To cover or not to cover in massages with a top-sheet?

During massage, the client may be partially or fully clothed depending on the type of massage. In a partially or fully disrobed massage, it is generally accepted that the client will be draped for modesty and warmth. But sometimes, new clients might not be very comfortable with the idea of taking off clothes, or keeping clothes on may be requested for cultural reasons. Is there any scientific reason or explanation why a fully-clothed client should be draped? Should the client be given a choice of draping with a top sheet irrespective of the client being partially or fully clothed?

Except where it is legally mandatory, this dilemma about draping does not belong to most of the western massages as oils or lotions are used in almost all of them. However, with increasing acceptance of Yoga and Ayurveda, more and more beneficial effects of Yoga/ Ayurvedic massages are being brought to light and different kinds of massages are being introduced to the Western consumer. Whereas oily massages have to be done while unclothed to an acceptable and required level of undress, non-oily massages do offer a choice to remain fully clothed. 

Some of the more commonly known non-oily massages, Thai-Yoga Massage for example, can be done fully clothed. But in Thai-Yoga massage, a client would go through passive movements, so, a top sheet won’t stay in place. So, loose clothes, a towel or a gown will have to be used. Marma massages, those done without oil, are also becoming better known in the west. In these massages, a client does not need to disrobe and would lie down passively all through the massage. As it is a subjective matter, the final decision should rest with the client, unless it is a legal requirement. Considering that litigation-happy clients do exist, and lop-sided legal systems do not help much to keep them in check either, absence of clarity on this subject might be dangerous for some poor, unsuspecting, calm and inwardly focused Yogi masseur!

Is the tendency to cover up people, even when fully clothed, a cultural matter? Is there any scientific reason to do this? We’ll examine that soon.

I have always held that Yoga is a science, but it is an experiential science. Modern science carries the advantage of being able to explain phenomena in clear, physically demonstrable, scientific terms. So, in the absence of any clear guidelines or explanations in Yoga/ Ayurveda circles, we can make use of modern scientific research for explanations. And to the discerning, curious, analysing, right-thinking, balanced mind, science does have a lot to say!

Roots of the answer to this question lie in observation of natural behavior of humans and animals. We often associate feeling warm with a sense of relaxation and well-being – lying on the beach in the midday sun on a Caribbean island, a few minutes in the sauna or spa after work, or sitting in a hot bath. It might come as a surprise to some that most of the people like to cover themselves while trying to sleep, even when they are fully clothed, or even when lying down just to relax! 

An Indigenous educator who once worked in the remote Australian outback reported that he had met an elder who said to him “I’ve been here since before blankets!” (before European settlers introduced cloth blankets) and he told him of digging a shallow depression in the ground to sleep in ¹⁴.

Digging a pit to take a nap is very commonly observed behaviour in animals also. Animals huddle together or dig a hole in the ground to take rest or to sleep. Snakes like to feel the walls of a hole around their body before they go to sleep.

Very interestingly, when given the opportunity, animals like to even cover themselves ⁵ !

In a recent, very interesting experiment, chimpanzees in captivity were provided blankets as a part of enrichments. Out of all the enrichments provided, they chose blankets more than 50% of times during their resting hours! 

Another age-old practice also gives us some indication – infants, already fully clothed, are swaddled, or wrapped  in a snugly wrapped sheet or blanket, to help them sleep better. It’s a very common North American practice ¹³ – 9 out of 10 infants in North America are swaddled! 

The reason might be the cocooning effect of the close-fitting blanket which may mimic the mother’s womb and help soothe baby to sleep. This practice has existed for over 4000 years ¹³! Probably the most famous record of swaddling is found in the New Testament concerning the birth of Jesus in Luke 2:6–2:7: “And so it was, that, while they were there, the days were accomplished that she should be delivered. And she brought forth her firstborn son, and wrapped him in swaddling clothes and laid him in a manger; because there was no room for them in the inn.”

In biblical times, cloth held tight by bandage-like strips was used to swaddle babies.

Interestingly, Australian Indigenous babies are often cradled in wooden bowls called coolamons ¹⁴ made from bark of trees. It is believed that swaddling, in addition to other benefits, allows infants to sleep better and longer.

