The Fainting Phenomenon

This week I got an email from Katy who writes: “I was about 20 minutes into the chair massage when the massage therapist began to work in and around my right shoulder blade.  I began to feel clammy and tried to breathe deeply and out of nowhere, I began to black out.  I sat up and just said “water” and wasn’t really aware of anything around me.  I almost dropped the water he had handed to me.  I sat down on a different chair (with much help) and in about 5 minutes felt much better.  I declined the offer to finish the massage.”

In the mid-1980’s, when chair massage was shifting from an occasional massage tool to being a discrete bodywork specialty, practitioners began to notice a phenomenon almost never encountered in table massage: seated customers experiencing symptoms of fainting or even passing out completely.

While a rare occurrence, episodes 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. “Pre-syncope” is the experience of symptoms leading up to a loss of consciousness. All syncope is caused by a loss of adequate blood flowing to the brain.

If a person is upright when this happens, then oxygen no longer reaches the brain in sufficient quantities to maintain consciousness and the individual passes out. The cure for fainting is simple. Get the customer 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 table massage practitioners rarely experience customers  fainting. 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.
  • Fainting is rarely life threatening, unless someone hits their head on the way to the floor.
  • Everyone who faints revives spontaneously.

Etiology

There are literally dozens of possible causes of syncope but the ones that concern chair massage practitioners most are:

  1. Low blood volume is most often caused by stimulation of the vasovagal nerve reflex, which expands the blood vessels (vasodilation) causing a rapid drop in blood pressure. That reflex can be triggered by such factors as anxiety, pain and fatigue.  Dehydration also causes a drop in blood volume so recent exercise or overheating need to be considered.
  2. Reduced blood flow because of medical conditions that narrow the blood vessels (smoking, high blood pressure, high cholesterol, diabetes) or mechanical restriction of blood flow to the brain. This last point has been highlighted by some practitioners who believe that the positioning of the customer’s head in the face cradle is key. Some lower edges of a face cradle may press in to the carotid artery and trigger a syncope reaction.
  3. Low blood sugar can also cause a sudden drop in blood pressure often times in combination with another risk factor. That means empty stomachs can actually be a hazard in this regard.
  4. Certain medications such as diuretics, beta blockers, calcium blockers, and other CNS depressants that might slow the heart rate, cause fainting symptoms to more likely to occur.
  5. Other conditions where syncope and pre-syncope have been seen include migraines, epileptic seizures, hyperventilation (extremely nervous customers), alcohol intoxication, and cardiac arrhythmia.

Given these known causes, a practitioner should be especially alert to nervousness, hot days, recent exertion and careful positioning of the neck in the face cradle of the massage chair.

Screening and monitoring

While the actual incidence is low, the single greatest determining factor for syncope is whether you screen before and monitor your customers during a massage. Thorough screening and monitoring can eliminate 100% of the episodes of customers passing out. With proper management, the occasional customer who does feel symptoms of fainting will not lose consciousness.

Before you seat customers 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 customer has any current or chronic medical conditions or is taking medications, pay particular attention to the ones 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 customer get a glass of juice or a muffin before the massage.

A history of fainting. Carefully question a customer 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, a history of fainting or a medical condition does not mean that a customer 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.

If there are any yellow flags raised during screening, then it is a good idea to ask the customer to report any dizziness or queasiness 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 customer, then you should not proceed. Tell the customer that you are not certain whether the 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, during the massage you will also pay particular attention to syncope precursors in the customer’s body. The most common sign is a customer fidgeting in the chair or lifting the head slightly out of the face cradle as though to yawn or take a breath. These are involuntary reactions to not enough oxygen getting to the brain.

Less frequently you might feel the customer’s skin become hot and sweaty or cold and clammy. If you become aware of any of these symptoms, immediately stop the massage and ask the customer if he or she is feeling okay. If not, then you need to quickly either get him or her turned around in the massage chair or into another chair with the head dropped between the knees, or lying on the floor with the knees pulled up.

After an episode has occurred

Customers 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 customer 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 that might underlie syncope and pre-syncope and this episode should become part of the customer’s medical history.

Summary

While the incidence of syncope or pre-syncope in a customer 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 customer and the practitioner. Being competent and knowing your limits will buy you the cheapest and most effective liability policy you can own.

If you have your own fainting experience, I would love to hear your stories.

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14 Responses to The Fainting Phenomenon

  1. Mary Cheers says:

    Good article.
    If someone cannot lower their head between their knees (low back pain, large belly,etc), blood can also be forced to the brain by asking them to tighten their abdominal muscles. Just be sure to remind them to keep breathing.

    • David says:

      Good one, Mary. I hadn’t run across that bit of advice. Thanks!

