On Solid Ground
A Prudent Approach to Safe Stone Massage

By Shirley Vanderbilt

Almost fifteen years ago massage therapist Mary Nelson was sitting in a sauna and became inspired to create a modality based on heated stones. She now teaches her LaStone Therapy in forty-seven countries, continuing a practice founded in spiritual connection to the stones themselves. While the use of stones in healing has been around since ancient times, this modern application of the work captured the hearts and souls of therapists and their clients. The trend has spread, with stone massage being offered in a variety of venues and extended to use in facials and pedicures, energy work, reflexology, aromatherapy, and even sports massage. Some therapists have branched out from LaStone, establishing their own brand and approach, as is usual in industry when a good idea takes off. This healthy competition has contributed to the popularity of stone work and increased the creativity involved in both application and equipment. But there has been a downside in that some therapists are getting themselves into hot water with the stones, ill-trained and ill-prepared to provide a safe treatment for the client.

Katie Armitage, executive director and vice president of operations for Associated Bodywork & Massage Professionals (ABMP) says, “Basically, we have had a disproportionate number of claims from hot stone massage. These claims have all been burns—some worse than others—but some have been third-degree burns.” The ramifications go far beyond the thousands of dollars paid out. The client can be scarred for life, as happened in one third-degree case Armitage cites. The therapist’s reputation is also scarred and that, too, can have long-lasting effects.  
These insurance claims, as well as comments from experts in the field, have revealed somewhat of a gaping hole in the stone massage business—that of therapists engaging in the practice without having proper instruction. In many cases, it’s a matter of the therapist not knowing enough to know what she’s missing. To counter this trend, we offer—with the help of qualified experts—an overview of some basic concepts, and misconceptions, of stone work. The information here is intended to increase awareness, not serve as a basic primer, so that those floundering in this gaping hole can find a helping hand to pull them to solid ground and safety.

Show Up for Training
If nothing else, let the one take-home message from this article be the importance of quality, hands-on training. You need to show up in person at the seminar, learn all you can, and then continue to learn as your stone massage practice grows. And you need to learn from a certified instructor, not your office partner.
“We believe in education,” says Patricia Mayrhofer, founder and president of Nature’s Stones, Inc., a major traveler along the stone massage path. “I will tell our students, don’t go home and teach somebody else. You only retain about thirty percent of what you learn.” Turn around and teach someone else, and the information is cut by another two-thirds. “Another therapist will show the new person how to do it but the problem is they show them, they don’t teach them, so they don’t get all the information.”         
                                                    
Debbie Higdon is special services manager for ABMP and risk management/special services manager for ABMP’s sister association, Associated Skin Care Professionals. She provides claims examples to back this up, wherein spa therapists in question had been given abbreviated training by other employees. “In some cases the spa will have someone that is trained in stone massage, or they will send one person to a class and then that employee comes back and trains the rest of the staff.” Unless that employee is a qualified instructor, training will be inadequate. Lack of certification could also be an issue, leaving the trainee without a legal leg to stand on should problems arise.

Another less-than-adequate training scenario is that of the two- or three-hour overview presented in massage schools. “This is not quality training,” Mayrhofer says. “Our belief is therapists are more likely to give a good, safe treatment if they have been trained properly. This is the same for aromatherapy, reflexology, shiatsu, and any other modality. These two- and three-hour exposures are just teasers, not a training, and students need to realize a little knowledge can be dangerous, or at the very least just inadequate. Because everyone teaches differently, we feel a certificate of sixteen hours minimum should be the standard.”

A seminar’s benefits go beyond the formal material presented, offering an opportunity for instructors to answer questions, provide guidance, and solve problems, Mayrhofer says. “Massage therapists learn best by doing and receiving, and we have structured our seminars this way. We have found that after the first day some therapists are still fumbling with stones. The second day is like the light has dawned and they are completely fluid with their moves.”

Videos are helpful and often incorporated into professional instruction, but do not serve well as a stand-alone training tool. Although Nature’s Stones has several videos on the market, Mayrhofer says, “Even videos won’t give them all the information they need.” LaStone will be adding a mini-video to their upcoming home-study course, but the sole purpose is to allow   students to absorb basic material before attending the seminar for the hands-on work.

