Julie Onofrio

Guidelines, Guidelines and more guidelines from our associations and organizations and from the CDC, OSHA, WHO and more…. but now what?

Should you reopen during a pandemic in which there is NO absolute positive way to screen effectively for the virus? Where you work in a closed room and are unable to social distance?

How can you weed through all of this information and make sure you do the right thing?

Massage Association Guidelines

There are many different guidelines from our various associations available for you to help you make the best informed decisions about going back to work. In some ways all of these guidelines have made it more confusing and challenging when planning on reopening although most say the same thing. It is just a ton of info to read and process and can add to the confusion, anxiety and stress of reopening.

ABMP – Back to Practice Guide

Special Issue from ABMP – COVID -19

ABMP State Updates

AMTA- Reopening guidelines

AMTA State updates

Federation of Massage State Boards – Guidelines for Practice (PDF) with COVID-19 considerations

WSMTA – (WA State Massage Therapy Association) – Resources and Links

Healwell.org – Back to practice free course

Massage Mastery Online– Preventing Disease Transmission in a Massage Practice

Government Guidelines (nothing specific for massage therapists)

OSHA – FAQ’s on Facemaks

OSHA- Return to Work

CDC – page on coronavirus

WHO- Coronavirus

Dept of Labor – Coronavirus

Figuring out YOUR Guidelines

You need to be following your state rules or guidelines if you want your liability insurance to continue to cover you. If you are not following the state guides, your liability insurance might be invalidated.

The thing is that the governors and department of health or whoever is creating the guidelines are not really up to date on what a massage therapist does or is faced with so you are basically left trying to figure it out on your own.

Find your state guidelines. Use the ABMP website list of states AND the AMTA website list of state guidelines as the links on each site may vary or provide more direct links to the information you need for your state.

Think about everything you do and everything the client does before coming into your office and giving a massage and also what happens after they leave. You have to adapt the best you can because the many various guidelines are confusing and overwhelming.

Social distancing is key to stopping the transmission of viruses. Since Massage therapists can not do that, we have to depend on cleaning and PPE, or wait it out.

Screening for COVID-19 — There are no amount of questions or procedures that can effectively screen for the virus. Taking a persons temperature or pulse ox doesn’t mean they don’t have it. Many people are asymptomatic. No-touch temperature tools are inaccurate and people’s temperatures vary anyway. People with immune disorders often have a higher temp and with warmer temperatures outside many others may run higher.

Get the touchless temperature tool or the pulse oximeter if required or you want to have fun testing and comparing. People are also lying on their intake and may also have a different definition of what self isolating means.

Office Prep – Cover cloth chairs with plastic to clean easier. Space waiting rooms out to leave 6 feet between people or space out appointments so two people are not in the waiting room at the same time. Have hand sanitizer for the client to use upon entering the office (or hand washing station/sink). Leave office door open so client doesn’t have to touch it. Get water for the person if they need it.

Use no contact payment processing systems.

Table and room cleaning – Use a CDC approved product. Some popular ones. Barbicide wipes, Chlorox wipes (no clorox actually in the product), Citrus II, .

Facerest – The pillowcase draped down does NOT do anything to protect anyone. People need to wear a mask even lying face down. If they can’t lie face down with a face mask on, work on them sidelying. Teach them how to breath wearing a facemask. Have a protective cover over a sheepskin cover or buy enough covers to wash every time.

Air filters for room – HEPA filters. Keep windows open if you have windows. Open the door if you can.

Document EVERYTHING! If you don’t document it, it did not happen.

Lotions/Oils – Automatic lotion dispenser (for soap or hand sanitizer too)

Get rid of the lotion/oil holders or buy enough to wash after every client.

Facemasks — Just wear them and make the client wear one. Learn how to breathe and teach the client how to breath wearing one. Read more on what type and how to breathe wearing a facemask.

Faceshields— I am not sure why people are wearing these because they are open at the bottom and often the top letting droplets spread or enter your space. My dentist friend wears one over a mask and over her glasses and can see droplets on the shield so she knows it has to be cleaned and knows that there are still droplets around but she is poking in people’s mouths.

Changing clothes in between clients – doesn’t make any sense since nurses don’t even do that in between patients.

