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There is nothing better on a cold day than lying on a heated massage table, muscles melting under the added warmth of a hot stone massage. Not all hot stone massages are created equal, however, and there are several things that therapists (and clients) should know in order to ensure that this delightful service remains a yummy treatment.

Typically the term “hot stone massage” refers to a technique that involves the therapist holding heated stones in his or her hands while working on the client with gliding strokes. These stones are usually heated in water, in either a roaster or crock pot, but can be heated in a dry hot cabbie.

Unfortunately, this service can go horribly wrong very quickly. Clients get burned due to overheated stones and stones that are placed directly on bare skin or worse, placed under the body. Many therapists have argued that additional training is not necessary for hot stone massage, that the use of hot stones is nothing more than the addition of a simple tool and the training most therapists receive in massage school is sufficient. But there is basic safety information specific to hot stone massage that may not be covered in every massage school that is necessary in order to ensure clients do not become injured.

According to a statement from the Associated Bodywork & Massage Professionals (ABMP):

While not widely regarded as an entry-level staple, hot stone massage is popular with the public and employers at spas and franchise massage clinics. This system of bodywork shows up regularly in entry-level training programs.

Burns from hot stone massage most often occur (in order of frequency) when therapists:

  1. Placed heated stones on bare skin and left the stones in this static position.
  2. Placed stones underneath clients and left them (even when a layer of insulation like a towel is used) in this static position.
  3. Performed hot stone massage on children under the age of 18 (children tend not to speak up when something about the massage feels uncomfortable and they have less adipose and thinner skin than adults).
  4. Performed hot stone massage on older adults (usually between the ages of 68-80 who have thinner skin and less adipose than younger adults do).

In January of 2012, ABMP launched an aggressive safety campaign related to hot stone massage. The campaign included special e-blasts and newsletter articles. ABMP also began requiring therapists and teachers at member schools who practice or teach stone massage to watch a 7-minute safety video, and review and acknowledge safety guidelines to activate their stone massage insurance. The results have been exciting. Therapists have written letters and emails thanking us for helping them increase their safety. Considering our loss experience two years prior to the new safety campaign our loss experience two years following the launch we have determined the frequency of hot stone claims has decreased by 75%.  The severity of our hot stone claims (in terms of settlements and loss related legal expenses) has decreased by 85%.

As we can see, a few minutes of basic safety training specific to hot stone massage has significantly reduced the number of injuries and the severity of remaining injuries by a significant amount. There is no denying the payoff of this basic safety training program.


The average human skin temperature is 92 degrees. Hot tubs are usually around 104 degrees and most people find them to be right about at the threshold of nice and hot and too hot.

For hydrotherapy, following range of temperatures will feel as follows:

  • 35 – 56 degrees: Very Cold
  • 56 – 65 degrees: Cold
  • 65 – 92 degrees: Cool
  • 92 – 98 degrees: Tepid/Neutral
  • 98 – 104 degrees: Warm to Hot
  • 104+ degrees: Very Hot

If the average skin temperature is 92 degrees, stone temperatures should never be higher than 120 degrees and will usually be hot enough for most clients at about 105-110 degrees.

Example: Many new therapists have asked me, “Where are the tongs?” as they go into their first hot stone massages. My response has always been: “Why do you need tongs? If you can’t stick your hand in there and pick up a stone, don’t put one on me!” Think about that – if the water and stones are so hot that you cannot reach in and pull a stone out, would you want someone to place that stone on your bare skin?

Effects of Cold and Hot Therapies

The effects of cold are increased stimulation and circulation, decreased inflammation and decreased pain. Cold acts as an analgesic, reducing nerve sensitivity and is stimulating to the body.

The effects of heat on the body are increased circulation (especially at the surface), metabolism and inflammation, and a decrease in pain, muscle spasm and tissue stiffness. Heat quiets and relaxes the entire body, is efficient, nontoxic and promotes sleep.

