Massage for people with neurological disorders

Patients with neurological conditions, just like any other individuals, may request massage to achieve a feeling of well being. In mainstream health care, the use of massage with this client group is an adjunct to active exercise therapy through which abnormal reflexes are managed and normal reflex activity is facilitated as muscle function and balance are improved. Restoration and maintenance of normal movement is the priority for use of patient–therapist contact time, to maximise natural neuroplastic changes and increase function. Massage should therefore be used selectively, to enhance the effects of other forms of physiotherapy. Where massage is used, for example in an attempt to reduce excess muscle tone, the type of spasticity must be understood because spastic reflexes are easily triggered by inappropriate handling. Examples of this are in flexor spasticity, when stroking the palm of the hand can stimulate the grasp reflex, or in extensor spasticity in the lower limb, when stroking the ball of the foot can trigger an extensor thrust response. As spasticity is due to loss of inhibitory control from the higher centres, reduction through peripheral stroking techniques is not of permanent value but can be used to evoke a temporary response, which enhances the effectiveness of subsequent movement techniques.

Slow stroking over the posterior primary rami region, based on the Rood approach, has been advocated by O’Sullivan (1988). Her suggested mechanism for the resulting reduction in muscle tone is activation of the inhibitory reticular system, which temporarily replaces the lost descending inhibition. In a study by Brouwer and Sousa de Andrade (1995), 10 patients with multiple sclerosis had measures taken of H-reflex amplitude, H-reflex amplitude during vibration and Achilles tendon jerk, in the triceps surae muscle. The measurements were taken before, immediately after and 30 minutes after stroking. The technique consisted of 3 minutes of continuous stroking from the occiput to the coccyx (with the patients lying prone), by the therapist’s index and middle fingers on either side of the spinous processes. A significant reduction in H-reflex amplitude was found in the group with multiple sclerosis, particularly 30 minutes after the stroking ended. The study was well controlled except for use of baclofen (an antispastic drug), although analysis showed that subjects taking the drug demonstrated the same trend in results, albeit to a lesser degree. In addition, the subjects reported subjective feelings of relaxation. Farber (1982) suggests that 3–5 minutes should be the maximum length of time this type of massage is given to neurological patients, to avoid rebound effects of the autonomic nervous system (ANS) or skin irritation.

Sirotkina (1964) used massage on flaccid muscles in the hemiparetic arms of stroke patients, in an attempt to increase muscle tone. Electrical activity was shown to increase following massage. Massage has been shown to have a positive psychological effect on multiple sclerosis sufferers. Hernandez-Reif et al (1998) compared ‘medical treatment’ with massage and found that the massage group improved anxiety and depression scores after ten 45-minute massages over 5 weeks.

Massage can be used to mobilise and stretch shortened muscle groups, in conjunction with active exercise therapy techniques. This can be useful in the flexor muscles of the forearm. Soft tissue mobilisations (STMs) are commonly used, to stretch muscle and its surrounding tissues and to restore muscles in excess torsion back to their more usual position. The muscle belly is grasped within the therapist’s palm and the muscle is lifted and rotated towards its normal position, repeated numerous times. This is done in conjunction with active exercise therapy, to help normalise muscle tone and increase the effectiveness of muscle activity.

Massage in respiratory disorders

Massage is not in widespread use with this client group. Asthma and other conditions which cause breathlessness, however, can lead to feelings of panic and anxiety so it may be that massage has a use in assisting patients to manage these conditions. Connective tissue manipulation has been used to reduce bronchospasm. Beeken et al (1998) studied the effects of neuromuscular release massage therapy in five individuals. Four of the subjects had an increase in thoracic gas volume, peak flow and forced vital capacity. The authors report significant improvements in heart rate, oxygen saturation and systolic blood pressure following 24 weekly treatments. These findings are of interest and may be worth repeating with a larger sample to explore whether the findings can be generalised to other individuals, and whether massage was the only causative factor in the improved physiological measures. Massage was found to be superior to relaxation therapy in children with asthma (Field et al 1998a). The children were more relaxed after massage and over time experienced improvement in lung function. It is unclear whether the effects were psychological or physical, as again this research group did not control with another touch therapy. It also had poor reporting characteristics (Hondras et al 2001).

Pain

Pain is an important symptom. Pain caused by cancer is experienced as ‘negative’ pain, possibly perceived to indicate a severity or worsening of the condition, therefore provoking fear and anxiety. This contrasts with ‘positive’ pain which can be endured more readily as it leads to reward, such as the pain of childbirth or athletic achievement. Massage can help an individual to cope with pain. Several approaches can be taken: whole body massage can be given to induce relaxation; local Swedish massage can be applied to close the pain ‘gate’ or to have a counterirritant effect. Reflex techniques such as acupressure can be used to promote relaxation and a feeling of general well being or to improve specific organic functions.

