Category Archives: Dealing with Medical Conditions

Massage with the Eyes in Your Fingers

There is a time in every massage when the therapist begins to rub the posterior neck. For many of our computer-burdened clients, it presents an opportunity to relieve the congestion of technology.

The head is supported by these many muscles, embedded with many layers, often adhesed, and near the source of many functions from sleep to mood to respiration.

Headaches emerge from these groups, as do disorders such as head-forward posture, and as some suspect even problems such as chronic fatigue.

So what do many of us do when we approach the root of these many complex problems? We effluerage upward, in the direction of the cranial vault and away from the shoulders.

Medical Illustrations by Patrick Lynch, generated for multimedia teaching projects by the Yale University School of Medicine, Center for Advanced Instructional Media, 1987-2000.

Let me make a case that we are drawing our hands in the wrong direction. Take a look at the accompanying picture from Wikipedia. See all the muscular origins? The SCMs, the traps, the cervical erectors?

The upward effluerage comes from the general direction of Swedish massage, which is in the direction of the heart, following venous flow.

But at the shoulders, we are no longer drawing toward the heart, but away from it. This draws thumbs and hands into the great space at the under-cranium, the place where those headaches and balanced-head issues hide.

With congestion disorders from headaches to fibromyalgia, we may do much good for our clients by drawing down from the hairline toward the mid-trapezius.

Try drawing congestion away from the source, toward the crux of the trapezius. You might be surprised by the results.

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Massage to Measures

Massage therapists like to think we help people deal with stress, injuries and fatigue. But how do we know we help?

Massage is, after all one-on-one. We are stars or idiots one hour at a time, and we often don’t take much credit for our clients’ successes or failures. Is a massage therapist a facilitator or a game-changer? Do we really know?

I’m reminded of the times I thought I had no clue what I was doing, only to have the client hop off the table and give me a compliment and a big tip.

But I also remember that once on vacation – after one particularly hideous massage from someone who thought they were fantastic – that I said thank you and left a tip anyway. I made a mental note of the therapist’s name in case I ever happened to go to this resort again so I could get someone else.

How we measure ourselves and our effectiveness in massage therapy is something of an emerging issue. In a practice that is more art than science, can we really measure ourselves?

People have often received treatments for medical conditions that have no proof or promise – but the treatments are tried in the belief that they may relieve suffering or repair the underlying condition. That is the art of medicine.

Can we also preserve the art of massage while some therapists attempt to move into the medical – and the reimbursed – field?

A recent post by long-time and very respected massage instructor Noel Norwick of Los Angeles asked the question on Facebook.

His question on medicalmassage@groups.facebook.com group referred to a study. It found that soothing talk – reassurance – worked just as well as physical therapy treatment after whiplash. Here’s the link: http://www.bodyinmind.org/treating-whiplash

It appears to say that treatment versus soothing talk have the same results. My comment was that it might say much about the quality or delivery of treatment instead of its effectiveness in the right hands.

Would that be the case if reassuring talk were compared to massage? I think not. Hope not. But let us ask this question another way – if we could offer nothing hands-on, would we offer reassuring speech? Isn’t that sometimes the de facto treatment for stress disorders – even though many of us would propose that massage would be much better?

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Providing Post-Surgery massage to clients

Clients seek massage therapy for many reasons, and one of the most challenging for a therapist is chronic pain following surgery.

It’s a tough spot – here we are dealing with tissues that have had a direct surgical intervention – moved, touched, cut or compressed. We also are dealing with structures altered when the body’s healing response forms scar tissue and adhesions.

Massage therapy, thankfully, is low-tech when it comes to post-surgery pain. When I first began treating clients for this type of problem, I referred to muscular patterns of pain and overlapped them with “dermatome” patterns – meaning areas where disturbed nerves can cause pain.

Often stabbing or sharp pains can come from nerves that have developed adhesions or stress patterns from scar tissue pulling on them. These changes may occur far above the area where pain is felt. The massage is always gentle and soothing, following the course of nerves through plexuses and their redundant branches.

Another technique is pain mapping – each time the client returns we again map the pain areas to see if they have changed. If has altered or lessened the pain then the areas treated may be part of the disturbance.

Abdominal breathing is also an important part of these recovery massages. The diaphragm is inhibited by pain and restoring its function – awakening the “bellows” of the body allows for gentle stretching of muscles, organs and nerves. Ultimately diaphragm breathing is the gentlest massage of all.

