By Ruth Werner

As a pathology educator, I am often called on to describe situations in which bodywork must be adjusted to be safe for a client who has some kind of health-related limitation. I describe a person’s ability to receive massage therapy or bodywork safely as “adaptive capacity.” This term makes sense to me, but others may find it less clear, so I thought I’d take this opportunity to explain what I mean.

Way back when I was in massage school, we were taught that some situations indicate massage, others contraindicate massage, and some might be OK for massage in a subacute stage. And our job as massage therapists was to memorize which was which. This is wrong, wrong, wrong.

Instead, when we have a client whose health is challenged, our job is to try to determine their adaptive capacity. Then, we must design and deliver a session that stays within those parameters. With the exception of contagious conditions that put the massage therapist at risk, this approach works for almost all pathology situations.

A person with a reasonably wide skill set can almost always figure out a way to work safely, even with clients whose health is compromised. And, although this is a simple idea, it has some complex roots. To explore this concept, let’s review some basic vocabulary:

• Homeostasis: tendency to maintain a stable (but not static) internal environment that is optimal for physical function
• Allostasis: process of restoring homeostatic parameters to preserve physical function
• Adaptive capacity: way of describing how easy or difficult it is for a person to achieve allostasis in the presence of environmental challenges

Homeostasis is a word every massage student learns in the first week of school. “Steady state” is a common interpretation. “Balance” is another—although this is so vague it’s not terribly useful. But the ability to maintain homeostasis—some consistency in our internal environment—is such a vital function that it is fair to suggest that a person’s ability to maintain homeostasis is a reflection of their overall health.

The changes in our bodies that help us maintain homeostasis are our allostatic responses. Allostasis, from the Greek allo or “variable,” plus stasis or “stable,” means (a little confusingly) “staying stable by being variable.” And how difficult—or easy—it is to do that is what I mean by the term “adaptive capacity.”

Every change in our environment generates an allostatic response. Sometimes that response is mild and undemanding, like when we ease our hands into a sink full of pleasantly warm water, which doesn’t require a large-scale reaction to stay within our optimal functional boundaries. By contrast, jumping into a pool of ice water requires a lot. We have to constrict blood vessels and then dilate them again, which means big alterations in blood pressure and heart rate. We may hold our breath until we know whether it’s safe to inhale again—lungs don’t like super-cold air! Shivering helps generate internal heat, so we don’t risk losing tissue to the sudden cold. This impacts metabolism, so those muscles have enough fuel to do their work. These are all allostatic responses to restore us to our established comfort zone—homeostasis.

If we are good at allostasis, then challenges like an ice water plunge are not threatening. Our heart, blood vessels, lungs, and other organs adapt and recover quickly—especially if we get out of the ice water right away. Overall, our adaptive capacity is strong.

But a person whose health is more fragile may not have the capacity to easily recover from a big change in their environment.

Massage therapy can offer some challenges in external environment, to be sure: the room may be warmer than usual; the lubricant may or may not stimulate an allergic reaction. Any scents or odors in the room—and even the sounds that surround us—are stimuli that demand allostatic adaptation.

Massage therapy also invites changes to the body’s internal environment—for instance, lower blood pressure, a drop in blood sugar, and a shift in hormonal secretion may occur during massage. If we stimulate a parasympathetic response, then we’ll see changes in heart rate, breath rate, and digestive motility. All these changes are associated with feeling safe and relaxed, which is a great gift to offer our clients—if they have the adaptive capacity to keep up with these changes.

Some people may not be able to keep up with the challenges our work presents. Their hearts are not capable of rapid changes in rate or volume; their blood vessels don’t stretch as widely or contract as tightly; their skin isn’t as strong and doesn’t tolerate being stretched without tearing; or their skin is hyperreactive to allergens. Maybe their kidneys are already working at full capacity, and having a sudden extra load of fluid to filter could be overwhelming. This is why I insist that establishing guidelines about massage therapy in the context of pathologies cannot be rubber-stamped.

The answer to the question, “Is massage safe for this person?” is always “It depends.” It depends on the type of massage and the strength of the person’s allostatic processes—their adaptive capacity.  

Our clients who have limited capacity for adaptation may enjoy a soothing session that offers supportive touch, but they are not good candidates for hot stones, ice massage, salt rubs, passive stretching that challenges ROM, or other techniques that may be welcomed by clients who are more physically resilient. This all boils down to a saying I did not make up, but I wish I had—it comes from our friends at Healwell: The more complicated a person’s health situation is, the simpler their massage needs to be.

The more I think about it, the more I love the concept of “staying stable by being variable.” We can see demonstrations of this everywhere. Trees that sway with the wind are more resilient than rigid ones that break before they bend—this is a decent analogy for human posture too. Even our heart rate shows strength in flexibility. Heart rate variability (HRV) is the ability of the heart to make moment-to-moment changes in the speed of its beating, and is a reflection of health and fitness.

Where in your life are you resilient with great allostatic responses? Where are you more rigid than serves you well? How will you increase your adaptive capacity?

Always be learning,