Wearing gloves – Think about it…this does nothing to protect you from getting it. You are still spreading it around if you leave the gloves on and go in and out of the room. If you touch anything in the room, then you have to change gloves. If you are massaging someone and then have to touch something in the room, you need to change gloves. Just wash your hands and clean the room.

This frustrating and overwhelming process of figuring out what to do to reopen safely really is showing the massage profession that we don’t have good relationships with governors, legislators and boards of massage or department of health in each state. We really should be a part of the process of giving input to the various powers that be to create the guidelines we want along with getting the best information that will help us do that.

Think about it. You can clean and clean and rearrange your room and disinfect and change your clothes and shoes and put up sneeze guards and buy fancy table covers and face rest covers and in walk the client who unknowingly has the Novel coronavirus. They don’t have a temperature (many don’t) and no symptoms of a cold or cough or anything that resembles allergies or whatever. They talk for an hour in your closed room that may now have a fancy air filter, but you are standing close to them and sitting at the head of the table working on their neck and shoulders sharing air. They are laying face down breathing into your pants, legs, shoes and the facerest and the endplates of the massage table.

The longer you stay in the room with the virus, the more likely you are to get it and to get a worse case of covid-19. The closer you are to someone, the higher the risk of you inhaling or getting the virus in your eyes.

SARS-CoV-2, the virus that causes COVID-19, spreads primarily through respiratory droplets emitted by infected people when they cough, sneeze, talk, or simply exhale; the droplets are then breathed in by others. (Loud talking has even been shown to generate measurably more droplets than quieter talking.) This is why physical distancing is so important. We have all now learned the six-foot rule for preventing transmission of contagion-containing droplets. ~Atul Gawande, a surgeon and public-health researcher, became a staff writer at The New Yorker in 1998.

Social distancing is the main way to stop the spread of the virus. When you can’t social distance you need to be wearing a facemask.

But it is soooo uncomfortable.

Yes it is. It makes breathing challenging. It also depends on the type of mask you are wearing. Think of it as a new breathing exercise. Nurses and doctors, police are wearing them…you can get used to it too. Think it violates your freedom of choice? How about when you spread it and people end up dead?

If you think this is uncomfortable, you really won’t like a ventilator. ~Facebook meme

Learn to wear a mask and teach you r clients how to breathe comfortably wearing one.

Posted by Shelley Protte on Monday, May 18, 2020

ID’s Masked Breathing Tips

In this video, ID co-founder Dr. Kathy Dooley shows how you can optimize masked breathing to improve comfort and prevent anxious breathing.

Posted by Immaculate Dissection on Saturday, April 25, 2020

Clients may be uncomfortable wearing a mask especially lying prone. I have seen many variations of the new facerest cover that uses a pillow case or other material placed in a way to allow breathing but it is not made out of protective material that actually stops the virus from spreading.

Help them learn to breath comfortably or use the sidelying position to allow for better breathing.

People may be prone to anxiety attacks from wearing a facemask especially when lying prone so be sure to be prepared and be able to help someone through it all. If you as a therapist get anxiety attacks from wearing them, it is best practices to stay home and not go back to work until the pandemic is over.

Facemasks 101

Not all facemasks are the same. The blue and white facemasks that are so readily available are just dust masks as far as I can tell.

Surgical masks and N95s are the top rated masks but there is still such a shortage that these are reserved for healthcare providers, police and people on the front lines…oh wait…we are healthcare providers. N95s or equivalents need special fitting that massage therapists are not trained in.

A proper surgical mask is usually made of three layers, including an outer hydrophobic non-woven layer, a middle melt-blown layer, and an inner soft absorbent non-woven layer. These three layers have their specific functions: the outer layer is intended to repel water, blood and body fluids; the middle melt-blown layer is the critical highlight of a surgical mask, it is designed as the filter to stop germs from entering or exiting the mask; and the inner layer is intended to absorb water, sweat and spit. the biggest difference between surgical masks and ordinary face masks is the melt-blown layer in surgical masks.

Beckers Hospital Review provide some info on the difference between procedure masks and surgical masks.

Procedure masks are easily identifiable by the presence of two ear loops to secure the mask to the face and are used on hospital floors, isolation units, and labor and delivery units, among other areas of the hospital. Additionally, these masks may be used in the emergency department and the intensive care unit for bedside procedures. However, they are not suitable for use in the operating room.