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Massage for Shingles ‘Ghost’

A new massage client had a request: eight months after an outbreak of shingles, she still had a strip of weird-feeling and painful skin.

“I call it my shingles ghost,” she said. “It’s haunting me still.”

What she described sounded like post-herpetic neuralgia, a sensation that an area afflicted by herpes “chickenpox” virus is still active.

And no, she didn’t need an exorcist. Just a good massage.

As a massage therapist I have seen shingles outbreaks in many clients, and for the most part the clients are older than 50. Occasionally I have seen it in young people, usually after a period of high stress at school or in their family life.

Massage therapists steer clear of active shingles, asking clients to get a doctor’s clearance before having a massage. The reason is not for self-protection. Shingles is not catchy. But massage of an active outbreak area can worsen the attack and slow recovery.

That said I have never had someone with active shingles ask for a massage. They have generally been embarrassed by the outbreak and have called to cancel or beg off massages for a while.

Opportunity knocks, however, after the outbreak has ceased. The outbreaks are painful, screwing up sleep patterns and requiring odd sleeping positions to avoid a painful side or back area. When the client is cleared to come on for a massage, he/she is more than ready.

As was this client, who had suffered through an outbreak that crawled along a spinal nerve from T-5 or t-6, circling the left side from spine to sternum, roughly even with her lower bra-line.

This presentation is classic in shingles, and very painful. Somehow this client had mustered on through a huge deadline at work. When she told me about this determination I had my first clue about how to massage her.

With the client prone, I checked the area of the outbreak for any reddish, hive-looking sores. None. The left side looked same as the right side. I palpated along the spine and asked her to let me know when I was on the spot. I began at T-2, and she pinpointed the spot roughly over T-6. Sometimes the lightest technique can be the most freeing. I tried to skin-roll the section, listening for a pop or some other sign of release.

Lucky for us all it seemed to release the sensation. I suspect the feelings were the result of an adhesion over the area, probably aggravated by the bra. I massaged the length of the T-6 dermatome, under the bra line and to the sternum.

All the area really needed was some TLC. Massage after a shingles outbreak is good indeed. She told me next time she came in that the “shingles ghost” was gone for good.

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Massage Finger Maps Helps Reduce Numbness

Massage therapists will often have clients ask about foot or finger pain, or a strip of tightness around the knees or hips, but when is this a symptom of something gone wrong?

As we rub away with our talented hands, we may have an opportunity to assess if a nerve root or disc has been pinched or altered by time or trauma.

Recently a client sought help for numbness in the fingertips of the thumb, index and middle finger. Massage therapists are aware that numbness or weakness calls for evaluation by a doctor. This client had already seen her doctor, and an evaluation had shown disc problems in the neck.

My client was hoping for some improvement brought about by massage instead of more drastic measures.

A quick frisk of Google for numbness in these areas yields lots of articles regards dermatomes and myotomes, showing the body sliced into grids labeled with the common nerve root/disc source. The thumb, index and middle fingers are associated with the medial and radial nerves, and with C5-C6. Tingles in these areas might be caused anywhere from the spine and disc to the carpal tunnel.

By tracking the radial nerve from neck to fingers, I used several techniques to warm, stretch and free the nerve from adhesions. I also massaged the scalenes and applied light traction to the head, in hopes of opening the pinched off areas.

Her symptoms were greatly reduced, and my client is hopeful that massages and some physical therapy will keep her out of the operating room. Will my client have neck surgery? I don’t know, but her symptoms took a turn for the better, and that is what clients seek.

If dermatomes and myotomes are new to you, try a Google of them for some great information that will help your massage practice. I also keep a printed chart handy in my massage appointment book.

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Knowing Your Client – What Works For One Person Doesn’t Work For All

In the early days of a massage therapist’s career, discovering which techniques work well in a treatment session can be baffling.

Is it deep tissue? Soothing strokes? Is it short sessions? Long sessions? Is it movement? Breath? Is it the clients’ mindset? Perceived value? Desire?

Somehow fumbling about in our dim-lit treatment rooms we establish our patterns of understanding, and hopefully we can match those up to our clients’ expectations.

But ask a room full of massage therapists what works can be maddening. Folks who otherwise feel compassion for others can get rigid about their thinking. After all, if something works for them, should it not work for everyone?

It’s a hard fact of life that what works for one person doesn’t work for all. Yet we as a profession are constantly trying to define and establish “scientific” protocols for what works. An effort of little reward, it seems, for therapists and their clients. It does seem to fill up chat rooms and discussion groups.