    • Chris says:

      As a paramedic, I would not recommend tightening one’s abdominal muscles to “force blood back to the brain.” Doing so would more than likely trigger a vasovagal response which would *lower* blood pressure, not raise it. This could, in turn, cause another episode of fainting.

      We use this technique in the field as a means of triggering that same response in order to lower a fast heart rate. Decreased blood pressure is a side effect.

      • David says:

        Thanks for the input, Chris. I did a bit of research and it appears you are referring to the effects brought on by the “Valsalva Maneuver.” We mostly know it as “popping” the ears open (equalizing the pressure in the middle ear by opening the eustacheon tubes) where a person is asked “to inhale, hold their breath, and bear down while tightening the chest and abdominal muscles as if they were straining while having a bowel movement.”

        However, as I understand it from the literature, holding your breath is a critical element for bringing the heat rate down, i.e. if you don’t hold your breath the heart rate won’t drop. As Mary noted, it is important that you instruct someone who is having pre-syncope sensations to keep breathing, the deeper the better. One reference suggests tightening the leg muscles to prevent the blood pressure from dropping, which may be easier to do and still keep breathing than tightening the leg muscles.

  2. Jeffrey Palmer says:

    Great article.
    The vagus nerve in addition to dilating blood vessels, usually slows the heart as well. The most dramatic case I ever dealt with was an 80+ year old woman who stated since a teen whenever she vomited, she passed out. When being monitored in the ER one day, she vomited, turned pale, then “flat lined”. She fell back on stretcher, and as nurses were racing to her with the paddles, her heart restarted, she sat up & said “what happened?” Bottom line is the heart recovers. You can always check the pulse if you feel so inclined. Keep up the good work!

  3. Isabelle A Bridge says:

    Hi,

    Just wanted to share my experience of fainting on the chair. Over about 10 years, I’ve had 4 clients who either fainted or were near fainting. The first was at the Vitality Show in London, where it was hot and people were queuing for chair massage. I did the screening, but this lady told me that she had eaten in the previous 4 hours (I ask if they’ve eaten in the past 4 hours, to be on the safer side). During the massage, she told me she was feeling very faint. I got her off the chair… she nearly fainted, but then felt better quickly when she lay on the floor and I held her feet up. Not a great thing to happen at a show though! When she felt better, she said to me that she so wanted the massage, that she had lied to me and she had not in fact eaten anything since the day before, about 15 hours previously! The 2nd and 3rd cases were of ladies feeling faint and telling me, so we stopped the massage, asked them to lay down and put their feet up and we didn’t carry on with the massage. Nothing obvious had come up during the screeing and they assured me that they had eaten properly in the previous 4 hours. One of them has since had episodes of fainting in pregnancy (not during a massage!), so perhaps she is prone to it. The final case was the scariest, just over a year ago. I was offering chair massage in the workplace. This lady came to me for the first time and I did the usual screening. When I asked about being prone to fainting, she said that she had fainted in the past, but had not fainted for a long time and she was sure she would be ok. I decided to go ahead with the massage and asked her a few times if she was ok. When it came to the very end, when I was doing the percussions, she fainted! She was a very big lady, so I couldn’t help her off the chair and she was totally unconscious anyway. Fortunately, this workplace was a health centre, so as soon as I went to call for help in the corridor, I found a doctor and then a nurse came too. Together, we got the lady off the chair and onto the floor. She drifted in and out of consciousness for quite a while. It was really scary. They called for an ambulance. I was really shaken and suddenly, I lost my confidence as a chair massage practitioner. Fortunately, the lady’s colleagues told me that she was always fainting at work and had fainted the previous week. So again, she didn’t tell me the truth during the screening! Her colleagues told me that she was very squeemish and that she fainted at the mere sight of physiotherapy manoeuvres, so I think that the percussions caused her to panick and that is why she fainted, rather than the usual points on the hands (the other 3 times clients felt faint or nearly fainted, I was doing the arms and hands). Anway, since then, I have changed my screening and it’s much more thorough now and I make it very clear that it’s important that they tell me if they have had any fainting in the past and when (and low blood sugar levels, low blood pressure, etc). I must say, I never totally recovered my confidence after the episode of the lady fainting and taken to hospital by ambulance. I sometimes offer chair massage at home, but I’m always worried of giving a chair massage at home when there is no one else around, in case the same happens again.

    • David says:

      Isabelle, your stories remind me of the mantra “Everyone lies” emphasized by the perennially dyspeptic Dr. House on a popular US medical TV show of the same name. Thanks for so dramatically re-iterating the importance of careful screening.
      Your work history is typical. Only one out of four people in your ten years of doing chair massage actually blacked out. As scary as these instances can be, as long as we don’t panic and follow proper protocol, the actual danger is infinitesimal. Keep providing that positive touch and sending more talented British actors like Hugh Laurie our way!