Surgical masks are primarily used by OR staff and have two straps that secure the mask to the face instead of loops. They are intended to protect against a high risk of fluid exposure.

They further clarify the levels of protection for masks:

Three levels of ASTM barrier protection

ASTM International tests products to improve quality and safety. It defines more than 12,500 international standards across a wide variety of services and industries, including barrier protection standards for medical masks. Here are the three levels of ASTM barrier protection:

Level 1: low barrier protection for general use for low-risk, nonsurgical procedures and exams that do not involve aerosols, sprays and fluids. An ear loop mask is a level 1 mask. ASTM level 1 masks are the general standard for both surgical and procedural use.

Level 2: moderate barrier protection for low-to-moderate levels of aerosols, sprays and fluids.

Level 3: maximum barrier protection for any situation that has the potential for exposure to heavy levels of aerosols, sprays and fluids. Cardinal Health recommends this level as a best practice for supporting OR safety initiatives.

Health care workers who use these n95 or n100 respirators are required by law to undergo an annual fit test — a check to make sure the mask forms a tight seal on the wearer’s face so that contaminated air can’t leak in. If you are wearing one and can smell the coffee in the grocery store or the scented lotions in your office, they are not working properly.

Since we don’t do fit tests and don’t have N95s anyway the other options don’t do as much to protect the spread of the virus unless both parties wear one correctly.

Homemade facemasks are NOT considered to be PPE but the shortages of official PPE have made them popular despite them not being very effective to protect the wearer from getting the virus.

Before the pandemic, half the world’s face masks were made in China and most US companies that have converted the factories to make N95 face masks get their melt-blown fabric from China.

We have guidelines from everyone.

WHO- When and How to wear masks

CDC Guide to Masks

ABMP recommendations PPE Use -says use them but not what type and recommended number of uses. Cloth masks are not official PPE and not effective from stopping one from getting the virus but they supposedly protect others from getting the virus. Face masks, surgical masks or procedural masks protect from spreading but not from getting. Wear an N95 mask if client refuses to wear one. (Make sure it is not the N95 with the valve on the front.

Federation of Massage State Boards recommendations in their Guidelines to Practice (PDF) says wear masks but not what kind, how many uses, or any specifics.

The AMA and others are saying things like “we urge you to use the highest level of PPE available when treating patients to reduce the risk of exposure. If masks and either goggles or face shields are not available, there is a higher risk for infection; therefore, the use of professional judgment is key along with knowing the patient’s risk factors.”

This is just the best way of saying our country has messed up big time and we are caught without the best protective gear so we are trying to hide that so just use your best judgement and hope/pray you don’t get sick. We do not have an adequate supply chain in place so just make toilet paper masks if you don’t have anything else.

FDA FAQs on shortages.

Masks and information everywhere but what should you and your client wear?

The great mask shortage of 2020 will go down in history on our country leaders shoulders.

But what if our associations were to step up and get the correct masks and provide them for their members like the WA State Dental Association did for dentists in WA State. I have heard that ABMP members have a link to some site for a discount on N95s- the one’s that need fit tests to work properly.

The N95s are just starting to come back into the supply chain. There is also the option to purchase masks that are similar called HN95s but some of them have been found to be not as effective as they have been claimed to.

But as I researched the fit tests it was beyond me.

As far as I can tell those blue and white masks available on amazon are mainly dust masks and most say they are not meant for medical procedures. I could only find a few that actually say they are a Level 1 or Level 2 Facemask.

You can also purchase masks and other PPE on www.amazon.com/business when you have an NPI number. Click on the orange button at the top that says sign up for access.

Wearing a facemask helps others from getting the virus from you. If your client does not wear one, you will need a fit tested, N95 to protect YOU from getting it. If both are wearing a mask, it helps prevent the spread.

WEAR the Mask Already

The most innovative face mask 💚👍 #coronavirus #CODVID19

Hygienic haircuts, psychic Skype readings and a black cab boom: Britain responds to the coronavirus crisis. pic.twitter.com/ykwNSPEopR

— Elphège Kolingba (@Elphege2020) March 5, 2020

And this is what it is.