A study conducted on volunteer healthy subjects found that massage produced hypoalgesic effects on experimental pain (Kessler et al 2006). Weinrich and Weinrich (1990) studied 28 patients with cancer, assigning them to two groups of 14 in matched pairs. The treatment group received 10 minutes of massage (performed by senior nursing students who had received less than 1 hour of massage training), while the control group was visited for 10 minutes. The back massage significantly reduced pain in men but not in women. This was short-term relief, as no significant differences remained after 1 hour. The levels of pain before the massage were, in fact, quite low, so significant falls would have been difficult to demonstrate in a sample of this size.

In a larger study, Marin et al (1991) studied the effect of massage on 116 patients who had had a thoracotomy. A visual analogue scale was used, as in the Weinrich study, and it was found that massage and physiotherapy reduced pain significantly. This is a French paper and unfortunately the English abstract does not give further details. Massage therapy was found to have superior effects to transcutaneous electrical nerve stimulation (TENS), a common treatment for chronic pain, and placebo TENS in fibromyalgia patients. The massage therapy group enjoyed improved sleep patterns and decreased pain, fatigue, anxiety, depression and cortisol levels following ten 30-minute massages over 5 weeks. The TENS group also improved across several parameters by the last treatment. The massage therapy was compared to modalities which were less intensive in terms of touch and direct individual contact, so the psychological effects of massage cannot be differentiated from any physiological effects in this study (Sunshine et al 1996). In a more recent study of the same client group, massage was found to have a positive effect on pain intensity, number of tender points in the neck and upper back region and functional status in fibromyalgia patients. Massage was added to a treatment regimen of heat and exercise and compared with heat, exercise and mobilisations. Neither approach was found to be superior but the sample sizes were small (n = 7) in this study which contained multiple variables (Aslan et al 2001). A randomised controlled trial undertaken by Hulme et al (1999) explored the effects of foot massage on patients’ perceptions of daycare following laparoscopic sterilisation. The mean pain scores following surgery differed between the two groups (foot massage and analgesia compared with analgesia only), with the foot massage group reporting less pain over time, although this was not statistically significant. Field et al (2000) studied the effects of burn scar massage and found that twice-weekly massage reduced the incidence of itching, pain and anxiety and improved mood. Unfortunately, the mechanical effects on the scar itself were not measured. Massage appears to be a promising intervention for pain relief but studies differentiating between the psychological and physiological effects would inform work with this client group.

Plastic surgery

Patients with cancer may be offered reconstructive (‘plastic’) surgery following disfiguring surgery. Massage following mastectomy is advocated by Field and Miller (1992) for reducing the thickening of the scar, facilitating revascularisation and promoting mobility and elasticity of the skin. These authors also describe massage of silicone breast implants to prevent capsular contracture, a common cause of disfigurement. These massage ‘exercises’ are recommended from 24 to 48 hours after operation and should then become a permanent routine for the patient. The implant under the skin is displaced superior and medially to counteract the effects of gravity. Laterally and inferiorally directed movements can be included, but are optional.

Bodian (1969) reported the efficacy of massage following ophthalmic plastic surgery to reduce thickening of scars and keloid formation and to prevent deformity caused by scar contracture. A technique whereby the skin of the eyelid is stretched to full excursion in a direction opposite to the tightening was described. This method, using approximately 20 excursions three times a day, was taught to the patient or parent 2 weeks or more after surgery. Reported results were softening and thinning of the eyelid, smoothing of the scar as underlying adhesions were released and reduction of keloid formation.

Massage with older people

Within the client group termed the young old (65–74 years) and the old (over 75 years) (Rosenberg & Moore 1995), widely varying degrees of physical and mental health can be found. This is not a homogeneous group and, as far as health is concerned, there is no reason to assume they all have health or functional problems. It is noteworthy that about 80% of older people in the UK perceive their health and activity levels to be satisfactory (Partridge et al 1991). Since then, Western society has seen a move towards increased activity, employment and active leisure pursuits in this age group. However, some of the changes associated with ageing can cause physical discomfort, loss of function and psychological change. Collectively these may lead to a loss of coping skills, which means that these elderly people will require varying levels of support to remain independent in their own home, or will require admission to long-term residential care. In both cases, the prime goals of care are to improve or maintain functional abilities for as long as possible and to enhance the quality of life (QoL). These aims are unlikely to prove successful in the long term if adequate attention is not given also to intellectual and emotional function. Thus, it is especially important to view a programme of care holistically and it may then be found that improvement in one function will often be followed quickly by improvement in others.

Some elderly and very old people are admitted to residential care because their support system has failed, for example when a carer has fallen ill. If the client does not deteriorate functionally then a return to semi-independent living is possible once the support is reinstated. However, the majority of people in residential care are there because, even with a high level of support, they cannot function satisfactorily and safely in their own home. Many of these clients have multiple pathologies and other problems associated with old age. Physical discomfort, impaired function, social isolation, bereavement, decreased financial status and loss of home are also likely to have had a significant effect on people in this environment. While some clients display remarkable resilience in coping psychologically with these events, others suffer a consequent impairment in mental health.

