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