Novel coronavirus is SARS-CoV2 (severe acute respiratory syndrome coronavirus 2). It is NOT a flu virus or anything like the flu virus.

The symptoms are cough, difficulty breathing, fever, chills, body aches and pains, blood clots, kidney failure, heart failure, pneumonia, lung damage. It can cause headaches, fatigue, gastrointestinal symptoms and loss of smell/taste.

It is spread through droplets from the mouth and nose that land on objects and are picked up by another person on their hands and is transmitted to their mouth or nose or eyes. It can be picked up in the air before it lands on surfaces. It is thought to be in the air at least 6 feet away from the source yet the number is really just the best information we currently have.

The incubation period is 2-15 days and people can have it and not know it. Symptoms are often non-existent to mild to severe. People with other health conditions like immune system problems, lung problems and diabetes get it worse along with the elderly. We don’t know why some healthy people also get very bad cases of it.

There is no known treatment or vaccine.

There is no way to effectively screen clients for having COVID-19 without having a test but even the tests are inaccurate.

There are not enough tests yet in the US. Anyone with a cold or other symptoms could have this. Many could have had it last fall and early January as there were no tests being done. Many massage therapists are coming up with intake forms to try to do this and talking about taking people’s temperatures and O2 levels but this will NOT rule out that they have it.

Liability waivers will not protect you from law suits. Your liability insurance does not cover the spread of disease and pandemics. There are law suits already starting. They are mainly involving negligence on the part of the spa or massage therapist.

Our professional liability companies have yet to say whether or not we are covered if we are found to be spreading the virus. Then there is the added risk of being an employer and not having proper PPE or protocols in place to also keep your employees safe from getting or spreading the virus.

If you are an employee and are not provided the required PPE and the place you work is not providing adequate cleaning and social distancing, you could report them to OSHA or even sue them if you get it.

States are starting to implement contact tracing that will be able to trace where the virus is coming from and who came in contact with it. You will be required to share information with your clients and with the government contact tracers.

The tests are inaccurate. Negative tests are 30-40% inaccurate meaning if you test negative you still could have it. (My neighbor was tested a few weeks ago and was told this.)

Testing is one of the keys to getting things back to normal. There still are not enough tests. People need to be tested and then if found positive, tracked to see where they have been and quarantined. People who are found to have been in contact with the person will also be quarantined. Contact tracing is allowed under HIPAA Privacy Laws.

When You Open

This is not written to scare you, it is written to inform you. If you feel like it is some scare tactic or fear mongering then it might be good to check to see what is driving that feeling you are having. It may be because you know that the risks of being a massage therapist and spreading this disease are great and there is much to think about and have in place to reopen.

You should know how to clean your office at this point from all of the information out there. No amount of cleaning will stop this. A person with the infection can come in and spread the virus all over the office.

The most effective way of stopping it is social distancing. Next after that is having a set up where you can keep the virus particles from hitting you if you are less than 6feet away. (See hierarchy of defense by the CDC.) That of course is impossible for giving a massage. You are in a closed room, less than 6 feet apart making it the highest risk of spreading the virus. The last line of defense is wearing a facemask and eye protection. That is not 100% effective either but it is the best chance you have of not getting it and spreading it to your clients. Most of the facemasks that are available are just dust masks and do not stop the spread of the water droplets. The N95 masks will protect you from getting it and spreading it but they need special fitting and they need to be worn all day long and taken off in specific says to reduce the spreading. Massage therapists are not trained in the use of these masks. They also need to be reserved for nurses, doctors, police and fire departments.

Still researching masks…most of them for sale are just dust masks. https://healthcentricadvisors.org/wp-content/uploads/2017/04/3_MaskEnomics_Poster_2012.pdf

Posted by Massage Practice Builder on Thursday, May 7, 2020

Surgical masks are the next best thing. I am starting to find them on Amazon Business where they are reserving products for healthcare providers. You have to have an NPI number to be able to purchase them. I also found hand sanitizer and eye protection there. I am not yet sure if they are able to fill the supply to hospitals and doctors, nurses, police, firefighters and rescue workers who need them first.

Your state Department of Health or Governors office will inform you of the specific things you will need to do to reopen. Our professional associations AMTA and ABMP should be informing them about massage and our work to help them create the best guidelines. I did see where one state was asking for input from the Federation of Massage State Boards. Your AMTA State Chapters are working on this too and the states that have a lobbyist are using that to make the connections needed to give input into the best practices guidelines. Each state is different.