Although depression is commonplace in the elderly (Gurland & Toner 1982), the therapist should guard against mistaking the symptoms of depression for dementia, which is an organic brain syndrome. A depressed person may appear confused and lack motivation but the condition may be helped by appropriate interventions. Highly developed interpersonal skills are required of the therapist to maximise the possibility of successful treatment. Empathy and an unconditional positive regard are prerequisites to developing a therapeutic relationship which may partially compensate for the social isolation and anxiety caused by a change in the client’s environment.

Personal autonomy—the freedom to make one’s own choices—is largely denied to elderly people in residential care. This frequently engenders a loss of self-esteem and sense of self, which is damaging to QoL and can also affect motivation. It is important, therefore, that clients should be empowered in such a way that they feel that they have some choices. This is pertinent to the therapist when considering massage with this group of clients. It should not be assumed that every elderly person will welcome touch or that it is necessarily appropriate. However, there is a body of opinion which supports the view that some institutionalised elderly and chronically sick people may be tactually deprived (Barnett 1972, Fakouri & Jones 1987). It has been reported that a group of elderly clients with anxiety and depression responded well to hand massage, experiencing feelings of relaxation and an improved sense of well being (Cole 1992). Back massage with conversation has been shown to reduce anxiety in the elderly. Fraser and Kerr (1993) compared back massage with conversation to a conversation-only and a no-intervention group, in a population of institutionalised elderly clients. The results showed a significant difference in the mean anxiety score between the back massage and the no-intervention group; the results approached statistical significance between the back massage and the conversation-only group. Although the sample size was small (n = 21), which makes the validity of the statistics questionable, this study does lend some support to the use of massage as an intervention with anxious elderly clients in residential care.

The therapist should ensure that privacy is maintained throughout the massage and require the client to remove only the items of clothing essential for facilitating the treatment. Many elderly people are embarrassed to remove clothing in the presence of another and the therapist will be rewarded if she first takes time to establish a good rapport and remains sensitive to this issue. Care and attention need to be paid to the type of massage administered, particularly in relation to the soft tissues, which are not so resilient as those found in a younger age group. Extra lubricant should be used on dry skin to avoid stretching and uncomfortable friction; light techniques should be used in the presence of fragile blood vessels. The client may not be able to lie in the usual positions for massage: climbing on to a non-adjustable treatment couch may be impossible or unsafe, and for some elderly people the prone position will be uncomfortable. If a treatment couch is used the supine and side-lying positions may be more comfortable, but many clients will require the therapist to use ingenuity in achieving a position that both is effective for the massage and remains comfortable and ergonomically sound for client and therapist (Fig. 14.1). Massage to the upper and lower limbs can be administered with the client seated in a comfortable chair; back massage is facilitated when the client is seated on a stool of suitable height and supported anteriorly by pillows placed on the couch or a table. If positioning is problematic, or if the client does not wish to remove clothing, then a hand massage may be acceptable. This is a useful alternative when privacy cannot be assured and can also be utilised as a component of a group programme for promoting social interaction and shared enjoyment.

Figure 14.1 • • Enabling massage in a seated position by use of a portable head rest.

Dementia

This term denotes a global intellectual impairment associated with most areas of mental function and may be accompanied by decreased motor abilities. It is commonly the result of Alzheimer’s disease, multiple cerebral infarcts, metabolic disorders or some degenerative diseases. Most dementias are chronic, with an unremitting deterioration in the condition. Occasionally a form of acute dementia is diagnosed which can be treated, for example in the case of vitamin B₁₂ deficiency. The challenge facing health professionals, when caring for clients with dementia, is to provide an environment that offers opportunities for optimum QoL for each individual.

The therapist must be prepared to take much time in building a relationship of trust with the client and in acquiring the skills needed to communicate in the presence of intellectual and sensory deficits. Several studies support the view that the use of two sensory stimuli during communication are more effective than one, so that the addition of caring touch to a verbal approach may facilitate verbal or non-verbal responses (Kleinke 1977, Langland & Panicucci 1982). The utilisation of touch may not have a universal application: in some patients with high agitation and severe cognitive impairment touch was found to be linked with an increase in aggressive behaviour (Cohen-Mansfield et al 1989). This work supports that of De Wever (1977), who found that nursing home clients often perceived discomfort when an arm was placed around their shoulder by a nurse. Thus, great care should be taken by the therapist to ensure that physical contact is not misinterpreted by the client: ensure that the client is able to observe your approach; attempt to maintain eye contact during communication; always explain what you require from the client; avoid making sudden movements which may startle the client; and, where possible, ensure that the client is in a familiar environment with minimal extraneous sensory distractions. Ballard et al (2002) demonstrated a clinically significant reduction in agitation in patients with severe dementia but these positive effects are attributed to the essential oil melissa. This is regarded as a good study (Thorgrimsen et al 2003).

Massage of the hands may help to accustom the client to being touched, assist in building trust and promote relaxation. Poon (1991) found a 40% increase in self-reported relaxation scores after elderly clients with dementia were treated with hand massage. When the massage was combined with music, the scores increased to 60%. Hand massage may be taught to the family, carers and significant others of dementia sufferers; these are people who often feel helpless in the face of the unremitting nature of the disease and the difficulties in communicating with their loved one. Giving a massage may enable them to enjoy a form of caring touch once again.