in addition to those in the wider community setting such as gyms, spas, and private facilities.29–32 Beyond diligence in disinfecting their treatment environment, manual therapists followed CDC guidelines for PPE use by health care providers.31 Administrative changes include redesigning everyday policy and procedures for contactless exchanges and adjusting aspects of each patient encounter as described hereunder. Adaptive Massage Therapy Service Delivery Protocols During the Pandemic People with active COVID-19 infections are fully contraindicated for touch therapies. They may be cleared for massage therapy if they are 14 days from symptom onset or a positive test and are symptom free, or if cleared by a physician. (Note that protocols may vary by jurisdiction or institution.) Recommended treatment adjustments during the pandemic are as follows: Include patient consent language of accepting risk of transmission, noting every effort being made to keep all safe from exposure to infection.29 Follow PPE use guidelines for close or prolonged contact.29–31 Reduce conversation during treatment for comfort adjustments or efficacy.29 Shorten treatment duration, if necessary, depending on practice setting. Hospital-Based Massage Therapy During COVID-19 In the United States, many clinics and hospitals resumed massage therapy patient services earlier than settings outside of conventional medical environments. In the authors’ experiences, patient response has been enthusiastic and full of appreciation. Some providers also report to the authors, gratitude for the opportunity to serve and share in collegial support. The specific skills and techniques of hospital-based touch therapists are designed for virtually any patient condition.33 Due to visitor restrictions, those hospitalized during the pandemic may experience significant loss of the comfort and nurturing family and friends normally provide. An encounter with a massage therapist may be the only time a provider enters the room for the sole purpose of providing comfort and caring touch. In the absence of access to a physical support network, a bodywork session may be anxiety reducing,1,17,34–36 immune supporting,13,37–40 and effective symptom management of common conditions such as distress,34 constipation,41,42 and cancer treatment pain.35,36,43 Also related to hospitals, medical staff members work as teams for patient-centered care. Inpatient massage therapists offer effective and appropriate interventions that support staff by functioning as additional team members.6,44 Patients report a high level of satisfaction when massage therapy is a part of their conventional care.45 Possible Long-Term Side Effects from COVID-19 Infection—Implications While great progress has been made in the treatment of active COVID-19 infection, and vaccines are coming available in record time, the long-term side effects for the millions who experienced the illness46 are still unfolding.47 Late-term side effects are also a possibility in these cases considering the common central nervous system involvement in many COVID-19 patients48 and possible long-term damage to organs or the cardiovascular system.49–51 Given prior evidence of the value of massage for individuals with cardiac interventions, optimal patient care suggests that research granting agencies and the research communities should engage an initiative to explore how these may translate to COVID-19 survivors.10–12,17 Recommendations New protocols for patients with a history of COVID-19 need to be further developed to ensure safe encounters.29,49–52 Based on work in the field and our research, the authors have prepared the following service delivery protocols for COVID-19 survivors. With these modifications and continued monitoring of related research, massage therapists can provide a safe intervention at a time when it may be needed most. In addition to the aforementioned guidelines, massage therapists working with post-COVID-19 clients should include the following adjustments: Specific in-take questions to assess for any long-term health consequences, including symptoms of coagulopathy. If coagulopathy is present, massage treatment should be postponed.46,49 Adjust bodywork for pressure, positioning, or site restrictions based on presenting conditions.49,52 Increase follow-up assessments to build knowledge base of working with COVID-19 survivors.49,52 This could include adding a section to the electronic medical record or treatment notes both for provider use and to document for case series. As information accrues, disseminate by publishing the data and through presentations to field associations. MT IN COVID 469 Downloaded by 76.229.153.206 from www.liebertpub.com at 04/27/22. For personal use only. As just mentioned, research is needed for both safety and efficacy of massage therapy for survivors of COVID-19. Possible studies could include implications of coagulopathies,46,47,49 chronic fatigue syndrome/myalgic encephalomyelitis,45 ‘‘longhaulers’’ pain and symptom management,44,48 effectiveness in relieving stressors of stigmatization and isolation,53 and the modulating effects of massage therapy on lymphocyte circulation and cytokine levels.54,55 Conclusion Massage therapy has a long history and important place within health care. The