For more info on reopening see what some states are recommending as guidelines. Article Review for Best Massage Practices in a Post Covid-19 Economy For review to the New Hampshire Re-opening Economy Task ForceThursday May 7, 2020Prepared by Linda Garvey LMT

It is what it is.

When this pandemic started for me back on March 4 it took me a few weeks of grieving, researching, worrying and saying this can’t be right to get to the point of being able to say… It is what it is.

It is what it is

Posted by Massage Practice Builder on Saturday, March 21, 2020

Now 2 1/2 months later, I am getting to the same point of being able to say it is what it is. Everyone is on their own path of figuring out when it is the right time to reopen their massage business. The fighting on Facebook has to stop now. There is no right or wrong time to reopen. You just have to be able to handle the risks of opening.

I am watching the numbers. I am preparing what I can. I am thinking I might start reopening slowly and just have clients in who I know have been socially distancing and not taking any new clients at this time. It is just a waiting game now. Waiting for the specific guidelines for my state. Waiting to see if the PPE orders come in. (It looks like they are not coming in until June right now.)

I have worked to provide people with the best information that I found at the time and will continue to do so.

How can we all get to the point of not reacting and just being informed. This isn’t fear mongering. It isn’t stepping on your civil rights. You can have your fears and reactions but don’t let them have you. Can you just accept what it is and work towards reopening safely?

It is what it is.

Intake and Screening Clients

No amount of screening in a massage therapy office can effectively rule out COVID-19 or coronavirus. Intake forms may ask questions and you may be taking the person’s temperature but that does not mean that the person is free from infecting others with the coronavirus.

Since the virus is often undetected in people for 2-10 days before they get symptoms and also after they have had the virus, there is nothing besides a swab test that will guarantee that someone does not have the virus. Even that is not 100% effective as they could have just picked it up on the way to your office. The test is really inaccurate too and no one is talking about that. My neighbor was tested last week and it was negative but the doctor said that that does not mean he doesn’t have it. The tests are 30-40% false negatives.

It isn’t just older people and people with compromised immune systems. Younger people are having strokes and heart attacks.

People with muscle aches and pains could also have the virus. How will you be able to screen those people out?

Not even using thermal scanners will help.

No screening questions or processes can 100% rule out that the person does not have the virus.

Having waivers won’t protect you either from what I understand. They need to be written carefully by lawyers. I wonder if AMTA and ABMP have their attorneys on this to write effective waivers for their members?

Will your liability insurance cover you if the virus is spread through your office? How will anyone ever be able to track that? They are. The first wave of lawsuits are being filed now according to the news.

Facemasks

Should you wear them when you get back to the office? What kind? Will the home made masks protect you enough?

The wearing of face masks is more about protecting others from getting the virus in case you unknowingly have the virus (which is generally the case as people are contagious for 2-14 days before they show symptoms.)

The N95 masks will protect You from getting the virus but they need to be properly fitted and worn properly in order to do that.

The CDC guidance stated that masks are primarily meant to prevent the spread of disease from the wearer to others. The CDC has moved to recommending home made masks mainly because the other masks cannot be found anywhere and are needed for the frontline workers who are exposed to the virus.

CMS has this to say about facemasks for Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I

Consistent with CDC’s recommendations for universal source control, CMS recommends that healthcare providers and staff wear surgical facemasks at all times. Procedures on the mucous membranes including the respiratory tract, with a higher risk of aerosol transmission, should be done with great caution, and staff should utilize appropriate respiratory protection such as N95 masks and face shields.
•Patients should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks.
•Every effort should be made to conserve personal protective equipment.

The WHO still says you on their website that you do not need to wear a mask unless you are taking care of an infected person. I did some searching though and found that it was mentioned in one of their briefings on April 3.

It doesn’t negate the need for everyone to protect themselves and try to protect others so we can certainly see circumstances in which the use of masks, but home-made or cloth masks, at community level may help in an overall, comprehensive response to this disease and we will support governments in making those decisions based on the situation they find themselves in in terms of transmission, based on the context in which they’re dealing and the resources they have at their disposal.

