, just like that hair professional who they traced 91 exposures to after a week, just like that person, we’re going to know fairly quickly if this is a really bad idea that we’re practicing massage.

And I would say, even if you practice every precaution that the FSMTB has outlined, that I’ve outlined in my book, you are still at risk. And if you have an underlying condition — and the underlying conditions that really complicate or really make it likely that you’ll get a serious infection, are things like high blood pressure, heart disease, Diabetes type 1 and 2, emphysema, bronchitis, lung issues, severe and moderate asthma, a body mass index of 40 or higher, so severe obesity, anyone who’s aged 65 or higher, chronic kidney diseases and chronic liver diseases. And I hope I’m not missing any of them.

Those are the high-risk conditions that mean if you do catch it, you are much more likely to have a very serious infection and end up in the hospital, on a respirator, and potentially dead. Eighty-eight percent of people who end up in the hospital have one of these high-risk conditions, underlying conditions.

KM: Well, many, many thousands of massage therapists feel, and not only feel but need to get back to practice, or believe they need to get back to practice because they need to be earning an income.

AW: Absolutely.

KM: That is the reality of what’s happening across the United States now as more and more states open up. If people do employ these new procedures and protocols, as overwhelming as it might seem, it will give them some [measure] of safety going forward.

AW: They’ll absolutely be at much less risk if they follow all the protocols then they would be if they didn’t. But I think where I’m trying to find balance is by saying, “Will they be completely safe?” And I don’t think anybody can promise you that right now. We just don’t know enough. I hope so. I really hope so.

KM: I do too.

AW: It feels so weak to say that. It feels so pitiful. I hope if you follow all of this kind of exhaustive detail in the book or in FSMTB’s guidelines, I really hope that you’ll be safe then. But nobody can make you that promise. That’s the truth.

KM: Yeah, I understand.

I think we probably are ready to wind down our interview a little bit right now. I’m going to just read this statement about the book that you can read, anyone here in our audience can read the book, “Preventing Disease Transmission in a Massage Practice” at massagemastery.online.

And you can read it free of charge. You’ve made this available to massage therapists, which is just fantastic. Again, the website is massagemastery.online. And you can also visit massagemag.com/coronavirus for news and advice on navigating business in the age of COVID-19.

KM: Anne Williams, I want to thank you again for your time today. It’s been just wonderful.

AW: Thanks so much, Karen, for having me. I appreciate you helping us get the word out.

About Anne Williams:

Anne Williams is a licensed massage therapist of 23 years. She has worked as a massage educator and was also the director of education for ABMP for several years. Today, she’s focused on instructional design for adult learners through her company, Massage Mastery Online. She co-wrote the book “Preventing Disease Transmission in a Massage Practice,” which massage therapists may access free of charge at massagemastery.online.

About Karen Menehan:

Karen Menehan is MASSAGE Magazine’s editor in chief. Her reporting on coronavirus (COVID-19) includes “Voices of COVID-19: Massage Therapists Share Stories of Challenge & Hope,” “Some Georgia Massage Therapists are Reopening Their Practices. Some are Not,” and “Do You Need Help? Here are 17 Resources on Finances, Business & Self-Care for Massage Therapists Coping with the COVID-19 Shut-Down.”