COVID: What about clotting?

You might have seen headlines about the problem of clotting that comes with COVID-19 infection. This should set off alarms in your mind when thinking about massage or manual therapy. Blood clots are a sure contraindication for certain techniques. How can we sort out this risk when getting back to work?


At this point, our best understanding is that clotting happens from two mechanisms. The first mechanism involves the body’s immune response to damage the virus wreaks on lung tissue. Also known as a ‘cytokine storm,’ the immune response includes both an increase in pro-coagulants and a decrease in anti-coagulants. This is a clear set-up for blood clots. Scientists are finding a high number of micro-clots in lung tissue; in and of itself a cause for difficulty in breathing.

The second mechanism likely happens as the virus progresses within the body. Part of the initial phase includes a ‘porousness’ of the capillary bed. This porousness also allows the virus to travel into the blood stream. Then the virus can attack the inner wall of the blood vessels (a condition called endotheliitis). Blood clots within vessels themselves are an outcome. This happens in small or large vessels, with clots that are small or large. Once in the blood stream, the virus can travel to other organs, doing similar damage (heart, liver, kidneys, brain). More and more, clotting is understood as one of the primary threats of this disease.

Things to keep in mind

• First and foremost, there’s still a lot about this that we don’t know. Importantly, we don’t know much about the role of clotting in mild cases. (It is logical to assume that asymptomatic cases don’t include significant clotting; but we don’t know.)

• Significant clotting is seen primarily in severe cases. Most of the time, people with a high level of clotting are already diagnosed and usually hospitalized. That said, a very small number of patients present with stroke as their first sign/symptom and then being tested for COVID.

• As more people survive the critical stage of COVID, clotting is recognized as one of the long-standing side-effects of the illness. In recovery, people will be taking meds to decrease the risk of clots.

• As massage practitioners we have always been cautious relative to the risk of clotting. We need to refresh ourselves about those precautions and expand them to our general clientele, just to be cautious.

Screening questions

• Difficulty breathing, nausea, headache, fatigue can all be signs of poor physiological exchange.
• Do they exercise vigorously? If yes, how to they feel?
• Do they have other conditions that put them at risk for clotting? Are those conditions being actively managed at this time?
• Screen for standard COVID symptoms: dry/productive cough, fatigue, difficulty breathing, fever. (See previous post.)
• If they’ve had COVID, where are they in their recovery? Is the risk of clotting being managed?

If you have any concerns about their answers (or their candor in answering), it’s best to postpone the session. Ask them to get screened by their primary HCP before seeing them.

Adapting your massage in light of risk of clotting

Given the kind of massage or manual therapy you practice, you’ll need to do more or less to adapt your work. Here are some suggestions for what to avoid or how to alter your work.

• Avoid deep draining, vigorous petrissage, or heavy effleurage (Swedish style).

• Avoid deep compressive methods combined with long uninterrupted strokes (deep tissue/fascial release).

• If you want to access a deep structure, be patient. Go to 1/2 the depth you might ordinarily and then ask the client to engage the muscle. See how much change you can get with less.

• Avoid recoil or compression techniques (visceral mobilization). Engage the organs and blood vessels with motility (light touch) methods at least at first.

• Omit the thoracic pump-directed breathing technique in the sinus protocol taught in the Core Series (craniosacral therapy). Let the body’s regular breathing do the job of drainage for now.

• Avoid CV4 or other compressive techniques on the cranium or membrane system. In the cranial wave rhythm, treat only during flexion phase.

• If in doubt, use biodynamic methods; reserve biomechanical methods for later.

These are the adjustments that I’ve been making in my work. Given your skill set, how can you make your work as safe as possible for your clients?

Lastly: remembering signs of stroke and heart attack

Since it may have been a while since your last First Aid class, here’s a refresher on the signs of these two high-risk problems created by blood clots:

Stroke: “FAST”

• Face: Does the face droop to one side when the person tries to smile/speak?

• Arms: If they try to raise both arms, is one arm lower/weaker?

• Speech: Can the person repeat a simple sentence? Is their speech slurred or hard to understand?

• Time: It’s important to act quickly. Call 911 immediately if you suspect someone’s having a stroke.

Other signs may include: weakness or numbness on one side of the body; dimness/blurred vision especially in one eye; severe sudden headache; and unexplained dizziness or dis-coordination.

Heart Attack:

Chest pain is the most common symptom for all people. Additional symptoms include nausea/vomiting; shortness of breath; jaw/neck pain.

Several symptoms differ between biological males and females.

Females: upper back pain; (not always chest pain/pressure); pain/pressure in lower chest/upper abdomen; fainting; indigestion; and extreme fatigue.

Males: mid-back pain; squeezing pressure in chest.

Staying educated about the risks with COVID is another aspect of practicing safely. It’s always better to err on the side of caution. Work as part of a team, letting your client’s HCPs do what they do best–tending the big stuff, like blood clots and life threatening conditions. When your clients are on the road to recovery, manual therapy can be one of the many complementary treatments and health enhancements they receive.



• Science Daily: Blood Clotting a significant cause of death in patients with COVID-19, 4/30/20.
• Web MD: Blood Clots are Another Dangerous COVID-19 Mystery, 4/24/20.
• New York Times: Coronavirus May Pose a New Risk to Younger Patients: Strokes, 5/24/20.
• MedRxiv: Etiologic Subtypes of Ischemic Stroke in SARS-COV-2 Virus patients, 5/15/20.
• MedScape: Kawasaki Disease, 7/29/18.
• New York Times: New Inflammatory Condition in Children Probably Linked to Coronavirus, Study Finds, 5/13/20.
• Medscape: Life After COVID-19: The Road to Recovery, 5/14/20.
• Ninja Nerd Science: Epidemiology, Pathophysiology and Testing, Update 4/20/20.
• Mayo Clinic: Stroke: First Aid
• Healthline: Everything You Should Know about Stroke
• American Heart Association: Heart Attack Symptoms: Men vs. Women