As vital as stone massage training itself is the basic background of the therapist embarking on this journey. Margaret Avery-Moon, former owner of the Desert Institute of the Healing Arts in Tucson, Arizona, and now consultant to LaStone Therapy, is a seasoned educator. She stresses the importance of a solid foundation for students to build upon, beginning with a comprehensive training in massage for fluid movement and body mechanics, and education in hydrotherapy and the sciences to understand the physiological effects of hot and cold on the body’s lymphatic system.

Amply Supplied
One of the things you’ll learn in professional stone massage training—as well as to whom, how, and when you can apply this modality—is the proper equipment for this work. For instance, you’ll need a professionally designed heater, not an electric frying pan or similar substitute. You’ll also need specially harvested stones, not just a bag of rocks. “Every stone on the planet wants to aid the body in healing,” Nelson says. “People have been using stones forever for healing the body. However, not all stones hold heat or cold well, or can be massaged with, or support the wrist while massaging. The configuration of the stone varies according to the type of work.”

For hot stone treatment, basalt stones are used because of their heat-retaining properties and natural smoothness. Marble stones are hand cut for use in cold stone therapy. Stone sets can be purchased from reputable companies that carefully select and prepare the stones for therapeutic use. Sets vary from those used for full-body massage to specialty applications such as facial, pedicure and manicure, reflexology, and the chakras.
  
Thanks to Nelson’s trial and error process in heating stones, you don’t have to—and shouldn’t try to—reinvent the wheel. Nelson started her LaStone modality in 1993 using a hot plate, but found it didn’t heat the stones evenly. Her dad suggested using a turkey roaster for more even heat distribution. Although it worked wonderfully, she says, there was a problem in that the conventional roaster was not made for continuous use because it goes off and on throughout the cooking process. Eventually, the Nesco company reconfigured the electrical components of their roaster so the heater could be on for ten hours a day over a period of years. The product now bears the name of Spa Pro and is a standard in stone massage practices, along with a few other brands. “There are some really fancy heaters, but I haven’t seen any I like better than Spa Pro,” Nelson says, noting its efficiency and economical price. 

Although Mayrhofer cites other acceptable products on the market, she also praises the Spa Pro for its performance. “When the unit is new, it takes a while to settle in before the temperature holds steady,” she says. “After a couple of hours of working, we find the Spa Pro unit maintains its temperature, is dependable, and lasts a very long time.”

When it comes to stone placement, some therapists make the mistake of simply using a thin sheet between the client’s skin and the warm stone, putting the client at risk of a burn. The barrier should be a heavier material, such as a flannel sheet or terry cloth towel, Mayrhofer says. In fact, there are specially designed products you can now purchase for placement use, including mitts, booties, wraps, and belly bags. Nature’s Stones has even developed a unique hot stone drape that fits around the neck and shoulders, to be worn in a waiting room or during salon services to enhance relaxation.  
   
Another essential tool is a thermometer for checking water temperature. Mayrhofer uses a digital type that doesn’t need calibrating and can be set to ring an alarm if the temperature varies. But a hardware store thermometer will serve just as well, if you keep it calibrated. Avery-Moon says you can easily calibrate the thermometer by immersing it into a substance with a known temperature, such as a glass of ice with a little water. If it’s not reading thirty-two degrees, just adjust the nut on the back to correct the reading needle.     

Speaking of  Temperature
The recommended water temperature for heating stones varies from 110°F–120°F at the low end, but never more than 130°F. “If you go higher than 130°F, you can burn somebody,” says Judy Ford, RN and director of education for Nature’s Stones. An important aspect of training, she says, is teaching students how the water should feel. “If you think the water’s too hot, use the thermometer.” At the correct temperature you should be able to reach in, take the stones out, and hold them in your fists. If it’s too hot for you, it will definitely be too hot for your client.

Armitage says in one ABMP claim, the therapist used a hot pad to handle the stones. Surprising? Not considering an instructional video Ford has seen showing a therapist using rubber gloves to retrieve stones. Once again, proper training with hands-on instruction is essential to protect your client and your practice.
 