I saw a lot of this discussion in other professions, as I spent much of my first career reporting on medicine and health sciences. People in these professions don’t want to do any harm, but they want to alleviate suffering and improve lives. Complicating that is the fact that outcomes vary widely. Protocols often work far better for one doctor over another, and for one facility versus another.

The human factor, a long-time friend explained, is what drives people a bit crazy in clinical practice. Was it the protocol or the nurse/doctor/therapist/team/facility or the family prayer group in the waiting room? Is the new drug a wonder pill or is it the selection of patients and monitoring of its use?

I suspect the answers in massage therapy may be about as difficult to vet as it is in medicine. Meanwhile, we practice in the dim-lit rooms of our vocation. If lucky, our clients will tell us what we need to know.

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Providing Quadriceps Massage

My massage therapy client has been working very hard to lose weight. She is going to the gym four times a week, training under the watch of two very good kiniesiology trainers, and eating a diabetic diet. She has lost more than 70 pounds in the past year.

That is a little fast to lose weight, but she has been a trooper. This past holiday season she stayed on track, upping her workouts to make up for time spent traveling and enjoying a few extra carbs. I had not seen her for nearly more than 6 weeks when she limped into my office.

“It’s my knee,” she said. “My good knee!”

Sharp pain was curling around her kneecap. I recognized that look of dread. Try losing weight when you have knee surgery and you are going to spend a month on the couch. A few years ago she experienced that with her bad knee.

Knee pain can be anything, a testy sciatic nerve, nerve root impingement, a poorly tracking kneecap, and osteo-arthritis in the joint. But I do massage, so I follow my muse. Chances are, a sore knee is a sore, entrapped quadriceps – or more likely a sore, entrapped group of quadriceps.

It’s not the easiest massage, but opening the quads can bring a lot of relief. I have learned to start slow, with a lot of warming Swedish massage, to reduce the pain and agony of myofascial release and trigger point work on the most adhesed muscles of all.

Quadriceps that have become trapped in their fascia feel like stone. They lack the softness and rubbery bounce of muscle, feeling sharp and bumpy, almost lifeless.

Warming Swedish can get at the overlay of skin and adipose tissue but that will leave the quadriceps unchanged. Trigger point maps of the quads show so many “x” spots it is hard to see the anatomy. I have learned to start at the top of the muscle, near the trochanter and ISIS, using forearm rather than fingers. Both of these moves reduce the pain.

As trigger points fade, the muscles start to soften. Then add a layer of myofascial release, again using forearm to reduce the strain on the therapist and the client. I slowly move down each quadriceps in strips, starting with the medialis. As I work, I using overall Swedish strokes in between to structurally integrate and encourage circulation.

I am used to feeling the major changes in the quads as they soften. What is remarkable is that my client noticed this, too.

“They feel like they are getting softer and warmer,” she said.

The monster trigger points hide in the area of the vastus lateralis nearest to the knee. I work those last as they are the worst. On these points the knee pain finally subsided.

“Those ball squats you have been doing at the gym have been very effective,” I told my client. “We need to do the bad knee, too.”

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Goals and Perceptions

Massage therapists need enough information from our clients to understand where we are heading in a massage session.

Working at spas, therapists get used to brief intakes and a question or two before starting a massage. In my practice, I get to take the time to do a longer intake and get more detail.

Yet I have learned not to ask the P-word upfront. The P-word is a big turn-off for clients, and makes them associate massage with illness instead of wellness. Even though it is very important to know about it before starting a session, it is very delicate to handle.

The P-word? Pain.

I like to list some goals on my intake sheet. I ask clients to circle their choices: recovery from stress, recovery from work, relax/improve sleep, reduce soreness from sports/exercise, reduce headaches and all of the above.

What I don’t list as a goal is relief of pain, largely because many people do not like the word itself. For some, admission of pain is some sort of failing. I see this particularly in men, but not exclusively. Later in the intake, after asking about discomfort and tense areas, I do ask if there is an area of pain.

Many people, no matter how ice-picked they feel, admit to discomfort and tension only. The P-word is off limits to them. On the other hand, for people whose primary complaint really is pain, they have answered enough questions to allow an admission that there is pain they want addressed.

It’s a bit tucked away in the middle of the intake, where I think I can get a heads-up on pain issues without the psychological politics involved in using the word. It helps get the conversation about the session going, and allows people in pain to step out with more safety.