 The recommendation of covering yourself with a blanket or sheet for meditation has been around from times immemorial.

 Different schools even insist on a particular color of the blanket, depending on the intent and emotion involved for meditation. Almost all of them instruct that the blanket used for meditation be treated  as sacred and an integral part of the process.

Some schools recommend covering yourself right from head to toes while sitting for meditation, or even for studying. Many experienced meditation teachers insist on placing a folded blanket at least over your shoulders during meditation. This is said to help one get into meditative state faster and deeper. This also depends on type of meditation technique being practiced. Similar concepts are followed in other different religions and cultures too, to the same or lesser extent, for similar activities.

Incidentally, without the almost 500 km thick blanket of atmosphere that the earth wears all the time, we won’t even be alive today!

While these observations leave no doubt that most normal humans, almost all infants, and even some animals, given the choice, like to cover themselves while resting or sleeping, the question is why do we like to cover ourselves while relaxing or sleeping?

The Science behind Draping

Relaxation and Sleep

Relaxation is one of the major aims and benefits of massages, though massages are used for other therapeutic reasons also. One of the most obvious and striking features of massages is how they help the client relax, uncoil and unwind; masseurs try to artificially create conditions which help the person unwind – calming music, low-lit room and draping are just a few of them.

In the eyes of Science, relaxation and sleep are a continuum of the same phenomenon – both depend on kicking in of parasympathetic nervous system. Studies of brainwave activity also suggest similarities in relaxation and sleep cycles ^{15, 16, 17, 18}.

Brain-wave activity slows down and we slip from awake β-brain wave activity into α-brain waves as we relax or fall into light sleep, and then into θ-brain waves in our deeper sleep. Brain activity is reduced just by closing eyes. We keep switching between REM and NREM phases of sleep, and different stages of sleep, while we sleep, jumping from  α-brain waves to θ-brain waves multiple times, and sometimes going even deeper. One thing to keep in mind is that similar brain wave patterns are seen in light sleep and relaxation.

So, same principles apply to relaxation and sleep  ^{15, 16, 17, 18}. Anything which helps you relax better and faster, helps you get into sleep faster and better too, and vice versa. 

The Act of Lying Down

The act of lying down (from standing to supine position) decreases Core Body Temperature (CBT). It prepares the body for sleep. Skin temperature increases, and core temperature decreases, prior to and during sleep onset (Van Someren, 2004; van den Heuvel, et al., 1998; Gilbert et al., 2000). 

It’s due to your body’s thermoregulation pattern during sleep or relaxation ^{3, 4}. Thermoregulation is controlled by hypothalamus in brain. It gets feedback from blood and through various sensors in skin and other organs.

Even in humans, body temperatures are never constant and keep changing (within a normal range) during day and night, with different environments and in different seasons. Temperatures of body’s core – thorax, head and abdomen, and, shell – appendages (arms and legs) along with skin and muscles, show diurnal and nocturnal variations – they vary over a 24 hr period. There is also a gradient between core and shell temperatures ⁸. When we lie down to relax or sleep, the heart rate slows down, breathing becomes more calm and deeper, metabolic rate comes down, blood vessels dilate and circulation to internal organs and peripheries improves – all under the effect of parasympathetic nervous system.

Covering – Creating Your Own World

It is a natural instinct in humans to cover when sleeping (or trying to relax) ^{1, 2, 3, 14}.  Many studies have been done on the subject. In addition to covering for modesty, there is overwhelming scientific evidence which supports and explains why one feels more secure, comfortable and relaxed when covered. Fighting for covering sheets in childhood is an age-old cultural meme. Covering oneself while trying to sleep, or elicit relaxation response, is more in line with natural human behavior. To preserve heat, people would normally cover themselves with blankets to create a micro-climate of 34 °C (Muzet et al., 1984), which is much warmer than the normal environment for comfort when awake (28–30 °C for a nude person).

Being under a blanket also isolates one from the surrounding environment. Significant changes in ambient temperature while you sleep can be disruptive; being under a blanket creates an isolated micro-climate that varies less significantly with ambient temperature changes. So, creating that isolated micro-climate under your blanket helps you sleep better, undisturbed and longer. 