Some therapists experience problems with water temperature because of going to extremes, Mayrhofer says. Starting with cold water extends the heating time required, and what can follow is a back and forth, lid on-lid off attempt to regulate. “The best way to do it is to cover the stones with hot water, use a medium to high temperature, put the lid on, and it should be hot in ten to fifteen minutes. Then take the lid off and turn the temperature gauge down to a moderate setting.” You’ll need to tweak the process depending on the type of heating unit, as well as the external environment. An air conditioner blowing on or near the heater will have an effect, and if the unit is on an extension cord, the temperature gauge may have to be raised. To control the applied heat of the stone, dry the stone off before massage or placement, Ford says. “If you have a wet stone and a towel, the heat will go through the wet towel right into the skin.”

With all of this in mind, there is still the matter of the client’s comfort. “If a client tells you when you start that it’s too hot, do not continue until you regulate the temperature,” Ford says. What fits your comfort level may not hold true for clients and it’s important to check in, as well as giving them permission to speak up.

Keep It Clean
Just as you would clean your kitchen utensils after use, you have to keep your stones and equipment clean and free of contamination. Simply put, some therapists are not doing that. Mayrhofer encourages washing stones and changing the water after every client. “Every time you put your hands in there you’ve touched the body. We teach a system where it only takes six to ten minutes to wash the stones and change the water. Once you have the core of the stone hot and you don’t let it cool down, it will heat up again very quickly.”

Nelson takes another approach, using a spa oxidizer that breaks down bacteria in the hot water, keeping the stones sanitized all day. At day’s end, empty the heating unit and wash and sanitize all equipment. This includes sanitizing cold stones before placing them back on ice or in the cooler. Chemicals applied to the cooler will allow germs to be dormant, so instead she recommends using hot soapy water. Nelson says Listerine mouthwash is a great sanitizer, even better than alcohol. “There are many forms of sanitation methods and different ones from country to country,” she says. “It doesn’t matter how you choose or what chemical you choose, as long as you choose one. The bottom line is the stones—all of them—and everything you use with them need to be sanitized every single day you use them.”

Not for Every Body
Before you even think about touching a client with a heated or chilled stone, you need to know who is, and is not, an appropriate candidate for this work. “There are always a lot of things to learn about precautions and the physiological effects of hot and cold on the body,” Avery-Moon says. “Even a top-notch education can’t cover it all. Each human body brings in their own way how they express a health condition. Two people with arthritis are not presenting the same symptoms. You need to continue to build upon that scientific foundation you got in anatomy, pathology, and physiology courses.”

Any quality training program will cover precautions and contraindications. Of course standard massage guidelines apply, but the elements of heat and cold are an additional factor in specific health conditions, a few of which we address here. “Diabetics have a decrease in sensation in the extremities,” Mayrhofer says. “You need to be more aware of the temperature you use and of their comfort.” Take care with placement of hot stones and check in with them constantly, paying close attention to the color of the skin.

Experts have differing opinions on this work for expectant mothers. Elaine Stillerman, author of Prenatal Massage: A Textbook of Pregnancy, Labor, and Postpartum Bodywork (Mosby, 2007), emphasizes, first, that MTs shouldn’t be massaging pregnant clients unless they’re specifically trained. And pregnant clients should not have a full-body stone massage, although spot work is good, Mayrhofer says. “Expecting mothers need work on their low back, piriformis, arms, neck, and shoulders.” Along with use of warm stones, you can place cold stones on the feet, behind the neck, or in the hand. But hot stones should never be used below the navel or placed on the abdomen. An expectant mom’s core temperature is sensitive and, if raised, can stress both her and the baby, Ford says.

Stillerman underscores this client’s temperature is already elevated due to her increased blood volume. “My rule—no hot stones during pregnancy. As far as the feet are concerned, her poor, hot, achy, swollen feet could benefit from a cool soak, but unless a practitioner knows which points to avoid, I would recommend only cooling her feet in water or with a cool, damp cloth,” she says. “The tops of the shoulders and hands also have contraindicated points, so the therapist needs to be very careful when working around these areas.”

Ford practices in a continuing care community with seniors up to age ninety-eight. “The number one safest thing you can say is that I never do a full-body hot stone on the elderly. Period. And I teach that.” She incorporates some hand and placement work with these clients, but cautions to be aware of the client’s history and condition “Hot stone therapy can really dehydrate and increase the blood pressure, and put stress on the cardiac system.” Although thinness of skin is always an issue in geriatric massage, Ford says, “What I am more concerned about is whether or not the person is on a blood-thinning medication because the pressure alone could make a difference with the hot stone.” And do not massage with a hot stone in the area of a pacemaker. At the core, and this goes for all clients, “You have to look at the individual, know what the stone can and can’t do, and what will protect both you and the client from being burned.”

