The caller sounded frantic. “Last week I was doing chair massage at the gym and one of my customers passed out,” he said. “I caught her as she was collapsing to the floor, but I couldn't revive her right away. There was a crowd of people around and someone called 911. Then the paramedics came and took her to the hospital. She recovered with no problem, but can you tell me what just happened?”

What happened, indeed, I wondered to myself. Was this caller asking what happened to the client, or what happened that he had ended up in such an unfortunate and avoidable state of affairs?

In the mid-1980s, when chair massage was shifting from an occasional massage tool to being a discrete bodywork specialty, practitioners began to notice a phenomenon rarely encountered in table massage: Seated clients experiencing symptoms of fainting or even passing out completely.
While a relatively rare occurrence, it happened often enough that those of us practicing and teaching chair massage became concerned about its cause, prevention and management when it did occur.

Why On a Chair?

The medical term for fainting is “syncope” [sing’kuh-pee] and is defined as a sudden, brief loss of consciousness. “Near- syncope” is the experience of symptoms leading up to a loss of consciousness. There are literally hundreds of possible causes of syncope, most of which fall into the “vasovagal” category. That is to say, when the vasovagal nerve reflex is invoked, the smooth muscles in the blood vessels relax, dilating them, and cause a sudden drop in blood pressure.

If a person is upright when this happens, then blood, and thus oxygen, no longer reach the brain in sufficient quantities to maintain consciousness and the individual passes out. The cure for fainting is simple. Get the client horizontal, preferably with his knees up to allow gravity to restore blood flow to the brain. If the person is only experiencing near-syncope, then it may be enough for them, while in a seated position, to drop their head between their knees.

In one sense, fainting is nature’s way of telling us to lie down by falling down. This is the reason massage practitioners rarely have clients fainting on a table. They are already lying down and gravity is working in their favor.

The three most important things to know about syncope are:
• Most episodes are transient; that is, they happen once and never again.
• Only rarely is someone who has fainted in a life-threatening situation.
• Someone who faints revives spontaneously.

Etiology

So what stimulates the vasovagal reflex during a massage? Since the exact cause in most syncope episodes is never discovered, this can be a complicated mystery.

We at the TouchPro Institute began by closely questioning clients who had experienced syncope, as well as the practitioners who worked on them. Over the course of a few years we noticed some patterns.

By far, perhaps 80% of the time, when we questioned clients who had fainted, we found they had not eaten recently, or missed a meal entirely. It seemed that low blood sugar (hypoglycemia) was the most common contributing factor. We also learned that, not surprisingly, people with a history of fainting, typically caused by a low blood pressure condition or a slow heart rate, were also more susceptible.

Much less frequently, if the client is just getting over, or coming down with, a common illness (flu or a cold) or if the client is on certain medications such as diuretics, beta blockers, calcium blockers, or other CNS depressants which might slow the heart rate, then fainting symptoms are more likely to occur. Syncope and near-syncope have also been seen in relationship to migraines, epileptic seizures, hyperventilation (extremely nervous clients), alcohol intoxication and cardiac arrhythmia.

We also asked practitioners where on the client’s body they had been working when the client felt faint. We noticed that it was often when they were working on the inside (extensor compartment) of clients’ lower arms or on their necks. It is possible that these areas of the body are more likely to stimulate the vasovagal reflex in combination with the primary causes noted above. However, syncope could happen at any time during a massage.

Frequency

To a certain extent, frequency will depend upon your client population. If you are doing chair massage in the morning at a fitness center on clients who have skipped breakfast, you will see a higher incidence of fainting or near-fainting. This will also be true if you are working with a population that is taking large amounts of medications, such as nursing home residents.

Some chair massage practitioners have noted syncope occurring with clients while working outside at street fairs and similar events. There is probably no single dynamic at play in these environments, and all of the factors previously mentioned could contribute. However, there is the additional possibility of severe dehydration on a hot, sunny day (perhaps combined with alcohol dehydration), resulting in a drop in blood volume and thus, blood pressure (known as hypovolemic shock).

While the incidence is low, even in these higher-risk populations, the single greatest determining factor for syncope is whether you screen before, and monitor your clients during, a massage. I have had many chair massages by practitioners whose screening was limited to perhaps one question (e.g. Do you like firm or light pressure?). Thorough screening and monitoring can eliminate close to 100 percent of the episodes of clients passing out. The occasional client who does feel symptoms of fainting, with proper management, will not lose consciousness.

Screening and Monitoring

Before you seat clients in your massage chair, they should be screened just as you would for your table massage, preferably with a written card to save time. If the client has any current or chronic medical conditions or is taking medications, pay particular attention if any of the conditions or medications were discussed above in Etiology.