In addition to the issue of temperature, some people feel psychologically safer inside a physical cocoon while sleeping or relaxing. Perhaps, it is also reminiscent of experience in womb and during infancy! Covering with a sheet while trying to relax might immediately reconnect us to that experience at a subconscious level.

Heavy blankets additionally provide the Deep Pressure Touch Stimulation.

Distal to Proximal Skin Temperature Gradient (DPG) and Sleep Onset

Studies have shown that we actually tend to sleep better and longer with slightly lower shell temperatures than normal ². So, the body may lose more heat during normal sleeping hours. According to one study ²,  decreasing shell temperature by even 0.4°C led to significant decrease in early waking or frequency of waking during the night, and more time was spent in deep sleep (stage 3 and 4). It has been seen that sleep (and therefore, relaxation!) happens in close relation to changes in body temperature ^{1, 2, 3, 14}.

If lower shell temperature facilitates longer undisturbed sleep, then why do we use blankets? Blankets keep us warmer and should interfere with sleep, but actual observation is exactly opposite!

This is because warming the skin before sleep increases sleep propensity, or in other words, aids in onset of sleep. In preparation for sleep, core temperature drops and temperature of extremities goes up. This establishes a favorable Distal-to-Proximal-Skin-Temperature-Gradient (DPG). It has been clearly established through studies done on the onset of sleep ¹. It helps elicit an early relaxation response. Measures that increase skin temperature may also help people fall asleep (Van Someren, 2004), as long as the high skin temperature does not evoke warm discomfort. Providing an isolated micro-environment also helps. Somewhat similar objective is also achieved in a hole, or a depression in ground, or a coolamon, albeit only partially.

Cutaneous Temperature Manipulation

Sleep onset, sleep depth and sleep consolidation can be manipulated through cutaneous temperature manipulation. Warming extremities by 0.2 to 0.4°C is sufficient to set up favorable DPG. This can be achieved through various measures, covering extremities being the simplest of all. Artificially warming the extremities (esp. feet) facilitates a favorable DPG and is especially important to accelerate sleep onset (Krauchi et al., 1999).

The theory of Social Thermoregulation works on the same principle – by raising shell temperature through cutaneous warmth ⁸. A striking feature of this type of thermoregulation is its social nature: across many species, fellow animals help to warm in times of danger, disease, and distress, because the net energy cost of thermoregulation decreases when it is done through bodily contact with others. 

More recent Human studies ⁶ indicate that increasing physical warmth activates brain circuits associated with cognitive and affective functions, promotes interpersonal warmth and prosocial behavior, and has antidepressant effects. Consistent with these effects, preclinical studies in rodents demonstrated that physical warmth activates brain serotonergic neurons implicated in antidepressant-like effects ⁷.

Practical Applications of Cutaneous Temperature Manipulation

Studies suggest that social behavior can be manipulated through cutaneous warmth – increase in brain serotonin levels with optimized cutaneous warmth can positively affect mood and social behavior, appetite and digestion, sleep, memory and sexual desire and function. Affective Warmth Hypothesis conceptualizes the embodied, multifaceted, brain-body physiology of well-being, and suggests that afferent signals from the body may contribute to cognitive and emotional states. This study also claims that activating warm thermosensory pathways promotes a sense of well-being and even has a therapeutic potential in the treatment of affective disorders and major depressive disorders (MDD) ⁷.

Better understanding about the mechanism of sleep and its thermoregulation also has the potential for use in treatment of narcolepsy (Fronczek R, Overeem S, Lammers GJ, van Dijk JG, Van Someren EJ, 2006).

This simple fact that increasing temperature of extremities by covering with a blanket increases sleep propensity is already being promoted for treatment of various disorders:

• Anxiety and Stress
• All Affective Disorders (Mood Disorders)
• Multiple Depressive Disorders (MDD)
• Narcolepsy, and more….

Invention/ evolution of various new gadgets is based on the same and similar concepts, like:

• Cozy Caterpillar Body Sock
• TJacket
• SnugVest
• Heavy Blankets
• Weighted Blankets etc.

The use of these and many more similar gadgets is being promoted for an ever-growing list of diseases.

Is This a Cultural Issue?

Is this tendency to cover up a cultural issue? This message of this whole discussion is loud and clear – tendency to cover is a matter of basic human physiology! All we have discussed here applies to all humans, everywhere. This kind of behavior is exhibited by humans and animals alike and is readily explainable on the basis of normal human sleep physiology.