When pain is an issue I will ask about pain on the 1-10 scale used in medical settings, with 10 being unbearable and 4 just being annoying. When doing trigger point work and follow-up questions after sessions, I use the scale to note any increase or reductions in perception of pain.

The scale gets people to realize if the pain is up or down and opens the door to the idea that the pain can decrease with treatment. The only time I find the pain scale unreliable is when the person is also habituated to opiates. These drugs are known to create pain arcs in the body to satisfy a craving for more drugs.

(Note: Research has shown this pain is real. In the past, there has been a mistaken assumption that the habituated person is lying just to get drugs. Obviously it affects the healing relationship for a therapist to assume someone is not truthful.)

So dealing with the P-word is an important part of massage work, but it is best tread with empathy and kindness. It carries a lot of baggage for some folks and can get in the way of a healing touch.

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What Good Would Massage Do?

A friend shared an experience with me. His stiff back had become worse recently. After sitting for a while at his desk, if he turned the wrong way when getting up or reached too far, ZAP! A pain would

shoot down his leg from the low back to the knee.

“It just takes my breath away,” he said. “It really gets my attention.”

This gentleman has played football, fought in the war, and built suburbs. If the pain is bad enough to rob his breath, I am on alert.

A few trips to the doctor and he was diagnosed with foramen stenosis, a term that means osteoarthritis – calcifications and inflammation – were taking up residence in the area where spinal nerves exit L4-L5. The osteoarthritis pushed against the nerve bundle as he tried to move. Hence the ZAP!

I inquired about the plan.

“Well, I went to p.t. and at first the stretches seemed to help, but then they made things worse. It’s not bad enough to operate on yet. I am just trying to move my back as little as possible.”

Good heavens. I had to speak.

“Have you considered doing some massage?”

“What good would massage do?”

Oh yes, sometimes this question comes up. I happily urge all massage therapists to answer it when it does.

Too often people think inflammation and calcifications of osteoarthritis are set in stone. They move less and less, giving the condition a wide-open opportunity to get much, much, worse.

Well, massage therapy alleviates back pain, inflammation and swelling. It is why we train to do what we do. I mentioned a recent study that found general, non-specific massage helped reduce stenosis pain.

He asked if massage could fix the problem.

The study didn’t go long enough to figure that out, I explained. The big result is that people felt better and thus did more and felt healthier.

Do massage therapists think gentle rubbing can reduce osteoarthritis? Or “just“relieve it? I think we know the answer, don’t we?

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The Diabetic Foot

Some regular massage therapy is a good thing for most diabetics. Swedish strokes tend to help lower blood sugar, and structures suffering from loss of blood – from bones to the soft tissues, enjoy a boost of circulation.

Most people think of diabetes as an imbalance of insulin hormones, but we massage therapists see the true disease – lack of circulation throughout the system as cells struggle with basic movement of nutrients.

With many clients this massage therapist works intently to improve circulation, especially in areas of the hands and feet. Such detail as massaging each toe can help prevent diabetic ulcers and other skin breakdowns. I am always on the lookout for any signs of skin compromise so it can be evaluated quickly.

With insulin-resistant diabetics, Type 2, I also look for ways to improve their ability to walk moderately to lessen the effects of the disease. Some diabetics, however, who have had the disease for a long time can develop a softening of the foot bones that can lead to collapse of the structures. The condition is called “Charcot foot.“

I had seen Charcot only in books until a recent client came in hoping to relieve some back pain. Massage for the back pain and hip muscles relieved her troubles for a few days, but as time passed her lumbar pain returned.

When I looked to her feet, I found bumpy surface lacking all three arches. The main medial arch was flat and had a very hard, round spot dead center – a foot bone had possibly dropped down through the arch. The lateral arch was also flat with another dropped bone. The last arch at the base of the big toe and second toes was also flattened and most of the toes had hammered down in response.

Her ambition to walk 30 minutes a day on the line, she checked with her doctors, and they diagnosed the Charcot foot.

Her doctors have advised her to wear orthotic, supportive shoes at all times – not just when out of the house. Also, she has to wear supportive arched wet shoes when doing pool exercises.

As massage therapists, we are often telling people with arch problems to make sure their feet are supported around the house and patio in addition to when they walk outside.

With this and other diabetic clients, we massage folks can help not only with suggesting people have their feet checked closely for ulcers and skin breaks, but also for structural problems worsened by the disease.

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