In addition, we recommend screening for the following:
• Consumption of food or liquids (other than water) within the past five hours. Not having eaten may signal a hypoglycemic state. If convenient, suggest the client get a glass of juice or a muffin before the massage.
• A history of fainting. Carefully question a client to determine if the recurrent syncope is related to a low blood pressure or other medical condition. What does their primary health care professional attribute these episodes to?
• Just having an empty stomach or a history of fainting does not mean that a client can’t receive the seated massage. But it does mean that if you decide to give the massage, you will need to be extra alert.

Whether you get a positive response to these questions, or not, it is also advisable to caution the client to report any dizziness, queasiness or rapid changes in skin temperature during the massage.

Finally, as with all screening protocols, the ultimate rule is “when in doubt, don’t.” If you have any question in your mind about whether to work on a particular client, then you should not proceed. Tell the client you are not certain whether massage is appropriate for their condition and that they, or you, should check with their primary care provider. Never practice beyond the level of your training and experience.

During the Massage

Since syncope can occur for so many reasons, you will also pay particular attention to syncope precursors in the client’s body during the massage. The most common sign is a client fidgeting in the chair. This is generally obvious because typically, when a client is receiving a chair massage, they feel so relaxed that any movement is an effort.

You might also notice the client lifting his head slightly out of the face cradle as though to yawn or take a breath. This is an involuntary reaction to not getting enough oxygen to the brain.

Less frequently you might feel the client’s skin become hot and sweaty or cold and clammy. If you become aware of any of these symptoms, immediately stop the massage, lean over close to the client and ask if he is feeling okay.

If the client indicates he is not, then, depending upon how the client feels, you need to quickly get him turned around in the massage chair or into another chair with his head dropped between his knees, or lying on the floor with his knees pulled up.

After an Episode has Occurred

Clients who have near-syncope experiences will recover within a few minutes. Explain that they have had a temporary drop in blood pressure and reassure them that they will be fine as soon as normal circulation resumes. After the episode has subsided, you might spend a few minutes exploring the causes of the episode. If there were red flags raised during the screening, you probably already know the reason associated with the episode. If the initial screening brought nothing obvious to the surface, ask the client if this has ever happened to them before and then go over the screening questions again. Perhaps you will discover they are diabetic or have low blood pressure and it didn’t come out in the initial screening.

In any case, let them know that most fainting spells are benign, but they should mention it to their primary care provider at the earliest opportunity. There are, in fact, some serious cardiac and neurological conditions which might underlie a syncope and near-syncope and this episode should become part of the client’s medical history.

And If They Pass Out?

Rarely will a client go completely unconscious if you follow the procedures described above. However, if it should happen, here is what to do. Don’t panic. This is a first aid situation, so just put on your Red Cross thinking hat (you are certified, aren’t you?) and get busy.

Unless you are very strong or the client is very small, you will need assistance getting the client out of the massage chair. Do not leave the side of the client, since it is possible for someone unconscious to fall out of the chair. Call for help and then, supporting them under the arms, carefully lift the client out of the chair and onto the floor.

Check for breathing. If there is no breath, open an airway if necessary and begin rescue breathing. Check for pulse. If there is none, begin CPR. Look for a medical identification bracelet, necklace or card that identifies a medical problem, such as epilepsy or diabetes.

If the client has a pulse and is breathing, it is not necessary to call 911 unless the client does not regain consciousness in a few minutes or if the person is a diabetic. In that case, the person may be in insulin shock and require additional support. If there are other people around, try to reassure them that everything is under control and the best thing they can do is stay calm, step back and “give the person some air.” Besides being what they always say in the movies, oddly enough oxygen is in fact what the person needs.

And, it can hardly be stressed enough, don’t panic.

Summary

While the incidence of syncope or near-syncope in a client receiving a chair massage is slight, an ounce of prevention is worth a pound of cure. Proper screening and awareness of symptoms during a massage will prevent virtually all syncope episodes. Knowledgeable management of syncope and near-syncope occurrences will prevent undue distress on the part of the client and the practitioner. Being competent and knowing your limits will buy you the cheapest and most effective liability policy you can own.

David Palmer is David is the Founder and Executive Director of TouchPro Institute. He lives and works in San Francisco and can be reached at dpalmer@touchpro.com.

Online References
The Merck Manual: http://www.merck.com/pubs/mmanual.
University of Iowa Family Practice Handbook: http://www.vh.org/Providers/ClinRef/FPHandbook/FPContents.html.
Healthwise(R) Handbook: http://www.allhealth.com/healthwise/.