WA State massage therapists are still considered essential workers and the Department of Health (PDF) has provided specific direction for working on clients and cleaning offices.

Ensure that massage therapists have the following personal protective equipment (PPE) and are familiar with its use: facemask (surgical mask with ear loops or mask with ties), eye protection (for example, goggles or disposable face shield that covers front and sides of face), gown, and Updated April 27,2020clean, nonsterile gloves. Alternatively to a gown or other covering, massage therapists can change clothes after each massage.

CDC’s Optimizing the Use of PPE provides guidance on actions to take when PPE is short or you do not have PPE, including contingency and crisis strategies. Using crisis measures is not ideal and could put health care providers at risk for disease.

Provide a face mask or cloth face covering for each patient to wear during the entire treatment.

Other resources on masks:

WHO – Advice on the use of masks in the context of
COVID-19 6 April 2020  |

CDC – Use of Cloth Face Coverings to Help Slow the Spread of COVID -19

Understanding the difference it types of masks -CDC

MSNBC video of how much masks protect you.

Cleaning and Preparing the Office

Think about everything that you touch on the way to the office. Think about everything that a client touches on the way to the massage office. Think about doorknobs, shoes, clothes and everything.

Can you effectively clean and manage everything?

Taking things out of your room like carpets and cloth furniture might help.

Will air filters and UV lights help with keeping your office clean?

Is cleaning really enough to stop the spread? It is just one part of this.

Gloves

Wearing gloves has not show to be necessary to limit the spread of Coronavirus since the virus is not transmitted through skin contact. If you wash your hands after every client and follow room cleaning procedures you should be OK.

What will it take for YOU to get back to giving massage?

The White House directives for reopening call for specific things to happen before reopening. Many states are not following the orders and have gone rogue. States like WA are following the science in hope that we only have to do this once! We need to have a consistent reduction of cases in each state and have the downtrend for 14 days consistently. We need adequate testing to be able to test everyone who needs or wants one to show they are not infected. (My neighbor was just tested and was told they were negative and the doctor said the negative tests were 30-40% incorrect so there is that to deal with and no one is talking about it.)

Governors and state health departments are beginning to reopen states and get businesses back to work but does that mean YOU have to go back to work? Our Governors and legislators don’t seem to understand what massage is about and that most have us have NOT been properly trained in the use of PPE, let alone are able to get the required PPE. (This is something that needs to be worked on after this is over–hopefully through our associations.)

We need to have systems in place to track who gets it and where they have been to notify those who were in the vicinity so they can get tested or be in quarantine until the infection phase is past.

We need to be able to limit the number of cases we have according to the number of hospital beds that we have to handle the cases.When there is a known treatment that works most of the time and when we get a vaccine that would help reduce the number of cases, opening up will be easier but both of those are a long way off.

One of the biggest issues is whether or not your unemployment will stop if you are ordered back to work. If you are employed you risk losing your job if you don’t back—or do you?

I don’t yet have an answer for this.…but we really need to find out.

As far as the other part of this in keeping your clients from getting this, keeping YOU from getting this and keeping your family and your clients families from getting this—what will YOU need to have in place in order to do that. This isn’t just about YOU anymore either. It is about everyone who you are in contact with and everyone your client is in contact with on a daily basis.

It also depends on where you live and how wide this virus is spread in your community. The thing is though that even if you are in an area that has low number of cases, the testing has to be adequate so you know it isn’t all around you. This was one of the problems when this first started. It was all around us here in the Seattle area with one of the first cases in January and we didn’t know it. Later it was found that there was actually a case in CA that was earlier and we again did not know it was all around us.

My criteria right now is facemasks. We need to have at least real surgical masks – not the homemade or dust masks that are available. We need real protection from spreading the virus. Since those are not available and probably won’t be for some time, the next thing would be that the number of cases has significantly been reduced and the hospitals have the capacity to effectively care for the number of people who have the virus. There needs to be enough testing and accurate testing so that people can get tested once a week or more. Accurate testing doesn’t seem like it will be here anytime soon.

There is just no way in hell that you can stay 6 feet away from someone—there is that.

Resources:

OSHA – Guidance on Preparing Workplaces for COVID-19

Georgia (one of the first state to open) Safety Guidelines for reopening Barber and Cosmetology Salons