      • Isabelle A Bridge says:

        Thank you for your reply and encouragement David :-). I’m not doing much work at the moment, as I’m home-educating my son, aged 4 1/2. His name is David by the way (but pronounced the French way).

  4. walter says:

    hello all,

    i expirienced that phenomena by seeing the people turn into this “one-minute-sleep” (time doesnt matter really) when they are on my chair for more then 15 minutes often, nearly always …

    i realise it when the body relaxes really deep inbetween the kata where there was before the individual tension at some points

    i never expirienced that what is described at the long explanations

    i wanna say that im really aware about the customer, sometimes more then about the technique and im glad about this “gift”

    my hands simply follow what people are on the chair and sometimes i also go into individual parts and points on the body by following the learned kata

    im not finished in learning chairmassage as well as maybe its interesting for others what i shared

    even the people in the team where i was working are aware sometimes of that “one minute sleep” phenomena, the result is always the same, people are really deeply relaxed

    ah, before i forget, i remember some of the customers come back and are in sweat

    this means for my view that they did not really relax enough since a long time as well as then its in our hands to do the best for them, bringing them really back after the kata with the best intention and as it is teached to finish the session 🙂

    • walter says:

      thank you for your precise and understandable explanations, david

      i appreciate the teachings … and also the sharings from all the others here

  5. Samantha says:

    Hi David – I have a weird incidence to share with you. I am traveling in Asia (25 yrs old) and just had a 4 hour couples spa treatment (I guess I got carried away with the idea of a luxurious vacation). The spa is nice and well acclaimed. I had a body scrub, full body massage (flat not on a chair), and facial. I ate a full lunch at 1pm and the treatment was at 3. I felt completely fine all day and after the scrub -and all vacation for that matter – but a bit hungry. I drank plenty of water throughout the treatment. During the massage I felt particularly sensitive and and started to feel cold.. After the massage I got up and went to the bathroom and still felt hungry so I asked the therapist for candy thinking that would curb my hunger until the treatment was over . I have zero history of hypoglycemia and only fainted once in my life -10 years ago under very different circumstances). The therapist said I would be provided with tea, candy and cookies after the treatment was over in 20 mins. During the facial I still felt very cold and uncomfy. When it was complete they had me sit up to do a little more back work then the treatment was over. I got up fairly quickly and felt incredibly dizzy and a bit nauseous. I walked around room to collect my stuff, the dizziness got worse and I collapsed. The therapist sort of caught me and led me up to the table. The staff brought me candy and cookies and water and I felt relatively better pretty quickly. Although, it is now 2 hours after the incidence and I still feel feverish and achey. I am wondering if after affects like this could be the result of the massage, or if the massage brought out some sort of virus in me….I plan to contact my doc if the systems continue but I figure i should share since your research is related.

  6. Pam O'Dea says:

    Hi David,
    I had a client faint while doing a chair massage years ago and someone had told me a few weeks before if someone faints press the governing vessel between the nose and upper lip. After requesting someone call 911, I leaned her head back against my tummy and pressed the point and she jolted back to “life” immediately. I had her sitting up and was doing ROM with her neck at the time she fainted .Upon her coming to I tried to narrow down the cause and when I asked about motion sickness she said she would experience vertigo on boats so the motion may have set off a “hit the deck ” response!

  7. Kathy Brown says:

    Last night my 15 year old daughter was studying and having some abdominal discomfort (bloating), which is pretty common for her (it rarely causes significant pain, although on one occasion a few months ago, she did faint from an episode of abdominal pain, however last night she did not complain of pain). In an effort to relieve the bloating sensation, we decided to try a little light reflexology. I looked up the topic online and gently stimulated a few of the reflexology points (web of the hand, above the wrist, below the knee). The very first point (web of her left hand) made her dizzy within a minute, so she laid down on the floor. She asked me to continue, but when I put pressure on a few more of the points, she lost consciousness suddenly – while she was lying down! It was the normal fainting that I have experienced with her many times – she “recovered” within 5 minutes and was able to stand, but was extremely tired and unable to focus. She fell asleep after several delirious comments and this morning she seems fine.

    It is true that she has an excessive vaso-vagal response, which we have investigated with her doctor and a cardiologist. She typically faints in response to pain, getting her blood drawn, losing a tooth, etc, but I was surprised at this response to reflexology and interested in why. Can you help shed some light on this situation, and is there anything in particular I should follow up on?

    Thank you!

    • David Palmer says:

      Sounds like you have a good professional team. My daughter used to have seizures and the trigger was invariably a sharp, often unexpected pain. You may want to add a neurologist to your team to see if there is brain connection with your daughter. I would also check with the reflexology community to see if they have any experience with this phenomenon. Often, as you probably know, kids outgrow these conditions in their 20s.

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