Contraindications for Hot Stone Massage

Contraindications for hot stone massage begin with the same cautions as for any type of massage therapy: fever, contagious diseases such as colds and flu, being under the influence of drugs or alcohol, recent surgery or acute injuries. And, similarly, local contraindications such as severe bruises, cuts and abrasions should be avoided along with varicose veins and sunburn.

Hot stone massage, however, is going to have an increased effect on certain conditions due to the additional heat added to the body. Pregnant clients should not receive a very hot stone massage, but warm stones can be used so long as the client is otherwise able to receive massage therapy.  Edema, cardiovascular conditions and high blood pressure can all be aggravated more by hot stone massage, as the effects can be even greater than those of other massage modalities due to the additional heat. Similarly, those with diabetes who are suffering from decreased sensitivity may not be aware they are being burned, so very hot stones should not be used on them.


Just as hand washing is vital to the health of the therapist and client, so too is it vital to properly clean and sanitize the stones and heating unit. Stones should be washed (scrubbed) with hot, soapy water, specifically with an antibacterial/antiviral agent and dried thoroughly before being stored. Stones are porous and so need to be washed with a coarse rag or brush and a clean towel used to dry them and the unit. Stones should never be stored wet or with the oil residue still on them or the heating unit, as this is a breeding ground for bacteria and viruses to grow. Stones should always be properly cleaned between clients to avoid passing along any bacteria, viruses or diseases between clients.

9 Tips for Successful Stone Massage

In order to provide a successful hot stone massage that is safe and comfortable for the client, keep these guidelines in mind:

  1. Begin by sanitizing the stones and heater you are using by washing (scrubbing) in hot, soapy water and drying stones and heater thoroughly.
  2. A white hand towel or washcloth in the bottom of your roaster or crock pot helps you see the stones and quiets the noise the stones make while you are in session.
  3. Leave the lid off; when you place the lid on squarely, the heat gets trapped and the stones tend to overheat – even on low or warm.
  4. Regardless of which type of heater used, be sure to use a thermometer to accurately gauge the temperature of the stones, keeping the temperature well under 140 degrees. Be sure you can reach in and grab a stone in your hand.
  5. Try keeping a small bowl of cold water for too hot stones. If you accidentally overheat the stones, you can use this bowl of cold water to cool them down by dipping the hot stones in quickly. This allows you to work with the stones while you wait for the heater to cool down.
  6. Try using cold stones (quarts or granite) on the face for contrast. Allow stones to rest in a small bowl of ice water to get them cold.
  7. When working with stones, be sure to avoid hyperextending the wrist as this can lead to fatigue and pain in the therapists’ wrists, hands and forearms.
  8. Heat will absorb faster in different areas of the body so be on the lookout for this. It typically feels great for the client when you slow the stones and allow the heat to be absorbed in these areas. Also, stones can be used to address trigger points or to activate tsubos (shiatsu points), and reflexology points. Other nice touches are tapping one stone with another over trigger points or placing a large stone to rest (on a towel) on the abdomen and rotating clockwise.
  9. Do not allow the stones to rest in a static position on bare skin or place the stones under the client. Also be aware that damp towels, sheets or blankets will transfer heat very fast so be sure the towel, sheet or blanket is dry before placing a hot stone to rest on it.

Any type of heater can be used to heat stones for massage therapy, but it is the responsibility of the therapist to be sure they do not become overheated. It is also important that the stones and heater be cleaned and sanitized properly between each client. Therapist must also be aware of the additional risks and contraindications that may arise due to the addition of hot stones and be able to work with clients to ensure they receive appropriate services.

Almost any modality or product can be abused and become harmful to the client if not administered appropriately. The ABMP, by virtue of their education campaign, demonstrated significant improvements in the massage therapy field. There are less injuries overall, less severe injuries when they do occur, and better client outcomes with a minimal amount of education for therapists. As massage therapists, it is our responsibility to make sure we have the best possible training in whatever modality we offer to clients.

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