Stones at Work
Some of the more basic guidelines for stone massage are simple to understand in regard to preventing burns. Number one rule, credited to Nelson’s original work, is never place a hot stone on bare skin without moving it. Nor should you have a client lie down on a hot stone. When hot, the stone should be kept moving with sufficient pressure to go into the muscle, thus bypassing surface nerve endings, Mayrhofer says. For placement, use an appropriate barrier, as noted previously. Above all, keep in mind the client may not sense the stone is too hot and it’s your responsibility to constantly monitor the treatment. But there’s another side to this work that is not so simple, that of alternating hot and cold applications.

“There are many factors to consider when choosing the correct temperatures for the client,” Nelson says. At the forefront is clients’ honesty about their health and the therapist’s comfort and grounding in the principles and theories involved. Nelson, who completed fourteen weeks of hydrotherapy study before starting her stone modality, notes many therapists don’t have this background. “I recommend that anyone who is using any form of alternating temperatures, or even just hot stones in their body therapy practice, purchase at least three hydrotherapy books and study them on a regular basis. This will give them the clinical information they need in a general way to be able to support their clients in choosing the correct temperatures to use on the body on any given day.

“Keep in mind that every person’s body chemically changes daily and what temperature challenges me today to allow change to occur may not be the same temperature I need to support my healing process tomorrow.” Other issues include sleep and exercise habits, prescription drug use, and diet. “All of these are part of the determining factor in what stone therapy treatment should be offered to them that very day in order to satisfy their need at that very moment. What the therapist needs to understand is that not everyone can receive the same temperatures. ‘Less is more’ in the case of alternating temperatures to the body.”

Acute illness or a chronic health condition, even menopause, can compromise the body’s resources to react to heat or cold in a healthy way, Avery-Moon says. But in addition to caution regarding the client’s medical status, Ford brings up another concern. “The whole concept behind using hot and cold therapy is to manipulate the circulation and boost the immune system. Blood will move in response to the hot and cold treatments. Boosting the immune system (or adding more white blood cells) isn’t necessarily a good thing to do. You’re also creating a problem if you’re just increasing white blood cells without something for those blood cells to work with.” As the body’s defense system, white blood cells remove debris, bacteria, and viruses, but if these materials are not in abundant supply, the cells may go after healthy tissue.                                

Partnering with Stones
One of the beauties of stone massage is its benefits for both therapist and client. “The stones share the work with the therapist and they become part of your hand,” Mayrhofer says. “With a client with dense muscle, you don’t have to use all the might you have. It will help to soften the muscle so you can work more deeply with less effort and get in there a lot easier.” But you still need to maintain proper body mechanics, as in any modality, or you will tire easily. Nelson suggests students learn qigong. “This will teach them the power of ‘breath’ and how to ‘move’ energy through and around their body.”

Learning how to hold the stone properly will also enhance your work. “It’s not holding with your fingertips as much as it is cupping the stone with your palms,” Mayrhofer says. “It is possible to be able to use your fingers as well as the stone while you’re massaging. The larger the body part, the larger the stone you use.” She notes any technique done with the hands can be adapted to stones, such as myofascial release, connective tissue, trigger point, even craniosacral.

“It is not only how to hold the stone,” Nelson says, “but what size and shape is the stone and what job does this stone do for you in your therapy sessions. Each different size and shape of a stone offers support to the therapist’s hands and wrists. Along with the proper stone for the job, the therapist needs to understand the modality they are providing the client in conjunction with the stone therapy being offered.”

Avery-Moon shares a final caution for the therapist. While doing this work, remember you’re heating up your own body. To maintain healthy hands, she uses a sufficient amount of oil. After working with hot stones, she cools her hands by washing them in warm water then cold water. And she stays hydrated by drinking lots of water. “No matter what type of treatment I’m doing, it’s important that I’m maintaining a self-care component to make sure my health is good.”

Shirley Vanderbilt is a staff writer for Massage & Bodywork.

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