How it all applies to massages

1. Lying down for massage decreases Core Body Temperature, irrespective of the state of dress.
2. Covering with a sheet serves many purposes:
   1. It helps preserve body heat.
   2. It provides an isolated micro-climate.
   3. It provides a cocooning effect.
3. Warming extremities, esp. feet, leads to favorable DPG. This induces release of ‘happy hormones’ from the brain and helps the client relax. Again, state of dress does not matter.

The same principles as discussed here, based on sound scientific explanations, can be applied when trying to induce a relaxation response –  covering up a person (esp. extremities), naked, partially or fully clothed with a blanket or top-sheet makes all the sense if your intention is to help the person relax. This claim is very well supported by instinctive, experiential, age-old practices, and substantiated by modern scientific studies which confirm a legitimate physiological basis for such normal human behavior. 

Rather, the opposite of this is not in line with normal human physiology, though it might be the personal preference or personal belief of some people modified by learned adaptive behavior or a result of complex psychological phenomena. As per the available scientific data, this kind of behavior does not conform to scientific documentation of normal human physiology of sleep and relaxation! If at all, this is likely to be exhibited only by a small minority.

In my personal experience, I am still to come across a person who ever objected to being covered by a top sheet for a massage, even when fully clothed.

Legal Perspective

Draping laws vary in North America. In USA, an increasing number of massage boards (most states in USA, e.g., Oregon, Illinois, New York, Washington etc.) have it as a legal requirement to drape the client; draping is considered ‘not optional‘ there, irrespective of the state of dress or undress. In some other US states, draping may be optional if agreed to by both – the client and the therapist, but the client has to sign additional consent for this.  

In Canada, the provinces of Ontario, British Columbia, Newfoundland and Labrador, and New Brunswick have established regulatory authorities (Colleges). Canadian Massage Therapy Alliance (CMTA) recommends providing non-transparent draping materials to the client, and arranging and securing draping so that only the part of the patient’s body that is being assessed or treated is exposed. Also, reasoning for removal of clothing and respect for the client’s right to decline the removal of certain or any clothing is to be explained. Use of sheets to cover themselves once they are in position for treatment should also be explained to the client. CMTO also gives directions for draping.

Carry home message for masseurs and their present and prospective clients

Drape a client, whether fully or partially clothed. Only the area to be treated should be exposed. If the client does not want to be covered, and the law of the land permits it, you may go with an undraped massage. Getting additional consent for that might be a good idea, especially if it is legally required. Massage is for the client’s benefit and (s)he has to be comfortable all through the massage. When the choice falls upon you, covering the client during massage – naked, partially or fully clothed, is always better.   

It just makes all the sense in the world! 

References

Here are some studies/ scientific articles which confirm various points related to thermoregulation in sleep (read relaxation):

1. Cutaneous warming promotes sleep onset

2. Skin deep: enhanced sleep depth by cutaneous temperature manipulation.

3. Effects of thermal environment on sleep and circadian rhythm

4. The Body’s Thermoregulation During Sleep
5. Nighttime Enrichment Preferences of 3 Captive Chimpanzees (Pan troglodytes)
6. Somatic influences on subjective well-being and affective disorders: the convergence of thermosensory and central serotonergic systems

7. Somatic influences on subjective well-being and affective disorders

8. A theory of social thermoregulation in human primates

Here are discussion groups/ blogs which confirm that most people tend to cover themselves in sleep, or look to cuddle themselves with a partner

9. Why do we feel a need to sleep with a blanket? Is it biological or cultural?

10. that-freakin-guy explains, why do humans have such a strong desire to sleep under a blanket or sheet even when it is hot?

11. Why We Sleep Together

12. Relaxation, Stress & Sleep

13. Swaddle your baby for a better, longer sleep

14. Why do people want to put on something like a blanket while sleeping?

Neurological data on brain-wave activity, relaxation and sleep:

15. Brainwaves Overview

16. Types and Stages Of Sleep

17. What is the function of the various brainwaves?

18. Brain Basics: Understanding Sleep

Dr Jitender K Sahdev

President and Director of Teaching

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